However you decide to rearrange your life, it will be easier if you don't have to go it alone. Beside most successful moms is a dad who not only shares equally in household chores but also is a full partner in parenting, in every department from diapering to bathing to cuddling. If dad's not available as much as you'd like (or isn't in the picture at all), then you are going to need to consider other sources of assistance: baby's grandparents or other relatives, child care or household help, baby-sitting co-ops, or child-care centers.

A Birth Plan "A friend who recently delivered said she worked out a birth plan with her doctor before delivery. Should I?"

Decisions, decisions. Childbirth involves more decisions than ever before, and expectant women and their partners are involved in making more of those decisions than ever before. But how can you and your practitioner keep track of all those decisions-from how you'll manage the pain to who'll catch your emerging baby? Enter the birth plan.

Some Cookies with That Birth Plan?

Once you've passed your approved birth plan on to your practitioner, it should become part of your chart and find its way to your delivery. But just in case it doesn't make it in time, you might want to print up several copies of the plan to bring along to the hospital or birthing center, just so there's no confusion about your preferences. Your coach or doula can make sure that each new shift (with any luck, you won't have to labor through too many of these) has a copy for reference. Some expectant parents have found that placing the birth plan in a small basket of goodies makes it even more welcome.

A birth plan is just that-a plan (or more aptly, a wish list). In it, pregnant women and their partners can offer up their best-case birthing scenario: how they'd ideally like labor and delivery to play out if all goes according to "plan." Besides listing those parental preferences, the typical birth plan factors in what's practical, what's feasible, and what the practitioner and hospital or birthing center find acceptable (not everything on a birth plan may fly medically, obstetrically, or policywise). It isn't a contract but a written understanding between a patient and her practitioner and/or hospital or birthing center. Not only can a good birth plan deliver a better birth experience, it can head off unrealistic expectations, minimize disappointment, and eliminate major conflict and miscommunication between a birthing woman and her birth attendants. Some practitioners routinely ask an expectant couple to fill out a birth plan; others are happy to oblige if one is requested. A birth plan is also a springboard for dialogue between patient and practitioner.

Some birth plans cover just the basics; others are extremely detailed (down to the birthing room music and lighting). And because every expectant woman is different-not only in what she'd like out of the birth experience but what she can likely expect, given her particular medical and obstetrical background-a birth plan should be individualized (so don't fill yours out based on your friend's). Some of the issues you may want to tackle in your birth plan, should you decide to fill one out, are listed below. You can use it as a general guideline, then flesh it out as needed (you can refer to the appropriate pages before making your decisions). For a more detailed list and sample birth plan, see the What to Expect Pregnancy Journal and Organizer. What to Expect Pregnancy Journal and Organizer.

Your Main Squeeze Your baby might not be ready for delivery yet, but it isn't too soon to start getting your body-and your pelvic floor muscles, in particular-geared up for the big day. Never thought much about your pelvic muscles-or maybe never even realized you had any? It's time to start paying attention. They're the muscles that support your uterus, bladder, and bowels, and they're designed to stretch so your baby can come out. They're also the muscles that keep your urine from leaking when you cough or laugh (a skill set you're only likely to appreciate when it's gone, as can happen with postpartum incontinence). These multitalented muscles can also make for a much more satisfying sexual experience.Luckily, there are exercises that can easily work these miracle muscles, whipping them into shape with minimal time and minimal effort (no workout clothes necessary, no visit to a gym required, and you don't even have to break a sweat). Just 5 minutes of these amazing exercises, called Kegels, three times a day and you'll tone your way to a long list of both short- and long-term benefits. Toned pelvic floor muscles can ease a host of pregnancy and postpartum symptoms from hemorrhoids to urinary and fecal incontinence. They can help you prevent an episiotomy or even a tear during delivery. Plus doing your Kegels faithfully during pregnancy will help your vagina snap back more gracefully after your baby's grand exit.Ready to Kegel? Here's how: Tense the muscles around your vagina and anus and hold (as you would if you were trying to stop the flow of urine), working up to 10 seconds. Slowly release and repeat; shoot for three sets of 20 daily. Keep in mind when you Kegel that all your focus should be on those pelvic muscles-and not any others. If you feel your stomach tensing or your thighs or buttocks contracting, your pelvics aren't getting their full workout. Make this exercise your main squeeze during pregnancy (doing them each time you stop at a traffic light, while you check your e-mail, in line at the ATM, while waiting for the cashier to ring up your groceries, or while working at your desk), and you'll reap the benefits of stronger pelvic floor muscles. Try doing them during sex, too-both you and your partner will feel the difference (now that's a workout you can get excited about!).

[image]How far into your labor you would like to remain at home and at what point you would prefer to go to the hospital or birthing center[image] Eating and/or drinking during active labor ( Eating and/or drinking during active labor (page 369)[image] Being out of bed (walking around or sitting up) during labor Being out of bed (walking around or sitting up) during labor[image] Personalizing the atmosphere with music, lighting, items from home Personalizing the atmosphere with music, lighting, items from home[image] The use of a still camera or video camera The use of a still camera or video camera[image] The use of a mirror so you can see the birth The use of a mirror so you can see the birth[image] The use of an IV (intravenous fluid administration; The use of an IV (intravenous fluid administration; page 372 page 372)[image] The use of pain medication and the type of pain medication ( The use of pain medication and the type of pain medication (page 301)[image] External fetal monitoring (continuous or intermittent); internal fetal monitoring ( External fetal monitoring (continuous or intermittent); internal fetal monitoring (page 372)[image] The use of oxytocin to induce or augment contractions ( The use of oxytocin to induce or augment contractions (page 368)[image] Delivery positions ( Delivery positions (page 376)[image] Use of warm compresses and perineal massage ( Use of warm compresses and perineal massage (pages 352 and and 375 375)[image] Episiotomy ( Episiotomy (page 374)[image] Vacuum extractor or forceps use ( Vacuum extractor or forceps use (page 375)[image] Cesarean delivery ( Cesarean delivery (page 398)[image] The presence of significant others (besides your spouse) during labor and/or at delivery The presence of significant others (besides your spouse) during labor and/or at delivery[image] The presence of older children at delivery or immediately after The presence of older children at delivery or immediately after[image] Suctioning of the newborn; suctioning by the father Suctioning of the newborn; suctioning by the father[image] Holding the baby immediately after birth; breastfeeding immediately Holding the baby immediately after birth; breastfeeding immediately[image] Postponing cutting the cord, weighing the baby, and/or administering eye drops until after you and your baby greet each other Postponing cutting the cord, weighing the baby, and/or administering eye drops until after you and your baby greet each other[image] Having the father help with the delivery and/or cut the cord Having the father help with the delivery and/or cut the cord[image] Cord blood banking ( Cord blood banking (page 330) You may also want to include some postpartum items on your birth plan, such as: [image] Your presence at the weighing of the baby, the pediatric exam, and baby's first bath Your presence at the weighing of the baby, the pediatric exam, and baby's first bath[image] Baby feeding in the hospital (whether it will be controlled by the nursery's schedule or your baby's hunger; whether supplementary bottles and pacifiers can be avoided if you're breastfeeding) Baby feeding in the hospital (whether it will be controlled by the nursery's schedule or your baby's hunger; whether supplementary bottles and pacifiers can be avoided if you're breastfeeding)[image] Circumcision (see Circumcision (see What to Expect the First Year What to Expect the First Year)[image] Rooming-in ( Rooming-in (page 431)[image] Other children visiting with you and/or with the new baby Other children visiting with you and/or with the new baby[image] Postpartum medication or treatments for you or your baby Postpartum medication or treatments for you or your baby[image] The length of the hospital stay, barring complications ( The length of the hospital stay, barring complications (page 430) Of course, the most important feature of a good birth plan is flexibility. Since childbirth-like most forces of nature-is unpredictable, the best-laid plans don't always go, well, according to plan. Though chances are very good that your plan can be carried out just the way you drew it up, there's always the chance that it won't. There is no way to predict precisely how labor and delivery will progress (or not progress) until those contractions start coming, so a birth plan you design in advance may not end up being obstetrically or medically wise, and it may have to be adjusted at the last minute. After all, there's no greater priority than your well-being and your baby's-and if your birth plan doesn't end up being consistent with that priority, it'll have to take a backseat. A change of mind (yours) can also prompt a change of plan (you were dead set against having an epidural, but somewhere around 4 cm, you become dead set on having one).

