A “package” of all the above-mentioned symptoms would surely indicate to an anxious woman that she is probably pregnant. But to the physician these signs are not truly diagnostic of pregnancy.
Pain Relief in Childbirth

If the patient is well prepared and understands the mechanism of labor, effective results can usually be obtained with minimal amounts of pain-relieving agents. The physician assesses the progress of labor by frequent examinations and gives the medication most appropriate to the exact stage of labor the patient is in.

Barbiturates may be given orally or rectally early in labor to produce sleepiness and relaxation. After labor has progressed to cervical dilation of about two inches, various morphine derivatives can be used effectively. Meperidine is a popular agent which reduces the pain threshold and makes the patient more comfortable. She may even fall asleep between contractions and wake up during the contractions.

If contractions become more violent, and the patient is somewhat apprehensive, scopolamine may be used. Scopolamine (called “twilight sleep” many years ago) is an amnesic or memory suppressing drug. Adequate amounts of it abolish the patient’s memory of the pain of labor and delivery.

After the cervix has opened to seven or eight centimeters in the second stage of labor it is usually inadvisable to give sedation. Contractions then are less painful and there is a great desire to push or “bear down.” The pushing sensation is similar to having a bowel movement. A large amount of sedation at this stage may make pushing less effective and slow the progress of labor.

It is the first stage in pregnancy cycle. During the first three months the uterus enlarges to about three times its non-pregnant size. This places it approximately at the pelvic brim so that it is usually not palpable (perceptible by touch) in the abdomen.

Bleeding of some severity is the most frequent unusual feature of the first trimester. About 20 per cent of women will stain or have a blood smudge on their underwear for one to three days. Usually this is “implantation bleeding” as the fertilized egg nests into the uterine wall after its descent down the Fallopian tube (oviduct) where fertilization occurs. Implantation usually occurs about three weeks after the last menstrual period. At this stage the developing egg is barely visible to the naked eye, about the size of the point of a sharp pencil.

No further bleeding may occur. But if bleeding continues, with some slight cramps, there is threatened abortion with survival of the fetus in precarious balance. If cramps become severe and rhythmical, similar to labor contractions, bleeding becomes profuse, and on vaginal examination the doctor finds the neck of the uterus opening up, the condition is described as inevitable abortion. If the fetus is expelled but the placenta remains, this is an incomplete abortion. This usually requires a curettage of the uterus to remove the remaining products of conception. Thereafter bleeding is usually moderate for a day or two and then staining ensues for several more days. Usually the uterus returns to its normal size in three to four weeks and a normal menstrual cycle intervenes at about the same time.

A spontaneous abortion – or “miscarriage” – is a natural process that occurs without artificial intervention. The vast majority of such abortions probably occur as a result of a developing egg with serious defects incompatible with life, or destined to give rise to a cruelly malformed fetus. The untimely occurrence of a spontaneous abortion is infinitely less of a burden than the presence of an infant that could not live long, and this is nature’s way of ending a defective pregnancy and reestablishing the reproductive machinery for off-spring.

Sometimes the fetus dies in the womb and the womb fails to grow. This is called missed abortion, and again, a curettage may be required. An induced abortion is one in which the uterus is emptied by human intervention. A therapeutic abortion is one justified in the eyes of the law, usually because continuation of pregnancy threatens the mother’s life. Such indications are quite rare. If a woman has three or more consecutive spontaneous abortions, she is designated as an habitual aborter.

The embryo, a mere pinpoint in size at the beginning of the first trimester, grows to a length of some three inches and a weight of one ounce by the end of the third month. During this time, all of the vital organs heart, lungs, intestines, brain, eyes, ears and skeleton-are formed. It is at this crucial period, when some women do not even know that they are pregnant, that outside insults such as drugs and illnesses of the mother can inflict disaster on the fetus. Once the basic structures are well developed, the fetus is somewhat better able to fend off insults of its environment.

