Your Pregnancy

Overview

Pregnancy is broken into three time periods -- called trimesters. Most women feel differently, both physically and mentally, during each trimester. In addition to weight and body shape, other alterations in your body chemistry and function also take place. The heart works harder, your temperature registers slightly higher, body secretions increase, joints and ligaments are more flexible and hormones are altered. Mood changes also are common, resulting from a combination of hormonal changes and greater fatigue, as well as normal anxiety over body image, sexuality, finances, partner roles and impending parenthood.

The Three Trimesters

Each trimester is marked by specific fetal developments. Full term pregnancy is considered 40 weeks and infants delivered before the end of 37th week are considered premature. Premature infants may have problems with their growth and development, as well as difficulties in breathing and digesting.

First Trimester -- 0 to 13 Weeks

The first trimester is the most crucial to your baby's development. During this period, your baby's body structure and organ systems develop. Most miscarriages and birth defects occur during this period.

Your body also undergoes major changes during the first trimester. These changes often cause a variety of symptoms, including nausea, fatigue, breast tenderness and frequent urination. Although there are common symptoms of pregnancy, every woman has a different experience. For example, while some may experience an increased energy level during this period, others may feel very tired and emotional.

Second Trimester -- 13 to 26 Weeks

The second trimester of pregnancy is often called the "golden period" because many of the unpleasant effects of early pregnancy have ended. During the second trimester, you're likely to experience decreased nausea, better sleep patterns and an increased energy level. However, during this period you may experience a whole new set of symptoms and feelings, such as back pain, abdominal pain, leg cramps, constipation and heartburn.

You will probably hear your baby's heartbeat for the first time at around 12 weeks. An ultrasound is typically performed around 19 weeks. And, somewhere between 16 weeks and 20 weeks, you may feel your baby's first fluttering movements.

Third Trimester -- 26 to 40 Weeks

You have now reached your final stretch of pregnancy and are probably very excited and anxious for the birth of your baby. Some of the physical symptoms you may experience during this period include shortness of breath, hemorrhoids, urinary incontinence, varicose veins and sleeping problems. Many of these symptoms arise from the increase in the size of your uterus, which expands from approximately 2 ounces before pregnancy to 2.5 pounds at the time of birth.

Prenatal Care

Expert prenatal care ensures that both you and your baby are as healthy as possible throughout your pregnancy. Once you think that you are pregnant, contact your doctor to make an appointment and establish your prenatal care schedule. Many factors affect the number of visits you have, and the same formula does not work for everyone. Your schedule may vary depending on your personal health as well as your doctor's preference. Additional prenatal care may be necessary if you have any preexisting medical conditions, such as diabetes, and/or complications arise during your pregnancy. However, if all things are going well with your pregnancy, visits are planned around key pregnancy developments and certain tests that need to be performed. In addition, visits are a time for your doctor to give you important information as your pregnancy progresses.

The goal of prenatal care is not only to provide the best care for you and your unborn child, but also to prepare you for birth. During prenatal visits, tests are performed on you and your baby to assess any potential risks, to treat any maternal or fetal complications, and to monitor the growth and development of your baby.

Create a Birth Plan

You also will be provided with a Birth Plan, a form asking about your preferences for delivery. This promotes communication with your health care provider and helps them meet your individual needs. You will complete your Birth Plan and discuss it with your health care provider at your 34 to 36 week visit. Make photocopies of your Birth Plan. Give one to your health care provider to put in your medical record and bring one with you when you come to the hospital in labor.

Danger Signs

Although numerous symptoms are a normal part of pregnancy, there are certain danger signs that may indicate problems with your pregnancy. You should notify your doctor immediately if you experience any of the following:

• Persistent vomiting
• Chills or fever
• Continuous pain
• Burning with urination
• Blurred vision
• Continuous headache
• Sudden swelling of the hands or face
• Five or more uterine contractions per hour
• Decreased fetal movements
• Leaking of fluid from the vagina (blood or water). If you have vaginal bleeding at any time during your pregnancy, have someone call your doctor immediately.

