Babies Tale

“A woman’s place is in the house… and in the Senate” is a popular saying that has grown out of the woman’s movement in recent years. Besides expressing a woman’s right to work at any job she is qualified for, it connotes the choices women have today. The luckiest of career women who become mothers are those who can ask three questions: “Should I go back to work or be an at home mother for a few months or a few tears?” “If I decide to go back to work, when is the best time-how long should I wait?” “Should I return to my old job or type of work, or should I move on to something different?” Unfortunately, not every woman has these options; economic necessity frequently forces a mother’s return to her old job the day after whatever maternity leave she is entitled to has ended.

If you are one of the lucky ones who can make choices, and you choose to stay home, you may find yourself having second thoughts about your decision after a few weeks of uninterrupted baby care. On the bad days when everything goes wrong, you may feel hemmed in, trapped, and angry. You may be jealous of your spouse who escapes every day to the adult world. And if you go back to work, either because you want to or because you must, you probably will not be entirely satisfied either. First, you will need to come to terms with the daily separation from your baby, then with the fact that you will almost surely miss some “firsts”-the first time she smiles, or turns over, or says “Mama.” In addition, you may be bothered by another problem common to working women. One who does not feel pressure and guilt as she tries to satisfy her responsibilities as a wife, mother, and worker is indeed a rarity, even if she is able to stay home for several months, or even years, after the baby’s birth. As some have put it, she takes on three full time jobs and tries to do all three part time. A fragmented feeling of being too much needed, of being pulled in several directions at once, seems to go with the territory of being a working mother.

Of course, many mothers go back to work very soon after their babies are born and neither they nor their babies suffer. Most are gone from home eight to ten hours a day. A few manage to work at home, to work part time, or to have the advantage of working under the flexible-hours provisions that some forward-looking companies now offer, but every arrangement has its disadvantages.

However, many of those mothers and most medical professionals recommend that you wait, until you can, until your baby is four to six months old before you return to work for several reasons. One, of course, is the matter of your health, both physical and mental. Your recovery will probably be complete by that time and your baby’s sleeping habits are likely to have become fairly well established. Proper rest, nutrition, and exercise remain essential for you, even though time for them becomes more scarce. And along with the roles of worker, spouse, and parent, you should devote at least some time and attention to your own needs.

Recently publicity has been given to a number of foods that may contain micro-organisms that can cause harmful disease in pregnancy. Listeria is an illness caused by bacteria called listeria monocytogenes. Listeria is a mild, flu-like disease in adults, but in a pregnant woman it can cause miscarriage, stillbirth or severe illness in the newborn baby. Listeria can be found in soft cheeses such as Brie, Camembert and blue-veined cheeses, and can also be found in pates. Cooked foods that tend to sit out, such as rotisserie chicken, food in buffet lines or deli counters, can also contain low quantities of listeria and must therefore be thoroughly reheated. Salmonella, which can cause acute food poisoning, may be found in undercooked chicken and in raw or soft-boiled eggs, so some women prefer to avoid these. Recent research has shown high levels of vitamin A are concentrated in liver. High amounts of vitamin A can be harmful, so don’t overdo eating liver as an iron source.

Toxoplasmosis is another organism that causes only mild symptoms in an adult but that can injure the fetus, causing blindness or hydrocephalus, which can cause brain damage. Toxoplasmosis is found in some raw meat, unpasteurized goat’s milk or cheese, unwashed raw fruit and vegetables, and in anything contaminated by cat feces. Someone else will have to empty the cat’s litter box while you are pregnant. Also, keep the cat off all counters and tabletops. Wash them off frequently.

Since a pregnancy is not usually confirmed until six or eight weeks after conception, and it may take a little time for the body to build up depleted stores of vitamins and essential minerals, it is very important to adjust your diet before you become pregnant if at all possible. A good diet will also make you feel stronger and healthier and help you through the demanding months of pregnancy, through the birth itself and through the postnatal period. If you feel better, you will be more likely to enjoy your baby to the utmost.

Preconception Care

As we learn more about how diet, drugs and other substances in the environment might affect an unborn baby, more and more mothers are trying to prepare well in advance for the birth of their baby. Genetic counselors are available if you know of any genetic disorder in the family or if you are at greater risk of having a baby with disabilities. Advice on diet and general health care in pregnancy may be available at your prenatal clinic or your doctor’s office. Talk with your doctor about getting this extra attention if you would like it.

It is worth having your health checked before you conceive.

You might want a Pap smear. You can also have a swab done to check that there are no harmful micro-organisms in the vagina. Recent research shows that thrush and gardnerella, bacteria that causes bacterial vaginosis, may be linked to a difficulty to conceive, that an organism called mycoplasma may be linked to miscarriage, and gardnerella to premature deliveries. Not all such infections cause symptoms normally, but they may cause problems in pregnancy. Checking on them before you’re pregnant maybe wise.

It is also true that the majority of women do not want to wait months to conceive, and many conceive by accident, or experience problems in conceiving, and these mothers may feel guilty that they are not doing the right thing: “We started out with all the best intentions, stopping smoking and drinking, taking vitamin pills and eating only health-foody things without any additives. But it took me nearly two years to get pregnant. By the end I was fed up with the whole thing-we never enjoyed ourselves, we felt guilty about everything we ate or didn’t eat. In the end I just ate what I felt like and let it go at that.”

Genetic counseling is available at many hospitals for those who are worried that they may be at extra risk of having a baby with disabilities-this includes older mothers and those who have some hereditary illness or genetic defect in their family.

“We had genetic counseling at the hospital because I was 40 and my husband was too, and his child by his previous marriage had had problems. There was a blockage at the entrance to her stomach. She had to be operated on at birth, but she’s fine now. We were told doctors could pick up on this with an ultrasound scan, because the baby would not be able to swallow the amniotic fluid, which otherwise would show up in the stomach. The ultrasound was reassuring. By knowing of any problems in advance, our doctors would be set to do immediate surgery after the baby’s birth. I was also concerned about the extra risk of having a baby with Down syndrome-I was surprised at how greatly the risk went up between the ages of 40 and 41. We decided to have the amniocentesis and other tests done because we felt we couldn’t have coped with a baby with severe disabilities. I thought the counseling was very helpful and reassuring.”

Genetic counseling can be helpful. It enables the couple to talk through any worries they have and to put the risks they are facing into proportion. This is especially true for older mothers who may feel this pregnancy is their only chance to have a baby. It can also be helpful in establishing the reasons for any previous babies born with disabilities in the family, or for several miscarriages, and point toward ways of overcoming them. For example, it has been shown that mothers of babies with spina bifida had far fewer affected babies in subsequent pregnancies if they took supplements of vitamin B and folic acid. Some couples who have had several miscarriages have been told this was linked to a genetic problem but that if they kept going they had a chance of having a normal pregnancy, and this has encouraged them to continue trying to conceive.

Once labor is established, the baby’s heartbeat and the strength of your contractions can be measured electronically. It can be reassuring to be able to hear and actually see throughout the delivery that the baby is well and not in distress, though this can also be checked using an old-fashioned ear trumpet or a fetal stethoscope. The disadvantage of electronic fetal monitoring is, you will be attached to a machine during labor. You may feel it is getting more attention than you are! You will not be free to move around. Sometimes the machines do not work well. Some women have noticed that the slightest change in the baby’s heartbeat will lead to intervention, which may not have been necessary.

There is now evidence that continuous electronic fetal monitoring does not make any difference to the labor outcome as far as the baby’s health and safety are concerned, although it results in a higher risk of intervention. However, in any individual case in which monitoring was not performed and a baby dies, the doctor or staff may be sued. For that reason, monitoring is almost always done to protect them, even though there may be no evidence that it is necessary.

Monitoring can be done with an external monitor strapped to your abdomen. Most women find this is awkward because they have to remain still. Also, the monitor has a tendency to slip off during a contraction:

“They kept fussing around; trying to put it back on… I couldn’t concentrate on what I was doing. Most of the time it wasn’t in the right place and we just heard a lot of noise, not the baby’s heartbeat.”

An internal monitor works better and is less restrictive for the mother. However, the waters must be broken and the cervix must be at least 2cm to 3cm dilated for this to be attached to the baby’s head. A tiny scar, like a pinprick, will be left after the monitor is removed but it is unlikely to cause the baby much discomfort. In cases where it is thought the baby may be distressed, a blood sample may be taken from the baby’s head and analyzed.

Whether you choose to breastfeed or not, your breasts will begin making and secreting milk. At first, they make colostrums, the perfect food for a new baby. Within two or three days the colostrum turns to milk. Sometimes when the milk “comes in,” your breasts become very engorged [full to the point of discomfort]. If you are breastfeeding, the best way to prevent excessive engorgement is to let your baby nurse frequently. If your baby is a sleeper or lazy nurser, you may relieve engorgement by expressing [forcing out] milk from your breasts, either by hand or with a breast pump.

