Chapter 6
Pregnancy and Childbirth
Historical Dimensions
Eighteenth century
• America—Physicians at births
• France—Childbirth moves to hospitals
• England—Surgical techniques and
development of instruments
Nineteenth century
• Physician-controlled hospital births
• Interventions—Medications, anesthesia,
birthing instruments
Historical Dimensions
Early twentieth century
• Greater technology, medicalization,
hospitalization
• Greater mystification of childbirth for woman
• Controlling fertility
Mid- to late twentieth century
• Natural-birth relaxation techniques leading
toward “prepared births”
• 1970s: Benefits of breastfeeding resurfaced
• Childbirth = joy and knowledge vs. fear and
ignorance
Pregnancy
Conception
Fertilization = Sperm Cell + Egg Cell = Zygote
• Sperm cell: 300 million deposited per
ejaculation
• Egg cell: 1 egg released per month
• Dizygotic twins = fraternal twins
• Monozygotic twins = identical twins
Pregnancy
23 chromosomes from sperm +
23 female chromosomes from egg =
46 chromosomes total = ZYGOTE
Sex Chromosomes
Sex of individual:
XY for male;
XX for female
Selected sex chromosome abnormalities
•
•
•
•
Turner syndrome (Monosomy X, XO)
Triple X (XXX)
Klinefelter syndrome (Trisomy XXY)
XYY male
After Conception
• Within 36 hours of
fertilization: Zygote divides
• 1 to 2 days: Blastocyte floats
freely before implanting in
uterus
• Within 3 to 5 days: Reaches
uterus and is known as a
blastocyte
• First 8 weeks: Known as
embryo
• 9 weeks to birth: Known as
fetus
Early Signs of Pregnancy
Early signs of pregnancy often occur within the
first 6 weeks
• Missed period(s)
• Breast swelling/tenderness
• Fatigue
• Queasiness or nausea/vomiting
• Elevated body temperature
• Mood swings
• Frequent urination
Confirming Pregnancy
• Pregnancy tests: detect hCG
– Home urine pregnancy tests available
• Digital and non-digital
• Clinical pregnancy test
– Performed by clinician
• Urine or blood tests
• Pelvic examination
Hormonal Changes
Fertilization
• Follicle-stimulating hormone (FSH) and
luteinizing hormone (LH) produced by the
anterior pituitary gland are suppressed
• Pregnancy-specific hormones increase
Implantation
• Embryo cells secrete hCG
• hCG stimulates corpus luteum to secrete
estrogen and progesterone
Hormonal Changes
After three months:
1. Corpus luteum no longer needed; hCG levels
decrease
2. Placenta produces estrogen and progesterone
3. Fetal adrenal glands produce precursor
hormone to be converted into estrogen
4. Estrogen—regulates progesterone, stimulates
fetal maturation (lungs, liver, organs mature),
prepare breasts for lactation
5. Progesterone—suppresses uterine contractions,
stimulates alveoli of breasts
Physical and Emotional
Symptoms
First trimester
• Enlarged and tender breasts
• Morning sickness (nausea and/or vomiting)
• Extreme fatigue
• Decreased interest in sex
• Moodiness and irritability
• Darkening of nipple and areola
Physical and Emotional
Symptoms
Second trimester
• Morning sickness subsides
• Gastrointestinal problems (heartburn, gas,
constipation)
• Gain majority of weight (12–14 pounds)
• Breathing problems
• Backache
• Leg cramps and numbness/tingling of hands
• Swollen and bleeding gums
• Swelling of feet, hands, and ankles
• Braxton-Hicks contractions
Physical and Emotional
Symptoms
Third trimester
• Heartburn and constipation
• Leg cramps
• Backache
• Breathlessness
• Braxton-Hicks contractions
•  Leukorrhea
•  Colostrum
• Hemorrhoids
• Pelvic and buttock discomfort
• Itchy abdomen
A Pregnant Woman’s Body Changes
Fetal Development
Terms
• Amnion: Fetal sac that envelops the embryo
• Amniotic fluid: Provides protection and
constant environment for floating embryo
• Placenta: Supplies fetus with oxygen and
nutrients from maternal bloodstream and
filters waste back to mother for disposal
Fetal Growth
Fetal
Month
Length
(in inches)
Weight
(in ounces)
1
1/10-1/4
1/7
2
1.2
1/6
3
2-3
1/ 2
4
4-5
2-4
Fetus – 4-5 Weeks
Fetal Growth
Fetal
Month
Length
(in inches)
Weight
(in pounds)
5
6.5-10
0.75-1.4
6
10-11.5
2.1
7
14-15
2.5-3
8
15-17
4-4.5
Fetus - Near Term
9
16-22
6-9
Preconception Care
Preconception care: The steps that a woman
can take before she decides to become
pregnant to ensure that she is in good health
when conception occurs
Folic acid
Proper immunizations
Healthy behaviors
Nutrition
Prenatal Care- Nutrition
• Consume additional 100
calories/day during 1st
trimester
• Consume additional 300
calories/day 2nd- 3rd trimester
• Folic acid
• Calcium
• Iron
• Increase fluid intake
• Weight gain: Average 25–35
pounds total
Exercise
Benefits
• Feel better throughout
trimesters
• Shorter labor
• Quicker recovery
Forms
•
•
•
•
Swimming
Walking
Low-impact aerobics
Kegel exercises
Avoiding Toxic Substances
Cigarette smoking
• 13% of women smoke during pregnancy
• Complications
– Lower birthweight
– Physical and mental problems for infants
– Infertility
