# Human Physiology/Pregnancy and birth

## Introduction

In this chapter we will discuss the topics covering pregnancy, from
conception to birth. The chapter will cover fertilization, implantation
of the zygote, to becoming a fetus, the three trimesters, and the
progressive development of the fetus through the weeks of pregnancy. It
will cover the topic of birth and different birthing methods.

## Fertilization

!A sperm fertilizing an
ovum{width="300"}
Fertilization is the joining of a sperm and an egg. A sperm is a male
gamete that is released into the vagina of a female during intercourse.
In order for fertilization to occur there must be a mature ovum present.
Every month one of the ovaries releases an egg which will meet one of
the A 4 million sperm the male ejaculates into the vagina. The sperm
swim through the cervix and into the uterus which lead to the fallopian
tubes. This is where fertilization is most likely to take place. The
high amount of sperm in the ejaculate is needed because only around 100
survive to enter reach the fertilization site. In order to penetrate the
egg the sperm must first break through two barriers surrounding the
ovum. The acrosome of sperm comes in contact with the corona radiata and
releases digestive enzymes that break down a gelatinous layer around the
egg called, the zona pellucida. Once a sperm reaches the plasma membrane
of the egg it sets off a reaction that spreads across the membrane of
the egg preventing other sperm from breaking through the egg membrane.
Once the sperm reaches the inside of the egg it sheds its tail and the
two nuclei fuse and now the 23 chromosomes from the egg and the 23
chromosomes of the sperm join and they become a *zygote*. Chromosomes
contain all the information needed to determine the genetic structure of
the new baby. Normally all human beings have two chromosomes that
determine sex: A combination of X and Y makes a male or a combination of
X and X makes a female. All ovum have X sex chromosomes where as sperm
have both X or Y sex chromosomes. Therefore, the male gametes determine
the sex of the baby. !An 8-cell embryo in the process of
cleavage.{width="300"}

## Pre-embryonic Period

After fertilization, the zygote begins a process of dividing by
*mitosis* in a process called *cleavage*. It divides until it reaches 16
cells. It is now referred to as a *morula*. As the morula floats freely
within the uterus, it starts to bring nutrients into the cells. The
morula fills with fluid and the cells inside start to form two separate
groups. At this stage it is now a *blastocyst*. The inner layer of cells
is called the embryoblast, and will become the fetus. The outer layer is
called a trophoblast which will develop into part of the placenta. At
this point the zona pellucida is disintegrating. The trophoblast
contains specialized cells that become extensions, like fingers, that
grow into the endometrium once in contact with the well thickened
endometrium.

### Implantation

The blastocyst preserves itself by secreting a hormone that indirectly
stops menstruation. The trophoblast cells secrete hCG hormones that help
maintain the corpus luteum that would normally regress. In turn, the
corpus luteum continues to secrete progesterone, which maintains the
endometrium of the uterus in the secretory phase. This helps the
blastocyst to continue to grow and stay embedded within the endometrium.
The fetal life support system and the placenta begin to form, and
eventually the placenta will take over the job of producing
progesterone.

-   Gastrulation and Formation

The embryoblast within the blastocyst forms 3 primary germs layers:
ectoderm, mesoderm, and endoderm.

#### Ectoderm

This forms the nervous tissue and the epithelium covering the outer body
surface. Epidermis of skin, including hair and nails, glands of skin,
linings of oral cavity, nasal cavity, anal canal, vagina, brain, spinal
cord, sensory organs, lens of eye and epithelium of conjunctiva (a
membrane that covers the sclera and lines the inside of the eyelids),
pituitary gland, adrenal medulla, and enamel of teeth.

#### Mesoderm

This forms all of the muscle tissue and the connective tissue of the
body, as well as the kidneys and the epithelium of the serous membranes
and blood vessels. All muscle tissue (skeletal, smooth, cardiac), all
connective tissue (fibrous connective tissue, bone, blood, cartilage),
dentin of teeth, adrenal cortex, kidneys and ureters, internal
reproductive viscera, epithelium lining vessels, joint cavities, and the
serous body cavities.

#### Endoderm

Forms the lining epithelium and glands of the visceral body systems.
Lining epithelium and glands of digestive, respiratory, and parts of
urogenital systems, thyroid and parathyroid glands, and thymus.

## Formation of Placenta

As changes to the endometrium occur, cellular growth and the
accumulation of glycogen cause fetal and maternal tissue to come
together. This formation makes the functional unit called the placenta.
The placenta does not mix blood between mother and fetus, but allows
nutrients and waste products to diffuse between the two blood systems.
The placenta provides protection by filtering out many harmful
substances that the mother comes in contact with. The placenta cannot
protect against some teratogens including but not limited to:

-   Thalidomide
-   Heroin
-   Cocaine
-   Aspirin
-   Alcohol
-   Chemicals in cigarette smoke
-   Propecia, also known as Finasteride, which can cause birth defects
    simply by a woman handling a broken pill during pregnancy.

## Amniotic Fluid

Attached to placenta is the membranous sac which surrounds and protects
the embryo. This sac is called the amnion. It grows and begins to fill,
mainly with water, around two weeks after fertilization. This liquid is
called Amniotic fluid, it allows the fetus to move freely, without the
walls of the uterus being too tight against its body. Buoyancy is also
provided here for comfort. After a further 10 weeks the liquid contains
proteins, carbohydrates, lipids and phospholipids, urea and
electrolytes, all which aid in the growth of the fetus. In the late
stages of gestation much of the amniotic fluid consists of fetal urine.
The fetus swallows the fluid and then voids it to prepare its digestive
organs for use after birth. The fetus also \"breathes\" the fluid to aid
in lung growth and development.

!A small part of the placenta is shown at the bottom, while the
fluid-filled amnion surrounds
it

Not enough amniontic fluid, or oligohydramnios, can be a concern during
pregnancy. Oligohydramnios can be caused by infection, kidney
dysfunction or malformation (since much of the late amniotic fluid
volume is urine), procedures such as chorionic villus sampling (CVS),
and preterm, premature rupture of membranes (PPROM). One possible
outcome of oligohydramnios can cause is underdeveloped, or hypoplastic,
lungs. This condition is potentially fatal and the baby can die shortly
after birth. Babies with too little amniotic fluid can also develop
contractures of the limbs, including clubbing of the feet and hands.

As with too little fluid, too much fluid or polyhydramnios, can be a
cause or an indicator of problems for the mother and baby.
Polyhydramnios is a predisposing risk factor for cord prolapse and is
sometimes a side effect of a macrosomic pregnancy. In both cases,
however, the majority of pregnancies proceed normally and the baby is
born healthy.

Preterm, premature rupture of membranes (PPROM) is a condition where the
amniotic sac leaks fluid before 38 weeks of gestation. This can be
caused by a bacterial infection or by a defect in the structure of the
amniotic sac, uterus, or cervix. In some cases the leak can
spontaneously heal, but in most cases of PPROM, labor begins within 48
hours of membrane rupture. When this occurs, it is necessary that the
mother receive treatment immediately to postpone labor if the fetus is
not viable, for as long as is safe, and for antibiotic treatments to
avoid possible infection in the mother and baby. If rupture occurs too
early in pregnancy little can be done to save the fetus.

A very rare and most often fatal obstetric complication is an amniotic
fluid embolism, or leakage of amniotic fluid into the mothers vascular
systems causing an allergic reation. This allergic reaction results in
cardiorespiratory (heart and lung) collapse, developing into a condition
known as disseminated intravascular coagulation in which the mothers
blood looses it\'s ability to clot.

Amniotic band syndrome, or ABS, occurs when the inner fetal membrane
(amnion) ruptures without injury to the outer membrane (chorion).
Fibrous bands from the ruptured amnion float in the amniotic fluid and
can entangle the fetus, reducing blood supply and causing congenital
limb abnormalities dysmelia. In some cases a complete \"natural\"
amputation of a digit(s) or limb may occur before birth or the digit(s)
or limbs may be necrotic (dead) requiring surgical removal.