If you have decided not to breastfed, effects will be made to reduce milk production. Cold packs, a well fitting bra, or medication may be used to slow down or prevent milk production. Usually within a few days, milk production stops.

As you wind down towards the birth of your baby, you will want to be conscientious about your diet and rest needs. This is the time to take childbirth preparation classes; to prepare your birth plan; to make the decisions on employment, child care, infant feeding, and health care for your baby; and to prepare the baby’s space and equipment. If they have not already done so, this is when most people take a good look at their financial situation, and figure out the impact the birth of the baby will have. There may be a loss of income at least for while, extra bills associated with the birth, other expenses associated with the baby’s equipment, and more. Try to prepare yourself for these financial changes as much as possible so you are not caught in a financial bind because of the birth of your child.

If your income is low, you may qualify for federal or state programs. There are also organizations that can assist you with food, health care, free or low cost baby clothing and equipment, and other help. This is a good time to look into these matters if you have not already. If you have health insurance, find out exactly what it does and does not cover.

Pack your bag a few weeks before your due date and place on top of it a list of any last minute items to add just before leaving.

Suggested Packing List

For Mother in Labor:

• Toothbrush and toothpaste
• Massage oil [not lotion] or powder [cornstarch is best]
• Lip cream or gloss
• Rolling pin or massage aids
• Hot-water bottle and camper’s ice [for comfort]
• Juice or ice-pops [if not supplied by the hospital]
• Music tapes and a tape recorder [battery operated]
• Home-birth supplies ordered by your mid-wife

For Partner:

• Food/snacks
• Breath mints or toothbrush

Maintaining a healthy diet during pregnancy is the best thing you can do for yourself and your baby. Junk food can be harmful in pregnancy because it does not provide enough of the vitamins and nutrients the growing baby needs. It is also high in salt and other additives. That increases stress on the liver and kidneys, which have to eliminate the excess sodium from the body. If you eat the right foods, you will be doing the best for your baby. Your doctor may have you take a prenatal vitamin in addition. Be careful of taking large quantities of vitamin supplements otherwise, because some vitamins, notably vitamin A, can be harmful if taken in excess. Also, if you eat healthfully you won’t need to worry about whether you’re putting on the right amount of weight or not; your body will do that automatically.

Weight Gain

It is normal to gain weight in pregnancy. Most additional weight appears during the second three months. The increased weight is the weight of the baby, the placenta, the waters surrounding the baby, increased fluid and tissue in the breasts as they prepare to produce milk, and a greater quantity of blood circulating in the body. Some women also experience fluid retention, which will adjust itself after the baby is born.A normal weight gain during pregnancy is 20 to 30 pounds (9 to 13.5 kg). Some women gain less, others more-this can be normal, too. If you are planning to breast-feed your baby, remember that you will be laying down some stores of fat to feed your new baby and that the pounds will roll off as you produce milk.

Doctors used to worry a lot about “excessive” weight gain in pregnancy, because it can put an additional strain on the body, making high blood pressure and cardiovascular problems more likely. However, this situation was largely a reaction to the exhortations previously made to women to “eat for two;” that is, very heartily. But aiming for the other extreme and trying to stay slim in pregnancy is equally harmful.

It is particularly damaging to try to diet and lose weight in pregnancy unless you are overweight and under medical supervision, because you may be denying your baby vital nourishment. Again, eating the right food is the key. If you eat well, you will feel well, be less inclined to want to “fill up” on sweet things, and your body will gain and shed weight naturally during and after the pregnancy.

A Healthful Diet

A healthful diet means eating a balanced combination of proteins, carbohydrates, fats and vitamins. This can be achieved by eating reasonable quantities of fresh meat and fish, eggs, pasteurized cheese and milk, fresh fruits and vegetables, whole-grain bread and cereals. Fresh green vegetables in particular are full of the minerals and vitamins your body and your baby need.

Avoid Junk Food

• Avoid foods with “empty” calories, such as:
• Highly refined, sugary cakes and other desserts
• Sweet carbonated drinks
• Cookies
• Fried and fatty foods, such as potato chips and creamy dips
• Salty foods (they encourage fluid retention)
• Drinks such as coffee, tea and cocoa
• All alcoholic beverages

The majority of mothers over the age of 35 who become pregnant can expect a normal pregnancy and a healthy baby. However, older mothers are at greater risk of developing complications. For that reason, an older mother is screened to detect these at an early stage. Older mothers are also at higher risk of having a baby with disabilities, so most are eager to take advantage of the screening tests available.
There can hardly be a mother who has not worried at some time in her pregnancy whether her baby will be normal, and this may be particularly true for the older mother. Fortunately, a number of screening tests are now offered to women at higher risk of having a baby with severe problems. These tests can be very important in easing the parents’ worries. In cases where an abnormality is shown, the screening enables them to decide whether or not to proceed with a pregnancy. However, it is important to remember that not all abnormalities can be detected in pregnancy and that accidents at birth can also lead to disabilities. The tests eliminate certain problems but do not guarantee the “perfect baby.”

How the Baby Develops

A human embryo is more or less completely formed by the end of the twelfth week of pregnancy. After this time it simply has to grow in size and its organs have to mature to make it capable of living outside the womb. All the major developments take place in the early weeks of pregnancy, which is why it is especially important to look after yourself before you even know you are pregnant. The baby’s spinal column, for example, begins to form in the fifth week of pregnancy. You are likely at this stage to realize that your period is late, but have not had the pregnancy confirmed. In the sixth week arm and leg buds are formed. In the seventh week the beginnings of the fingers and toes are visible and dramatic changes are occurring to the head and face. In the ninth week the nose and mouth take shape. By the eleventh week the genitals are formed, and all the internal organs are functioning.
Abnormalities in a baby are usually caused by genetic problems or by an environmental influence, such as poor diet, the use of drugs in early pregnancy or by hazards in the workplace, such as toxic chemicals or radiation. Genetic problems fall into two categories: those caused by either or both parents carrying a faulty gene, or those that occur when the sperm or egg are formed. In the second case, the formation involves an extra chromosome or part of a chromosome being included in the fertilized egg.

Most women want to know they are pregnant as soon as possible, especially if they have had problems conceiving. Over-the counter pregnancy tests available now can tell you whether you are pregnant or not as soon as, or even before, your period is due. They are quite accurate. You can buy them at larger grocery stores and at pharmacies. Each box usually contains two tests, so if the first isn’t positive, you can repeat it a few days later to make sure. They are not cheap, so it may be wise to wait for your period, and take the test if you are late.

“When my period was overdue I did a home test and it was positive. Then my doctor did one and it was negative. We were both disappointed. But my period didn’t start, and I felt pregnant. So I did another home test, which was positive. I called my husband and asked him to come home from work to make sure I wasn’t imagining it. He did and agreed it was positive. But the next test from the hospital was negative too-until the doctor called and said they had made an error. It seemed crazy to us that a home test was so much better than the hospital one!”

Having your pregnancy confirmed early lets you, if you haven’t already, stop all drinking of alcohol, take care of your diet, and get the soonest possible prenatal appointment. Once you know you are pregnant, talk things over with your healthcare professional and explain any preferences you have for the kind of birth you would like, which hospitals you prefer, whether you would like a hospital delivery or a home birth if that can be arranged. Your doctor will know the options in the area and will be able to discuss with you what is best. In practice this is not always the case, and older mothers in particular may find they are only offered a hospital birth or are under strong pressure to have the baby in the hospital. In some areas, your choice of hospital is limited.

The vast majority of births take place in hospitals, and most people still have their prenatal appointments under an obstetrician’s care. Although things seem to have improved in prenatal care, the majority of women find the wait for office appointments is still a problem. There are usually no facilities for occupying the attention of older children and toddlers. In some managed care systems, women complain that they are seen by someone different each time and may not even see the professional they were supposed to see. Many women find the care impersonal and offhand. But despite these kinds of problems, on the whole, older pregnant women do not find themselves much of an oddity at prenatal clinics.

“I realized I could be the mother of the woman sitting next to me, but it didn’t seem to matter. We were both going through the same thing. I was never once made to feel that I was old or doing anything unusual by the other women or by the office staff. I’d guess the average age of mothers at my clinic was 30 to 35. My doctor does specialize in women with potential difficulties and older mothers, and I live in a major metropolitan area. I think all that makes a difference. Still, I was surprised at the number of older women I saw.”

Routine Prenatal Tests

Ideally, you will have seen your doctor before you conceived, or as soon after conception as possible. At your first appointment, your healthcare provider will take your medical history, together with any details of previous pregnancies. You will be weighed. You are likely to be given an internal examination to confirm the pregnancy, check the womb is the size it should be for your dates, check for any abnormalities of the pelvis and check that the cervix (neck of the womb) is tightly closed. A cervical smear (Pap smear) is also usually taken. Lab tests may be done now or at a later visit.

