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PREGNANCY AND BIRTH Pregnancy is a normal physiologic process, which begins with conception, follows through development and

growth of the fetus and delivery, and ends with return to a fully normal state approximately 6 weeks after birth. Pregnancy causes physiologic changes in the mother's bodily functions to allow for growth and development of the fetus. For the fetus, pregnancy is a time of dependency on the mother for nutrition and, thus, exposure to whatever agents to which the mother is exposed. Although a healthy pregnancy is normal for the ma ority of women, for some there may be complications that can lead to adverse outcome for the mother or the fetus. !he average biological length of human gestation, from conception to delivery, is "66 days. #ue to the difficulty in assessing the exact date of conception, however, the clinical length of pregnancy is considered to be "$%, days or &% weeks, calculated from the last normal menstrual period before the cessation of menses, or menstrual flow. !his calculation assumes that ovulation occurs '& days after the last menstrual period. (uman gestation is further divided into trimesters, each of which lasts slightly more than ') weeks. F*!A+ #*,*+-P.*/! After the ovum, or egg, is fertili0ed by a sperm 1see F*2!3+34A!3-/5 898!*., (6.A/:, the fertili0ed ovum becomes implanted in the uterus. First !rimester .ost fetal development, with the exception of such complex functions as brain development, occurs in the first trimester. !he heart begins to beat after & weeks. ;y $ weeks, the eyes, ears, nose, mouth, fingers, and toes are easily recogni0able and male and female reproductive systems have differentiated. ;y '" weeks, all of the recogni0able organs have developed. #uring these first weeks, the fetus is most vulnerable to potential teratogenic or birth<defect<inducing agents, such as drugs, radiation, and viruses. #rugs taken in by the mother during the first weeks can be of particular harm, demonstrated in *urope in the late '=>%s when the drug !(A+3#-.3#*, commonly administered to treat nausea and vomiting, was found to be associated with congenital malformations. 8econd !rimester #uring the second trimester, thin<walled skin develops, organs begin to function, and blood begins to be formed in the bone marrow. 3n addition, scalp hair appears, subcutaneous fat increases, and bones begin to harden. Although the fetus begins to move in the first trimester, it is not until about "% weeks gestation that the mother begins to perceive the movements, the onset of which is called ?@uickening.? !hird !rimester !he ma ority of fetal weight gain occurs in the third trimester. *ar lobes begin to develop cartilage, testes begin to descend into the scrotum, nails begin to grow over the tips of the digits, and creases develop over the soles of the feet. 3n addition, the fetus begins to demonstrate coordinated patterns of behavior that are similar to the cycles of wakefulness and activity of a newborn. 2*P2-#67!3,*

!(* P2*A/A/! ;-#9 A woman's body undergoes a variety of changes to prepare for the growth, nourishment, and birth of a child. First !rimester An early sign of pregnancy is the cessation of menses, which occurs due to the rising levels of human chorionic gonadotrophin 1(7A:, a hormone produced by the placenta 1see P2*A/A/79 !*8!:. !he first trimester is characteri0ed by a number of common discomforts. /ausea and vomiting may begin at approximately eight weeks gestation. 3ncreased urinary fre@uency is common due to the pressure of the enlarging uterus on the bladder. ;reast soreness or tingling often occurs due to hormonal stimulation. Fatigue is also a common complaint. 8econd !rimester 3ncreasing abdominal girth and pressure from the growing uterus can lead to constipation. /ormal intermittent uterine contractions, called ;raxton<(icks contractions, may occur. !he mother may experience lightheadedness and may even pass out due to the effects of the hormones on the blood vessels and the amount of blood diverted to the uterus, placenta, and fetus. (eartburn becomes an ever<increasing problem because of the increasing pressure on the stomach by the enlarging uterus and delayed emptying of the stomach. #espite these discomforts, women are generally more comfortable during the second trimester than the first. !hird !rimester !he last weeks of pregnancy become increasingly uncomfortable. (eadaches, hemorrhoids, varicose veins, and swelling of the legs may occur. 8hortness of breath is common due to the enlarged uterus, which prevents full expansion of the lungs. 3n the last days of gestation increased pelvic discomfort develops, caused by the dropping of the fetal head into the pelvis. False labor pains, or contractions of the uterus that do not lead to progressive dilatation, or opening, of the cervix, can be particularly uncomfortable. 3nsomnia may also be common in the days before delivery. P2*/A!A+ 7A2* 3t is widely accepted that women who receive prenatal care have fewer complications of pregnancy and birth and have healthier babies. 3t is also known that the earlier and more consistently the care is received, the better the outcome. *ducation about pregnancy and child<bearing is an important part of prenatal care, as are detection and treatment of abnormalities. Assessment and reassessment of risk to the mother and fetus are inherent in the provision of prenatal care. 3n fact, the best time to assess many of these risks is before a woman conceives. !herefore, it is becoming popular for childbearing women to receive preconception care while still planning a pregnancy. !hese preventative health visits are designed to achieve optimum health from the moment of conception to birth. 8P*73A+ P2-;+*.8 3/ P2*A/A/79