Ectopic pregnancy usually occurs in the first trimester. The infinitesimal embryo is trapped in the blind alley of a Fallopian tube and will grow at this ectopic (“outside of the uterus”) point. Space for growth in the narrow tube is very limited, and rupture usually ensues in the second or third month.

Symptoms of ectopic pregnancy begin when the tube is overdistended. There is severe one-sided pain, bleeding as in amiscarriage, and a small swelling in the tubal area may be felt by the doctor. Blood in the abdomen frequently reaches and irritates the diaphragm and this is felt as pain in the shoulder. Surgery to remove the portion of the tube containing the pregnancy is the only satisfactory treatment. Recovery is rapid and the patient will be walking about the hospital in one day and home in five or six.

Is normal pregnancy possible after an ectopic pregnancy? Yes, but it is not uncommon for a woman who has had one ectopic pregnancy to have another on the other side. The doctor will be alert for this possible complication if the patient has had an ectopic pregnancy.
The Second Trimester
The second trimester or the second stage of pregnancy cycle is the most peaceful time of pregnancy with the fewest complications.
Growth

From a length of three inches and a weight of one ounce, the fetus grows to some 14 inches and a weight of two and a quarter pounds at the end of the second trimester. The accommodating uterus enlarges steadily to an edge two and a half inches above the navel. Movements of the fetus (“quickening”) become noticeable at about 20 weeks or midway in the second trimester. Usually the obstetrician will be able to hear the fetal heartbeat. The mother’s weight gain is most rapid during these three months, averaging close to a pound a week.
Premature Labor

The greatest hazard of this trimester is premature labor and delivery. The patient should report immediately any continued weak contractions, vaginal staining, or thin watery vaginal discharge. Any of these may suggest that the neck of the uterus is opening and a vaginal examination will confirm or deny it.

Premature birth in the second trimester ends unhappily with death of the infant nine times out of ten. The other ten percent of larger “premies” survive after a long period of many months in an incubator. There is some hope that threatened premature birth when the infant is too tiny to survive may be delayed by a Shirodkar operation, named for a doctor in India who had a patient who had three premature deliveries ending in stillbirths. In desperation, he placed a suture around the neck of the uterus and was able to maintain the pregnancy until the infant reached a weight of five pounds and survived. Occasionally the neck of the womb is closed carefully in selected patients and the technique has been considerably improved.

Toxemia may occur in the second trimester but is much more frequent in the last three months.
The Third Trimester or third stage in Pregnancy cycle

The last months of pregnancy are naturally subject to some increase in discomfort. The infant grows from a little over two pounds to seven pounds, on the average, and the uterus gradually continues to enlarge. There is almost constant activity of the womb’s occupant, most noticeable to the hostess when she is inactive and most sensitive to internal gyrations, as when sitting, or just before going to bed, or waiting for a traffic light to change when driving.

Abnormal bleeding, again, is always something to report immediately to the doctor. There are two principal causes of such bleeding in the last trimester, and both arise from abnormalities that involve the placenta or afterbirth. Each occurs in about one out of 250 pregnancies.

Placenta previa is a mislocation of the placenta in an abnormally low position in the uterus. The placenta may be implanted directly over the outlet of the womb (central placenta previa), or it may be attached at the margin of the outlet or slightly higher on the uterine wall. As the neck of the uterus opens toward the end of pregnancy, a disruption of placental and uterine structures causes bleeding. The characteristic symptom is painless vaginal bleeding.

Bed rest in the hospital is usually compulsory. Transfusions may be necessary if bleeding is profuse, and cesarean section (delivery of the baby through the abdomen) may be required. Since every extra week of maturity counts heavily in the baby’s favor, delivery is usually delayed until about the onset of the ninth month unless there are compelling reasons to the contrary. With careful obstetrical management, the outcome is usually happy for mother and baby. Placenta previa occurs somewhat more frequently in women who have had many children, especially in rapid succession, and in women who have had fibroid tumors.