## Endocrine Function of the Placenta

There are pituitary like hormones and steroid hormones secreted from the
placenta. The pituitary like hormones are hCG and hCS. HCG is similar to
LH and helps maintain the mothers corpus luteum. HCS is like prolactin
and growth hormone and help aid in increasing fat breakdown that spares
the use of glucose from the mothers tissues. This effect leaves more
glucose available to the placenta and the fetus for necessary growth.
The steroid hormones are progesterone and estrogen. Progesterone helps
maintain the endrometrium and supports the growth of mammary glands.
Estrogen also helps maintain the endrometrium and growth of mammary
glands as well as inhibits prolactin secretion.

## Developing Baby

The womb is expanding, the baby is growing and taking all the
nourishment from the mother. What once started as a microscopic
two-celled egg, will be formed into a baby in just twelve weeks. The
baby develops from conception to term, in a month-to-month progress.

### Overview of Developmental Milestones

  WEEK          CHANGES IN MOTHER                                                                                                                                 DEVELOPMENT OF BABY
  ------------- ------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                                                  **Pre-embryonic Development**
  1 week        Ovulation Occurs                                                                                                                                  Fertilization occurs, cell division begins and continues, chorion appears
                                                                                                                                                                  **Embryonic Development**
  2 weeks       Symptoms of early pregnancy (nausea, breast swelling and tenderness, fatigue); blood pregnancy tests may show positive                            Implantation occurs; amnion and yolk sac appear; embryo has tissue; placenta begins to form
  3 weeks       First period missed; urine pregnancy test may show positive; early pregnancy symptoms continue                                                    Nervous system begins to develop; allantois and blood vessels are present and placenta is well formed
  4 weeks                                                                                                                                                         Limb buds form; heart is beating; nervous system further develops; embryo has tail; other systems are forming
  5 weeks       Uterus is the size of a hen\'s egg; mother may need to urinate frequently                                                                         Embryo is curved, head is large, limb buds are showing division, nose, ears and eyes are noticeable
  6 weeks       Uterus is the size of an orange                                                                                                                   Fingers and toes are present and skeleton is cartilaginous
  8 weeks       Uterus can be felt above the pubic bone                                                                                                           Fetus begins to look human; limbs are developing and major organs forming; facial features are becoming refined
                                                                                                                                                                  **Fetal Development**
  12 weeks      Uterus is the size of a grapefruit                                                                                                                Head grows faster than the rest of the body; facial features are apparent, but there is no layer of fat yet and the skin is translucent; gender can be distinguished via ultrasound; fingernails appear
  16 weeks      Fetal movement can be felt                                                                                                                        Fine hair (lanugo) grows over the body; fetus resembles a tiny human being; skeleton is visible
  20-22 weeks   Uterus reaches up to the level of umbilicus and pregnancy is obvious                                                                              Vernix caseosa, the protective fatty coating, begins to be deposited; heartbeat can be heard
  24 weeks      Doctor can tell where baby\'s head, back and limbs are; breasts have enlarged and nipples and areola are darker, colostrum is produced            Fully formed but still thin; much larger and very active, all major organs are working, the lungs and digestive system need more time to develop; body is covered in fine hair called lanugo
  32 weeks      Uterus reaches halfway between umbilicus and rib cage                                                                                             Most babies are in a head down position in the womb; head is more in proportion to the body; eyes are open; babies born at this stage have a good chance of living
  36 weeks      Weight gain is averaging about a pound a week; standing and walking are becoming very difficult because the center of gravity is thrown forward   Body hair begins to disappear, fat is being deposited
  40 weeks      Uterus is up to the rib cage, causing shortness of breath and heartburn; sleeping is very difficult                                               Not much room to move in the womb; fully mature, baby moves less, and the surrounding fluid reduces and the womb expands its limits
                                                                                                                                                                  

## Embryonic Development at Specific Stages

### First trimester

!An embryo this tiny shows very distinct anatomic features, including
tail, limb buds, heart (which actually protrudes from the chest), eye
cups, cornea/lens, brain, and prominent segmentation into somites. The
gestational sac is surrounded by a myriad of chorionic villi resembling
elongate party balloons. This embryo is about five weeks old (or seven
weeks in the biologically misleading but eminently practical dating
system used in
obstetrics)., eye cups, cornea/lens, brain, and prominent segmentation into somites. The gestational sac is surrounded by a myriad of chorionic villi resembling elongate party balloons. This embryo is about five weeks old (or seven weeks in the biologically misleading but eminently practical dating system used in obstetrics)."){width="300"}

***4 Weeks***

-   There are only the beginnings of facial features. All the major
    organs are starting to form. Gill-like folds that develop into
    facial features, beginnings of the spinal cord, skin is translucent,
    and rudimentary (basic; minimal) heart develops.

***6 Weeks***

-   The length from crown to rump is about the size of a finger tip, ¾
    \". The beginnings of all the major organs will have formed.
-   The embryo floats in a fluid filled bubble that will develop into
    the amniotic sac. The sac is covered by a protective layer of cells,
    called chorion. The yolk sac supplies the embryo with all its
    nutrients until the placenta is fully developed and takes over at
    around the twelfth week. During the first 12 weeks, the embryo will
    develop features and major organs of a human being. The embryo is
    susceptible to harmful environmental influences. This is a vital
    time for the embryo to develop healthily; taking supplements of
    folic acid, avoiding certain foods, and eliminating alcohol,
    cigarettes, and any unnecessary drugs or medicines.

***9 Weeks***

-   The length from crown to rump approximately 1 1/4\". The facial
    features are becoming more distinct, and the "tail" has disappeared.
    The muscles are also developing. Eyes are formed but eyelids are
    still closed over them. Arms now bend at the elbow and rudimentary
    hands and fingers develop. Knees will have formed and developing
    feet with distinct toes.
-   Heart- is now a four-chambered and fully formed organ; it beats
    about 180 times per minute.
-   Brain and nervous system- is four times the size it was at 6 weeks.
    Special glial cells are being formed within the neural tube; they
    allow nerve cells to be joined so that messages can be transmitted
    from the brain to the body.
-   Digestive system- the mouth, intestine, and stomach are developing
    very rapidly, but do not function yet.
-   The fetal life-support system- the placental tissue that initially
    surrounds the fetus and the amniotic sac is becoming concentrated in
    one circular area on the womb wall to form the placenta.

!Sonogram of a fetus at 14 weeks
(Profile)")

***12 Weeks***

-   At twelve weeks the fetus looks like a tiny human. It is about 2
    1/2\" long and weighs 1/2 oz. Arms and legs are now beginning to
    move. Skin is red and translucent. Fingers and toes are more
    defined, and nails are starting to grow.
-   Heart is complete and working, pumping blood to all parts of the
    body. Digestive system has formed and is linked to the mouth and
    intestines. Sexual organs have formed inside the body, but cannot
    yet establish the sex of the baby.

### Second Trimester

***20 Weeks***

-   By 20 weeks the fetus will be about 6 1/3\" long and weighs 12 oz.
    Movements are for more coordinated. The sexual organs are well
    developed and are usually visible on ultra sound.
-   The fetus is growing very quickly. At this stage, the mother should
    feel the movements of the fetus. Movements are more noticeable as
    the fetus\'s leg bones achieve their final relative proportions in a
    process called *quickening*. Quickening is the process of muscles
    contracting that cause movement at the fetus\'s synovial joints. The
    joint movement enhances the nutrition of the articular cartilage and
    prevents the fusion of connective tissues within the joint. It also
    promotes bone hardening.
-   From now on, the fully developed placenta will provide all the
    fetus\' needs until birth; oxygen, nutrients and protective
    antibodies.

