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Infectious diseases may complicate pregnancy. It has been well publicized that an attack of German measles up to the ninth or tenth week of pregnancy may produce serious congenital malformations of the baby. If a pregnant woman has German measles or knows she has been exposed to the disease, she should consult her obstetrician immediately. Poliomyelitis is a serious complication of pregnancy, but easily averted by vaccination as directed by the doctor. Influenza vaccination, though not recommended for everybody in the population, is an important protection for the pregnant woman.

All States in this country require a serologic test for syphilis in pregnant women. This is done routinely from a blood specimen obtained at the time of pre-natal examination. People can have syphilis without knowing it. The disease can be a serious complication for the baby, or result in late miscarriage, pre­mature delivery, and even infant death. Syphilis discovered early in pregnancy can be cured readily with penicillin.

Most women have been vaccinated against smallpox, diphtheria and whooping cough, and many have acquired immunity to measles and chickenpox, by recovery from these diseases. However, it is prudent to avoid direct exposure to childhood diseases such as mumps, scarlet fever, and others. These diseases may not directly affect the fetus, but high fever may result in premature labor and termination of the pregnancy.
A physician cannot anticipate every question that may come up during the nine months of pregnancy. The intelligent patient will call her doctor at any time of the day or night when she considers it necessary. If a long trip is contemplated, the doctor should be informed. Old-wives’ tales about pregnancy still persist, and the doctor can give reassurance about worrisome questions if they are asked. The keystone of modern obstetrics is continued observation of the patient throughout pregnancy. Most of the complications of pregnancy, associated in the past with lack of medical attention, can be prevented when the patient is seen at frequent intervals.

During the first six months the patient should be seen every three to four weeks; during the seventh month, every three weeks; during the eighth month, every two weeks; and during the last month, every week.

The first visit to the physician includes a physical examination and blood-urine tests. Thereafter, visits include discussion of problems that may have come up, a review of the patient’s progress, and a brief examination. This includes examination of the abdomen, listening for the fetal heart, palpating the size of the baby, and examination of a urine specimen. During the last month of pregnancy there is usually a weekly vaginal examination to determine the “ripening” of the neck of the uterus, the position of the baby, and the proximity of onset of labor.

As Labor Nears

As pregnancy nears its end, there is natural concern about getting to the hospital in time and recognizing the signs of imminent events.

During the final weeks of pregnancy (thirty-eighth to fortieth weeks) there is frequently no increase in weight. Even the baby may seem to be preparing for his advent by some reduction of activity. The patient may notice an increased sense of well-being, less discomfort from heavy weight of the uterus, and more energy for her usual household activities.

Mild, fleeting, irregular uterine contractions coming every ten or 15 minutes or so and lasting ten or 15 seconds may be noted. Most women do not notice these mild contractions, but some feel slight pain, or occasional association with mild, transient low backache. If contractions come more frequently than every ten minutes, and last for 30 seconds, the obstetrician should be notified. It is advisable that neither fluids or solid food be taken once labor has begun.

A woman about to go into labor often notices the discharge of a mucus plug. This plug extrudes from the small remnant of the cervical canal which remains at the onset of labor, and when it is passed the surface of the fetal membranes is in direct contact with the vagina. Also, at the onset of labor there may be a discharge of clear watery material, which does not indicate rupture of the membranes but that rupture is imminent. A small amount of reddish or pink discharge known as “show” frequently indicates onset of labor.

Though contractions at tenminute intervals are a warning to inform the doctor, the real beginning of labor is measured from the onset of contractions which occur at five-minute intervals and last at least 30 seconds. In general, a woman whose office examinations have been normal can wait at home until 30­second contractions occur every five or six minutes. However, if she has given birth before, it is advisable to have her in the hospital when contractions occur at ten-minute intervals.

In some patients (ten to 20 per cent) the membranes rupture spontaneously. This speeds up the entire mechanism of labor. If the membranes rupture and labor does not commence in a few hours, the doctor should examine the patient to determine whether labor is in progress. In a first pregnancy, the cervix may be long and thick and take two or three days to thin out. This is called cervical effacement which precedes the onset of labor.

Decisions as to whether the patient may stay at home, in bed or up and about, or in a hospital where frequent nursing observations can be made, are of course made by one’s doctor. In a woman who has had more than one baby, labor usually commences from three to 25 hours after the membranes rupture.
Understanding Labor

It is important for a pregnant woman to have some understanding of the mech­anism of labor, which means “work” ­the bringing forth of a child.

