Chapter 8

A Healthy Pregnancy

In this chapter, you’ll learn what happens during each trimester when you are pregnant. This includes information that I feel is crucial: when you can have sex and when you can’t.

For millennia, women had their babies without the help of doctors. They birthed them out in the fields or in their caves or wherever, perhaps with the help of other women and perhaps not. In some places in the world, that’s still the way it happens. So why does a woman need an obstetrician when she discovers she’s pregnant? The biggest reason is that so many of those women who went into labor without the benefits of modern medicine died in the process, as did their children. Although giving birth is the most natural of occurrences, it also carries a lot of risks.

Assuming that you’re not going to chance giving birth without medical supervision, what do you need to know? I will go over some of the basics, but there are dozens of books devoted to just this subject, where you can find a lot more detail than I have room for here. What I’m going to concentrate on in this chapter are two areas that are not covered in depth in most books on pregnancy—sex during pregnancy and how to make best use of your Ob/Gyn.

Your Due Date

The due date is among the most important pieces of information to be determined during pregnancy. Everything in pregnancy revolves around the due date. Every woman wants her obstetrician to tell her the date her baby will be born, even though only 5 percent of babies are born on their due date; most are born within two weeks before or after their due date. For a doctor to accurately answer that question, he or she would have to know the exact day you became pregnant, and often there may be no precise answer to that question, which in turn is why there are many different ways of timing your pregnancy.

Knowing the first day of the last menstrual period is usually the first step in determining the due date. if you’re trying to get pregnant and want to know your due date to the greatest degree of accuracy, I suggest that you keep a diary of your menstrual periods and the days you had unprotected intercourse (if you also keep track of your basal body temperature, that will help increase the accuracy of the prediction). Yes, offering these statistics to your doctor might be a little embarrassing, but that type of information is very useful in coming up with a due date.

The method that doctors use most frequently to calculate your due date is called the gestational age method, and it is measured by adding 280 days from the first day of your last period. A more accurate method would be to add 266 days from the day of ovulation or fertilization, if you know that day. With this method, pregnancy is determined in weeks and days from the first day of your last period. This can sometimes be confusing, because when your gestational age is, for example, fourteen weeks, you are in fact only twelve weeks pregnant, because in most cases fertilization and ovulation happen around two weeks after the first day of your menstrual period. The fetal age is the actual age of the growing fetus from the time of conception, but, as I said, that may not be known unless you’re aware of exactly when you ovulated, you had a basal body temperature curve or took drugs to induce ovulation, or you had in vitro fertilization. So while a pregnancy is supposed to last nine months (or, more precisely, your due date is supposed to occur 266 days from ovulation/fertilization or 280 days from your last period), calculating your due date is far from an exact science, both because your doctor often simply estimates the exact date you became pregnant and because your body may decide to go into labor either earlier or later than what is considered average.

Other ways to determine how far along you are in your pregnancy are by having sonograms done and by measuring the fetus. The earlier in pregnancy that a sonogram is done, the more precise it is in determining the due date, which is another reason that you need to see a doctor as soon as you know you are pregnant, assuming you haven’t gone beforehand as I suggested.

The Trimester System

Pregnancy is usually divided into three trimesters, based on the development of the fetus and the changes that you will undergo, although, for your growing baby, development occurs every day, and these trimesters actually have little meaning other than as an indication of how you may feel.

Your first trimester begins at the time of conception, when a sperm enters an egg you’ve released. This usually occurs in the fallopian tubes, and it takes from six to twelve days for the fertilized egg to make its way down into the uterus and implant itself into the uterine lining. Until that happens, your body has no idea that pregnancy has begun, but once implantation occurs, you will often begin to notice some changes within days, especially if you are attuned to them. These changes are caused by the increase in your hCG pregnancy hormone levels. Your breasts might swell a bit and feel tender. You might also see a difference in the coloration of the areolas. You might feel nauseous, especially in the morning, and have some unexpected bleeding, which will occur as a direct result of implantation. Don’t be surprised if you feel more tired and if the time between trips to the bathroom grows a lot shorter. While you’re experiencing these symptoms, your baby is making quite a lot of progress as well. In fact, by seven weeks into your pregnancy, it’s possible to pick up a tiny heartbeat with a sonogram.