Don't Hold It In Making a habit of not urinating when you feel the need increases the risk that your inflamed bladder may irritate the uterus and set off contractions. Not going when you've got the urge could also lead to a UTI, another cause of preterm contractions. So don't hold it in. When you gotta go, go ... promptly.

Lifesaving Screenings for Newborns Most babies are born healthy and stay that way. But a very small percentage of infants are born apparently healthy and then suddenly sicken. Luckily, there are ways to screen for such metabolic disorders. Most babies born in the U.S. live in states that require screening for at least 21 life-threatening disorders-and there is an effort under way to push all 50 states to screen for 29 universally recommended diseases. These include phenylketonuria (PKU), congenital hypothyroidism, congenital adrenal hyperplasia, biotinidase deficiency, maple syrup urine disease, galactosemia, homocystinuria, and sickle cell anemia.If your state doesn't offer at least the core group of these tests, you can request that a private lab arrange testing. The lab will use blood that's collected in the hospital during your baby's routine heel stick (when drops of blood are drawn from baby's heel after a quick stick with a needle).In the very unlikely event your baby screens positive for any of the disorders, your baby's pediatrician and a genetic specialist can verify the results and begin treatment, if necessary (there is a high rate of false positives, so any positive result should be followed up by retesting). Early diagnosis and intervention can make a tremendous difference in the prognosis. For more information on private lab screening and newborn screening in general, contact Baylor University Medical Center: (800) 4BAYLOR (422-9567); baylorhealth.com/medicalspecialties/ metabolic/newbornscreening.htm; or Pediatrix Screening: (954) 384-0175; pediatrixscreening.com.To find out if your state screens for the 29 conditions that the March of Dimes recommends, go to genes-r-us.uthscsa.edu/.

Bottom line: Birth plans, though by no means necessary (you can definitely decide to go with the flow when it comes to childbirth, and you'll give birth with or without one), are a great option, one that more and more expectant parents are taking advantage of. To find out more, and to figure out whether a birth plan is right for you, talk it over with your practitioner at your next visit.

Doulas: Best Medicine for Labor?

Think three's a crowd? For many couples, not when it comes to labor and delivery. More and more are opting to share their birth experience with a doula, a woman trained as a labor companion. And for good reason. Studies have shown that women supported by doulas are much less likely to require cesarean deliveries, induction, and pain relief. Births attended by doulas may also be shorter, with a lower rate of complications.Doula is a term that comes from ancient Greece, where it was used to describe the most important female servant in the household, the one who probably helped mom out the most during childbirth. What exactly can a doula do for you and your birth experience? That depends on the doula you choose, at what point in your pregnancy you hire her, and what your preferences are. Some doulas become involved well before that first contraction strikes, helping with the design of a birth plan and easing prelabor jitters. Many, on request, come to the house to help a couple through early labor. Once at the hospital or birthing center, the doula takes on a variety of responsibilities, again depending on your needs and wishes. Typically, her primary role is as a continuous source of comfort, encouragement, and support (both emotional and physical) during labor. She'll serve as a soothing voice of experience (especially valuable if you're first-timers), help with relaxation techniques and breathing exercises, offer advice on labor positions, and do her share of massage, hand holding, pillow plumping, and bed adjusting. A doula can also act as a mediator and an advocate, ready to speak for you as needed, to translate medical terms and explain procedures, and to generally run interference with hospital personnel. She won't take the place of your coach (and a good doula won't make him feel like she's taking his place, either) or the nurse on duty; instead, she will augment their support and services (especially important if the nurse assigned to you has several other patients in labor at the same time or if labor is long and nurses come and go as shifts change). She will also likely be the only person (besides the coach) who will stay by your side throughout labor and delivery-a friendly and familiar face from start to finish. And many doulas don't stop there. They can also offer support and advice postpartum on everything from breastfeeding to baby care.Though an expectant father may fear that hiring a doula will relegate him to third-wheel status, this isn't the case. A good doula is also there to help your coach relax so he can help you relax. She'll be there to answer questions he might not feel comfortable broaching with a doctor or nurse. She'll be there to provide an extra set of hands when you need your legs and back massaged at the same time, or when you need both a refill on ice chips and help breathing through a contraction. She'll be an obliging and cooperative member of your labor team-ready to pitch in, but not to push dad aside and take over.How do you locate a doula? Many birthing centers and hospitals keep lists of doulas, and so do some practitioners. Ask friends who've recently used a doula for recommendations, or check online for local doulas. Once you've tracked down a candidate, arrange a consultation before you hire her to make sure both of you are comfortable with her. Ask her about her experience, her training, what she will do and what she won't do, what her philosophies are about childbirth (if you're planning on asking for an epidural, for instance, you won't want to hire a doula who discourages the use of pain relief), whether she will be on call at all times and who covers for her if she isn't, whether she provides pregnancy and/or postpartum services, and what her fees are (some doulas command hefty fees, especially those in big cities). For more information or to locate a doula in your area, contact Doulas of North America: (888) 788-DONA (788-3662); dona.com.An alternative to a doula, which could also be beneficial, is a female friend or relative who has gone through pregnancy and delivery herself and with whom you feel totally comfortable. The plus: Her services will be free. The drawback: She probably won't be quite as knowledgeable. One way to remedy that is having a "lay doula," a female friend who goes through four hours of training in doula techniques (ask if your hospital has such a training course). Researchers have found that a "lay doula" can provide the same benefits as a professional one.

Glucose Screening Test Don't feel too picked on. Almost all practitioners screen for gestational diabetes in almost all patients at about 24 to 28 weeks (though those at higher risk for gestational diabetes, including older or obese mothers or those with a family history of diabetes, are screened earlier in their pregnancies and more often). So chances are the test your practitioner ordered is just routine.

"My practitioner says I need to take a glucose screening test to check for gestational diabetes. Why would I need it, and what does the test involve?"

And it's simple, too, especially if you have a sweet tooth. You'll be asked to drink a very sweet glucose drink, which usually tastes like flat orange soda, one hour before having some blood drawn; you don't have to be fasting when you do this. Most women chugalug the stuff with no problem and no side effects; a few, especially those who don't have a taste for sweet liquids, feel a little queasy afterward.

If the blood work comes back with elevated numbers, which suggests the possibility that you might not be producing enough insulin to process the extra glucose in your system, the next level of test-the glucose tolerance test-is ordered. This fasting three-hour test, which involves a higher-concentration glucose drink, is used to diagnose gestational diabetes.

Gestational diabetes occurs in about 4 to 7 percent of expectant mothers, which makes it one of the most common pregnancy complications. Fortunately, it's also one of the most easily managed. When blood sugar is closely controlled through diet, exercise, and, if necessary, medication, women with gestational diabetes are likely to have perfectly normal pregnancies and healthy babies. See page 546 page 546 for more. for more.

A Low-Birthweight Baby "I've been reading a lot about the high incidence of low-birthweight babies. Is there anything I can do to be sure I won't have one?"

Some cases of low birthweight are preventable, so you can do a lot-and, inasmuch as you're reading this book, chances are good you already are. Nationally, 8 of every 100 newborns are categorized as low birthweight (under 5 pounds 8 ounces, or 2,500 grams), and slightly more than 1 in 100 babies as very low birthweight (3 pounds 5 ounces, or 1,500 grams, or less). But that rate is much lower among women who are conscientious about both medical care and self-care (and are lucky enough to be able to afford the first and informed enough to do a good job on the second). Most of the common causes of low birthweight-use of tobacco, alcohol, or drugs (particularly cocaine), poor nutrition, extreme emotional stress (but not normal stress levels), and inadequate prenatal care, for example-are preventable. Many others, such as chronic maternal illnesses, can be controlled by a good working partnership between the mother and her practitioner. A major cause-premature labor-can sometimes be prevented.

