What are the first symptoms of pregnancy?
Missing a period is usually the first signal of a new pregnancy, although women with irregular periods may not initially recognize a missed period as pregnancy. During this time, many women experience a need to urinate frequently, extreme fatigue, nausea and/or vomiting, and increased breast tenderness. All of these symptoms can be normal. Most over-the-counter pregnancy tests are sensitive 9-12 days after conception, and they are readily available at most drug stores. Performing these tests early helps to allay confusion and guesswork. A serum pregnancy test (performed in a provider's office or laboratory facility) can detect pregnancy 8-11 days after conception.
How long after conception does the fertilized egg implant?
The fertilized conceptus enters the uterus as a 2- to 8-cell embryo and freely floats in the endometrial cavity about 90-150 hours, roughly 4-7 days after conception. Most embryos implant by the morula stage, when the embryo consists of many cells. This happens, on average, 6 days after conception. The new embryo then induces the lining changes of the endometrium, which is called decidualization. It then rapidly begins to develop the physiologic changes that establish maternal-placental exchange. Prior to this time, medications ingested by the mother typically do not affect a pregnancy.
What is the most accurate pregnancy test to use?
Serum beta–human chorionic gonadotropin (hCG) is the hormone produced by the syncytiotrophoblast beginning on the day of implantation, and it rises in both the maternal blood stream and the maternal urine fairly quickly. The serum hCG test is the most sensitive and specific, and the hormone can be detected in both blood and urine by about 8-9 days after conception. This test can be performed quantitatively or qualitatively. Urine pregnancy tests differ in their sensitivity and specificity, which are based on the hCG units set as the cutoff for a positive test result, usually 2-5 mIU/mL.
Urine pregnancy tests can produce positive results at the level of 20 mIU/mL, which is 2-3 days before most women expect the next menstrual period. The kits are very accurate and widely available. The test can be completed in about 3-5 minutes. The kits all use the same technique—recognition by an antibody of the beta subunit of hCG. Falsely high readings of the hCG hormone can occur in cases of hydatidiform molar pregnancy or other placental abnormalities. Also, test results can remain positive for pregnancy weeks after a pregnancy termination, miscarriage, or birth. On the other hand, false-negative test results can occur from incorrect test preparation, urine that is too dilute, or interference by several medications.
Serum pregnancy tests can be performed by a variety of methods. The enzyme-linked immunosorbent assay (ELISA) is the most popular in many clinical laboratories. This test is a determination of total beta-hCG levels. It is performed using a monoclonal antibody to bind to the hCG; a second antibody is added that also interacts with hCG and emits color when doing so. This form of ELISA is commonly called a "sandwich" of the sample hCG. Radioimmunoassay (RIA) is still used by some laboratories. This test adds radiolabeled anti-hCG antibody to nonlabeled hCG of the blood sample. The count is then essentially determined by the amount of displacement of the radiolabeled sample.
The hCG level doubles approximately every 2 days in early pregnancy. However, it should be noted that even increases of only 33% can be consistent with healthy pregnancies. These values increase until about 60-70 days and then decrease to very low levels by about 100-130 days and never decrease any further until the pregnancy is over.
Is cramping during pregnancy normal?
Early in pregnancy, uterine cramping can indicate normal changes of pregnancy initiated by hormonal changes; later in pregnancy, it can indicate a growing uterus. Cramping that is different from previous pregnancies, worsening cramping, or cramping associated with any vaginal bleeding may be a sign of ectopic pregnancy, threatened abortion, or missed abortion.
Other physical effects that are normal during pregnancy, and not necessarily signs of disease, include nausea, vomiting, increase in abdominal girth, changes in bowel habits, increased urinary frequency, palpitations or more rapid heartbeat, upheaving of the chest (particularly with breathing), heart murmurs, swelling of the ankles, and shortness of breath.
Why do pregnant women feel tired?
Fatigue in early pregnancy is very normal. Many changes are occurring as the new pregnancy develops, and women experience this as fatigue and an increased need for sleep. Lower blood pressure level, lower blood sugar levels, hormonal changes due to the soporific effects of progesterone, metabolic changes, and the physiologic anemia of pregnancy all contribute to fatigue. Women should check with their health care provider to determine if an additional work up, prenatal vitamin changes, and/or supplemental iron would be beneficial.
