Heed 3350 Women Health

1. Chapter 6
Pregnancy and
Childbirth

2. Historical Dimensions (1 of 2)
Eighteenth century
• America—Physicians at births
• France—Childbirth moves to hospitals
• England—Surgical techniques and
development of instruments
Nineteenth century
• Physician-controlled hospital births
• Interventions—Medications, anesthesia,
birthing instruments

3. Historical Dimensions (2 of 2)
Early 20th century
• Greater technology, medicalization,
hospitalization
• Greater mystification of childbirth for woman
• Controlling fertility
Mid-to-late 20th century
• Natural-birth relaxation techniques leading
toward “prepared births”
• 1970s: Benefits of breastfeeding resurfaced
• Childbirth = joy and knowledge vs. fear and
ignorance

4. Pregnancy (1 of 2)
Conception
Fertilization = Sperm cell + Egg cell = Zygote
• Sperm cell: 300 million deposited per
ejaculation
• Egg cell: 1 egg released per month
• Dizygotic twins = fraternal twins
• Monozygotic twins = identical twins

5. Pregnancy (2 of 2)

6. Sex Chromosomes
Sex of individual
• XY for male
• XX for female
Selected sex chromosome abnormalities
• Turner syndrome (Monosomy X, XO)
• Triple X (XXX)
• Klinefelter syndrome (Trisomy XXY)
• XYY male

7. After Conception
• Within 36 hours of
fertilization: Zygote divides
• 3 to 5 days: Reaches
uterus and is known as a
blastocyst
• 1 to 2 days: Blastocyst
floats freely before
implanting in uterus
• First 8 weeks: Known as
embryo
• 9 weeks to birth: Known as
fetus
Figure 6-3A Fetal development.
Human embryo between four and
five weeks of development.
© Ngo Thye Aun/Dreamstime.com

8. Early Signs of Pregnancy
Early signs of pregnancy often occur within the
first 6 weeks
• Missed period(s)
• Breast swelling/tenderness
• Fatigue
• Queasiness or nausea/vomiting
• Elevated body temperature
• Mood swings
• Frequent urination

9. Confirming Pregnancy
• Pregnancy tests: detect hCG
– Home urine pregnancy tests available
o Digital and non-digital
• Clinical pregnancy test
– Performed by clinician
o Urine or blood tests
• Pelvic examination

10. Hormonal Changes (1 of 2)
Fertilization
• Follicle-stimulating hormone (FSH) and luteinizing
hormone (LH) produced by the anterior pituitary gland
are suppressed.
• Pregnancy-specific hormones increase.
Implantation
• Embryo cells secrete hCG.
• hCG stimulates corpus luteum to secrete estrogen and
progesterone.

11. Hormonal Changes (2 of 2)
After 3 months
1. Corpus luteum no longer needed; hCG levels
decrease.
2. Placenta produces estrogen and progesterone.
3. Fetal adrenal glands produce precursor hormone to
be converted into estrogen.
4. Estrogen—regulates progesterone, stimulates fetal
maturation (lungs, liver, organs mature), prepare
breasts for lactation.
5. Progesterone—suppresses uterine contractions,
stimulates alveoli of breasts.

12. Physical and Emotional
Symptoms (1 of 3)
First trimester
• Enlarged and tender breasts
• Morning sickness (nausea and/or vomiting)
• Extreme fatigue
• Decreased interest in sex
• Moodiness and irritability
• Darkening of nipple and areola

13. Physical and Emotional
Symptoms (2 of 3)
Second trimester
• Morning sickness subsides.
• Gastrointestinal problems (heartburn, gas,
constipation)
• Gain majority of weight (12–14 pounds)
• Breathing problems
• Backache
• Leg cramps and numbness/tingling of hands
• Swollen and bleeding gums
• Swelling of feet, hands, and ankles
• Braxton-Hicks contractions

14. Physical and Emotional
Symptoms (3 of 3)
Third trimester
• Heartburn and constipation
• Leg cramps
• Backache
• Breathlessness
• Braxton-Hicks contractions
• ↑ Leukorrhea
• ↑ Colostrum
• Hemorrhoids
• Pelvic and buttock discomfort
• Itchy abdomen

15. A Pregnant Woman’s Body Changes
Figure 6-2 Changes in a woman's body during pregnancy. Through the three
trimesters, the shape of the pregnant woman’s body changes dramatically.

