Pregnancy and Childbirth

Few words trigger a wider range of emotional reactions in women than, "You're pregnant!" Some women are simply ecstatic about their new pregnant state and almost ready to name the baby they won't meet for many months. Other women are frightened and uncertain about their condition and not quite ready for the upheaval a child can bring. Yet no matter how a woman reacts psychologically, ignorance is never bliss when it comes to pregnancy and childbirth. The more information a woman has about this special time, the better equipped she is to meet its challenges.

In almost no other stage of life are there so many changes and challenges in such a brief time. For most women, pregnancy lasts approximately 40 weeks or 280 days, counting from the first day of the last menstrual period (see "How to Calculate Your Due Date"). Compared to the number of years in a healthy woman's life, 280 days isn't a very long time.

During pregnancy, a woman is really two people at once; she's eating, breathing, and being responsible for her own health as well as that of her baby. It is an exciting time, but one that can be filled with conflicting emotions. Most pregnant women face uncertainties about pregnancy and some anxiety about what the future holds. You can be better prepared if you plan for your pregnancy and what it will entail, understand the changes that are taking place and learn ways to cope with them, and become actively involved in your prenatal care.

Preconceptional Care

A woman who is planning to become pregnant may benefit from preconceptional care (see "Components of Preconceptional Care"). Such care is usually provided by an obstetrician-gynecologist. It is designed to identify risks or problems before pregnancy, provide information about any special needs a woman may have to prepare for pregnancy, and make sure a woman is as healthy as possible before she becomes pregnant.

Components of Preconceptional Care

The following items may be covered during a preconceptional visit:

  • Assessment of medical, reproductive, and family history; nutritional status; drug exposures; social concerns
  • Possible effects of pregnancy on existing medical conditions
  • Genetic concerns
  • Immunization against infections
  • Laboratory tests
  • Nutritional counseling
  • Discussion of social, financial, and psychological issues

Preconceptional care is important because the organs of the fetus (unborn baby) begin to form as early as day 17 of the pregnancy. The fetus may be exposed to health risks before a woman or her doctor even know she is pregnant. Preconceptional care is especially important for women who have certain medical conditions, such as hypertension and diabetes, which can affect the health of the fetus if they are not under control before pregnancy. Multivitamins containing at least 400 micrograms of folic acid reduce fetal malformations.

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In the Beginning

Every month, at about day 14 of a 28-day menstrual cycle, one of a woman's ovaries releases an egg; this is called ovulation. If a man's sperm penetrates the egg, fertilization takes place. The sperm fuses with the egg and forms a single cell. This cell begins to divide and travel down the fallopian tube. It reaches the uterus about the fourth day after fertilization. Now a cluster of about 100 fluid-filled cells, the egg floats until day five to eight when it becomes implanted in the lining of the uterus (endometrium).

The outer cells start to spread into the lining to form a blood supply right next to the mother's blood system, called the placenta.The placenta is actually a life- support system because it provides the fetus with food and oxygen and takes away waste products. The placenta also produces human chorionic gonadotropin (hCG), the hormone which signals the beginning of a new life. This hormone maintains the corpus luteum in the ovary which provides progesterone to the growing fetus.

How to Calculate Your Due Date

To calculate your due date...

  • Count 280 days from the first day of your last period.
  • Count back three months from the first day of the last menstrual period and add seven days.

This is only a guide. Very few women actually deliver their babies on this expected day of arrival.

The placenta connects the mother and the fetus. The umbilical cord links the fetus to the placenta. The fetus floats in a sac of amniotic fluid throughout pregnancy. This fluid regulates the unborn baby's temperature and acts as a shock absorber, protecting the fetus from injury.

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Confirming Pregnancy

Even though every woman is different, in the first weeks after conception, some early signs of pregnancy occur. Some of these symptoms may disappear completely after the end of the first three months of pregnancy.

  • Missing a period (it is possible to be pregnant and still bleed around the time a period would normally occur)
  • Tender breasts
  • Nausea and vomiting, often (but not always) in the mornings
  • Fatigue
  • Need to urinate frequently
  • Aching or heaviness in the pelvic area

Kits for home pregnancy testing are available in most pharmacies. All rely on a chemical that, when combined with your urine in a little test tube, changes colors in the presence of hCG. Follow the directions of home kits carefully. Though up to 98 percent correct, if the test is performed too early, before hCG levels have risen, the results can be falsely negative. The test should be done at least 10 -14 days after a period has been missed. It may be necessary to repeat the test.

About two weeks after a missed period, a doctor, nurse-midwife, or health care practitioner can confirm the pregnancy by testing a sample of blood or urine and examining the pelvic organs to detect changes that occur during pregnancy. Make plans then to begin a prenatal care program.

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Professional Support

Care during pregnancy and birth can be provided by an obstetrician, a family practitioner, or a nurse- midwife. Ideally, a health professional should be selected before pregnancy. If you don't already have a doctor or nurse-midwife in whom you have confidence and trust, start searching for one right away. Recommendations can be made by family and friends, as well as the local medical society.

The American College of Obstetricians and Gynecologists can provide a list of specialists in the area. Write to their resource center at 409 Twelfth Street SW, Washington, DC 20024. To find a nurse-midwife, contact the American College of Nurse-Midwives, 1522 K Street NW, Washington, DC 20005, and send a self- addressed, stamped envelope.