If you have had a history of miscarriage the doctor may agree not to examine you internally at this stage if you wish, though there is no particular evidence to suggest this might cause a miscarriage.

A blood test is also taken to find your major blood group, particularly whether you are rhesus positive or negative. About 85% of the population is rhesus positive. If you are rhesus negative and your baby is rhesus positive, and it is a second or subsequent pregnancy, there is a small chance that you may make sufficient antibodies to rhesus-positive blood to damage your baby’s blood cells. Because of this, if you are rhesus negative, blood samples will be taken at various times throughout your pregnancy to check on antibody levels, which only rarely become too high. Very rarely a baby suffering from rhesus incompatibility may have to be delivered by Cesarean section and receive a blood transfusion.

Rhesus incompatibility is becoming rarer because most rhesus-negative mothers now have an injection of Rh-immune globulin, which prevents them from producing antibodies. If this is done after every delivery or abortion, future babies are safe from rhesus incompatibility.

Your hemoglobin level is checked to make sure you are not anemic (this test will be repeated later in the pregnancy). You are also screened for immunity to rubella (German measles) and for any sexually transmitted diseases.

Your breasts are usually examined at the first visit to check for lumps. They are not being checked to see whether you can breastfeed. No matter what size or shape your breasts or nipples are, you should be able to breast-feed successfully. If your nipples are inverted, you will still be able to breast-feed; you may just need a little extra help at first in getting the baby to latch on properly.

At every visit you will be weighed to check the growth of the baby and to see that your weight gain is satisfactory. Your urine is tested at every visit-the first time it will be screened for any infection. At every other visit it will be tested for the presence of protein in the urine, which could indicate you have pre-eclampsia and to check that you are not developing diabetes.

The abdomen is measured at every visit to check that the womb is growing in size according to your dates. After 20 to 24 weeks your baby’s heartbeat can be monitored with a stethoscope. Your blood pressure is also measured at every visit, because high blood pressure can indicate a number of problems, including preeclampsia. Your ankles and fingers will be checked for puffiness, a sign of water retention.

Pre-Eclam Psia

Pre-eclampsia, also called toxemia of pregnancy, is a disorder of unknown cause. Symptoms include water retention and high blood pressure. If the condition is allowed to progress unchecked, the blood pressure rises further and the mother suffers headaches and even seizures (eclampsia). Pre-eclampsia puts the baby at risk. The baby may not get enough nourishment. Mothers with pre-eclampsia have an increased risk of going into premature labor.

Doctors look carefully for signs of pre-eclampsia or toxemia, because it can be prevented if caught early, and the risk to the unborn baby can be reduced. Although the cause of pre-eclampsia is unknown, it has been linked to poor nutrition in some cases. Older mothers are at greater risk of developing this condition, so it’s important to keep all your regular prenatal appointments.

Pre-eclampsia is usually treated with bed rest. Women with this condition are often admitted to the hospital so they and the baby can be monitored. Usually complete rest takes care of the problem. If it does get worse, the baby may have to be born early by Cesarean-section delivery (C-section).

Amniocentesis consists of taking a sample of amniotic fluid in the sac surrounding the baby and analyzing it. Amniotic fluid contains some of the baby’s cells, which can be cultured to reveal any chromosomal abnormalities. Amniocentesis can also be used to detect neural-tube defects, because there will be a very high level of AFP in the amniotic fluid in that case. This is much more accurate than the AFP blood test.

Amniocentesis is usually offered to women 35 or older, although the policy may change in the future. Age 35 was chosen originally because at this point it was believed that the risk of potential chromosomal problems with the baby was about the same as the risk of miscarrying the baby as a result of the amniocentesis test. However, amniocentesis is even safer now, so the mother’s age at which the test is recommended is being reconsidered upward.

The risk of miscarriage attached to amniocentesis is small.

Studies used to quote a rate of about 0.5%, but today it is closer to 0.3%. Some doctors dispute whether there is a real risk at all.

However, for older mothers, especially those with a history of miscarriage or infertility and for whom a pregnancy is particularly precious, there is a real fear of inducing a miscarriage. This can make the decision to have an amniocentesis very difficult.

Cindy was unlucky and had a miscarriage a week after her amniocentesis at the age of 39. “I was devastated. I blamed myself. They had told me the risk but it seemed so small. I’d never heard of anyone actually losing a baby. They said it might not have been the amnio that it might have happened anyway. But [the amniocentesis] seemed to me to be the most likely reason, because there was nothing wrong with the baby. It was a girl, and I had wanted a girl. I felt I had gone against nature and been punished. It was a terrible, terrible time for me.

“I did get pregnant again a year later and I had a boy. I decided against an amnio and he is fine. Everything is fine, but now I’m 41 and I may not get pregnant again. If I do, now I don’t know whether to have an amnio or not. I keep thinking that if I hadn’t had one I could now have had two children and my family would be complete. On the other hand, perhaps I should just count myself lucky that I am now a mother and have a healthy child.”

An amniocentesis is usually carried out at about 16 weeks into the pregnancy. This is about the earliest time that sufficient amniotic fluid can be withdrawn for testing. Usually an ultrasound scan will also be done at this time, to help the doctor locate the fetus and to identify the best place from which to draw the fluid. You will be asked to have a full bladder for the ultrasound scan, and then asked to empty your bladder before the amniocentesis is performed.

You will change into an examination gown, and the area on the abdomen where the needle is inserted will be swabbed with antiseptic. The needle is usually inserted without local anesthetic. The doctor directs the needle into the amniotic fluid and takes a small amount of the pale-yellow fluid. When ultrasound is used as well, the danger of the needle hitting the baby or placenta is very small. Most women do not find the procedure painful. They describe a slight cramp or pressure in the womb as the needle passes through the uterine wall. Some women feel a little sore for a day or two afterwards. You are usually advised to take it easy because of the slight risk of miscarriage.

For some women, however, the test is not so straightforward:

“We went along [with it] at 16 or 17 weeks. My husband came and we were all keyed up. They did the scan first and said the baby was lying all spread-out and there were no big pockets of fluid to get the needle into, so it wasn’t worth trying. We had to go back the following week-the anticlimax was awful.”

“While pregnant with Josh at the age of 35, I did worry a lot that he might have disabilities. I was feeling very aware of my age. When I was pregnant with Douglas at 37 I said I wanted an amnio. I was told the risk of this causing a miscarriage was about the same as the risk of the baby having Down syndrome and that I should only consider the test if I was prepared to have an abortion.

“I felt I couldn’t handle having a child with disabilities and that it wouldn’t be fair to the two boys. I had baby-sat for a child with mental disabilities and I had no illusions about how difficult it was and how it had affected her brother. I would certainly have had a termination if anything had been wrong.

“They made light of the procedure, said I didn’t need someone with me, it wouldn’t take long and it wouldn’t hurt. I was I6 weeks pregnant. Allen drove me to the hospital and waited outside. I was not given an anesthetic. Ultrasound was used to locate the baby and the bag of fluid. An enormous-looking needle was stuck into my very tender belly and it was excruciatingly painful. I gripped the nurse’s hand and counted to 60; the nurse kept saying, ‘It doesn’t usually hurt.’ Then it was all over. I was shaking and very distressed. Allen had to help me into the car; there is no way I could have gotten home by myself. I started having contractions when I got home and these lasted for four hours, but I didn’t bleed. I thought, ‘Oh God, what have I done? I’m going to lose the baby.’ I had to stay in bed all day and took things easy the next day.

“Waiting was OK for the first three weeks. Then the results were late, more than four weeks, so I thought something had to be wrong. I started to get very depressed. Although they said they would only tell the mother the results, I couldn’t face calling myself and got Allen to phone from his office. They told him all was well and we were both thrilled, though my mother burst into tears when I told her it was another boy. The whole thing was horrible, but it was still better than another four months of worrying. Now I could look forward to the baby happily.”

Others find the process much easier than they had thought:

“It was simple. I felt nothing. My husband was there and he said, ‘Did you really not feel anything? They seemed to take a ton of fluid!’ Everyone was extremely helpful and reassuring. It was much, much easier than I had imagined it would be.”

Once the test is completed, the drawn fluid is analyzed. Cells in the fluid are cultured and grown over a couple of weeks. Then they are crushed and put under a microscope so the chromosomes can be examined. Very occasionally the test fails and has to be repeated two or three weeks further into the pregnancy:

“I had an amnio at 16 weeks after much thought and consultation. The first one didn’t take, and I had another at 20 weeks, by which time I had felt the baby moving. I couldn’t understand what was wrong with the first test. I was worried it meant something was wrong with the baby.”

The fluid is also tested for high levels of alpha-fe top rote in, which can indicate the presence of a neural-tube defect.

If you are the possible carrier of a genetic disease, tests can be carried out to identify up to almost 80 hereditary diseases. These tests are time-consuming and expensive, so they will only be done if your family has a history of an inherited illness that technicians can test for.

