What are the first symptoms of pregnancy? Missing a period is usually the first signal of a new pregnancy, although women with irregular periods may not initially recognize a missed period as pregnancy. During this time, many women experience a need to urinate frequently, extreme fatigue, nausea and/or vomiting, and increased breast tenderness. All or some of these symptoms are normal. Most over-the-counter pregnancy tests are sensitive 9-12 days after conception, and they are readily available at most drug stores. Performing these tests early helps to allay confusion and guesswork. A serum pregnancy test (performed in a physician's office or laboratory facility) can detect pregnancy 8-11 days after conception. How long after conception does the fertilized egg implant? The fertilized conceptus enters the uterus as a 2- to 8-cell embryo and freely floats in the endometrial cavity about 90-150 hours, roughly 4-7 days after conception. Most embryos implant by the morula stage, when the embryo consists of many cells. This happens, on average, 6 days after conception. The new embryo then induces the lining changes of the endometrium, which is called decidualization. It then rapidly begins to develop the physiologic changes that establish maternal-placental exchange. Prior to this time, medications ingested by the mother typically do not affect a pregnancy. What is the most accurate pregnancy test to use? Serum beta–human chorionic gonadotropin (hCG) is the hormone produced by the syncytiotrophoblast beginning on the day of implantation, and it rises in both the maternal blood stream and the maternal urine fairly quickly. The serum hCG test is the most sensitive and specific, and the hormone can be detected in both blood and urine by about 8-9 days after conception. This test can be performed quantitatively or qualitatively. Urine pregnancy tests differ in their sensitivity and specificity, which are based on the hCG units set as the cutoff for a positive test result, usually 2-5 mIU/mL. Urine pregnancy tests can produce positive results at the level of 20 mIU/mL, which is 2-3 days before most women expect the next menstrual period. The kits available are very accurate and widely available. The test can be completed in about 3-5 minutes. The kits all use the same technique—recognition by an antibody of the beta subunit of hCG. Falsely high readings of the hCG hormone can occur in cases of hydatidiform molar pregnancy or other placental abnormalities. Also, test results can remain positive for pregnancy weeks after a pregnancy termination, miscarriage, or birth. On the other hand, false-negative test results can occur from incorrect test preparation, urine that is too dilute, or interference by several medications. Other urine tests use the agglutination inhibition method. This test requires a drop of urine to be mixed with hCG antibody and hCG-coated latex particles. If the pregnancy test result is positive and hCG is present, then the mixture remains smooth. If no hCG is present, or test result is negative, then the particles of latex agglutinate. After pregnancy termination, these tests are useful because they are not as sensitive and prove negativity more quickly. Serum pregnancy tests can be performed by a variety of methods. The enzyme-linked immunosorbent assay (ELISA) is the most popular in many clinical laboratories. This test is a determination of total beta-hCG levels. It is performed using a monoclonal antibody to bind to the hCG; a second antibody is added that also interacts with hCG and emits color when doing so. This form of ELISA is commonly called a "sandwich" of the sample hCG. Radioimmunoassay (RIA) is still used by some laboratories. This test adds radiolabeled anti-hCG antibody to nonlabeled hCG of the blood sample. The count is then essentially determined by the amount of displacement of the radiolabeled sample. The hCG level doubles approximately every 2 days in early pregnancy. However, it should be noted that even increases of only 33% can be consistent with healthy pregnancies. These values increase until about 60-70 days and then decrease to very low levels by about 100-130 days and never decrease any further until the pregnancy is over. What is the best home pregnancy test? Most commonly available home pregnancy tests use similar technology, are easy to perform, and are very low cost. How is the baby's due date calculated? Pregnancy lasts 281-282 days, according to most studies of normal pregnancies. The Naegele rule is a mathematical calculation that makes the day and month of the presumed due date easy to determine. Determine the first day of the last menstrual period, add 7 days, and then subtract 3 months. This is the expected month and date the baby will be due. This is fairly accurate, and stating weeks or months of the pregnancy based on this calculation provides the gestational age or menstrual age. Most obstetrical literature uses this calculation. A more correct ovulatory age can be determined by counting the weeks from presumed ovulation, which would be about 2 weeks from the first day of the last menstrual period. The trimesters end after 14 weeks and 28 weeks of pregnancy, according to convention. What is meant by the term nullipara? Obstetricians use various terms to describe pregnant women. A nulligravid woman is one who has never been pregnant and who is not currently pregnant. A gravid woman is or has been pregnant in her life. For a woman who has been pregnant but has not completed a pregnancy past an abortion (elective or spontaneous), the term used is nullipara. When a woman enters her first pregnancy, she is designated a primipara. Once a woman has had 2 successful, viable pregnancies, she is termed a multipara. A parturient is a woman in labor, and a puerpera is a woman who has recently given birth and is no more than 6 weeks postpartum. When obstetricians use these abbreviations to communicate with each other, it is more complicated. Someone who has had a single twin pregnancy is only a gravid 1, para 1, although she may have 2 living children. The gravid 1 means that she has had 1 pregnancy, the para 1 means that she has had 1 complete pregnancy and the number 2 means she has 2 children or twins from the 1 complete pregnancy. The obstetrician may label her as a G1P1002 because she has had no miscarriages and no abortions. With the parity figures (numbers that come after the letter P), the first number is designated for full-term pregnancies, the second for preterm pregnancies (20-37 weeks' gestation), the third for abortions (pregnancies ending before 20 weeks, regardless of whether it was a miscarriage or an abortion), and the last number is designated for the number of living children. So, in the example, G1P1002, this mother would have had 1 full-term twin pregnancy and both babies are alive. Using the same example, if the twins were born prematurely, this woman would be defined as G1P0102. Ectopic and tubal pregnancies are treated as abortions in this terminology. How does a woman know if she has an ectopic or tubal pregnancy? Because pregnancy tests are so widely available, many physicians can diagnose a tubal pregnancy before it becomes symptomatic. The most common symptom of an ectopic pregnancy is cramping or tenderness on 1 side of the lower abdomen. If tubal rupture ensues, pain becomes very sharp and steady before spreading throughout the entire pelvic region. Other symptoms include brown vaginal spotting, light bleeding, or heavier bleeding if the tube ruptures. If rupture leads to bleeding severe enough to cause anemia, a patient may experience dizziness or weakness. Physical findings, pelvic ultrasonography, and hCG testing all are used to make an accurate diagnosis of a tubal pregnancy. Quantitative hCG tests are commonly used to monitor hCG levels with respect to gestational age. If the patient has a serum hCG test and a second test repeated in 48 hours, the values obtained can be compared to the expected values discussed above. An approximate doubling of hCG levels in the 48- to 72-hour period are indicative of a normal early pregnancy, but even a 66% increase might be consistent with a viable pregnancy. Unchanging hCG levels are suggestive of a tubal (or abnormal) pregnancy. If a patient is stable, monitoring hCG levels over several blood draws is acceptable. Transvaginal pelvic ultrasonography can also be performed to determine if a fetal sac is present in the uterus or if a swelling or color-flow is present in the tube (that would be more indicative of a tubal pregnancy). An intrauterine sac rules out tubal pregnancy in most cases, although 1 in 