Posts Tagged ‘relaxation techniques’

LABOUR AND BIRTH
It’s all your fault, stop the pain!
choices for pain relief
What is the best form of pain relief in labour?
As each woman and labour is very different, it is difficult to say which is the ”best” form of pain relief. This will also depend on an individual’s coping mechanisms and pain threshold. There are many different types of pain relief (see p 174) including alternative therapies such as aromatherapy acupuncture, homeopathic kits, reflexology and hynobirthing (using self-hypnosis to reach a state of deep relaxation); natural methods, such as water, massage, TENS, and the positions you adopt; and drugs, such as gas and air and pethidine, and epidural. Your midwife will talk to you about the different choices available and the advantages and disadvantages of each one.
Last time I made a real idiot of myself. I don’t want to lose control again - what do you advise?
The best advice is to know your options, have an open mind, and be guided by labour and how you are feeling. Being positive and having appropriate support can not only result in a good experience, but can reduce your preception of the pain, and feeling empowered helps you to stay in control
Are relaxation and childbirth classes helpful?
Relaxation and breathing techniques taught in antenatal chidbirth classes are extremely useful when used together and at the correct times in labour (see p.176). This, combined with working with your partner and the midwife, can help to make the pain more bearable and thus the birth experience more pleasurable. It is worth pointing out that people have different pain thresholds and relaxation and breathing techniques alone may not be enough to help you cope with the pain of labour, especially as
labour advances. Practising breathing and relaxation techniques before labour begins increases the benefit so classes are helpful.
Can moving around during labour help with the pain?
Providing the labour is straightforward, it does
seem to be the case that being as active as possible can help the progress of labour. Not only does this help with the pain, but it can also encourage more effective contractions so that labour is faster As the labour advances, it may be difficult to get into a position that is comfortable, and often women move around to try to find the best one. Favoured positions are standing, kneeling, or squatting, and rocking the pelvis, either on a birthing ball with your legs astride or leaning onto the bed or into the wall
Being prepared
practical and mental preparation for labour
Inevitably, labour will involve a degree of pain. Although this can be a frightening prospect, accepting this and thinking in advance about how you might deal with the pain may help you to cope better when the time comes. * Be as informed as possible about pain-relief options to help you make choices you are happy with in labour, Find out if you need to do anything in advance, such as inform staff if you want a water birth. * Try to think about the final outcome of labour and view the pain as part of the process that brings you closer to your baby.
How can a birthing ball help during labour?
Using a birthing ball during labour has the advantage of opening up the pelvis to allow the baby to move down more easily You can take your own birthing ball into hospital, and this may be advisable as supplies may be limited.
What is a TENS machine and how do they work?
TENS (transcutaneous electrical nerve stimulation) works by stimulating the production of endorphins, the body’s natural painkillers, and also by blocking some of the pain pathways Electrodes placed on
your back or abdomen are attached to a unit that fires electrical impulses when a button is pressed, blocking pain pathways The strength and frequency of the current can be altered according to your needs. This is a natural form of pain relief that requires no drugs and is a good way to involve your partner, who can position electrodes.
The machines will produce a tingly sensation,
but this does not hurt. Some people do not like the sensation, while for others it works very well, so it’s a good idea to hire a machine before labour to see if this form of pain relief suits you.
The advantages of TENS are that you are in control of your pain relief and are free to move around while you are using it. Check in advance whether the unit supplies TENS, or whether you need to hire one before going to hospital
Will I be able to use my TENS machine at the same time as other types of pain relief?
TENS can be used with pethidine or diamorphine and gas and air, but not with water (because it is electrical) or with an epidural (because of the position of the electrodes on your back).
My midwife says that I can have my baby at home, but what pain relief will I be able to have?
There are a variety of, mainly natural forms of pain relief that you can use in your own home. Alternative therapies, such as aromatherapy, homeopathic kits,reflexology. and acupuncture can all be used, as long as an appropriately trained person is providing them. Many women having home births opt for warm water. either in the bath or in a hired pool, as this is an effective form of pain relief. The midwife can also offer gas and air and pethidine as alternatives, if natural forms of pain relief are not working.
However, you may find that just by having your baby at home, you are less likely to need much pain relief. This is because evidence suggests that women who stay at home for as long as possible during tabour, or for the whole of their labour, have a more positive experience, which includes needing less pain relief. By adopting the correct positions, using massage, and breathing and relaxation techniques, you may find that you limit the amount of medical pain relief you need.
How an epidural works
An epidural is an injection into your back that numbs your body so that you are unable to feel the contractions. For about 90 per cent of women it completely blocks the pain. Epidurals work by blocking pain nerves as they enter the spinal cord Setting up an epidural is a medical procedure that can only be done by an anaesthetist. A local anaesthetic is injected to numb the area of the lower back before the procedure is carried out. A special needle is then carefully inserted into the space near to where the nerves enter the spinal cord. A fine tube is pushed carefully through the needle and left in place so that drugs can be run through it The procedure usually takes around 20-30 minutes, and it takes approximately 15-20 minutes for the epidural to start working effectively.
HOW THE EPIDURAL IS INSERTED:
Will I be able to cope through all the stages of labour using breathing techniques alone?
Relaxation and breathing techniques are extremely useful when used together and used at the correct times. It is common for women to breathe short, rapid breaths at the strongest part of the contraction. Studies show that this can cause a panic-type response in your body that can increase tension and heighten the pain. Learning to “sigh out slowly’ (SOS) and keeping your shoulders down can help you in labour, if you have practised during pregnancy, At the end of tabour, when it is necessary to control the head as it delivers, the midwife will ask you to pant or blow. This is two short breaths out followed by a longer breath out. Combining breathing techniques with working with your partner and the
midwife can help to make the pain more bearable and thus the birth experience more pleasurable. It is worth pointing out that people have different pain thresholds, and breathing alone may not be enough, especially as labour advances.
Can a water birth help with pain?
It is well documented that water can help with labour pains (see p 156). The heat of the water reduces muscle spasms, and the buoyancy of the water relieves pressure on the pelvis, which lessens the overall pain experienced The water is kept around body temperature by topping up with warm water and needs to be covering your ”bump” to be effective. Studies have shown that it can reduce the length of labours and the risk of tearing. Babies can be born completely under water so that they do not gasp until they hit the cold air. Most hospitals allow you to use gas and air in a pool as an additional form of pain relief.
I want to remember everything about the birth - how can I achieve this?
Probably the most effective way to remember as much as you can about your labour and the birth of your baby is to try to remain as healthy and rested as possible prior to the start of your labour, which will give you the best chance of staying strong and clearheaded during labour Feeling strong and having plenty of energy may also help you to remain upright and active during the course of your labour, reducing the need for opioids, such as pethidine, which can create a mild state of amnesia, meaning that you may have some difficulty remembering the finer details of the birth It’s also helpful to have a partner or close friend with you throughout your labour so that they too can help fill in any blanks later, and photographs and videos are good prompts If you do find after the birth that there are parts you can’t remember, you could ask your midwife to let you see your birth notes Or you could try to keep a birth journal between contractions!
