Babies Tale

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.

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!

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.”

Neural-tube defects, which include spina bifida and anencephaly, occur in about three in every 1,000 live births. There is no evidence these problems appear more commonly in the babies of older mothers. Early in pregnancy, a groove appears down the baby’s back and this develops into the brain and spinal cord. Normally the groove closes into a tube in which the spinal cord and brain develop, but in rare cases the tube does not close properly. If the defect is in the part of the tube that forms the brain, anencephaly results. This development is always fatal because the upper skull and brain do not form. If the defect occurs lower than around the brain, then part of the spinal cord and nerves protrude, covered by a fragile membrane; the baby is usually paralyzed from this site down. Sometimes, however, spina bifida can be less severe, is not noticeable from outside and results in minimal disability.

As many as 85% of babies severely affected with spina bifid an also have a defect called hydrocephalus. Cerebro-spinal fluid accumulates in the head, causing mental retardation if untreated. Today the fluid can be drained after birth. Surgery can repair the opening in the spine to reduce the risk of infection. Surgery and other techniques have improved the outlook for children suffering from this disability.

Spina bifida can probably be largely prevented by an adequate diet before and during early pregnancy. Evidence has shown that taking vitamin supplements rich in B-group vitamins and folic acid has greatly reduced the incidence of spina bifida, even in mothers at greater risk because the disability is in their family.

Cleft Lip and Palate

This is one of the most common abnormalities, affecting about one in 1,000 babies. This is another condition that does not seem to be more common in the babies of older mothers. The cleft is caused when the tissues that move together to form the face in very early pregnancy do not fuse, leaving a gap that can involve the lip alone, the palate, or both. The cleft can be on one or both sides of the face and varies in its seriousness. The vast majority of children with cleft lip or palate are fine in other respects, but sometimes another abnormality is present also.

Cleft palate can cause serious feeding problems in the early months, because the baby is unlikely to be able to suck well. The child will have difficulties speaking. Teeth are likely to be missing or malformed in the area of the cleft. Plastic surgery, however, can completely repair the cleft, inside and out, by the time the child reaches maturity. Speech therapy and orthodontic work are usually necessary.

Although cleft lip and palate are correctable, it is understandably distressing to give birth to an affected child:

“Our son was born with a double cleft palate and lip. When he was born it was badly disfiguring, because the middle of his upper lip and jaw were pushed forward, sort of like a beak. He had terrible feeding problems. He couldn’t suck and had to be fed with a spoon at first. You can imagine how difficult this is with a hungry, crying baby whose every instinct is to suck! He had to have a series of operations throughout his childhood. The end result is very good. But the emotional effect of hospital stays and of looking different to other children is harder to deal with than the physical repairs.”

Abnormalities in the Digestive Tract

Abnormalities in the digestive tract are other relatively common and correctable defects. They are not normally related to maternal age. These include a blockage of the entrance to the stomach, often accompanied by a situation in which the windpipe and esophagus are joined; and blockages at various points in the digestive tract, including the anus. All are easily corrected by surgery. Some can even be detected in the womb by ultrasound.

Detecting Abnormalities

Some tests are now available to screen all pregnant women. Others are available for women who are at higher risk of having a child with disabilities. Some of these tests are offered to women routinely. Others are offered only to women over certain ages that are already known to be at risk either because of family history or because of previous difficulties with pregnancies. Your healthcare professionals will explain at one of your early prenatal appointments what their procedure is and which tests they offer to women. If they don’t, and you would like to know, ask which tests they offer and when during the pregnancy they are performed.

Screening tests include:

• Ultrasound scans, which may be used as needed, from the fifth week of pregnancy to delivery
• A blood test that can detect raised levels of a substance called alpha-fetoprotein in the blood, which may indicate a neural-tube defect
• Amniocentesis (a sample of the waters surrounding the baby) enables chromosomes to be examined, shows any chromosomal abnormality and, incidentally, the child’s sex
• Rarer techniques, such as fetoscopy, in which the baby is examined through a tube inserted into the womb
• Chronic villi sampling, a technique that one day may replace amniocentesis

Women are always prone to an iron deficiency because they lose blood every month through menstruation. If a woman does not have sufficient reserves before pregnancy, anemia may result because of the increased volume of blood circulating through the body. Symptoms of anemia include tiredness, lethargy, irritability and pale skin. Anemia is treated easily with iron supplements.

Diabetes

Women with diabetes run special risks in pregnancy and are usually kept under careful medical supervision. However, today it is perfectly possible for a woman with diabetes to have a normal pregnancy and labor.

