Pregnancy and child birth

1. Pregnancy and child birth • 1. To look at health issues surrounding pregnancy • 2. To look at stages of development of the foetus • 3. To look at the stages of birth • 4. To look at care for the mother during pregnancy • 5. To look at care of mother and baby at birth • 6. Health and infancy • 7. Health complications for mother and baby

2. Preparing to get pregnant • Get fit • Loose extra weight • Take folic acid to prevent spina bifida • Give up smoking (Mum and Dad) and drugs/misuse of alcohol. • Save cash • Have lots of sex • Monitor body temperature to identify ovulation • See doctor about any pre-existing medical conditions and medication • Get counseling and genetic testing if relevant.

3. Conception • Normally through natural fertilisation • Risk of STD transmission • May be unwanted • Can take place outside the womb (in vitro) fertilisation followed by implantation.

4. Fertilisation

5. Development within the mother • Baby develops within the womb (uterus) • Supplied with food and oxygen from mother’s blood • Wastes removed via mother’s blood • Baby and mother’s blood separate • Transfer is by diffusion between blood vessels in the placenta

6. Function of the placenta

7. Stages of pregnancy

8. Medical issues in pregnancy • 1. Ectopic pregnancy – baby develops in fallopian tube – potentially fatal and compromises future chances of pregnancy • 2.Excess weight gain – may also affect blood pressure • 3. Pre-eclampsia –high blood pressure, inflammation and odema (in last trimester) bed rest • 4. Eclampsia – potentially fatal blood pressure can lead to strokes Immediate caesarian • 5. Gestational diabetes associated with obese mothers/diabetic families. After birth, mother must be treated as type 2 diabetic until her glucose levels normalise. • 6. Miscarriage – very traumatic for mother. May be result of compromised pregnancy or trauma during pregnancy. Smokers, drug use, malnutrition.

9. Rhesus negative mother. • Mother is Rhesus negative • 1st Baby is rhesus positive and fine • 2nd baby is rhesus positive and mother become very ill and terminates pregnancy • Rhesus +ve baby causes mother to create antibodies which kill second baby • Mother can receive vaccination immediately after 1st birth to prevent this • If mother has had a rhesus positive blood transfusion there is nothing that can be done and all rhesus positive babies will die.

10. Medical issues in pregnancy (baby) • 1st Trimester • Placenta previa (placenta too low in uterus) – can lead to miscarriage. Next pregnancy will not normally have same problem • 2nd trimester • Genetic and developmental malformations such as hare lip, heart defects, kidney. Can be operated in utero saving many post partem operations. • May be traumatic to foetus – science cannot agree.

11. Third trimester • Birth may occur early due to eclampsia • Placenta can start to die and calcify early • This has to be carefully monitored • May result in early delivery of baby. • Babies of smokers small and undeveloped with respiratory problems • Babies of drug and alcohol misuse small with other developmental problems: often neurological or mental • Caffeine in pregnancy and whilst breast feeding up to 3 months: irritable baby syndrome

12. Birth Usually supported by another woman “midwife”. May be medically trained or may not.

13. Stages of Labour • Length of time very variable • Baby’s head is engaged at top of cervix • Hormone oxytocin initiates contractions • Contractions gradually become stronger and more frequent • Mucus plug in cervix is expelled “the show” • Vagina starts to dilate • Amniotic sac is burst and fluids expelled (breaking of waters) • Vagina dilates further and contractions become increasingly frequent and stronger • Baby is delivered down vagina

14. Possible complications • Breech birth (baby comes legs first and head may get stuck) • Baby may get cord tied around neck • Vagina may tear or be cut (episiotomy). Good episiotomy thought to aid healing and reduce risk of incontinence and loss of sexual pleasure • Mother may become exhausted and stop pushing (poor antenatal education; too early to go into labour ward) • Post-natal depression • Still birth (poor medical care or practice)

15. Birthing choices • Most births are natural and proceed perfectly without event. • But if something goes wrong mother and baby are in mortal danger thus choices involve weighing risks

16. Birthing choices continued • Mother can opt to have baby under medical supervision in a hospital • Or at home • She may opt for a birthing pool • She may opt for a sitting kneeling or squatting position. You don’t have to be on your back • May have support of midwife and birthing partner (doula) • A caesarian may be offered or needed. • Pain control may be offered. • There are opinions in favour or against most of these. • Mothers may feel deeply unsatisfied with the birth process or treatment and it is up to the midwife to aid them to understand events.

