Pregnancy and maternity

Tests Done Under Special Circumstances

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If problems with the baby's development are detected by other means or the parents have risk factors for various genetic diseases, special tests may be required. For example, if the mother is age 34 or older, she has an increased risk of having a baby with Down syndrome. So, the parents, in consultation with the obstetrician, may elect to sample fluid or tissue from the baby to determine its genetic make-up. These samples can be obtained through three procedures:

amniocentesis
chorionic villus sampling
fetal blood sampling
fetal monitoring

In these tests, the doctor uses a needle or suction tube to sample fluids or the baby's tissue with the aid of ultrasound to see what he/she is doing. The tissue/fluid samples are analyzed in a laboratory to determine the number of chromosomes (karyotype) and other biochemical tests (e.g., AFP). The results from the tests can be used to make decisions about possibly terminating the pregnancy or preparing the parents to deal with any genetic defects (genetic counseling).

Amniocentesis
Amniocentesis is a test in which the doctor samples the fluid (amniotic fluid) that surrounds the growing baby in the uterus. Floating in the amniotic fluid, there are cells from the baby as well as fluids from the baby (urine). The cells can be grown and the fluid analyzed for various biochemical markers.

Amniocentesis is usually done between 15 to 18 weeks and for mothers with two or more risk factors (e.g., older than age 34, and/or family history of Down syndrome or other genetic diseases). If you were to have this test done, you would go into an examination room with your doctor, an ultrasound technician, and your partner or other family member. The procedure goes like this:

The technician swabs your abdomen with an antiseptic (Betadine).

The technician will use ultrasound to determine where the baby is in your uterus and where there are pockets of fluid away from the baby.

Once these areas are located, your doctor will insert a needle through your abdomen and into the uterus. The doctor constantly monitors the ultrasound to avoid poking the baby.

The doctor withdraws about 30 to 60 ml of amniotic fluid, which the baby will replace within a day.

The doctor places this fluid in one or more sterile cups, marks the cups, and sends them off to a laboratory.

The doctor removes the needle and places a bandage over the site.
You may have another ultrasound exam to assess the baby's health after the procedure.

It takes about two to three weeks before the results of the amniocentesis can be reported.

Amniocentesis has a quoted risk of 0.5 percent, meaning that 1 in 200 procedures have some type of complication (e.g., infection, miscarriage or poking the baby with the needle). In most cases, these percentages are much lower, especially since ultrasound has been used to guide the doctor.

Chroionic Villus Sampling
Like amniocentesis, chorionic villus sampling (CVS) is done to obtain a sample of the baby's tissue for determining genetic disorders. In contrast, CVS obtains tissue from the placenta (chorion) instead of fluid. Because the chorion is derived from the baby, not the mother, it bears the genetic characteristics of the baby. The procedure is similar to amniocentesis except that the tissue can be taken by inserting a needle through the abdomen or a sample tube through the cervix.

Like amniocentesis, CVS is done when the mother has one or more risk factors for genetic diseases. CVS can be done earlier than amniocentesis, usually in the latter part of the first trimester ( between weeks nine and 11). The results of CVS can be obtained sooner than amniocentesis because no culturing of the tissue is required. However, because CVS only gets tissue, some of the biochemical tests done with amniocentesis cannot be done with CVS. Also, CVS carries a higher risk (about 1 percent), mostly because it is a newer procedure relative to amniocentesis.

Fetal Blood Sampling
Fetal blood sampling can be done from 18 weeks to full term. In this procedure, fetal blood is obtained from the umbilical cord for analysis. Like amniocentesis, the doctor (aided by ultrasound) inserts a needle through the mother's abdomen into the umbilical cord and withdraws a blood sample. The blood sample is sent to a lab for analysis. The genetic results from fetal blood sampling can be obtained much faster than with amniocentesis because no tissue culturing is involved. In addition, this technique can be used to transfuse the fetus with compatible blood in the event that the baby's and mother's Rh factors do not match. The overall risk of the fetal blood sampling procedure is 0.5 - 1 percent.

Fetal Monitoring
Fetal monitoring is usually done in the third trimester (for high-risk pregnancies, pre-term labor or overdue babies) and during delivery. This test involves strapping an electronic monitor to the mother's abdomen that measures the electrical activities of the following:

fetal heart beat
mother's heart beat
mother's uterine muscle contractions
The baby's movements inside the uterus can be assessed and correlated with its heart rate. There are two types of test done:

Non-stress test - the baby's heart rate should increase when the baby moves (about 15 beats for 15 seconds at least twice in a 20 minute period).

Stress test - the baby's heart rate should increase when the uterus contracts. Uterine contractions are caused by infusing a medication (Pitocin) or by stimulating the mother's nipples.

These tests are used by obstetricians to determine how well the baby will handle the stress of delivery.

As you can see, there are a wide variety of ways to measure your baby's growth and development before it is born. Prenatal testing is completely normal during pregnancy and can often detect problems early, before they progress.

Ultrasound

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You may have one or more ultrasound tests during your pregnancy. The first test may be done within the first four weeks to date the pregnancy and determine the due date. This is done by measuring the baby's crown to rump length. Accurate charts are available to determine the age of the fetus from these measurements.
By about weeks 11 to 13, ultrasound may be used to examine various aspects of your baby's developments, such as:

Is the neural tube closed?
Are the internal organs developing properly?
Does the heart beat OK, and at what rate?
By 20 weeks, you may be able to determine the sex of the baby by observing its sex organs with ultrasound.

Swab Tests

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At different times during pregnancy, your doctor may take swab samples (Q-tip) from your vagina or rectum. The cells on the swab will be examined under a microscope or cultured to determine various conditions or diseases.

In the first trimester, you may have a Pap smear in which cells from your cervix are examined to look for signs of cervical cancer. Later, when you are closer to delivery (around week 35), your doctor will take swabs from your vagina and rectum. These swabs will be cultured to look for Group B streptococcus bacteria. These bacteria are common in many women and are considered a normal part of an adult woman's reproductive system. For an unborn child, however, these bacteria can spread during delivery and cause several problems:

respiratory distress - problems with breathing that threaten the baby's life
mental retardation
vision problems
hearing loss
Group B strep infections can be treated with IV antibiotics before delivery.

Blood Sampling Tests

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In the first trimester of pregnancy, you may have blood drawn to determine the following:

hCG levels (discussed above)
Blood iron content - important for hemoglobin and delivering sufficient oxygen to the growing baby

Blood type and Rh compatibility - assess problems between mother and baby's blood types (see Rh Blood Testing for details)

Presence of antibodies to viruses (e.g., HIV, hepatitis B) or presence of bacteria (e.g., syphilis).

The hCG, viral antibody, syphilis and blood type tests look for and/or quantify the amount of antibodies to these substance in the blood. The iron test directly measures the iron by burning a sample in a high temperature flame and quantifying the amount of light given off at the wavelength of light specific for iron, which is related to the amount of iron present.

Glucose Tolerance Test
Between week 25 to 28 gestation, you will have a glucose screening test for gestational diabetes. You will drink a soda containing high amounts of glucose, or sugar, and will have your blood drawn one hour later. Blood glucose will be measured by a glucose oxidase reaction described in the previous section. If the glucose level is high, you may be asked to take an additional glucose-tolerance test. In this test, you drink a high-glucose solution on an empty stomach and blood samples will be taken at regular intervals (usually every hour) for three hours. Blood glucose levels will be measured again. The timecourse information from a glucose tolerance test is a better indication of your body's response to a glucose load to diagnose gestational diabetes.

Neural Tube Defects
The baby's brain and spinal cord develop from the outer layer of the embryo called the ectoderm. The ectoderm dimples inward along the long axis of the embryo, the two edges come together, the edges seal and the folded portion pinches off to form a tube (neural tube). The nervous system, including the brain and spinal cord, develop from the neural tube. If the neural tube does not close, then a condition called spina bifida develops and the baby's brain and spinal cord do not develop properly, resulting in mental handicaps and even death. Neural tube defects can be prevented by supplementing the mother's diet with folic acid (a major component of prenatal vitamins).

Triple Screen Test
This test is done in the second trimester and measures three parameters:

alpha-fetoprotein (AFP)
hCG
estriol
AFP is produced by the baby and makes its way into the mother's blood. Typically, AFP levels are low. However, high levels of AFP indicate that the baby's neural tube has failed to close (i.e., a neural tube defect). An ultrasound examination may then be done to confirm this finding.

At this time in development, hCG levels in combination with AFP levels can tell us whether the baby has any abnormalities in the number of chromosomes. A high level of hCG in combination with a low level of AFP suggests a chromosomal abnormality. The most common disorder of this type is Down syndrome (extra chromosome #21 -- see Human Chromosomal Abnormalities for more details). If the level of hCG is high and no fetal heartbeat is detected, then there may be a molar pregnancy. A molar pregnancy is when a piece of tissue, usually leftover from a previous pregnancy, grows rapidly, destroys the baby and forms a benign tumor. An ultrasound examination may then be done to confirm this finding.

Estriol is a hormone made by the baby's adrenal glands. The levels of estriol in the mother's blood indicate the health of the baby. If the estriol levels drop, then the baby may be threatened and need to be delivered. Low levels of estriol may also indicate Down syndrome or neural tube defect.