!Fetus at 29 weeks gestation in
3D

### Third Trimester

***29 Weeks***

-   By 29 weeks the baby is about 10\" long and weighs about 2 lbs. 7
    oz.
-   The brain grows much larger, and fatty protective sheath covers the
    nerve fibers; this important development allows brain impulses to
    travel faster, enhancing the ability to learn. The lungs have
    developed most of their airways and air sacs. The placenta is quite
    selective in what it allows to pass from the mother to the baby\'s
    blood, stopping some harmful substances, such as certain drugs, from
    crossing over.

***40 Weeks***

-   The baby is now ready to be born. When the head of the baby moves
    down from high in the mother\'s abdomen and settles deeper into her
    pelvis in preparation for birth, it is called engagement. This can
    happen any time between 36 weeks and labor.
-   In the last four weeks of pregnancy the baby puts on a lot of weight
    and develops a thick layer of fat. All organs are completely formed
    and functioning.

### Umbilical Cord

This is the life support for a growing embryo. The umbilical cord
stretches between the placenta and the fetus. This cord contains the
umbilical arteries and vein. The umbilical cord forms by week 5 of
conception. The average cord is close to 22 inches long and may have the
appearance of a coil. The umbilical cord is very rich in stem cells and
is often used for parents who choose to store their stem cells in a
blood bank or donate it to a blood bank. These stem cells can be used to
treat over 45 disorders and is an alternative from extracting the stem
cells from a donor.

!Human placenta shown a few minutes after birth. The side shown faces
the baby with the umbilical cord top right. The unseen side connects to
the uterine wall. The white fringe surrounding the bottom is the
remnants of the amniotic sac. You can see the differences in the
umbilical vein and
arteries.{width="350"}

-   *Umbilical Arteries*

The exchange of gases, nutrients and oxygen takes place between the
maternal blood and fetal blood. There are 2 main arteries.

-   *Umbilical Vein*

Vein that carries nutrients and oxygen away from the placenta to the
growing fetus. It also carries oxygen and nutrient rich blood. There is
only 1 main vein.

-   Fetus doesn\'t use its lungs for gas exchange, only a small amount
    of blood is pumped to fetal lungs in order to support their
    development.

#### Umbilical Abnormalities

-   *Single Umbilical Artery*

One artery instead of two will result in chromosomal abnormalities. Some
of these defects include poor fetal growth, preterm delivery, and still
births. This can be detected by a routine ultrasound. If an ultrasound
is done and no other complications or abnormalities are detected, the
baby will usually be born healthy.

-   *Umbilical Prolapse*

This condition usually happens when a cord is too long. The baby may be
born prematurely or will be breech.

-   *Umbilical Nuchal Loops*

This condition happens when the umbilical cord is wrapped around the
baby\'s head at least one or more times. This can be detected when a
baby is in stress or by a simple ultrasound. In most cases the mother
will have a cesarean delivery. In other cases the cord may be wrapped
around the hands or feet.

-   *Vasa Previa*

This occurs in one in every 3,000 births, which can become
life-threatening for the unborn baby. This complication happens when the
umbilical cord inserts abnormally in the fetal membranes of the
placenta, which appears abnormally shaped or positioned. Major risks
include unprotected fetal blood vessels cross the cervix, oftentimes
rupturing the membranes. Also, lack of blood pressure due from pressure,
causes the loss of oxygen to the baby. Women who will be at risk for
this would be those who already have experienced placenta previa or have
used in vitro fertilization.

-   *Umbilical Cord Knots*

About 1% of babies are born with one or more knots in their umbilical
cord. Some knots happen during labor; others happen from moving around
in the womb. Most knots occur when the umbilical cord is too long. In
some cases the knots can become tight, cutting off the oxygen supply to
the baby. Cord knots result in miscarriages and stillbirth in 5% and 10%
of most cases. Most will require a cesarean delivery.

-   *Umbilical Clotting*

This is more common with genetic defects, such as Factor V Leiden. This
complication will prevent blood flow to and from the baby and many times
will cause the placenta to also clot and die. If this is not caught
early enough, the baby will die of starvation in the womb. A simple
ultrasound can determine if there are problems with the blood flow.

## Pregnancy from the mother\'s perspective

!Growth of the uterus in a pregnant
female.
An initial sign of pregnancy is amenorrhea, or the absence of
menstruation. Menses cease because the blastocyte begins the release of
hCG or human chorionic gonadotropin. Most pregnancy tests are
specifically designed to recognize the presence of hCG, and hCG levels
can be tested through the mothers blood to learn whether or not a
pregnancy is progressing normally.

Human pregnancy lasts approximately 40 weeks from the time of the last
menstrual cycle to childbirth (38 weeks from fertilization). The medical
term for a pregnant woman is genetalian, just as the medical term for
the potential baby is embryo (early weeks) and then fetus (until birth).
A woman who is pregnant for the first time is known as a primigravida or
gravida 1: a woman who has never been pregnant is known as a gravida 0;
similarly, the terms para 0, para 1 and so on are used for the number of
times a woman has given birth.

In many societies\' medical and legal definitions, human pregnancy is
somewhat arbitrarily divided into three trimester periods, as a means to
simplify reference to the different stages of fetal development. The
first trimester period carries the highest risk of miscarriage
(spontaneous death of embryo or fetus). During the second trimester the
development of the fetus can start to be monitored and diagnosed. The
third trimester marks the beginning of viability, which means the fetus
might survive if an early birth occurs.

### Changing Body

!(38 weeks) A fully developed fetus in the mothers
abdomen\|250px A fully developed fetus in the mothers abdomen|250px")
As soon as a woman becomes pregnant, her body begins to change so that
it can support both herself and the unborn baby. All of the body
functions start to work much harder. The heart has to pump more blood
around the body, in particular to the womb, placenta, and the fetus. As
well as physical demands, pregnancy also causes a range of emotional
reactions.

-   The first trimester, the first twelve weeks, little is visible.
-   The second trimester, 13-27 Weeks, the waistline is rapidly growing,
    the abdomen becomes noticeably pregnant.
-   The third trimester, 28-40 weeks, the body expands rapidly and the
    womb enlarges and presses against the diaphragm.

#### First Trimester

In the early weeks the mother is likely to be more tired. As the uterus
begins to grow, the \"bump\" becomes noticeable. This is a good time to
start looking into options on birthing and doctors.

-   Physical feelings: tiredness, nausea, constipation, frequent
    urination, food cravings, change in size of breasts, fainting or
    dizziness, bloated stomach, and high emotions.

#### Second Trimester

The mother will probably be feeling full of energy and excitement.

:\*Physical feelings: More energy, constipation, heartburn, and
indigestion. The breasts continue to grow, as does an increase in
appetite. There is mild swelling in the feet, ankles, hands, and face.
There is also more baby movement. There may be emotional ups and downs
in the feeling of pregnancy, and short-term memory may be poor.

:\*The hormones estrogen, progesterone, human placental lactogen,
oxytocin, and prolactin prepare the body for feeding the baby, and cause
the breasts to enlarge, becoming painful and tender.

:\*The fetus, placenta, and amniotic fluid account for just over a third
of the weight gain during pregnancy. The remaining weight comes from
increased blood volume, fluid retention, and extra body fat. The
suggested weight gain in most pregnancies is between 25-40 lbs.

#### Third Trimester

Physical feelings: Shortness of breath, tiredness, difficulty in moving and sleeping, and frequent urination. The emotional mood swings ease off, but the mother begins to feel less enthusiastic about being pregnant. She may become impatient and restless and just wants for the birth to be over.

:\*The body is changing to cope with the ever increasing size of the
womb. The baby grows and pushes out the lower back of the mother. The
breathing rate of the baby is growing very quickly. At this stage, the
mother should feel the movements of the fetus. Other signs may be the
nipples secreting colostrum, Braxton-Hicks\' contractions may begin, and
blood flow to the womb has increased tenfold since conception.

