Antepartum

ANTEPARTUM (PREGNANCY) Preparation for Labor and Delivery

How Labor is induced? • Your due date came and went a week and a half ago. Your telephone rings constantly and every time you answer it, a friend or relative exclaims, "You're still home!" These last few days seem longer than the previous nine months. Your practitioner told you at this week's appointment that if you haven't gone into labor by next week, you will need to be admitted to the hospital so labor can be induced. Emotionally, you're relieved to have an end to the waiting in sight, but you wonder whether inducing labor is necessary

Because no one really understands how normal labor starts, we are at a loss to explain why some labors don't start until weeks after the due date. This would not be of concern, except that after nine months of pregnancy have passed, the placenta often fails to keep up with the growing oxygen and nutritional needs of the overdue baby. In fact, the mortality rate of babies born after 43 weeks is double that of those born on time. After 44 weeks, the mortality rate is triple the normal rate. That is why most practitioners are extremely reluctant to allow pregnancies to continue much past 42

Antepartum testing determines which babies are at highest risk for difficulties before and during labor. Most practitioners routinely recommend such testing after 41 weeks. It includes a non-stress test and a biophysical profile performed during an ultrasound exam. If this testing reveals abnormalities, induction of labor is recommended. Even if the test results are normal, induction is recommended at 42 weeks. How is labor induced? There are a variety of methods, used alone or in combination, which can induce labor. If the cervix is more than slightly dilated, the simplest way is to rupture the membranes artificially. Most women will go

• There are a number of disadvantages to using this method alone, however. First, not all women will go into labor. Second, as soon as the membranes are ruptured, the potential exists for chorioamnionitis, infection of the membranes and amniotic fluid. This type of infection affects the mother as well as the baby. The risk of infection increases over time. There is not much chance for infection to occur if the labor is well along and the delivery will happen within the next few hours. However, if labor has not even started, the delivery may not take place for 24 hours or more, which significantly raises the possibility of infection. Chorioamnionitis can be treated with

The second method of inducing labor is the use of Prostaglandin gel. This technique became available only a few years ago, but it has become popular very quickly. Prostaglandin gel contains one type of the hormone prostaglandin, which naturally causes the cervix to soften and thin out in preparation for labor. Prostaglandin gel may even stimulate mild contractions and, for some women, this is enough to start labor. Prostaglandin gel is applied directly to the cervix during a cervical exam. Because of its potential to cause contractions, it is usually applied in the hospital setting and the baby is monitored for several hours thereafter. If no

Prostaglandin gel may stimulate labor alone, but more commonly it is used in conjunction with Pitocin. Pitocin is the synthetic version of the naturally occurring hormone oxytocin, which causes uterine contractions. The advantage of giving prostaglandin gel first is that the cervix tends to become thinner and even slightly dilated after the gel is applied, making the Pitocin more likely to be effective at smaller doses. Pitocin is administered initially in minute quantities, and the amount is

The fetus is monitored during administration of Pitocin to make sure that the amount given does not cause the baby stress or contractions that are too frequent. If labor has not started within 12 to 24 hours after application of prostaglandin gel, the mother is readmitted to hospital to receive Pitocin through an intravenous line.

Are there disadvantages to Pitocin? Some practitioners believe that Pitocin causes stronger contractions than those that occur naturally. Most research suggests, however, that Pitocin-induced contractions are very similar to those of normal active labor. The potential does exist to cause contractions that are more frequent than naturally occurring contractions and, therefore, these contractions may be more stressful for the baby. That's why careful monitoring is essential during administration of Pitocin. It is easy to decrease the frequency of contractions just by lowering the dose of

The disadvantages must be weighed against the risks, of course. It would be inappropriate to induce labor just to have the delivery occur on a convenient date. The use of Pitocin for induction is justified only if the baby is at significant risk for serious problems, either because an abnormality has been found on antepartum testing, or because the

• There are other, less common reasons for inducing labor. These include preeclampsia, gestational diabetes (but not before 38 weeks), and intrauterine growth retardation (IUGR) if the fetus is in less than the 10th percentile for gestational age. In the case of preeclampsia, induction is performed to treat the mother. In the case of

Instructions

Step 1: • comfortable birthing clothes (if your caregiver isn't already providing you one.) • clothes to change into for after the birth . • snacks (if your caregiver will allow you to bring some) • relaxing music- mp3/cd player • books/magazines • massage lotions, oils (try Aveda's Blue Oil it's my favorite) • Nursing bra

Step 2: • Pads for bleeding • Toothbrush, hair brush, shampoo, conditioner, etc. • Numbers of relatives to call • Camera/video camera • Newborn diapers • Burp cloths • Baby blankets • Baby new born hat

Step 3: • Newborn onesies- baby's coming home outfit • Car seat • And anything else that would make you feel comfortable! If you are delivery your baby in a hospital and have specific request about how you would like your delivery to 'run' make sure to create a detailed 'birthing plan' that you can give to your doctor and nurses to follow. Many mothers have specific requests that may not be met that make a birthing plan necessary for a happy, successful experience delivering