Most women find that they’ve never felt better than during their second trimester. You’ll be wearing maternity clothes, because your belly will have made your old wardrobe obsolete, but that means your baby has grown a lot and is getting ready to greet the world. In fact, it’s during the second semester, usually around the fourteen-week mark, that the quickening occurs. This means that you’ll be able to feel your baby move around. What a great feeling that is!

On the down side, you may start to see stretch marks on your belly and may notice some skin discoloration, even on your face, which is sometimes called the mask of pregnancy. Itchy skin on your abdomen, your palms, and the soles of your feet may be annoying, but if the itching is accompanied by a sudden, extreme weight gain, nausea, and jaundice, let your doctor know as soon as possible, because these symptoms could be signs of a liver problem. You may also notice swelling of your ankles, fingers, and face. If that swelling becomes extreme, and you also gain a lot of weight suddenly, go see your doctor immediately because those could be signs of preeclampsia, which is a dangerous condition.

Communicating with Your Doctor

Your third trimester is when you really begin to feel as if you’re going to have a baby. You’ll want to be reading those books you bought so that you can get the answers to the flood of questions that you’ll have, especially about how labor will be for you. Those books, if you’ve selected the right ones, can give you more information than you can digest, and because you know your doctor is a busy person, you might think that you shouldn’t bother him or her with all of your questions. (Of course, some women have the reverse problem and bombard their doctor with questions that they could easily get the answers to elsewhere.) But what I want to point out here is that talking to your doctor at this point isn’t so much about transferring information as it is about team building.

From Dr. Amos’s Office: The Importance of Communication

I’ve lost count of how many babies I’ve delivered. Hearing that patient X or Y has gone into labor doesn’t cause me to panic; it’s just part of my normal workday. But for my patients, it’s very important that they have full confidence in me because the more confident they are, the better the outcome of labor will be for them. Sometimes they have to push very hard to avoid having a C-section. They have to believe me when I tell them that they can do it. They mustn’t think that I don’t really care, that I’m only some stranger with medical knowledge. That’s why the communications that I have with my patients during the entire course of their pregnancies are so important. The closeness of our relationship will really come into play in the delivery room, but it’s not something that can happen instantly. It’s a relationship that needs to form over time. That’s why it’s important that you ask your doctor questions. It’s not what he or she tells you, it’s the fact that you’re communicating and building a relationship, so that when the time comes for you to give birth, the two of you will work together as a team, confident in each other’s abilities.

Sex during Pregnancy

Although engaging in sex is what causes pregnancy, the issue of whether a couple can continue to have sex during pregnancy is often a stumbling block. While the answer to the basic question of whether it’s okay to have sex is yes, it’s not always as simple as that.

Assuming this is your first baby, it’s important even during pregnancy that this child doesn’t have a serious, long-term negative impact on your sex life with your partner. The key word is long-term. If a couple doesn’t have sex for a short period of time because of pregnancy and postpartum issues, that shouldn’t have an effect on their overall relationship. Yet sometimes other issues can develop during this nonsexual time period that can have long-lasting and damaging repercussions. Some new moms become so engrossed with and exhausted by motherhood that they lose their desire for sex, and the couple’s sex life can become permanently damaged. Some new dads suddenly see their wives more as mothers than as sexual beings, and they may have difficulties becoming aroused by their wives. A sexless marriage is one that is in great danger, so you have to overcome these obstacles, rather than ignore them. I’ll get into more detail in a bit.

The basic answer to whether it’s safe to engage in intercourse is that the penis entering the vagina cannot harm the child unless there is some sort of medical complication. Some women are more likely to have a premature birth if they have sex. Also, if you have a condition called placenta previa, your doctor will forbid you from having intercourse. But for most couples, other than making adjustments for the woman’s growing belly, which will render some positions impossible during the third trimester, intercourse poses no danger to the child.

From Dr. Amos’s Office: Restrictions on Sex

Examples of when your doctor may suggest that you do not make love during pregnancy include

If you are at risk of having a premature birth or labor.

If you are having multiples (twins, triplets).

If you have a weak or short cervix.

If you have placenta previa (where part of the placenta is covering the cervix).

If your water has broken.

If you experience vaginal bleeding.

If you or your partner has an active sexually transmitted disease.

