Pregnancy, Labor and Delivery

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A few highlights re. pregnancy and delivery
Conditions: Comments:
Abnormal delivery what's happenning with abnormal deliveries
Brief dictionary of obstetrics this links you to a table that explains some of the most important obstetrical terminology
Care after the delivery what to expect after the baby is born and what to look out for
High risk pregnancies each pregnancy is unique, but there are common high risk denominators. High risk pregnancies need close monitoring by experts (obstetrician, neonatologist)
"how do I know I am in labor?" some practical guidelines to recognize when you are in labor
In the delivery room (normal and emergencies) what's happening, why am I rushed to the operating room for an emergency cesarean section?
Normal delivery what's happening in the delivery room during a normal delivery
Normal pregnancies prenatal care; the goal is to protect the pregnancy from poisons and diseases and keep things normal
Other common conditions other conditions in women's health
Prenatal visits a means to spot problems early and to intervene so that child mortality is minimized
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Contents

[edit] Pregnancy, labor and delivery (normal and abnormal):

Introduction: This topic is rather ambitious as many full textbooks have been written about this topic.

My intent here is to only give a brief overview of pitfalls and dangers to minimize risk for the pregnant woman and her baby. Whoever has worked in this field for a number of decades will agree with me that sometimes during delivery of a baby within seconds or minutes terrible emergencies can occur, some of which could have been anticipated or prevented. Other bad outcomes again, no matter how careful the physician or the midwife follows the patient, cannot be averted. The following topics will be dealt with here.

Home page Women's Health Labor and delivery

[edit] Normal deliveries

Introduction:

Since 1940 the infant mortality in the United States has dropped from 47 per 1000 births to just under 8 per 1000 births in 1994.

Infant mortality is the measure of all deaths of infants up to one year after birth. Half of all these deaths occur in the first day of life. Many of these are due to risk factors that can be identified during the pregnancy and many of these risks can be further minimized by closely monitoring high risk pregnancies during the birthing process. I will touch on the high risk factors under High risk pregnancies. Here I will mainly concentrate on the normal pregnancy and the importance of regular prenatal visits.

Home page Women's Health Labor and delivery

Brief dictionary of obstetrics
Obstetric term (alphabetically): Translation:
Cesarean delivery quick delivery by surgery
eclampsia syndrome with leakage of protein into urine, high blood pressure, edema, kidney and liver damage. This can suddenly lead to seizures, shock and death of the mother
epidural injection anesthetic procedure (a needle in the back) to be able to inject anesthetic into epidural space to numb pain
episiotomy cut in soft tissue of perineum to create extra room for the presenting part of the baby
fetal monitoring applis to electronic equipment to monitor baby's heart beat with scalp clip and recording pressure inside uterus during high risk delivery process
forceps delivery assisting delivery by pulling on presenting part with forceps
meconium greenish staining of the amniotic fluid from bowel secretions of the baby (often a sign of baby distress)
multigravida woman with another pregnancy (all after the first)
pre-eclampsia precursor condition of eclampsia; the clinician will aggressively monitor for these signs and symptoms to prevent eclampsia
presenting part usually the head, but could be breech presentation (behind first)
primigravida woman with first time pregnancy
rescucitation reviving of a person (usually applied to baby after birth)
term baby baby born 38 to 42 weeks after 1st day of last menstrual period
vertex presentation normal head first position
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[edit] High risk pregnancies

