The New Labor Laws

By Aviva Patz

You wouldn’t dream of driving without a seat belt or skipping sunscreen at the beach. So why would you settle for anything less than the most up-to-the-minute facts about labor and delivery—the event that will bring your child into this world and change your life forever?

“We’re finally stepping up this century to help women give birth with modern information,” says California-based labor nurse Sarah McMoyler, R.N., author of The Best Birth. “The more that expecting parents know going into childbirth, the more they can participate in the decision-making and the easier it is for them to keep their focus on what’s really important, a healthy mom and a healthy baby—however you get there.”

To have the most positive, satisfying birth experience possible, arm yourself with the newest thinking on labor and delivery from doctors, nurses, and midwives with the following do’s and don’ts.

DO draw up a realistic birth plan.
On one hand, it’s great to have a personal vision for your labor. It can help you explore your feelings about birthing methods, pain medications, and medical interventions and prompt you to find out which are available at the health care facility you’ve chosen—all good.

On the other hand, it’s unwise to plot out a single path and call it a day. A recent study from England’s Newcastle University found that women’s expectations of labor and delivery differed markedly from reality—they were totally unprepared for the intensity of the pain, lack of access to pain relief, their own level of participation in the decision-making, and their amount of control during labor.

“No one can predict how your labor is going to go,” McMoyler says. “If complications arise, you need to have options. Just like if you’re going skydiving, you should have a parachute.”
How? McMoyler recommends discussing with your partner not just your dream birth but contingency plans as well. For example, you may want to get an epidural immediately, but if your doctor says it’s not time yet—or that the window of opportunity has passed—what pain-management techniques will you use? Narrow your list to five or six major points and discuss them with your caregiver in advance. Then write them on an index card for the labor and delivery nurses.

DO tell your doctor you’d like to avoid an episiotomy.
Doctors used to believe that an episiotomy—a cut into the perineum to enlarge the vaginal opening—would help you out: Save you from a jagged tear that would be tough to fix, lower your risk of urinary stress incontinence, improve healing, and prevent fetal trauma. But researchers have since found that not only doesn’t the episiotomy deliver on those promises, but it also introduces new risks, including excessive blood loss, blood clots, and infection.

“It’s still used occasionally to speed up delivery if the baby’s in distress or if you’re having a hard time getting baby over that last little hump,” says Shelley Chapman, M.D., assistant professor of maternal fetal medicine at Greenville Hospital System Children’s Hospital in Greenville, SC. “But it need not be done routinely.” And many doctors actually believe natural tearing heals better than a cut.

How? Add “Try to avoid episiotomy” to your wish list. To prevent tearing, apply a warm compress to the perineum and have your partner perform perineal massage to make the skin more pliable. While you’re at it, skip the pre-delivery enema. It’s absolutely not medically necessary.

DON’T blow off childbirth classes, even if you’re banking on an epidural.
Lamaze, Bradley, and even your hospital’s generic childbirth classes are not a waste of time. They’ll show you what to expect on D-day, arm you with information that will empower you to make informed choices, and give you coping mechanisms that can help you feel more in control.

“At some point during labor and delivery, you will feel pain, guaranteed,” McMoyler says. “Without realistic childbirth education, you may not be able to cope with the pain, your partner will be clueless as to how to help you, and neither of you will know how to communicate with the health-care team.”

How? Take a childbirth class, be it Lamaze, Bradley, or a hybrid offered at your hospital. Also consider an educational title such as The Best Birth DVD. The more you know, the easier your labor will be.

DON’T opt for a Caesarean section, unless it is medically necessary.
There’s no doubt that C-sections save lives when mom and baby are in distress, when baby is in a breech position, or under other emergency circumstances. But electing to have one for non-medical reasons—your doctor’s leaving town, you don’t want your baby born on Halloween, or you fear for your future sex life—is downright risky.

“I discourage elective Caesarean,” Chapman says. “It’s major abdominal surgery with all the risks that that entails, including wound infection, infections in general, blood transfusions because of blood loss, damage to other organs—plus a longer, more intense recovery.”

