Babies Tale

Infertility and late motherhood are linked in two ways. First, many women come late to motherhood because they have had trouble conceiving. Second, fertility declines with age, and many women who leave childbearing to their mid- or late 30s or early 40s experience some difficulty in getting pregnant.

Although every doctor and medical textbook will state that fertility declines with age, finding out exactly when and how fast fertility declines is not so easy. Figures from the Office of Population Censuses and Surveys show that in I996, 400,8I0 women aged 35 to 39, and 74,643 women aged 40 to 49 gave birth, out of a total of 3,9I7,933 births for women of all ages-clearly a minority. This figure doesn’t really prove anything, however. The smallness of the figure may be due more to women choosing to have their babies earlier rather than experiencing difficulty in having them later. According to the Report of Final Nativity Statistics, I995 (National Center for Health Statistics), “Birth rates for women in their thirties is still increasing, but the pace has slowed. The birth rate for women aged 40 to 44 years rose 20% between I990 and I995, and increased 74% during I98I-95. The rising birth rate, along with the increasing number of women in this age group, has meant that there were more babies born in I995 to mothers in their forties than in any year since I966.”

A study by Professor James Trussel of Princeton University, published in I985, shows that between the years I550 and I849, when people did not have access to birth control, only about 7% of women who married young were infertile, while one-third of women who married at the age of 35 did not give birth and nearly 60% of women who married at 40 had no children.

When and how fast does fertility decline? One recent study to try to answer this question was carried out in the Netherlands on a group of 75I women attending clinics for artificial insemination by donated sperm. This study showed the decline in fertility began at the age of 3I, and that after this age the chance of conceiving per monthly cycle fell by about I2% with each year of age. The chance of a woman aged 35 getting pregnant and giving birth to a healthy baby was about half that of a woman aged 25. The study also showed that for older women, continuing beyond I2 cycles was important, since older women took longer to conceive. While 54% of women over 3I became pregnant after I2 cycles, 75% did after 24. These figures may be slightly different compared to those found from women who conceive normally, because we know there is a slightly lower rate of conception through donor insemination than natural conception. Still, they are likely not to be much different.

Older women tend to be infertile for the same reasons as younger women, but the problems arise more frequently. The most common reason is probably a failure to ovulate. As women age, they are likely to have more menstrual cycles without ovulating than younger women; eventually most cycles will be anovulatory (menstruation without releasing an egg). Women usually continue to have periods long after they cease to be fertile, for perhaps ten years before they reach menopause.

Older women are also more likely to have suffered from some infection or illness that might scar the Fallopian tubes, the second most common cause of female infertility. Older women are also more likely to develop fibroids or other uterine disorders that affect fertility.

Research into infertility and a host of new treatments have meant more women with fertility problems are able to have a baby than ever before. Advances such as IVF (in-vitro fertilization, the “test-tube baby” treatment) have put infertility very much in the public eye. Infertility is no longer the hush-hush issue it used to be. Because of this, many women are now aware their fertility may be a problem. They are much more likely to seek help quickly if they do not become pregnant soon after stopping contraception.

Women who have spent years on the Pill or worrying about contraception, who may never have had an act of unprotected intercourse or fretted till their period turned up if they did, may be surprised to find pregnancy does not automatically result as soon as they abandon contraception, In fact, it has been estimated that the average length of time for a fertile couple having regular sexual intercourse to conceive a baby is about six months. This means that for every lucky couple who gets pregnant the first month, another couple will wait a year. It’s a little like throwing the dice and getting the certain number you’re hoping for-your chances are the same for each throw, but over a number of throws, your number is more likely to come up.

Similarly, the chance of conceiving each month is probably the same, but for the woman in her late 30s, not conceiving right away will probably ring alarm bells. She will be aware all the time that a delay of a year in conceiving may considerably reduce her chances. She may rush off for fertility investigations before she has given her body a chance to conceive naturally.

If a couple has not conceived after a year, and especially if the mother is older, most doctors will go ahead and refer them to a fertility specialist. The specialist will decide if there is really a problem and what this might be.

The other major causes of infertility in women are scarring of the reproductive organs by past disease or surgery, or structural abnormalities present from birth.

• Untreated sexually transmitted diseases, especially gonorrhea, can result in infertility. As many as 80% of infected women never have any severe symptoms with the disease, and may not realize that they have it and that infection has spread to the Fallopian tubes, causing damage.
• PID (pelvic inflammatory disease), which can start after an induced abortion or miscarriage, after childbirth, after surgery in the pelvic region or after infection with a sexually transmitted disease, can cause tubal scarring and blockage.
• Other infections that can affect fertility are chlamydia and mycoplasmas. Chlamydia, a bacterium that closely resembles a virus, has deceptively mild symptoms. An untreated “silent” infection can destroy the inside of a woman’s Fallopian tubes. Mycoplasmas, another organism, may affect fertility and has been held responsible for miscarriages.

Other causes

Endometriosis is a disease that may affect as many as 5% to I0% of women at some stage of their reproductive lives. Normally endometrial tissue lines the womb, or endometrium. The condition is caused by patches of the endometrial tissue becoming deposited outside the womb. This tissue, like the womb lining, thickens and bleeds with each menstrual cycle. Scar tissue is formed that may block the ends of the Fallopian tubes, or adhesions may form that prevent the tube from picking up the egg on its release from the ovary.

Endometriosis can be treated by a number of drugs: birthcontrol pills, progesterone or a drug called Danazol’v, which blocks production of the two pituitary hormones, and now new drugs called LHRH analogs, which are given as a nasal spray or an injection. These treatments serve to “switch off” the menstrual cycle, stopping the patches of endometrial tissue from bleeding; then they fade away and any adhesions or scar tissue can be removed by careful surgery.

About one-third of all women have fibroids or polyps by the age of 40. These are benign swellings in the womb, usually only the size of a grape but sometimes swelling to the size of a grapefruit. Fibroids seldom cause symptoms in women who are not pregnant and rarely cause problems in pregnancy, but women with fibroids may find their fertility is affected. They can be removed by surgery. Malformations of the womb, such as the presence of a dividing wall or septum, can sometimes be corrected by surgery.

Previous surgery in the abdominal region can also be a cause of damage to the tubes. Bleeding or injury to the tissues may cause scar tissue or adhesions to form, which may block or freeze the tubes, ovaries or uterus in unnatural positions. That makes it impossible for the egg to pass from the ovaries into the Fallopian tubes, so conception becomes impossible.

More women with blocked Fallopian tubes have a better chance to achieve pregnancy today because doctors are practicing delicate microsurgeries with increasing skill. However, if surgery is not effective, there is still hope through the test-tube baby treatment or IVF.

Occasionally a fertilized egg fails to move through the tube and into the uterus. Instead, it grows in the tube. Eventually the pregnancy will abort, or the egg may burst the tube, causing considerable bleeding and damage. This is called an ectopic or tubal pregnancy. It results in both the loss of one pregnancy and a possible barrier to future conception. One Fallopian tube is often lost. The other may be damaged by bleeding caused by the ruptured tube, or by the surgery to remove the pregnancy. It is estimated that about half the women who have an ectopic pregnancy may never conceive again. Increasingly, delicate surgery by laparoscopy may be able to save a tube, however.

Often an ectopic pregnancy occurs when there has been some damage to the tube, perhaps caused by past infections or surgery. Tubal pregnancy is also more common if a woman becomes pregnant with an IUD in place or has been using the progestogenonly (or “mini”) Pill. An ectopic pregnancy is very painful and can be life-threatening. However, prompt medical attention to remove the developing embryo before the tube can burst avoids many risks and improves the chances of successfully reconstructing the damaged tube.

Your perineum may be sore and swollen for a few days after birth, due to stretching of the birth canal or to the episiotomy or tearing that might have occurred. It helps to put an ice pack on your perineum off and on for the first twenty four hours or so after delivery to reduce swelling and discomfort from stitches. The area is sensitive to touch, so after going to the bathroom, rather than wiping, squirt the area with some warm water from a bottle, then pat it dry with a clean, soft tissue.

Sitting in about four inches of either very warm or very cold clean water in a tub is also very soothing. You can take such sitz baths several times a day for twenty to thirty minutes. Keep the water clean, don’t bathe in this water, Showers are better than baths for the first few weeks after birth because soapy, dirty water could contaminate the healing areas of your perineum.

For some women, hemorrhoids [swollen, painful blood vessels of the anus] may be a problem. Sitz baths may help, as may gently patting the area with cotton pads or tissues soaked in witch hazel. Hemorrhoids tend to improve with time, but if you have a lot of trouble, see your doctor.