30,000 women have coexistent tubal and intrauterine gestations. For an accurate diagnosis of abnormal pregnancies, serial readings of hCG levels must be performed, allowing for some expected test variation. For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education article Ectopic Pregnancy. When should a woman have her first prenatal visit? After the first visit, how often should a woman see her doctor? Ideally, patients should see their physician for preconception counseling. If this is not accomplished, patients should see their physician as soon as pregnancy is suspected to maximize prenatal health care and to minimize risk for birth defects and complications. Seeing a health care provider to begin prenatal care by the 10th week of pregnancy is recommended. Screening blood tests, starting prenatal vitamins, and early detection of problems are better accomplished sooner rather than later. A physical examination and screening for sexually transmitted diseases are part of the first prenatal visit. Ultrasonography is recommended for women who are uncertain of their menstrual cycle. A woman who experiences bleeding, unusual pain, or unrelenting vomiting should seek care immediately. In the first trimester and early second trimester, prenatal visits are typically once every 4 weeks; most physicians recommend visits of every 2 weeks after the second trimester and weekly in the third trimester. For patients who are past their delivery date (>40 wk), more intense monitoring usually requires 2-3 visits per week. When should a woman have her first ultrasonography? Each obstetrician has his/her own guidelines. The earliest a pregnancy can be visualized on transvaginal sonography is at 4-5 weeks' gestation; the pregnancy is a gestational sac at that point, and the hCG level is typically 1500-2000 mIU/mL. If the patient has bleeding, a suspected ectopic pregnancy, or a suspected error in the dating of the pregnancy, first trimester ultrasonography is indicated. If the pregnancy is proceeding normally, most women will have their first ultrasonography early in the second trimester. A scan at 18-20 weeks' gestation is a common and acceptable time for accurate detection of most major fetal anomalies. This timing allows a woman to make a decision regarding termination; however, diagnosing problems is easier with a slightly later scan at 22-24 weeks' gestation. Later in pregnancy, at 23-28 weeks' gestation, growth and development can be better evaluated, and second ultrasonographies are usually performed at that time. Research shows few positive benefits of routine ultrasonography early in pregnancy other than the following: (1) fewer women who elect routine ultrasonography earlier in pregnancy have induced labor for having a postdate pregnancy, and (2) when provided a choice (instead of desire) to terminate if fetal anomalies are detected, the number of fetal abnormalities is reduced at birth. Central nervous system abnormalities are most likely to be detected and cardiac and skeletal anomalies are more likely to be missed when routine ultrasonography is performed early in pregnancy rather than after 23 weeks' gestation. What are the signs of a miscarriage? The medical term for a miscarriage is a spontaneous abortion. Abortions that are in the process of occurring are called inevitable abortions. Pregnancies that have actually passed tissue (but not all tissue) are called incomplete abortions; those in which all tissue is passed are referred to as complete abortions. An abortion is always inevitable if the cervix is dilated. Also, if the membranes have ruptured in a very early pregnancy, this is an inevitable abortion. Bleeding, passing tissue, rupturing membranes (passing clear fluid), and clotting are all typical signs of an aborting fetus. However, not all women who bleed during pregnancy progress to an abortion. If all the tissue is passed, the bleeding has slowed, and the cervix has closed, the pregnancy is termed a complete abortion. After 20 weeks' gestation, the term premature delivery is used, and a lost pregnancy is not called a miscarriage. Almost one fourth of women experience implantation bleeding. Fewer than half of women with first trimester bleeding proceed to a spontaneous abortion. Typically, a spontaneous abortion is preceded by a decrease in hCG titers and a cessation of ultrasonographic-detected pregnancy growth. Women also report a loss of the usual side effects of pregnancy, such as resolution of nausea or loss of breast tenderness. Many spontaneous abortions are due to chromosomal abnormalities. Almost 90% of pregnancies lost in the first trimester have chromosomal abnormalities, and almost one third of pregnancies lost in the second trimester have a chromosomal abnormality. Is cramping during pregnancy normal? Early in pregnancy, uterine cramping can indicate normal changes of pregnancy initiated by hormonal changes; later in pregnancy, it can indicate a growing uterus. Cramping that is different from previous pregnancies, worsening cramping, or cramping associated with any vaginal bleeding may be a sign of ectopic pregnancy, threatened abortion, or missed abortion. Why do pregnant women feel tired? Fatigue in early pregnancy is very normal. Many changes are occurring as the new pregnancy develops, and women experience this as fatigue and an increased need for sleep. Lower blood pressure level, lower blood sugar levels, hormonal changes, metabolic changes, and the physiologic anemia of pregnancy all contribute to fatigue. Women should check with their physician to determine if an additional prenatal vitamin and/or iron would be beneficial. Other physical effects that are normal during pregnancy, and not necessarily signs of disease, include nausea, vomiting, increase in abdominal girth, changes in bowel habits, increased urinary frequency, palpitations or more rapid heartbeat, upheaving of the chest (particularly with breathing), heart murmurs, swelling of the ankles, and shortness of breath. Do older fathers have an increased risk of fathering children with birth defects? No medical information exists to support the hypothesis that increased paternal age causes increased numerical chromosomal abnormalities as increased maternal age does. As males age, however, structural spermatozoa abnormalities are increased. The literature suggests that older fathers have a 20% higher risk of transmitting autosomal dominant diseases as a result of abnormal cell division. Autosomal dominant disorders include neurofibromatosis, Marfan syndrome, achondroplasia, and polycystic kidney disease. In fact, the American Society of Reproductive Medicine recommends an age limit of 50 years for semen donors. Any family with a history of birth defects should seek individual genetic counseling. To determine whether an individual has a family history of risk, patients should inform their physician or genetic counselor about any birth defects that have occurred in the past 3 generations. What is the best way to detect abnormalities in the fetus? No absolute test to detect fetal abnormalities exists; each test has advantages and disadvantages. The earliest possible abnormality detection tests are available only through in vitro fertilization programs. After IVF, the blastocyst can be sampled by removing one of its cells prior to placement into the uterus, a procedure called preimplantation genetic diagnosis. Experimental methods involve detecting fetal cells through the cervix or in the maternal blood stream and performing DNA analysis on these cells. The next earliest tests involve early ultrasonography looking for fetal structural defects. In chorionic villus sampling (CVS), the physician obtains a small sample of placenta by passing a needle through the abdomen or the cervix. This is performed at 10-12 weeks' gestation, and results are available in 24-48 hours. An amniocentesis, which acquires fetal cells in the amniotic fluid, can be performed at 14-18 weeks' gestation with results available in approximately 9-10 days. Earlier amniocentesis can be performed at about 11-14 weeks' gestation, and a faster genetic karyotype can be performed with a fluorescence in situ hybridization (FISH). This earlier amniocentesis test may be preferable for genetic testing if the fetus is at risk for serious genetically inherited diseases. The earlier amniocentesis or CVS occurs, the greater the risk for spontaneous abortion. For women considering pregnancy termination, the risk of complications is slightly lower with a dilatation and curettage (D&C) procedure rather than a dilatation and evacuation (D&E) procedure. It is also less difficult to