How Long Will it Last?

I overheard this question being asked between two pregnant employees at work yesterday.  They weren't talking about the length of their pregnancies, or even how long labor would last. They were talking about nausea.

NAUSEA AND VOMITING IN PREGNANCY 

Nausea, and even vomiting, especially in the first trimester of pregnancy are two of the most common symptoms reported by pregnant women. Up to 85% of pregnant women report some degree of nausea with the first few months of pregnancy.

No one knows for sure what causes this nausea, although it is suspected to be caused by hormonal changes. Human chorionic gonadotropin, a pregnancy hormone, rises during the first trimester, as does the hormone Estrogen.

It is difficult to predict exactly when episodes of nausea will occur as well, although many women report feeling nauseated first thing in the morning. Hence the term, "morning sickness". This has led some to theorize the underlying cause of some nausea to be related to an imbalance in blood sugar.

For most women, the nausea and vomiting will subside after the first three months of pregnancy, however for some unfortunate women, it will continue for four or five months. A very few women will have nausea the entire pregnancy.  

HOW TO COPE WITH MORNING SICKNESS

Many experts recommend not allowing your stomach to become empty.  This doesn't mean you have to walk around with a full stomach, in fact, just the opposite is more helpful.  

Try to eat frequent, very small meals.  Carry some saltine crackers in your purse to nibble on.  Keep them on your bedside table, too,  to snack on during one of those middle-of-the-night trips to the bathroom.   This often helps prevent nausea in the morning.  Avoiding heavy and greasy foods can also help to limit nausea and vomiting.  Nausea can often be triggered, or made worse, by strong scents and smells, so it may help to avoid those.  You may need to ask someone else to do the cooking for you for a few weeks.


Image via WikipediaIf you do become nauseated, you can try to suck on lemon drops, or lemon flavored candy.  Some women have had great success with these.  Ginger candy is also helpful.   Eating something salty, such as potato chips, may calm your nausea enough to allow you to eat a meal.


Don't forget to drink enough fluid to keep you well-hydrated, but you may want to limit the amount of fluids you actually drink with meals.  Drinking before or 15-30 meals after, can help prevent nausea.  Also, don't lie down immediately after eating.


If you experience severe nausea, so that you are unable to keep down fluids or any food at all, you need to contact your health care provider. If morning sickness lasts beyond the first thirteen weeks, or into the second trimester, tell your health care provider.  There may be medications available which may help you to deal with the nausea and vomiting.

Avoiding Colds and Flu

Cold and flu season is here.  The best way to treat a cold or the flu when you are pregnant is to avoid catching it in the first place.  Here are some simple suggestions to minimize your chances of catching a cold or the flu this winter:

• Wash your hands -- Wash your hands often and keep your hands away from your face.  This is one of the most important things you can do to prevent colds and flu.
•  
• Eat well -- eat a balanced diet and take your prenatal vitamins.  Keeping your health level at it's highest will help you prevent infection.
•  
• Avoid crowded areas -- the more people, the more chance you will encounter someone with the flu or a cold.
•  
• Hit the sack -- getting adequate rest helps maintain a healthy immune system.
•  
• Quit smoking -- if you smoke, quit.  This will boost your immune system and be better for you and your baby.
•  
• Work out -- regular exercise not only helps prepare your body for labor, but it will enhances immune function.
•  
• Roll up your sleeve -- get your flu shot!

For Your Family

This post is not for the expectant mother, or even for the expectant father.  It is for everyone else who will enter the room before, during or after the baby is born.  So if you are the mother, send them this link and tell them I told you to!

Having a baby is an exciting an a stressful time for new parents and even those who have been through it before.  Birthing a new baby not only brings a new little one into the world, it often births a new family:  a new mother, new father, often new grandparents as well.  Everyone is excited and a little nervous.  Everyone in some way is concerned about how the day will affect them.

In over three decades I have seen families who deal with this stress and excitement well, and those who don't.  I have a few tips for family members to help the day go easier and to help the new parents have an easier adjustment in their very stressful day.

JUST WHO'S THE MOTHER AROUND HERE?

