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Preparation for Labor and
How Labor is induced?
• Your due date came and went a week and a
half ago. Your telephone rings constantly
and every time you answer it, a friend or
relative exclaims, "You're still home!" These
last few days seem longer than the previous
nine months. Your practitioner told you at
this week's appointment that if you haven't
gone into labor by next week, you will need
to be admitted to the hospital so labor can
be induced. Emotionally, you're relieved to
have an end to the waiting in sight, but you
wonder whether inducing labor is necessary
Because no one really understands how
normal labor starts, we are at a loss to
explain why some labors don't start until
weeks after the due date. This would not be
of concern, except that after nine months of
pregnancy have passed, the placenta often
fails to keep up with the growing oxygen
and nutritional needs of the overdue baby.
In fact, the mortality rate of babies born
after 43 weeks is double that of those born
on time. After 44 weeks, the mortality rate
is triple the normal rate. That is why most
practitioners are extremely reluctant to
allow pregnancies to continue much past 42
Antepartum testing determines which babies
are at highest risk for difficulties before and
during labor. Most practitioners routinely
recommend such testing after 41 weeks. It
includes a non-stress test and a biophysical
profile performed during an ultrasound exam. If
this testing reveals abnormalities, induction of
labor is recommended. Even if the test results
are normal, induction is recommended at 42
How is labor induced? There are a variety of
methods, used alone or in combination, which
can induce labor. If the cervix is more than
slightly dilated, the simplest way is to rupture
the membranes artificially. Most women will go
• There are a number of disadvantages to using
this method alone, however. First, not all
women will go into labor. Second, as soon as
the membranes are ruptured, the potential
exists for chorioamnionitis, infection of the
membranes and amniotic fluid. This type of
infection affects the mother as well as the baby.
The risk of infection increases over time. There
is not much chance for infection to occur if the
labor is well along and the delivery will happen
within the next few hours. However, if labor has
not even started, the delivery may not take
place for 24 hours or more, which significantly
raises the possibility of infection.
Chorioamnionitis can be treated with
The second method of inducing labor is the
use of Prostaglandin gel. This technique
became available only a few years ago, but it
has become popular very quickly. Prostaglandin
gel contains one type of the hormone
prostaglandin, which naturally causes the cervix
to soften and thin out in preparation for labor.
Prostaglandin gel may even stimulate mild
contractions and, for some women, this is
enough to start labor.
Prostaglandin gel is applied directly to the
cervix during a cervical exam. Because of its
potential to cause contractions, it is usually
applied in the hospital setting and the baby is
monitored for several hours thereafter. If no
Prostaglandin gel may stimulate labor
alone, but more commonly it is used in
conjunction with Pitocin. Pitocin is the
synthetic version of the naturally
occurring hormone oxytocin, which
causes uterine contractions. The
advantage of giving prostaglandin gel
first is that the cervix tends to become
thinner and even slightly dilated after
the gel is applied, making the Pitocin
more likely to be effective at smaller
doses. Pitocin is administered initially in
minute quantities, and the amount is
The fetus is monitored during
administration of Pitocin to make
sure that the amount given does not
cause the baby stress or contractions
that are too frequent. If labor has not
started within 12 to 24 hours after
application of prostaglandin gel, the
mother is readmitted to hospital to
receive Pitocin through an
intravenous line.
Are there disadvantages to Pitocin? Some
practitioners believe that Pitocin causes
stronger contractions than those that occur
naturally. Most research suggests, however,
that Pitocin-induced contractions are very
similar to those of normal active labor. The
potential does exist to cause contractions
that are more frequent than naturally
occurring contractions and, therefore, these
contractions may be more stressful for the
baby. That's why careful monitoring is
essential during administration of Pitocin. It
is easy to decrease the frequency of
contractions just by lowering the dose of
The disadvantages must be
weighed against the risks, of course.
It would be inappropriate to induce
labor just to have the delivery occur
on a convenient date. The use of
Pitocin for induction is justified only if
the baby is at significant risk for
serious problems, either because an
abnormality has been found on
antepartum testing, or because the
• There are other, less common
reasons for inducing labor. These
include preeclampsia, gestational
diabetes (but not before 38 weeks),
and intrauterine growth
retardation (IUGR) if the fetus is in
less than the 10th percentile for
gestational age. In the case of pre-
eclampsia, induction is performed to
treat the mother. In the case of
Step 1:

• comfortable birthing clothes (if your caregiver

isn't already providing you one.)
• clothes to change into for after the birth .
• snacks (if your caregiver will allow you to
bring some)
• relaxing music- mp3/cd player
• books/magazines
• massage lotions, oils (try Aveda's Blue Oil it's
my favorite)
• Nursing bra
Step 2:
• Pads for bleeding
• Toothbrush, hair brush, shampoo,
conditioner, etc.
• Numbers of relatives to call
• Camera/video camera
• Newborn diapers
• Burp cloths
• Baby blankets
• Baby new born hat
Step 3:
• Newborn onesies- baby's coming home outfit
• Car seat
• And anything else that would make you feel
If you are delivery your baby in a hospital and
have specific request about how you would
like your delivery to 'run' make sure to create
a detailed 'birthing plan' that you can give to
your doctor and nurses to follow. Many
mothers have specific requests that may not
be met that make a birthing plan necessary
for a happy, successful experience delivering
Hormonal Changes
• Levels of progesterone and oestrogens rise
continually throughout pregnancy, suppressing the
hypothalamic axis and subsequently the menstrual
cycle. The woman and the placenta also produce
many hormones. Prolactin levels increase due to
maternal Pituitary gland enlargement by 50%.
This mediates a change in the structure of the
Mammary gland from ductal to lobular-alveolar.
Parathyroid hormone is increased due to
increases of calcium uptake in the gut and
reabsorption by the kidney. Adrenal hormones such
as cortisol and aldosterone also increase.
Placental lactogen is produced by the placenta
and stimulates lipolysis and fatty acid metabolism
Musculoskeletal changes
• The body's posture changes as the pregnancy
progresses. The pelvis tilts and the back arches to
help keep balance. Poor posture occurs naturally from
the stretching of the woman's abdominal muscles as
the fetus grows. These muscles are less able to
contract and keep the lower back in proper alignment.
The pregnant woman has a different pattern of gait.
The step lengthens as the pregnancy progresses, due
to weight gain and changes in posture. On average, a
woman's foot can grow by a half size or more during
pregnancy. In addition, the increased body weight of
pregnancy, fluid retention, and weight gain lowers the
arches of the foot, further adding to the foot's length
and width. The influences of increased hormones such
Physical Changes
• One of the most noticeable alterations in pregnancy is
the gain in weight. The enlarging uterus, the growing
fetus, the placenta and liquor amnii, the acquisition
of fat and water retention, all contribute to this
increase in weight. The weight gain varies from person
to person and can be anywhere from 5 pounds
(2.3 kg) to over 100 pounds (45 kg). In America , the
doctor-recommended weight gain range is 25 pounds
(11 kg) to 35 pounds (16 kg), less if the woman is
overweight, more (up to 40 pounds (18 kg)) if the
woman is underweight Other physical changes during
pregnancy include breasts increasing two cup sizes.
Also areas of the body such as the forehead and
cheeks (known as the 'mask of pregnancy') become
darker due to the increase of melanin being
produced.The female body experiences many changes
as the fetus grows through each trimester as shown
and discussed in this pregnancy video. Two women
at different stages in their pregnancy illustrate what
Cardiovascular Changes
• Blood volume increases by 40% in the first two
trimesters. This is due to an increase in plasma
volume through increased aldosterone. Progesterone
may also interact with the aldosterone receptor, thus
leading to increased levels. Red blood cell numbers
increase due to increased erythropoietin levels..
Cardiac function is also modified, with increase heart
rate and increased stroke volume. A decrease in vagal
tone and increase in sympathetic tone is the cause.
Blood volume increases act to increase stroke volume
of the heart via Starling's law. After pregnancy the
change in stroke volume is not reversed. Cardiac
output rises from 4 to 7 liters in the 2nd trimester.
Blood pressure also fluctuates. In the first trimester it
falls. Initially this is due to decreased sensitivity to
angiotensin and vasodilation provoked by increased
blood volume. Later, however, it is caused by
Respiratory Changes
• Decreased functional residual capacity is
seen, typically falling from 1.7 to 1.35 litres,
due to the compression of the diaphragm by
the uterus. Tidal volume increases, from
0.45 to 0.65 litres, giving an increase in
pulmonary ventilation. This is necessary to
meet the increased oxygen requirement of
the body, which reaches 50ml/min, 20ml of
which goes to reproductive tissues.
Progesterone may act centrally on
chemoreceptors to reset the set point to
a lower partial pressure of carbon dioxide.
This maintains an increased respiration rate
even at a decreased level of carbon dioxide.
Metabolic Changes
• An increased requirement for
nutrients is given by fetal growth and
fat deposition. Changes are caused
by steroid hormones, lactogen, and
cortisol. Maternal insulin resistance
can lead to gestational diabetes.
Increase liver metabolism is also
seen, with increased
gluconeogenesis to increase
maternal glucose levels.
Renal Changes

