Pregnancy, Childbirth

We calculate pregnancy from the first day of the last period (TEP) and lasts forty weeks. We divide it into three unequal quarters. The first trimester lasts until the twelfth week. After that, the second trimester lasts from the twelfth to the twenty-fourth week.

Finally the third trimester, which is the longest in duration, starts from the twenty-fourth week and lasts until childbirth. The first visit takes place after the sixth week, when we are late 15 days on our period.

Historical Context

The doctor will obtain a full and detailed history on the first visit. He/she will ask you about inherited diseases that you or your partner may have, as well as your families. For illnesses you have had in the past or are suffering from, as well as medications given before pregnancy.

The gynecologist will ask you about your period, its duration, or any problems you may have. They may also ask you about first intercourse, your partners, frequency of contact and any sexually transmitted diseases you may have had in the past. For the contraception you were taking, for previous pregnancies or their abortion.

Finally, we will ask you for any gynecological surgeries, as well as, other surgeries. In case it is not the first pregnancy we will ask you about the duration of the previous pregnancy or the previous ones, as well as about the outcome and the weight of the child/children.

Physical Examination

In each visit, the doctor will examine your legs for varicose veins and swelling. A slight swelling as the pregnancy progresses is normal due to fluid retention, but excessive swelling is a sign of preeclampsia usually in the third trimester.

The gynecologist will palpate the breasts to see if there are any tumors. He/she will measure your weight and pressure.

Gynecological examination

During the gynecological examination, the gynecologist will inspect the vagina to determine any anatomical abnormalities of the vagina or the cervix. The doctor must always do the examination carefully due to pregnancy. If you have not had a Papanicolaou smear (Pap test) for more than a year, he will do that test too.

The Pap test is especially useful for us. It helps us know the condition of the cervix in early pregnancy, since during pregnancy a large increase in hormones can differentiate the condition of the cervix faster than usual.

Weight measurement

During the first visit, the doctor will record the weight of the pregnant woman. The gynecologist will weigh the pregnant woman at each visit to check if it is in line with the week of pregnancy she is going through. The total weight gain should be 9-12 kilos throughout pregnancy.

A slight weight loss during the first trimester is normal due to morning sickness and vomiting. But a larger-than-normal increase should draw our attention to nutrition.

A sharp increase may be a sign of preeclampsia.

Excessive weight gain during pregnancy creates fetuses larger than the woman’s body type and disproportional during childbirth. The disproportion (large fetus in relation to the pregnant woman’s pelvis) leads to a cesarean section.

Excessive weight gain is also responsible for diabetes mellitus in pregnancy, a dangerous situation during pregnancy.

Vaginal Fluid Culture

In the first weeks of pregnancy, we always do a vaginal fluid culture to see if there is an infection that could cause problems throughout pregnancy. It is cultured for common germs, such as streptococcus B, gardenela vaginalis, etc., sexually transmitted diseases, gonorrhea, hair follicles, etc., as well as for chlamydia, mycoplasma, ureaplasma. Germs can cause problems in pregnancy, premature birth and fetus infection. In case of infection, we give the appropriate treatment and we repeat the culture after its end.

Fertility specialists repeat the vaginal fluid culture during the eighth month to investigate any germs that could infect the fetus during childbirth.

Ultrasound

We do the first ultrasound on the first visit. We will determine the kind of the pregnancy (intrauterine or ectopic) as well as the number of fetuses (one or more). Also, after 6 weeks we can see on the transvaginal ultrasound the heart of the fetus that beats.

We will measure the fetus so that we can determine its ultrasound age and determine the probable date of birth.

Examination

In the first trimester, the woman will do a series of blood tests. Their results will provide useful information.

In general blood tests, we check the basic characteristics of the blood, such as hemoglobin (Hb) levels, white blood cells, hematocrit, platelets. Hemoglobin is the basic protein that contains iron and carries oxygen to the tissues and the fetus.