Signs of Preterm Labor Though the chances of your baby arriving early are pretty low, it's a good idea for every expectant mom to be familiar with the signs of premature labor, since early detection can have a tremendous impact on outcome. Think of the following as information you'll probably never use but should know, just to be on the safe side. Read this list over, and if you experience any of these symptoms before 37 weeks, call your practitioner immediately:[image] Persistent cramps that are menstrual-like, with or without diarrhea, nausea, or indigestion Persistent cramps that are menstrual-like, with or without diarrhea, nausea, or indigestion[image] Regular painful contractions coming every 10 minutes (or sooner) that do not subside when you change positions (not to be confused with the Braxton Hicks contractions you might be already feeling, which don't indicate early labor; see Regular painful contractions coming every 10 minutes (or sooner) that do not subside when you change positions (not to be confused with the Braxton Hicks contractions you might be already feeling, which don't indicate early labor; see page 311 page 311)[image] Constant lower back pain or pressure or a change in the nature of lower backache Constant lower back pain or pressure or a change in the nature of lower backache[image] A change in your vaginal discharge, particularly if it is watery or tinged or streaked pinkish or brownish with blood A change in your vaginal discharge, particularly if it is watery or tinged or streaked pinkish or brownish with blood[image] An achiness or feeling of pressure in the pelvic floor, the thighs, or the groin An achiness or feeling of pressure in the pelvic floor, the thighs, or the groin[image] Leaking from your vagina (a steady trickle or a gush) Leaking from your vagina (a steady trickle or a gush)Keep in mind that you can have some or all of these symptoms and not be in labor (most pregnant women experience pelvic pressure or lower back pain at some point). In fact, the majority of women who have symptoms of preterm labor do not deliver early. But only your practitioner can tell for sure, so pick up the phone and call. After all, it's always best to play it safe.For information on preterm labor risk factors and prevention, see pages 44 pages 4447. For information on the management of preterm labor, see page 557 page 557.

Of course, sometimes a baby is small at birth for reasons that no one can control: the mother's own low weight when she was born, for example, or an inadequate placenta, or a genetic disorder. A very short interval (less than nine months) between pregnancies may also be a factor. But even in these cases, excellent diet and prenatal care can often compensate and tip the scales in baby's favor. And when a baby does turn out to be small, the top-notch medical care currently available gives even the very smallest an increasingly good chance of surviving and growing up healthy.

If you think you have real reason to worry about having a low-birthweight baby, share your concern with your practitioner. An exam and/or an ultrasound will probably reassure you that your fetus is growing at a normal pace. If it does turn out that your baby is on the very small side, steps can be taken to uncover the cause and, if possible, correct it. See page 550 page 550 for more information. for more information.

Easing Labor Pain Let's face it. Those 15 or so hours it takes to birth a baby aren't called labor because it's a walk in the park. Labor (and delivery) is hard work-hard work that can hurt, big time. And if you actually consider what's going on down there, it's really no wonder that labor hurts. During childbirth, your uterus contracts over and over again to squeeze a relatively big baby through one relatively tight space (your cervix) and out through an even tighter one (your vagina, the same opening you once thought was too small for a tampon). Like they say, it's pain with a purpose-a really cute and cuddly purpose-yet it's pain nonetheless.

But while there may be no getting around the pain of labor altogether (unless you're scheduled for a cesarean delivery, in which case you'll be skipping labor and labor pain), there are plenty of ways to get through it. As a laboring mom, you can select from a wide menu of pain-relief options, both the medicinal kind and the nonmedicinal variety (and you can even opt for a combo from both columns). You can choose to go unmedicated throughout your entire labor or just through part of labor (like those easier first centimeters). You can turn to alternative medicine and nondrug approaches to manage the pain (acupuncture, hypnosis, or hydrotherapy, for instance). Or you can birth your baby with a little help-or a lot of help-from an analgesic, such as the very popular epidural (which leaves you with little or no pain during labor but allows you to remain awake during the entire process).

Which option is for you? To figure that out, look into them all. Read up on childbirth pain management (the section that follows covers the gamut). Talk to your practitioner. Get insights from friends who have recently labored. And then do some thinking. Remember that the right option for you might not be one option but a combination of several (reflexology with an epidural chaser, or a variety of relaxation techniques topped off with a round of acupuncture). Remember, too, the value of staying flexible-and not just so you can stretch yourself into some of those pushing positions you learned in childbirth class. After all, the option or options you settle on now may not sit well later, and may need to be adjusted midlabor (you were planning on an epidural but found you could handle the pain-or vice versa). Most of all, remember that (barring any obstetrical situation that would dictate how you labor and deliver), it's completely your choice to make-your birth, your way.

Managing Your Pain with Medications When it comes to pain relief during labor, there's a wide variety of medications to choose from, including anesthetics (substances that produce loss of sensation or put you to sleep), analgesics (pain relievers), and ataraxics (tranquilizers). In most circumstances, it'll be up to you to select the pain medication you want to make your labor and delivery as comfortable as possible, though your choice may be limited depending on the stage of labor, whether it's an emergency situation, or your past health history or your present condition (and that of your baby) precludes a particular drug, and the anesthesiologist's preference and expertise.

Something else to keep in mind as you begin to explore your options: How effective a drug is in relieving pain will depend on how it affects you (different drugs affect different people differently), the dosage, and other factors. There's always a remote chance that a drug won't provide you with the relief you're looking for, or that it might not give you any at all. Most of the time, though, pain medications work exactly the way they are supposed to-offering up just what you (and your practitioner) ordered.

Here are the most commonly used labor and delivery pain medications: Epidural. The epidural is the pain relief of choice for two thirds of all laboring women delivering at hospitals. The major reasons for the epidural's current surge in popularity are its relative safety (only a small amount of medication is needed to achieve the desired effect), its ease of administration, and its patient-friendly results (local pain relief in the lower part of the body that allows you to be awake during the birth and alert enough to greet your baby immediately after it). It's also considered safer for your baby than other anesthetics because the epidural is injected directly into the spine (technically, into the epidural space, which is located between the ligament that sheathes the vertebrae and the membrane that covers the spinal cord), which means the drug barely reaches the bloodstream (unlike other anesthetics). And even better news: An epidural can be given to you as soon as you ask for one-no need to wait until you're dilated a certain amount (3 or 4 cm, for instance). Studies show that even an early epidural doesn't increase the chances of a C-section as was once believed, nor does it slow down labor significantly. And even if labor does slow down a bit with an epidural, your doctor can give you Pitocin (a synthetic version of oxytocin, the hormone that triggers contractions naturally) to help get your labor back up to speed again. The epidural is the pain relief of choice for two thirds of all laboring women delivering at hospitals. The major reasons for the epidural's current surge in popularity are its relative safety (only a small amount of medication is needed to achieve the desired effect), its ease of administration, and its patient-friendly results (local pain relief in the lower part of the body that allows you to be awake during the birth and alert enough to greet your baby immediately after it). It's also considered safer for your baby than other anesthetics because the epidural is injected directly into the spine (technically, into the epidural space, which is located between the ligament that sheathes the vertebrae and the membrane that covers the spinal cord), which means the drug barely reaches the bloodstream (unlike other anesthetics). And even better news: An epidural can be given to you as soon as you ask for one-no need to wait until you're dilated a certain amount (3 or 4 cm, for instance). Studies show that even an early epidural doesn't increase the chances of a C-section as was once believed, nor does it slow down labor significantly. And even if labor does slow down a bit with an epidural, your doctor can give you Pitocin (a synthetic version of oxytocin, the hormone that triggers contractions naturally) to help get your labor back up to speed again.