Second Trimester
When do the postural changes of pregnancy occur?
Women experience a progressive increase in the anterior convex shape of the lumbar spine during pregnancy. This change, termed lordosis, helps keep the center of gravity stable and over the legs as the uterus enlarges (see Media file 1). Late in pregnancy, aching, weakness, and numbness of the arms may occur secondary to compensatory anterior positioning of the neck and hunching of the shoulders in positional response to exaggerated lordosis. These positional responses put traction on the ulnar and median nerves, resulting in the previously mentioned symptoms.
Lumbar lordosis of pregnancy.
Relaxin in pregnancy is secreted by the corpus luteum, the placenta, and part of the decidual lining of the uterus. It is thought to cause remodeling of the connective tissue of the reproductive tract, especially inducing biochemical changes of the cervix. Although relaxin levels are more than 10-fold higher than nonpregnant levels, it is not currently thought that this hormone has a direct effect on actual ligamentous loosening. Joint laxity and shifting center of gravity can contribute to an increase in gait unsteadiness. These changes are most exaggerated in later pregnancy. More than 50% of gravid females complain of back pain during pregnancy, which may also be due to sacroiliac joint dysfunction or paraspinous muscle spasm.
About 4-6 per 1000 women will have scoliosis. This is not accompanied by any functional osteoporosis, although pregnancy is a very high bone turnover state, approximately equivalent to double the bone loss rates of a menopausal female, reversibly losing about 2% of bone during the first 20 weeks of gestation. Spinal changes are usually not severe enough to affect the pregnancy or the lung's functional capacity. Also, the pregnancy rarely affects the degree of lateral curvature in these cases of scoliosis. If a pregnant patient has had correction with prior Harrington distraction rod insertion, the pregnancy, labor, and delivery are not typically affected. The epidural space may be distorted, and some anesthesiologists may refuse to place epidural anesthetics in these patients.
When do changes in the pelvic contour occur?
The pelvis continues to grow until about 3 years after menarche, which is why it is more common for younger women, and women sooner after menarche to have greater risk for obstructed labor due to the relative size discrepancy between the fetal head and the maternal pelvis. Relaxin was also thought to loosen pelvic ligaments when secreted from the ovaries, contributing to enlargement of the pelvis, but this is not proven in human pregnancies. The symphysis pubis can enlarge from about 3-4 mm in nulliparas to about 4.5 mm (or as much as 8 mm) in multiparas, but during gestation itself the average separation is about 7-8 mm.
When is fetal movement usually felt?
Most women feel the beginnings of fetal movement before 20 weeks' gestation. In a first pregnancy, this can occur around 18 weeks' gestation, and in following pregnancies it can occur as early as 15-16 weeks' gestation. Early fetal movement is felt most commonly when the woman is sitting or lying quietly and concentrating on her body. It is usually described as a tickle or feathery feeling below the umbilical area. As the fetus grows in size, these feelings become stronger, regular, and easier to feel. The medical term for the point at which a woman feels the baby move is quickening. Babies should move at least 4 times an hour as they get larger, and some clinicians advise patients to count fetal movement to follow the baby's well-being.
What kind of breast changes are normal during pregnancy?
Bumps that appear to enlarge around the areola are called Montgomery tubercles, and they normally appear during mid pregnancy.
Third Trimester
How much does the uterus grow during pregnancy?
The uterus grows from an organ that weighs 70 g with a cavity space of about 1 mL to an organ that weighs more than 1000 g that can accumulate a fluid area of almost 20 L. The shape also evolves during pregnancy from the original pearlike shape to a more round form, and it is almost a sphere by the early third trimester. By full term, the uterus becomes ovoid. The uterus is completely palpable in the abdomen (not just by pelvic examination) at about 12-14 weeks' gestation. After 20 weeks' gestation, most women begin to appear pregnant upon visual examination.
Uterine fundal size and relative position on abdomen throughout gestation.
Is it normal to secrete milk from the breast prior to delivery?
Galactorrhea (milk secretion from the nipple) is the product of the combined effects of prolactin, glucocorticoids, progesterone, and human placental lactogen. Galactorrhea is not uncommon in the first trimester, although it usually does not occur until milk let-down soon after delivery. At that time, the high levels of progesterone, which block milk excretion, drop with the delivery of the placenta. In mid pregnancy a woman reaches lactogenesis stage I and she is able to secrete colostrum.
