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Neural-tube defect prevention

Related Terms

3-D ultrasound, abortifacient, acquired immunodeficiency syndrome, adrenal gland disorders, AFP test, AIDS, alcohol-related birth defects, alcohol-related neurodevelopmental disorder, alpha-fetoprotein test, amniocentesis, anemia, anovulation, ARBD, ARND, artificial insemination, asthenospermia, asthma, autoimmune disorders, birth control pills, birth defects, breech birth, breech presentation, cervical dilator, cervical stenosis, cervix, chlamydia, chorionic gonadotropin, chorionic villi sampling, cleft lip, cleft palate, condom, cone biopsy, Crohn's disease, Cushing's syndrome, CVS, cystic fibrosis, DES, diabetes, diabetes mellitus, diethylstilbesterol, Doppler ultrasound, Down's syndrome, duodenal atresia, ectopic pregnancy, egg, embryonal stage, emergency contraceptive pill, endometriosis, epilepsy, estriol, FAS, fertility, fertilization, fetal Alcohol Syndrome, fetal echocardiography, fetal stage, fetus, first trimester, flu shots, fluoride, gastrointestinal disorders, genital warts, gonorrhea, Goodell's sign, Group B strep, Hegar's sign, hemorrhoids, hepatitis B, herpes, high blood pressure, HIV, HPV, human immunodeficiency virus, human papilloma virus, hyperemesis gravidarum, hyperparathyroidism, hyperpigmentation, hyperthyroidism, hypoparathyroidism, hypothyroidism, hysterectomy, idiopathic spermatozoa, induced labor, infertility, intrauterine device, itrauterine growth retardation, IUD, kidney disease, labor, labor and delivery, labor induction, labor pain, lactation, lactation suppression, LEEP, limb-reduction defects, linea nigra, loop electrosurgical excision procedure, low birth weight, low sperm counts, lupus, menstruation, miscarriage, morning sickness, myasthenia gravis, neural tube defect, neural-tube defect prevention, neurological disorders, oocyte, oxytocic, parathyroid disorders, pelvic girdle pain, pelvic inflammatory disease, phenylketonuria, PID, pituitary disorders, pituitary insufficiency, pituitary tumor, PKU, placenta, placenta previa, postcesarean endometritis, postpartum depression, post-partum perineal discomfort, preeclampsia, pregnancy nausea, pregnancy-induced nausea and vomiting, pregnancy-related complications, prenatal care, prenatal support, preterm, progesterone, Rh factor, Rh-immune globulin, scleroderma, second trimester, sickle-cell anemia, sperm motility, spermatogenesis, spina bifida, spontaneous abortion, syphilis, Tay-Sachs, thyroid disorders, toxemia (pregnancy), toxoplasma, transvaginal scans, trichomoniasis, trimester, tubal ligation, ultrasound, unborn baby, vagina, varicose veins, vulva, weight gain.

Background

Pregnancy is the carrying of one or more offspring in an embryonic or fetal stage of development by females, between the stages of conception and birth.

Childbirth usually occurs about 38 weeks from fertilization, approximately 40 weeks from the start of the last menstruation. Thus, pregnancy lasts about nine months. Though this time length is an average, the actual length of pregnancy depends on various factors, such as fetal development and health and the mother's health. In general, the first pregnancy tends to last longer than subsequent pregnancies. Fewer than 10% of births occur on the due date; 50% of births are within a week of the due date, and almost 90% are within two weeks.

The due date is typically calculated as 40 weeks from the last menstrual period.

Before pregnancy begins, a female oocyte (egg) must join with a sperm in a process referred to in medicine as "fertilization" or commonly known as "conception." Fertilization usually occurs through the act of sexual intercourse, in which a man ejaculates inside a woman's vagina, thus releasing his sperm. However, artificial insemination has made it possible for women to become pregnant when pre-existing medical conditions from either the woman or the man make fertilization through sexual intercourse difficult, or if a woman chooses to become pregnant without a male partner.

After fertilization, the combination of the egg and sperm is called a zygote. The zygote becomes embedded in the uterus wall where it can begin growth. The human zygote undergoes cellular division to become an embryo. The term embryo is used until the end of the eighth week of gestational age, when it is then called a fetus or unborn baby until birth.

Human pregnancy is divided into three trimester periods. The first trimester period carries the highest risk of miscarriage (natural death of embryo or fetus). During the second trimester, the development of the fetus can be monitored and diagnosed more easily. The third trimester often marks the beginning of viability, or the ability of the fetus to survive, with or without medical help, outside of the mother's womb.

According to the Centers for Disease Control and Prevention (CDC), nearly four million American women give birth every year in the United States.

Signs and symptoms

Early signs and symptoms:

Early signs typically appear, if at all, within the first few weeks after conception. Presence of human chorionic gonadotropin (hCG) in the blood and urine, detectable by laboratory or home testing, is the most reliable early sign of pregnancy. Other early signs and symptoms of pregnancy include: missed menstrual period; implantation bleeding, light spotting that occurs at implantation of the embryo in the uterus, in the third or fourth week after LMP; increased basal body temperature (body temperature at rest) sustained for over two weeks after ovulation; Chadwick's sign, a darkening of the cervix, vagina, and vulva; Goodell's sign, a softening of the vaginal portion of the cervix; and Hegar's sign, a softening of the cervical isthmus (the portion of the cervix between the uterus and the vaginal portion of the cervix).

Physical symptoms of pregnancy vary. Of the symptoms listed, not all will occur for every woman and individuals may experience different symptoms during different pregnancies.

Nausea and vomiting: Nausea and vomiting may come as early as one week into the pregnancy. Many women experience illness in the morning (morning sickness), some in the afternoon or evening, others feel nausea throughout the entire day. There is no explanation as to why pregnant women feel this or even a solution as to how to prevent it; however, eating small frequent meals, and snacking on saltine crackers, seems to give some kind of relief. Eating a protein/carbohydrate at bedtime (an apple and a glass of milk) tends to lessen the nausea that occurs in the morning.

Breast tenderness: Breasts may be very tender, swollen, and start to enlarge. Many times, the veins within the breast will become more visible. Nipples may start to darken in color, become more erect, and be extremely sensitive.

Frequent urination: Pregnancy causes the uterus to swell and it will start to enlarge for the growing fetus immediately. The uterus puts pressure on the bladder, making the individual feel the need for more frequent urination. Many women start to feel this symptom within a week or two after pregnancy has occurred.

Fatigue: When a pregnant body is going through some major hormonal changes, fatigue, or excessive tiredness, may occur.

Light bleeding: Light bleeding (spotting) may occur approximately eight to 10 days from ovulation. Bleeding usually happens around the same time the woman would have gotten her menstrual period. Some women assume they have started their period when in fact they are pregnant. The spotting is caused from implantation, which is when the fertilized egg burrows into the lining of the uterus.

Dizziness or fainting: When standing in one place, an individual may feel dizzy or even faint. The growing uterus compresses major arteries in the legs, which causes blood pressure to drop. This sudden drop in blood pressure can make the individual dizzy. Skipping meals or going too long without eating may cause the individual to feel dizzy or faint. When not eating frequently enough, low blood sugar may develop. Blood sugar is the primary source of food for the baby, so blood sugar in the mother will be depleted much more quickly. Eat regular meals to avoid drops in blood sugar.

Constipation: Pregnancy hormones will slow down bowel functions to give maximum absorption time of vitamins and nutrients. Unfortunately, this symptom usually only gets worse as the pregnancy progresses.

Irritability: Hormonal changes may lead to irritability. Symptom should decrease soon into the second trimester but until then, a healthy diet, moderate exercise, and plenty of sleep should help the mood disturbances.

Heartburn: During pregnancy, digestion may slow, making the stomach not empty as fast increasing stomach acid levels.

Later signs and symptoms:

Later signs of pregnancy include linea nigra, a darkening of the skin in a vertical line on the abdomen. Linea nigra is caused by hyperpigmentation resulting from hormonal changes. Linea nigra usually appears around the middle of pregnancy. Later symptoms include increasing abdominal swelling, the most visible sign of pregnancy.

Other symptoms may be experienced specifically during the later stages, such as lower backache. Balance and ease of walking may be affected; flatulent and gas; hemorrhoids and rectal irritation; hair loss, others have more body or "facial" hair; and sensitivity in teeth. There is a higher risk for gum disease during pregnancy.

Diagnosis

Physical symptoms:

Missed period: A missed period, or monthly menstruation, is probably one of the more reliable signs of pregnancy. Although some women will experience implantation bleeding about the time of their period, it is usually lighter and/or shorter than their normal period. This is why women are asked for the first day of their last normal period. There are a few women who will have period throughout their pregnancy, however, this is rare.

Home pregnancy test: These tests measure the levels of human chorionic gonadotropin (hCG, a hormone secreted during pregnancy) in the urine. The amount of urine each test can detect varies widely. The amount of hormone each woman secretes may also vary, but not as widely.

First morning urine will always contain the highest concentration of hCG. However, most tests do not require that the individual use first morning urine. It is advised to wait a few hours after the last urination to use the test so as to have enough hCG in the urine. This will allow hCG to build up in the urine. These tests rarely give false results. A negative answer that is later found to be a pregnancy is usually the result of the test being performed too early. Talk to a doctor if there are questions about the pregnancy tests and consider calling the toll-free number provided by the test manufacturer.