### Prenatal Care

Once the female confirms her pregnancy, she will need to find out her
physical condition and what to expect in the coming months. Women
typically begin pre-natal care at approximately 8-10 weeks gestation,
and pregnancy care should continue until approximately 6 weeks
postpartum. The main purpose of the prenatal visits is to perform
preventative medicine. Most complications in pregnancy are best treated
if they are caught early on. A series of tests will be performed
throughout the pregnancy to judge the mother and fetus\' well-being
including:

-   Mother\'s history
-   Urine tests for glucose, protein, and infection
-   The mother\'s weight
-   Blood tests such as a complete blood count, HIV test, or the triple
    screen which is test used most commonly to look for neural tube
    defects and Downs Syndrome.
-   Physical examination
-   Blood pressure
-   Fetal heart monitoring
-   Ultrasound scans
-   Non-stress tests

Continuous care is the best way to ensure a healthy mother and baby.

## Labor and Birth

Labor is defined as contractions *and* cervical change, contractions
alone are not labor.

-   Pre-Labor Signs: as your body is preparing for labor, there are a
    few things that should be expected to happen within four to six
    weeks of labor.

1.  Pressure on the pelvic area
2.  Occasional brownish discharge
3.  Energy level is noticeably increasing or decreasing
4.  Loss of the mucus plug (does not always exist)/increasing discharge
5.  Braxton Hicks contractions (painless contraction of the uterus)
6.  Movement of the baby into the pelvis

-   False Labor Signs: there are a few signs that indicate false labor.

1.  Timing of the contractions are irregular and do not become more
    frequent or more intense
2.  Contractions stop during rest, stopping what the mother is doing,
    walking, or changing position
3.  Inconsistent in strength (strong one minute then weak the next)
4.  Location of pain is in the front only

-   True Labor

1.  Pain in the lower back, radiating towards the front abdomen,
    possibly also the legs
2.  Contractions increase in strength and are closer together; coming
    now on a regular basis, 30 to 70 seconds apart
3.  The mucous plug is detached, showing bloody discharge
4.  The water breaks (usually this does not break until the doctor does
    it), when this happens, contractions become much stronger
5.  Some women have the sudden need to go to the bathroom, diarrhea is
    common
6.  Contractions continue despite movement
7.  The cervix is thinning and dilating

When the contractions of labor begin, the walls of the uterus start to
contract. They are stimulated by the release of the pituitary hormone
*oxytocin*. The contractions cause the cervix to widen and begin to
open. As labor progresses the amniotic sac can rupture causing a slow or
a fast gush of fluids. Labor usually begins within a 24 hour period
after the amniotic sac has ruptured. As contractions become closer and
stronger the cervix will gradually start to dilate. The first stage of
labor is broken into three parts:

-   **Early Phase** First is the early phase of labor, when the cervix
    dilates from 1-4 centimeters, this can be the longest and most
    exhausting part for the mother.

```{=html}
<!-- -->
```
-   **Active Phase** The cervix dilates on average 1 cm per hour in the
    active phase of labor dilating from 4-7 centimeters. If an epidural
    is requested it is usually given in this phase.

```{=html}
<!-- -->
```
-   **Transition** This is often considered the most intense part of
    labor with contractions lasting longer and having shorter rest
    periods in between them. Dilation from 8-10 centimeters occurs
    during transition. Some women experience nausea and vomiting during
    this phase as well as rectal pressure and an urge to push.

At this point the labor enters the second stage, or the birth of the
baby. The mother begins pushing to aid in the birth of the baby, this
part of labor can last minutes, or even hours. A fetus usually delivered
head first. \'Crowning\' is the term used when the fetus\' head can be
seen between the mothers labia as it emerges. At this point if necessary
the birth attendant may perform an episiotomy, which is a small surgical
incision on the perineum. This procedure is usually done to deliver the
baby more quickly in response to fetal distress. !Diagram showing an
episiotomie

The third stage of labor is the delivery of the afterbirth (placenta).

Oxytocin continues to be released to shrink the size of the uterus and
aid in the limiting of blood loss from the site of the placenta. As the
uterus shrinks the attachment site blood vessels, some of which can be
as large as an adult finger, shrink also. The average blood loss in a
routine vaginal delivery is 400-500 cc.

There are times when a mother may need outside aid in the delivery of
the baby, some of these methods include:

-   Forceps, an instrument used to cradle the fetus\' head and
    manipulate the head under the pubic bone to more easily pass through
    the birth canal.

```{=html}
<!-- -->
```
-   Vacuum Extraction, a suction cup is applied to the baby\'s head, and
    a plunger is used to suck any air from between the suction cup and
    the head to create a good seal. The babies head is then manipulated
    through the birth canal. This usually leaves a baby\'s head bruised,
    but the mark fades within weeks after birth.

!C-section Birth

-   Cesarean section, or C-section, is the delivery of a baby through a
    surgical abdominal incision (Abdominal delivery - Abdominal birth -
    Cesarean section). A C-section delivery is performed when a vaginal
    birth is not possible or is not safe for the mother or child.
    Surgery is usually done while the woman is awake but anesthetized
    from the chest to the legs by epidural or spinal anesthesia. An
    incision is made across the abdomen just above the pubic area. The
    uterus is opened, and often brought through the incision after
    delivery for better visualization. The amniotic fluid is drained,
    and the baby is delivered. The baby\'s mouth and nose are cleared of
    fluids, and the umbilical cord is clamped and cut. After delivery a
    nursery nurse or pediatrician check the make sure that the baby is
    breathing and responding. Due to a variety of medical and social
    factors, C-sections have become fairly common; around 25% of births
    are performed by C-section. C-sections carry some risks to mother
    and baby. Compared to a vaginal birth, the risks to mother include
    increased risk of death, surgical injury, infection, postpartum
    depression, and hemorrhage, although these are rare. Babies born by
    c-section are more likely to be admitted to the ICU for breathing
    problems. Mothers are advised to carefully weigh the risks of
    C-section versus vaginal birth.

!Newborn baby

### Delivery Options

Hospital Births: The chances of having natural, uncomplicated birth are optimized by carefully selecting your obstetrician and hospital. Doctors who work with midwives have lower cesarean section rates because midwives handle less complicated pregnancies. Delivering babies by abdominal surgery has been steadily rising in America over the past two decades, so that now 22-30% of births in American hospitals are cesarean section. The U.S., despite having the most advanced technology and highly trained medical personnel, ranks 23rd in infant mortality and 18th in perinatal mortality.

```{=html}
<!-- -->
```

:   Medical interventions such as epidural anesthesia, pitocin
    augmentation of labor, vacuum extraction of fetus, episiotomy and
    separation of newborn and mother are common in American hospitals.
    There are circumstances where medical procedures such as these are
    necessary, but many parents and professionals now question the
    routine use of such interventions. In some cases, the routine use of
    these procedures have lead to further complications. For example,
    the epidural anesthetic, while providing pain relief, has shown to
    increase the operative vaginal delivery rate (i.e. forceps and
    vacuum extraction rates slightly) especially in first time mothers.
    Epidurals have not been shown to increase the cesarean section rate
    in recent well documented studies.

```{=html}
<!-- -->
```

Freestanding Birth Centers & Water Birth:\"Freestanding\" Birth Centers are not inside of or affiliated with a hospital. They are run by collaboration of midwives or physicians. This is an alternative choice for the woman who does not wish to birth in a hospital environment yet is not comfortable giving birth at home. Birth centers do not provide any additional measure of safety than most planned home births with qualified midwives; they may provide the expectant couple with the physiological comfort necessary to enable the mother to relax.

```{=html}
<!-- -->
```

