Information, tips and encouraging words for Mums, Dads and their support people

Sarah-Jane Holton Childbirth Educator

Pregnancy discomforts There are many changes both physical and hormonal which occur in a womans body during pregnancy and its these which lead to the discomforts which some will experience. Ive listed the most common and included some remedies which may be helpful: Morning (or all-day!) sickness Increase rest periods fatigue will make you feel much, much worse When you wake in the morning have some crackers or other carbohydrate food on hand to eat before getting out of bed If you wake in the night snack on a small banana or pottle of yoghurt. This will help keep your blood sugars stable so they are not really low in the morning (low blood sugar levels can make you feel worse). Ginger can be useful fresh, tablets, ginger beer, biscuits. Vitamin supplements (esp. B group) or homeopathic remedies may be helpful. Sea bands worn around your wrists use the principle of acupressure and many women swear by them There are medications which can be taken while pregnant for severe cases of morning sickness (hyperemesis) Be aware that sometimes none of these will work. Speak to your LMC if you are not able to keep down food and fluids

Breast changes Wear a good, well-fitting and supportive bra professional bra fittings are a good idea as you may find you are a completely different size to what you think 2

Consider wearing a bra to bed Wear two bras when exercising

Haemorrhoids Topical creams prescribed by your midwife to reduce pain and swelling Eat lots of fruit and veges and drink plenty of water to avoid constipation Exercise regularly

Heartburn/indigestion Avoid fatty, spicy or fried foods as well as tea, coffee, alcohol and cigarettes Stay upright after eating for 2 hours Sleep with extra pillows

Varicose veins Sit with your feet elevated ensuring your whole leg is supported and not just your feet Try not to sit or stand for long periods. If you must then circle your feet and regularly take walks Support stockings may be of use

Leg cramps Calcium and magnesium supplements may help Stretch the muscle Have a warm bath before bed to improve circulation

Back pain Fatigue Have your iron levels checked Rest, rest, rest Eat protein rich foods and lots of fruit and veges Pay attention to posture! Watch how you lift dont bend your back like a crane, avoid twisting as you lift. Massage (good practice for your support person...)

Symphysis pubis separation (pain around your pubic bone area) Use a pillow between the legs when sleeping Avoid straddle movements keep your legs together Sit on a plastic bag in the car so you can easily swing your legs round and out

Stretch marks Moisturising oils and creams probably wont help (but a bit of pampering is always nice anyway) Avoid excessive and fast weight gain

Pelvic structure and pelvic floor If you can maintain an upright and forward leaning position during your labour this will help your babys journey to the outside world. The average weight gain for a woman is 11-16kgs and is made up of placenta, uterus, increased blood volume, breast changes, amniotic fluid, mums extra fluid and fat stores as well as baby. The extra weight puts lots of stress on the pelvic floor muscles so its important to keep these strong. Practice pelvic floor exercises several times a day. Use cues to remind you to do them e.g. sitting at the traffic lights, while having a coffee, during the ads of your fave TV programme. Some studies have shown that strong gluteal muscles (your bum muscles) may help in keeping your pelvic floor strong so get squatting girls but be careful of your knees.

Signs you are in labour Bloody show (though this can happen a couple of weeks before labour begins). A show is a great sign as it means your cervix is softening and opening Waters breaking Contractions

When should I leave for North Shore Hospital or Warkworth Birthing Centre? Most LMCs will suggest leaving home when you are having 53 contractions in 10 minutes with each one lasting at least 1 minute.

Informed Decision Making You have already had to make some decisions regarding your pregnancy e.g. who your LMC will be and where you will give birth. It always pays to know what all your options are so you feel confident in your decisions. At antenatal classes youll be given lots of information but its important you do some reading and talking to others too so you are fully informed. Remember the BRAIN analogy. Benefits (mum and baby) Risks (mum and baby) Alternatives Intuition Nothing (for 10 minutes, for an hour, at all) This is your baby and your body you have every right to ask questions and make choices and feel supported in doing so by your LMC. If you are unhappy for whatever reason with your current LMC then find someone else who will be a better fit for you and your partner/support person.

