[image] Hand a copy of the birth plan to each nurse or other attendant at the birth, so everyone's on the same page about preferences. If the shift changes, make sure the new nurses receive a copy. Hand a copy of the birth plan to each nurse or other attendant at the birth, so everyone's on the same page about preferences. If the shift changes, make sure the new nurses receive a copy.[image] If mom wants medication, let the nurse or practitioner know. Respect whatever decision she makes-to continue unmedicated or to go for pain relief. If mom wants medication, let the nurse or practitioner know. Respect whatever decision she makes-to continue unmedicated or to go for pain relief.[image] Take your cues from her. Whatever mom wants, mom should get. Keep in mind that what she'll want may change from moment to moment (the TV blaring one second, no TV the next). Ditto for her mood and her reaction to you. Don't take it personally if she doesn't respond to, doesn't appreciate-or is even annoyed by-your attempts to comfort her. Ease up, if that's what she seems to prefer-but be prepared to step it up 10 minutes later, if she wants. Remember that your role is important, even if you sometimes feel superfluous or in the way. She'll appreciate you in the morning (or whenever it's all over). Take your cues from her. Whatever mom wants, mom should get. Keep in mind that what she'll want may change from moment to moment (the TV blaring one second, no TV the next). Ditto for her mood and her reaction to you. Don't take it personally if she doesn't respond to, doesn't appreciate-or is even annoyed by-your attempts to comfort her. Ease up, if that's what she seems to prefer-but be prepared to step it up 10 minutes later, if she wants. Remember that your role is important, even if you sometimes feel superfluous or in the way. She'll appreciate you in the morning (or whenever it's all over).[image] Set the mood. If possible, keep the door to the room closed, the lights low, and the room quiet to promote a relaxed and restful atmosphere. Soft music may also help (unless she'd rather watch TV; remember, she's the boss). Continue encouraging relaxation techniques between contractions and breathing with her through the contractions-but don't push if she's not into them or if pushing the relaxation agenda is starting to stress her out. If distractions seem to help her, turn to cards or handheld video games, light conversation, or TV. But distract her only as much as she seems to want to be distracted. Set the mood. If possible, keep the door to the room closed, the lights low, and the room quiet to promote a relaxed and restful atmosphere. Soft music may also help (unless she'd rather watch TV; remember, she's the boss). Continue encouraging relaxation techniques between contractions and breathing with her through the contractions-but don't push if she's not into them or if pushing the relaxation agenda is starting to stress her out. If distractions seem to help her, turn to cards or handheld video games, light conversation, or TV. But distract her only as much as she seems to want to be distracted.[image] Pump her up. Reassure her and praise her efforts (unless your verbal reassurance is making her more edgy), and avoid criticism of any kind (even the constructive type). Be her cheerleader (but keep it low-key-she probably won't appreciate full-on exuberance). Particularly if progress is slow, suggest that she take her labor one contraction at a time, and remind her that each pain brings her closer to seeing the baby. If she finds your cheers irritating, however, skip them. Stick to sympathy if that's what she seems to need. Pump her up. Reassure her and praise her efforts (unless your verbal reassurance is making her more edgy), and avoid criticism of any kind (even the constructive type). Be her cheerleader (but keep it low-key-she probably won't appreciate full-on exuberance). Particularly if progress is slow, suggest that she take her labor one contraction at a time, and remind her that each pain brings her closer to seeing the baby. If she finds your cheers irritating, however, skip them. Stick to sympathy if that's what she seems to need.[image] Keep track of the contractions. If she's on a monitor, ask the practitioner or the nurse to show you how to read it. Later, when contractions are coming one on top of the other, you can announce each new contraction as it begins-unless she starts to find that annoying. (The monitor may detect the tensing of the uterus before she can, and can let her know when she's having one if she can't feel them, thanks to an epidural.) You can also encourage your spouse through those tough contractions by telling her when each peak is ending. If there is no monitor, ask a nurse to show you how to recognize the arrival and departure of contractions with your hand on her abdomen (unless she doesn't want it there). Keep track of the contractions. If she's on a monitor, ask the practitioner or the nurse to show you how to read it. Later, when contractions are coming one on top of the other, you can announce each new contraction as it begins-unless she starts to find that annoying. (The monitor may detect the tensing of the uterus before she can, and can let her know when she's having one if she can't feel them, thanks to an epidural.) You can also encourage your spouse through those tough contractions by telling her when each peak is ending. If there is no monitor, ask a nurse to show you how to recognize the arrival and departure of contractions with your hand on her abdomen (unless she doesn't want it there).[image] Massage her abdomen or back, or use counterpressure or any other techniques you've learned, to make her more comfortable. Let her tell you what kind of stroking or touching or massage helps. If she prefers not to be touched at all, then it might be best to comfort her verbally. Remember, what feels good one moment might irk her the next, and vice versa. Massage her abdomen or back, or use counterpressure or any other techniques you've learned, to make her more comfortable. Let her tell you what kind of stroking or touching or massage helps. If she prefers not to be touched at all, then it might be best to comfort her verbally. Remember, what feels good one moment might irk her the next, and vice versa.[image] Remind her to take a bathroom break at least once an hour if she doesn't have a catheter. She might not feel the urge, but a full bladder can stand in the way of labor progress. Remind her to take a bathroom break at least once an hour if she doesn't have a catheter. She might not feel the urge, but a full bladder can stand in the way of labor progress.[image] Suggest a change of position periodically; take her for a hallway walk, if that's possible. Suggest a change of position periodically; take her for a hallway walk, if that's possible.[image] Be the ice man. Find out where the ice machine is, and keep those chips coming. If she's allowed to sip on fluids or snack on light foods, offer them periodically. Popsicles may be especially refreshing; ask the nurse if there's a stash you can help yourself to. Be the ice man. Find out where the ice machine is, and keep those chips coming. If she's allowed to sip on fluids or snack on light foods, offer them periodically. Popsicles may be especially refreshing; ask the nurse if there's a stash you can help yourself to.[image] Keep her cool. Use a damp washcloth, wrung out in cold water, to help cool her body and face; refresh it often. Keep her cool. Use a damp washcloth, wrung out in cold water, to help cool her body and face; refresh it often.[image] If her feet are cold, offer to get out a pair of socks and put them on her (reaching her feet isn't easy for her). If her feet are cold, offer to get out a pair of socks and put them on her (reaching her feet isn't easy for her).[image] Be her voice and her ears. She has enough going on, so lighten her load. Serve as her go-between with medical personnel as much as possible. Intercept questions from them that you can answer, and ask for explanations of procedures, equipment, and use of medication, so you'll be able to tell her what's happening. For instance, now might be the time to find out if a mirror will be provided so she can view the delivery. Be her advocate when necessary, but try to fight her battles quietly, perhaps outside the room, so she won't be disturbed. Be her voice and her ears. She has enough going on, so lighten her load. Serve as her go-between with medical personnel as much as possible. Intercept questions from them that you can answer, and ask for explanations of procedures, equipment, and use of medication, so you'll be able to tell her what's happening. For instance, now might be the time to find out if a mirror will be provided so she can view the delivery. Be her advocate when necessary, but try to fight her battles quietly, perhaps outside the room, so she won't be disturbed.

Phase 3: Transitional Labor Transition is the most demanding phase of labor but, fortunately, typically the quickest. Suddenly, the intensity of the contractions picks up. They become very strong, 2 to 3 minutes apart, and 60 to 90 seconds long, with very intense peaks that last for most of the contraction. Some women, particularly women who have given birth before, experience multiple peaks. You may feel as though the contractions never disappear completely and you can't completely relax between them. The final 3 cm of dilation, to a full 10 cm, will probably take place in a very short time: on average, 15 minutes to an hour, though it can also take as long as 3 hours.