Low hemoglobin levels mean anemia. You need to enrich your diet with iron supplements and foods rich in iron. White blood cells are part of the immune system and if they increase, it means that you have an infection.

Platelets show the ability of blood to coagulate in the event of bleeding.

In the general urine tests we check the condition of the kidneys, organs that are overactive during pregnancy. Detection of many pyospheres is an indication of a urinary tract infection, which is more common during pregnancy due to an increase in vaginal fluid.

In this case, we will perform a urine culture to detect the germ and give the appropriate treatment.
If we find urine sugar in two consecutive tests, this is a sign of gestational diabetes. In this case you should have a special blood test to check your blood glucose levels.

High urine albumin is a sign of preeclampsia or urinary tract infection.

The presence of ketone in the urine indicates metabolic disorders and is a sign of diabetes. It is the cause of malignant vomiting during pregnancy.

Blood sugar testing is very important that can detect gestational diabetes. Even from the beginning of pregnancy, which is more common today. If we find an increase in blood sugar in early stages of pregnancy, then we will perform a frequent examination.

These tests will reveal blood type and rhesus factor. The blood type is important in case of transfusion. Rhesus factor is more important in pregnancy. It is a protein that when it is on the red blood cells we have rhesus positive, in its absence we have rhesus negative.

In a rhesus negative woman, if her partner is rhesus positive, or has given birth to another rhesus positive child, then she needs special attention during pregnancy. We check the Rhesus factor every month.

Iron is a key component in the production of hemoglobin and the transport of oxygen. Usually, women with menstrual blood loss due to menstruation are deficient in iron. We give iron supplements during pregnancy, due to the increased need of the mother and the fetus.

Ferritin is the iron transporter in the blood.

Hemoglobin electrophoresis shows whether you are a carrier of the stigma of Thalassaemia or other anemia. If the test is positive, the father should be checked to see if he is also a carrier.

If we have two positive results we must check the fetus for Thalassaemia or other type of anemia.

Doctors test the patient for toxoplasma. Toxoplasma is a parasite that lives in cat feces. In case of infection, apart from pregnancy, the woman develops antibodies against the germ that usually protect her for the rest of her life.

However, if she is infected during the first trimester of pregnancy, when there are no antibodies, then the germ infects the fetus, causing miscarriages or severe problems in the fetus. In case the pregnant woman has not come in contact with toxoplasma, special attention to hygiene is recommended and the antibodies are checked regularly.

This test determines if the pregnant woman has antibodies against rubella. If he is not immune then he should avoid contact with people who have it. If she gerts infectioned during the first trimester, then the fetus is at risk of blindness, deafness and heart problems.

In case of infection in the first trimester, the pregnancy is usually terminated. In non-pregnant women who are planning a pregnancy, the vaccine is recommended if there is no immunity.

It is a virus that should not affect the pregnant woman in the first and second trimester, because it creates problems in the fetus.

If the pregnant woman suffers from hepatitis, she must take special care in any operation during pregnancy to prevent the virus from being transmitted to the fetus. The period of childbirth and the puerperium is more important so that we do not have a virus infection of the fetus.

After childbirth, we perform immunoprophylaxis and vaccination in the fetus.

Listeria is a germ we find in feces. There must be special hygiene and in case of infection treatment. It can cause premature births and miscarriages.

Syphilis is a rare disease today. If a woman is infected with this germ she should be treated before pregnancy. During pregnancy, it transmits the germ to the fetus, which causes severe damage.

The heart is an organ that over-functions in pregnancy, so a cardiological examination and an electrocardiogram are necessary to rule out any problems that may be caused by the pregnant woman’s heart.

It is the use of ultrasonic acoustic waves, which we do not hear or feel but give the image of the fetus and placenta. Ultrasounds are safe for both you and your fetus, so you can repeat them as often as your doctor recommends. During pregnancy, ultrasound is a very useful diagnostic tool. At the beginning of pregnancy, we use them to determine the time of pregnancy, the number of fetuses and their viability.