To check the credentials of any physician in a specialty, phone the American Board of Medical Specialists' toll-free number, 800-776-2378. Specialists like obstetrician-gynecologists have 4 years of extra training beyond medical school and have passed certifying exams in their area of expertise. This information is available via the hotline.

Following are some points to consider when selecting a health care provider:

  • In what hospital does the doctor or midwife have privileges to practice? Is the location convenient?
  • How much will care cost and what does the fee include? What type of insurance is accepted? What does it cover?
  • What type of birthing rooms are available? Are there choices regarding the setting?
  • What are the health professionals' policies regarding episiotomies (a cut made between the vagina and the anus near the end of labor to help the baby's head pass through)? What options are available for pain relief?
  • Can special care be provided for any complications that you may have?
  • Is there a special neonatal unit or, if not, where will any baby who needs extra help be transferred?

The setting for giving birth should also be considered. Some hospitals have equipped labor rooms, called birthing rooms, with special beds and technical supports so labor and delivery can take place in one room, instead of moving the woman to a delivery room for birth. An alternative birthing center is a facility separate from the hospital where women give birth. Some have a relationship with a hospital so facilities can be shared and others do not. Most have comfortable settings for childbirth.

An interview with a provider being considered may be useful to answer these questions or any others that arise. Once a provider has been selected, prenatal care (a program of care for a pregnant woman before the birth of her baby) should begin.

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Prenatal Care

With an uncomplicated pregnancy, visits to the doctor or nurse-midwife usually take place once a month during the initial six months and then every two or three weeks thereafter. The first visit is longer than the others and includes a health history, a thorough physical examination (including blood pressure, height and weight measurements), a health history, and tests. The internal reproductive organs are examined to check for changes in the cervix and the size of the uterus. Tests performed at the first visit include:

  • Blood tests to check for the blood type, Rh factor, anemia, immunity to rubella (German measles), hepatitis B virus, and some sexually transmitted diseases (STDs).
  • Urine tests to give information about sugar (which might be a sign of diabetes), protein (signaling possible kidney changes), and signs of infection.
  • A Pap test to detect changes in the cervix that could be an early sign of cancer.

Some tests may be repeated at subsequent visits. Other tests may be offered based on risk factors (see "Prenatal Care"). These tests include those to detect genetic disorders, some of which are offered routinely and some of which are recommended for special circumstances. (See Chapter 14).

After the first visit, most visits can be brief. Each one, however, is a good opportunity to ask questions and gather information on prenatal classes (see "Childbirth Preparation"). Each prenatal visit includes:

  • Sampling urine to check for sugar and protein
  • Measuring blood pressure to see if levels are normal
  • Assessing weight to be sure you are gaining enough
  • Listening to the heartbeat of the fetus (after 12 weeks)
  • Checking the size and position of the uterus and fetus

At each prenatal visit you should discuss with your doctor any changes that may have occurred since the last visit. Also, share any concerns you have and discuss how you should modify your lifestyle to promote a healthy pregnancy.

Prenatal Tests

The following prenatal tests may be offered to certain women based on their patient histories and the results of routine tests:

Maternal Serum Screening. Certain tests can be performed on the mother's blood to detect substances from the fetus that could signal a birth defect. These tests are usually offered to all women at about 15 -18 weeks of pregnancy. One of the substances tested is alpha-fetoprotein (AFP). High levels could be a sign of a neural tube defect, which results when the brain or spinal cord do not develop properly. Low levels could be a sign of Down's syndrome. In some cases, the AFP test is combined with other tests to give more accurate results. Abnormal results require further testing, but most babies tested turn out to be normal.

Ultrasound. Ultrasound creates a picture of the fetus by beaming sound waves into the body and reflecting them on a screen. It is done if there is a question about the status or age of the fetus or to confirm the results of other tests. It can be done at various times during pregnancy, depending on the reason. A thin layer of jelly is rubbed on the mother's belly, and a handheld instrument, called a transducer, is passed over it. Ultrasound determines whether the baby is growing normally, positioning in the womb, abnormalities, or if there is more than one fetus.

Amniocentesis. For an amniocentesis test, the fetal cells in the amniotic fluid are analyzed for signs of birth defects. This test is performed between the 14th and 18th week of pregnancy. A small amount of fluid is removed with a needle from the sac surrounding the baby. The test is recommended for women 35 or older at the time of delivery because they have a higher risk of having a baby with Down's syndrome. In addition, it is given to women who have had a previous child with a birth defect, or who have a family or personal history that places them at risk for an inherited disease. Amniocentesis also may follow abnormal serum tests. There is a small risk of miscarriage with the test. (See Fig. 17.1)

Chorionic Villus Sampling (CVS). A sample of chorionic villi, the fetal blood vessels that form part of the placenta, is removed and analyzed for this test. It is done at 10 -12 weeks of pregnancy. CVS is offered for chromosomal screening. This test may not be available in all areas, and there is a slight risk of miscarriage. Some women choose this test over amniocentesis because the results are available earlier.