You'll feel plenty when you're in transition (unless, of course, you're numbed by an epidural or other pain relief), and may experience some or all of the following: [image] More intense pain with contractions More intense pain with contractions[image] Strong pressure in the lower back and/or perineum Strong pressure in the lower back and/or perineum[image] Rectal pressure, with or without an urge to push or move your bowels (you might even feel the urge to grunt-so let it out!) Rectal pressure, with or without an urge to push or move your bowels (you might even feel the urge to grunt-so let it out!)[image] An increase in your bloody show as more capillaries in the cervix rupture An increase in your bloody show as more capillaries in the cervix rupture[image] Feeling very warm and sweaty or chilled and shaky (or you might alternate between the two) Feeling very warm and sweaty or chilled and shaky (or you might alternate between the two)[image] Crampy legs that may tremble uncontrollably Crampy legs that may tremble uncontrollably[image] Nausea and/or vomiting Nausea and/or vomiting[image] Drowsiness between contractions as oxygen is diverted from your brain to the site of the delivery Drowsiness between contractions as oxygen is diverted from your brain to the site of the delivery[image] A tightening sensation in your throat or chest A tightening sensation in your throat or chest[image] Exhaustion Exhaustion Emotionally, you may feel vulnerable and overwhelmed, as though you're reaching the end of your rope. In addition to frustration over not being able to push yet, you may feel discouraged, irritable, disoriented, restless, and may have difficulty concentrating and relaxing (it might seem impossible to do either). You may also find excitement reaching a fever pitch in the midst of all the stress. Your baby's almost here!

What You Can Do. Hang in there. By the end of this phase, which is not far off, your cervix will be fully dilated, and it'll be time to begin pushing your baby out. Instead of thinking about the work ahead, try to think about how far you've come. Hang in there. By the end of this phase, which is not far off, your cervix will be fully dilated, and it'll be time to begin pushing your baby out. Instead of thinking about the work ahead, try to think about how far you've come.

[image] Continue to use breathing techniques if they help. If you feel the urge to push, resist. Pant or blow instead, unless you've been instructed otherwise. Pushing against a cervix that isn't completely dilated can cause it to swell, which can delay delivery. Continue to use breathing techniques if they help. If you feel the urge to push, resist. Pant or blow instead, unless you've been instructed otherwise. Pushing against a cervix that isn't completely dilated can cause it to swell, which can delay delivery.[image] If you don't want anybody to touch you unnecessarily, if your coach's once comforting hands now irritate you, don't hesitate to let him know. If you don't want anybody to touch you unnecessarily, if your coach's once comforting hands now irritate you, don't hesitate to let him know.[image] Try to relax between contractions (as much as is possible) with slow, deep, rhythmic breathing. Try to relax between contractions (as much as is possible) with slow, deep, rhythmic breathing.[image] Keep your eye on the prize: That bundle of joy will soon be arriving in your arms. Keep your eye on the prize: That bundle of joy will soon be arriving in your arms.

When you're a full 10 cm dilated, you'll be moved to the delivery room, if you aren't already there. Or, if you're in a birthing bed, the foot of the bed will simply be removed to prepare for delivery.

For the Coach: What You Can Do. Again, the doula, if one is present, can share these comforting techniques with you: Again, the doula, if one is present, can share these comforting techniques with you: [image] If your laboring spouse has an epidural or other kind of pain relief, ask her if she needs another dose. Transition can be quite painful, and if her epidural is wearing off, she won't be a happy camper. If it is, let the nurses or the practitioner know. If mom's continuing unmedicated, she'll need you more now than ever (read on). If your laboring spouse has an epidural or other kind of pain relief, ask her if she needs another dose. Transition can be quite painful, and if her epidural is wearing off, she won't be a happy camper. If it is, let the nurses or the practitioner know. If mom's continuing unmedicated, she'll need you more now than ever (read on).[image] Be there, but give her space if she seems to want it. Often, women in transition don't like being touched-but, as always, take your cues from her. Abdominal massage may be especially offensive now, though counterpressure applied to the small of her back may continue to provide some relief for back pain. Be prepared to back off-even from her back-as directed. Be there, but give her space if she seems to want it. Often, women in transition don't like being touched-but, as always, take your cues from her. Abdominal massage may be especially offensive now, though counterpressure applied to the small of her back may continue to provide some relief for back pain. Be prepared to back off-even from her back-as directed.[image] Don't waste words. Now's not the time for small talk, and probably not for jokes, either. Offer quiet comfort, and help her with instructions that are brief and direct. Don't waste words. Now's not the time for small talk, and probably not for jokes, either. Offer quiet comfort, and help her with instructions that are brief and direct.[image] Offer lots of encouragement, unless she prefers you to keep quiet. At this moment, eye contact or touch may communicate more expressively than words. Offer lots of encouragement, unless she prefers you to keep quiet. At this moment, eye contact or touch may communicate more expressively than words.[image] Breathe with her through every contraction if it seems to help her through them. Breathe with her through every contraction if it seems to help her through them.[image] Help her rest and relax between contractions, touching her abdomen lightly to show her when a contraction is over. Remind her to use slow, rhythmic breathing in between contractions, if she can. Help her rest and relax between contractions, touching her abdomen lightly to show her when a contraction is over. Remind her to use slow, rhythmic breathing in between contractions, if she can.[image] If her contractions seem to be getting closer and/or she feels the urge to push-and she hasn't been examined recently-let the nurse or practitioner know. She may be fully dilated. If her contractions seem to be getting closer and/or she feels the urge to push-and she hasn't been examined recently-let the nurse or practitioner know. She may be fully dilated.[image] Offer her ice chips or a sip of water frequently, and mop her brow with a cool damp cloth often. If she's chilly, offer her a blanket or a pair of socks. Offer her ice chips or a sip of water frequently, and mop her brow with a cool damp cloth often. If she's chilly, offer her a blanket or a pair of socks.[image] Stay focused on the payoff you're both about to get. It's been a long haul, but it won't be long before the pushing begins-and that anticipated bundle arrives in your arms. Stay focused on the payoff you're both about to get. It's been a long haul, but it won't be long before the pushing begins-and that anticipated bundle arrives in your arms.

Stage Two: Pushing and Delivery Up until this point, your active participation in the birth of your child has been negligible. Though you've definitely taken the brunt of the abuse in the proceedings, your cervix and uterus (and baby) have done most of the work. But now that dilation is complete, your help is needed to push the baby the remainder of the way through the birth canal and out. Pushing and delivery generally take between half an hour and an hour, but can sometimes be accomplished in 10 (or even fewer) short minutes or in 2, 3, or even more very long hours.

The contractions of the second stage are usually more regular than the contractions of transition. They are still about 60 to 90 seconds in duration but sometimes further apart (usually about 2 to 5 minutes) and possibly less painful, though sometimes they are more intense. There now should be a well-defined rest period between them, though you may still have trouble recognizing the onset of each contraction.

Common in the second stage (though you'll definitely feel a lot less-and you may not feel anything at all-if you've had an epidural): [image] Pain with the contractions, though possibly not as much Pain with the contractions, though possibly not as much[image] An overwhelming urge to push (though not every woman feels it, especially if she's had an epidural) An overwhelming urge to push (though not every woman feels it, especially if she's had an epidural)[image] Tremendous rectal pressure (ditto) Tremendous rectal pressure (ditto)[image] A burst of renewed energy (a second wind) or fatigue A burst of renewed energy (a second wind) or fatigue[image] Very visible contractions, with your uterus rising noticeably with each Very visible contractions, with your uterus rising noticeably with each[image] An increase in bloody show An increase in bloody show[image] A tingling, stretching, burning, or stinging sensation at the vagina as your baby's head emerges (it's called the "ring of fire" for good reason) A tingling, stretching, burning, or stinging sensation at the vagina as your baby's head emerges (it's called the "ring of fire" for good reason)[image] A slippery wet feeling as your baby emerges A slippery wet feeling as your baby emerges Emotionally, you may feel relieved that you can now start pushing (though some women feel embarrassed, inhibited, or scared); you may also feel exhilarated and excited or, if the pushing stretches on for much more than an hour, frustrated or overwhelmed. In a prolonged second stage, you may find your preoccupation is less with seeing the baby than with getting the ordeal over with (and that's perfectly understandable-and normal).