Unexpected Outcomes Certainly not a topic we like to think about but for some families things just dont go to plan. It may be that mum develops gestational diabetes or pre eclampsia in pregnancy which can change the way pregnancy and labour unfolds. Baby may have a disability, a medical issue or be born early. Mum may need an induction, a caesarean or other intervention. Sometimes babies are stillborn or pass in the days, weeks or months after birth. While not something anyone should dwell on its worthwhile to at least have given some thought as to how you would access support or how you would support a friend, family member, work colleague or even coffee group member if things didnt turn out as planned. We all have hopes and dreams for our children and if those hopes and dreams are dashed in some way there is a grieving process that must unfold. This is true of labour as well. If mum has her heart set on labouring in a particular way but for whatever reason that doesnt happen she will need time to grieve. Talking with her LMC, family and friends can be helpful in this process. Regardless of how well a labour goes I suggest a good debrief with your LMC afterwards. As parents we need time for ourselves, humour, patience, support and encouragement along with practical help. If we are met with unexpected outcomes we need all of that plus expert advice and care, long term support, lots of information, to be allowed to feel sad or angry, counselling and support groups. And remember - never be afraid to ask for help. Heres a link for the piece I read out, Welcome to Holland: http://www.our-kids.org/Archives/Holland.html 7

Due dates You all stood in order of due dates and then indicated if you thought baby would be early, bang on time or late. It can seem like every day past your due date (if you go over) is a week but remember a normal term pregnancy is anywhere from 37 weeks to 42 weeks and that your due date is an estimate only. So try not to become too focused on that date. Its most common for first time mums to go over their due date with only 3% of babies born on it. Induction will probably be discussed around 10 days after your due date. Elective Caesareans will normally be scheduled a week or two before your due date to avoid you going into labour.

Stages of Labour First Stage Latent labour Also known as early labour Irregular contractions which may feel like period pain Diarrhoea Often the longest stage of labour and may last 24 hours or more Important to rest Eat well porridge, yoghurt, bananas. Good carbs that will give you lasting energy. And this goes for support people as well Stay well hydrated Carry on with normal activities to avoid becoming really focused on this stage especially if it turns out to be quite long You will probably still be able to talk through contractions 8

Cervix is softening and opening and will dilate to 3cms in this stage Contractions will be about 45 seconds long

Active labour You will probably want to call your LMC if you havent touched base already Effacement is when the cervix softens and shortens Dilatation is when the diameter of the cervix increases Remaining in an upright position ensures the baby puts even pressure on all aspects of the cervix Cervix will open from 4-7cms Walking will probably feel good though you will need to stop and concentrate for each contraction Remember to stay upright and forward leaning though if you are tired rest on your left side rather than on your back Contractions will be about 60 seconds long and coming every 3-5 minutes

Transition I cant do this!!; Im going home! This is the hardest part of labour Cervix is opening the last two centimetres Usually lasts less than two hours Mum may become anxious or frightened because of the overwhelming nature of the contractions Contractions will be around 90 seconds long and will feel like they are coming one on top of the other This is the time when dads/partners and support people will really come into their own 9

Mum needs encouragement and a reminder that baby will be here soon Mums vocalisations should come from down low no screaming!

Second stage Time to push The most rewarding part of labour because mum gets to really work with her body here Mum may experience a sudden surge of energy Mum may make deep grunting or groaning noises some even liken the sounds to a cow mooing! When the babys head crowns the LMC will advise mum to pant or blow rather than push to give the perineum a chance to stretch There is no need to push until you really feel you need to listen to your body no purple pushing! Try different positions and remember to work with gravity When babys head is born your LMC will check to see if the cord is away from its neck The baby rotates to allow the shoulders to pass through and then the rest of the body quickly follows This stage usually takes an hour or two

Third stage Birth of the placenta Some things to consider for your birthplan are when you will clamp and cut the cord, who will cut the cord and if you are going to keep the placenta. Do you want an actively managed third stage or physiological? 10

Role of the placenta Allows baby to receive nutrients Carries oxygen to baby Takes carbon dioxide and waste products from baby

Birthing the placenta Active Syntocinon injected into the thigh muscle strong contractions Clamp and cut the cord Midwife applies some traction 5-15 minutes Recommended if there has been an intervention or lots of bleeding Less chance of post partum haemorrhage Chance of trapped placenta which will lead to manual removal in theatre Physiological Wait and watch No traction applied to cord 15 60 minutes Natural oxytocins released by breastfeeding will help uterus contract

Examining the placenta Midwife will carefully check the placenta Checking for retained placenta Can tell if the placenta is getting old Condition of placenta Cord two arteries and one vein

11

Positions for labour Try lots of different positions and avoid being on your back if you can.