Diabetes can be unmasked by pregnancy because pregnancy puts extra strain on the body. Older mothers are more susceptible to this. If diabetes is detected with a urine test, the mother’s blood-sugar levels will be monitored. Diabetes may be controlled by diet alone or with insulin injections, the dosage of which may be altered as the pregnancy progresses. Because a woman with diabetes is at risk of having an unusually large baby, birth is sometimes induced early or the mother may be advised to have a Cesarean-section delivery.

Jenny is diabetic and had two children in her thirties. “I knew from the beginning of my first pregnancy that I was going to have a Cesarean. When my first child was born, almost all diabetic women ended up with a Cesarean. It was done with an epidural so I would be awake to see the baby, but the epidural went wrong. I had a headache and had to lie flat on my back for 48 hours after the birth, and I had pain in my legs for about ten days afterwards.

“I waited five years to get pregnant again. I wanted to have the same kind of birth a healthy person does, because that’s how I see myself. There was a little scare because the baby was overdue, but when I was one week late I went in, was induced and had a normal, easy birth.”

Pre-eclampsia

This is a metabolic disturbance in pregnancy with symptoms of high blood pressure, swelling of the feet, hands and ankles and protein in the urine. It occurs more frequently in older women, but is also linked to obesity and poor nutrition. If untreated, the woman will get headaches, blurred vision and may go on to develop eclampsia, in which she suffers from seizures. The main risk is not to the mother but to the baby, because there is a high risk of premature labor.

Pre-eclampsia is usually treated with bed rest. The mother’s blood pressure is watched carefully. If it is late in the pregnancy and her blood pressure goes too high, the baby will typically be delivered early by Cesarean section.

Postpartum Hemorrhage

Bleeding before 28 weeks in pregnancy usually results in a miscarriage. After 28 weeks any bleeding is known as postpartum hemorrhage and has two main causes: placental abruption, a rare condition in which the placenta separates from the wall of the uterus, and placenta previa. Both conditions are slightly more common in older mothers.

Placenta previa is a condition in which the placenta is attached to the lower part of the womb, near or even over the cervix. This results in bleeding during pregnancy and more bleeding as soon as labor starts. Usually the condition can be identified with an ultrasound scan. Most mothers with placenta previa have to rest in the hospital until the baby is due. This helps prevent bleeding. The baby is delivered by Cesarean section.

Miscarriage

Miscarriage is a problem of great concern to older mothers. This risk is particularly disturbing for mothers who have had problems conceiving.

The risk of miscarriage for older mothers is greater than for younger mothers. It is not commonly known that as many as one in six recognized pregnancies end in miscarriage; the numbers would be higher still if all pregnancies were counted, including those that end so soon that a period is only slightly delayed or not delayed at all. There seems to be a slightly higher risk of miscarriage in a first pregnancy.

Miscarriages are even more common for older mothers. One study of women who conceived through artificial insemination by donor showed that by the age of 40 a mother had a 50% chance of having a miscarriage. Studies have shown that about 50% of miscarried fetuses are genetically abnormal. This is why many people try to comfort the woman who has lost her baby with “It’s nature’s way of getting rid of babies that are not normal.” In older mothers, the proportion of fetuses with abnormalities may be higher. New research on helping older women conceive using hormone replacement and donated eggs has shown that it is more likely to be the quality of the embryo than deficiencies in the mother’s womb that cause a pregnancy to fail.

Having one miscarriage does not mean you have any greater chance of a second. After two miscarriages, the risk does go up, from about one in five to one in three; after three subsequent miscarriages, the chances are about 50/50 that the pregnancy will go to term. But the great majority of women who have miscarriages will have a healthy baby eventually.

Medically, a distinction is made between miscarriages that occur up to about I2 or I3 weeks and those that occur after this time, because they usually have different causes. The great majority of miscarriages-about 85%-occur before the end of the twelfth week of pregnancy.

This technique involves passing a very small tube containing a light and a lens into the uterus so the developing baby can be seen. The tube is introduced through a small incision made just above the pubic bone under a local anesthetic. Fetoscopy is carried out in the second three months of pregnancy. Samples of the baby’s blood, skin and liver can be taken. A number of abnormalities can be detected by fetoscopy that cannot be learned any other way. The procedure has recently been used to “operate” on the unborn baby, enabling drugs and transfusions to be put directly into the baby’s bloodstream.