Labor usually takes between six and 12 hours for a first baby, three to six hours in subsequent pregnancies. Labor under two hours, which is rare, is called very rapid labor and it is usually desirable to slow it down. A slow progressing type of labor is less likely to tear tissues than a fast labor.

The first stage of labor is the period from onset of dilation of the cervix, when complete thinning has taken place, to full dilation up to ten centimeters (one inch equals two and a half centimeters) to allow the baby’s head to go through. Usually the head is down in the pelvis at about the level of the spine, a landmark about midway down the pelvis.

Intensity of contractions usually increases as the first stage progresses. When the cervix is slightly dilated, contractions will be mild to moderate but toward the end of the first stage will be more severe. Severe contractions last 40 to 50 seconds at the most, compared to ten to 20 seconds early in the first stage. If the membranes have not ruptured by the time the cervix is dilated about two inches, the doctor will rupture them. This improves the quality of contractions and lessens the duration of labor.

Transition in labor is the stage when the cervix is almost fully dilated. There is a tendency, even though dilation is not complete, for feelings of pressure and pushing to occur during contractions.

The second stage of labor is the time between full dilation of the cervix and the birth of the baby. This lasts from 30 minutes to two hours for a first baby, and from five or ten to 30 minutes in subsequent deliveries. The infant is born at the end of the second stage.

The third stage of labor is the period between the birth of the baby and delivery of the placenta. This usually takes five to ten minutes but may last as long as half an hour. If the placenta has not separated in half an hour, the obstetrician removes it manually. This manual removal usually requires ten or 15 minutes of general anesthesia.

The technological ability to control your fertility gives you choices not available when your parents were born. The loosening of social restrictions in the areas of marriage and parenting also affords single men and women the opportunity to become parents. Regardless of whether you are married or single, the preparation to become a parent involves similar considerations and decisions. If you are in the process of deciding whether to have children, you need to take the time to evaluate your emotions, finances, and health.
Emotional Health

The first and foremost evaluation you should make in pregnancy planning is why you want to have a child: To fulfill an inner need to carry on the family? Out of loneliness? Can you care for this new human being in a loving and nurturing manner? Are you ready to make all the sacrifices necessary to bear and raise a child? You can prepare yourself for this change in your life in several ways. Reading about parenthood, taking classes, talking to parents of children of all ages, and joining a support group are all helpful forms of preparation. If you choose to adopt, you will find many support groups available to you as well.
Maternal Health

Before becoming pregnant, a woman should have a thorough medical examination. Preconception care should include assessment of possible pregnancy complications. Medical problems such as diabetes and high blood pressure should be discussed as should any genetic disorders that run in either family.
Paternal Health

It is common wisdom that mothers-to-be should steer clear of toxic chemicals that can cause birth defects. Even women who are trying to conceive are cautioned to avoid toxic environments and to eat a nourishing diet, to stop smoking and drinking alcohol, and to avoid most medications.

Now similar precautions are being urged for fathers-to­be. New research suggests that a man’s exposure to chemicals influences not only his ability to father a child but also the future health of his child. Fathers-to-be have been overlooked in the past for several reasons. Researchers assumed that the genetic damage leading to birth defects and other health problems always occurred while a child was in the mother’s womb. After all, they reasoned, that’s where embryonic and fetal development take place. Conventional medical wisdom also held that defective-looking sperm(those with misshapen heads, crooked tails, or retarded swimming ability) were incapable of fertilizing an egg.

Scientists have recently discovered that how sperm look has little to do with how they act. Misshapen sperm can penetrate an egg, and they do not necessarily carry defective genetic goods. Moreover, sperm that look healthy and swim well can be the true genetic culprits. DNA fluorescent markers have identified normal-looking, yet genetically flawed, sperm that carry too many or too few chromosomes. Fathers contribute the extra chromosome 21 in about 6 percent of children with Down syndrome, which causes mental retardation; the extra X chromosome in 50 percent of boys with Klinefelter’s syndrome, which causes abnormal sexual development; and the shortened chromosome 15 in about 85 percent of children with Prader-Willi syndrome, a disorder characterized by retardation and obesity.

Although some birth defects are caused by the random errors of nature, it now appears that some disorders can be traced to sperm damaged by chemicals. Sperm are naturally vulnerable to toxic assault and genetic damage. Many drugs and ingested chemicals can readily invade the testes from the bloodstream; others ambush sperm after they leave the testes and pass through the epididymides, where they mature and are stored. By one route or another, half of 100 chemicals studied so far (including by-products of cigarette smoke) apparently harm sperm.

