Maternity Leave from Babycenter.com

What is maternity leave?
Maternity leave, now often called parental or family leave, is the time a mother (or father) takes off from work for the birth or adoption of a child. Actual paid "maternity leave" — while the norm in every other developed country — is unusual in the United States, although some enlightened companies do offer new parents paid time off, up to six weeks in some cases.

Most likely, you'll use a combination of short-term disability (STD), sick leave, vacation, personal days, and unpaid family leave during your time away from work.

The picture did improve in 1993 with the passage of the Family and Medical Leave Act (FMLA), which entitles most workers to up to 12 weeks of job-protected medical leave for birth or adoption. However, the FMLA doesn't cover those who work for smaller companies and guarantees only unpaid leaves.

Which benefits are available to you will depend very much on which state you live in. In 2002, California led the way in enacting paid family leave, and other states such as Massachusetts and New Jersey are considering following suit. And not all states allow women to take short-term disability leave to cover pregnancy, birth, and postpartum recovery.

Your employer may have policies that dictate the order in which you can take different kinds of leave. In any case, you'll want to start looking into your options as early as you can during your pregnancy and make sure you have all your paperwork sorted out before the baby arrives.

How does short-term disability work?
Short-term disability is meant to cover your salary — or a portion of it — during the time that you're unable to do your job due to illness, injury, or childbirth. Many large employers and unions offer it, as do several states. (It's generally provided automatically to all employees or residents, not as an optional benefit you have to sign up for.)

If your state provides STD, you may pay a small amount out of each paycheck to cover your share. If your employer or union provides it, the cost may be covered for you. If none of them provides STD, or if the coverage is insufficient, you can purchase your own policy or additional coverage through an insurance provider for a monthly premium.

Private STD insurance through your employer or a provider will generally pay between 50 and 100 percent of your salary for a certain number of weeks, depending on how many years you've worked for the company. (The maximum amount you can receive is usually capped.)

Six weeks is the standard amount of time covered for pregnancy. Some plans allow more time if you've had complications or a cesarean delivery, and many also cover bedrest before birth.

State STD benefits typically cover half to two thirds of your salary, and the coverage for pregnancy usually lasts four to six weeks but can last up to 12 weeks. In California, for example, you're covered at 55 percent of your usual salary for up to six weeks per 12-month period. You may be able to get coverage for eight weeks or longer after the birth if you've had a c-section or medical complications, but your doctor must certify this.

If both your state and your company offer STD, you may be required to use the full state benefit and have your employer's coverage make up the rest. You'll still end up with the same amount of pay as if you were getting your employer's full benefit, but you'll get it in two checks, one from the state and one from your company's provider.

Many programs require that you be out of work for up to a week before you can start to collect disability benefits. Your employer or your state's program may require you to use up your accrued sick days or vacation days before your disability benefits kick in. That's not necessarily a bad thing, as those days are paid at your full salary.

Will I have to pay income tax on disability income?
It depends on who's paying the insurance premiums for your coverage. The portion of your salary that you receive from your employer's coverage is taxable, but no income taxes will be taken out of your checks, so you'll end up owing the money in April. (On the other hand, you'll be able to take an extra deduction for having a new dependent, so that may offset the amount.)

Money you receive from a state disability program is generally not subject to federal or state income taxes. If you pay for the disability insurance yourself, the benefits you receive are also tax-free.

What do I do when my short-term disability coverage runs out?
Some new moms decide to return to work once their coverage runs out, which is typically after about six weeks. (Of course, some have to return even sooner if they're relying on a state benefit that only pays half of their normal salary and they can't afford to make up the difference.)

If you've accrued vacation, personal, or sick days, you may want to use them to extend your leave. Some companies will even allow you to take vacation or sick days that you haven't yet accrued. In some cases, however, you may be asked to reimburse the company for those days if you decide not to return to work after your leave.

You may also be eligible for unpaid disability leave. If you're unable to return to work when your STD coverage runs out, some states allow you to take a certain amount of unpaid pregnancy disability leave. (California has a particularly generous provision, allowing up to four months for women disabled by pregnancy, something that has to be certified by a doctor.)

You won't get paid during this time, but your employer will be required to hold your job for you until you're able to return (or until the leave runs out). Your employer may require that you use up your sick days before taking unpaid disability leave.

How can I find out whether I'm entitled to unpaid leave?
Start by asking your company's human resources department. Under the FMLA, many employers are required by federal law to allow their employees (both men and women) 12 weeks of unpaid leave after the birth or adoption of a child. At the end of your leave, your employer must allow you to return to your job or a similar job with the same salary, benefits, working conditions, and seniority.

You are among the 60 percent of U.S. workers who are eligible if you meet both of the following conditions:

You work for the federal government, a state or local government, or any company that has 50 or more employees working within 75 miles of your workplace.

You've worked for your employer for at least 12 months and for at least 1,250 hours during the previous year (an average of 25 hours per week for 50 weeks).

There are a few exceptions: Your employer isn't required to keep your job open for you if you're in the highest-paid 10 percent of wage earners at your company and your employer can show that your absence would cause substantial economic harm to the organization.

Another exception is if you and your partner work for the same company. In this case, you're only entitled to a combined 12 weeks of parental leave between the two of you.

Even if you're not eligible under the FMLA, you may still be eligible for leave under your state's provisions, which are usually more generous than the FMLA, or under your company's family leave policy.

Your employer may require that all the paid leave you take (STD, vacation, sick leave) count toward the 12 weeks required by the FMLA. But some states allow you to take the full 12 weeks in addition to whatever paid leave you take. Individual employers may also allow this.

You can use your unpaid leave in any way you want during your pregnancy or during the year after your child is born. That means you can take it all at once — right after the birth or placement of your child, for example — or, as long as your employer agrees, you can spread it out over your child's first year by taking it in chunks or by reducing your normal weekly or daily work schedule.

If you're considering unpaid leave, think about how much time you can reasonably afford to take. Also think about whether your partner can take any time off and when it would be best for him or her to do that.

You and your partner may decide to take leave at the same time, but if you want to stretch out the time that at least one of you is home with the baby, consider overlapping your leaves, taking them consecutively, or spreading your time off over the year.

What happens to my benefits while I'm out on leave?
According to the FMLA, your company must continue to keep you on its health insurance plan while you're on leave, whether it's disability or family leave. Most typically, a company will pay your premiums but ask to be reimbursed for your share (the amount that's usually taken out of your paycheck).

If your company is particularly generous, it may cover your share and not ask you to pay it back. However, in rare cases, your employer may choose to put you on COBRA, a program in which you continue to be covered under the same plan but you must pay the entire premium yourself (at an average of about $500 a month).