• Renal plasma flow increases, as does

aldosterone and erthropoietin
production as discussed. The tubular
maximum for glucose is reduced,
which may precipitate gestational
• Now that you're pregnant, taking care
of yourself has never been more
important. Of course, you'll probably
get advice from everyone — your
doctor, family members, friends, co-
workers, and even complete strangers
— about what you should and shouldn't
be doing. But staying healthy during
pregnancy depends on you, so it's
crucial to arm yourself with information
about the many ways to keep you and
• Back pain - A particularly common
complaint in the third trimester when
the patient's center of gravity has
• Constipation - A complaint that is
caused by decreased bowel motility
secondary to elevated
progesterone (normal in
pregnancy), which can lead to
greater absorption of water.
• Braxton Hicks Contractions -
Occasional, irregular, and often
painless contractions that occur
several times per day.
• Edema (swelling) - Common
complaint in advancing pregnancy.
Caused by compression of the
inferior vena cava (IVC) and pelvic
veins by the uterus leads to
increased hydrostatic pressure in
• Regurgitation, heartburn, and
nausea - Common complaints that
may be caused by
Gastroesophageal Reflux Disease
(GERD); this is determined by
relaxation of the lower esophageal
sphincter (LES) and increased
transit time in the stomach (normal
in pregnancy), as well as by
increased intraabdominal pressure,
• Hemorrhoids - Complaint that is
often noted in advancing pregnancy.
Caused by increased venous stasis
and IVC compression leading to
congestion in venous system, along
with increased abdominal pressure
secondary to the pregnant space-
occupying uterus and constipation.
• Pelvic girdle pain - PGP disorder is
complex and multi-factorial and likely to
be represented by a series of sub-
groups with different underlying pain
drivers from peripheral or central
nervous system, altered laxity/stiffness
of muscles, laxity to injury of
tendinous/ligamentous structures to
‘mal-adaptive’ body mechanics.
Musculo-Skeletal Mechanics involved in
gait and weightbearing activities can
be mild to grossly impaired. PGP can
begin peri or postpartum. There is pain,
• Increased urinary frequency - A
common complaint referred by the
gravida, caused by increased
intravascular volume, elevated GFR
(glomerular filtration rate), and
compression of the bladder by the
expanding uterus.
• Varicose veins - Common complaint
caused by relaxation of the venous
smooth muscle and increased
What is a Teratogen?
• A teratogen is an agent, which can
cause a birth defect. It is usually
something in the environment that
the mother may be exposed to
during her pregnancy. It could be a
prescribed medication, a street drug,
alcohol use, or a disease present in
the mother which could increase the
chance for the baby to be born with a
birth defect.
What are the most
sensitive periods for
• Once the egg is fertilized
(conception), it takes about six to
nine days for implantation (anchoring
into the uterus) to occur. Once the
fertilized egg is connected to the
uterus, a common blood supply
exists between the mother and the
embryo. In other words, if something
is in the mother's blood, it can now
cross over to the developing fetus.
Teratogens are thought to have the
During the development of a baby,
there are certain organs forming at
certain times. If a teratogen has the
potential to interfere with the closure of
the neural tube, for example, the
exposure to the teratogen must occur
in the first 3.5 to 4.5 weeks of the
pregnancy, since this is when the
neural tube is closing. There are some
organ systems that are sensitive to
teratogens throughout the entire
The central nervous system is the
baby's brain and spine. One
teratogen that affects the central
nervous system is alcohol. Alcohol, at
any time during the pregnancy, has
the potential to cause birth defects
and health problems in the baby,
since the central nervous system is
sensitive to teratogens the entire
nine months of gestation. This is why
alcohol consumption should be
• A balanced, nutritious diet is an
important aspect of a healthy
pregnancy. Eating a healthy diet,
balancing carbohydrates, fat, and
proteins, and eating a variety of
fruits and vegetables, usually
ensures good nutrition. Those whose
diets are affected by health issues,
religious requirements, or ethical
beliefs may choose to consult a
• Adequate periconceptional folic acid (also
called folate or Vitamin B9) intake has been
proven to limit fetal neural tube defects,
preventing spina bifida, a very serious
birth defect. The neural tube develops
during the first 28 days of pregnancy,
explaining the necessity to guarantee
adequate periconceptional folate intake.
Folates (from folia, leaf) are abundant in
spinach (fresh, frozen, or canned), and are
also found in green vegetables, salads,
citrus fruit and melon, chickpeas (i.e. in the
form of hummus or falafel), and eggs. In
the United States and Canada , most wheat
• DHA omega-3 is a major structural
fatty acid in the brain and retina, and
is naturally found in breast milk. It is
important for a mother to consume
adequate amounts of DHA during
pregnancy and while nursing to
support her well-being and the health
of her infant. Developing infants
cannot produce DHA efficiently, and
must receive this vital nutrient from
the mother through the placenta
• Several micronutrients are
important for the health of the
developing fetus, especially in areas
of the world where insufficient
nutrition is prevalent. In developed
areas, such as Western Europe and
the United States, certain nutrients
such as Vitamin D and calcium,
required for bone development, may
require supplementation.
• Dangerous bacteria or parasites may
contaminate foods, particularly listeria and
toxoplasma, toxoplasmosis agent.
Careful washing of fruits and raw vegetables
may remove these pathogens, as may
thoroughly cooking leftovers, meat, or
processed meat. Soft cheeses may contain
listeria; if milk is raw the risk may increase.