It sounds cruel, but the first thing I have to say to every family member, be it the patient's mother, grandmother, the father of the baby's mother or grandmother (dad's just don't seem to have this problem too much):  IT'S NOT ABOUT YOU! 

This is her day.  She is now the mother.  She is the one having the baby.  The doctor wants to talk to her.  The nurse wants to talk to her.  It really isn't necessary for you to be there at all unless she desires  you to be there.  And sometimes, she won't want you there -- no matter how much you want to be there.  You do not have an inherent right to be in her labor room or in her delivery simply because you are "The Grandmother".  I was not present in the birth of either of my grandchildren.  I knew my son and his wife had a right to their privacy and to go through the delivery of their children without anyone else present if they wanted.  The decisions the new parents make are theirs and should be honored with respect. Now, that was hard, but it is true.  That being said, there are some things which can make things easier on the new parents, and easier on yourself if you prepare ahead.

TIPS FOR FAMILY MEMBERS

• Don't get there too soon -- believe it or not we have often had family members make it to the hospital before the patient arrives.  Labor is often a long process, there is not much need to get there as soon as she does.  Often too, the nurses need some time without visitors for the admission process.  It can stress the laboring mother to know she has visitors in the waiting room.  She feels the responsibility of "hostess"  and will try to make everyone as comfortable as possible.  That unfair burden needs to be removed from her.
• Make your visits short -- even if she seems comfortable, she is still in a stressful time.  She needs as much rest as she can get.  She will not rest if people are having conversations in her room.  She will still be listening and trying to make sure everyone is happy.
• Keep your visits quiet -- You will be happy and excited that your new little one is coming, but you never know what the patient in the next room is experiencing.  She could even be in very pre-term labor and frightened of what the future holds for her baby!  Keeping your voice low will keep your loved-ones room calm and will keep your voices from carrying to other rooms.
• Don't eat in her room -- She may tell you it's fine, but if she can't eat, it is just plain cruel to eat in front of her.  Not only that, nausea is common in labor and the smell of food may trigger nausea and vomiting for her.
• Bring the new father food -- He can eat in the waiting room if he wants, but he shouldn't feel as if he has to leave to find something to eat.  Take good care of him throughout the day and you will reduce her stress significantly.
• Bring things to keep yourself and little ones occupied in the waiting room -- if there are small children present, bring plenty of things for them to do.  Bring things to keep yourself occupied as well.  Don't plan to store it all in her room, however, you don't want to be going in and out and in and out to get things. That is not only stressful, it's annoying.
• Don't ask "what's taking so long?" -- even if you mean it as a joke, she has no control over the length of her labor and if it has been a while, she is likely to be concerned about that,  Your question will only raise more concerns.  That fear can actually hinder her body working efficiently and effectively.  Be supportive, encouraging and loving.
• Don't tell your horror stories -- No one in the room wants to hear how long you were in labor and how much it hurt, and she especially doesn't need to hear it.  Don't tell her how badly she is going to hurt, either.  The fear you cause in her will increase tension which will stimulate nociceptors to actually increase her pain levels.  Follow the "Thumper Rule":  if you can't say anything nice, don't say anything at all!
• Don't wear perfume or cologne -- laboring women are sensitive to smells and very susceptible to nausea.  Strong perfumes and colognes can trigger vomiting.
• Don't smoke or eat strongly flavored foods before visiting -- for the same reason.  If you must have those onions on that hamburger, use some breath mints before you visit.
• Give privacy when privacy is due -- Please leave the room for exams or times when she is exposed.  Even if you will be present during delivery, please give her all the privacy you can.  If you are her mother, you may remember changing her diapers, but she doesn't.  You would want the same privacy if you were disabled and she were caring for you.
• Listen to the nurse -- She may look young, but she wouldn't be where is is if she didn't know what she was doing.  Things aren't done the same way they used to be done.  Listen to her, she can tell you what to expect and why hings are happening the way they are.
• When it's time to go, go - After the baby has arrived, keep your stay short.  The new parents will need their sleep.  They will not sleep as long as they have visitors and in their mind anyone who is not the baby is a visitor.
• Ask her permission before you video, take pictures or put posts on facebook --no explanation needed!