LOCAL AND SYSTEMIC PHYSIOLOGICAL, PSYCHOLOGICAL, AND

Hormonal Changes • Levels of progesterone and oestrogens rise continually throughout pregnancy, suppressing the hypothalamic axis and subsequently the menstrual cycle. The woman and the placenta also produce many hormones. Prolactin levels increase due to maternal Pituitary gland enlargement by 50%. This mediates a change in the structure of the Mammary gland from ductal to lobular-alveolar. Parathyroid hormone is increased due to increases of calcium uptake in the gut and reabsorption by the kidney. Adrenal hormones such as cortisol and aldosterone also increase. Placental lactogen is produced by the placenta and stimulates lipolysis and fatty acid metabolism

Musculoskeletal changes • The body's posture changes as the pregnancy progresses. The pelvis tilts and the back arches to help keep balance. Poor posture occurs naturally from the stretching of the woman's abdominal muscles as the fetus grows. These muscles are less able to contract and keep the lower back in proper alignment. The pregnant woman has a different pattern of gait. The step lengthens as the pregnancy progresses, due to weight gain and changes in posture. On average, a woman's foot can grow by a half size or more during pregnancy. In addition, the increased body weight of pregnancy, fluid retention, and weight gain lowers the arches of the foot, further adding to the foot's length and width. The influences of increased hormones such

Physical Changes • One of the most noticeable alterations in pregnancy is the gain in weight. The enlarging uterus, the growing fetus, the placenta and liquor amnii, the acquisition of fat and water retention, all contribute to this increase in weight. The weight gain varies from person to person and can be anywhere from 5 pounds (2.3 kg) to over 100 pounds (45 kg). In America , the doctor-recommended weight gain range is 25 pounds (11 kg) to 35 pounds (16 kg), less if the woman is overweight, more (up to 40 pounds (18 kg)) if the woman is underweight Other physical changes during pregnancy include breasts increasing two cup sizes. Also areas of the body such as the forehead and cheeks (known as the 'mask of pregnancy') become darker due to the increase of melanin being produced.The female body experiences many changes as the fetus grows through each trimester as shown and discussed in this pregnancy video. Two women at different stages in their pregnancy illustrate what

Cardiovascular Changes • Blood volume increases by 40% in the first two trimesters. This is due to an increase in plasma volume through increased aldosterone. Progesterone may also interact with the aldosterone receptor, thus leading to increased levels. Red blood cell numbers increase due to increased erythropoietin levels.. Cardiac function is also modified, with increase heart rate and increased stroke volume. A decrease in vagal tone and increase in sympathetic tone is the cause. Blood volume increases act to increase stroke volume of the heart via Starling's law. After pregnancy the change in stroke volume is not reversed. Cardiac output rises from 4 to 7 liters in the 2nd trimester. Blood pressure also fluctuates. In the first trimester it falls. Initially this is due to decreased sensitivity to angiotensin and vasodilation provoked by increased blood volume. Later, however, it is caused by

Respiratory Changes • Decreased functional residual capacity is seen, typically falling from 1.7 to 1.35 litres, due to the compression of the diaphragm by the uterus. Tidal volume increases, from 0.45 to 0.65 litres, giving an increase in pulmonary ventilation. This is necessary to meet the increased oxygen requirement of the body, which reaches 50ml/min, 20ml of which goes to reproductive tissues. Progesterone may act centrally on chemoreceptors to reset the set point to a lower partial pressure of carbon dioxide. This maintains an increased respiration rate even at a decreased level of carbon dioxide.

Metabolic Changes • An increased requirement for nutrients is given by fetal growth and fat deposition. Changes are caused by steroid hormones, lactogen, and cortisol. Maternal insulin resistance can lead to gestational diabetes. Increase liver metabolism is also seen, with increased gluconeogenesis to increase maternal glucose levels.

Renal Changes • Renal plasma flow increases, as does aldosterone and erthropoietin production as discussed. The tubular maximum for glucose is reduced, which may precipitate gestational diabetes.

NEEDS OF PREGNANT WOMEN AND MINOR

• Now that you're pregnant, taking care of yourself has never been more important. Of course, you'll probably get advice from everyone — your doctor, family members, friends, coworkers, and even complete strangers — about what you should and shouldn't be doing. But staying healthy during pregnancy depends on you, so it's crucial to arm yourself with information about the many ways to keep you and

• Back pain - A particularly common complaint in the third trimester when the patient's center of gravity has shifted. • Constipation - A complaint that is caused by decreased bowel motility secondary to elevated progesterone (normal in pregnancy), which can lead to greater absorption of water.

• Braxton Hicks Contractions Occasional, irregular, and often painless contractions that occur several times per day. • Edema (swelling) Common complaint in advancing pregnancy. Caused by compression of the inferior vena cava (IVC) and pelvic veins by the uterus leads to increased hydrostatic pressure in

• Regurgitation, heartburn, and nausea - Common complaints that may be caused by Gastroesophageal Reflux Disease (GERD); this is determined by relaxation of the lower esophageal sphincter (LES) and increased transit time in the stomach (normal in pregnancy), as well as by increased intraabdominal pressure,

• Hemorrhoids - Complaint that is often noted in advancing pregnancy. Caused by increased venous stasis and IVC compression leading to congestion in venous system, along with increased abdominal pressure secondary to the pregnant spaceoccupying uterus and constipation.