Premature separation of the placenta is responsible for the second type of abnormal bleeding. In this instance a normally implanted placenta separates from its attachment to the wall of the uterus. Vaginal bleeding is usually accompanied by severe abdominal pain. The womb may become very hard. Frequently such separations are associated with high blood pressure.

Important abdominal pain and bleeding must be reported to the doctor immediately. Management of this condition calls for discriminating obstetrical judgment. Labor may be induced forthwith, or cesarean section may be required, de­pending upon individual circumstances.

There are other causes of bleeding in the third trimester, such as polyps and inflammation, but the important thing to remember is that every instance of vaginal bleeding should be reported to your doctor immediately.

Toxemia of pregnancy is another complication which is watched for in pre­natal visits. The most frequent early sign is fluid retention, demonstrated by swelling of the fingers, tight wedding ring, swelling of the eyelids, tight shoes, and weight gain which may amount to five pounds in a week. (Some swelling of the feet at the end of the day, disappearing with rest, is common in normal pregnancies). There is abnormal protein in the urine. The more serious forms of toxemia are associated with eclampsia or convulsions.

Toxemia is an increased danger to the baby and the mother. Hospitalization for one or two weeks, and sometimes early delivery, may be necessary. Milder signs of toxemia may be controlled less drastically. A low-salt diet is important. Smoked meats, pickles, sea foods, pastries, cakes, sharp cheeses and cocktail snacks are forbidden. Long periods of rest, prolonged night sleep, and afternoon naps are helpful. Effective diuretic drugs are eminently successful in reducing fluid-swollen tissues.

Toxemia is more frequent in women with high blood pressure, previous toxemia or kidney trouble, or who have a twin pregnancy. It is much less severe in areas where good obstetrical care is the rule than in areas of poor nutrition and mediocre medical services. Acute onset of toxemia with severe headaches, convulsions, blurring of vision, and rapid rise in blood pressure and weight is rare in women who receive good prenatal care at regular intervals.

Writing Your Birth Plan

To begin with, you may want to make a list of your most important desires for your birth experience. Typically, these include the type of birth you want ranging from home birth to hospital birth and who you would like to be present at your birth, your partner, relatives, friends, and your older children. You can then go on to list your most significant preferences for your birth experience. Discuss your birth plan with your partner or support person and, if appropriate, with your doula. Make sure that they understand your concerns and preferences.

Contingency Plans

You also need to consider situations where birthing does not proceed as expected. You should expect that your care provider will keep you informed about your options and include you in decision making. However, in some cases, he or she will have to act quickly and the counseling and discussion phase may be significant abbreviated. Make sure you are in the hands of a care provider who has a similar approach to birthing as you, some one you can trust to make optimal decisions for you in an emergency.

Discuss Your Birth Plan

Near the beginning of your last trimester, bring your birth plan to one of your checkups and ask your care provider to give you feedback. He or she knows about your individual health and the course of your pregnancy up to this point and can help you make realistic decisions that optimize the chances for a safe birth of your baby. It is important to listen to the responses you receive, although, in some instances, you may want to emphasize specific preferences, especially about episiotomy, so that your care provide understands what is most important to you. After your conference with your care provider, you can prepare the final copy of your birth plan, incorporating all your care provider’s input. It is important to make your birth plan as concise and easy to read as possible ideally.

Make Sure The Right People Receive A Copy

A copy of the final version of your birth plan goes in to your care provider’s file, which should be handed to the staff at your hospital when you go in to labor. Your doula also needs a copy. To ensure that a copy is available if normal information channels fail, it is also a good idea to carry a copy in your birthing bag and to give one to your partner or support person.

