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Thursday, August 28, 2014
- Do I need "preconception counseling"?
- What should be in a prenatal vitamin?
- I'm pregnant - When should I have my first visit with an obstetrician?
- How early do Braxton Hicks contractions start and how can I know that's what I'm feeling?
- How can I know my cervix is dilating and get to the hospital at a good time? Can I check for dilation myself?
- What happens during labor?
- What should I do if I don't have a birth partner?
- Can nitrous oxide be used for pain relief during labor and delivery?
- Statistically speaking, what is the probability of my delivering on my due date?
- How soon does a period start after a pregnancy?
- How long is it normal to bleed for after a normal vaginal delivery?
Preconception counseling is the term used to describe a health care provider discussing pertinent issues of a healthy pregnancy with a woman, prior to her attempts to conceive. Although this type of visit is essential to any pregnancy, many times this interaction only occurs with women with serious medical conditions that may complicate pregnancy (i.e. diabetes, heart disease, and lupus). For an otherwise healthy woman, the key issues before trying to conceive are that, with diet or supplements, you are receiving 400 micrograms of folic acid each day. This will reduce the risk to the fetus of developing a neural tube defect. Other considerations are to avoid medications (prescription or over-the-counter) that may be harmful to a developing fetus. You will not know you are pregnant until the fetus is 2 weeks old. Prevention in this situation means to avoid anything that can cause a birth defect.
In the U.S., the recommended dietary allowances (RDA) are published by the Food and Nutrition Board, Institute of Medicine of the National Academy of Sciences, to serve as a goal for good nutrition.
The current recommended dietary allowances for pregnant women are:
You may already get the RDA of some vitamins and minerals through your diet. There is some evidence that prevention therapy with folic acid initiated before pregnancy can reduce the risk of fetal neural tube defects. For this reason, adequate folic acid intake (400 mcg of folic acid daily) is important in all women of child-bearing potential. It has been suggested that higher doses of folic acid be used in women with a history of prior pregnancy complicated by fetal development of a neural tube defect. It is also important not to take too much of a vitamin or mineral because this may be harmful during pregnancy.
Multivitamin/mineral products including prenatal supplements vary in content. Some individuals may have special needs and require a different amount of one or more nutrients. It may be best to check with your doctor who can determine if you have any special needs in preparing to become pregnant.
There is very little hard scientific data to support or refute the use of nutritional supplements in pregnancy, with the exception of folic acid (which is beneficial) or large amounts of vitamin A (which is harmful). The majority of US women are placed on supplements (although many do not take them) and there seems to be no harm in doing so.
The recommendation of most obstetricians is to have the first prenatal visit between 6 and 8 weeks from the first day of a missed menses in an uncomplicated pregnancy. If there are high-risk factors (pre-existing medical conditions, vaginal bleeding, etc) the visit should occur earlier and at the discretion of the physician.
Braxton-Hicks contractions can really start anytime. The only way to tell these contractions from true contractions is their intensity, time between contractions, and if the contractions cause the cervix to dilate.
You are right that dilation of the cervix is evidence of labor. However, a non-medically trained person should not try to assess dilation through a vaginal exam. It is difficult to learn how far dilated a woman is and there is a risk of infection and rupture of membranes.
Labor is defined as regular contractions that lead to progressive cervical dilation. Unless you have been through it before, it may be difficult to determine when true labor starts. Anyone who is experiencing vaginal bleeding, ruptured membranes (water breaking) or contractions before 36 weeks should alert her caregiver. In general, true labor occurs when contractions have been progressively getting closer together and have been about 3-5 minutes apart for an hour or more. The contractions are usually hard enough that you are unable to talk through them. When you have to stop and pant through them or they take your breath away, it may be true labor. When you have these contractions and have been shown to demonstrate cervical change, you are considered to be in true labor. Despite all this, you still may go to the hospital and be told that you are not in true labor. Do not fret, this is very common and is all a part of the experience of pregnancy and childbirth. Some women have what seems to them as mild contractions and arrive 6-7 centimeters dilated, and some contract for hours and are only 1 centimeter
When labor begins, many changes are occurring within your body. These changes allow for the baby to be born. Prior to labor beginning, many women experience the baby dropping. This is when the baby moves into the pelvis in preparation for birth. You might notice that you can breathe easier because the baby no longer presses on the diaphragm. However, you might notice that you urinate more frequently, have more edema in your legs, and experience pelvic pressure. These are common changes that occur once the baby is in the pelvis. Another way your body prepares for labor is through Braxton Hicks contractions, which are irregular contractions. If you have taken childbirth classes and learned breathing and relaxation techniques during a Braxton Hicks contraction is a good time to practice. The cervix will also become softer in order to stretch and dilate in preparation for birth. Bloody show, (a pink tinged discharge) is a sign of impending labor. This occurs when the cervix softens and thins and small surface capillaries bleed. The rupture of membranes (breaking of your bag of water) occurs sometimes prior to beginning contractions. When your membranes rupture you need to notify your health care provider and follow their instructions.