• Pelvic girdle pain - PGP disorder is complex and multi-factorial and likely to be represented by a series of subgroups with different underlying pain drivers from peripheral or central nervous system, altered laxity/stiffness of muscles, laxity to injury of tendinous/ligamentous structures to ‘mal-adaptive’ body mechanics. Musculo-Skeletal Mechanics involved in gait and weightbearing activities can be mild to grossly impaired. PGP can begin peri or postpartum. There is pain,

• Increased urinary frequency - A common complaint referred by the gravida, caused by increased intravascular volume, elevated GFR (glomerular filtration rate), and compression of the bladder by the expanding uterus. • Varicose veins - Common complaint caused by relaxation of the venous smooth muscle and increased

TERATOGENS AND THEIR EFFECTS/ DANGER SIGNS

What is a Teratogen? • A teratogen is an agent, which can cause a birth defect. It is usually something in the environment that the mother may be exposed to during her pregnancy. It could be a prescribed medication, a street drug, alcohol use, or a disease present in the mother which could increase the chance for the baby to be born with a birth defect.

What are the sensitive periods

most for

• Once the egg is fertilized (conception), it takes about six to nine days for implantation (anchoring into the uterus) to occur. Once the fertilized egg is connected to the uterus, a common blood supply exists between the mother and the embryo. In other words, if something is in the mother's blood, it can now cross over to the developing fetus. Teratogens are thought to have the

During the development of a baby, there are certain organs forming at certain times. If a teratogen has the potential to interfere with the closure of the neural tube, for example, the exposure to the teratogen must occur in the first 3.5 to 4.5 weeks of the pregnancy, since this is when the neural tube is closing. There are some organ systems that are sensitive to teratogens throughout the entire

The central nervous system is the baby's brain and spine. One teratogen that affects the central nervous system is alcohol. Alcohol, at any time during the pregnancy, has the potential to cause birth defects and health problems in the baby, since the central nervous system is sensitive to teratogens the entire nine months of gestation. This is why alcohol consumption should be

HEALTH TEACHING FOR THE PREGANT WOMEN

Nutrition • A balanced, nutritious diet is an important aspect of a healthy pregnancy. Eating a healthy diet, balancing carbohydrates, fat, and proteins, and eating a variety of fruits and vegetables, usually ensures good nutrition. Those whose diets are affected by health issues, religious requirements, or ethical beliefs may choose to consult a

• Adequate periconceptional folic acid (also called folate or Vitamin B9) intake has been proven to limit fetal neural tube defects, preventing spina bifida, a very serious birth defect. The neural tube develops during the first 28 days of pregnancy, explaining the necessity to guarantee adequate periconceptional folate intake. Folates (from folia, leaf) are abundant in spinach (fresh, frozen, or canned), and are also found in green vegetables, salads, citrus fruit and melon, chickpeas (i.e. in the form of hummus or falafel), and eggs. In the United States and Canada , most wheat

• DHA omega-3 is a major structural fatty acid in the brain and retina, and is naturally found in breast milk. It is important for a mother to consume adequate amounts of DHA during pregnancy and while nursing to support her well-being and the health of her infant. Developing infants cannot produce DHA efficiently, and must receive this vital nutrient from the mother through the placenta

• Several micronutrients are important for the health of the developing fetus, especially in areas of the world where insufficient nutrition is prevalent. In developed areas, such as Western Europe and the United States, certain nutrients such as Vitamin D and calcium, required for bone development, may require supplementation.

• Dangerous bacteria or parasites may contaminate foods, particularly listeria and toxoplasma, toxoplasmosis agent. Careful washing of fruits and raw vegetables may remove these pathogens, as may thoroughly cooking leftovers, meat, or processed meat. Soft cheeses may contain listeria; if milk is raw the risk may increase. Cat feces pose a particular risk of toxoplasmosis.. Pregnant women are also more prone to catching salmonella infections from eggs and poultry, which should be thoroughly cooked. Practicing

Exercises

• Move daily - Mommies-to-be can engage in most exercises with few worries. Once your doctor gives you the green light, move as much as you can. The American College of Obstetrics and Gynecology recommends 30 minutes or more of moderate-intensity activity each day. • Warm up to fitness - Warming up muscles and joints prepares your body for exercise and prevents strains and injuries. Begin your workout with a few

• Keep it fresh - Stay psyched for fitness by linking exercise with a fun pastime. Walking is one of the best cardiovascular exercises for pregnant women since it's easy on joints and muscles. Swimming also is ideal because it provides a total-body workout and the weightless effect of the water makes it easier to move with extra pounds. Yoga and stretching maintain muscle tone and flexibility and lull your body into a state of relaxation, while dancing and low-impact aerobics

• Exercise caution - Avoid any activities that could make you slip or fall, risking injury to your abdomen. No bicycling, roller-blading, horse-back riding, break dancing or contact sports like football and basketball. After your first trimester, avoid lying on your back to exercise, which can make you dizzy. Drink plenty of water before, during and after your workout to avoid dehydration and skip outdoor activities in hot and humid weather, otherwise you risk overheating and harming the baby.