If you tell your company that you don't plan to return to work following your leave or if your job is eliminated while you're gone, your employer may stop paying your premiums and may even require you to pay back the money spent to maintain your health insurance while you were on leave. That's unless the reason you're not returning to work is that you've developed a serious medical condition or some other circumstance beyond your control (say, your spouse is transferred to a job in another city and you have to move).

The FMLA doesn't require employers to allow you to accrue benefits or time toward seniority when you're out on leave. That means the clock may stop on things like vacation accrual and the amount of time you can say you've been with the company in order to qualify for things like raises based on seniority, additional vacation days, participation in your company's 401k plan or vesting of your company's matching investment, or vesting of stock options.

Finally, you won't be able to contribute to your 401(k) or flexible spending account while you're on leave because you're not receiving a paycheck from your employer and thus can't contribute pre-tax dollars.

What if I'm adopting a child or taking in a foster child?
You're not qualified for disability leave in this case, but you are allowed 12 weeks of unpaid leave under the FMLA — or possibly more under your state's provisions or your company's policy.

Generally this leave begins once the child arrives at your home or when you leave to go get the child if you're adopting from another country. You may also be eligible to take time off during the adoption process to meet with lawyers or attend home visits. You can take paid vacation time as well, and some states and employers even allow you to use your sick leave.

How and when should I request leave?
Federal guidelines require you to request leave at least 30 days before you plan to take it, but it may be best to give your boss more advance notice — you don't want to wait until you're obviously showing to tell your employer about your pregnancy. But you may want to wait until after your first trimester, when your risk of miscarriage goes down significantly.

After that, think about breaking the news as soon as you've thought through your leave request and your post-pregnancy work schedule. You'll be in a stronger position to negotiate a leave if you approach your boss with a specific plan and allow him or her plenty of time to help you implement it. (If you have trusted co-workers who have been through this before, ask them how they handled their leave and what kind of reaction they got.)

How do I decide when to start my leave?
There's no "right time" to stop working. A lot will depend on your energy level, how easy or complicated your pregnancy becomes after the initial exhausting months, and the stress and physical labor involved in your job. Your financial situation will also be a factor, as the sooner you start your leave, the sooner it will run out after your baby's born.

Some women start their leave when they're seven or eight months pregnant, while others work right up until delivery. You'll need to monitor your pregnancy to determine the right time to start maternity leave. If your doctor puts you on bedrest or complications develop that require you to be out of work before you give birth, you'll most likely be put on short-term disability if your state or company offers it.

Under the FMLA, you can start taking unpaid leave anytime during your pregnancy — or anytime thereafter — as long as you conclude your leave within the first 12 months after your child's arrival. Check with your human resources department to find out if any limitations apply under your company's leave policies.

What if my employer denies my request for unpaid leave?
If you're sure you qualify under the FMLA or your state's provisions, make sure you've given the required notice and you have a plan to get your responsibilities covered while you're gone. Then, gently let your employer know more about these laws. Contact the U.S. Department of Labor for an FMLA fact sheet and advice on how to get your employer to comply. But start by being reasonable. You don't want to alienate your boss by making demands unless you have to.

If reason doesn't work and you believe you're entitled to leave, contact your regional office of the Labor Department's Wage and Hour Division to file a complaint. A phone call from the Labor Department to your employer can resolve most problems.

If the problem is not resolved, the Labor Department will investigate your complaint and may sue your employer on your behalf. If you don't get immediate results, consider hiring a lawyer who is familiar with employees' rights to help you.
You may also want to get in touch with Equal Rights Advocates, a national nonprofit organization that advocates for women's rights in the workplace. Call ERA's confidential, toll-free hotline at (800) 839-4372 for advice on issues related to maternity leave and pregnancy discrimination.

Where can I get more information?
To find out what kind of disability or unemployment insurance and other family leave provisions are currently available or coming soon to your state, check with your state's Department of Labor. You can also search the Internet for your state's disability insurance policies.

For a directory of companies that offer private short-term disability coverage for individuals, contact the Health Insurance Association of America.

For more information on the FMLA and family leave policies, contact:

U.S. Department of Labor
Wage and Hour Division
200 Constitution Avenue NW
Washington, D.C. 20210
Phone: (866) 487-9243

National Partnership for Women & Families
1875 Connecticut Avenue NW, Suite 710
Washington, D.C. 20009
Phone: (202) 986-2600
Fax: (202) 986-2539

Families and Work Institute
267 Fifth Avenue, 2nd Floor
New York, NY 10016
Telephone: (212) 465-2044
Fax: (212) 465-8637

Group B Streptococcus from American Pregnancy Association

Group B streptococcus (GBS) is a type of bacterial infection that can be found in a pregnant woman’s vagina or rectum. This bacteria is normally found in the vagina and/or rectum of about 25 % of all healthy, adult women.

Those women who test positive for GBS are said to be colonized. A mother can pass GBS to her baby during delivery. GBS is responsible for affecting about 1 in every 2,000 babies in the United States. Not every baby who is born to a mother who tests positive for GBS will become ill.

Although GBS is rare in pregnant women, the outcome can be severe, and therefore physicians include testing as a routine part of prenatal care.

How can I find out if I have Group B Strep infection?
The Centers for Disease Control and Prevention (CDC) has recommended routine screening for vaginal strep B for all pregnant women. This screening is performed between the 35th and 37th week of pregnancy (studies show that testing done within 5 weeks of delivery is the most accurate at predicting the GBS status at time of birth.)

The test involves a swab of both the vagina and the rectum. The sample is then taken to a lab where a culture is analyzed for any presence of GBS. Test results are usually available within 24 to 48 hours.

The American Academy of Pediatrics recommends that all women who have risk factors PRIOR to being screened for GBS (for example, women who have preterm labor beginning prior to 37 completed weeks' gestation) are treated with IV antibiotics until their GBS status is established.

How does someone get group B strep?
The bacteria that causes group B strep normally lives in the intestine, vagina, or rectal areas. Group B strep colonization is not a sexually transmitted disease (STD). Approximately 25% of all healthy women carry group B strep bacteria. For most women there are no symptoms of carrying the GBS bacteria.

What if I test positive for Group B Strep infection?
If you test positive for GBS this simply means that you are a carrier. Not every baby who is born to a mother who tests positive for GBS will become ill. Approximately one out of every 200 babies whose mothers carry GBS and are not treated with antibiotics, will develop signs and symptoms of GBS disease. There are, however, symptoms that may indicate that you are at a higher risk of delivering a baby with GBS. These symptoms include:

Labor or rupture of membrane before 37 weeks
Rupture of membrane 18 hours or more before delivery
Fever during labor
A urinary tract infection as a result of GBS during your pregnancy
A previous baby with GBS disease
In this case your physician will want to use antibiotics for prevention and protection.