I want an epidural but I’m afraid about having one -should I be worried?
Epidurals work by blocking pain nerves as they enter the spinal cord (see opposite). The doctor performing the procedure will be very experienced as it is a very small area they need to aim for. You need to sit very still in the position demonstrated to avoid any problems. There is a slight chance that if the needle goes in too far, it can cause a leak of fluid causing a aural tap”, which can result in a severe headache Other fears include future backache, which may be prevented by changing your position frequently in labour There is a very small risk (although this is highly unlikely) that damage is caused to the nerves.
I’m scared to death about going into labour - will I get an epidural?
The availability of epidurals will depend on each hospital It is best to ask your midwife what the procedure is at the hospital you are booked at If you think in advance that you would like an epidural, or decide in labour that you would like one, let the midwife know as soon as possible so that she can contact the anaesthetist and arrange this.
Will having an epidural slow down my labour?
As epidurals numb your feelings, this can make it hard to know when to push As a result, it may slow the labour or increase the risk of a forceps
or ventouse delivery slightly However, if this occurs the midwife or doctor will gently lay a hand on -your abdomen and will be able to feel as soon as a new contraction begins in your uterus. This will be a
sign to them to encourage you to actively push, even though you do not feel the sensation of the actual contraction due to the epidural anaesthesia. Following the advice of the midwife in this way may reduce the need for an assisted delivery, as pushing with a contraction is safer and more effective in terms of easing your baby through the birth canal.
I’m very keen to stay active in labour - can I do this if I have an epidural?
One of the side effects of an epidural is that your legs may feel numb and unable to hold your weight, which can restrict your movements. Some maternity units do offer “mobile” epidurals. These work in the same way as a standard epidural, but you are given a lower dose of the analgesic drug. This means that you are unable to feel the pain of the contractions, but the nerves controlling your legs, abdomen, and bladder are relatively unaffected so you are still able to remain mobile. This leaves you free to move around and be upright during labour and can also mean that you do not need to have a catheter inserted to empty your bladder. A mobile epidural can also increase the likelihood of a vaginal delivery, as being able to move around will assist the progress of labour, and being less numb means that you will be able to push more instinctively during labour contractions You may want to check in advance with your midwife whether your local maternity unit provides this facility
I’ve heard that pethidine can make you feel sick, and the baby drowsy after birth. Is this true?
Pethidine is from the family of drugs called opiates and is the most commonly used drug during labour. It is usually given by injection and its side effects include nausea, vomiting, dizziness, or drowsiness; it can also delay the baby’s breathing.
To combat the nausea and vomiting, an anti-sickness drug is usually given with pethidine If the baby’s breathing is noticeably affected, an antidote injection is sometimes given to reverse the effects of the pethidine, although this is not usually necessary and would only be given if the baby didn’t respond well to other types of stimulus, such as gently rubbing the baby’s back with a warm towel, or gently stimulating and rubbing the feet of a baby, which can be enough to make him inhale. Your baby’s ability to breastfeed can be affected if he is drowsy, and midwives are now encouraged to
provide extra support to mothers choosing to breastfeed if they have had pethidine during labour in an attempt to overcome this side effect.
When is it best to start using gas and air?
Gas and air, or Entonox, is a combination of 50 per cent oxygen and 50 per cent nitrous oxide (laughing gas). It is widely available in maternity units and can be used in home births. This method of pain relief works by reducing the pain messages that the brain receives. It starts to take effect within 20 seconds, so it is advisable to time your intake of gas and air with your contractions, so that you start taking it just before or at the beginning of a contraction to get the maximum benefit, at around 45-50 seconds.
Gas and air can be used from the onset of your labour. However, some women report that they feel slightly drowsy and light-headed and therefore out of
Pethidine and diamorphine
Opiate drugs used for pain relief during labour
These drugs are useful in the early stages of labour, helping you to relax and deal with the pain, and pethidine in particular is widely used. They can only be administered in the form of an injection by a midwife or doctor, usually in the hospital or a maternity unit. As with much pain relief, these drugs have advantages and disadvantages.
* Pethidine has a sedative effect, relaxing the muscles of the uterus, and is especially useful if you are feeling anxious or experiencing a long labour as it helps you to rest.
* Both drugs can make you feel nauseous and they can enter the baby’s system. If given too close to the time of delivery, they can make the baby sleepy and can even cause problems with the baby’s breathing.
control while taking gas and air and therefore you may find that you want to stop taking it while you are pushing if it is distracting you too much and stopping you focusing on the contractions. Some women manage their entire labour on gas and air alone, while others find that they need another form of pain relief in the later stages of labour
How will I use the gas and air and is it likely to make me feel sick?
Gas and air is breathed in through a mouthpiece or mask that is connected to a cylinder or pipes in the wall that lead to larger cylinders elsewhere You administer it yourself, so are more in control of how much you take and when.
Gas and air can make your lips and mouth feel tingly and dry, and in some cases women report feeling nauseous while taking it. Using a mouthpiece rather than a mask may help to reduce feelings of nausea brought on by the smell of the gas and the sensation of having a mask over your face, and taking sips of water may help. As the effect of gas and air is short-lived, you only need to use it during contractions; taking gas and air between contractions will not help with the pain of the next contraction and is likely to increase the sensation of nausea.
I want to have a great birth but you hear such awful stories -how can I stay positive?
For every awful birth story there is an equally positive one — it does tend to be the case that you are less likely to hear about the positive birth stories as these aren’t such good topics of discussion! However your labour and birth proceeds, the birth of your baby will be amazing because you will finally meet the little person who has dominated your life for the past nine months.
It is sensible to remain open minded about labour and birth, because it’s impossible to foresee exactly how things will go on the day. However, there is a lot that you and your partner can do to help prepare yourselves for labour and birth so that you
Gas and air
A form of self-controlled pain relief in labour
A mixture of oxygen and nitrous oxide that is self-administered in labour.
Gas and air, also known as Entonox, is taken through a mask or a mouthpiece during labour. This dulls the pain centres in the brain and produce a sense of euphoria. This needs to be timed with your contractions as the effects are short-lasting, with the gas being breathed in just prior to and during a contraction You will feel normal once you stop using it
Gas and air tends to be the preferred choice for managing pain in women who want to labour as naturally as possible. The reason for this is that gas and air has several advantages, including the fact that you can remain mobile and active while using it; it can be used during a water birth; it doesn’t affect the baby in any way, and it doesn’t make you feel drowsy during labour, which allows you to feel more in control throughout and to remain as focused as possible on your contractions However, although it is a widely available and a popular choice of pain relief in the UK, it doesn’t tend to be used in the United States.
have the best chance of having a positive overall birth experience For example, you can both learn as much as possible about the process of labour and birth so that you can make informed decisions in labour. You can chat with your midwife, read books, find information on the internet, and attend antenatal classes. Also, knowing how labour progresses helps to demystify the experience and therefore removes some of the fear that accompanies labour and birth. Learning basic relaxation and breathing exercises also helps (see p 173), as being able to relax as much as possible during labour helps you to feel less anxious, which in turn can help the labour to proceed as quickly and smoothly as possible

