Childbirth is one of nature's greatest wonders. We live in an age where we expect a perfect outcome but throughout history until just a couple of generations ago, childbirth was a most precarious event. Mercifully mortality has been reduced to just 2% compared to a century ago and we can now concentrate more on the outcome for the baby.
We are increasingly turning to the internet for information. Questions about health are amongst the more common reasons for Web searches.atients rightly wish to be involved in decisions about their care. There are often options relating to investigations and management. The purpose of this Web site is to present the background for decision making and to explore areas of current debate.
2 Women's Health .com'provides illustrated answers for those women who have a pregnancy related problem and for those who know someone who has.
For those without medical training, all medical terms in the text have a link to the explanation. '2 Women's Health .com' is for discerning people who wish to appreciate the background to pregnancy related treatment options. Health professionals, including nurses, medical students, junior doctors and general practitioners looking for a text that provides a balanced discussion of the issues, rather than a basic review of the essential clinical facts, may find this book helpful not only for obstetrics and midwifery but as a framework for the caring aspects in the art of medicine.Those studying for postgraduatequalifications, may find the presentation, with links to clinically relevant medical abstracts, to be of assistance.
Links to the abstracts of selected medical papers are provided to allow a more in depth understanding. This area of the Web site will be an ongoing project. The ethos of this e-book is to explain the advantages and disadvantages of the various options whilst leaving it to each individual to come to their preference according to their particular circumstance.
During pregnancy one (or more) offspring, known as an embryo (early pregnancy) or fetus (from about 8 weeks into the pregnancy), develop inside the uterus of a woman. Pregnancy occurs as the result of the female gamete or oocyte (egg) being penetrated by the male gamete spermatozoon in a process referred to, in medicine, as "fertilization", or more commonly as "conception". The fusion of male and female gametes usually occurs through the act of sexual intercourse. However, the advent of artificial insemination and in vitro fertilization (IVF) has also made achieving pregnancy possible in such cases where sexual intercourse is not potentially fertile (through choice or male/female infertility). In the majority of human pregnancies, only one baby develops (singleton pregnancy) but there can be more (multiple pregnancy) as in the case of twins or triplets. Some infertility treatments, particularly IVF, are prone to result in multiple pregnancy. The outer layers of the embryo grow and form a placenta, for the purpose of receiving oxygen and essential nutrients and removing carbon dioxide and waste products. The umbilical cord in a newborn child consists of the remnants of the connection to the placenta. The developing embryo undergoes tremendous growth and changes during the process of foetal development.
Pregnancy is the carrying of one or more offspring, known as a fetus or embryo, inside the uterus of a female. More than one baby may develop, as in the case of twins or triplets. Obstetrics is the medical field that studies and treats pregnant patients. Childbirth usually occurs about 38 weeks from fertilization, which is approximately 40 weeks from the start of the last menstruation. Thus, pregnancy lasts about nine months. One scientific term for the state of pregnancy is gravid, and a pregnant female is sometimes referred to as a gravida. Both words are rarely used in common speech. The term embryo is used to describe the developing human during the initial weeks, and the term fetus is used from about two months of development until birth. A woman who is pregnant for the first time is known medically as a " primigravida" or " gravida 1", while a woman who has never been pregnant is known as " gravida 0". Similarly, the terms " para 0", " para 1" and so on are used for the number of times a woman has previously given birth. If a woman has never given birth, she is referred to as nulliparous. In many societies' medical and legal definitions, human pregnancy is somewhat arbitrarily divided into three trimester periods, as a means to simplify reference to the different stages of prenatal development. The first trimester (until 16 weeks) carries the highest risk of miscarriage. During the second trimester (from 16-28 weeks), the development of the fetus can be more easily monitored and diagnosed. The beginning of the third trimester often approximates the point of viability, or the ability of the fetus to survive, with or without medical help, outside of the uterus.
