3.5: Pregnancy and Childbirth

Complications of Pregnancy

Minor complications: There are a number of common side effects of pregnancy. Not everyone experiences all of these nor to the same degree. And although they are considered "minor" this is not to say that these problems are potentially very uncomfortable. These side effects include nausea (particularly during the first 3‐4 months of pregnancy as a result of higher levels of estrogen in the system), heartburn, gas, hemorrhoids, backache, leg cramps, insomnia, constipation, shortness of breath or varicose veins (as a result of carrying a heavy load on the abdomen). What is the cure? Delivery!

Major Complications: The following are some serious complications of pregnancy which can pose health risks to mother and child and that often require hospitalization. Ectopic pregnancy occurs when the zygote becomes attached to the fallopian tube before reaching the uterus. About 1 in 50 pregnancies in the United States are tubal pregnancies and this number has been increasing because of the higher rates of pelvic inflammatory disease and Chlamydia (Carroll, 2007). Abdominal pain, vaginal bleeding, nausea and fainting are symptoms of ectopic pregnancy. Toxemia or blood poisoning due to kidney malfunction is experienced by 6 to 7 percent of women during their last months of pregnancy. If untreated toxemia can lead to preeclampsia or swelling and hypertension or progress to eclampsia which is can involve coma or death.

Maternal Mortality: Approximately 1000 women die in childbirth around the world each day (World Health Organization, 2010). Rates are highest in Subsaharan Africa and South Asia although there has been a substantial decrease in these rates. The campaign to make childbirth safe for everyone has led to the development of clinics accessible to those living in more isolated areas and training more midwives to assist in childbirth. Listen to this story about a midwife's experience in a remote region of Afghanistan.

http://www.npr.org/blogs/thetwo‐way/2010/09/28/130180983/afghan‐midwives‐save‐ lives

Spontaneous abortion is experienced in an estimated 20‐40 percent of undiagnosed pregnancies and in another 10 percent of diagnosed pregnancy. Usually the body aborts due to chromosomal abnormalities and this typically happened before the 12th week of pregnancy. Cramping and bleeding result and normal periods return after several months. Some women are more likely to have repeated miscarriages due to chromosomal, amniotic, or hormonal problems; but miscarriage can also be a result of defective sperm (Carroll et. al., 2003).

Problems of the Newborn

Low Birth weight

We have been discussing a number of teratogens associated with low birth weight such as cocaine, tobacco, etc. A child is considered low birth weight if he or she weighs less than 5.8 pounds (2500 grams). About 8.2 percent of babies born in the United States are of low birth weight (Center for Disease Control, 2010). A low birth weight baby has difficulty maintaining adequate body temperature because it lacks the fat that would otherwise provide insulation. Such a baby is also at more risk for infection. And 67 percent of these babies are also preterm which can make them more at risk for respiratory infection. Very low birth weight babies (2 pounds or less) have an increased risk of developing cerebral palsy. Many causes of low birth weight are preventable with proper prenatal care, however.

Premature Birth

A child might also have a low birth weight if it is born at less than 37 weeks gestation (which qualifies it as a preterm baby). Early birth can be triggered by anything that disrupts the mother's system. For instance, vaginal infections or gum disease can actually lead to premature birth because such infection causes the mother to release anti‐inflammatory chemicals which, in turn, can trigger contractions. Smoking and the use of other teratogens can lead to preterm birth.

Anoxia

Anoxia is a temporary lack of oxygen to the brain. Difficulty during delivery may lead to anoxia which can result in brain damage or in severe cases, death. Babies who suffer both low birth weight and anoxia are more likely to suffer learning disabilities later in life as well.

Childbirth

Approaches to Childbirth

Prepared childbirth refers to being not only physically in good condition to help provide a healthy environment for the baby to develop, but also helping a couple to prepare to accept their new roles as parents and to get information and training that will assist them for delivery and life with the baby as much as possible. The more a couple can learn about childbirth and the newborn, the better prepared they will be for the adjustment they must make to a new life. (Nothing can prepare a couple for this completely). Once a couple finds that they are to have a child, they begin to conjure up images of what they think the experience will involve. Once the child is born, they must reconcile those images with reality (Galinsky, 1987). Knowing more of what to expect does help them in forming more realistic images thus making the adjustment easier.

Let's explore some of the methods of prepared childbirth.

The Dick‐Read Method of Natural Childbirth

Grantley Dick‐Read was an English obstetrician and pioneer of prepared childbirth in the 1930s. In his book Childbirth Without Fear, he suggests that the fear of childbirth increases tension and make the process of childbearing more painful. He believed that if mothers were educated, the fear and tension would be reduced and the need for medication could frequently be eliminated. The Dick‐Read method emphasized the use of relaxation and proper breathing with contractions as well as family support and education. (For more current information on this method go to www.hypnobirthing.com) This method influenced the most commonly taught method in the U.S. today, the Lamaze Method.