Morning sickness: Morning sickness affects many pregnant women, but by no means all of them. It is estimated that only 50% of women will experience morning sickness. Some women are sick only in the night, some are sick all day, and in other women it comes and goes with its own pattern. There is also a difference in whether it's merely a queasy feeling or actual vomiting. Some women will actually have a severe form of morning sickness called hyperemesis gravidarum. This can lead to dehydration and other problems.

Breast tenderness: Breast tenderness is experienced by many women, both during pregnancy and prior to their periods. Breast tenderness usually goes away during the second trimester and may be replaced by a heightened sensitivity in the breasts.

Headaches: Headaches are more common in pregnancy due to the changes in hormones. This may be a pregnancy symptom, but it is not necessarily a pregnancy sign. There are many things that could cause this symptom, including stress.

Bloating: Some women begin to bloat nearly immediately after becoming pregnant.

Vaginal discharge: Excess vaginal discharge, without itching or burning, may be a sign of pregnancy. The cervix is building a mucous plug to block the opening of the cervix to help protect the baby from infections and other complications. The individual may notice a slight increase in vaginal secretions. Again, this discharge should not smell, burn, or itch. These would be signs of infection not related to pregnancy that would require proper medical treatment.

Diagnostic therapies:

Diagnostic therapies help ensure that the developing fetus is healthy and remains healthy during the pregnancy.

Ultrasound: An ultrasound exam is a procedure that uses high-frequency sound waves to scan a woman's abdomen and pelvic cavity, creating a picture of the baby and placenta. This picture is called a sonogram. Although the terms ultrasound and sonogram are technically different, they are used interchangeably and both reference the same exam.

Transvaginal scans: Transvaginal scans are types of ultrasounds that use specially designed medical devices (probes) used inside the vagina to generate sonogram images. One or two of these scans may be performed during the first trimester.

Standard ultrasound: A standard or traditional ultrasound exam uses a transducer over the abdomen to generate 2-D images of the developing fetus. Ultrasounds may be performed at any point during a pregnancy.

Advanced ultrasound: Advanced ultrasound exams are similar to the standard ultrasound, but the exam targets a suspected problem and uses more sophisticated equipment to determine the health of the fetus.

Doppler ultrasound: Doppler ultrasound imaging procedure measures slight changes in the frequency of the ultrasound waves as they bounce off moving objects, such as blood cells.

3-D ultrasound: 3-D ultrasound uses specially designed probes and software to generate 3-D images of the developing fetus.

4-D or dynamic 3-D ultrasound: 4-D or dynamic 3-D ultrasound uses specially designed scanners to look at the face and movements of the baby prior to delivery.

Fetal echocardiography: Fetal echocardiography ultrasound waves to assess the baby's heart anatomy and function are used to help assess suspected congenital heart defects.

They may be performed at any point during pregnancy, and the results are seen immediately on a monitor during the procedure.

Amniocentesis: Amniocentesis involves extracting and examining DNA and chromosomes from the mother in order to determine if the baby has a chromosome disorder or for fetal lung maturity. Amniocentesis can be recommended under many different circumstances. These include if the woman is over 35 years of age. This is done mainly to determine if the fetus has Down's syndrome, which is more prevalent among children with older mothers. If the woman has had another child or a close relative that has had a neural tube defect in the past, a doctor may recommend an amniocentesis to rule out the possibility of a defect in the child. If both the mother and the father are carriers for an autosomal recessive inherited disorder such as Tay-Sachs or sickle-cell anemia, or if a child has already been born with a chromosomal abnormality such as Down's syndrome, an amniocentesis will be able to determine if the fetus exhibits the same abnormality. If the mother is a carrier for a genetic disorder, an amniocentesis can identify whether the baby has inherited the gene from the mother and determine the gender in order to see if the baby will be affected by the presence of the genetic defect. If the mother or the father has an autosomal dominant disorder such as Huntington's chorea, if any type of infection of the fetus or the mother is suspected, or if it is necessary to evaluate the maturity of the lungs of the fetus late in the pregnancy, an amniocentesis may be recommended.

Amniocentesis is best performed at 15-17 weeks of gestation, but occasionally as early as the 14th or as late as the 20th week. Amniocentesis can also be performed in the last trimester to assess the maturity of the fetal lungs. Test results are usually conclusive within one week.

The expectant mother is positioned on her back with her abdomen exposed. The ultrasound finds the location of the fetus and placenta in the mother in order to reduce the chance of accidentally pricking the fetus. The abdomen is then swabbed with antiseptic solution and sometimes a local anesthetic. A long, hollow needle is then inserted through the abdomen and into the uterus. A small amount of amniotic fluid is then withdrawn. Before, during, and after the procedure, the mother's vital signs and the baby's heart tones are monitored to ensure no complications, such as high blood pressure, are experienced. The parents may also have the option of learning the baby's gender with the test results. From start to finish, the entire procedure should not take more than 30 minutes.

If a genetic disorder is detected, the parents will be referred to a genetic counselor for further counseling and decision making. The genetic counselor can answer questions, and suggest further tests to help see how the child's health may be affected. In many cases, a genetic counselor can reassure the parents that the risk to the baby is lower than feared.

Amniocentesis may result in symptoms in the mother. Side effects may include fatigue, mild cramping, and slight vaginal bleeding or leakage of amniotic fluid. In rare occasions, the individual may experience infection as a result of the procedure or even more severe complications that may lead to miscarriage. Some experts estimate that the risk of miscarriage ranges from one out of 200-400 patients; it is highest when the procedure is done early in pregnancy, before the two layers of fetal membranes have sealed. A woman's particular risk depends in large part on the skill and experience of the doctor performing the procedure. Amniocentesis should only be used when the benefits outweigh the risks.

Chorionic villus sampling: Chorionic villus sampling (CVS) is done to determine if the child has a chromosomal disorder such as Tay-Sachs, sickle-cell anemia, most types of cystic fibrosis, or Down's syndrome. Chorionic villus sampling involves placing a small needle or catheter either through the abdomen or through the vagina near the uterus in order to collect a small sample of placental tissue called chorionic villi. Ultrasound is used at the same time in order to guide the needle or catheter away from the baby and the placenta. The test can be done as early as 10 weeks and is most commonly done between the 10th and 13th weeks of pregnancy.

CVS is normally performed in the first trimester in a hospital setting. The sample of cells from the placenta is taken via the vagina and cervix (transcervical CVS) or via a needle inserted in the abdominal wall (transabdominal CVS). Though this is a fairly common procedure, some discomfort - ranging from mild to severe - may be present during a CVS.

Transcervical CVS involves the insertion of a long thin tube into the vagina. Guided by ultrasound imaging, the doctor directs the tube to the fetal tissue. A sample is then trimmed off for further study.

With the transabdominal CVS procedure, the doctor will use an ultrasound to determine the exact location of the placenta to find a safe place for needle insertion to minimize any damage to the mother or child. A needle is then inserted through the abdomen and uterus to the edge of the placenta. At this point, a narrower needle is inserted through the guiding needle and a small sample of cells is taken from the chorionic villi for diagnostic study. It is generally recommended that those undergoing the procedure arrange to have someone drive them home afterward and that they make no other plans for the rest of the day since it can be emotionally and physically demanding.

After the samples have been taken, further diagnostic study is performed on them. Since the cells in the sample are actually of fetal origin, they can be used to generate a detailed picture of the genetic makeup of the developing fetus. In most circumstances, the results from the test are available within three to five days.

Most studies so far have indicated that CVS is safe and reliable. However, the procedure is slightly riskier than amniocentesis. Miscarriage occurs in about two percent of women who undergo this procedure. There appears to be an even higher risk of miscarriage with the transcervical CVS technique compared to the transabominal technique. Other factors that further increase the risk of CVS include having the procedure three or more times and having a fetus that is smaller than normal for their age. The physician's skill and experience also play an important role. There are also some studies that suggest that there may be a slight increase in the number of limb deformities from amniotic banding syndrome.

The primary advantage of chorionic villus sampling is that results are available much earlier in pregnancy than other tests. Since it can be performed in the first trimester, CVS can give results earlier in pregnancy than amniocentesis, which is usually performed after the 16th week. Thus, if results are abnormal, the fetus can be treated before being born. Also, when normal results are found, this decreases parental anxiety earlier. The risks have to be weighed against this benefit of earlier diagnosis and should be discussed at length with a doctor. If a genetic disorder is detected, parents will be referred to a genetic counselor for further counseling and decision-making.

Glucose screening: With good medical care, women with preexisting or gestational diabetes can have an uncomplicated pregnancy and a healthy baby, as long as blood sugar levels are well controlled. A glucose screening can let the woman know if she is at risk. Most practitioners check for gestational diabetes at about 28 weeks.

Alpha-feto protein: The alpha-fetoprotein test (AFP test) is where a blood sample is drawn from the mother to check the levels of AFP. AFP is a protein secreted by the fetal liver and excreted in the mother's blood. It is generally used to provide a screening for neural tube defects like spina bifida and ancephaly. Alpha-feto protein testing can also indicate: abdominal wall defects, esophageal and duodenal atresia, some renal and urinary tract anomalies, Turner syndrome, some low birth-weight fetuses, placental complications, and the presence of Down's syndrome.

