Pregnancy Child Birth

The third stage of labor is the placental stage. It begins after the birth of the baby and ends with the birth of the placenta or afterbirth. It can be managed in one of two ways: expectantly or actively.

Expectant management means watchful waiting for signs of placental separation followed by delivery of the placenta through the mother’s pushing efforts. It may also include giving natural assistance to separation of the placenta by using nipple stimulation or taking advantage of gravity.

Active management is advocated by many physicians and some midwives and involves three steps:

1. Giving medication to help the uterus contract before delivery of the placenta.
2. Early cord clamping and cutting.
3. Controlled traction of the umbilical cord for delivery of the placenta.

Research has shown active management to result in less blood loss and fewer episodes of postpartum hemorrhage for the mother. It is also associated with nausea and vomiting, and possibly high blood pressure. depending on the medication given to cause uterine contractions.

Even with expectant management, many practitioners will give oxytocin in the intravenous line or as an injection routinely following delivery of the placenta. This may cause unpleasant uterine contractions. Other physicians or midwives will use this medication only if there is excess bleeding, a soft(noncontracting) uterus, or a risk for postpartum hemorrhage. (Risks for postpartum hemorrhage include a very large baby or multiple pregnancy, very rapid labor, induction or augmentation of labor, or a history of postpartum hemorrhage.)

Cervical Inspection

Some physicians and midwives routinely inspect the cervix for bleeding after delivery. Others use this intervention only in the case of excessive bleeding that is not due to another cause, such as a noncontracted uterus or blood vessels torn in a lacerated area of the vagina or perineum. In this procedure, clamps are placed on the cervix, which is soft and easy to grab right after delivery. The cervix is pulled into the vagina and each area inspected for tears. Suturing may be called for if any tears are bleeding. Of course, the vagina and perineum always are inspected. This usually requires manipulation of the tissues. Blood will need to be wiped away and the tissues gently separated for better exposure. This can be uncomfortable, but generally is brief.

Manual Removal of the Placenta

It is done with the hands, using sterile technique. It is sometimes an emergency procedure if bleeding is heavy and the placenta cannot be delivered easily with traction and maternal pushing. It is also a procedure utilized by some practitioners after a set period of time if the placenta has not yet delivered. The time period before manual removal is utilized varies from institution to institution and practitioner to practitioner, but 30 minutes is an acceptable time to wait for placental separation without intervening. In out-of-hospital births, this time period is often stretched, if the woman is not bleeding excessively.

Uterine Exploration

The question of whether to check routinely for a nonsymptomatic uterine rupture after a VBAC is controversial. Usually such a rupture, called a dehiscence, requires no treatment and whether or not it is significant for a future vaginal delivery is not established. This intervention, then, is utilized with a good deal of variation among physicians and institutions. It is done after delivery by feeling the lower portion of the uterus through the vagina. The physician or midwife performing the inspection will wear long sterile gloves or regular sterile gloves and a sterile gown. This is an uncomfortable, but brief, procedure.

The forceps has been used in delivering babies for about 400 years. The instrument consists of two separate thin steel blades with inner surfaces curved to fit the sides of the infant’s head. The blades are inserted separately into the vagina, opposite each other. When their handles are brought together, the child’s head is securely grasped between the blades. With moderate traction on the handles, exerted in the axis of the vagina, the head is delivered.

The word forceps in Latin means “a pair of tongs.” It is said to have been derived from the earlier Latin words fornus = oven and capere = to take. The obstetric forceps, in variations of its modern form, have been used since the early seventeenth century to deliver a living child without injury to it or to the mother. Prior to this, single-bladed and even double­bladed instruments, called hooks, were in use, but probably only for the extraction of a dead child. The old double-bladed instruments had a permanent articulation so that the blades could not be inserted separately. They looked like ice tongs.

History of the Forceps

The history of the forceps is a story worth telling, calling attention to great changes in the practice of medicine and medical ethics over the past 4 to 5 centuries. The inventors of the modern obstetrical forceps were a singular medical family-the Chamberlens. In 1569 the first of the English line, William, emigrated from France to England to escape persecution, Most of the Chamberlens were royal surgeons or royal physicians, and they attended the labors and births of several queens. This obstetrical dynasty of Chamberlen extended uninterrupted from Peter the Elder’s admission to the Guild of Barber-Surgeons in about 1596 to the death of Hugh, Junior; in 1728.

The forceps was probably invented in about 1600 by Peter the Elder and kept as a hereditary family secret to be buried with Hugh, Junior; more than 100 years later. The retention of an important medical secret transmitted from generation to generation for a century and a quarter is unique in history. The Chamberlens were crafty(and by modern medical standards, unethical) enough to exclude all others from the room when they used the forceps and they used the instrument unassisted.

How was the secret finally revealed? The existence of the forceps was hinted at as early as 1616 at a meeting of the Royal College when a reference was made to the boast of Peter Chamberlen the Younger “that he and his brother, and none others, excelled in the management of difficult labors.”