The Lamaze Method

This method originated in Russia and was brought to the United States in the 1950s by Fernand Lamaze. The emphasis of this method is on teaching the woman to be in control in the process of delivery. It includes learning muscle relaxation, breathing though contractions, having a focal point (usually a picture to look at) during contractions and having a support person who goes through the training process with the mother and serves as a coach during delivery.

Birthing Centers/Birthing Rooms

The trend now is to have birthing rooms that are hospital rooms that look more like a suite in a hotel equipped with a bed that can be converted for delivery. These rooms are also equipped with a bed and monitoring systems for the newborn. However, many hospitals have only one or two of these rooms and availability can be a problem.

The LeBoyer Method

Other birthing options include the use of birthing chairs, which make use of gravity in assisting the woman giving birth and the Leboyer Method of "Gentle Birthing". This method involves giving birth in a quiet, dimly lit room and allowing the newborn to lie on the mother's stomach with the umbilical cord intact for several minutes while being given a warm bath.

Home Birth and Nurse‐Midwives

Historically in the United States, most babies were born under the care of lay midwives. In the 1920s, middle class women were increasingly using doctors to assist with childbirth but rural women were still being assisted by lay midwives. The nursing profession began educating nurse‐midwives to assist these women. Nurse‐midwives continued to assist most rural women with delivery until the 1970s and 1980s when their growth is thought to have posed a threat to the medical profession (Weitz, 2007). Since that time, nurse‐midwives have found it more difficult to sustain practices with the high costs of malpractice insurance. (Many physicians have changed areas of specialization in response to these costs as well.) Women who are at low risk for birth complications can successfully deliver under the care of nurse‐midwives but only 1 percent of births occur at home. Because one out of every 20 births involves a complication, most medical professionals recommend that delivery take place in a hospital. However, some couples choose to have their baby at home. About 1 percent of births occur out of a hospital in the United States. Two‐thirds of these are homebirths and more than half of these are assisted by midwives. Midwives are trained and licensed to assist in delivery and are far less expensive than the cost of a hospital delivery. One‐third of out‐of‐hospital births occur in freestanding clinics, birthing centers, or in physicians offices or other locations. In the United States, women who have had previous children, who are over 25 and who are white are more likely to have out‐of‐hospital births (MacDorman, et. als., 2010).

The Process of Delivery

The First Stage of labor begins with uterine contractions that may initially last about thirty seconds and be spaced fifteen to twenty minutes apart. These increase in duration and frequency to more than a minute in length and about three to four minutes apart. Typically, doctors advise that they be called when contractions are coming about every five minutes. Some women experience false labor or Braxton‐Hicks contractions, especially with the first child. These may come and go. They tend to diminish when the mother begins walking around. Real labor pains tend to increase with walking. Labor may also be signaled by a bloody discharge being expelled from the cervix. In one out of eight pregnancies, the amniotic sac or water in which the fetus is suspended may break before labor begins. In such cases, the physician may induce labor with the use of medication if it does not begin in order to reduce the risk of infection. Normally this sac does not rupture until the later stages of labor.

The first stage of labor is typically the longest. During this stage the cervix or opening to the uterus dilates to ten centimeters or just under four inches. This may take around twelve to sixteen hours for first children or about six to nine hours for women who have previously given birth. It takes one woman in nine over twenty four hours to dilate completely. Labor may also begin with a discharge of blood or amniotic fluid. If the amniotic sack breaks, labor will be induced if necessary to reduce the risk of infection.

The Second Stage involves the passage of the baby through the birth canal. This stage takes about ten to forty minutes. Contractions usually come about every two to three minutes. The mother pushes and relaxes as directed by the medical staff. Normally the head is delivered first. The baby is then rotated so that one shoulder can come through and then the other shoulder. The rest of the baby quickly passes through. At this stage, an episiotomy may be performed to avoid tearing the tissue of the back of the vaginal opening. The baby's mouth and nose are suctioned out. The umbilical cord is clamped and cut.

The Third Stage is relatively painless. During this stage, the placenta or afterbirth is delivered. This typically within twenty minutes after delivery. If an episiotomy was performed it is stitched up during this stage.

Assessing the Neonate

There are several ways to assess the condition of the newborn. The most widely used tool is the Neonatal Behavioral Assessment Scale (NBAS) developed by T. Berry Brazelton. This tool has been used around the world to help parents get to know their infants and to make comparisons of infants in different cultures (Brazelton & Nugent, 1995). The baby's motor development, muscle tone, and stress response is assessed. The Apgar is conducted one minute and five minutes after birth. This is a very quick way to assess the newborn's overall condition. Five measures are assessed: the heart rate, respiration, muscle tone (quickly assessed by a skilled nurse when the baby is handed to them or by touching the baby's palm), reflex response (the Babinski reflex is tested), and color. A score of zero to two is given on each feature examined. An Apgar of five or less is cause for concern. The second Apgar should indicate improvement with a higher score.

Now watch this video entitled Life's Greatest Miracle

www.pbs.org/wgbh/nova/miracle/program.html