Guide to Pregnancy and its related disorders and complications. Tips for caring of your baby properly while in pregnancy and after pregnancy.

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.

All pregnancies are divided into three parts (by the medical profession) . Each part is a trimester - a period of three months, or more precisely, of 13 weeks. This division is useful because various events, signs, and developments tend to appear in different trimesters.
The First Trimester

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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A decision as to whether the mother wishes to breast feed the baby must be made on the first day after delivery. Realistically, the decision is motivated by factors such as her background, whether she would really enjoy it, and the opinions of her husband and mother. The fact that it might be beneficial for her does not often predominate.

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.

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).