find a provider who will perform a D&C. Fewer providers perform a D&E procedure. A maternal serum triple screen (alpha-fetoprotein, estriol, and hCG) or quadruple screen (triple screen plus inhibin) can be performed at 15-20 weeks' gestation (most ideally performed at 17-18 weeks' gestation). These screening methods provide a statistical calculation of risk, but they do not provide a definite answer regarding chromosomal composition. In order to be accurate, these serum tests must be calculated with both accurate maternal age and accurate assessment of fetal number. A newer test also exists. It is referred to as the UltraScreen (GeneCare, Medical Genetics Center). This serum test detects 2 proteins—free beta-hCG and pregnancy-associated plasma protein A (PAPPA). This blood test detects 68% of fetuses with Down syndrome (DS) and 90% of fetuses with trisomy 18 (T-18). The biochemical test can be combined with an ultrasonographic measurement of nuchal translucency (NT), which is the fluid accumulation under the skin in the back of the fetal neck. The combined test (UltraScreen) detects 91% of cases of DS and 97% of cases of T-18. Furthermore, an investigation (Monni, 1999) indicates that this test is preferred by all patients surveyed. Newer tests, which can be used in the first trimester, are being developed for other pregnancy-associated proteins. The newest tests combine ultrasonography of the fetal neck (observing for NT) with the serum tests. Detection discovers 70% of abnormalities (range is 40-100%) in random populations of women. The literature suggests that recommendations regarding amniocentesis should be based on these screening tests, which are more sensitive guidelines than using maternal age of 35 years at conception. Should all women have testing for cystic fibrosis? Cystic fibrosis (CF) testing is available from genetic counselors, but it has not been considered part of routine maternity care until the new recommendations by the American College of Obstetricians and Gynecologists (ACOG) in 2001. Current testing procedures cannot detect many of the mutations that occur in the CF gene. As with most medical tests, this test has limitations because not all CF gene mutations are known. This has led to a delay in the introduction of these tests for pregnant women. In spring 2001, however, ACOG released some new recommendations regarding CF testing. In conjunction with the Cystic Fibrosis Foundation, patients may want to be tested if the chance of being a CF carrier seems high. For example, about 1 out of every 29 white people (approximately 3% of the white population) carries the changed gene. African Americans have a risk of 1 in 65, risk in Hispanic Americans is 1 in 46, and Asian American people have a carrier risk of less than 1 in 90 or approximately less than one tenth of 1%. Note that both parents must be carriers of the CF gene for the baby to develop CF. In the rare event that both parents are carriers of the CF gene, significant risk (25%) exists that the baby will have this disease. Specifically, new ACOG recommendations include that (1) testing information and brochures be provided to all couples whether pregnant or planning pregnancy, (2) the couples in the highest risk groups, which are Europeans and Ashkenazi Jews, should be encouraged to get screening, and (3) the most high-risk couples also should have follow-up to determine their decision. The director of the National Human Genome Project, Francis Collins, MD, PhD, has been quoted as saying that the human genome project will have the first and broadest-range impact on the practice of obstetrics and gynecology. Note that ACOG and the National Human Genome Project have confined their recommendations to the scientific and medical aspects of testing, and practitioners are likely to find insurance modules that do not cover the broad range of these services. Providers are encouraged to seek specific information from carriers and provide patients with the documentation the carrier may need, or their patients may not be able to avail themselves of the testing. What is PKU disease? Classical phenylketonuria (PKU) is a rare metabolic disorder that usually results from a deficiency of a liver enzyme known as phenylalanine hydroxylase (PAH). This enzyme deficiency leads to elevated levels of the amino acid phenylalanine (Phe) in the blood and other tissues. The untreated state is characterized by mental retardation, microcephaly, delayed speech, seizures, eczema, behavior abnormalities, and other symptoms. Approximately 1 in 15,000 infants in the United States is born with PKU. Because effective treatments exist to prevent symptoms, all states screen infants for PKU. When PKU is diagnosed early in the newborn period and these children are treated to achieve good metabolic control, they can have normal health and development and can likely expect a normal life span. In the United States, about 3000 women have the disease. If these women stay on a diet with no, or very low amounts of, phenylalanine during pregnancy, they will remain healthy and their babies will be healthy. Should all women have a test for Tay-Sachs disease? Tay-Sachs is a relatively rare disease that causes accumulation of substances called gangliosides in the central nervous system. The eventual result is a severe, progressive neurologic illness with death at a very young age. Jewish individuals of Eastern European descent (Ashkenazi) have a 1 in 30 chance of carrying the gene. Parents of Cajun descent also have an increased incidence of carrying the gene for Tay-Sachs. In others, the risk is about 1 in 300. If 2 individuals who are carriers have a baby, risk that their baby will have the disease is significant (25%). The carrier status of a woman can be determined by a blood test prior to pregnancy. However, even if one parent does not appear to be from a group at high risk for carrying the mutant Tay-Sachs gene, the parents should still be offered testing. ACOG also recommends testing for Canavan disease in women at risk for Tay-Sacks. This disease occurs when the person lacks the liver enzyme (canavanase), which catalyzes the hydrolysis of canavanine into urea and canaline. What are the safest treatments for nausea and vomiting in early pregnancy? Nausea and vomiting occur frequently in pregnant women, especially during the first trimester. Severe nausea and vomiting is often termed hyperemesis gravidarum, which is a diagnosis by exclusion. As in the nonpregnant state, causes of nausea and vomiting include gastrointestinal problems (infection, gastritis, cholecystitis, peptic ulcer, hepatitis, pancreatitis), urinary tract infection (UTI), ear/nose/throat disease (motion sickness, labyrinthitis), drugs (digoxin, morphine), metabolic disorders (hypercalcemia, hyperparathyroidism), and psychological problems. Nausea and vomiting are often difficult to treat, especially because they generally occur in the first trimester. Because this is the most critical time for fetal organ development, minimal pharmaceutical usage is recommended. Dietary strategies are usually the best treatment. Some patients should only consume foods they know they tolerate well. For others, dry crackers, lemonade, and ginger products may be helpful. Vitamin B-6 also can decrease nausea and may be administered orally, intramuscularly, or intravenously. How much alcohol is safe to consume during pregnancy? No amount of alcohol is considered safe. Fetal alcohol syndrome (FAS) has been reported with very low levels of consumption. Pregnant women who drink even minimal amounts of alcohol may be compromising fetal development. Heavy drinking (3.5 drinks per d) during pregnancy remains an established risk factor for FAS and other adverse perinatal outcomes. FAS is completely preventable, but it is not curable once alcohol has damaged the fetus. Fetal consequences of FAS include mental retardation or borderline mental deficiencies and intrauterine growth restriction with all parameters of growth lagging—length, weight, and head circumference. Further consequences include abnormal brain development and/or behavioral difficulties. Craniofacial abnormalities consist of a smooth groove in the upper lip; narrow, small, and unusual eye shape; a small cranium; an upturned nose; and a small or malformed upper jaw. Cardiac anomalies have been reported but remain relatively rare, as are other limb abnormalities, such as hand and feet deformities. In the United States today, doctors diagnose about 1 in 750 newborns with FAS. While some debate still exists regarding the effects of light or moderate drinking during pregnancy (light