Waiting for the results can be the hardest part of the whole procedure. Usually women are told the results will take three weeks, though sometimes they are received sooner and rarely, later:

“They said the results would take three weeks but it only took two. They had tried to call but we were out, so they wrote us a very nice letter saying all was well.”

You are usually informed by letter or by telephone; you can telephone yourself if the results are overdue. You can also ask to know the sex of the baby if you want to, though some hospitals insist on talking this over with you first:

“We had asked to know the sex of the baby but they were reluctant to tell us. They said to go home and think about it, and asked probing questions about did we want a girl or boy. When they called to say the results were fine, they didn’t volunteer the information. We pressed for it and were told it was a girl. We didn’t really care about the sex, but we both had a slight preference for a girl. We were delighted and it was wonderful to know, which I hadn’t in my earlier pregnancies. In fact, knowing was one of the most important parts of the pregnancy.”

There is some evidence that people who desperately want either a son or daughter have problems adjusting to the baby if they know in advance that it is the “wrong” sex. In the heat of the birth itself, most parents are so pleased to know the baby is all right that they don’t think much about its sex. The baby is there to love and care for. Knowing this fact while pregnant, however, gives a parent time to brood over the as-yet unknown person and sometimes to reject the baby, making it more difficult to adjust when the baby arrives.

This is an individual matter of course and people have different attitudes about it:

“I wanted to know. I thought if it was there in my notes and other people knew, then of course I had the right to know.”

“I told them, ‘Don’t tell me!’ I didn’t want to know-it would have ruined everything, like unwrapping a present before your birthday.”

“If it’s a first baby, I think once you know you feel a little sad no matter what, because you want both - you can’t really decide which your preference is. So when they said it’s a girl, I felt sad in a way that it wasn’t a boy. But it wasn’t that I actually had wanted a boy.”

Most hospitals respect people’s wishes in the matter, but some provide limited counseling to help a couple decide if they want to know or not. Occasionally one partner wants to know the sex and the other doesn’t; this is hard to deal with. If one partner is told and hides it from the other, it puts considerable strain on a relationship at a time when a couple should be as close and open with one another as possible.

Women who have spent some time considering pregnancy in general want to make sure they are in the best health and have done everything possible to ensure they have a healthy child. Older women in particular may be anxious to do everything they can to offset the possible risks involved in being an older mother. You can take practical steps in advance to prepare yourself for the healthiest possible pregnancy.

It’s important to check that you are immune to rubella (German measles) before you start trying to conceive. Catching this disease, particularly in the first months of pregnancy, causes severe disabilities in the child or a miscarriage. If you are not immune, you can be vaccinated against rubella before you conceive. It is also a good idea to check whether you may be carrying a sexually transmitted disease. Hard-to-diagnose infections such as Chlamydia, Gardnerella and Mycoplasmas may be implicated in miscarriage and premature delivery. Blood tests for viruses such as cytomegalovirus, which can cause abnormalities in the baby, may also be worthwhile.

Stopping Contraception

If you have been relying on an IUD, you will need to have it removed by a doctor before you conceive. As soon as an IUD is removed, you can get pregnant. If you get pregnant by chance with an IUD in place, it does carry risks for mother and baby. You are more likely to have an ectopic pregnancy-a pregnancy that occurs outside the womb, usually in the Fallopian tubes-and there is a high risk of miscarriage. As many as 60% of such pregnancies end before term. The miscarriages are more likely to occur in the second three months of pregnancy. IUDs are usually removed while you have a period, because the cervix is slightly dilated then and this aids removal.

If you have been taking the Pill, stop taking it two or three months before you wish to conceive. You can use a barrier method, such as the condom or diaphragm, or natural family planning (rhythm method) during this time. (But be aware you are unlikely to use natural family planning effectively if you have not spent some time learning the technique and observing your menstrual cycle.) Studies have shown that women who took the Pill inadvertently in early pregnancy have only a very slight extra risk of having an abnormal pregnancy or a child with disabilities. Those who conceive as soon as they stop taking the Pill face no extra risk.

All the same, it is a good precaution to make sure that your body is free of all drugs before you get pregnant. It also helps to date the pregnancy if you have had one or two normal menstrual cycles before you conceive because this allows for good pregnancy care.

There is, however, some evidence that women who conceive while using spermicides, whether on their own or in combination with the diaphragm, cap or condom, run a slightly higher risk of a miscarriage (and, incidentally, also a greater chance of having a girl). It is obviously better to conceive when there are no traces of spermicide in the vagina. If you intend to try to conceive, it may be a good idea to ask your doctor to do a cervical smear and perhaps to take a swab to check that you do not have any vaginal infection, such as thrush, before you get pregnant. This will usually be done at your first prenatal appointment when you are pregnant anyway, but some women prefer not to have a vaginal examination in early pregnancy, especially if they have had a miscarriage or threatened miscarriage in the past. It also makes sense to clear up any infection before rather than after a pregnancy has begun.

What about the mother? What changes do you experience in preparation for the birth? The changes that come with pregnancy affect not only the baby, the uterus, and the placenta, but also the mother’s entire body, her mind, and her emotions.

For example, your breasts began changing as soon as you became pregnant. You may have noticed some breast changes [for example, tenderness, tingling sensations, and feelings of heaviness] very early, even before you knew you were pregnant. These changes indicate that your body is beginning to get ready for breastfeeding. By late pregnancy, you may notice more veins in your breasts, indicating the increased blood supply in the area. You may notice that your breasts are somewhat larger than before, and the areolae [the circles around your nipples] may have darkened. Inside the breasts, the milk producing glands have grown larger. They even begin producing a type of milk called colostrums, which enables you to breastfeed whenever the baby is born.

Other parts of your body also change in preparation for the birth. For example, the ligaments begin to soften. This is particularly helpful in the pelvis, through which the baby passes during birth.. Flexible ligaments allow the pelvis to enlarge somewhat, making more room for the baby. These changes sometimes cause shooting pains in the hips, stiffness in the lower part of your back, and soreness in the front joint of your pelvis [symphysis pubis] and the sacroiliac joints. Although inconvenient now, these changes really are a benefit during the birth process.
Like many women, you may experience heartburn and constipation, partly due to slowing of digestion and partly due to the size of the uterus, which is crowding your stomach and intestines and causing you to burp up acid and to have trouble moving your bowels. You can prevent or reduce heartburn by eating smaller amounts of food at a time and by not eating right before going to bed. Constipation can be helped with regular exercise, drinking plenty of fluids, and eating vegetables and fruits. Discuss with your doctor the use of antacids for heartburn and laxatives for constipation during pregnancy. Despit these discomforts, there are benefits. Your body is able to absorb more nutrients from your digestive tract because of the slowing of digestion.

Your uterus undergoes vast changes in the last trimester of pregnancy. Obviously, it becomes much larger. It must accommodate the growing baby,. the placenta [which weighs about one-sixth of the baby’s weight], and about one quart of amniotic fluid. As your uterus stretches around the growing baby inside, it becomes more “irritable’ and sensitive. If you sneeze or bump your abdomen, your uterus often contracts immediately afterward. It is very sensitive to sudden pressure. Sometimes while you are resting, your uterus will spontaneously contract several times in a rhythm. More than one woman has wondered if she is in labor when this kind of contraction pattern occurs. These contractions are called Braxton Hicks contractions, are an indication that the uterus has become more sensitive to the circulating oxytocin.

While Braxton Hicks contractions are not labor, they probably are causing changes in your cervix that prepare it for labor. These changes include ripening [softening], effacement [thinning], and some dilation [opening] of the cervix prior to the onset of labor. Although you are probably unaware of it, the cervix, which is usually quite firm and thick, becomes soft and thin before labor begins. A ripe, thin cervix opens up much more easily than a unripe, thick cervix. The amount of ripening and thinning can be determined only with a vaginal exam. Effacement is measured as a percentage, For example, if your cervix is twenty-five percent effaced, it is twenty-five percent thinner than usual. [The cervix is approximately two centimeters long. Twenty-five percent effaced means that one and a half centimeters remains]

Your cervix opens slightly before you go into labor. This is referred to as dilation, and is measured during a vaginal exam by feeling the circular rim of the cervix and estimating [in centimeters] the diameter of the opening. Many women will be one or two centimeters dilated before they are aware of any signs of labor. During labor your cervix will continue dilating to about ten centimeters [a circle about four inches across].

This preliminary work of the uterus in preparation for labor is thought to be controlled by the changing hormone production of the placenta, the baby, and the mother.

Contraceptive methods are only very rarely a cause of infertility. The interuterine device (IUD) can increase a woman’s chance of suffering from pelvic inflammatory disease (PID), which can lead to infertility. The contraceptive pill sometimes leads to a condition called post-Pill amenorrhoea, in which a woman’s periods do not return when she stops taking the Pill. Research has shown that this condition lasts for a maximum of two years after Pill use. It can also be treated with drugs.

