Some women (less than 1 out of 100) may get a headache after the procedure. A woman can help decrease the risk of a headache by holding as still as possible while the needle is placed. If a headache does occur, it often subsides within a few days. If the headache does not stop or if it becomes severe, a simple treatment may be needed to help the headache go away.

The veins located in the epidural s.p.a.ce become swollen during pregnancy. Because of this, there is a risk that the anesthetic medication 505 Pregnancy and Birth Sourcebook, Third Edition could be injected into one of them. If this occurs, you may notice dizziness, rapid heartbeat, a funny taste, or numbness around the mouth when the epidural is placed. If this happens, let your doctor know right away.

Spinal block: A spinal block-like an epidural block-is an injection in the lower back. While you sit or lie on your side in bed, a small amount of medication is injected into the spinal fluid to numb the lower half of the body. It brings good relief from pain and starts working fast, but it lasts only an hour or two. A spinal block can be given using a much thinner needle in the same place on the back where an epidural block is placed. The spinal block uses a much smaller dose of the drug, and it is injected into the sac of spinal fluid below the level of the spinal cord. Once this drug is injected, pain relief occurs right away. A spinal block-like an epidural block-is an injection in the lower back. While you sit or lie on your side in bed, a small amount of medication is injected into the spinal fluid to numb the lower half of the body. It brings good relief from pain and starts working fast, but it lasts only an hour or two. A spinal block can be given using a much thinner needle in the same place on the back where an epidural block is placed. The spinal block uses a much smaller dose of the drug, and it is injected into the sac of spinal fluid below the level of the spinal cord. Once this drug is injected, pain relief occurs right away.

A spinal block usually is given only once during labor, so it is best suited for pain relief during delivery. A spinal block with a much stronger medication (anesthetic, not a.n.a.lgesic) is often used for a cesarean delivery. It also can be used in a v.a.g.i.n.al birth if the baby needs to be helped out of the birth ca.n.a.l with forceps or by vacuum extraction. Spinal block can cause the same side effects as epidural block, and these side effects are treated in the same way.

Combined spinalepidural block: A combined spinalepidural block has the benefits of both types of pain relief. The spinal part helps provide pain relief right away. Drugs given through the epidural provide pain relief throughout labor. This type of pain relief is injected into the spinal fluid and into the s.p.a.ce below the spinal cord. Some women may be able to walk around after the block is in place. For this reason this method sometimes is called the "walking epidural." In some cases, other methods, such as an epidural or a spinal block, also can be used to allow a woman to walk during labor. A combined spinalepidural block has the benefits of both types of pain relief. The spinal part helps provide pain relief right away. Drugs given through the epidural provide pain relief throughout labor. This type of pain relief is injected into the spinal fluid and into the s.p.a.ce below the spinal cord. Some women may be able to walk around after the block is in place. For this reason this method sometimes is called the "walking epidural." In some cases, other methods, such as an epidural or a spinal block, also can be used to allow a woman to walk during labor.

General Anesthesia General anesthetics are medications that put you to sleep (make you lose consciousness). If you have general anesthesia, you are not awake and you feel no pain. General anesthesia often is used when a regional block anesthetic is not possible or is not the best choice for medical or other reasons. It can be started quickly and causes a rapid loss of consciousness. Therefore, it is often used when an urgent cesarean delivery is needed.

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Pain Relief during Labor A major risk during general anesthesia is caused by food or liquids in the woman's stomach. Labor usually causes undigested food to stay in the stomach. During unconsciousness, this food could come back into the mouth and go into the lungs where it can cause damage. To avoid this, you may be told not to eat or drink once labor has started. If you need general anesthesia, your anesthesiologist will place a breathing tube into your mouth and windpipe after you are asleep. If you are having a cesarean delivery, you also will be given an antacid to reduce stomach acid. In some cases, ice chips or small sips of water are allowed during labor. Talk to your doctor about what is best for you.

Anesthesia for Cesarean Births Whether you have general, spinal, or epidural anesthesia for a cesarean birth will depend on your health and that of your baby. It also depends on why the cesarean delivery is being done. In emergencies or when bleeding occurs, general anesthesia may be needed.

If you already have an epidural catheter in place and then need a cesarean delivery, most of the time your anesthesiologist will be able to inject a much stronger drug through the same catheter to increase your pain relief. This will numb the entire abdomen for the surgery.

