Pregnancy and Birth Sourcebook Part 36

Intravenous or Intramuscular a.n.a.lgesic A doctor gives you pain medicine through a tube inserted in a vein (intravenous) or by injecting the medicine into a muscle (intramuscular). These medicines go into your blood and help ease the pain. Opioids including morphine, fentanyl, and nalbuphine are usually used for this type of pain relief. This option does not get rid of all the pain. Instead it usually just makes the pain bearable. After getting this kind of pain relief, you can still get an epidural or spinal pain relief later.

Some disadvantages of getting intravenous or intramuscular a.n.a.lgesics include: * They make you feel sleepy and drowsy.

* They can cause nausea and vomiting.

* They can make you feel very itchy.

* These medicines cross into the baby's bloodstream. So they can affect the baby's breathing, heart rate, and cause him/her to be very sleepy after birth.

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All about Labor and Delivery Epidural Anesthesia A doctor injects medicine into the lower part of your backbone or spine. The medicine blocks pain in the parts of the body below the shot.

During a contraction, the feeling of pain travels from the uterus to the brain along nerves in the backbone. Epidurals block the pain of contractions by numbing these nerves.

Epidurals allow most women to be awake and alert with very little pain. Many women who get epidurals do not feel any pain during contractions and childbirth. Medicines used in epidurals include novocaine-like drugs that block the pain in that region combined with opioids like fentanyl.

Some disadvantages of getting an epidural include: * It can make you s.h.i.+ver.

* It can lower your blood pressure.

* It can make you feel very itchy.

* It can cause headaches.

* It may not numb the entire painful area. So women continue to feel pain in an area of the abdomen and back.

Pudendal Block A doctor injects numbing medicine into the v.a.g.i.n.a and a nearby nerve called the pudendal nerve. This nerve carries sensation to the lower part of your v.a.g.i.n.a and v.u.l.v.a. This is only used late in labor, usually right before the baby's head comes out. With a pudendal block, you have some pain relief but remain awake, alert, and able to push the baby out. The baby is not affected by this medicine and it has very few disadvantages.

Spinal Anesthesia A doctor injects a medicine into the lower part of your backbone.

This medicine numbs the body below where the medicine was injected.

Spinal anesthesia gives immediate pain relief. So they are often used for women who need an emergency Cesarean section. Spinal anesthesia uses numbing medicines similar to novocaine combined with opioids like fentanyl.

Some disadvantages of spinal anesthesia include: * It numbs the body from the chest down to the feet.

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Pregnancy and Birth Sourcebook, Third Edition * It makes you feel short of breath.

* It can lower your blood pressure.

* It can cause headaches.

Cesarean Sections Most healthy pregnant women with no risk factors for problems during labor or delivery have their babies v.a.g.i.n.ally. Still, the rate of babies born by cesarean section (c-section) in the United States is on the rise. In 2004, 29.1 percent of babies were born by c-section in this country. This is an increase of more than 40 percent since 1996.

Many experts think that up to half of all c-sections are unnecessary. Thus, the U.S. government is trying to reduce the rate. So it is important for pregnant women to get the facts about c-sections before they deliver. Women should find out what c-sections are, why they are performed, and the pros and cons of this surgery.

What Is a C-Section?

During a c-section, the doctor makes a cut in the mother's abdomen and uterus and removes the baby. So, the baby is delivered through surgery instead of coming out of the v.a.g.i.n.a. Most women get spinal or epidural anesthesia during a c-section. This allows her to stay awake without feeling pain. But sometimes general anesthesia is needed. With general anesthesia the woman is asleep during the procedure.

A c-section can save the life of a baby or mother. If health problems come up before or during labor and delivery, a c-section can get the baby out very quickly. Most c-sections result in a healthy mother and baby.

Still, a c-section is major surgery. And all surgeries have risks.

These include infection, dangerous bleeding, blood transfusions, and blood clots. Women who have c-sections stay at the hospital for longer than women who have v.a.g.i.n.al births. Plus, recovery from this surgery takes longer and is often more painful than that after a v.a.g.i.n.al birth. So, c-sections should only be done when the health or the mother of baby is in danger.

When Do Doctors Recommend C-Sections?

Doctors recommend c-sections when the health of the baby or mother is in danger. Even so, there are risks of delivering by c-sections. Limited 468 All about Labor and Delivery studies show that the benefits of having a c-section may outweigh the risks when: * the mother is carrying more than one baby (twins, triplets, etc.); * the mother has health problems including HIV [human immunodeficiency] infection, herpes infection, and heart disease; * the mother has dangerously high blood pressure; * the mother has problems with the shape of her pelvis; * there are problems with the placenta; * there are problems with the umbilical cord; * there are problems with the position of the baby (e.g., breech presentation); * the baby shows signs of distress (e.g., slowed heart rate); or * the mother has had a previous c-section.