Fetal Monitoring. Two forms of monitoring may be done during pregnancy, usually in the last 10 weeks, to check the well-being of the fetus. One is the nonstress test, which measures the fetal heartrate in response to its own movements. The other is the contraction stress test that measures how the fetal heart rate responds to the stress of a uterine contraction. For both tests, a device is strapped to the mother's abdomen and the results are recorded on a tracing. For the contraction stress test, mild uterine contractions are induced with a drug called oxytocin.

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Growth and Development

When the fertilized egg becomes implanted in the uterus it begins to divide and grow. For the first 8 weeks of pregnancy, the egg is called an embryo. After that, it is called a fetus, which literally means "young one."

First Month

  • Inside a fluid-filled sac, the embryo has a simple brain, spine, and central nervous system.
  • The circulatory system as well as the start of a digestive system have begun to form.

Second Month

  • The heart begins to beat in the tiny body, somewhere between the size of an apple seed and a green grape ( inch).
  • Spots appear where eyes will form and a face is almost recognizable.
  • Arms and legs are present as little buds growing longer each day.
  • An outline of the nervous system is present and major internal organs appear in a simple form.

Third Month

  • The fetus is the size of a tennis ball, about
    2 inches long and weighs about one- twentieth of a pound (14 grams).
  • Fingers and toes are now in place.
  • Ears, as well as earlobes, are developed.
  • Eyelids close over the eyes and the muscles of the face are mature enough to allow movement of the face and lips.
  • Vocal cords are complete.

Fourth Month

  • The fetus is fully formed and approximately 5 inches long, weighing about 4 ounces (110 grams). Using the placenta as a lifeline, the fetus now takes in lots of oxygen, food, and water.
  • The fetus can suck a thumb.
  • Eyebrows and eyelashes are growing.
  • The fetal heart beats twice as fast as the mother's and can be heard with a special listening device (doppler unltrasound).

Fifth Month

  • An old-fashioned term referring to fetal movement is quickening, generally thought to mean "feeling life." It feels like a faint flutter, a slight tickling sensation, or perhaps even bubbles.
  • The unborn baby has hair on the head and is developing teeth. It is 6 inches long and weighs of a pound (350 grams).
  • A white, greasy substance called vernix covers the skin and protects it.
  • Fine hair called lanugo covers the fetus.
  • Facial features are wrinkled and shriveled.

Sixth Month

  • The fetus tries out leg and arm muscles often and can have periods of frenzied activity, kicking, punching, and even turning somersaults.
  • Ten inches long and about 2 pounds (1000 grams), the fetus can cough, hiccup, and respond to sudden noises.

Seventh Month

  • The baby's eyes have opened and taste buds are forming. The part of the brain that controls intelligence and temperament is developing. Soon evidence of a personality appears.
  • The baby's skin is wrinkled but an underlayering of fat is slowly building. Lungs are better developed, but a substance called surfactant is still missing. Surfactant keeps newborn lungs from collapsing between each breath.
  • The baby is now 12 inches long and weighs about 3 pounds (1700 grams).

Eighth Month

  • The fetus is probably in the position in which most babies are born: head down, pushing on the pubic area, especially if this is a first birth. This is the cepholic position.
  • Bones harden, but the head bones remain soft and flexible for delivery.
  • The baby measures about 16 inches and weighs about 5 pounds (2500 grams).

Ninth Month

  • The baby gains about an ounce a day now. If it's a boy, the testicles have descended.
  • Nails have grown to cover fingers and toes.
  • The lanugo hair and most of the vernix disappear.

Full Term

  • A substance called meconium is now present in the baby's intestines. This becomes the first bowel movement after birth.
  • At term (40 weeks) the average baby is about 20 inches long and weighs 7 pounds (normal range is 6-9 pounds).

Childbirth Preparation

Childbirth preparation can include lectures, exercise instructions, and tours of maternity/obstetrics departments. They may combine several theories of how to manage labor. There are various techniques. Most courses can be taken in a hospital or privately.

Lamaze. Named after a French doctor, Fernand Lamaze, these classes stress breathing exercises for each stage of labor, along with relaxation techniques. Also emphasized is the need to focus on something almost hypnotically to take your mind off your labor pains.

Dick-Read. Grantly Dick-Read is a British doctor whose theories and classes emphasize abdominal breathing and focusing on the feelings and signals the body sends during labor.

Bradley. The method developed by Denver obstetrician Robert Bradley is closer to Dick-Read than to Lamaze in theory. Couples learn how to relax and breathe deeply. Emphasis is on doing what comes naturally, the presence of fathers at labor and delivery, nutrition during pregnancy, and knowing all the options beforehand.

La Leche. The Spanish phrase, the milk, is the name of this organization founded in the 1950s to promote breast-feeding in the United States. Its local groups and books provide information as well as emotional support for breast-feeding mothers.