A woman used to taking the Pill for several years, or using an IUD or cap regularly and worrying every time her period is late, may well expect to get pregnant as soon as she stops using her chosen contraception. But often she does not. This does not necessarily mean she is infertile. However, as a woman gets older her fertility declines. Using contraception for years may mean she is less fertile by the time she stops and tries to get pregnant. Also, using contraception, and particularly the Pill, can disguise infertility problems for years. The Pill usually means that a woman has a regular cycle; she may not realize she is not ovulating.

Hormonal Problems

One of the most common causes of infertility in women is a malfunctioning of the complex hormonal interactions that govern a woman’s menstrual cycle. The woman’s monthly cycle is controlled by the pituitary gland in the brain which, in tum, is governed by another gland called the hypothalamus. The pituitary produces a follicle-stimulating hormone (FSH), which controls the production of the hormone estrogen by the ovary. It also prepares one of the follicles inside the ovary to release the egg. A second pituitary hormone, luteinizing hormone (LH), enables the ovary to release its egg. Estrogen causes the lining of the womb to thicken in readiness to receive the fertilized egg.

If the egg is not fertilized, the corpus luteum begins to shrink, levels of estrogen and progesterone decrease, the lining of the womb disintegrates and menstrual bleeding results. Falling levels of estrogen and progesterone stimulate the pituitary to produce more FSH, and the cycle begins again.

If the egg is fertilized, however, and implants into the womb, the corpus lute urn continues to produce estrogen and progesterone until the placenta attaching the fetus to the wall of the womb is mature enough to produce the necessary hormones itself.

Failure to ovulate is normally caused by the woman’s body’s failure to produce enough of the pituitary hormones, or by their release at the wrong time. Since the pituitary is ultimately controlled by the hypothalamus, anything that affects the hypothalamus can also affect this gland. The hypothalamus can be affected by severe physical and emotional stress, as many women know when the stress of travel, work, illness or emotional turmoil disrupts their menstrual cycle. As women age, fewer menstrual cycles actually involve ovulation, so that in her early forties as few as one in every two or three cycles will produce an egg.

Treatment

Help for women unable to ovulate has been available for many years in the form of fertility drugs. There are two main types: those that prod the pituitary into producing FSH and LH on time and those that replace FSH and LH if this approach fails.

Clomiphene citrate (Clomid’P) is an artificial drug that triggers the release of FSH and LH in the pituitary. It seems to induce ovulation in about 80% of women treated with it, though not all will succeed in getting pregnant. One reason for this is that clomiphene tends to prevent the cervical mucus from becoming fluid at the fertile time in the month to enable the sperm to enter the womb. This problem can sometimes be overcome by giving estrogen as well in the few days before ovulation.

Sometimes a combination of clomiphene and human chorionic gonadotrophin (HCG, a hormone produced by the placenta and young embryo) given on the fourteenth day of the cycle will induce women to ovulate who would not do so on clomiphene alone. Clomiphene also seems to help women with a progesterone deficiency. It has been in use for many years and is considered safe, although a few women do have unpleasant side effects, such as nausea, a bloated feeling, or very rarely, enlargement of the ovaries accompanied by pain in the pelvis. Some infertility specialists deny the severity of these symptoms, or fail to inform women of them. Severe symptoms may indicate over-stimulation of the ovaries.

Recently there has been some concern that clomiphene citrate might cause more eggs, which have chromosomal abnormalities, to be released following its use. Others have questioned whether there might be other long-term effects on the children who are conceived after their mothers took fertility drugs, as happened with the children of women who took the drug DES (diethylstilbestrol) in early pregnancy to prevent a miscarriage. This is of particular concern to women who take large doses of fertility drugs to make them produce more than one egg, as is done for IVF and other treatments. However, there is no evidence to support such fears yet.

Human menopausal gonadotrophin (HMG), trade name Pergonalf and Humegonw, is a hormone extracted from the urine of pregnant women. It stimulates the follicles containing the egg. HMG is usually given as a daily injection, followed by the injection of another drug, HCG, which actually triggers ovulation. About 90% of women will ovulate with this treatment, though again, not all will conceive and some will miscarry. About 20% to 30% of pregnancies resulting from this treatment will be multiple births. HMG is responsible for most of the multiple pregnancies that occur with fertility drugs.

The hormone HMG is potent and may over-stimulate the ovaries, so the level of estrogen in the blood must be monitored daily and the follicles are often monitored by ultrasound. A new development, which might overcome this problem, is a small “pump” about the size of a wallet that, attached to the woman’s arm, provides small, even doses of hormone through a fine needle. However, having a pump attached day and night and having to have the needle repositioned when necessary can be unpleasant.

Some women do not ovulate because their blood contains a high level of a hormone called prolactin, which is normally produced in quantity only while breastfeeding and which tends to prevent ovulation. For women with this problem there may be hope with a drug called bromocriptine. Bromocriptine prevents the pituitary from producing prolactin, and after treatment ovulation occurs in about 95% of women who previously produced too much.

My husband and I knew we wanted to try to get pregnant as soon as we were married. I was just shy of 30 and my husband was on his way to 40. We both knew it could take time before we had any news to share with family. As luck would have it, the news came quickly! No sooner were we home from our honeymoon when the telltale “hit-by-a-bus” feeling swept over me one afternoon. I knew without test or missed period that I was pregnant. We felt so blessed and were so excited; we couldn’t wait to share the news with our families. But, we were cautious as well. We wanted to wait at least 10 weeks before spilling the beans.

At five weeks, my mom called me and asked me if I wanted a favorite family hutch. It had been in my aunt’s kitchen, and she no longer had room for it. Mom told me my husband and I could carry it, “No problem.” Yes, problem. I was pregnant! I couldn’t carry furniture! I tried to dance my way around it, telling my mom I recently pulled my back and suggesting one of the male cousins be on hand to help with the move. My usually sympathetic mother wasn’t making things easy. She suggested I just wait a week and move it when my back felt better. She told me the boys were busy, again reassuring me I had moved heavier and would have no problem with the hutch. I talked the dilemma over with my husband, and we came to only one conclusion; we had to tell them we were pregnant.

Despite our original plan to wait, I couldn’t contain my excitement. We planned on driving to Pennsylvania that weekend, and I spent the rest of the week planning the perfect way to break the news. At first, my husband and I thought we’d divide and conquer. We would catch my dad when he was on the computer and my mom in the kitchen. We would go our separate ways, share the good news and watch as they ran across the house to share it with each other. It was perfect! Perfect, that is, until I thought of something better.

I went to the store and bought two baby bibs. One said, “I love Grandma”, and the other proclaimed the same love for Grandpa. I wrapped the bibs individually, being careful to mark them correctly. I didn’t want to spoil the surprise by giving Grandma Grandpa’s present!

When we arrived at my parents’ house, we brought them together on the front porch. I excused myself and returned with two tiny packages in hand. I casually told my parents we brought something back for them from our honeymoon (which was really the truth!) and handed them each their coded gift bag.

Seconds passed like hours as they opened their gifts. Each pulled out and unfolded a dainty little bib. Each looked closely at the writing, then at each other and then at me. I just started crying. So did my husband. So did my parents.

The news spread like wildfire after that. We took turns on the phone and cell phone, first calling my husband’s parents, then the rest of the family. So much for waiting 10 weeks! Good news is too hard to keep secret!

With motherhood comes power. It’s not the power to fix a skinned knee with a simple kiss or even the power to decipher between an infant’s cries of hunger and her cries of pain, although those skills are well worth noting. Instead, it is the power to know exactly what to get a new mom when it is her turn to join the ranks.

I have always loved babies and baby showers. But, before I was a mom, I was guilty of buying frivolous presents: complicated outfits. Not only that, I was guilty of buying them in the smallest size. I smiled proudly as the swollen mom-to-be opened the package and thanked me for the sweet gift. Never once did I guess that my perfect gift would go unworn, or even worse, would be returned!

At my own baby shower, I echoed the cooing noises of the mothers before me as I opened each adorable gift. I couldn’t wait to put my baby in the cute little outfits. I thought the hardest decision I’d have to make would be choosing which one she would wear!

Then came baby. I quickly learned baby wears nothing more than onsies and layettes for the first several weeks of life, and even then there are certain ones baby favors. I also learned that there is no such thing as too many of either item. Between full-blown dirty diapers and spit-up with every feeding, I would have accepted hundreds of the things if offered!

It took only a few practices on the changing table to learn my baby hated having anything put over her head. Thankfully, a powerful mom had given me several snap-front layettes that saved me from further tantrums. Another powerful mom, my own aunt, sent the cutest onsies with the same snap-front closures. Needless to say, these were always in the rotation.

Once I learned how to harness this newfound power of mine, I set off shopping at the baby stores. I returned all of the complicated outfits the non-moms kindly gave me and gathered up as many snap-front “anythings” as I could find in every size imaginable. I refused to fall victim to my infant’s fussy taste in clothing.