Common causes of high risk pregnancies
Risk setting (causes): Comments:
Cardiovascular disease heart disease, heart valve problems, clots in deep veins
Genetic cause Down syndrome and other chromosomal abnormalities
Hormonal risks diabetes mellitus, thryoid disease, pituitary disease
Hypertension associated with pre-eclampsia
Kidney disease leads to pre-eclampsia
Lung disease severe asthma leads to small fetus, intrauterine death, prematurity
Maternal age lowest risk when age 15 to 35, ideally 20 to 25 because of genetics
Maternal infections genital herpes, AIDS, viral hepatitis, toxoplasmosis, Cytomegaly virus etc.
Multiparity more than 5 previous deliveries
Placenta previa sudden bleeding and shock, if missed; needs elective Cesarean section
Pre-eclampsia this is what physicians monitor for in an attempt to prevent eclampsia
Premature labor often with twins or triplets, but also in a smoker; premature babies have a higher mortality than regular babies
Small fetus placental problems or genetic abnormalities can lead to a small fetus, associated with high death rate of fetus or prematurely born baby
Tubal pregnancy often the end result of PID in the past; dangerous, if not detected as it leads to internal bleeding and death
Twins, triplets etc. often from fertility treatments, often associated with higher mortality and premature labor
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[edit] High risk pregnancies

There are a number of situations that are associated with higher than normal risks for a pregnancy. Most are only a higher risk for the fetus, but others are a higher risk for both the fetus and the mother. In the table above are a few examples with links to more detail on the subject.

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High risk pregnancy Changes after delivery

[edit] Hormonal risks in pregnancy

Hormones are essential for normal body function. This is even more important when a woman is pregnant. With diabetes, which is called gestational diabetes, there are higher risks for mother and child and these are discussed under this link.

Thyroid disease in the mother is not uncommon during pregnancy. If it occurs an endocrinologist and obstetrician is required. Thyroid hormones cross the placental barrier. Treatments for hyperthyroidism in the pregnant woman can affect the fetus profoundly and can cause hypothyroidism in the fetus. Radioactive therapy for pregnant patients has to be postponed until after the delivery as this a;lso would cross the placental barrier and alternative medicine is given instead. For treatment of hypothyroidism in the pregnant woman thyroid replacement is given and blood tests of TSH are used to guide in the dosing.

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High risk pregnancy Changes after delivery

[edit] Maternal age

The age of a pregnant woman by itself carries a certain risk.

Generally speaking all of the factors taken together the time between 20 and 25 is ideal for getting babies. One factor is a stasticially increased risk between age and chromosomal abnormalities (see link).

A younger person usually adapts easier to the many emotional and hormonal changes that pregnancy and childbirth brings with it. The soft tissues in the pelvic and perineal areas including the joint between the sacral bone and the coccyx bone are more pliable below the age of 28 to 30 and medical problems such as hypertension and diabetes are less frequent as well. It is therefore not surprising that cesarean section rates are 10% higher for women above 35 compared to women below age 20 (Ref. 18, p.564).

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High risk pregnancy Changes after delivery

[edit] Multiparity

Every obstetrician knows that when a woman carries her 6 th baby or even a higher number than that, this pregnancy is at a higher risk than her earlier pregnencies. There likely are a multiple number of reasons for his. She is older with every subsequent pregnancy and cardiac risks, hormonal risks (diabetes) as well as deteriorating kidney function with risks for hypertension are becoming more prominent. Genetic abnormalities of the fetus as well as higher twin rates with older age are also contributing risk factors. These pregnancies warrant closer monitoring.

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High risk pregnancy Changes after delivery

[edit] Small fetus

There are a variety of reasons why a baby might be small. The second twin or one of the fetuses of triplets often is significantly smaller.

Often this may have been because of disadvantages of the placental blood distribution to the fetus. There can also be genetic reasons and intrauterine exposure to life style habits of the pregnant woman (smoking, cocaine addiction, alcohol abuse). Often these babies will be born at term, but they are more vulnerable to complications such as hypoglycemia (lack of glycogen stores), aspiration of meconium and lung problems subsequently. These babies require special care for a period of time.

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High risk pregnancy Changes after delivery

Tubal pregnancy: This topic has been dealt with in another chapter and this link will get you there: tubal pregnancy.