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Good Health During Pregnancy

There are ways a pregnant woman can help ensure the health of her baby. They include avoiding things that could be harmful to the fetus in crucial stages of development. During the first three months of pregnancy, often referred to as the first trimester, the unborn baby's organs are forming. Anything that the mother eats, drinks, and breathes is passed on to the fetus. For this reason, pregnant women should avoid things that can cause complications during pregnancy or be harmful to the fetus:

  • Do not smoke tobacco, drink alcohol, or take any form of drug unless it is prescribed by a doctor. Tobacco deprives the fetus of oxygen. Alcohol can lead to fetal alcohol syndrome (mental retardation plus other effects). Drugs can prevent the baby from developing properly. Babies can also be born addicted to drugs.
  • Avoid sources of infection. Certain infections can cause birth defects when passed to the fetus during pregnancy or birth. They include toxoplasmosis, an infection caused by a parasite in cat feces and raw meat, rubella (if a woman is not immune), syphilis, hepatitis B, and other sexually transmitted diseases.
  • Avoid hazards in the workplace. They include chemicals, gas, dust, fumes, or radiation. Also, avoid lifting heavy loads or standing all day.
  • Avoid household hazards such as cleaning products, fumes, or paints.
  • Avoid high body temperature whether due to illness, baths, saunas, or hot tubs.

To maintain your health and that of your baby eat right to support the growth of the fetus, exercise to strengthen muscles and ease discomforts, and get enough sleep.

Where Does the Weight Go? ?

A woman of average weight should gain about 30 pounds during her pregnancy. Here is how it's distributed:

38%  baby
22%  blood and fluid
20%  womb, breasts, buttocks, legs
11%  amniotic fluid
9%  placenta

A woman of normal weight should gain approximately 30 pounds during pregnancy (see "Where Does the Weight Go?"). Women who are overweight should gain less. Teenagers and women who are underweight or carrying twins should gain more. Pregnancy is not a time to try to lose weight. You need about 2,400 calories per day during pregnancy (about 300 calories more than a nonpregnant woman). You also need extra iron, folic acid, and calcium to provide nutrients for the fetus.

Exercise can help a pregnant woman prepare for birth and make her more comfortable during pregnancy. Although this is not the time to take up a hard new sport, if you had been exercising before becoming pregnant, you could continue to do so. Your exercise program may need to be modified because of some of the changes that take place during pregnancy. Your center of gravity, and thus your balance, changes with the added weight, and the hormones of pregnancy cause joints to become more flexible and subject to injury. When exercising, avoid becoming overheated or very tired, drink lots of water, and move more slowly and without jarring motions. Moderate exercise, such as swimming and walking, are good choices; exercises to strengthen back muscles can relieve back pain. However, exercise while lying on the back reduces blood flow to the fetus and is best avoided.

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Changes During Pregnancy

A woman goes through many emotional and physical changes during her pregnancy. Each woman is different, however, and these changes don't occur in all women or at the same times. Many of these changes are related to the pressure exerted on various parts of the body as the fetus grows.


Pregnancy is a turning point in a woman's life. As with other phases of transition, psychological issues may resurface during this time. Often the woman revisits her own childhood experience and recalls the way in which she was raised.

The first three months of pregnancy are a time of adjusting to, or coming to terms with, the pregnancy. The middle of pregnancy is a relatively quiet time, during which the woman begins the process of bonding with the baby. Knowing the sex of the child in advance, which is available through some prenatal tests, may promote bonding. The pregnant woman may withdraw from outside activities and focus on her relationship with the baby's father and her home life. These feelings continue to grow into the last part of pregnancy. There may be increased anxiety and fear of problems about the delivery at this time.


Sexuality changes during pregnancy. For some women, the increased levels of hormones enhance their desire for sex during pregnancy. For others, sexual functioning increases at certain phases and decreases at others. A number of factors may interfere with sexual functioning. They include nausea, physical discomfort, fear of harming the fetus, feeling less desirable with increased weight, and bodily changes. Changes in the partner's responsiveness are also a factor. Some men draw closer to their partner during pregnancy and the postpartum period, but others may go through psychological changes, causing them to withdraw from the relationship. The woman's new maternal role, and her new physical appearance, may bring out unresolved conflicts in her partner.

Some couples are concerned that having sex during pregnancy can harm the fetus. In most cases it will not because the fetus is cushioned by the sac of amniotic fluid. A couple may find it more comfortable to try different positions that don't place pressure on a woman's abdomen. If there is a complication or concern, the doctor or nurse-midwife may suggest that the couple abstain from sex.

Sleeping Problems

Early pregnancy is often associated with prolonged sleep and fatigue. Sleep disturbance is also noted during pregnancy. For some women it may be the first symptom of pregnancy. It is quite common for women to have difficulty falling asleep or staying asleep at any given time during the pregnancy. Sleep may be particularly disturbed as term approaches. Some women dream vividly. Sleeping medications are best avoided because they could harm the fetus, especially during early pregnancy. Warm baths, relaxation exercises, and lying on one side propped by a pillow may help. (See Fig. 17.11)


As they get ready for the strain of delivery, joints and ligaments in your body relax. The result could be a backache. Exercises can help promote good posture and relieve aching muscles. To avoid back injury, avoid lifting whenever possible. If you must lift, bend from the knees, keeping the back straight. Do not lie flat on your back because the supine position can make it hard to breathe, and reduce blood flow to the baby.

Breast Changes

One of the first signs of pregnancy is tender breasts. The breasts continue to grow and change throughout pregnancy to prepare for breast-feeding. The nipples and surrounding skin might become darker, and the nipples and veins become more prominent. A woman's bra size may increase to twice the original size during pregnancy. Wear a comfortable cotton bra with wide shoulder straps and deep bands under the cups. Late in pregnancy, a woman may notice a yellow, watery fluid leaking from her nipples. This is called colostrum, and it nourishes the baby in the first days of life. It is rich in protective substances, called antibodies, which fight infection.