When your perineum is swollen and sore, straining for a bowel movement is painful and a little scary, because you may worry about putting too much stress on your stitches. It is important to have a bowel movement within three days or so after delivery. Make a point of eating high fiber foods, and raw vegetables and fruits. Also, drink plenty of fluids, including prune juice. These foods and liquids help prevent constipation. If you are unable to move your bowels, you may need a laxative. For that, contact your doctor.

At first, you may be surprised at the amount of urine you pass. Whereas in late pregnancy the baby crowded your bladder, requiring that you empty it frequently, now it may seem that your bladder can hold a tremendous amount of urine. Urinating is one way your body rids itself of all excess fluid it carried during the pregnancy. Occasionally, the urethra [the tube from your bladder to the outside] is swollen after childbirth, causing trouble with urination. Your doctor can help with that.

Men’s fertility also falls with age, but more slowly and later than it does in women. Since most older mothers have partners the same age or older, male infertility can exert its own effect. A combination of slightly lowered fertility in both partners can combine to make pregnancy less likely.

Male infertility can be caused by blocked tubes. These tubes, called the vasa deferentia, carry sperm from the testes, where they are made, to the penis. Tubes can be blocked from birth because of a congenital defect, through scarring caused by sexually transmitted diseases, and through surgery, as in a vasectomy. An increasing number of men choose vasectomy once their families are complete, but if the marriage breaks up and they remarry, vasectomy can be the cause of infertility in the second marriage.

Male infertility can also be caused by:

• Undescended testicles. If these are not diagnosed early in a boy’s life, permanent infertility will result.
• Infections involving the testicles. Orchitis, inflammation of the testicles following mumps, can result in infertility rarely.
• Varicocele. A “varicose vein” of the testicle; it may be a cause of male infertility.
• Disorders of ejaculation. Sometimes, as a result of illness, such as diabetes, or surgery, such as a prostatectomy, sperm is ejaculated backwards into the bladder at orgasm.
• Low sperm count, or a large proportion of the man’s sperm being abnormal. Although research is being done, no one really understands what causes low sperm counts. However, their origin is believed to be hormonal.

Treatments

Because so little is understood about the causes of much male infertility, only limited help is available for the majority of men with a low or absent sperm count. Some causes are known (see above) but there is little that can be done about them.

One form of male infertility can be caused by a varicocele, or varicose vein, around the testicle. This can be treated, although its link with infertility has been questioned. A simple operation to tie off the vein may improve sperm quantity and quality in about two-thirds of cases, thus increasing the chances of conception.

Blocked or scarred vasa deferentia, especially after vasectomy, may be restored surgically but there is only a 50% success rate. A man with blocked tubes often produces antibodies to the sperm because they cannot be ejaculated and have to be reabsorbed by the body. A procedure called percutaneous epididymal sperm aspiration can now remove sperm from the testes, and they are used to fertilize an egg.

Other causes of a low sperm count are resistant to treatment.

Various hormone treatments have been tried, with a low success rate. Some studies have shown the success rate is actually lower among treated men than among those who have not received any partner to conceive and bear a child. In 0I, semen is donated by an anonymous donor. The semen has been screened to verify it does not contain any infectious diseases. Then it is introduced through a tube into the woman’s vagina, close to the cervix, by a doctor or nurse. Donors are screened carefully. There is usually an attempt to match the donor’s physical characteristics with that of the woman’s partner.

The woman goes to the clinic once a month at the most fertile time in her cycle (this is usually worked out with temperature charts). If

her periods are irregular, she may be given ovulation-inducing drugs so the doctors will be able to predict the best time for insemination. The woman is usually advised to lie on her back for about half an hour to enable the sperm to swim into the uterus. Rates of conception with 0I seem to be about the same as with ordinary sexual intercourse.

Going through the tests and treatments already described is in itself a remarkable testament to most couple’s desire for a child. By the time these couples consider the new assisted-reproduction techniques, they have probably been through months or years of tests and the more orthodox fertility treatments. At the same time, it can be difficult to decide when to stop. “You feel you’ve already invested so many years and so much pain in all this, you just have to follow through to the end,” said one woman undergoing fertility treatment.

This is a routine blood test carried out at between 16 and 18 weeks of pregnancy. It measures the level of a substance called alpha-fetoprotein (AFP), which gets into the mother’s bloodstream from the baby. A high level of alpha-fetoprotein can mean a number of things: that the pregnancy is further advanced than was thought, that the mother is expecting twins, or that the baby is suffering from a neural-tube defect. It can also mean nothing at all!

If a woman does have a higher-than-normal level of AFP, a second blood test will be done to confirm it. If this test is positive also, there is a roughly l-in-7 chance the fetus has a neural-tube defect. It is usually recommended that the woman have an ultrasound scan to check for the presence of anencephaly or spina bifida. If results are inconclusive, an amniocentesis is usually recommended so that the level of AFP in the amniotic fluid can be measured (see section below).

The problem with the AFP blood test is that for every ten women with a raised AFP level, only one will have a cause found for it. The other nine will have a normal baby, although they may have a slightly greater risk of having a small-for-dates baby. The majority of women with a high AFP level will have a “positive” result and then an amniocentesis performed, accompanied by a lot of stress and worry, when there is actually nothing wrong with their baby. The chance of the AFP level being high from other causes is greater than the risk of a neural-tube defect.

Rather than perform the AFP test routinely without fully consulting the mother, healthcare professionals might do better to explain what the test is for, what it involves, and let the mother choose whether to have it. Some people welcome the test, but others prefer to do without it.

“I had just had the scan, seen the baby moving [and] that its head was there and it was kicking its legs. I thought we would have seen if there was anything really wrong. Its head would have been the wrong shape or its legs paralyzed. Anyway, I couldn’t possibly have aborted that baby once I had seen him like that. So I decided not to have the test. What was the point of having it done when I could see there was nothing so wrong with the baby and I wouldn’t have wanted an abortion anyway?”

Besides, not all neural-tube defects are detected by the test.

There is no absolute level of AFP in the amniotic fluid at which one can say, “This baby is affected and this one isn’t.” An artificial line has to be drawn. If the level is set too high, more neural-tube defects will go undetected. If it is too low, more women will have further tests with all the worry that goes with it.

A new test known as the triple-screen test has been developed.

A blood test is taken at 16 weeks and levels of alpha-fe top rote in are measured, together with two other “markers,” unconjugated estriol and human chronic gonadotropin (HCG). High levels of AFP may indicate higher likelihood of a baby with spina bifida, while low levels of AFP and unconjugated estriol, together with high levels of HCG, and indicate a higher risk of having a baby with Down syndrome.

Results from the test are combined with the woman’s age to give her a “risk factor.” A risk of one in 250 or higher is considered “screen positive”-that is, an amniocentesis or further screening is advised. A risk of less than one in 250 is considered “screen negative.” However, a positive result means, on average, only a 1-in-50 chance of the woman having a baby with Down syndrome. Again, some experts are concerned that this test will put too many women under great stress who don’t need to be by receiving a “positive” test result and having an amniocentesis.

In a more refined version of the test, called the quad-screen test, a fourth marker is measured in the blood, neutrophil alkaline phosphatase. This makes the test even more accurate at determining whether or not a fetus may have Down syndrome.

In the last decade, doctors have seen considerable changes in the way childbirth is handled. More and more, mothers are able to choose their position during labor and delivery, and their wishes during the birth are given much higher profile. Hospitals may now offer birthing stools, water pools and other “natural childbirth” props. Birthing rooms in hospitals are more common. Home births may be marginally more common and accepted than they were a decade ago.

However, despite this progress, many women are still concerned that there is too much medical intervention in the process of childbirth. This is especially true for older mothers, who are considered to be at higher risk and are much more likely to receive medical intervention.

Home births are still very rare-planned home deliveries account for less than 1% of the total-and few doctors are happy about a first-time mother over 35 giving birth at home. Of course, the ultimate decision is yours, and you still have the option of a home birth if you want one, perhaps with the help of an independent midwife.

A first-time mother over 40 is likely to be offered an elective Cesarean, and this is especially true if she has had fertility problems. A high proportion of IVF babies are born by Cesarean section; first, because doctors do not want to put the baby at any risk, and second, because the whole pregnancy has become so medicalized that many mothers who could not conceive naturally doubt their ability to give birth naturally too.