drinking is defined as 1.2 drinks per d, moderate drinking as 2.2 drinks per d), research has shown that even minimal consumption can have detrimental effects on fetal development. Children exposed to moderate levels of alcohol during pregnancy show growth deficits and intellectual deficits along with behavioral problems similar to, although less severe than, those found in children with FAS. Drinking during month 7 increases the odds of preterm delivery, even for light or moderate drinking. Additionally, moderate consumption of alcohol by pregnant women can have significant consequences on the developing nervous system of the fetus. Research has begun to examine the extent to which these problems affect the child's ability to function on a day-to-day basis at school and with peers. Findings indicate that alcohol has a greater impact on child development when the mother consumes several drinks in a single day than when she consumes several drinks over several days (ie, 1-2 drinks per d). A number of factors, including gestational period, periodicity of mother's drinking, and genetic factors, play important roles in determining the effects of drinking alcohol on the fetus. Should pregnant women avoid certain foods to prevent listeriosis? Listeriosis is an illness caused by the bacteria Listeria monocytogenes, which produces a mild to more moderate gastrointestinal illness with nausea, vomiting, and diarrhea. It is typically food born or found in veterinary clinics and can cause fetal damage or miscarriage. ACOG recommends that pregnant women should not consume unpasteurized milk or soft cheeses; cold meats; or undercooked or raw animal foods, such as meat, fish, shellfish, or eggs. Furthermore, all fresh fruits and vegetables should be washed thoroughly before consumption by a pregnant woman. Additional current guidelines from the Food and Drug Administration (FDA) include the following:
Are other foods that should be avoided while pregnant? Other food concerns while pregnant include raw vegetables, unpasteurized juices, liver, and undercooked meat, poultry, or eggs. Be aware of food poisoning. Raw vegetables, unpasteurized juices, and undercooked meat, poultry, or eggs have been linked with Salmonella species and Escherichia coli (including the dangerous E coli 0157). Cooking properly kills bacteria; the proper temperature can be determined by a meat thermometer, although cooking until well done is safe for most meat. Ground beef should be cooked to at least 160°F, roasts and steaks to 145°F, and whole poultry to 180°F. Eggs should have a firm yolk and white after cooking. Eggnog and hollandaise sauce have raw or partially cooked eggs and are not considered safe. Liver can contain extremely high levels of vitamin A and is probably safe, but it should be eaten in moderation. Can women safely eat fish while pregnant? ACOG issued a warning regarding eating fish in response to the US FDA recently issued consumer advisory about the dangers of eating fish for nursing mothers and women who are or who may become pregnant. The fish themselves are not harmful, but extensive fish consumption increases exposure to the naturally occurring compound methylmercury, levels of which have been increasing in the waters because of industrial pollution. Mercury is very toxic and can cause danger to the fetus and to the newborn nursing infant. Mercury exposure can actually occur via inhalation and/or skin absorption, and all fish contain trace amounts. However, longer-lived and larger fish, such as shark, swordfish, king mackerel, and tilefish, have increased mercury levels and cause the most concern for consumption by pregnant women. The FDA, as of March of 2004, therefore advises that pregnant or nursing women should not eat shark, swordfish, king mackerel, or tilefish, but they can safely eat 12 ounces of cooked fish per week if they eat smaller fish and eat a variety of fish. The safest fish that are low in mercury are shrimp, canned light tuna, salmon, Pollock, and catfish. Specifically, the FDA states that albacore (white) tuna has more mercury than light tuna. So, pregnant women should eat only up to 6 ounces (one average meal) of albacore tuna per week. In addition, the Environmental Protection Agency (EPA) also recommends that pregnant women and young children limit their consumption of freshwater fish caught by family and friends to no more than one meal per week and to follow all local advisories as to fish safety. The EPA specifies no more than 8 ounces of uncooked fish per week for adults. Can women safely dye their hair during pregnancy? Women absorb chemicals through their skin, and chemicals applied to the scalp can be a source of toxic chemical exposure. Because hair dying was not established as safe in the past, obstetricians have been advising women against exposure to both hair dyes and perm chemicals. Hair dyes are thought (most likely) to be safe to use during pregnancy because actually very little is absorbed through the skin. The hormonal changes of pregnancy and the speed of hair growth (usually improved during pregnancy because of better nutrition and more vitamin use) will make the color of the hair vary in response to dying and the roots growing out faster. Can pregnant women safely take medications during pregnancy? Each medication has specific considerations, and when in doubt, pregnant women should check with their individual health care providers. However, some generalities do apply. The FDA requires a system of ranking drugs that appears on the labels and in the package inserts and is reprinted in the Physician Desk Reference (PDR) as follows:
Most physicians recommend avoiding aspirin use in pregnancy. The FDA keeps track of some medications. For a current list of the drugs tracked by the FDA see Office of Women's Health.
When do the postural changes of pregnancy occur? Women experience a progressive increase in the anterior convex shape of the lumbar spine during pregnancy. This change, termed lordosis, helps keep the center of gravity stable as the uterus enlarges. Late in pregnancy, aching, weakness, and numbness of the arms may occur secondary to compensatory anterior positioning of the neck and hunching of the shoulders in positional response to exaggerated lordosis. These positional responses put traction on the ulnar and median nerves, resulting in the previously mentioned symptoms. Relaxin in pregnancy is secreted by the corpus luteum, the placenta, and part of the decidual lining of the uterus. It is thought to cause remodeling of the connective tissue of the reproductive tract, especially inducing biochemical changes of the cervix. Joint laxity and shifting center of gravity can contribute to an increase in gait unsteadiness. These changes are most exaggerated in later pregnancy. Over 50% of gravid females complain of back pain during pregnancy, which also may be due to sacroiliac joint dysfunction or paraspinous muscle spasm. About 4-6 per 1000 women will have scoliosis. Spinal changes are usually not severe enough to affect the pregnancy or the lung's functional capacity. Also, the pregnancy rarely affects the degree of lateral curvature in these cases of scoliosis. If a pregnant patient has had correction with prior Harrington distraction rod insertion, the pregnancy, labor, and delivery are not typically affected. The epidural space may be distorted, and some anesthesiologists may refuse to place epidural anesthetics in these patients. When do changes in the pelvic contour occur? The pelvis continues to grow until about 3 years after menarche, which is why it is more common for younger women, and women sooner after menarche to have greater risk for obstructed labor due to the relative size discrepancy between the fetal head and the maternal pelvis. Relaxin may loosen ligaments when secreted from the ovaries, contributing to enlargement of the pelvis, but this is not proven in human pregnancies. The symphysis pubis can enlarge from about 4 mm in nulliparas to about 4.5 mm (or as much as 8.0 mm) in multiparas. When is fetal movement usually felt? Most women feel the beginnings of fetal movement before 20 weeks' gestation. In a first pregnancy, this can occur around 18 weeks' gestation and, in following pregnancies, as early as 15-16 weeks' gestation. Early fetal movement is felt most commonly when the woman is sitting or lying quietly and concentrating on her body. It is usually described as a tickle or feathery feeling below the umbilical area. As the fetus grows in size, these feelings become stronger, regular, and easier to feel. The medical term for the point at which a woman feels the baby