The baby is usually viewed at around 16 weeks and blood samples taken between 17 and 22 weeks. External defects (to the face or limbs) and neural-tube defects are clearly visible. Hemophilia and other blood disorders can be detected; so can some diseases of metabolism. The technique is not used lightly, however, because it carries a substantially increased risk of miscarriage, death of the baby in the womb or premature labor.

Chorionic Villi Sampling (CVS)

This is a relatively new technique being offered in some hospitals as an alternative to amniocentesis. The advantage of the test is that it can be carried out much earlier than amniocentesis. CVS gives the mother who finds that her baby has serious birth defects the chance to terminate the pregnancy earlier, when it can be carried out simply, rather than as induced labor after she has felt the baby moving.

The CVS test is carried out by passing a thin tube through the cervix (neck of the womb) and removing a tiny fragment of tissue from the placenta. This can be done without an anesthetic and, as with amniocentesis; ultrasound is used to show the exact position of the fetus and placenta. The vagina is cleaned with antiseptic solution beforehand to prevent germs from being introduced into the womb.

The test is usually not painful, but it is uncomfortable for many women, a little like having a Pap smear or, some women say, like having an IUD (intrauterine device) fitted. The test takes 10 to 20 minutes and you will be allowed to go home after about an hour. As with amniocentesis, you may be advised to take things easy for a day or two because of the risk of miscarriage. At the moment, this risk seems to be about one in 50, two or three times more likely than with amniocentesis. At present, the test is performed in medical centers. Going to a medical center with a good track record for giving these tests may help reduce the associated risks.

CVS detects chromosomal abnormalities in the same way amniocentesis does, but it does not identify neural-tube defects. Women who have this test will also be given the AFP blood test to detect spina bifida. The results can be available quickly, sometimes in a matter of days.

When an Abnormality is Found

The vast majority of women who have these screening tests in pregnancy are reassured that all is well, and this enables them and older mothers in particular, to relax and enjoy the rest of their pregnancy. But tests do not detect all problems, and tests are not foolproof. In addition, problems can occur at birth, which can result in a disability.

In the small number of cases where an abnormality is found, however, the pregnancy is transformed from a happy event into a nightmare. Some women feel this is just as traumatic as losing a full-term baby. Knowing you are carrying a child with disabilities and having to decide whether or not to have a termination is one of the most difficult experiences anyone can face. Hospitals often lack adequate support services and do not know how to deal with a couple’s distress and grief. A number of organizations can help; one with a wide network is SHARE.

Doctors may fail to explain the news well or there may be confusion over the results:

“They called and said the baby was a girl, and there was a problem. She mentioned Down syndrome, and my thoughts went into a tailspin. She gave me an appointment to see the doctor. I walked around in a daze; I couldn’t bring myself to tell anyone. When I saw the consultant, she explained that my daughter would not suffer from Down syndrome herself, but one chromosome was abnormal, so any children she had would suffer from Down syndrome. In other words, the baby I had for days been considering aborting would be perfectly normal.”

Another mother felt that the way the news was broken to her was far from satisfactory:

“They didn’t call with the results of the amnio so finally I called them. They said, ‘Oh, yes, but we can’t discuss this over the phone. You have to make an appointment to come in.’ I knew then something was wrong, so I asked, ‘What is it? Is it Down syndrome?’ She said no, it wasn’t, and I would have to wait till I saw the doctor. We had to wait another day. They told us there was a high level of alpha-fetoprotein in the fluid and that it was likely the baby had spina bifida. They would like to do another scan to check because they hadn’t picked it up before. This time they did. They all looked at the screen, not me, although there were tears pouring down my face the whole time. The consultant explained what the outlook was and painted this dismal picture for the child. We decided on an abortion right then, but for some bureaucratic reason had to wait. In the meantime I was given no support.”

A study carried out in the United States by the National Institutes for Child Health showed that of parents who discover their baby is abnormal, 95% decide on a termination. Some hospitals advise that if a couple knows they do not want to have a termination they should not have the tests, to spare them “unnecessary” expense. However, not all couples know until the decision is upon them. Others feel they have the right to know, no matter what, so they can prepare themselves-both in a practical sense and from an emotional point of view:

“I was 40 and had had years of infertility problems. In fact, a couple of months before I did conceive I had been told I would never conceive. We discussed the possibility of a child with disabilities and decided to have an amnio, because we didn’t want to cope with a baby with severe problems. Before the scan we had decided on a termination if anything was wrong. But when we actually saw the baby, we both came out and said, ‘This is it, we won’t have a termination.’ But we still went ahead and had the amnio.”