According to the CDC, if you have tested positive and are not in the high risk category, then your chances of delivering a baby with GBS are:

1 in 200 if antibiotics are not given
1 in 4000 if antibiotics are given
How can I protect my baby from Group B Strep infection?
If you test positive for GBS and meet the high risk criteria, then your physician will recommend giving you antibiotics through IV during your delivery to prevent your baby from becoming ill. Taking antibiotics greatly decreases the chances of your baby developing early onset group B strep infection..

For women who are group B strep carriers, antibiotics given before labor begins are not effective at preventing the transmission of the group B bacteria. Since they naturally live in the gastrointestinal tract (guts), the bacteria can come back after antibiotics. A woman may test positive at certain times and not at others. That’s why it is important for all pregnant women to be tested for group B strep between 35 to 37 weeks of every pregnancy.

If you are at a low risk, the decision to use antibiotics is up to you. There are herbal remedies that you can take 2-3 weeks before delivery that a midwife or homeopathic physician can recommend.

How does Group B Strep infection affect a newborn baby?
Babies may experience early or late-onset of GBS.

The signs and symptoms of early onset GBS include:

Signs and symptoms occurring within hours of delivery
Breathing problems, heart and blood pressure instability
Gastrointestinal and kidney problems
Sepsis, pneumonia and meningitis are the most common complications
Newborns with early-onset are treated the same as the mothers, which is through intravenous antibiotics.

The signs and symptoms of late-onset GBS include:

Signs and symptoms occurring within a week or a few months of delivery
Meningitis is the most common symptom
Late-onset GBS is not as common as early-onset
Late-onset of GBS could be a result of delivery, or the baby may have contracted it by coming into contact with someone who has GBS.

Frequently Asked Questions:
How serious is GBS? GBS can cause bladder infections and uterine infections for the mother. In serious cases GBS can cause meningitis, sepsis, pneumonia or result in stillbirth of the newborn.

If I test positive for GBS does that mean my baby is going to get it also? No. Approximately 1 out of every 200 babies who are born to mothers who carry GBS will become ill. However, there are certain symptoms that put a mother at a higher risk than others.

What can I do to prevent my baby from getting GBS disease? Intravenous antibiotics (antibiotics given through IV) are recommended during delivery to reduce the chance of your baby becoming sick. It is recommended that antibiotics are given once labor has begun and every 4 hours during active labor until baby is delivered.

Do I have to take antibiotics, or is there a natural alternative? It is your choice if you want to take antibiotics. There are certain herbal methods that you can take 2-3 weeks before delivery that a midwife or homeopathic physician can provide for you.

If I am having a cesarean delivery, do I need to be treated for GBS? If you tested positive for GBS and labor has not begun ( including your water has not broken) than you do not need to be treated for GBS during delivery. If you are GBS positive, your water has been broken and/or labor has begun, most health care providers will still require you to be treated for GBS even if you are having a cesarean delivery.

If I had a positive group b strep culture done early in pregnancy, will they test me again? The latest recommendation from the CDC states that if a woman has a positive culture anytime during the current pregnancy, she will not need to be re screened and will automatically need to be treated with antibiotics during labor.

Is Group B Strep related to strep throat? No, the two are not related.

Can a woman who tests positive take oral antibiotics before delivery? Treating the mother with oral antibiotics during the pregnancy may decrease the amount of GBS for a short time, but it will not eliminate the bacteria completely and will leave the baby unprotected at birth. Also, waiting to treat the baby with antibiotics after birth is often too late to prevent illness if the baby is at high risk for contracting it.

Are antibiotics safe for the baby? Penicillin (Category B) is commonly used during pregnancy in non-allergic patients. There are substitute drugs for those who are allergic to penicillin, but they could still experience an allergic reaction. It is best to discuss the pros and cons with your health care provider.

Inducing Labor from WebMD

Inducing Labor

In many cases if a pregnancy isn't proceeding as it should, or if the health of the mother or baby is threatened, doctors have to speed up the process by inducing labor.

Why Is Labor Induced?

According to the CDC, about one out of every five pregnant women in the U.S. has their labor induced. There are a number of reasons for inducing labor, from a late delivery to a medical complication in the pregnancy.

Your doctor might induce labor if:

*You are one to two weeks past your due date. Past 42 weeks, you and your baby are at greater risk for complications, and the placenta that nourishes your baby in the womb may have diminished so much that it can no longer properly feed your baby. The baby also may breathe in his first bowel movement (called meconium), which can block his airways.

*The membrane that holds the amniotic sac surrounding your baby breaks (your "water breaks") and you don't go into labor on your own (once your water breaks, you and your baby are at greater risk for infection).

*You have a health condition, such as high blood pressure (preeclampsia), gestational diabetes, bleeding, or an infection in your uterus, which puts your health or your baby's health at risk.

*Your placenta is partially or totally covering the opening to the uterus (placenta previa), or has separated from the wall of the uterus (placenta abruption).
*The umbilical cord drops down into the vagina (prolapses).

*The baby is sideways (transverse) in the uterus.

*Tests show that your baby is no longer growing or developing at a normal rate, or the baby's heart rate is abnormal.

Sometimes women (or their doctors) decide to induce labor for nonmedical reasons, for example if they live far away from the hospital and their doctor is worried that they won't get there in time if they do go into labor. Inducing labor for nonmedical reasons is controversial, however, because there are some minor risks involved.

How Is Labor Induced?

Normally during labor, the lower end of the uterus (cervix) softens. This is called ripening. The cervix thins out (effaces) and opens (dilates). In order for the baby to be born, the cervix must be fully effaced and dilated to allow the baby's head to get through.

Before the doctor will induce labor, she will check your cervix and the baby's position to find out whether you are far enough along for induction will work.

Doctors use medications and other methods to efface and dilate the cervix artificially so that the baby can be born. Labor induction techniques include:

*Stripping the membranes. The doctor will insert a gloved finger into your vagina and move it back and forth to separate the membrane that connects the amniotic sac to the wall of the uterus. This is called "stripping the membranes," and it causes the body to release hormones called prostaglandins, which ripen the cervix and may lead to contractions. You may feel some cramping and have some spotting after this procedure. Usually this method of inducing labor is done in your doctor's office, and you'll be sent home to wait until contractions begin.

*Ripening the cervix. Medications called prostaglandins can dilate your cervix enough to prepare it for labor. Prostaglandins are manmade versions of chemicals in the body that both ripen the cervix and stimulate the uterus to contract. You take prostaglandins either by mouth or via a gel or suppository inserted in the vagina. (Your doctor shouldn't give you prostaglandins if you've had a previous c-section because of the increased risk of uterine rupture.) Another way to ripen the cervix is by inserting a thin tube called a catheter with a balloon at the tip. When the catheter is placed in your uterus, the balloon is inflated with water, which causes the cervix to expand.