Breathing techniques
Using relaxation and breathing techniques can help you to relax and cope with the contractions throughout your labour. Try practising techniques with your partner before labour. Learning to control your breathing has many benefits, including helping you to increase your energy reserves and let go of tension and anxiety so that you can breathe with the rhythm of the contraction. In the earlier stages of labour, you may want to practise longer, deeper breaths between contractions to help keep you calm and focused You can also try breathing in slowly at the start of a contraction and then exhaling slowly and continuing this pattern until the contraction has passed. Later in labour as contractions become stronger, you may find taking shorter, lighter breaths helps you to ride over the contraction.

How to manage the pain

There are a range of pain relief options available It’s wise to think about which method you would prefer before going into labour.
Relaxation, breathing, keeping mobile,
and massage: You remain in control and avoid intervention. Being upright can help the position of the baby and there are no side effects. This may not be sufficient pain relief for strong contractions
Water: Using a birthing pool in labour and possibly for delivery can hale you to labour quicker and less painfully, with no side effects.
TENS (transcutaneous electrical nerve
stimulation): Sticky pads placed on your back send small electrical impulses to trigger the release of endorphins. You control the current
with a hand-held device. This may not provide sufficient relief for very strong contractions.
Gas and air: 50 per cent oxygen and 50 per cent nitrous oxygen. This is easy to use and drugs don’t accumulate in your body, Some women feel sick or sleepy and find this isn’t strong enough.
Pethidine or diamorphine: These can lessen
the pain, but can cause sickness and affect the baby’s breathing if given too close to delivery.
Epidural anaesthesia: A local injection near the spine, this is the most effective form of pain relief and doesn’t enter the baby’s system. It increases the chance of forceps, ventouse, and Caesarean, as you may not be able to feel when to push. You will be less mobile and will need monitoring

