How common is it? Preterm labor is a fairly common problem; about 12 percent of babies are born premature in the United States. Preterm labor is a fairly common problem; about 12 percent of babies are born premature in the United States.

Risk factors leading to premature labor include smoking, alcohol use, drug abuse, too little weight gain, too much weight gain, inadequate nutrition, gum infection, other infections (such as STDs, bacterial vaginosis, urinary tract infections, amniotic fluid infection), incompetent cervix, uterine irritability, chronic maternal illness, placental abruption, and placenta previa. Women who are younger than 17 or older than 35 years old, those who are carrying multiples, and those with a history of premature delivery are also at increased risk. Preterm births are also more common among African American and disadvantaged women. In addition, a fairly large number of premature labors are induced by practitioners in an appropriate response to a medical condition that requires an early birth, such as preeclampsia or PPROM.

Still, much more needs to be learned about what causes labor to begin early; at least half of the women who go into preterm labor have no known risk factors.

What are the signs and symptoms? Signs of premature labor can include all or some of the following: Signs of premature labor can include all or some of the following: [image] Menstrual-like cramps Menstrual-like cramps[image] Regular contractions that intensify and become more frequent even if you change positions Regular contractions that intensify and become more frequent even if you change positions[image] Back pressure Back pressure[image] Unusual pressure in your pelvis Unusual pressure in your pelvis[image] Bloody discharge from your vagina Bloody discharge from your vagina[image] Rupture of membranes Rupture of membranes[image] Changes in the cervix (thinning, opening, or shortening) as measured by ultrasound Changes in the cervix (thinning, opening, or shortening) as measured by ultrasound What can you and your practitioner do? Because each day a baby remains in the womb improves the chances of both survival and good health, holding off labor as long as possible will be the primary goal. Unfortunately, however, there isn't much that can be done to stop early labor. The measures that were once routinely recommended (bed rest, hydration, home uterine activity monitoring) don't seem to work to stop or prevent contractions, though many doctors still prescribe them. Other steps your practitioner may advise if you're experiencing early contractions include progesterone supplementation to decrease uterine activity (usually reserved only for women with a prior preterm delivery or with a short cervix who are not carrying multiples or receiving tocolytics); antibiotics (if a GBS culture-see Because each day a baby remains in the womb improves the chances of both survival and good health, holding off labor as long as possible will be the primary goal. Unfortunately, however, there isn't much that can be done to stop early labor. The measures that were once routinely recommended (bed rest, hydration, home uterine activity monitoring) don't seem to work to stop or prevent contractions, though many doctors still prescribe them. Other steps your practitioner may advise if you're experiencing early contractions include progesterone supplementation to decrease uterine activity (usually reserved only for women with a prior preterm delivery or with a short cervix who are not carrying multiples or receiving tocolytics); antibiotics (if a GBS culture-see page 326 page 326-is positive); or tocolytics (that can temporarily halt contractions, and give your practitioner time to administer steroids to help your baby's lungs mature more quickly, so that he or she will fare better should a preterm birth become inevitable or necessary). If at any point your practitioner determines that the risk to you or your baby from continuing the pregnancy outweighs the risk of preterm birth, no attempt will be made to postpone delivery.

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A baby born prematurely will likely need to spend time in a neonatal intensive care unit (NICU) for the first few days, weeks, or, in some cases, months of his or her life. Though prematurity has been linked to slow growth and developmental delays, most babies who arrive too early catch up and have no lasting problems at all. Thanks to advances in medical care, your chances of bringing home a normal, healthy infant after a premature birth are very good.

Can it be prevented? Not all preterm births can be avoided, since not all are due to preventable risk factors. However, all the following measures may reduce the risk of preterm delivery (while boosting your chances of having the healthiest pregnancy possible): taking folic acid before pregnancy; getting early prenatal care; eating well (and getting enough vitamins, especially vitamin D); getting good dental care; avoiding smoking, cocaine, alcohol, and other drugs not prescribed by your doctor; getting tested for and, if necessary, treated for any infections such as BV and UTIs; and following your practitioner's recommendations as to limitations on strenuous activity, including sexual intercourse and hours spent standing or walking on the job, especially if you have had previous preterm deliveries. The good news is that 80 percent of women who go into preterm labor will deliver at term without any interventions at all. Not all preterm births can be avoided, since not all are due to preventable risk factors. However, all the following measures may reduce the risk of preterm delivery (while boosting your chances of having the healthiest pregnancy possible): taking folic acid before pregnancy; getting early prenatal care; eating well (and getting enough vitamins, especially vitamin D); getting good dental care; avoiding smoking, cocaine, alcohol, and other drugs not prescribed by your doctor; getting tested for and, if necessary, treated for any infections such as BV and UTIs; and following your practitioner's recommendations as to limitations on strenuous activity, including sexual intercourse and hours spent standing or walking on the job, especially if you have had previous preterm deliveries. The good news is that 80 percent of women who go into preterm labor will deliver at term without any interventions at all.

Predicting Preterm Labor Even among women who are at high risk for preterm labor, most will carry to term. One way to predict preterm labor is to examine cervical or vaginal secretions for a substance known as fetal fibronectin (fFN). Studies show that some women who test positive for fFN stand a good chance of going into preterm labor within one to two weeks of the test. The test, however, is better at diagnosing women who are not at risk for going into preterm labor (by detecting no fFN) than as an accurate predictor of women who are at risk. When fFN is detected, steps should be taken to reduce the chances of preterm labor. The test is now widely available, but is usually reserved for high-risk women only. If you aren't considered high risk for preterm birth, you don't need to be tested.

Another screening test is one for cervical length. Via ultrasound before 30 weeks, the length of your cervix is measured to see if there are any signs that the cervix is shortening or opening. A short cervix puts you at an increased risk of going into early labor, especially if it began shortening early in pregnancy.