:   Out of hospital birth centers are designed for women having low-risk
    pregnancies who want drug-free birth with minimal intervention in a
    home-like environment. Family members may participate in the birth.
    C-sections rates are lower than most hospitals because the
    pregnancies are low risk. Freestanding Birth Centers are an
    alternative choice for a woman who has had a previous cesarean and
    wishes to maximize her chances of a vaginal delivery. However,
    vaginal birth attempts after a prior cesarean section have a 1-2%
    risk of uterine rupture. Health insurance may cover costs. Many
    birth centers offer birthing tubs where one can give birth in water.

```{=html}
<!-- -->
```

Homebirth:Birth at home provides parents with intimacy, privacy, comfort and family-centered experience. Childbirth at home may be a safe option for healthy women having normal pregnancies. It is for those who have a very strong desire for natural childbirth and who are willing to take high degree of responsibility for their health care and baby\'s birth. At home, the parents and midwife are in control of the birthing environment, and strict time perimeters for length of labor are not imposed, or routine medical interventions such as IVs done. However, the World Health Organization (WHO) states that \"giving birth in a health facility (not necessarily a hospital) with professional staff is safer by far than doing so at home.\" (The World Health Report 2005). Also, the American College of Obstetricians and Gynecologists (ACOG) opposes out of hospital births. In choosing the comfort of home parents are also choosing to be further away from lifesaving measures should complications arise.

```{=html}
<!-- -->
```

:   Homebirth midwives provide complete prenatal care including monthly
    visits, laboratory tests, screening for infections. They provide
    nutritional counseling and support for psycho-social issues. There
    is a chance that a rare, but critical emergency might occur during
    the birth where hospital services may not be able to be obtained
    quick enough. Again, the WHO states that \"it is just before,
    during, and in the very first hours and days after birth that life
    is most at risk,\" (The World Health Report 2005) and that \"many of
    the complications that result in maternal deaths and many that
    contribute to perinatal deaths are unpredictable, and their onset
    can be both sudden and severe.\" (WHO Birth and Emergency
    Preparedness in Antenatal Care, 2006) Home birth midwives are
    trained to know when an emergency requires medical interface and can
    provide stabilizing measures until critical care can be obtained.
    While homebirth midwives generally have the training, equipment, and
    medicine to handle many complications, there is great variation in
    training and skill level among midwives. In choosing a homebirth
    midwife one should careful examine credentials and training.

!A newborn with umbilical cord still attached (3
minutes.)"){width="200"}

### Postpartum care

After the baby is born the umbilical cord is clamped and cut and the
baby is looked over by a doctor or nurse. The baby is given an APGAR
score at one and five minutes after birth. This is an analysis of how
well the baby is performing its vital functions.

+-------------+-------------+-------------+-------------+-------------+
|             | Score of 0  | Score of 1  | Score of 2  | Acronym     |
+=============+=============+=============+=============+=============+
| Skin color  | blue all    | blue at     | normal      | **A         |
|             | over        | extremities |             | **ppearance |
+-------------+-------------+-------------+-------------+-------------+
| Heart rate  | absent      | \<100       | \>100       | **P**ulse   |
+-------------+-------------+-------------+-------------+-------------+
| Reflex i    | no          | gri         | sneeze/     | **G**rimace |
| rritability | response\   | mace/feeble | cough/pulls |             |
|             | to          | cry\        | away\       |             |
|             | stimulation | when        | when        |             |
|             |             | stimulated  | stimulated  |             |
+-------------+-------------+-------------+-------------+-------------+
| Muscle tone | none        | some        | active      | *           |
|             |             | flexion     | movement    | *A**ctivity |
+-------------+-------------+-------------+-------------+-------------+
| Respiration | absent      | weak or     | strong      | **R*        |
|             |             | irregular   |             | *espiration |
+-------------+-------------+-------------+-------------+-------------+

: The five criteria of the Apgar score:

If tearing, or an episiotomy occurs the wound is closed with absorbable
suture. The mother is closely watched for blood loss, infection, or any
other possible complications. Breastfeeding should be initiated as soon
as possible after delivery as the stimulation of oxytocin in the mother
aids in hemostasis.

## Risks in Pregnancy

Pregnancies that warrant close attention usually come from an existing
medical condition such as asthma, diabetes, epilepsy, or a condition
developed because of pregnancy. Conditions that arise during pregnancy
will require special treatment. The purpose of prenatal care is to
detect these conditions, and to monitor and deal with them before they
become serious.

-   **Preeclampsia** is the medical term for high blood pressure during
    pregnancy. It is also characterized by edema, blurry vision, liver
    pain, and can progress into Eclampsia in which the mother can
    experience seizures, coma or even death.

```{=html}
<!-- -->
```
-   **Gestational Diabetes** is diabetes mellitus that develops during
    pregnancy. All women should be tested for the condition at about 28
    weeks gestation. Gestational and pre-existing diabetes can cause
    large for gestational age babies, a sudden drop in a neonates blood
    sugar after birth, and has a high risk for stillbirth

Other serious risks include:

-   **Teratogens** (substances that cause birth defects including
    alcohol and certain prescription and recreational drugs)

```{=html}
<!-- -->
```
-   **Infection** (such as rubella or cytomegalovirus) An infection in
    the eleventh week is less likely to damage the heart, but the baby
    may be born deaf.

```{=html}
<!-- -->
```
-   **Genetics** (such as Factor V Leiden) Diabetes, blood conditions,
    etc.

```{=html}
<!-- -->
```
-   **Radiation** (ionizing radiation such as X-rays, radiation therapy,
    or accidental exposure to radiation)

```{=html}
<!-- -->
```
-   **Nutritional deficiencies**

```{=html}
<!-- -->
```
-   **Fetal Alcohol Syndrome** or **FAS** exposure is the leading known
    cause of mental retardation in the Western world. It is a disorder
    of permanent birth defects that occurs in the offspring of women who
    drink alcohol during pregnancy, depending on the amount, frequency,
    and timing of alcohol consumption. Alcohol crosses the placental
    barrier and can stunt fetal growth or weight, create distinctive
    facial stigmata, damage neurons and brain structures, and cause
    other physical, mental, or behavioral problems. Drinking during
    pregnancy should be avoided. Women who drink more than 4 or 5 drinks
    per day may cause permanent damage to their fetus, including,
    behavioral problems, sight and hearing loss, deformed organs and
    central nervous system dysfunction.

```{=html}
<!-- -->
```
-   **Smoking** can cause low birth weight, still birth, birth defects,
    preterm births and immature lung development. It can also contribute
    to addiction in the child\'s later teen years.

```{=html}
<!-- -->
```
-   **Illegal Drugs** can be the most devastating. Risks include SIDS
    (Sudden Infants Death Syndrome), learning disorders, birth defects,
    uncontrollable trembling, hyperactive, and drug dependency. Most
    drugs can be tested by a simple urine or blood test.

```{=html}
<!-- -->
```
-   **Medications**. All medication use should be discussed with your
    doctor. Many over the counter and prescription drugs have warning
    labels. Follow these precautions to help avoid birth defects or
    other related problems.

### Miscarriage

Miscarriage or spontaneous abortion is the natural or spontaneous end of
a pregnancy at a stage where the embryo or the fetus is incapable of
surviving, generally defined in humans at a gestation of prior to 20
weeks. Miscarriages are the most common complication of pregnancy. Basic
Facts: 15-20% of pregnancies end in miscarriage, 70% of the time there
is a chromosomal abnormality with the fetus, and one miscarriage does
not increase your risk in the next pregnancy. Miscarriage is almost
never the mother\'s fault.

If the products of conception are not completely expelled after fetal
death this is known as a missed abortion and is usually treated
surgically by a procedure known as a D&C or dilation and curettage.