Later we evaluate the fetus growth rate, the position of the placenta, the amount of amniotic fluid as well as any anatomical abnormalities of the fetus.

If your pregnancy is going smoothly, you will not need to do more than three ultrasounds. An ultrasound is also used as an adjunct to invasive methods such as amniocentesis and trophoblast retrieval. It can diagnose 70% of serious abnormalities and 40% of minor abnormalities with which a child may be born.

The most usual are during:

  • The 6th week. This is the first and most important ultrasound. The doctor will determine that everything is alright and the position of the fetus.

  • About the 8th week. In this stage of pregnancy, the doctor can precisely determine the age of the fetus. At the same time they confirm the normal development of the pregnancy, with the main point of reference being the indication of the fetus heart function.

  • Between the 11th and 14th week, they perform an ultrasound to determine the cervical transparency (thickness of the tissue above the fetal neck). They also do an examination for any abnormalities in the fetus (such as Down syndrome).

  • The 20th – 22nd week, they perform the B-level ultrasound. In this process they can examine 75% of the fetus. During this ultrasound, they examine the anatomy of the fetus in detail and they determine the position of the placenta. Also, we measure the amount of amniotic fluid, the development of the fetus and we investigate any chromosomal abnormalities. The ultrasound also identifies those pregnancies that show a higher risk of residual intrauterine growth or preeclampsia.

  • Finally, at about week 30, we have a Doppler ultrasound of the blood vessels. This measures blood flow to the umbilical cord in both uterine arteries, to see if the placenta is getting enough blood or if there are signs of placental insufficiency. Some obstetricians advise that this test be performed on all women and others on those who have complications in the present or previous pregnancies.

The ideal time to perform this test is between the 28th and 32nd week. Then the baby’s facial features are well developed and there is enough amniotic fluid to capture quality 3D images. The advantage of 3D and 4D ultrasound is that it gives the pleasure to see the fetus in real time moving in its natural environment. This results in an easier diagnosis of anatomical defects and genetic dysfunctions in the formation of the upper and lower limbs, as well as various abnormalities, such as the larynx, lycostoma or split spine.

The conclusions that will be drawn can be very helpful in planning the treatment and care that will be given to the baby after birth. The images are stored on the computer in digital format and can be re-studied in a future examination.

We usually do the A-Fetoprotein test at the end of the fourth month. It is a special substance, which we find in your blood in various quantitative levels throughout pregnancy. It comes from the neural tube of the fetus. Measurement of α-fetoprotein is mainly used to check for neural tube defects in the fetus, such as spina bifida and cerebellum.

We do the test between the 15th and 20th week of pregnancy. It is not completely diagnostic for the existence of genetic abnormalities. However, if α-fetoprotein (AFP) is unusually high, additional tests including ultrasound and amniotic fluid testing for AFP are necessary.

The α-fetoprotein test is performed in combination with the measurement of estriol and chorionic gonadotropin. The combination of the 3 tests is known as the “triple test” or “alpha test”. Measurement of these three molecules provides information for neural tube defects, trisomy 18 and trisomy 21 (Down syndrome). The exact fetal age is necessary for the exact result of the test, because the levels of the measured factors differ depending on the age of the pregnant woman.

You will do it between the 36th and 38th week, in order to assess the risk of premature birth or intrauterine infection.

Special exams

If and when it is determined that there is a possibility of an abnormality in the baby, the doctor resorts to special tests that reveal possible damage to the fetus. With these prenatal tests, the baby’s state of health is examined so that it is not born with serious diseases, such as Down syndrome or Thalassaemia or fibrocystic disease. Only expectant mothers whose history – or that of their partner – has risks on the baby’s health undergo these special tests such as:

  • If the expectant mother is over 35 years old, the chances of her baby being born with chromosomal abnormalities such as Down syndrome increases.

  • Whether she or her partner are carriers of a chromosomal abnormality, but without getting sick, carriers of Thalassaemia or other serious diseases or have inherited diseases.