Although it is a normal process, some women have severe problems during pregnancy. !he maternal mortality rate is the number of maternal deaths occurring per '%%,%%% live births. 3n most Bestern countries this number is as low as '% deaths per '%%,%%% live births. 3n developing countries, however, maternal mortality rates can be as high as ',%%% per '%%,%%% live births. 3t is estimated that in the '=$%s, approximately >%%,%%% women worldwide died every year from pregnancy<related causes. !hese deaths were related to either direct causes where the pregnancy itself or pregnancy complications led to maternal complications5 or indirect causes where the pregnancy aggravated a maternal condition such as diabetes or heart disease. Problems of pregnancy include the following. 8pontaneous Abortion Anywhere from '% to &% percent of human pregnancies end in miscarriage, or spontaneous abortion. -ften, increased vaginal bleeding and cramping occurs around the time of a normal menstrual period and may go unnoticed by the woman. Aenetic analysis of this material suggests that at least >% percent of these spontaneous miscarriages are due to ma or chromosomal abnormalities. *ctopic Pregnancy A pregnancy that occurs at a site other than inside the uterus, such as in the fallopian tube, on the ovary, or at sites outside the abdomen, are termed ectopic. 8uch pregnancies are generally not viable and can in fact be life threatening to the mother. 3nfectious #iseases A variety of infectious diseases, especially A*2.A/ .*A8+*8 1rubella:, !-C-P+A8.-838, and 7(37D*/ P-C, can lead to abnormalities of fetal growth and development. 8ome venereal diseases can be transmitted to the fetus, particularly gonorrhea, syphilis and Ac@uired 3mmunodeficiency 8yndrome 1A3#8:. 2outine tests are conducted before and during pregnancy to test for these infections and, if possible, treat them before harm is done to the fetus. 2h #isease !he 2( FA7!-2 is a specific antigen located on red blood cells. 3f a mother has 2h negative blood and carries an 2h positive child, there is a possibility that the 2h positive blood cells of the child will cross the placental barrier, triggering antibody production to the 2h factor in the mother. !hese maternal antibodies may attack the blood of a subse@uent 2h positive fetus, causing a severe and often fatal type of anemia. #octors are now able to prevent 2h disease with a vaccine. -nce common, the disease is now a rare problem and its eradication is one of the ma or triumphs of modern obstetrics. #iabetes #3A;*!*8, or glucose intolerance, is a common complication of pregnancy. #iabetic women develop an increase in their insulin re@uirements when pregnant, which often makes their diabetes difficult to control. !he outcome for these mothers and babies is significantly impaired. For instance, maternal high blood sugar leads to very large babies. 3n cases, where diabetes is advanced kidney and placental impairment may occur, which also may lead to fetal growth problems.

Alucose intolerance that develops during pregnancy is called gestational diabetes. managed with diet alone, or in combination with insulin. (ypertension