17. Care for the infant • Checks immediately after birth • Breathing • Check anus is connected to rectum • Check passages are clear of muconium • Check sex • Weight • Temperature • APGAR

18. APGAR Score

19. Interpreting APGAR • Done one and five minutes after birth, and may be repeated later if the score is low. Scores 3 and below are generally regarded as critically low, • 4 to 6 fairly low, and • 7 to 10 generally normal • Low score on the one-minute test may show that the neonate requires medical attention • not necessarily an indication of long-term problems, particularly if there is an improvement by the stage of the five-minute test. • If the Apgar score remains below 3 at later times such as 10, 15, or 30 minutes, there is a risk that the child will suffer longer-term neurological damage

20. Possible complications • Infant jaundice. Normally not a problem as it is due to break down of foetal haemoglobin and its replacement with normal. • Blue baby – may indicate heart or lung problems. May naturally heal or may need surgery • Diabetic cherub. V large but not very well developed.

21. Why breast is best • Mother’s milk is obviously evolutionary designed to be best for baby’s needs it’s personal mother produces exactly what her baby needs • Has exactly right quantities of each nutrient • Provides baby passive immunity • Is better for baby’s breathing • Prevents later allergies and milk intolerance • Is better for mother’s health – reduces chances of osteoporosis and breast cancer • Helps mother loose weight • Semi-contraceptive • All women can breast feed – breast size and nipple shape not an issue. • Must not do it if HIV +ve • Adoptive mothers can have induced lactation but it is not necessarily the best for baby or mother

22. Weaning • At ages 6 months (after which quality of mother’s milk falls) • First start on liquidised food (best at 6 months) • Avoid any foods with added sugar or salt • Liquidise your meals • Continue to breast feed • Cease breast feeding when you and baby feel ready (no right age) • No eggs, citric fruits, strawberries, chocolate, pea nuts, spices, chillies because they may produce allergies • Mother must allow child to try all flavours, not just those she likes. Start veg before fruit

23. Baby illnesses • Weak immune system – more prone to colds etc and any communicable diseases • Never let baby get too warm – only put second or third layer on when ready to walk out the door. Baby easily overheats • Prone to colic and other gastrointestinal inflammations – especially if not breast fed Linked to mother’s diet. If food upsets mother it will upset baby. • Delicate so cannot be shaken or dropped

24. Foetal testing and monitoring • For things like spina-bifida and Down’s syndrome • Done by amniocentesis – usually following a less invasive protein test • Can test for CF – makes for much better treatment of child

25. Ultrasound • Need one per trimester • (unscrupulous doctors here give you more because you pay) • Advise • Week 8 – 10 • Week 18 • Week 30 • More if problems identified

27. Pre-implantation genetic testing • Done if parents carry genetic diseases such as cystic fibrosis and Huntington’s disease • Requires IVF • A series of embryos are created • Tested to see if they have the healthy or diseased genetic compliment • Several healthy embryos implanted

28. What if you don’t want it. • Option 1 contraception • Barrier methods (prevent transmission of STDs as well • Chemical measures. Pills or for the forgetful implants and injections • Cervical implants (coils) • Copper implants in arm • Behavioural methods

29. If it’s too late • The morning after pill can be taken up to 3 days after pregnancy • Similarly a course of antivirals can be taken if it is thought you’ve been exposed to HIV • Abortion (legal only in DF) • Adoption (huge shortage of potential babies in US and Europe) Not so here?

30. Plenary • Imagine you’re an expectant mother and write down three questions you have about pregnancy, birth or care for the child. • Carefully review the presentation • Ask question of expert panel members • Be prepared to be on the expert panel and to get asked questions as well.