What You Can Do. It's time to get this baby out. So get into a pushing position (which one will depend on the bed, chair, or tub you're in, your practitioner's preferences, and, hopefully, what's most comfortable and effective for you). A semi-sitting or semi-squatting position is often the best because it enlists the aid of gravity in the birthing process and may afford you more pushing power. Tucking your chin to your chest when you're in this position will help you focus your pushes to where they need to be. Sometimes, if the pushing isn't moving your baby down the birth canal, it may be helpful to change positions. If you've been semi-inclined, for example, you might want to get up on all fours or try squatting. It's time to get this baby out. So get into a pushing position (which one will depend on the bed, chair, or tub you're in, your practitioner's preferences, and, hopefully, what's most comfortable and effective for you). A semi-sitting or semi-squatting position is often the best because it enlists the aid of gravity in the birthing process and may afford you more pushing power. Tucking your chin to your chest when you're in this position will help you focus your pushes to where they need to be. Sometimes, if the pushing isn't moving your baby down the birth canal, it may be helpful to change positions. If you've been semi-inclined, for example, you might want to get up on all fours or try squatting.

Once you're ready to begin pushing, give it all you've got. The more efficiently you push and the more energy you pack into the effort, the more quickly your baby will make the trip through the birth canal. Frantic, disorganized pushing wastes energy and accomplishes little. Keep these pushing pointers in mind:

A Baby Is Born 1. The cervix has thinned (effaced) somewhat but has not begun to dilate much.

2. The cervix has fully dilated and the baby's head has begun to press into the birth canal (vagina).

3. To allow the narrowest diameter of the baby's head to fit through the mother's pelvis, the baby usually turns sometime during labor. Here, the slightly molded head has crowned.

4. The head, the baby's broadest part, is out. The rest of the delivery should proceed quickly and smoothly.

[image]Relax your body and your thighs and then push as if you're having a bowel movement (the biggest one of your life). Focus your energy on your vagina and rectum, not your upper body (which could result in chest pain after delivery) and not your face (straining with your face could leave you with black-and-blue marks on your cheeks and bloodshot eyes, not to mention do nothing to help get your baby out).[image] Speaking of bowel movements, since you're bearing down on the whole perineal area, anything that's in your rectum may be pushed out, too; trying to avoid this while you're pushing can slow your progress. Don't let inhibition or embarrassment break the pushing rhythm. A little involuntary pooping (or passage of urine) is experienced by nearly everyone during delivery. No one else in the room will think twice about it, and neither should you. Pads will immediately whisk away anything that comes out. Speaking of bowel movements, since you're bearing down on the whole perineal area, anything that's in your rectum may be pushed out, too; trying to avoid this while you're pushing can slow your progress. Don't let inhibition or embarrassment break the pushing rhythm. A little involuntary pooping (or passage of urine) is experienced by nearly everyone during delivery. No one else in the room will think twice about it, and neither should you. Pads will immediately whisk away anything that comes out.[image] Take a few deep breaths while the contraction is building so you can gear up for pushing. As the contraction peaks, take a deep breath and then push with all your might-holding your breath if you want or exhaling as you push, whatever feels right to you. If you'd like the nurses or your coach to guide you by counting to 10 while you push, that's fine. But if you find it breaks your rhythm or isn't helpful, ask them not to. There is no magic formula when it comes to how long each push should last or how many times you should push with each contraction-the most important thing is to do what comes naturally. You may feel as many as five urges to bear down, with each push lasting just seconds-or you may feel the urge to bear down just twice, but with each push lasting longer. Follow those urges, and you'll deliver your baby. Actually, you'll deliver your baby even if you don't follow your urges or if you find you don't have any urges at all. Pushing doesn't come naturally for every woman, and if it doesn't for you, your practitioner, nurse, or doula can help direct your efforts, and redirect them if you lose your concentration. Take a few deep breaths while the contraction is building so you can gear up for pushing. As the contraction peaks, take a deep breath and then push with all your might-holding your breath if you want or exhaling as you push, whatever feels right to you. If you'd like the nurses or your coach to guide you by counting to 10 while you push, that's fine. But if you find it breaks your rhythm or isn't helpful, ask them not to. There is no magic formula when it comes to how long each push should last or how many times you should push with each contraction-the most important thing is to do what comes naturally. You may feel as many as five urges to bear down, with each push lasting just seconds-or you may feel the urge to bear down just twice, but with each push lasting longer. Follow those urges, and you'll deliver your baby. Actually, you'll deliver your baby even if you don't follow your urges or if you find you don't have any urges at all. Pushing doesn't come naturally for every woman, and if it doesn't for you, your practitioner, nurse, or doula can help direct your efforts, and redirect them if you lose your concentration.[image] Don't become frustrated if you see the baby's head crown and then disappear again. Birthing is a two-steps-forward, one-step-backward proposition. Just remember, you are moving in the right direction. Don't become frustrated if you see the baby's head crown and then disappear again. Birthing is a two-steps-forward, one-step-backward proposition. Just remember, you are moving in the right direction.[image] Rest between contractions. If you're really exhausted, especially when the pushing stage drags on, your practitioner may suggest that you not push for several contractions so you can rebuild your strength. Rest between contractions. If you're really exhausted, especially when the pushing stage drags on, your practitioner may suggest that you not push for several contractions so you can rebuild your strength.[image] Stop pushing when you're instructed to (as you may be, to keep the baby's head from being born too rapidly). If you're feeling the urge to push, pant or blow instead. Stop pushing when you're instructed to (as you may be, to keep the baby's head from being born too rapidly). If you're feeling the urge to push, pant or blow instead.[image] Remember to keep an eye on the mirror (if one is available) once there's something to look at. Seeing your baby's head crown (and reaching down and touching it) may give you the inspiration to push when the pushing gets tough. Besides, unless your coach is videotaping, there won't be any replays to watch. Remember to keep an eye on the mirror (if one is available) once there's something to look at. Seeing your baby's head crown (and reaching down and touching it) may give you the inspiration to push when the pushing gets tough. Besides, unless your coach is videotaping, there won't be any replays to watch.

While you're pushing, the nurses and/or your practitioner will give you support and direction; continue to monitor your baby's heartbeat, with either a Doppler or fetal monitor; and prepare for delivery by spreading sterile drapes and arranging instruments, donning surgical garments and gloves, and sponging your perineal area with antiseptic (though midwives generally just don gloves and do no draping). They'll also perform an episiotomy if necessary, or use vacuum extraction or, less likely, forceps if necessary.

A First Look at Baby Those who expect their babies to arrive as round and smooth as a Botticelli cherub may be in for a shock. Nine months of soaking in an amniotic bath and a dozen or so hours of compression in a contracting uterus and cramped birth canal take their toll on a newborn's appearance. Those babies who arrived via cesarean delivery have a temporary edge as far as appearance goes.

Fortunately, most of the less-than-lovely newborn characteristics that follow are temporary. One morning, a couple of weeks after you've brought your wrinkled, slightly scrawny, puffy-eyed bundle home from the hospital, you'll wake to find that a beautiful cherub has taken its place in the crib.