The end of pregnancy

When will I start my antenatal classes and what types are there?
Antenatal, or parent education, classes start around 32 weeks and, if you are attending classes run by your local NHS trust, are free. The classes may run for 4-6 weeks, or some trusts have a monthly afternoon session. Some hospitals provide women-only classes evening or weekend classes and yoga and pilates classes (see p 60). There are also private or independent, midwives in most areas who may offer antenatal classes on a one-to-one or small group basis.
Antenatal classes are also available from the National Childbirth Trust (NCT), run by trained NCT teachers Classes are usually held in the evenings, making them more accessible to partners and friends, and they often provide ongoing postnatal support for up to six months after the birth. There is a fee, although in some cases a reduced fee or assisted places may be offered
Aquanatal classes are also popular These are gentle exercises in the swimming pool along with other pregnant women and often the teacher is a midwife who also provides antenatal information. Also many obstetric physiotherapists run relaxation and breathing technique sessions; your hospital antenatal clinic may have information on these.
What will I learn in my hospital antenatal classes?
Antenatal classes usually cover a different topic each week, including the physical changes that occur in pregnancy, the three stages of labour; hospital, home, and water births; pain relief, which should include breathing and relaxation techniques; breastfeeding; postnatal care of the baby; and changes in your relationships The most popular topics tend to be the stages of labour and pain relief, along with a tour of the maternity unit
Is it useful to learn and practise breathing and relaxation exercises before the birth?
Preparation before labour and delivery is
for most women and their partners, and breathing relaxation techniques in particular help you to focus on your breathing. which in turn can help you to fee- less tense and increase your confidence for dealing with the contractions Antenatal classes teach you
specific techniques and antenatal yoga (see p 60) also helps you to gain control through breathing
Should I practise positions for labour and birth beforehand?
Practising for labour is a good idea as you may find some positions suit you and others don’t (see below). This information can be documented in a birth plan (see p.149) so that it is available for your midwife to discuss with you. It’s also good for your partner to know your preferred positions during labour
Do you have any suggestions for labour positions?
Some popular positions for labour area
* Leaning on a work surface or the back of
a chair. Putting your arms round your partner’s neck or waist to lean against.
•    Leaning on to the bed in the delivery room
•    Kneeling on a large cushion or pillow on the floor and leaning forwards on to the seat of a chair * Sitting astride a chair and resting on a pillow placed across the top
* Sitting on the toilet; leaning forwards, or sitting astride. leaning on to the cistern.
•    Kneeling on all fours.
•    Kneeling on one leg with the other bent
•    Rocking your hips backwards and forwards or in a circled this can also be done using a birthing ball Ally of these positions can make your contractions Breech presentation
Breech position is when your baby is bottom first instead of head first. Breech babies lie in one of three positions: a flexed, or ”complete’ , breech, when the hips are bent, the thighs against the chest, and the knees bent with the calves against the back of the thighs and feet above the bottom; an extended. or
‘frank”, breech when the hips are flexed or bent the thighs against the chest, and the feet by the ears; and a ”footling” breech, like a flexed breech, but the hips aren’t so bent and the feet are below the bottom If your baby is breech at term, your doctor may recommend delivery by Caesarean section
more efficient and help you feel in control When you are in strong labour, you may find that you don’t want to move around much and will find a position that suits you If possible, keep rocking, leaning forwards during contractions, and straightening up in between. If you get tired, lie down on your left-hand side, rather than propped up on your back, which stops the pelvis being able to open effectively. Lying on your left side is much better for your baby than lying on your back because he receives more oxygen, and the contractions are still effective in this position. If you feel rested after a while, push yourself up with your hands into a sitting position and get up again
I’m 36 weeks and my baby is breech. Is this a concern?
Breech position is when your baby is bottom first instead of head first (see above) Quite a lot of
babies sit in the breech position in pregnancy and there is still a chance your baby will turn. It’s not until about 37 weeks that your midwife or doctor will focus on your baby’s position.
Is there anything I can do to help my baby turn?
If your baby is breech towards the end of pregnancy there are some exercises you can try in an attempt to turn your baby A ‘knee-chest” position can help To do this, kneel on your bed with your bottom in the air and your hios bent at just over 90 degrees Try to keep your head, shoulders and upper chest flat on the mattress Adopt this position for 15 minutes every two waking hours for five days If you feel nauseous or light-headed, do not continue. Positions in which the buttocks are elevated can also help, and sleeping with a pillow under your buttocks or kneeling on all fours so the weight of your pregnancy is unsupported may help You can combine ”all fours’ positions with household chores, such as cleaning the floor. If these are not successful, there are other ways to try to turn your baby (see below).
I’ve heard about doctors “turning” breech babies. How does this work?
Some obstetricians may try to turn a breech baby in late pregnancy, known as external cephalic version (ECV), which has a success rate of around 50 per cent. During an ECV, an obstetrician gently moves your baby by pressing his hands on your abdomen, using an ultrasound as a guide You may be given a drug to relax the uterine muscles You will be scanned first and if the baby is in an awkward position the procedure may not continue. Also, if your baby is large this can affect the procedure, as can the amount of fluid around the baby, as a low amount of fluid offers less protection to the baby, If you are Rhesus negative, you will have an injection of anti-D after the ECV (see p.79) because of a small risk of a bleed around the placenta An ECV is not recommended if you have a multiple pregnancy, have had bleeding in pregnancy, your placenta is low-lying, your membranes have ruptured, or there is a known problem with the baby
The procedure is not without risk and some think it only works with babies who would have turned anyway. If your baby remains breech, a Caesarean may be advised, although some obstetricians are willing to try a vaginal delivery You are not obliged to have an ECV and should discuss your options.
Finally, a form of acupuncture called
I f moxibustion”is sometimes used, whereby a fragrant herb is held over an acupuncture point, the aim being to relax the uterine muscles to help the baby turn Talk to your doctor or midwife before trying this and seek advice from a qualified acupuncturist.
What triggers labour?
While there are many theories, no one really knows what triggers labour One is that the mother’s pituitary gland secretes oxytocin, the hormone that
stimulates contractions, when the baby is ready to be born Others now believe that the baby starts labour by sending a signal to the mother’s body One theory is that a baby’s lungs secrete an enzyme when they are developed that causes a substance called prostaglandin, which triggers contractions, to be released into the mother’s body. Another theory is that, when the baby is ready to be born, its adrenal glands produce hormones; these cause hormonal changes in the mother that start labour
I don’t want to go overdue. How can I help labour to start?
Various methods have been tried, although none is proven. Popular methods include having sex, as the prostaglandins in semen are similar to the ones used to induce labour; stimulating your breasts to trigger the release of the hormone oxytocin, which stimulates the uterus; eating spicy food to bring on a loose bowel movement, thought to stimulate labour (see p 48) ; and taking long walks to help the baby move down in the pelvis and put pressure on the cervix Homeopathic remedies are also available; consult a registered practitioner for advice.
I’ve heard that raspberry leaf tea can start labour. Is this true?
Unfortunately this is a misconception as raspberry leaf tea doesn’t actually help to bring on labour, but it may help to reduce the length of labour In a study m Sydney, 192 first-time mums were given either a 1.2g raspberry leaf tablet or a placebo twice a day from 32 weeks. The tablet had no harmful effects. and the women who had taken the supplement had a shorter second stage of labour and a lower rate of assisted delivery (19.3 per cent to 30.4 per cent).
Raspberry leaf tea contains an alkaloid, ”fragine”, said to strengthen and tone uterine muscles, helping them to contract more efficiently. You should start taking raspberry leaf tea during the last eight weeks of pregnancy At 32 weeks, you could have one cup of raspberry leaf tea a day, gradually increasing to four cups or tablets a day (depending on the strength of the blend). The tea can be sipped in labour, too.