12

Pain in labour We have a perception in our culture that labour is terribly painful and dramatic but remember it doesnt have to be this way. If you go into labour believing in your bodys ability to birth well you wont be frightened. Fear leads to tension which leads to increased pain. So stay calm and relaxed this is where support people come into their own. Why do we experience pain in labour? So we know were in labour So we know to call our support people So we can find a safe place to labour in e.g. home, Warkworth Birthing Centre, North Shore or Auckland Hospital. To be encouraged to take up different positions to aid in the birthing process So we know how far along in labour we are is baby about to be born? Helps in second stage. If women tune in to what their bodies are doing they know when and how to push in labour. Its not necessary to be directed how to do this.

An experienced midwife will be able to tell at what stage in your labour you are by watching you or even listening on the phone vaginal exams are often not necessary at all.
Did you know: nocturnal animals give birth during the day and diurnal (active in the daytime) animals give birth at night? Its thought that this is so the birthing mother has privacy from members of her own species and to decrease the risks from predators. Most women will go into labour in the wee small hours.

13

Where does the discomfort come from? Uterine contractions Cervix thinning and opening Pressure of the baby on cervix, vagina, urethra, bladder and rectum Compression of some of mums nerves and bones by the babys head Stretching of the pelvic floor muscles, vagina and cervix Extra work being applied by the uterus on the cervix during transition to get those last couple of centimetres opened up Crowning

What might increase a womans experience of pain in labour? Fear, stress and anxiety Poor body posture and positioning Muscle tension Poor physical fitness Pressure on a full bladder Lack of support Frightening comments from caregivers Poor labour environment Previous bad experiences relating to birth or hospitals

So what will be helpful to a woman in labour? Her support person Her natural pain relieving hormones or ENDORPHINS Confidence in herself and her body

14

Medical Pain Relief Options Gas and air Pethidine Epidural

Self Help Methods Pack in your labour bag whatever you think will be helpful to you in keeping you calm, comfortable and relaxed. You may use it all or you may not use any of it but its much nicer to know you have it there just in case. Dont be afraid to make the delivery room your own. Some ideas of things you may like to take: Pillow(s) I really recommend this as generally there is only one pillow per room available at North Shore Hospital Wheat bag Lavender oil Rescue remedy Massage oil or talc Music Hair ties Lip balm Snacks Large sipper bottle of water (sips of water after each contraction) Magazines Socks (your feet become surprisingly cold while in labour) Tennis ball for massage Your own soft toilet paper (for after the birth) 15

Dim the lights, make use of the swiss balls and pregnancy rockers, take the mattress off the bed and put it on the floor if you want to try some positions down there. Suck on ice chips, place icy cold flannels on the back of your neck and forehead. Water is a brilliant pain reliever as it helps relax you so use the shower and/or birthing pool. Visualise a great birth, visualise your baby and body working together. Use your breathing effectively no screaming! Keep your vocalisations low in order that they help your body to birth your baby. Remember your baby is an active participant and is pushing and turning. Mum and baby are working together. Talk to your baby, tune in to your baby. Try different positions. You can do this

16

Interventions Induction Augmentation Artificial Rupture of Membranes (ARM) Episiotomy Ventouse Forceps Electronic foetal monitoring Caesarean section

The downside of any intervention is that you run the risk of needing another one and then another. This is commonly known as the cascade of interventions.

Natural methods of induction include: Sex but remember it has to be good sex. Dads semen contains prostaglandins which may work on the cervix to begin the softening and opening process and mums orgasm releases oxytocin which may help stimulate the uterus. Nipple stimulation encourages oxytocin release. 15 minutes at a time and one nipple at a time. This can be done with a breast pump, hands or orally. Nipple stimulation may get a labour that has slowed down to start up again. 17

Hot curries which probably work by giving you diarrhoea which in turn irritates the uterus and may cause contractions. Walking on soft sand Kerb walking one foot on the path and one on the road Acupuncture Reflexology Evening primrose oil inserted up close to the cervix at bedtime Homeopathics

These methods generally only work if youre close to going into labour anyway but if youre past your due date and medical induction is looming why not give some of these things a try and have fun!

