Pregnancy and childbirth is the most important period in a woman’s life. In a menstrual cycle that is normal for a person and has the duration of 28 days the release of an egg called ovulation generally takes place in the range between the 12th and 14th days of the cycle. Egg must be fertilized in the fallopian tube not later than 24 hours after that, or it dies and dissolves.
Pregnancy on average lasts for 280 days if we count from the first day of the last menstrual period and 266 days from the time of ovulation. To calculate the due date, it is necessary to subtract 3 months from the date the last menstrual period started and add 7 days to it. However, most of the birth cases do not match the calculated date; deviation within two weeks either side of it is normal.
Pregnancy detection. Today there are many different affordable pregnancy tests available that are accurate and do not require a lot of time. They work by detecting hCG - human chorionic gonadotropin - a hormone which in the early stages of pregnancy is made in great amount by the placenta and available for detection in the urine of the mother (Zhang et al., 2010). Using commercially available kits based on this hormone cannot detect pregnancy earlier than after the 42th day from the last period. Still, it is better to wait until the 45-50-th day for the confirmation of pregnancy.
Since 12th week pregnancy can be verified by listening to the heart rate of fetus with Doppler sound detector. Ultrasound (using sound waves of high frequency and low energy) provides images of the placenta, fetus, and amniotic cavity, which is a very accurate method for confirmation of pregnancy. At week 16 the mother has a markedly enlarged abdomen and uterus is easily detectable. Over the following month the woman begins to feel fetal movement. At present, in all the drugstores there are diagnostic kits for determination of pregnancy, but the results obtained through them should be treated with caution, as they are not as good as the standard laboratory methods (Duncan & Bardacke, 2010).
Symptoms and signs of pregnancy. Many of them are usually manifested quite early, sometimes before a positive test result for pregnancy. However, some women begin to feel they are pregnant only after 3-4 months. Absence of menstruation, when previously it was regular, with very high probability indicates pregnancy. Apparently, one of the most common and early sign of pregnancy is fatigue. Apathy and lethargy can develop, periods of sleep lengthen, and there is a necessity for rest frequently felt by women, the state of mammary glands changes, many women experience morning sickness.
Physiological changes. When a woman is pregnant, the state of almost all her organs is changing. The size of the uterus is increasing very fast, its weight rising from about 70 to 1100 g (without fetus). Still, the number of muscle fibers of the uterus remains constant, they only stretch and swell. Increasing pressure of the uterus on bladder that is located nearby reduces its capacity and causes discomfort and the necessity to go to the toilet frequently. The gastrointestinal tract’s mobility that it naturally has is also reduced, which is often accompanied by heartburn and constipation. Breasts are being rebuilt so as a mother could brastfeed, and before labor there can be seen viscous turbid liquid (colostrum). Increased pigmentation of skin is manifested by darkening midline abdomen, face and nipples.
There are numerous changes in heart and the entire circulatory system. Heart rate, heart size, cardiac output and blood volume increase by around 50% from the baseline. Due to the increasing pressure of the uterus there may occur varicose veins in the vulva and legs, which sometimes causes serious concern.
Antenatal Period
It is perfect if the first visit to the doctor should take place in 1-1.5 months after detection of pregnancy. Within this period of time, one can most accurately determine its duration and identify any serious disease. In anticipation of pregnancy woman should accurately remember the date of her last period.
When a woman first visits a doctor, he should carefully collect her history, asking her of all medical history, operations, and pregnancies that she had before. Special attention is required to any existing illness and family problems such as diabetes, high blood pressure, and the presence of twins in the previous birth or congenital disorders that can affect the mother or baby. A complete examination has to be made, including pelvic, uterus size is assessed, comparing it to the one expected for the period calculated from the last period. Swab to detect cancer (Pap test) is taken and gonorrhea seeded (Zhang et al., 2010). The doctor should also determine the proportions and size of the female pelvis to assess the normal vaginal birth. If the duration of pregnancy is over 12 weeks, it is possible to try to determine the fetal heart using Doppler detector. From 20 weeks it becomes possible to listen to the heartbeat using fetoscope.
Urine and blood tests. Besides the described examination, samples of urine and blood are taken. The number of red blood cells is determined, as well as blood group, Rh factor, serological tests for syphilis (Wassermann) are taken and other serological tests, including the one to determine whether a woman was infected with rubella. Judged by the number of red blood cells, it is determined whether a future mother suffers from anemia and whether she needs iron supplements. In the last three months of pregnancy the number of red blood cells is usually redefined. About 15% of women are Rh-negative and require additional repeated blood tests during pregnancy (Duncan & Bardacke, 2010).