True labor will result in progressive changes in cervical dilatation and effacement (thinning). The contractions of labor are usually regular, and increase in frequency, length and strength. The pain of labor will start in the back and move around to the abdomen, and is often worst when walking. False labor does not produce changes in the cervix. The contractions are irregular and do not change in frequency, length, or strength. They are often described as a hardening of the abdomen without much discomfort. When discomfort is present, it is usually in the lower abdomen and often goes away with walking. Often times it is difficult to know the difference between true and false labor without a cervical evaluation. It is important to discuss with your health care provider when they want you to call them regarding labor, and when you should go to the hospital. This varies depending on your personal history, distance from hospital and preference of your health care provider.
During true labor you can expect mild discomfort to begin with. The contractions will get closer together, last longer and become more uncomfortable as labor progresses. Labor is a slow process. Early labor will usually last much longer than hard labor. The length of labor varies with each person and each pregnancy. It helps to be prepared for labor, knowing that labor is not pain free, but is something that many women are able to cope with, and use little if any medication for relief of pain. Prior to entering the hospital you need to discuss with your health care provider your options for pain control which will vary widely depending on where you are delivering.
You are faced with a situation that many other women experience. One route you may consider is hiring a doula. These are trained labor coaches who, for a fee, assist you in labor. They are most commonly used for women who are trying to have a completely "natural" childbirth, but it may be worth asking around to see if there are doulas is your area.
Nitrous oxide is not used for analgesia in labor, but is sometimes used if general anesthesia is needed for a Cesarean section. The risk of using nitrous is that it can cross the placenta and cause the infant to become sedated at delivery, making it difficult for the baby to breathe on its own. With epidural anesthesia and narcotics (i.e. morphine and its related drugs) being proven safe and effective for pain relief in labor, nitrous oxide is not advised.
The vast majority of women will deliver within 2 weeks of their due date. It is difficult to give you exact statistics because due dates are fairly arbitrary. When assigning a due date based on a woman's last menstrual period, we assume that all women have 28 day cycles and conceive on day 14 of their cycle. Ultrasound in the first trimester can be off by 5 days. More important is the risk of preterm delivery (less than 37 completed weeks of pregnancy). The statistical chance of this in a first pregnancy is 7%.
Following birth, the resumption of menstruation is variable. When a woman is not breastfeeding, menstruation usually resumes between 6 and 10 weeks following birth. In the breastfeeding woman, the return of menstruation is variable, depending on the amount of time she is breastfeeding and whether she is using supplements. The average time for resumption of menstruation in breastfeeding women is 30-36 weeks following birth. It is important to remember that ovulation may occur prior to menstruation, and if another pregnancy is not desired a form of contraception must be used each time the woman has sexual intercourse.
The length of time varies for every woman. The average is somewhere between 8-12 weeks. It takes at least 7 weeks just for the uterus to return to normal size. Once that is achieved, some women start menstruating (even those who are breastfeeding although it is less likely). Other causes for prolonged bleeding can be infection of the lining of the uterus, an injury or tear that has failed to heal, or a piece of the placenta that has been retained in the uterus. Your caregiver can examine you to determine if your bleeding is abnormal and deserves further investigation.
Last Reviewed: May 28, 2002
Arthur T Ollendorff, MD
Associate Professor of Obstetrics and Gynecology
College of Medicine
University of Cincinnati