Routine Non-Invasive Tests

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These tests are done every time you visit your obstetrician and include:

blood pressure
urine glucose
urine protein
fetal heartbeat - beginning when the baby's heart is developed enough to to be heard
Blood Pressure

The increased blood volume and fetal blood circulation that occurs in pregnancy increases the demands on your cardiovascular system, especially your heart. So, your blood pressure will be measured regularly to detect any signs of high blood pressure or pregnancy-induced hypertension. About five percent of pregnant women experience pregnancy-induced hypertension starting about the 20th week of pregnancy. This condition can can lead to the following complications:

Pre-term labor
Separation of the placenta, leading to bleeding
Reduced kidney function or failure
Reduced blood flow to the baby, which can retard its growth and development
Pregnancy-induced hypertension, along with swelling (edema) and protein in the urine (albuminuria), comprise a condition known as preeclampsia. The cause of pre-eclampsia is unknown and the treatment is premature delivery of the baby, if possible. Sometimes, high doses of magnesium sulfate can be given to delay the symptoms until the baby can be delivered safely; no one knows why this treatment can work.

Your blood pressure will be measured with a blood pressure gauge or sphygmomanometer (read this question about blood pressure gauges for more details).

Urine Glucose
During each doctor's visit, you will be asked to pass a test strip through your urine stream or collect a sample of urine, which will be tested with a strip that measures the amount of glucose in your urine. The presence of glucose in the urine is an indication of gestational diabetes, a form of diabetes that usually develops around the 20th week of pregnancy. Gestational diabetes causes the following complications:

The baby grows larger than normal and develops more fat. Large babies are difficult to deliver.

The baby's pancreas must secrete large amounts of insulin to get rid of the excess sugar coming from the mother. After birth, when the baby is no longer receiving these high amounts of sugar from the mother, the high insulin levels can cause the baby's blood sugar to fall dangerously low (i.e., hypoglycemia).

Some babies from mothers with gestational diabetes have trouble breathing when they are delivered (i.e., respiratory distress).

Gestational diabetes can be treated usually by monitoring the mother's diet. However, sometimes the mother must take insulin to control her blood glucose levels. Gestational diabetes in the mother usually goes away once the baby has been delivered.

The test strip contains two enzymes (glucose oxidase and peroxidase), a chemical (orthotolidine) and a yellow dye impregnated in the paper. The reactions go like this:

Glucose oxidase converts glucose into gluconic acid and hydrogen peroxide.
Peroxidase reacts the hydrogen peroxidase with orthotolidine to produce a blue color.
The yellow dye spreads the color change out over a wider range in proportion to the amount of glucose present.
If no glucose is present, then the test strip remains yellow. If glucose is present, then the color can vary from light green to dark blue, depending upon the concentration of glucose in the urine.

Urine Protein
The presence of protein in the urine indicates a problem in kidney function and is one of the symptoms of pre-eclampsia, as mentioned above. To detect protein in the urine, the test strip has a pH buffer (citrate buffer) and a color indicator (bromphnol blue) impregnated in the paper. At the normal pH of the paper, most of the indicator is not ionized. Proteins can bind to the nonionized form and release hydrogen ions, which changes the pH and the color of the paper. If protein is present, then the color of the paper will change from yellow to green or blue, depending upon the concentration of protein.

Fetal Heartbeat
One of the more emotional times in an early pregnancy may be the first time you hear the baby's heartbeat. The baby's heartbeat can be seen in a Doppler ultrasound as early as five to six weeks of development. By 12 to 13 weeks, your doctor can hear the heartbeat using a specialized ultrasound stethoscope or Doppler stethoscope. The Doppler stethoscope works like a regular ultrasound machine except that it does not give an image. Instead, the echoes are counted and the count is displayed on a LCD readout. If the stethoscope has a speaker, you can hear the baby's amplified heart beat.

The Pregnancy Test

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This test is usually the first test conducted when you suspect that you may be pregnant. There are a variety of home testing kits available over-the-counter and all detect a protein hormone called human chorionic gonadotropin (hCG). When an egg is fertilized, the embryo begins to produce hCG. Levels of hCG increase after conception and can be detected in the mother's urine. By 10 days after conception, hCG levels are about 25 milli-International Units (mIU).

Typically, the home test is a urine test for hCG:

You collect a sample of urine. You would usually use the first urine in the morning, when hCG levels are the most concentrated, or wave the test wand through the urine stream.
If you collected the urine, you can either dip the test wand into the cup or place a drop on the test wand.

The test wands or dipsticks have a plastic coating embedded with antibodies to hCG.
The test wands also have a second antibody to hCG linked with some color tag (e.g., colored latex beads, enzyme that produces a color reaction).

If sufficient levels of hCG are present in the urine (more than 25 mIU), then the hCG will bind with the second antibody and cause a color reaction to occur (i.e., a positive test result).

If a positive test occurs, you generally call your doctor and a second test is performed at the office to confirm the pregnancy. The doctor may also order a blood test to determine the precise quantity of hCG present, which can be used to assess the baby's health.

Pregnancy Involves Many Tests

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Throughout the course of a pregnancy, an expecting mother will have many tests. They fall into the following categories:
pregnancy test - the first test
routine, non-invasive tests - these occur during each visit to the obstetrician's office
blood pressure
urine glucose/protein
fetal heartbeat
blood sampling tests - usually done once at various times during pregnancy
blood type, Rh Factor
determine iron levels
HIV, Hepatitis B, syphilis
glucose tolerance test
triple screen test
swab tests - usually done once at various times during pregnancy
Pap smear - to check for STDs, various bacteria (varies according to the laws of each state)
Group B streptococcus screening
ultrasound - done at least one time during pregnancy
tests done under special circumstances
amniocentesis
chorionic villus sampling
fetal blood sampling or percutaneous umbilical blood sampling
fetal monitoring
Let's look at the various tests to see how they work and what they can tell us about the developing baby.

Labor

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In movies, pregnant women experience a dramatic rush of fluid as their water breaks. But in reality, very few women will have their water "break" (which is actually the breaking of the amniotic sac). Most of the time, the nurse or midwife will break the amniotic sac once labor has already begun.

Signs of labor include:

Contractions that increase in frequency, duration, and intensity
Lower back pain that doesn't go away
Cervical dilation (opening up), revealed during a pelvic examination
A mother has many options when it comes to giving birth. She can deliver in a hospital or birthing center with the help of an obstetrician or midwife, or at home with the help of a midwife. She can also hire a doula -- a trained professional who offers support during the birthing process. Doctors recommend that women with high-risk pregnancies deliver in a hospital, because medical facilities are best equipped to handle emergencies should they occur.

The labor process typically consists of several stages.

During early labor, the mother will feel the first contractions. Her cervix will gradually efface and dilate in preparation for delivery. The contractions will be more frequent and become more painful. For many women, the early stage of labor can last for hours, and doesn't necessarily require an immediate trip to the hospital. The contractions come more frequently during active labor. They are also more painful -- sometimes too painful for the mother to talk through. Once the contractions start coming about every five minutes for an hour, the mother should call her doctor and get ready to go to the hospital. The mother's cervix continues to ripen -- it must stretch from about three centimeters to the full 10 centimeters before delivery can begin. Once she reaches the hospital and is dilated sufficiently, the mother can have medication for her pain if she chooses to do so. Options include an epidural (anesthesia injected into the woman's spinal cord, which blocks sensation in her lower body) and an intravenous pain reliever.

In the transition stage, the cervix reaches its full dilation as contractions become stronger and even more frequent. They may come every three minutes and last up to a minute each. The baby is also descending into the birth canal in preparation for delivery. As the baby moves down, the mother may feel pressure (as if she needs to have a bowel movement), and an urge to push. This stage may last anywhere from a few minutes to a few hours. Labor typically progresses more slowly for first-time moms.

Third Trimester

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During the next 12 weeks, the fetus will finish its development and prepare for the difficult birth process. It is now about 15 inches long and weighs between two and three pounds. Its eyes are a definite color (although they may change after it is born) and are fringed with lashes. Its body is rounding out as fat deposits under its skin. This fat will help its body regulate temperature once it is born. Its brain is becoming larger and more defined, and its skull is growing to accommodate it. If it is a boy, his testicles are descending into his scrotum. If the fetus is a girl, her clitoris is developed.

As the mother's belly swells, she may be in more discomfort, especially near the end of her pregnancy. She might experience hemorrhoids and insomnia. The pressure of the growing uterus on her diaphragm may also make her feel short of breath. It can press down on nerves, causing pain in her lower back and legs, and constrict her bladder, making her run to the bathroom constantly. Many women feel tired and have difficulty sleeping because of their increasing girth.

Sometime during the third trimester, the muscles of the mother's uterus begin contracting. These Braxton-Hicks contractions are practice to help the mother's body prepare for labor. Frequent or painful contractions could be a sign of premature labor.

By week 32, the fetus can move its eyes back and forth and tell the difference between light and dark. It is gaining weight quickly -- about a half pound per week. At this stage in the pregnancy, the fetus weighs just over four pounds and measures 15 to 17 inches long. It may have a full head of hair as well as fingernails and toenails.

The mother's uterus is getting very crowded. Although the fetus continues to move, its movements won't be as fervent as they were earlier in the pregnancy.

At week 35, the fetus measures between 15 and 18 inches long and weighs five-and-a-half to 6 pounds. The lanugo starts to fall off. The vernix caseosa, which protected its body in the amniotic fluid, also disappears. Its organs are almost fully developed.

From this point on, the mother will probably visit her doctor every week until the baby is born. The doctor may do a culture of the mother's vagina to test for bacteria called Group B streptococci, or Group B strep. Mothers who test positive for this bacteria will get intravenous antibiotics during labor to reduce their risk of passing the infection to their baby during labor.

By this point in the pregnancy, the fetus has probably rotated so that it is head down in preparation for birth. Babies that are turned the wrong way are called breech deliveries, but there are ways of turning the baby before labor begins. As her baby drops lower in her pelvis, the mother may feel relief from the breathlessness and other symptoms that have plagued her for the last few weeks.