16. Fetal Development
Terms
• Amnion: Fetal sac that envelops the embryo
• Amniotic fluid: Provides protection and constant
environment for floating embryo
• Placenta: Supplies fetus with oxygen and
nutrients from maternal bloodstream and filters
waste back to mother for disposal

17. Fetal Growth (1 of 2)
Figure 6-3B Fetal development.
Human fetus at about 11 to 12
weeks of development.
© Miroslav Ferkuniak/Dreamstime.com

18. Fetal Growth (2 of 2)
Figure 6-3D Fetal development. Human fetus nearly
full term—8 to 9 months.
© Amitai/Dreamstime.com

19. Preconception Care
Preconception care
• The steps that a woman can take before she
decides to become pregnant to ensure that
she is in good health when conception occurs
– Folic acid
– Proper immunizations
– Healthy behaviors
– Nutrition

20. Prenatal Care—Nutrition
• Consume additional 100
calories/day during first
trimester
• Consume additional 300
calories/day second and
third trimester
• Folic acid, calcium, iron
• Increase fluid intake
• Weight gain: average
25–35 pounds total
© allstars/Shutterstock
© Dennis Gray/Cole Group/Photodisc/Getty Images

21. Exercise
Benefits
• Feel better throughout
trimesters
• Shorter labor
• Quicker recovery
Forms
• Swimming
• Walking
• Low-impact aerobics
• Kegel exercises
Proper exercise during pregnancy can
have many benefits. Walking, swimming,
and low-impact aerobics are particularly
good choices for pregnant women.
© Jupiterimages/PHOTOS.com/Getty images

22. Avoiding Toxic Substances (1 of 5)
Cigarette smoking
• 13% of women smoke during pregnancy
• Complications
– Lower birth weight
– Physical and mental problems for infants
– Infertility
– Spontaneous abortions (miscarriages)
– Ectopic pregnancies
– Placental irregularities and intrauterine
growth retardation

23. Smoking During Pregnancy
Figure 6-4 Prevalence (%) of smoking during pregnancy by
race/ethnicity and age
Data from Drake, P., Driscoll, A.K., and Mathews, T.J. (2018). Cigarette smoking during pregnancy: United States, 2016. NCHS Data Brief No. 305.
Source: Tong, V. T., Dietz, P. M., Morrow, B., et al. (2013). Trends in smoking before, during, and after pregnancy—Pregnancy Risk Assessment
Monitoring System (PRAMS), United States, 40 sites, 2000–2010. Morbidity and Mortality Weekly Report 62(SS06);1–19.

24. Avoiding Toxic Substances (2 of 5)
Alcohol
• Especially risky in first trimester
• Fetal alcohol syndrome (FAS)
– Growth retardation
– Facial malformations
– Central nervous system dysfunction
• Increased risk of stillbirth

25. Avoiding Toxic Substances (3 of 5)
Alcohol
• 1 in 13 pregnant women reports alcohol use
• 1 in 71 pregnant women report binge
drinking

26. Avoiding Toxic Substances (4 of 5)
Other drug use
• OTC medications—physician should be consulted
before use.
• Marijuana use—causes smaller, sicker babies; higher
risk of stillbirths; excessive crying and trembling in
infants
• Cocaine use—associated with fetal distress; low birth
weight; impaired fetal growth
• Heroin—risk of miscarriage, premature delivery,
stillbirth, poor fetal growth; withdrawal symptoms at
birth; increased risk of SIDS

27. Avoiding Toxic Substances (5 of 5)
Environmental risks
As precautionary measure to protect herself and
her baby, a pregnant woman should avoid:
• Pollutants
• Toxic wastes
• Heavy metals
• Pesticides
• Gases
• Radiation treatment
• Diagnostic X-rays
• Heat exposure

28. Prenatal Testing: Screening
• First trimester
– Ultrasound tests and
maternal blood tests
to detect Down
syndrome and
trisomy 18
• Second trimester
– Multiple marker
screening
– Detailed ultrasound
exams
Performed at various times during
pregnancy, ultrasound uses sound waves
to show a picture of the fetus. Ultrasound
can check the age, growth, and size of a
fetus; identify multiple pregnancies; and
diagnose complications or birth defects.
© Chris Ryan/OJO Images/Getty Images

29. Prenatal Testing: Diagnostic
• Chorionic villus sampling (CVS):
10th–12th week
• Amniocentesis: 15th–20th week
• Fetal blood sampling

30. Chorionic Villus Sampling
Procedure
Figure 6-5B In chorionic villus
sampling, fetal cells from the
chorionic villi (fingerlike projections
on the developing placenta) are
suctioned out through the cervix.