Pregnancy occurs as the result of the female gamete or process known as "fertilisation", or more commonly known as "conception". The fusion of male and female gametes usually occurs through the act of sexual intercourse. However, the advent of artificial insemination has also made achieving pregnancy possible in such cases where sexual intercourse is not potentially fertile through choice or in some cases of infertility. Though pregnancy begins at implantation, it is more convenient to date from the first day of a woman's last menstrual period (LMP). This is used to calculate the expected date of delivery (EDD). Pregnancy usually lasts between 37 and 42 weeks, with the EDD at 40 weeks after the LMP. 40 weeks is e quivalent to a little more than nine months and six days, which forms the basis of Naegele's rule for estimating date of delivery. Pregnancy is considered 'at term' when gestation attains 37 complete weeks but is less than 42 (between 259 and 294 days since LMP). Events before completion of 37 weeks (259 days) are considered pre-term; from week 42 (294 days) events are considered post-term. When a pregnancy exceeds 42 weeks (294 days) it can begin to pose significant risks to mother and fetus. Obstetricians usually prefer to induce labour, in an otherwise uncomplicated pregnancy, at some stage between 41 and 42 weeks. Medical literature tends to use the terminology pre-term and post-term premature and post-mature. Pre-term and post-term are unambiguously defined as above, whereas premature and postmature have historical meaning and relate more to the infant's size and state of development rather than to the stage of pregnancy. Though these are the averages, the actual length of pregnancy depends on various factors. For example, the first pregnancy tends to last longer than subsequent pregnancies. Fewer than 10% of births occur on the due date; 50% of births are within a week of the due date, and almost 90% within two weeks. Accurate dating of pregnancy is important, because it is used in calculating the results of various prenatal tests such as the triple test used to screen for Down Syndrome (mongolism). A decision may be made to induce labour if a fetus is perceived to be overdue. Due dates are only a rough estimate, and the process of accurately dating a pregnancy is complicated by the fact that not all women have 28 day menstrual cycles, or ovulate on the 14th day following their last menstrual period. A number of medical signs are associated with pregnancy. These signs typically appear, if at all, within the first few weeks after conception. Although not all of these signs are universally present, nor are all of them diagnostic by themselves, taken together they make a presumptive diagnosis of pregnancy. These signs include the presence of human chorionic gonadotropin ( hCG) in the blood and urine, missed menstrual period, implantation bleeding that occurs at implantation of the embryo in the uterus during the third or fourth week after last menstrual period, increased basal body temperature sustained for over two weeks after ovulation, Chadwick's sign (darkening of the cervix, vagina, and vulva), Goodell's sign (softening of the vaginal portion of the cervix), Hegar's sign (softening of the Vaginal fornix), and Linea nigra, (darkening of the skin in a vertical line on the abdomen, caused by hyperpigmentation resulting from hormonal changes; it usually appears around the middle of pregnancy).[15][16]
Obstetrics and the Pregnant Woman
Obstetrics is the medical field that studies and treats pregnant women and the doctors who specialise in obstetric medicine are known as obstetricians.
Childbirth usually occurs about 38 weeks from fertilization, i.e., approximately 40 weeks from the start of the last menstruation.
A commonly used scientific term for the state of being pregnant is gravid, and a pregnant woman is sometimes referred to as a gravida. Similarly, the term "parity" (abbreviated as "para") is used for the number of previous deliveries occurring after 24 weeks. Women who have never been pregnant before are referred to as "nulliparous" and during a first pregnancy as a "primigravida" ("gravida 1, para 0") and in subsequent pregnancies as "multigravida" or "multiparous". Hence during a second pregnancy a woman would be described as "gravida 2, para 1".
Pregnancy is divided into three trimester periods. The first trimester of pregnancy concludes at 16 weeks and carries the highest risk of miscarriage. In some cases the fertilized egg might implant itself in a fallopian tube, causing an ectopic pregnancy. The second trimester of pregnancy tends to be less prone to complications. Most women feel more energized in this period, and begin to put on weight as the symptoms of morning sickness subside and eventually fade away. Although the fetus begins moving and takes a recognizable human shape during the first trimester, it is not until the second trimester that movement of the fetus, often referred to as "quickening", can be felt. This typically happens by the fourth month. The placenta is now fully functioning The third trimester of pregnancy commences at 28 weeks and approximates the point of viability, or the ability of the fetus to survive, with or without medical help, outside of the uterus. The use of modern medical intensive care technology has greatly increased the probability of premature babies living, and has pushed back the boundary of viability to much earlier dates than would be possible without assistance.0801 Theseadvances in the quality of neonatal care have resulted in survival of many babies delivered at 24 weeks and even earlier. An unfortunate complication of extreme prematurity is morbidity.