Oddly shaped head. At birth, the infant's head is, proportionately, the largest part of the body, with a circumference as large as his or her chest. As your baby grows, the rest of the body will catch up. Often, the head has molded to fit through Mom's pelvis, giving it an odd, possibly pointed "cone" shape. Pressing against an inadequately dilated cervix can further distort the head by raising a lump. The lump will disappear in a day or two, the molding within two weeks, at which point your baby's head will begin to take on that cherubic roundness. At birth, the infant's head is, proportionately, the largest part of the body, with a circumference as large as his or her chest. As your baby grows, the rest of the body will catch up. Often, the head has molded to fit through Mom's pelvis, giving it an odd, possibly pointed "cone" shape. Pressing against an inadequately dilated cervix can further distort the head by raising a lump. The lump will disappear in a day or two, the molding within two weeks, at which point your baby's head will begin to take on that cherubic roundness.

Newborn hair. The hair that covers the baby's head at birth may have little resemblance to the hair the baby will have later. Some newborns are virtually bald, some have thick manes, but most have a light cap of soft hair. All eventually lose their newborn hair (though this may happen so gradually that you don't notice), and it will be replaced by new growth, possibly of a different color and texture. The hair that covers the baby's head at birth may have little resemblance to the hair the baby will have later. Some newborns are virtually bald, some have thick manes, but most have a light cap of soft hair. All eventually lose their newborn hair (though this may happen so gradually that you don't notice), and it will be replaced by new growth, possibly of a different color and texture.

Vernix caseosa coating. The cheesy substance that coats the fetus in the uterus is believed to protect the skin from the long exposure to the amniotic fluid. Premature babies have quite a bit of this coating at birth; on-time babies just a little; postmature babies have almost none, except possibly in the folds of their skin and under their fingernails. The cheesy substance that coats the fetus in the uterus is believed to protect the skin from the long exposure to the amniotic fluid. Premature babies have quite a bit of this coating at birth; on-time babies just a little; postmature babies have almost none, except possibly in the folds of their skin and under their fingernails.

Swelling of the genitals. This can occur in both male and female newborns. The breasts of newborns, male and female, may also be swollen (occasionally even engorged, secreting a white or pink substance nicknamed "witch's milk") due to stimulation by maternal hormones. The hormones may also stimulate a milky-white, even blood-tinged, vaginal secretion in girls. These effects are normal and disappear in a week to 10 days. This can occur in both male and female newborns. The breasts of newborns, male and female, may also be swollen (occasionally even engorged, secreting a white or pink substance nicknamed "witch's milk") due to stimulation by maternal hormones. The hormones may also stimulate a milky-white, even blood-tinged, vaginal secretion in girls. These effects are normal and disappear in a week to 10 days.

Puffy eyes. Swelling around the newborn's eyes, normal for someone who's been soaking in amniotic fluid for nine months and then squeezed through a narrow birth canal, may be exacerbated by the ointment used to protect the eyes from infection. It disappears within a few days. Caucasian babies' eyes are often, but not always, a slate blue, no matter what color they will be later on. In babies of color, the eyes are usually brown at birth. Swelling around the newborn's eyes, normal for someone who's been soaking in amniotic fluid for nine months and then squeezed through a narrow birth canal, may be exacerbated by the ointment used to protect the eyes from infection. It disappears within a few days. Caucasian babies' eyes are often, but not always, a slate blue, no matter what color they will be later on. In babies of color, the eyes are usually brown at birth.

Skin. Your baby's skin will appear pink, white, or even grayish at birth (even if it will eventually turn brown or black). That's because pigmentation doesn't show up until a few hours after birth. A variety of rashes, tiny "pimples," and whiteheads may also mar your baby's skin thanks to maternal hormones, but all are temporary. You may also notice skin dryness and cracking, due to first-time exposure to air; these, too, will pass. Your baby's skin will appear pink, white, or even grayish at birth (even if it will eventually turn brown or black). That's because pigmentation doesn't show up until a few hours after birth. A variety of rashes, tiny "pimples," and whiteheads may also mar your baby's skin thanks to maternal hormones, but all are temporary. You may also notice skin dryness and cracking, due to first-time exposure to air; these, too, will pass.

Lanugo. Fine downy hair, called lanugo, may cover the shoulders, back, forehead, and temples of full-term babies. This will usually be shed by the end of the first week. Such hair can be more abundant, and will last longer, in a premature baby and may be gone in a postmature one. Fine downy hair, called lanugo, may cover the shoulders, back, forehead, and temples of full-term babies. This will usually be shed by the end of the first week. Such hair can be more abundant, and will last longer, in a premature baby and may be gone in a postmature one.

Birthmarks. A reddish blotch at the base of the skull, on the eyelid, or on the forehead, called a salmon patch, is very common, especially in Caucasian newborns. Mongolian spots-bluish-gray pigmentation of the deep skin layer that can appear on the back, buttocks, and sometimes the arms and thighs-are more common in Asians, southern Europeans, and blacks. These markings eventually disappear, usually by the time a child is 4 years old. Hemangiomas, elevated strawberry-colored birthmarks, vary from tiny to about quarter size or even larger. They eventually fade to a mottled pearly gray, then often disappear entirely. Coffee-with-cream colored (cafe-au-lait) spots can appear anywhere on the body; they are usually inconspicuous and don't fade. A reddish blotch at the base of the skull, on the eyelid, or on the forehead, called a salmon patch, is very common, especially in Caucasian newborns. Mongolian spots-bluish-gray pigmentation of the deep skin layer that can appear on the back, buttocks, and sometimes the arms and thighs-are more common in Asians, southern Europeans, and blacks. These markings eventually disappear, usually by the time a child is 4 years old. Hemangiomas, elevated strawberry-colored birthmarks, vary from tiny to about quarter size or even larger. They eventually fade to a mottled pearly gray, then often disappear entirely. Coffee-with-cream colored (cafe-au-lait) spots can appear anywhere on the body; they are usually inconspicuous and don't fade.

Once your baby's head emerges, your practitioner will suction your baby's nose and mouth to remove excess mucus, then assist the shoulders and torso out. You usually only have to give one more small push to help with that-the head was the hard part, and the rest slides out pretty easily. The umbilical cord will be clamped (usually after it stops pulsating) and cut-either by the practitioner or by your coach-and your baby will be handed to you or placed on your belly. (If you've arranged for cord blood collection, it will be done now.) This is a great time for some caressing and skin-to-skin contact, so lift up your gown and bring baby close. In case you need a reason to do that, studies show that infants who have skin-to-skin contact with their mothers just after delivery sleep longer and are calmer hours later.

What's next for your baby? The nurses and/or a pediatrician will evaluate his or her condition, and rate it on the Apgar scale at one minute and five minutes after birth (see box, page 379 page 379); give a brisk, stimulating, and drying rubdown; possibly take the baby's footprints for a keepsake; attach an identifying band to your wrist and to your baby's ankle; administer nonirritating eye ointment to your newborn to prevent infection (you can ask that the ointment be administered after you've had time to cuddle with your newborn); weigh, then wrap the baby to prevent heat loss. (In some hospitals and birthing centers, some of these procedures may be omitted; in others, many will be attended to later, so you can have more time to bond with your newborn.) Then you'll get your baby back (assuming all is well) and you may, if you wish to, begin breastfeeding (but don't worry if you and/or your baby don't catch on immediately; see Getting Started Breastfeeding, page 435 page 435).

Sometime after that, it's off to the nursery for baby (if you've delivered in a hospital) for a more complete pediatric exam and some routine protective procedures (including a heel stick and a hepatitis B shot). Once your baby's temperature is stable, he or she will get a first bath, which you (and/or dad) may be able to help give. If you have rooming-in, your baby will be returned as soon as possible and tucked into a bassinet next to your bed.