### Bleeding During Pregnancy

Vaginal bleeding at any stage should be taken seriously. Severe bleeding
in the early weeks may be a sign of miscarriage. However, 25% of
pregnant patient bleed in the first trimester. After 24 weeks the mother
should seek medical advice immediately. Third trimester bleeding in
pregnancy is often one of the first signs of placenta previa; placenta
is across the opening of the cervix. An ultrasound should be performed
to establish the location. Other causes of late term bleeding include:

-   **Preterm Labor** or labor that occurs before 38 weeks gestation
    that can have multiple causes

```{=html}
<!-- -->
```
-   **Placental Abruption** is a condition in which the placenta is torn
    away from the uterine wall causing loss of oxygen and nutrients to
    the baby, and hemorrhage of mother and baby from the large blood
    vessels in the placenta. Most women, but not all experience heavy
    bleeding and abdominal pain. This is a life threatening emergency as
    a fetus can only survive as long as 50% of the placenta is still
    attached.

### Blood Conditions

Individuals either have, or do not have, the Rhesus factor (or Rh D
antigen) on the surface of their red blood cells. This is usually
indicated by \'RhD positive\' (does have the RhD antigen) or \'RhD
negative\' (does not have the antigen) suffix to the ABO blood type i.e.
A+ B- blood typing. This is a problem only when an Rh-negative woman has
a partner who is Rh-positive resulting in an Rh-positive baby. If the
mother\'s and the baby\'s blood come into contact during the birth, her
body produces antibodies against the baby\'s blood. This problem usually
does not affect the current pregnancy but can be dangerous for future
pregnancies as the antibodies stay in the blood causing an immune
response against future Rh+ fetus. In essence the mother\'s body
\"rejects\" the fetus as it would a foreign body. A drug called Rhogam
is now given by injection given at 28-30 weeks gestation and given again
if there is confirmation that the baby is Rh positive within 24 hours
after birth to protect the future pregnancies. Rh isoimmunization is
rare in our day. Rh- mothers should also be given the injection after
miscarriage or abortion.

If a mother is untreated they are at risk to subsequently deliver babies
who suffer from hemolytic disease of the newborn. Hemolytic disease of
the newborn, also known as HDN, is an alloimmune condition that develops
in a fetus, when the IgG antibodies that have been produced by the
mother and have passed through the placenta include ones which attack
the red blood cells in the fetal circulation. The red cells are broken
down and the fetus can develop reticulocytosis and anemia. This fetal
disease ranges from mild to very severe, and fetal death from heart
failure (hydrops fetalis) can occur. When the disease is moderate or
severe, many erythroblasts are present in the fetal blood and so these
forms of the disease can be called erythroblastosis fetalis (or
erythroblastosis foetalis). Hemolysis leads to elevated bilirubin
levels. After delivery bilirubin is no longer cleared (via the placenta)
from the neonate\'s blood and the symptoms of jaundice (yellowish skin
and yellow discoloration of the whites of the eyes) increase within 24
hours after birth. Like any other severe neonatal jaundice, there is the
possibility of acute or chronic kernicterus. Profound anemia can cause
high-output heart failure, with pallor, enlarged liver and/or spleen,
generalized swelling, and respiratory distress. The prenatal
manifestations are known as hydrops fetalis; in severe forms this can
include petechiae and purpura. The infant may be stillborn or die
shortly after birth.

### Other Abnormalities

Physical and Genetic Defects: Physical anomalies are present at birth.
Examples are; cardiac, facial (such as cleft palate), club foot, etc.
These do not always endanger the baby\'s life. 1-2% of babies are born
with a significant congenital abnormality. 4-6% with something
relatively minor.

-   Chromosomal Abnormalities: Occur when there is a problem in the
    baby\'s genetic makeup; these include conditions such as Down
    syndrome. Other genetic defects, such as cystic fibrosis, can be
    inherited from the parents.

## Staying Healthy

Pregnancy and childbirth place great demands, it is important to keep
healthy. The more healthy and relaxed the mother is, the better it will
be to cope with the demands of pregnancy. A healthy lifestyle combines
many factors:

Balanced Diet: A poor diet can cause a low birth weight. Excessive weight gain during pregnancy can cause back problems, varicose veins, or indicate preeclampsia. Advice on diet often includes to eat foods that are high in nutritional content. Sufficient protein, vitamins, carbohydrates, fats, and minerals, as well as fiber. Limit intake of saturated fats and sugar, and salt. Drink plenty of fluids.\
Regular Exercise: Mild exercise, such as walking or swimming, is beneficial and will help cope with the workload of pregnancy and the demands of labor. Mother\'s should listen to her body and stop exercising when it tells her to. Exercise should never be painful.\
Baby\'s Health: Smoking reduces the oxygen and nutrients passing via the placenta to the baby. Avoid alcohol to avoid serious birth defects.

## In vitro Fertilization and Artificial Implantation

!Oocyte is injected with sperm outside of the
womb.{width="300"}
**An alternative when other methods of achieving contraception have
failed.**

In vitro fertilization (IVF) is a technique in which egg cells are
fertilized by sperm outside the woman\'s womb. IVF is a major treatment
in infertility when other methods of achieving conception have failed.
The process involves hormonally controlling the ovulatory process,
removing ova (eggs) from the woman\'s ovaries and letting sperm
fertilize them in a fluid medium. The fertilized egg (zygote) is then
transferred to the patient\'s uterus with the intent to establish a
successful pregnancy.

The term in vitro, from the Latin root, is used, because early
biological experiments involving cultivation of tissues outside the
living organism from which they came, were carried out in glass
containers such as beakers, test tubes, or petri dishes.

While the overall live birth rate via IVF in the U.S. is about 27% per
cycle (33% pregnancy rate), the chances of a successful pregnancy via
IVF vary widely based on the age of the woman (or, more precisely, on
the age of the eggs involved). Where the woman\'s own eggs are used as
opposed to those of a donor, for women under 35, the pregnancy rate is
commonly approximately 43% per cycle (37% live birth), while for women
over 40, the rate falls drastically - to only 4% for women over 42.
Other factors that determine success rates include the quality of the
eggs and sperm, the duration of the infertility, the health of the
uterus, and the medical expertise. It is a common practice for IVF
programmes to boost the pregnancy rate by placing multiple embryos
during embryo transfer. A flip side of this practice is a higher risk of
multiple pregnancy, itself associated with obstetric complications.

**Embryo cryopreservation** If multiple embryos are generated, patients
may choose to freeze embryos that are not transferred. Those embryos are
placed in liquid nitrogen and can be preserved for a long time. There
are currently 500,000 frozen embryos in the United States. The advantage
is that patients who fail to conceive may become pregnant using such
embryos without having to go through a full IVF cycle. Or, if pregnancy
occurred, they could return later for another pregnancy.

## Embryonic stem cells

!Pluripotent, embryonic stem cells originate as inner mass cells with
in a blastocyst. The stem cells can become any tissue in the body,
excluding a placenta. Only the morula\'s cells are totipotent, able to
become all tissues and a
placenta.{width="500"}

Embryonic Celtic cell lines (ES cell lines) are cultures of cells
derived from the epiblast tissue of the inner cell mass (ICM) of a
blastocyst. A blastocyst is an early stage embryo - approximately 4 to 5
days old in humans and consisting of 50-150 cells. ES cells are
*pluripotent*, and give rise during development to all derivatives of
the three primary germ layers: ectoderm, endoderm and mesoderm. In other
words, they can develop into each of the more than 200 cell types of the
adult body when given sufficient and necessary stimulation for a
specific cell type. They do not contribute to the extra-embryonic
membranes or the placenta. This means they can become any kind of human
tissue (ie. heart tissue, nerve tissue, etc.).

When given no stimuli for differentiation, ES cells will continue to
divide in vitro and each daughter cell will remain pluripotent. The
pluripotency of ES cells has been rigorously demonstrated in vitro and
in vivo, thus they can be indeed classified as stem cells.

Because of their unique combined abilities of unlimited expansion and
pluripotency, embryonic stem cells are a potential source for
regenerative medicine and tissue replacement after injury or disease. To
date, no approved medical treatments have been derived from embryonic
stem cell research. This is not surprising considering that many nations
currently have moratoria (suspension of practices) on either ES cell
research or the production of new ES cell lines.