*"Breaking your water." If your cervix is already at least partially dilated, your doctor can "break your water" by making a hole in your amniotic sac using a small plastic hook. Once your amniotic sac has broken, you should start having contractions. You'll need to deliver within about 24 hours to prevent infection.

*Triggering contractions. The drug Pitocin can bring on contractions to induce or move your labor along. Pitocin is an artificial form of the hormone oxytocin, which triggers and strengthens contractions. It's delivered through an intravenous (IV) tube in your arm. Your doctor will start with a small dose and will gradually increase it until your contractions are strong and frequent enough for the baby to be born.

Aside from stripping the membranes, which is typically performed in the doctor's office, these methods of inducing labor will be done in a hospital where both you and your baby can be carefully monitored.

Some women go into labor and deliver within a few hours after induction of labor begins. Others take one or two days to begin labor. If you don't go into labor with any of these methods, especially once your water is broken, you'll need to have a C-section.

What Are the Risks of Inducing Labor?

Generally, inducing labor is safe. The techniques used to induce labor shouldn't hurt, although they may cause your contractions to come on stronger and more often than they would naturally.


Inducing labor, especially with prostaglandins and Pitocin, may be more risky for women who have had a previous C-section or other surgery to the uterus. There is also a very small risk that the placenta will separate from the wall of the uterus (placental abruption) with these medications if the contractions become too intense. If the contractions are too strong, the doctor will reduce the dose of medication or stop it altogether.

Breaking the amniotic sac can lead to infection if you don't deliver within a day or two after your doctor tries to induce labor. In rare cases, the umbilical cord can slip out before the baby (prolapsed cord).

Can I Induce Labor Myself?

Tales abound of home remedies that supposedly bring on labor. Women past their due date have done everything from downing castor oil to rubbing their nipples to expedite the process. These methods can be uncomfortable, and there really isn't much scientific evidence to back them up.

Here is a rundown of a few popular home labor-induction methods:

*Sexual intercourse. The idea is that sex can trigger contractions, both from the sperm (which contain prostaglandins) and from the woman's orgasm. However, research is lacking on the subject, and one study found that sex didn't have any effect on time to labor.

*Nipple stimulation. Stimulating the nipples releases the hormone oxytocin, which naturally triggers contractions, but the cervix must already be ripe for this to work. Too much nipple stimulation also can produce very strong contractions that can actually be dangerous to the baby.

*Herbal remedies. A number of herbs, including blue cohosh and black cohosh, have been touted for triggering labor, but there isn't enough evidence to prove they work. What's more, herbs can be dangerous if not used properly, so don't take any herb for inducing labor without first talking to your doctor.

*Castor oil. Research shows castor oil probably won't do anything to induce labor, but it probably will irritate your gastrointestinal tract enough to make you feel sick to your stomach.

*Walking . It's always a good idea to stay active throughout your pregnancy, but studies haven't proved that walking can induce labor.

Unless your doctor feels that it's time to induce labor for medical reasons, it's always better to let nature take its course.

Antepartum Testing from Healthline.com

Definition

Antepartum testing involves the use of electronic fetal monitoring (EFM) or ultrasound (US) to assess fetal well-being as determined by the fetal heart rate (FHR) and other characteristics during the antepartal period, which is the period spanning from conception to labor. Antepartum tests include the nonstress test (NST), modified biophysical profile (MBPP), contraction stress test (CST), oxytocin contraction stress test (OCT), biophysical profile (BPP), doppler flow studies, amniocentesis, cordocentesis, and fetal echocardiography.

Purpose

Antepartum testing can start as early as 24 weeks but usually begins after 32 weeks of pregnancy depending on the mother's physical status. It provides a means for the physician and pregnant woman to identify any problems and be alert to any changes that may necessitate additional testing or interventions. The testing results reflect how well the placenta is functioning in its ability to adequately supply blood and, therefore, oxygen to the fetus.

The testing is done for pregnancies at risk for maternal and/or fetal complications. Some of these risks include:

any chronic illness in the mother, such as high blood pressure, diabetes, or autoimmune diseases, including systemic lupus erythematosus (SLE)
problems with previous pregnancies, such as a history of unexplained stillbirth
fetal complications, such as intrauterine growth restriction (IUGR) (growth in the fetus below the tenth percentile), birth defects, twins, or other multiple gestations in which a growth discrepancy occurs, such as twin-to-twin transfusion syndrome
problems in current pregnancy, including pregnancy-induced hypertension frequently referred to as preeclampsia); gestational diabetes (diabetes caused by pregnancy) requiring the use of insulin; premature rupture of the membranes (PROM); too little or too much amniotic fluid (the liquid surrounding the fetus) called oligohydramnios and polyhydramnios, respectively; vaginal bleeding; placental abnormalities, i.e., partial abruption (a portion of the placenta pulls away from the wall of the uterus), or placenta previa (a condition in which the placenta is covering the cervix instead of near the top of the uterus)
Antepartum testing is also used in low-risk pregnancies to evaluate decreased fetal activity, a lag in fundal height (as measured from top of the pubic area to the highest point in the midline at the top of the uterus), and postdates or post-term pregnancy. A normal pregnancy is 40 weeks and testing should begin at 41 weeks to assess the status of the placenta, which may no longer be capable of meeting the baby's needs. This can be indicated by the FHR pattern, amniotic fluid status, and fetal movement patterns.

Description

The spectrum of fetal assessment includes fetal movement (FM) counting, nonstress test (NST), modified biophysical profile (MBPP), contraction stress test (CST), oxytocin contraction stress test (OCT), biophysical profile (BPP), doppler flow studies, amniocentesis, cordocentesis, and fetal echocardiography. Fetal movement should be determined on a daily basis by all pregnant women regardless of risk status. The woman should be instructed to monitor fetal movement by selecting a consistent time of day to document how long it takes to feel 10 fetal movements. She should call her healthcare provider if there are fewer than 10 movements in a 10-hour period or immediately if there are no movements in any 10-hour period. She should also be instructed to report significant decreases in fetal activity from the baby's normal pattern. This daily monitoring of FM by all pregnant women is the least expensive and easiest of all antepartum tests to perform.