Early galactorrhea does not mean that a woman will produce less milk after delivery. Some women notice secretions beginning before the fifth month of pregnancy. Many women find they spontaneously leak or express some fluid by the ninth month.
The milk secretion is known as colostrum and is watery and pale. Colostrum has more protein and lower fat than mature milk.
Lactogenesis stages II and III occur postpartum and form more mature milk.
Physiological Adaptations to Pregnancy
Why do women undergo skin pigmentation changes during pregnancy?
Pigmentation changes are directly related to melanocyte-stimulating hormone (MSH) elevations during pregnancy. Some evidence suggests that elevated estrogen and progesterone levels cause hyperpigmentation in women. This is typically evident in the nipples, umbilicus, axillae, perineum, and linea alba, which darkens enough to be considered a linea nigra. More than 90% of patients have skin darkening. Facial darkening, called melasma, is a diffuse macular facial hyperpigmentation. When melasma occurs as a result of pregnancy, it is known as chloasma. This is due to the pigment being deposited in the epidermis itself. The distribution is usually malar but can be central or mandibular. Ultraviolet light exposure intensifies melasma and appropriate sunscreen decreases the effect. Because it is related to the hormones of pregnancy, it lessens with delivery.
Other pigmentation changes, such as palmar erythema, pseudoacanthosis nigricans, vulvar or dermal melanocytosis, or postinflammatory hyperpigmentation secondary to specific dermatologic conditions of pregnancy, are fairly common as well.
Do ocular changes occur in pregnancy?
Pregnant women report dry eyes, and some transient visual acuity changes have been reported as well. During pregnancy, the shift seems to be toward more far sightedness, and some corneal thickening can disturb contact wearers.
Why does acne increase during pregnancy?
Studies show a variable effect of acne in pregnancy. If treatment regimens that were working prior to pregnancy were abandoned, the patient can have initial flares that are not directly related to the pregnancy. Some studies show that as many as a third of cases actually improve in pregnancy, but most women will report some worsening. Progesterone, which has some androgenic components, is increased during pregnancy, resulting in more secretions from the skin glands.
Postpartum, some women will get acne for the first time (called postgestational acne). Maintaining hydration should help. Women should consult their doctor if a topical medication is needed. Azelaic acid, topical erythromycin or clindamycin, and oral erythromycin are all safe. Although topical tretinoin has not been reported to cause risk, no studies have established it's safety and it should be avoided. Tetracyclines are contraindicated during pregnancy. Appropriate cleansing with mild abrasion aids has been found to be helpful.
Will changes in headache patterns occur during pregnancy?
For most women, headaches remain unchanged during pregnancy. Some women improve, but some may worsen. Because migraines have a hormonal component, many women's migraines improve with increasing estrogen levels, such as those that occur during pregnancy. For women whose conditions remain unchanged or worsen, treatment options are limited, especially in the first trimester. Some clinicians suggest acetaminophen, narcotics, and antiemetics. Nonpharmacologic treatments include relaxation strategies, eliminating stressors, and a good exercise program. These should first be attempted before pharmacologic therapy.1,2
Is feeling the heart racing a common occurrence during pregnancy?
A significant number of cardiovascular changes occur during pregnancy, which may be accompanied by dyspnea and a reduced tolerance for endurance exercise. During pregnancy, women expand their blood volume by approximately 30-50%. This is accompanied by an increase in cardiac output. The heart rate may also increase by 10-20 beats per minute. The changes peak during weeks 20-24 and usually resolve completely within 6 weeks of childbirth.
The blood pressure in the upper extremities should change very little during pregnancy, but pressure in the lower extremities increases. This is accompanied by pedal edema. Because of extra blood flow, variances in the auscultated heart sounds may occur, such as murmurs, a wider split between the first and second heart sounds, or an S3 gallop. Some nonspecific ST-segment changes may occur, and some changes to the cardiac outline may appear on chest radiographs. The following is a summary of cardiovascular changes:
* Systolic blood pressure level decreases 4-6 mm Hg.
* Diastolic blood pressure level decreases 8-15 mm Hg.
* Mean blood pressure level decreases 6-10 mm Hg.