Cat feces pose a particular risk of
toxoplasmosis.. Pregnant women are also
more prone to catching salmonella
infections from eggs and poultry, which
should be thoroughly cooked. Practicing
• Move daily - Mommies-to-be can
engage in most exercises with few
worries. Once your doctor gives you the
green light, move as much as you can.
The American College of Obstetrics and
Gynecology recommends 30 minutes or
more of moderate-intensity activity
each day.
• Warm up to fitness - Warming up
muscles and joints prepares your body
for exercise and prevents strains and
injuries. Begin your workout with a few
• Keep it fresh - Stay psyched for fitness
by linking exercise with a fun pastime.
Walking is one of the best
cardiovascular exercises for pregnant
women since it's easy on joints and
muscles. Swimming also is ideal
because it provides a total-body
workout and the weightless effect of the
water makes it easier to move with
extra pounds. Yoga and stretching
maintain muscle tone and flexibility and
lull your body into a state of relaxation,
while dancing and low-impact aerobics
• Exercise caution - Avoid any activities
that could make you slip or fall, risking
injury to your abdomen. No bicycling,
roller-blading, horse-back riding, break
dancing or contact sports like football
and basketball. After your first
trimester, avoid lying on your back to
exercise, which can make you dizzy.
Drink plenty of water before, during and
after your workout to avoid dehydration
and skip outdoor activities in hot and
humid weather, otherwise you risk
overheating and harming the baby.
• Go for gain without pain - Ideal
exercise gets you in shape without
putting excessive stress on you or
your baby, so don't push yourself to
the limit. If you can't comfortably
carry on a conversation, slow down
and ease up. If you experience pain,
dizziness, shortness of breath, severe
headache, vaginal bleeding or
contractions during your workout,
Schedule of
Clinic Visit
Visit Schedule
• 6 weeks = First diagnosed pregnancy. First visit in
clinic to discuss:
= optional blood tests / confirmation
= urine tests are accurate IF showing positive (not
very useful in negative)
• ~ 8 weeks = Prenatal visit #1
= Prenatal physical and Antenatal form (paperwork)
• ~ 10 weeks = Prenatal visit #2
= Screening for genetic / birth defects discussion
= generally the Integrated Prenatal Screen (IPS) is
recommended; for certain populations (age, family
history) an amniocentesis would be offered.
• Second Trimester (14 to 28 weeks)
For most women, this trimester
consists of simple visits to the doctor
every 4 weeks or so. We should be able
to detect a fetal heart rate in office
starting approximately 14-16 weeks
and we welcome your spouse to attend
if they wish to listen. Around 19 weeks
is when the “quickening” happens
which is when you begin to notice fetal
Visit Schedule
• ~ 14 weeks = Prenatal visit # 3
= the last time dependent visit, here we
order your next stage of IPS#2 which
must be done between 15-17.5 weeks.
= we also generally order the 2nd
trimester ultrasound (not part of IPS) .
• (15-17.5 weeks) = IPS#2 bloodwork
(18-21 weeks) = 2nd trimester
• ~ every 4 weeks = Prenatal Visits
= (18, 22, 26 weeks approximately)
• Also, as soon as possible in the 2nd trimester,
we would like to get you set up to see the
obstetrician. For routine prenatal care in our
region (where there are only 9 obstetricians);
they specialists will take over at approximately
24-28 weeks (end of 2nd trimester). In fact, for
patients without a family physician, there is a
special walk-in clinic for obstetrical care only
based out of the hospital.
• Third Trimester (28+ weeks)
Visits will generally be taken over by the
obstetrician. Expect to attend visits every 2
weeks until the last month when visits are on a
weekly basis. It gets busy. Even busier when the
baby arrives.
• Measles Contraindicated No known
fetal effects, but theoretical
increased risk of preterm labour and
low birthweight with live vaccine.
• Mumps Contraindicated
• Rubella Contraindicated
• Varicella Contraindicated No known
fetal effects. Not reason for
• Varicella zoster immunoglobulin to be
considered if pregnant woman
exposed to virus .
• Poliomyelitis Sabin/ Salk To be
considered in high-risk situations .
• Consider if pregnant woman needs
immediate protection (high-risk
situation/travel) No known fetal
effects .
• Yellow fever generally
contraindicated unless high-risk
• No data on fetal safety, although
fetuses exposed have not
demonstrated complications.
• If travel to high-risk endemic area
unavoidable, suggest vaccination
• Influenza Indicated in pregnancy,
primarily for protection at 20 weeks
• No adverse effects in over 2000 fetuses
• Influenza may be associated with
greater morbidity in pregnancy, so
immunization recommended.
• Rabies No indication of fetal anomalies .
• Risks from inadequate treatment
• Pregnancy not contraindication to post-
exposure prophylaxis
• Vaccinia Contraindicated Has been
• Hepatitis A Low theoretical risk
Appropriate in the presence of medical
• Hepatitis B No apparent fetal risk
Vaccine recommended for pregnant
women at risk
• Pneumococcus Indicated in high-risk
• No safety data available, but no
adverse effects reported; high-risk
patients should therefore be vaccinated
• Vaccine to be administered using
same guidelines as for non-pregnant
• Cholera No data on safety To be used
if high-risk situation only (e.g.,
• Plague No data on safety Vaccination
to be considered only if benefits
outweigh risk
• Some preparations are live
• No data on safety To be considered
only in high-risk cases (e.g., travel to
endemic areas)
• Diphtheria/tetanus No evidence of
• Susceptible women to be vaccinated
as per general guidelines for non-
pregnant patients.
• Japanese encephalitis (inactivated
Japanese encephalitis vaccine).
• No data on safety Not to be given
routinely in pregnancy, as theoretical
risk exists .
• Consider only if travel where risk
exposure is high (benefit risk).
The Complete All
Around Travel