These tips come, not from my own observations, but from the hundreds of times I have had a patient turn to me after a family member has walked out and say something like one of the above items.  I hope they will help you to reduce some of the stress and anxiety that comes with having a new baby.  It is a wonderful time in your life, enjoy every minute!

Induction of Labor

I can't believe I haven't written on this subject before.  The daughter of a friend of was being induced today.  I wanted him to read about induction of labor and then realized I had never written about it!

According to ACOG, the American College of Obstetricians and Gynecologists, induction of labor is the use of medications or other methods to bring on (or induce) labor. Labor is induced in about 20% of women in the United States. The American Association of Family Physician sites the rate as between 9.5 and 33.7%, depending upon the area.  Obviously, in some areas there are more inductions and in others there are fewer.

The same methods can be used to speed up labor if it is going too slowly, but this is usually referred to as augmentation, instead of induction of labor.

REASONS WHY LABOR MIGHT BE INDUCED

Labor might be induced if conditions exist which put your health or the health of the baby at risk.  For the health of some women, having the baby is safer than continuing with the pregnancy.  For the health of some babies, the environment outside the uterus may be safer than the environment inside the uterus.  Reasons for inducing labor may include one or more of the following conditions:

• The pregnancy has lasted more than 42 weeks, or is postterm
• The mother has pregnancy-induced hypertension
• The mother is a gestational diabetic
• There is an infection in the uterus
• The mother has premature rupture of membranes (meaning the water has broken several hours before labor has begun)
• The baby's growth rate has slowed down considerably and is now considered IUGR
• The level of amniotic fluid is significantly decreased, called oligohydramnios

There may be other reasons for inducing labor.  For example, occasionally a woman may be induced if she lives a long distance from the hospital or if she has a history of very rapid labors.

HOW DOES MY HEALTH CARE PROVIDER DECIDE I NEED INDUCTION?

The decision for induction is based upon the need for induction, such as the factors listed above, as well as how far along your pregnancy is and the status of your cervix. Unless there is a significant risk factor or problem, labor is not induced before 39 weeks of pregnancy.

WHAT DOES MY CERVIX HAVE TO DO WITH IT?

Labor is the process by which contractions of uterus thin out and open up (or dilate) the cervix so that the baby can pass through.  At the end of pregnancy, hormones cause the cervix to become soft and able to thin out during labor.  This is called "ripening".  A health care provider may often refer to a cervix that is not yet soft as being "green", like a piece of un-ripe fruit. If the cervix has not yet "ripened", it will not be conducive to the induction agents used. 

If your cervix is not favorable for induction, your health care provider may decide to use an agent to help ripen your cervix.  There are dilators which can be inserted into the cervix which mechanically soften it.  There are also certain medications which can be used.

Prostaglandins are drugs that can be used to prepare the cervix for labor. They are synthetic forms of the same chemicals produced naturally by the body. They can be inserted into the vagina or taken by mouth.

A way of causing your body to release prostaglandins is called Stripping the Membranes.  During this procedure, your health care provider checks your cervix with a gloved finger.  He or she sweeps the finger over the thin membranes that connect the amniotic sac to the wall of the uterus.  After this is done you may notice some cramping and may even have some spotting.  The release of prostaglandins this causes can result in a softening of the cervix.  It can also cause contractions.  This is usually done in the doctor's office, or in the hospital.

INDUCING LABOR

Rupturing of the Amniotic sac is a way to attempt to start contractions.  Your health care providers can make a small opening in the amniotic sac during a vaginal exam.  It is important to stay as relaxed as you can during this exam to minimize any discomfort.  This is usually done only after the baby's head has moved down in the pelvis.  Most women will begin contractions within a few hours of the rupture of membranes.

OXYTOCIN

Perhaps the most common form of artificially beginning contractions is the use of oxytocin.  Oxytocin, or also called Pitocin, is a medication used to induce labor.  It is a synthetic form of the same hormone produced by the pituitary gland in laboring women.  It can be used to induce contractions, or to increase the strength of contractions.

Oxytocin is administered into your vein through an IV.  A pump will control the amount that is given.  In most instances, Oxytocin is started off very slowly and increased at regular intervals to mimic natural labor.  Your contractions will be monitored carefully to make sure they are not lasting too long or coming too close.  If that should occur, the rate of the Oxytocin drip can be adjusted.