move is quickening. Babies should move at least 4 times an hour as they get larger, and some obstetricians advise patients to count fetal movement to follow the baby's well-being. Should women wear seatbelts during pregnancy? Seatbelts should absolutely be worn during pregnancy. Trauma to the mother is more devastating to the child than any potential entrapment of the pregnant abdomen in the seatbelt. The seatbelt should be placed low, across the hip bones, and under the pregnant abdomen. The shoulder strap should be placed to the side of the abdomen, between the breasts, and over the mid-portion of the clavicle. No information indicates that air bags are unsafe during pregnancy. Pregnant women should try to keep their abdomen 10 inches from the airbag. Can pregnant women go to the dentist? Dental care during pregnancy is a very important part of overall health care. During pregnancy, the gums naturally become more edematous and may bleed after brushing. Epulis gravidarum, a type of gingivitis with violaceous pedunculated lesions, can occur. If treatment of cavities, surgery, or infection care is required, be sure the dentist is aware of the pregnancy. Most antibiotics and local anesthetics are safe to use during pregnancy. Radiographs can be obtained with abdominal shielding but are best avoided during pregnancy because a small, but statistically significant, increase in childhood malignancies exists in children exposed to in-utero radiographic irradiation. Why is heartburn more common during pregnancy? Stomach emptying was thought to be retarded during pregnancy, but hormonal influences of increased progesterone and/or decreased levels of motilin may be more responsible for pyrosis (heartburn) than the actual mechanical obstruction in the third trimester. Some studies also have shown decreased lower esophageal sphincter tone, which can lead to an excess of gastric acid in the esophagus. Why is back pain prevalent during pregnancy? Half of women report having back pain at some point during pregnancy. The pain can be lumbar or sacroiliac. The pain may also be present only at night. Back pain is thought to be due to multiple factors, which include shifting of the center of gravity caused by the enlarging uterus, increased joint laxity due to an increase in relaxin, stretching of the ligaments (which are pain-sensitive structures), and pregnancy-related circulatory changes. Treatment is heat and ice, acetaminophen, massage, proper posturing, good support shoes, and a good exercise program for strength and conditioning. Pregnant women may also relieve back pain by placing one foot on a stool when standing for long periods of time and placing a pillow between the legs when lying down. What tests can be performed to detect preterm labor? Many tests have been proposed, but few are considered universally reliable. First, a pelvic examination or ultrasonography can detect thinning or opening of the cervix. A swab test can detect ruptured membranes. A recently proposed test, called fetal fibronectin (fFN), has also been used to detect a preterm labor. In addition, fetal monitoring can detect uterine contractions. Finally, some hormone tests can be used to detect abnormalities (eg, salivary estrogen testing). Most cases of preterm labor cannot be predicted. Home monitoring units to detect contractions are not considered reliable. However, home monitoring units are used in some specific settings, especially in conjunction with nursing services. These nursing services stay in daily contact with the patient to ensure good communication with the patient and her physician. What is the fetal fibronectin test? fFN is a protein secreted by the trophoblasts and is thought to act as trophoblastic glue for forming the uteroplacental interface. In a term pregnancy, fFN levels are high until about 21 weeks' gestation, when the levels decrease. At approximately 37 weeks' gestation, fFN levels rise again. Levels rise earlier in women with preterm deliveries, which may make fFN a marker of impending labor. An fFN level greater than 50 ng/mL is considered positive for possible impending labor. This is a monoclonal antibody test on cervical swabs. The disadvantage of this test is the number of false-positive results. Because gels used for lubrication can invalidate test results, it must be performed after nothing is put in the vagina for 24 hours (including intercourse and vaginal or speculum examinations). It is not a screening test, but it is becoming standard of care for patients who present with contractions and do not yet have a firm diagnosis of preterm labor. What is the salivary estriol test? Salivary estriol (a hormone) is present in the plasma by week 9 and rises throughout pregnancy, with an accelerated rise approximately 2-5 weeks before delivery. This rise is thought to be associated with the induction of oxytocin receptors in the uterus, increased prostaglandin synthesis, and increased myometrial gap junction proteins. Increasing estriol appears to correlate with cervical ripening. Therefore, salivary estriol levels greater than 2.1-2.3 ng/mL are considered positive for oncoming labor. This hormone level is tested with an ELISA. This test should not be used in multiple-gestation pregnancies. The disadvantage of this test is an even greater number of false-positive results than the fFN test. Also, common pregnancy-related dental problems, such as gingivitis and bleeding gums, affect the test. This test is not recommended by ACOG. What does ACOG say about other screening strategies for preterm labor? Due to the lack of firm research data, ACOG does not support either home uterine activity monitoring (HUAM) or bacterial vaginosis screening strategies to identify the risk of or prevent preterm birth. No tests outperform a thorough historical risk assessment at the time of the first prenatal visit. ACOG also states that ultrasonography to determine the cervical length and/or fFN screening may be useful in determining who is at high risk for preterm labor, but the benefit may be mainly to rule out those who are not at high risk for preterm birth. fFN should be used only at 24-34 weeks' gestation in women with intact amniotic membranes and minimal cervical dilation (<4 cm). In addition, test results must be available from a laboratory in a timely fashion, ideally within a few hours, but ACOG recommends within 24 hours. At what stage of pregnancy are babies considered viable? This is a complex topic. No definite age or stage exists, but experts disagree. The survival rate of infants born after 23-25 weeks' gestation increases with each additional week of pregnancy. The survival rate of infants born before 23 weeks' gestation is very low. Babies born during these early weeks may require prolonged and intensive medical care, including care with a variety of life-support measures. The very premature infant is then at risk for cerebral palsy (CP), intraventricular hemorrhage (IVH), and necrotizing enterocolitis (NE). What are the effects of smoking on pregnancy? Low birth weight (LBW) is the most common problem with babies born from mothers who smoke. Babies born to mothers who smoke weigh about 170-200 g less than those whose mothers do not smoke. Premature rupture of the membranes and abruptio placenta are also 3-4 times more common in smokers than in nonsmokers. An increased risk of miscarriage is also a factor. In some studies, an increased incidence of mental retardation and cleft lip/palate has been associated with smoking. This may be a smoke-related effect, and, although not specifically approved for use during pregnancy, nicotine patches are probably safer than smoking cigarettes. What special risks are associated with multiple gestations? Twin pregnancies have a higher rate of complications than singleton pregnancies. This difference has been shown to be statistically significant. Maternal complications include anemia, polyhydramnios, hypertension, premature labor, postpartum uterine atony, postpartum hemorrhage, diabetes, preeclampsia, and cesarean delivery. Fetal complications include malpresentation, placenta previa, abruptio placentae, premature rupture of the membranes, prematurity, intrauterine growth restriction, umbilical cord prolapse, congenital anomalies, and increased perinatal morbidity and mortality. Although singleton pregnancies are considered term at 37 weeks' gestation, half of all twin pregnancies deliver at 36 weeks' gestation. The mean age of triplets is 33.5 weeks' gestation, and, in a small series of quadruplet pregnancies, the average gestational age at delivery was 31 weeks' gestation (Spellacy, 1999).