Non-stress test (NST)

The NST is performed with an electronic fetal monitor (EFM) that traces the fetal heart rate (FHR) and the presence of any contractions on a monitor strip. The mother reclines with a slight pelvic tilt to prevent compression of the large blood vessels by the pregnant uterus. The EFM is applied to her abdomen by two straps: one is to listen to the FHR by means of a transducer, and the other is to pick up any contractions by pressure on a tocodynameter. The NST indirectly provides information about fetal status by the observation of FHR accelerations that occur with fetal movement. If a fetus is not receiving adequate oxygen from the placenta, the FHR will not accelerate, but if the oxygen supply is sufficient, accelerations will be noted. If it is difficult to obtain fetal movements, a vibroacoustic stimulator (VAS) is sometimes used to provide a loud noise to awaken the fetus and produce the desired results. The minimum amount of time required for an NST is 20 minutes. During those 20 minutes, there must be two accelerations in the FHR that are 15 beats above the baseline FHR and last for 15 seconds, often called the 15 by 15 rule. Depending upon the conditions, however, it may sometimes take up to 60 to 90 minutes to obtain definitive results.

Modified biophysical profile (MBPP)

The MBPP is performed in the same manner as the NST with a limited ultrasound (US) performed to assess the amount of amniotic fluid, which is reported as the amniotic fluid index (AFI). Following the NST, an US is done to observe the amount of amniotic fluid present in four quadrants, which are divided along the umbilicus midline and perpendicular to the midline. There must be no fetal parts or any umbilical cord present in any of these pockets of fluid in order to be counted.

Contraction stress test (CST) and oxytocin contraction stress test (OCT)

The contraction stress test (CST) is similar to the NST except the FHR is evaluated for accelerations, 15 beats higher than baseline lasting 15 seconds, and in response to contractions as well. A CST requires the presence of three uterine contractions (UCs) within a 10-minute period lasting at least 40 seconds and of moderate intensity. During a contraction, the blood flow to the baby is temporarily restricted, which provides a form of "stress" to the baby. The baby's response to this stressor reveals significant information regarding available oxygen stores. If contractions are not spontaneously present, the pregnant woman will be instructed on the use of nipple stimulation to produce contractions through the release of natural oxytocin, or oxytocin can be administered through an intravenous infusion (IV) called pitocin to produce contractions. When oxytocin is administered IV, it is called an oxytocin contraction stress test (OCT). The CST/OCT is generally used after an abnormal NST is obtained in order to verify if there are problems present. Many clinicians require their diabetic patients to have at least one CST/OCT a week to assure fetal well-being. Maternal blood pressure is taken with each test.

Biophysical profile (BPP)

The biophysical profile (BPP) is performed by an ultrasound exam over a 30-minute period. The ultrasonographer/examiner looks for gross fetal movement, i.e., kicking and moving around; fetal tone, i.e., making a fist; breathing movements (which the mother can often perceive as hiccoughs); and amniotic fluid volume. A score of 0 or 2 points is assigned to each observation with the results of the NST also adding 2 points for a total possible score of 10 points.

Doppler flow studies, amniocentesis, cordocentesis, and fetal echocardiography

A physician or specially trained ultrasonographer performs Doppler flow studies, which examines the blood flow in the umbilical artery and the baby's middle cerebral artery. An experienced obstetrician/perinatologist performs the amniocentesis or the cordocentesis. For the amniocentesis, an US is used to determine an appropriate place to insert a needle and withdraw amniotic fluid for testing. In a similar manner, US is used with cordocentesis, but in this procedure a needle is guided into the umbilical cord to withdraw fetal blood for testing. Fetal echocardiography is a specialized ultrasound of a baby's heart. Since it detects most congenital heart defects, it is recommended if a baby is at a higher risk for a defect than the risk in the general population. The majority of health insurance companies do cover a portion, if not all, of the tests' costs.

Precautions

Clinicians should only prescribe these tests if they are ready to intervene when faced with worrying results. A fetus is considered viable at 24 weeks since that is the minimum gestational age for sufficient lung development. There are no significant risks to the mother or the fetus from the nonstress test (NST), modified biophysical profile (MBPP), or the biophysical profile (BPP). Ultrasound waves utilized in detecting the FHR and for the BPP are painless and safe because this method employs no harmful radiation. There is no evidence that sound waves cause any harm to the mother or the baby.

Aftercare

If the test results are acceptable, the pregnant woman is instructed to continue following her current medical regimen and return for additional testing on the dates prescribed. For NSTs/MBPPs/CSTs, the time period between tests should be no longer than three to four days under high-risk conditions with fetal movement counting taking place in between testing dates. Ultrasounds should be rescheduled as the need dictates per the physician. Electronic fetal monitoring occurs after an amniocentesis or cordocentesis to assure fetal well-being.

Risks

There are no complications per se from the tests themselves with the exception of unfavorable test results or supine (lying horizontality on the back) hypotension secondary to a pregnant woman lying on her back for an ultrasound. When a pregnant woman lies on her back, the vena cava (one of two large veins that return blood from peripheral circulation to the heart) can become compressed from the pressure of the pregnant uterus such that blood flow to the heart is significantly reduced. There are potential complications from an amniocentesis, i.e., preterm labor, spontaneous rupture of membranes, fetal or placental injury; and the clinician performing the procedure should explain what these are prior to the procedure. There are similar risks and potential complications from cordocentesis as well which should be explained.

Normal results

Usually, a report of normal results for NSTs provides reassurance that the fetus is healthy and should remain so for three to four days, at which time repeat testing will be necessary. A normal NST is reported as being reactive, which means the fetal heart is "reacting" to movement such that the FHR is accelerating 15 beats per minute above the baseline FHR for 15 seconds twice within a 20-minute period of time. A non-reactive NST is one that fails to meet this criterion within an 80 to 90 minute period of time. For an extremely preterm fetus, a normal NST is reported as being reactive for gestational age, which indicates the FHR demonstrated two accelerations of 10 beats per minute above baseline for 10 seconds over a 20–30 minute period. Typically, the central nervous system is not completely mature until approximately 32 weeks gestational age, and a report of reactive for gestational age takes this into consideration. It is important to remember that a normal result does not guarantee that no problems are present. Although very rare in occurrence, false normal results can be observed.

The CST results are reported as reactive/negative, reactive/suspicious, reactive/positive (a very unlikely result), or non-reactive/negative, non-reactive/suspicious, non-reactive/positive. The reactive/non-reactive part of the test report refers to the presence or absence of accelerations. The negative part refers to no decelerations being present with uterine contractions (UCs). "Suspicious" refers to the presence of some decelerations with UCs, and "positive" refers to the presence of decelerations more than 50 percent of the time with UCs. A suspicious or positive result requires further evaluation, i.e., prolonged EFM monitoring or a BPP. A normal BPP report without an NST is 8 points and 10 points with a reactive NST. Six points is suspicious and requires either a CST or a repeat BPP within 24 hours. A total of 4 points is not reassuring and requires immediate evaluation by prolonged EFM.