Baby Blues Affects up to 80% of women Kicks in around day three Sudden drop in pregnancy hormones plus tiredness Usually go away within a few hours or days Talk to LMC, partner, friends or family Exercise Good food Rest Practical help Limit visitors 18

PND Signs Anxious Irritable Trouble sleeping Reduced appetite Hopelessness Inadequacy Anger Guilt Thoughts of harming self or baby Some mums are very good at hiding these symptoms for fear of being classed as a bad mum The earlier it is diagnosed the easier it is to treat Up to 20% of new mums Can affect dads too huge changes emotionally and financially (overwhelming responsibilities) Not hormonal Any time in the first year

Risk factors Previous depression or mental health problem Difficult relationships Complicated birth or birth that was different to one planned (DEBRIEF WITH LMC) 19

Baby born with unexpected physical or other challenge e.g. down syndrome, heart condition, cleft lip/palate Where bonding is slow to develop Sleep deprived mum

Self help Good nutrition esp. vitamins B9 and 12, protein and carbs Evening primrose oil Reduce salt, eliminate alcohol and smoking Plunket family centre Coffee group PND support group Daily exercise Rest, relaxation and sleep

Professional help GP/LMC Counselling services Medication Maternal mental health team

Post Traumatic Stress Disorder (PTSD) 7% of women

20

Psychological term for set of reactions experienced by someone when something traumatic, scary or bad happens involving death or injury to others Usually within the first two weeks and always within the first months following childbirth

Risk factors Signs Hyper-arousal always jumpy or on guard Flashbacks Nightmares of the events Palpitations or panic attacks when thinking about the labour and birth Avoidance of pregnant women or other mothers Shut down emotionally Previous trauma, rape, sexual abuse Induction Inadequate pain relief Lack of explanations or consent Caesarean Actions of health professionals

Must be treated as it wont go away on its own TALK, TALK, TALK TABS Trauma and Birth Stress support group Medication Counselling Psychotherapy Maternal mental health team 21

Homeopathy

Psychosis Signs Help Psychiatrist Medication antidepressants and tranquillisers Hospitalisation usually required but mum and baby will be kept together if at all possible Hallucinations Delusions Hearing voices Obsessive behaviour Paranoia Very depressed or very high moods Excessive and repetitive behaviours writing, cleaning, spending 1 in 1000 women Immediate psychiatric intervention is required Usually within first two weeks but up to first three months Will not pass or resolve on its own

The days, weeks and months following birth are full of hormonal, emotional and physical shifts and it can be very easy for an ordinary day to be tipped into one of despair. 22

Good support, nutrition, rest and exercise will help mum to stay emotionally, mentally and physically strong. There will be days when things dont go as planned but thats okay. Take baby into bed with you, draw the curtains, have the phone off the hook and rest. Remember up to 20% of Dads may get PND too.

Optimal Foetal Positioning It can be really helpful to you during labour if baby is in the best position to start with. If starting with a baby in the posterior position labour may be longer and more painful especially in your lower back. Give up the comfy chairs over the next few weeks and keep your knees lower than your hips. What you can do: Swim (freestyle and breaststroke) Clean the floor on your hands and knees Turn your chair around and lean over the back Sit on a swiss ball Lean over a beanbag while watching TV 23

Put a cushion on your car seat to get your hips higher than your knees Dig a hole in the sand at the beach for your tummy and lie on your front if its summer Lie on your left side

Websites to have a look at: Optimal foetal position: www.spinningbabies.com Moxibustion: http://www.moh.govt.nz/moh.nsf/indexmh/integrativecaretherapies-a3

Breastfeeding The World Health Organisation (WHO) recommends exclusive breastfeeding for the first 6 months (no water, formula or solids). Then with the addition of appropriate solids continued breastfeeding until the child is the age of two or older. Remember breastfeeding is a skill that mum needs to learn and it may not come naturally but practice, perseverance and support will soon mean its second nature. Advantages Free Designed for human babies 24

Right temperature Easily digestible Boosts the immune system Lines the gut with beneficial bacteria No measuring No sterilising Ready wherever you are Helps jaw and tooth development Reduces the likelihood of diarrhoea and vomiting illnesses Protects against respiratory illnesses Protects against SUDI Less likelihood of allergies developing Higher IQ scores have been shown in children who were breastfed Lower cholesterol levels in later life Reduces the incidence of obesity Enhances bonding Helps the uterus get back to its pre pregnancy size Reduces fertility 25

Decreases mums anxiety Reduces risk of osteoporosis, breast cancer and ovarian cancer for mum May make it easier for pre pregnancy weight to be reached

Supply and demand The more baby feeds the more milk mum makes so lots and lots of feeds in the early days, although tiring, are essential for building up a great supply. Because baby will be working to increase the supply and because it has such a small tummy 12 feeds in 24 hours is very normal. Expect growth spurts at 1-3 weeks, 6-8 weeks, 12 weeks and 6 months. Baby will feed more often than usual and may cluster feed in the late afternoon (every hour or so for about four hours).