This impression is backed up by a study of 195 women having their first baby over 35, compared with another 196 women in the same situation who had a history of infertility. The study showed that the women with no history of infertility were four times more likely to have a preterm delivery (less than 37 weeks), five times more likely to undergo a Cesarean section and significantly increased rates of vaginal-assisted delivery, chronic hypertension and fibroids compared with women having their first baby between the ages of 20 and 25. Those who had suffered from infertility had twice as many elective Cesareans as those in the other group, but otherwise there was no difference in outcome.

Unfortunately, in medical litigation cases, inaction can be seen to be negligent while intervention is not. So even if in a particular labor mother and baby’s chances would be best served by doing nothing, doctors may feel they have to intervene to protect themselves. When a mother is older and her baby is considered a precious baby, intervention is much more likely.

However, mothers who opt for a natural, and in particular, a home birth, do so largely because they believe it is safer:

“I had my third child at home at the age of 35. I believe that home birth is safer if there are no special risk factors, and the labor was far quicker and in every way better than the previous two. I believe that probably more babies die as a result of infections picked up in a hospital and mismanaged, extended and messed around-with labor in the hospital than would die at home in the rare event that something goes wrong. However, I do accept that at 35 with a first baby I would not have had the confidence to have a home birth, and if I had no children or had a history of infertility I would probably feel different too.”

Marianne, pregnant with her first baby at 39 after two years of infertility treatment, disagreed. “This might be my only baby. I’ll do whatever the doctors suggest. I’d like a natural birth, of course, but if things go wrong, if they suggest a Cesarean, I’ll go along with it.”

One childbirth-education teacher says that in her experience, older mothers generally feel positive about their labors. “I think they are more realistic than the younger mothers. They want a baby rather than a wonderful natural-childbirth experience.”

However, older mothers may have to stand their ground if they are under pressure to allow intervention in the childbirth process. And, like all mothers, they will have to make a choice. This means finding out what the options are and understanding what labor, both normal and with complications, involves.

Since the 1970s, remarkable improvements in ultrasound technology have opened a real “window on the womb.” Ultrasound consists of high-frequency sound waves that are bounced off the baby to give a photographic picture of the fetus. Unlike X-rays, which have much higher powers of penetration, ultrasound will identify soft tissues. Thus, it can give a complete picture of the growing baby and is a very useful diagnostic tool.

An ultrasound scan may be used to date the pregnancy, and thereafter used as needed in hospitals with the equipment. If not, women who may be at special risk because of problems with a previous pregnancy, or who would like to have a scan, can often be referred to a hospital where it can be performed. The pregnancy can be very accurately dated at around 16 weeks by measuring the circumference of the baby’s head. This knowledge is useful in avoiding problems later if the mother is unsure of her dates and does not know when the baby is due. The scan can locate the position of the placenta, which can be helpful if there is any bleeding later in pregnancy, and it can be used to check that the baby has no major physical abnormalities such as anencephaly. Ultrasound can show congenital heart defects, kidney disease and other severe abnormalities. Ultrasound can also detect if the mother is expecting more than one baby.

There has been some controversy about the safety of ultrasound, which has concerned some women. They are not sure whether they should accept a scan. Ultrasound has now been in use for many years without any evidence of harmful effects to the baby.

All indications are that the benefits of having ultrasound outweigh any potential risk. Not least is the benefit of reassurance given to many women on seeing their baby is alive and well, particularly those who have waited a long time to have a baby or who have experienced a miscarriage. However, a large study carried out in the United States by the National Institutes of Health on 15,000 women with a low risk of problems in pregnancy showed that while detection of twins and malformations was increased, and pregnancy could be dated more accurately, the outcome-in terms of healthy babies-was not improved when ultrasound was employed. There was no difference in the rate of fetal or neonatal death or subsequent illness. Rates for preterm births, for the outcomes of postdate pregnancies and for low-birth-weight babies were similar for those who had had ultrasound and those who had not. Although the percentage of abnormal fetuses detected in the group who had ultrasound was three times higher, the termination rate was about the same in both groups.

So, while ultrasound is of undoubted benefit to women at high risk or in special situations where a problem is detected, its routine benefits are unproved for now. Ultrasound can help some mothers anxious about their pregnancies by reassuring them, but can also create anxieties for others:

“Towards the end of my pregnancy they started to worry about whether my baby was growing as he should. I don’t know what started it, but once they got this idea into their heads they wouldn’t leave me alone. I was in and out of the hospital having my blood pressure taken and having ultrasound scan after scan. My blood pressure was up-with worry, no doubt-and they couldn’t decide what to do. They said they would have to induce the baby early to make sure that all would be well. Then they changed their minds and decided to wait. I was in the hospital for the last few weeks of the pregnancy and, of course, the baby decided to be late. I was two weeks overdue before they decided induce the birth. By then I was so desperate I said, ‘Yes.’ It was a terrible birth, ending with an emergency Cesarean, and when he was born he was 7 pounds, 1 ounce. He didn’t look overdue. I asked my doctor later, ‘So what happened with this small baby?’ There was nothing wrong at all! My worries were for nothing. They said they couldn’t explain it but he had appeared small on the scan. So much for all their wonderful technology!”

Some women-and doctors and midwives, too-feel that, with the increased reliance on new technology, many of the old skills in obstetrics are being lost:

“1 had shared care and I noticed a tremendous difference between my visits to the well-baby clinic and my visits to my very experienced doctor. At the clinic, people seemed to poke and probe for a long time and suggested that I have another scan to see the baby was growing OK. When I went to my doctor, she examined me very quickly and said, ‘Oh, this baby’s doing fine, I think he weighs about 4 pounds now.’ I asked how she knew and she just said, ‘Experience.’ In the clinic, I feel like you only see the junior staff, with the senior staff called for special occasions. No wonder you don’t always get the best care and they give you all kinds of unnecessary tests!”
Having an Ultrasound Scan
An ultrasound scan is a simple, noninvasive procedure. In early pregnancy you are usually asked to drink a lot of water an hour or two before your appointment and not to empty your bladder. This pushes the womb up in the pelvis and will give the ultrasound operator a clearer view. You will be asked to lie down on a couch and remove any clothing that covers your abdomen. A cold gel is rubbed over the abdomen to enable the ultrasound operator to move the scanner smoothly over the area. As she does so you will see the baby’s outline appear on the television screen and you will also see the fetal movements.

It can be difficult to interpret what you are seeing, so ask if you are not told. The operator can freeze the picture at any time and point out things to you without exposing the baby to any more sound waves than necessary. You will usually be able to see the baby’s head, the arms and legs moving around, and some of the internal organs at work. You may even be able to see the baby sucking his thumb.

“The woman took a lot of time to explain to me what she was looking for and what she could see. I found all of it so reassuring. She pointed out the heart beating, the cord and the placenta, the kidneys and the spine and showed me how much he was moving around.”

Other women find the process unnerving, especially if nothing is explained.

“No one said anything to me and I was afraid to ask in case anything was wrong. She kept on looking at everything and taking measurements and I started to get very jumpy. Then she suddenly got up and said, ‘I just want to get a second opinion on this,’ and I was terrified. I thought, ‘This is it. Something’s really wrong.’ I was in tears. Someone else came back and they were both looking at the screen, still not saying anything to me. ‘What is it, what is wrong?’ I finally asked. ‘Nothing’s wrong, I’m just checking these measurements,’ she said. I felt as if I weren’t a person-just a scientific toy.”

Usually the baby’s father is welcome to come and watch the process and see the baby on the screen. Many dads find this is a very positive experience, not only because they are able to give support, but also because the baby becomes real to them in an even more dramatic way than to the woman: “It was hard for me to take in that she was pregnant until I saw the baby on the screen. It was fantastic-it made it come alive for me.”

As you enter the last three months of pregnancy, you may find yourself thinking more and more about the upcoming birth. Your large size and your baby’s movements are constant reminders that you will become a mother soon.

You may find yourself wanting to slow down a bit, preferring quiet evenings at home, slow walks, midday rests with your feet up, and a generally slower pace to your life. The twenty-four hour a day job of making a baby becomes tiring toward the end of pregnancy. When you add to that a job, child care, a social life, and the fact that you might be sleeping more lightly than usual, it is not surprising that you may want to simplify your life and take it easier from now until after your baby is born.

As you slow down and contemplate the upcoming birth and baby, you may be surprised to learn that your body has not slowed down at all. It is working at full speed, preparing for the birth. The baby is growing very rapidly, from about two to three pounds at the end of the twenty-eighth week to about six and a half to nine pounds at the end of the fortieth week. Many changes take place in your body to support such rapid growth. In this chapter we will examine these changes and the birth process itself. We will describe the newborn baby, what she looks like, what she can do, and her immediate care. In addition, we will discuss the first few weeks after birth-the immediate care of the mother and the emotional adjustments to new parenthood.