Symphysis Pubis Dysfunction (SPD) What is it? Symphysis pubis dysfunction, or SPD, means the ligaments that normally keep your pelvic bone aligned become too relaxed and stretchy too soon before birth (as delivery nears, things are supposed to start loosening up). This, in turn, can make the pelvic joint-aka the symphysis pubis-unstable, causing mild to severe pain. Symphysis pubis dysfunction, or SPD, means the ligaments that normally keep your pelvic bone aligned become too relaxed and stretchy too soon before birth (as delivery nears, things are supposed to start loosening up). This, in turn, can make the pelvic joint-aka the symphysis pubis-unstable, causing mild to severe pain.

How common is it? The incidence of diagnosed SPD is about 1 in 300 pregnancies, though some experts think that more than 2 percent of all pregnant women will experience SPD (but not all will have it diagnosed). The incidence of diagnosed SPD is about 1 in 300 pregnancies, though some experts think that more than 2 percent of all pregnant women will experience SPD (but not all will have it diagnosed).

What are the signs and symptoms? The most common symptom is a wrenching pain (as though your pelvis is coming apart) and difficulty when walking. Typically, the pain is focused on the pubic area, but in some women it radiates to the upper thighs and perineum. The pain can worsen when you're walking and doing any weight-bearing activity, particularly one that involves lifting one leg, such as when you're climbing up stairs, getting dressed, getting in and out of a car, even turning over in bed. In very rare cases, the joint may gape apart, a condition called diastasis symphysis pubis or symphyseal separation, which can cause more serious pain in your pelvis, groin, hips, and buttocks. The most common symptom is a wrenching pain (as though your pelvis is coming apart) and difficulty when walking. Typically, the pain is focused on the pubic area, but in some women it radiates to the upper thighs and perineum. The pain can worsen when you're walking and doing any weight-bearing activity, particularly one that involves lifting one leg, such as when you're climbing up stairs, getting dressed, getting in and out of a car, even turning over in bed. In very rare cases, the joint may gape apart, a condition called diastasis symphysis pubis or symphyseal separation, which can cause more serious pain in your pelvis, groin, hips, and buttocks.

What can you and your practitioner do? Avoid aggravating the condition by limiting weight-bearing positions and minimizing as best you can any activity that involves lifting or separating your legs-even walking, if it's very uncomfortable. Try stabilizing those floppy ligaments by wearing a pelvic support belt, which "corsets" the bones back into place. Kegels and pelvic tilts can help to strengthen the muscles of the pelvis. If the pain is severe, ask your practitioner about pain relievers or turn to CAM techniques, such as acupuncture or chiropractic. Avoid aggravating the condition by limiting weight-bearing positions and minimizing as best you can any activity that involves lifting or separating your legs-even walking, if it's very uncomfortable. Try stabilizing those floppy ligaments by wearing a pelvic support belt, which "corsets" the bones back into place. Kegels and pelvic tilts can help to strengthen the muscles of the pelvis. If the pain is severe, ask your practitioner about pain relievers or turn to CAM techniques, such as acupuncture or chiropractic.

Very rarely, SPD can make a vaginal delivery impossible and your practitioner may opt for a C-section instead. And in even rarer cases, SPD can worsen after delivery, requiring medical intervention. But for most moms, once your baby is born and production of relaxin (that ligament-relaxing hormone) stops, your ligaments will return to normal.

Cord Knots and Tangles What is it? Once in a while, the umbilical cord becomes knotted, tangled, or wrapped around a fetus, often at the neck (when it is known as a nuchal cord). Some knots form during delivery; others form during pregnancy when the baby moves around. As long as the knot remains loose, it's not likely to cause any problems at all. But if the knot becomes tight, it could interfere with the circulation of blood from the placenta to the baby and cause oxygen deprivation. Such an event happens only rarely, but when it does, it is most likely to occur during your baby's descent through the birth canal. Once in a while, the umbilical cord becomes knotted, tangled, or wrapped around a fetus, often at the neck (when it is known as a nuchal cord). Some knots form during delivery; others form during pregnancy when the baby moves around. As long as the knot remains loose, it's not likely to cause any problems at all. But if the knot becomes tight, it could interfere with the circulation of blood from the placenta to the baby and cause oxygen deprivation. Such an event happens only rarely, but when it does, it is most likely to occur during your baby's descent through the birth canal.

How common is it? True umbilical cord knots occur in about 1 in every 100 pregnancies, but only in 1 in 2,000 deliveries will a knot be tight enough to present problems for the baby. The more common nuchal cords occur in as many as a quarter of all pregnancies but very rarely pose risks to the baby. Babies with long cords and those who are large-for-gestational age are at greater risk for developing true knots. Researchers speculate that nutritional deficiencies that affect the structure and protective barrier of the cord, or other risk factors, such as smoking or drug use, carrying multiples, or having hydramnios, may make a woman more prone to having a pregnancy with a cord knot. True umbilical cord knots occur in about 1 in every 100 pregnancies, but only in 1 in 2,000 deliveries will a knot be tight enough to present problems for the baby. The more common nuchal cords occur in as many as a quarter of all pregnancies but very rarely pose risks to the baby. Babies with long cords and those who are large-for-gestational age are at greater risk for developing true knots. Researchers speculate that nutritional deficiencies that affect the structure and protective barrier of the cord, or other risk factors, such as smoking or drug use, carrying multiples, or having hydramnios, may make a woman more prone to having a pregnancy with a cord knot.

What are the signs and symptoms? The most common sign of a cord knot is decreased fetal activity after week 37. If the knot occurs during labor, a fetal monitor will detect an abnormal heart rate. The most common sign of a cord knot is decreased fetal activity after week 37. If the knot occurs during labor, a fetal monitor will detect an abnormal heart rate.

What can you and your practitioner do? You can keep a general eye on how your baby is doing, especially later in your pregnancy, by doing regular kick counts and calling your practitioner if you notice any change in fetal activity. If a loose knot tightens during delivery, your practitioner will be able to detect the drop in your baby's heart rate, and will make the appropriate decisions to ensure your baby's safe entry into the world. Immediate delivery, usually via C-section, is often the best approach. You can keep a general eye on how your baby is doing, especially later in your pregnancy, by doing regular kick counts and calling your practitioner if you notice any change in fetal activity. If a loose knot tightens during delivery, your practitioner will be able to detect the drop in your baby's heart rate, and will make the appropriate decisions to ensure your baby's safe entry into the world. Immediate delivery, usually via C-section, is often the best approach.