Fetal positions
Your baby in the uterus
Your baby can lie within your uterus in many different positions. Your midwife or doctor will palpate your abdomen (gently feel your tummy) to identify which way your baby is lying. There are two main positions in which your baby will lie: with his head downwards (cephalic presentation) or with his buttocks downwards (breech presentation). Occasionally your baby will lie across your uterus in a transverse position or even diagonally across you in an oblique position, particularly if there is too much fluid around the baby or you have had several babies previously. In about 17 per cent of cases, the midwives and doctors do not identify a breech presentation until the labour itself
What is LOA and ROA? Once your midwife has identified how your baby is lying, she will also try to determine whether the baby is lying on your right or left side The midwife will track where
Your baby’s position
your baby’s back is, and you will generally feel kicks on the opposite side. The midwife will describe your baby as being LOA or ROA, which stands for left or right occipital anterior -the occiput being the back of your baby’s head facing forwards, so your baby is actually facing backwards These are the best positions for your baby to lie in for labour.
What if the baby isn’t anterior? Sometimes babies lie in a posterior position, which means that their back is lying against your back and they are looking upwards This position may prolong your labour, which can be tiring If this is the case, you can try the same exercises for turning a breech baby (see p.143) to encourage your baby to turn to be in an anterior position towards the end of pregnancy Sometimes your baby will only turn with the help of strong, effective contractions when you are in fully established labour.

What is the “nesting instinct” and is this just a myth?
The nesting instinct is a well-documented natural phenomenon In the final weeks of pregnancy, many women have an uncontrollable urge to clean their house and to prepare and make the ”nest’ safe for the new arrival This is a primal instinct and females of the animal kingdom are all equipped with this need. Just as birds make their nests preparing for their young, mothers-to-be do exactly the same.
The act of nesting puts you in control and gives
•    sense of accomplishment You may also become
•    homebody and want to retreat into the comfort of your home and familiar people The nesting urge can be an indicator that labour is not too far away If you have the energy, take advantage and get on with tasks that you won’t have time for after the birth
Is it true that first babies are often late?
Birth normally occurs at a gestational age of 37 to 42 weeks and, while it certainly isn’t the case that all first babies are late, many do arrive after the predicted
due date. From the point of view of waiting if you approach the end of your pregnancy expecting your baby to be a couple of weeks late, then you may avoid feelings of frustration. It is worth considering that your body has never done this before and that your “due date” is an estimate, the majority of babies do not arrive on this date
I’m 39 weeks and my baby’s head isn’t engaged. Should I be worried?
Not all babies engage into the pelvis before
the beginning of labour It is likely, from about 36 weeks onwards of -your pregnancy, that you may experience your baby moving lower down in your abdomen, causing your baby’s head to enter the pelvis. This process is known as ”engagement’I and simply means that the leading part of the baby has ”engaged” the pelvic brim (see p.148) This is normal and helps to position your baby in preparation for the birth later on.
Engagement often happens earlier with first
babies because the uterine muscles have not been
Your hospital bag
Although hospital visits tend to be short, with many women staying around 24 hours or less after a normal delivery you will need a few essential items. Many mums have a bag for themselves and one for the baby, while others organize a labour bag and postnatal bag for mum and baby. It’s up to you. Basic requirements include:
•    Clothing for labour (including socks and/or footwear).
•    Nightwear.
Toiletries
A towel, sanitary pads disposable pants and a bra.
iIc Music, books, and magazines, as well as money, telephones, phone numbers, and cameras.
* A food bag with nutritious snacks to keep you going
For your baby you will need:
* Clothing, cleaning materials, and some clothes for returning home * Nappies (check with your midwife if the hospital provides these or whether you need to supply your own).