Here's what you can expect if you're having an epidural: [image] Before the epidural is administered, an IV of fluids is started (this is done to prevent a drop in blood pressure, a side effect some women have with an epidural; fluids will keep your blood pressure from going too low). Before the epidural is administered, an IV of fluids is started (this is done to prevent a drop in blood pressure, a side effect some women have with an epidural; fluids will keep your blood pressure from going too low).[image] In some hospitals (policies vary), a catheter (tube) is inserted into the bladder just before or just after administration of the epidural and stays in place to drain urine while the epidural is in effect (since the medication may suppress the urge to urinate). In other hospitals, the bladder is just drained intermittently with a catheter as needed. In some hospitals (policies vary), a catheter (tube) is inserted into the bladder just before or just after administration of the epidural and stays in place to drain urine while the epidural is in effect (since the medication may suppress the urge to urinate). In other hospitals, the bladder is just drained intermittently with a catheter as needed.[image] Your lower and midback are wiped with an antiseptic solution and a small area of the back is numbed with a local anesthetic. A larger needle is placed through the numbed area into the epidural space of the spine, usually while you're lying on your side or sitting up and leaning over a table or being supported by your spouse, coach, or nurse. Some women feel a little pressure as the needle is inserted. Others feel a little tingling or a momentary shooting pain as the needle finds the correct spot. If you're lucky (and many women are), you might not feel a thing while the epidural is being administered. Besides, compared to the pain of contractions, any discomfort from a needle poke is likely to be pretty minimal. Your lower and midback are wiped with an antiseptic solution and a small area of the back is numbed with a local anesthetic. A larger needle is placed through the numbed area into the epidural space of the spine, usually while you're lying on your side or sitting up and leaning over a table or being supported by your spouse, coach, or nurse. Some women feel a little pressure as the needle is inserted. Others feel a little tingling or a momentary shooting pain as the needle finds the correct spot. If you're lucky (and many women are), you might not feel a thing while the epidural is being administered. Besides, compared to the pain of contractions, any discomfort from a needle poke is likely to be pretty minimal.[image] The needle is removed, leaving a fine, flexible catheter tube in place. The tube is taped to your back so you can move from side to side. Three to five minutes following the initial dose, the nerves of the uterus begin to numb. Usually after 10 minutes, you'll begin to feel the full effect (hopefully, sweet relief). The medication numbs the nerves in the entire lower part of the body, making it hard to feel any contractions at all (and that's the point). The needle is removed, leaving a fine, flexible catheter tube in place. The tube is taped to your back so you can move from side to side. Three to five minutes following the initial dose, the nerves of the uterus begin to numb. Usually after 10 minutes, you'll begin to feel the full effect (hopefully, sweet relief). The medication numbs the nerves in the entire lower part of the body, making it hard to feel any contractions at all (and that's the point).[image] Your blood pressure will be checked frequently to make sure it's not dropping too low. IV fluids and lying on your side will help counteract a drop in blood pressure. Your blood pressure will be checked frequently to make sure it's not dropping too low. IV fluids and lying on your side will help counteract a drop in blood pressure.[image] Because an epidural is sometimes associated with slowing of the fetal heartbeat, continuous fetal monitoring is usually required as well. Though such fetal monitoring limits your movements somewhat, it allows your practitioner to monitor the baby's heartbeat and allows you to "see" the frequency and intensity of your contractions (because, ideally, you won't be feeling them). Because an epidural is sometimes associated with slowing of the fetal heartbeat, continuous fetal monitoring is usually required as well. Though such fetal monitoring limits your movements somewhat, it allows your practitioner to monitor the baby's heartbeat and allows you to "see" the frequency and intensity of your contractions (because, ideally, you won't be feeling them).

Happily, there are few side effects with an epidural, though some women might experience numbness on one side of the body only (as opposed to complete pain relief). Epidurals also might not offer complete pain control if you're experiencing back labor (when the fetus is in a posterior position, with its head pressing against your back).

Combined spinal epidural (aka "walking epidural"). The combined spinal epidural delivers the same amount of pain relief as a traditional epidural does, but it uses a smaller amount of medication to reach that goal. Not all anesthesiologists or hospitals offer this type of epidural (ask your practitioner if it'll be available to you). The anesthesiologist will start you off with a shot of analgesic directly into the spinal fluid to help relieve some pain, but because the medication is delivered only in the spinal fluid, you'll still feel and be able to use the muscles in your legs (which is why it's called a walking epidural). When you feel you need more pain relief, more medication is placed into the epidural space (through a catheter that was inserted at the same time the spinal medication was administered). Though you'll be able to move your legs, they'll probably feel weak, so it'll be unlikely you'll actually want to walk around. The combined spinal epidural delivers the same amount of pain relief as a traditional epidural does, but it uses a smaller amount of medication to reach that goal. Not all anesthesiologists or hospitals offer this type of epidural (ask your practitioner if it'll be available to you). The anesthesiologist will start you off with a shot of analgesic directly into the spinal fluid to help relieve some pain, but because the medication is delivered only in the spinal fluid, you'll still feel and be able to use the muscles in your legs (which is why it's called a walking epidural). When you feel you need more pain relief, more medication is placed into the epidural space (through a catheter that was inserted at the same time the spinal medication was administered). Though you'll be able to move your legs, they'll probably feel weak, so it'll be unlikely you'll actually want to walk around.

Pushing Without the Pain Does pushing have to be a pain? Not always. In fact, many women find they can push very effectively with an epidural, relying on their coach or a nurse to tell them when a contraction is coming on so they can get busy pushing. But if pain-free pushing isn't getting you (or your baby) anywhere-with the lack of sensation hampering your efforts-the epidural can be stopped so you can feel the contractions. The medication can then be easily restarted after delivery to numb the repair of a tear.

Spinal block (for cesarean delivery) or saddle block (for instrument-assisted vaginal delivery). These regional blocks, which are rarely used these days, are generally administered in a single dose just prior to delivery (in other words, if you didn't have an epidural during labor but want pain relief for the delivery, you'll get the fast-acting spinal block). Like the epidural, these blocks are administered with you sitting up or lying on your side while an anesthetic is injected into the fluid surrounding the spinal cord. The side effects of spinal and saddle blocks are the same as for an epidural (a possible drop in blood pressure). These regional blocks, which are rarely used these days, are generally administered in a single dose just prior to delivery (in other words, if you didn't have an epidural during labor but want pain relief for the delivery, you'll get the fast-acting spinal block). Like the epidural, these blocks are administered with you sitting up or lying on your side while an anesthetic is injected into the fluid surrounding the spinal cord. The side effects of spinal and saddle blocks are the same as for an epidural (a possible drop in blood pressure).

Pudendal block. Occasionally used to relieve early second-stage pain, a pudendal block is usually reserved for the vaginal delivery itself. Administered through a needle inserted into the vaginal area, the medication reduces pain in the region but not uterine discomfort. It's useful when forceps or vacuum extraction is used, and its effect can last through episiotomy (if needed) and repair of an episiotomy or tear. Occasionally used to relieve early second-stage pain, a pudendal block is usually reserved for the vaginal delivery itself. Administered through a needle inserted into the vaginal area, the medication reduces pain in the region but not uterine discomfort. It's useful when forceps or vacuum extraction is used, and its effect can last through episiotomy (if needed) and repair of an episiotomy or tear.

General anesthesia. General anesthesia is rarely used for deliveries these days and only used in specific cases for emergency surgical births. An anesthesiologist in an operating/delivery room injects drugs into your IV that put you to sleep. You'll be awake during the preparations and unconscious for however long it takes to complete the delivery (usually a matter of minutes). When you come to, you may be groggy, disoriented, and restless. You may also have a cough and sore throat (due to the tube that's routinely inserted through the mouth into the throat) and experience nausea and vomiting. General anesthesia is rarely used for deliveries these days and only used in specific cases for emergency surgical births. An anesthesiologist in an operating/delivery room injects drugs into your IV that put you to sleep. You'll be awake during the preparations and unconscious for however long it takes to complete the delivery (usually a matter of minutes). When you come to, you may be groggy, disoriented, and restless. You may also have a cough and sore throat (due to the tube that's routinely inserted through the mouth into the throat) and experience nausea and vomiting.

The major downside to general anesthesia (besides the fact that mom has to miss the birth) is that it sedates the baby along with the mother. The medical team will minimize those sedative effects by administering the anesthesia as close to the actual birth as possible. That way the baby can be delivered before the anesthetic has reached him or her in amounts large enough to have an effect. The doctor might also tilt you to your side or give you oxygen to get more oxygen to the baby, minimizing the drug's temporary effect.