The Third Trimester

All your baby’s systems were formed in the first trimester. The organs and skeleton took shape and your baby took on a tiny but complete human form. During the second trimester, your baby began to move noticeably, gained the ability to see and hear, and began reacting to outside stimuli-that is, sounds outside your body, light and dark, and your eating and activity patterns. Your baby began turning somersaults, sucked his thumb, hiccupped perceptibly, and generally made you aware of his presence. The third trimester [the last three months od pregnancy] might be best thought of as a time when the final touches are put on your baby in his journey toward life outside your body.

Nutritional Requirements

As your baby grows in size her nutritional requirements increase. For example, she requires about one third more protein in these last months of pregnancy because every cell in the human body has protein as a primary ingredient and with each passing day she has more cells. In addition, because the bones are growing and becoming strong, the need for calcium, which is important to bone strength, increase by about two thirds during the last three months of pregnancy. The baby’s absorption of iron also dramatically increases.

As you can see, with these increased nutritional requirements, it is very desirable that you eat well o supply your baby’s nutritional needs as well as your own. It’s a good idea to reassess your nutritional intake during this last trimester, to see if you are getting the recommended foods in each of the food groups.

Six weeks after the birth you will return to the hospital or your doctor’s office for a checkup to ensure that your body is returning to normal after the birth. The doctor will feel your abdomen to check that the uterus has returned to its normal size. Your blood pressure and weight will be noted. You will be asked if you have had any unusual bleeding, pain or discomfort. (It is quite common for the lochia-the blood loss after the birth-to continue for more than six weeks. Some women have already had a period by this time.) Any scars from tears or episiotomies will be checked. Your breasts and nipples may be examined if you have problems with breast-feeding.

You may also discuss contraception with your doctor if this has not already been arranged. Women who use a diaphragm will usually have it refitted at the postnatal check. Everything may not have returned to its normal shape and size by this time, so it may need checking again a few weeks later. An IUD can also be refitted at six weeks. It isn’t usually done right after the birth because the uterus is still contracting and may expel the device. If you want to take the Pill, the usual combined estrogen/progestogen pill is not suitable if you are breast-feeding because it affects the milk supply. The mini-pill or progestogen-only pill can be taken within seven days of the birth. Some mothers do not like the idea of taking any drug while breast-feeding, however. Small quantities of hormones do get through to the baby, but there is no evidence to date that this is harmful. Many couples rely on the condom as a temporary measure because it really is an ideal method at this time.

You will have the opportunity to raise any worries you have about your own health or that of the baby, including problems with breast-feeding. You may want to discuss problems you have with sex, especially if you have attempted intercourse and found it painful. It is very common not to have had sexual intercourse till after this postnatal stage. In fact, many women find they need the reassurance of the postnatal check that all is well before they do so.

If you did not have a Pap smear taken earlier in pregnancy, now is a good time to have it done.

Breastfeeding, obviously, is more economical than bottle-feeding. It also provides the baby with more intimate contact, and research has shown it releases hormones in the mother that stimulate maternal, tender feelings. Human milk is especially suited to human babies, is easy to digest, and actually helps the baby from getting sick.

Breastfeeding supplies are minimal:

1. Breast creams-aren’t necessary. If your breasts get sore, the best healer is fresh air and pure hydrous lanolin
2. Rubber nipple shields-don’t work well and interfere with the natural toughening process that eventually makes nursing more comfortable.
3. Nursing bras-come in a variety of styles that either fasten in the front center or have fold-down flaps. Flaps are easier. Some women prefer to use an ordinary stretch bra that they simply lift up. Whatever your choice, wait until your ninth month of pregnancy or until after the baby has been born to find your size, since you won’t be at your maximum size until then. If the bra is too tight, it will interfere with the down-flow of milk and be uncomfortable. Look for a bra that is machine washable. If your breasts are very heavy, select one with large, wide straps and extra support, like under wires. Try on several types and buy up to six of the most comfortable since milk leakage during the first few months will necessitate frequent washing [a damp bra can stimulate bacteria growth]
4. Breast pads-for milk leakage. You can use men’s cotton handkerchiefs tucked into your bra or mini-pads cut in half. Commercial breast pads are more expensive, but those made of washable layered fabric aren’t a bad investment. Disposable breast pads usually have plastic liners, which can irritate sore nipples by keeping moisture in.
5. Breast pump-you may need to pump milk if you will be separated from your baby for prolonged period. It’s best to pump while the baby is nursing on the opposite breast. There are four kinds of breast pumps. Hand operated pumps work with a rubber bulb for suction and can be purchased in drugstores. The problem with these is they usually don’t work well. To get them to work at all you must use an intermittent, gentle, tugging action rather than continual suction. Breast pumps that use piston or syringe cylinders also work with an intermittent tugging action, but are designed to be more effective than hand operated pumps. Get one that has adapters for different breast sizes and bottles for storage. You may prefer a battery operated pump; these are somewhat more expensive than hand operated or piston pumps, but are quicker and easier to use. Electric pumps are very expensive and are usually used by hospitals. They can be rented by the month; if you have a premature baby in the hospital you want to be breastfeeding, this may be the way to go until he is home.

All babies have sucking urges that go beyond feeding, and this sucking urge is at its highest at between three and seven months. By the age of two, most babies have lost the urge, except when they’re under stress. Pacifiers may prevent thumb sucking and other undesirable sucking habits. However, there is the danger that he pacifier will come apart and pieces will become stuck in the throat. There have also been strangulations from ribbons or cords when pacifiers were hung around the baby’s neck. New regulations require that there be two ventilation holes in the pacifier for air passage. The protrusions at the back of shields must be a specific size to prevent ingestion, and the pacifier must be tested for durability to ensure that it won’t come apart. There is also a warning on pacifiers that tells you not to tie the pacifier around your baby’s neck because of the strangulation danger.

Once your baby gets a little older, you’ll want to get her a training cup to make the transition from bottle. The cup should have a snap-on lid with a narrow spout and wide handles. Look for cups that are dishwasher safe and preferably transparent. Avoid cups that look like toys, they will encourage play, not drinking.

You’ll also want baby dishes. You can choose either electric or hot water dishes. The electric ones should have temperature regulations to prevent overheating, and they should have a cold section. If you’re using an electric dish, always unplug the cord from the wall socket before unplugging the dish. If you use a hot water dish, make sure the spout cap locks firmly so that he baby can’t pull it out and ingest it. Either kind should be completely immersible and preferably dishwater safe for easy cleaning. Dishes with steep sides and suction bases to prevent sliding will be easier for self-feeding. Feeding spoons used for a child who is beginning to feed herself should have semi-flat bowls and weighted handles that can be easily gripped by chubby little hands. Avoid spoons with rubber bowls; they taste bad.

The changes taking place in your body, placenta, and baby during the last three months of pregnancy accelerate at the end, culminating in labor. As the placenta ages and gradually loses its ability to maintain the pregnancy, the baby becomes strong and capable enough to survive outside the mother’s body; the uterus begins to let go and expel the baby; and the mother becomes ready to give birth and to feed and nurture her baby. Labor consists of rhythmic uterine contractions, which open the cervix and press the baby down through the birth canal and out of your body. The uterus is a big, long hollow muscle; when it contracts, it tightens and hardens. This may happen anywhere from twenty-five to three hundred times during labor, which may take anywhere from a few hours to more than a day. The process not only involves your uterus, but your entire body and mind; all your energy is devoted toward the one goal of giving birth to your baby.

How will you know when you are in labor? As basic as this question is, it is one of the most difficult to answer. It usually takes hours or even days to figure out whether your sensations are labor or something else [pre-labor or false labor]. This is because labor does not begin suddenly. It evolves gradually. At some point, you or your doctor will recognize that these sensations are true labor, meaning that they are accompanied by increasing dilation of the cervix.

The signs of labor may be divided into subtle signs, preliminary signs, and absolutely clear signs.

If you are within a week or two of your due date, you generally may wait until you have an absolutely clear sign of labor before going to the hospital, although your doctor may ask to let him or her know if your bag of waters [amniotic sac surrounding the baby] seems to be leaking. If your pregnancy has been complicated by diabetes, high blood pressure, or other medical conditions, or if you have twins or a breach fetus, your doctor may advise you to go to the hospital with the onset of preliminary signs. If you are several weeks before your due date, you should notify your doctor if you have any preliminary signs, because they could indicate early or premature labor. Premature labor can be stopped if treatment has begun early enough.