Two-Vessel Cord What is it? In a normal umbilical cord, there are three blood vessels-one vein (which brings nutrients and oxygen to the baby) and two arteries (which transport waste from the baby back to the placenta and the mother's blood). But in some cases, the umbilical cord contains only two blood vessels-one vein and one artery. In a normal umbilical cord, there are three blood vessels-one vein (which brings nutrients and oxygen to the baby) and two arteries (which transport waste from the baby back to the placenta and the mother's blood). But in some cases, the umbilical cord contains only two blood vessels-one vein and one artery.

How common is it? About 1 percent of singletons and 5 percent of multiple pregnancies will have a two-vessel cord. Those at greater risk include Caucasian women, women over age 40, those carrying a multiple pregnancy, and those with diabetes. Female fetuses are more likely to be affected by a two-vessel cord than males. About 1 percent of singletons and 5 percent of multiple pregnancies will have a two-vessel cord. Those at greater risk include Caucasian women, women over age 40, those carrying a multiple pregnancy, and those with diabetes. Female fetuses are more likely to be affected by a two-vessel cord than males.

What are the signs and symptoms? There are no signs or symptoms with this condition; it's detected on ultrasound examination. There are no signs or symptoms with this condition; it's detected on ultrasound examination.

What can you and your practitioner do? In the absence of any other abnormalities, a two-vessel cord in no way harms the pregnancy. The baby is most likely to be born completely healthy. So the first thing you can do is not worry. In the absence of any other abnormalities, a two-vessel cord in no way harms the pregnancy. The baby is most likely to be born completely healthy. So the first thing you can do is not worry.

If you've been found to have a two-vessel cord, your pregnancy will be monitored more closely, since the condition comes with a small increased risk of poor fetal growth.

Uncommon Pregnancy Complications The following complications of pregnancy are, for the most part, rare. The average pregnant woman is extremely unlikely to encounter any of them. So, again (and this deserves repeating), read this section only only if you need to-and even then, read just what applies to you. If you are diagnosed with any of these complications during your pregnancy, use the information here to learn about the condition and its typical treatment (as well as how to prevent it in future pregnancies), but realize that your practitioner's protocol for treating you may be different. if you need to-and even then, read just what applies to you. If you are diagnosed with any of these complications during your pregnancy, use the information here to learn about the condition and its typical treatment (as well as how to prevent it in future pregnancies), but realize that your practitioner's protocol for treating you may be different.

Molar Pregnancy What is it? In a molar pregnancy, the placenta grows improperly, becoming a mass of cysts (also called a hydatidiform mole), but there is no accompanying fetus. In some cases, identifiable-but not viable-embryonic or fetal tissue is present; this is called a partial molar pregnancy. In a molar pregnancy, the placenta grows improperly, becoming a mass of cysts (also called a hydatidiform mole), but there is no accompanying fetus. In some cases, identifiable-but not viable-embryonic or fetal tissue is present; this is called a partial molar pregnancy.

The cause of a molar pregnancy is an abnormality during fertilization, in which two sets of chromosomes from the father become mixed in with either one set of chromosomes from the mother (partial mole)-or none of her chromosomes at all (complete mole). Most molar pregnancies are discovered within weeks of conception. All molar pregnancies end in miscarriage.

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Having had one molar pregnancy doesn't put you at much higher risk for having another one. In fact, only 1 to 2 percent of women who have had one molar pregnancy go on to experience a second.

How common is it? Luckily, molar pregnancies are relatively rare, occurring only in 1 out of 1,000 pregnancies. Women under the age of 15 or over the age of 45, as well as women who have had multiple miscarriages are at a slightly increased risk for a molar pregnancy. Luckily, molar pregnancies are relatively rare, occurring only in 1 out of 1,000 pregnancies. Women under the age of 15 or over the age of 45, as well as women who have had multiple miscarriages are at a slightly increased risk for a molar pregnancy.

What are the signs and symptoms? The symptoms of a molar pregnancy can include: The symptoms of a molar pregnancy can include: [image] A continuous or intermittent brownish discharge A continuous or intermittent brownish discharge[image] Severe nausea and vomiting Severe nausea and vomiting[image] Uncomfortable cramping Uncomfortable cramping[image] High blood pressure High blood pressure[image] Larger than expected uterus Larger than expected uterus[image] Doughy uterus (rather than firm) Doughy uterus (rather than firm)[image] Absence of embryonic or fetal tissue (as seen on ultrasound) Absence of embryonic or fetal tissue (as seen on ultrasound)[image] Excessive levels of thyroid hormone in the mother's system Excessive levels of thyroid hormone in the mother's system What can you and your practitioner do? Call your practitioner if you experience any of the symptoms listed above. Some of these symptoms can be difficult to differentiate from normal early pregnancy signs and symptoms (many completely normal pregnancies include some spotting and cramping, and most include nausea), but trust your instincts. If you think something's wrong, talk to your practitioner-if only to get some much-needed reassurance. Call your practitioner if you experience any of the symptoms listed above. Some of these symptoms can be difficult to differentiate from normal early pregnancy signs and symptoms (many completely normal pregnancies include some spotting and cramping, and most include nausea), but trust your instincts. If you think something's wrong, talk to your practitioner-if only to get some much-needed reassurance.

If an ultrasound shows you do have a molar pregnancy, the abnormal tissue must be removed via a dilation and curettage (D and C). Follow-up is crucial to make sure it doesn't progress to choriocarcinoma (see next column), though luckily, the chances of a treated molar pregnancy turning malignant are very low. Your practitioner will probably suggest that you not get pregnant for a year following a molar pregnancy.

Choriocarcinoma What is it? Choriocarcinoma, an extremely rare form of cancer related to pregnancy, grows from the cells of the placenta. This malignancy most often occurs after a molar pregnancy, miscarriage, abortion, or ectopic pregnancy, when any left-behind placental tissues continue to grow despite the absence of a fetus. Only 15 percent of choriocarcinomas occur after a normal pregnancy. Choriocarcinoma, an extremely rare form of cancer related to pregnancy, grows from the cells of the placenta. This malignancy most often occurs after a molar pregnancy, miscarriage, abortion, or ectopic pregnancy, when any left-behind placental tissues continue to grow despite the absence of a fetus. Only 15 percent of choriocarcinomas occur after a normal pregnancy.