Although delivery is still a few weeks away, at week 37 the fetus is considered full term. This means that if it were delivered now, it would be able to function outside the womb. It should weigh at least 6 pounds and measure between 19 and 20 inches. At any time between now and the onset of labor, the mucus plug which had blocked the entrance to the mother's cervix to prevent bacteria from entering will come out. This is a sign that labor is on its way.

In the last few weeks of pregnancy, the mother's doctor will check to see how far she has "effaced" or "ripened." Effacement is the process by which the cervix softens and thins to prepare for delivery. When the mother is 100-percent effaced, she is almost ready for labor.

Week 40 officially marks the end of the pregnancy, but only a small percentage of women actually deliver on their due date -- many are either early or late. If the baby has still not been delivered by week 41 or 42, the doctor will probably induce labor.

Pregnancy Myths
Myth: If you are carrying low, the baby is a boy. If you are carrying high, it's a girl.
Reality: The fetus' position in the mother's abdomen bears no relation to its sex. There are only two ways to find out if you're having a girl or a boy: amniocentesis or ultrasound.
Myth: If you have heartburn often during pregnancy, your baby will be born with a lot of hair.
Reality: Heartburn is common to all pregnant women, whether their baby is born bald or with a full head of hair.

Myth: Spicy food (or a particular dish) will cause labor.
Reality: There is no evidence that any type of food -- no matter how spicy -- can trigger labor.

Myth: Having sex will trigger premature labor.
Reality: Although sex might be uncomfortable as the mother's tummy grows, no research indicates that it will trigger premature labor. However, if the mother is bleeding during pregnancy, or if her partner has a sexually transmitted disease, her doctor may advise her against having intercourse until the baby is born.

Myth: If the mother holds her arms above her head, the umbilical cord will strangle the baby.
Reality: Although a very small percentage of babies are born with the umbilical cord wrapped around their necks, the placement of the cord has absolutely nothing to do with the way the mother holds her arms.

Second Trimester: Halfway There

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At week 20 -- halfway through the pregnancy -- the fetus is about six inches long and weighs about 10 ounces. Its digestive system produces meconium, a black, tar-like substance that will make up its first few bowel movements. The fetus is coated in a white greasy substance called vernix caseosa, which will protect its skin from the amniotic fluid in utero.

To train its digestive system and lungs, the fetus will swallow and "breathe" amniotic fluid. Its lungs produce a substance called surfactant, which will enable the air sacs to inflate for breathing once it is born.

At this point in the pregnancy, the mother may develop acne because of her skin's increased oil production. She may also develop varicose veins, which are caused when valves malfunction and allow blood to pool in the legs. Other changes include larger breasts, skin discoloration, heartburn and constipation. Nasal congestion is common as more blood flows through the mucous membranes, and the mother's legs may cramp as her uterus puts pressure on veins. Some mothers are more prone to bladder infections due to hormonal changes.

Between 24 and 28 weeks, the Ob/Gyn will perform a glucose screening test to check the mother for gestational diabetes, a form of diabetes in which the mother does not produce enough insulin. If she does have gestational diabetes, she will have to control her blood sugar with diet and may need insulin injections.

Placenta previa may also become apparent during this time. Mothers with this condition have a placenta that hangs low in the uterus and blocks the cervical opening to the birth canal. If placenta previa continues into late pregnancy, the mother will have to deliver by caesarean section.

Week 27 marks the end of the second trimester. By now, the fetus has grown to about 14 inches long, and weighs about 2 pounds. It is already starting to look like a newborn baby. If born at this point, the baby may survive, but would face potentially serious problems.

Second Trimester: The Kicking Fetus

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For many women, the second trimester is a definite improvement. As the nausea recedes and exhaustion abates, many women feel better and have more energy -- and appetite -- during this period. However, some women develop other unpleasant symptoms, such as heartburn.

Other changes occur in the mother's body. Even though her fetus is just a few inches long, her belly is growing. Mammary ducts inside her breasts prepare to produce milk. During this trimester, the mother's breasts will start to produce a yellowish, nutrient-rich substance called colostrum, which will feed her baby during its first few days of life.

Inside her womb, the rapid activity continues. Although the mother may not be able to feel it yet, the fetus now kicks and moves. Its head -- which just a few weeks ago dwarfed the rest of its body -- is now more proportional. A fine hair called lanugo covers its body. The kidneys and urinary tract start to produce urine and release it into the amniotic fluid. The liver begins secreting bile, and the spleen begins to aid in the production of red blood cells.

By week 15, the fetus is around five inches long and weighs about two ounces. Although its eyelids are fused shut, its eyes are now sensitive to light.

The mother will make her second prenatal doctor visit between weeks 12 and 16 of her pregnancy. At this visit, her Ob/Gyn may perform an ultrasound to look at the baby. Sometimes the doctor can determine the sex during this visit. The doctor will probably also measure the fundus -- the distance between the top of the mother's pubic bone and the top of her uterus. This measurement will allow the doctor to track the fetus' growth throughout the pregnancy.

Tests done during this trimester include an Alpha-Fetaprotein (AFP) or triple test -- a blood test that detects levels of alpha-fetoprotein (a protein produced in the fetus's liver) to identify Down syndrome or spina bifida. If the mother is over age 35, she might also have an amniocentesis, a procedure in which the doctor inserts a thin needle into her abdomen and removes a small sample of amniotic fluid to test for birth defects and chromosomal abnormalities. Between weeks 16 and 20, the fetus begins to hear and may even be able to hear the sound of its mother's voice. It can frown, squint, and make other facial expressions. The fetus' scalp is sprouting tiny hair buds, its skeleton is hardening, and millions of tiny neurons in its brain help its muscles move. Its tiny heart pumps about 25 quarts of blood each day. Its reproductive organs are forming. If the fetus is a girl, her ovaries are beginning to produce the millions of eggs that she will possess for her entire lifetime. During this period, the mother may start to experience "quickening" -- feeling her tiny fetus kick.

The mother's body continues to undergo numerous changes. Often, pregnant women appear to "glow." Although many women are truly suffused with the joy of pregnancy, the glow is often due to increased blood flow to the face. Many women also have a dark line running from their belly button to their pubic bone. This line, called linea nigra, occurs because of an increase in skin pigmentation, or melanin. It should disappear shortly after the baby is born. Some women also develop stretch marks -- thin pink or brown lines on their belly which often fade soon after the baby is born. Another common problem is edema, swelling of the ankles and feet due to fluid retention. Severe swelling in the hands and face could be a sign of a potentially dangerous condition called pre-eclampsia, which prevents the placenta from getting enough blood.

First Trimester: From Embryo to Fetus

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Even though the embryo is still the size of a sesame seed, the mother-to-be will probably start feeling the first twinges of pregnancy. Morning sickness, frequent urination, sleepiness, and food cravings or aversions are all common. Her breasts may swell and become tender. Some women start to put on weight, but others actually lose weight from morning sickness. At this point in the pregnancy, the woman will have her first prenatal Ob/Gyn visit. By the fifth week, an ultrasound may be able to pick up a heartbeat.

The mother needs to be especially careful during this first trimester, during the formation of the delicate organs. Pregnant women should avoid alcohol, certain medications, caffeine, and smoking. They should also continue to take prenatal vitamins containing folic acid, eat a healthy diet and exercise regularly.

Between 9 and 12 weeks, women over age 35 and those who have a family history of chromosomal abnormalities will probably have a chorionic villus sampling (CVS). This test detects Down syndrome and other chromosomal abnormalities. Using an ultrasound to guide him, the doctor will remove a small piece of placental tissue and test it for these conditions.

In the last few weeks of the first trimester, the embryo really starts to take shape. The facial structures begin to form and become recognizable. The neural tube, which will form the brain and spinal cord, develops. Little buds emerge and grow into arms and legs.

Around week 8, the embryo becomes a fetus. The kidneys, liver, brain, and lungs are all beginning to function. The fingers and toes are separate and the external genitalia are formed. At 12 weeks, the fetus is about three inches long and weighs about one ounce. At the end of the first trimester, many pregnant women find that their clothes are getting tight, although they may not yet be ready for maternity clothes.

Miscarriage
About 15 percent of pregnancies end in miscarriage -- most within the first trimester [March of Dimes]. As many as 50 percent of pregnancies may end in miscarriage, but most occur so early that the woman did not even realize that she was pregnant.

Most pregnancies end because of a chromosomal abnormality, a problem with either the egg or the sperm. Women who are over the age of 35 are at greater risk for these abnormalities -- and at greater risk of having a miscarriage -- than younger women. Other causes of miscarriage are infections, hormonal problems, or an illness or disease (such as diabetes). Drinking alcohol, smoking cigarettes, and taking certain drugs can also increase the risk. Fortunately, most women who have a miscarriage can go on to have a healthy, problem-free pregnancy in the future.

First Trimester: From Conception to Embryo

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A man releases millions of sperm with each ejaculation. Once inside the woman's body, the sperm make a mad dash to find the egg. If one sperm reaches the egg and penetrates it, fertilization occurs.

Then things start progressing rapidly inside the mother's womb. The sperm and egg merge to form a little single-celled organism called a zygote, which consists of the 23 chromosomes from the man's sperm and the 23 chromosomes from the female's egg. These chromosomes will determine the baby's hair color, eye color and whether the baby will be a boy or a girl.

Soon after fertilization, the zygote makes the trip through the Fallopian tubes to the uterus. During this journey, the zygote divides. Within 72 hours, it will have gone from one cell to eight cells.