3t can be

Bomen who have chronic hypertension, or high blood pressure, have an increase in complications of pregnancy, particularly kidney disease. 3n addition there are certain hypertension diseases that can develop during pregnancy. !he causes of these diseases are poorly understood, and as a result they are given many names including pregnancy<induced hypertension, toxemia, preeclampsia, or *P( gestosis. !hese diseases are characteri0ed by protein in the urine and swelling or edema that can lead to sei0ures, liver damage, kidney damage, bleeding abnormalities, and poor fetal growth and outcome. Anemia Anemia, or a low blood cell count, is common during pregnancy. Bomen often have a chronic iron< deficiency anemia before pregnancy due to monthly blood loss from menstruation. #uring pregnancy this is compounded by the increased nutritional re@uirements to support the fetus. 3n addition to iron deficiency anemia, there are also other deficiency states that commonly cause anemia, such as vitamin ; deficiency. 3n developing countries, anemia due to malaria is a ma or cause of morbidity. Pregnancy over Age )> 3t is becoming an increasingly common event for women over age )> to become pregnant. Aenerally, these women do well if they were in good health prior to the pregnancy. 7ertain conditions are more common in older pregnant women, however, such as hypertension and gestational diabetes. 3n addition, for each year over the age of )>, there is an increased risk of giving birth to a child with chromosomal anomalies, such as #-B/'8 89/#2-.*. !his risk increases to ' out of every )$ births by the age of &&. A variety of prenatal chromosomal diagnostic tests are available for older pregnant women. Poor /utrition 3t is ideal for the growing fetus if the mother gains at least "><)% pounds during her pregnancy. +ow prepregnancy weight or low weight gain, particularly if food is low in protein, vitamins, and minerals, can impair fetal growth at the time when brain cells are rapidly developing. 8moking, Alcohol, #rugs 8moking during pregnancy affects fetal growth and development due to increased carbon monoxide and decreased oxygen in the blood. (eavy drinking of alcohol impairs the mother's nutrition and can cause damage to her liver. 3n addition, the fetus can develop F*!A+ A+7-(-+ 89/#2-.*, a cluster of mental and physical birth defects. !he use of such drugs as mari uana, amphetamines, cocaine, and heroin all adversely affect the fetus. ;abies are smaller, sicker, and more likely to be stillborn. 3n addition, babies born to women who used drugs during pregnancy may be addicted to the drug at birth. 7ocaine is a particularly dangerous drug during pregnancy because it constricts the blood flow to the developing fetus. 1see also ;32!( #*F*7!8.:

!*8!8 -F F*!A+ B*++<;*3/A 8ince the development of electronic fetal monitoring and the proliferation of the field of genetics in the late '=6%s, prenatal tests of fetal well<being have evolved. 3n addition to these highly technical tests, the value of some basic techni@ues, such as the mother counting fetal movements, are being used more often. Amniocentesis #uring an A./3-7*/!*838, a sample of the amniotic fluid surrounding the fetus is obtained. !his fluid contains cells from the fetus that can be cultured, or grown, to determine chromosomal makeup, fetal lung maturity, and other information about the fetus. Amniocentesis carries a risk of fetal<death of less than ' percent, particularly when performed by skilled practitioners. 7horionic ,illus 8ampling 17,8: 3n this procedure, a small amount of tissue is removed from the fetus at =<'% weeks gestation. !he genetic material of the tissue sample is tested for chromosomal abnormalities. !he advantage of this techni@ue is that it can be performed very early in pregnancy, and the results are generally available before the end of the first trimester. !he risks of fetal death due to the procedure are about the same as those of amniocentesis, or approximately ' percent. Percutaneous 6mbilical ;lood 8ampling #uring this procedure, also known as cordocentesis, blood is obtained directly from the umbilical cord using ultrasound guidance. 7hromosomal and biochemistry tests can be performed on this pure fetal blood sample. !hese results can be available within minutes to hours. !his relatively new procedure carries a higher risk of fetal loss than those above, somewhere in the range of two to five percent. Fetal .onitoring !echni@ues *lectronic fetal monitoring has become commonplace in the evaluation of fetal well<being. !racings of the fetal heart rate and uterine activity are used to evaluate the response to contractions, fetal movement, or external stimuli. !hese tests are begun after "$ weeks gestation, the time in pregnancy when a fetus has a reasonable chance of living outside the uterine environment, if that environment is determined to be potentially dangerous. !he nonstress test, which evaluates the fetal heart<rate response to fetal movement, is the most common method of antepartum 1prebirth: screening for well<being. 3f the fetus is in some eopardy, there will be no characteristic accelerations of the fetal heart rate accompanying fetal movement. Another common antepartum screening test is the contraction stress test. 7ontractions of the uterus are stimulated and the fetal heart rate response is monitored. #ecelerations in the heart rate during the contraction indicates that the placenta does not have an ade@uate reserve of oxygen to supply the fetus. 6ltrasound 6ltrasound has become an integral part of the evaluation and treatment of pregnancy. 8ound waves are passed over the maternal abdomen, and images of the fetus and surrounding tissues are observed on a viewing screen. 6ltrasound monitors the growth of the fetal head, limbs, kidneys, liver, lungs,