Breathing Problems

The pressure of the uterus on the bottom of the rib cage can cause a feeling of shortness of breath. The lungs do not have room enough to expand and take in enough air. In late pregnancy just before birth, the fetus drops and this often relieves that feeling.

Gastrointestinal Problems

Most women have morning sickness -- nausea and vomiting -- during the first three months of pregnancy. It usually, but not always, goes away in the middle of pregnancy. The condition is worse when the stomach is empty. Eating a number of small meals a day may help.

Heartburn, or indigestion, has nothing to do with the heart. It is caused by acids from the stomach that cause a burning sensation in the throat and chest. Changes in the hormone levels during pregnancy slow digestion and relax the muscles that keep the stomach acids where they belong. Again, more frequent small meals instead of fewer large ones may bring some relief. Avoid large, spicy meals or fried foods. Also, avoid exercising or going to bed within two hours of eating. Your doctor or nurse-midwife may be able to suggest something to counteract the acidity in your stomach.

Many pregnant women are constipated during pregnancy. This is partly because of the pressure from the fetus on the bowel and the hormones of pregnancy that slow the passage of food. Exercise, eating foods high in fiber, and drinking fluids can help relieve constipation.

Hemorrhoids are enlarged or weakened veins near the anus. The baby's head creates pressure on these veins, causing them to swell during pregnancy. Straining during bowel movements makes the situation worse, causing itching, soreness, and perhaps even bleeding. Increasing fiber and fluid intake, using products for treating hemorrhoids and relieving constipation may help. You should of course consult your doctor before taking any medication.

Skin Changes

A dark line, called the linea nigra, may appear down the center of the stretched stomach, and the skin may itch. Skin on the abdomen and breasts must expand, often causing streaks called stretch marks. There is no way to prevent these marks; many lighten after birth. In some women, the hormones produced during pregnancy cause a brown mask on the face called chloasma that often fades after birth when hormones return to normal.

Varicose Veins

Swollen and painful veins, called varicose veins, often occur in the calves, thighs, and the vagina. They are made worse by poor circulation in the legs, especially during long periods of standing. Special support stockings can be worn to relieve aching, sore legs. Also helpful is lying on your side, with legs elevated, as is floating in water. While standing, move around as much as possible, lifting heels or toes to promote circulation.


Most women have some degree of swelling in the legs or the hands during pregnancy. The face also may puff up because of the body's tendency to retain fluid. Although extreme swelling can be a sign that the kidneys are not working properly, some swelling is normal. Resting on your side with the feet elevated can help. In the third trimester, floating in water can help relieve swelling.

Other Changes

  • Swollen gums that bleed more easily
  • Muscle and leg cramps
  • Numbness and tingling in the extremities
  • Thicker hair growth
  • Need to urinate more often (remember, sudden increases may signal infection)

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Special Considerations

Some pregnancies require special care. In some cases this is known in advance. In others, warning signs occur during the course of pregnancy and are detected during prenatal care. Any warning signs should be reported to the clinician right away (see "Warning Signs").


Miscarriage, also called spontaneous abortion, is the loss of a pregnancy before the fetus can live on its own. It occurs in about 15 percent of pregnancies, usually in early pregnancy. Most miscarriages occur in the first trimester, before 12 weeks. After week 16, the chance of having a miscarriage is low. The risk of miscarriage increases with age.

Miscarriage usually cannot be prevented and often occurs because the pregnancy is not normal. A miscarriage doesn't mean that a woman can't have children in the future. There is no proof that stress or physical or sexual activity causes miscarriage.

An early warning may be vaginal spotting. Other signs of a miscarriage are pain in the lower back, cramps in the lower abdomen, and heavy bleeding with clots. After a miscarriage, a procedure called dilation and curettage (D&C) may be necessary to open and clean the uterus. Loss of a pregnancy through miscarriage is traumatic, emotionally as well as physically. Discuss any concerns about current or future pregnancies with your health care professional. Special tests, procedures, or medicine may be needed if a woman experiences a loss after 12 weeks or if she loses several pregnancies in a row.

Warning Signs

Any of the following symptoms could be a sign of a problem and require immediate medical attention:

  • Vaginal bleeding can be a sign of a miscarriage or a problem with the placenta.
  • Vaginal discharge -- either a change in the type or an increase in the amount -- could be a sign of preterm labor.
  • Cramps and back pain could signal miscarriage or preterm birth.
  • Swelling, headache, blurred vision occur with high blood pressure in pregnancy.
  • Severe, sharp abdominal pain should be evaluated if it doesn't improve with position changes.
  • Fever or chills are symptoms of infection.
  • Fluid discharge from your vagina is a sign that the amniotic sac has ruptured and labor will probably begin soon. This is a problem if it occurs before 38 weeks of pregnancy.
  • Decreased fetal movement for 12 hours after week 28 could mean the unborn baby is in

Preterm Labor

If labor begins before the 37th week of pregnancy, the baby may be born early. Often, labor can be stopped to allow the fetus more time in the uterus, where it has the best chance of growing and developing normally. Treatments to stop labor include bed rest, fluids given intravenously, and special agents to relax the uterus. The goal is to prolong the pregnancy until the fetus is fully developed. Today, even very early preterm infants can survive in neonatal intensive care units and drugs are available to help their lungs function better.

