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					Breathing patterns

atterned breathing simply means breathing at any number of possible rates and depths. Some
women prefer breathing deeply, using their diaphragm to fill their abdomen with air. Others
prefer light breathing, inhaling just enough to fill their chest. The goal is for you to find
breathing patterns that calm and relax you. Your breathing should be at a comfortable rate and
not cause you to feel short of breath or light-headed. The more you learn about labor and birth,
the more you will see how different patterns of breathing are used at different stages.

Here you will learn about using breathing to focus on each contraction and making each
contraction a productive part of birthing your baby. Patterned breathing is helpful when
experiencing various types of pain, discomfort, anxiety or fear. After reading this information
you will want to put patterned breathing into practice during every day stressors.

Benefits to practicing patterned breathing
      Breathing becomes an automatic response to pain
      Mom remains in a more relaxed state overall and will respond more positively to pain
      The steady rhythm of breathing is calming during labor
      Provides some sense of well being and a measure of control over behavior.
      Provides more oxygen, which provides more strength and energy for mother and baby
      Brings purpose to each contraction, making them more productive
      Patterned breathing and relaxation become habits for life’s every day stressors

How to practice patterned breathing
Traffic jams, headaches, and household chores provide opportunities to practice different
breathing techniques and make them part of your routine. To simulate labor, some child birth
educators suggest holding an ice cube in your hand or having your partner hold an ice cube to the
back of your ear to practice effective breathing techniques during momentary pain.

How to begin

At the beginning and ending of each contraction remember to take a deep, cleansing, relaxing
breath. This will help you focus, but it will also provide more oxygen for your baby, every
muscle in your body, and your uterus.
Breathing patterns for the first stage of labor

Slow Breathing: Begin slow breathing when contractions are intense enough that you can no
longer walk or talk through them without pausing. Use slow breathing for as long as you find it
helps you. Switch to another pattern if you become tense and can no longer relax during
contractions.

1.) Take an organizing breath—a big sigh as soon as the contraction begins. Release all tension
(go limp all over—head to toe) as you breathe out.
2.) Focus your attention
3.) Slowly inhale through your nose and exhale through your mouth, allowing all the air to flow
out with a sigh. Pause until the air seems to “want” to come in again.
4.) With each exhale, focus on relaxing a different part of your body (see Relaxation Techniques)

Light Accelerated Breathing: Most women feel the need to switch to light breathing at some time
during the active phase of labor. Let the intensity of your contractions guide you in deciding if
and when to use light breathing. Breathe in and out rapidly through your mouth about one breath
per second. Keep your breathing shallow and light. Your inhalations should be quiet, your
exhalation clearly audible.

1.) Take an organizing breath—a big sigh as soon as the contraction begins. Release all tension
(go limp all over—head to toe) as you breathe out.
2.) Focus your attention.
3.) Inhale slowly through your nose and exhale through your mouth. Accelerate and lighten your
breathing as the contraction increases in intensity. If the contraction peaks early, then you will
have to accelerate early in the contraction. It if peaks more gradually, you will work up to peak
speed more slowly. Keep your mouth and shoulders relaxed.
4.) As your breathing rate increases toward the peak of your contraction, breathe in and out
lightly through your mouth. Keep your breathing shallow and light at a rate of about one breath
per second.
5.) As the contraction decreases in intensity, gradually slow your breathing rate, switching back
to breathing in through your nose and out through your mouth.
6.) When the contraction ends, take you’re finishing breath—exhale with a sigh.

Variable (Transition) Breathing: This is a variation of light breathing. It is sometimes referred to
as “pant-pant-blow” or “hee-hee-who” breathing. Variable breathing combines light shallow
breathing with a periodic longer or more pronounced exhalation. Variable breathing is used in
the first stage if you feel overwhelmed, unable to relax, in despair, or exhausted.

1.) Take an organizing breath—a big sigh as soon as the contraction begins. Release all tension
(go limp all over—head to toe) as you breathe out.
2.) Focus your attention on your partner or some focal points you brought with you.
3.) Breathe through your mouth in light shallow breaths at a rate of 5-20 breaths in 10 seconds,
throughout the contraction.
4.) After every second, third, fourth, or fifth breath, blow out a longer breath. You might try
verbalizing this longer exhale with a “who or “puh”.
5.) When the contraction ends take one or two deep relaxing breaths with a sigh.

Breathing to avoid pushing at the wrong time
There will be times throughout both stages of labor when you will want to push or bear down
and it is not the right time. Most women want to hold their breath during these particularly
difficult moments. Avoid holding your breath, by breathing in and out constantly or by raising
your chin and blowing or panting. This keeps you from adding to the pushing that your body is
already doing.

Breathing patterns for the second stage of labor
Expulsion Breathing: Once the cervix is fully dilated, the second stage of labor has begun.

1) Take an organizing breath—a big sigh as soon as the contraction begins. Release all tension
(go limp all over—head to toe) as you breathe out.
2) Focus on the baby moving down and out, or on another positive image.
3) Breathe slowly, letting the contraction guide you in accelerating or lightening your breathing
as necessary for comfort. When you cannot resist the urge to push (when it “demands” that you
join in), take a big breath, tuck chin to chest, curl your body and lean forward. Then bear down,
while holding your breath or slowly releasing air by grunting, moaning or other verbalizing,
which ever feels best at the time. Tighten your abdominal muscles. Most important of all, relax
the pelvic floor. Help the baby come down by releasing any tension in the perineum.
4) After 5-6 seconds, release your breath and breathe in and out. When the urge to push takes
over join in by bearing down. How hard you push is dictated by your sensation. You will
continue in this way until the contraction subsides. The urge to push comes and goes in waves
during the contraction. Use these breaks to breathe deeply providing oxygen to your blood &
sufficient oxygen for the baby.
5) When the contraction ends, relax your body and take one or two calming breaths.