– Spontaneous abortions (miscarriages)
– Ectopic pregnancies
– Placental irregularities and intrauterine growth
retardation
Smoking during last trimester
Avoiding Toxic Substances
Alcohol
• Especially risky in 1st trimester
• Fetal alcohol syndrome (FAS)
–Growth retardation
–Facial malformations
–Central nervous system dysfunction
–Mental retardation
• Increased risk of stillbirth
Avoiding Toxic Substances
Alcohol
• 1 in 8 pregnant women reports alcohol use
• 1 in 50 pregnant women report binge drinking
Avoiding Toxic Substances
Other drug use
• OTC medications—physician should be consulted
before use
• Marijuana use—causes smaller, sicker babies; higher
risk of stillbirths; crying and trembling in infants
• Cocaine use—increases risk of premature birth,
stillbirths, and malformations; lower birthweight;
smaller head circumference; shorter in length; infant
feeding difficulties and sleep disturbances
• Heroin—risk of miscarriage, premature delivery,
stillbirth, poor fetal growth; withdrawal symptoms at
birth; increased risk of SIDS
Avoiding Toxic Substances
Environmental risks
A pregnant woman should avoid the following as
precautionary measures to protect herself and her
baby:
• Pollutants
• Toxic wastes
• Heavy metals
• Pesticides
• Gases
• Radiation treatment
• Diagnostic X rays
• Heat exposure
Prenatal Testing: Screening
• 1st Trimester
– Ultrasound tests and
blood tests to detect
Down Syndrome and
trisomy 18
• 2nd Trimester
– Multiple marker
screening
– Detailed ultrasound
exams
Prenatal Testing: Diagnostic
• Chorionic villus sampling (CVS): 10th–12th week
• Amniocentesis: 15th–18th week
• Fetal blood sampling
Chorionic Villus Sampling
Procedure
Amniocentesis Procedure
Complications of Pregnancy
Ectopic pregnancy
• Occurs in approximately 20 per 1,000
pregnancies
• Risk factors related to fallopian tube problems
• Fertilized egg grows outside uterine cavity
• Abdominal pain, spotting, ruptured fallopian
tube, PID
• Can be life threatening
Complications of Pregnancy
Gestational diabetes
• Usually in second half of pregnancy
• May or may not have symptoms
• Can present problems for mother and
baby
• Mothers at greater risk for developing
type 2 diabetes later in life
Complications of Pregnancy
Preterm delivery
• Defined as labor before week 37
• Risk factors:
• Previous preterm birth
• Multiple births
• Maternal abnormalities or medical
conditions
• Late or no prenatal care
• Mothers who smoke, drink, use drugs
Complications of Pregnancy
Stillbirth
• Defined as intrauterine death of fetus
• Multiple causes
• Multiple symptoms
• Counseling important
Complications of Pregnancy
Miscarriage
• Pregnancy that ends before 20th week
• Several factors associated with
miscarriage
• Symptoms: bleeding and cramping
• Causes vary and often aren’t clear
Complications of Pregnancy
Preeclampsia
• Pregnancy-related high blood pressure
• Several other symptoms
• Protein in urine; face and hands swelling;
sudden weight gain; blurred vision; severe
headaches; dizziness; stomach pain
• Cure is delivery of the baby
Genetic Disorders
and Congenital Abnormalities
• Caused in whole or part by variation or
mutation of a gene
• Over 6,000 abnormalities have been identified
• State-based screening programs
Infections in Pregnancy
• Gonorrhea, chlamydia, syphilis  miscarriages
• Bacterial vaginosis (BV)  lower birthweight,
higher risk of HIV
• Perinatal transmission of AIDS can be reduced
by the use of AZT
Infections in Pregnancy
• Cytomegalovirus (CMV)  smaller birth size,
brain damage, developmental problems, enlarged
liver, hearing and vision impairment,
malformations
• Rubella  birth defects
• Group B streptococcus (GBS)  sepsis,
pneumonia, meningitis, long-term disabilities,
death
Childbirth Preparation
Labor and Delivery
Three distinctive signs of labor
1. Uterine contractions every 5 minutes
2. Rupture of the membranes: leak of fluids
3. Bloody show: passage of mucous plug of
cervix when cervix dilates
Other signs
• Diarrhea
• Backache
• Increased Braxton-Hicks contractions
Three Stages of Labor
Dilation Through Stages of Labor
Labor Support During Childbirth
Nondrug strategies:
• Comfort measures
• Mental strategies
• Medication
Pain Relief in Childbirth
• Tranquilizers and analgesics
• Anesthetics
– Epidural: injected through a catheter
beside the spinal cord
– Spinal: injected directly into the spinal
canal
– Pudendal: injected into area around the
vagina and perineum
Cesarean Delivery
• Surgical incisions made in both the wall of the
mother’s abdomen and her uterus
• Reasons for Cesarean delivery
– Fetal distress
• Abruptio placentae
• Prolapsed umbilical cord
– Cephalopelvic disproportion
– Fetal position
– Multiple births
– Obstruction, including placenta previa
– “Failure to progress”
– Maternal infections
Cesarean Delivery Rates
Total Cesarean rates for first births, United States,
1991–2007.