I was lucky to be surrounded by many powerful moms during my first few weeks of motherhood, and I reaped the benefits of their knowledge. Now, I am proud to claim it as my own. I was able to flex my own mom muscles at a shower for my sister-in-law just five weeks after the birth of my daughter. Again, I smiled as she opened the gifts I offered, this time knowing that nothing would be returned.

I packed the ultimate diaper bag with the traveling necessities of any mom. I chose the diaper rash cream that works with one application. I sang the praises of the flexible leather infant shoes that keep socks on baby’s feet, and I made sure she had plenty of snap-front onsies and layettes to ward off any tantrums that may come her way.

My sister-in-law is due in two weeks. She has called upon me several times for my powers, and I am always glad to pass along what I have learned since my induction into motherhood. It’s a beautiful society to which we belong and one we are always happy to share with anyone who wants to join.

The other major causes of infertility in women are scarring of the reproductive organs by past disease or surgery, or structural abnormalities present from birth.

• Untreated sexually transmitted diseases, especially gonorrhea, can result in infertility. As many as 80% of infected women never have any severe symptoms with the disease, and may not realize that they have it and that infection has spread to the Fallopian tubes, causing damage.
• PID (pelvic inflammatory disease), which can start after an induced abortion or miscarriage, after childbirth, after surgery in the pelvic region or after infection with a sexually transmitted disease, can cause tubal scarring and blockage.
• Other infections that can affect fertility are chlamydia and mycoplasmas. Chlamydia, a bacterium that closely resembles a virus, has deceptively mild symptoms. An untreated “silent” infection can destroy the inside of a woman’s Fallopian tubes. Mycoplasmas, another organism, may affect fertility and has been held responsible for miscarriages.

Other causes

Endometriosis is a disease that may affect as many as 5% to I0% of women at some stage of their reproductive lives. Normally endometrial tissue lines the womb, or endometrium. The condition is caused by patches of the endometrial tissue becoming deposited outside the womb. This tissue, like the womb lining, thickens and bleeds with each menstrual cycle. Scar tissue is formed that may block the ends of the Fallopian tubes, or adhesions may form that prevent the tube from picking up the egg on its release from the ovary.

Endometriosis can be treated by a number of drugs: birthcontrol pills, progesterone or a drug called Danazol’v, which blocks production of the two pituitary hormones, and now new drugs called LHRH analogs, which are given as a nasal spray or an injection. These treatments serve to “switch off” the menstrual cycle, stopping the patches of endometrial tissue from bleeding; then they fade away and any adhesions or scar tissue can be removed by careful surgery.

About one-third of all women have fibroids or polyps by the age of 40. These are benign swellings in the womb, usually only the size of a grape but sometimes swelling to the size of a grapefruit. Fibroids seldom cause symptoms in women who are not pregnant and rarely cause problems in pregnancy, but women with fibroids may find their fertility is affected. They can be removed by surgery. Malformations of the womb, such as the presence of a dividing wall or septum, can sometimes be corrected by surgery.

Previous surgery in the abdominal region can also be a cause of damage to the tubes. Bleeding or injury to the tissues may cause scar tissue or adhesions to form, which may block or freeze the tubes, ovaries or uterus in unnatural positions. That makes it impossible for the egg to pass from the ovaries into the Fallopian tubes, so conception becomes impossible.

More women with blocked Fallopian tubes have a better chance to achieve pregnancy today because doctors are practicing delicate microsurgeries with increasing skill. However, if surgery is not effective, there is still hope through the test-tube baby treatment or IVF.

Occasionally a fertilized egg fails to move through the tube and into the uterus. Instead, it grows in the tube. Eventually the pregnancy will abort, or the egg may burst the tube, causing considerable bleeding and damage. This is called an ectopic or tubal pregnancy. It results in both the loss of one pregnancy and a possible barrier to future conception. One Fallopian tube is often lost. The other may be damaged by bleeding caused by the ruptured tube, or by the surgery to remove the pregnancy. It is estimated that about half the women who have an ectopic pregnancy may never conceive again. Increasingly, delicate surgery by laparoscopy may be able to save a tube, however.

Often an ectopic pregnancy occurs when there has been some damage to the tube, perhaps caused by past infections or surgery. Tubal pregnancy is also more common if a woman becomes pregnant with an IUD in place or has been using the progestogenonly (or “mini”) Pill. An ectopic pregnancy is very painful and can be life-threatening. However, prompt medical attention to remove the developing embryo before the tube can burst avoids many risks and improves the chances of successfully reconstructing the damaged tube.

Your perineum may be sore and swollen for a few days after birth, due to stretching of the birth canal or to the episiotomy or tearing that might have occurred. It helps to put an ice pack on your perineum off and on for the first twenty four hours or so after delivery to reduce swelling and discomfort from stitches. The area is sensitive to touch, so after going to the bathroom, rather than wiping, squirt the area with some warm water from a bottle, then pat it dry with a clean, soft tissue.

Sitting in about four inches of either very warm or very cold clean water in a tub is also very soothing. You can take such sitz baths several times a day for twenty to thirty minutes. Keep the water clean, don’t bathe in this water, Showers are better than baths for the first few weeks after birth because soapy, dirty water could contaminate the healing areas of your perineum.

For some women, hemorrhoids [swollen, painful blood vessels of the anus] may be a problem. Sitz baths may help, as may gently patting the area with cotton pads or tissues soaked in witch hazel. Hemorrhoids tend to improve with time, but if you have a lot of trouble, see your doctor.

When your perineum is swollen and sore, straining for a bowel movement is painful and a little scary, because you may worry about putting too much stress on your stitches. It is important to have a bowel movement within three days or so after delivery. Make a point of eating high fiber foods, and raw vegetables and fruits. Also, drink plenty of fluids, including prune juice. These foods and liquids help prevent constipation. If you are unable to move your bowels, you may need a laxative. For that, contact your doctor.

At first, you may be surprised at the amount of urine you pass. Whereas in late pregnancy the baby crowded your bladder, requiring that you empty it frequently, now it may seem that your bladder can hold a tremendous amount of urine. Urinating is one way your body rids itself of all excess fluid it carried during the pregnancy. Occasionally, the urethra [the tube from your bladder to the outside] is swollen after childbirth, causing trouble with urination. Your doctor can help with that.

This is a routine blood test carried out at between 16 and 18 weeks of pregnancy. It measures the level of a substance called alpha-fetoprotein (AFP), which gets into the mother’s bloodstream from the baby. A high level of alpha-fetoprotein can mean a number of things: that the pregnancy is further advanced than was thought, that the mother is expecting twins, or that the baby is suffering from a neural-tube defect. It can also mean nothing at all!

If a woman does have a higher-than-normal level of AFP, a second blood test will be done to confirm it. If this test is positive also, there is a roughly l-in-7 chance the fetus has a neural-tube defect. It is usually recommended that the woman have an ultrasound scan to check for the presence of anencephaly or spina bifida. If results are inconclusive, an amniocentesis is usually recommended so that the level of AFP in the amniotic fluid can be measured (see section below).

The problem with the AFP blood test is that for every ten women with a raised AFP level, only one will have a cause found for it. The other nine will have a normal baby, although they may have a slightly greater risk of having a small-for-dates baby. The majority of women with a high AFP level will have a “positive” result and then an amniocentesis performed, accompanied by a lot of stress and worry, when there is actually nothing wrong with their baby. The chance of the AFP level being high from other causes is greater than the risk of a neural-tube defect.

Rather than perform the AFP test routinely without fully consulting the mother, healthcare professionals might do better to explain what the test is for, what it involves, and let the mother choose whether to have it. Some people welcome the test, but others prefer to do without it.

“I had just had the scan, seen the baby moving [and] that its head was there and it was kicking its legs. I thought we would have seen if there was anything really wrong. Its head would have been the wrong shape or its legs paralyzed. Anyway, I couldn’t possibly have aborted that baby once I had seen him like that. So I decided not to have the test. What was the point of having it done when I could see there was nothing so wrong with the baby and I wouldn’t have wanted an abortion anyway?”

Besides, not all neural-tube defects are detected by the test.

There is no absolute level of AFP in the amniotic fluid at which one can say, “This baby is affected and this one isn’t.” An artificial line has to be drawn. If the level is set too high, more neural-tube defects will go undetected. If it is too low, more women will have further tests with all the worry that goes with it.

A new test known as the triple-screen test has been developed.

A blood test is taken at 16 weeks and levels of alpha-fe top rote in are measured, together with two other “markers,” unconjugated estriol and human chronic gonadotropin (HCG). High levels of AFP may indicate higher likelihood of a baby with spina bifida, while low levels of AFP and unconjugated estriol, together with high levels of HCG, and indicate a higher risk of having a baby with Down syndrome.