How common is it? Choriocarcinoma is extremely rare, occurring in only 1 out of every 40,000 pregnancies. Choriocarcinoma is extremely rare, occurring in only 1 out of every 40,000 pregnancies.

What are the signs and symptoms? The signs of the disease include: The signs of the disease include: [image] Intermittent bleeding following a miscarriage, a pregnancy, or the removal of a molar pregnancy Intermittent bleeding following a miscarriage, a pregnancy, or the removal of a molar pregnancy[image] Abnormal tissue discharge Abnormal tissue discharge[image] Elevated hCG levels that do not return to normal after a pregnancy has ended Elevated hCG levels that do not return to normal after a pregnancy has ended[image] A tumor in the vagina, uterus, or lungs A tumor in the vagina, uterus, or lungs[image] Abdominal pain Abdominal pain What can you and your practitioner do? Call your practitioner if you experience any of the above symptoms, but keep in mind that it's extremely unlikely that they indicate a choriocarcinoma. If you are diagnosed, the news is very reassuring. While any type of cancer carries with it some risk, choriocarcinoma responds extremely well to chemotherapy and radiation treatments and has a cure rate of more than 90 percent. Hysterectomy is almost never necessary because of this type of tumor's excellent response to chemotherapy drugs. Call your practitioner if you experience any of the above symptoms, but keep in mind that it's extremely unlikely that they indicate a choriocarcinoma. If you are diagnosed, the news is very reassuring. While any type of cancer carries with it some risk, choriocarcinoma responds extremely well to chemotherapy and radiation treatments and has a cure rate of more than 90 percent. Hysterectomy is almost never necessary because of this type of tumor's excellent response to chemotherapy drugs.

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With early diagnosis and treatment of choriocarcinoma, fertility is unaffected, though it's usually recommended that pregnancy be deferred for one year after treatment for choriocarcinoma is complete and there is no evidence of residual disease.

Eclampsia What is it? Eclampsia is the result of uncontrolled or unresolved preeclampsia (see Eclampsia is the result of uncontrolled or unresolved preeclampsia (see page 548 page 548). Depending on what stage of pregnancy a woman is in when she becomes eclamptic, her baby may be at risk of being born prematurely since immediate delivery is often the only treatment. Although eclampsia is life-threatening for the mother, maternal deaths from it are quite rare in the United States. With optimum treatment and careful follow-up, the majority of women with eclampsia return to normal health after delivery.

How common is it? Eclampsia is much less common than preeclampsia and occurs in only 1 out of every 2,000 to 3,000 pregnancies, typically among women who have not been receiving regular prenatal care. Eclampsia is much less common than preeclampsia and occurs in only 1 out of every 2,000 to 3,000 pregnancies, typically among women who have not been receiving regular prenatal care.

What are the signs and symptoms? Seizures-usually close to or during delivery-are the most characteristic symptom of eclampsia. Postpartum seizures can also occur, usually within the first 48 hours after delivery. Seizures-usually close to or during delivery-are the most characteristic symptom of eclampsia. Postpartum seizures can also occur, usually within the first 48 hours after delivery.

What can you and your practitioner do? If you already have preeclampsia and start to seize, you'll be given oxygen and drugs to arrest the seizures and your labor will be induced or a C-section performed when you're stable. The majority of women rapidly return to normal after delivery, though careful follow-up is necessary to be certain blood pressure doesn't stay up and seizures don't continue. If you already have preeclampsia and start to seize, you'll be given oxygen and drugs to arrest the seizures and your labor will be induced or a C-section performed when you're stable. The majority of women rapidly return to normal after delivery, though careful follow-up is necessary to be certain blood pressure doesn't stay up and seizures don't continue.

Can it be prevented? Regular checkups with your practitioner will allow him or her to pick up on any of the symptoms of preeclampsia. If you are diagnosed with preeclampsia, your practitioner will keep a close eye on you (and your blood pressure) to make sure your condition doesn't progress to eclampsia. Taking steps to try to prevent preeclampsia can also help avoid eclampsia. Regular checkups with your practitioner will allow him or her to pick up on any of the symptoms of preeclampsia. If you are diagnosed with preeclampsia, your practitioner will keep a close eye on you (and your blood pressure) to make sure your condition doesn't progress to eclampsia. Taking steps to try to prevent preeclampsia can also help avoid eclampsia.

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Very few women receiving regular prenatal care ever progress from the manageable preeclampsia to the more serious eclampsia.

Cholestasis What is it? Cholestasis of pregnancy is a condition in which the normal flow of bile in the gallbladder is slowed (as a result of pregnancy hormones), causing the buildup of bile acids in the liver, which in turn can spill into the bloodstream. Cholestasis is most likely to occur in the last trimester, when hormones are at their peak. It usually goes away after delivery. Cholestasis of pregnancy is a condition in which the normal flow of bile in the gallbladder is slowed (as a result of pregnancy hormones), causing the buildup of bile acids in the liver, which in turn can spill into the bloodstream. Cholestasis is most likely to occur in the last trimester, when hormones are at their peak. It usually goes away after delivery.

Cholestasis may increase the risks for fetal distress, preterm birth, or stillbirth, which is why early diagnosis and treatment are crucial.

How common is it? Cholestasis affects 1 to 2 pregnancies in 1,000. It's more common in women carrying multiples, women who have previous liver damage, and in women whose mother or sisters had cholestasis. Cholestasis affects 1 to 2 pregnancies in 1,000. It's more common in women carrying multiples, women who have previous liver damage, and in women whose mother or sisters had cholestasis.

What are the signs and symptoms? Most often, the only symptom noticed is severe itching, particularly on the hands and feet, usually late in pregnancy. Most often, the only symptom noticed is severe itching, particularly on the hands and feet, usually late in pregnancy.