Some researchers believe that Vitamin C is nature’s way of protecting sex cells from damage. Bad diets, exposure to toxic chemicals, cigarette smoking, and not enough foods rich in Vitamin C are probably the biggest culprits in sperm damage.
Financial Evolution

You also need to evaluate your finances. First check your medical insurance: Does it provide pregnancy benefits? If not, you can expect to pay between $1,500 and $5,000 for medical care during pregnancy and birth-and substantially more if complications arise. Both partners should find out about their employer’s policies concerning parental leave including length of leave available and conditions for returning to work.

Raising a child exacts a tremendous strain on most family’s finances. Expenses during the first year of life averaged $5,774 in 1990. The expense of raising a child from birth to 21 years of age is presently estimated to be over $250,000­ not including the cost of a college education!

The cost and availability of quality child care should also be considered. Prospective parents should realistically assess how much family assistance they can expect with a new baby as well as the availability of nonfamily child care. While you may be aware of the federal tax credit available for child care, you may not be aware of how little assistance it provides: between a maximum of $480 for one child in a family having income of over $28,000 to a maximum of $720 for one child in a family having income of under $10,000. A second child doubles the credit; but no further assistance is provided for a third child or more children. How much does full-time child care cost? It averages between $5,000 and $10,000 a year, depending on your location(urban areas tend to cost more).
Contingency Planning

A final consideration is how to provide for the child should something happen to you and your partner. If both of you were to die while the child is young, do you have relatives or close friends who would raise the child? If you have more than one child, would they have to be split up or could they be kept together? Unpleasant though it may be to think about, this sort of contingency planning is highly important. Children who lose their parents are usually heartbroken and confused. A prearranged plan of action may help smooth their transition into new families.

RU-486 A steroid hormone that induces abortion by blocking the action of progesterone. Testing in the United States began in late 1994.

Preconception care Medical care received prior to becoming pregnant that helps a woman assess and address potential maternal health.
What do You Think?

Do you think most parents plan when they will have their children? At what point in your life do you think you will be ready to take on the responsibilities of becoming a parent? What are your biggest concerns about parenthood?

Erythroblastosis is a disease of newborn infants associated with the Rh blood factor. A blood factor is a physical substance which some people have in their blood and some do not. If a blood factor gets into the blood of a person who has not inherited it, it acts like a foreign protein, and the body creates antibodies that antagonize the factor, much the same as antibodies against measles viruses are built up to give immunity to measles. But some anti­bodies do not protect, but cause damage.

“Rh” gets its name from Rhesus monkeys, in which the factor was first discovered in 1940. About 85 per cent of women have the Rh factor and are Rh­positive or Rh+. The remainder are Rh-negative or RH-. If an Rh- mother and an Rh+ father conceive a baby, the fetus growing in the uterus produces Rh factor and some of it may pass into the mother’s bloodstream. In that case the mother produces an antibody that is hostile to the Rh factor which to her body is a foreign substance. This antibody may cross back to the baby with destructive action on its red blood cells. The extent of this destruction determines the severity of “Rh disease” or erythroblastosis.

Most Rh- women with Rh+ husbands can produce one or two healthy babies or even more. Usually Rh disease does not manifest itself until the third or subsequent pregnancy. The maternal and fetal circulations do not intermingle, and it is thought that the back-and-forth transfer of Rh factor and antibodies may be effected by “leaks” in minute capillaries.

Blood studies of pregnant women determine their Rh status. If a patient is Rh+ there is nothing to worry about. If she is Rh- and has an Rh+ husband, the physician is watchful of a possible complication in an existing or future pregnancy. Even so, the odds are quite favorable. About five per cent of Rh­mothers, or one out of twenty, will have a baby with Rh disease, and this usually happens in a third or later pregnancy. Some evaluation can be made by frequent measurement of Rh levels in the mother’s blood during the last two months of pregnancy. At the time of delivery a delicate test called the Coombs test may confirm the presence of erythroblastosis in the infant. If the disease is severe an exchange transfusion may be required at birth. This is done by replacing all the baby’s blood with appropriate fresh blood of a donor. Occasionally, if the baby is alive in the womb and Rh disease appears to be worsening, early delivery at the thirty-fifth week may be indicated. A baby with Rh disease who is born in good condition will be watched carefully in the first few days after birth for signs of jaundice which may be due to a delay in onset of the disease.

At present there is no way of preventing Rh disease other than to forbid matrimony to an Rh- woman and an Rh+ man, which a devoted couple would hardly tolerate. However, “Rh babies” are uncommon even among couples who theoretically could produce them, and many severely affected babies are being saved .