Demerol. Demerol is one of the most frequently used obstetrical analgesics. This shot (sometimes given in the buttocks) or IV-administered drug is used to dull the pain and relax the mother so she is better able to cope with contractions. It can be repeated every two to four hours, as needed. But not all women like the drowsy feeling Demerol imparts, and some find they are actually less able to cope with labor pains while under the effects of Demerol. Demerol is one of the most frequently used obstetrical analgesics. This shot (sometimes given in the buttocks) or IV-administered drug is used to dull the pain and relax the mother so she is better able to cope with contractions. It can be repeated every two to four hours, as needed. But not all women like the drowsy feeling Demerol imparts, and some find they are actually less able to cope with labor pains while under the effects of Demerol.

There may be some side effects (depending on a woman's sensitivity), including nausea, vomiting, and a drop in blood pressure. The effect Demerol will have on the newborn depends on the total dose and how close to delivery it has been administered. If it has been given too close to delivery, the baby may be sleepy and unable to suck; less frequently, respiration may be depressed and supplemental oxygen may be required. Any effects on the newborn are generally short-term and, if necessary, can be treated.

Demerol is not generally administered until labor is well established and false labor has been ruled out, but no later than two to three hours before delivery is expected.

Tranquilizers. These drugs (such as Phenergan and Vistaril) are used to calm and relax an extremely anxious mom-to-be so that she can participate more fully in childbirth. Tranquilizers can also enhance the effectiveness of analgesics such as Demerol. Like analgesics, tranquilizers are usually administered once labor is well established, and well before delivery. But they are occasionally used in early labor if a mother's anxiety is slowing down the progress of her labor. Reactions to the effects of tranquilizers vary. Some women welcome the gentle drowsiness; others find it interferes with their control and with their memory of this memorable experience. Dosage definitely makes a difference. A small dose may serve to relieve anxiety without impairing alertness. A larger dose may cause slurring of speech and dozing between contraction peaks, making it difficult to use prepared childbirth techniques. Though the risks to a fetus or newborn from tranquilizers are minimal, most practitioners prefer to stay away from tranquilizers unless they're really necessary. If you think you might be extremely anxious during labor, you may want to try learning about some nondrug relaxation techniques now (such as meditation, massage, hypnosis; see below), so you won't end up needing this kind of medication. These drugs (such as Phenergan and Vistaril) are used to calm and relax an extremely anxious mom-to-be so that she can participate more fully in childbirth. Tranquilizers can also enhance the effectiveness of analgesics such as Demerol. Like analgesics, tranquilizers are usually administered once labor is well established, and well before delivery. But they are occasionally used in early labor if a mother's anxiety is slowing down the progress of her labor. Reactions to the effects of tranquilizers vary. Some women welcome the gentle drowsiness; others find it interferes with their control and with their memory of this memorable experience. Dosage definitely makes a difference. A small dose may serve to relieve anxiety without impairing alertness. A larger dose may cause slurring of speech and dozing between contraction peaks, making it difficult to use prepared childbirth techniques. Though the risks to a fetus or newborn from tranquilizers are minimal, most practitioners prefer to stay away from tranquilizers unless they're really necessary. If you think you might be extremely anxious during labor, you may want to try learning about some nondrug relaxation techniques now (such as meditation, massage, hypnosis; see below), so you won't end up needing this kind of medication.

Managing Your Pain with CAM Not every woman wants traditional pain medication, but most still want their labor to be as comfortable as possible. And that's where complementary and alternative medicine (CAM) therapies can come in. These days, it's not just CAM practitioners who are touting the benefits of these techniques. More and more traditional physicians are hopping on board the CAM bandwagon, too. Many recommend CAM techniques to their patients-either as an alternative to pain medication or as a relaxing supplement to it. Even if you're sure there's an epidural with your name on it waiting at the hospital, you may want to explore the world of CAM, too. (And to explore it well before your due date, since many of the techniques take practice-or even classes-to perfect, and most take plenty of planning.) But remember to seek out CAM practitioners who are licensed and certified, not to mention ones who have plenty of experience with pregnancy, labor, and delivery.

Just Breathe Hoping to skip the meds but can't-or don't want to-CAM? Lamaze (or other kinds of natural childbirth techniques) can be very effective in managing the pain of contractions. See page 279 page 279 for more. for more.

Acupuncture and acupressure. Scientific studies now back up what the Chinese have known for thousands of years: Acupuncture and acupressure are effective forms of pain relief. Researchers have found that acupuncture, through the use of needles inserted in specific locations, triggers the release of several brain chemicals, including endorphins, which block pain signals, relieving labor pain (and maybe even helping boost labor progress). Acupressure works on the same principle as acupuncture, except that instead of poking you with needles, your practitioner will use finger pressure to stimulate the points. Acupressure on the center of the ball of the foot is said to help back labor. If you're planning to use either during labor, let your prenatal practitioner know that your CAM practitioner will be with you through labor. Scientific studies now back up what the Chinese have known for thousands of years: Acupuncture and acupressure are effective forms of pain relief. Researchers have found that acupuncture, through the use of needles inserted in specific locations, triggers the release of several brain chemicals, including endorphins, which block pain signals, relieving labor pain (and maybe even helping boost labor progress). Acupressure works on the same principle as acupuncture, except that instead of poking you with needles, your practitioner will use finger pressure to stimulate the points. Acupressure on the center of the ball of the foot is said to help back labor. If you're planning to use either during labor, let your prenatal practitioner know that your CAM practitioner will be with you through labor.

Reflexology. Reflexologists believe that the internal organs can be accessed through points on the feet. By massaging the feet during childbirth, a reflexologist can relax the uterus and stimulate the pituitary gland, apparently reducing the pain of childbirth and even shortening the duration of labor. Some of the pressure points are so powerful that you should avoid stimulating them unless you Reflexologists believe that the internal organs can be accessed through points on the feet. By massaging the feet during childbirth, a reflexologist can relax the uterus and stimulate the pituitary gland, apparently reducing the pain of childbirth and even shortening the duration of labor. Some of the pressure points are so powerful that you should avoid stimulating them unless you are are in labor. in labor.

Physical therapy. From massage and hot compresses to ice packs and intense counterpressure on your sore spots, physical therapy during labor can ease a lot of the pain you're feeling. Massage at the hands of a caring coach or doula or a skilled health professional can bring relaxing relief and can help diminish pain. From massage and hot compresses to ice packs and intense counterpressure on your sore spots, physical therapy during labor can ease a lot of the pain you're feeling. Massage at the hands of a caring coach or doula or a skilled health professional can bring relaxing relief and can help diminish pain.

Hydrotherapy. There's nothing like a warm bath-especially one with jets kneading your sore spots and particularly if you're in labor. Settle into a jetted tub (or merely a soaking tub) for a session of hydrotherapy during your labor to reduce pain and relax you. Many hospitals and birthing centers now provide such tubs to labor-or even deliver-in. There's nothing like a warm bath-especially one with jets kneading your sore spots and particularly if you're in labor. Settle into a jetted tub (or merely a soaking tub) for a session of hydrotherapy during your labor to reduce pain and relax you. Many hospitals and birthing centers now provide such tubs to labor-or even deliver-in.