For the Coach: What You Can Do. Once again, these responsibilities can be shared with a doula. Once again, these responsibilities can be shared with a doula.

[image] Continue giving comfort and support (a whispered "I love you" can be more valuable to her during the pushing stage than anything else), but don't feel hurt if the object of your efforts doesn't seem to notice you're there. Her energies are necessarily focused elsewhere. Continue giving comfort and support (a whispered "I love you" can be more valuable to her during the pushing stage than anything else), but don't feel hurt if the object of your efforts doesn't seem to notice you're there. Her energies are necessarily focused elsewhere.[image] Help her relax between the contractions-with soothing words, a cool cloth applied to forehead, neck, and shoulders, and, if feasible, back massage or counterpressure to help ease backache. Help her relax between the contractions-with soothing words, a cool cloth applied to forehead, neck, and shoulders, and, if feasible, back massage or counterpressure to help ease backache.[image] Continue to supply ice chips or fluids to moisten her mouth as needed. She's likely to be parched from all that pushing. Continue to supply ice chips or fluids to moisten her mouth as needed. She's likely to be parched from all that pushing.[image] Support her back while she's pushing, if necessary; hold her hand, wipe her brow-or do whatever else seems to help her. If she slips out of position, help her back into it. Support her back while she's pushing, if necessary; hold her hand, wipe her brow-or do whatever else seems to help her. If she slips out of position, help her back into it.[image] Periodically point out her progress. As the baby begins to crown, remind her to keep an eye on the mirror so she can have visual confirmation of what she is accomplishing. When she's not looking, or if there's no mirror, give her inch-by-inch descriptions. Take her hand and touch baby's head together for renewed inspiration. Periodically point out her progress. As the baby begins to crown, remind her to keep an eye on the mirror so she can have visual confirmation of what she is accomplishing. When she's not looking, or if there's no mirror, give her inch-by-inch descriptions. Take her hand and touch baby's head together for renewed inspiration.[image] If you're offered the opportunity to catch your baby as he or she emerges or, later, to cut the cord, don't be afraid. Both are relatively easy jobs, and you'll get step-by-step directions and backup from the attendants. You should know, however, that the cord can't be snipped like a piece of string. It's tougher than you may think. If you're offered the opportunity to catch your baby as he or she emerges or, later, to cut the cord, don't be afraid. Both are relatively easy jobs, and you'll get step-by-step directions and backup from the attendants. You should know, however, that the cord can't be snipped like a piece of string. It's tougher than you may think.

Stage Three: Delivery of the Placenta The worst is over, and the best has already come. All that remains is tying up the loose ends, so to speak. During this final stage of childbirth (which generally lasts anywhere from five minutes to half an hour or more), the placenta, which has been your baby's life support inside the womb, will be delivered. You will continue to have mild contractions approximately a minute in duration, though you may not feel them (after all, you're preoccupied with your newborn!). The squeezing of the uterus separates the placenta from the uterine wall and moves it down into the lower segment of the uterus or into the vagina so it can be expelled.

Your practitioner will help deliver the placenta by either pulling the cord gently with one hand while pressing and kneading your uterus with the other or exerting downward pressure on the top of the uterus, asking you to push at the appropriate time. You might get some Pitocin (oxytocin) via injection or in your IV to encourage uterine contractions, which will speed expulsion of the placenta, help shrink the uterus back to size, and minimize bleeding. Once the placenta is out, your practitioner will examine it to make sure it's intact. If it isn't, he or she will inspect your uterus manually for placental fragments and remove any that remain.

Now that the work of labor and delivery is done, you may feel overwhelmingly exhausted or, conversely, experience a burst of renewed energy. If you've been deprived of food and drink, you are likely to be very thirsty and, especially if labor has been long, hungry. Some women experience chills in this stage; all experience a bloody vaginal discharge (called lochia) comparable to a heavy menstrual period.

How will you feel emotionally after you've delivered your baby? Every woman reacts a little differently, and your reaction is normal for you. Your first emotional response may be joy, but it's just as likely to be a sense of relief. You may be exhilarated and talkative, elated and excited, a little impatient at having to push out the placenta or submit to the repair of an episiotomy or a tear, or so in awe of what you're cuddling in your arms (or so beat, or a little bit of both) that you don't notice. You may feel a closeness to your spouse and an immediate bond with your new baby, or (and this is just as normal) you may feel somewhat detached (who is this stranger sniffing at my breast?), even a little resentful-particularly if the delivery was a difficult one (so this is the little person who made me suffer so much!). No matter what your response now, you will come to love your baby intensely. These things just sometimes take time. (For more on bonding, see page 430 page 430.) What You Can Do.

[image] Have a good cuddle with your new arrival! Once the cord is cut, you'll have a chance to breastfeed or just do some snuggling. Speak up, too. Since your baby will recognize your voice, cooing, singing, or whispered words will be especially comforting (it's a strange new world, and you'll be able to help baby make some sense out of it). Under some circumstances, your baby may be kept in a heated bassinet for a while or be held by your coach while the placenta is being delivered-but not to worry, there's plenty of time for baby bonding. Have a good cuddle with your new arrival! Once the cord is cut, you'll have a chance to breastfeed or just do some snuggling. Speak up, too. Since your baby will recognize your voice, cooing, singing, or whispered words will be especially comforting (it's a strange new world, and you'll be able to help baby make some sense out of it). Under some circumstances, your baby may be kept in a heated bassinet for a while or be held by your coach while the placenta is being delivered-but not to worry, there's plenty of time for baby bonding.[image] Spend some time bonding with your coach, too-and enjoying your cozy new threesome. Spend some time bonding with your coach, too-and enjoying your cozy new threesome.[image] Help deliver the placenta, if necessary, by pushing when directed. Some women don't even have to push at all for the placenta to arrive. Your practitioner will let you know what to do, if anything. Help deliver the placenta, if necessary, by pushing when directed. Some women don't even have to push at all for the placenta to arrive. Your practitioner will let you know what to do, if anything.[image] Hang in there during repair of any episiotomy or tears. Hang in there during repair of any episiotomy or tears.[image] Take pride in your accomplishment! Take pride in your accomplishment!

All that's left to do, then, is for your practitioner to stitch up any tear (if you're not already numbed, you'll get a local anesthetic) and clean you up. You'll likely get an ice pack to put on your perineum to minimize swelling-do ask for one if it's not offered. The nurse will also help you put on a maxipad or add some thick pads under your bottom (remember, you'll be bleeding a lot). Once you're feeling up to it, you'll be transferred to a postpartum room (unless you've delivered in an LDRP-a labor, delivery, recovery, and postpartum-room, in which case you'll get to stay put).

For the Coach: What You Can Do. If a doula is present, she can continue to help out, concentrating on the more practical aspects of postdelivery care while you spend some quality time with the two stars of the show. If a doula is present, she can continue to help out, concentrating on the more practical aspects of postdelivery care while you spend some quality time with the two stars of the show.