Pregnancy Tests

Some women know immediately that they're pregnant -- call it a new mother's intuition. However, the only way to know for sure is to take a pregnancy test. All pregnancy tests look for the same thing: the presence of human chorionic gonadotropin (hCG), a hormone produced only during pregnancy.

Home pregnancy tests measure hCG in urine, while a test in the doctor's office will identify hCG in a blood sample The blood test can pick up very tiny amounts of the hormone and identify pregnancy earlier than a home pregnancy test. Still, most home tests are 97 to 99 percent accurate if taken correctly.

Remember the zygote? This little ball of cells divides until it contains about 100 cells. Then it becomes known as a blastocyst. The inner group of cells will form the embryo. The outer group of cells forms the placenta, which will provide nourishment.

Three weeks into the pregnancy, the blastocyst implants itself into the mother's uterine wall and releases hCG. This occurs only a few days after conception. Her doctor will begin counting the 40 weeks of pregnancy from the start of her last period, although conception normally occurs about two weeks after that.

The fertilized egg makes the journey through the Fallopian tube to the uterus, where it will implant.

By the fifth week of the pregnancy, the brain, spinal cord, heart, and other organs begin to form. The embryo is now made up of three layers: the ectoderm, mesoderm, and endoderm. Every organ and tissue will develop out of these three layers. The ectoderm will form the nervous system and backbone; the mesoderm will form the heart and circulatory system; and the endoderm will form the lungs, gastrointestinal tract, thyroid, liver and pancreas. The placenta has already begun to form, as well as the umbilical cord, which will deliver nutrients to -- and remove wastes from -- the growing embryo.

How Pregnancy Tests Work

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In the first few weeks after conception, you may notice changes in your body and in the way you feel. A late menstrual period is usually the first pregnancy symptom. However, many other conditions, from stress to certain chronic illnesses, can delay the onset of menses, so a late period is not always a reliable sign until at least two weeks after the date you expect it.

On the other hand, you can have spotting while pregnant, so the presence of some bleeding doesn't eliminate the possibility of pregnancy.

In the first weeks of pregnancy, you may feel more fatigued than usual. You may experience nausea or vomiting, especially in the morning, a week or two after your missed period. Your breasts may have some tingling or tenderness and may even enlarge. The areolae (the dark areas around the nipples) may darken even more. If you have been having trouble getting pregnant and are recording your basal body temperature, the temperature may remain elevated. But just as with a late period, all of these signs and symptoms, if they occur at all, can have other causes. They do not prove you are pregnant.

If you go to see your doctor when your period is two weeks late, he or she may find physical changes that suggest you are pregnant. Your vagina and cervix may be blue to purplish because of increased blood flow. This is known as the Chadwick sign. The uterus may feel softer, larger, and more round.

Many women know they are pregnant before they see their doctor, however, because they perform a pregnancy test themselves at home. Nonprescription home pregnancy tests are available in any pharmacy and cost $10 to $20. These tests are designed to detect the presence in the urine of human chorionic gonadotropin (HCG), a hormone produced by the placenta shortly after fertilization.

Home pregnancy tests on the market today vary in sensitivity. Some can detect HCG one day after the missed period. Others require one to two weeks. Some tests must be done on a urine specimen obtained in the morning, when the concentration of HCG is the highest; others can be performed on a specimen collected anytime. Some tests react within one minute, but others require one to two hours. If you follow the directions carefully, the results are 90 to 95 percent accurate.

The tests are easy to perform. You immerse a trip of paper into a collected urine sample, or you urinate on a strip of paper. Positive tests usually are indicated by the formation of a lone or a plus sign on the paper. Now, there are even digital tests that display the results in a window so that there is no need to interpret lines or plus signs.

Even though these tests are extremely sensitive and accurate, it is possible to receive a false-positive or false-negative result. If you are taking fertility drugs, they may affect the outcome of the test and produce a false-positive result -- that is, the test result is positive even though the woman is not pregnant. However, more common than a false-positive test result is a false-negative one -- that is, the test result is negative even though the woman is pregnant. This usually occurs when the test is done too early after the missed period.

In some cases, the level of HCG is too low to detect, or the embryo hasn't become implanted yet. In approximately ten percent of women, the embryo implants after the first day of the missed period. Low levels of HCG may also be caused by an ectopic pregnancy (a pregnancy that develops outside the uterus). If the first test result is negative and your period doesn't start, repeat the test in five to ten days. If it is still negative, and you believe you may be pregnant, consult your doctor.

Your doctor will probably order a urine pregnancy test similar to the home pregnancy tests. If your doctor needs to know if you are pregnant at a time too early for the urine test to be used or if he or she suspects a false-negative test result, your doctor may order a blood test that is more sensitive and specific. Because it can measure very small amounts of HCG, your doctor can use it to diagnose pregnancy before a missed period (seven to nine days after fertilization) or to diagnose a tubal pregnancy (one that develops in one of the fallopian tubes). The test takes longer (two to three hours) to complete, and it is more expensive because it requires special equipment and personnel. Therefore, it is not used routinely to diagnose pregnancy.

When you finally know for sure that you are pregnant, your next question will undoubtedly be "When will my baby be born?" Delivery usually occurs 280 days after the first day of the last menstrual period. An easier way to calculate the delivery date, or due date, is to add nine months and seven days to the first day of your last normal menstrual period. Most women don't give birth on the exact date, but 80 percent give birth within ten days of this date -- either ten days before or ten days after.

As your pregnancy progresses, your doctor can double-check your due date with the timing of certain events. For example, the baby's heart is usually heard at 10 to 12 weeks. The level at which the top of the uterus can be palpated (felt) by the doctor is another clue; at 20 to 22 weeks, for example, it is usually at the umbilicus (navel). If your physician performs an ultrasound examination, the technician can measure the baby's head and compare the result with standard tables to estimate gestational age.

Discovering that you are pregnant is a thrilling moment. The next nine months will be filled with excitement both for you and your family.

Potty-Training Problems

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Accidents happen, whatever method you use and however quickly your child learns. When one does, clean up quickly, making very little of it. Console your child if she is upset, and do not punish, scold, or shame her. If accidents are so frequent you can see training will be unsuccessful, stop at once and put your child back in diapers. Try again in a few weeks or a month, when you think the child is ready.

A child who is completely potty trained sometimes has accidents when she is ill. Sometimes a child regresses -- seems to forget entirely control of bowels or bladder or both. Regression sometimes accompanies or follows an illness.

A child who regresses (or one who can't seem to master the control training requires, though apparently ready) may have a lactose intolerance or other food intolerance or allergy or a urinary infection. The latter is usually accompanied by pain and a burning sensation when urinating and sometimes also by changed color or a foul odor in the urine. If you suspect a physical problem, consult your doctor.

In most cases, regression has an emotional, rather than a physical, cause. It may occur when a new baby comes into the house, when someone close to the family dies, when parents separate or divorce, or at some other stressful time. It's best to go along with it as best you can: Do not show anger or scold, but put your child back into diapers without comment.

Nighttime bladder control usually comes later than daytime control, although some children go through the night dry even before they are daytime-trained. Good control is needed because a child who sleeps through the night may have to wait as long as 12 hours. You may want to encourage nighttime control by holding back on liquids before bedtime and getting her up when you go to bed. Bed-wetting (enuresis) is considered a real problem only after a child is about six years of age.

Potty training is a major milestone in your child's life, but some parents can put too much pressure on the stage and make it harder on their child. If you follow our simple potty training advice, your child will be well on his way to independence.

How to Start Potty Training

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The most common order for potty training is bowel control first, then daytime bladder control, and, later, nighttime bladder control, but all children do not follow that pattern. If your child has bowel movements at a regular time most days, you may have him trained in that department long before you try for bladder control; some parents try with good success when their children are about 18 to 24 months old.

A good time to try for a child who is not regular is about 30 minutes after a meal. Sit with your child for a few minutes, perhaps reading a book as you wait, but only as long as the child is willing. Be prepared for your child to feel proprietary about his feces, and be careful not to imply they are dirty or bad in any way. Some children are upset when their feces are flushed away, and some are frightened of the flushing noise. If your child is one of these, you may decide to flush only after he has left the bathroom.

One reason some children have trouble managing bowel control is that they are constipated. Constipation is not so much a matter of infrequency of bowel movements (having as few as three or four normal movements a week is perfectly natural for some children) as it is of hard stools that are painful and difficult for a child to pass. Discomfort makes a child hold back and compounds the problem. To help a constipated child, decrease his intake of milk and milk products and increase whole grain and dried fruit in his diet. Prune juice is helpful for a child who will drink it. If constipation continues, see your doctor for advice.

Summer is the best time to start potty training, if you have a choice, because the fewer clothes a child must bother with, the easier the process is. As often as you can, let your child wear underpants only to cut down the problems of dealing with outer pants or skirts and shirts.

You may find it helpful to plan to concentrate heavily on training for about a week, staying close to home with your child and not trying to accomplish much of anything else. The 24-hour method of training, advanced a few years ago by two psychologists, who designed it first to help persons with mental retardation (Nathan Azrin and Richard Foxx, Toilet Training in Less Than a Day), is championed by some parents and disapproved of by others. It involves very concentrated effort from both child and parent, and some believe it is overly manipulative and somewhat punitive. Potty training in one day may be too good to be true, as reports of the timing of success vary.

Your ultimate objective is to get your child to go into the bathroom alone when he needs to, pull down his pants, clean himself when finished, pull up his pants, empty the pot if one is used, and flush the toilet. Obviously, all this self-care does not occur at first, and you may help and remind your child to use the bathroom, and even lead your child physically to the bathroom for some time. The best times to give reminders or to take a child to the bathroom are when he first wakes in the morning, before and after naps, 30 minutes after meals, and before bed.