There are some other blood groups that may produce cross reactions somewhat similar to the Rh factor, but these are usually mild and disappear without requiring transfusions.

Twins present additional problems to the expectant mother, the obstetrician, and for that matter the father. The statistical chance of having twins is one to 92.

Identical twins (always of the same sex) develop from a single fertilized egg which divides in two early in its development. One identical twin is the mirror image of the other.

Fraternal twins originate from two separate eggs fertilized by two separate spermatozoa. The eggs arise from one or both ovaries, embed in the uterus separately, and grow independently. Fraternal twins may be of different sex and their relationship is no closer than that of brothers and sisters. They are more common (70 per cent) than identical twins.

Fraternal and identical twins cannot be positively identified from their appearance. The question can be settled at delivery by examination of the placenta and the membranes separating the twins. If two layers of membranes are present, the twins are identical; if four layers, they are fraternal. Also, study of their blood groups will usually distinguish the two types of twins. A tendency to produce fraternal twins (but not identical twins) seems to run in families.

Triplets occur about once in 9,000 births, quadruplets once in 500,000 births, and the odds against having quintuplets are about40million to one. Nevertheless, in 1963, thriving quintuplets were born to a family in South Dakota and another in Venezuela.

What makes a doctor suspect that a woman may have a twin or multiple pregnancy? For one thing, the uterus is usually much larger than expected for the stage of pregnancy. Rapid weight gain, sometimes ten pounds in three to four weeks, suggests possible twins. But these are only suspicions unless the obstetrician is able to feel two heads, two trunks, or to hear two independent fetal heartbeats. X-ray films which show two fetal skeletons clinch the diagnosis.

Multiple pregnancy is a weighty matter, notoriously uncomfortable. Labor usually begins about three weeks earlier than the expected date of delivery. Toxemia is a frequent but usually controllable complication of multiple pregnancy. Twins, individually, tend to be much smaller than a single-born infant. Twins at term may weigh five and a half to six pounds each, compared to seven to seven and a half pounds for a single infant.

The hazard to twins of very early labor and premature birth must always be kept in mind. Twins will be recognized relatively soon if the pregnant woman makes regular visits to her doctor, and not infrequently twins may be saved by simple measures to prevent prematurity.

Labor with twins tends to be long and slow. The large distended uterus does not contract with normal force. Usually the membranes of the lower twin will rupture, reducing the size of the uterus and improving uterine muscle contractions. Risks are slightly greater for the second twin. Occasionally the presence of twins is not known until the first baby is delivered and the uterus remains large and a second fetal heart is heard. In the very obese woman, or when the second baby is very small, or when the mother has had no prenatal care, twins may easily be overlooked by the doctor.

Several decades ago, some experts proposed that elimination of the stresses of labor by delivering all preterm babies by cesarean would increase the newborn survival rate. The rationale was that reduced stress on the infant’s head would reduce the possibility of bleeding into the skull. This complication, called intraventricular hemorrhage, is another major cause of death in premature newborns. The best evidence now shows that cesarean delivery does not prevent ventricular hemorrhage. The best currently available evidence does not support performing a cesarean if the only reason for the surgery is a premature infant. Of course, there are times when cesarean is performed for the same reasons as it is in mature babies.

Episiotomy is another procedure that has been advocated as a way of reducing stress on the skull of the immature fetus. Studies are not available to demonstrate whether this is beneficial. The resistance of the perineal muscles, through which the infant passes just as it leaves the vagina and which are cut with an episiotomy, is less than the resistance of the cervix and the vaginal muscles through which the infant has already passed. Despite a lack of definitive evidence, some experts recommend episiotomy for the delivery of preterm infants. Others recommend it only when there is resistance in these muscles, rarely seen except in women having a first baby. This is an area worth further research.

Most important for the premature infants is the presence at the birth of personnel skilled in resuscitation and care of premature infants. Whenever possible, the delivery should take place in a hospital with a neonatal intensive care unit and with constant attendance of physicians, nurse practitioners, and nurses who are knowledgeable in caring for these tiny infants. A staff member, or team of staff members, should be present in the delivery room whenever a premature baby is born, ready to provide expert care from the moment of birth.

A physical examination when the physician first meets the expectant mother is essential. This may pick up variations which are correctible, prevent later complications, and save the pregnant woman time in the hospital.
General Examination

The blood pressure is taken to establish a baseline level. Elevated blood pressure may presage a complication known as toxemia which usually occurs in the last three months of pregnancy. The heart is examined for function, rate and rhythm. The breasts are examined to note the pattern of the nipples, their suitability for nursing at a later date, and to determine whether cysts or tumors are present.