* Heart rate increases 12-18 beats per minute.
* Stroke volume increases 10-30%.
* Cardiac output increases 33-45%.
What are common respiratory system changes during pregnancy?
Pregnant women experience nasal stuffiness due to estrogen-induced hypersecretion of mucus. Epistaxis is also common. The safest treatment of these symptoms is a saline nasal spray. The following is a summary of respiratory changes:
* Respiratory rate does not change.
* Tidal volume increases 0.1-0.2 L.
* Expiratory reserve volume (ERV) decreases 15%.
* Residual volume decreases.
* Vital capacity does not change.
* Inspiratory capacity increases 5%.
* Functional reserve capacity decreases 18%.
* Minute volume increases 40%.
Is gallbladder disease more common during pregnancy?
Gallbladder disease may be more common during pregnancy. Estrogen is an important risk factor for gallstone formation; it increases the concentration of cholesterol in the bile leading to an increased risk of forming gallstones.
Is liver disease more common during pregnancy?
Pregnant women can experience spider angiomata and palmar erythema. About two thirds of white women and only 10% of black women experience these symptoms. In addition, women may have reduced serum albumin concentration, elevated serum alkaline phosphate activity, and elevated cholesterol levels. These are common symptoms of liver disease, but they are not evidence of liver disease if they occur during pregnancy.
What hair changes are common during pregnancy?
Hair changes in pregnancy are very common, and body hair changes are common as well. Many women develop mild hirsutism that may be due to levels of male hormone production by the ovary and adrenal gland.
In nonpregnant patients, hair grows in the anagen phase and rests in the telogen phase. About 15-20% of all hairs are in the telogen phase at any given time. During pregnancy, however, more scalp hairs are in the anagen phase, so more growth is documented. During the telogen resting phase, it is normal for hair to fall out so new hair can regrow. During late pregnancy, fewer hairs are in the telogen phase; immediately postpartum, more hairs are in the telogen phase. This often results in a dramatic loss of hair immediately postpartum; this is termed telogen effluvium. Although this may be disturbing, it is normal.
Normal hair loss is probably in the range of 60-100 hairs a day and most patients do not notice a dramatic loss unless 40% of all hair is lost. This process spontaneously resolves in about 1-5 months, but has been reported to last more than a year. The frontal and parietal areas are usually most affected. No effective treatment is known.
How do sleep patterns change in pregnancy?
Women do have functional changes in their sleep, and while a pregnancy-related sleep disorder is not a specific diagnosis, it has been proposed as a new categorization by the American Sleep Disorder Association. Disruptions such as positional discomfort, contractions, leg cramps, gastric reflux, and more frequent urination may lead to disordered sleep patterns. Changes in the amount of total sleep required is not uncommon. Typically the amount of sleep needed is increased in the first and second trimester and actually decreased in the third trimester. This may have to do with the patterns of sleep. The amount of REM and deeper staged sleep also changes in pregnancy.
Nutrition in Pregnancy
What are the most common dietary complaints during pregnancy?
During early pregnancy, most women experience an increased appetite, with extra caloric needs of approximately 200 kcal/d. Stomach motility does decrease, probably due to reduced production of motilin. Reduced peptic ulcer disease is due to reduced gastric acid secretion. Prolonged transit times through the colon are also reported, with transit from the stomach to the cecum occurring in about 58 hours instead of 52.
The common myths surrounding food desires are individually and culturally determined. Among rural Southern American women, the most common food cravings include clay, laundry starch, or pica, while British women commonly crave coal. Women experiencing nausea or hyperemesis may develop ptyalism (spitting). Reported fluid losses of 1-2 L/d can occur in these women.
See also Prenatal Nutrition.
Should certain foods be avoided during pregnancy?
Food concerns during pregnancy include raw vegetables, unpasteurized juices, liver, and undercooked meat, poultry, or eggs. Be aware of food poisoning. Raw vegetables, unpasteurized juices, and undercooked meat, poultry, or eggs have been linked with Salmonella species and Escherichia coli (including the dangerous E coli 0157).