Children usually urinate about eight times a day and more often when they are excited or tired. Remember that part of potty training is teaching your child good habits of hygiene -- careful and thorough hand-washing and, for girls especially, wiping from front to back instead of the reverse (to prevent urinary tract infections).

When to Potty Train a Child

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You will suspect your child is ready for potty training if wearing a wet or soiled diaper has become uncomfortable and distasteful to him or if he sometimes tells you or lets you know in some other way that urination or defecation is about to take place. Before you start, let the child observe you and any sibling in the bathroom; an older brother or sister is usually a great role model and an enthusiastic one. Get several pairs of underpants -- the looser, the better -- and let your child practice pulling them up and down. Look in your bookstore or library for some of the excellent potty-training books available for children, and read them to your child.

Decide whether your child will use a potty chair or the big toilet, with or without an adapter. The advantages of the potty chair are that it is childsize, close to the floor, and easy to get on and off. The adapter takes no extra space, doesn't need emptying, and allows your child to skip the middle step of changing from the chair to the big toilet. Simply teaching your child to use the big toilet is, of course, easiest of all, if the child is large enough and not frightened.

If you choose the potty chair, look for one in which the pot removes easily for emptying; you want your child to take over this task as soon as possible. If you opt for the seat adapter, consider one that folds up conveniently for travel. If your child is a boy, you need a shield, either built-in or attachable, to deflect the flow of urine because boys do not stand up to urinate at first. Do not use a chair or adapter that has a shield for a little girl; instances of injury to the labia have been reported. If you decide on the potty chair, set it up some time before you start training your child so it becomes familiar. Let the child sit on it, fully clothed, if he or she wishes, when you are in the bathroom together.

Another decision you must make concerns terminology. Children can handle the words for body parts easily enough, but the words urinate and defecate are more difficult, and they or substitutes for them will, of course, be used far more frequently. Most families settle on more casual words, such as pee and BM. Remember, there is a fine line between the acceptable and the crude; a word or term that sounds cute coming from a two year old may not be so at all from a five year old.

Still another decision to make regards rewards for successful performance during potty training. Parents disagree; some disapprove heartily of using material rewards for the accomplishment of what they see as a natural and normal step in development, while others see no harm in the practice and think it helps inspire a child to earlier success.

Among the latter, there are those who reward their children with treats, such as cookies, nuts, or raisins, and those who prefer to use small, inexpensive presents instead of food. One material gift all children get is a supply of "big girl" or "big boy" pants, often introduced with some fanfare by parents and usually thrilling to a child. Some parents who don't believe in any kind of concrete reward other than potty-training pants like to mark a child's progress with colored stars on a calendar.

All parents do agree that praise is a highly suitable and effective reward. Praise generously, they say, but not so lavishly your child begins to think of bowel and bladder control as earth-shaking achievements, more important than they really are and, possibly, as tools to manipulate their parents.

Hopefully now you've assessed that you and your child are ready to start potty training. In the next section, we will learn how to begin the process.

Potty-Training Overview

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Potty training is a developmental skill your child cannot master until he is physically and mentally ready, however anxious you may be to have a "grown-up" child and be through with diapers. Actually, the process of potty training is perhaps more properly called potty learning, since your child teaches himself. Your part is to provide the setting and materials, a description of the methods used, and the necessary encouragement.

Among parents who keep close track of such events and brag a bit, the age at which their children were potty trained is almost as important as the age at which they slept through the night. Some studies show the average child is usually potty trained at about 30 months, but comparing your child with another is a waste of time; the differences among children in mastering this skill are vast. Girls are usually potty trained before boys of the same age, but a boy may be trained at age two and a girl not until age four.

The advantages of having a potty-trained child are obvious, and many parents consider starting training when their child is about the age of two, if the child seems ready. It's advisable to back off quickly, however, if your timing seems to be wrong. The self-esteem of a child who cannot yet succeed in this test of control suffers, and the anxiety engendered may lead to extended bed-wetting problems. In this article, we will answer your potty-training questions and offer you some potty-training tips over the following sections:

When to Potty Train a Child

There's a lot of debate around when you should potty train a child. Some parents take pride in having their child potty trained as soon as they possibly can. The truth is, pressuring your child to begin potty training before he is ready can only cause emotional pain and trauma that is completely unnecessary. In this section, we will show you how to read some of the signs that your child may be giving you that it is time to begin potty training.

How to Start Potty Training

Though your child might begin to display signs that he is ready to move on from diapers, this does not mean they are ready to embrace potty training. The concept might be strange or even scary to your child, and it is up to the parent to create an atmosphere that is encouraging and comfortable. On this page, we will offer some tips to make starting potty training easier. We will show when to begin toilet training, how you should arrange you time while training, and how you should prompt your child to go to the bathroom.

Potty-Training Problems

Potty-training accidents are bound to occur. Just like any of the new skills that your child will master over the years, toilet training takes patience and time. On this page, we will look at common potty-training problems and show you how to deal with them. Most accidents usually take place at night while the child is sleeping or when they are sick. However, in some cases, potty-training regression may have an emotional, instead of a physical, cause.

How to Prevent a Miscarriage

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The first, and perhaps most important, step in a healthy pregnancy is getting prenatal care. This means finding an obstetrician right after a positive pregnancy test. The doctor will recommend prenatal vitamins, which are rich in many nutrients expectant mothers need, like calcium, iron and folic acid. Folic acid is especially important in the first few weeks of pregnancy, when the fetus is developing its neural tube, which eventually develops into the brain and spinal cord. A lack of folic acid during this period can result in birth defects. The recommended daily amount is 400 micrograms. There is enough folic acid in prenatal vitamins, and even in some multivitamins, but you can't get too much of it, so a healthy diet with foods rich in folic acid is recommended as well.

Between doctor's visits, pregnant women should follow a healthy diet, exercise on a regular basis, keep their "baby weight" within healthy limits, and try to manage stress levels. Many doctors believe that good health should begin before you even conceive in order to ensure the healthiest pregnancy possible. In fact, taking folic acid even before you get pregnant can help prevent birth defects.

While there are plenty of vitamins and foods that you should ingest, there are a few things expectant mothers should avoid. They shouldn't smoke or even be around smoke. Either of these behaviors doubles the risk of placental problems and low birth weight. It also increases the risk of having a premature baby. However, there is good news. If a woman quits smoking during her first trimester, the risk returns to that of a woman who never smoked. Other things to avoid while pregnant include excessive amounts of caffeine, exposure to X-rays and, of course, contact sports or other dangerous physical activities.

It's also important for any woman who may suffer from a chronic health condition to take extra special care of herself. Women with high blood pressure should start checking their pressure at home and discussing medication changes with their doctors. Also, women with diabetes should check their blood sugar several times a day and adjust their insulin or oral medications as needed. Finally, pregnant women should treat any bacterial or viral infections. Some viral infections, like chlamydia or herpes, can determine if baby will be born vaginally or via Caesarean section.

Treating the Emotional Pain of a Miscarriage

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A woman's physical health is important during and after a miscarriage, but her emotional health should not be ignored. The loss of a pregnancy can be felt just as strongly as a loss of a child. Women can also experience postpartum depression after a miscarriage. There is a wide variety of emotional treatments, including grief counseling, depression or anxiety medications, or simply opening up to friends and family. There are plenty of resources out there to help both the expectant mother and her partner.

Here are a few common tips for dealing with the loss of pregnancy:

Decide for yourself. Well-meaning friends and family will suggest ways to deal with your pain, but right after the miscarriage, don't do anything that makes you feel uncomfortable, such as returning baby clothes.
Take your time. There is no set time limit on how long you can grieve. As the cliché says, take it one day at a time and do things on your schedule.
Know your triggers. Seeing a baby, going to a baby shower or even walking past the Baby Gap could cause a swelling of emotion. It's OK to avoid these situations until you feel strong enough to handle them.

Postpone major decisions. When you're experiencing an especially emotional time, big decisions -- like buying a house, selling a car or changing your career -- should be delayed.

Don't cut your partner off. Keep the lines of communication open.
Set up a support network. While some friends and family may not understand the degree of your grief, and many are sure not to know what to say, they will all probably offer support. Many women also find comfort in going to support groups or joining an online chat group.

What Doesn't Cause a Miscarriage

There are many mixed signals out there about what may cause a miscarriage. Should women err on the side of safety and give up any type of physical activity, including sex? Happily, the answer is no. Here is a quick list of five things that DON’T cause miscarriage in uncomplicated pregnancies.

exercise
sex
working or lifting heavy objects
a minor fall or injury
stress

Miscarriage Treatment

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Post-miscarriage treatment focuses on preventing further blood loss or infection. Of course, the goal of therapy is different for women who have suffered a threatened miscarriage. In these cases, prevention of further complications is key and may include bed rest or a reduction of activity.

Treatment depends on the type of miscarriage and when in the pregnancy it occurred. If it was early, additional treatment isn't usually required because all of the fetal tissue is usually expelled by the body. When a woman has suffered an incomplete or missed miscarriage, a procedure known as a dilation and curettage, or D&C, is performed to retrieve the tissues from the womb and stop any further bleeding or infection.

If a woman is in the process of having an inevitable miscarriage, she can have a D&C or wait and let the miscarriage occur naturally. She can choose the latter option if she was in the first trimester of pregnancy, has no signs of infection and has stable vital signs. Her body will usually expel the tissues within two weeks. Patients who prefer to miscarry this way should return to their doctor to confirm that all the tissues have been expelled. Another option is medication that helps the uterus expel the pregnancy, which usually works within a few days.

