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.

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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.

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If the nipples are inverted or the baby is premature it is not advisable to breast feed. If the mother decides to nurse, the baby is brought to her about 12 hours after delivery and allowed to suck no more than five or ten minutes on each side. Usually the baby is not very desirous of sucking until the second or third day. Around the third day the breasts become engorged (very heavy and firm) and the milk comes in or is “let down.”

Before each nursing session the breasts, and particularly the nipples, should be washed carefully with an anti­septic to prevent breast infection. The nurse will assist the mother. If there is scantiness of milk the baby should be brought out every four hours through the night. But if the milk is plentiful and the mother wishes to sleep, the two a. m. feeding may soon be eliminated, particularly if the baby is large.

The uterus and tissues of the nursing mother tend to recover their normal state more rapidly. Bleeding following delivery ceases sooner. However, lactation may prevent the menstrual period from returning for as long as six months (the average duration of breast feeding) .

The only way to determine whether nursing is feasible is to try it. Capacity for milk production varies. Enthusiasm and encouragement by the husband help. If a woman is very active in social or other activities outside the house, nursing should be discouraged.

Pregnancy may occur during the nursing period even though menstruation does not. This is unusual but if pregnancy occurs, nursing should be stopped. The baby can be weaned by giving a bottle at alternate nursing periods and gradually diminishing breast feeding until feeding is completely by the bottle after a week or ten days.

Many mothers do not wish to nurse and for them there are various compounds that prevent the milk from coming in. These are principally the estrogens which prevent the pituitary gland from secreting lactogenic hormone that stimulates milk flow. If the estrogens are taken, usually by mouth, for ten days to two weeks, there is usually no engorgement of the breasts. Sometimes the breasts become engorged after the estrogens have been stopped. With breast engorgement, a tight brassiere should be worn and fluid intake should be restricted to a minimum. A little aspirin and codeine for 24 hours will alleviate the pain.

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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).

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There is no completely safe drug that will predictably and reliably turn off true preterm labor. Besides the uncertain value of the medications in stopping preterm labor, they all carry risks to the mother or the fetus or both. They must be used only with close observation. If a woman clearly has a vaginal or urinary tract infection, that condition is treated, although once labor has begun, antibiotic therapy will not stop it.

Without a known cause of preterm labor, treatment is aimed at stopping the contractions, rather than alleviating the cause. This is sometimes effective, although studies have shown that most treatments postpone birth for only 48 hours. This is enough time, however, to give the mother a medication that many experts believe speeds up maturation of the fetal lungs, helping to increase survival. It is also sufficient time to transfer the pregnant woman to a hospital that has a neonatal intensive care unit(NICU), called a tertiary care center or a Level III hospital. This is preferable to transferring a premature infant after birth, which poses more risks for the newborn and separates the mother and baby.

Promoting Fetal Lung Maturity: A corticosteroid drug called betamethasone or dexamethasone is given to the mother to promote fetal lung maturity. This drug is thought to cause the fetal lung to produce surfactant-a chemical that keeps the lungs expanded after each breath. In respiratory distress syndrome(previously called hyaline membrane disease), the lungs of the premature newborn collapse after each breath, making each breath as difficult as the first. This is a major cause of death in premature infants. Surfactant appears in the fetal lung in the second trimester, but may not be present in sufficient quantity to be effective before 34 weeks of pregnancy.

In 1995, the National Institutes of Health(NIH) hailed the use of corticosteroids as a major breakthrough in care for preterm newborns. Since this report, the therapy has been used widely in preterm labor. Recent studies, however, have not consistently supported its value.

For corticosteroids to be beneficial in causing lung maturity, there must be a delay of at least 24 hours between treatment and birth. If birth is delayed for 7 days, their effectiveness is unclear.

Standard regimens for administering the medication vary. One major obstetrical text reports the use of two doses of 12 mg betamethasone, injected into the muscle, 24 hours apart, or 12 hours apart if labor seems likely to occur before 48 hours have passed. Another major text reports use of 5 mg of dexamethasone every 12 hours for four doses. The therapy may be repeated every 7 days until 34 weeks gestation, although some controversy exists about whether repeated courses of steroid treatment might impair brain or immune system development in the fetus. More research is needed in this area.

Stopping Labor: Various drugs have been used to stop preterm labor, including beta-adrenergic receptor agonists, magnesium sulfate, prostaglandin inhibitors, calcium channel blocking agents, and oxytocin inhibitors. The act of stopping uterine contractions is called tocolysis(Greek: tocos = birth; lysis = dissolution). Women with medical diseases may not be able to use some or any of these drugs as they aggravate certain conditions.

Beta-Adrenergic Receptor Agonists. A group of cells called adrenergic receptors are found on the surface of smooth muscle cells. An agonist is a drug or other substance that can combine with the receptor cells. In the uterine muscle, stimulation of the beta-adrenergic receptors by an agonist causes the receptors to inhibit uterine contractions. Two beta-adrenergic agonists used to stop preterm contractions are ritodrine and terbutaline, although only ritodrine is approved for this use by the Food and Drug Administration.

Studies have found that these medications, given intravenously, stop labor for a day or two, at most. While this doesn’t give the fetus much time to grow, it may allow for the adminstration of corticosteroids or maternal transfer.

Since beta-adrenergic receptors are found in smooth muscle cells all over the body, these drugs affect many body systems. This limits their use. They can cause heart and lung problems, as serious as rapid or irregular heartbeat, decreased blood pressure, chest pain, and pulmonary edema(fluid in the lungs). They cause changes in body chemistry, including increased blood sugar, decreased blood potassium, and increased blood insulin levels. They cause less serious but quite unpleasant side effects such as vomiting, headaches, fever, and hallucinations. They may cause anxiety in the woman.