31. Amniocentesis Procedure
Figure 6-5A Amniocentesis
is a test for fetal abnormalities
that involves withdrawing
amniotic fluid and inspecting
the cells contained within it.

32. Complications of Pregnancy
(1 of 4)
Ectopic pregnancy
• Occurs in approximately 20 per 1000
pregnancies
• Risk factors related to fallopian tube
problems
• Fertilized egg grows outside uterine cavity
• Abdominal pain, spotting, ruptured fallopian
tube, PID
• Can be life threatening

33. Complications of Pregnancy
(2 of 4)
Gestational diabetes
• Usually in second half of pregnancy
• May or may not have symptoms
• Can present problems for mother and
baby
• Mothers at greater risk for developing
type 2 diabetes later in life

34. Complications of Pregnancy
(3 of 4)
Preeclampsia
• Pregnancy-related high blood pressure
• Several other symptoms
– Protein in urine; face and hands swelling;
sudden weight gain; blurred vision; severe
headaches; dizziness; stomach pain
• Cure is delivery of the baby

35. Complications of Pregnancy
(4 of 4)
Preterm labor and delivery
• Defined as labor before week 37
• Risk factors
– Previous preterm birth
– Multiple births
– Maternal abnormalities or medical
conditions
– Late or no prenatal care
– Mothers who smoke, drink, use drugs

36. Infections in Pregnancy (1 of 2)
• Gonorrhea, chlamydia, syphilis → preterm
delivery, miscarriages
• Bacterial vaginosis (BV) → preterm delivery,
lower birth weight, higher risk of HIV
• Perinatal transmission of HIV can be reduced by
the use of AZT

37. Infections in Pregnancy (2 of 2)
• Cytomegalovirus (CMV) → smaller birth size,
brain damage, developmental problems,
enlarged liver, hearing and vision impairment,
malformations
• Rubella → birth defects
• Group B streptococcus (GBS) → sepsis,
pneumonia, meningitis, long-term disabilities,
death

38. Miscarriage
• Pregnancy that ends before 20th week
• Several factors associated with
miscarriage.
• Symptoms: bleeding and cramping
• Causes vary and often are not clear

39. Stillbirth
• Defined as intrauterine death of fetus
• Multiple causes
• Multiple symptoms
• Counseling important

40. Genetic Disorders
and Congenital Abnormalities
• Caused in whole or part by variation or
mutation of a gene
• Over 6000 abnormalities have been
identified
• State-based screening programs

41. Childbirth
Childbirth education classes help a couple prepare for delivery
by teaching relaxation and pain management techniques. The
classes also provide the opportunity for the couples to discuss
their concerns and excitement.
© Purestock/Getty Images

42. Labor and Delivery
Three distinctive signs of labor
1. Uterine contractions every 5 minutes
2. Rupture of the membranes: leak of fluids
3. Bloody show: passage of mucous plug of cervix
when cervix dilates
Other signs
• Diarrhea
• Backache
• Increased Braxton-Hicks contractions

43. Three Stages of Labor
Figure 6-6 Labor and delivery. Stage I: the cervix becomes fully dilated;
stage II: the infant is born; stage III: the afterbirth is delivered.

44. Dilation Through Stages of
Labor
Figure 6-7 Dilation through stages of labor.

45. Labor Support During
Childbirth
Nondrug strategies
• Comfort measures
• Mental strategies
• Medications

46. Pain Relief in Childbirth
• Tranquilizers and analgesics
• Anesthetics
– Epidural—injected through a catheter
beside the spinal cord
– Spinal—injected directly into the spinal
canal
– Pudendal—injected into area around the
vagina and perineum

47. Cesarean Delivery
• Surgical incisions made in both the wall of the
mother’s abdomen and her uterus
• Reasons for cesarean delivery
– Fetal distress
o Abruptio placentae
o Prolapsed umbilical cord
– Cephalopelvic disproportion
– Fetal position
– Multiple births
– Obstruction, including placenta previa
– “Failure to progress”
– Maternal infections

48. Cesarean Delivery Rates
Figure 6-8 Total Cesarean rates for first births, United States, 1991-2013.
Data from Martin, J.A., Hamilton, B.E., Osterman, M.J.K., et al. (2018). Births: final data for 2017. National Vital Statistics Reports 67(8). Available at:
https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_08-508.pdf