The following tips will alleviate dry mouth during labor
      Touch the tip of your tongue to the roof of your mouth just behind your teeth as you
       breathe. This slightly moistens the air you breathe.
      With your fingers spread, loosely cover your nose and mouth so that your palm reflects
       the moisture from your breath.
      Sip fluids or suck on ice chips between contractions
      Brush your teeth or rinse your mouth with mouth wash periodically.

A Guide for Expecting Parents

BREATHING PATTERNS FOR LABOR

Breathing Basics

This chapter provides several different examples of breathing patterns for you to

try. We encourage you to be flexible in adapting the breathing patterns to your own needs. Most
childbirth educators now teach deep relaxed breathing and shallow chest breathing as options.
Try the patterns offered here and then decide how to adapt them to your own needs and comfort
level.

Many women are very creative about finding what helps them to relax and stay focused. Some
do not care to focus on breathing at all, but instead try to focus on music or a focal point such as
a favorite photograph. If your partner is very observant, he or she will note your strengths and
weaknesses during labor practice sessions and each phase of labor, and then she/he can help you
focus on what you are doing.

The following comprise the common qualities of the two primary breathing patterns.
Relaxation
Relaxation is the key to comfortable control during labor, and breathing patterns augment the
relaxation of your mind and body.

Individuality
Individuality should be considered when choosing breathing patterns. Breathing patterns should
be modified to complement individual breathing styles and to meet particular physiological and
psychological needs.

Oxygenation
Oxygenation for the baby and contracting uterus can be maintained with the help of breathing
patterns.

Flexibility
Flexibility is important. Trust your physical sensations and adapt breathing patterns to meet your
individual contractions.

Comfort
Comfort with your breathing patterns, as well as relaxed breathing, will help you conserve
energy and decrease fatigue. Comfort is also important because you may be using the breathing
patterns for many hours.

Pacing
Pacing your breathing and being able to adjust the rate of speed at which you breathe helps you
meet your changing physiological and psychological needs during labor. In general, breathing
should be kept as slow and rhythmic as possible.

Attention Focusing
Attention focusing can be achieved through breathing patterns. Such purposeful activity will help
decrease pain perception. To help maintain concentration, use a focal point as you breathe. Your
eyes may be opened (for a visual image) or closed (for a mental image), whichever is most
comfortable and effective for you.

Cleansing Breath
Cleansing breaths—a slow breath in through your nose and out through your mouth—should
begin and end each breathing pattern. The cleansing breath acts as a signal to your body and
coach that a contraction is beginning or ending, and thus you must completely relax.

Effleurage
Effleurage, a stroking massage over the abdomen and/or groin region, may be done concurrently
with the breathing patterns during some or all of your contractions if it feels good to you. As
your contractions increase in intensity, it may feel better to use a firmer massage.

Respiratory Balance
Respiratory balance refers to the proper oxygen/carbon dioxide balance in your blood. To
maintain this balance, inhale and exhale equal amounts of air.
Practice
Practice and learn your breathing patterns before labor begins to make them effective, familiar
responses to uterine contractions.

Breathing Awareness
Awareness of your normal breathing rate is helpful before you begin practicing the breathing
patterns. Counting your breaths for one minute may do this. It is helpful to focus your attention
on your breathing in order to become aware of how the breath feels in your nose, mouth, throat,
shoulders, chest, abdomen, and back. You may also want to become aware of the temperature of
the air inhaled and exhaled and the sounds you make as you breathe.

Deep Relaxed Breathing
Begin this basic breathing pattern when you need additional assistance in maintaining
comfortable control and relaxation. Use it as long as you can and return to it whenever possible.

Shallow Chest Breathing
Use this pattern when deep relaxed breathing is not effective in maintaining relaxation and
comfortable control. The defined, repetitive rhythm of shallow chest breathing can produce a
general physiological and psychological calming effect. Return to deep relaxed breathing
whenever possible.

The Coach’s Role

Relaxation: As mother breathes during practice and labor, check her relaxation. Help her relax
through your touch and words.

Breathing: Keep her breathing slow and rhythmical. Become her focal point and breathe with her
(at her rate) when she is having difficulty.

Practice Strategies

• Count off the seconds for practice contractions and use verbal cues to assist mother through the
contraction; for a 60-second contraction, you would say,
• “contraction begins...”
• “15 seconds...”
• “30 seconds...”
• “45 seconds...”
• “contraction ends” (60 seconds).
• During actual labor, you will time and count off the seconds for her real contractions.
• Practice contractions may be incorporated into daily life, i.e., a contraction may be the length of
a TV commercial, a song, or it may be a part of a daily walk.
Breathing often reflects our state of relaxation or excitation. When at rest, breathing is usually
slow and rhythmic, (such as when asleep). When tense, breathing may be erratic, or we may hold
our breath. Controlling breathing may help you become aware of your state so you can stay
relaxed. Breathing techniques are helpful to many women in labor.

The theory behind childbirth breathing patterns is based on the concentration required to focus
on your breathing. During a contraction, your thought process is redirected from a pain response
such as tension and breath holding to a learned relaxed breathing response. The successful
development of a relaxed response to painful stimuli is most effective through a lot of practice.

Allow your body to relax as completely as possible and work with the contractions while using
the breathing and relaxation techniques. There is no right or wrong way to breathe. The
breathing techniques are only guidelines and should be adapted to your individual preference and
comfort.

Guidelines for Breathing Techniques

Begin focusing on your breathing when you feel you need help relaxing or can no longer walk or
talk through a contraction. For many women, this may be hours into labor. Your breathing
should be at a comfortable rate and not cause you to feel short of breath or light-headed.

Your breathing style should be your own. The breath may be taken in and out of your nose or
mouth, or in your nose and out your mouth. The key is to have the breathing feel natural, relaxed
and even.

Each of the breathing techniques has two common features: a cleansing breath and a focal
point.