and brain. !he techni@ue can also be used to evaluate fetal movement, breathing, and the amount of amniotic fluid and the condition of the placenta. 3nformation gained from the use of ultrasound is useful throughout pregnancy to determine gestational age, the presence of more than one fetus, any fetal malformations and defects, and the position of the fetus and placenta. Fetal 8urgery Fetal surgery has been performed to correct fetal kidney obstruction, fetal hydrocephalus, and diaphragmatic hernia. Fetal surgery is beneficial only to a small number of fetuses and the procedure is still considered experimental. ;32!( !he onset of labor is a complex neuroendocrine event involving the release of the hormone oxytocin from the baby's pituitary gland into the maternal circulation. !his hormone stimulates uterine contraction. +abor +abor is divided into three stages. !he first stage begins at the onset of regular contractions which cause progressive dilatation of the cervix. !he latent phase of this stage is from the start of labor to approximately & cm dilatation, and the active phase is from the end of the latent phase to approximately '% cm dilatation. !he second stage of labor begins at the onset of complete dilatation and continues to the birth of the baby. !he third stage of labor begins at the birth of the baby and continues through the expulsion of the placenta. 3n general, the contractions of the uterus get progressively stronger and closer together over the course of labor. 7-.P+37A!3-/8 -F ;32!( .ost often, pregnancy and birth results in an uncomplicated spontaneous vaginal delivery. (owever, complications of labor and birth may occur, many of which can pose serious problems for the mother or fetus or both. Premature +abor and ;irth Premature labor is defined as labor that begins before the )Eth week of pregnancy. Barning signs of preterm labor include mild menstrual<like cramps, low backache, pelvic pressure, increased vaginal discharge or light bleeding, and diarrhea. A prompt exam will determine if preterm labor exists and if it should be treated with medications in an attempt to stop labor. #epending on gestational age, preterm birth fre@uently leads to respiratory distress, leading to a large proportion of neonatal 1newborn: deaths. #ue to the danger to the fetus, every attempt is made to recogni0e and stop preterm labor. Premature 2upture of the .embranes 2upture of the amniotic fluid sac occurring prior to the onset of labor in a pregnancy of any gestation is considered premature rupture of the membranes. !his may pose danger to the mother and baby due to the possibility of infection and preterm birth. +abor is sometimes induced if the

pregnancy is far enough along, and at other times the woman is placed at rest in the hospital or home to reduce the risk of infection and prematurity. .alpresentation About =6 percent of babies are born head first. Approximately ) percent are born breech, with the buttocks and legs delivering first, and these babies may be delivered vaginally or by 7*8A2*A/ 8*7!3-/. About ' percent of babies are born in a transverse 1sideways: position. !hese babies must be delivered by cesarean. Bhatever method of delivery is used, malpresentations pose added risk to the mother and fetus. #isorders of +abor #eviation from the expected progress of labor may result in abnormal patterns of labor contraction, dilatation of the cervix, or descent of the fetus through the pelvic passage. .any disorders are treated by administration of a contraction inducing drug called Pitocin. -ther ways of managing labor disorders include maternal rest, maternal and fetal position change, and occasionally the administration of anesthesia. 3f treatment is unsuccessful, operative delivery is almost always necessary. Pregnancy<3nduced (ypertension 1P3(: P3( is also known as preeclampsia or toxemia of pregnancy. !he symptoms include swelling or edema, high blood pressure, and protein in the urine. Bhen unrecogni0ed or untreated in pregnancy it can be life threatening to the mother and the fetus, but when treated early it can be well controlled. Placenta Previa !he placenta normally implants itself at the top of the uterus. Bhen it implants lower in the uterus, near or over the cervix, it can cause mild to severe bleeding during the last half of the pregnancy or during labor. 3f the placenta covers the entire cervix at the time labor begins, a cesarean delivery is necessary to save the mother and baby. .ultiple ;irths !wins occur once in $% births, triplets once in '%,%%%, and @uadruplets almost one in a million. 2ecent advances in the use of fertility drugs has increased the incidence of multiple births. .ultiples are more likely to be born prematurely and these pregnancies are conse@uently at higher risk for complications as compared to single infant births. 7horioamnionitisF*ndometritis 7horioamnionitis is an infection of the chorion of the placenta that may spread to surrounding maternal and fetal tissues. 3t is characteri0ed by maternal fever, increased maternal and fetal heart rate 1tachycardia:, and uterine tenderness. 3n about => percent of cases, the infection also affects the fetus and can be life threatening. *ndometritis is an infection of the uterine lining and is the most common cause of postpartum infection. 3t is common in women with chorioamnionitis and most