WHAT ARE THE RISKS OF INDUCTION OF LABOR?

Image via WikipediaEvery intervention has some risk factors, even those that seem the most benign.  Although problems rarely occur with inductions, there can be increased risks.  These may include:

• Changes in the fetal heart rate
• Increased risk of infection (which is true anytime you have an IV)
• Overstimulation of the uterus (contractions too close, or lasting too long)
• Umbilical cord problems,  (Labor induction increases the risk of prolapsed cord - the umbilical cord slipping into the vagina before delivery, which may compress the cord and decrease the baby's oxygen supply)
• Uterine rupture - a rare but serious complication in which the uterus tears open along the scar line from a prior C-section. An emergency C-section is needed to prevent life-threatening complications.

To avoid the problems, the fetal heart rate will be monitored continuously.  The duration and frequency and force of the contractions will also be monitored.

WILL I BE MORE LIKELY TO HAVE A CESAREAN SECTION?

There are conflicting studies on this question.  The answer for this is partially because of the great number of women who are induced also have risk factors which would predispose them to a Cesarean Section.  For example, a mother who has oligohydramnios, or a low level of amniotic fluid, may experience more fluctuations of the fetal heart rate during labor due to the compression of the umbilical cord by the contractions. 

A study done by Ochsner Clinic of women who had previously given birth, who were being induced for subsequent babies, showed there was little difference in the Cesarean Rate for those who were induced and those in the control group.  When women who have never had babies before are added into studies, then the risk of having a C-Section appears to increase.  The key factor is the favorability of the cervix prior to the initiation of the induction agent.  The more favorable the cervix, the greater the likelihood of a vaginal delivery.

CONCLUSION

The decision of whether or not to induce labor must be made between you and your health care provider.  All risk factors of mother and baby, the risks of the procedure as well as the perceived benefits must be discussed.

Be sure that you ask questions, and that you understand the answers fully.  Don't be afraid to say you didn't understand. If you feel as if you need time to "think it over", ask if you can take that time.

The majority of inductions occur each day in our country without any problems.  If you decided upon an induction, throughout the process you can ask your nurse any questions that might arise.  She will be happy to keep you informed of your progress, the process and your baby's status.

Keep in mind the goal of a healthy mother and a healthy baby and look forward to being a mother!

The Physics of Labor

I had a sweet couple the other night whose labor reminded me of the physics involved in the work of labor.

Although she was only 2 centimeters dilated when she was admitted, her cervix was paper-thin and her contractions in a close, regular pattern.  I had a feeling she would go quickly and she did, mainly because of physics.

 The cervix, the opening to the uterus, begins thick and closed. The first action it takes, before ever opening up any appreciable amount, is to thin out, or efface. The muscles of the uterus pull upward toward the top and this pulls on and effaces the cervix.

A woman will usually be 90% or more effaced before she begins to dilate any significant amount. With a first baby the cervix will efface as thin as a piece of paper. Never again will the cervix be this thin.

                        Image via WikipediaThe action of the uterine muscles pulling upward on the cervix is similar to that of putting on a turtle-neck sweater. Most people don't begin by pulling open the turtle-neck as wide as they can and then pulling it over their head. No, they pull the sweater over their head and let the neck portion rest on top of their head, thick and closed.

As they pull the fabric of the sweater from the bottom, the neck portion gradually thins out. Once the neck has thinned out as much as it can, then the opening will begin to open up more and more and begin to slide over the person's head, until finally, their head slides through.

This is the same mechanism for labor. The uterine muscles pull on the cervix, as the baby's head, pressing against it, help it to thin out. Then when the cervix is as thin as it can get, it begins to dilate, or open up, more and more until the baby finally begins to descend through it.

While it is possible for woman who has had several babies to have a cervix that is still thick and dilated at the same time, that is not due to dilation as much to the elasticity of the cervix that multiple labors has caused, much like the stretchiness of a balloon which has been blown up over and over again.

When in labor, it is important to remember that progress in any number -- dilation, effacement or station, is still progress -- especially in early labor.   Don't be discouraged if those first early exams only show changes in effacement, those are necessary before the big numbers in dilation can be made possible!