Hypnobirthing. Though hypnosis won't mask your pain, numb your nerves, or quell contractions, it can get you so deeply relaxed (some women describe it as becoming like a floppy rag doll) that you are totally unaware of any discomfort. Hypnosis doesn't work for everyone; you have to be highly suggestible (some clues are having a long attention span, a rich imagination, and if you enjoy-or don't mind-being alone). Still, more and more women these days are seeking the help of a medically certified hypnotherapist (you'll want to shy away from someone without such credentials) to train them to get through labor by self-hypnosis; sometimes, you can have a hypnotherapist with you during the process. It's not something you can just start when that first contraction hits; you'll have to practice quite a bit during pregnancy to be able to achieve total relaxation, even with a certified therapist at your side (and while you're practicing, you can use hypnosis to get relief from pregnancy aches, pains, and stress, too). One big benefit of hypnobirthing is that while you're completely relaxed, you're also completely awake and aware of every moment of your baby's birth. There are also no physical effects on the baby (or on you). Though hypnosis won't mask your pain, numb your nerves, or quell contractions, it can get you so deeply relaxed (some women describe it as becoming like a floppy rag doll) that you are totally unaware of any discomfort. Hypnosis doesn't work for everyone; you have to be highly suggestible (some clues are having a long attention span, a rich imagination, and if you enjoy-or don't mind-being alone). Still, more and more women these days are seeking the help of a medically certified hypnotherapist (you'll want to shy away from someone without such credentials) to train them to get through labor by self-hypnosis; sometimes, you can have a hypnotherapist with you during the process. It's not something you can just start when that first contraction hits; you'll have to practice quite a bit during pregnancy to be able to achieve total relaxation, even with a certified therapist at your side (and while you're practicing, you can use hypnosis to get relief from pregnancy aches, pains, and stress, too). One big benefit of hypnobirthing is that while you're completely relaxed, you're also completely awake and aware of every moment of your baby's birth. There are also no physical effects on the baby (or on you).

Distraction. Even if you're not the type to try hypnosis (or you didn't plan far enough ahead), you can still try to get your mind off the pain of labor by using distraction techniques. Anything-watching TV, listening to music, meditating-that takes your mind off the pain can decrease your perception of it. So can focusing on an object (an ultrasound picture of your baby, a soothing landscape, a photo of a favorite place) or doing visualization exercises (for example, picturing your baby being pushed gently by contractions, preparing to exit the uterus, excited and happy). Keeping your pain in perspective is also key to an easier labor. Staying rested, relaxed, and positive (remember that the pain of a contraction is actually accomplishing something-each one getting you closer to your baby-and keep telling yourself that it won't last forever) will help you stay more comfortable. Even if you're not the type to try hypnosis (or you didn't plan far enough ahead), you can still try to get your mind off the pain of labor by using distraction techniques. Anything-watching TV, listening to music, meditating-that takes your mind off the pain can decrease your perception of it. So can focusing on an object (an ultrasound picture of your baby, a soothing landscape, a photo of a favorite place) or doing visualization exercises (for example, picturing your baby being pushed gently by contractions, preparing to exit the uterus, excited and happy). Keeping your pain in perspective is also key to an easier labor. Staying rested, relaxed, and positive (remember that the pain of a contraction is actually accomplishing something-each one getting you closer to your baby-and keep telling yourself that it won't last forever) will help you stay more comfortable.

Transcutaneous electrical nerve stimulation (TENS). This technique uses electrodes that deliver low-voltage pulses to stimulate nerve pathways to the uterus and cervix, supposedly blocking pain. Studies aren't clear on whether TENS is really effective at reducing labor pain, but some do show that it leads to a shorter first-stage labor and less need for pain meds. This technique uses electrodes that deliver low-voltage pulses to stimulate nerve pathways to the uterus and cervix, supposedly blocking pain. Studies aren't clear on whether TENS is really effective at reducing labor pain, but some do show that it leads to a shorter first-stage labor and less need for pain meds.

Making the Decision You now have the lowdown on pain relief options for labor and delivery-the information you'll need to make an informed decision. But before you decide what's best for you and your baby, you should: [image] Discuss the topic of pain relief and anesthesia with your practitioner long before labor begins. Your practitioner's expertise and experience make him or her an invaluable partner-though not usually the deciding vote-in the decision-making process. Well before your first contraction, find out what kinds of drugs or CAM techniques he or she uses most often, what side effects may be experienced, when he or she considers medication absolutely necessary, and when the option is yours. Discuss the topic of pain relief and anesthesia with your practitioner long before labor begins. Your practitioner's expertise and experience make him or her an invaluable partner-though not usually the deciding vote-in the decision-making process. Well before your first contraction, find out what kinds of drugs or CAM techniques he or she uses most often, what side effects may be experienced, when he or she considers medication absolutely necessary, and when the option is yours.[image] Consider keeping an open mind. Though it's smart to think ahead about what might be best for you under certain circumstances, it's impossible to predict what kind of labor and delivery you'll have, how you will respond to the contractions, and whether or not you'll want, need, or have to have medication. Even if you're absolutely convinced that you'll want an epidural, you may not want to close the door completely to trying some CAM approaches-either first, or on the side. After all, your labor may turn out to be more manageable (or a lot shorter) than you'd thought. And even if you're sold on an all-med-free delivery, you may want to think about leaving the medication window open-even if it's just a crack-in case your labor turns out to be tougher than you'd bargained for. Consider keeping an open mind. Though it's smart to think ahead about what might be best for you under certain circumstances, it's impossible to predict what kind of labor and delivery you'll have, how you will respond to the contractions, and whether or not you'll want, need, or have to have medication. Even if you're absolutely convinced that you'll want an epidural, you may not want to close the door completely to trying some CAM approaches-either first, or on the side. After all, your labor may turn out to be more manageable (or a lot shorter) than you'd thought. And even if you're sold on an all-med-free delivery, you may want to think about leaving the medication window open-even if it's just a crack-in case your labor turns out to be tougher than you'd bargained for.

Most important of all, remember, as you sort through those pain relief options, to keep your eye on the bottom line-a bottom line that has a really cute bottom. After all, no matter how you end up managing the pain of childbirth-and even if you don't end up managing it the way you planned to or the way you really hoped to-you'll still manage to give birth to your baby. And what could be a better bottom line than that?

CHAPTER 13.

The Eighth Month Approximately 32 to 35 Weeks IN THIS NEXT-TO-LAST MONTH, you may still be relishing every expectant moment, or you may be growing increasingly weary of, well, growing-and growing. Either way, you're sure to be preoccupied with-and super-excited about-the much-anticipated event: your baby's arrival. Of course, along with that heaping serving of excitement (the baby's almost here!), you and your partner are likely experiencing a side of trepidation (the baby's almost here!)-especially if this is your first foray into parenthood. Talking those very normal feelings through-and tapping into the insights of friends and family members who've preceded you into parenthood-will help you realize that everyone feels that way, particularly the first time around.

Your Baby This Month Week 32 This week your baby is tipping the scales at almost 4 pounds and topping out at just about 19 inches. And growing isn't the only thing on the agenda these days. While you're busy getting everything ready for baby's arrival, baby's busy prepping for that big debut, too. In these last few weeks, it's all about practice, practice, practice, as he or she hones the skills needed to survive outside the womb, from swallowing and breathing to kicking and sucking. And speaking of sucking, your little one has been able to suck his or her thumb for a while now (okay, maybe it's not a survival skill, but it sure is cute). Another change this week: Your baby's skin is no longer see-through. As more and more fat accumulates under the skin, it's finally opaque (just like yours!). This week your baby is tipping the scales at almost 4 pounds and topping out at just about 19 inches. And growing isn't the only thing on the agenda these days. While you're busy getting everything ready for baby's arrival, baby's busy prepping for that big debut, too. In these last few weeks, it's all about practice, practice, practice, as he or she hones the skills needed to survive outside the womb, from swallowing and breathing to kicking and sucking. And speaking of sucking, your little one has been able to suck his or her thumb for a while now (okay, maybe it's not a survival skill, but it sure is cute). Another change this week: Your baby's skin is no longer see-through. As more and more fat accumulates under the skin, it's finally opaque (just like yours!).

Your Baby, Month 8 Week 33 Baby's gaining weight almost as fast as you are these days (averaging out to about half a pound a week), which puts the grand total so far at more than 4 pounds. Still, your baby has plenty of growing up (and out) to do. He or she may grow a full inch this week alone and may come close to doubling in weight by D-day. And with that much baby inside your uterus now, your amniotic fluid level has maxed out (there's no room for more fluid now). Which explains why those pokes and kicks are sometimes extremely uncomfortable: There's less fluid to cushion the blows. Antibodies are also being passed from you to your baby as your little one continues to develop his or her own immune system. These antibodies will definitely come in handy on the outside and will protect your baby-to-be from many of those playground germs. Baby's gaining weight almost as fast as you are these days (averaging out to about half a pound a week), which puts the grand total so far at more than 4 pounds. Still, your baby has plenty of growing up (and out) to do. He or she may grow a full inch this week alone and may come close to doubling in weight by D-day. And with that much baby inside your uterus now, your amniotic fluid level has maxed out (there's no room for more fluid now). Which explains why those pokes and kicks are sometimes extremely uncomfortable: There's less fluid to cushion the blows. Antibodies are also being passed from you to your baby as your little one continues to develop his or her own immune system. These antibodies will definitely come in handy on the outside and will protect your baby-to-be from many of those playground germs.