Elective C-Sections: Can Women Choose?

A growing number of women are asking their doctors for c-sections when there is no medical reason. Some women want a c-section because they fear the pain of childbirth. Others like the convenience of being able to decide when and how to deliver their baby. Still others fear the risks of v.a.g.i.n.al delivery including tearing and s.e.xual problems.

But is it safe and ethical for doctors to allow women to make medical decisions? The answer is unclear. Only more research on both types of deliveries will provide the answer. In the meantime, many obstetricians feel it is their ethical obligation to talk women out of elective c-sections. Others believe that women should be able to choose a c-section if they understand the risks and benefits.

Experts who believe c-sections should only be performed for medical reasons point to the risks. C-sections can be dangerous for the mother and baby. This major surgery increases the risk of infection, bleeding, and pain in the mother. C-sections also increase the risk of problems in future pregnancies. Women who have had c-sections have a higher risk of uterine rupture. If the uterus ruptures, the life of the baby and mother is in danger. Babies born by c-section have more breathing problems right after birth and are very rarely cut during the surgery.

Supporters of elective c-sections say that this surgery may protect a woman's pelvic organs, reduces the risk of bowel and bladder problems, 469 Pregnancy and Birth Sourcebook, Third Edition and is as safe for the baby as v.a.g.i.n.al delivery. The American College of Obstetricians (ACOG) is not opposed to elective c-sections. ACOG states that "if the physician believes that (cesarean) delivery promotes the overall health and welfare of the woman and her fetus more than v.a.g.i.n.al birth, he or she is ethically justified in performing" a c-section.

Can I Try a v.a.g.i.n.al Birth If I've Had a C-Section (VBAC)?

Some women who have delivered previous babies by c-section would like to have their next baby v.a.g.i.n.ally. This is called v.a.g.i.n.al delivery after c-section or VBAC. Women give many reasons for want-ing a VBAC. Some want to avoid the risks and long recovery of surgery. Others want to experience v.a.g.i.n.al delivery.

Studies show that VBACs are more risky for the woman and baby than a repeat c-section. The most serious danger of VBACs is the chance that the c-section scar on the uterus will open up during labor and delivery. This is called uterine rupture. While very rare, uterine rupture is very dangerous for the mother and baby. Less than 1 percent of VBACs lead to uterine rupture. Even so, uterine rupture can lead to life-threatening bleeding for the mother and brain damage or even death for the baby.

The biggest and best study on VBACs was published in the New New England Journal of Medicine England Journal of Medicine in 2004. The researchers studied more than 30,000 women who had had a c-section and were pregnant again. in 2004. The researchers studied more than 30,000 women who had had a c-section and were pregnant again.

Some of these women chose to have a VBAC. Others decided on a repeat c-section. The doctors compared the health of the women and babies after both types of delivery.

Almost three-quarters (73%) of women had a successful VBAC. The other 27% of women who tried to deliver v.a.g.i.n.ally ended up having another c-section. While rare, problems with the woman and baby were more common among VBACs compared with repeat c-sections.

Only 0.8 % of women had a uterine rupture. Women who tried VBACs had more blood transfusions and a greater risk of endometriosis than those who had repeat c-sections. Babies born by VBAC had a higher risk of brain damage than those born by repeat c-section.

The percent of VBACs is dropping in the United States for many reasons. Women, doctors, and hospitals are worried about the rare, yet possible problems of VBACs. A growing number of doctors and hospitals are banning VBACs. They are afraid of lawsuits that might follow VBACs that go wrong. In 2004 the American College of Obstetricians and Gynecologists recommended that hospitals have a surgical team "immediately available" whenever a woman is having a 470 All about Labor and Delivery VBAC. In other words, ACOG suggests that a surgeon, nurses, and an anesthesiologist be standing by in case an emergency c-section is needed. Guaranteeing this stand-by team is just too expensive for many hospitals.

Doctors are also discouraging or flat out refusing to perform VBACs. Sometimes this is because their affiliated hospital does not allow them. In other cases, doctors can not get malpractice insurance to cover claims related to VBACs. And some doctors admit they are afraid of getting sued if a VBAC goes wrong.

Choosing to try a VBAC is a difficult decision for many women. If you are interested in a VBAC, talk to your doctor and read up on the subject. Only you and your doctor can decide what is best for you.

VBACs and planned c-sections both have their benefits and risks.

Learn the pros and cons and be aware of possible problems before you make your decision.

The American College of Obstetricians and Gynecologists (ACOG) recommends that doctors consider VBACs when: * a woman has had one previous planned c-sections done with a low, horizontal cut or incision ("bikini" incision); * a woman has no other uterine scars (aside from the prior c-section) or problems; * a woman has no known problems with her pelvis; * a doctor is present during all of labor and delivery and can perform an emergency c-section if needed; and * an anesthesiologist and other members of a surgical team are standing by in case an emergency c-section is needed.