[image] Offer some well-earned words of praise to the new mom-and congratulate yourself, too, for a job well done. Offer some well-earned words of praise to the new mom-and congratulate yourself, too, for a job well done.[image] Begin bonding with your little one-with some holding and cuddling, and by doing soft singing or talking. Remember, your baby has heard your voice a lot during his or her stay in the uterus and is familiar with its sound. Hearing it now will bring comfort in this strange new environment. Begin bonding with your little one-with some holding and cuddling, and by doing soft singing or talking. Remember, your baby has heard your voice a lot during his or her stay in the uterus and is familiar with its sound. Hearing it now will bring comfort in this strange new environment.[image] Don't forget to do some cuddling and bonding with the new mom, too. Don't forget to do some cuddling and bonding with the new mom, too.[image] Ask for an ice pack to soothe her perineal area, if the nurse doesn't offer one. Ask for an ice pack to soothe her perineal area, if the nurse doesn't offer one.[image] Ask for some juice for the new mom; she may be very thirsty. After she's been rehydrated, and if both of you are in the mood, break out the bubbly-champagne or sparkling cider if you brought some along. Ask for some juice for the new mom; she may be very thirsty. After she's been rehydrated, and if both of you are in the mood, break out the bubbly-champagne or sparkling cider if you brought some along.[image] If you've brought along the necessary equipment, take baby's first photos or capture your amazing newborn on video. If you've brought along the necessary equipment, take baby's first photos or capture your amazing newborn on video.

Cesarean Delivery You won't be able to participate actively at a cesarean delivery the way you would at a vaginal one, and some would consider that a definite plus. Instead of huffing, puffing, and pushing your baby into the world, you'll get to lie back and let everybody else do all the heavy lifting. In fact, your most important contribution to your baby's cesarean birth will be preparation: The more you know, the more comfortable you'll feel. Which is why it's a good idea to look this section over ahead of time, even if you're not having a planned cesarean.

Thanks to regional anesthesia and the liberalization of hospital regulations, most women (and their coaches) are able to be spectators at their cesarean deliveries. Because they aren't preoccupied with pushing or pain, they're often able to relax (at least to some degree) and marvel at the birth. This is what you can expect in a typical cesarean birth: [image] An IV infusion will be started (if it isn't already in) to provide speedy access if additional medications or fluids are needed. An IV infusion will be started (if it isn't already in) to provide speedy access if additional medications or fluids are needed.[image] Anesthesia will be administered: either an epidural or a spinal block (both of which numb the lower part of your body but don't knock you out). In rare emergency situations, when a baby must be delivered immediately, a general anesthetic (which does put you to sleep) may be used. Anesthesia will be administered: either an epidural or a spinal block (both of which numb the lower part of your body but don't knock you out). In rare emergency situations, when a baby must be delivered immediately, a general anesthetic (which does put you to sleep) may be used.[image] Your abdomen will be washed down with an antiseptic solution. A catheter (a narrow tube) will be inserted into your bladder to keep it empty and out of the surgeon's way. Your abdomen will be washed down with an antiseptic solution. A catheter (a narrow tube) will be inserted into your bladder to keep it empty and out of the surgeon's way.[image] Sterile drapes will be arranged around your exposed abdomen. A screen will be put up at about shoulder level so you won't have to see the incision being made. Sterile drapes will be arranged around your exposed abdomen. A screen will be put up at about shoulder level so you won't have to see the incision being made.[image] If your coach is going to attend the delivery, he will be suited up in sterile garb. He will sit near your head so that he can give you emotional support and hold your hand; he may have the option of viewing the actual surgery. If your coach is going to attend the delivery, he will be suited up in sterile garb. He will sit near your head so that he can give you emotional support and hold your hand; he may have the option of viewing the actual surgery.[image] If yours is an emergency cesarean, things may move very quickly. Try to stay calm and focused in the face of all that activity, and don't let it worry you-that's just the way things work in a hospital sometimes. If yours is an emergency cesarean, things may move very quickly. Try to stay calm and focused in the face of all that activity, and don't let it worry you-that's just the way things work in a hospital sometimes.[image] Once the physician is certain that the anesthetic has taken effect, an incision (usually a horizontal bikini cut) is made in the lower abdomen, just above the pubic hairline. You may feel a sensation of being "unzipped" but no pain. Once the physician is certain that the anesthetic has taken effect, an incision (usually a horizontal bikini cut) is made in the lower abdomen, just above the pubic hairline. You may feel a sensation of being "unzipped" but no pain.[image] A second incision is then made, this time in your uterus. The amniotic sac is opened, and, if it hasn't already ruptured, the fluid is suctioned out; you may hear a sort of gurgling or swooshing sound. A second incision is then made, this time in your uterus. The amniotic sac is opened, and, if it hasn't already ruptured, the fluid is suctioned out; you may hear a sort of gurgling or swooshing sound.[image] The baby is then eased out, usually while an assistant presses on the uterus. With an epidural (though not likely with a spinal block), you will probably feel some pulling and tugging sensations, as well as some pressure. If you're eager to see your baby's arrival, ask the doctor if the screen can be lowered slightly, which will allow you to see the actual birth but not the more graphic details. The baby is then eased out, usually while an assistant presses on the uterus. With an epidural (though not likely with a spinal block), you will probably feel some pulling and tugging sensations, as well as some pressure. If you're eager to see your baby's arrival, ask the doctor if the screen can be lowered slightly, which will allow you to see the actual birth but not the more graphic details.[image] Your baby's nose and mouth are then suctioned; you'll hear the first cry, the cord will be quickly clamped and cut, and you'll be allowed a quick glimpse of your newborn. Your baby's nose and mouth are then suctioned; you'll hear the first cry, the cord will be quickly clamped and cut, and you'll be allowed a quick glimpse of your newborn.[image] While the baby is getting the same routine attention that a vaginally delivered infant receives, the doctor will remove the placenta. While the baby is getting the same routine attention that a vaginally delivered infant receives, the doctor will remove the placenta.[image] Now the doctor will quickly do a routine check of your reproductive organs and stitch up the incisions that were made. The uterine incision will be repaired with absorbable stitches, which do not have to be removed. The abdominal incision may be closed with either stitches or surgical staples. Now the doctor will quickly do a routine check of your reproductive organs and stitch up the incisions that were made. The uterine incision will be repaired with absorbable stitches, which do not have to be removed. The abdominal incision may be closed with either stitches or surgical staples.[image] An injection of oxytocin may be given intramuscularly or into your IV, to help contract the uterus and control bleeding. IV antibiotics may be given to minimize the chances of infection. An injection of oxytocin may be given intramuscularly or into your IV, to help contract the uterus and control bleeding. IV antibiotics may be given to minimize the chances of infection.

You may have some cuddling time in the delivery room, but a lot will depend on your condition and the baby's, as well as hospital rules. If you can't hold your baby, perhaps your spouse can. If he or she has to be whisked away to the NICU nursery, don't let it get you down. This is standard in many hospitals following a cesarean delivery and is more likely to indicate a precaution than a problem with your baby's condition. And as far as bonding is concerned, later can be just as good as sooner-so not to worry if the snuggles have to wait a little while.

Congratulations-You've done it ...

Now relax and enjoy your new baby!

PART 3.

Twins, Triplets & More When You're Expecting Multiples

CHAPTER 16.

Expecting More Than One.

HAVE TWO (OR MORE) PASSENGERS aboard the mother ship? Even if you'd been hoping for multiples, your first response to the news that you're carrying more than one can be all over the emotional map-ranging from disbelief to joy, from excitement to trepidation (make that fear). And in between all the whoops of delight and buckets of tears will come the questions: Will the babies be healthy? Will I be healthy? Will I be able to stick with my regular practitioner, or will I have to see a specialist? How much food will I have to eat, and how much weight do I have to gain? Will there be enough room inside of me for two babies? Will there be enough room in my house for two babies? Will I be able to carry them to term? Will I have to go on bed rest? Will giving birth be twice as hard? aboard the mother ship? Even if you'd been hoping for multiples, your first response to the news that you're carrying more than one can be all over the emotional map-ranging from disbelief to joy, from excitement to trepidation (make that fear). And in between all the whoops of delight and buckets of tears will come the questions: Will the babies be healthy? Will I be healthy? Will I be able to stick with my regular practitioner, or will I have to see a specialist? How much food will I have to eat, and how much weight do I have to gain? Will there be enough room inside of me for two babies? Will there be enough room in my house for two babies? Will I be able to carry them to term? Will I have to go on bed rest? Will giving birth be twice as hard?