There exists a widespread controversy over stem cell research that
emanates from the techniques used in the creation and usage of stem
cells. Embryonic stem cell research is particularly controversial
because, with the present state of technology, starting a stem cell line
requires the destruction of a human embryo and/or therapeutic cloning.
Opponents of the research argue that this practice is a slippery slope
to reproductive cloning and tantamount to the instrumentalization of a
human being. Contrarily, some medical researchers in the field argue
that it is necessary to pursue embryonic stem cell research because the
resultant technologies are expected to have significant medical
potential, and that the embryos used for research are only those meant
for destruction anyway (as a product of in vitro fertilization). This in
turn, conflicts with opponents in the pro-life movement, who argue that
an embryo is a human being and therefore entitled to dignity even if
legally slated for destruction. The ensuing debate has prompted
authorities around the world to seek regulatory frameworks and
highlighted the fact that stem cell research represents a social and
ethical challenge.

-   **Reproductive Cloning**

Reproductive Cloning is a technology used to generate an animal that
contains the same nuclear DNA as another currently or previously
existing animal. Scientists transfer the genetic material from the
nucleus of a donor adult cell to an egg whose nucleus, and thus its
genetic material has been removed. The egg containing the DNA, now
reconstructed, has to be treated with chemicals or electric current in
order to stimulate cell division. Once the cloned embryo reaches a
suitable stage, it is transferred to the uterus of a female host to
continue development until birth. Currently this is illegal to practice
in the United States.

-   **Therapeutic Cloning**

Recent research by researchers led by Anthony Atala of Wake Forest
University and a team from Harvard University has found that amniotic
fluid, in addition to its main functions of cushioning a growing fetus
and providing buoyancy, is also a plentiful source of non-embryonic stem
cells. These cells have demonstrated the ability to differentiate into a
number of different cell-types, including brain, liver and bone.

Therapeutic Cloning refers to a procedure that allows the cloning of
specific body parts and organs to be used for medical purposes. Although
this has not been realized, much research is being done on the subject.

## Pregnancy and Lactation

A mother\'s milk is ideal because it meets the baby\'s specific needs.
Lactation is a neuroendocrine response in *milk production*. Sucking
stimulates the sensory nerve endings in the nipples and sends stimulus
to the hypothalamus. The hypothalamus stimulates anterior pituitary and
prolactin is released. In *milk let-down* the sucking stimulates sensory
nerves in the nipples. This stimulates the hypothalamus which then
stimulates the posterior pituitary and releases oxytocin. Sucking also
stimulates contraction of the cells around the alveoli in the mammary
cells. Milk then flows into the milk ducts causing milk let-down.

Breast milk provides all the nutrients required for the first 4-6
months. It contains carbohydrates (such as lactose), fats (such as
linoleic acid), and easily digestible proteins (such as
alpha-lactalbumin). Breast milk also contains an adequate supply of
vitamins and minerals, digestive enzymes, hormones and immunological
factors.

The first milk produced after birth is called *colostrum*. This is
synthesized during the end of pregnancy and 3-5 days of postpartum. It
is very high in protein and low in fat and carbohydrates, and contains
immunoglobulins. This help the baby have a first bowel movement and
prevent jaundice. The bowel movement that results from the colostrum is
a different color and consistency than future bowel movements once the
mother\'s milk comes in. In some cultures the colostrum is discarded
because of the difference, but what they do not know is that it is the
best thing for the baby.

The composition varies in breast milk during feeding, and over time with
development of the baby. When breastfeeding there are three names for
the composition of the milk: the fore milk, present during the beginning
of breastfeeding; mid is the middle of feeding; and hind which is toward
the end of the feeding and contains a composition high in fat.

When breastfeeding the female should consider the types of food that
will be consumed. If the mother is on a low fat diet or if foods like
garlic, broccoli, and onions are eaten, it may affect the baby\'s
preference for breast feeding. Also, the mother should consider not
breastfeeding after the consumption of alcohol, caffeine, smoking, and
certain medications.

Barriers of breastfeeding are lack of professional and social support,
misinformation, embarrassment, early discharge form the hospital without
instruction, and returning to work or school without adequate lactation
rooms and if the mother refuses to tend breastfed infant.

When breastfeeding initiate as soon after delivery as possible, position
the baby correctly, feed on demand from both breasts at each feeding and
at least 10 minutes on each breast. Additionally there should be a good
educator in the case the infant is not latching on.

A common problem that may happen when breastfeeding is *mastitis*, which
is an inflammation of one or both breasts and is usually associated with
the infection of a blocked milk duct during lactation. The symptoms
include flu-like symptoms, red streaks on the breast, and hot skin.
Antibiotics may be necessary to clear the infection. *Thrush* may also
happen and could be passed between mom and baby. A symptom of thrush
includes white flecks on tongue, and the baby and mother should be
treated by a doctor.

Breast milk is recommended through the first 12 months. Supplementation
of cow\'s milk is not recommended due to the high protein that would
cause liver damage to the baby.

Why breastfeed?

-   It is easily digested
-   Composition changes with infant needs
-   Changes during a feeding, high in fat at the end of feeding
-   Antibodies in milk
-   Breastfeeding moms miss less work because babies are sick less
-   Fewer allergies
-   Less spit-up
-   Less constipation and diarrhea
-   Better jaw development
-   Decreased risk of SIDS (Sudden Infant Death Syndrome)
-   Higher IQ
-   Decreased risk of diabetes, Crohn\'s Disease, Celiac Sprue
-   Bonding
-   Convenient, always at the correct temperature and ready to go
-   Less expensive
-   Helps the uterus return to normal size more quickly
-   Less incidence of postpartum "blues"
-   Lower risk of breast cancer
-   Lower risk of osteoporosis

## Postpartum Depression

Having a baby is usually one of the happiest times in a woman\'s life,
but for some women, it can include times of sadness and depression. More
women actually suffer from postpartum depression than we really know.
Women usually ignore the emotional and physical signs, dealing with
their feelings on their own.

Postpartum depression affects approximately 10 to 15 percent of new
mothers. It often causes anxiety and obsession about caring for the baby
or the cleanliness of the home. It may cause changes in sleep patterns
and affect relationships including the ability to form a bond with the
baby and other family members. Some mothers with postpartum depression
have thoughts of wanting to die or of hurting the baby. If the symptoms
are so severe that they keep the mother from being able to function,
medical treatment is necessary.

Baby blues are common due to rapid hormonal changes but resolve after
1-2 weeks. Postpartum depression is characterized by persisting
symptoms, and the mother should notify her provider immediately.

## Testing Your Knowledge

Answers for these questions can be found here

1\. Is at this stage that an egg implants in the uterine lining

:   A\) morula
:   B\) zygote
:   C\) blastocyst
:   D\) embryoblast

2\. Which part of the embryoblast will become the central nervous system
in development

:   A\) ectogerm
:   B\) mesoderm
:   C\) endoderm

3\. This hormone is only produced in the human body when a woman is
pregnant

:   A\) estrogen
:   B\) HCG
:   C\) progesterone
:   D\) FSH
:   E\) LH

4\. By this week of pregnancy, the beginnings of all major organs have
formed

:   A\) 4
:   B\) 7
:   C\) 5
:   D\) 6
:   E\) 8

5\. Stem cells are found in the embryoblast and use of them is very
controversial, another place to find stem cells that are usable to treat
leukemia and other disorders is the

:   A\) morula
:   B\) chorion
:   C\) amnion
:   D\) amniotic fluid
:   E\) umbilical cord

6\. The cervix dilates on an average of \_\_\_\_\_\_ per hour in the
active phase of labor

:   A\) 2 mm
:   B\) 2 cm
:   C\) 1mm
:   D\) 1 cm

7\. The contractions of the uterus are stimulated by the release of

:   A\) oxytocin
:   B\) FSH
:   C\) LH
:   D\) prolactin
:   E\) estrogen

8\. A sign of pre-labor is

:   A\) irregular contractions
:   B\) pain in the front only
:   C\) loss of the mucus plug
:   D\) contractions stop during rest

9\. This is the most common complication of pregnancy

:   A\) preclampcia
:   B\) miscarriage
:   C\) smoking
:   D\) Rh factor
:   E\) teratogens

10\. Sue decides to breastfeed because she has been told that colostrum
contains

:   A\) high protein
:   B\) low fat
:   C\) immunoglobulins
:   D\) all of the above
:   E\) none of the above

11\. What is the first milk after birth called?