All results are given to the primary physician who must then make a decision as to the appropriate course of action. Abnormal CST results generally indicate the baby is not receiving sufficient oxygen and may not be capable of withstanding the stress of labor and subsequent vaginal delivery. If this is the case, a cesarean section may be performed. The final outcome depends on the mother's individual circumstances. Severe pregnancy-induced hypertension may require immediate delivery via cesarean section. In some cases, medications such as betamethasone may be given to the mother to speed up the lung maturity of the baby. If the mother's cervix is favorable for induction, labor may be induced.

KEY TERMS

Amniotic fluid—The liquid in the amniotic sac that cushions the fetus and regulates temperature in the placental environment. Amniotic fluid also contains fetal cells.

Deceleration—A decrease in the fetal heart rate that can indicate inadequate blood flow through the placenta.

Fundal height—Measured by a tape measure from the top of the symphysis pubis, over the arch of the growing uterus, to the top of the fundus.

Oxytocin—A hormone that stimulates the uterus to contract during child birth and the breasts to release milk.

Pitocin—A synthetic hormone that produces uterine contractions.

Vibroacoustic stimulation—In the biophysical profile, use of an artificial larynx to produce a loud noise to "awaken" the fetus.

Parental concerns

The healthcare provider should give a complete explanation to the pregnant woman and her partner regarding the tests, i.e., what to expect, how long the test may take, what it means, and why it is being done. It frequently helps if the pregnant woman has eaten prior to undergoing the test. Pregnant women should know that every test is not compulsory, and that if the results of the test do not matter to the parents, it may not have to be performed.

See also High-risk pregnancy.

BOOKS

Freeman, Roger, et al. Fetal Heart Rate Monitoring, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2003.

Gabbe, Steven, et al. Obstetrics, 4th ed. London: Churchill Livingstone, 2001.

Neilson, J. P., and Z. Alfirevic. "Doppler ultrasound for fetal assessment in high risk pregnancies (Cochrane Review)." In The Cochrane Library, vol. 3. Chichester, UK: John Wiley & Sons, Ltd., 2004.

Pattison, N., and L. McCowan. "Cardiotocography for antepartum fetal assessment (Cochrane Review)." In The Cochrane Library. Chichester, UK: John Wiley & Sons, Ltd., 2004.

Tucker, Susan. Pocket Guide to Fetal Monitoring and Assessment, 4th ed. St. Louis, MO: Mosby, 2000.

ORGANIZATIONS

American College of Obstetricians and Gynecologists. 409 12th Street, SW, PO Box 96920, Washington, DC 20090. Web site: .

Association of Women's Health, Obstetric, and Neonatal Nursing. 2000 L Street, NW, Suite 740, Washington, DC 20036. Web site: .

Linda K. Bennington, RNC, MSN, CNS

California Screening Program- FAQ

April, 2009
Prenatal Screening Tests
To help detect birth defects
THE CALIFORNIA PRENATAL SCREENING PROGRAM

It is important to get prenatal care as soon as you think you are pregnant....
Early care can help you have a healthy baby.

Prenatal Screening Tests:
One or two blood tests, plus a special ultrasound, can help detect some birth defects. For example, they can help find spina bifida and Down syndrome in babies before they are born. Spina bifida is a birth defect that often causes paralysis. Down syndrome causes mental retardation. The Prenatal Screening tests also help find some other birth defects.

Can I have prenatal screening tests to help find birth defects?
Yes. If you want the tests, talk to your doctor or clinic. You will receive a booklet to read.

How can I get the Prenatal tests?
A doctor or clinic will order one or two blood tests:
1. Get a blood test between 10 weeks and 13 weeks 6 days of pregnancy. This is called a First Trimester test.
2. Get a second blood test between 15 and 20 weeks of pregnancy. This is called a Second Trimester test.
Sometimes you can also get a special ultrasound called Nuchal Translucency (NT). It is done between 11 weeks 2 days and 14 weeks 2 days of pregnancy.

If the results of these tests are put together, it is called Integrated Screening.

What do the results show?
Most of the time screening will be "normal" or "Screen Negative". This means your baby probably does not have spina bifida, Down syndrome or some other birth defects.

What if the screening test results are "Screen Positive"?
This means that there is a higher than usual chance for some birth defects. But diagnostic tests are needed to know if there really is a birth defect.
You would be offered free follow- up services at a State-approved Prenatal Diagnosis Center. A Genetic Counselor will explain the test results and offer free diagnostic testing.
Most of the time, no birth defects are found during diagnostic tests. Most babies are healthy.
Once in a while, diagnostic tests will detect a birth defect. A counselor will help the woman or couple make decisions about the pregnancy.



How much does screening cost?
The fee is $162. Most prepaid health plans and insurance companies pay the fee. Medi-Cal also pays it.
The $162 fee covers the blood tests as well as authorized diagnostic tests.
This fee does not cover Nuchal Translucency Ultrasound (NT).

How can I get more information?
Please talk to your doctor or clinic about these prenatal screening tests.
All pregnant women will receive a booklet called "The California Prenatal Screening Program." Patients should sign the consent form "Yes" or "No".

Note: Patients with a family history of birth defects may want to go directly to diagnostic testing instead of screening. Talk to your doctor or clinic.
Please visit our website for more information:
www.cdph.ca.gov/programs/pns
California Department of Public Health
Genetic Disease Screening Program
850 Marina Bay Parkway, F175 Richmond, CA 94804 (866)718-7915 toll free


␣␣␣

Gestational Diabetes

Pregnancy and Gestational Diabetes by WebMD

Gestational diabetes is a condition characterized by high blood sugar (glucose) levels that is first recognized during pregnancy. The condition occurs in approximately 4% of all pregnancies.

What Causes Gestational Diabetes in Pregnancy?

Almost all women have some degree of impaired glucose intolerance as a result of hormonal changes that occur during pregnancy. That means that their blood sugar may be higher than normal, but not high enough to have diabetes. During the later part of pregnancy (the third trimester), these hormonal changes place pregnant woman at risk for gestational diabetes.

During pregnancy, increased levels of certain hormones made in the placenta (the organ that connects the baby by the umbilical cord to the uterus) help shift nutrients from the mother to the developing fetus. Other hormones are produced by the placenta to help prevent the mother from developing low blood sugar. They work by stopping the actions of insulin.

Over the course of the pregnancy, these hormones lead to progressive impaired glucose intolerance (higher blood sugar levels). To try to decrease blood sugar levels, the body makes more insulin to get glucose into cells to be used for energy.

Usually the mother's pancreas is able to produce more insulin (about three times the normal amount) to overcome the effect of the pregnancy hormones on blood sugar levels. If, however, the pancreas cannot produce enough insulin to overcome the effect of the increased hormones during pregnancy, blood sugar levels will rise, resulting in gestational diabetes.

What Are the Complications of Gestational Diabetes?