Seeing Double-Everywhere?

If it looks like multiples are multiplying these days, it's because they are. In fact, about 3 percent of babies in the United States are now born in sets of two, three, or more, with the majority (about 95 percent) of these multiple births comprised of twins. At least twice as amazing, the number of twin births has jumped more than 50 percent in recent years, and higher-order multiple births (triplets and more) has risen an astonishing 400 percent.

So what's up with this multiple-baby boom? The surge in older moms has a lot to do with it. Moms over the age of 35 are naturally more likely to drop more than one egg at ovulation (thanks to greater hormone fluctuations, specifically FSH, or follicle-stimulating hormone), upping the odds of having twins. Another factor is the increase in fertility treatments (also more common among older moms), which multiplies the chances of a multiple pregnancy. And yet another surprising factor, say some experts, might be the increase in obesity. Women with prepregnancy BMIs higher than 30 are significantly more likely to have fraternal twins than women with lower BMIs.

Carrying one baby comes with its share of challenges and changes; carrying more than one-well, you've probably already done the math. But not to worry. You're up for it-or at least you will be once you're armed with the information in this chapter (and the support of your partner and your practitioner). So sit back (comfortably, while you still can) and get ready for your marvelous multiple pregnancy.

What You May Be Wondering About Detecting a Multiple Pregnancy "I just found out I'm pregnant and I have a feeling it's twins. How will I find out for sure?"

Gone are the days when multiples took their parents by surprise in the delivery room. Today, most parents-to-be of multiples discover the exciting news pretty early on. Here's how: Ultrasound. The proof is in the picture-the ultrasound picture, that is. If you're looking for indisputable confirmation that you're carrying more than one baby, an ultrasound is the best way to get it. Even an early first-trimester ultrasound done at six to eight weeks (which you're very likely to have if your blood hCG level is high or if you've conceived using fertility treatments, though some practitioners also do them routinely) can sometimes detect multiples. But if you want to be absolutely sure you're seeing double, you'll want to look to an ultrasound done after the 12th week (because very early ultrasounds don't always uncover both babies). The proof is in the picture-the ultrasound picture, that is. If you're looking for indisputable confirmation that you're carrying more than one baby, an ultrasound is the best way to get it. Even an early first-trimester ultrasound done at six to eight weeks (which you're very likely to have if your blood hCG level is high or if you've conceived using fertility treatments, though some practitioners also do them routinely) can sometimes detect multiples. But if you want to be absolutely sure you're seeing double, you'll want to look to an ultrasound done after the 12th week (because very early ultrasounds don't always uncover both babies).

Doppler. The beat goes on ... and on. Your practitioner can usually pick up a baby's heartbeat sometime after the ninth week. And though it's hard to distinguish two heartbeats with just a Doppler, if your practitioner is an experienced listener and thinks he or she detects two distinct beats, there's a good chance that you're carrying multiples (an ultrasound will confirm the news). The beat goes on ... and on. Your practitioner can usually pick up a baby's heartbeat sometime after the ninth week. And though it's hard to distinguish two heartbeats with just a Doppler, if your practitioner is an experienced listener and thinks he or she detects two distinct beats, there's a good chance that you're carrying multiples (an ultrasound will confirm the news).

Hormone levels. The pregnancy hormone hCG is detectable in your urine about 10 days postconception, and its level rises rapidly throughout the first trimester. Sometimes (but not always), a higher-than-usual hCG level may indicate multiple fetuses. That said, the range of normal hCG levels for twins also falls within the normal range for singletons, so an elevated level of hCG does not, in and of itself, indicate a multiple pregnancy. The pregnancy hormone hCG is detectable in your urine about 10 days postconception, and its level rises rapidly throughout the first trimester. Sometimes (but not always), a higher-than-usual hCG level may indicate multiple fetuses. That said, the range of normal hCG levels for twins also falls within the normal range for singletons, so an elevated level of hCG does not, in and of itself, indicate a multiple pregnancy.

Fraternal or Identical?

Fraternal twins (first image), which result from two eggs being fertilized at the same time, each have their own placenta. Identical twins (second image), which come from one fertilized egg that splits and then develops into two separate embryos, may share a placenta or-depending on when the egg splits-may each have their own.

Fraternal twins are the more common type of twin, with your chances of having fraternal twins increasing with your age and the number of children you have. Your chance of having twins in general increases if you have twins in your family on your mother's side.

Test results. An unusually high (positive) result on the triple (or quad) screen (see An unusually high (positive) result on the triple (or quad) screen (see page 63 page 63) in the second trimester can sometimes indicate a multiple pregnancy.

Your measurements. Not surprisingly, the more babies, the bigger the uterus. At each visit, your practitioner feels for the height of the fundus (the top of your uterus) to measure that growth. Measuring larger than would be expected for gestational age may be a sign that you have more than one baby on board (but not always; see Not surprisingly, the more babies, the bigger the uterus. At each visit, your practitioner feels for the height of the fundus (the top of your uterus) to measure that growth. Measuring larger than would be expected for gestational age may be a sign that you have more than one baby on board (but not always; see page 162 page 162).

Bottom line on your hunch: Lots of clues can point to a multiple pregnancy (including your mom-to-be instincts), but only an ultrasound can tell you for sure. Check with your practitioner.

Choosing a Practitioner "I just found out I'm having twins. Can I use my regular ob-gyn, or do I need to see a specialist?"

If you're happy with your practitioner, there's no reason to trade in for a specialist's care just because you have two babies to care for. (Just make sure you are really happy with your practitioner, since you'll be spending more time with him or her during your twin pregnancy-more babies equals more office visits). Even if your regular practitioner is a midwife, you'll likely be able to continue seeing her as long as you also have a physician on board for regular checkups and for delivery.

Do you like your regular ob but also like the idea of extra-careful care? Many ob-gyn practices send patients who are pregnant with multiples to a specialist for periodic consultations-a good compromise if you'd like to combine the familiar comfort of your practitioner's care with the expertise of a specialist's. Moms-to-be of multiples who have specific special needs (such as advanced age, history of miscarriage, or a chronic health condition) may want to consider switching to a maternal-fetal medicine specialist (also known as a perinatologist). Talk that possibility over with your practitioner if your pregnancy falls into a higher risk category.

When choosing a practitioner for your multiple pregnancy, you'll also need to factor in his or her hospital affiliation. Ideally, you'll want a facility with the ability to care for premature babies (one with a neonatal intensive care unit) in case your bundles arrive early, as multiples often do.

Also ask about the practitioner's policy on topics specifically related to multiple births: Will you be induced at 37 or 38 weeks as a matter of course, or will you have the option of carrying beyond that time frame if all is going well? Will a vaginal birth be possible, or does the practitioner routinely deliver multiples via cesarean delivery? Will you be able to give birth in an LDR (labor and delivery room), or is it routine to deliver multiples in an OR as a precautionary measure?

For more general information about choosing a practitioner, see page 21 page 21.

Pregnancy Symptoms "I've heard that when you're pregnant with twins, your pregnancy symptoms are worse than with just one baby. Is that true?"

Twice the babies sometimes spell twice the pregnancy discomforts, but not always. Every multiple pregnancy, like every singleton pregnancy, is different. An expectant mom of one may suffer enough morning sickness for two, while a mom-to-be of multiples might sail through her pregnancy without a single queasy day. The same with other symptoms, too.