Wassermann's test allows for revealing syphilitic infection in the present or past. It is necessary because in the absence of treatment agent of syphilis can infect the fetus through placenta. Rubella in the time of pregnancy is also among the few infections that have a damaging effect on the baby. Just around 10% of women of childbearing age have not previously suffered from rubella or been vaccinated against it. After birth, they should be vaccinated to prevent the possibility of infection during the next pregnancy.
Most women are recommended to limit weight gain during pregnancy to 11-16 kg. This extra weight is easily lost in labor, and in the next two to 3 months. Since the first morning sickness expectant mothers often develop strong appetite, which is why not to get excessive weight a diet is often required. In many cases, it is necessary to take iron and vitamins supplements. Physical activity and exercises should be encouraged to the extent that they do not cause discomfort, and a lot of mothers prefer swimming within the last months.
Some medications can be dangerous to the fetus and pregnant women should be warned about it. Before taking any medication, they must consult a doctor if it is necessary and whether the potential benefits are greater than the risks. Women should also stop smoking, consume excessive alcohol and take any other drugs.
Repeated visits to the doctor. Normally, that is in case of uncomplicated pregnancy, until 28 weeks it is required to see the doctor every month. Then pregnant women should increase the frequency of visits, bringing in the last period to weekly. In the time of every visit, the woman has her blood pressure, as well as body weight determined, they do a urine test for sugar and protein, doctor listens to the heart rate of the fetus using fetoscope and the uterus size is recorded. Usually enlarged uterus starts being palpable through the abdominal wall at 12 to 14 weeks, on the 20th it reaches the umbilicus level, and at the end of pregnancy it is palpable beneath the breastbone. In the middle of the pregnancy the expecting mother is recommended to begin visiting the special sessions, and at the end - to prepare for the baby and watch for signs of impending birth (Morris & McInerney, 2010).
Labor
What triggers the process of birth is still unknown in full details. Most probably, the signal comes from the pituitary glands and adrenal of baby, but there may be important factors in the mother's body as well. Premature birth may be associated with disorders of the cervix and uterus, and with some types of infection in the mother.
The process of childbirth is subdivided in 3 periods. The first starts with labor onset and terminates with full cervical dilatation and cervix effacement. Beginning of the delivery is considered the time when the force and frequency of contractions can smooth and dilate the cervix. At the beginning of the initial period contractions can be irregular and of varying strength. But later they get more constant, taking place with 2-3 minute intervals continuing up to 45-60 seconds. The first labor is usually the longest (Zhang et al., 2010).
The second period begins with the full cervical dilatation and terminates with the birth of the child. Like the first, the second period at first birth is longer and on average takes 50 minutes; in subsequent labor it gets shorter to an average of 20 minutes. Uterine contractions retain the same strength and frequency, that was in the initial period, but the mother has to make extra efforts to expel the fetus.
The last stage starts with birth and terminates with placenta separation. On average, it takes 2 to 4 additional uterine contractions after birth. Then within a few minutes afterwards the uterus gets on rhythmically contracting, but with lower strength and frequency, which accelerates the subsequent restoration of its former size.
A few weeks before labor start a woman can observe some changes. Sometimes the frequency of the so-called false contractions increases. In contrast to the real contractions, these ones are short, irregular, less powerful and easier to carry. It is often possible to reduce discomfort by taking a warm bath or walking.
Often, two weeks before labor a woman is feeling a relief and the shape of the abdomen is changing. Most often this is due to the lowering of the fetal head in the pelvic cavity of the mother. Pressure on the pelvic organs can be increased as a result, including the bladder, but the pressure to the diaphragm decreases, and it becomes easier for the woman to breathe. Another, later symptom of approaching childbirth is mucous or bloody discharge from the cervix at an early stage of its dilatation. If it is not provoked by vaginal examination, it is pretty reliable for detecting the start of labor in several days or hours.
Start of labor. Uterine contractions in the early stage of labor are difficult to differentiate from the false ones, but in labor they are much heavier. Contractions first go at intervals of 5-20 minutes, and then become more frequent. When they occur each ten minutes, and their strength is growing, it is necessary to send women to the maternity hospital (Morris & McInerney, 2010).
Here a woman is placed in a prenatal office, where women’s history is collected; blood pressure and weight are measured. The cervix dilatation and the extent of the fetal head descent into the pelvic cavity of the mother are assessed. At the beginning of labor, a woman may continue to sit in a chair or walk, although in the future it is generally better to stay bed. Blood pressure is measured regularly the heart rate of fetus is checked. As the process is progressing, doctors check the condition of the cervix. If this is the first birth, the doctor and the midwife should teach a woman how to breathe and relax properly.