You may have noticed that I’ve been using the word intercourse. A couple can still give each other sexual satisfaction even if intercourse is off limits. I would strongly suggest that the woman continue to play a role in her partner’s sex life, even if she doesn’t feel like having orgasms herself. What happens if she doesn’t? The man will feel sexually frustrated, so he’ll masturbate. In most cases, that’s not a big deal. Many people with partners masturbate when they feel the desire for sexual release and their partners don’t. Yet what’s different about this situation is that the period of time when the couple’s normal love life is interrupted could last for months. Reestablishing normal relations after such a long time could be problematic. Maybe the man has felt free to use porn during this time and finds that he doesn’t want to give it up so easily. If the woman needs a kick-start to get her sexual desire going again, and he’s not that eager to help because he’s found other outlets, their sex life could wind up seriously damaged.

To most men, the whole process of pregnancy is a bit mysterious, so they give a lot of leeway to their pregnant partners. They’re a little afraid that if something goes wrong, they’ll get blamed, so they’re willing to go out of their way to please their wives. When it comes to little things, such as getting ice cream at midnight, that’s more a sign for the woman that her partner is there for her than it is a need for ice cream. It’s a confidence builder more than anything else. Yet sex is also a confidence builder. It tells the woman that her partner still finds her attractive, and it tells the man the same thing. When sex is taken out of the equation, it reduces both of their confidence levels. It’s natural to feel a little nervous when your family is about to undergo such a drastic change, and maintaining your sexual relationship is an important bond.

So, what am I suggesting? First, that you not put sex on the back burner. Even if you can’t have intercourse, maintain as much of your sexual relationship as possible. Don’t just give each other a peck on the cheek but really kiss. Touch each other’s bodies sensually. Give each other orgasms, no matter what method you use. Continue to be sexual partners, as well as new parents. Make sex a priority, and you, your relationship, and therefore even your child will benefit.

If you have any questions, ask your doctor. Even if your doctor says you shouldn’t do X, Y, or Z, you’ll also know that you can do A, B, and C. Having the confidence that certain sexual activities are entirely safe will make it more likely that you engage in sexual activity. But if you’re in the dark and secretly worried that having sex might endanger your pregnancy in some way, then you’ll avoid all sexual activity. For example, you won’t kiss sensually because you’ll be afraid of producing feelings of arousal. So although you absolutely need to carefully nurture that new baby growing inside of you, at the same time you also have to nurture and pay attention to your sex life.

Your twenty-ninth week of pregnancy announces the beginning of your third trimester, and the finish line is almost in sight. With your baby having grown so much, many of your organs are being squeezed, which will undoubtedly cause you to feel the urge to urinate more often, may give you constipation, and could even make breathing more difficult. By the beginning of your third trimester, you should have begun any childbirth classes you and your partner were planning to take, just in case you don’t make it all of the way, which can be the result of faulty calculations or a baby who is impatient and can’t wait for the full term to be up. As you near the end of the road, you’ll be visiting your doctor more often because you’ll both want to see how you’re progressing.

Your uterus will have to put on quite a show to force the baby out. In order for it to have the necessary strength, it’s going to practice from time to time. These practice contractions you may feel are called Braxton-Hicks. They are harmless, unless they happen before thirty-seven weeks. If you do feel regular contractions before thirty-seven weeks, you should contact your doctor or go to the hospital to make sure you are not in premature labor.

With Braxton-Hicks contractions, at first you may think that you’re going into labor, but although this will be the first time you feel these sensations and they will feel odd, these practice contractions are not strong enough and regular enough and do not last long enough to cause your baby to come out.

As I said earlier, having sex while pregnant poses no dangers to the baby. Of course, you’ll be a lot less comfortable, and you may lose your desire for sex because of that. In some cases, your partner will lose his desire, mostly out of fear that he could endanger the baby. As in the second semester, if you both feel like having sex, know that you can safely have sex, including orgasms; you simply have to find comfortable positions. Although I never want any couple to have sex under pressure, as I’ve stated, it’s important not to allow your sex life to die out altogether, so don’t take what may appear to be the easy way out and avoid sex.

As the time approaches for you to have your baby, you’ll discover that your doctor is most concerned about how dilated your cervix is. No matter how strongly you feel the practice contractions, until your cervix starts to efface (to grow flatter and wider), you’re not ready to give birth. But once that starts to happen, you’ll know the moment is at hand. Your doctor will also take note of the placement of the baby. Up until the end, the baby is up high, around your abdomen. But near the time when you’re going to give birth, the baby “drops,” that is, the bump will get lower on your abdomen, which is another sign that you’re almost due.