But though you shouldn't expect a double dose of morning sickness (or heartburn, or leg cramps, or varicose veins), you can't count it out. The miseries do, on average, multiply in a multiple pregnancy, and that's not surprising given the extra weight you'll be carrying around and the extra hormones you're already generating. Among the symptoms that might be-but won't necessarily be-exponentially exacerbated when you're expecting twins or more: [image] Morning sickness. Nausea and vomiting can be worse in a multiple pregnancy, thanks to-among other things-the higher levels of hormones circulating in a mom's system. Morning sickness can also start earlier and last longer. Morning sickness. Nausea and vomiting can be worse in a multiple pregnancy, thanks to-among other things-the higher levels of hormones circulating in a mom's system. Morning sickness can also start earlier and last longer.[image] Other tummy troubles. Hello, heartburn, indigestion, and constipation. More gastric crowding (and more gastric overloading, since moms of multiples are eating for three or more) can lead to an increase in the kinds of digestive discomforts pregnancy's known for. Other tummy troubles. Hello, heartburn, indigestion, and constipation. More gastric crowding (and more gastric overloading, since moms of multiples are eating for three or more) can lead to an increase in the kinds of digestive discomforts pregnancy's known for.[image] Fatigue. This is a no-brainer: The more weight you're dragging around, the more you're likely to drag. Fatigue can also increase with the extra energy an expectant mom of multiples expends (your body has to work twice as hard to grow two babies). Sleep deprivation can also wear you out (it's difficult enough to settle down with a watermelon-size belly, let alone one that's the size of two watermelons). Fatigue. This is a no-brainer: The more weight you're dragging around, the more you're likely to drag. Fatigue can also increase with the extra energy an expectant mom of multiples expends (your body has to work twice as hard to grow two babies). Sleep deprivation can also wear you out (it's difficult enough to settle down with a watermelon-size belly, let alone one that's the size of two watermelons).[image] All those other physical discomforts. Every pregnancy comes with its share of aches and pains; your twin pregnancy might just come with a little more than its share. Toting that extra baby can translate to extra backache, pelvic twinges, crampiness, swollen ankles, varicose veins, you name it. Breathing for three or more can also seem an extra effort, especially as your babies get big enough to push up on your lungs. All those other physical discomforts. Every pregnancy comes with its share of aches and pains; your twin pregnancy might just come with a little more than its share. Toting that extra baby can translate to extra backache, pelvic twinges, crampiness, swollen ankles, varicose veins, you name it. Breathing for three or more can also seem an extra effort, especially as your babies get big enough to push up on your lungs.[image] Fetal movement. Though every pregnant woman might feel at some point that she's expecting an octopus, the eight limbs you'll be carrying will really pack a punch. Make that many punches, and kicks. Fetal movement. Though every pregnant woman might feel at some point that she's expecting an octopus, the eight limbs you'll be carrying will really pack a punch. Make that many punches, and kicks.

Whether your pregnancy ends up bestowing you with double the discomforts or not, one thing's for sure-it'll also bestow you with twice the rewards. Not bad, for nine months' work.

Eating Well with Multiples "I'm committed to eating well now that I'm pregnant with triplets, but I'm not sure what that means-eating three times as much?"

Belly up to the buffet table, Mom-feeding four means it's always time to chow down. While you won't literally have to quadruple your daily intake (any more than a woman expecting a single baby has to double it), you will need to do some serious eating in the months to come. Moms-to-be of multiples should indulge in an extra 150 to 300 calories a day per fetus, doctor's orders (good news if you're looking for a license to eat, not so good news if queasiness or tummy crowding has your appetite cramped). Which translates to an extra 300 to 600 calories if you're carrying twins, an extra 450 to 900 calories for triplets (if you've started out with an average prepregnancy weight). But before you take that extra allotment as a free pass to Burritoville (extra guacamole for Baby A; extra sour cream for Baby B; refried beans for Baby C), think again. The quality of what you eat will be just as important as the quantity. In fact, good nutrition during a multiple pregnancy has an even greater impact on baby birthweight than it does during a singleton pregnancy.

So just how do you eat well when you're expecting more than one? Check out the Pregnancy Diet (see Chapter 5) and: Keep it small. The bigger your belly gets, the smaller you'll want your meals to stay. Not only will grazing on five or six healthy mini meals and snacks ease your digestive overload (and your tummy crowding), but it'll keep your energy up-while delivering the same nutritional bottom line as three squares. The bigger your belly gets, the smaller you'll want your meals to stay. Not only will grazing on five or six healthy mini meals and snacks ease your digestive overload (and your tummy crowding), but it'll keep your energy up-while delivering the same nutritional bottom line as three squares.

Make your calories count. Pick foods that pack plenty of nutrients into small servings. Studies show that a high- calorie diet that's also high in nutrients significantly improves your chances of having healthy full-term babies. Wasting too much of that premium space on junk food, on the other hand, means you'll have less room for nutritious food. Pick foods that pack plenty of nutrients into small servings. Studies show that a high- calorie diet that's also high in nutrients significantly improves your chances of having healthy full-term babies. Wasting too much of that premium space on junk food, on the other hand, means you'll have less room for nutritious food.

Go for extra nutrients. Not surprisingly, your need for nutrients multiplies with each baby-which means you'll have to tack on some extra servings to your Daily Dozen (see Not surprisingly, your need for nutrients multiplies with each baby-which means you'll have to tack on some extra servings to your Daily Dozen (see page 93 page 93). It's usually recommended that women carrying multiples get one extra serving of protein, one extra serving of calcium, and one extra serving of whole grains. Be sure to ask your practitioner what he or she recommends in your case.

Pump up the iron. Another nutrient you'll need to ramp up is iron, which helps your body manufacture red blood cells (you'll need lots of those for the increased blood your multiple-baby factory will be using) and helps keep you from becoming anemic, which often happens in multiple pregnancies. Red meat, dried fruit, pumpkin seeds, and spinach are great sources of iron (you can find more iron-rich foods on Another nutrient you'll need to ramp up is iron, which helps your body manufacture red blood cells (you'll need lots of those for the increased blood your multiple-baby factory will be using) and helps keep you from becoming anemic, which often happens in multiple pregnancies. Red meat, dried fruit, pumpkin seeds, and spinach are great sources of iron (you can find more iron-rich foods on page 100 page 100). Your prenatal vitamin and possibly a separate iron supplement should fill in the rest; ask your practitioner.

Keep the water flowing. Dehydration can lead to preterm labor (something moms-to-be of multiples are already at risk for), so make sure you drink at least eight 8-ounce glasses of liquid a day. Dehydration can lead to preterm labor (something moms-to-be of multiples are already at risk for), so make sure you drink at least eight 8-ounce glasses of liquid a day.

For more information on eating well for multiples, check out What to Expect: Eating Well When You're Expecting. What to Expect: Eating Well When You're Expecting.

Weight Gain "I know I'm supposed to gain more weight with twins, but just how much more?"

Get ready to gain. Most practitioners advise a woman expecting twins to gain 35 to 45 pounds and a woman expecting triplets to gain an average of 50 pounds (a little less if you were overweight prepregnancy; a little more if you were underweight). Sounds like a piece of cake, right? Or maybe two pieces of cake (or heck, maybe the whole cake). But the reality is, gaining enough weight isn't always as easy as it seems when you've got two-or more-on board. In fact, a variety of challenges you may face throughout your pregnancy can keep the numbers on the scale from climbing fast enough.

Standing between you and weight gain in the first trimester might be nausea, which can make it difficult to get food down-and then keep it down. Eating tiny amounts of comforting (and, hopefully, sometimes nutritious) food throughout the day can help get you through those probably queasy months. Aim for a pound-a-week gain through the first trimester, but if you find you can't gain that much, or have trouble gaining any at all, relax. You can have fun catching up later. Just be sure to take your prenatal vitamin and stay hydrated.