Even though a live birth has not taken place, women do need to receive certain medications after a miscarriage that relate to the fetus. For example, if the mother and the fetus have incompatible blood types, this could cause complication in any later pregnancies. If the mother is Rh factor negative, she will receive a shot called RhoGAM, which works to prevent any blood-type interaction between the woman and her miscarried pregnancy. This will protect a future fetus. If the mother doesn't get the shot, her Rh-negative blood can cross over to the fetus and cause complications. Antibiotics are also often used to reduce the chance of infection or to fight a current infection. Finally, the mother could require medication if she has been bleeding for a prolonged period -- and she should also be aware of symptoms of an infection, which can occur as late as six weeks after the miscarriage. These signs include fever, severe pain, heavy bleeding and chills.

After a miscarriage a women is usually encouraged to avoid putting anything in the vagina, like tampons or douches. Also, sex is discouraged immediately following a miscarriage. However, contraception, including IUDs, can be used again immediately, and a woman's period usually returns within four to six weeks. Studies are not clear on a safe waiting period between a miscarriage and a new pregnancy, but doctors usually advise waiting two to three months

Types of Miscarriage

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Health care providers use the blanket term "miscarriage," so it may be surprising to learn that there are several different types.

Threatened: Sometimes a woman will experience vaginal bleeding in the early months of pregnancy. This bleeding is usually mild and may be accompanied by cramps or backaches. But the cervix remains closed and, as the name suggests, the miscarriage is not successful. In fact, the majority of pregnancies continue successfully after a threatened miscarriage.

Inevitable: This occurs when a woman experiences vaginal bleeding in conjunction with back or abdominal pain. In this type, the cervix is open, or dilated, and some of the uterine membranes may be ruptured. In these cases, the miscarriage has already begun.

Incomplete: An incomplete miscarriage results when only part of the pregnancy has been miscarried, leaving some products of conception in the womb. Symptoms often include heavier bleeding and severe abdominal pain after tissues have expelled from the womb. An ultrasound usually reveals the remaining tissue.

Complete: A complete miscarriage includes the expulsion of all products of conception, including the fetus and the placenta. While symptoms are similar to those seen in incomplete miscarriages, they subside quickly after the tissue is expelled. An ultrasound is often performed to ensure that no tissues remain and the womb is empty.

Missed: Basically, this is a miscarriage that the woman wasn't aware even happened. In these cases, there is embryonic death but the woman's body does not expel the tissues. So, cramping, bleeding and back aches are not present, and the only symptoms are loss of pregnancy symptoms such as nausea, weight gain and breast tenderness. These types of miscarriages are generally discovered when the fetal heartbeat isn't located during a routine doctor's visit.

Recurrent: Only about 1 percent of women have three or more first-trimester miscarriages.

Septic: A septic miscarriage can risk the health, and sometimes life, of the expectant mother. This type of miscarriage occurs as a result of either a missed or incomplete miscarriage. After the miscarriage, some or all of the remaining pregnancy tissue becomes infected. This tissue then infects the uterus, which can result in the spread of the infection throughout the body. Symptoms of this type of miscarriage can include vaginal bleeding, abdominal pain, fever, chills, exhaustion and a thick, foul-smelling vaginal discharge.

Miscarriage Warning Signs

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There are often warning signs before a miscarriage actually occurs. It is important for pregnant women, as well as those planning to get pregnant, to know the most common of them.

Bleeding can range from mild to severe and can be brown or bright red in color. In some cases, women may have several bouts of bleeding. But it doesn't always mean that a miscarriage will soon follow. Up to 30 percent of all pregnancies involve some level of bleeding. In fact, studies have shown that as long as there is fetal cardiac activity, approximately 96 percent of pregnancies in which the mother experiences vaginal bleeding between seven and 11 weeks do not miscarry.

Mild to severe back pain and cramping is another common warning sign. The location of the cramps can vary widely and can be felt on one or both sides or in the middle of the abdomen. They usually occur in the lower abdomen but can move to the lower back.

Both mucus and clotlike vaginal discharge are symptoms of a miscarriage. The mucus is usually white to pink in color. Again, this is not necessarily a sign of inevitable miscarriage, but any tissue that passes through the vagina should be saved in a sterile container and brought to the doctor's office for examination.
Oftentimes, one of the first warning signs of a miscarriage is a decrease in pregnancy side effects. This can mean weight loss, absence of nausea or breasts that are no longer tender. A word of caution should be used here -- some of these symptoms, like weight loss in early pregnancy, may be normal for some women. But any woman experiencing these symptoms should consult her doctor.

Contractions are extreme pains that usually occur every five to 20 minutes.
If a woman does experience one of these symptoms, her doctor will usually perform an examination to determine how the pregnancy is progressing. This exam can consist of an internal pelvic examination, an ultrasound and blood tests. The internal exam is performed to establish if the cervix is dilated. If it isn't, the pregnancy usually continues. But if the cervix is dilated, a miscarriage is normally inevitable. An ultrasound can find a fetal heartbeat and assess if the fetus is developing normally. Finally, blood tests can determine if pregnancy hormones are still at the expected levels.

Causes of Miscarriage

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A miscarriage doesn't necessarily mean that there's a problem with the mother's reproductive function. The most common -- and unpreventable -- cause of first-trimester miscarriage is an abnormality in the fetus's chromosomes. This is usually a result of a mishap in the division process or an abnormal egg or sperm cell. But a miscarriage that occurs in the second trimester of pregnancy is usually related to an issue in the mother's reproductive system. Remember, though, this is just a general rule.

Hormonal factors include illnesses that involve an imbalance in the mother's hormone levels. Such illnesses include Cushing's syndrome, thyroid disease and polycystic ovary syndrome.

Not surprisingly, a poorly controlled chronic condition can have adverse effects on a pregnancy. Conditions like diabetes, if they're not taken care of properly, can increase the risks of miscarriage and birth defects. High blood pressure, lupus and an underactive or overactive thyroid can also cause problems.

Certain acute infections can be passed to the fetus or placenta and also put the mother at risk. In developing countries, malaria is a main cause of miscarriages. In these areas, pregnant women are two to three times more likely to get malaria than nonpregnant women [source: MedScape]. Malaria can also cause low birth weight, premature delivery and stillbirth. In developing countries, common infections include walking pneumonia, rubella, chlamydia, gonorrhea, herpes and toxoplasmosis, which can acquired from being around cat feces.

Abnormalities in a woman's reproductive anatomy can also cause a miscarriage. For example, some women may have a septum (dividing membrane) that separates the uterus into sections. Because this septum has poor blood supply, the placenta will have trouble growing, depriving the embryo of nourishment. Lack of muscle tone at the cervix (the opening of the uterus into the vaginal canal) also makes a miscarriage more likely. Many women develop uterine fibroids. Although they're benign, a poorly placed fibroid -- like one that blocks the embryo's implantation and blood supply -- can cause a miscarriage.

Lifestyle factors are also an important factor. Smoking has been shown to increase the risk of miscarriage. And it doesn't have to be the mother's smoking -- one study focused on fathers who smoke. It found that if the father smokes 20 or more cigarettes a day, the mother's risk of miscarriage increases by 81 percent [source: American Journal of Epidemiology]. Alcohol consumption during pregnancy is also harmful. One study showed that a mother who drinks more than 30 ounces of alcohol a month doubles her miscarriage risk. Another study showed that women who have more than three drinks a week in the first trimester had an increased risk of miscarriage. It is important to note that it has not been determined how much alcohol is safe during a pregnancy, and most American doctors recommend complete abstinence. And not surprisingly, the use of illicit drugs greatly increases the chance of miscarriage and birth defects [source: UpToDate Patient Information].

Some (not as conclusive) studies have shown an increased risk of miscarriage in women who drink excessive amounts of caffeine. Many doctors recommend limiting caffeine intake to 200 milligrams or less per day, which equals about two cups of coffee.

It's just as important to consume the right things as it is to avoid the wrong things. Malnourished mothers also have an increased chance of miscarriage. Severly underweight women are often not healthy enough to get pregnant. And certain conditions that develop during pregnancy -- such as the rare illness hyperemesis gravidarum, which may result in severe malnutrition and dehydration -- can cause a woman to have excessive vomiting,

Finally, trauma can cause a miscarriage. It is important here to distinguish between physical trauma and emotional trauma. There is little proof that emotional trauma -- fear, grief, anger or stress -- results in an increased risk of miscarriage. However, physical trauma does greatly increase the risk. This includes surgeries that could possibly compromise the safety of the uterus. These types of procedures are usually performed only in emergency situations.

How Miscarriage Works

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A miscarriage -- a pregnancy that ends spontaneously before the fetus can survive -- is an often devastating event. About 15 to 20 percent of recognized pregnancies end in miscarriage, but almost 75 percent of those are attributed to chemical pregnancy. This type of miscarriage occurs very soon after the egg has implanted into the uterus. It can go unnoticed because the resulting bleeding often occurs at the time of a woman's period, and she may not realize she had been pregnant at all.

Miscarriages usually occur within the first 13 weeks of pregnancy. While the chance of a miscarriage in all pregnancies is approximately 15 to 20 percent, studies show that once a fetal heart function has been noted, the chance of miscarriage falls to less than 5 percent [source: MedicineNet]. Unfortunately, the miscarriage rate can change with the mother's health and age. Women between 35 and 45 have a 20 to 35 percent chance of a miscarriage, while women over the age of 45 have a 50 percent chance. Having a miscarriage also increases your chance of having another, but only slightly. A woman under 35 who has had one previous miscarriage carries a 25 percent chance of having another one.