Common Tests

Common tests performed during pregnancy include the following:

• Amniocentisis -- This test is performed between the 15th and 20th weeks of pregnancy. Although not all women decide to have an amniocentesis, it is routinely performed on women who are at risk for genetic disorders or are over age 35. During the procedure a small sample of the amniotic fluid surrounding the fetus is obtained. The fluid is used to help identify chromosomal and genetic disorders and certain birth defects. When done during the third trimester, this procedure also can assess the maturity of your baby's lungs.

• Chorionic Villus Sampling (CVS) — CVS is usually performed between the 10th and 13th weeks of pregnancy. Like amniocentisis, CVS is a prenatal test that can often detect genetic abnormalities and chromosomal disorders. However, the primary advantage of a CVS versus amniocentesis is that it can be performed much earlier in pregnancy.

• Expanded Alpha-Fetoprotein Screening — This blood test is performed during your 15 to 20 week visit. It measures the levels of alpha-fetoprotein (AFP), a protein released by the baby's liver and found in your blood, as well as hCG and estriol. Abnormal results on the expanded AFP test may indicate fetal brain or spinal cord defects, multiple fetuses, a miscalculated due date, or Down syndrome, a chromosomal abnormality that includes mental retardation and distinct physical features.

  Typically, this AFP screening is performed by your obstetrician. You may be referred to the UCSF Prenatal Diagnosis Center for a follow-up if your test result indicates a potential risk.

• Fetal Monitoring — During pregnancy, your doctor may want to monitor the fetal heart rate and uterine activity. Fetal monitoring involves the use of an ultrasound transducer to measure the fetal heart rate and a toco transducer to identify uterine activity.

• Genetic Screening — Many genetic abnormalities, such as cystic fibrosis, sickle cell anemia and hemophilia A, can be diagnosed before birth. Your doctor may recommend genetic testing during the pregnancy if you are over the age of 35, you or your partner have a family history of genetic disorders and/or you have had a fetus or baby with a genetic abnormality.

• Glucose Tolerance Test — This test is usually performed during the fifth month of pregnancy. It measures the levels of sugar (glucose) in your blood. Abnormal glucose levels may indicate gestational diabetes, diabetes that may develop during pregnancy and requires monitoring.

• Group B Strep Culture — Group B Streptococcus is an infection in the mother that can lead to complications and sometimes death in the newborn, if the infection is transmitted to the baby, which can occur during delivery. Group B strep has become more prevalent in the last two decades. Doctors now routinely perform cultures on the mother's vagina and rectum to diagnose the infection. Group B strep can easily be treated with antibiotics.

• Nuchal Translucency Screening (NT) — UCSF Medical Center is one of the few centers nationwide to offer nuchal translucency screening (NT) screening, a new, non-invasive test performed early in pregnancy to identify women at increased risk for Down syndrome and other birth defects. NT screening is performed between 11 and 14 weeks of pregnancy. It is offered to women of all ages.

  The screening is done via a high-resolution ultrasound exam of the nuchal area — a fold of skin at the back of the neck of the fetus. The results are combined with the mother's age to determine an adjusted risk for Down syndrome. The rate of detection for Down syndrome is about 80 percent. Based on the results, a woman has the option of undergoing CVS or amniocentesis for diagnosis.

• Ultrasound — This machine generates a picture of the fetus using sound waves. By looking at the image, your doctor can tell the age of the fetus and whether there are twins. A detailed ultrasound also can detect certain birth detects.

Labor and Delivery

Labor is a series of progressive and continuous contractions of the uterus that help the cervix to open and thin, allowing the baby to travel through the birth canal. Labor usually starts within two weeks before or after your estimated delivery date. However, this can vary widely.

Labor and delivery are hard work and involve some discomfort. The level of discomfort experienced during childbirth varies from woman to woman and from pregnancy to pregnancy. Each woman chooses a different way to experience her birth -- some prefer to go through it without medication, while others choose to have medication or anesthesia. Many decide to "see how it goes" and make choices as their labor unfolds.

We offer a spectrum of options for managing your pain during labor and delivery. You will be assigned to your own nurse during your stay in the birthing suite. He or she will help keep you comfortable and guide you through non-drug approaches to pain management, such as whirlpool soaks and position changes.