A recent study of more than 97,000 deliveries, published in British Medical Journal, found that women who opted for Caesareans had twice the risk of illness and even death, as women who had a vaginal delivery. C-section babies were also twice as likely to have to stay in a neonatal intensive care unit.

How? Give vaginal birth your best shot. “For most women, the cons of a C-section outweigh any benefits,” Chapman says.

DON’T get induced early just because it’s convenient.
A full-term pregnancy is 39 weeks, according to the American College of Obstetricians and Gynecologists, but because of medical advances, it’s getting more and more common to induce earlier, even at 36 weeks. In 1996, 6.9 percent of all births occurred between weeks 34 and 36, and by 2005, that number had jumped to more than 8 percent.

“The hottest topic right now is inducing late preterm birth out of convenience instead of necessity,” says James Woods, M.D., professor of obstetrics and gynecology at the University of Rochester Medical Center in Rochester, NY. “It’s a big deal,” Woods says.

Going a little earlier may feel like a godsend to an expecting mom, but several new studies confirm the risks to both mom and baby: In a review of multiple studies, published in Clinical Obstetrics and Gynecology, researchers found that first-time moms who undergo elective induction are more likely to have a C-section or instrumental deliveries (with forceps or vacuum extraction) and are more likely to hemorrhage.

In another study, from The Ohio State University Medical Center, delivering a baby just two weeks early was linked to several newborn complications.

How? Avoid induction before 39 weeks, unless it’s a true medical necessity. And if you must induce for non-emergency reasons, Woods advises, do an amniocentesis first to check for proper lung development.

DO consider hiring a doula.
Who couldn’t use a personal cheerleader—especially when it comes to the physical triathlon we call childbirth? That’s why many women choose to hire a doula, a layperson trained in the basics of childbirth who provides laboring moms with continuous support through the birth and sometimes beyond.

Research shows that having a doula present is linked to decreased use of pain medications, fewer instrumental deliveries (forceps), a lower C-section rate, and increased breastfeeding.

How? Visit DONA International, the professional organization of doulas, for more information and a referral.

DON’T rush to the hospital at the first twinge of a contraction.
In spite of how it’s portrayed by Hollywood, labor can be slow. There may be as many as 14 to 28 or more hours between your first contraction and baby’s arrival. In fact, studies show that waiting to head to the hospital until you’re in active labor can help you progress with fewer interventions and increase your odds of having a vaginal delivery.

“First-time moms should wait till contractions are under 10 minutes apart and it’s difficult to walk around and breathe through them before going to the hospital,” Woods says. When timing your contractions, count from the start of one contraction to the start of the next.

How? Spend the hours of your early labor in the comfort and quiet of your own home. Try soaking in the tub, watching a movie, or other comforting activities to distract yourself.

DO be patient when it comes to an epidural.
Many moms will tell you that epidural anesthesia—a medication that numbs the nerves to the uterus, vagina, and perineum—is a gift to laboring women. But the drug, which is administered via a long needle into your lower back, is not without risk, especially if given too early.

A recent review of previously published research has found that if epidural anesthesia is given before active labor (when the cervix is dilated at least 4 centimeters and contractions are less than 5 minutes apart), it can more than double the likelihood that you’ll end up giving birth via Caesarean. “If it’s given too early, you have relaxation of the pelvic floor and diaphragm, and it’s conceivable that baby will not stay lined up and rotated in the right way to exit,” Woods says.

The result, if not a C-section, can be increased use of Pitocin, a drug that intensifies contractions; use of forceps and vacuum extraction; greater trauma to the perineum; and even maternal fever. You should also know that an epidural can have some ugly side effects: intense headache, shaking, and itching and numbness in the limbs.

How? If you want an epidural, note that on your wish list. But be prepared to wait until you’re in active labor.

DON’T accept narcotics without reading this.
While you’re waiting for your epidural—or trying to go without one—your doctor may recommend a narcotic such as Demerol, Stadol, or Nubain. These depressant drugs, called opioids, work by dulling the brain’s perception of pain. Or do they?