Cooking properly kills bacteria; the proper temperature can be determined by a meat thermometer, although cooking until well done is safe for most meat. Ground beef should be cooked to at least 160°F, roasts and steaks to 145°F, and whole poultry to 180°F. Eggs should have a firm yolk and white after cooking. Eggnog and hollandaise sauce have raw or partially cooked eggs and are not considered safe. Liver can contain extremely high levels of vitamin A and is probably safe, but it should be eaten in moderation.
In 2007, the FDA warned that Salmonella can be found on the outer skin and shell surfaces of small pet turtles and cautioned those handling turtles without properly washing their hands after handling the animals.
Mad cow disease, Bovine spongiform encephalopathy, has become a growing concern. The disease can be transmitted to humans who eat infected meat, causing Creutzfeldt-Jakob disease. The chances of contracting this disease in the United States is relatively small, but chances can be reduced even further by choosing cuts of meat that are likely to be free of nervous system tissue such as boneless steaks, chops, and roasts. Grass-fed and organic cattle should not have been exposed to any animal products in their feed and are considered to have no known risk. The risk of mad cow disease cannot be lowered by cooking beef more thoroughly because the prions that cause mad cow disease are not destroyed by heat.
Can women safely eat fish while pregnant?
The American College of Obstetricians and Gynecologists (ACOG) issued a warning regarding eating fish in response to the US FDA's consumer advisory about the dangers of eating fish for nursing mothers and women who are or who may become pregnant. The fish themselves are not harmful, but extensive fish consumption increases exposure to the naturally occurring compound methylmercury, levels of which have been increasing in the waters because of industrial pollution. Mercury is very toxic and can cause danger to the fetus and to the newborn nursing infant. Mercury exposure can actually occur via inhalation and/or skin absorption, and all fish contain trace amounts. However, longer-lived and larger fish, such as shark, swordfish, king mackerel, and tilefish, have increased mercury levels and cause the most concern for consumption by pregnant women.
The FDA, as of March of 2004, therefore advises that pregnant or nursing women should not eat shark, swordfish, king mackerel, or tilefish. However, these women can safely eat 12 ounces per week of varieties of fish thought to be low in mercury if they eat a variety of cooked, smaller fish. The safest fish that are low in mercury are shrimp, canned light tuna, salmon, Pollock, and catfish. Specifically, the FDA states that albacore (white) tuna has more mercury than light tuna. So, pregnant women should eat only up to 6 ounces (one average meal) of albacore tuna per week. In addition, the Environmental Protection Agency (EPA) also recommends that pregnant women and young children limit their consumption of freshwater fish caught by family and friends to no more than one meal per week and to follow all local advisories as to fish safety. The EPA specifies no more than 8 ounces of uncooked fish per week for adults.
Other Questions Related to Pregnancy
What is the recommended weight gain in pregnancy?
Nearly 20 years have passed since guidelines for pregnancy weight gain have been reissued from the Institute of Medicine (IOM). In that time, more research has been completed to better understand the effects of weight gain during pregnancy on the health of both the mother and the infant. Important variables to take into consideration regarding recommended weight gain include twin or triplet pregnancies, the mother’s age, and the mother’s prepregnancy weight.
These variables can add to the burden of chronic disease for the mother and baby; excessive weight gain is associated with an increased risk for gestational diabetes, pregnancy-associated hypertension, and delivery of large-for-gestational-age infants. Because of these risks, the Institute of Medicine has developed new guidelines for weight gain during pregnancy.3
Guidelines for weight gain during pregnancy* are as follows:
* Underweight women (BMI <18.5) should gain 28-40 pounds.
* Normal-weight women (BMI, 18.5-24.9) should gain 25-35 pounds.
* Overweight women (BMI, 25-29.9) should gain 15-25 pounds.
* Obese women (BMI, 30 or higher) should gain 11-20 pounds.
*Weight gain guidelines are for singleton pregnancy; weight gain should be higher for multiple pregnancies.
Clinicians are urged to supplement these guidelines with individualized counseling about diet and exercise, and preconception counseling should emphasize the importance of conceiving when the mother is at a normal body mass index (BMI).