Vaginal Birth

Non-Medical Approaches for Labor and Vaginal Birth

The Birth Center rooms provide a number of options for comfort during labor including space to move around, tubs for soaking, rocking chairs and beds that convert into different positions. Relaxation and breathing techniques ease the discomfort for many, as does the presence of family and friends and the support of health care providers. Comfort measures can be learned from classes or from books and videos available through UCSF's Great Expectations.

Medical Approaches for Labor and Vaginal Birth

Injections of a narcotic can be given intravenously (through an IV) during labor. The narcotic works quickly and can be given every hour during labor. However, it is not given immediately before delivery to ensure that the effects will have worn off before the baby is born. For some women medication takes the edge off and allows them to rest and relax between contractions.

• Nitrous oxide gas (the same gas that is used at the dentist) can be inhaled during contractions through a mask you hold. The gas can lessen but not eliminate the pain of labor. The effect occurs only while the gas is being inhaled and disappears rapidly when the mask is removed. It can be used through delivery.

• Epidural anesthesia offers the most complete pain relief during labor and birth. A tiny tube or catheter is placed through a needle into a space (the "epidural space") outside the spinal cord sac in the lower part of the back. The needle is removed and the tubing is taped in place. Similar to an IV, medication is given continuously through the tube during labor and birth. The medication blocks the pain of contractions. Because of the numbness produced by the epidural, a woman with an epidural cannot get out of bed (but usually takes the opportunity to get some rest). A "walking epidural" (also called a "combined spinal-epidural") is a technique that allows a woman to continue to move around while receiving a lighter form of medication.

Our anesthesiologists are available to the Birth Center 24 hours a day. The anesthesiologist on-call meets every woman who is admitted in labor regardless of whether she is planning anesthesia for her birth. The purpose of this visit is two-fold:

1. To learn of any medical problems a woman may have in the unlikely event of an emergency
2. To answer any questions a woman may have about the pros and cons of medical approaches to pain relief during labor

Caesarean Birth

While most women will have a vaginal delivery, some may need abdominal surgery referred to as Caesarean section. Most often women have a Caesarean birth when labor does not progress -- the cervix does not completely dilate or the baby cannot be pushed out -- over a long period of time. It is a decision made by the woman and her doctor when both feel everything else has been tried and this is the only alternative.

Sometimes a Caesarean birth is planned. Situations that might require a scheduled Caesarean include:

• Breech position
• Previous Caesarean section
• Placenta previa, when the placenta is covering the cervix

Rarely, Caesarean birth is due to an emergency situation that endangers the woman's or her baby's health. In these situations, there is no time to wait for the regular process of labor and the decision to perform a Caesarean section must be made very quickly. Indications for an emergency Caesarean may include:

• Maternal bleeding
• The baby being in "distress"

For a planned or non-emergency Caesarean an epidural or spinal anesthesia is the anesthesia of choice. This allows the woman to be awake and able to see her baby as soon as it is born. In an emergency situation, the woman would be put to sleep using general anesthesia. This is the fastest anesthesia to administer when time is of the essence.

If the woman is awake, a support person can be with her for the birth. If general anesthesia is used and the woman is asleep, support people need to wait in the labor room or waiting room until the surgery is completed.

Most often a "bikini cut" or low transverse incision is made both on the skin, just above the pubic hair, and on the uterus itself. This is a preferable cut for both comfort and recovery. Occasionally an "up and down" or vertical incision is made on the skin and/or uterus. This is a faster cut and may be used in an emergency. The size and position of your baby also may determine the need for this kind of incision.

Recovery from surgery takes longer than recovery from a vaginal birth. Usually it requires an extra night or two in the hospital, for a total of three to four nights, and more help at home in the first few weeks.

Many women choose to attempt a vaginal birth after Caesarean (VBAC) and many will succeed. Every woman who has had a Caesarean will need to discuss the subject of VBAC with her provider. Many factors including the reason for the Caesarean, the type of incision and the number of prior Caesareans will influence the safety of vaginal birth.