Laboratory examinations on this visit include complete urinalysis, a hematocrit (amount of red cells in the blood), blood grouping (A, AB, or 0), blood test to rule out syphilis and determination of the Rh factor. About 86 per cent of the population is Rh positive, 14 per cent Rh negative. If the blood is Rh negative, tests to determine the presence of antibodies will be done later.

A dentist should examine the teeth during the first three months of pregnancy. There is no real evidence of rapid destruction of teeth because of pregnancy, but frequently there is swelling and bleeding from the gum margins, which good dental treatment can minimize. There is some evidence to indicate that addition of small amounts of fluoride will be beneficial to the teeth of the developing fetus. Most of the new vitamin preparations for pregnancy have fluoride added.
Pelvic Examination

The cervix or neck of the uterus is examined and Papanicolaou smears are taken (these are cells from the cervical area, which, stained and examined under a microscope, may reveal early and curable cancer of the cervix). The position of the ovaries and tubes is noted, as well as the size of the uterus at this initial visit. The physician can determine if its rate of growth is normal during the early months of pregnancy.

Pelvic measurements may be done at the first visit, though it may be preferable to do this in the last two months of pregnancy, when the vagina is softer and larger and there is good rapport between physician and patient so the examination may be done without tension or muscular spasm. Measurements are made of the outlet between the two bones which rim the birth passage, as well as measurements made through the vagina to determine the distance across the pelvis through which the infant must pass to enter the world.
Predicting the Birth Date

As soon as pregnancy is confirmed, the patient’s first question is usually “when will the baby be born ?” The general formula is that birth occurs 280 days from the last menstrual period or 267 days from the time of last ovulation. But duration of pregnancy is highly variable, ranging from 250 to 310 days from the last men­strual period, and perhaps only one out of ten babies is born on the EDC (expected date of confinement). Frequently in a first pregnancy the baby is born a week or so beyond the expected date. Many mothers tend to repeat early or late delivery dates in subsequent preg­nancies; but there is no general rule about it and there are many exceptions.
Miscarriage

Pregnancy that termi., nates prior to the twentieth week, with a fetus weighing less than one pound, invariably incapable of life, is, in medical language, an abortion – usually called a “miscarriage” by laymen. Spontaneous abortions occur in about ten per cent of pregnancies.

Pregnancies ending between the twentieth and twenty-eighth week produce a fetus or infant weighing between one and two and a half pounds. These are called previable infants, and all will require a long period of care in a premature nursery, with a ten to 25 per cent chance of survival.

Premature infants are born between the twenty-eighth and thirty-fifth week of pregnancy. Their weights run from two and a half to five pounds. Chances of survival for the largest prematures are 80 to 90 per cent.

The term or mature infant is born between the thirty-fifth and forty-fifth week. These infants have an excellent chance of survival and almost invariably may return to the home with the mother when she is discharged from the hospital.

Education for expectant parents has played an increasingly important role in recent years. In many obstetrical clinics throughout the country a series of six to eight sessions is given, usually at weekly intervals. These generally begin when the pregnancy is six to seven months along. Much of the mystery of the experience to come is cleared away by comforting understanding of the development of the fetus, body changes related to pregnancy, and the mechanism of labor. These courses are given by the American Red Cross, the Child Study Association of America, the Maternity Center Association of New York, and by most of the large teaching centers.

The expectant mother immediately gets heartening assurance that the risk of childbirth is scarcely greater than the risks of living without pregnancy. A half-hour trip by car on a congested highway is a distinctly greater hazard. The achievements of modern obstetrics are of course closely related to advances in all fields of medicine.
Concerns

The concerns regarding child birth preparaion are:

Exercises

Exercises which develop muscles important in labor (principally of the abdomen, back, and pelvic floor) are practiced. Breathing exercises are particularly stressed as an aid during labor. The rhythmic activity of breathing has a calming effect, gives the woman in labor something to concentrate on, and helps to disassociate uterine contractions from overall tensions of the entire body. The first stage of labor is that during which contractions gradually increase in frequency and intensity. Slow, long, deep breathing is practiced for application in the early and middle parts of the first stage. Shallow, rapid breathing is substituted when first stage contractions become strong, on the verge of transition to the second stage of labor which terminates with expulsion of the baby. During the transition from first to second stage, a “pant, pant, blow” rhythm of breathing prevents pushing or bearing-down effort before the neck of the uterus is fully dilated. The “blow” part is exhalation through parted lips without contracting the abdomen.