Engagement
Engagement is when your baby’s head starts to move down into the pelvic brim in preparation for birth, and this can occur any time from around 36 weeks until the start of labour In the last weeks of pregnancy, your midwife will palpate your abdomen to see if the head has started to engage. The degree to which a baby’s head is engaged is measured in fifths. If three- or four fifths of the head can be felt above the pubic bone, then
the baby is not engaged If only two-
fifths of the head can be felt, then the baby is said to be fully engaged, and if just one-fifth is felt, the baby is recorded as being deeply engaged.
previously stretched and so they tend to exert more pressure on the baby, moving it down into the pelvis earlier: whereas a second or third baby may not become engaged until your labour actually starts. When your baby’s head engages can also depend on other factors, such as the position in which your baby is lying within the womb (see p.145) and the shape of your pelvis
Am I likely to feel any different once my baby’s head has engaged?
Many women report feeling more physically at ease following the engagement of their baby’s head as there is a release of pressure within the abdomen As a result, you may find that it feels easier to breathe, sleep, and walk around
On the other hand, sometimes when the baby’s head engages this can increase the pressure on your bladder and you may experience a sensation of fullness and pressure between your legs. Many women also report shooting vaginal pains. Engagement is also likely to affect bowel sensations.
My midwife mentioned checking the position of the placenta. Is this normal?
This is not routine, but if your 20-week scan indicated that the placenta was low-lying, known as placenta praevia (see p.92), your midwife would suggest a further scan at 34 weeks to see if the placenta had moved up and away from the cervix.
My baby isn’t moving so much now - should I be worried?
There is some natural reduction in the range of your baby’s movements towards the end of pregnancy as he has less room to stretch his limbs However, you should still be familiar with your baby’s pattern of movement in later pregnancy as this is a good indicator of your baby’s health and is just as important as the number of movements a day (see p.103) You may find at this stage that your baby is developing a pattern for waking and sleeping, often different to yours, so your baby may be awake when you go to bed and may start kicking Or your baby may get the hiccups and you will feel the jerk of each hiccup, a sign that your baby is preparing for life after delivery. If your baby’s movements have reduced or stopped, contact your maternity unit. You could also try things like having a cold or hot drink, having a bath or shower or massaging your tummy. A formal assessment may be recommended and if there are concerns, you will be asked to make a conscious effort to increase your awareness of when your baby moves. There should never be fewer than 10 individual groups of movements a day between 9am. and 9pm. Some areas have walk-in antenatal day units (ANDLJ) where you can have a cardiotograph (see p.192) to record your baby’s movements.
I’m practically incontinent. Is there anything I can do to stop this?
During pregnancy, many women find that they leak urine slightly when they cough, laugh, exercise, bend over, or lift something. This is known as stress incontinence. The pelvic floor muscles are under strain during pregnancy as they have to support the weight of your growing uterus and cope with the changes caused by pregnancy hormones. As a consequence, a sharp increase in abdominal pressure when you cough and so on may be too much for the muscles to hold back the flow of urine. Stress incontinence may happen at any time in pregnancy, but is more common towards the end.
The best treatment for incontinence is regular pelvic floor exercises to keep the muscles toned (see p.57). Taking some gentle exercise each day can also help and, although you may not make a full recovery during pregnancy, regular exercise now will minimize the problem and help you towards a full recovery after your baby is born. Stress incontinence is often worse for a few days following the birth, when the muscles of the pelvic floor and other structures are recovering If it does not get better after this time, talk to your health visitor or doctor as you should not have to suffer long term without help.
Ask your midwife to refer you to your obstetric physiotherapist, who can review the problem and offer you advice and monitoring.
Birth plan
Stating your preferences for labour and birth
The purpose of a birth plan is to communicate your wishes for labour and birth.
Your plan can be as detailed or as brief as you like Do bear in mind that circumstances may dictate that not all of your preferences are met Discuss this plan with your midwife before the birth. Here are some suggestions of what to include:
* You may want to state who your birth partner will be, whether you want more than one birth partner, and if you want them present throughout. * You could include your preferences for managing labour pain Do you want to labour naturally (maybe using a birthing pool), or do you have a preferred type of medical pain relief? *You can state which positions would you like to use in the different stages of labour? Do you want to be active in the first stage, and in which position would you prefer to deliver your baby?
* Do you have concerns about being strapped to a fetal monitor? If so, do you want to request that this be done intermittently only?
* State your preferences for after the birth. Do you want your baby delivered on to your tummy, and how soon do you want to breastfeed?

Not Getting Pregnant FAQs.

We’re not getting pregnant what do we do now?
We’ve been trying to conceive for 12 months - can the doctor identify the problem?
There are many factors that can increase or decrease your chances of becoming pregnant, but if you have been trying for a year, it would be sensible to contact your doctor. After an initial assessment of your general health and lifestyle, your doctor will offer your partner a sperm test (see below) and you will be offered tests to see if you are producing eggs and check whether or not your Fallopian tubes are blocked. Blood tests will be carried out to check your iron levels, your red and white blood cell count, and to check how organs such as your liver and kidneys are functioning In addition, couples are asked to agree to a sexual health screening to check for previous or current STls, such as HIV and syphilis.

My wife has been tested and has the all clear - how can I tell if I’m causing our fertility problem?
You will be offered a semen analysis to determine your sperm quantity and quality — how sperm move (motility) and whether they are a normal form. A healthy sperm count should have a concentration of 20 million spermatozoa per millilitre of semen, with
75 per cent of these alive and 50 per cent of these ‘motile”, or moving as well as possible Differences can occur over time in both the quality and quantity of sperm, so if your first sample is poor, you will probably be tested again a couple of months later.
You are also likely to be advised to give up smoking, reduce alcohol intake to 1-2 units once or twice a week, and to wear loose-fitting underwear to avoid overheating the testes If a problem is found, you will be referred to a specialist for a consultation Try to avoid becoming stressed as this can also affect fertility Learning relaxation techniques with your partner and practising these regularly will help.