Anesthesia. In case women want it, doctors can consider applying a particular method of anesthesia. If labor process is good, it is acceptable to introduce limited doses of opioids. Another common way of pain relief in labor is injection of local anesthetics, including Novocaine. Novocaine blockade of the cervix and perineum at the late stage of labor relieves the vagina and cervix. Such a method provides a local, i.e. more localized, effect of anesthesia and is associated with less overall impact on the body when compared to the drug. The third commonly used method of anesthesia is introduction of anesthetics into spinal cord membranes. There are variants of this method (spinal, epidural or caudal block), but they all almost completely relieve pain during labor without altering its normal flow.
After full dilatation of the cervix woman should assist expulsion of the fetus by straining the muscles of the abdomen (pushing) simultaneously with contractions of the uterus. If this is the first birth, the doctor and the midwife can provide significant assistance to her (Marcus, 2009).
Delivery. In the maternity ward, as in the operating room, there is all that is necessary not only for labor, but also for emergency aid to newborn. The doctor is involved in the process, helping the passage of the shoulders and head of the child through the birth canal. To speed up delivery and prevent ruptures of soft tissue of the pelvis episiotomy is done (short incision of the perineum). After birth, it is sutured carefully by absorbable suture material.
At birth lungs of the baby are straightened, mucus and blood is sucked out of mouth and nose of the newborn. The umbilical cord is pinched and cut, and the woman is given to hold the baby. In the first minutes newborn is wiped and inspected to detect any deviation from the norm, requiring urgent remedial measures. On the first and fifth minute the child is evaluated by a scale developed by Virginia Apgar. This scale allows doctors to assess the condition of the newborn on a scale from 1 to 10 taking into account the color of skin, heart rate, muscle activity and volume of cry. A child, who received low score by the Apgar, is often in need of additional assistance right after birth, is in the high-risk group regarding further development.
Usually after 2-4 uterine contractions following the birth of a child placenta goes out. Then the woman is being watched for some time and then transferred to a ward, where she remains until discharge.
Complications
Complications arising in the course of pregnancy are usually associated with both already existing diseases in women, and with the pregnancy. Early complications can lead to miscarriage (spontaneous abortion). About 15% of the known conception end in miscarriage, a careful study of aborted fetuses shows that over a half of them have certain irregularities. Another serious problem at the early stages of pregnancy is attachment of a fertilized egg not to the uterus, but to the wall of the fallopian tube. This ectopic or tubal pregnancy takes place in about 1 in 200 cases of pregnancy and often requires prompt surgical removal of tube to prevent bleeding and rupture.
Premature birth. In the middle of pregnancy complications are rare, but closer to its end, their frequency increases. The main danger in the last trimester is premature labor; it is observed in about one out of 20 cases, and is the main cause of death in newborns. Currently, there are no reliable methods for inhibiting preterm labor, but a number of drugs brings some advantages and is often used (Marcus, 2009).
Toxemia is a pathological condition, known only from pregnancy. Developing closer to its completion or during delivery, its main features are appearance of protein in the urine, high blood pressure, and edema of feet, hands, and face. In case it is left untreated, severe consequences for the woman and newborn are possible. Toxemia is more common in first pregnancies, with multiple pregnancies, as well as the presence in the mother of diabetes or hypertension.
Labor induction. In case of severe toxemia often it is necessary to resort to artificial induction of labor. This can be achieved by intravenous administration of synthetic oxytocin (the hormone of the pituitary gland). In the past, the stimulation of labor often used to speed up the process, but then it was found that this approach presents some danger, and now it is used much less frequently. The need for artificial induction of labor does not occur only in toxemia, but also in case of other deficiencies. These involve rupture of membranes before labor process, post-term pregnancy, and Rh factor.
References
Duncan, L.G., & Bardacke, N. (2010). Mindfulness-Based Childbirth and Parenting Education: Promoting Family Mindfulness During the Perinatal Period. Journal of Child and Family Studies, 19(2), 190-202.
Marcus, S.M. (2009). Depression during pregnancy: rates, risks and consequences--Motherisk Update 2008. Can J Clin Pharmacol, 16(1), 15-22.
Morris, T., & McInerney, K. (2010). Media Representations of Pregnancy and Childbirth: An Analysis of Reality Television Programs in the United States. Birth, 37(2), 134–140.
Zhang, J., Troendle, J., Mikolajczyk, R., Sundaram, R., Beaver, J., & Fraser, W. (2010). The Natural History of the Normal First Stage of Labor. Obstetrics & Gynecology, 115(4), 705-710.