Dietz et al found that prepregnancy body mass index (BMI) modifies the relationship between pregnancy weight gain and newborn weight for gestational age. In a population-based cohort study of 104,980 singleton, term births from 2000-2005, women who gained 36 lb or more during pregnancy were more likely to bear an infant who was large for gestational age (birthweight >90th percentile) if the mother was lean before pregnancy than if she was overweight or obese. Compared with women who gained 15-25 lb, the adjusted odds ratio (aOR) for a gain of 26-35 lb was 1.5 (95% confidence interval [CI], 1.2-1.9); for a gain of 36-45 lb, the aOR was 2.1 (95% CI, 1.7-2.7); and for a gain of 46 lb or more, the aOR was 3.9 (95% CI, 3.0-5.0). The risk of macrosomia (birthweight 4500 g or more) was not modified by prepregnancy BMI.4
Do older fathers have an increased risk of fathering children with birth defects?
No medical information exists to support the hypothesis that increased paternal age causes increased numerical chromosomal abnormalities as increased maternal age does. As males age, however, structural spermatozoa abnormalities are increased and these sperm usually cannot fertilize an egg. The literature suggests that older fathers have a 20% higher risk of transmitting autosomal dominant diseases as a result of abnormal cell division.5 Autosomal dominant disorders include neurofibromatosis, Marfan syndrome, achondroplasia, and polycystic kidney disease. The American Society of Reproductive Medicine recommends an age limit of 50 years for semen donors.
Any family with a history of birth defects should seek individual genetic counseling. To determine whether an individual has a family history of risk, patients should inform their clinician or genetic counselor about any birth defects that have occurred in the past 3 generations.
Should women wear seatbelts during pregnancy?
Seatbelts should absolutely be worn during pregnancy.6 Trauma to the mother is more devastating to the child than any potential entrapment of the pregnant abdomen in the seatbelt. The seatbelt should be placed low, across the hip bones and under the pregnant abdomen. The shoulder strap should be placed to the side of the abdomen, between the breasts, and over the midportion of the clavicle. No information indicates that air bags are unsafe during pregnancy. Pregnant women should try to keep their abdomen 10 inches from the airbag.7
Correct use of seat belts in pregnancy.
Should travel be restricted during pregnancy?
Prolonged sitting can cause lower extremity venous stasis and ambulation, particularly at 2-hour intervals. Most planes are pressurized to around 8000 feet so altitude is not an issue. Recirculated air can be dehydrating so drinking water is important as well.
Can pregnant women go to the dentist? Dental care during pregnancy is an important part of overall healthcare.8 During pregnancy, the gums naturally become more edematous and may bleed after brushing. Epulis gravidarum, a type of gingivitis with violaceous pedunculated lesions, can occur. If treatment of cavities, surgery, or infection care is required, be sure the dentist is aware of the pregnancy. Most antibiotics and local anesthetics are safe to use during pregnancy. Radiographs can be obtained with abdominal shielding but are best avoided during pregnancy because a small, but statistically significant, increase in childhood malignancies exists in children exposed to in-utero radiographic irradiation.
See also Psychosocial and Environmental Pregnancy Risks.
Why is heartburn more common during pregnancy?
Stomach emptying was thought to be retarded during pregnancy, but hormonal influences of increased progesterone and/or decreased levels of motilin may be more responsible for pyrosis (heartburn) than the actual mechanical obstruction in the third trimester. Some studies have also shown decreased lower esophageal sphincter tone, which can lead to an excess of gastric acid in the esophagus.
Why is back pain prevalent during pregnancy and can it be treated?
Half of women report having back pain at some point during pregnancy. The pain can be lumbar or sacroiliac. The pain may also be present only at night. Back pain is thought to be due to multiple factors, which include shifting of the center of gravity caused by the enlarging uterus, increased joint laxity due to an increase in relaxin, stretching of the ligaments (which are pain-sensitive structures), and pregnancy-related circulatory changes.
Treatment is heat and ice, acetaminophen, massage, proper posturing, good support shoes, and a good exercise program for strength and conditioning. Pregnant women may also relieve back pain by placing one foot on a stool when standing for long periods of time and placing a pillow between the legs when lying down.
In a randomized, placebo-controlled trial, Lacciardone et al studied the effect of osteopathic manipulative treatment of back pain during pregnancy. No statistically significant differences were achieved between treatment and control groups; however, back pain decreased in the usual obstetric care and osteopathic manipulative treatment group, remained unchanged in the usual obstetric care and sham ultrasound treatment group, and increased in the usual obstetric care only group.9
Is sexual intercourse safe during pregnancy?