We can’t conceive naturally - what do we do now?
Assisted conception; or assisted reproduction, is the term used when women are helped to conceive without having intercourse There are five main procedures available, listed below. Your consultant will go through each one with you, and together you can make a decision about which is most suitable depending on your problem. You can also contact the National Institute for Health and Clinical Excellence (NICE) for more information (see p.310)
* Ovarian Stimulation (OS), or Super Ovulation (SO), involves injections of fertility hormones to boost egg production This is followed by intrauterine insemination (IUI) of sperm, whereby sperm are collected and sorted so that only the strongest remain and these are then artifically placed inside the uterus via a catheter. This is ideal for couples when the man’s sperm is “slow” or the woman has problems ovulating, or there is a combination of both. * Gamete Intra-Fallopian Transfer (GIFT). This is suitable for couples for whom no cause for infertility has been found. It involves stimulating the ovaries to produce eggs, which are removed, mixed withsperm and replaced directly into the Fallopian tubes, allowing conception to occur inside the body.
* In Vitro Fertilization (IVF). This is the most widely used treatment and involves a seven-step process (see below and p.30) This is ideal for most problems including blocked tubes
* Intra-Cytoplasmic Sperm Injection (ICSI). This is used if the man’s sperm count is low, the motility of the sperm is very poor, or the woman is allergic to her partner’s sperm. The treatment involves injecting just one viable sperm into an egg (see box right). * Artificial Insemination by Donor (AID). This is simply the injection of donated sperm into the cervix This is used when a man is unable to maintain an erection or is sterile Similarly, women may require an egg donation if they are unable to produce their own eggs, although this is more complicated.
Whatever treatment is provided, it is important that you and your partner are treated as a couple rather than separate patients. It is also essential that you are kept informed throughout the process and given information on any risks and benefits.

What does IVF involve?
IVF, or In Vitro Fertilization, involves the surgical removal of an egg which is then mixed with sperm in a laboratory dish to fertilize and produce an embryo outside of the womb (see p.30).
IVF treatment occurs in cycles, as there are various stages that must be completed for it to be successful. Initially, a drug is used in the form of a nasal spray or injection to switch off the woman’s natural cycle of egg production in the ovaries, known as ”clown-regulation”. Fertility drugs are then given to stimulate the ovaries to produce more than one egg (ovulation induction). Mature eggs are collected from the ovaries using a fine needle guided by ultrasound. The procedure is usually uncomfortable rather than painful. On the same day, the partner’s sperm is collected and then the eggs and sperm are mixed in a dish. Within a few days, one or sometimes two embryos are transferred into the womb. If an embryo successfully attaches to the inside of the womb and continues to grow, a pregnancy results.

ICSI

This procedure may be used when it is thought that the quality of the partner’s sperm may be responsible for fertility problems. If the sperm count is low or movement is poor, sperm may be ”assisted” in fertilizing the egg. An individual sperm is injected directly into the egg and, if fertilization takes place, the resulting embryo is placed in the uterus.
What are the success rates of fertility treatments?
Success rates for treatments vary, depending on the treatments used and the health of the couple If you want to know the success rates of individual clinics, you can ask for their ratio of “live-births-per-cyclestarted”. This information is available from each clinic, but there are currently no nationally held data
Overall, couples have a better success rate if the woman is aged 23-39 years, has been pregnant or has had a baby, and has a normal body weight (a body mass index between 19 and 24). The older a woman is, the less likely she is to get pregnant
Figures show that for every 100 women who are 23 to 35 years, more than 20 will get pregnant after one PVT cycle; from 36 to 38 years around 15 will get pregnant at 39, around 10 will get pregnant; and in women over 40, around 6 will get pregnant

IVF is so expensive - can we get help with funding?
Since April 2005, women between the ages of 23 and 39 are entitled to one free IVF cycle on the NHS. However, you must meet the eligibility criteria set by your local Primary Care Trust (PCT), which varies across the country and depends on factors such as your marital status, weight, and whether you or your partner smoke Couples who can afford to, or who may have had one unsuccessful cycle already, often opt for a private clinic Although these are regulated by the Human Fertilisation and Embryology Authority (HFEA), this cannot set costs, and a private course of IVF can cost from E4,000 to £10,000
My partner is worried about producing his sperm sample. How can I reassure him?
As fertility problems affect 1 in 7 couples in the UK reassuring your partner that this is not an unusual situation is always a good start. You could try leaving out a leaflet on fertility problems for him to read for more information Try to empathize with him as much as possible by sharing your experiences and the tests you have undergone.
Your partner may be worried about ejaculating at the required time when he is already feeling anxious and is in a clinical environment Some men require a sex toy, magazines, or video clips to help. For others, restraining from sexual intercourse for a few days can make ejaculation easier If you live fairly close to the clinic, your partner may be able to produce the sample at home and deliver it.
Sometimes a medical condition such as diabetes prevents a man ejaculating If this is the case, sperm can be obtained through ‘’sperm recovery”, whereby a small needle is passed through the skin of the scrotum into the testes and sperm is withdrawn.