In a 2002 study published in American Journal of Obstetrics and Gynecology, researchers reported that women were dissatisfied with narcotics only marginally less than they were with a placebo (71 percent versus 83 percent), meaning the narcotics eased pain only slightly better than sugar pills. Other downsides are the side effects, including nausea, vomiting, extreme drowsiness (which can make it difficult to cope with the contractions), and a drop in blood pressure. Narcotics also cross the placenta and may make your baby sleepy and unresponsive at birth.

How? Talk to your health-care provider about your concerns about narcotics and explore alternative pain-management options.

DO stay on the move as much as possible during labor.
“A bed is not the best place for a laboring woman to be,” McMoyler says. “Getting out of bed and into different positions and environments will help you cope with the pain and move labor along.” She recommends these maneuvers:

• Get on your hands and knees or lean over a bed to take the pressure off the lower back and help baby’s head descend into the right position.

• Squat, which opens the pelvis and allows it to expand during labor.

• Slow dance with your partner and gently sway your hips to bring on stronger, more frequent contractions.

• Sit in a rocking chair between contractions to help you release and allow the baby to descend.

• Sit on an exercise ball, which loosens the pelvic muscles.

• Stand in a warm shower, which enhances your ability to manage contractions, allowing labor to progress.

How? Practice the maneuvers with your partner in advance and jot them down on an index card for easy referral during labor.

DON’T clamp the umbilical cord immediately.
Umbilical cord blood is a rich source of iron for baby, who won’t begin producing her own iron for several months. That’s why researchers are now recommending that instead of clamping the cord immediately, doctors wait a minimum of two minutes—about the time it takes to gently suction baby’s mouth and nose (a routine procedure), according to Woods—before making the cut.

How? Let your health-care team know in advance that you’d like to delay the cord-cutting by two minutes if possible.

DO give baby some skin right away
It’s a great idea to put naked baby on mom’s bare chest as soon as possible after birth to promote both breastfeeding and mother-baby attachment, according to a recent review of the best research. “Babies are more likely to be breastfed, and for longer, if they have early skin-to-skin contact right after birth,” says Maureen Corry, M.P.H., executive director of Childbirth Connection, a national nonprofit organization that uses research, education, advocacy, and policy to improve maternity care. “There is no need to separate you and your healthy baby after delivery.”

How? Let your delivery team know that you want your baby placed on your chest as soon as possible after delivery.

Surprises Not Found In the Books

Real moms reveal what shocked them about labor and delivery.
“In one second I went from the worst pain in my life to feeling wonderful. The second after I gave birth, I felt great, even while they were stitching me up. I had the same feeling—both without an epidural and with one.”
—Lisa Swanson, Bloomington, MN
“I was very surprised at how painful it was getting the epidural! It took the nurse a long time, the injection was quite painful, and it was extremely uncomfortable to bend far over my big stomach, so much so that I yelled out!”
—Jan Gunneson, Montville, NJ
“Once the baby is delivered, the doctor is pretty much ‘done’ with you. That was surprising to me. The doctor who delivered my son said, ‘I never hold the babies, I just get them here.’”
—Robin Nolan, Raleigh, NC
“I was surprised that even though I got a small epidural at 10 centimeters with my first child, they wouldn’t give me one at 8 centimeters with my second! So, with the second birth, it was natural childbirth and hurt so badly. On the other hand, the recovery period after natural childbirth is an hour. An hour! I had my body back and didn’t feel all drugged out like when I recovered from an epidural.”
—Juliette Coulter, Dallas
“I was surprised that the doctor was sewing up my episiotomy while I was trying to hold and ‘bond’ with my baby. I mean, c’mon, couldn’t you wait a couple minutes?”
—Kathryn S. Mahoney, Groton, MA
“Recovery was the worst part. I experienced a spinal headache two days after my son Luis was born. I was told that I was leaking spinal fluid caused by the epidural injection or needle. I had caffeine pumped through an IV for 15 hours!”
—Marilyn Fajardo, Coral Gables, FL
“You think you will love your baby, but when you finally meet that baby, there are no words to express the love and emotions you experience, regardless of whether it’s your first, second, third, or beyond.”
—Jodi Arlen, Bethesda, MD

Aviva Patz has written for Parenting, Self, and Redbook. She learned many of these lessons the hard way with the births of her two daughters, now 7 and 4.

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