Although there is no pain, there may be a feeling of pressure.

Finally Many women worry that receiving pain relief during labor will some-how make the experience less "natural." The fact is, no two labors are the same, and no two women have the same amount of pain. Some women need little or no pain relief, and others find that pain relief gives them better control over their labor and delivery. Talk with your doctor about your options. In some cases, he or she may arrange for you to meet with an anesthesiologist before your labor and delivery. Be prepared to be flexible. Don't be afraid to ask for pain relief if you need it.

Easing Discomforts Following are some ways to ease discomfort you may feel during labor: * Do relaxation and breathing techniques taught in childbirth cla.s.s.

* Have your partner ma.s.sage or firmly press on your lower back.

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Pregnancy and Birth Sourcebook, Third Edition * Change positions often.

* Take a shower or bath, if permitted.

* Place an ice pack on your back.

* Use tennis b.a.l.l.s for ma.s.sage.

* When contractions are closer together and stronger, rest in between and take slow, deep breaths.

* If you become warm or perspire, soothe yourself with cool, moist cloths.

Side Effects and Risks Although most women have epidurals with no problems, there may be some drawbacks to using this pain relief method: * An epidural can cause your blood pressure to decrease. This, in turn, may slow your baby's heartbeat. To decrease this risk, you'll be given fluids through an intravenous line before the drug is injected. You also may need to lie on your side to improve blood flow.

* After delivery, your back may be sore from the injection for a few days. However, an epidural should not cause long-term back pain.

* If the covering of the spinal cord is pierced, you can get a bad headache. If it's not treated, this headache may last for days. This is rare.

* When an epidural is given late in labor or a lot of anesthetic is used, it may be hard to bear down and push your baby through the birth ca.n.a.l. If you cannot feel enough when it is time to push, your anesthesiologist can adjust the dosage.

Serious complications are very rare: * If the drug enters a vein, you could get dizzy or, rarely, have a seizure.

* If anesthetic enters your spinal fluid, it can affect your chest muscles and make it hard for you to breathe.

As long as your a.n.a.lgesia or anesthesia is given by a trained and experienced anesthesiologist, there's little chance you'll run into trouble. If you are thinking regional block may be the choice for you, bring up any concerns or questions you have with your doctor.

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Chapter 64.Is It Labor?

Chapter Contents.Section 64.1-True Labor and False Labor ............................... 510 Section 64.2-When Does the Bag of Waters Break? ............... 512 509.

Pregnancy and Birth Sourcebook, Third Edition Section 64.1 True Labor and False Labor "True Labor or False Labor," 2004 University of Pittsburgh Medical Center (www.upmc.com). Reprinted with permission. Reviewed by David A. Cooke, MD, FACP, April 12, 2009. Dr. Cooke is not affiliated with the University of Pittsburgh Medical Center.

"How will I know when it is real labor?" This is a question you may have as you near the end of your pregnancy.

Many women have periods of "false" labor late in their pregnancy.

During false labor, you have contractions that seem to come and go.

False labor pains are called "Braxton Hicks" contractions. These contractions help soften and thin your cervix. They tend to happen more often as you get closer to your due date (two to four weeks before birth).

Sometimes it is hard to tell the difference between false labor and true labor. Don't be upset or embarra.s.sed if you think labor is beginning when it is actually a false alarm.

Differences between False Labor and True Labor There are several ways to tell the difference between true and false labor.

Timing of Contractions * False labor: Contractions are often irregular. They don't get closer together over time.

* True labor: Contractions come regularly and get closer together.

Each contraction lasts about 30 to 60 seconds.

Strength of Contractions * False labor: Contractions are often weak and do not get stronger.

* True labor: Contractions get stronger as time goes on.

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Change with Movement * False labor: Contractions may stop or slow down when you walk, lie down, or change positions.

* True labor: Contractions continue no matter what you do.

Pain with Contractions * False labor: Discomfort is usually felt in the front, like menstrual cramps.

* True labor: Discomfort or pressure starts in the back and moves to the front.

If Your Water Breaks Sometimes labor begins when the bag of waters, or membranes, breaks. This may happen with your early contractions. Or your water may not break until later into your labor. If your water breaks, you may notice a near constant trickle of fluid from the v.a.g.i.n.a or a sudden gush of fluid.