Other Assisted Reproductive Technology Treatments

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IVF is only one of the assisted reproductive technology (ART) treatments. Here are some of the others:

Gamete intrafallopian transfer (GIFT)
This method is very similar to IVF, but the fertilization process takes place in the woman's fallopian tubes. The downsides are that it requires laparoscopic surgery and fertilization can't be visually confirmed like it is in IVF. Women with damaged fallopian tubes can't use this procedure, so they usually go with IVF. GIFT accounts for about 2 percent of all ART procedures in the United States [source: American Society for Reproductive Medicine].

Zygote intrafallopian transfer (ZIFT)
ZIFT procedures comprise a mere 1 percent of all ART cases in the United States [source: ASRM]. Fertilization takes place in the laboratory, and the embryo is transferred to the fallopian tube (not the uterus) using laparoscopy.

While neither GIFT nor ZIFT is as successful as IVF, they may be the first option for women who have tried other methods but whose infertility problems are not yet considered severe. Couples can try GIFT and ZIFT after six unsuccessful intrauterine insemination cycles. One advantage of GIFT is that the embryo isn't developed in the lab. This eliminates the moral dilemma of choosing how many embryos to transfer and how many to destroy. But ZIFT has a higher success rate because the egg is fertilized before being placed in the fallopian tube.

Intracytoplasmic sperm injection (ICSI)
ICSI is an adjunctive treatment used in more than 40 percent of all ART procedures [source: ASRM]. The use of ICSI is indicated when fertilization rates are expected to be lower than normal, usually because of problems with the sperm. ICSI is a micromanipulation technique -- doctors inject a single sperm into the egg to ensure fertilization.

Embryo cryopreservation
This process involves the freezing embryos for future use in IVF. Frozen embryos can be stored for many years, which allows couples to skip steps in future cycles, saving them money and cutting down on invasive procedures.

Risks of In Vitro Fertilization

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The stages of IVF have different risks associated with them. During ovarian stimulation, women can get ovarian hyperstimulation syndrome (OHSS), which causes swollen, painful ovaries. Nearly 30 percent of IVF patients experience at least a mild case of OHSS. Mild cases can usually be treated with over-the-counter pain medication and a reduction in activity level -- OHSS generally resolves on its own in the absence of pregnancy. In moderate cases, which are less common, ovaries swell and fluid accumulates in the abdominal cavities. Symptoms of moderate OHSS include heartburn, gas, nausea, vomiting and loss of appetite. About 1 to 2 percent of women undergoing IVF develop severe OHSS, which may require hospitalization and involves sudden and excessive weight gain, severe abdominal pain with nausea or vomiting, and shortness of breath.

During egg retrieval, risk depends on the retrieval process. Transvaginal ultrasound aspiration carries a small risk of bleeding and infection and, sometimes, damage to surrounding structures like the bowel and bladder. The risks associated with laparoscopy include difficulty breathing, chest infection, allergic reactions to medications and nerve damage -- the same as with any surgery in which anesthesia is required.

When more than one embryo is transferred, there is always the risk of a multiple pregnancy. An infertile couple may take this as good news, but the presence of more than one embryo increases the risk to the embryos and to the mother. The most common is premature delivery. The babies could develop complications after birth or be born too early to survive. About 5 percent of IVF pregnancies are ectopic, which means that the fertilized egg develops outside the uterus, usually in the fallopian. This complication, unfortunately, requires immediate destruction of the fetus.

The In Vitro Process

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The saying "nothing worth having comes easy" could refer to the process of trying to conceive via IVF. An IVF cycle takes four to six weeks to complete and usually costs about $12,000. Some women may have to endure multiple cycles before getting pregnant. In fact, in the United States, women under the age of 35 have only a 30 to 35 percent chance of having a baby after an IVF cycle, with the chance dropping to 20 to 25 percent in women between 35 and 40. Women over 40 have a 6 to 10 percent chance of a live birth per cycle of treatment

Ovarian stimulation. This step involves the use of ovulation, or fertility, drugs. These hormones, taken over a period of eight to 14 days, stimulate a woman's ovaries to produce several eggs per menstrual cycle instead of one. Successful IVF usually requires the fertilization of multiple eggs -- some may not fertilize or develop normally after fertilization. During this process, the physician will use ultrasounds or blood testing to determine when the eggs are ready for retrieval.

Egg retrieval. Once the eggs are deemed ready for retrieval, the doctor performs a transvaginal ultrasound aspiration. This is a simple surgical procedure that uses a small amount of anesthesia, such as a mild sedative. Once the ultrasound locates the mature follicles in the ovary, the doctor inserts a needle into the follicles and removes the eggs with suction. If the ultrasound can't find or access the ovaries, doctors might have to perform laparoscopic surgery. This technique -- in which doctors cut a small incision in the abdomen and locate the ovaries with a tiny fiber-optic lens -- is still simple and short, but it requires stronger anesthesia.

Insemination. After retrieval, doctors examine the eggs and decide which of them hold the most potential for a successful pregnancy. They place these eggs in an IVF culture medium to await insemination. Meanwhile, they separate the father's sperm from his semen. The most motile sperm (the "best swimmers") are then added to the eggs in the incubator.

Fertilization and embryo culture. Usually within a matter of hours, a sperm cell penetrates an egg and fertilizes it. The following day, doctors visually confirm fertilization if they can see two pronuclei. These pronuclei are the basis of the embryo formation -- they will unite to form the nucleus of the zygote, which divides to become an embryo. A two- to four-cell embryo appears approximately two days after fertilization. On the third day, a six- to 10-cell embryo is seen. Five days after fertilization, the embryo can be called a blastocyst, which means it has formed a fluid cavity that results in the formation of fetal tissues and placenta. However, many embryos are not observed for this long. They can be placed in the uterus as early as one day and as late as six days after fertilization. In most cases, they're observed for two to three days to determine if the development is normal.

Embryo transfer. About two to three days after fertilization, the resulting embryo or embryos are transferred to the woman's uterus. Doctors suspend them in a drop of fluid and draw it into a transfer catheter -- a long, thin, flexible tube that has a syringe on one end. They then guide the catheter into the vagina, past the cervix and into the uterus. The patient is encouraged to remain in a resting position for an hour or two to prevent any stress on the body. If the embryo or embryos do attach to the uterine wall, a positive pregnancy test will result.

Coping With a Child Who Has a Hereditary Illness

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Until two centuries ago, the death of a baby was an accepted, although tragic, risk of childbirth. Infectious diseases claimed many young lives. In mid-seventeenth century Europe, only one in four children survived to celebrate his fifth birthday. As recently as the late nineteenth century in the United States, one in five children died before the age of one year. Largely due to improved hygiene, immunizations, and antibiotics, babies in developed nations now die infrequently.

Although infant death is an uncommon occurrence, families sometimes have to cope with babies who have serious, chronic, and even fatal illnesses. Parents may walk an emotional tightrope between hope and despair for the long months that their child is ill.

Upon facing the diagnosis of serious illness in their infant or child, parents may at first feel nothing except shock and disbelief. Grief follows as a response to any loss. This loss may be the dissipation of their dreams of a healthy child. If the disease is expected to be fatal, parents may mourn in anticipation of the child's death. Despair, fear, anger, remorse, and loneliness are all emotions of the normal grieving reaction.

Dealing With Guilt

Guilt is another emotion many parents feel when they learn their infant is gravely ill. Parents can torment themselves or each other with feelings of responsibility for the illness. If the baby has a hereditary disease, feelings of self-blame may be especially overwhelming.

Self-reproach can be destructive. Negative feelings about oneself make it difficult for a parent to nurture the sick baby and the other members of the family. Guilt-ridden parents may either lavish excessive attention on the baby or turn away from her. Both responses amplify an older infant's or toddler's sense that something is wrong with her.

Parents may suffer further if communication between husband and wife is impaired. Their coping styles may be incompatible. Resentments may arise if one parent quits working to undertake the care of the sick child.

Sadly, having a child with a chronic or fatal disease can add enormous stress to a marriage. While it is safe to say that no marriage is the same after a child is diagnosed with a serious illness, families that recognize this stress are better equipped to cope. Marriage or family counseling is a vital part of coping with the stress, and your child's doctor or nurses can refer you to a therapist.

Helping Siblings to Cope

Parents often wonder whether their other children are too young to be told about the fatal illness or death of their sibling. Most psychologists feel it is crucial that the other children be told the truth in a straightforward manner that they can understand. Children who are not informed will still know something is frightfully wrong and may invent their own fantastic explanations.

A child's ability to comprehend death and dying depends on his age and prior experience with death (of a friend, family member, or pet). Before the age of two years, infants and toddlers are unable to grasp the concept of death. However, even very young children do react with distress to prolonged separations from loved ones.

After two years of age, given proper assistance from an adult, children are able to achieve a basic and concrete understanding of death. Still, they may have difficulty comprehending the permanence of death. Active imaginations lead to wild fantasies about where the deceased has gone. Because it is normal for children to have occasional negative feelings about their siblings, they may worry that their own thoughts or actions caused the illness. This sort of magical thinking and self-blame is especially common in children between the ages of five and eight.

A young child's response to the death of a sibling may be exasperating for parents. Using denial as a defense, he may act overtly as though nothing were wrong. Clues to inner turmoil include demanding, clinging behavior; regression to infantile behavior, such as lapses in toilet training; and increased aggression. Your warmth, understanding, and sharing of thoughts and feelings help him to grieve in a more appropriate fashion.

By 8 to 12 years of age, a child's understanding of death is similar to an adult's. However, the severe illness or death of a sibling may make him overly fearful of his own mortality.

Caring for Your Baby

As the family grapples with the serious illness and perhaps imminent death of the baby, the infant must also cope with the consequences of her ill health. An infant's need to be cuddled is just as great as her requirement for food. She thrives on consistent care from her parents. A baby quickly comes to know and love these special people.