Week 34 Your baby could be as tall as 20 inches right now and weighs about 5 pounds. Got male (a male baby, that is)? If you do, then this is the week that his testicles are making their way down from his abdomen to their final destination: his scrotum. (About 3 to 4 percent of boys are born with undescended testicles, which is nothing to worry about; they usually make the trip down south before the first birthday.) And in other baby-related news, those tiny little fingernails have probably reached the tip of his or her fingers by this week, so make sure you have baby nail clippers on your shopping list! Your baby could be as tall as 20 inches right now and weighs about 5 pounds. Got male (a male baby, that is)? If you do, then this is the week that his testicles are making their way down from his abdomen to their final destination: his scrotum. (About 3 to 4 percent of boys are born with undescended testicles, which is nothing to worry about; they usually make the trip down south before the first birthday.) And in other baby-related news, those tiny little fingernails have probably reached the tip of his or her fingers by this week, so make sure you have baby nail clippers on your shopping list!

Week 35 Your baby stands tall this week-if he or she could stand, that is-at about 20 inches, and continues to follow the -pound-a-week plan, weighing in at about 5 big ones. While growth will taper off when it comes to height (the average full-termer is born at about 20 inches), your baby will continue to pack on the pounds up until delivery day. Something else he or she will be packing on in the few weeks that remain are brain cells. Brain development continues at a mind-boggling pace, making baby a little on the top-heavy side. And speaking of tops, it's likely your baby's bottom is. Most babies have settled into a head-down, bottoms-up position in Mom's pelvis by now, or will soon. That's a good thing, since it's easier on you if baby's head (the biggest part of his or her body) exits first during delivery. Here's another plus: Baby's head may be big, but it's still soft (at least, the skull is), allowing that tight squeeze through the birth canal to be a little less tight. Your baby stands tall this week-if he or she could stand, that is-at about 20 inches, and continues to follow the -pound-a-week plan, weighing in at about 5 big ones. While growth will taper off when it comes to height (the average full-termer is born at about 20 inches), your baby will continue to pack on the pounds up until delivery day. Something else he or she will be packing on in the few weeks that remain are brain cells. Brain development continues at a mind-boggling pace, making baby a little on the top-heavy side. And speaking of tops, it's likely your baby's bottom is. Most babies have settled into a head-down, bottoms-up position in Mom's pelvis by now, or will soon. That's a good thing, since it's easier on you if baby's head (the biggest part of his or her body) exits first during delivery. Here's another plus: Baby's head may be big, but it's still soft (at least, the skull is), allowing that tight squeeze through the birth canal to be a little less tight.

What You May Be Feeling As always, remember that every pregnancy and every woman is different. You may experience all of these symptoms at one time or another, or only a few of them. Some may have continued from last month; others may be new. Still others may be hardly noticed because you've become so used to them. You may also have other, less common, symptoms. Here's what you might experience this month:

A Look Inside An interesting bit of pregnancy trivia: Measurement in centimeters from the top of your pubic bone to the top of your uterus roughly correlates with the number of weeks you're up to; so, at 34 weeks, your uterus measures close to 34 cm from the pubic bone.

Physically [image] Strong, regular fetal activity Strong, regular fetal activity[image] Increasing vaginal discharge Increasing vaginal discharge[image] Increased constipation Increased constipation[image] Heartburn, indigestion, flatulence, bloating Heartburn, indigestion, flatulence, bloating[image] Occasional headaches, faintness, or dizziness Occasional headaches, faintness, or dizziness[image] Nasal congestion and occasional nosebleeds; ear stuffiness Nasal congestion and occasional nosebleeds; ear stuffiness[image] Sensitive gums Sensitive gums[image] Leg cramps Leg cramps[image] Backache Backache[image] Pelvic pressure and/or achiness Pelvic pressure and/or achiness[image] Mild swelling of ankles and feet, and occasionally of hands and face Mild swelling of ankles and feet, and occasionally of hands and face[image] Varicose veins of legs Varicose veins of legs[image] Hemorrhoids Hemorrhoids[image] Itchy abdomen Itchy abdomen[image] Protruding navel Protruding navel[image] Stretch marks Stretch marks[image] Increasing shortness of breath as the uterus crowds the lungs, which eases when the baby drops Increasing shortness of breath as the uterus crowds the lungs, which eases when the baby drops[image] Difficulty sleeping Difficulty sleeping[image] Increasing "practice" (Braxton Hicks) contractions Increasing "practice" (Braxton Hicks) contractions[image] Increasing clumsiness Increasing clumsiness[image] Enlarged breasts Enlarged breasts[image] Colostrum, leaking from nipples (though this premilk substance may not appear until after delivery) Colostrum, leaking from nipples (though this premilk substance may not appear until after delivery) Emotionally [image] Increasing eagerness for the pregnancy to be over Increasing eagerness for the pregnancy to be over[image] Apprehension about labor and delivery Apprehension about labor and delivery[image] Increasing absentmindedness Increasing absentmindedness[image] Trepidation about becoming a parent, if it's your first time Trepidation about becoming a parent, if it's your first time[image] Excitement-at the realization that it won't be long now Excitement-at the realization that it won't be long now What You Can Expect at This Month's Checkup After the 32nd week, your practitioner may ask you to come in every two weeks so your progress and your baby's can be more closely watched. You can expect the following to be checked, depending on your particular needs and your practitioner's style of practice: [image] Weight and blood pressure Weight and blood pressure[image] Urine, for sugar and protein Urine, for sugar and protein[image] Fetal heartbeat Fetal heartbeat[image] Height of fundus (top of uterus) Height of fundus (top of uterus)[image] Size (you may get a rough weight estimate) and position of the fetus, by palpation (feeling from the outside) Size (you may get a rough weight estimate) and position of the fetus, by palpation (feeling from the outside)[image] Feet and hands for swelling, and legs for varicose veins Feet and hands for swelling, and legs for varicose veins[image] Group B strep test Group B strep test[image] Symptoms you have been experiencing, especially unusual ones Symptoms you have been experiencing, especially unusual ones[image] Questions and problems you want to discuss-have a list ready Questions and problems you want to discuss-have a list ready What You May Be Wondering About Braxton Hicks Contractions "Every once in a while my uterus seems to bunch up and harden. What's going on?"

It's practicing. With delivery right around the corner, your body is warming up for the big day by flexing its muscles-literally. Those uterine calisthenics you're feeling are called Braxton Hicks contractions-practice-for-labor contractions that usually begin sometime after the 20th week of pregnancy (though they're more noticeable in the last few months of pregnancy). These rehearsal contractions (typically experienced earlier and with more intensity in women who've had a previous pregnancy) feel like a tightening sensation that begins at the top of your uterus and then spreads downward, lasting from 15 to 30 seconds, though they can sometimes last as long as two minutes or more. If you check out your belly while you're having a Braxton Hicks, you might even be able to see what you're feeling; your usually round abdomen might appear pointy or strangely bunched up. Weird to watch, but normal.

Though Braxton Hicks contractions are not true labor, they may be difficult to distinguish from real labor-especially as they become more intense, which they often do as pregnancy draws to a close. And though they're not efficient enough to deliver your baby (even when they get really uncomfortable), they may give you a leg up on labor by getting effacement and early dilation of the cervix started when the time is right.