“We would never have had a termination; I don’t believe it’s right. But if it had been Down syndrome or something, I would have wanted to know so we could prepare ourselves, read up about it, and tell the family in advance. I don’t see why that should be kept from you.”

It is a particularly harrowing experience if the mother is carrying a sex-linked genetic disease that affects only boys, such as hemophilia or Duchenne muscular dystrophy. The latter is a particularly distressing disease in which a child who appears normal at birth suffers a gradual loss of muscular strength, becomes progressively paralyzed and dies at about the age of 20. If the mother is known to carry the disease, her male offspring has a 50% chance of having the disease. Amniocentesis can tell the parents the child’s sex, but not whether he has the disease, so parents can be faced with the agonizing choice of terminating the pregnancy if they are carrying a boy without knowing if he is affected or not. A girl has a 50% chance of being a carrier, but will not have the disease.

IVF has opened up a new possibility for people carrying genetic diseases with pre-implantation diagnosis. Here the woman’s ovaries would be stimulated to produce several eggs, which are collected and fertilized “in vitro.” About three days after fertilization, one cell can be removed from each embryo and tested for presence of the faulty gene. Only normal embryos would be reimplanted and the woman would have the hope of a pregnancy in which she didn’t have to worry about carrying an affected child. However, she would have to go through the full IVF procedure. So far, about 10 pregnancies have been achieved world-wide following pre-implantation diagnosis.

As your baby grows, he also becomes stronger. All that exercise in the uterus pays off. The amniotic fluid serves as a wonderful medium for the baby to exercise in; its buoyancy allows him to move around freely. The muscles develop, and the baby becomes more and more physically capable.

He also gains a layer of fat, which will help him maintain his body temperature after birth. Also helping the baby maintain body temperature is the maturing of the adrenal glands, which make adrenalin [also called epinephrine]. Adrenalin, secreted when the body is chilled, mobilizes energy to warm him up.

Another major area of development in the last three months is the maturing of the baby’s lungs. Of course, while your baby is in the uterus, he does not need to use his lungs for breathing. In fact, they are filled with fluid. Oxygen is breathed in by you and is carried to the placenta and through the umbilical chord to the baby’s body. But towards the end of the pregnancy, the lungs gain the ability to perform the breathing functions. Within seconds after birth the baby takes his first breath, which is usually followed by a good bellow or two. It is with this first breath that hiss lungs become inflated, and they will not stop functioning for as long as he lives. So this dramatic first breath of life is being prepared for in the last trimester of pregnancy.
The Placenta

The placenta is a complex organ that develops along with the baby. Here the exchange of nutrients, oxygen, carbon dioxide, and waste products between mother and baby takes place. The mother sends to the placenta via the blood stream all the nutrients and other substances that the baby needs to grow and develop. The baby sends waste products and his own hormones to the placenta for the mother to take up and either dispose or use.

The placenta is also an endocrine gland. It produces hormones that maintain the pregnancy. By the mid-point of pregnancy, the placenta has taken over many of the functions of the ovaries, producing many of the same hormones, including progesterone. Progesterone causes relaxation of involuntary muscles, including the uterus. It is present in large quantities throughout most of the pregnancy, and keeps the uterus from contracting very much. But during the last few weeks of pregnancy, the amount of progesterone produced by the placenta decreases. This is associated by stronger contractions of the uterus.

Many women report that they are aware of stronger contractions of the uterus in late pregnancy. You may wonder if this is true for you. How can you tell if your uterus is contracting, or whether your baby is simply moving? The best way to tell is to press your hand in several places around the uterus when you feel any strange sensations in the area. If the sensation is caused by the baby’s moving, you will feel firmness in only one area and softness in other areas of the uterus. The firmness may be the baby’s back, and the strange sensations may be caused by the baby’s stretching and pressing his back against your abdomen. If it is a contraction, your entire uterus will be very firm.

The structure of the placenta changes as it ages. For example, the membrane separating the mother’s circulation from the baby’s becomes more open to the exchange of some substances, allowing the baby to extract from the mother’s blood supply some beneficial substances. For example, we all have immunoglobulins and antibodies circulating in our bodies, which protect us from many illnesses. During late pregnancy you are able to pass some of these to your baby, giving him protection against some illnesses that lasts for months after birth.. This protection continues for as long as you breastfeed your child, because these same immunoglobulins and antibodies also pass into breast milk.