Triple screening: The triple screen, also known as a maternal serum screening test or MSS, is a simple and completely safe blood test that measures not only AFP, but hCG and estriol as well. These are all hormones produced by the fetus and passed into the mother's bloodstream. The test is performed between the 15th and 18th weeks, with the results usually available within one week. Elevated levels of AFP in the mother's blood may indicate a neural tube defect in the baby such as a deformity of the spinal canal known as spina bifida. Lower levels of AFP suggest with the possibility of the presence of Down's syndrome or other chromosomal defects.

Triple screening is more accurate and screens for additional genetic problems and is beginning to replace the standard AFP. Generally speaking, any combination of the testing will identify 60% of the babies with Down's syndrome and 80-90% of the babies with neural tube defects. The AFP test is generally most sensitive between the 15th and 17th weeks of pregnancy, while the triple screen can be done a bit earlier.

Quadruple screening: A fairly recent addition to the screening tests, the quadruple test is almost identical to the triple screen, using a sample of the mother's blood, a quadruple screen measures a woman's levels of alpha feto protein, hCG, estriol, and inhibin to indicate her baby's risk of Down's syndrome. The quadruple test is about 81% effective and is usually performed around the 16th week of pregnancy. If a risk of Down's syndrome is indicated, amniocentesis can be performed to help with the diagnosis.

Rh incompatibility: One of the first prenatal tests a doctor will give the mother is a blood test to see if she is Rh negative or positive. On the surface of many red blood cells is a protein commonly referred to as Rh factor. Those individuals with Rh factor are thought to be Rh-positive while those without it are Rh-negative. If the mother is Rh-negative (which means the blood cells do not have Rh factor on them) but the child is Rh-positive (meaning the child does have Rh factor on their blood cells), the mother's body's immune system may attack the child's blood cells, which can cause life-threatening complications to the baby and the mother.

Women who are Rh positive have little chance of an adverse reaction to their child's blood. If, however, it is deemed that the mother is Rh-negative and there is a chance that the baby is Rh-positive (such as if the father is Rh positive), then both the mother and the baby will be at an increased risk for potential problems during pregnancy. Administration of a vaccine-like injection of Rh known as a RhoGAM can help avoid these problems.

RhoGAM?, or Rh-immune globulin, is an injection given to Rh negative women during their 28th week of pregnancy and then again within 72 hours of birth, miscarriage, amniocentesis, or chorionic villus sampling. This injection contains antibodies that will help kill off any of the baby's red blood cells that may have entered the mother's blood stream, thereby preventing the woman's body from developing its own antibodies to the baby's blood.

Cystic fibrosis (CF) carrier screen: Cystic fibrosis is an inherited disease that affects breathing and digestion. It is caused by an abnormal gene involved in mucus production in the body. The mucus is important in preventing infections and absorbing food within the body. Sufferers of cystic fibrosis lead an average lifespan of 30 years. A test can determine if the baby will potentially develop cystic fibrosis.

Complications

According to the Centers for Disease Control and Prevention (CDC), nearly 4 million American women give birth every year. Of these women, almost one-third will have some form of pregnancy complication. However, the vast majority of women have normal, uncomplicated pregnancies and deliveries.

Premature labor: Pregnancy takes about 40 weeks. If contractions cause the cervix to open earlier than normal, between the 20th and 37th week, labor may be premature. This may result in the birth of a premature baby. Babies born before the 37th week may have trouble breathing, eating, and keeping warm. The signs of premature labor include: uterine contractions every 10 minutes or faster; repeating or constant menstrual-like cramps in the lower abdomen; abdominal cramps with or without diarrhea; pelvic pressure that feels like the fetus is pushing down; increase or change in vaginal discharge; sudden gush of watery fluids from the vagina (water breaking); or a feeling like the fetus is "balling up."

Other complications: Signs of other potentially serious problems during pregnancy include: heavy bleeding from the vagina; constant severe lower abdominal pain or cramps on one or both sides; dimness or blurring of vision that lasts two or three hours; dizziness and/or double vision; severe or continued vomiting; chills and/or fever of 101?F or more; fever of 101?F or more with pain or burning during urination; sudden severe swelling or puffiness of the face, hands, legs, ankles, or feet, especially if headaches or vision changes occur; after six months of pregnancy, if the woman notices a significant decrease in the movement of the fetus; and after six months of pregnancy, if the mother thinks the fetus has not moved in eight hours or more. If any of these symptoms occur, it is recommended by healthcare professionals to call a doctor immediately.

In some pregnancies, known as high-risk pregnancies, the mother and/or fetus are at an increased risk of experiencing complications. Doctors and patients will need to treat high risk pregnancies with extra care. A pregnancy may be classified as high risk for a number of reasons, including:

Age: Women over age 35 have an increased risk of certain chromosome abnormalities and placental problems (such as placenta previa). Studies also suggest an increased risk of miscarriage and low birth weight in pregnant women in this age group. There is also an increased chance of developing gestational diabetes and high blood pressure (preeclampsia).

In addition, teen mothers are more likely to give birth prematurely than woman over the age of 20.

Multiple births: Women carrying two or more babies are at an increased risk for a number of complications, including premature labor and low birth weight.

Preexisting medical conditions: Many medical conditions can increase a woman's risk of pregnancy complications. These conditions may include: anemia; diabetes mellitus; obesity; hyperemesis gravidarum (excessive nausea and vomiting); high blood pressure; asthma; kidney disease; thyroid disorders (such as hyperthyroidism, hypothyroidism); parathyroid disorders (such as hyperparathyroidism, hypoparathyroidism); pituitary disorders (such as pituitary tumors, pituitary insufficiency); adrenal gland disorders (such as Cushing's syndrome); blood disorders (such as blood-clotting disorders, anemia, sickle-cell anemia); autoimmune disorders (such as lupus, scleroderma, myasthenia gravis); gastrointestinal disorders (such as Crohn's disease); neurological disorders (such as epilepsy); phenylketonuria (PKU); and Group B strep infection.

Women with a history of pelvic inflammatory disease (PID), endometriosis, and certain other gynecological conditions are more likely to have complications, including ectopic pregnancy.

Women who have had certain cervical procedures (such as a loop electrosurgical excision procedure [LEEP] or cone biopsy) may have an increased risk for pregnancy complications. Women who have an incompetent or weak cervix or cervical stenosis may also result in labor problems.

Women with a history of pregnancy loss (such as abortion, miscarriage, stillbirth, or ectopic pregnancy) have an increased risk of developing complications with their pregnancies. Ectopic pregnancies, also known as tubal pregnancies, result in a pregnancy loss and can be extremely dangerous to the mother.

Women who have already delivered a premature baby are more likely to have pregnancy complications, including additional premature births. A number of STDs can be transmitted to a baby before, during, or after birth, resulting in medical complications. STDs include: herpes; human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS); genital warts (caused by human papilloma virus, or HPV); hepatitis B; chlamydia; syphilis; gonorrhea; and trichomoniasis.

Women with a history of two or more second-trimester abortions are more likely to have an incompetent cervix, a condition linked to numerous complications.

Women who were exposed to diethylstilbesterol (DES, a hormonal drug) when their mothers took the drug during pregnancy are at an increased risk for a number of complications, including ectopic pregnancy and preterm delivery.

Women who conceive while using an IUD as a form of contraception are more likely to experience a miscarriage. Women who become pregnant while using the progesterone-releasing type of IUD are also more likely to have an ectopic pregnancy.

Alcohol-related birth defects: Physical or brain deficits (which can range form mild to severe) that a child experiences can be the result of alcohol consumption by the mother during pregnancy. These defects may include, but are not limited to, fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE).

Fetal alcohol syndrome (FAS): Fetal alcohol syndrome (FAS) refers to certain birth defects and serious, life-long mental and emotional impairments that may be suffered by a child as the result of heavy alcohol consumption by its mother during pregnancy. Symptoms of mental and emotional deficits may include significant learning and behavioral disorders (including attention deficits and hyperactivity), poor social judgment, diminished cause-and-effect thinking, and impulsive behaviors.

Fetal alcohol effect (FAE): Fetal alcohol effect (FAE) is a disorder associated with cognitive and behavioral difficulties in children whose birth mothers drank alcohol during their pregnancies. Symptoms are similar to Fetal Alcohol Syndrome (FAS), but less severe or comprehensive.

Treatment

Normal pregnancy is not an illness and needs no treatment other than standard prenatal care. After the initial visit, during the first six months of pregnancy, the individual should see a doctor about once per month. Visits should be scheduled every two weeks during the seventh and eight month and weekly during the ninth month. If a woman's pregnancy is difficult or complicated, her treatment can vary from simple bed rest to diagnostic testing such as an amniocentesis. An ultrasound physical assessment or a stay in the hospital for testing or medication may also be part of the treatment.

Flu shots: Flu shots are recommended for women who are pregnant. A doctor can determine which shot is best for the mother.

Electronic fetal monitoring: Sometimes late in pregnancy, a woman who is pregnant may be placed on a fetal monitor to verify the health of the fetus or to see if the woman is in early labor.

Ultrasound biophysical profile test: This is a noninvasive test that can assess whether or not the baby is obtaining an adequate supply of oxygen. It is typically performed in high risk pregnancies or if a woman has gone past her due date.