Finally, in the second stage of labor, long “pushing” similar to that practiced with a bowel movement is substituted. As the baby’s head is born, rapid panting breaths begun at the obstetrician’s command help to prevent injury to the mother’s tissues as the head emerges.

These well known special breathing rhythms are excellent for lessening the pain in labor by giving the mother a distracting and useful activity with assurance that everything is proceeding normally. Constant attention of an obstetrician or obstetrical nurse is necessary for best results with these techniques that the patient has practiced.

A great advantage of “training for childbirth” is that the need for sedatives at delivery is almost always reduced. High or even moderate doses of pain relieving drugs may depress the onset of breathing in the newborn. Small amounts of sedation are necessary in most labors, but large or frequent doses are practically always unnecessary in the “educated” patient.

A woman may not desire or be able to attend formal preparation classes. The gap can be bridged very satisfactorily by conversations with the obstetrician and a “learn as you go” course guided by the obstetrical nurse during the actual progress of labor.
Hypnosis

True hypnosis goes far beyond suggestibility, distraction and reassurance instilled in preparation for childbirth classes. The obstetrician must spend a great deal of time in inducing and releasing the patient from the hypnotic state, and his almost constant attendance is necessary. Patients suitable for and desirous of hypnosis are usually rather carefully selected. Hypnosis, although dramatic in its relief of pain, is not a routine technique but one useful in particular circumstances. There is a tendency for a patient prepared for a normal delivery to be taken by surprise by complications. She may wish and expect events to continue normally although some complication may compel a departure from her expectations. Thus, childbirth preparation courses stress that there are particular considerations which may require anesthesia, forceps delivery, or even cesarean section, which are unpredictable but which the obstetrician will recognize and deal with effectively.

The causes of preterm labor are not entirely understood and, so far, its prevention eludes medical science. Obvious preventive measures include the elimination of the risks noted earlier. Avoid smoking, drinking, and recreational drug use. Report signs of urinary tract or vaginal infections to your physician or midwife so they can be treated promptly. Let your physician or midwife know if you have had a prior preterm birth .

If your work involves heavy physical labor, rotating or night shifts, long periods of standing, or makes you excessively tired, consider changing or reducing your workload. Unfortunately, women in the United States are not uniformly guaranteed paid maternity leave.

As sexually transmitted infections may be implicated in premature rupture of the membranes and preterm labor, you should use a condom if you are at risk for such an infection. Being at risk means that either you or your partner has more than one sexual partner. If you have any doubt about whether this is the case for your partner, or you have had a pre term birth, you should use condoms. In fact, because semen contains prostaglandins-body chemicals that cause uterine contractions-use of a condom from midpregnancy to 37 weeks gestation is a good idea for any woman who has had a previous preterm birth. The condoms provide a barrier between your body and your partner’s semen.

If you have a history of pre term labor or signs of preterm labor, avoid nipple or breast stimulation in the third trimester, before 37 weeks gestation, as this initiates uterine contractions. Abstain from orgasm if there is any question of threatened preterm labor, as it can lead to contractions.

There is some evidence, although not conclusive, that calcium supplementation may help prevent preterm labor. Routine calcium supplementation is not currently advised in pregnancy, but you should certainly maintain an adequate dietary intake of calcium sources. Except for sometimes causing constipation, a calcium supplement is not dangerous in pregnancy. If you have had a preterm birth, discuss with your physician or midwife whether or not they advise calcium supplementation as a possible preventive measure.

In the 1980s, some promising studies showed that preterm birth might be prevented with frequent prenatal visits and vaginal examinations for women at risk for preterm labor. A number of “Prevention of Preterm” birth programs were funded by various governmental and private agencies. Unfortunately, these did not demonstrate that such measures were uniformly valuable in preventing preterm birth. Whether or not to do weekly or biweekly vaginal examinations or ultrasounds to check the cervix in the third trimester for women with a previous preterm birth remains controversial.

Researchers have tried to find biochemical markers in the blood, saliva, or vaginal secretions of a pregnant woman that might predict a preterm birth. One such chemical is fetal fibronectin. This can be detected in vaginal secretions. Unfortunately, while the absence of fetal fibronectin seems to be very predictive that preterm labor will not occur, its presence does not necessarily signal impending preterm labor. To date, it is not useful as a test for preterm labor. The benefit of testing for estriol in a pregnant woman’s saliva is also being investigated. Estriol is a hormone produced from chemicals secreted by the fetus’s adrenal gland and liver. Maternal estriol levels show a steep rise approximately three weeks before delivery-term or preterm. This hormone can be detected in the mother’s saliva. Saliva testing for women at high risk for a preterm birth might prove to be of predictive value, but then the question of what treatment to implement must be considered.