Of all the new fertility treatments that have been developed, IVF has had the greatest impact. Since the dramatic news of the birth of baby Louise Brown in England on July 25, I978, IVF has given new hope to women who previously had no hope of a baby due to blocked or scarred Fallopian tubes. At the same time, it is important to remember that IVF is demanding in terms of time and emotional stress. It is expensive, is not readily available, and the failure rate is still high.

The success rate of IVF varies, but the most accurate figures show that just over I0% of all treatments actually result in a live baby. In specialist centers where larger numbers of IVF treatments are performed, the success rate is higher than in small centers, and the success rates also depend on the age of the women treated. If the treatment is at least a partial success-for example, the embryo may be fertilized and divide normally but fail to implant, or the woman might have an early miscarriage-most centers will probably give the woman another chance, but few recommend more than three or four attempts. The success rate of IVF also decreases with the woman’s age, especially once a woman reaches the age of 39. Official figures show that live birth rates per cycle went from I6% of women aged 25 to 34, to II % of women aged 35 to 39, to 5% of women aged 40 to 44. When donated eggs were used, the figures were higher.

IVF is a lengthy process. First, the woman’s menstrual cycle has to be controlled with drugs such as clomiphene or HMG (Pergonal or Humegon) to ensure she will ovulate at the right time for treatment. Drugs are usually used to stimulate her ovaries to produce more than one egg at a time. To do this, the woman’s hormone levels have to be carefully monitored by blood tests and often by ultrasound scanning. This is done so that several eggs can be fertilized at once, increasing the chance of success. Also, more than one embryo may be transferred, to increase the chance of at least one implanting and developing further.

The woman then goes into the hospital for an egg-retrieval operation, which involves a local and sedation anesthesia. A gas is pumped into her abdomen and an instrument called a laparoscope is introduced through a small incision in her abdomen. With the laparoscope, the doctor views the ovaries and can remove any ripe eggs from the follicles. Today, vaginal egg collection is sometimes done. The retrieved eggs are kept in a special culture fluid to allow them to mature. Then they are fertilized with the husband’s sperm, which he is expected to produce by masturbation. Fresh semen is used if possible, because this increases the chance of success slightly, but under the stress of the procedure some men are unable to produce any. For this reason, sometimes semen is collected earlier and frozen in readiness for use at the appropriate time.

The sperm and eggs are mixed in the special culture solution to aid fertilization. If fertilization does take place, the embryos are allowed to develop for two or three days, so doctors can make sure development is normal. The embryos then are introduced into the woman’s uterus in a process usually called embryo transfer. When the eggs are ready to be transferred, the woman will have to lie on her back with legs raised while the doctor passes a sterile catheter containing the culture fluid and embryos through the cervix (neck of the uterus). This procedure is usually done with the help of ultrasound monitoring. A mild sedative may be given to help the woman relax during this procedure, because passing anything through the cervix can be uncomfortable. Following the transfer, most women are asked to rest in bed for I0 to 30 minutes before leaving the clinic.

If there is a choice of embryos available, only the best will be introduced. If not, some embryos that appear less suitable may be used, because they do sometimes develop normally and produce a healthy baby. Most abnormal embryos are lost early. There is no evidence that babies born through IVF are any more likely to have serious health problems than those conceived naturally.

Over a period of months or years, attempts to conceive with the help of IVF can take over a couple’s life. For the woman, it can be difficult to keep a job or do anything else while IVF is being attempted. The frequent disappointments can seem overwhelming. Many mothers also find the existence of IVF, and the opportunity it represents, makes it harder to “let go” and accept childlessness, or, if they already have one child, that their child will never have a brother or sister.

In GIFT, eggs and sperm are collected in the same way as in IVE But then the eggs and sperm are reintroduced together into the Fallopian tube, through the uterus, in a process similar to embryo transfer. It is hoped fertilization will take place naturally. This procedure does not require sophisticated equipment for embryo culture. The embryo is formed not in a culture medium but in the woman’s own tubal fluid. This may mean there is a greater chance of the embryo developing normally and implanting.

GIFT can only be used when the woman still has one functioning Fallopian tube, so it is not an alternative to IVE It is normally used when no reason can be found for infertility (unexplained infertility) or when there is evidence the woman’s cervix is hostile to the man’s sperm, or the sperm are failing to make it to the egg. Success rates of 25% to 30% have been claimed, but in reality the success rate is likely to be similar to that of IVE In cases of male infertility, IVF is probably preferable to GIFT.