• Talk to your doctor about your travel

plans, you may need your prenatal
chart and a reference to a doctor at
your destination.
• Make sure your travel insurance
covers your pregnancy. This may
mean paying extra premiums.
• Take plenty of water and sick bags
for the journey. If travelling by car,
make sure there are plenty of regular
stops at services so you can stretch
your legs and visit the bathroom. If
travelling by plane book a seat near
the middle of the plane over the wing
for a smooth ride and pick out an
aisle seat to ensure you can easily
get up and walk about.
• If travelling by plane check with the
airlines beforehand to make sure you
will be able to fly both on the way
there and on the way back. Most
airlines refuse boarding for anyone
over 35 weeks pregnant if not before.
This can also be true of ferries.
On The Journey
• Drink plenty of fluids to stay
hydrated during your trip and make
sure you can visit the bathroom
• Make sure you can get up and move
around freely during your journey. If
not make sure there are plenty of
regular stops along the way so you
can get out and move around.  While
sitting down, rotate your ankles and
wiggle your toes.
• Avoid heavy meals, greasy food and
caffeinated beverages. Eat light
snacks like fruit to settle your
On Holiday
• Make sure you have your referred
doctor’s contact details, your
insurance policy, your prenatal chart
and your EH1C card with you (If you
are a UK resident) at all times.
• Carry an emergency contact list with
you at all times so people know who
to call if anything happens.
• Either get a list of local hospitals
from the tourist information centre
or, if you have a doctor assigned to
you, make sure you have an address
to go to in an emergency.
•  Wear a very high sunscreen factor
and avoid staying in the sun for too
• Avoid insect repellents containing
DEET, try natural alternatives
• Do not engage in diving, water sports
or other such activities.
Safety Concerns
• It is perfectly safe to wear your seat
belt whilst pregnant and studies have
shown it to be much more beneficial
considering the risks involved. Tuck the
lap belt under your stomach with the
shoulder strap over your bump.
• Car airbags are perfectly safe so don’t
disable them. You may want to move
back a little from the dashboard though
to make room for your bump.
• You cannot get radiation poisoning from
plane travel in any way. Metal detectors
do not use x-rays and are perfectly
harmless for you and your baby.
Luggage scanners are focused so you
can’t be exposed to any radiation by
standing near them, you would have to
put your hand directly inside the
machine to become exposed. Finally,
cosmic radiation exposure during flight
is minimal and perfectly safe; you can
even travel by plane up to 200 hours
during the length of your pregnancy.
Sexual Relations
• Most pregnant women can enjoy sexual
intercourse throughout gravidity. Most
research suggests that, during
pregnancy, both sexual desire and
frequency of sexual relations decrease.
In context of this overall decrease in
desire, some studies indicate a second-
trimester increase, preceding a
decrease. However, these decreases
are not universal: a significant number
of women report greater sexual
Sex during pregnancy is a low-risk
behaviour except when the physician
advises that sexual intercourse be
avoided, because it may, in some
pregnancies, lead to serious
pregnancy complications or health
issues such as a high-risk for
premature labour or a ruptured
uterus. Such a decision may be
based upon a history of difficulties in
Some psychological research studies in the
1980s and '90s contend that it is useful for
pregnant women to continue to have sexual
activity, specifically noting that overall sexual
satisfaction was correlated with feeling happy
about being pregnant, feeling more attractive in
late pregnancy than before pregnancy and
experiencing orgasm. Sexual activity has also
been suggested as a way to prepare for induced
labour; some believe the natural prostaglandin
content of seminal liquid can favour the
maturation process of the cervix making it more
flexible, allowing for easier and faster dilation
and effacement of the cervix. However, the
efficacy of using sexual intercourse as an
During pregnancy, the fetus is
protected from penetrative thrusting
by the amniotic fluid in the womb
and by the woman's cervix.
After giving birth sexual
intercourse can begin when the
couple are both ready. However most
couples wait until after six weeks and
they should consult their GP if they
have any concerns.
Stages of
• The baby goes through a lot of
changes over the course of her nine
months inside your uterus. Here is a
brief look at just some of the fetal
development changes that occur
over those many months. Click on
the links in each heading to see color
photos of how the baby grows and
Week 2
• Although this is considered to be the
second week of your pregnancy, you
are not actually 2 weeks pregnant yet.
During this week, your body will release
an egg. As it travels down the fallopian
tube, it will be met by your partner's
sperm and fertilization will take place.
The fertilized egg, now known as a
zygote, will then continue traveling
down the fallopian tubes finally
reaching the uterus three to four days
Week 4
• By the time you are four weeks
pregnant, the fertilized egg will have
implanted itself into your uterine
lining. At this point, the zygote is now
known as an embryo. After
implantation, the embryo begins to
divide itself into two: one part of it
will develop into the placenta while
the other will go on to become your
Week 6
• During the sixth week of your
pregnancy, your baby's heart will
begin to beat and blood will start to
circulate throughout his body. His
umbilical cord will also start to form,
as will his head, eyes, intestines and
Week 10
• This week marks the end of the
embryonic stage of development. For
the rest of your pregnancy, your baby
will be known as a fetus. Your baby's
external genitalia begin to form this
week while her facial features as well as
limbs become more apparent. By the
end of the week, your baby's vital
organs will not only be formed but will