Research indicates that sexual intercourse is safe in the absence of ruptured membranes, bleeding, or placenta previa, but pregnant women engage in sex less often as their pregnancy progresses. No studies have suggested that any particular position is unsafe, although a 1993 study demonstrated a 2-fold increased incidence of preterm membrane rupture with the male-superior position compared to other positions.10 ACOG states that sexual activity during pregnancy is safe for most women right up until labor, unless there is a specific contraindication.
ACOG specifically cautions that a women should limit or avoid sex if she has had preterm labor or birth, more than one miscarriage, placenta previa, infection, bleeding, and/or breaking of the amniotic sac or leaking amniotic fluid. ACOG discusses that, as part of natural sexuality, couples may need to try different positions as the woman's stomach grows. Vaginal penetration by the male is not as deep with the male facing the woman's back, and this may be more comfortable for the pregnant woman.
Why do women get varicose veins during pregnancy?
Varicose veins are more common as women age; weight gain, the pressure on major venous return from the legs, and familial predisposition increase the risk of developing varicose veins during pregnancy. These can occur in the vulvar area and be fairly painful. Rest, leg elevation, acetaminophen, topical heat, and support stockings are typically all that is necessary. Determining that the varicosities are not complicated by superficial thrombophlebitis is important. Having a venous thromboembolism in association with superficial thrombophlebitis is rare. Hemorrhoids, essentially varicosities of the anorectal veins, may first appear during pregnancy for the same reasons and are aggravated by constipation during pregnancy.
Why are urinary tract infections more common during pregnancy?
Pregnancy predisposes women with bacteruria, which in the nonpregnant state is usually self-limiting. Normal pregnancy-related physiologic changes contribute to UTIs and include dilatation of the upper collecting systems, increased urinary tract dead space, increased vesicoureteral reflux, hypotonic renal pelvises, decrease in the natural antibacterial activity in the urine, and a decrease in the phagocytic activity of leukocytes at the mucosal surfaces. UTIs in pregnant women usually do not present with typical symptoms and may be asymptomatic. Pyelonephritis is a serious complication of UTIs.
How can stretch marks be prevented?
Unfortunately, striae (stretch marks) cannot be prevented. The degree to which a woman experiences stretch marks is determined genetically. Stretch marks usually occur when weight is lost or gained quickly. Using creams and gels rarely make a difference. Fortunately, stria fades with time and marks become silvery white, but they do not tan. Stria managed early can be reduced and with new medical laser technology.
Work and Exercise During Pregnancy
What kind of exercise can women engage in during pregnancy?
Maintaining an active lifestyle during pregnancy adds to a woman's overall health and may reduce complications. Some research shows that women who exercise have shorter easier labors, better newborn health, and higher newborn IQs. However, these same women are known to be more likely to have had routine prenatal care, overall better health prior to conception, and compliance with prenatal vitamin instructions (see Media file 1). Therefore, designing studies to discern specifically if exercise alone provides an increased benefit to these basically healthy mothers is difficult. Hence, specific benefit has yet to be demonstrated.
In studies that have looked at exercise during pregnancy, pulse rates did not exceed 140 beats per minute during exercise. These studies, therefore, do not advise women to perform extreme levels of exercise, such as competitive running, during pregnancy. Some consider swimming to be the ideal exercise for pregnant women because exercise is not affected by joint changes, balance alterations, or weight gain.
If a woman is already participating in an exercise program, she may continue with minor alterations. Women should ask their healthcare providers for specific restrictions, especially if they experience bleeding, are at risk for premature labor, or have other high-risk concerns. Pregnancy is not an appropriate time to begin aerobics classes, weightlifting, or a new sport. Walking is good for the heart and may be performed by most women. Pregnant women should avoid contact sports and activities that could result in injury. Pregnancy can make recovery from injury prolonged or more complicated.
Should women restrict work during pregnancy?
Maintaining an active and productive lifestyle helps make time pass faster and adds to a feeling of accomplishment. Working during pregnancy is usually not a problem unless a woman has risk factors or a complicated pregnancy. Women should check with their healthcare providers for specific restrictions. With an uncomplicated pregnancy, working close to or near the due date should not be a problem. Pregnant women should wear comfortable clothing, move around frequently if sedentary, drink plenty of fluids, and have time to rest and take breaks. Women with strenuous jobs, those who work with heavy machinery, or those who work with toxic chemicals should consult their healthcare providers and their job's occupational department for restrictions or concerns.