Calculating Dates In Pregnancy
Most pregnant women do not have any specific signs or symptoms of implantation, although it is not uncommon to experience light bleeding at implantation. Though pregnancy begins at implantation, it is more convenient to date from the first day of a woman's last menstrual period (LMP). Starting from one of these dates, the expected date of delivery (EDD) can be calculated. Counting from the LMP, pregnancy usually lasts between 37 and 42 weeks, with the EDD at 40 weeks, or 38 weeks following conception. 40 weeks is nine months and six days, which forms the basis of Naegele's rule for estimating date of delivery. Less than 10% of births occur spontaneously on the EDD; 50% of births are within a week of the due date, and almost 90% within two weeks. Dating a pregnancy is only a rough estimate, and the process of accurately dating a pregnancy using the LMP method is complicated by the fact that not all women have 28 day menstrual cycles, nor ovulate on the 14th day following their last menstrual period. Unless a woman's recent sexual activity has been limited, or she has been charting her cycles, or the conception is as the result of some types of fertility treatment (such asIUI or IVF) the exact date of fertilization is unknown.
Pregnancy is considered 'at term' when gestation attains 37 complete weeks but is less than 42. Events before completion of 37 weeks (259 days) are considered pre-term; from week 42 (294 days) events are considered to be post-term. When a pregnancy exceeds 42 weeks (294 days), the risk of complications for mother and fetus increases significantly. This is one indication for obstetricians to recommend induction of labour, generally between 41 and 42 weeks.(Induction of Labour)Obstetricians have tended to refer increasingly topre-term and post-term rather thanpremature andpost-mature.
Accurate dating of pregnancy is important for several reasons. It is used in determining the significance of results of various prenatal tests such as the triple test - a screenig test for Down syndrome. Assessment of the appropriateness of the fetal size depends on an accurate knowledge of the gestational age. Interventions may be indicated if the fetus is small or large for dates. A decision may be made to delay delivery if labour begins prematurely and to administer steroids to reduce complications or to induce labour(Induction of Labour) if a fetus is believed to be overdue.
A number of symptoms and signs are associated with pregnancy:-
Symptoms and signs of pregnancy:-
Missed Period
If you have normal regular cycles then a missed period is more than likely can indicate a pregnancy. On occasion or it may be related to an illness or stress. It is considered one of the major possible symptoms of pregnancy.
Unusual or abnormal period
A period or menstrual cycle that is different in some way. The period may be last longer or shorter. It may be a difference in the amount of flow. Any of these variances may indicate that you are pregnant.
Just "feeling" pregnant
Many women just know when they are pregnant.
Nausea and Vomiting
If you were to ask women to name a single pregnancy symptom, morning sickness would be at the top of everyone's list.
Increased urinary voiding
The urgent need to empty the bladder, even small amounts, throughout the day and night is caused by pressure of the enlarging uterus on the bladder. It is helpful not to drink too much just before going to bed. No treatment is needed for urinary Frequency alone but if micturition becomes painful, urinary infection should be excluded.
Food aversions or cravings
When you're pregnant, you might find yourself turning up your nose at certain foods, such as coffee or fried foods. Food cravings are common, too. Like most other symptoms of pregnancy, these food preferences can be chalked up to hormonal changes ? especially in the first trimester, when hormone changes are the most dramatic.
Heartburn and Constipation
The smooth muscle of the stomach and bowel relax more in pregnancy in response to progesterone, the pregnancy hormone. You may require antacids for the heartburn. Ensure adequate fluid intake to reduce constipation. Mild laxatives may occasionally be required.
Positive Pregnancy Test
Modern pregnancy tests are extremely accurate, often being positive even before a missed period.
Ultrasound
Ultrasound may be able to show the pregnancy from about 5 weeks.
Fetal Heart Tones
With modern sonicaid monitors, the baby's heart beat can be heard from about 14 weeks.
Tender Breasts
Early in the first trimester you may notice that your breasts are sore or tender. For some women this is also a sign of an impending period, so it may go unnoticed. You may have a slight tenderness when you touch your breasts or you can have the severe pain whenever you wear a bra. Both variants are normal and are usually most intense in the first trimester. This is one of the reasons that sex in the first trimester is often avoided by some women. Sex in pregnancy is safe, you may just want to avoid having anyone touch your nipples.