What are the extra food needs during pregnancy? The 1989 Recommended Dietary Allowances (RDAs) suggested that pregnant women consume an additional 300 kcal/d. Newer guidelines of Estimated Average Requirements (EAR) from the 2002 Dietary Reference Intakes (DRI) estimate that Estimated Energy Requirement (EER) increases are not necessary in the first trimester and that increases of about 340 kcal/d in the second trimester and 452 kcal/d in the third trimester are indicated. Pregnant women are getting enough calories, and more than 80% of women will meet or exceed the recommended weight gain guidelines set out by the Institute of Medicine. These calorie suggestions translate into different healthy gains for the baby. An underweight woman should gain 35-45 pounds during pregnancy. An obese woman should gain about 15 pounds. Women of normal body weight should gain about 25 pounds. The March of Dimes suggests that pregnant women should increase their daily food portions to include the following:
Calcium needs can be met by calcium products or calcium supplements. Very inexpensive calcium carbonate antacids can be taken to achieve the target intake of about 1200 mg/d. Why do women undergo skin pigmentation changes during pregnancy? Pigmentation changes are directly related to melanocyte-stimulating hormone (MSH) elevations during pregnancy. Some evidence suggests that elevated estrogen and progesterone cause hyperpigmentation in some women. This typically is evident in the nipples, umbilicus, axillae, perineum, and linea alba, which darkens enough to be considered a linea nigra. Facial darkening, known as chloasma, also may occur. Other skin changes are fairly common, including some patchy palmar erythema. Why does acne increase during pregnancy? Progesterone, which has some androgenic components, is increased during pregnancy, resulting in more secretions from the skin glands. Maintaining hydration should help. Women should consult their doctor if a topical medication is needed. Most acne medications including tetracycline are contraindicated during pregnancy. Will changes in headache patterns occur during pregnancy? For most women, headaches remain unchanged during pregnancy. Some women improve, but some may worsen. Because migraines have a hormonal component, many women's migraines improve with increasing estrogen levels, such as those that occur during pregnancy. For women whose conditions remain unchanged or worsen, treatment options are limited, especially in the first trimester. Some physicians suggest acetaminophen, narcotics, and antiemetics. Nonpharmacologic treatment includes relaxation strategies, eliminating stressors, and a good exercise program. These should first be attempted before pharmacologic therapy. Is feeling the heart racing a common occurrence during pregnancy? A significant number of cardiovascular changes occur during pregnancy, which may be accompanied by dyspnea and a reduced tolerance for endurance exercise. During pregnancy, women expand their blood volume by approximately 30-50%. This is accompanied by an increase in cardiac output. The heart rate may also increase by 10-20 beats per minute. The changes peak during weeks 20-24 and usually resolve completely within 6 weeks of childbirth. The blood pressure in the upper extremities should change very little during pregnancy, but pressure in the lower extremities increases. This is accompanied by pedal edema. Because of extra blood flow, variances in the auscultated heart sounds may occur, such as murmurs, a wider split between the first and second heart sounds, or an S3 gallop. Some nonspecific ST segment changes may occur, and some changes to the cardiac outline may appear on chest radiographs. The following is a summary of cardiovascular changes:
What are common respiratory system changes during pregnancy? Pregnant women experience nasal stuffiness due to estrogen-induced hypersecretion of mucus. Epistaxis is also common. The safest treatment of these symptoms is a saline nasal spray. The following is a summary of respiratory changes:
Is gallbladder disease more common during pregnancy? For some, gallbladder disease is more common during pregnancy. Estrogen is an important risk factor for gallstone formation; it increases the concentration of cholesterol in the bile leading to an increased risk of forming gallstones. Is liver disease more common during pregnancy? Pregnant women can experience spider angiomata and palmar erythema. About two thirds of white women and only 10% of black women experience these symptoms. In addition, women may have reduced serum albumin concentration, elevated serum alkaline phosphate activity, and elevated cholesterol levels. These are common symptoms of liver disease, but they are not evidence of liver disease if they occur during pregnancy. What are the most common dietary complaints during pregnancy? During early pregnancy, most women experience an increased appetite, with extra caloric needs of approximately 200 kcal/d. Stomach motility does decrease, probably due to reduced production of motilin. Reduced peptic ulcer disease is due to reduced gastric acid secretion. Prolonged transit times through the colon also are reported, with transit from the stomach to the cecum occurring in about 58 hours instead of 52. The common myths surrounding food desires are individually and culturally determined. Among rural Southern American women, the most common food cravings include clay, laundry starch, or pica, while British women commonly crave coal. Women experiencing nausea or hyperemesis may develop ptyalism (spitting). Reported fluid losses of 1-2 L/d can occur in these women. What hair changes are common during pregnancy? Hair grows in the anagen phase and rests in the telogen phase. About 15-20% of all hairs are in the telogen phase at any given time. During this resting phase, it is normal for hair to fall out so a new hair can regrow. During late pregnancy, fewer hairs are in telogen; immediately postpartum, more hairs are in telogen phase. This often results in a dramatic loss of hair immediately postpartum. This may be very disturbing, but it is normal. |
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What are Leopold maneuvers? These are performed at each third trimester visit to assess the presentation, position, and engagement of the fetus by using 4 different maneuvers.