If you think your bag of waters is leaking or broken, call your doctor right away.

Other Physical Changes You also may have physical changes that occur as your body gets ready for labor. It is normal to have a slight increase of thin, white discharge at the end of pregnancy. Activities like coughing, sneezing, or laughing may cause leaking of urine.

You also may notice a change in appet.i.te, nausea, diarrhea, or constipation. The loss of your mucus plug often precedes labor by a few days. Mucus may be present 2 to 14 days before true labor begins.

Everyone experiences labor in a different way. Call your doctor if you think you are in labor.

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Pregnancy and Birth Sourcebook, Third Edition Section 64.2 When Does the Bag of Waters Break?

"When Does the Bag of Waters Break?" Journal of Midwifery and Women's Journal of Midwifery and Women's Health, Health, September/October 2004. 2004 American College of Nurse-Midwives (www.midwife.org). Reprinted with permission. Reviewed by David A. Cooke, MD, FACP, April 12, 2009. Dr. Cooke is not affiliated with the American College of Nurse-Midwives. September/October 2004. 2004 American College of Nurse-Midwives (www.midwife.org). Reprinted with permission. Reviewed by David A. Cooke, MD, FACP, April 12, 2009. Dr. Cooke is not affiliated with the American College of Nurse-Midwives.

What is my bag of waters?

The bag of waters-or amniotic sac-is a bag or membrane filled with fluid that surrounds your baby in your uterus during pregnancy.

The bag of waters is very important to your baby's health. The fluid protects your baby and gives your baby room to move around. The bag itself protects your baby from infections that may get into your v.a.g.i.n.a.

When does the bag of waters usually break?

Usually the bag of waters breaks just before you go into labor or during the early part of labor. It happens most often when you are in bed sleeping. You may wake up and think you have wet the bed. Sometimes women feel or even hear a small "pop" when the bag breaks.

Sometimes there is a gush of fluid from the v.a.g.i.n.a that makes your underwear wet; or maybe just a trickle that makes you feel damp.

Sometimes the bag does not break until the baby is being born. In about one in every 10 women, the bag of waters breaks several hours before labor starts. Although rare, the bag of waters can break days before labor starts.

Is it a problem if the bag breaks and the labor does not start right away?

If your bag of waters breaks more than three weeks before your due date, your health care provider may try to stop labor if the baby would be too premature. Because the bag of waters protects against infection, you will be checked to make sure there is no infection in your uterus.

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If your bag of waters breaks within three weeks of your due date, your health care provider will recommend either waiting to let your labor start on its own or inducing your labor right away. You can discuss the pros and cons of each of these options with your health care provider. If you have a bacteria, such as Group B strep [streptococcus] in your v.a.g.i.n.a, your health care provider may want to give you antibiotics or get your labor started (induction). The longer the bag of waters is broken before birth, the more chance there is that infection will get to the baby.

What should I do if my bag does break?

Information at the end of this text gives instructions on what to do if your bag of waters breaks. If you think your bag of waters has broken, your health care provider might check in your v.a.g.i.n.a with a sterile speculum to find out for sure. Except for that one examination, it is very important that nothing is put in your v.a.g.i.n.a.

Every time you have a v.a.g.i.n.al examination after the bag of waters is broken, your risk of getting an infection gets higher. You can help protect yourself and your baby by asking your care providers to only do v.a.g.i.n.al examinations when absolutely necessary.

What should I do if I feel wet but am not sure the bag of waters has broken?

Your health care provider can do a simple test using a sterile speculum to see inside your v.a.g.i.n.a. A sample of the fluid in the v.a.g.i.n.a will be collected and placed on special paper that turns very dark blue if it touches amniotic fluid.

What if your bag of waters breaks, and you are not in la- bor yet?

Labor contractions can start any time from right away to many hours or a few days after your water breaks. If you think your bag of waters has broken, call your health care provider.

Call your health care provider right away if: * your due date is more than three weeks away from today; * the water is green, or yellow, or brown, or has a bad smell; * you have a history of genital herpes, whether or not you have any herpes sores right now; 513.

Pregnancy and Birth Sourcebook, Third Edition * you have a history of Group B strep infection ("GBS positive"); * you don't know if you have GBS or not; * your baby is not in the head-down position, or you've been told it is very high in your pelvis; * you have had a very quick labor in the past, or feel rectal pressure now; * you are worried or discouraged.