Cleansing Breath
The use of a cleansing breath before and after every contraction is important. It is an
exaggerated, deep breath, usually done by breathing in through the nose and out through the
mouth. The purposes of this breath are to:

      Allow for increased oxygen to the baby
      Internally signal you that a contraction is beginning and to remind you to begin
       concentrating on breathing, focusing, and relaxing.
      Externally signal your partner and anyone else assisting with the labor that a contraction
       is beginning. They can then offer assistance, such as a back massage or verbal
       encouragement.
      Allow for blowing off residual tension after a contraction is over.
      Give your baby a boost of oxygen at the end of the contraction.

Focal Point
The use of a focal point will help enhance your relaxation and increase your concentration during
a contraction. An internal focal point, such as a peaceful scene or serene setting may work well
for some; others may find that they need to concentrate on an object in the room or the partner's
eyes. This focus may change during labor, as contractions gain strength. Practice using different
focal points that enhance your contraction and help eliminate distractions. (Note: a clock is not
used as a focal point.

      Allow the breathing to continue on its own quietly, easily, and evenly. Concentrate on
       letting yourself completely relax and let your body go limp with each exhale. Picture a
       rag doll.
      Your body may begin to feel warm and heavy.
      When ready to rouse yourself, breathe in deeply, stretching arms and legs, as you exhale.

Slow Paced Breathing

      Take a "cleansing" breath at the beginning of a contraction
      Continue to breathe evenly in and out with slow,easy abdominal breathing.
      Pace is approximately half your normal respiratory rate.
      You may use Attention Focusing strategies such as:
          o Inhalation/exhalation through nose
          o Inhalation/exhalation through mouth
          o Counting rhythms, imagery, affirming phrases, etc.
          o Movement, stroking, massage, tapping, etc.
          o A visual focal point
      As contraction ends, take a "cleansing" breath, breathing out slowly, and relaxing
       completely.

Modified Paced Breathing

      Easy, rhythmical breathing with a frequency of approximately twice your normal
       respiratory rate.
      Relaxed movement in chest and abdomen with more use of intercostal (chest) muscle.
      Use as needed for more challenging contractions
      Use same steady rate throughout contraction or use attention focusing strategies as
       needed.

Patterned Paced Breathing

      Even, rhymthmical breathing approximately twice your normal respiratory rate.
      Breathing pattern does not change rate or volume of air exchange.
      Pattern 3 breath/1 "blow"
      Use Attention Focusing strategies as needed.

Variations of Patterned Paced Breathing

      Pattern can be from 1 breath/1 blow to 6 breaths/1 blow.
      Can use Patterned Paced breathing in 1 breath/1 blow (He/Who)
      Try pattern of 5/1, 4/1, 3/1, 2/1, 1/1, 2/1, 3/1, 4/1, 5/1
      Combine paced breathing techniques in one contraction.
      Use attention focusing strategies as needed.
regnancy: Labor and                               From Our Sponsors

Delivery
(From the PDR Family Guide to Women's Health)




hildbirth is one of the most memorable and rewarding events of a couple's
life. No matter how often a woman gives birth, each experience is an
intimate and unique celebration of life. Though labor and delivery are not
without pain and some degree of anxiety, if you remain confident, well-
informed and fully supported by your partner and your doctor, you're likely
to have no problem handling the awesome task of bringing a child into the
world

Because the unexpected can happen at any time, you may not always be
able to control every aspect of your labor and delivery, but don't let this
bother you. You can maintain a sense of emotional control by asking
questions, challenging assumptions about routine procedures, and openly
sharing your hopes and fears with your partner and your physician.
Whether you deliver vaginally or by cesarean section, receive anesthesia or
experience “natural” childbirth, use a hospital delivery room or birthing
center, the experience is yours alone, and every decision will be made in
your best interest and that of your child.

Toward the end of your pregnancy, you eagerly await the arrival of your
child as the culmination of nine months of careful planning and preparation.
If this is your first child, you may feel a mixture of excitement and
nervousness when you think about the delivery. And to be perfectly honest,
you may also feel restless and irritable as the growing baby exerts greater
demands on your body.

This jumble of emotions is completely normal and natural. As your due
date draws near, you'll want to know exactly when labor will start and
when your baby will be born. But although the process of labor is well
understood, no one knows exactly why it starts, and your doctor won't be
able to predict either the start of labor or how long it will last. Your due
date is a best estimate, but only about 5 percent of women who carry their
babies to term actually deliver on that day. The rest deliver from several
days to several weeks before or after their due dates.

Nevertheless, you may begin to notice changes in your body that are
commonly recognized as signs of impending labor. During a first
pregnancy, the baby may “drop,” or engage in the birth canal 2 to 3 weeks
before labor begins. You may suddenly feel as though you can breathe
more easily, though the increased pressure on your bladder may also cause
you to urinate more frequently. In subsequent pregnancies, this
“lightening” may occur only a few hours before labor.

The irregular contractions you may have experienced throughout your
pregnancy or the third trimester may increase in frequency and intensity.
You may have a sudden burst of energy, often referred to as the “nesting
instinct,” and feel compelled to take on a major domestic project, such as
waxing a floor, baking bread, or reorganizing a closet. Hours to days before
labor, the small mucus “plug” that has sealed your cervix throughout
pregnancy may begin to stretch, then break apart as the cervix shortens
and thins out in a process called “effacing.” Once this occurs, pink-tinged
mucus, or “bloody show,” may be discharged from your vagina.

When you notice these signals, you should begin to finalize plans for the
care of other children, arrange your transportation to the hospital, and call
your doctor for last-minute instructions. Pack a small suitcase, placing any
items you will need during labor in a separate bag. Continue to practice any
breathing techniques you may have learned during childbirth preparation or
Lamaze classes. They can help to distract you from pain and relax you
during labor. (See the box “Breathing Techniques Help Bring Relief.”)