Another sign that you’re close to giving birth is when your water breaks. When this happens, the sac that contains the fluid that your baby floats in ruptures, and it all comes pouring out of your vagina. If this happens at a time when you’re not yet in labor and not feeling strong contractions, don’t let that stop you from rushing to the hospital. Your baby needs that fluid, and even if you’re not ready to deliver, your doctor will do whatever is necessary to bring your baby into the world.

Labor

Labor is a very appropriate name for this stage of your pregnancy, because it won’t happen without a lot of effort on your part. Babies have been descending through the vaginal canal since time immemorial, so you have to accept that you can push a baby’s head through your vagina. Just don’t let anyone talk you into believing that it’s going to be easy, because it’s not.

Now, in general, women who’ve delivered a baby before have faster labors, and women who have their first baby have slower labors. Some women take twenty-four hours, and others take less than an hour, and there’s no way to tell ahead of time what your labor will be like. From a psychological point of view, it’s better not to think about it ahead of time and just accept whatever happens. There are couples who try to plan out everything, down to what music will be playing, but once you’re in labor, you won’t care about anything but pushing that baby out.

Cesarean Section

Not every woman can give birth vaginally. As I mentioned earlier, many women used to die in childbirth because of long labor or hemorrhaging, but today, if this happens, the situation is far from grave. Your doctor can make an incision in your abdomen and remove the baby safely. The main difference between giving birth this way and vaginally is that you’ll have a scar in your uterus and on your skin and it will take longer to heal, although your vagina won’t undergo any stretching and will not need any healing time at all. In addition, any future pregnancies will be different because of your cesarean section. Your baby may also look better, because a long labor, especially if forceps are required to help the baby through the vaginal canal, can make the heads of some newborns misshapen and bruised. Yet all of that doesn’t matter because in a few weeks’ time, you’ll never know the difference.

There can be several reasons that your doctor will decide during labor that this delivery needs to be made via C-section; these include

Some women and their doctors decide ahead of time that their babies are going to be delivered by a C-section.

The Top Ten Reasons for Having a C-Section

1. You’ve had a C-section or another uterine surgery before and are not a candidate for vaginal birth.

2. Your labor is too slow or it stops.

3. The baby shows signs of compromise that necessitate an expeditious delivery.

4. Your baby is in the wrong position, such as the breech position, that is, feet first, rather than head first, or transverse lie. Although a vaginal breech birth is possible, many doctors feel that it’s safer to deliver such babies via C-section.

5. The baby is very large, making a vaginal birth risky or even impossible.

6. You develop placenta previa, which means that your placenta is covering the cervix, so that the baby can’t go through it to enter the vaginal canal.

7. You’re carrying more than one baby, and multiple births are considered too risky for vaginal delivery.

8. It’s discovered that you or your baby has some medical condition that would make vaginal delivery too risky.

9. You have an outbreak of herpes.

10. Another reason is “cesarean delivery on maternal request,” which means the mother requests a cesarean, but there are no specific medical or other indications.

Because of these possibilities, more than 30 percent of all deliveries in the United States are done via C-section these days, up from only 6 percent in 1970. Have matters changed medically to such a degree that so many more C-sections are being done? Probably. Here are some possible reasons for this rise in C-sections:

One factor that has changed is that doctors can now perform a C-section using a horizontal skin incision (the “bikini cut” or “Pfannenstiel incision”) so that the resulting scar is much smaller and can be placed below the bikini line. In addition, anesthesia and surgical care have become better, and these advances mean that more women are open to having Cesarean sections, which allow them both to avoid the hard work of labor and to plan the exact date that they will give birth. These days, when mothers who work outside the home remain at the office until the last possible moment, such timing may be considered important.

Your partner will probably be allowed to stay in the operating room during a cesarean section, unless it is an emergency C-section, and there isn’t enough time to have him get completely gowned. Also, if he reacts poorly in the operating room, he may be asked to stay outside.

Pregnancy Complications

Although it is common for a pregnant woman to experience some bleeding during her first trimester, this is not true for the second and third trimesters. If you experience any bleeding, report it to your doctor. It’s important to judge how much you are bleeding, so try to keep track. Wear a pad that will help you do this. Do not insert anything in your vagina while you are bleeding, so don’t use a tampon and don’t have intercourse.