Diabetes can affect the developing baby throughout the pregnancy. In early pregnancy, a mother's diabetes can result in birth defects and an increased rate of miscarriage. Many of the birth defects that occur affect major organs such as the brain and heart.

During the second and third trimester, a mother's diabetes can lead to over-nutrition and excess growth of the baby. Having a large baby increases risks during labor and delivery. For example, large babies often require caesarean deliveries and if he or she is delivered vaginally, they are at increased risk for trauma to their shoulder.

In addition, when fetal over-nutrition occurs and hyperinsulinemia results, the baby's blood sugar can drop very low after birth, since it won't be receiving the high blood sugar from the mother.

However, with proper treatment, you can deliver a healthy baby despite having diabetes.

Who Is at Risk for Gestational Diabetes?

The following factors increase the risk of developing gestational diabetes during pregnancy:

Being overweight prior to becoming pregnant (if you are 20% or more over your ideal body weight).
Being a member of a high risk ethnic group (Hispanic, Black, Native American, or Asian).
Having sugar in your urine.
Impaired glucose tolerance or impaired fasting glucose (blood sugar levels are high, but not high enough to be diabetes).
Family history of diabetes (if your parents or siblings have diabetes).
Previously giving birth to a baby over 9 pounds.
Previously giving birth to a stillborn baby.
Having gestational diabetes with a previous pregnancy.
Having too much amniotic fluid (a condition called polyhydramnios).
Many women who develop gestational diabetes have no known risk factors.

How Is Gestational Diabetes Diagnosed?

High risk women should be screened for gestational diabetes as early as possible during their pregnancies. All other women will be screened between the 24th and 28th week of pregnancy.

To screen for gestational diabetes, you will take a test called the oral glucose tolerance test. This test involves quickly drinking a sweetened liquid, which contains 50g of sugar. The body absorbs this sugar rapidly, causing blood sugar levels to rise within 30-60 minutes. A blood sample will be taken from a vein in your arm 1 hour after drinking the solution. The blood test measures how the sugar solution was metabolized (processed by the body).

A blood sugar level greater than or equal to 140mg/dL is recognized as abnormal. If your results are abnormal based on the oral glucose tolerance test, another test will be given after fasting for several hours.

In women at high risk of developing gestational diabetes, a normal screening test result is followed up with another screening test at 24-28 weeks for confirmation of the diagnosis.

Learn more about diagnosing diabetes.

How Is Gestational Diabetes Managed?

Gestational diabetes is managed by:

Monitoring blood sugar levels four times per day (before breakfast and 2 hours after meals. Monitoring blood sugar before all meals may also become necessary.)
Monitoring urine for ketones (an acid that indicates your diabetes is not under control).
Following specific dietary guidelines as instructed by your doctor. You'll be asked to distribute your calories evenly throughout the day.
Exercising after obtaining your health care provider's permission.
Monitoring weight gain.
Taking insulin, if necessary. Insulin is currently the only diabetes medication used during pregnancy.
Controlling high blood pressure.
How Do I Monitor My Blood Sugar Levels?

Testing your blood sugar at certain times of the day will help determine if your exercise and eating patterns are keeping your blood sugar levels in control, or if you need extra insulin to protect your developing baby. Your health care provider will ask you to maintain a daily food record and ask you to record your home sugar levels.

Testing your blood sugar involves pricking your finger with a lancet device (a small, sharp needle), putting a drop of blood on a test strip, using a blood sugar meter to display your results, recording the results in a log book, and then disposing the lancet and strips properly (in a "sharps" container or a hard plastic container, such as a laundry detergent bottle).

Bring your blood sugar readings with you to your doctor appointments so your doctor can evaluate how well your blood sugar levels are controlled and determine if changes need to be made to your treatment plan.

Your health care provider will show you how to use a glucose meter. He or she can also tell you where to get a meter. You may be able to borrow it from your hospital, as many hospitals have loaner meter programs for women with gestational diabetes.

The goal of monitoring is to keep your blood sugar as close to normal as possible. The ranges include:

Time of Test Target Blood Sugar Reading
Before breakfast plasma below 105; whole blood below 95
2 Hours After Meals plasma below 130; whole blood below 120
Insulin treatment is started if above levels are not maintained.

Do I Need to Take Insulin for Gestational Diabetes?

Based on your blood sugar monitoring results, your health care provider will tell you if you need to take insulin in the form of injections during pregnancy. Insulin is a hormone that controls blood sugar. If insulin is prescribed for you, you may be taught how to perform the insulin injection procedure.

As your pregnancy progresses, the placenta will make more pregnancy hormones and larger doses of insulin may be needed to control your blood sugar. Your health care provider will adjust your insulin dosage based on your blood sugar log.

When using insulin, a "low blood glucose reaction," or hypoglycemia, can occur if you do not eat enough food, skip a meal, do not eat at the right time of day, or if you exercise more than usual.

Symptoms of hypoglycemia include:

Confusion
Dizziness
Feeling shaky
Headaches
Sudden hunger
Sweating
Weakness
Hypoglycemia is a serious problem that needs to be treated right away. If you think you are having a low blood sugar reaction, check your blood sugar. If your blood sugar is less than 60 mg/dL (milligrams per deciliter), eat a sugar-containing food, such as 1/2 cup of orange or apple juice; 1 cup of skim milk; 4-6 pieces of hard candy (not sugar-free); 1/2 cup regular soft drink; or 1 tablespoon of honey, brown sugar, or corn syrup. Fifteen minutes after eating one of the foods listed above, check your blood sugar. If it is still less than 60 mg/dL, eat another one of the food choices above. If it is more than 45 minutes until your next meal, eat a bread and protein source to prevent another reaction.

Record all low blood sugar reactions in your log book, including the date, time of day the reaction occurred and how you treated it.

How Will My Diet Change With Gestational Diabetes?

If you have gestational diabetes, follow these diet tips:

Eat three small meals and two or three snacks at regular times every day. Do not skip meals or snacks. Carbohydrates should be 40%-45% of the total calories with breakfast and a bedtime snack containing 15-30 grams of carbohydrates.
If you have morning sickness, eat 1-2 servings of crackers, cereal, or pretzels before getting out of bed. Eat small, frequent meals throughout the day and avoid fatty, fried, and greasy foods. If you take insulin and have morning sickness, make sure you know how to treat low blood sugar.
Choose foods high in fiber such as whole-grain breads, cereals, pasta, rice, fruits, and vegetables. All pregnant women should eat 20-35 grams of fiber a day.
Fats should be less than 40% of calories with less than 10% consumed being from saturated fats.
Drink at least 8 cups (or 64 ounces) of liquids per day.
Make sure you are getting enough vitamins and minerals in your daily diet. Ask your health care provider about taking a prenatal vitamin and mineral supplement to meet the nutritional needs of your pregnancy.