Week 14
• Now that you are 14 weeks pregnant,
you have officially started your second
trimester. The risk of miscarriage is
significantly decreased at this point. In
addition to your baby's reproductive
organs developing, your baby will also
begin to grow some hair as well as form
eyelids, fingernails and toenails. You
may even be able to feel your baby
Week 18
• By the time your are 18 weeks
pregnant, your baby's finger and toe
pads will have formed, which means the
fingerprints won't be far behind. The
bones in your baby's inner ear will have
developed enough by this point that he
may start responding to loud outside
sounds. Additionally, your baby could
weigh as much as 7 ounces now and
Week 22
• Your baby’s sense are so developed
by the time you are 22 weeks
pregnant that she is likely to starting
experimenting. Don’t be surprised to
if you see her sucking her thumb on
an ultrasound. Your baby’s sweat
glands also begin to develop this
week while her brain begins to
quicken its development.

Week 26
• During this week, development of the
retinas will finish and your baby’s eyes
will begin to open and even blink. If
your baby were born now, he would
have a 50% chance of survival with
proper medical care. This week also
marks the end of your second trimester.
Next week, when you are 27 weeks
pregnant, you will officially be in your
Week 30
• As your baby begins practicing how
to breathe this week, she may end
up with a case of the hiccups if she
swallows too much amniotic fluid.
Your baby is also putting on more
body fat, which will help keep her
warm when she is born. Although
your baby would be premature if she
was born now, she would have a
good chance of surviving.
Week 40
• This is the official end of the
gestational period. Even though your
baby is ready and able to live outside
of you, it is perfectly normal for your
baby to arrive as much as two weeks
after his due date.
Menstrual cycle

• The menstrual cycle is a cycle of

physiological changes that occurs in
fertile females. Overt menstruation
(where there is blood flow from the
vagina) occurs primarily in humans and
close evolutionary relatives such as
chimpanzees. Females of other species
of placental mammal undergo estrous
cycles, in which the endometrium is
completely reabsorbed by the animal
(covert menstruation) at the end of its
• Menstruation is also called menstrual
bleeding, menses, catamenia or a
period. The flow of menses normally
serves as a sign that a woman has not
become pregnant. (However, this
cannot be taken as certainty, as a
number of factors can cause bleeding
during pregnancy; some factors are
specific to early pregnancy, and some
can cause heavy flow.) During the
reproductive years, failure to
menstruate may provide the first
indication to a woman that she may
• Eumenorrhea denotes normal, regular
menstruation that lasts for a few days (usually 3
to 5 days, but anywhere from 2 to 7 days is
considered normal). The average blood loss
during menstruation is 35 milliliters with 10–80
ml considered normal. (Because of this blood
loss, women are more susceptible to iron
deficiency than are men.) An enzyme called
plasmin inhibits clotting in the menstrual fluid.
Cramping in the abdomen, back, or upper
thighs is common during the first few days of
menstruation. When menstruation begins,
symptoms of premenstrual syndrome (PMS)
such as breast tenderness and irritability
generally decrease. Many sanitary products are
Follicular phase
• This phase is also called the proliferative phase
because a hormone causes the lining of the
uterus to grow, or proliferate, during this time.
• Through the influence of a rise in follicle
stimulating hormone (FSH) during the first days
of the cycle, a few ovarian follicles are
stimulated. These follicles, which were present
at birth and have been developing for the better
part of a year in a process known as
folliculogenesis, compete with each other for
dominance. Under the influence of several
hormones, all but one of these follicles will stop
growing, while one dominant follicle in the
ovary will continue to maturity. The follicle that
reaches maturity is called a tertiary, or
• As they mature, the follicles secrete
increasing amounts of estradiol, an
estrogen. The estrogens initiate the
formation of a new layer of
endometrium in the uterus,
histologically identified as the
proliferative endometrium. The
estrogen also stimulates crypts in the
cervix to produce fertile cervical
mucus, which may be noticed by