What can you and your practitioner do? The goals of treating cholestasis of pregnancy are to relieve the itching and prevent pregnancy complications. Itching can be treated with topical anti-itch medications, lotions, or corticosteroids. Medication is sometimes used to help decrease the concentration of bile acids. If cholestasis is endangering the well-being of the mother or fetus, an early delivery may be necessary. The goals of treating cholestasis of pregnancy are to relieve the itching and prevent pregnancy complications. Itching can be treated with topical anti-itch medications, lotions, or corticosteroids. Medication is sometimes used to help decrease the concentration of bile acids. If cholestasis is endangering the well-being of the mother or fetus, an early delivery may be necessary.

Deep Venous Thrombosis What is it? Deep venous thrombosis, or DVT, is the development of a blood clot in a deep vein. These clots show up most commonly in the lower extremities, particularly the thigh. Women are more susceptible to clots during pregnancy and delivery, and particularly in the postpartum period. This happens because nature, wisely worried about too much bleeding at childbirth, tends to increase the blood's clotting ability-occasionally too much. Another factor that can contribute is the enlarged uterus, which makes it difficult for blood in the lower body to return to the heart. If untreated, a DVT can result in the clot moving to the lungs and becoming life threatening. Deep venous thrombosis, or DVT, is the development of a blood clot in a deep vein. These clots show up most commonly in the lower extremities, particularly the thigh. Women are more susceptible to clots during pregnancy and delivery, and particularly in the postpartum period. This happens because nature, wisely worried about too much bleeding at childbirth, tends to increase the blood's clotting ability-occasionally too much. Another factor that can contribute is the enlarged uterus, which makes it difficult for blood in the lower body to return to the heart. If untreated, a DVT can result in the clot moving to the lungs and becoming life threatening.

How common is it? Deep venous thrombosis occurs once in every 1,000 to 2,000 pregnancies (it can also occur postpartum). DVT is more common if you are older, a smoker, have a family or personal history of clots, or have hypertension, diabetes, or a variety of other conditions, including vascular diseases. Deep venous thrombosis occurs once in every 1,000 to 2,000 pregnancies (it can also occur postpartum). DVT is more common if you are older, a smoker, have a family or personal history of clots, or have hypertension, diabetes, or a variety of other conditions, including vascular diseases.

What are the signs and symptoms? The most common symptoms of a deep vein thrombosis include: The most common symptoms of a deep vein thrombosis include: [image] A heavy or painful feeling in the leg A heavy or painful feeling in the leg[image] Tenderness in the calf or thigh Tenderness in the calf or thigh[image] Slight to severe swelling Slight to severe swelling[image] Distention of the superficial veins Distention of the superficial veins[image] Calf pain on flexing the foot (turning the toes up toward the chin) Calf pain on flexing the foot (turning the toes up toward the chin) If the blood clot has moved to the lungs (a pulmonary embolus), there may be: [image] Chest pain Chest pain[image] Shortness of breath Shortness of breath[image] Coughing with frothy, bloodstained sputum Coughing with frothy, bloodstained sputum[image] Rapid heartbeat and breathing rate Rapid heartbeat and breathing rate[image] Blueness of lips and fingertips Blueness of lips and fingertips[image] Fever Fever What can you and your practitioner do? If you've been diagnosed with DVT or any kind of blood clot in previous pregnancies, let your practitioner know. In addition, if you notice swelling and pain in just one leg at any time during your pregnancy, call your practitioner right away. If you've been diagnosed with DVT or any kind of blood clot in previous pregnancies, let your practitioner know. In addition, if you notice swelling and pain in just one leg at any time during your pregnancy, call your practitioner right away.

Ultrasound or MRI may be used to diagnose the blood clot. If it turns out that you do have a clot, you might be treated with heparin to thin your blood and prevent further clotting (though the heparin may need to be discontinued as you near labor to prevent you from bleeding excessively during childbirth). Your clotting ability will be monitored along the way.

With a clot that reaches the lungs, clot-dissolving drugs (and, rarely, surgery) may be needed, as well as treatment for any accompanying side effects.

Can it be prevented? You can prevent clots by keeping your blood flowing-getting enough exercise and avoiding long periods of sitting will help you do this. If you're at high risk, you can also wear support hose to prevent clots from developing in your legs. You can prevent clots by keeping your blood flowing-getting enough exercise and avoiding long periods of sitting will help you do this. If you're at high risk, you can also wear support hose to prevent clots from developing in your legs.

Placenta Accreta What is it? Placenta accreta is an abnormally firm attachment of the placenta to the uterine wall. Depending on how deeply the placental cells invade, the condition may be called placenta percreta or placenta increta. Placenta accreta increases the risk of heavy bleeding or hemorrhaging during delivery of the placenta. Placenta accreta is an abnormally firm attachment of the placenta to the uterine wall. Depending on how deeply the placental cells invade, the condition may be called placenta percreta or placenta increta. Placenta accreta increases the risk of heavy bleeding or hemorrhaging during delivery of the placenta.

How common is it? One out of 2,500 pregnancies will have this attachment abnormality. Placenta accreta is by far the most common of these attachment problems, accounting for 75 percent of cases. In placenta accreta, the placenta digs deeply into the uterine wall, but does not pierce the uterine muscles. In placenta increta, which accounts for 15 percent of cases, the placenta pierces the uterine muscles. In placenta percreta, which accounts for the final 10 percent, the placenta not only burrows into the uterine wall and its muscles, but also pierces the outer part of the wall and may even attach itself to other nearby organs. One out of 2,500 pregnancies will have this attachment abnormality. Placenta accreta is by far the most common of these attachment problems, accounting for 75 percent of cases. In placenta accreta, the placenta digs deeply into the uterine wall, but does not pierce the uterine muscles. In placenta increta, which accounts for 15 percent of cases, the placenta pierces the uterine muscles. In placenta percreta, which accounts for the final 10 percent, the placenta not only burrows into the uterine wall and its muscles, but also pierces the outer part of the wall and may even attach itself to other nearby organs.

Your risk of placenta accreta increases if you have placenta previa and have had one or more cesarean deliveries in the past.