Sometimes intercourse can cause a woman to bleed. Because the cervix of a pregnant woman has bigger and more plentiful blood vessels, if the penis comes into contact with one, a little bleeding may occur. You might be tempted not to mention anything to your doctor if this happens, especially because pregnant couples are already a little afraid to have sex. If they feel that they might have endangered the pregnancy in any way because they’ve had sex, they’ll feel especially guilty and are more likely to give up on having sex than talk to their doctor about the bleeding that occurred. The fact is that you are very unlikely to harm your baby by having sex, and this type of bleeding is not dangerous. But your doctor still needs to know about it, in case the timing of the bleeding during intercourse was only coincidental, and the true cause is something more serious.

It’s amazing how much privacy you lose in the process of having a baby, so that you even have to share your sex life, but in the end, that can be a good thing. Too much inhibition isn’t good for a couple’s sex life, so if you lose some of those inhibitions during pregnancy, you may be able to put your newfound freedom from prudishness to good use later on.

Postpregnancy Care

It takes longer for you to heal from a C-section, because it’s a relatively major surgical procedure. Yet no matter how you give birth, your body will soon recover. When it does, it’s important to work on regaining your previous physical conditioning, the muscle tone and stamina you had before your pregnancy. If you’ve put on a lot of weight and are breast-feeding, some of it will come off naturally but not all of it. Although having a new baby is tiring and will seem like a lot of exercise, you’ll need to begin working out again so that you stay healthy.

Breast-feeding is encouraged because it’s healthier for both babies and mothers. If you have problems with breast-feeding, by all means let your doctor know about it, and consider talking to a lactation consultant.

You also need to make sure that you are psychologically healthy. Some new mothers get the blues, while others become severely depressed. The blues can be normal, but depression is not. Even though being a new mother is supposed to be one of the happiest times in a woman’s life, anywhere from 10 to 20 percent of women will experience some symptoms of postpartum depression. A shocking fact is that 50 percent of women who have depression symptoms will experience major depression. Depression is hard to handle at any point during life, but the hormonal changes of being pregnant, combined with the duties of new motherhood, make depression even harder to bear. The following information will help you determine the difference between a simple pregnancy-induced hormonal imbalance and a more serious depression issue so that you will know what you are up against.

What Is Pregnancy Depression?

Pregnancy depression is the same as any other depression, in terms of being a mood disorder and a chemical imbalance. The only difference is that this depression occurs during or after pregnancy or is brought on by the hormones of the pregnancy itself.

If you are experiencing any of the following symptoms for two weeks or longer, you may have pregnancy depression and should talk with your doctor.

Signs of Pregnancy Depression

Following is a list of things that could possibly cause the onset of a depression during pregnancy.

Treatment of Pregnancy Depression

Depending on the severity of the depression, your doctor has to decide whether it can be treated without medication or whether you do need medication. For mild forms of depression, here are several options that you and your doctor can use to help you.

Many forms of depression will respond only to medication. Your doctor will choose a medication that’s safe for both you and your baby. Not taking medication to treat the depression may be counterproductive because women who are depressed are less able to take good care of themselves and their babies.

Keep in mind that feeling sad from time to time or worrying about the baby is normal, and it will usually pass. You are not depressed if you have these feelings occasionally, due to either circumstance or hormones, and you should not worry excessively about being depressed. The depression becomes an issue only when these feelings do not go away, and you start to suffer because of them. If you think any of the symptoms in this section describe how you feel, you should definitely speak to your doctor right away.

If you become depressed, it’s important to recognize it and combat it. If you wallow in sadness, it won’t be good for your health, your baby’s well-being, or your relationship with your partner. When you feel a flood of sadness coming on, do something to change your thoughts. Put on some lively music. Call your best friend who makes you laugh. Watch a sitcom. Strap your baby into a carrier and go for a fast walk. (Exercise causes your body to release endorphins that make you feel better.) Although I know that your new baby will occupy your mind most of the time, don’t forget about your partner. Keep in mind that your relationship should last forever, long after your children will have gone off on their own, so while your partner can take care of himself physically, your mutual relationship needs tending, and that includes your sex life. You do have to wait for your doctor to give you the go-ahead for intercourse, but once that happens, no matter how tired you are and no matter how low your feelings of sexual arousal, make the effort to jump-start your sex life. It may take a little concentration on your part, but once you get it going again, it should do quite well on its own momentum. Yet getting that engine going can be difficult at first, so be prepared to put a little extra energy into that part of your life, and you’ll ensure that your relationship will be there for you well into the future.