Women receiving ritodrine or terbutaline must be hospitalized and watched with extreme care. Women with poorly controlled diabetes or poorly controlled high blood pressure should not be given beta-adrenergic agonists.

Magnesium Sulfate. Another medication used in the effort to stop preterm labor is magnesium sulfate, usually given intravenously. Studies show its effects on labor to vary from none to stopping labor for the same duration as ritodrine. Magnesium can depress maternal respiration, although this effect is rare. A woman must be closely observed while the drug is being given. Magnesium therapy may also cause nausea and vomiting, decreased blood pressure, and headache. Magnesium eventually crosses the placenta and may affect newborn respirations as well.

Magnesium sulfate cannot be used in women with kidney failure, low blood calcium levels, or a disease called myasthenia gravis(characterized by severe muscle weakness).

Prostaglandin Inhibitors. Prostaglandins are a group of body chemicals involved in normal uterine contractions. Prostaglandins can be given to induce labor. Conversely, prostaglandin inhibitors can be used to stop labor. These inhibitors work by either reducing the formation of prostaglandins or blocking their action. Indomethacin is an example of a prostaglandin inhibitor that has been used to arrest labor.

Research studies have found prostaglandin inhibitors more effective than beta-agonists for delaying labor up to 48 hours, with fewer maternal side effects. Prostaglandin inhibitors, however, are associated with severe adverse effects on the fetus, including cardiac defects and brain hemorrhage. They can also cause bleeding in the mother. The use of these drugs for stopping labor is still under investigation.

Indomethacin cannot be used with maternal asthma, coronary artery disease, gastrointestinal bleeding, kidney failure, and oligohydramnios. Suspected heart or kidney abnormalities in the fetus also preclude its use.

Calcium Channel Blocking Agents. Reducing calcium levels in muscle cells reduces muscle contraction. Calcium channel blockers stop the entry of calcium into cells. (These drugs are used to treat high blood pressure because they relax the muscles in blood vessels.) An example of a calcium channel blocker that has been used to stop preterm labor is nifedipine.

Studies have shown that nifedipine can postpone delivery by 3 days­a greater delay than that seen with ritodrine. Maternal side effects are less than with ritodrine. The effect of this drug on the fetus, however, has not been studied extensively. Because it relaxes the muscles in blood vessels, it could lead to decreased blood pressure in the mother. This, in turn, could lead to decreased blood flow to the placenta. The extent to which this occurs warrants further study.

Nifedipine should not be used with magnesium sulfate as it enhances the effect of magnesium, leading to serious lung and heart problems. Women with liver disease cannot use nifedipine.

Oxytocin Inhibitors. Atosiban is a type of drug currently under development. It works by inhibiting oxytocin, a chemical responsible for uterine contractions. Its use has been limited but it may prove to be beneficial in the future.

The search for safer and more predictable drugs continues. It is difficult to slow down or speed up the uterus without affecting other body systems. The best drug would be one that limits its effects to the uterine muscle. Such a substance has not been identified.

Treatment of Premature Rupture of the Membranes

Premature rupture of the membranes(PROM) occurs as an uncontrollable gush or leakage of fluid. By definition, PROM is rupture of the membrane that occurs more than 12 hours before the onset of labor. If this occurs before 37 weeks gestation, it may be called preterm premature rupture o/the membranes(PPROM).

In the past, due to concern that prolonged rupture of membranes would lead to maternal and fetal infection, babies were all delivered shortly after rupture, regardless of gestational age. Research has not shown this to be beneficial to mother or baby.

Today, one of two care paths generally is followed when a woman has PPROM without labor:

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Nothing is done except to wait for labor with monitoring of maternal temperature and avoidance of all vaginal examinations.
2. Corticosteroid therapy is initiated, with or without medications to try to stop labor.

Delivery is only induced in the presence of maternal fever, indicating infection. Most women with PPROM will be in labor, either immediately or within 2 days.

Women with ruptured membranes before 37 weeks usually are admitted to the hospital for observation. The woman may be discharged home before the baby is born if the leakage of fluid stops and certain other conditions exist. The baby should be in the vertex or head down position; there must be no sign of infection; the woman must be able to rest and avoid vaginal intercourse at home; the woman or somebody in her family must be able to read a thermometer; the woman must be able to return for prenatal care visits at least weekly. This is a decision to be made individually for each woman.

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Internal version is correctly termed internal podalic version(Greek: pous = foot) because the obstetrician inserts a hand into the uterus and grasps the fetus by one or both feet to turn the baby-usually from a transverse presentation into a footling breech. While the baby’s feet are grasped, the upper body is turned through the abdomen. The fetus is then delivered by breech extraction.

Internal version was used in antiquity, lost for intervening centuries, and reintroduced in 1550, prior to the development of forceps. At that time, if labor was obstructed, the only way to extract the baby without using hooks was pulling it out by its feet. Cesareans were not done because mothers were not expected to survive major surgery.

Internal version should be done only by those experienced in its performance. Nowadays, the indication for it is the extraction of a second twin, soon after the birth of the first child, when this twin is not in a breech or vertex presentation. If a second twin presents in a transverse lie, internal s version ordinarily is not difficult. The uterus is relaxed since the first twin has recently been delivered. Twins are usually smaller than other term babies and the foot or feet are readily grasped. The mother must be given appropriate anesthesia, but profound general anesthesia usually is not needed.

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