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Chapter 58.Birthing Centers and Hospital Maternity Services You'll make plenty of decisions during pregnancy, and choosing where to give birth-whether in a hospital or in a birth center setting-is one of the most important.

Hospitals Many women fear that a hospital setting will be cold and clinical, but that's not necessarily true. A hospital setting can accommodate a variety of birth experiences.

Traditional hospital births (in which the mother-to-be moves from a labor room to a delivery room and then, after the birth, to a semi-private room) are still the most common option. Doctors "manage" the delivery with their patients. In many cases, women in labor are not allowed to eat or drink (possibly due to anesthesia or for other medical reasons), and they may be required to deliver in a certain position.

Pain medications are available during labor and delivery (if the woman chooses); labor may be induced, if necessary; and the fetus is usually electronically monitored throughout the labor. A birth plan "Birthing Centers and Hospital Maternity Services," December 2008, reprinted with permission from www.kidshealth.org. Copyright 2008 The Nemours Foundation. This information was provided by KidsHealth, one of the largest resources online for medically reviewed health information written for parents, kids, and teens. For more articles like this one, visit www.KidsHealth.org, or www.TeensHealth.org.

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Pregnancy and Birth Sourcebook, Third Edition can help a woman communicate her preferences about these issues, and doctors will abide by these as much possible.

In response to a push for more "natural" birth events, many hospitals now offer more modern options for low-risk births, often known as family-centered care. These may include private rooms with baths (birthing suites) where women can labor, deliver, and recover in one place without having to be moved.

Although a doctor and medical staff are still present, the rooms are usually set up to create a nurturing environment, with warm, soothing colors and features that try to simulate a home-like atmosphere that can be very comforting for new moms. Rooming in-when the baby stays with the mother most of the time instead of in the infant nursery-also may be available.

In addition, many hospitals offer a variety of childbirth and prenatal education cla.s.ses to prepare parents for the birth experience and parenting cla.s.ses after birth.

The number of people allowed to attend the birth varies from hospital to hospital. In more traditional settings, as many as three support people are permitted to be with the mother during a v.a.g.i.n.al birth. In a family-centered approach, more family members, friends, and sometimes even kids may be allowed. During a routine or non-emergency C-section [cesarean section], usually just one support person allowed.

If you decide to give birth in a hospital, you will encounter a variety of health professionals.

Obstetrician/gynecologists (OB/GYNs) are doctors with at least four additional years of training after medical school in women's health and reproduction, including both surgical and medical care. They can handle complicated pregnancies and also perform C-sections.

Look for obstetricians who are board-certified, meaning they have pa.s.sed an examination by the American Board of Obstetrics and Gynecology (ACOG). Board-certified obstetricians who go on to receive further training in high-risk pregnancies are called maternal-fetal specialists or perinatologists.

If you deliver in a hospital, you also might be able to use a certified nurse-midwife (CNM). CNMs are registered nurses who have a graduate degree in midwifery, meaning they're trained to handle normal, low-risk pregnancies and deliveries. Most CNMs deliver babies in hospitals or birth centers, although some do home births.

In addition to obstetricians and CNMs, registered nurses (RNs) attend births to take care of the mother and baby. If you give birth in a teaching hospital, medical students or residents might be present 474 Birthing Centers and Hospital Maternity Services during the birth. Some family doctors also offer prenatal care and deliver babies.

While you're in the hospital, if you choose or if it's necessary for you to receive anesthesia, it will be administered by a trained anesthesiologist. A variety of pain-control measures, including pain medication and local, epidural, and general anesthesia, are available in the hospital setting.

Birth Centers Women who experience delivery in a birth center are usually those who have already given birth without any problems and whose current pregnancies are considered low risk (meaning they are in good health and are the least likely to develop complications).Women giving birth to multiples, who have certain medical conditions (such as gestational diabetes or high blood pressure), or whose baby is in the breech position are considered higher risk and should not deliver in a birth center. Women are carefully screened early in pregnancy and given prenatal care at the birth center to monitor their health throughout their pregnancy.

Natural childbirth is the focus in a birth center. Since epidural anesthesia usually isn't offered, women are free to move around in labor, get in the positions most comfortable to them, spend time in the Jacuzzi, etc. The baby is monitored frequently in labor typically with a handheld Doppler. Comfort measures such as hydrotherapy, ma.s.sage, warm and cold compresses, and visualization and relaxation techniques are often used. The woman is free to eat and drink as she chooses.