One additional sign often indicates that labor is imminent. The downward
pressure of the baby's head against the amniotic sac may cause these
membranes to rupture. The breaking of your “water” can occur as a trickle
or a gush of odorless, colorless amniotic fluid. Alert your medical
attendants as soon as this happens. Once the sac has broken, labor is
imminent, often beginning spontaneously within 12 to 24 hours. In fact, in
many women, the membranes don't rupture until labor is already
underway.

Once your water breaks, keep your vagina clean to minimize the risk of
infection. Don't take a bath, douche, or engage in sexual intercourse. Be
prepared to describe when and how the membranes ruptured, and also be
alert to any discoloration of the fluid—from yellow or tan to brown or
green. This indicates the presence of meconium, a waste product
discharged by your baby's bowels, which can be an indicator of fetal
distress.

When Labor Begins

Your uterus is a powerful muscle that tightens and relaxes rhythmically
during labor, allowing the cervix to stretch open and help to push your
baby through the birth canal. Although every woman's labor is different, at
the outset, you may begin to feel a pattern of dull cramps similar to
menstrual cramps in your lower back or pelvis. If these remain regular for
an hour or more, last at least 30 seconds, and gradually increase in
intensity—even if you change position or move around—your labor has
begun.

Your physician will probably have given you some guidelines about when to
contact him or her once labor begins. If this is your first pregnancy, stay
home awhile, so you can relax and remain unencumbered by the hospital
routine and environment. Take a walk, catch a nap, enjoy a long shower,
sip liquids (clear liquids only), read a book, or engage in any activity that
will entertain and distract you and allow you to preserve your energy. Most
physicians recommend that during a first labor, a woman wait until
contractions are five minutes apart for an hour before coming to the
hospital or birth center. In subsequent pregnancies, you may be advised to
come sooner, since your labor can progress much more quickly.

You should contact your physician immediately if you notice any vaginal
bleeding other than the pinkish “show,” if the baby doesn't move for an
unusually long time, or if you have constant, severe pain rather than
intermittent contractions. These signs can indicate such potentially serious
conditions as placenta previa, in which the placenta may be blocking the
exit from the uterus, or placental abruption, in which the placenta begins to
prematurely separate from the uterus and limit the baby's oxygen supply.
If your physician suspects any complications, you'll be asked to come to
the birth center as quickly as possible so your condition can be checked
and your baby can be monitored throughout the remainder of your labor.


               LABOR FROM BEGINNING TO END




As the first contractions of labor begin, the baby's head lies waiting on
the inner side of the still-closed cervix (A). During the early and active
phases of the first stage of labor, the cervix begins to open (dilate),
finally reaching a diameter of 8 centimeters (B). In the transition phase
that follows (C), the cervix dilates an additional 2 centimeters and the
baby's head advances towards the birth canal.

During the second stage of labor (D and E), the baby's head emerges
from the birth canal, followed almost immediately by the rest of the body.
In the third stage, which quickly follows delivery, the placenta and
membranes are expelled by a few final, weak contractions. From start to
finish, the process averages 12 hours for a first baby, less for later
children.


After you are admitted to the hospital, your physician, nurse or birth
attendant will want to discuss the events leading to labor. Your vital signs
will be checked and recorded, and special attention will be paid to your
baby's fetal heart tones and fetal heart rate (FHR), both important
indicators of the baby's response to the stress of childbirth. You will be
asked when you last ate and how much you consumed. Be sure to tell your
physician if you want your partner or older children to be present at the
delivery, or if you have made any other special arrangements.

Unless there's concern about complications such as placenta previa or the
risk of infection, your doctor will perform a vaginal examination to check
the baby's position, the dimensions of your pelvis, and the effacement and
dilation of your cervix. A blood sample may be taken and a urine specimen
may be tested for protein. You should challenge any hospital procedures
that seem medically unnecessary, such as extensive shaving of your pubic
area or administration of an enema. There is rarely any need for these
outdated rituals, but though they have been eliminated in many birth
centers, they persist in some institutions.

Depending on the status of your labor, your baby's position and heart rate,
and additional factors such as a previous cesarean delivery or a post-term
pregnancy, your physician may recommend electronic fetal monitoring now
or at some point during your labor. Many hospitals routinely use external
electronic FHR monitoring for 20 to 30 minutes after admission to establish
the baby's baseline heart rate and check variations, such as beating slower
during uterine contractions. If you need fetal monitoring, the doctor or
birth attendant will place two belts around your abdomen to hold two small
monitoring instruments in place.

Once your membranes have ruptured, the baby can be monitored internally
with a small electrode threaded through your vagina. At the same time, if
there's any question about the force of labor, your doctor may place a
small plastic tube, or catheter, in your uterus to measure the strength of
your contractions.

Numerous studies comparing continuous FHR monitoring and listening to
the baby's heart rate with a stethoscope or other device have shown little
difference in detecting fetal distress during labor in an otherwise uneventful
pregnancy. If your baby's heart rate is normal and your labor is
progressing steadily, continuous monitoring is probably unnecessary—and
unduly restrictive. Instead, your birth attendant should encourage you to
walk around, lean against your partner, urinate when necessary or simply
change positions to stay as comfortable as possible.

Occasional intervals of FHR monitoring may still be recommended
throughout labor. You will need continuous monitoring only if there are any
signs of fetal distress, such as the presence of meconium-stained amniotic
fluid, vaginal bleeding, a drop in your blood pressure, or an interruption in
your cervical dilation despite regular contractions.

The Stages of Labor

Labor is divided into three stages. The first stage begins with the onset of
contractions and ends when the cervix is fully dilated (to 10 centimeters).
The second stage involves delivery of the baby, and the third stage entails
delivery of the placenta and membranes, or “afterbirth.” Although the
length of labor varies considerably, women experiencing their first full-term
childbirth usually have the longest labors. About half will exceed 12 hours,
and 2 in 10 will last longer than 24 hours. After the first baby, labor is
usually shorter. Three-quarters of women deliver within 12 hours, and only
one in 50 labor for more than 24 hours.