Results from the test are combined with the woman’s age to give her a “risk factor.” A risk of one in 250 or higher is considered “screen positive”-that is, an amniocentesis or further screening is advised. A risk of less than one in 250 is considered “screen negative.” However, a positive result means, on average, only a 1-in-50 chance of the woman having a baby with Down syndrome. Again, some experts are concerned that this test will put too many women under great stress who don’t need to be by receiving a “positive” test result and having an amniocentesis.

In a more refined version of the test, called the quad-screen test, a fourth marker is measured in the blood, neutrophil alkaline phosphatase. This makes the test even more accurate at determining whether or not a fetus may have Down syndrome.

Since the 1970s, remarkable improvements in ultrasound technology have opened a real “window on the womb.” Ultrasound consists of high-frequency sound waves that are bounced off the baby to give a photographic picture of the fetus. Unlike X-rays, which have much higher powers of penetration, ultrasound will identify soft tissues. Thus, it can give a complete picture of the growing baby and is a very useful diagnostic tool.

An ultrasound scan may be used to date the pregnancy, and thereafter used as needed in hospitals with the equipment. If not, women who may be at special risk because of problems with a previous pregnancy, or who would like to have a scan, can often be referred to a hospital where it can be performed. The pregnancy can be very accurately dated at around 16 weeks by measuring the circumference of the baby’s head. This knowledge is useful in avoiding problems later if the mother is unsure of her dates and does not know when the baby is due. The scan can locate the position of the placenta, which can be helpful if there is any bleeding later in pregnancy, and it can be used to check that the baby has no major physical abnormalities such as anencephaly. Ultrasound can show congenital heart defects, kidney disease and other severe abnormalities. Ultrasound can also detect if the mother is expecting more than one baby.

There has been some controversy about the safety of ultrasound, which has concerned some women. They are not sure whether they should accept a scan. Ultrasound has now been in use for many years without any evidence of harmful effects to the baby.

All indications are that the benefits of having ultrasound outweigh any potential risk. Not least is the benefit of reassurance given to many women on seeing their baby is alive and well, particularly those who have waited a long time to have a baby or who have experienced a miscarriage. However, a large study carried out in the United States by the National Institutes of Health on 15,000 women with a low risk of problems in pregnancy showed that while detection of twins and malformations was increased, and pregnancy could be dated more accurately, the outcome-in terms of healthy babies-was not improved when ultrasound was employed. There was no difference in the rate of fetal or neonatal death or subsequent illness. Rates for preterm births, for the outcomes of postdate pregnancies and for low-birth-weight babies were similar for those who had had ultrasound and those who had not. Although the percentage of abnormal fetuses detected in the group who had ultrasound was three times higher, the termination rate was about the same in both groups.

So, while ultrasound is of undoubted benefit to women at high risk or in special situations where a problem is detected, its routine benefits are unproved for now. Ultrasound can help some mothers anxious about their pregnancies by reassuring them, but can also create anxieties for others:

“Towards the end of my pregnancy they started to worry about whether my baby was growing as he should. I don’t know what started it, but once they got this idea into their heads they wouldn’t leave me alone. I was in and out of the hospital having my blood pressure taken and having ultrasound scan after scan. My blood pressure was up-with worry, no doubt-and they couldn’t decide what to do. They said they would have to induce the baby early to make sure that all would be well. Then they changed their minds and decided to wait. I was in the hospital for the last few weeks of the pregnancy and, of course, the baby decided to be late. I was two weeks overdue before they decided induce the birth. By then I was so desperate I said, ‘Yes.’ It was a terrible birth, ending with an emergency Cesarean, and when he was born he was 7 pounds, 1 ounce. He didn’t look overdue. I asked my doctor later, ‘So what happened with this small baby?’ There was nothing wrong at all! My worries were for nothing. They said they couldn’t explain it but he had appeared small on the scan. So much for all their wonderful technology!”

Some women-and doctors and midwives, too-feel that, with the increased reliance on new technology, many of the old skills in obstetrics are being lost:

“1 had shared care and I noticed a tremendous difference between my visits to the well-baby clinic and my visits to my very experienced doctor. At the clinic, people seemed to poke and probe for a long time and suggested that I have another scan to see the baby was growing OK. When I went to my doctor, she examined me very quickly and said, ‘Oh, this baby’s doing fine, I think he weighs about 4 pounds now.’ I asked how she knew and she just said, ‘Experience.’ In the clinic, I feel like you only see the junior staff, with the senior staff called for special occasions. No wonder you don’t always get the best care and they give you all kinds of unnecessary tests!”
Having an Ultrasound Scan
An ultrasound scan is a simple, noninvasive procedure. In early pregnancy you are usually asked to drink a lot of water an hour or two before your appointment and not to empty your bladder. This pushes the womb up in the pelvis and will give the ultrasound operator a clearer view. You will be asked to lie down on a couch and remove any clothing that covers your abdomen. A cold gel is rubbed over the abdomen to enable the ultrasound operator to move the scanner smoothly over the area. As she does so you will see the baby’s outline appear on the television screen and you will also see the fetal movements.

It can be difficult to interpret what you are seeing, so ask if you are not told. The operator can freeze the picture at any time and point out things to you without exposing the baby to any more sound waves than necessary. You will usually be able to see the baby’s head, the arms and legs moving around, and some of the internal organs at work. You may even be able to see the baby sucking his thumb.

“The woman took a lot of time to explain to me what she was looking for and what she could see. I found all of it so reassuring. She pointed out the heart beating, the cord and the placenta, the kidneys and the spine and showed me how much he was moving around.”

Other women find the process unnerving, especially if nothing is explained.

“No one said anything to me and I was afraid to ask in case anything was wrong. She kept on looking at everything and taking measurements and I started to get very jumpy. Then she suddenly got up and said, ‘I just want to get a second opinion on this,’ and I was terrified. I thought, ‘This is it. Something’s really wrong.’ I was in tears. Someone else came back and they were both looking at the screen, still not saying anything to me. ‘What is it, what is wrong?’ I finally asked. ‘Nothing’s wrong, I’m just checking these measurements,’ she said. I felt as if I weren’t a person-just a scientific toy.”

Usually the baby’s father is welcome to come and watch the process and see the baby on the screen. Many dads find this is a very positive experience, not only because they are able to give support, but also because the baby becomes real to them in an even more dramatic way than to the woman: “It was hard for me to take in that she was pregnant until I saw the baby on the screen. It was fantastic-it made it come alive for me.”

Six weeks after the birth you will return to the hospital or your doctor’s office for a checkup to ensure that your body is returning to normal after the birth. The doctor will feel your abdomen to check that the uterus has returned to its normal size. Your blood pressure and weight will be noted. You will be asked if you have had any unusual bleeding, pain or discomfort. (It is quite common for the lochia-the blood loss after the birth-to continue for more than six weeks. Some women have already had a period by this time.) Any scars from tears or episiotomies will be checked. Your breasts and nipples may be examined if you have problems with breast-feeding.

You may also discuss contraception with your doctor if this has not already been arranged. Women who use a diaphragm will usually have it refitted at the postnatal check. Everything may not have returned to its normal shape and size by this time, so it may need checking again a few weeks later. An IUD can also be refitted at six weeks. It isn’t usually done right after the birth because the uterus is still contracting and may expel the device. If you want to take the Pill, the usual combined estrogen/progestogen pill is not suitable if you are breast-feeding because it affects the milk supply. The mini-pill or progestogen-only pill can be taken within seven days of the birth. Some mothers do not like the idea of taking any drug while breast-feeding, however. Small quantities of hormones do get through to the baby, but there is no evidence to date that this is harmful. Many couples rely on the condom as a temporary measure because it really is an ideal method at this time.

You will have the opportunity to raise any worries you have about your own health or that of the baby, including problems with breast-feeding. You may want to discuss problems you have with sex, especially if you have attempted intercourse and found it painful. It is very common not to have had sexual intercourse till after this postnatal stage. In fact, many women find they need the reassurance of the postnatal check that all is well before they do so.

If you did not have a Pap smear taken earlier in pregnancy, now is a good time to have it done.

Breastfeeding, obviously, is more economical than bottle-feeding. It also provides the baby with more intimate contact, and research has shown it releases hormones in the mother that stimulate maternal, tender feelings. Human milk is especially suited to human babies, is easy to digest, and actually helps the baby from getting sick.