• Go for gain without pain - Ideal exercise gets you in shape without putting excessive stress on you or your baby, so don't push yourself to the limit. If you can't comfortably carry on a conversation, slow down and ease up. If you experience pain, dizziness, shortness of breath, severe headache, vaginal bleeding or contractions during your workout,

Schedule of Clinic Visit

Visit Schedule • 6 weeks = First diagnosed pregnancy. First visit in clinic to discuss: = optional blood tests / confirmation = urine tests are accurate IF showing positive (not very useful in negative) • ~ 8 weeks = Prenatal visit #1 = Prenatal physical and Antenatal form (paperwork) completion. • ~ 10 weeks = Prenatal visit #2 = Screening for genetic / birth defects discussion = generally the Integrated Prenatal Screen (IPS) is recommended; for certain populations (age, family history) an amniocentesis would be offered.

• Second Trimester (14 to 28 weeks) For most women, this trimester consists of simple visits to the doctor every 4 weeks or so. We should be able to detect a fetal heart rate in office starting approximately 14-16 weeks and we welcome your spouse to attend if they wish to listen. Around 19 weeks is when the “quickening” happens which is when you begin to notice fetal

Visit Schedule • ~ 14 weeks = Prenatal visit # 3 = the last time dependent visit, here we order your next stage of IPS#2 which must be done between 15-17.5 weeks. = we also generally order the 2nd trimester ultrasound (not part of IPS) . • (15-17.5 weeks) = IPS#2 bloodwork (18-21 weeks) = 2nd trimester ultrasound • ~ every 4 weeks = Prenatal Visits = (18, 22, 26 weeks approximately)

• Also, as soon as possible in the 2nd trimester, we would like to get you set up to see the obstetrician. For routine prenatal care in our region (where there are only 9 obstetricians); they specialists will take over at approximately 24-28 weeks (end of 2nd trimester). In fact, for patients without a family physician, there is a special walk-in clinic for obstetrical care only based out of the hospital. • Third Trimester (28+ weeks) Visits will generally be taken over by the obstetrician. Expect to attend visits every 2 weeks until the last month when visits are on a weekly basis. It gets busy. Even busier when the baby arrives.

Immunizations

Live • Measles Contraindicated No known fetal effects, but theoretical increased risk of preterm labour and low birthweight with live vaccine. • Mumps Contraindicated • Rubella Contraindicated • Varicella Contraindicated No known fetal effects. Not reason for termination.

• Varicella zoster immunoglobulin to be considered if pregnant woman exposed to virus . • Poliomyelitis Sabin/ Salk To be considered in high-risk situations . • Consider if pregnant woman needs immediate protection (high-risk situation/travel) No known fetal effects .

• Yellow fever generally contraindicated unless high-risk situation. • No data on fetal safety, although fetuses exposed have not demonstrated complications. • If travel to high-risk endemic area unavoidable, suggest vaccination • Influenza Indicated in pregnancy, primarily for protection at 20 weeks

• No adverse effects in over 2000 fetuses exposed • Influenza may be associated with greater morbidity in pregnancy, so immunization recommended. • Rabies No indication of fetal anomalies . • Risks from inadequate treatment significant • Pregnancy not contraindication to postexposure prophylaxis • Vaccinia Contraindicated Has been

Non-Live • Hepatitis A Low theoretical risk Appropriate in the presence of medical indication • Hepatitis B No apparent fetal risk Vaccine recommended for pregnant women at risk • Pneumococcus Indicated in high-risk patients. • No safety data available, but no adverse effects reported; high-risk patients should therefore be vaccinated

• Vaccine to be administered using same guidelines as for non-pregnant patients. • Cholera No data on safety To be used if high-risk situation only (e.g., outbreak) • Plague No data on safety Vaccination to be considered only if benefits outweigh risk

• Some preparations are live • No data on safety To be considered only in high-risk cases (e.g., travel to endemic areas) • Diphtheria/tetanus No evidence of teratogenicity. • Susceptible women to be vaccinated as per general guidelines for nonpregnant patients.

• Japanese encephalitis (inactivated Japanese encephalitis vaccine). • No data on safety Not to be given routinely in pregnancy, as theoretical risk exists . • Consider only if travel where risk exposure is high (benefit risk).

The Complete All Around Travel

Preparation • Talk to your doctor about your travel plans, you may need your prenatal chart and a reference to a doctor at your destination. • Make sure your travel insurance covers your pregnancy. This may mean paying extra premiums.

• Take plenty of water and sick bags for the journey. If travelling by car, make sure there are plenty of regular stops at services so you can stretch your legs and visit the bathroom. If travelling by plane book a seat near the middle of the plane over the wing for a smooth ride and pick out an aisle seat to ensure you can easily get up and walk about.

  • If travelling by plane check with the airlines beforehand to make sure you will be able to fly both on the way there and on the way back. Most airlines refuse boarding for anyone over 35 weeks pregnant if not before. This can also be true of ferries.

On The Journey • Drink plenty of fluids to stay hydrated during your trip and make sure you can visit the bathroom regularly. • Make sure you can get up and move around freely during your journey. If not make sure there are plenty of regular stops along the way so you can get out and move around.  While sitting down, rotate your ankles and wiggle your toes.