Problems with the Placenta

In late pregnancy, bleeding can be a sign of problems with the placenta. The placenta may pull away from the wall of the uterus (placental abruption), or it may cover the cervix (placenta previa). Both of these conditions can interfere with the oxygen supply of the fetus and require medical attention. These conditions may be best treated with a cesarean section.

Medical Conditions

High blood pressure and diabetes can develop during pregnancy in women who did not previously have these conditions. They often go away after delivery, although they can recur. These conditions can become worse in women who had them before they became pregnant. In either case, they require treatment.

High blood pressure, coupled with protein in the urine and swelling, is called preeclampsia. Symptoms include headaches, swelling of the hands and face, dizziness, blurred vision, sudden or uneven weight gain, and stomach pain. It can cause seizures and preterm birth and should be treated right away.

Diabetes that occurs during pregnancy is called gestational diabetes. Women with this condition have too much sugar in their blood because the hormones of pregnancy alter the way in which the body processes sugar. When blood sugar is high, the baby may become too large to pass through the mother's birth canal. Diabetes may be controlled through diet, exercise, or insulin (the hormone that processes sugar in the blood). Pills to control glucose are best avoided in pregnancy.

Rh Disease

Antigens are proteins found on the surfaces of blood cells that cause an immune response. One type of antigen is the Rh factor. If the mother's blood lacks the Rh antigen (Rh negative) and the father's blood contains it, the fetus can get the antigen from the father and be Rh positive.

The blood cells from an Rh positive baby can cause an Rh negative mother to produce anti-Rh antibodies as if she were allergic to the fetus. This is called sensitization. Her antibodies cross the placenta, causing anemia or Rh disease. This disease can be prevented by giving the mother a blood product called Rh immunoglobulin (RhIG). This product should be given at any time fetal blood might mix with mother's blood -- for example, after an abortion, amniocentesis or chorionic villus testing -- to keep antibodies from forming. Once antibodies are formed, they do not go away. RhIG is recommended at 28 weeks of pregnancy for women who are Rh-negative and not sensitized, unless the baby's father is also Rh negative. If her baby has Rh- positive blood, she should be given another dose shortly after she gives birth.

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Labor and Birth

No two women experience exactly the same sensations during labor. Nor are all labors and the accompanying contractions the same length of time. Even expectant mothers who already have children can't be too sure about what might happen. Each baby is different, just as each birth experience holds surprises. What's important is that you understand the various stages of labor and delivery and, if possible, have someone available for support.

True Versus False Labor

In true labor, contractions are

  • Regular and get closer together
  • Continuous in spite of movement
  • Usually felt in the back and move to the front
  • Increasing steadily in strength

In false labor, contractions are Irregular and do not get closer

  • Stopped with movement or a change in position
  • Often felt in the abdomen
  • Weak and do not get stronger

Stages of Labor

There are two main parts of the uterus: the upper part is muscular and can expand -- its very top part is called the fundus -- and at the bottom of the uterus the opening or cervix. In active childbirth, both parts of the uterus work together, contracting and pushing the baby down until the cervix dilates, or opens. The cervix is closed by a ring of muscles that gradually opens and thins (or effaces) during labor. (See Fig. 17.12)

A woman's body gradually prepares for labor and delivery during the last weeks of pregnancy. In those last weeks, the uterus may start to cramp. The cramps become stronger as the due date approaches. These are called Braxton-Hicks contractions or false labor. These contractions differ from true labor in a number of ways (see "True versus False Labor").

About 24 hours before active labor begins, the tiny mucus plug that has guarded the entrance to the cervix may break loose. This is called bloody show because blood could be present in the mucus.

Once contractions begin, start timing how long each one lasts and how long it is from the start of one to the start of the next and note the times. If the contractions last 30 -70 seconds, if they occur regularly, and if they don't go away with movement, it's probably the real thing. Contact your clinician. A first labor lasts on average 12-14 hours. Labor may be shorter for subsequent births.

There are three stages of labor. Changes take place in each stage, although they vary from one woman to another.

First Stage

The first stage of labor begins when the cervix starts to open and ends when it is fully open. It occurs in three parts: early, active, and transition. In the hospital or clinic, an exam is done to see how labor is progressing.

  • Early Phase. Contractions are usually mild, lasting 60 -90 seconds and occurring every 15 -20 minutes. They gradually become more regular and occur less than 5 minutes apart.
  • Active Phase. Contractions are much stronger, lasting for about 45 seconds and occurring every 3 minutes. Tensing or pushing during this phase is discouraged.
  • Transition. Transition is the most difficult stage of labor. The cervix is fully dilated, and contractions occur 2-3 minutes apart and last about 60 seconds. A wave of nausea is commonly noted, which passes rapidly.

Second Stage

The cervix is fully dilated and the baby is ready to be pushed out. Though it's tough physical work -- especially in a long labor -- it may be more rewarding and contractions may seem less intense. This stage includes the birth of the baby.