  • If the pregnant woman has already given birth to a child with chromosomal abnormalities or has a history of miscarriage.

  • When the B-level ultrasound shows that the fetus has a congenital anomaly, or if the cervical smear together with PAP-A is abnormal.

Prenatal diagnosis methods

Today we have various techniques, invasive and non-invasive, for prenatal diagnosis, as long as there are “suspicious” indications.

The most common techniques are:

It takes place in the first trimester, in the 10th to 12th week of pregnancy. Trophoblast retrieval involves examination of the chorionic villi (very small pieces of the placenta). The fetus and placenta grow from the same cell and so the chromosomes of the placenta cells can be used to control the chromosomes of the fetus. A local anesthetic is given and a thin needle is pierced through the uterus to remove a small sample of chorionic villi. The needle is constantly monitored via ultrasound to avoid possible injury to the fetus. The whole process takes 2-3 minutes and then the heart function of the fetus is checked.

It occurs in the 16th to 18th week of pregnancy, especially when a woman is pregnant and over 35 years old, or when there is a family history of a genetic disease. The doctor with a needle pierces the abdomen, the uterus and reaches the amniotic sac. With the needle he takes amniotic fluid in which there are cells of the fetus. The goal is to find or not chromosomal abnormalities.

This is an examination performed after the eighteenth week of pregnancy, in rare cases, and safely reveals the possibility of Rhesus incompatibility and whether or not the fetus suffers from a chromosomal abnormality.

The PGD (preimplantation genetic diagnosis) technique is a pioneering development in the field of prenatal diagnosis, applied in recent years by infertility specialists, in conjunction with in vitro fertilization (IVF) and detects genetic diseases of the fetus before embryonic non-fetal transfer cavity. It enables couples with an indication of a problematic pregnancy with monogenic inherited diseases for the fetus, such as Thalassanemia and fibrocystic disease, or with chromosomal abnormalities, to choose a pregnancy with normal markers and healthy fetuses. The procedure involves a biopsy of a cell from each IVF embryo, which is tested for a genetic disease. The cells with no chromosomal abnormalities and other inherited diseases are then implanted in the mother-to-be.

Childbirth

Childbirth is different for each woman. But the only true sign of the onset of labor is frequent and periodic contractions. The duration of childbirth also varies from woman to woman. The average duration of the first birth is 12 to 14 hours, while in the next ones last less.

When to call the doctor

As the crucial moment of childbirth comes, most women are very worried and therefore often need to be reassured by their doctor about whether or not labor has begun. You should call your doctor if:

  • The contractions are every 10 minutes.
  • You have a rupture of membranes (water breaks) especially if they are not clear.
  • You have vaginal bleeding.

  • There is severe pain and difficulty walking during contractions.

  • Worry about your health or the health of your baby.

If you have any symptoms that concern you, do not hesitate to tell your doctor at any time of the day or night.

At the hospital

When going to the hospital, take with you the things you have prepared in advance. Go to the hospital reception and there the doctor or midwife will listen to the heart of the baby to make sure everything is going well.

A gynecological examination will be performed to assess the thickness, texture and dilation of your cervix.

You will take a quick shower and wear a nightgown. The nurse will then accompany you to a room with a cardiotocograph to measure uterine contractions and fetus heartbeats.

The stages of childbirth

Childbirth is divided into 3 stages:

Dialation. This stage begins when a pregnant woman begins to have normal contractions, which help to dilate the cervix. Usually this stage is divided into two phases. The 1st phase, ‘latent’, lasts from the beginning of cervical dilation to 4cm dilation.

From 4cm onwards, the ‘active’ phase of dilation begins, with which the contractions expand the cervix up to 10cm. The first stage of childbirth can occur in a woman gradually having for several hours uncoordinated contractions.

In other women, the onset of labor may be clear and the contractions may begin with a fixed duration and period from the beginning. The average duration of the first stage of a normal birth is 10 hours.