[edit] Changes after delivering the baby

Changes after delivering the baby
Clinical observations: Comments:
Bleeding following delivery menstrual period-like flow called "lochia"
Cardiovascular system it takes 6 weeks to normalize, risk for clots for 2 weeks
Hormonal changes thyroid, ovarian and prolactin hormones experience changes
Infections after delivery wound infections, UTI's, vaginitis, mastitis, endometritis, but also infected clots in veins
Kidney function takes 6 to 8 weeks to normalize, higher risk for UTI's
Monitoring after delivery careful monitoring prevents complications
Postpartum blues normal emotional and hormonal adjustment reaction after delivery
Postpartum depression potentionally extremely serious and needs proper psychiatric attendance, otherwise suicide and homicide danger!
Weight changes at 6 months most women have returned to pre-pregnant weight; some women need special diet counselling

Care after the delivery: There are tremendous changes after the delivery of the baby, both physically as well as emotionally in the mother. The major changes are listed in the table above. Choose a topic and the link will provide you with more information.

Home page Women's Health Labor and delivery
High risk pregnancy Changes after delivery

[edit] Kidney function after delivery

The kidney function, which had increased during the pregnancy by 50%, returns to the baseline function in most of its parameters within 6 to 8 weeks after the delivery. However, because of the manipulation in the vaginal and adjacent urethral area during the course of the delivery there is a higher risk for post delivery UTI's, which are attended to in a normal fashion (see link: urinary tract infection).

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High risk pregnancy Changes after delivery

[edit] Postpartum blues

With the enormous psychological and hormonal adjustments and the sleep deprivation associated with the delivery of a baby it is no wonder that many women experience apart from the great joy that comes with the delivery of a new baby also periods where things appear overwhelming, difficult or draining. This is normal. However, this will need reassurance from the care providers and support from the family and will pass within a few weeks. It is important to separate the postpartum depression, which can be a danger to the mother and the child. This entity occurs more in families where there is a history of depressions and suicide.

Home page Women's Health Changes after delivery
High risk pregnancy Changes after delivery

References:

1. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 235.

2. B. Sears: "Zone perfect meals in minutes". Regan Books, Harper Collins, 1997.

3. Ryan: Kistner's Gynecology & Women's Health, 7th ed.,1999 Mosby, Inc.

4. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 245.

5. AB Diekman et al. Am J Reprod Immunol 2000 Mar; 43(3): 134-143.

6. V Damianova et al. Akush Ginekol (Sofia) 1999; 38(2): 31-33.

7. Townsend: Sabiston Textbook of Surgery,16th ed.,2001, W. B. Saunders Company

8. Cotran: Robbins Pathologic Basis of Disease, 6th ed., 1999 W. B. Saunders Company

9. Rakel: Conn's Current Therapy 2001, 53rd ed., W. B. Saunders Co.

10. Ruddy: Kelley's Textbook of Rheumatology, 6th ed.,2001 W. B. Saunders Company

11. EC Janowsky et al. N Engl J Med Mar-2000; 342(11): 781-790.

12. Wilson: Williams Textbook of Endocrinology, 9th ed.,1998 W. B. Saunders Company

13. KS Pena et al. Am Fam Physician 2001; 63(9): 1763-1770.

14. LM Apantaku Am Fam Physician Aug 2000; 62(3): 596-602.

15. Noble: Textbook of Primary Care Medicine, 3rd ed., 2001 Mosby, Inc.

16. Goroll: Primary Care Medicine, 4th ed.,2000 Lippincott Williams & Wilkins

17. St. Paul's Hosp. Contin. Educ. Conf. Nov. 2001,Vancouver/BC

18. Gabbe: Obstetrics - Normal and Problem Pregnancies, 3rd ed., 1996 Churchill Livingstone, Inc.

19. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 251.

20. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 250.

21. Ignaz P Semmelweiss: "Die Aetiologie, der Begriff und die Prophylaxis des Kindbettfiebers" ("Etiology, the Understanding and Prophylaxis of Childbed Fever"). Vienna (Austria), 1861.

22. Rosen: Emergency Medicine: Concepts and Clinical Practice, 4th ed., 1998 Mosby-Year Book, Inc.

23. Mandell: Principles and Practice of Infectious Diseases, 5th ed., 2000 Churchill Livingstone, Inc.

24. Horner NK et al. J Am Diet Assoc Nov-2000; 100(11): 1368-1380.

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