  • The second stage may last 2 hours or longer
  • Contractions slow to 2-5 minutes apart and last 60 -90 seconds.
  • Pushing should only be done during contractions, with resting and deep breathing between contractions.
  • Maternal coordination and effort can speed delivery.

As the baby's head moves closer to the vaginal opening, it bulges and bumps against the pelvic floor with each contraction. In between contractions, the head may slip back inside. This back and forth motion is normal.

Pushing should stop as soon as the head crowns or becomes visible, to prevent tearing of your skin. At this point an episiotomy, or surgical cut, may be performed to widen the opening. (See Fig. 17.13) You may notice a stinging sensation or numbness as the baby is born because the skin has stretched so much.

In a normal birth, the baby's head slips out first, face down. The attendant checks to make sure the umbilical cord is not wrapped around the neck. The head turns so one side is lined up with the shoulders. Fluid or mucus may need to be sucked from the baby's mouth and nose. With the next contractions, the body slides out.

Third Stage

After the baby is born, the placenta is expelled. This stage may last up to 30 minutes.

  • Contractions are closer together and may be less painful.
  • The placenta is usually expelled as it separates from the wall of the uterus.
  • A check will be made to ensure that the entire placenta is out and that no harmful tears are present in the vagina or cervix.

Pain Relief

Natural childbirth has come to mean an awake, aware, undrugged mother. It does not mean, as some people believe, a painless birth. (In childbirth, some women have a lot of pain and some have much less.) Many women wrongly feel they've failed if they can't stand the pain and need medication. There are various options available, and you need not hesitate to take advantage of them.

Epidural Block

Epidural anesthesia relieves pain during labor, by numbing the area from the waist down. It takes about 10 minutes for an anesthesiologist to administer the medication through a needle inserted between the vertebrae of the backbone. (See Fig. 17.14) An intravenous line is inserted so fluids and medication can be given to prevent blood pressure changes. Complications can include a drop in the mother's blood pressure, which may affect the baby's heartbeat, and a headache, relieved by lying down for a few days after the birth.

Spinal Block

Similar to an epidural, a spinal block is injected into the spinal fluid sac and anesthesizes the body from the waist down. (See Fig. 17.14A) Pain relief lasts about 1-2 hours. The injection is given only once during labor, so it is best suited for pain relief during delivery. Complications are similar to those of epidural block.

Pudendal Block

An injection is given shortly before delivery to block pain in the vagina and rectum as the baby is born. It is one of the safest forms of anesthesia.

General Anesthetic

Medications that produce loss of consciousness can be used during cesarean delivery if there is an emergency. One complication is aspiration, when food from a woman's stomach enters the windpipe and lungs, causing injury. This is why a woman should not eat once active labor has begun.

Pain Medications

Drugs can be injected into a muscle or vein to relieve pain. These drugs can have side effects and slow the baby's reflexes and breathing. They usually are given in small doses and avoided just before delivery.

Monitoring the Fetus

During labor, the status of the baby is monitored by listening to its heartbeat. This process, called auscultation, is done with a special stethoscope, or an electronic fetal monitor, a machine which records the heartbeat.


The heartbeat is monitored by a doctor or nurse, who listens to it at regular intervals. Usually the heartbeat is checked and recorded after a contraction. The frequency of monitoring depends on the stage of labor.

Electronic Fetal Monitoring (EFM)

The two kinds of EFM are external and internal. With external monitoring, an instrument using sound waves (dopples ultrasound) is attached to the mother's abdomen to record the heart rate of the fetus. With internal monitoring, a small device called an electrode is attached to the scalp of the fetus. Sometimes a tube called a catheter is inserted in the uterus to measure uterine contractions. External and internal monitoring techniques may be used together. Both techniques are done to assess whether the fetus is getting enough oxygen and prevent stress. With internal monitoring, the amniotic sac is broken for the device to be inserted in the uterus.

Assisted Delivery

Sometimes the mother needs a helping hand. If she is having trouble during labor, or if labor is delayed, the doctor may use certain tools designed to help speed delivery.


Forceps are used to guide a baby through the birth canal; these metal instruments look a little like two big spoons hooked together. Often forceps are used if a baby seems to be in distress. During the pushing stage of labor, forceps can help an exhausted mother.

Vacuum Extraction

A plastic or metal suction cup is placed on the baby's head during delivery; vacuum extraction also helps speed up a delivery.


Also called pitocin, it is a drug that causes contractions. It can be used to induce labor if a woman needs early delivery or has passed beyond 42 weeks of pregnancy and labor has not begun. Oxytocin also can be used to make the contractions stronger if the labor is not progressing well or the contractions are too weak. It is given intravenously to the mother a little bit at a time.

Cesarean Delivery

In a cesarean birth the baby is delivered through an incision in the mother's abdomen. Sometimes cesarean deliveries are arranged and scheduled in advance. On other occasions, the decision for a cesarean delivery will be done on an emergency basis because labor is not proceeding normally or the baby is having difficulty. Some of the reasons for cesarean delivery include:

  • Cephalopelvic disproportion, in which the baby is too large to pass safely through the mother's pelvis.
  • Fetal distress caused by the baby having difficulty withstanding labor or compression of the umbilical cord.
  • Placental problems.
  • Abnormal presentation, in which the baby lies bottom or feet first in the mother's birth canal (sometimes, the baby can be repositioned to allow a vaginal delivery).