• When the egg has nearly matured, the level of

estradiol in the body has increased enough to
trigger a sudden release of luteinizing hormone
(LH) from the anterior pituitary gland. In the
average cycle this LH surge starts around cycle
day 12 and may last 48 hours. The release of LH
matures the egg and weakens the wall of the
follicle in the ovary, causing the fully developed
follicle to release its secondary oocyte. The
secondary oocyte promptly matures into an
ootid and then becomes a mature ovum. The
mature ovum has a diameter of about 0.2 mm.
Which of the two ovaries—left or right—ovulates
appears essentially random; no known left/right
co-ordination exists. Occasionally, both ovaries
• After being released from the ovary, the egg is
swept into the fallopian tube by the fimbria,
which is a fringe of tissue at the end of each
fallopian tube. After about a day, an unfertilized
egg will disintegrate or dissolve in the fallopian
• Fertilization by a spermatozoon, when it occurs,
usually takes place in the ampulla, the widest
section of the fallopian tubes. A fertilized egg
immediately begins the process of
embryogenesis, or development. The developing
embryo takes about three days to reach the
uterus and another three days to implant into the
endometrium. It has usually reached the
blastocyst stage at the time of implantation.
Luteal phase
• The luteal phase is also called the
secretory phase. An important role is
played by the corpus luteum, the solid
body formed in an ovary after the egg
has been released from the ovary into
the fallopian tube. This body continues
to grow for some time after ovulation
and produces significant amounts of
hormones, particularly progesterone.
Progesterone plays a vital role in
making the endometrium receptive to
implantation of the blastocyst and
supportive of the early pregnancy; it
• After ovulation, the pituitary hormones FSH and LH
cause the remaining parts of the dominant follicle to
transform into the corpus luteum, which produces
progesterone and estrogens. The hormones produced
by the corpus luteum also suppress production of the
FSH and LH that the corpus luteum needs to maintain
itself. Consequently, the level of FSH and LH fall
quickly over time, and the corpus luteum
subsequently atrophies. Falling levels of progesterone
trigger menstruation and the beginning of the next
cycle. From the time of ovulation until progesterone
withdrawal has caused menstruation to begin, the
process typically takes about two weeks, with ten to
sixteen days considered normal. For an individual
woman, the follicular phase often varies in length from
cycle to cycle; by contrast, the length of her luteal
phase will be fairly consistent from cycle to cycle.

• The loss of the corpus luteum can be prevented by

fertilization of the egg; the resulting embryo produces
human chorionic gonadotropin (hCG), which is very
similar to LH and which can preserve the corpus
luteum. Because the hormone is unique to the
Leopold’s Maneuver

• Leopold's Maneuvers are a common and systematic

way to determine the position of a fetus inside the
woman's uterus; they are named after the
gynecologist Christian Gerhard Leopold.
• The maneuvers consist of four distinct actions, each
helping to determine the position of the fetus. The
maneuvers are important because they help
determine the position and presentation of the fetus,
which in conjunction with correct assessment of the
shape of the maternal pelvis can indicate whether the
delivery is going to be complicated, or whether a
Cesarean section is necessary.
• The examiner's skill and practice in performing the
maneuvers are the primary factor in whether the fetal
lie is correctly ascertained, and so the maneuvers are
not truly diagnostic. Actual position can only be
determined by ultrasound performed by a competent
• Procedure in LM
• The health care provider should first
ensure that the woman has recently
emptied her bladder. If she has not, she
may need to have a straight urinary
catheter inserted to empty it if she is
unable to micturate herself. The woman
should lie on her back with her
shoulders raised slightly on a pillow and
her knees drawn up a little. Her
abdomen should be uncovered, and
most women appreciate it if the
First maneuver

• While facing the woman, palpate the

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

• After the upper abdomen has been palpated

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

• In the third maneuver the health care provider

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

• The last maneuver requires that the

health care provider face the woman's
feet, as he or she will attempt to locate
the fetus' brow. The fingers of both
hands are moved gently down the sides
of the uterus toward the pubis. The side
where there is the resistance to the
descent of the fingers toward the pubis
is greatest is where the brow is located.
If the head of the fetus is well flexed, it
should be on the opposite side from the
fetal back. If the fetal head is extended
though, the occiput is instead felt and is
Anatomy and Physiology
The function of the external female reproductive structures (the genital) is
twofold: To enable sperm to enter the body and to protect the internal
genital organs from infectious organisms. The main external structures of
the female reproductive system include:

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

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

• Exercising regularly is beneficial because it

helps build your bones and muscles,
increases your energy level, and keeps you
healthy. Exercise during pregnancy has the
added benefit of helping you look and feel
your best at a time when you're
experiencing many changes in your body.
• Read the following information from the
American College of Obstetricians and
Gynecologists and learn how pregnancy
affects your ability to exercise and how
The Benefits of
Pregnancy Exercise
Exercising and staying active during your pregnancy can help
you with some of the symptoms of pregnancy like feeling
tired and sluggish, and gaining too much weight. Exercise
during pregnancy is beneficial because it:

• Reduces backaches, constipation, bloating, and swelling

• Increases energy and stamina
• Lifts your spirits and balances your mood
• Improves posture
• Helps build better muscle tone and strength
• Promotes better sleep
• Gives you a sense of control and self-confidence
• Provides you with time for yourself to do something for
• Gives you the opportunity to do some socializing. A
• In addition to keeping you fit and
healthy now, regular activity during
pregnancy also helps improve your
ability to cope with the rigors of
labor. And after baby is born, it is
easier for you to get back in shape if
you've been staying fit all along.
While moderate and pregnancy-safe
exercises are good for you, it's not
advisable that you exercise for
Pregnancy Changes