                DECIDING WHERE TO DELIVER
Today, women have more options about how and where to deliver their
babies than ever before. A hospital remains the choice of many, since it
provides the security of extensive medical technology in the event of a
complication for the mother or child. Many hospitals offer single rooms
that allow you and your partner the privacy to participate more fully in
childbirth and care of the newborn. Be sure the staff understands and
respects the role your partner wants to play in the birth of your baby
well before you check in.

Some medical centers now have separate birthing centers in place of
their old labor and delivery wards. These centers are more homelike
than the maternity section of the hospital, though a woman still has
access to medical help, should it become necessary. Home delivery is
another alternative advocated by some women who want childbirth to
be as natural as possible, but because emergencies, though rare, can be
catastrophic when they do occur, most physicians advise against this.
Many obstetrical practices now include one or more midwives. Midwifery
is one of the world's oldest and most respected professions. Some
midwives only work in medical centers, while others also offer
assistance with home deliveries. In one study, women who were
assisted by midwives in hospital birth centers reported significantly
higher satisfaction than those under the care of physicians in traditional
hospital settings. There were no differences in Apgar scores in either
group, despite the fact that the midwife-assisted mothers were not
monitored electronically, and the rate of cesarean deliveries in both
groups was similar. The study concluded that women should be offered
choices in obstetrical care, including the selection of a birth attendant.

Women who receive competent and compassionate care throughout
labor and delivery are much more likely to remain calm and self-
controlled during childbirth and experience the greatest satisfaction.
Because of the complications that can arise, a hospital birthing center,
combining a warm environment for routine deliveries with access to
intensive medical care if necessary, appears to offer women, their
babies, and their partners with the best of both worlds.


The first and longest stage of labor has three distinct phases: the early, or
latent, phase; the active phase; and the transition. During the early phase
of labor, contractions are often widely spaced—perhaps 10 minutes or more
apart—and feel like a tightening or pulling in your back or groin. They can
vary considerably in frequency and intensity. At this point you may feel
excited, sociable and talkative, or you may be a bit nervous. Most women
remain at home during this phase, during which the cervix dilates from 0 to
4 centimeters, and later arrive at the birth center in active labor.

The Active Phase

As you progress from the early to the active phase, your attention focuses
completely on labor. Your contractions occur about 3 minutes apart, last
about 45 to 60 seconds, and become more centered in your abdomen.
They also become stronger and more rhythmic, peaking and receding like
waves.

Your determination may waver during this phase of labor. Extra
reassurance from your partner and birth attendant can help you stay
focused. Breathing exercises and other relaxation techniques also become
more important as your cervix dilates to 8 centimeters—nearly wide
enough to allow for your baby's birth.

During the active phase, you may begin to long for relief from the pain and
tension of labor. Though medication is an obvious solution for your
discomfort, you must consider the safety of the baby. Many drugs cross the
placenta and affect the baby, making its heartbeat and breathing more
sluggish throughout the remainder of labor and after delivery. For this
reason, many doctors recommend concentrating on one contraction at a
time and relying on your partner, rather than medication, to help maintain
your focus.

If your pain is so intense that it actually impedes your progress, however,
medication may help you to relax so that contractions can remain steady
and vigorous. Two basic kinds of pain medication—analgesics and
anesthetics—are used during childbirth.

Analgesics will relieve most of the pain. Drugs used include Demerol,
Sublimaze, Nubain, Stadol, morphine, and fentanyl injected into a muscle
or vein. These medications are not designed to provide a pain-free labor,
but, in appropriate dosages, they can make you more comfortable.

Potential side effects of these drugs include nausea, vomiting and an
abnormally fast heartbeat. They present some additional risk to the baby,
but if handled properly pose no significant threat. Large doses, however,
can interrupt your labor pattern, and if this happens, additional medications
such as oxytocin (Pitocin, Syntocinon) may be needed to reestablish strong
contractions.
Regional anesthetics completely eliminate the pain. The most common
types used during labor include:

Paracervical block. Medication is injected into your cervix, usually during
the first stage of labor, to provide you with pain relief from contractions
and dilation without interfering with the urge or ability to push. This drug
may not work properly in up to one-third of women, and it must be
repeated every hour to maintain numbness. It is no longer used frequently.

Pudendal block. The anesthetic is injected through the vaginal wall during
the second stage of labor to relieve pain in the perineum (the area between
the vagina and the rectum). It may be used in an otherwise unmedicated
childbirth. The medication does not interfere with the urge or ability to
push and generally masks the effects and repair of an episiotomy—the
incision made to enlarge the vaginal opening.

Spinal or saddle block. A single injection of regional anesthetic is made
into your spinal canal, numbing the complete lower abdominal and perineal
area. This type of anesthetic is rarely used during labor but may be
suggested if a forceps or cesarean delivery is required. Administration of a
spinal block completely removes the urge to push and may lower your
blood pressure. In rare cases, it causes a severe headache when it wears
off.

Epidural or caudal block. A needle holding a thin, flexible tube is
threaded into the space between your spinal cord and your vertebrae.
When the needle is removed, the anesthetic can flow continuously through
the tube. Like a spinal block, this procedure provides full pain relief in the
perineal area. Dosages can easily be changed or discontinued. Most
physicians consider the epidural block to be the optimal method of pain
relief for uncomplicated labor or non-emergency cesarean births because it
allows a woman to remain fully alert. Nevertheless, the anesthetic requires
up to 20 minutes to take full effect and may leave a painful “hot spot”. In
addition, it may diminish uterine contractions, bringing on the need for
oxytocin. The risk of a forceps delivery is also increased.

Transition

Transition is the time when the cervix dilates the final two centimeters.
This is the most difficult phase of labor, and produces the hardest, longest,
and most frequent contractions. Fortunately, transition is relatively short,
sometimes lasting for only two or three contractions. Even in a first labor,
transition rarely takes longer than one hour.