• Avoid heavy meals, greasy food and caffeinated beverages. Eat light snacks like fruit to settle your stomach.

On Holiday • Make sure you have your referred doctor’s contact details, your insurance policy, your prenatal chart and your EH1C card with you (If you are a UK resident) at all times. • Carry an emergency contact list with you at all times so people know who to call if anything happens.

• Either get a list of local hospitals from the tourist information centre or, if you have a doctor assigned to you, make sure you have an address to go to in an emergency. •  Wear a very high sunscreen factor and avoid staying in the sun for too long.

• Avoid insect repellents containing DEET, try natural alternatives instead. • Do not engage in diving, water sports or other such activities.

Safety Concerns • It is perfectly safe to wear your seat belt whilst pregnant and studies have shown it to be much more beneficial considering the risks involved. Tuck the lap belt under your stomach with the shoulder strap over your bump. • Car airbags are perfectly safe so don’t disable them. You may want to move back a little from the dashboard though to make room for your bump.

• You cannot get radiation poisoning from plane travel in any way. Metal detectors do not use x-rays and are perfectly harmless for you and your baby. Luggage scanners are focused so you can’t be exposed to any radiation by standing near them, you would have to put your hand directly inside the machine to become exposed. Finally, cosmic radiation exposure during flight is minimal and perfectly safe; you can even travel by plane up to 200 hours during the length of your pregnancy.

Sexual Relations

• Most pregnant women can enjoy sexual intercourse throughout gravidity. Most research suggests that, during pregnancy, both sexual desire and frequency of sexual relations decrease. In context of this overall decrease in desire, some studies indicate a secondtrimester increase, preceding a decrease. However, these decreases are not universal: a significant number of women report greater sexual

Sex during pregnancy is a low-risk behaviour except when the physician advises that sexual intercourse be avoided, because it may, in some pregnancies, lead to serious pregnancy complications or health issues such as a high-risk for premature labour or a ruptured uterus. Such a decision may be based upon a history of difficulties in

Some psychological research studies in the 1980s and '90s contend that it is useful for pregnant women to continue to have sexual activity, specifically noting that overall sexual satisfaction was correlated with feeling happy about being pregnant, feeling more attractive in late pregnancy than before pregnancy and experiencing orgasm. Sexual activity has also been suggested as a way to prepare for induced labour; some believe the natural prostaglandin content of seminal liquid can favour the maturation process of the cervix making it more flexible, allowing for easier and faster dilation and effacement of the cervix. However, the efficacy of using sexual intercourse as an

During pregnancy, the fetus is protected from penetrative thrusting by the amniotic fluid in the womb and by the woman's cervix. After giving birth sexual intercourse can begin when the couple are both ready. However most couples wait until after six weeks and they should consult their GP if they have any concerns.  

Stages of fetal development

• The baby goes through a lot of changes over the course of her nine months inside your uterus. Here is a brief look at just some of the fetal development changes that occur over those many months. Click on the links in each heading to see color photos of how the baby grows and develops.

FIRST TRIMESTER Week 2 • Although this is considered to be the second week of your pregnancy, you are not actually 2 weeks pregnant yet. During this week, your body will release an egg. As it travels down the fallopian tube, it will be met by your partner's sperm and fertilization will take place. The fertilized egg, now known as a zygote, will then continue traveling down the fallopian tubes finally reaching the uterus three to four days

Week 4 • By the time you are four weeks pregnant, the fertilized egg will have implanted itself into your uterine lining. At this point, the zygote is now known as an embryo. After implantation, the embryo begins to divide itself into two: one part of it will develop into the placenta while the other will go on to become your baby.

Week 6 • During the sixth week of your pregnancy, your baby's heart will begin to beat and blood will start to circulate throughout his body. His umbilical cord will also start to form, as will his head, eyes, intestines and liver.

Week 10 • This week marks the end of the embryonic stage of development. For the rest of your pregnancy, your baby will be known as a fetus. Your baby's external genitalia begin to form this week while her facial features as well as limbs become more apparent. By the end of the week, your baby's vital organs will not only be formed but will

SECOND TRIMESTER Week 14 • Now that you are 14 weeks pregnant, you have officially started your second trimester. The risk of miscarriage is significantly decreased at this point. In addition to your baby's reproductive organs developing, your baby will also begin to grow some hair as well as form eyelids, fingernails and toenails. You may even be able to feel your baby

Week 18 • By the time your are 18 weeks pregnant, your baby's finger and toe pads will have formed, which means the fingerprints won't be far behind. The bones in your baby's inner ear will have developed enough by this point that he may start responding to loud outside sounds. Additionally, your baby could weigh as much as 7 ounces now and

Week 22 • Your baby’s sense are so developed by the time you are 22 weeks pregnant that she is likely to starting experimenting. Don’t be surprised to if you see her sucking her thumb on an ultrasound. Your baby’s sweat glands also begin to develop this week while her brain begins to quicken its development.