To determine whether your contractions are progressing [that is, becoming longer, stronger, and closer together] , you need to time them. On a sheet of paper, list the time when the contractions begin, and how long they last. Time them in this way for an hour or two. If they are not progressing, stop for a while until they seem different, then try timing again.

You should call your doctor or your hospital’s labor and delivery ward to tell them you are in labor or to ask for advice. Be sure to report the status of your bag of waters; whether you have had a bloody discharge [called bloody show, which you will continue to pass while you are in labor]; how long and how many minutes apart your contractions are; and how strong and painful they feel to you.

The majority of new mothers leaving the hospital today breast-feed their babies, at least at the beginning-about 60%. This is especially true for middle-class and professional women, which the majority of older mothers are likely to be. Age does not seem to have any great effect on breast-feeding. It is not commonly known that any woman who has had a baby can breast-feed, and that in other cultures grandmothers breast-feed their daughter’s children. Occasionally a much older mother may find it a problem to produce enough milk, due to hormonal problems, but this is rare.

Many hospitals now give great support and encouragement to mothers who want to breast-feed, recognizing that it is the best food for a baby and that there are emotional rewards for the nursing mother. The American Academy of Pediatrics issued a strongly worded policy in 1997 that suggests women nurse for six to 12 months, because of a strong association between breastfeeding and immunities for babies from a variety of ailments. But some women decide they do not want to breast-feed. There is no reason to feel guilty about this. There are excellent baby formulas available now that are made to match the nutrition of mother’s milk as closely as possible. Bottle-fed babies also thrive. Love is more important than the way you choose to feed, though many mothers choose to express their love through breast-feeding.

Breast-feeding is best for a baby because it is a living substance transmitted directly from mother to baby, containing white blood cells, antibodies and other substances that help protect the baby against disease. We haven’t yet identified all these protective properties. It is composed of exactly the right nutrients for human babies and is produced in exactly the quantities the baby demands.

After the birth a mother produces colostrum, a yellowish fluid rich in antibodies, which protects the baby from infection. Colostrum also contains protein, water and minerals in just the right proportion for the baby’s first few days, and a natural laxative, which helps the baby’s bowels start working. When the milk comes in, it is also perfectly balanced for the baby’s needs. The milk changes slightly in composition as the baby grows. Research has shown that milk produced by the mothers of premature babies is different from normal breast milk, and is ideally suited for them.

When the baby first goes to the breast and sucks, it takes the watery foremilk stored in ducts behind the areola, the pigmented area around the nipple. The baby’s sucking sends a message to the brain to let down the bulk of the milk, and the hormone oxytocin the same hormone that makes the womb contract in labor and at orgasm-is released, causing the muscles around the glands producing the milk to contract and squeeze the milk through the breast to the nipple. The baby usually takes the bulk of the feeding in the first ten minutes or so at the breast. But enough milk is always produced so the feeding can last much longer than this.

Most hospitals have made-up bottles of formula readily available. This is a great temptation to a mother who is having problems with breast-feeding and who is very tired. If you are certain you want to breast-feed, resist this temptation! It takes some time to establish breast-feeding and there are often some initial problems, but they should resolve themselves shortly. Some babies who get used to the bottle find it is more difficult to take the breast. Babies who have had bottles sometimes reject the breast altogether. Mothers who want to avoid cow’s milk because of eczema and asthma in the family should also resist the temptation to give a bottle.

More and more women today are choosing to have their babies later in life - that is, in their thirties and early forties. Statistics from the March of Dimes Prenatal Data Center show that, yes, later motherhood is on the increase. Most of the births occurring each year are to women in their mid- to late twenties. But the proportion of births to women 35 years and older has increased by 84% between 1983 and 1993, from 5.7% of births to 10.5%. In 1976, 19 of 1,000 U.S. births were to women between 35 and 39 years old. By 1996, births to women in this age group accounted for 35.4 of 1,000 births. Women over 40 accounted for 4.5 births per 1,000 in 1976. By 1996, women between 40 and 44 accounted for 6.8 births per 1,000.

Between 1980 and 1990 the number of births outside marriage to women over 30 tripled. It is estimated that about three-quarters of these births were to divorced or separated women. Many of these women were living with their new partners.

While most women who delay motherhood choose to have children in their late thirties, a few decide to become mothers for the first time in their forties. More and more women are establishing their careers first and then embarking on motherhood. Recently, many career women have embarked on motherhood later in their lives, presenting an image of the youthful, sexy, attractive older mother. You may know some of them yourself! Actresses Jane Seymour and Priscilla Presley are two well-known examples of women who have given birth to children in their forties.

Many pregnancies to older women are still accidental, as is shown by the number of women over 40 who choose to terminate their pregnancies. In 1988, 109,642 U.S. women over 40 were pregnant. Of these, 44% chose to terminate the pregnancy. 56% chose to give birth. (Alan Guttmacher Institute, Facts in Brief; January 4, 1993).

Although menopause in most women occurs sometime between the age of 45 and 55, most women trying to have a baby in their forties do experience fertility problems. Now new infertility treatment has given hope to older women unable to conceive naturally. The news in 1997 that a 63-year-old American woman had conceived was greeted with some controversy and confusion. Public debate centered on whether it was “right” for a woman who could be a grandmother to give birth and whether she would be an adequate mother for her children, not to mention whether it was moral for doctors to use artificial means to induce a pregnancy in women over the natural age of child rearing. (In fairness to the doctors, she had told them she was years younger.) But what is the “natural” age at which fertility ends? The oldest mother on record to have conceived naturally appears to be Mrs. Ruth Kistler of Los Angeles, who gave birth to her daughter at the age of 57 years, 129 days.

The reduction in the numbers of women who have very late babies has probably changed people’s attitudes so that today it seems more “unnatural” for women to have a very late baby than it seemed to earlier generations. For women to have a late baby by accident seems to require help and sympathy, while to choose to have a baby late-perhaps with help from medical science seems to inspire judgmental attitudes. Late motherhood is seen as an indulgence in a generation of women who want to “have it all;” it is not meant to be good for the baby.

Everyone seems to accept that late motherhood carries some risk-for the woman’s health, the baby’s health, and perhaps their happiness later on. But what are the risks of late motherhood? What chances is the older mother taking with her health and life? What are the chances of her succeeding in having a healthy pregnancy and normal labor? What are the actual risks of having a baby with disabilities? And how successful is parenthood for the older mother, her family, and, especially, for the child? This book will try to answer these questions for those of you who are considering having a baby later in life.

Another group of older mothers are those who have large families, sometimes increasing over many years. These are the “earth mothers” who find having a small baby at the breast the most fulfilling time of their lives and are reluctant to move on. Sally married at 32 and had four children, when she was 33, 35, 37 and 39. Then, unable to leave the experience behind her, she had another “last-minute” fifth child at the age of 43.

“I’m prepared to admit there might be something wrong with me, that I had all these children for my own pleasure and that I’m postponing facing up to life beyond small children, but they’re all healthy, they’re all happy. I believe you get to be a much better mother with experience, so I don’t think anyone can really criticize me. And if anyone mentions the population problem, I just say my sister doesn’t want children so she’s let me have her 2.3 for her.”

Afterthoughts

Other late babies are born to women after the mother has decided that her family is complete. Most of these late babies are “mistakes,” or “afterthoughts,” but some are planned. James and Diane had been married for I5 years and had two teenage children when Diane found out James was having an affair. “This development really shook things up. Things were fairly desperate for weeks,” Diane recalls. But the couple had a strong enough relationship to withstand the hidden dissatisfactions the affair brought up. Once those had been discussed and resolved, they became closer again. “We took a second honeymoon. I suggested another baby, and to my amazement James agreed with me. Marianne was the result. She has been wonderful; she’s brought nothing but joy to the whole family. She’s brought all of us closer together, including the children.”

Single Women

A woman living on her own reaching her late 30s may decide she cannot wait any longer to find the “right man.” Or she may not even want to live with a man but still want a child. More women than ever are deciding to become a parent alone, partly because social attitudes toward single mothers have become more accepting. Women may either choose to conceive through a male friend, with his consent or by stealth, or may seek artificial insemination by donor.

For all older women who decide to get pregnant, however, there are two main worries: Will I conceive, how long will it take-and will I be able to have a normal pregnancy and birth, and a healthy child?

Each and every day a new baby is welcomed into the world. Not just one baby but many. Statistics say that over a quarter of a million babies are born into the world each and every day.