      BREATHING TECHNIQUES HELP BRING RELIEF
During active labor, your goal is to remain as relaxed as possible so
your cervix can continue to dilate, and you can provide your baby with a
generous oxygen supply in preparation for birth. The following breathing
techniques, used alone or in combination, can be effective throughout
labor. If you master these techniques during your pregnancy, you may
find you can vary the patterns during labor to provide the most effective
relief.
       Deep, cleansing breaths. Take these long, deep breaths at the
        beginning and end of each contraction.
       Slow, chest breathing. Take these slow, focused breaths 8 to
        10 times per minute during the early, milder contractions of the
        first stage of labor.
       Rapid chest breathing. Using the same technique as you
        employed in early labor, double the speed of these more focused
        chest breaths as the first stage of labor continues and
        contractions increase in frequency and intensity.
       Shallow chest breathing. Use this shallow, panting technique
        at the peak of your most intense contractions.



During transition, contractions occur every two to three minutes and last
60 to 90 seconds. You have little relief between them, and their intensity
may cause you to feel frightened and overwhelmed. While you may have
enjoyed your partner's presence and physical touch throughout the early
part of labor, transition may suddenly make you feel withdrawn, irritable,
and short-tempered. You may develop chills, become nauseous, or feel the
urge to have a bowel movement. These physical sensations reflect the
descent of your baby into the birth canal and can become more intense as
you enter the second stage of labor.

Though you may feel overwhelmed by the power of your own body,
transition is not the time to begin analgesics. The best strategy for
withstanding transition is to cooperate with your contractions instead of
fighting them. Heating pads, hot water compresses, changes in position,
breathing exercises, music, meditation, and visualization techniques all can
serve as effective alternatives for pain relief. Even women who have
received a regional anesthesia may want to consider withdrawing their
medication as their cervix nears full dilation so they can begin to feel their
contractions and push more effectively.

Common Complications of Labor

The rate of cesarean births in the United States has skyrocketed from 5
percent in the 1960s to nearly 25 percent since the 1980s. Many factors
have contributed to this increase, including the frequency of repeat
cesarean delivery, the use of electronic fetal monitoring, the declining use
of vaginal breech and forceps deliveries, and the drift toward surgical
intervention for “failure to progress” in labor. While cesarean delivery is
certainly safer today than during the 1960s and obviously indicated in
extremely high-risk situations or emergencies, it still causes a higher rate
of maternal injuries than vaginal delivery.

Cesarean delivery is often accepted as the inevitable outcome to a
complication arising during labor. Based on the experience of the past two
decades, however, most experts agree that surgical intervention is not
always in the best interests of the woman or baby. In order to make an
informed decision, it's important to understand some of the common
complications that can occur during labor.
Premature Rupture

Most women begin labor spontaneously when their membranes rupture and
their pregnancies have reached full term. When labor does not begin within
12 to 24 hours, the situation is described as “premature rupture of the
membranes” (PROM). Because PROM certainly plays a role in high cesarean
rates, more doctors are proceeding with a quick induction of labor after a
PROM at full-term. Although the “wait-and-see” approach has been
associated with fewer cesarean deliveries than the use of oxytocin to
stimulate contractions, one large study has concluded that induction of
labor using vaginal suppositories containing prostaglandin E2 is a viable
option for handling PROM—especially in women experiencing a first labor.
In the study, the rate of cesarean section in the women who received
prostaglandin was half that of those who either received oxytocin or waited
for the onset of labor.

Failure to Progress

Physicians generally agree that once active labor has begun, a woman's
cervix should dilate 1.2 cm to 1.5 cm per hour. Sometimes dilation falters
during the active phase despite regular contractions. This condition is
known as “failure to progress.” Because labor can be interrupted for a
variety of reasons, the immediate cause is not always clear to the woman
or her physician. Should this occur, your doctor will perform a pelvic exam,
check your vital signs, and monitor the baby for a short period of time. If
all appears well, he or she can take a hands-off approach or consider the
possibility of “actively managing” your labor.

A number of procedures are effective in reestablishing labor. If your
amniotic sac has not yet broken, your doctor may suggest breaking it
manually, a procedure known as amniotomy. Because rupturing the
membranes commits a woman to delivery, this can be a risky strategy
during the latent phase, when false labor is always a possibility. Several
research studies have concluded, however, that amniotomy performed
during active labor actually shortens its duration by up to 2 hours.
Moreover, the rate of vaginal delivery increases, and there is no added risk
of injury to the woman or baby.

Physicians disagree on how to handle the 10 percent of pregnancies that
extend beyond 40 weeks. The main goal is to avoid injury or death to the
baby due to lack of oxygen or intake of meconium in the lungs—established
risks in post-term pregnancies. Some doctors advocate inducing labor at 41
to 42 weeks, while others recommend fetal monitoring until labor begins
spontaneously. In one large study of women with post-term but otherwise
uncomplicated pregnancies, the induction of labor resulted in a lower rate
of cesarean delivery, mainly because there was less fetal distress. In any
event, few clinicians allow a pregnancy to continue past 42 weeks. In these
rare instances, labor is often induced with prostaglandin gel or oxytocin.

Pelvic Size

Certain variations in a woman's anatomy also can lead to complications
during labor. During vaginal delivery, the baby must be propelled through
your pelvic area by the contractions of your uterus and your own “bearing
down.” In general, a woman's pelvis is large enough and shaped properly
to allow for the baby's passage. In fact, unless you have a history of pelvic
fracture or bone or neuromuscular disease, your physician should not
discourage you from trying a natural delivery strictly on the basis of your
pelvic dimensions. Even if your pelvic area is smaller than average, it may
still be big enough for your baby if the rest of your labor progresses
normally.