:   A\) thrush
:   B\) mastitis
:   C\) colostrum
:   D\) milk let down

## Glossary

**Abruption**: Premature separation of the placenta from the wall of the
womb

**Amnion**: An embryonic membrane that encircles a developing fetus and
contains amniotic fluid.

**Amniocentesis**: A procedure in which a small sample of amniotic fluid
is removed from around the fetus

**Amniotic fluid**: The fluid surrounding the fetus

**Amniotomy**: (artificial rupture of membranes, ARM) Breaking the
membranes using a special plastic hook

**Anemia**: Lack of hemoglobin in red blood cells, due to iron
deficiency or disease

**Antepartum Hemorrhage**: (APH) Vaginal bleeding that happens after 24
weeks of pregnancy and before delivery

**Breech**: The baby is lying bottom down in the womb

**Celiac sprue**: Nutrient absorption impairment which is improved when
gluten is removed form the diet. Characteristic mucosal lesion of the
small intestine.

**Cephalic**: The baby is lying head down in the womb

**Chorion**: The embryonic membrane that forms the outermost covering
around the developing fetus.

**Chorion Villus Sampling**: (CVS) A method for sampling placental
tissue for genetic or chromosome studies.

**Colostrum** the fluid that is made late in pregnancy and the first few
days postpartum in the breast that contains immunologic substances and
essential nutrients.

**Cleavage**: The early successive divisions of embryonic cells into
smaller and smaller cells.

**Cilia**: The fine hairs that line the fallopian tubes\'

**Cordocentesis**: The procedure for taking blood from the fetal
umbilical cord via a needle through the mother's abdomen

**Copulation**: (Coitus, sexual intercourse) is the procreative act of a
man\'s erect penis is inserted into a woman\'s vagina. At climax, semen
is ejaculated from the penis at the cervix of the uterus. Sperm then
propel themselves into the uterine tubes where fertilization may occur
if an egg is present.

**Crohn\'s disease**: Skip lesions in the colon and is a malabsorptive
disease.

**Cystitis**: Infection of the bladder

**Dizygous**: Not identical (fraternal) twins

**Doppler**: A form of ultrasound used specially to investigate blood
flow in the placenta or in the fetus

**Down Syndrome**: (Trisomy 21) A disorder caused by the presence of an
extra chromosome 21 in the cells

**Ectopic Pregnancy**: A pregnancy that develops outside of the womb

**Edema**: Swelling of the fingers, legs, toes, and face.

**Embryo**: The medical term for the baby from conception to about six
weeks

**Engagement**: The process in which the head of the baby moves down
from high in the mother\'s abdomen and settles deeper into her pelvis in
preparation for birth. This can happen any time between 36 weeks and
labor.

**Epidural Anesthesia**: A method of numbing the nerves of the lower
spinal cord to ensure a pain-free labor

**Episiotomy**: A cut of the perineum and vagina performed to make the
delivery easier

**External Fetal Monitor**: An electronic monitor used to record the
fetal heartbeat and mother's contractions

**Fallopian Tubes**: (uterine tubes) Two tubular structures (one on each
side of the womb) leading from the ovaries to the uterus

**Fertilization**: The union of an egg cell and a sperm cell is present
wherein 23 chromosomes from each parent come together to form a zygote.
After sperm penetrates, the ovum undergoes a chemical change to prevent
other sperm from entering. Multiple births can occur from complete
division of the conceptus during early cleavage or from fertilization of
multiple ova. Birth control techniques are designed to prevent ovulation
or to prevent fertilization by barriers, that keep sperm and ova
separated.

**Fetus**: Medical term for the baby from six weeks after conception
until birth

**Forceps**: Metal instruments that fit on either side of the baby\'s
head and are used to help deliver the baby

**Fundus**: The top of the womb

**Germ layer**: Layers of cells within an embryo that form the body
organs during development.

**Glial Cells** (neuroglia; glia): Non-neuronal cells that provide
support and nutrition, maintain homeostasis, form myelin, and
participate in signal transmission in the nervous system. In the human
brain, glia are estimated to outnumber neurons by about 10 to 1.

Glial cells provide support and protection for neurons, the other main
type of cell in the central nervous system. They are thus known as the
\"glue\" of the nervous system. The four main functions of glial cells
are to surround neurons and hold them in place, to supply nutrients and
oxygen to neurons, to insulate one neuron from another, and to destroy
pathogens and remove dead neurons.

**Hemoglobin**: (Hb)The oxygen carrying constituent of red blood cells

**Induction of labor**: (IOL) the procedure for initiating labor
artificially

**In utero death**: (IUD)the death of the unborn fetus after 24 weeks

**In vitro fertilization**: (IVF) a method of assisted conception in
which fertilization occurs outside the mother\'s and the embryo is
replaced in the womb

**Lanugo**: fine hair that covers the fetus in the womb

**Lochia**: blood loss after birth

**Mastitis** inflammation of the breast most frequently in lactation.

**Neonatal**: baby less than 28 days old

**Nuchal scan**: special ultrasound scan that gives an estimate of the
risk of Down syndrome

**Oocyte**: one egg that is released from the ovary at each ovulation

**Placenta**: The structure by which an unborn child is attached to
it\'s mother\'s uterine wall and through which it is nourished.

**Postnatal**: After birth

**Prenatal**: Before birth

**Quickening**: The process that occurs between the seventeenth and
twentieth weeks of fetal development, the fetus\'s leg bones achieve
their final relative proportions. In this process the muscles contract,
causing movement at the fetus\'s sinovial joints. The joint movement
enhances the nutrition of the articular cartilage and prevents the
fusion of connective tissues within the joint. It also promotes bone
hardening. It is this stage, where the fetus\'s bones become more
developed and harder, that the mother begins to notice fetal movement.

**Rudimentary**: Basic; minimal; with less than, or only the minimum,
necessary

**Thrush**: Creamy white flakes on a red papillae on tongue and tongue
may be enlarged.

**Umbilical cord**: The cord like structures that connects the fetus to
the placenta.

**Zygote**: A cell produced by the fusion of an egg and a sperm; a
fertilized egg cell.

## Reference

-   \'\'\"as your baby grows From Conception to Birth\"published by
    American Baby

```{=html}
<!-- -->
```
-   <http://www.babybluesconnection.com>

```{=html}
<!-- -->
```
-   *\"Pregnancy and Birth\"* authors: Dr. Karina Reynolds, Dr.
    Christoph Lees, Grainne McCartan

```{=html}
<!-- -->
```
-   *\"Fundamental Concepts of Human Anatomy\"* authors: M.J. Shively
    D.V.M., M.S., Ph.D. and D.P. Homan B.S., M.S.
-   \'\'\"Essentials of Anatomy and Physiology\" authors:Valerie C.
    Scanlon and Tina Sanders, fourth edition
-   <http://www.MERLOT.com> Stanford Site
-   \'\'\"The New Parent\" author DR. Miriam Stoppard
-   \'\'www.marchofdimes.com
-   \'\'<http://health.allrefer.com/health/fetal-development-info.html>
-   *American Pregnancy Association*

Internet groups: International Awareness Network: www.ican-online.org