After the journey of pregnancy, many loving parent are blessed with the long-awaited arrival of their special bundle of joy. Single parents who have chosen to take the journey of parenthood solo are also overjoyed to see their baby for the first time. Surrogate mothers have blessed the expectant couple with a bouncing baby.

However, there are often circumstances such as unwanted teenage pregnancies, babies born of individuals who cannot financially afford a baby, and babies born of individuals who have addictions where, after thoughtful decision-making, the newborn baby is placed up for adoption. Other circumstances also occur such as a baby losing his/her parents in tragedies, or babies born of families in third world countries where food and money are so scarce.

A good number of adoptions are arranged prior to the baby being born. When the baby enters the world and he/she is placed in the loving arms of his/her adoptive parents. These babies are fortunate that they are promptly placed with their forever parents and are able to form a parent/baby bond right away.

On the other hand, a good number of babies throughout the world are born without a family awaiting their arrival. Have you ever wondered how many babies are born without a loving family? I don’t have the statistical numbers but I can be quite certain that the number would be alarming. These special babies who have been placed in institutions or foster care await someone to open their arms and heart and let them into their family.

These special babies do have hope. Their first hope is that they were given life and a wonderful chance in life because their natural parent chose not to abort. Their second hope is that they may have a good chance to be welcomed into a loving family.

Let us not forget the children. What about the older children who longingly await a loving family to open their homes to them?

Adoption is a lifelong commitment by everyone involved and making a difference to a child’s life. When you adopt you provide a secure, loving home to a child for life. Ensure that you are ready to adopt a baby or child and want to adopt for all the right reasons.

So what is a loving individual or couple do if they wish to adopt a new baby or child?

1. Get all of the information you can obtain on adoption.
2. Check with your social service agency.
3. Inquire about state/provincial adoption programs and inter-country adoption.
4. Join a parent group that can that consists of others that are seeking to adopt or have succeeded in adopting.
5. Inform everyone you know - your neighbors, friends, family and church.
6. Utilize an adoption agency.

When planning an adoption, keep open minded and explore all possibilities. Adoption often does not happen overnight and waiting is part of the adoption process. Keep busy and spend the time preparing for the arrival of your child.

Babies and children need hope, love and family. Give them the chance and opportunity to spread their wings and soar through the journey of life. They need someone to believe in them and to be there for them. Take them, have them and love them!

Car seats save lives and prevent serious injury in infants and small children. While states regulate their use, the federal government regulates the construction of car seats. Child seats must meet federal standards that are based on dynamic rather than static testing.

Car seats come in three basic designs: infant seats, shields, and harnesses. Infant seats position the baby in a half-upright position, facing rear-ward. The baby is secured in the carrier by a harness, and the carrier is strapped to the seat with a lap belt. When the child is old enough to sit unsupported, he should be placed in a seat that sits him straight up facing frontward. The carrier should be placed in the back seat. Either a shield or harness seat can be used. The shield type has a protector, which is lowered in front of the child.. it is padded on the inside surface to guard the child in a crash. Because it requires only the safety belt to lock it in place, it is easy to use. Older children can get in and out themselves, which is an advantage for the busy mother. For younger children, though, the shield type can be uncomfortable, because there is little arm room and it is difficult to see above it.

The harness type holds the child in the seat with two shoulder straps, two lap straps, and one crotch strap, all of which converge on a buckle. The seat itself is held in place by a lap belt and may have a tethering strap as well. It is comfortable for the child, but adjusting the straps can sometimes be a nuisance. there are other seats that combine the harness and shield, so that the adjustment difficulties oft the harness and the discomfort of the shield are minimized.

When buying a car seat, there are a number of factions to consider. Besides looking for the best seat at the lowest price, you will need a seat that will be comfortable for your child that can be secured in your ca, and that is easy to use. First, check the construction of the seat. Be sure it meets federal standards [car seats that do are labeled as such]. The most durable seats are those with molded seat shells, and tubular steel under-framing. To save money, consider buying a convertible seat, with dual positions for infants and children, rather than buying two separate seats. Next, check the seat to be sure your child is comfortable in it. She should have enough arm room and the seat should be high enough so that she can see out the car windows easily. This not only helps keep her entertained, but helps to prevent car sickness. Be sure the seat fits in your car and that your lap belts are long enough to secure it. Some seats require a tether. While this type of seat is superior in safety, it does require the installation of a bolt in the car to anchor it. Be sure you can you can, and want to install this. Check the number of straps, and be sure they are easily adjustable. Check the latch of the seat for ease of operation.

Which ever kind of seat you choose, be sure to use it each and every time your child is in the car- and use it properly. The seat must anchored appropriately to the car, including using the tether strap if applicable and the child must be secured correctly in the restraint. Improperly used, a seat becomes a missile, causing more injury than if the child were unrestrained.

There are other advantages to car seats besides safety. Children in car seats are better behaved than unrestrained children. While this is a benefit in itself, well behaved children are also less of a distraction to the driver and thereby contribute to overall auto safety. In addition, children accustomed to riding in car seats are more likely to use seat belts when they get older. Teaching your children good habits now thus may contribute to their future safety.

You should exercise similar care when shopping for and when using other safety restraint items. Such as baby bicycle-seats [the kind that attach behind you your own] and bicycle helmets. Never skimp on quality in order to save a few dollars. Solid construction and secure fasteners are vital.

When is the best time to wean your baby or toddler? The answer is, there is no real solid answer, and it is really a matter of when you or child is comfortable with weaning. The American Academy of Pediatricians recommends that babies be breastfed a minimum of one year, and the World Health Organization recommends a minimum of two years. This is because research has shown that breast milk is the best source of nutrition for a baby. Studies also show that in cultures where children are allowed to nurse for as long as they want the children usually will wean themselves at about three or four. However babies in the US usually are only nursed for their first year of life. Weaning is a very personal decision and should be done whenever mommy or baby is ready based on your needs and lifestyle.

It is recommended that a mother who is breastfeeding does not abruptly stop. It can be hard on the baby who has grown accustom to breastfeeding and can lead to hormonal changes during the first few months of the child’s birth and bring on depression for the mother. It can also make the mother’s breast very painful as her body still produces milk and it can bring on mastitis, a breast infection. Experts also recommend that weaning be done during a time that is not stressful as this is a big change for mother and baby and a stressful time can make it much more difficult. When you want to stop breastfeeding you should do it little by little over several weeks to ease the transition for mom and baby.

The beginning of weaning for most children begins at about six to eight months when your child is introduced to solid foods. Your child will be getting nutrients from solid foods and may not need as much breast milk as before. Try to start by skipping one nursing session everyday and try to make it a time that is not the baby’s favorite nursing time, usually early morning, naptime and bedtime. Instead of this session give your baby a cup or bottle to drink from with either formula or whole milk or it is sometimes recommended to use a mixture of formula and whole milk and gradually introduce whole milk. Keep doing this for a few days every so often eliminating a nursing session until you are no longer breastfeeding. If your baby does not want to take a bottle from mommy try these tips to get your baby drinking from the bottle.

• Have someone other than mommy give the baby the bottle and have mommy stay in another room as even her voice can distract the baby’s feeding.
• Hold the baby in a different position that is not like he or she is breastfeeding. For example hold them facing you on your lap. Once the baby takes the bottle you can cradle them again.
• Propping a bottle up is dangerous for the baby make sure someone is there holding the bottle at all times, the baby could choke because the bottle milk may come out too fast.

Whenever you decide the time to wean is right for you just remember to take it slow and listen to your body and your baby.

What’s more difficult than raising a child? Raising your Mom! Beginning soon after the big news has been broken, parents-to-be find they may have a struggle on their hands. Well-meaning moms, looking forward to grandparenting, have wonderful ideas they are bursting to share. Ideas on how to eat during pregnancy, how much weight the pregnant mom should gain, why mom should bottle feed or breast feed or give new baby bottles of water when she’s fussy and solid food at two months.

Some of these ideas are well worth hearing, but others have Mom and Dad wondering if they will be able to reprogram Grandma before her first babysitting session!

What are new parents to do? Simple. Read up and be educated in the latest concerning child rearing, listen to the older generations offerings, and be ready to stand firm when information and opinions collide!

For example:

Grandmom: How much weight have you gained? Is your doctor happy with that? I only gained 18 pounds with you. I gained 25 with your brother, and my doctor put me on a diet. Did your doctor put you on a diet?