Nevertheless, in some cases, the size of the baby's head does exceed the
dimensions of the birth canal. If this happens, labor will almost certainly
fail to progress during the second stage; and the first stage of labor may
be irregular as well. If the size of the baby is the cause of a woman's
“failure to progress,” she will need a cesarean.

Position of the Baby

In more than 95 percent of full-term labors, the baby's head is “presenting”
—pointed toward— the cervix. Typically, the baby's head is tucked against
its chest, with the crown of the head facing the birth canal in preparation
for delivery. In some unusual situations, a baby's face, forehead, or top of
the head is presenting. If the baby remains in either of the latter two
positions throughout labor, a cesarean delivery may be necessary since the
broadest part of the baby's head may be too wide to clear your pelvis. A
full-face presentation is very rare. Unless you've already had several
children, your physician will almost certainly insist on cesarean delivery
should this occur. Vaginal delivery increases the risk of injury to the baby's
neck or spinal cord.


           DANGERS OF A BREECH PRESENTATION
When the baby passes head-first through the birth canal—as it does 95
percent of the time—the rounded top of the cranium has a chance to
mold to the contours of the passage and slide through without incident.
But when the baby is delivered buttocks or feet-first, the chances that the
head will be caught in the narrow canal increase dramatically. Deaths
following breech deliveries are 4 times more likely than normal, usually
as a result of nerve damage or suffocation. A breech presentation is now
generally considered a signal for cesarean delivery.


When the baby's buttocks or feet are presenting at labor, the position is
commonly called “breech.” Prior to the 1960s, when cesarean delivery
carried much higher risks for the mother, these infants were nearly always
delivered vaginally, even though they faced a greater risk of injury or death
during childbirth. Safer cesarean procedures have all but eliminated the
rigors of labor for breech babies. Nevertheless, some physicians are
attempting to reduce the incidence of breech cesarean deliveries by
attempting to reposition the baby just prior to labor—a procedure known as
“external version.” Documented reports indicate that version is often
successful, though 1 out of 3 babies may revert to breech presentation
afterwards, and there is a risk of complications such as a twisted umbilical
cord. An attempt at vaginal delivery in a breech presentation under well-
managed conditions, including continuous fetal monitoring, is gaining some
support within the medical community.

The position—or attitude—of the baby is another consideration in
determining the safest method of birth. More than 99 percent of the time, a
full-term baby lies vertically in the uterus. In the remaining cases, known
as a transverse lie, the baby's back faces the birth canal. A baby in this
position when labor begins almost always must be delivered by cesarean.

A Past Cesarean

More and more women are being encouraged to attempt a vaginal birth,
after a previous cesarean delivery (VBAC). If you are considering VBAC,
you and your doctor need to discuss several factors, including the type of
incision made in your uterus during your previous cesarean delivery, the
size of your pelvis, whether you are carrying twins or have a breech
presentation, and certain medical conditions you may have, such as
diabetes or high blood pressure. Despite the slightly higher risk, none of
these factors necessarily eliminates the VBAC option.

Fear of uterine rupture has been the reason most often cited for the
outdated medical dictum, “Once a cesarean, always a cesarean.” Rupture
of a uterine scar can result in the baby's death and severe injury to the
mother. Nevertheless, widespread adoption of the low transverse, or
horizontal, cesarean incision in the uterine wall has dramatically reduced
the risks faced in future vaginal deliveries. Moreover, many of the factors
that led to an initial cesarean—breech presentation, fetal distress, failure to
progress—may not be present during a second labor. Counterbalancing the
risks is the fact that vaginal delivery has fewer complications and a shorter
recovery period than a cesarean.
In 1988, the American College of Obstetricians and Gynecologists issued
guidelines making VBAC a preferred, rather than optional, procedure under
most circumstances. Specifically, the College recommends that women with
one previous low transverse cesarean should be encouraged to attempt
labor in a later pregnancy, and women with two or more low transverse
incisions should not be discouraged from trying vaginal birth. However, the
group cautions that women with a classic vertical incision should not risk
labor, and it advises physicians offering the VBAC option to have the staff
and equipment available to perform an emergency cesarean if necessary.


            MEASURING LABOR IN CENTIMETERS




The second stage of labor officially begins when the baby's head settles
into the upper end of the birth canal, 3 centimeters from the center of the
pelvis. When the top of the head reaches the center point, the baby has
achieved “0” station. Three centimeters later, the baby has reached the
lower end of the birth canal, and delivery is underway. This centimeter-
by-centimeter advance can last more than 2 hours—or be over in 15
minutes!

Vaginal Delivery

When the widest part of the baby's head has settled into the birth canal, it
is said to be engaged, or positioned for the second stage of labor. At this
point, your contractions may slow to four or five minutes apart and become
less intense. Your birth attendant will encourage you to push when each
contraction begins and will monitor the baby's “descent” on a regular basis.
When the baby's head is even with the lower bones of your pelvis, its
position will be recorded as “0” station. As the baby's head continues to
move through the birth canal, the stations will be identified as +1, +2, +3,
etc., in reference to the baby's progress in centimeters.

Throughout the second stage of labor—which can last from 15 minutes to
more than 2 hours—your baby will continue to descend through the birth
canal. As the force of your contractions, combined with your conscious
pushing, propel the baby, you may become very tired—especially if your
labor has been long or rigorous. Most women find, however, that the
second stage of labor is physically and emotionally satisfying. The
contractions are often easier to tolerate, and your excitement over the
baby's imminent birth usually outweighs your fatigue.

Your partner can help at this point by bracing you as you push. If you're
attempting a VBAC delivery, don't hesitate to push vigorously. The nine
months of pregnancy and the rigors of your labor have provided a reliable
test of your incision's strength.

As the second stage of labor progresses, the perineal area between the
vagina and rectum will begin to stretch. Your doctor may make a small
incision or episiotomy, in this region, to prevent the perineal skin from
tearing during childbirth. Though fewer physicians advocate episiotomies as
a routine part of every delivery, they are still commonly performed. Some
women vigorously object to episiotomies as the antithesis of the natural
birth process. If you have strong feelings about this procedure, tell your
physician or birth attendant beforehand.