Some companies have marketed home uterine monitors in an effort to pick up uterine contractions before a woman might feel them. The American College of Obstetricians and Gynecologists has stated, “It is not clearly demonstrated that this expensive and burdensome system can be used to actually affect the rate of preterm delivery.” Women who have had previous preterm labors can use their own hands to palpate the top of their uterus one hour each day in the third trimester to feel for contractions that they do not perceive.

Managing Your Fertility

You should realize that pregnancy, childbirth, and reproductive issues are not to be taken lightly. The choices between different types of birth control and the ethical issues surrounding fertility are complex. It’s important to take control of your own fertility and to share this responsibility in your relationships. Is birth control an option for you? Have you considered birth control options and which would be most appropriate for you? Be sure to examine all potential side effects and drug interactions. The following questions can help you determine your level of readiness regarding reproduction and sexual health.
Checklist For Change

Making Personal Choices

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If you are in a stable relationship and are considering having a child, is it something both you and your partner want?
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Do you know and feel comfortable with your philosophical beliefs about children?
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Do you feel comfortable discussing birth control with your partner?
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Do you feel comfortable choosing a method of birth control that meets the needs of both yourself and your partner?
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Are you familiar with the resources available if you have trouble conceiving?
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Have you discussed alternatives should you become or get someone pregnant?

Making Community Choices

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Have you taken the time to become educated about the issues and concerns related to parenting?
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Do you listen with an open mind to issues involving reproduction and sexual health and then make informed decisions?
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When you think about having children, do you think of it in terms of long-range planning?
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Are you an advocate for people making choices that are in their best interest, regardless of your own personal philosophy or opinions?
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Do you believe in providing support for community agencies and social services that assist in meeting the sexual and reproductive health needs of your community?
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Do you try to volunteer your time to other people or agencies that may need your assistance?

Summary

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Only latex condoms, when used correctly for oral sex or intercourse, are effective in preventing sexually transmitted diseases. Other contraceptive methods include abstinence, outercourse, oral contraceptives, foams, jellies, suppositories, creams, the female condom, the diaphragm, the cervical cap, intrauterine devices, withdrawal, Norplant, Depo-Provera, and the vaginal ring. Fertility awareness methods rely on altering sexual practices to avoid pregnancy. Sterilization is permanent contraception.
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Abortion is currently legal in the United States through the second trimester. Abortion methods include vacuum aspiration, dilation and evacuation(D&E), dilation and curettage(D&C), hysterotomy, induction abortion, and RU-486 “abortion pills.”
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Parenting is a demanding job requiring careful planning. Emotional health, maternal health, financial evaluation, and contingency planning all need to be taken into account.
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Prenatal care includes a complete physical exam within the first trimester, avoidance of alcohol and drugs, cigarettes, X-rays, and chemicals having teratogenic effects. Full-term pregnancy covers three trimesters.
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Childbirth occurs in three stages. Birth alternatives include the Lamaze, Harris, “childbirth without fear,” and Leboyer methods. Parents should jointly make decisions about labor early in the pregnancy to be better prepared for labor when it occurs. Complications of pregnancy and childbirth include miscarriage, ectopic pregnancy, stillbirth, and cesarean section.
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Infertility in women may be caused by pelvic inflammatory disease or endometriosis. In men, it may be caused by low sperm count. Treatment may include alternative insemination, in vitro fertilization, gamete intrafallopian transfer, nonsurgical embryo transfer, and embryo transfer. Surrogate motherhood involves hiring a fertile woman to be alternatively inseminated by the male partner.

A pregnant woman may become aware of uterine contractions by 24 weeks of pregnancy. These contractions are normal. They are called Braxton­Hicks contractions. On occasion, Braxton-Hicks contractions are rather severe. In addition, the cervix often shortens and occasionally dilates during the early part of the third trimester. If these two events combine in a single woman, deciding whether or not she is in early labor may be extraordinarily difficult. If in fact she is not, any treatment or none at all will appear equally successful. Evaluating the treatment thus is very difficult, as the measure of success is that nothing has happened. Often, we cannot be sure that there was ever a condition that required treatment.