Mom-to-Be: No, Mom. My doctor did not put me on a diet. He is very happy with my weight gain and says I’m right on target. Nowadays, medical studies show a healthy weight gain is between 25 and 30 pounds, and I am within that range. I feel great and I’m eating healthy, and my doctor says the baby is thriving, so I am happy!

Or

Grandmom: Why do you make him sleep on his back? He will be much more comfortable on his tummy. You slept on your tummy.

Mom: True. I did sleep on my stomach, but the most recent research links stomach sleeping to SIDS. They are not exactly sure why, but I feel safer having Junior sleep on his back. Please make sure he is always on his back if you put him down.

Or

Grandmom: Where are baby’s cotton swabs? I’ll clean her ears for you.

Mom: Thanks, Mom, but I don’t use cotton swabs. The doctor says there is more danger of clogging her ears up by using them than not. They say ‘never put anything smaller than an elbow in the baby’s ear.’ You can use a washcloth to wash around it if you like.

The conversations may need repeating several (million) times before Grandma gets it straight, but the battle will be easier won by acknowledging her choices and backing up your own.

Get ready to stage similar mini battles on the following subjects:

Washing hands before handling baby Putting blankets on baby (”What is a sleep sack?” she will ask.) Breast vs. Bottle (especially if you yourself were a bottle baby) Fencing areas – Grandma’s swear by them! Sunning Baby Baby’s sleep schedule

Despite the many disagreements new parents will find they have with Grandma’s way of raising a baby, credit must be given. Mom did something right, or you wouldn’t be where you are today, right?

Where is Grandpa in all of this? He is happily cuddling baby and making cute cooing noises, that is, as long as the little one doesn’t cry. Grandpa isn’t worried about his two cents. He is happy to follow anyone’s suggestions, as long as he doesn’t have to change diapers.

All of the moms I know, work-at-office or work-at-home, suffer from the same lack of status. At the end of the day, no matter how present or absent Mom has been, it’s Daddy’s homecoming that gets the fireworks.

I figure it’s a timeless dilemma, dating back way past the ‘Father Knows Best’ era, when Kitten and Bud would jump for joy as Mother, freshly coiffed and smiling, handed Father his martini. Maybe back to cave days, when Girl and Boy would grunt for joy as Woman stoked the fire and Man dragged home the mastodon. So it’s a little ingrained, by now.

That doesn’t make it right, though. The cost to replace a full-time, home-bound mom is hovering around $140K now. And to replace an office-working mom would cost over $100K, plus her salary. The bottom line is, moms aren’t exactly cheap. So why do we still get treated like what’s scraped off the bottom of a shoe?

I love that my kids love their dad. I love him, too. I love watching them run up to him, jumping and antic with hugs. I love the easy way he scoops them up and they swing, the way my son’s eyes close in satisfaction and my daughter’s little body folds against him, tight. It’s a beautiful thing to watch, when Daddy comes home.

In our house, all of this homecoming drama is compounded by Daddy’s travel. Our Daddy can be gone for a week or more each month, off to far away places with weird names, funny money, and strange foods. We get phone calls and emails and computer calls, but none of that can satisfy the true Daddy jones of his most adoring fans. Every morning and every night we have the same discussion: how many more weeks, days, hours, minutes?

So I can’t really begrudge our Daddy his moments of glory. I have to admit he earns them. Even if he earns them in exotic locales and pricey hotel rooms, he earns them alone. And that’s what I don’t have to be.

Sure, I’d like, every once in a while, to be the celebrated one. I’d love to have some jumping and spinning upon my arrival now and then. I could scoop them up, too, and I’m pretty cushy in a hug-probably softer than him by far. I go out now and then and do some cool stuff… well, okay, maybe I don’t do any cool stuff, but I go out. I mean, I’m actually gone sometimes, just like him. I deserve a little fanfare.

I deserve it, but don’t expect it. My kids take me for granted, just like the kids of every other mom. Dad is the different one, the one left out, the one alone. But moms and kids are so connected, they’re more like one entity; after all, they were one entity for a while. So in a way, celebrating mom is too much like patting themselves on the back-which, of course, we wouldn’t want them to do. At least that’s what I’m going to tell myself the next time I hear, “Daddy’s home!” right after I hear, “Mom! What took you so long?”

The second stage ranges in length from fifteen minutes to three or more hours. The baby is born during the second stage.

When your cervix is fully dilated, the intense out-of-control feelings may subside. The contractions seem to space out somewhat, and you may even get a short break from contractions [this is more likely with first time mothers]. It is always wonderful news when you are told that your cervix is fully dilated and you can begin pushing whenever you feel like it.

During the second stage, you may behave differently than in the first stage. You may find yourself holding your breath or slowly letting it out, while bearing-down [something like, but much more than, what you do when having a bowel movement] and releasing your pelvic floor [relaxing the muscles in the area around your vagina]. This last is most important, because tensing the pelvic floor is actually fighting against the birth of your baby-and it hurts much more than letting go.

You will probably notice a real change in your contractions in the second stage. Most contractions will contain a reflex need to strain or grunt, called an “urge to push”, which comes and goes three to five times per contraction. With each urge to push, the combination of the uterine contraction and your bearing-down effort pushes the baby closer to the outside. It is hard work and it hurts, but it is also an exciting time with lots of cheering and praise for your efforts. Most women find they have the strength to keep pushing.

The best way to push is to push only when your body makes it happen-only when the urge to push comes. That way you won’t hold your breath so long that you or the baby gets too little oxygen. The following is a routine many women use during second stage contractions.

1. Get the contraction with a long breath, and curl your body forward whether you are reclining, lying on your side, squatting, or even sitting on a toilet or birthing chair.
2. Breathe as you did in second stage contractions.
3. When you feel the reflux urge to push [it is unmistakable], follow it by grunting or holding your breath and bearing down. You will need reminders to relax your pelvic floor. The urge to push will go away after a few seconds. Then breathe again until the urge returns. Repeat until the contraction ends.
4. Relax or change positions between contractions.

Positions for the Second Stage

Unless the baby is coming fast, you will have time to change positions. Many childbirth educators encourage women to learn to squat comfortably before labor because this is such a helpful position for the second stage. When you squat, you are giving the baby more room to come down through your pelvis than in other positions. Sitting on the toilet may help if you have trouble relaxing your pelvic floor.

Lying on your side is a good position if the baby is coming fast, if you have painful hemorrhoids, or if you must lie down for some reason. Resting on your hands and knees may help if the baby is large or is having a slowing of the heartbeat during contractions. Semi-sitting is a good position because you can see your doctor and the baby as he comes out. It is also a convenient position for your doctor.

Lying on the back with the legs up in stirrups [the lithotomy position] used to be the way all women gave birth. Most women disliked the position. Their objections to it, plus the fact that it sometimes caused slowing of the baby’s heartbeat and other problems for the mother, finally led to its being discontinued as a routine position by most midwives and many physicians. It is still used however, particularly in anesthetized births and deliveries assisted with forceps or vacuum extraction.

You may use several positions during the second stage, ending with semi-sitting or lying on your side for the actual birth. Discuss positions for the second stage with your doctor in advance.

If you know in advance you are going to have a Cesarean, you can plan for it. You can choose to have the operation done under an epidural anesthetic. That way, you can see and participate in the birth and see or hold your baby as soon as he or she is born. Your husband or partner is also likely to be present for the entire operation. You can make plans for the extra support you will need when you come out of the hospital. If the operation is done as an emergency, however, you are likely to be given a general anesthetic, because setting up an epidural takes time. Your partner may not be able to be with you. In addition, you are likely to suffer aftereffects of the anesthetic, making it more difficult to bond with your new baby right after birth.

A typical Cesarean section usually takes about 45 minutes from start to finish. The baby is delivered in the first 5 to 10 minutes, and the rest of the operation is concerned with stitching you up. The surgeon makes a cut about 12cm long, usually horizontally and just below the “bikini line.” He or she then cuts horizontally through the lower part of the uterus, where there are no main blood vessels. The bag of waters may break of its own accord or have to be broken, and the fluid is sucked away. The surgeon then puts his or her hands into the uterus and rotates the baby’s head so that it appears in the incision. The surgeon helps deliver the baby’s head using his or her hands, or sometimes forceps, and an assistant usually presses gently on the top part of the uterus. A drug to make the uterus contract and stop any bleeding is given, and the rest of the baby is brought out. Then the placenta is delivered. Next, the uterus is sewn up and then the abdominal wall.