Medications: Because so many medicines are not safe to take during pregnancy, it is extremely important that a woman take only those that have been approved by her doctor. The U.S. Food and Drug Administration (FDA) lists five categories of labeling for drug use in pregnancy. A doctor or pharmacist can provide advice on the safety level (indicated by category) of medications before a woman who is pregnant takes anything. Expert recommend that expectant mothers follow the doctor's advice when taking prescription and non-prescription medications.

Integrative therapies

Strong scientific evidence:

Folic acid: Folic acid and folate are forms of a water-soluble B vitamin. Folate occurs naturally in food and folic acid is the synthetic form of this vitamin. Folic acid is well-tolerated in amounts found in fortified foods and supplements. Sources include cereals, baked goods, leafy vegetables (spinach, broccoli, lettuce), okra, asparagus, fruits (bananas, melons, lemons), legumes, yeast, mushrooms, organ meat (beef liver, kidney), orange juice, and tomato juice. Folic acid is frequently used in combination with other B vitamins in vitamin B complex formulations. Studies have found that folate consumption during pregnancy prevents deficiency and anemia in pregnant women. Low folate levels during pregnancy may contribute to birth defects and pregnancy loss. Consuming a high dietary intake of folate and taking folic acid supplements orally may aid in the prevention of pregnancy complications such as reducing the risk of neural tube birth defects in infants.

Avoid if allergic or hypersensitive to folate or folate product ingredients. Use cautiously if receiving coronary stents and with anemia and seizure disorders. It is recommended that pregnant women consume 400 micrograms daily in order to reduce the risk of fetal defects. Folate is likely safe if breastfeeding.

Unclear or conflicting scientific evidence:

Acupressure, shiatsu, tuina: The practice of applying finger pressure to specific acupoints throughout the body has been used in China since 2000 BC, prior to the use of acupuncture. Shiatsu technique involves finger pressure at acupoints and along body meridians. It can incorporate palm pressure, stretching, massaging, and other manual techniques. Shiatsu practitioners commonly treat musculoskeletal and psychological conditions, including neck/shoulder and lower back problems, arthritis, depression, and anxiety. One study reports that LI4 and BL67 acupressure may reduce labor pain specifically during the first stage of labor. Further study is needed.

With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. No serious long-term complications have been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles"), carotid dissection, and retinal and cerebral artery embolism cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.

Acupuncture: Acupuncture has been reported to encourage uterine contractions during labor and to reduce the pain of labor. However, results of formal studies are mixed, and research designs have been weak. Early evidence also suggests that acupuncture may substantially reduce low back pain in pregnancy. Additionally, moxibustion, practiced along with acupuncture in some individuals, has been used historically for correction of breech presentation by turning the baby's head in utero. More studies are needed to clarify the potential of acupuncture in pregnancy and labor.

Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, or neurological disorders. Avoid if taking drugs that increase the risk of bleeding (e.g. anticoagulants). Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (e.g. asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers because therapy may interfere with the device.

L-arginine: L-arginine, or arginine, is a semi-essential amino acid needed by the body. Early studies in pregnant mothers suggest that arginine supplements may improve growth in fetuses that are smaller than average. Additional studies are needed to better understand the potential role of arginine for prevention of intrauterine growth retardation.

Avoid if allergic to arginine, or with a history of stroke, liver, or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin?) and blood pressure drugs or herbs or supplements with similar effects. Blood potassium levels should be monitored. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels. Arginine is generally regarded as safe in recommended dosages.

Aromatherapy: Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. Preliminary evidence on use of lavender oil in bath water suggests no benefit for post-partum perineal discomfort. More studies are needed before conclusions can be reached about the application of essential oils for postpartum care.

Beta-carotene: Beta-carotene is a member of the carotenoids, which are highly pigmented (red, orange, yellow), fat-soluble compounds naturally present in many fruits, grains, oils, and vegetables (green plants, carrots, sweet potatoes, squash, spinach, apricots, and green peppers). All-trans beta-carotene (synthetic beta-carotene) taken weekly before, during, and after pregnancy may reduce pregnancy-related complications such as mortality, night blindness, post partum diarrhea, and fever. A regular intake of a micronutrient supplement at a nutritional dose may be sufficient to improve micronutrient status of apparently healthy pregnant women and could prevent low birth weight in newborns. However, further research is necessary to consolidate the evidence. Avoid if sensitive to beta-carotene, vitamin A or any other ingredients in beta-carotene products.

Biotin: Biotin, or vitamin H, is an essential water-soluble B vitamin. Marginal biotin deficiency has been found to commonly occur during pregnancy. Biotin supplementation during pregnancy in not currently standard practice, and prenatal vitamins generally do not contain biotin. However, individual patients may be considered for biotin supplementation by healthcare practitioners on a case-by-case basis. Additional study is needed in this area. Avoid if hypersensitive to constituents of biotin supplements.

Borage seed oil: Borage (Borago officinalis) is an herb native to Syria that has spread throughout the Middle East and Mediterranean. Borage flowers and leaves may be eaten and borage seeds are often pressed to produce oil very high in gamma-linolenic acid (GLA). Gamma linolenic acid supplementation in preterm and very low birth weight infants may increase cognitive development, weight gain, and length gain, particularly in boys. Other studies are needed to confirm these results.

Avoid if allergic or hypersensitive to borage, its constituents, or members of the Boraginaceae family. Use cautiously with bleeding disorders or epilepsy. Use cautiously if taking anticoagulants (e.g. warfarin or aspirin) or anticonvulsants. Avoid if immunocompromised. Avoid in pregnant patients as borage oil may be contraindicated in pregnancy given the teratogenic and labor-inducing effects of prostaglandin E agonists, such as borage oil's GLA. Avoid if breastfeeding.

Flaxseed and flaxseed oil: Flaxseed and flaxseed oil/linseed oil are rich sources of the essential fatty acid alpha-linolenic acid. Alpha-linolenic acid is a building block in the body for omega-3 fatty acids. It has been proposed that alpha-linolenic acid, provided as flax oil capsules, may aid in prevention of spontaneous delivery, but the available evidence does not support this use.

Flaxseed has been well-tolerated in studies for up to four months. Avoid if allergic to flaxseed, flaxseed oil, or other plants of the Linaceae family. Avoid with prostate cancer, breast cancer, uterine cancer, or endometriosis. Avoid ingestion of immature flaxseed pods. Avoid large amounts of flaxseed by mouth and mix with plenty of water or liquid. Avoid flaxseed (not flaxseed oil) with a history of esophageal stricture, ileus (loss of bowel motility), gastrointestinal stricture, or bowel obstruction. Avoid with a history of acute or chronic diarrhea, irritable bowel syndrome, diverticulitis (bowel inflammation), or inflammatory bowel disease. Avoid topical flaxseed in open wounds or abraded skin surfaces. Use cautiously with a history of a bleeding disorders, high triglyceride levels, diabetes, mania, seizures, or asthma. Avoid if pregnant or breastfeeding.

Folate: Based on preliminary data, applying folate topically may improve pregnancy-related gingivitis. Well-designed clinical trials are needed to confirm these results.

Avoid if allergic or hypersensitive to folate or any folate product ingredients. It is recommended that pregnant women consume 400 micrograms daily in order to reduce the risk of fetal defects. Folate is likely safe if breastfeeding.

Ginseng: Limited available study found that ginseng (Panax ginseng) saponins may be useful for prevention of intrauterine growth retardation. High-quality studies are needed to understand this relationship.

Avoid with known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.

Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. There is preliminary research of the effects of giving birth in water on labor pain, duration of labor, perineal damage to the mother, and birth complications. Further studies are necessary before a conclusion can be drawn.

Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices like pacemakers, defibrillators, or hepatic (liver) infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, and impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physician(s) before starting hydrotherapy.

Hypnotherapy, hypnosis: Several studies report the effects of pre-natal hypnotherapy on duration of labor and pain medication use. Additional evidence is necessary before a clear conclusion can be drawn.

Use cautiously with mental illnesses (e.g. psychosis, schizophrenia, manic depression, multiple personality disorder, or dissociative disorders) or seizure disorders.

Lavender: Lavender has been evaluated as an additive to bathwater to relieve perineal pain in women following birth. Preliminary poor-quality research reports no benefits. Better research is needed before a firm conclusion can be drawn.

Avoid if allergic or hypersensitive to lavender. Avoid with history of seizures, bleeding disorders, eating disorders (anorexia, bulimia), or anemia (low levels of iron). Avoid if pregnant or breastfeeding.

L-carnitine: L-carnitine, also known as acetyl-L-carnitine or carnitine, has been used in limited studies for miscarriage prevention. Currently, there is insufficient evidence to support the use of carnitine for this indication.

Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, or diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.

Massage: Various forms of therapeutic superficial tissue manipulation have been practiced for thousands of years across cultures. Different massage approaches have been used during pregnancy and labor, and are more commonly used in Europe than in the United States. Reduction of pain or anxiety is a common goal. It is not clear how birth outcomes are affected, or if this is a safe intervention. Women who are pregnant should consult with their obstetrician before beginning massage therapy.

Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin?). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with history of physical abuse or if breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.

Meditation: Various forms of meditation have been practiced for thousands of years throughout the world. Some evidence suggests that meditation may help to reduce complications in pregnancy or childbirth. However, more studies are needed to recommend meditation for specific benefits during pregnancy.

Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professionals before starting a program of meditation and should explore how meditation may or may not fit in with their current treatment plans. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnose or treat the condition with more proven techniques or therapies. Meditation should not be used as the sole approach to illnesses.

Moxibustion: Moxibustion is a traditional Chinese medicine technique that involves the burning of mugwort, a small, spongy herb, to facilitate healing. Moxibustion is a long-used traditional remedy in China for cephalic version (a way to try to turn a baby from breech position to head-down position while it's still in the mother's uterus), including as a self-administered technique at home by mothers. The available evidence confirming its efficacy, while showing some promise, is mixed. More studies are needed to verify whether there are predictable benefits of moxibustion for correction of breech presentation.

Avoid with aneurysms, any kind of "heat syndrome," heart disease, convulsions, cramps, diabetic neuropathy, extreme fatigue, anemia, fever, or inflammatory conditions. Avoid over areas with allergic skin conditions, ulcerated sores, skin adhesions, or inflamed areas or organs. Do not use over the face, genitals, head, or nipples. Use cautiously over large blood vessels and thin or weak skin. It is considered not advisable to bathe or shower for up to 24 hours after a moxibustion treatment. Avoid if pregnant or breastfeeding.

Physical therapy: Physical therapy with a focus on specific stabilizing exercises may be more effective than a regimen without specific stabilizing exercises in the treatment of pelvic girdle pain, functional status, and quality of life. Physical therapy may help with an individual's comfort level during pregnancy as well.

Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with their qualified healthcare professionals before beginning any treatments. Physical therapy appears generally safe when practiced by a qualified physical therapist; however, complications are possible. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Morning stiffness, bone erosion, and erectile dysfunction have been reported. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

Prayer, distant healing: Prayer can be defined as a "reverent petition," the act of asking for something while aiming to connect with God or another object of worship. Prayer on behalf of the ill or dying has played a prominent role throughout history and across cultures. Initial studies report fewer labor and birth complications in people who are religious or pray, although due to methodological problems these results cannot be considered conclusive.

Prayer is not recommended as the sole treatment approach for potentially serious medical conditions and should not delay the time it takes to consult with a healthcare professional or receive established therapies.

Probiotics: Probiotics are beneficial bacteria (sometimes referred to as "friendly germs") that help to maintain the health of the intestinal tract and aid in digestion. They also help keep potentially harmful organisms in the gut (harmful bacteria and yeasts) under control. Most probiotics come from food sources, especially cultured milk products. Probiotics can be consumed as capsules, tablets, beverages, powders, yogurts and other foods. Probiotic supplementation may foster better growth and higher counts of healthful bacteria in the gut of preterm infants. Saccharomyces boulardii when added to formula for preterm infants may bring their stool flora closer to that of breastfed babies, and E. coli Nissle 1917 may stimulate immune responses. Lactobacillus GG, however, is considered a relatively poor colonizer in infants, especially those with low birth weight. Furthermore, Lactobacillus GG may not be effective in reducing the incidence of urinary tract infections, NEC, and sepsis in preterm infants. More studies are needed to clarify specific guidelines for probiotic supplementation in preterm and very low birth weight infants. There is currently not enough evidence to determine if probiotics may be of benefit for premature labor prevention.

Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant.

Raspberry: Raspberry leaf has been traditionally used during pregnancy and childbirth to improve labor. Early study shows that raspberry leaf may be safe for both mother and child. More studies are needed to make a firm recommendation.

Avoid if allergic or hypersensitive to raspberry, its constituents, or any members of the Rosaceae family. Use cautiously with asthma or if taking Clotrimoxazole, antibiotics (especially clarithromycin), antispasmodic agents or muscle relaxants, diuretics, salicylates, or laxatives, sedatives or operating heavy machinery. Cyclosporiasis associated with contaminated fresh raspberries has been reported. Always thoroughly wash raspberries before ingestion.

Reflexology: Reflexology involves the application of manual pressure to specific points or areas of the feet that are believed to correspond to other parts of the body. A small study reported that foot massage increased fetal development in midgestation. Hand massage did not increase fetal activity. Early research also suggests that reflexology may reduce the need for pain relief during labor. Further research is necessary to explore the safety of using reflexology for these indications.

Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle, or severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease or the presence of a pacemaker, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, or kidney stones. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.

Scotch broom: Scotch broom (Cytisus scoparius), also referred to as broom, is a perennial woody plant native to Europe. Scotch broom herb has been used historically to stimulate uterine contractions at birth, and to reduce post-partum hemorrhage (bleeding after birth). There is a scientific basis of this use, due to the presence in scotch broom of small amounts of the alkaloid sparteine, which was studied and used through the 1970s as an oxytocic drug (to induce labor). This use was discontinued due to serious toxicities associated with sparteine. Currently, other drugs such as oxytocin (Pitosin) are used for this purpose. The safety and efficacy of scotch broom preparations in labor are not well studied or established. Women who may require labor induction should be evaluated and supervised by a physician.

Avoid if allergic or hypersensitive to scotch broom or any of its constituents, including sparteine. Smoking or taking the flower or above-ground parts of scotch broom by mouth may not be safe, due to the presence of toxic alkaloids. Poisoning of livestock grazing on scotch broom has been reported. Nausea/vomiting has developed in children from sucking on the flowers of the related species, French broom.

Selenium: Selenium is a trace mineral found in soil, water, and some foods. It is an essential element in several metabolic pathways. Selenium supplementation has been studied in low birth weight infants. Additional evidence is warranted in this area before a clear conclusion can be drawn.

Avoid if allergic or hypersensitive to products containing selenium. Avoid with a history of non-melanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.

TENS: Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Electrodes are temporarily attached with paste in various patterns, depending on the specific condition and treatment goals. TENS is often used to treat pain, as an alternative or addition to pain medications. TENS is normally used in conjunction with acupuncture. Therapy sessions may last from minutes to hours. The effect of TENS on labor pain remains controversial, and multiple controlled trials have been published in this area. Better-designed research is needed before a firm conclusion can be reached. It is not clear if passage of electricity using TENS has harmful effects on the fetus.

Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.

Vitamin A: Vitamin A is a fat-soluble vitamin, which is derived from two sources: preformed retinoids and provitamin carotenoids. Retinoids such as retinal and retinoic acid are found in animal sources like liver, kidney, eggs, and dairy. Carotenoids like beta-carotene (which has the highest vitamin A activity) are found in plants such as dark or yellow vegetables and carrots. Maternal vitamin A deficiency is common in developing countries. Beta-carotene may reduce pregnancy-related complications and mortality in such individuals. However, excess intake of vitamin A has been reported to increase the risks of some birth defects. Vitamin A supplementation above the RDA is therefore not recommended by healthcare professionals for use in pregnancy.

Avoid if allergic or hypersensitive to vitamin A. Vitamin A toxicity can occur if taken at high dosages. Use cautiously with liver disease or alcoholism. Smokers who consume alcohol and beta-carotene may be at an increased risk for lung cancer or heart disease. Use cautiously if breastfeeding because the benefits or dangers to nursing infants are not clearly established.

Vitamin B6: Vitamin B6 (pyridoxine) is required for the synthesis of the neurotransmitters serotonin and norepinephrine and for myelin formation. Studies of the use of pyridoxine alone or in combination with other treatments for pregnancy-induced nausea and vomiting have yielded conflicting results. Studies of birth outcomes with vitamin B6 supplementation during pregnancy have also yielded mixed results. Further well-designed clinical trials might be helpful.

Avoid if sensitive or allergic to any vitamin B6 product ingredients. Some individuals seem to be particularly sensitive to vitamin B6 and may have problems at lower doses. Avoid excessive dosing. Vitamin B6 is likely safe when used orally in doses not exceeding the recommended dietary allowance (RDA). Use cautiously if pregnant or breastfeeding.

Vitamin C: Vitamin C (ascorbic acid) is a water-soluble vitamin, which is necessary in the body to form collagen in bones, cartilage, muscle, and blood vessels, and aids in the absorption of iron. Dietary sources of vitamin C include fruits and vegetables, particularly citrus fruits such as oranges. The data are too few to say if vitamin C supplementation alone or combined with other supplements is beneficial during pregnancy. Preterm birth may increase with vitamin C supplementation. However, some study results show that daily supplementation can effectively lessen the incidence of premature rupture of chorioamniotic membranes (PROM). A gynecologist and pharmacist should be consulted before taking any herbs or supplements.

Avoid if allergic or sensitive to vitamin C product ingredients. Vitamin C is generally considered safe in amounts found in foods. Vitamin C supplements are also generally considered safe in most individuals if taken in recommended doses. Avoid high doses of vitamin C with glucose 6-phosphate dehydrogenase deficiency, kidney disorders or stones, cirrhosis (inflammation of the liver), gout, or paroxysmal nocturnal hemoglobinuria (bleeding disorder).

Vitamin E: Vitamin E is a fat-soluble vitamin with antioxidant properties. Premature infants are at risk of vitamin E deficiency, particularly when they are born with very low birth weight. There are numerous studies of vitamin E given to premature infants to try to prevent potentially serious complications such as intraventricular hemorrhage (bleeding into the brain), retinopathy (eye damage), or death. The quality of published research is variable, and is not clearly conclusive. Decisions regarding vitamin supplementation in preterm and very low birth weight infants should be made with the infant's physician.