Breastfeeding supplies are minimal:

1. Breast creams-aren’t necessary. If your breasts get sore, the best healer is fresh air and pure hydrous lanolin
2. Rubber nipple shields-don’t work well and interfere with the natural toughening process that eventually makes nursing more comfortable.
3. Nursing bras-come in a variety of styles that either fasten in the front center or have fold-down flaps. Flaps are easier. Some women prefer to use an ordinary stretch bra that they simply lift up. Whatever your choice, wait until your ninth month of pregnancy or until after the baby has been born to find your size, since you won’t be at your maximum size until then. If the bra is too tight, it will interfere with the down-flow of milk and be uncomfortable. Look for a bra that is machine washable. If your breasts are very heavy, select one with large, wide straps and extra support, like under wires. Try on several types and buy up to six of the most comfortable since milk leakage during the first few months will necessitate frequent washing [a damp bra can stimulate bacteria growth]
4. Breast pads-for milk leakage. You can use men’s cotton handkerchiefs tucked into your bra or mini-pads cut in half. Commercial breast pads are more expensive, but those made of washable layered fabric aren’t a bad investment. Disposable breast pads usually have plastic liners, which can irritate sore nipples by keeping moisture in.
5. Breast pump-you may need to pump milk if you will be separated from your baby for prolonged period. It’s best to pump while the baby is nursing on the opposite breast. There are four kinds of breast pumps. Hand operated pumps work with a rubber bulb for suction and can be purchased in drugstores. The problem with these is they usually don’t work well. To get them to work at all you must use an intermittent, gentle, tugging action rather than continual suction. Breast pumps that use piston or syringe cylinders also work with an intermittent tugging action, but are designed to be more effective than hand operated pumps. Get one that has adapters for different breast sizes and bottles for storage. You may prefer a battery operated pump; these are somewhat more expensive than hand operated or piston pumps, but are quicker and easier to use. Electric pumps are very expensive and are usually used by hospitals. They can be rented by the month; if you have a premature baby in the hospital you want to be breastfeeding, this may be the way to go until he is home.

All babies have sucking urges that go beyond feeding, and this sucking urge is at its highest at between three and seven months. By the age of two, most babies have lost the urge, except when they’re under stress. Pacifiers may prevent thumb sucking and other undesirable sucking habits. However, there is the danger that he pacifier will come apart and pieces will become stuck in the throat. There have also been strangulations from ribbons or cords when pacifiers were hung around the baby’s neck. New regulations require that there be two ventilation holes in the pacifier for air passage. The protrusions at the back of shields must be a specific size to prevent ingestion, and the pacifier must be tested for durability to ensure that it won’t come apart. There is also a warning on pacifiers that tells you not to tie the pacifier around your baby’s neck because of the strangulation danger.

Once your baby gets a little older, you’ll want to get her a training cup to make the transition from bottle. The cup should have a snap-on lid with a narrow spout and wide handles. Look for cups that are dishwasher safe and preferably transparent. Avoid cups that look like toys, they will encourage play, not drinking.

You’ll also want baby dishes. You can choose either electric or hot water dishes. The electric ones should have temperature regulations to prevent overheating, and they should have a cold section. If you’re using an electric dish, always unplug the cord from the wall socket before unplugging the dish. If you use a hot water dish, make sure the spout cap locks firmly so that he baby can’t pull it out and ingest it. Either kind should be completely immersible and preferably dishwater safe for easy cleaning. Dishes with steep sides and suction bases to prevent sliding will be easier for self-feeding. Feeding spoons used for a child who is beginning to feed herself should have semi-flat bowls and weighted handles that can be easily gripped by chubby little hands. Avoid spoons with rubber bowls; they taste bad.

The majority of new mothers leaving the hospital today breast-feed their babies, at least at the beginning-about 60%. This is especially true for middle-class and professional women, which the majority of older mothers are likely to be. Age does not seem to have any great effect on breast-feeding. It is not commonly known that any woman who has had a baby can breast-feed, and that in other cultures grandmothers breast-feed their daughter’s children. Occasionally a much older mother may find it a problem to produce enough milk, due to hormonal problems, but this is rare.

Many hospitals now give great support and encouragement to mothers who want to breast-feed, recognizing that it is the best food for a baby and that there are emotional rewards for the nursing mother. The American Academy of Pediatrics issued a strongly worded policy in 1997 that suggests women nurse for six to 12 months, because of a strong association between breastfeeding and immunities for babies from a variety of ailments. But some women decide they do not want to breast-feed. There is no reason to feel guilty about this. There are excellent baby formulas available now that are made to match the nutrition of mother’s milk as closely as possible. Bottle-fed babies also thrive. Love is more important than the way you choose to feed, though many mothers choose to express their love through breast-feeding.

Breast-feeding is best for a baby because it is a living substance transmitted directly from mother to baby, containing white blood cells, antibodies and other substances that help protect the baby against disease. We haven’t yet identified all these protective properties. It is composed of exactly the right nutrients for human babies and is produced in exactly the quantities the baby demands.

After the birth a mother produces colostrum, a yellowish fluid rich in antibodies, which protects the baby from infection. Colostrum also contains protein, water and minerals in just the right proportion for the baby’s first few days, and a natural laxative, which helps the baby’s bowels start working. When the milk comes in, it is also perfectly balanced for the baby’s needs. The milk changes slightly in composition as the baby grows. Research has shown that milk produced by the mothers of premature babies is different from normal breast milk, and is ideally suited for them.

When the baby first goes to the breast and sucks, it takes the watery foremilk stored in ducts behind the areola, the pigmented area around the nipple. The baby’s sucking sends a message to the brain to let down the bulk of the milk, and the hormone oxytocin the same hormone that makes the womb contract in labor and at orgasm-is released, causing the muscles around the glands producing the milk to contract and squeeze the milk through the breast to the nipple. The baby usually takes the bulk of the feeding in the first ten minutes or so at the breast. But enough milk is always produced so the feeding can last much longer than this.

Most hospitals have made-up bottles of formula readily available. This is a great temptation to a mother who is having problems with breast-feeding and who is very tired. If you are certain you want to breast-feed, resist this temptation! It takes some time to establish breast-feeding and there are often some initial problems, but they should resolve themselves shortly. Some babies who get used to the bottle find it is more difficult to take the breast. Babies who have had bottles sometimes reject the breast altogether. Mothers who want to avoid cow’s milk because of eczema and asthma in the family should also resist the temptation to give a bottle.

More and more women today are choosing to have their babies later in life - that is, in their thirties and early forties. Statistics from the March of Dimes Prenatal Data Center show that, yes, later motherhood is on the increase. Most of the births occurring each year are to women in their mid- to late twenties. But the proportion of births to women 35 years and older has increased by 84% between 1983 and 1993, from 5.7% of births to 10.5%. In 1976, 19 of 1,000 U.S. births were to women between 35 and 39 years old. By 1996, births to women in this age group accounted for 35.4 of 1,000 births. Women over 40 accounted for 4.5 births per 1,000 in 1976. By 1996, women between 40 and 44 accounted for 6.8 births per 1,000.

Between 1980 and 1990 the number of births outside marriage to women over 30 tripled. It is estimated that about three-quarters of these births were to divorced or separated women. Many of these women were living with their new partners.

While most women who delay motherhood choose to have children in their late thirties, a few decide to become mothers for the first time in their forties. More and more women are establishing their careers first and then embarking on motherhood. Recently, many career women have embarked on motherhood later in their lives, presenting an image of the youthful, sexy, attractive older mother. You may know some of them yourself! Actresses Jane Seymour and Priscilla Presley are two well-known examples of women who have given birth to children in their forties.

Many pregnancies to older women are still accidental, as is shown by the number of women over 40 who choose to terminate their pregnancies. In 1988, 109,642 U.S. women over 40 were pregnant. Of these, 44% chose to terminate the pregnancy. 56% chose to give birth. (Alan Guttmacher Institute, Facts in Brief; January 4, 1993).

Although menopause in most women occurs sometime between the age of 45 and 55, most women trying to have a baby in their forties do experience fertility problems. Now new infertility treatment has given hope to older women unable to conceive naturally. The news in 1997 that a 63-year-old American woman had conceived was greeted with some controversy and confusion. Public debate centered on whether it was “right” for a woman who could be a grandmother to give birth and whether she would be an adequate mother for her children, not to mention whether it was moral for doctors to use artificial means to induce a pregnancy in women over the natural age of child rearing. (In fairness to the doctors, she had told them she was years younger.) But what is the “natural” age at which fertility ends? The oldest mother on record to have conceived naturally appears to be Mrs. Ruth Kistler of Los Angeles, who gave birth to her daughter at the age of 57 years, 129 days.

The reduction in the numbers of women who have very late babies has probably changed people’s attitudes so that today it seems more “unnatural” for women to have a very late baby than it seemed to earlier generations. For women to have a late baby by accident seems to require help and sympathy, while to choose to have a baby late-perhaps with help from medical science seems to inspire judgmental attitudes. Late motherhood is seen as an indulgence in a generation of women who want to “have it all;” it is not meant to be good for the baby.

Everyone seems to accept that late motherhood carries some risk-for the woman’s health, the baby’s health, and perhaps their happiness later on. But what are the risks of late motherhood? What chances is the older mother taking with her health and life? What are the chances of her succeeding in having a healthy pregnancy and normal labor? What are the actual risks of having a baby with disabilities? And how successful is parenthood for the older mother, her family, and, especially, for the child? This book will try to answer these questions for those of you who are considering having a baby later in life.