Although the Cesarean section is a very safe operation, it is major surgery. The risk of complications, although small in this case, exists wherever surgery is concerned. Many women experience a lot of postoperative pain and may find they cannot get comfortable for breast-feeding. Mothers often find it takes them longer to bond with their baby because they feel so uncomfortable in the days following the delivery:

“Having a Cesarean leaves you so incapacitated that it takes much longer to do things for the baby. Everything the baby does makes you feel so uncomfortable-lifting, feeding-and you are tied down with drips and bottles draining the wound for two days. Your mind is geared to you and not to the baby-it is harder to bond. Because of this I really appreciated the time I had with her at the beginning. My Cesarean was planned, so it was done with an epidural and I was awake. She was born onto me, although I couldn’t feel it. I was able to hold her right away. I was able to think, ‘This is my baby, all right,’ and the three of us had about 1-1/2 hours together after the birth. Without that I think it would have been really hard.”

Parents of twins or larger sets of multiples report feeling either exaltation or resentment; some feel blessed, others feel as if they have been unfairly afflicted. There’s no denying that caring for twins is extremely difficult for the first few months. Later, say some parents, twins become easier than two children who are merely close in age. They can be treated alike as far as daily care goes, and they amuse and teach each other. They may learn to dress and feed themselves rather early, if the one waiting gets impatient as you tend the other.
The names you choose for your multiples will reflect your personal tastes. Some parents like names that rhyme, like Ronald and Donald; others like those that begin with the same letter like Sandra, Susan, and Steven. Still others prefer to use names that are not at all similar like Elizabeth and Christopher. Do be careful not to give your multiples [or any child] names that are herd to pronounce or so unusual or fanciful that they will hate them. Naming one child after one of the parents or another relative may be considered a sign of favoritism later.
The thing that will probably be of the most help to you with your infant twins will be to get them on approximately the same schedule of eating and sleeping. Of course this is easier said then done, but putting them down at the same time and occasionally even waking one for a feeding may help. Feeding on demand will probably be impossible, but you will be tempted sometimes to prop a bottle for one baby while you hold the other to feed. This practice is discouraged as a general rule, but if you have two ravenous babies and will be present to carefully watch the one with the propped bottle, no harm will be done.

You will soon learn which times of the day are most difficult, with both babies awake, fussy and hungry. One of these times is apt to be late in the afternoon, when you yourself are worn out and badly in need of a rest. Adjust whatever schedule you are trying to establish so that you have as little as possible to do at these times, and try to arrange some help for yourself, if your husband or another relative or friend can’t be with you, try to get a teenager to come in for an hour or so to assist you, under your supervision…

Be aware that while you might never let a single baby cry for more than a moment or two, there will be times when one of your twins will have to cry until you have time to attend to his or her wants. Babies are surprisingly adaptable and even screaming for a quarter of an hour will not hurt your twins. Bath-time will probably be one of these times. Do not try to bathe two infants at the same time, possibilities for injury to a baby, not to mention stress and tension for a parent, are more than double when both are wet and wiggling. Indeed, bath time may be the one time, at which it is most helpful and practical to have two caregivers present to split up the tasks of bathing, drying, and dressing the babies.

One common problem with multiples is keeping track of such routine things as which has been fed or bathed, which has had a bowel movement, which has slept for several hours. The solution is simple: Write down everything. Some mothers of multiples find it convenient to hang a chart at the foot of each baby’s crib to record such important events. If you have trouble telling one identical twin from another, paint a finger or toenail of one with nail polish or leave the hospital bracelet on one.

Right from the beginning, become conscious of treating your twins as individuals, not as a “matched set.” Of course they are adorable together, but dress them differently sometimes, and take at least some pictures of each of them individually. Sing and talk to one, and then to the other, and use their names when you talk to them or about them. Try to avoid complaining to others about how much work your babies are, and using the old clichés about “double trouble.” Your twins won’t understand you right now,, but one day they will, and if they learn to think of themselves as problems who cause their parents nothing but drudgery, their self-esteem will be damaged and they may live up to the negative description.

The death of a baby is a traumatic experience and one that hospital staff may find it difficult to deal with. They are geared up to deal with the joy of birth and not the tragedy of death. At the same time, doctors and nurses may be consumed with the aftermath of the delivery or in trying to save a baby’s life. They have little time for the mother and father, leaving both in a state of uncertainty:

“The delivery was awful and he was rushed off to the NICU [neonatal intensive care unit] the moment he was born. I remember they were all fussing around, giving me stitches and cleaning me up, but nobody mentioned the baby. I just assumed he was dead; at first I couldn’t believe it. I felt numb, and then I started crying. Nobody said anything to me and my husband went off to find someone who would tell him what was going on. Then they came to take me back to my room and I said, in tears, ‘I’m not going, I’m not going to the ward to see those mothers and babies.’ ‘Why not?’ they asked. ‘Because my baby’s dead!’ I bawled. At that there was a flurry, and someone came to say he wasn’t dead at all! He was in intensive care but they were sure he’d be all right, and I could go back and look at him later. It was, in fact, touch and go, but they didn’t say so at the time.”

If a woman is kept uninformed and uninvolved, the consequences can be quite tragic:

“It was obvious that something was wrong as soon as he was born. He was taken to the NICU immediately. There was some confusion over what different doctors said about whether he would live or not and that was hard, because I didn’t know whether there was hope. Meanwhile I was in the regular maternity ward with mothers and babies. I wasn’t with him when they disconnected the life-support system and let him die-there was no point in doing anything. If I had been more involved and helped by them, I think I would have chosen to be with him and to have held him when he died.”

There are probably many women who would have very similar feelings and reactions. Until very recently parents were not encouraged even to see their baby, who was whisked away as soon as it was confirmed that the baby was dead. Today, hospital staffs are increasingly aware that many parents want to see their baby, accept its death and have time to grieve. This applies even if the baby is born with a congenital abnormality. The imaginings of someone who has given birth to a baby with physical abnormalities are likely to be much worse than the reality; again, seeing, being with and holding the child can help parents accept the situation:

“They said the baby was deformed and [so] I didn’t want to see her. But my husband did, and he said, really it’s all right, she’s quite beautiful, you can look. They had wrapped her up so that her face and arms and tiny feet showed. She was very beautiful, and her face had a peaceful expression that made me immediately feel much better about her death.”

A mother whose baby has died can ask not to go to the postnatal ward, but to be given a room of her own or perhaps go to the general gynecological ward. Hormones can be given to suppress the milk supply, though this is less typical now because the drugs can have side effects. The mother may continue to produce milk for some days, to her great distress. The mother whose baby has died will have all the usual hormonal and emotional changes following a birth, but no baby; she is in a kind of emotional limbo, neither a mother nor not a mother.

If the baby has died because of some lack of intervention or action by medical staff, parents usually take out their anger on the hospital. This can make the situation worse immediately after the baby has died: “They should have figured out he was in distress. I can’t forgive them.” Anger is a normal part of the grieving process; being able to blame someone can help the situation seem more bearable for the parents in the short term. Most stillbirth or neonatal deaths, however, could not have been prevented, and blaming the hospital will not bring back a baby who has died.

How the hospital staff deals with a tragedy can make an enormous difference to the experience. If you have worries, it can help to talk to your team in advance about what you would like to happen in the event of the baby’s death, even if this sounds as if you are being unnecessarily morbid:

“I told them that if the baby was dead I didn’t want them to whisk her away. I would like to see and hold the baby right then and deal with my emotions then and there. They brushed this aside and said of course nothing will go wrong. In fact, my baby was born perfectly healthy. But I felt it was important for me to say what I wanted in case the unthinkable happened, so we knew where we stood and I wouldn’t be faced with half-truths or well-meaning attempts to protect me from reality.”

Women-and men-who have experienced a baby’s death are often told by doctors, hospital staff, relatives and friends to “forget about this experience-you’ll have another baby soon.” This is very distressing for the parents, who need to acknowledge the death and mourn the loss of their baby before going on to another pregnancy. Some hospitals will help the parents by encouraging them to see and hold the baby, perhaps taking a photograph they can keep, and discussing what sort of funeral arrangements should be made. Hospitals usually arrange for a cremation or burial free of charge, but some parents find they hastily go along with such arrangements and later are distressed because they did not attend a ceremony and because the baby is buried with others or in an unmarked grave.

You will also need to register the baby’s birth or death. You can ask that the baby’s name be recorded so that he or she can be acknowledged as your child, a real individual, and not just “a baby.” If you feel the hospital is not paying attention to your wishes, be firm and ask for what you want. Taking action in this positive way may help you feel a lot better about the experience when you look back on it and help you in the natural process of grieving. (See Further Reading, starting on page 165, for helpful books.)