A variety of health care professionals operate in the birth center setting. A birth center may employ registered nurses, CNMs, and doulas (professionally trained providers of labor support and/or postpartum care). Although a doctor is seldom present and medical interventions are rarely done, birth centers may work with a variety of obstetric and pediatric consultants. The professionals affiliated with a birth center work closely together as a team, with the nurse-midwives present and the OB/GYN consultants available if a woman develops a complication during pregnancy or labor that puts her into a higher risk category.

Birth centers do have medical equipment available, including intravenous (IV) lines and fluids, oxygen for the mother and the infant, infant resuscitators, infant warmers, local anesthesia to repair tears and episiotomies (although these are seldom performed), and oxytocin to control postpartum bleeding.

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Pregnancy and Birth Sourcebook, Third Edition A birth center can provide natural pain control and pain control with mild narcotic medications, but if a woman decides she wants an epidural, or if complications develop, she must be taken to a hospital.

Birth centers often provide a homey birth experience for the mother, baby, and extended family. In most cases, birth centers are freestanding buildings, although they may be attached to a hospital.

Birth centers may be located in residential areas and generally include amenities such as private rooms with soft lighting, showers, and whirlpool tubs. A kitchen may be available for the family to use.

Look for a birth center that is accredited by the Commission for the Accreditation of Birth Centers (CABC). Some states regulate birth centers, so find out if the birth center you choose has all the proper credentials.

Which One Is Right for You?

How do you decide whether a hospital or a birth center is the right choice for you? If you've chosen a particular health care provider, he or she may only practice at a particular hospital or birth center, so you should discuss your decision. You should also verify your choice with your health insurance carrier to make sure it's covered. In many cases, accredited birth centers as well as hospitals are covered by major insurance companies.

If you have any conditions that would cla.s.sify your pregnancy as higher risk (such as being older than 35, carrying multiple fetuses, or having gestational diabetes or high blood pressure, to name a few), your health care provider may advise you to have your child in a hospital where you and your baby can receive the required medical treatment, if necessary. In fact, you may be ineligible to deliver in a birth center because of your risk factors.

If you desire interventions such as an epidural or continuous fetal monitoring, a hospital is probably the better choice for you.

For a woman without significant problems in her medical history and whose pregnancy has been cla.s.sified as low risk, a birth center might be an option. Someone who desires a natural birth with minimal medical intervention or pain control may feel more comfortable in a birth center. Because the number of labor and support people you can choose to be present is less limited, if you want to have your entire family partic.i.p.ate in the birthing experience, you might consider a birth center.

Once you've decided on either a hospital or a birth center, you may still have to choose which hospital or which birth center. Before you 476 Birthing Centers and Hospital Maternity Services make a choice, you'll have to verify if your health care provider, whether he or she is a doctor or a CNM, will only deliver at certain facilities. In addition, try to get a tour of the hospital or birth center so you can determine for yourself if the staff is friendly and the atmosphere is one in which you'll feel relaxed.

Choosing a Hospital: Questions to Ask Before your labor pains start, get answers to the following questions.

* Is the hospital easy to get to?

* How is it equipped to handle emergencies?

* What level nursery is available? (Nurseries are rated I, II, or III-a level III neonatal intensive care unit [NICU] is equipped to handle any neonatal emergency. A lower rating may require transportation to a level III NICU.) * How many deliveries take place at the hospital each year? (A higher number means the hospital has more experience with various birth scenarios.) * What is the nurse-to-patient ratio? (A ratio of 1:2 is considered good during low-risk labor; a 1:1 ratio is best in complicated cases or during the pus.h.i.+ng stage.) * What are the hospital's statistics for cesarean sections, episiotomies, and mortality? (Keep in mind, though, that these numbers include high-risk and complicated deliveries.) * How many labor and support people may be present for the birth?

* What procedures are followed after your baby's birth? Can you breastfeed immediately if desired? Is rooming in available?

* How long is the typical postpartum stay for v.a.g.i.n.al deliveries?

For C-sections?

* Can the baby and the father stay with you in your room around the clock, if you desire?

Choosing a Birth Center: Questions to Ask * Is the birth center accredited by the Commission for the Accreditation of Birth Centers?

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Pregnancy and Birth Sourcebook, Third Edition * Is the birth center easy to get to?

* What situations during labor would lead to a transfer to a hospital? How are transfers handled? What emergencies are the transfer facilities able to handle?

* What professionals (such as midwives, doctors, and nurses) are available on staff? On a consulting basis? Are they licensed?

* What childbirth and prenatal education cla.s.ses are offered?

* What are the center's statistics for hospital transfers, episiotomies, and mortality?

* What procedures are followed after your baby's birth? How long is the typical postpartum stay and how will your baby be examined?

It's wise to choose where to deliver your baby as early in your pregnancy as possible. That way, if complications do arise, you'll be well informed and can concentrate on your health and the health of your baby.

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