THIRD TRIMESTER Week 26 • During this week, development of the retinas will finish and your baby’s eyes will begin to open and even blink. If your baby were born now, he would have a 50% chance of survival with proper medical care. This week also marks the end of your second trimester. Next week, when you are 27 weeks pregnant, you will officially be in your

Week 30 • As your baby begins practicing how to breathe this week, she may end up with a case of the hiccups if she swallows too much amniotic fluid. Your baby is also putting on more body fat, which will help keep her warm when she is born. Although your baby would be premature if she was born now, she would have a good chance of surviving.

Week 40 • This is the official end of the gestational period. Even though your baby is ready and able to live outside of you, it is perfectly normal for your baby to arrive as much as two weeks after his due date.

Menstrual cycle • The menstrual cycle is a cycle of physiological changes that occurs in fertile females. Overt menstruation (where there is blood flow from the vagina) occurs primarily in humans and close evolutionary relatives such as chimpanzees. Females of other species of placental mammal undergo estrous cycles, in which the endometrium is completely reabsorbed by the animal (covert menstruation) at the end of its

Menstruation • Menstruation is also called menstrual bleeding, menses, catamenia or a period. The flow of menses normally serves as a sign that a woman has not become pregnant. (However, this cannot be taken as certainty, as a number of factors can cause bleeding during pregnancy; some factors are specific to early pregnancy, and some can cause heavy flow.) During the reproductive years, failure to menstruate may provide the first indication to a woman that she may

• Eumenorrhea denotes normal, regular menstruation that lasts for a few days (usually 3 to 5 days, but anywhere from 2 to 7 days is considered normal). The average blood loss during menstruation is 35 milliliters with 10–80 ml considered normal. (Because of this blood loss, women are more susceptible to iron deficiency than are men.) An enzyme called plasmin inhibits clotting in the menstrual fluid. Cramping in the abdomen, back, or upper thighs is common during the first few days of menstruation. When menstruation begins, symptoms of premenstrual syndrome (PMS) such as breast tenderness and irritability generally decrease. Many sanitary products are

Follicular phase • This phase is also called the proliferative phase because a hormone causes the lining of the uterus to grow, or proliferate, during this time. • Through the influence of a rise in follicle stimulating hormone (FSH) during the first days of the cycle, a few ovarian follicles are stimulated. These follicles, which were present at birth and have been developing for the better part of a year in a process known as folliculogenesis, compete with each other for dominance. Under the influence of several hormones, all but one of these follicles will stop growing, while one dominant follicle in the ovary will continue to maturity. The follicle that reaches maturity is called a tertiary, or

• As they mature, the follicles secrete increasing amounts of estradiol, an estrogen. The estrogens initiate the formation of a new layer of endometrium in the uterus, histologically identified as the proliferative endometrium. The estrogen also stimulates crypts in the cervix to produce fertile cervical mucus, which may be noticed by

Ovulation • When the egg has nearly matured, the level of estradiol in the body has increased enough to trigger a sudden release of luteinizing hormone (LH) from the anterior pituitary gland. In the average cycle this LH surge starts around cycle day 12 and may last 48 hours. The release of LH matures the egg and weakens the wall of the follicle in the ovary, causing the fully developed follicle to release its secondary oocyte. The secondary oocyte promptly matures into an ootid and then becomes a mature ovum. The mature ovum has a diameter of about 0.2 mm. Which of the two ovaries—left or right—ovulates appears essentially random; no known left/right co-ordination exists. Occasionally, both ovaries

• After being released from the ovary, the egg is swept into the fallopian tube by the fimbria, which is a fringe of tissue at the end of each fallopian tube. After about a day, an unfertilized egg will disintegrate or dissolve in the fallopian tube. • Fertilization by a spermatozoon, when it occurs, usually takes place in the ampulla, the widest section of the fallopian tubes. A fertilized egg immediately begins the process of embryogenesis, or development. The developing embryo takes about three days to reach the uterus and another three days to implant into the endometrium. It has usually reached the blastocyst stage at the time of implantation.

Luteal phase • The luteal phase is also called the secretory phase. An important role is played by the corpus luteum, the solid body formed in an ovary after the egg has been released from the ovary into the fallopian tube. This body continues to grow for some time after ovulation and produces significant amounts of hormones, particularly progesterone. Progesterone plays a vital role in making the endometrium receptive to implantation of the blastocyst and supportive of the early pregnancy; it

• After ovulation, the pituitary hormones FSH and LH cause the remaining parts of the dominant follicle to transform into the corpus luteum, which produces progesterone and estrogens. The hormones produced by the corpus luteum also suppress production of the FSH and LH that the corpus luteum needs to maintain itself. Consequently, the level of FSH and LH fall quickly over time, and the corpus luteum subsequently atrophies. Falling levels of progesterone trigger menstruation and the beginning of the next cycle. From the time of ovulation until progesterone withdrawal has caused menstruation to begin, the process typically takes about two weeks, with ten to sixteen days considered normal. For an individual woman, the follicular phase often varies in length from cycle to cycle; by contrast, the length of her luteal phase will be fairly consistent from cycle to cycle. • The loss of the corpus luteum can be prevented by fertilization of the egg; the resulting embryo produces human chorionic gonadotropin (hCG), which is very similar to LH and which can preserve the corpus luteum. Because the hormone is unique to the