The drugs I’m taking for IVF are giving me terrible mood swings. Is this normal?
The drugs used in IVF treatment are female hormones (see p.30) to stimulate your ovaries to mature more than one egg at a time, and progesterone, which helps to sustain a pregnancy. Different levels of hormones can result in mood swings, as any woman who suffers with premenstrual tension (PMT) can testify, and this is also a common side effect of IVF treatment It’s worth considering too that couples undergoing IVF are under incredible stress, which has been linked to an increased risk of developing depression, so it’s important to decide whether you are feeling ”hormonal” or are in fact depressed. Your doctor can advise you and refer you if necessary.
My partner has a low sperm count - can you tell us what help is available for us?
Usually, two or three semen samples are taken to work out the average sperm count and to see if there are abnormal sperm present. A healthy semen sample of 2-5ml contains more than 20 million sperm per ml; a count below this is considered low If your partner has abnormal sperm, further testing may be necessary Lifestyle changes can boost sperm (see below). There are also hormonal treatments to improve sperm count and surgery to remove blockages You may be reassured to know that even poor-quality semen can be used to fertilize an egg with IVF or with ICSI (see p.29).
Can lifestyle changes really improve sperm?
Poor quality sperm has been linked to excessive drinking (more than three or four units of alcohol per day), smoking, and to wearing tight-fitting underwear,
which overheats the testicles and can affect their efficiency Excessive stress and a poor diet are also thought to affect sperm So yes, it is worth reviewing your lifestyle to see if improvements can be made Jobs that may expose you to harmful agents, such as pesticides, may also affect sperm, so if you think your partner’s job may pose a risk, it’s worth investigating.
I’m pregnant using a donor -what happens if my child wants to trace her biological dad?
From April 2005, children who were conceived using donor sperm have had a right when they reach 18 years of age to find out their parent’s identity. This also applies to children conceived using donor eggs and embryos. This right applies only to children conceived after this date and not retrospectively. Prior to this date, children had the right to know at 18 years of age if they were conceived using donor sperm, eggs, or embryos and to find out if they were related to someone they wanted to marry. The reason for this change in the law is that children conceived in this way are being given the same rights as adopted children regarding information on their genetic parents. However, some fertility experts fear that this will deter potential donors.
Is surrogacy allowed in the UK?
Currently, surrogacy is legal in the UK, although it is illegal to advertise it as a service However, the law does not recognize surrogacy
as a fixed agreement, which means that a surrogate can change her mind about the arrangement during the pregnancy and up to six weeks after the birth. It is usual for a surrogate to receive ”reasonable expenses”, although there is no definition of what is deemed as reasonable. Usually, this includes costs incurred by the surrogate relating to her pregnancy, If the father of the child is named on the birth certificate, this gives him equal rights to the child. If this is not the case, then six weeks after the birth the new parents can apply for a parental order that gives them full parental status At this point, the surrogate gives up any parental rights to the child.

Conception problems

There are a range of reasons why a couple may have difficulty in conceiving. Investigations and tests may uncover specific conditions, which may be treatable, or you may be offered help to conceive.
What can affect a man’s fertility? A semen analysis may reveal various reasons why sperm have difficulty in fertilizing an egg The sperm count may be low (less than 20 million sperm per ml); the motility of the sperm (how they move) may be poor, and there may be a high percentage of abnormally formed sperm Some men experience a failure to ejaculate at orgasm There may also be damage to the tubes that connect the testicles to the seminal vesicles where sperm are produced, and this may have been present from birth or caused by a later infection
What can affect a woman’s fertility? Conditions such as polycystic ovary syndrome
(a hormonal imbalance that causes ovarian cysts) and endometriosis (see p 19) can disrupt fertility. Other hormonal imbalances, such as low levels of FSH and LH, can affect ovulation; or levels of progesterone may be too low to sustain a fertilized egg. Damaged Fallopian tubes, caused by an ectopic pregnancy (see p 25), surgery endometriosis, or pelvic inflammatory disease, which may be caused by an infection such as chlamydia, can prevent conception. Damage to the ovaries can occur from scarring as a result of surgery or infection, or the supply of eggs may be low Some women have an abnormally shaped uterus, or have uterine scarring, that can prevent the successful implantation of an egg.

IVF treatment

In vitro fertilization or IVF, is a complex procedure with several stages, from the stimulation and harvesting of your eggs to the successful fertilization of the eggs, development of embryos and transfer of the embryos into the womb for implantation. Undergoing IVF can be a stressful and time-consuming undertaking, but knowing in advance how the procedure works and what you can expect at each stage can reduce anxiety and help you and your partner to cope.
What happens first? To optimize the chances of success with IVF more than one egg at a time is removed for fertilization Normally, your body produces one egg each month. In rVF, you will inject yourself with drugs, such as clomiphene and hMG (human menopausal gonadotrophin) to stimulate your ovaries to produce several eggs. While you are undergoing this treatment, you will need to visit your clinic every one to two days over one or two weeks to monitor the development of the eggs. Once it is thought that the eggs are mature, you will be given a blood test to measure your levels of oestrogen, which is released around ovulation.

What happens next? Once your follicles are ripe and ready for ovulation, your eggs will be collected at the clinic using ultrasound or laparoscopy to guide a probe. Once the eggs have been collected, they will be mixed with your partner’s sperm in a Petri dish in a laboratory ready for fertilization Your partner needs to produce the sperm on the same day as the egg collection. He can either do this at home, or come into the clinic with you and produce the sperm while you are undergoing the egg collection procedure.What happens in the laboratory? Once the egg and the sperm have been mixed, they are placed in the laboratory and monitored closely for the next few days. They will first be inspected around 18 hours later to see how many of the eggs have been fertilized and the clinic will usually pass this information on to you the day after the procedure It’s quite common for not all of the eggs to be fertilized and for only two or three to develop into embryos. The fertilized eggs are incubated in the laboratory over the next couple of days and their progress measured. The laboratory technician watches cell division under a microscope, waiting for the eggs to divide into two or more cells on their journey to becoming a blastocyst (see p.21).
If one or more fertilized eggs develop in the laboratory, you will be called back in for the embryo transfer, This is done by injecting eggs through a catheter into the uterus. No more than two eggs will be transferred and you will have the option to freeze any remaining embryos.

Surrogacy
A surrogate mother is a woman who reaches an agreement to carry a baby on behalf of another woman. She can either conceive the baby with the partner’s sperm, in which case she is the maternal mother, or the infertile couple may fertilize their own egg through fertility treatment, which is then transferred into the uterus of the surrogate mother for her to carry the baby through pregnancy and deliver at birth. This process can be beset with problems: such as the conflicting emotions of both the surrogate mother and the receiving couple, or legal issues if, for example, the surrogate mother has a change of heart after the birth and wishes to keep the baby, For this reason, it is important that all parties entering into the agreement have carefully considered the implications and are confident and happy in their roles.