Some experts feel GIFT is used too often for couples with unexplained infertility, who have no signs of abnormalities and might conceive normally. One example is Jenny, who had her first son at 33. Two years later, she and her husband decided to try for another baby but seven months later, when nothing had happened, they went for fertility tests. Her husband Tom was told his sperm count was on the low side, but after he had given up alcohol, tried acupuncture and generally improved his level of fitness, they were told there wasn’t a problem. “All the time there was hope; after all, we had had Jake. Time was marching on; Jake was four, I was nearly 38, and still no baby. I felt some pressure. We tried GIFT, but this was very invasive, stressful and didn’t work. My whole life was consumed with treatment and worrying about having a second baby. I worried that Jake was missing out. Once I reached 40 I decided just to give up. Soon after, I discovered I was pregnant with Bradley, who was born safely when I was 4I. Who knows whether I could have become pregnant sooner if we hadn’t been messing around with GIFT?”

Because most infertility treatments do become less successful with age, some doctors and clinics may decline to treat women over 40. However, some doctors strongly disagree with this policy and will treat women regardless of age if they believe the woman has a strong argument in her favor, and there is no reason why she shouldn’t have a baby.

If a woman cannot use her own eggs because the chance of pregnancy is too low, she may succeed with donor eggs. This leads to a situation in which a woman may give birth to a child who is genetically not her own. When donor eggs are used, the embryos are likely to be of better quality and more likely to implant. The risks of a multiple pregnancy in an older-age woman are very real with this method.

The new treatment of using egg donation in women who have had premature menopause or indeed in menopausal women up to the age of 50 was first used in Britain in I986. The first mother gave birth to twins at 46; the second was 43. Research has shown that, provided a woman has no problems with her uterus and she responds well to hormone-replacement therapy, the success rate following egg donation can be high. The oldest woman to date to give birth, in Los Angeles in I997, was 63. She relied on a donated egg and her husband’s sperm.

The success rate when donor eggs are used seems to depend more on the age of the donor than on the woman who receives the egg. In particular, miscarriage rates are the same as those of younger women rather than the higher rates usually found in older mothers.

Following the success of egg donation in helping women in their 40s to conceive, other doctors-notably Professor Severino Antinori in Rome and Dr. Mark Sauer at the University of Southern California-have used the same treatment on women in their fifties with great success.

Many criticize the treatment because it overturns the “natural” order although we know that it can be natural for a woman to conceive as late as 57. But how many women will want to choose that option? Women who have suffered infertility problems for years and given up the hope of ever having a baby may now be able to step forward and receive help. This was the case with Giuseppina Maganuco, a 54year-old homemaker from Sicily, who had spent years unsuccessfully trying to conceive. She had had surgery for blocked Fallopian tubes before being told she was too old to have a baby. Dr. Antinori used donated eggs mixed with her husband’s sperm to achieve the birth of baby Anna Maria in December I99I.

Using donor eggs raises further ethical considerations, They have been used for various infertility treatments, where the woman has no ovaries but has a healthy uterus, where her eggs are unsuitable for transfer in IVF, or where she has some genetic abnormality she does not want passed on to her children, Donating eggs involves the donor going through the IVF procedure except for the embryo transfer. She takes fertility drugs to induce her to produce more than one egg for donation, and she has to undergo a minor operation-called a laparotomy-to collect the eggs. She must be highly motivated to agree to these procedures. Some women who have experienced fertility problems themselves donate eggs, as do sisters, friends or other relatives of the infertile woman. Some doctors are wary of using eggs from close relatives because they fear this may cause stress in the family and confusion in the child as to his or her “real” mother; however, unknown donors are hard to find.

Christine became an egg donor in I99I when her friend Jane was turned down for egg donation at a private fertility clinic. “They told her that, at 4I, she was too old and that they would only give the treatment to a younger woman for whom the chances of success were higher. This was the end of a long saga of fertility problems and miscarriages; she had also been turned down by adoption agencies because of her age.

“I asked her if they would do an egg donation if she found a donor and offered myself. They were reluctant; we had to bully them into it. I had to have counseling to make sure I understood what I was doing, and I had to sign a piece of paper waiving all my rights to the eggs. I had an AIDS test, and I had to have a course of ten injections and use a nasal spray every four hours or so. My cycle had to be synchronized with hers so they could use some of the eggs fresh to increase her chances.

“I did the injections myself, every morning in my rear, for ten days. I had to remember to use the nasal spray, which I didn’t