Because cesarean deliveries are surgical procedures, recovery takes longer. Today, most clinicians encourage women who had a previous cesarean delivery to try a vaginal delivery, provided there are no reasons not to do so.

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After the Baby Is Born

Having a baby is hard work. New mothers need sleep, nourishment, quiet unpressured time to see and touch their new babies, and lots of support. The mother's body undergoes dramatic physical changes as it tries to shift gears and go back to its previous state. Many hospitals now send mothers home within the first 24 hours, which can be both a blessing and curse. While it can be comforting to be home, taking care of an infant is a 24-hour-a-day, seven-day-a-week proposition. Someone should be there to help with the beginning stages of motherhood. The body undergoes various physical changes over the next 6 weeks to return to a nonpregnant state.


Most women lose at least 13 pounds immediately after birth and an additional 3 -4 pounds in the first days of the baby's life. Weight loss during the first six weeks after birth (postpartum) can be dramatic, especially for breast-feeding mothers.


Women who breast-feed need extra vitamins, minerals, and calories to support the baby. Breast milk is the best source of nutrition for a newborn baby because it has special nutrients that help the baby grow and combat diseases (see Chapter 18, Breast-feeding). If it is not possible to breast-feed at all times, consider storing your breast milk so it can be given to the baby with a bottle.


As the uterus contracts to its prepregnant size, cramping sensations, called afterpains, may occur in the lower abdomen for a few days. This happens more often if a woman is breast-feeding. The cramps can be relieved with a mild painkiller. However, most painkillers are passed along into breast milk and may be hazardous to the newborn. Check with your pedatrician before taking medication.

Painful Urination

After childbirth, the bladder, bowel, and pelvic floor may be tender and sore, making every trip to the bathroom something to dread. What's more, eliminating all the built up extra fluid causes more frequent urination. A warm shower can relax the muscles and help ease urination, especially with an episiotomy.


Vaginal bleeding occurs for several weeks; anywhere from two to six is considered normal. If the mother is breast-feeding, bleeding might stop sooner. The flow is bright red and heavy at first, turning brownish as the days pass and healing begins. Nothing should be placed in the vagina, including tampons, until healing is complete. Intercourse should be avoided.

Bowel Movements

It may take a day or so for stool to pass after delivery. Drinking lots of water, walking, and eating high fiber foods can stimulate the system and get it back in working order. Straining should be avoided. A laxative or stool softener may help.


Stitches take up to 2 weeks to heal and dissolve. Soreness can be relieved by applying ice to the area and lying down to keep pressure at a minimum. The area should be kept as clean as possible.


A woman can resume sexual activity as soon as she has healed. The physical effects of increased levels of hormones in breast-feeding women may reduce sexual desire and function. Many women need extra lubrication. A woman may not have menstrual periods if she is breast-feeding but she could become pregnant. Select a method of birth control and begin using it soon after birth.

Postpartum Depression

About 30 -80 percent of women feel down or depressed following delivery (see Chapter 8). This is called postpartum blues. These symptoms usually go away spontaneously within 10 weeks of birth, without professional help. If symptoms persist beyond that point, or if a woman thinks about hurting herself or others, she should seek professional help and possibly antidepressant medication.

Postpartum depression occurs in approximately 10 percent of women after birth. If a woman has had a previous postpartum depression, the risk increases to approximately 30 percent. Panic disorder and obsessive-compulsive disorder also may arise during the postpartum period. Some of the symptoms of postpartum depression are feelings of worthlessness, anxiety, low self-esteem, insomnia, unusual weight loss, digestive problems, social isolation, feelings of inadequacy as a mother, obsessions about the baby's health or a dissatisfying relationship, mourning the loss of her former appearance or lifestyle, and, at times, suicidal thoughts. It is important to contact your clinician for help.

Postpartum psychosis is the most severe form of postpartum psychiatric illness. It affects a very small percentage of women who deliver. Postpartum psychosis is a medical emergency and requires prompt professional attention. There may be severe agitation, insomnia, and paranoia, as well as delusions and hallucinations that can lead to suicide or an impulse to kill the baby. Despite its severity, the prognosis for full recovery from postpartum psychosis is excellent.


Every new mother should pick up at least one good book on child care. Your doctor or midwife can give recommendations.

  • The Good Housekeeping Illustrated Book of Pregnancy and Baby Care (Hearst Books), edited by Maryann Bucknum Brinley.
  • Dr. Spock's Baby and Child Care (Dutton) A practical, easy-to-read guide, Benjamin Spock's book has been updated at various times during the last 50 years.
  • Your Baby and Child: From Birth to Age Five (Knopf) by Penelope Leach, a British psychologist.
  • What To Expect When You Are Expecting (Workman) by Arlene Eisenberg, Heidi Eisenberg Murkoff, and Sandee Eisenberg Hathaway. Now part of a series of three books by this mother-daughter team, these books are packed with pertinent advice and information.
  • Caring for Your Baby and Young Child, Birth to Age 5, The Complete and Authoritative Guide from The American Academy of Pediatrics, edited by Steven P. Shelov, M.D., F.A.A.P.