Enlargement of the Breasts
Towards the end of the first trimester or the beginning of the second trimester you may notice that your breasts begin to grow. This is again the tissues inside the breast preparing for nursing. Towards the end of pregnancy you will want to be fitted for a nursing bra to help accommodate the larger breasts.
Nipple Colour Changes
Your nipples and the area around the nipples (areola) get darker and broader.
Montgomery's Tubercules
These are small goose bump like raised areas on the areola of your breast.
Colostrum from the breasts
Colostrum is a pre-milk substance that is high in antibodies and works to get the meconium out of your baby's system after birth. It can appear at any point during pregnancy, but is not seen in all women.
Changes in libido
You and your partner may find your desire for sex increased because you do not have to think about birth control. The vagina is more lubricated and the clitoris and vagina are more engorged. Many women will become orgasmic or multi-orgasmic for the first time during pregnancy because of this added engorgement.
Strange Cravings
Some studies show that up to 68% of women will have a craving at some point during pregnancy.
Fatigue
This is nature's way of making you take some extra rest which is probably healthy in pregnancy.
Skin Changes
Striae gravidarum, or stretch marks, are probably the most discussed of the skin changes during pregnancy. They appear in 50 - 90 of all pregnant women, usually showing up in the later half of pregnancy. While the majority will be on the lower abdomen they can also be found on the thighs, hips, buttocks, breasts and arms of women. They reflect the separation of collagen of the skin. While not painful the stretching of the skin may cause a tingling or itchy sensation.
These are most commonly seen as small depressions in the skin. They tend to be pinkish in light skinned women, and in dark skinned women they will be lighter than the surrounding skin.
While many people will swear by certain creams or lotions, the truth is there's there is no evidence that any of them are effective. Striae gravidarum are exacerbated if you gain weight excessively and so you may help yourself by taking care of your diet.
Quickening (Fetal Movement)
This is the time that you feel your baby move for the first time. Fetal movement begins around eighteen weeks into the pregnancy.
Enlarged abdomen
As the baby grows the pregnancy begins to 'show'.
Braxton Hicks Contractions
The uterus is a muscular organ and contractions occur throughout pregnancy. As term approaches, they become stronger. This is normal.
Fetus palpable
From about 28 weeks you may be able to feel the parts of the baby particularly the head.
X rays
With the advent of ultrasound, x-rays are rarely used nowadays in pregnancy.
Emotional Changes
Most women experience emotional mood swings. It's natural to feel doubt, anxiety, and fear about pregnancy and childbirth, as well as happiness, excitement, and anticipation.
Weight gain
The average weight gain is 25lb with about 1 pound per week in later weeks.
Fainting
This is more common in late pregnancy, particularly if the pregnant woman lies flat on her back and the pressure of the pregnant uterus reduces the blood flow in the big vessels returning blood to the heart. Fainting may occur in early pregnancy and is usually related to sudden change of position, such as when sitting up from recumbency, or standing up from the sitting position. If you feel faint, lie down with your feet elevated and your head flat. Avoid standing for long periods and don't rush around. Be particularly careful getting up.
Although not all of these signs are universally present, nor are all of them diagnostic by themselves, taken together they make a presumptive diagnosis of pregnancy. These signs include the presence of human chorionic gonadotropin (hCG) in the blood and urine, missed menstrual period, implantation bleeding that occurs at implantation of the embryo in the uterus during the third or fourth week after last menstrual period, increased basal body temperature sustained for over two weeks after ovulation, Chadwick's sign (darkening of the cervix, vagina, and vulva), Goodell's sign (softening of the vaginal portion of the cervix), Hegar's sign (softening of the Vaginal fornix), and Linea nigra, (darkening of the skin in a vertical line on the abdomen, caused by hyperpigmentation resulting from hormonal changes; it usually appears around the middle of pregnancy).
The beginning of pregnancy may be detected in a number of ways, including various pregnancy tests which detect hormones generated by the newly-formed placenta (afterbirth). Clinical blood and urine tests can detect pregnancy within a few days of implantation, which is as early as 6-8 days after fertilization.
Following the development of the blastocyst (early embryo) a hormone named human chorionic gonadotropin (HCG) is produced and this stimulates the corpus luteum in the woman's ovary to produce progesterone (hormone in favour of pregnancy). This maintains the lining of the uterus so that the embryo will continue to be nourished.
An early ultrasound examination can accurately determine gestational age. This method is slightly more accurate than methods based on LMP.9901