To relieve any discomfort you may feel during these contractions, try changing your position-lying down and relaxing if you've been on your feet, or getting up and walking around if you've been sitting. Be sure, too, that you're getting enough to drink. Dehydration (even minor dehydration) can sometimes cause contractions, including these practice ones. You can also use this labor rehearsal to practice your breathing exercises and the various other childbirth techniques you've learned, which can make it easier to deal with the real contractions when they do arrive.

If the contractions don't subside with a change in activity, and if they become progressively stronger and more regular, you may be in real labor, so be sure to put in a call to your practitioner. A good rule of thumb: If you have more than four Braxton Hicks in an hour, call your practitioner and let him or her know. If you're having a hard time distinguishing Braxton Hicks contractions from the real thing-especially if this is your first pregnancy and you've never experienced the real thing-read up about the different kinds of contractions on page 359 page 359 and give your practitioner a call, being sure to describe exactly what you're feeling. and give your practitioner a call, being sure to describe exactly what you're feeling.

Not-So-Funny Rib Tickling "It feels as though my baby has his feet jammed up into my rib cage, and it really hurts."

In the later months, when fetuses run out of stretching room in their cramped quarters, the resourceful little creatures often do seem to find a snug niche for their feet between their mother's ribs, and that's one kind of rib tickling that doesn't tickle. Changing your own position may convince your baby to change his or hers. A gentle nudge from you or a few pelvic tilts may dislodge him. Or try relocating him with this exercise: Take a deep breath while you raise one arm over your head, then exhale while you drop your arm; repeat a few times with each arm.

If none of these tactics works, hang in there. When your little pain-in-the-ribs engages, or drops into your pelvis, which usually happens two or three weeks before delivery in first pregnancies (though often not until labor begins in subsequent ones), he probably won't be able to stretch his toes quite so high up.

Another reason for rib cage pain that you can't blame on your baby-at least not directly-comes from a loosening of the joints in the area, courtesy of pregnancy hormones. Acetaminophen (Tylenol) can help ease the ache, but also avoid heavy lifting, which can make it worse (and which you shouldn't be doing now anyway).

Shortness of Breath "Sometimes I have trouble breathing, even when I'm not exerting any energy. Why is that happening to me? And does it mean my baby isn't getting enough oxygen?"

It's not surprising you're feeling a little spare on air these days. Your ever-expanding uterus is now crowding out all your other internal organs in an effort to provide spacious-enough accommodations for your ever-growing baby. Among those organs feeling the crunch are your lungs, which your uterus has compressed, limiting their ability to expand fully when you take a breath. This, teamed with the extra progesterone that has already been leaving you breathless for months, explains why a trip upstairs these days can make you feel as if you've just run a marathon (winded, big time). Fortunately, while this shortness of breath may feel very uncomfortable to you, it doesn't bother your baby in the least. He or she is kept well stocked with all the oxygen he or she needs through the placenta.

Choosing a Pediatrician Choosing a pediatrician (or a family practitioner) is one of the most important decisions you'll make as a parent-and actually, you shouldn't wait until you become a parent to make it. Sifting through your choices and making your selection now, before your baby starts crying inexplicably at 3 a.m., will ensure that your transition to parenthood will be that much easier. It will also allow for an informed-not hasty-decision.If you're not sure where to begin your search, ask your practitioner (if you've been happy with his or her care) or friends, neighbors, or coworkers who have young children for recommendations. Or contact the hospital or birthing center where you'll be delivering (you can call the labor and delivery floor or pediatrics, and ask a nurse on duty for some suggestions; no one gets a better look at doctors than nurses do). Of course, if you're on a health insurance plan that limits your choices, you'll have to choose from that list.Once you've narrowed your choices down to two or three, call for consultations; most pediatricians or family practitioners will oblige. Bring a list of questions about issues that are important to you, such as office protocol (for instance, whether there are call-in hours for parents or when you can expect calls to be returned), breastfeeding support, circumcision, the use of antibiotics, whether the doctor handles all well-baby visits or whether they are typically handled by nurse-practitioners in the practice. Also important to know: Is the doctor board certified? Which hospital is the doctor affiliated with, and will he or she be able to care for the newborn in the hospital? For more questions to ask and issues to consider, check out the What to Expect Pregnancy Journal and Organizer. What to Expect Pregnancy Journal and Organizer.

Relief from that winded feeling usually arrives toward the end of pregnancy, when your baby drops into your pelvis in preparation for birth (in first pregnancies this generally occurs two to three weeks before delivery, in subsequent deliveries often not until labor begins). Until then, you may find it easier to breathe if you sit straight up instead of slumped over and sleep in a semi-propped-up position, bolstered by two or three pillows.

Sometimes breathlessness can be a sign that iron stores are low, so check in with your practitioner about it. Call immediately (or head to the ER) if shortness of breath is severe and accompanied by rapid breathing, blueness of the lips and fingertips, chest pain, and/or rapid pulse.

Lack of Bladder Control "I watched a funny movie last night and I seemed to be leaking urine every time I laughed. Why is that?"

As if frequent bathroom runs weren't annoying enough lately, the third trimester has added another bladder issue to the mix: stress incontinence. This lack of bladder control-causing you to spring a small leak when you cough, sneeze, lift something heavy, or even laugh (though there's nothing funny about that)-is the result of the mounting pressure of the growing uterus on the bladder. Some women also experience urge incontinence, the sudden, overwhelming need to urinate (gotta go now! now!) during late pregnancy. Try these tips to help prevent or control stress or urge incontinence: [image] Empty your bladder as completely as possible each time you pee by leaning forward. Empty your bladder as completely as possible each time you pee by leaning forward.[image] Practice your Kegel exercises. Being faithful to your Kegels will help strengthen the pelvic muscles and prevent or correct most cases of pregnancy-induced incontinence-plus, looking ahead, they'll also help prevent postpartum incontinence. For a Kegel how-to, see Practice your Kegel exercises. Being faithful to your Kegels will help strengthen the pelvic muscles and prevent or correct most cases of pregnancy-induced incontinence-plus, looking ahead, they'll also help prevent postpartum incontinence. For a Kegel how-to, see page 295 page 295.[image] Do Kegels or cross your legs when you feel a cough, sneeze, or laugh coming on. Do Kegels or cross your legs when you feel a cough, sneeze, or laugh coming on.[image] Wear a panty liner if you need one, or you're afraid you'll need one. Graduate to a maxipad when leaks might be especially inconvenient. Wear a panty liner if you need one, or you're afraid you'll need one. Graduate to a maxipad when leaks might be especially inconvenient.[image] Stay as regular as you can, because impacted stool can put pressure on the bladder. Also, straining hard during bowel movements (as you're likely to do when you're constipated) can weaken pelvic floor muscles. For tips on fighting constipation, see Stay as regular as you can, because impacted stool can put pressure on the bladder. Also, straining hard during bowel movements (as you're likely to do when you're constipated) can weaken pelvic floor muscles. For tips on fighting constipation, see page 173 page 173.[image] If it's the urge that's driving you crazy (and sending you to the bathroom in a hurry all the time), try training your bladder. Urinate more frequently-about every 30 minutes to an hour-so that you go before you feel that uncontrollable need. After a week, try to gradually stretch the time between bathroom visits, adding 15 minutes more at a time. If it's the urge that's driving you crazy (and sending you to the bathroom in a hurry all the time), try training your bladder. Urinate more frequently-about every 30 minutes to an hour-so that you go before you feel that uncontrollable need. After a week, try to gradually stretch the time between bathroom visits, adding 15 minutes more at a time.[image] Continue drinking at least eight glasses of fluids a day, even if you experience stress incontinence or frequent urges. Limiting your fluid intake will not limit leaks and it may lead to UTIs and/or dehydration. Not only can either of these lead to a lot of other problems (including preterm contractions), but UTIs can exacerbate stress incontinence. See Continue drinking at least eight glasses of fluids a day, even if you experience stress incontinence or frequent urges. Limiting your fluid intake will not limit leaks and it may lead to UTIs and/or dehydration. Not only can either of these lead to a lot of other problems (including preterm contractions), but UTIs can exacerbate stress incontinence. See page 499 page 499 for tips on keeping your urinary tract healthy. for tips on keeping your urinary tract healthy.