                      THE EPISIOTOMY ISSUE




As the baby emerges, there's a chance that skin between the vagina and
anus will be stretched to the breaking point. To prevent uncontrolled
tearing, many physicians routinely make the minor incision called an
episiotomy. Because the procedure is considered routine, if you don't
want it done you should be sure to let your doctor know in advance.


As your baby approaches the bones and soft tissue of your pelvis, its
pliable head will mold slightly to the contours of the birth canal. Once its
head slips under your pubic bone, delivery is imminent. At this juncture,
your partner can help support your back or legs, or with the delivery itself.

As the top of your baby's head appears, or “crowns,” your birth attendant
will apply subtle pressure with one hand while reaching beneath your pelvis
to prepare for the baby's birth. In rare cases, forceps or vacuum extraction
may be necessary to help guide the baby's head through the birth canal.
At this point, you may be told to pant, rather than continuing to push, so
the baby's head can be delivered gently rather than bursting out. You may
want to watch the birth in a mirror. When the head is through, your birth
attendant will check to ensure that the umbilical cord remains free of the
baby's neck. He or she will then immediately clear the baby's mouth and
nostrils of mucus. With your next contraction, the attendant will deliver the
baby's body, then clamp and cut the cord. As soon as the infant's general
condition has been assessed—usually using Apgar scores—you will be able
to cuddle and enjoy your baby.

Within a few minutes of birth, your rapidly diminishing uterine contractions
will cause the placenta to separate from the uterine wall. Generally, you
can expect the placenta to be expelled rapidly. You may be given oxytocin
to stimulate contractions while your uterus is massaged to reduce bleeding.
If you delivered by VBAC, your birth attendant will carefully check your old
incision for any evidence of injury.

The doctor will examine the placenta, and inspect your cervix and vagina
for any tears or bruises. If you have had an episiotomy, the doctor will
stitch it closed. In the meantime, you and your partner will probably be
oblivious to these final details as you share the joy of your new child.

Cesarean Delivery

Despite its detractors, cesarean delivery continues to be one of medicine's
most important and—often lifesaving—operations. Physicians continue to
recommend cesarean delivery when they consider labor unsafe for either
mother or baby, when delivery is necessary but labor cannot be induced,
when the baby's size or presentation precludes vaginal birth, and when a
medical emergency occurs.

A cesarean may be called for if the placenta is blocking the exit of the
uterus (placenta previa), if you have had a classic cesarean incision, or if
you have a history of uterine surgery or abnormalities. If such medical
conditions as diabetes mellitus or hypertension threaten the baby's welfare,
you may need preterm cesarean delivery if labor induction fails. Cesarean
birth also is a safe alternative when anatomical problems of the uterus or
birth canal prevent successful vaginal delivery.

Maternal or fetal emergencies necessitate immediate delivery. These
include untimely separation of the placenta from the uterus, bleeding from
placenta previa, protrusion of the umbilical cord, or an active vaginal
infection such as herpes. Roughly one-fifth of all cesarean deliveries are
prompted by an emergency condition.

Although repeat cesarean delivery is no longer mandatory, approximately
40 percent of women attempting VBAC ultimately require another
cesarean. If this occurs, you should be proud of your efforts and never feel
that you have failed yourself or your baby.

Cesarean deliveries are classified by the type and location of uterine
incision. The two most common incisions in the United States are vertical
cut in the upper portion of the uterus—often called a “classic” incisiony—
and the transverse, or “Kerr” incision in the lower portion of the uterus.
The transverse incision is a safer procedure than the classic.

Although a variety of anesthetic techniques are used, an epidural block is
often the anesthesia of choice for a cesarean delivery. During a particularly
difficult or emergency cesarean, when there's no time to wait for an
epidural anesthetic to take effect, the doctor may use general anesthesia.
Though it can slightly increase such additional risks to the mother as the
chance of inhaling gastric backflow (aspiration) and the danger of cardiac
or respiratory arrest, the value of the surgery usually outweighs the risks of
anesthesia. The baby usually suffers no harm because delivery often takes
place before the anesthesia has time to cross the placenta.

Prior to surgery, a nurse or attendant may wash and shave your abdomen
and cleanse the area with a special antiseptic lotion. You will probably need
a catheter to remove urine from your bladder during the operation and will
likely be given an intravenous (IV) line to provide you with additional fluid.

As the cesarean delivery begins, the physician will cut open your abdomen
and uterus in quick succession, rupture the membranes, and carefully
guide the baby's head through the incision. You may feel a tugging
sensation around your abdomen. The baby's mouth and nostrils will be
suctioned, then the body gently delivered. The entire process can take less
than five minutes.

Once the doctor has checked the baby, you or your partner may be able to
hold the infant while the doctor manually removes your placenta, checks
your uterus, and begins to stitch the incisions closed. The doctor will gently
massage your uterus to expel any blood clots. You will be carefully watched
for any signs of bleeding or infection during the period immediately
following the birth.

Possible complications of cesarean delivery include fever, wound infection,
bleeding, aspiration during general anesthesia, urinary tract infections,
inflammation of the endometrium and blood clots. Complications are
estimated to occur in 25 percent of all cesarean operations; the mother
dies in roughly one out of every 1,000 cesarean deliveries. As many as
one-fourth of these deaths are related to anesthesia.

Most women should begin walking within a day of their cesarean delivery,
when a urinary catheter is no longer necessary. You can usually start
eating a soft diet on the day after the operation, and you'll probably leave
the hospital approximately 3 days after delivery. During your recovery, you
may have to use a stool softener and a mild pain reliever. You will probably
need to visit your doctor 2 to 3 weeks after leaving the hospital so he or
she can examine your incision and remove any sutures or staples.
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