Witch hazel: Witch hazel has a long history of use for treating inflammation and hemorrhage when applied to the skin. Its use to reduce perineal discomfort after childbirth requires well-designed human study before recommendations can be made.

Avoid if allergic or sensitive to witch hazel. Avoid if pregnant or breastfeeding. Use cautiously in people with liver or kidney disorders, diabetes, and in children.

Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Yoga has been described as "the union of mind, body, and spirit," which addresses physical, mental, intellectual, emotional, and spiritual dimensions towards an overall harmonious state of being. Early research suggests yoga during pregnancy is safe and may improve outcomes. Additional research is needed before a clear recommendation can be made. Pregnant women who wish to practice yoga should discuss this with their obstetrician or nurse-midwife.

Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, cervical spondylitis, or if at risk for blood clots. Certain yoga breathing techniques should be avoided with heart or lung disease. Use cautiously with a history of psychotic disorders.

Zinc: Zinc is necessary for the functioning of over 300 different enzymes and plays a vital role in an enormous number of biological processes. There is currently insufficient evidence to suggest that zinc supplementation offers benefits during pregnancy, although there is a possible reduction in labor complications and pre-term deliveries. Results from individual studies suggest a possible benefit of zinc supplementation on blood pressure during pregnancy. Further research is needed before a conclusion can be drawn.

Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. While zinc appears safe during pregnancy in amounts lower than the established upper intake level, caution should be used since studies cannot rule out the possibility of harm to the fetus.

Fair negative scientific evidence:

Copper: Copper is a mineral that occurs naturally in many foods, including vegetables, legumes, nuts, grains, and fruits, as well as shellfish, avocado, and beef (organs such as liver). Because copper is found in the earth's crust, most of the world's surface water and ground water used for drinking purposes contains small amounts of copper. The risk of neural-tube defects is decreased in women who take folic acid and multivitamins during the periconception period. However, supplementation with trace-elements alone (such as copper) does not appear to be of benefit for neural-tube defect prevention.

Avoid if allergic or hypersensitive to copper. Avoid use of copper supplements during the early phase of recovery from diarrhea. Avoid with a high amount of copper in the blood (hypercupremia), genetic disorders affecting copper metabolism (e.g. Wilson's disease, Indian childhood cirrhosis, or idiopathic copper toxicosis), or HIV/AIDS. Use cautiously with water containing copper concentrations greater than 6 milligrams per liter. Use cautiously with anemia (low red blood cell count), arthralgias (painful joints), or myalgias (muscle pain). Use cautiously if taking oral contraceptives. Use cautiously if at risk for selenium deficiency. Pregnant and breastfeeding women should not consume doses that exceed the recommended dietary allowance (RDA).

Physical therapy: Physical therapy does not appear to help motor performance in infants born very preterm with very low birth weight. Besides the lack of benefit, available studies show a risk of causing fractures in preterm infants.

Author information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

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Prevention and self-management

Self-management of physical symptoms:

Many health problems that occur during pregnancy can be managed at home using methods recommended by healthcare professionals.

Constipation and hemorrhoids: One of the reasons for constipation may be changes produced in the digestive tract due to hormones slowing down the movement of food. Additionally, during the last trimester of pregnancy there is more pressure on the rectum from the uterus. To avoid these problems, healthcare professionals recommend drinking plenty of water and eating fruit and vegetables with a high fiber content, such as green, leafy vegetables. Some pregnant women experience relief drinking a glass of room temperature water before breakfast. Over-the-counter (OTC) stool softeners may be used, such as docusate sodium (Colace?). It is recommended to tell the doctor of any OCT medication or dietary supplement taken during pregnancy.

Nausea: Nausea occurs due to metabolic changes. In the morning before getting up, eating crackers and standing up very slowly is recommended to decrease feelings of nausea. It is best to try to eat in small quantities every three hours (fractionated diet). During pregnancy, it is good to eat proteins (meat, eggs, beans) before going to bed at night.

Heartburn: Heartburn can occur when stomach acid from digesting food is pushed into the esophagus. During pregnancy, all digestive processes are slowed down and the engrossed uterus presses up on the stomach. To avoid heartburn, eat in small quantities, several times a day. Avoiding spicy and greasy foods and not eating at least one hour before going bed is important. Some pregnant women experience relief resting at night by elevating their heads with two or three pillows.

Fatigue: Pregnancy may stress a woman's body. It is important to try to sleep eight hours daily and if possible, take a nap during the day. Avoiding hard work and eating a balanced diet throughout pregnancy is recommended by healthcare professionals.

Headaches: Headaches may develop during pregnancy. This may be in part due to stress or in some cases it is cased by the higher level of blood in the body during pregnancy. Relaxing in a dark room may help decrease the pain and length of a headache. It is recommended by healthcare professionals to not take medications for headaches while pregnant unless directed by a doctor.

Frequent urination: During pregnancy, the uterus is pressing down on the bladder. Even if the bladder is almost empty, this pressure produces the same sensation as if it were full. Do not avoid the urge to urinate.

Cramps: Cramps are due to circulatory problems associated with the weight gain as the individual progresses in pregnancy. Exercises can be recommended by a healthcare professional to alleviate these discomforts.

Chloasma: Chloasmas are obscure marks in the skin caused by the hormones secreted during pregnancy. They tend to disappear after delivery. Common areas of chloasmas include the forehead, temples, cheeks, or upper lip. Avoiding sunlight on sensitive areas can help prevent chloasma.

Stretch marks: Skin tissue that has to support extra weight causes these marks. They appear on the abdomen and breasts and in most cases slowly disappear after delivery. Creams that contain cocoa butter may be useful in preventing stretch marks.

Varicose veins: Varicose veins are produced by the pressure of the uterus on the lower part of the abdomen that causes difficulty in circulation during the nine months of pregnancy. Varicose veins usually appear in the legs especially if the mother must stand or sit for long periods of time. Moving frequently helps improve circulation. Elevate the legs when possible or lie in bed with a pillow under the feet. While sitting, try to keep the feet up. Do not wear tight clothing. A doctor may recommend support stockings.

Breathing difficulties: Breathing difficulties may happen during the third trimester of pregnancy because the fetus is occupying more space in the abdomen; breathe deeply several times a day but avoid hyperventilation. Sleep propped up and avoid crowded places and smoggy environments.

Backaches: Backaches are a consequence of the growing of the abdomen and weight increase associated with pregnancy. If an individual is suffering from backaches, healthcare professionals recommend: to avoid wearing high-heeled shoes; try to keep the back straight; and avoid lifting heavy weights. It is good to practice some relaxation exercises that will help to lower the tension in the muscles.

Swelling: Swelling can occur due to the retention of water in the tissues. Swelling has a high occurrence in the feet. Try to elevate the legs whenever possible and avoid tight clothes that bind the legs. It is important to notify a doctor if swelling is taking place in uncommon areas, such as the face, or if weight increases suddenly.

Pregnancy prevention, family planning:

Abstinence: Abstinence is a lack of sexual relations. There are many ways to prevent pregnancy, but only abstinence is 100% effective.

Natural family planning (NFP): Researchers have found that a method of natural family planning that uses two indicators to identify the fertile phase in a woman's menstrual cycle is as effective as the contraceptive pill for avoiding unplanned pregnancies if used correctly. The study specifically investigated the efficacy and the acceptability of the symptothermal method (STM), a method that uses two indicators of fertility, temperature and cervical secretions observation. In the largest study of STM, the researchers found that if the couples either abstained from sex = during the fertile period, the rate of unplanned pregnancies per year was 0.4%. The study authors suggested that the effectiveness of STM is comparable to the effectiveness of modern contraceptive methods such as oral contraceptives, and is an effective and acceptable method of family planning.

A number of fertility awareness based methods of family planning have been advocated over the years, but comparisons between different methods and studies of their effectiveness have been limited and hampered by problems such as differences in cultural backgrounds, different ways to measure the effectiveness of a FAB method, different ways of classifying unintended pregnancies and other study design problems. Researchers recommend that women or couples who want to learn the method should buy a book, attend an NFP course, or get some teaching by a qualified NFP teacher.

Early studies have also suggested that couples who practice NFP: have a dramatically low (0.2%) divorce rate; experience happier marriages; are happier and more satisfied in their everyday lives; have considerably more marital relations; share a deeper intimacy with their spouse; and realize a deeper level of communication with their spouse. Further, more well-designed studies are needed.

Sterilization: Sterilization in the male is termed vasectomy and in the female tubal ligation, or tubal sterilization.

Tubal sterilization, or tubal ligation, is surgery to block a woman's fallopian tubes. Tubal sterilization is a permanent form of birth control. After this procedure, eggs cannot move from the ovary through the tubes (a woman has two fallopian tubes), and eventually to the uterus. Also, sperm cannot reach the egg in the fallopian tube after it is released by the ovary. Thus, pregnancy is prevented.

Vasectomy is a procedure in which the two tubes that carry sperm from the testicles to the urinary tract are surgically altered so sperm cannot pass through and be released to fertilize a woman's egg during sexual intercourse. For couples who have made the decision not to have any further children, vasectomy is the safest and easiest form of surgical sterilization. While reversible in many cases, vasectomy should be considered a permanent form of birth control.

Hormonal contraception: Hormonal contraception to prevent pregnancy includes birth control pills, birth control patches, and birth control vaginal rings.