What are the signs and symptoms? There are usually no apparent symptoms. The condition is usually diagnosed via color Doppler ultrasound or may only be noticed during delivery when the placenta doesn't detach (as it normally would) from the uterine wall after the baby is born. There are usually no apparent symptoms. The condition is usually diagnosed via color Doppler ultrasound or may only be noticed during delivery when the placenta doesn't detach (as it normally would) from the uterine wall after the baby is born.

What can you and your practitioner do? Unfortunately, there is little you can do. In most cases, the placenta must be removed surgically after delivery to stop the bleeding. Very rarely, when the bleeding cannot be controlled by tying off the exposed blood vessels, removal of the entire uterus may be necessary. Unfortunately, there is little you can do. In most cases, the placenta must be removed surgically after delivery to stop the bleeding. Very rarely, when the bleeding cannot be controlled by tying off the exposed blood vessels, removal of the entire uterus may be necessary.

Vasa Previa What is it? Vasa previa is a condition in which some of the fetal blood vessels that connect the baby to the mother run outside the umbilical cord and along the membrane over the cervix. When labor begins, the contractions and opening of the cervix can cause the vessels to rupture, possibly causing harm to the baby. If the condition is diagnosed before labor, a C-section will be scheduled and the baby will be born healthy nearly 100 percent of the time. Vasa previa is a condition in which some of the fetal blood vessels that connect the baby to the mother run outside the umbilical cord and along the membrane over the cervix. When labor begins, the contractions and opening of the cervix can cause the vessels to rupture, possibly causing harm to the baby. If the condition is diagnosed before labor, a C-section will be scheduled and the baby will be born healthy nearly 100 percent of the time.

How common is it? Vasa previa is rare, affecting 1 in 5,200 pregnancies. Women who also have placenta previa, a history of uterine surgery, or a multiple pregnancy are at greater risk. Vasa previa is rare, affecting 1 in 5,200 pregnancies. Women who also have placenta previa, a history of uterine surgery, or a multiple pregnancy are at greater risk.

What are the signs and symptoms? There are usually no signs of this condition, though there may be some bleeding in the second or third trimester. There are usually no signs of this condition, though there may be some bleeding in the second or third trimester.

What can you and your practitioner do? Diagnostic testing, such as with ultrasound or, better yet, a color Doppler ultrasound, can detect vasa previa. Women who are diagnosed with the condition will deliver their babies via C-section, usually before 37 weeks, to make sure labor doesn't begin on its own. Researchers are studying whether vasa previa can be treated using laser therapy to seal off the abnormally positioned vessels. Diagnostic testing, such as with ultrasound or, better yet, a color Doppler ultrasound, can detect vasa previa. Women who are diagnosed with the condition will deliver their babies via C-section, usually before 37 weeks, to make sure labor doesn't begin on its own. Researchers are studying whether vasa previa can be treated using laser therapy to seal off the abnormally positioned vessels.

Childbirth and Postpartum Complications Many of the following conditions can't be anticipated prior to labor and delivery-and there's no need to read up on them (and start worrying) ahead of time, since they're very unlikely to occur during or after your childbirth. They are included here so that in the unlikely event you experience one, you can learn about it after the fact, or in some cases, learn how you can prevent it from happening in your next labor and delivery.

Fetal Distress What is it? Fetal distress is a term used to describe what occurs when a baby's oxygen supply is compromised in the uterus, either before or during labor. The distress may be caused by a number of factors, such as preeclampsia, uncontrolled diabetes, placental abruption, too little or too much amniotic fluid, umbilical cord compression or entanglement, intrauterine growth restriction, or simply because the mother is in a position that puts pressure on major blood vessels, depriving the baby of oxygen. Sustained oxygen deprivation and/or decreased heart rate can be serious for the baby and must be corrected as quickly as possible-usually with immediate delivery (most often by C-section, unless a vaginal birth is imminent). Fetal distress is a term used to describe what occurs when a baby's oxygen supply is compromised in the uterus, either before or during labor. The distress may be caused by a number of factors, such as preeclampsia, uncontrolled diabetes, placental abruption, too little or too much amniotic fluid, umbilical cord compression or entanglement, intrauterine growth restriction, or simply because the mother is in a position that puts pressure on major blood vessels, depriving the baby of oxygen. Sustained oxygen deprivation and/or decreased heart rate can be serious for the baby and must be corrected as quickly as possible-usually with immediate delivery (most often by C-section, unless a vaginal birth is imminent).

How common is it? The exact incidence of fetal distress is uncertain, but estimates range from 1 in every 25 births to 1 in every 100 births. The exact incidence of fetal distress is uncertain, but estimates range from 1 in every 25 births to 1 in every 100 births.

What are the signs and symptoms? Babies who are doing well in utero have strong, stable heartbeats and respond to stimuli with appropriate movements. Babies in distress experience a decrease in their heart rate, a change in their pattern of movement (or even no movement altogether), and/or pass their first stool, called meconium, while still in the uterus. Babies who are doing well in utero have strong, stable heartbeats and respond to stimuli with appropriate movements. Babies in distress experience a decrease in their heart rate, a change in their pattern of movement (or even no movement altogether), and/or pass their first stool, called meconium, while still in the uterus.

What can you and your practitioner do? If you think your baby might be in distress because you've noticed a change in fetal activity (it seems to have slowed down significantly, stopped, become very jerky and frantic, or otherwise has you concerned), call your practitioner immediately. Once you are in your practitioner's office or in the hospital (or in labor), you'll be put on a fetal monitor to see whether your baby is indeed showing signs of distress. You may be given oxygen and extra fluids via an IV to help better oxygenate your blood and return your baby's heart rate to normal. Turning onto your left side to take pressure off your major blood vessels may also do the trick. If these techniques don't work, the best treatment is a quick delivery. If you think your baby might be in distress because you've noticed a change in fetal activity (it seems to have slowed down significantly, stopped, become very jerky and frantic, or otherwise has you concerned), call your practitioner immediately. Once you are in your practitioner's office or in the hospital (or in labor), you'll be put on a fetal monitor to see whether your baby is indeed showing signs of distress. You may be given oxygen and extra fluids via an IV to help better oxygenate your blood and return your baby's heart rate to normal. Turning onto your left side to take pressure off your major blood vessels may also do the trick. If these techniques don't work, the best treatment is a quick delivery.