How Much Exercise Is Safe for Gestational Diabetes?

Regular exercise during pregnancy can improve your posture and decrease some common discomforts such as backaches and fatigue. Being fit during pregnancy means safe, mild to moderate exercise at least three times a week. But, regardless of gestational diabetes, every pregnant woman should consult with her health care provider before beginning an exercise program. He or she can give you personal exercise guidelines, based on your medical history.

Since both insulin and exercise lower blood sugar, you should follow these additional exercise guidelines to avoid a low blood glucose reaction:

Always carry some form of sugar with you when exercising, such as glucose tablets or hard candy.
Eat one serving of fruit or the equivalent of 15 grams of carbohydrate for most activities lasting 30 minutes. If you exercise right after a meal, eat this snack after exercise. If you exercise 2 hours or more after a meal, eat the snack before exercise.
Pregnancy Weight Gain

The recommended amount of weight gain during pregnancy depends on your pre-pregnancy weight, whether there is more than one fetus, and the trimester. Typically more weight gain is expected during the second and third trimester and recommended intakes of calories should increase at that time.

Gaining the right amount of weight during pregnancy by eating a healthy, balanced diet is a good sign that your baby is getting all the nutrients he or she needs and is growing at a healthy rate.

It is not necessary to "eat for two" during pregnancy. It's true that you need extra calories from nutrient-rich foods to help your baby grow, but you generally need to consume only 200 to 300 more calories than you did before you became pregnant to meet the needs of your growing baby.

Ask your health care provider how much weight you should gain during pregnancy. A woman of average weight before pregnancy can expect to gain 25 to 35 pounds during pregnancy. You may need to gain more or less weight, depending on what your doctor recommends.

In general, you should gain about 2-4 pounds during your first 3 months of pregnancy and 1 pound a week for the remainder of your pregnancy.

How Much Exercise Is Safe for Gestational Diabetes?

Regular exercise during pregnancy can improve your posture and decrease some common discomforts such as backaches and fatigue. Being fit during pregnancy means safe, mild to moderate exercise at least three times a week. But, regardless of gestational diabetes, every pregnant woman should consult with her health care provider before beginning an exercise program. He or she can give you personal exercise guidelines, based on your medical history.

Since both insulin and exercise lower blood sugar, you should follow these additional exercise guidelines to avoid a low blood glucose reaction:

Always carry some form of sugar with you when exercising, such as glucose tablets or hard candy.
Eat one serving of fruit or the equivalent of 15 grams of carbohydrate for most activities lasting 30 minutes. If you exercise right after a meal, eat this snack after exercise. If you exercise 2 hours or more after a meal, eat the snack before exercise.

Pregnancy Weight Gain

The recommended amount of weight gain during pregnancy depends on your pre-pregnancy weight, whether there is more than one fetus, and the trimester. Typically more weight gain is expected during the second and third trimester and recommended intakes of calories should increase at that time.

Gaining the right amount of weight during pregnancy by eating a healthy, balanced diet is a good sign that your baby is getting all the nutrients he or she needs and is growing at a healthy rate.

It is not necessary to "eat for two" during pregnancy. It's true that you need extra calories from nutrient-rich foods to help your baby grow, but you generally need to consume only 200 to 300 more calories than you did before you became pregnant to meet the needs of your growing baby.

Ask your health care provider how much weight you should gain during pregnancy. A woman of average weight before pregnancy can expect to gain 25 to 35 pounds during pregnancy. You may need to gain more or less weight, depending on what your doctor recommends.

In general, you should gain about 2-4 pounds during your first 3 months of pregnancy and 1 pound a week for the remainder of your pregnancy.

Pain Management Options in Labor & Delivery by Lori Meinking, CNM

Pain Management Options in Labor & Delivery

If you're like most women, the pain of labor and delivery is not something to which you are looking forward to. Though some women do experience little pain during labor, they are a minority. Most women experience labor as a painful process. For this reason, it is important to educate yourself about your options for pain management during labor, and to decide which methods will best fit your needs. Keep in mind that your best bet is to be well informed and flexible in your options because you won’t know how painful labor will be until you actually experience it. Work with your midwife or doctor to decide which types of pain relief you are interested in, so that there is no confusion once you are in labor! Generally, mothers and their providers want to use the safest and most effective method of pain relief for both mother and baby.
There are three main types of pain management for labor and birth:

Natural Labor or Non-Medicated Measures
Analgesics (IV pain medication or a shot)
Anesthesia (epidural)

Natural labor

Lamaze teaches that birth is a normal, natural, and healthy process and that a woman should be empowered to approach it with confidence. Lamaze teaches women ways to decrease their perception of pain, such as through relaxation techniques, breathing exercises, distraction, or massage by a supportive coach.
Breathing techniques help by calming and relaxing you as labor contractions intensify. Childbirth classes can help you harness the power of breathing to help you through your contractions. There are many methods of patterned breathing techniques that can be very effective in labor.
Focusing on something other than contractions helps women cope with labor. Some women prefer an internal focus. They visualize their bodies working for them, or mentally “remove” themselves to a pleasant and peaceful place. Others prefer an external focus. Concentration on an object or a face, listening to music, or movement such as swaying or massage helps many women cope.
Relaxation is one of the most important skills you can learn to reduce the pain and discomfort of labor. When under stress, most people are unaware of how tense their necks, shoulders, arms, etc., really are. The less your body has to “work” in these areas, the more progress it can make during each contraction. Although you won’t have a lot of time between contractions, you should try to rest and relax as much as possible between each one.

Analgesics

Analgesics (systemic painkillers) are medications to relieve pain such as Fentanyl, Stadol, Morphine, Demerol, and Nubain. These narcotics dull the pain but do not completely eliminate it. They are either delivered into the bloodstream through an IV or injected into a muscle, and they affect your entire body rather than concentrating pain relief in the uterus and pelvic area. You may feel sleepy and/or light headed after receiving IV pain medication. The smallest dose possible is given because of the potential adverse effects of these drugs on the fetus. These drugs easily cross the placenta to the fetus and may take a long time to clear from the baby’s system even after birth. Analgesics can cause respiratory depression in the baby and for this reason; analgesics are not given to the mother an hour or two before the birth.

Anesthesia

Epidural: The basics behind an epidural are that it can greatly reduce or eliminate the pain of labor and delivery. It is a form of continuous pain relief to the lower part of your body while allowing you to remain fully conscious. Medication is delivered through a small catheter (or tube) that is inserted into the epidural space just outside the membrane that surrounds your spine. The catheter is inserted through a needle into your back after your back has been numbed. The medications used in an epidural are usually a combination of local anesthetic and narcotics. The medication is controlled by a pump that infuses continuously and is set up by the anesthesiologist.