Birth control pills, also known as oral contraceptives, have been marketed in the United States since 1962. Over the past 40 years, the type of estrogen and progestin (hormones) used in the pills has changed and the amounts of those hormones has been lowered. Birth control pills today are designed to improve safety and reduce side effects. Lower doses of estrogen are associated with a decrease in side effects, such as weight gain, breast tenderness, and nausea.

Over 30 different combinations of birth control pills are available in the United States. Most of the combinations of these pills have 21 hormonally active pills followed by seven pills containing no hormones. A woman begins taking a pill on the first day of her period or the first Sunday after her period has begun.

If a dose of oral contraceptive is missed, the individual may not be protected from pregnancy. A backup method of birth control, such as condoms, may be used for seven days or until the end of the cycle. Every brand of oral contraceptives comes with specific directions to follow if one or more doses have been missed. It is recommended to call a doctor or pharmacist with questions regarding missed oral contraceptive dosages. It is recommended by healthcare professionals to continue to take the tablets as scheduled and use a backup method of birth control until the questions are answered. Advantages of using birth control pills include their use to treat irregular menstrual periods. Women can manipulate the cycle to avoid a period during certain events, such as vacations or weekends by extending the number of intake days of hormonally active pills or by skipping the non-active pill week. Birth control pills may help prevent certain conditions, such as benign breast disease, pelvic inflammatory disease (PID), and functional cysts. Functional cysts are reduced by the suppression of stimulation of the ovaries. Ectopic pregnancies are prevented by the cessation of ovulation. The relationship between birth control pills and certain types of cancer is still being studied.

Disadvantages of birth control pills include nausea, breast tenderness, breakthrough bleeding, no periods, headaches, depression, anxiety, and lower sexual desire. Birth control pills do not provide protection from sexually transmitted diseases (STDs). Taking the pills daily and consistently (same time every day) is important. If a woman stops taking birth control pills, she may need a few months to get her normal ovulatory cycle back. After six months, her healthcare provider may need to examine her.

Additional risks include blood clots (venous thrombosis). At particular risk are heavy smokers (especially those older than 35 years), women with high or abnormal blood lipids (cholesterol levels), and women with severe diabetes, high blood pressure, and obesity. The association of birth control pill use and breast cancer in women remains controversial.

The relationship between birth control pill use and cervical cancer is also quite controversial. Important risk factors include early sexual intercourse and exposure to the human papillomavirus (HPV). Women who use birth control pills should have a periodic Pap test.

Intra-uterine device (IUD): An intrauterine device (IUD) is a small T-shaped plastic device that is placed in the uterus to prevent pregnancy. A plastic string is attached to the end to ensure correct placement and for removal. IUDs are an easily reversible form of birth control, and they can be easily removed. However, an IUD should only be removed by a medical professional.

Birth control barriers: Birth control barriers such as diaphragms, cervical caps, and condoms may also be used.

Spermicides: Spermicides are chemical barriers to conception. They are a reversible method of birth control, meaning that when a woman stops using them, full fertility returns. Vaginal spermicides are available in forms such as foam, cream, jelly, film, suppository, or tablet. Spermicides are not as effective as many other forms of birth control when used alone. They are often used with barrier methods of birth control and are much more effective when used in this context.

Emergency contraception: Plan B is the only emergency contraceptive pill ("morning after pill" or "day after pill") being sold in the United States today, although women can also use many kinds of daily birth control pills to prevent pregnancy after sex.

Plan B contains the hormone progestin. Other options for emergency contraception include taking a different dose of daily birth control pills (most of which contain both progestin and estrogen, so they are called "combined" pills) or having a healthcare provider insert an IUD within five days after the birth control failed and having had sex without using contraception, or if the individual was forced to have sex. Preven?, the brand name of a combined emergency contraceptive pill that was approved for use in the United States, is no longer being sold here. Plan B is more effective and has fewer side effects than other emergency contraceptive pills.

Emergency contraceptive pills are available without prescription to women and men 18 and older in the United States, though women 17 and under will still need a prescription from a healthcare provider to buy them. In some states, women of all ages can get emergency contraceptive pills directly from a pharmacist, without having to see a doctor first.

Pregnancy timeline

Once pregnancy occurs, hormonal changes take place in the body of the woman. Also, development of the fetus in the womb produces many biochemical changes in the mother.

There are signs associated with pregnancy. The most common is a missed menstrual period. However, since all women do not have regular menstrual cycles, it is important to watch for other pregnancy signs such as: breast tenderness, nausea, heartburn, extreme tiredness, and frequent urination. (see Heading:Diagnosis)

Even if a woman has some or all symptoms it is important to reconfirm the diagnosis with a pregnancy test. This test will detect the presence of a hormone called chorionic gonadotropin, which is produced by the placenta and it is present in the blood and urine of the expecting woman.

Pregnancy is typically broken into three periods, or trimesters, each of about three months. While there are no hard and fast rules, these distinctions are useful in describing the changes that take place over time.

First trimester: Traditionally, doctors have measured pregnancy from a number of convenient points, including the day of last menstruation, ovulation, fertilization, implantation, and chemical detection. In medicine, pregnancy is often defined as beginning when the developing zygote becomes implanted into the endometrial lining of a woman's uterus to begin growth.

Most pregnant women do not have any specific signs or symptoms of implantation, although it is not uncommon to experience light bleeding at implantation. In some cases where complications may have arisen, the fertilized egg might implant itself in the fallopian tubes or the cervix, causing an ectopic pregnancy. Some women will also experience cramping during their first trimester. This cramping is usually of no concern unless there is spotting or bleeding as well. The outer layers of the embryo grow and form a placenta, for the purpose of receiving essential nutrients through the uterine wall. The umbilical cord connects the unborn baby to the placenta. The developing embryo undergoes tremendous growth and changes during the process of embryonic and fetal development.

Morning sickness afflicts about 70% of all pregnant women, typically only in the first trimester. Most miscarriages occur during this period.

Second trimester: Months four through six of the pregnancy are called the second trimester. Most women feel more energized in this period than the first or third trimester and begin to put on weight as the symptoms of morning sickness subside and eventually fade away. Although the fetus begins moving and takes a recognizable human shape during the first trimester, it is not until the second trimester that movement of the fetus, often referred to as "quickening," can be felt. This typically happens by the fourth month. The teeth are now formed inside the unborn baby's gums and the reproductive organs can be recognized allowing a doctor to know the sex of the child.

Third trimester: In the last or third trimester, final weight gain takes place and the fetus begins to move regularly. The mother's belly button will sometimes protrude due to her growing belly. This period of her pregnancy can be uncomfortable, causing symptoms such as weak bladder control and back-ache. Movement of the fetus becomes stronger and more frequent and the fetus prepares for viability outside the womb through improved brain, eye, and muscle function. The mother can feel the unborn baby moving and rolling, which may cause pain or discomfort around the mother's ribs.

If a fetus is born early or prematurely in the third trimester, advanced medical technology can help the baby survive. In most systems of human pregnancy, prematurity is considered to occur when the baby is born sooner than 37 weeks after the beginning of the last menstrual period (LMP). The opposite condition, postmature birth, is defined as birth more than 42 weeks after the LMP.

Pregnancy issues

Prenatal care:

Getting early and regular prenatal care is one of the best ways to promote a healthy pregnancy. Prenatal care is more than just healthcare. Prenatal care includes education and counseling about how to handle different aspects of pregnancy, such as nutrition and physical activity, what to expect from the birth itself, and basic skills for caring for the infant.

Prenatal visits also give the woman and her family a chance to talk to a healthcare provider about any questions or concerns related to pregnancy, birth, or parenthood.

Many healthcare providers recommend that a woman who is only thinking about getting pregnant see a healthcare provider about preconception health. Also, if the individual thinks they are pregnant she should also see a healthcare provider. There are steps she can take to reduce the risk of certain problems. The objective of prenatal care is to monitor the health of the pregnant mother and her unborn baby. It is important to visit the doctor as soon as an individual suspects they are pregnant. At each visit, a doctor will examine the individual and make sure that the baby and the mother are healthy. This examination includes: monitoring weight gain or loss, blood pressure, circumference of the abdomen, position of the fetus, and fetal heartbeat. Such variables are closely followed during the course of the pregnancy.

A doctor may schedule monthly visits during the first two trimesters (from week one to week 28 of pregnancy), every two weeks from 28-36 of pregnancy, and weekly after week 36 (until the day of delivery that could be between week 38-40 weeks).

Food and nutrition during pregnancy: It is important for an expectant mother to eat a healthy diet. Unless she has a specific health problem (such as diabetes mellitus or heart disease) common sense nutritional advice should be followed: balancing carbohydrates, fat, and proteins and eating a variety of foods, including dairy products and several fruits and vegetables, daily. A pregnant woman should consult her obstetrician for specific advice. Some specific nutritional needs for pregnancy include:

Folic acid, also called folate or vitamin B9, is strongly recommended by healthcare professionals at the start of pregnancy and even before conception. Folic acid is needed for the closing of fetus' neural tube. The neural tube is the fetus's precursor to the brain and spinal cord. Folic acid thus helps prevent spina bifida, a very serious birth defect. Folates are abundant in spinach (fresh, frozen or canned) and are also found in green vegetables, salads, melon, and eggs. In the United States and Canada, most wheat products, such as flour or noodles, are supplemented with folic acid.