Cord Prolapse What is it? A cord prolapse occurs during labor when the umbilical cord slips through the cervix and into the birth canal before the baby does. If the cord becomes compressed during delivery (such as when your baby's head is pushing against a prolapsed cord), the baby's oxygen supply is compromised. A cord prolapse occurs during labor when the umbilical cord slips through the cervix and into the birth canal before the baby does. If the cord becomes compressed during delivery (such as when your baby's head is pushing against a prolapsed cord), the baby's oxygen supply is compromised.

How common is it? Fortunately, cord prolapse is not common, occurring in 1 out of every 300 births. Certain pregnancy complications increase the risk of prolapse. These include hydramnios, breech delivery or any position in which the baby's head does not cover the cervix, and premature delivery. It can also occur during delivery of a second twin. Prolapse is also a potential risk if your water breaks before your baby's head has begun to "engage," or settle into the birth canal. Fortunately, cord prolapse is not common, occurring in 1 out of every 300 births. Certain pregnancy complications increase the risk of prolapse. These include hydramnios, breech delivery or any position in which the baby's head does not cover the cervix, and premature delivery. It can also occur during delivery of a second twin. Prolapse is also a potential risk if your water breaks before your baby's head has begun to "engage," or settle into the birth canal.

What are the signs and symptoms? If the cord slips down into the vagina, you may actually be able to feel it or even see it. If the cord is compressed by the baby's head, the baby will show signs of fetal distress on a fetal monitor. If the cord slips down into the vagina, you may actually be able to feel it or even see it. If the cord is compressed by the baby's head, the baby will show signs of fetal distress on a fetal monitor.

What can you and your practitioner do? There's really no way to know in advance if your baby's cord is going to prolapse. In fact, without fetal monitoring, you may not know until after the fact. If you suspect that your baby's umbilical cord has prolapsed and you are not in the hospital yet, get on your hands and knees with your head down and pelvis up to take pressure off the cord. If you notice the cord protruding from your vagina, gently support it with a clean towel. Call 911 or have someone rush you to the hospital (on the way to the hospital, lie down on the back seat, with your bottom elevated). If you are already in the hospital when the cord prolapses, your practitioner may ask you to move quickly into a different position, one in which it will be easier to disengage the baby's head and take pressure off the umbilical cord. Delivery of your baby will need to be very quick, most likely by C-section. There's really no way to know in advance if your baby's cord is going to prolapse. In fact, without fetal monitoring, you may not know until after the fact. If you suspect that your baby's umbilical cord has prolapsed and you are not in the hospital yet, get on your hands and knees with your head down and pelvis up to take pressure off the cord. If you notice the cord protruding from your vagina, gently support it with a clean towel. Call 911 or have someone rush you to the hospital (on the way to the hospital, lie down on the back seat, with your bottom elevated). If you are already in the hospital when the cord prolapses, your practitioner may ask you to move quickly into a different position, one in which it will be easier to disengage the baby's head and take pressure off the umbilical cord. Delivery of your baby will need to be very quick, most likely by C-section.

Shoulder Dystocia What is it? Shoulder dystocia is a complication of labor and delivery in which one or both of the baby's shoulders become stuck behind the mother's pelvic bone as the baby descends into the birth canal. Shoulder dystocia is a complication of labor and delivery in which one or both of the baby's shoulders become stuck behind the mother's pelvic bone as the baby descends into the birth canal.

How common is it? Size definitely matters when it comes to shoulder dystocia, which occurs most frequently in larger babies. Fewer than 1 percent of babies weighing 6 pounds have shoulder dystocia, but the rate is considerably higher in babies weighing more than 9 pounds. For that reason, mothers who have uncontrolled diabetes or gestational diabetes-and therefore may give birth to very large babies-are more likely to encounter this complication during delivery. The chances also rise if you go past your due date before delivering (since your baby will probably be larger) or if you've previously delivered a baby with shoulder dystocia. Still, many cases of shoulder dystocia occur during labors without any of these risk factors. Size definitely matters when it comes to shoulder dystocia, which occurs most frequently in larger babies. Fewer than 1 percent of babies weighing 6 pounds have shoulder dystocia, but the rate is considerably higher in babies weighing more than 9 pounds. For that reason, mothers who have uncontrolled diabetes or gestational diabetes-and therefore may give birth to very large babies-are more likely to encounter this complication during delivery. The chances also rise if you go past your due date before delivering (since your baby will probably be larger) or if you've previously delivered a baby with shoulder dystocia. Still, many cases of shoulder dystocia occur during labors without any of these risk factors.

What are the signs and symptoms? Delivery stalls after the head emerges and before the shoulders are out. This can occur unexpectedly in a labor that has progressed normally up to that point. Delivery stalls after the head emerges and before the shoulders are out. This can occur unexpectedly in a labor that has progressed normally up to that point.

What can you and your practitioner do? A variety of approaches may be used to deliver the baby whose shoulder is lodged in the pelvis, such as changing the mother's position by sharply flexing her legs onto her abdomen or applying pressure on her abdomen, right above the pubic bone. A variety of approaches may be used to deliver the baby whose shoulder is lodged in the pelvis, such as changing the mother's position by sharply flexing her legs onto her abdomen or applying pressure on her abdomen, right above the pubic bone.

Can it be prevented? Keeping your weight gain within the recommended range can help ensure that your baby doesn't get too big to maneuver through the birth canal, as can carefully controlling diabetes or gestational diabetes. Picking a labor position that allows your pelvis to open as widely as possible might also help you avoid dystocia. Keeping your weight gain within the recommended range can help ensure that your baby doesn't get too big to maneuver through the birth canal, as can carefully controlling diabetes or gestational diabetes. Picking a labor position that allows your pelvis to open as widely as possible might also help you avoid dystocia.