Labor and Delivery
Which form of psychoprophylaxis is the best and what are their differences?
Appropriate childbirth preparation varies with each birthing woman. Women are recommended to learn a variety of coping techniques because one philosophy may not be what is needed during the work of labor. Some of the most popular methods include Lamaze, Bradley, HypnoBirthing, and Birthing from Within.
Lamaze: Generally regarded as breathing focused. Involves focal points, relaxation, and partner coaching. Today the Lamaze International organization focuses on education to empower women to make informed choices in their healthcare. They support birth as a normal, natural experience that is guided by a woman's innate wisdom and ability to birth.
Bradley: Largely focused on "husband-coached childbirth." Bradley teaches coaching and coping techniques aimed at supporting unmedicated childbirth. The Bradley method supports deep abdominal breathing, body awareness, and relaxation techniques.
HypnoBirthing: HypnoBirthing teaches that labor does not have to involve severe pain. Through techniques of relaxation and environment modification, HypnoBirthing aims at eliminating fear and tension during labor. The fear of pain is believed to be what causes the pain itself.
Birthing from Within: Birthing from Within is a book and approach to childbirth education that sees birth as a rite of passage. The lessons, artwork exercises, and reflections are aimed at celebrating the spiritual, psychological, and emotional growth that comes with birth and motherhood. It provides a variety of coping techniques for labor aimed at reducing fear and anxieties surrounding childbirth.
What is the ACOG's position on home births?
The ACOG acknowledges that both labor and delivery, "while a physiologic process, clearly presents potential hazards to both mother and fetus before and after birth." The ACOG's statement continues to specifically state that "these hazards require standards of safety that are provided in the hospital setting and cannot be matched in the home situation." The ACOG supports those actions that improve the experience of the family while continuing to provide the mother and her infant with accepted standards of safety available only in hospitals. These safety standards are outlined by the American Academy of Pediatrics and ACOG. Women considering home births should investigate the standards of the midwifery or birthing organization to which the birth attendant belongs.
The American College of Nurse Midwifery is more flexible, supporting home births within certain defined parameters. They refer to this as a "planned home birth." They support the provision of protocols by hospitals, physicians, and insurers which define strict parameters for the care of patients at home.
What are the benefits of water birth?
ACOG's Committee on Obstetric Practice addressed the issue of warm-water immersion for laboring women and for delivery of infants. The Committee felt that there are "insufficient data, especially concerning rates of infection, to render an opinion on whether warm-water immersion is a safe and appropriate birthing alternative." The Committee also felt that "this procedure should be performed only if the facility can be compliant with OSHA [Occupational Safety and Health Act] standards regarding infection." This would include the specific tub and water recirculation systems used. Also, warm water exposure over time can cause hypotension, and careful attendance by an assistant is necessary to prevent drowning. The American College of Nurse-Midwives has no current position on either hydrotherapy or water births.
What is the ACOG's position on "role of allied personnel"?
Continuous support during labor from caregivers, including nurses, midwives, or lay individuals, has a number of benefits for women and their newborns, with no apparent harmful effects. The continuous presence of a support person may reduce the likelihood of the use of medication for pain relief, operative delivery, and patient dissatisfaction.11
Postpartum
When will the uterus return to normal size?
The uterus returns to prepregnancy size after approximately 6 weeks. This is accomplished through a process called involution. During this process, the uterus has contractions that women may be able to feel, especially with breastfeeding.
When can women resume sexual intercourse after pregnancy?
Women usually can resume their sex lives when they feel ready, typically this is 4-6 weeks after delivery and when bleeding has substantially decreased. Medically, this will be when the cervix has closed, which should occur at 4 weeks' postpartum, and uterine bleeding is minimal. Breastfeeding may cause increased vaginal dryness due to slightly decreased estrogen levels. Women who have had an episiotomy need at least 2-3 weeks to heal before intercourse. ACOG has pointed out in a recent bulletin that some women may find that they do not have much interest in sex after giving birth because of fatigue, stress, fear of pain, lack of opportunity, and/or lack of desire. This is usually temporary.