Minerals, such as calcium and iron, are particularly needed by the rapidly growing fetus. Pregnant women should eat enough dairy products (for calcium) and red meat (for iron) if they are not lactose intolerant or vegetarian. Women who do not eat dairy or meat can obtain calcium and iron from fortified soy milk and juice, soybeans, and certain leafy greens. Calcium is effective only if women also obtain enough vitamin D. Vitamin D can be made in the body after exposure to ultraviolet rays from the sun or from food sources. Although milk is fortified with vitamin D, dairy products made from milk, such as cheese and ice creams, are generally not fortified with vitamin D. Cold water fish such as salmon, mackerel, tuna, and sardines also good sources of vitamin D.

Healthcare providers may prescribe iron supplements if pregnant women develop anemia. Anemia, one of the more common blood disorders, occurs when the level of healthy red blood cells (RBCs) in the body becomes too low. RBCs contain hemoglobin, which carries oxygen to the body's tissues.

Fluoride helps to build strong teeth by changing the nature of calcium crystals. If drinking water or table salt does not contain fluoride, it is recommended by healthcare professionals to take fluoride supplements at the end of pregnancy and during breastfeeding. However, high doses of fluoride are toxic. In many American cities, drinking water is supplemented with fluoride.

Oils from salmon, trout, tuna, herring, sardine, mackerel, eggs, and some chicken contain omega-3 fatty acids that are needed to build brain tissue. Intake of omega-3 fatty acids during pregnancy may provide nutrition for proper brain and retina development of the fetus. However, large fish such as tuna and swordfish may contain high levels of mercury. Mercury can be toxic to the fetus and the mother. Eating omega-3 rich fish two or three times a week is recommended (no more than 12 ounces/week of low mercury fish should be consumed). Omega-3 fatty acids are also present in walnuts, flaxseed, and seaweed.

Dangerous bacteria or parasites, particularly Listeria and Toxoplasma, may contaminate foods. To avoid those two hazards, hygiene rules should be strictly adhered to, including carefully washing of fruits and raw vegetables, cooking leftovers and meats appropriately, and avoiding raw-milk cheeses (due to Listeria). The label will state if the cheese is from raw milk. It is best to try to avoid contact with cat feces (due to Toxoplasma).

It is best to maintain a healthy weight and diet and get regular physical activity before, during, and after pregnancy. It is recommended by healthcare professionals to avoid smoking, alcohol, or drug use before, during, and after pregnancy. These factors increase the chances of damage to the growing fetus.

Labor and delivery:

Labor and delivery, or childbirth, is the process by which an infant is born. When a baby is ready to be born, the mother will go through labor.

Common signs of labor: A common sign that labor is near is lightening or when the baby "drops" or moves into position within the pelvis. Lightening may occur two to four weeks prior to labor in first-time mothers and often not until labor begins in mothers who have previously had children.

The mother's abdomen usually appears lower and more protruding.

The mother may experience a greater ease in breathing, relief from heartburn, and an ability to eat larger portions. However, the lower position of the baby together with its greater size can lead to: increased backache and sacroiliac (the two joints where the hip bones connect to the sacrum) discomfort; increased awkwardness in walking; and increased frequency of urination.

Frequent bowel movements may be experienced within 48 hours of labor, cleansing the lower bowel in preparation for birth.

Diarrhea or flu-like symptoms without fever may be felt before labor. Indigestion, nausea, or vomiting are common a day or so before labor begins.

Increased vaginal discharge during the last few weeks of pregnancy as the body prepares for the passage of the baby through the birth canal may occur.

Increased Braxton-Hicks contractions during the last weeks of pregnancy, which are "practice" contractions that prepare the uterus for labor and may cause some effacement and dilation (thinning and opening) of the cervix, may occur. These contractions do not ordinarily cause pain but may be sufficiently strong and regular to be confused with true labor. This is referred to as false labor.

Possible "bloody show" or the release of slightly brown, pink, or blood-tinged mucus from effacement and dilation (the thinning and opening) of the cervix, causing the mucus plug to be released from the cervix, may occur.

An initial sign of labor is when the "water breaks." The amniotic sac is a fluid-filled membrane that cushions the fetus in the uterus. The sac leaks or breaks releasing amniotic fluid before labor begins. If this happens, the individual may notice a trickle of fluid or a more obvious gush.

Labor contractions are the periodic tightening and relaxing of the uterine muscle, the largest muscle in a woman's body. Contractions let the woman know labor is starting. Most doctors suggest going to a hospital when the contractions are five minutes apart and lasting 60 seconds and the individual has had this activity for about an hour. Contractions range from mild tightening to constant muscle spasms in the abdominal area. Contractions may be irregular at first but usually become regular. They get longer, stronger, and closer together as time progresses. Many mothers describe contractions that occur in early labor as similar to menstrual cramps, or as severe gas pains, which may be confused with flu symptoms or intestinal disorders. Walking usually makes the contractions stronger. Lying down does not make them go away. Often, the contractions begin in the back and move to the front.

During the first stage of labor, the cervix slowly opens, or dilates, to about four inches wide. At the same time, the cervix becomes thinner. This is called effacement. The individual should not push until the uterus is fully effaced and dilated. As the cervix dilates, some individuals describe cramping and pressure, similar to what would be felt during menstruation. When is the cervix is completely dilated, the baby delivery stage starts. Crowning is when the baby's scalp comes into view. Shortly afterward, the baby is born. The placenta that nourished the baby follows. Mothers and babies are monitored closely during labor. Most women are healthy enough to have a baby through normal vaginal delivery, meaning that the baby comes down the birth canal without surgery.

Pain in labor is a nearly universal experience for childbearing women giving birth naturally. Tears (rips) in the vagina during delivery will occur. In order to prevent these vaginal tears from occurring, doctors will often perform an episiotomy. In this procedure, an incision is made in the perineum, which is the area between the vagina and the anus. This incision allows the vaginal opening to enlarge, thereby giving the baby more space to emerge from.

A typical labor for a first time mother is eight to 14 hours, and is usually shorter for a second or subsequent birth.

Labor induction: Sometimes, if labor has not started on its own, doctors use medicines to make a woman's labor begin so that she can deliver the baby vaginally. This is called "labor induction" or induced labor. The most common reason for labor induction is that the pregnancy has gone two weeks or more past the due date. The baby may get too big if the mother carries it this far past the due date. The fetus may not be able to get enough food from inside the body. A doctor might also recommend labor induction if: the woman's water breaks before she goes into labor; she has high blood pressure; she has a serious infection; or if she has diabetes.

There are several ways to induce labor. Toward the end of pregnancy, the cervix (the opening to the uterus, or womb) gets soft. It may even open up a little. A doctor will check to see if the cervix is getting soft and opening up. If it is not, a doctor may put a medicine, called oxytocin (Pitocin?), into the woman's vagina near the cervix. Oxytocin will soften and open the cervix up, helping to start the contractions and get them strong and regular. A doctor may also "break the water" or use a finger to separate the cervix from the membranes (tissues) around the baby's head. This often makes labor start. Sometimes it may take two to three days to induce labor, but this is rare.

C-section: If labor will not start with medicine, a cesarean section (also called a "C" section) may be necessary. A Cesarean section (C-section) is surgery to deliver a baby. The baby is taken out through the mother's abdomen. In the United States, about one in four women have their babies this way. Most C-sections are done when unexpected problems happen during delivery. These include: carrying more than one baby; health problems in the mother, such as diabetes or high blood pressure; the position of the baby; not enough room for the baby to go through the vagina; or signs of distress in the baby. The surgery is relatively safe for mother and baby. Still, it is major surgery and carries risks. It also takes longer to recover from a C-section than from vaginal birth. After healing, the incision may leave a weak spot in the wall of the uterus. This could cause problems with an attempted vaginal birth later. However, more than half of women who have a C-section can give vaginal birth later. Individuals can discuss options during childbirth before the due date in order to alleviate any added stress during labor and delivery.

Causes of pregnancy

Pregnancy occurs with the fertilization of a woman's egg by a man's sperm, called conception. Fertility drugs, such as clomiphene (Clomid?), may improve a woman's odds of achieving pregnancy. Some of the most common causes of female infertility include polycystic ovarian syndrome, fibroids, and endometriosis. However, there are several other reasons why a woman may experience fertility problems, such as ovulatory disorders (like anovulation or the inability to ovulate), premature ovarian failure, and uterine factors. Egg quality also plays a role in infertility in many women. There are good and bad eggs from the very start in any female's body, but usually the number of eggs of superior quality are present at a higher volume at a younger age than after 30. Egg quality is also affected by external sources like radiation therapy, smoking, chemotherapy, and health conditions like endometriosis. Endometriosis is a condition in which the tissue that normally lines the uterus (endometrium) grows in other areas of the body, causing pain, irregular bleeding, and possible infertility. In men, hormone disorders, illness, reproductive anatomy trauma and obstruction, and sexual dysfunction can temporarily or permanently affect sperm and prevent conception. Some disorders become more difficult to treat the longer they persist without treatment. According to the National Institutes of Health (NIH), male infertility is involved in approximately 40% of the 2.6 million infertile married couples in the United States. One-half of these men experience irreversible infertility and cannot father children, and a small number of these cases are caused by a treatable medical condition.

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