49. Breastfeeding
Figure 6-9 The female breast.

50. Benefits of Breastfeeding (1 of 2)
For baby
• Breast milk is highly nutritious.
• Breast milk contains enzymes to aid in infant
digestion.
• Breast milk contains antibodies to protect against
infection.
• Fewer infant episodes of diarrhea
• Fewer infant cases of upper respiratory, ear, and
urinary infections
• Protects against type 1 diabetes, Crohn’s disease,
SIDS, chronic digestive disease, childhood cancers

51. Benefits of Breastfeeding (2 of 2)
For mother
• Uterus returns to normal size more quickly.
• Return to prepregnancy weight more quickly
• Lower risk of ovarian and breast cancer,
osteoporosis

52. Optimizing Breastfeeding
Promotion of breastfeeding
• Education and support for new mothers
• Worksite support
• Address sociocultural, racial, and ethnic
disparities
• Address geographical variances

53. Complications of Breastfeeding
(1 of 2)
A mother should not breastfeed if she:
• Is HIV infected
• Is an untreated active TB patient
• Uses alcohol, tobacco, or other drugs
(including certain medications)
• Is undergoing cancer therapy/radiation
treatment

54. Complications of Breastfeeding
(2 of 2)
Mothers may experience difficulties if:
• Nipples are inverted, flat, raw, or cracked
• Breasts are severely swollen
• Infant is having problems latching on
• There is pain during latch-on
• There is mastitis or thrush

55. Infertility
• Fecundity—a woman’s ability to have
a child
• Impaired fecundity—a woman who,
although is having regular sexual
relations without contraception for 36
months or more, fails to become
pregnant

56. Infertility Causes
• Female infertility = 25 to 35% of couples
– Ovulation disorder
• Male infertility = 25 to 35% of couples
– Azoospermia, oligospermia
Diagnosis
• Ovulation test, cervical mucus test, postcoital test
• Blood test for hormone levels
• Hysterosalpingogram, laparoscopic surgery
• Semen analysis

57. Infertility Treatment (1 of 2)
• Improve quality of cervical mucus = estrogen,
prednisone
• Stimulate ovulation = Clomid, Serophene
• GnRH to improve response to ovulation
stimulants
• Surgery to open blocked sperm ducts or repair a
varicocele
• Artificial insemination (AI)

58. Infertility Treatment (2 of 2)
Assisted reproductive technologies (ART)
• In vitro fertilization (IVF)
• Gamete intrafallopian transfer (GIFT)
• Zygote intrafallopian transfer (ZIFT)
• Intracytoplasmic sperm injection (ICSI)
• Egg donation
• Embryo transfer
• Host uterus
• Surrogacy

59. Emotional Effects of Infertility
• Anger and resentment toward partner
• Guilt and blame toward self
• Depression and frustration
• Miscommunication
• Confusion
• Grief
• Despair
• Loss of control

60. Types of ART Cycles
Figure 6-12 Types of ART cycles: United
States, 2016.

61. Maternal Mortality
Figure 6-11 Trends in pregnancy-related mortality in the United States:
1987–2014.
Centers for Disease Control. (2018). Pregnancy mortality surveillance system. Available online at:
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/ pregnancy-mortality-surveillance-system.htm

62. Epidemiology
Figure 6-10 Birth rates for teenagers aged 15 to 19 years
Data from Martin, J. A., Hamilton, B. E., Osterman, M. J. K., et al. (2015). Births: Final data for 2014. National Vital Statistics Reports 64(1).
Hyattsville, MD: National Center for Health Statistics; Martin, J.A., Hamilton, B.E., Osterman, M.J.K., et al. (2018). Births: final data for 2017.
National Vital Statistics Reports 67(8).

63. Breastfeeding
Figure 6-1 Healthy People 2020 Breastfeeding Objectives
Data from Centers for Disease Control and Prevention (CDC). (2018). Breastfeeding report card—United States,
2018. Available at: https://www.cdc.gov/breastfeeding/data/reportcard.htm

64. Fertility
• Denotes successful production of offspring
• Trends
– 16% of women in their 40s are childless
– Women are having fewer children
– Recent drops in teen childbirth
– Increases in non-marital births
– Hispanic women have more children than
other groups

65. Infertility
• Defined as not being able to get pregnant after
trying for 1 year
• Women aged 25 to 44: 17% used infertility
services between 2006–2010.
• ART is associated with risk of multiple births.

66. Informed Decision Making
• Regular prenatal care—proper nutrition;
adequate exercise; avoidance of alcohol, drugs,
and tobacco
• Childbirth—preparation
• Breastfeeding—learned behavior, adjusting
positions, anticipating the infant’s hunger,
relaxing during feeding
• Infertility—information, support, and procedures
to address infertility issues