What is Rh disease? Why is a pregnant woman's blood type important? Knowing the blood type of a pregnant woman is an important part of preventing a potentially fatal disease called fetal erythroblastosis and hemolytic disease of the newborn. About 15% of the US population is Rh negative. If the mother's blood type is Rh negative and the baby's blood type is Rh positive (inheriting this type from the father) the mother may make antibodies (immunoglobulin G [IgG]) that can cross over the placenta into the baby's blood stream and attack the baby's red blood cells. Sensitization can occur at any time, including after spontaneous abortion. The first pregnancy usually poses no problems because sensitization typically occurs at delivery. Subsequent pregnancies are at risk if the mother was not protected with an injection of RhoGAM, which prevents the mother from forming antibodies. This condition eventually leads to fetal anemia and heart failure. Administering RhoGAM (RH immunoglobulin) to a pregnant woman early in the third trimester (before the baby's blood type is known) or after miscarriage or abortion can prevent formation of these attack immunoglobulins, but failures to prevent immunoglobulin formation can occur. After birth, the newborn's blood type is checked; if the baby is Rh negative like the mother, no further treatment is necessary. Other antibodies and incompatibilities can produce similar problems, but they are rare and less likely to cause severe disease. How much does the uterus grow during pregnancy? The uterus grows from an organ that weighs 70 g with a cavity space of about 1 mL to an organ that weighs more than 1000 g that can accumulate a fluid area of almost 20 L. The shape also evolves during pregnancy from the original pearlike shape to a more round form, and it is almost a sphere by the early third trimester. By full term, the uterus becomes ovoid. The baby is completely palpable in the abdomen (not just by pelvic examination) at about 12-14 weeks' gestation. After 20 weeks' gestation, most women begin to appear pregnant upon visual examination. Is sexual intercourse safe during pregnancy? Research indicates that sexual intercourse is safe in the absence of ruptured membranes, bleeding, or placenta previa, but pregnant women engage in sex less often as their pregnancy progresses. No studies have suggested that any particular position is unsafe, although a 1993 study demonstrated a 2-fold increased incidence of preterm membrane rupture with the male-superior position compared to other positions. ACOG states that sexual activity during pregnancy is safe for most women right up until labor, unless a woman's doctor has advised against it. ACOG specifically cautions that a women should limit or avoid sex if she has had preterm labor or birth, more than one miscarriage, placenta previa, infection, bleeding, and/or breaking of the amniotic sac or leaking amniotic fluid. ACOG discusses that, as part of natural sexuality, couples may need to try different positions as the woman's stomach grows. Vaginal penetration by the male is not as deep with the male facing the woman's back, and this may be more comfortable for the pregnant woman. Why do women get varicose veins during pregnancy? Varicose veins are more common as women age; weight gain, the pressure on major venous return from the legs, and familial predisposition increase the risk of developing varicose veins during pregnancy. These can occur in the vulvar area and be fairly painful. Rest, leg elevation, acetaminophen, topical heat, and support stockings are typically all that is necessary. Determining that the varicosities are not complicated by superficial thrombophlebitis is important. Having a venous thromboembolism in association with superficial thrombophlebitis is rare. Hemorrhoids, essentially varicosities of the anorectal veins, may first appear during pregnancy for the same reasons and are aggravated by constipation during pregnancy. Is it normal to secrete milk from the breast prior to delivery? Galactorrhea (milk secretion from the nipple) is not uncommon in the first trimester, although it usually does not occur until milk let-down soon after delivery. Early galactorrhea does not mean that a woman will produce less milk after delivery. Each woman is different, and some women notice secretions beginning before the fifth month of pregnancy. Many women find they spontaneously leak or express some fluid by the ninth month. Colostrum, which is the initial milk, may be watery and pale. Bumps that appear to enlarge around the areola are called Montgomery tubercles, and they normally appear during mid pregnancy. What is group B streptococcal disease? Group B streptococcal disease (GBS) is caused by Streptococcus agalactiae, a type of beta-hemolytic streptococci. GBS is a cause of potentially dangerous maternal and fetal infections. GBS is a type of streptococcal infection that can be acquired by the baby in the birthing process, which is known as vertical transmission. Women with a premature delivery, prolonged rupture of membranes, fever while in labor, or positive cultures for GBS during pregnancy are more likely to have an infant with GBS disease. Many different treatment strategies are endorsed by various medical groups. ACOG suggests treating laboring women with antibiotics under the following conditions:
Women should discuss this issue with their physicians to find out their plan for GBS prevention. The average woman has a risk of GBS colonization of about 5-20%. Debate continues regarding whether all women should be tested during pregnancy, when women should be tested, and which women should receive antibiotic treatment following a positive culture. Testing can be from the cervix, vagina, rectum, or vaginal introitus. Once cultures are positive for GBS, most physicians treat when the patient is in labor. Intravenous penicillin, ampicillin, and erythromycin are acceptable treatments. With the routine use of antibiotics, almost 40% of GBS occurrences after birth occur in babies whose mothers tested negative. Pediatricians will want to observe the baby for 48 hours after birth when the mother had positive culture results tested after 35 weeks' gestation or if the culture results are unknown. Should pregnant woman store umbilical cord blood? As stem cell research has continued, many beneficial therapies are thought to exist and much scientific value has been ascribed to cord blood and its cells. Human placental cord blood contains a large number of hematopoietic progenitor cells, which can be used as a source of stem cells for treatment of hematological disorders and malignancies. Most physicians, if asked, advocate public banking for the storage of cord blood, as for other banked blood. This, however, is not yet available in most areas. Most physicians, therefore, do not recommend going to a private bank because saving cord blood for many years is extremely costly. ACOG believes that many questions about this technology remain unanswered and asks that parents should not be sold this service without a realistic assessment of their likely return on the investment. The odds of needing a stem cell transplant are low—estimated at between 1 in 1000 and 1 in 200,000 by age 18 years. Commercial cord blood banks should not represent the service they sell as part of "doing everything possible" to ensure the health of children, nor should parents be made to feel guilty if they are not eager or able to invest considerable sums in such a highly speculative venture. What does ACOG say regarding water births? ACOG's Committee on Obstetric Practice addressed the issue of warm-water immersion for laboring women and for delivery of infants. The Committee felt that there are "insufficient data, especially concerning rates of infection, to render an opinion on whether warm-water immersion is a safe and appropriate birthing alternative." The Committee also felt that "this procedure should be performed only if the facility can be compliant with OSHA [Occupational Safety and Health Act] standards regarding infection." This would include the specific tub and water recirculation systems used. Also, warm water exposure over time can cause hypotension, and careful attendance by an assistant is necessary to prevent drowning. What is ACOG's position on home births? ACOG acknowledges in a recent position statement that both labor and delivery, "while a physiologic process, clearly presents potential hazards to both mother and fetus before and after birth." ACOG's statement continues to specifically state that "these hazards require standards of safety that are provided in the hospital setting and cannot be matched in the home situation." ACOG supports those actions that improve the experience of the family while continuing to provide the mother and her infant with accepted standards of safety available only in hospitals that meet the standards outlined by the American Academy of Pediatrics and ACOG. For women considering home births, they should investigate the standards of the midwifery or birthing organization to which the birth attendant belongs. Is having a vaginal birth after a cesarean delivery safe? Most women can safely have a vaginal birth after a cesarean delivery (VBAC), although this depends on the circumstances of the previous cesarean delivery and the status of the current pregnancy. Special considerations must be given to women with vertical or classic uterine incisions, women with uterine or pelvic abnormalities, women delivering in hospitals without 24-hour anesthesia or obstetrical coverage, women with more than 1 previous cesarean birth, women with a recurrent reseason for cesarean birth, and women carrying multiple pregnancies. Almost 70% of women can have a VBAC, and the risk of a uterine rupture during the attempt is less than 1%. If the pregnancy is induced or contractions are augmented with oxytocin (Pitocin), incidence