Serious Perineal Tears What is it? The pressure of your baby's large head pushing through the delicate tissues of your cervix and vagina can cause tears and lacerations in your perineum, the area between your vagina and your anus. The pressure of your baby's large head pushing through the delicate tissues of your cervix and vagina can cause tears and lacerations in your perineum, the area between your vagina and your anus.

First-degree tears (when only the skin is torn) and second-degree tears (when skin and vaginal muscle are torn) are common. But severe tears-those that get close to the rectum and involve the vaginal skin, tissues, and perineal muscles (third degree) or those that actually cut into the muscles of the anal sphincter (fourth degree)-cause pain and increase not only your postpartum recovery time, but your risk of incontinence, as well as other pelvic floor problems. Tears can also occur in the cervix.

How common is it? Anyone having a vaginal delivery is at risk for a tear, and as many as half of all women will have at least a small tear after childbirth. Third- and fourth-degree tears are much less common. Anyone having a vaginal delivery is at risk for a tear, and as many as half of all women will have at least a small tear after childbirth. Third- and fourth-degree tears are much less common.

What are the signs and symptoms? Bleeding is the immediate symptom; after the tear is repaired, you may also experience pain and tenderness at the site as it heals. Bleeding is the immediate symptom; after the tear is repaired, you may also experience pain and tenderness at the site as it heals.

What can you and your practitioner do? Generally, all lacerations that are longer than 2 cm (about 1 inch) or that continue to bleed are stitched. A local anesthetic may be given first, if one wasn't administered during delivery. Generally, all lacerations that are longer than 2 cm (about 1 inch) or that continue to bleed are stitched. A local anesthetic may be given first, if one wasn't administered during delivery.

If you end up tearing or having an episiotomy, sitz baths, ice packs, witch hazel, anesthetic sprays, and simply exposing the area to air can help it heal more quickly and with less pain (see page 423 page 423).

Can it be prevented? Perineal massage and Kegel exercises (see Perineal massage and Kegel exercises (see pages 352 pages 352 and and 295 295), done during the month or so before your due date, may help make the perineal area more supple and better able to stretch over your baby's head as he or she emerges. Warm compresses on the perineum and perineal massage during labor may help avoid tearing.

Uterine Rupture What is it? A uterine rupture occurs when a weakened spot on your uterine wall-almost always the site of a previous uterine surgery such as a C-section or fibroid removal-tears due to the strain put on it during labor and delivery. A uterine rupture can result in uncontrolled bleeding into your abdomen or, rarely, lead to part of the placenta or baby entering your abdomen. A uterine rupture occurs when a weakened spot on your uterine wall-almost always the site of a previous uterine surgery such as a C-section or fibroid removal-tears due to the strain put on it during labor and delivery. A uterine rupture can result in uncontrolled bleeding into your abdomen or, rarely, lead to part of the placenta or baby entering your abdomen.

How common is it? Fortunately, ruptures are rare in women who've never had a previous C-section or uterine surgery. Even women who labor after a previous C-section have only a 1 in 100 chance of rupture (and the risk is far lower when a woman undergoes a repeat C-section without labor). Women at greatest risk of uterine rupture are those who are attempting a vaginal birth after cesarean (VBAC) and have been induced with prostaglandins and/or Pitocin (oxytocin). Abnormalities related to the placenta (such as placental abruption, a placenta that separates prematurely; or placenta accreta, a placenta that is attached deeply in the uterine wall) or to the fetus's position (such as a fetus lying crosswise) can also increase the risk of uterine rupture. Uterine rupture is more common in women who have already had six or more children or have a very distended uterus (because of multiple fetuses or excess amniotic fluid). Fortunately, ruptures are rare in women who've never had a previous C-section or uterine surgery. Even women who labor after a previous C-section have only a 1 in 100 chance of rupture (and the risk is far lower when a woman undergoes a repeat C-section without labor). Women at greatest risk of uterine rupture are those who are attempting a vaginal birth after cesarean (VBAC) and have been induced with prostaglandins and/or Pitocin (oxytocin). Abnormalities related to the placenta (such as placental abruption, a placenta that separates prematurely; or placenta accreta, a placenta that is attached deeply in the uterine wall) or to the fetus's position (such as a fetus lying crosswise) can also increase the risk of uterine rupture. Uterine rupture is more common in women who have already had six or more children or have a very distended uterus (because of multiple fetuses or excess amniotic fluid).

What are the signs and symptoms? Searing abdominal pain (a sensation that something is "ripping") followed by diffuse pain and tenderness in the abdomen during labor are the most common signs of uterine rupture. Most typically, the fetal monitor will show a significant drop in the baby's heart rate. The mother may develop signs of low blood volume, such as an increased heart rate, low blood pressure, dizziness, shortness of breath, or loss of consciousness. Searing abdominal pain (a sensation that something is "ripping") followed by diffuse pain and tenderness in the abdomen during labor are the most common signs of uterine rupture. Most typically, the fetal monitor will show a significant drop in the baby's heart rate. The mother may develop signs of low blood volume, such as an increased heart rate, low blood pressure, dizziness, shortness of breath, or loss of consciousness.

What can you and your practitioner do? If you have had a previous C-section or abdominal surgery in which the uterine wall was cut through completely, you'll need to weigh your risks when considering your labor options, especially if you want to attempt a vaginal birth. Discuss with your practitioner the data that show that prostaglandins should not be used to induce labor in a woman who's had previous uterine surgery. If you have had a previous C-section or abdominal surgery in which the uterine wall was cut through completely, you'll need to weigh your risks when considering your labor options, especially if you want to attempt a vaginal birth. Discuss with your practitioner the data that show that prostaglandins should not be used to induce labor in a woman who's had previous uterine surgery.

If you do have a uterine rupture, an immediate C-section is necessary, followed by repair of the uterus. You may also be given antibiotics to prevent infection.

Can it be prevented? For women with increased risk factors, fetal monitoring during labor can alert your practitioner to an impending or occurring rupture. Women who are trying for a VBAC delivery should not be induced. For women with increased risk factors, fetal monitoring during labor can alert your practitioner to an impending or occurring rupture. Women who are trying for a VBAC delivery should not be induced.