Hugh Senior emigrated to Holland in 1699 under suspicion of debt. While in Holland, he sold the secret of the forceps to Hendrik van Roonhuyze, the leader of Dutch obstetrics. William Giffard of London used the forceps openly in April 1726, calling it “extractors.” He is generally considered “the altruistic and honorable physician who should receive full credit for introducing the forceps into general use in England.” By 1733, when Edmund Chapman published the first account of the forceps, there were already several models, and their use “was well known to all the principal men of the profession, both in town and country.”

Classifications of Forceps Deliveries

Forceps deliveries are categorized into four types:

1. High forceps refers to a delivery in which the fetal head is above 0 station or unengaged. This procedure is no longer used as it is too dangerous for mother and fetus.
2. Midforceps are forceps deliveries when the head is higher than +2 station, but is engaged or at least 0 station .
3. Low forceps describe a forceps delivery when the baby’s head is at least at +2 station.
4. Outlet forceps are used when the baby’s head is visible in the entrance to the vagina but has failed to deliver, either because of resistance by the perineum, inadequate contractions, or the mother’s difficulty bearing down.

With low or midforceps deliveries, the fetal head may not have rotated into the occiput anterior(OA) but may be in one of the transverse or oblique positions.

Outlet or low forceps can be done easily under pudendal block or even with local infiltration of the perineum. Midforceps call for more potent anesthesia, not only to relieve the pain of the procedure for the mother, but also to relax her muscles and facilitate the birth. A significant variable in the outcome from midforceps deliveries is the experience and skill of the operator, both in deciding when to deliver and how to do it.

Unfortunately, we know very little about the cause of most instances of preterm labor. Occasionally it is due to an abnormality of the uterine body or cervix. As these abnormalities also may cause spontaneous abortion or miscarriage. Miscarriage is different from preterm birth in that a miscarried fetus cannot survive. Today, 24 weeks gestation is the usual cutoff used to distinguish preterm from miscarried babies.

One of the most likely causes of preterm labor is an infection in the uterus. This is called chorioamnionitis-an inflammation of the chorion and amnion, or the two membranes surrounding the fetus. Infection also may be a cause of rupture of the membranes-the bag of waters breaking. Preterm rupture of the membranes often leads to preterm labor.

Although infection is thought to be an important cause of preterm rupture of the membranes and preterm labor, the specific infectious organisms involved have not been identified conclusively. Bacterial vaginosis, a rather common condition in which the usual “flora” of the vagina is disturbed, is a possible cause. This may involve the organism Mycoplasma hominis, frequently found with premature rupture of the membranes. Chlamydia trachomatis, the most common sexually transmitted organism in the United States today, also may be involved in preterm birth and preterm rupture of the membranes, but studies do not prove this association.

Group B streptococcus is an organism possibly associated with preterm labor. It is also a major cause of severe newborn infection. It does not always cause any unusual symptoms in a woman, although it may cause urinary tract or uterine infection during pregnancy or after birth. The Centers for Disease Control and Prevention, in collaboration with the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, have developed specific guidelines for testing and treatment for Group B “strep” in pregnancy.

Treatment of Group B strep(GBS) in labor is intended to prevent the consequences of GBS disease in newborns. As CBS is one possible cause of preterm labor, treatment is recommended for any woman in labor or with ruptured membranes before 37 weeks gestation, unless a culture from her vagina and rectum taken at 35 to 36 weeks gestation is avaIlable and shows no GBS. If a prior culture is unavailable, then a culture can be taken at the time the woman sees her care provider or comes to the hospital. Antibiotics(usually penicillin) are started. If the culture is negative, the medication can be stopped. If the culture is positive, antibiotics are continued until and through labor. If delivery does not occur within 4 weeks, the culture should be repeated.

A urinary tract infection might lead to preterm labor if untreated. Any condition that causes the uterus to be overdistended(unusually large) may result in preterm labor. These conditions include hydramnios and multiple pregnancy. Among multiples, quadruplets deliver earlier than triplets, triplets deliver earlier than twins. Placental problems.

A pregnancy that occurs with an intrauterine device(IUD) in place has an increased chance of ending in preterm labor. If you have an IUD and become pregnant, you should have the IUD removed if you want to keep the pregnancy. Sometimes, however, the IUD strings have moved up into the cervical canal and removing the device would be dangerous to the pregnancy. While a retained IUD increases the chances of preterm birth, it does not cause anomalies in the fetus.

A recent review of studies on work and pregnancy found a number of work-related risks for preterm labor. These include heavy and/or repetitive lifting or carrying loads; manual labor; physical exertion; prolonged standing; shift work; and work fatigue.