common in women delivered by cesarean. Although both conditions are very serious, if recogni0ed promptly, they can be effectively treated with antibiotics. 3n addition to these complications of birth, emergencies can occur during labor, such as placental detachment before birth 1abruptio placenta:, worrisome changes in the fetal heart rate 1fetal distress:, and the umbilical cord slipping in front of the fetal head 1cord prolapse:, any of which often lead to an operative birth. -perative #elivery 7lose to one<fourth of all births in the 6nited 8tates are born by cesarean section, the surgical delivery of a baby through the maternal abdomen. A cesarean, when needed, can be a life<saving measure for the mother or the baby. 2easons for a cesarean includeG cephalopelvic disproportion 1baby is too large for mother's pelvis:, transverse lie, fetal distress, prolapsed cord, failure to progress in labor, active genital herpes, and maternal diseases such as preeclampsia, diabetes, or heart disease. !he number of cesarean sections performed in the 6nited 8tates has increased in recent years and there is growing concern that many of these operative deliveries were unnecessary. 2ecent studies have demonstrated that many women who have had a cesarean may safely give birth vaginally in a subse@uent delivery. !hese vaginal births after cesarean 1,;A7s: are becoming more popular and should help decrease the cesarean birth rate. -ther operative deliveries can be conducted using forceps or a vacuum extractor. !hese techni@ues are used most often to ?lift? the baby out of the birth canal during the very last stages of labor. 6sing proper techni@ue, these procedures can be very safe for mother and baby but are used only when a reason exists to ustify their use. .-#*2/ ;32!( P2A7!37*8 A variety of health care professionals are involved in providing care to women during pregnancy. !hese include nurses, nurse<practitioners, nurse<midwives, family physicians, obstetricians, and perinatologists. !here is no doubt that some women who are at very high risk for pregnancy complications must be under the care of a physician. (owever, most pregnant women who are healthy with normal pregnancies can receive care from midwives with appropriate consultation from physicians. !he role of other health professionals such as dieticians and social workers is also valued in providing optimum resources. -ver the years there has been an increased emphasis on childbirth as an experience to be shared in some way with the entire family. !his has given rise to alternatives in the location and the way in which birth has been handled. ;irth can now safely take place outside the hospital, depending on a woman's risk for complication and the training and expertise of the care providers. Approximately =% percent of all births in the 6nited 8tates occur in the hospital. ;irthing centers that create a home like atmosphere and home birth sites for very low risk women account for most of the remaining births. /atural 7hildbirth /atural childbirth is based on the belief that fear of anticipated pain of childbirth creates body and muscle tensions that in turn make the process more difficult and unnecessarily painful. 3t is very common for women to attend some type of childbirth preparation class during the latter weeks of

pregnancy to prepare for some of the anticipated events. .any techni@ues are available, but three that are the most common are the +ama0e .ethod or phychoprophylaxis techni@ue, the +eboyer !echni@ue, or gentle birth techni@ue, and the ;radley .ethod or ?husband coached? techni@ue. 6se of any of these methods has the potential to enhance the family's birth experience and lead to a decrease in the amount of analgesia and anesthesia needed for birth. 3n fact, many women find these techni@ues all that is necessary for pain management. Pain 2elief Bhen pain of labor re@uires pharmacologic treatment, or when an operative birth is re@uired, several methods of analgesia and anesthesia are available. /arcotics and sedatives are used intravenously or intramuscularly to reduce anxiety and give some pain relief at certain times in labor. 2egional anesthesia is also used. Aeneral anesthesia is usually used for obstetrics and includes various combinations of barbiturates, narcotics, and muscle relaxants. P-8!PA2!6. .A!*2/A+ A/# 7(3+# 7A2* !he length of the postpartum period is traditionally six weeks. !his is the length of time re@uired for the mother's uterus and other reproductive tissues to return to their former condition. 3t may take this number of weeks for the woman to return to her previous emotional state and her previous level of vigor as well. For the most part, however, a well rested woman en oys these early weeks after delivery. Bomen who give birth in a hospital are usually discharged within two days after a vaginal birth and within )<& days after a cesarean birth. #uring the first weeks of life, the baby ad usts to conditions outside the mother's body. !he neonatal period, which extends from birth to "$ days of life, is the time when the baby's feeding 1either breast or bottle: and sleep patterns are established. At "$ days of life, the newborn enters the period of 3/FA/79, which extends throughout the first year. !imothy 2. #. Hohnson and +isa +. Paine ;ibliographyG Aabbe, 8. A., et al., eds., -bstetrics, "d ed., 1'==':5 (ales, #., and Hohnson, !.2.;., 3ntensive 7aring<</ew (ope for Problem Pregnancies, 1'==%:5 .ac7artney, .arion, and van der .eer, Antonia, !he .idwife's Pregnancy and 7hildbirth ;ook, 1'==%:5 2ussell, D.P. and /eibyl, H.2., *astman's *xpectant .otherhood, $th ed. 1'=$=:.