How to know baby is getting enough milk Overall growth weight, length and head circumference 6-8 heavy, wet nappies per day Baby settles between feeds

How milk is made up In the first 3-4 days mum produces colostrum liquid gold Thick, yellow and sticky 26

Provides lots of antibodies to baby Has a laxative effect helps pass meconium High in protein, sodium and minerals Low in carbs, fats and vitamins Encourages the growth of good bacteria in the gut (helping avoid vomiting and diarrhoea bugs)

Around day 3 or 4 milk comes in and youll know because your breasts will probably become engorged hot, heavy, hard and sore This milk is made up of foremilk and hindmilk. Foremilk is the thirst quenching lower fat milk while hindmilk is higher fat and has lots of calories the main meal. This is why its important to let baby finish one side before offering the second side. You want baby to be getting the rich hindmilk. When baby first latches she will give lots of quick sucks until there is a letdown then youll notice longer slower sucks with a swallow in between. Youll have two or three let downs per feeding session but might not even notice.

Latching and positioning Breastfeeding should not be painful and if you can get your latching right you shouldnt end up with painful, cracked and bleeding nipples. 27

Remember: Nose to nipple Chin to breast Tummy to mummy Bring baby to breast Wait for open mouth Aim nipple to top of mouth

Have everything you need Water you get really thirsty when breastfeeding A snack The remote control Your phone Go to the loo before you start a feed Look at this as a time to rest and look after yourself too not just a time to nurture your baby. In the early days it can feel as though all you are doing is feeding your baby and some women start to feel anxious and restless and worry about other things they could be doing instead of sitting. Dont. Its not for long enjoy being able to rest its what your body needs right now.

28

Coping with challenges Engorgement Usually days 2-4 when milk comes in Cold flannel on breast during feed Lots of feeds Express a little before feed to help baby to latch Warm shower between feeds Good bra at night as well as during the day

Sore nipples Painful throughout feed Cracked Bleeding Thrush Usually incorrect latching Blocked ducts Breastmilk on nipple Air dry 29

Avoid using soap on nipples

Mastitis Flu like symptoms Lump in breast Pain Redness Aches & pains Fever Shivery Apply heat Rest Feed frequently Paracetamol Extra fluids Lots of rest Change feeding position chin to blocked duct Massage to unblock 30

May need antibiotics

Contraception If youre exclusively breastfeeding - no formula or solids - feeding during the night, your period hasnt returned and baby is less th an 6 months old then breastfeeding is 98% reliable as a form of contraception Mini pill progestogen only - Every day at the same time (window of 3 hours) Natural family planning IUD Condoms Diaphragm need to check it still fits properly after having a bab

Exercise The fitter you can go into labour the better. Studies have shown youre your labour may be shorter for fitter women. If you havent exercised for a while now is not the time to start a rigorous training programme but try walking for around 30 minutes a day. Remember you have lots of the hormone relaxin in your body right now so be careful not to overstretch or you could damage your joints and ligaments. The 31

leisure centre has aqua classes which you might like to go to as a group or perhaps organise walks on the beach. Once baby has arrived there is a bums and tums class at the Leisure Centre and you can take baby with you. Get out the strollers or slings/wraps and go for coffee group walks.

Embrace labour! There is no doubt that labour is an incredibly intense experience. There may be moments when you feel frightened or overwhelmed, moments when it all feels too hard but by surrounding yourself with a support team who will encourage you, offer loving touch and massage and quiet words of encouragement you will find a way through. Move around, eat well and stay hydrated. Turn down the lights and turn up the music. Rock those hips and vocalise. Allow yourself to surrender to the power of it, go with 32 it, find your zone. Try going within yourself as you meet each contraction and trust that you can do this.