Leopold’s Maneuver • Leopold's Maneuvers are a common and systematic way to determine the position of a fetus inside the woman's uterus; they are named after the gynecologist Christian Gerhard Leopold. • The maneuvers consist of four distinct actions, each helping to determine the position of the fetus. The maneuvers are important because they help determine the position and presentation of the fetus, which in conjunction with correct assessment of the shape of the maternal pelvis can indicate whether the delivery is going to be complicated, or whether a Cesarean section is necessary. • The examiner's skill and practice in performing the maneuvers are the primary factor in whether the fetal lie is correctly ascertained, and so the maneuvers are not truly diagnostic. Actual position can only be determined by ultrasound performed by a competent

• Procedure in LM • The health care provider should first ensure that the woman has recently emptied her bladder. If she has not, she may need to have a straight urinary catheter inserted to empty it if she is unable to micturate herself. The woman should lie on her back with her shoulders raised slightly on a pillow and her knees drawn up a little. Her abdomen should be uncovered, and most women appreciate it if the

First maneuver • While facing the woman, palpate the woman's upper abdomen with both hands. A professional can often determine the size, consistency, shape, and mobility of the form that is felt. The fetal head is hard, firm, round, and moves independently of the trunk while the buttocks feel softer, are symmetric, and have small bony processes; unlike the

Second maneuver • After the upper abdomen has been palpated and the form that is found is identified, the individual performing the maneuver attempts to determine the location of the fetal back. Still facing the woman, the health care provider palpates the abdomen with gentle but also deep pressure using the palms of the hands. First the right hand remains steady on one side of the abdomen while the left hand explores the right side of the woman's uterus. This is then repeated using the opposite side and hands. The fetal back will feel firm and smooth while fetal extremities (arms, legs, etc.) should feel like small irregularities and protrusions. The fetal back, once determined, should connect

Third maneuver: Pawlick's Grip • In the third maneuver the health care provider attempts to determine what fetal part is lying above the inlet, or lower abdomen. The individual performing the maneuver first grasps the lower portion of the abdomen just above the symphysis pubis with the thumb and fingers of the right hand. This maneuver should yield the opposite information and validate the findings of the first maneauver. If the woman enters labor, this is the part which will most likely come first in a vaginal birth. If it is the head and is not actively engaged in the birthing process, it may be gently pushed back and forth. The Pawlick's Grip, although still used by some obstetricians, is not recommended as it is more uncomfortable for the woman. Instead, a two-handed approach is favored by placing the fingers of both hands laterally on either side of the presenting part.

Fourth maneuver • The last maneuver requires that the health care provider face the woman's feet, as he or she will attempt to locate the fetus' brow. The fingers of both hands are moved gently down the sides of the uterus toward the pubis. The side where there is the resistance to the descent of the fingers toward the pubis is greatest is where the brow is located. If the head of the fetus is well flexed, it should be on the opposite side from the fetal back. If the fetal head is extended though, the occiput is instead felt and is

Anatomy and Physiology The function of the external female reproductive structures (the genital) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include:

•Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the labia majora are covered with hair. •Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body). •Bartholin's glands: These glands are located next to the vaginal opening and produce a fluid (mucus) secretion. •Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect.

The internal reproductive organs include:

• Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal. • Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit. • Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones. • Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the

Benefits of Pregnancy Exercise • Exercising regularly is beneficial because it helps build your bones and muscles, increases your energy level, and keeps you healthy. Exercise during pregnancy has the added benefit of helping you look and feel your best at a time when you're experiencing many changes in your body. • Read the following information from the American College of Obstetricians and Gynecologists and learn how pregnancy affects your ability to exercise and how

The Benefits of Pregnancy Exercise Exercising and staying active during your pregnancy can help you with some of the symptoms of pregnancy like feeling tired and sluggish, and gaining too much weight. Exercise during pregnancy is beneficial because it: Reduces backaches, constipation, bloating, and swelling Increases energy and stamina Lifts your spirits and balances your mood Improves posture Helps build better muscle tone and strength Promotes better sleep Gives you a sense of control and self-confidence Provides you with time for yourself to do something for yourself • Gives you the opportunity to do some socializing. A • • • • • • • •

• In addition to keeping you fit and healthy now, regular activity during pregnancy also helps improve your ability to cope with the rigors of labor. And after baby is born, it is easier for you to get back in shape if you've been staying fit all along. While moderate and pregnancy-safe exercises are good for you, it's not advisable that you exercise for

Pregnancy Changes • Joints Due to pregnancy hormones, the ligaments that support your joints become more relaxed. Because of this added mobility in your joints, your risk of injury increases. For this reason, you should avoid bouncy, high-impact or jerky exercises. • Balance As your pregnancy progresses, the extra weight in your belly shifts your center of gravity and stresses your joints and muscles — particularly those in the pelvis and lower back. The result is greater instability, back pain, loss of balance, and increased risk of falling. • Heart Rate because your weight increases during pregnancy, your heart has to work harder. Exercise increases your

Diagnosis • the identification of the nature of anything, either by process of elimination or other analytical methods. Diagnosis is used in many different disciplines, with slightly different implementations on the application of logic and experience to determine the cause and effect relationships. Below are given as examples and tools used by the respective professions in medicine, science, engineering, business. Diagnosis also is used in many other trades and professions to determine the causes of symptoms, mitigations for problems, or solutions to

Health History

• The health history is a current collection of organized information unique to an individual. Relevant aspects of the history include biographical, demographic, physical, mental, emotional, sociocultural, sexual, and spiritual data.