Substance abuse, including cigarettes, drugs, or alcohol, may lead to preterm labor. Because more than 10 percent of pregnant women smoke, tobacco use is responsible for a large number of preterm births. Young adolescent mothers are more likely to deliver preterm and women living in poverty have a greater chance of having a preterm birth. Poor weight gain during pregnancy and some severe diseases of the mother can contribute to preterm labor.

Women who have had a preterm birth have an increased chance for another preterm birth. This does not explain the cause for preterm birth, but is a major risk factor.

Managing Your Fertility

Fertility is a mixed blessing for some women. The ability to participate in the miracle of birth is an overwhelming experience for many. Yet the responsibility to control one’s fertility can also seem overwhelming. Today, we not only understand the intimate details of reproduction but also possess technologies designed to control or enhance our fertility. Along with information and technological advance comes choice, and choice goes hand in hand with responsibility. Choosing if and when to have children is one of our greatest responsibilities. A woman and her partner have much to consider before planning or risking a pregnancy. Children, whether planned or unplanned, change people’s lives. They require a lifelong personal commitment of love and nurturing.

Before you plan or risk a pregnancy, you have the responsibility to make certain you are physically, emotionally, and financially prepared to care for another human being. One measure of maturity is the ability to discuss reproduction and birth control with one’s sexual partner before succumbing to sexual urges. Men often assume that their partners are taking care of birth control. Women often feel that if they bring up the subject, it implies that they are or “loose.” You will find embarrassment-free discussion a lot easier if you understand human reproduction and contraception and honestly consider your attitudes toward these matters before you get into compromising situations.

What Do You Think?

Paige is pregnant with her first child. During the pregnancy, she and her boyfriend Matt, the father of the child, occasionally meet up with their friends at their usual haunts on weekends. On these occasions, Paige limits herself to one or two beers and sometimes bums an occasional cigarette from Matt or one of their friends.

Is Paige’s behavior appropriate? Which behavior is more worrisome, her alcohol consumption or the occasional cigarette? Explain your answer. What is Matt’s responsibility in these instances? Do the friends have a responsibility as well?

In 1973, the landmark Supreme Court decision in Roe v. Wade stated that the “right to privacy … founded on the Fourteenth Amendment’s concept of personal liberty .. is broad enough to encompass a woman’s decision whether or not to terminate her pregnancy.” The decision maintained that during the first trimester of pregnancy, a woman and her practitioner have the right to terminate the pregnancy through abortion without legal restrictions. It allowed individual states to set conditions for second-trimester abortions. Third­trimester abortions were ruled illegal unless the mother’s life or health was in danger.

In July 1989, in Webster v. Reproductive Health Services, the Supreme Court, by a vote of five to four, gave states the right to impose certain new restrictions on abortions. This decision, along with three subsequent rulings, paved the way for individual state interpretations of abortion acceptability. In recent years, strict abortion laws have been proposed in many states. There is intense political debate as abortion opponents put pressure on state and local governments to pass laws prohibiting the use of public funds for abortion as well as for abortion counseling. Abortions cannot be performed in publicly funded clinics in some states, and other states have laws requiring parental notification before a teenager can obtain an abortion. Although Roe v. Wade has not been overturned, it faces many future challenges.

Prior to the legalization of first and second-trimester abortions, women wishing to terminate a pregnancy had to travel to a country where the procedure was legal, consult an illegal abortionist, or perform their own abortions. The last two methods led to death from hemorrhage or infection in some cases and to infertility from internal scarring in others.

Before the 1973 Supreme Court ruling, approximately 480,000 illegal abortions were performed in the United States each year, one-third of them on married women. Since the 1973 decision, the law has been continually challenged by groups that are convinced that the termination of a pregnancy is murder. Those who oppose abortion believe that the embryo or fetus is a human being with rights that must be protected. Although many opponents work through the courts and the political process, attacks on abortion clinics and on doctors who perform abortions are increasingly common. Nearly all clinics have faced some form of violent threats or acts of violence. Recent legal changes, such as the Freedom of Access to Clinic Entrance Act (FACE), offer some relief to the harassment and violence directed at abortion clinics. However, because of such acts, the biggest threat to a woman’s access to an abortion now is the clinical supply rather than legal restrictions.

More than 1.5 million abortions are performed in the United States every year, representing almost a fourth of all pregnancies. It is estimated that 3 of every 100 American women will have had one abortion by the age of 44. About one half of all abortions are performed because of failed contraception; the others occur in the 9 percent of sexually active women who do not use birth control. The majority of abortions, 90 percent, are performed within 12 weeks of fertilization; only 2 of every 1,000 are performed more than 20 weeks after fertilization.

The best birth control methods can fail. Women may be raped. Pregnancies can occur despite every possible precaution. When an unwanted pregnancy does occur, the decision whether to terminate, to carry to term and keep the baby, or to carry to term and give the baby away must be made. This is a personal decision to be made by each woman based on her personal beliefs, values, and resources after careful consideration of all alternatives.