Breastfeeding
The Female Breast
Benefits of Breastfeeding
For baby
• Breast milk is highly nutritious
• Breast milk contains enzymes to aid in infant
digestion
• Breast milk contains antibodies to protect against
infection
• Fewer infant episodes of diarrhea
• Fewer infant cases of upper respiratory, ear, and
urinary infections
• Protects against type 1 diabetes, Crohn’s disease,
SIDS, chronic digestive disease, childhood cancers
Benefits of Breastfeeding
For mother
• Uterus returns to normal size more quickly
• Return to prepregnancy weight more quickly
• Lower risk of ovarian and breast cancer,
osteoporosis
Optimizing Breastfeeding
Promotion of breastfeeding
• Education and support for new mothers
• Worksite support
• Address sociocultural, racial, and ethnic
disparities
• Address geographical variances
Complications of Breastfeeding
A mother should not breastfeed if she:
• Is HIV infected
• Is an untreated active TB patient
• Uses alcohol, tobacco, or other drugs
(including certain medications)
• Is undergoing cancer therapy/radiation
treatment
Complications of Breastfeeding
Mothers may experience difficulties if:
•
•
•
•
•
Nipples are Inverted, flat, raw, or cracked
Breasts are severely swollen
Infant is having problems latching-on
There is pain during latch-on
There is mastitis or thrush
Infertility
• Fercundity – a woman’s ability to have a
child
• Impaired fercundity- a woman who
although is having regular sexual relations
without contraception for 36 months or
more fails to become pregnant
Infertility Causes
• Female infertility = 25% to 35% of
couples
– Ovulation disorder
• Male infertility = 25% to 35% of couples
– Azoospermia, oligospermia
Diagnosis
• Ovulation test, cervical mucus test, postcoital
test
• Blood test for hormone levels
• Hysterosalpingogram, laparoscopic surgery
• Semen analysis
Infertility Treatment
• Improve quality of cervical mucus =
estrogen, prednisone
• Stimulate ovulation = Clomid, GnRH
• Surgery to open blocked sperm ducts or
repair a varicocele
• Artificial Insemination (AI)
Infertility Treatment
• Assisted reproductive technologies
(ART)
– In vitro fertilization (IVF)
– Gamete intrafallopian transfer (GIFT)
– Zygote intrafallopian transfer (ZIFT)
– Intracytoplasmic sperm injection (ICSI)
– Egg donation
– Embryo transfer
– Host uterus
– Surrogacy
Emotional Effects of Infertility
• Anger and resentment toward partner
• Guilt and blame toward self
• Depression and frustration
• Miscommunication
• Confusion
• Grief
• Despair
• Loss of control
ART Cycles and Live-Birth Outcomes
Epidemiology
Maternal Mortality
Infant Mortality
Leading causes: congenital malformations, disorders
relating to short gestation and low birth weight, SIDS
Breastfeeding
Rates are increasing but fail
to meet national objectives.
DHHS, 2011
Fertility
• Denotes successful childbearing
• Trends:
– More women in their 40s are childless
– Women are having fewer children
– Hispanic women have more children than other groups
– Unemployed women have more babies than working
women
– One fourth of all women who had a child in past year
were living below poverty level
Infertility
• Defined as not being able to get pregnant after
trying for one year
• 2% prevalence
• ART is associated with risk of multiple births
Informed Decision Making
• Regular prenatal care—proper nutrition;
adequate exercise; avoidance of alcohol, drugs,
and tobacco
• Childbirth—preparation
• Breastfeeding—learned behavior, adjusting
positions, anticipating the infant’s hunger,
relaxing during feeding
• Infertility—information, support, and procedures
to address infertility issues