Purpose • The health history aids both individuals and health care providers by supplying essential information that will assist with diagnosis, treatment decisions, and establishment of trust and rapport between lay persons and medical professionals. The information also helps determine an individual's baseline, or what is

Demographics • Every person should have a thorough health history recorded as a component of a periodic physical. These occur frequently (monthly at first) in infants and gradually reach a frequency of once per year for adolescents and adults.

Description • The clinical interview is the most common method for obtaining a health history. When a person or a designated representative can communicate effectively, the clinical interview is a valuable means for obtaining information. • The information that comprises the health history may be obtained from a person's previous records, the individual, or, in some cases, significant others or caretakers. The depth and length of the history-taking process is affected by factors such as the purpose of the visit, the urgency of the complaint or condition, the person's willingness or ability to contribute information, and the environment in which information is sought. When circumstances allow, a history may be holistic and comprehensive, but at times only a cursory review of the most pertinent facts is

Health histories can be organized in a variety of ways. Often an organization such as a hospital or clinic will provide a form, template, or computer database that serves as a guide and documentation tool for the history. Generally, the first aspect covered by the history is identifying data. Identifying or basic demographic data includes facts such as: • • • • • • •

name gender age date of birth occupation family structure or living arrangements source of referral

• Once the basic identifying data is collected, the history addresses the reason for the current visit in expanded detail. The reason for the visit is sometimes referred to as the chief complaint or the presenting complaint. Once the reason for the visit is established, additional data is solicited by asking for details that provide a more complete picture of the current clinical situation. For example, in the case of pain, aspects such as location, duration, intensity, precipitating factors, aggravating factors, relieving factors, and associated symptoms should be recorded. The full

• The review of systems is a useful method for gathering medical information in an orderly fashion. This review is a series of questions about the person's current and past medical experiences. It usually proceeds from general to specific information. A thorough record of relevant dates is important in determining relevance of past illnesses or events to the current

The names for categories in the review of systems may vary, but generally consists of variations on the following list: head, eyes, ears, nose, throat (HEENT) cardiovascular respiratory gastrointestinal genitourinary integumentary (skin) musculoskeletal, including joints endocrine nervous system, including both central and peripheral components • mental, including psychiatric issues • • • • • • • • •

Past and current medical history includes details on medicines taken by the person, as well as allergies, illness, hospitalizations, procedures, pregnancies, environmental factors such as exposure to chemicals, toxins, or carcinogens, and health maintenance habits such as breast or testicular self-examination or immunizations. An example of a series of questions might include the following: • How are your ears? • Are you having any trouble hearing? • Have you ever had any trouble with your ears or with your hearing? • If an individual indicates a history of auditory difficulties, this would prompt further questions about medicines, surgeries, procedures, or associated problems related to the current or past condition.

• In addition to identifying data, chief complaint, and review of systems, a comprehensive health history also includes factors such as a person's family and social life, family medical history, mental or emotional illnesses or stressors, detrimental or beneficial habits such as smoking or exercise, and aspects of culture, sexuality, and spirituality that are relevant to each individual. The clinicians also tailor their interviewing style to the age, culture, educational level, and attitudes of the

Diagnosis/Preparation • Because the information obtained from the interview is subjective, it is important that the interviewer assess the person's level of understanding, education, communication skills, potential biases, or other information that may affect accurate communication. Thorough training and practice in techniques of interviewing such as asking open-ended questions, listening effectively, and approaching sensitive topics such as substance abuse, chemical dependency, domestic violence, or sexual practices assists a clinician in obtaining the maximum amount of information without upsetting the person being questioned or disrupting the interview. The interview should be preceded by a review of the chart and an introduction by the clinician. The health care professional should explain the scope and purpose of the interview and provide privacy for the person being

Aftercare • Once a health history has been completed, the person being queried and the examiner should review the relevant findings. A health professional should discuss any recommendations for treatment or follow-up visits. Suggestions or special instructions should be put in writing. This is also an opportunity for persons to ask any remaining

Risks • There are virtually no risks associated with obtaining a health history. Only information is exchanged. The risk is potential embarrassment if confidential  details are inappropriately distributed. Occasionally, a useful piece of information or data may be overlooked. In a sense, complications may arise from the findings of a health history. These usually trigger further investigations or initiate treatment. They are usually far more beneficial than negative as they often begin a

Normal Results • Normal results of a health history correspond to the appearance and normal functioning of the body. Abnormal results of a health history include any findings that indicate the presence of a disorder, disease, or underlying condition.

Morbidity and Mortality Rates • Disease and disability are identified during the course of obtaining a health history. There are virtually no risks associated with the verbal exchange of information.

Alternatives • There are no alternatives that are as effective as obtaining a complete health history. The only real alternative is to skip the history. This allows disease and other pathologic or degenerative pro cesses to go undetected. In the long run, this is not conducive to optimal health.