of rupture is closer to 2%. Controversy exists as to the qualifications of the medical facility performing the VBAC with the current American Academy of Family Practice guidelines much more liberal than the ACOG guidelines. Most physicians and hospitals require a signed permit specifying the woman's wish to have an elective repeat cesarean delivery or a VBAC. Women should also understand that even in cases of planned repeat cesarean delivery, a woman occasionally presents in an advanced stage of labor, when operating is not possible due to lack of time. A repeat cesarean delivery is known to be riskier for the mother but safer for the newborn. When is it safe to have a tubal ligation? Tubal ligations can be performed at the time of cesarean delivery or immediately after a vaginal birth through a small minilaparotomy periumbilical incision. Risk of complications is low. A Pomeroy operation, which removes a portion of the midsection of the tube, is typically performed. Tubal ligations are intended to be permanent, but they can be reversed successfully in some cases. Lifetime failure rate following a tubal ligation is 3-4 cases out of 1000. A tubal ligation also can be performed at a time other than immediately after birth, and then it is performed laparoscopically. Why is a baby born in the breech position? Can this pose a problem? Most babies settle into a head down (vertex) position before labor. At 28 weeks of pregnancy, about one third of babies remain breech; by term, only 3% are still breech. The head is the largest part of the baby, and, because it comes down first in the birth canal, the body usually follows without difficulty. When the baby presents in a breech position, the head is the last to emerge, which may pose a risk to successful vaginal birth. The specific risks of a breech birth include minor stretching of the shoulder area of the arm (which can lead to transient compromise in arm function), more dramatic arm entanglement (which can cause Erb palsy), or fetal head entrapment (which is fatal in rare cases). Many ways exist to detect breech position before birth (sonography and manual examination). Women should check with their physicians to determine how this delivery will be handled (vaginal or elective cesarean delivery) and if the physician would consider trying to turn the baby before birth (external version). Some physicians routinely perform cesarean deliveries on breech pregnancies. What is an Apgar score? This is a quick numbering system used to assess the health of the newborn. By convention, it is performed at 1 minute and 5 minutes after delivery. The Apgar score assesses respiratory effort, tone, heart rate, color, and reflex irritability. Each of these categories is given a score of 0 to 2 and summed. One-minute Apgar scores of less than 7 represent CNS depression, and those less than 4 represent severe depression requiring immediate resuscitation. What is the best kind of birthing technique to use? Many popular techniques are available, and most instructors take advice from a variety of sources. The Lamaze, Leboyer, and Bradley methods are most common. Lamaze focuses on an external focal point, relaxation, partner coaching, and several different breathing techniques. The Bradley method is known as "husband-coached childbirth" and emphasizes internal focus (closed eyes), deep relaxation, partner-coaching, and full participation in the birthing plan. Leboyer was named after a French obstetrician who emphasized bathing the baby in warm water after birth and providing a dark, calming birthing environment with hushed voices. Some people call underwater birthing (delivering in a pool or tub) the Leboyer technique. How often does a woman put on the fetal monitor in labor? Once active labor is diagnosed, the baby's heart rate needs to be checked every 15 minutes; during the second stage of labor, the heart rate should be checked every 5 minutes. This can be performed by auscultation or by electronic fetal monitors held in place by belts. Continuous fetal monitoring is necessary for all cases in which a question of fetal well-being or previous abnormal tracings exist. Unfortunately, once strapped to the fetal monitor, walking around in labor is not possible. Many physicians choose to monitor on a schedule of 15 min/h to allow time for the woman to move around. This is an individual choice made between a woman and her obstetrician. Is urinary incontinence normal during pregnancy? In the nonpregnant reproductive-aged population, prevalence of incontinence is 8%. This number increases to 30-50% in the pregnant population. The growing uterus impinges on the bladder, limiting its storage capacity. Also, hormones (especially progesterone) decrease sphincter tone, which allows urine to escape more easily. Incontinence tends to worsen as the pregnancy progresses and tends to recur with subsequent pregnancies. For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education article Bladder Control Problems. Why are urinary tract infections more common during pregnancy? Pregnancy predisposes women with bacteruria, which in the nonpregnant state is usually self-limiting. Normal pregnancy-related physiologic changes contribute to UTIs and include dilatation of the upper collecting systems, increased urinary tract dead space, increased vesicoureteral reflux, hypotonic renal pelvises, decrease in the natural antibacterial activity in the urine, and a decrease in the phagocytic activity of leukocytes at the mucosal surfaces. UTIs in pregnant women usually do not present with typical symptoms and may be asymptomatic. Pyelonephritis is a serious complication of UTIs. Are yeast infections more common during pregnancy? Yeast infections are more common during pregnancy. The increased acidity of vaginal secretions that occurs with pregnancy favors the growth of yeast. How can stretch marks be prevented? Unfortunately, striae (stretch marks) cannot be prevented. The degree to which a woman experiences stretch marks is determined genetically. Stretch marks usually occur when weight is lost or gained quickly. Using creams and gels rarely make a difference. Fortunately, stria fades with time, and marks become silvery white, but they do not tan. Stria may be considered the "stripes of motherhood."
Should newborn boys be circumcised? Circumcision of male newborns has evolved from a religious and cultural ceremony. Many women choose circumcision for hygienic reasons. Circumcision has become commonplace among many American cultural and social groups. Most fathers are circumcised and want their sons to be the same. The procedure is usually performed in the hospital 24-48 hours after birth by a pediatrician or obstetrician. Religious circumcisions in the Jewish faith occur a week after birth. The procedure is not painless, and anesthesia may or may not be used. Circumcised infants may be at lower risk for rare penile cancer and some infections. The choice of circumcision is a private and personal decision. For a more in-depth discussion, please read the American Academy of Pediatrics position on this issue. What are the benefits of breastfeeding? All mothers are encouraged to breastfeed (unless they are HIV positive). Trying is easy, and stopping is easy if the process is not successful. Breastfeeding has many benefits for both mother and child. Colostrum, the first fluid to be secreted from the breast, has a high level of immune protection, including the secretory immunoglobulin A (IgA). After the first few days, protein and mineral concentration decrease and the milk takes on more water, fat, and sugars, particularly lactose. The constituents of breast milk change as the infant's nutritional needs change, and human milk contains factors that act as biological signals to promote baby's growth. Additional immunoglobulins begin to be secreted into the milk, and the baby is protected against infections. Jaw and speech development is also promoted in the breastfed infant. If a mother breastfeeds, she is more relaxed, she attaches to her baby better, and she has less uterine bleeding because hormones released during feeding cause the uterus to contract. Some evidence indicates that breastfeeding decreases the risks of breast cancer. For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education article, Breastfeeding. How can a woman know if the baby is getting enough milk? A baby should produce 6-8 wet diapers a day. For mothers who are not providing supplemental fluids, this amount of urine production is considered sufficient. Stools from breastfed babies are very soft, may be produced at each feeding, and may be mistaken for diarrhea. Formula causes formed stools, which may be more infrequent. Some breastfed babies may not gain weight as rapidly in the first few weeks after birth, but they usually catch up to their formula-fed counterparts within 3 months. How long should a baby be breastfed? The American College of Pediatrics recommends that women breastfeed their babies for at least 6 months and encourages it for a full year. After solid food supplementation at 4-6 months, breastfeeding should be continued for maximum nutritional benefit. How do women "dry up" their breast milk? Most physicians do not prescribe medication to dry up milk. Simply wearing a tight bra or jogging bra and avoiding any stimulation of the breasts is adequate in most women to suppress lactation. Some leakage is normal, but this disappears within a few days to a week after the birth. Women with breasts that become very hard or painful sometimes find that hot packs relieve the pressure. Medications such as bromocriptine can be used for drying up the milk, but, because of sporadic reports of severe complications with postpartum use, it is not a currently recommended treatment. Occasionally, a breast infection (mastitis) or a plugged duct can occur; women should see | ||||||||||||||||||||||||||||||||||||||||