• Joints
Due to pregnancy hormones, the ligaments that
support your joints become more relaxed. Because of
this added mobility in your joints, your risk of injury
increases. For this reason, you should avoid bouncy,
high-impact or jerky exercises.
• Balance
As your pregnancy progresses, the extra weight in
your belly shifts your center of gravity and stresses
your joints and muscles — particularly those in the
pelvis and lower back. The result is greater instability,
back pain, loss of balance, and increased risk of
• Heart Rate
because your weight increases during pregnancy, your
heart has to work harder. Exercise increases your
• the identification of the nature of anything,
either by process of elimination or
other analytical methods. Diagnosis is used
in many different disciplines, with slightly
different implementations on the application
of logic and experience to determine
the cause and effect relationships. Below
are given as examples and tools used by the
respective professions in medicine, science,
engineering, business. Diagnosis also is
used in many other trades and professions
to determine the causes of symptoms,
mitigations for problems, or solutions to
• The health history is a current
collection of organized information
unique to an individual. Relevant
aspects of the history include
biographical, demographic, physical,
mental, emotional, sociocultural,
sexual, and spiritual data.

• The health history aids both

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

• Every person should have a thorough

health history recorded as a
component of a periodic physical.
These occur frequently (monthly at
first) in infants and gradually reach a
frequency of once per year for
adolescents and adults.
• The clinical interview is the most common
method for obtaining a health history. When a
person or a designated representative can
communicate effectively, the clinical interview
is a valuable means for obtaining information.
• The information that comprises the health
history may be obtained from a person's
previous records, the individual, or, in some
cases, significant others or caretakers. The
depth and length of the history-taking process
is affected by factors such as the purpose of the
visit, the urgency of the complaint or condition,
the person's willingness or ability to contribute
information, and the environment in which
information is sought. When circumstances
allow, a history may be holistic and
comprehensive, but at times only
a cursory review of the most pertinent facts is
Health histories can be organized in a variety
of ways. Often an organization such as a
hospital or clinic will provide a form, template,
or computer database that serves as a guide
and documentation tool for the history.
Generally, the first aspect covered by the
history is identifying data.

Identifying or basic demographic data includes

facts such as:

• name
• gender
• age
• date of birth
• occupation
• family structure or living arrangements
• source of referral
• Once the basic identifying data is collected,
the history addresses the reason for the
current visit in expanded detail. The reason
for the visit is sometimes referred to as the
chief complaint or the presenting complaint.
Once the reason for the visit is established,
additional data is solicited by asking for
details that provide a more complete picture
of the current clinical situation. For example,
in the case of pain, aspects such as
location, duration,
intensity, precipitating factors, aggravating
factors, relieving factors, and associated
symptoms should be recorded. The full
• The review of systems is a useful
method for gathering medical
information in an orderly fashion.
This review is a series of questions
about the person's current and past
medical experiences. It usually
proceeds from general to specific
information. A thorough record of
relevant dates is important in
determining relevance of past
illnesses or events to the current
The names for categories in the review of
systems may vary, but generally consists of
variations on the following list:

• head, eyes, ears, nose, throat (HEENT)

• cardiovascular
• respiratory
• gastrointestinal
• genitourinary
• integumentary (skin)
• musculoskeletal, including joints
• endocrine
• nervous system, including both central and
peripheral components
• mental, including psychiatric issues
Past and current medical history includes details on
medicines taken by the person, as well as allergies,
illness, hospitalizations, procedures, pregnancies,
environmental factors such as exposure to chemicals,
toxins, or carcinogens, and health maintenance habits
such as breast or testicular self-examination or

An example of a series of questions might include

the following:

• How are your ears?

• Are you having any trouble hearing?
• Have you ever had any trouble with your ears or with
your hearing?
• If an individual indicates a history
of auditory difficulties, this would prompt further
questions about medicines, surgeries, procedures, or
associated problems related to the current or past
• In addition to identifying data, chief
complaint, and review of systems, a
comprehensive health history also
includes factors such as a person's
family and social life, family medical
history, mental or emotional illnesses or
stressors, detrimental or beneficial
habits such as smoking or exercise, and
aspects of culture, sexuality, and
spirituality that are relevant to each
individual. The clinicians also tailor their
interviewing style to the age, culture,
educational level, and attitudes of the

• Because the information obtained from the interview

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

• Once a health history has been

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

• There are virtually no risks associated

with obtaining a health history. Only
information is exchanged. The risk is
potential embarrassment if confidential 
details are inappropriately distributed.
Occasionally, a useful piece of
information or data may be overlooked.
In a sense, complications may arise
from the findings of a health history.
These usually trigger further
investigations or initiate treatment.
They are usually far more beneficial
than negative as they often begin a
Normal Results

• Normal results of a health history

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

• Disease and disability are identified

during the course of obtaining a
health history. There are virtually no
risks associated with the verbal
exchange of information.

• There are no alternatives that are as

effective as obtaining a complete
health history. The only real
alternative is to skip the history. This
allows disease and
other pathologic or degenerative pro
cesses to go undetected. In the long
run, this is not conducive to optimal