Call your health care provider within a few hours if: * your due date is within the next three weeks and; * you are not in labor and; * the fluid is clear, pink, or has white flecks in it and; * your baby is in the head-down position.

Some health care providers will want you to come in to the office to confirm that the bag of waters has broken and listen to the baby's heartbeat as soon as you notice that the bag of waters has broken.

Others will suggest you stay home for several hours to wait for labor to start.

What do I do until labor starts?

Most women will go into labor within 48 hours. If you are waiting for labor to start and your bag of waters has broken: * put on a clean pad; * do not put anything in your v.a.g.i.n.a; * drink plenty of liquids-a cup of water or juice each hour you are awake; * get some rest; * take a shower or bath; * if there is any change in your baby's movements, call your health care provider right away; * check your temperature with a thermometer every four hours- call right away if your temperature goes above 99.6.

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Chapter 65.Inducing Labor It's common for many women, especially first-time mothers, to watch their baby's due date come and go without so much as a contraction. The farther away from the expected delivery date (called the EDD) you get, the more anxious you may become. You may start to feel like a ticking time bomb. You may wonder-is this baby ever going to come?

Late pregnancy can be challenging-you may feel large all over, your feet and back may hurt, you might not have the energy to do much of anything, and you're beyond ready to meet the little one you've nurtured all this time. Which is why waiting a little longer than you'd expected can be particularly hard.

Still, being past your due date doesn't guarantee that your doctor (or other health care provider) will do anything to induce (or artificially start) labor-at least not right away.

What is it?

Labor induction is what doctors use to try to help labor along using medications or other medical techniques. Years ago, some doctors routinely induced labor. But now it's not usually done unless there's a true "Inducing Labor," July 2006, reprinted with permission from www.kidshealth .org. Copyright 2006 The Nemours Foundation. This information was provided by KidsHealth, one of the largest resources online for medically reviewed health information written for parents, kids, and teens. For more articles like this one, visit www.KidsHealth.org, or www.TeensHealth.org.

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Pregnancy and Birth Sourcebook, Third Edition medical need for it. Labor is typically allowed to take its natural course, with less medical intervention, in most birthing settings today.

Why is it done?

Your doctor may suggest an induction if: * your water broke; * your baby still hasn't arrived by 2 weeks after the due date (when you're considered post-term-more than 42 weeks into your pregnancy); * you have an infection in the uterus called chorioamnionitis; * you're having a pregnancy with certain risks (i.e., if you have gestational diabetes or high blood pressure, or your baby has growth problems).

Some doctors will perform "elective inductions"-in other words, they will induce labor if the mother wants it for nonmedical reasons.

However, this isn't always the best option because inductions do come with risks.

Doctors try to avoid inducing labor early because the due date may be wrong and/or the woman's cervix may not be ready yet.

How is it done?

Some methods of induction are less invasive and carry fewer risks than others. Ways that doctors may try to induce labor by getting contractions started include: * Stripping the membranes: Stripping the membranes: The doctor puts on a glove and inserts a finger into your v.a.g.i.n.a and through your cervix (the opening that connects the v.a.g.i.n.a to the uterus). He or she moves the finger back and forth to separate the thin membrane connecting the amniotic sac (which houses the baby and amniotic fluid) to the wall of your uterus. When the membranes are stripped, the body releases hormones called prostaglandins, which help prepare the cervix for delivery and may bring on contractions. This method works for some women, but not all. The doctor puts on a glove and inserts a finger into your v.a.g.i.n.a and through your cervix (the opening that connects the v.a.g.i.n.a to the uterus). He or she moves the finger back and forth to separate the thin membrane connecting the amniotic sac (which houses the baby and amniotic fluid) to the wall of your uterus. When the membranes are stripped, the body releases hormones called prostaglandins, which help prepare the cervix for delivery and may bring on contractions. This method works for some women, but not all.

* Breaking your water (also called an amniotomy): Breaking your water (also called an amniotomy): The doctor ruptures the amniotic sac. During a v.a.g.i.n.al exam, he or she uses a little plastic hook to break the membranes. This usually brings on labor in a matter of hours. The doctor ruptures the amniotic sac. During a v.a.g.i.n.al exam, he or she uses a little plastic hook to break the membranes. This usually brings on labor in a matter of hours.

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