Despite the inexact nature of diagnosis, certain steps usually are taken when a woman complains of any of the symptoms at any time between 23 and 37 weeks of pregnancy. (There is some disagreement regarding when to initiate treatment, although generally before 23 or 24 weeks, survival of the preterm infant is unlikely. Delivery at that time is considered a miscarriage, not a preterm birth. After 37 weeks, there is no worry about prematurity of the baby.)

If you have any of the symptoms noted in the box, call your physician or midwife or go to the hospital where you will have your baby(or your “back-up” hospital if you had planned a home or birth center birth). The physicians and midwives in the practice or clinic where you have your prenatal care will have given you instructions on how to contact somebody in case of an emergency or whether to go to the hospital’s labor unit or emergency room. Signs of preterm labor can be considered an emergency.

You will most likely be advised to meet your physician or midwife at the office or hospital. First, you will have an abdominal examination to determine if the examiner can feel any contractions and to estimate the size and position of the baby. You may be placed on a fetal monitor so that a recording of contractions can be made, although this is not always necessary. The straps placed around your abdomen may be irritating to the uterus and increase the contractions, if there are any. Usually, a recording of the fetal heart tones will be made.

An examination of the cervix with a speculum may be done next. If there is any question about whether or not the membranes have ruptured, this examination will be carried out under sterile conditions. The physician or midwife will look to see any signs of cervical opening and will check to see if the membranes are ruptured. There are a variety of ways to do that. Sometimes, there is an obvious pooling of fluid in the vagina. Other times, a sterile swab can be placed into the vagina. The secretions picked up by the swab are looked at under a microscope. When amniotic fluid dries on a slide, it forms a characteristic pattern that resembles a fern. This is called ferning, and indicates that the membranes have ruptured. A type of litmus paper, called nitrazine paper, may be placed on the discharge. If the yellow paper turns blue, this shows an alkaline pH. Since the vagina is acidic, the alkalinity often is due to amniotic fluid and means that the membranes have ruptured. A number of other secretions are alkaline, however, such as blood, the vaginal discharge of certain infections, and even cervical mucus. This test, then, is not completely reliable.

During this sterile speculum examination, vaginal or cervical cultures for organisms including group B strep, gonorrhea, and chlamydia may be taken. This feels no different from a Pap smear.

If the membranes are ruptured, the physician or midwife should refrain from doing a bimanual examination-an examination with his or her fingers. When the protective membranes are torn, vaginal examinations increase the risk of infection-a danger for both mother and baby. Usually, once an examination is done, the delivery needs to occur within 24 hours. Avoiding examinations minimizes the possibility of infection and allows for more flexibility in handling the situation. This is especially important if you have ruptured membranes without signs of labor.

If the membranes have not ruptured(said to be intact), then a bimanual or digital(finger) examination allows the physician or midwife to check with more accuracy whether the cervix is effaced(thinned) or dilated(opened). Ultrasound is an alternative way of checking, used in some medical centers. If the cervix is thick and closed or just a bit open or thinned, most likely you will be observed for several hours, lying in bed on your side, and reexamined. If there is cervical change, then the diagnosis of preterm labor is made. If there is no cervical change, then you will continue to be watched or sent home, depending on whether contractions are still present. Contractions consistent with preterm labor are 5 to 8 minutes apart, or occur at a rate of 4 in 20 minutes or 8 in 60 minutes.

If the cervix is open to at least 2 centimeters(a bit more than the width of the average finger), or 80 percent or more effaced, and contractions are occurring, then the diagnosis may be made without waiting to see if the cervix changes. Under these circumstances, if treatment is delayed, the opportunity to stop the labor may be missed.

If your physician or midwife determines that you are not in preterm labor, or you become aware that your contractions have stopped, you will most likely go home with instructions to rest, to refrain from heavy work, including housework and lifting of toddlers, and to avoid vaginal intercourse, nipple or breast stimulation, and orgasm until all signs of possible preterm labor are gone or you have reached 37 weeks gestation.

If your physician or midwife determines that you are in preterm labor, then an attempt usually will be made to stop the labor if you are less than 4 centimeters dilated and less than 34 weeks gestation. After 34 weeks gestation, most babies will survive and the risks of treatment usually render such treatment inadvisable. Other reasons for not treating preterm labor are:

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Dilation of 5 centimeters or more.
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Fetal death or an anomaly known to be incompatible with life(both of which may predispose to preterm labor).
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Fetal distress or growth restriction(meaning that the baby may do better outside the uterus, despite being premature).
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Maternal bleeding.
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Maternal preeclampsia or eclampsia.
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Abruptio placentae.
* Chorioamnionitis(infection of the membranes).