The most important considerations in deciding where to birth are your own health and your own preferences, as well as those of your partner or support persons. If you are completely healthy, you can choose any place and your birth will be safe, assuming it is attended by a qualified midwife or physician, as discussed in the previous section. However, you need to be comfortable. If you are fearful of being at home, then you shouldn’t be there. If you are fearful of the interventions that are sometimes unavoidable in hospitals, like speeding labor if it does not adhere to a certain time frame, then perhaps that is not the best place for you. If you want nonintervention if at all possible, but do not want the responsibility of preparing the environment for birth, then perhaps a birthing center is where you should have your baby.

Each individual will assess the advantages and disadvantages of various birthing options differently. For example, having lots of personnel available at a hospital may be an advantage to one woman and her partner and a disadvantage to another woman who wants a quiet, private birthing experience. The accompanying table provides generally accepted pros and cons of each birth setting, but remember that your own interpretations may differ. Remember, also, that anybody can have a baby in a hospital but only healthy women with uncomplicated pregnancies can deliver in an out-of-hospital setting. Women and families should not merely consider the number of advantages and disadvantages at each site, but what each of these advantages and disadvantages means to them-how important each is. Worrying about a transfer may be enough to negate all other advantages of an out-of-hospital site.

Naturally, if you have any medical complications at the start of pregnancy, or develop a pregnancy complication at any time during prenatal care or labor, or even following the birth, you will need to be in a hospital. This may require a transfer from the birthing center or home. If you are uncomfortable with the idea of transferring, possibly during the throes of labor, then you should choose a hospital from the outset. If you are willing to take the risk of having to transfer, but would prefer to be out of ­hospital if at all possible, then you can choose an out-of-hospital site. The willingness to be transferred to a hospital should the need arise is absolutely essential for anyone choosing to have a baby outside of a hospital.

Of course, another criterion for where you birth is where your physician or midwife will attend. Some practitioners only attend births in a hospital, or only attend birthing center deliveries. Others have exclusively home birth practices. Some women and their partners will first choose the place of birth and then find a practitioner who will attend their birth at their chosen location. Some women, however, have already established a close relationship with a provider and will choose to have that provider attend their birth regardless of the location.

In general, our philosophy is that the attitude and practices of the physician or midwife are more important than the place of birth. You can choose an in-hospital birthing center, for example, because it has carpeted rooms with patterned wallpaper and dainty sheets, and an old­ fashioned wooden cradle for the baby, but hidden behind the wall is every piece of technological equipment that will fit. If your physician or midwife believes rigidly in the use of that technology, you can be sure it will come out from behind those closed doors, regardless of whether it is really needed, and regardless of your wishes. So, be certain you and your provider agree philosophically.

The appearance of the birthing environment is not necessarily indicative of the birth experience you will have. One of us used to work in a large inner-city hospital. The rooms were small and had minimal adornments but most births were in the labor rooms and technology was used only as necessary-even with a population considered high-risk by socioeconomic need. If the personnel attending a birth truly believe that pregnancy is a normal, non medical event, then even in the most hospital-looking environments, birth can be kept natural with minimal interventions. Conversely, unless the personnel are committed to a philosophy of nonintervention, the most homelike room will not make for a natural birth.

In addition to learning about the philosophy of your physician or midwife, you need to discover something about the policies of the institution. You can ask your physician or midwife about the policies at the institution or institutions with which he or she is affiliated: sometimes you have a choice of birth place even with the same practitioner. Or you can go on a tour of the facility. Many childbirth education classes, especially if given at a hospital, will take you on a tour. This, however, is usually late in pregnancy. Call the facility and see if tours are available outside of the childbirth class or call the instructor and see if you can at­tend the tour early in your pregnancy. If you have limited choices, you can sometimes have a birth experience more to your liking by staying home as long as possible, assuming, again, that everything remains nor­mal. (When to go to the hospital, of course, is something to discuss in advance with your physician or midwife.)

Both in-hospital and free-standing birthing centers are eligible to apply for accreditation by the National Association of Childbearing Centers. We recommend choosing centers that are so accredited. Freestanding birthing centers are more likely to follow safe guidelines if accredited and in-hospital birthing centers are more likely to be more family-centered if accredited.