Extrusion. This stage begins when the cervix is fully dilated (10cm) and ends with the birth of the baby. The average duration of this stage is 1 to 2 hours, but this varies from woman to woman and from childbirth to childbirth.

Delivery of the placenta. This stage begins immediately after the baby is born and lasts until the placenta and membranes inside the uterus come out. This takes from 10 minutes to 1 hour.
Usually the placenta detaches within 5-10 minutes.
After childbirth

After birth and the placenta the uterus continues to contract, much lighter, to shrink, strangling the blood vessels that supply blood to the placenta, thus avoiding bleeding. They check the uterus periodically to make sure it stays contracted and dry (non-bleeding).

The vagina is cleaned of blood, amniotic fluid and mucus. Then, they suture the small incision made in the vulva. A specialized pediatrician takes care and monitors the baby, in order to receive the best care in the first minutes of his life.

If the uterus is not contracted enough, the woman receives oxytocin (a hormone that causes the uterus to contract). Small contractions continue to penetrate the uterus, so as to prevent bleeding and give the feeling of period pains.

The uterus is now at or below the navel. The doctor examines the placenta to make sure it is whole. In case of epidural, the anesthesiologist removes the catheter from which he was giving the medicine.

This lasts for a while and does not hurt. From now on you can have the baby in your arms, as you get acquainted with it and the miracle of birth.

Childbirth after 40

It is quite common now for women over the age of forty to have children with or without the help of science.

We need to clarify an issue. The woman’s body will either be ready to conceive, so she can go through the pregnancy on her own without any particular problems or she will not be ready for the pregnancy (the age will be quite advanced) where the conception will become very difficult and in many cases impossible.

So, when we see a pregnant woman who is over 35 years old or even over 40 years old, it is normal to conclude that the body is able to carry out this pregnancy.

We will refer to pregnancies, in which conception is normal but the pregnant woman is older. We will not refer to pregnancies in which the woman has conceived while she was menopausal. It is a special chapter and needs special supportive hormonal treatment.

A woman who is older and gets pregnant makes almost no difference from a younger woman. However, due to advanced age, various diseases, which have nothing to do with pregnancy, may develop.

Thus, she may develop diabetes, some gallstones or kidney stones or even a tumor. These conditions can certainly occur at a younger age, but the older they are the more likely they are to exist.

So, a woman who gets pregnant at an older age may face various other conditions along with pregnancy, such as those mentioned above, as well as others such as heart disease, varicose veins, neurological and hematological syndromes, herpes, ulcers, breast disease.

The gynecologist closely monitors the pregnant woman, who is at a somewhat advanced age. He/she performs regular blood tests, in an attempt to better control the woman. The initial check-up in pregnancy involves much more than the regular check-up on a young pregnant woman.

Also, they obtain a very detailed history.

In the subsequent follow-up of the pregnancy, the gynecologist performs regular ultrasounds as well as other tests with which he tries to diagnose a syndrome of the child, which may be caused of the age of the mother, such as Down syndrome, spina bifida etc.

Amniocentesis is a test performed mostly on women over the age of 35, in which the doctor takes amniotic fluid from the inner cavity of the uterus and then he examines it cytologically to find some of the syndromes mentioned above.

In addition to the possibility of congenital anomalies in the fetus, the gynecologist will perform regular vaginal cultures to keep the vagina clean, as well as regular ultrasounds to check the vitality and physical integrity of the fetus.

The gynecologist may also adopt some special tests, which are often necessary when the pregnant woman is in advanced age.

The doctor should take particular care during childbirth, as the pregnant woman has less endurance to complete the labor, as well as more chances of having a complication, such as uterine inactivity (especially if the woman gives birth for the first time) etc.

There should be close monitoring of labor after childbirth, because the chances of developing psychological and physical syndromes are increased. If there were any diseases before pregnancy and during it, which the doctor monitored, he should retest them.

The expectant mother who is at an advanced age should pay special attention on her diet, as well as be in good physical and psychological health, so that she can get pregnant in the best possible conditions.