Separations, such as during hospitalizations, can be very distressing for an infant. Parents of children with chronic diseases can sometimes arrange to care for the child at home with or without the assistance of a nurse. Should parents decide to bring their dying baby home, many communities have resources to assist them during this period (such as visiting nurses, home care nursing, and hospice care).

During necessary hospitalizations, most hospitals allow parents unrestricted visiting privileges and often provide facilities for parents to room-in with the child. This gives parents the opportunity to participate in the care of their sick baby. Caution must be exercised not to spend so much time with the ill child that the well-being of the parents and other family members suffers.

To help you cope with an ill or dying baby, do the following:

Tell the physician and other hospital staff about your needs and your baby's needs.

Provide the hospitalized baby with her favorite toys and food. Display pictures of the family where she can see them. The entire family should visit the baby as often as is feasible.

Obtain counseling with a skilled professional. Ask your doctor or contact the hospital for a referral.

Read about the subject. Most bookstores and libraries have many books for all age groups about coping with the illness or death of a loved one.

Search out support groups, which exist for many types of chronic illnesses of childhood. There are also support groups to help parents adjust to the death of an infant.

Allow siblings to visit the baby in the hospital.

Attending funeral services that are brief and not morbid help all family members to understand and accept the finality of their loss.

Keep lines of communication open between family members. Families that can share their feelings and console each other learn that even an enormous loss can be mastered.

However, it is important for new parents to keep in mind that this is the worst-case scenario. The overwhelming majority of children are born health or with only minor genetic fluctuations that are easily corrected. While it is a good idea to stay informed to all of the possibilities, there is also no reason to focus on the negative.

Genetic Diseases

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There are several different categories of genetic diseases that are divided by the type of gene or chromosome that transmits the disease.

Autosomal Recessive Diseases

In most cases, a woman who inherits a defective recessive gene from one parent and a normal dominant gene from the other parent does not exhibit any symptoms of that illness but is a carrier of that abnormal gene. However, if she has children with a man who is also a carrier, their children have a 50 percent chance of inheriting one defective gene and being nonsymptomatic carriers, and a 25 percent chance of inheriting two defective recessive genes and expressing the disease. This pattern is called autosomal recessive inheritance. The better-known of these disorders include sickle cell anemia, Tay-Sachs disease, and cystic fibrosis.

Sickle cell anemia: Anemia is sometimes caused by a deficiency of hemoglobin. Hemoglobin is the substance in red blood cells that carries oxygen to the other cells in the body. In sickle cell disease, the hemoglobin is abnormal. People who carry only one defective recessive gene usually have no symptoms of the disease. People who inherit two sickle cell genes develop many problems due to the structure of their abnormal hemoglobin.

This defective hemoglobin molecule causes the normally round blood cell to sickle (assume a crescent shape). Anemia occurs because sickled red blood cells are more fragile, hence more easily destroyed. Sickled cells are also less able to bend as they squeeze through tiny blood vessels. Thus, these cells become trapped and obstruct small vessels.

Episodic clogging of the vessels with sickled blood cells causes tissue damage and pain, especially in the hands, feet, joints, and abdomen. Children with sickle cell anemia are prone to more frequent infections than children without the condition.

At present, no cure for sickle cell anemia exists. Treatment includes administration of painkillers and antibiotics as necessary. Children with sickle cell anemia who develop a fever should be seen by their doctor as soon as possible to determine treatment, which may include hospitalization for intravenous fluids and antibiotics. More children with sickle cell anemia are surviving into adulthood because of improved therapy and new, effective vaccines for many illnesses. Such vaccines are vital because children with sickle cell anemia are at increased risk for certain bacterial infections.

Because sickle cell anemia is most common among black persons, black adults are encouraged to undergo screening to determine if they are carriers of sickle cell anemia. Carriers can be identified by means of a simple blood test. Approximately eight percent of black people in the United States are carriers.

If both parents are carriers, they have a one in four chance of giving birth to a child with sickle cell disease. Sickle cell disease can be diagnosed before birth with the use of amniocentesis (see page 14 for an explanation of this procedure). In many states, most newborn babies are screened for sickle cell disease at birth by means of a blood test.

Tay-Sachs disease: Tay-Sachs disease is a metabolic disorder marked by the accumulation of a type of fatty acid in the liver, spleen, and brain. It is caused by a deficiency in the enzyme that normally degrades this fatty acid. After four to six months of normal development, children with Tay-Sachs exhibit deterioration in neurologic development. The disease progresses to mental retardation, blindness, and convulsions. Death usually occurs by age three or four. No treatment exists.

Preventive measures are available. The Ashkenazim, the Jews of eastern Europe, are disproportionately affected by Tay-Sachs, with nearly 100 times the rate of occurrence as other groups. Carriers have no symptoms of the disease and sometimes have no family history of the disease. It is recommended that all Jewish couples of eastern European descent undergo screening for the Tay-Sachs gene before they start their families. If both parents are carriers, diagnosis of Tay-Sachs disease in the baby can be made during pregnancy with the use of amniocentesis.

Cystic fibrosis: Cystic fibrosis is a serious childhood illness that causes the glands of the body to secrete abnormal sweat and mucus. The sweat glands secrete too much salt. The abnormally thick, sticky mucous secretions accumulate in and obstruct the lungs and pancreas. Since the pancreas is an important organ for digestion, these children fail to grow properly. The thick mucus in the lungs makes breathing difficult and leads to infections. Death is usually due to respiratory failure. Although no cure exists, improved treatment has brightened the prognosis of children with cystic fibrosis, giving them a good chance for survival into adulthood.

Cystic fibrosis is much more common in white people of northern European extraction. In the United States, approximately 1 in 29 white people are carriers. One infant in every 3,000 live births has cystic fibrosis. Traditionally, the disease has been diagnosed on the basis of sweat test results obtained only after the appearance of the symptoms. However, now diagnosis can be made before birth with amniocentesis.

Phenylketonuria: Phenylketonuria (PKU) is a rare disorder that can cause severe mental retardation. It is caused by an inability to convert an amino acid called phenylalanine into another amino acid called tyrosine. (Amino acids are the building blocks of proteins.) At elevated levels, phenylalanine damages brain cells, causing retardation.

In the United States, all newborns are screened for PKU by means of a blood test. Early detection and prompt treatment can prevent the mental retardation. Treatment consists of limiting a child's dietary intake of phenylalanine. If this dietary regimen is followed, children with PKU can have essentially normal development. Pregnant women who have PKU need to stick to this special diet to protect the baby's developing nervous system. All people with PKU must completely avoid the artificial sweetener aspartame, which contains phenylalanine. New research is in progress to help identify carriers of PKU and to diagnose PKU prenatally.

Autosomal Dominant Diseases

Another category of hereditary disease is called autosomal dominant disease. Because the defective gene is dominant, the disease is expressed even if only one gene is defective. A normal gene cannot mask the harmful effects of an abnormal gene as it can in autosomal recessive disease. If one parent has an autosomal dominant disease, the chances are 50 percent that each child will inherit the disorder.

Huntington chorea: An example of an autosomal dominant disease is Huntington chorea, a brain disease marked by abnormal body movements and mental deterioration beginning in middle age.

Although a few medicines have been found to make the symptoms more tolerable, the disease has no cure. Researchers have been able to identify carriers in families with Huntington chorea with a genetic test. It is hoped this procedure will be perfected and also extended to prenatal diagnosis.

Sex Chromosomes and Sex Determination

As previously stated, most cells in the body have 46 chromosomes, consisting of 22 pairs of autosomes and 2 sex chromosomes. The sex chromosomes determine whether a person is male or female. Women have two X chromosomes. Men have one X and one Y chromosome.

The sex cells (eggs and sperm) contain only 23 chromosomes -- 22 autosomes and 1 sex chromosome. Each ovum (egg) contains one X chromosome. Half of a man's sperm cells carry an X chromosome; the other half carry a Y chromosome. During fertilization, the genetic material of the egg and sperm unite to create the full complement of 46 chromosomes. If the ovum is fertilized by a Y sperm, the baby will be a boy; fertilization by an X sperm results in a girl.

X-Linked Recessive Diseases

In sex-linked inheritance, the gene responsible for the disease is located on the X chromosome. Usually, the abnormal gene is recessive. For these reasons, the resultant disorder is called an X-linked recessive disease. In a woman with such a defective gene, the effects of the abnormal gene are masked by those of the normal gene on the other X chromosome. Although she does not have the disease herself, she is a carrier, capable of transmitting the defective gene to her children.

In X-linked recessive disease, the Y chromosome lacks the corresponding normal gene to mask the harmful effects of the abnormal gene on the X chromosome. Thus, all male offspring of a woman who is a carrier of an X-linked recessive disease have a 50 percent chance of having the condition. All female offspring have a 50 percent chance of being carriers. Following are examples of X-linked recessive disorders:

Color blindness: A person with the most common form of color blindness cannot distinguish red from green hues.

Hemophilia: In hemophilia, the blood does not clot properly. Persons with hemophilia bleed excessively, even from minor cuts. There are several forms of hemophilia, each caused by a deficiency of a different protein called a clotting factor. The disease is managed by giving transfusions of the deficient clotting factor and of whole blood to replace blood losses. Research continues toward the accurate identification of carriers and prenatal diagnosis of this disease.

Duchenne muscular dystrophy: Muscular dystrophy refers to a group of rare diseases characterized by progressive muscular weakness. Duchenne type muscular dystrophy is the most common. Between the ages of two and six years of age, children with this condition develop weakness first in their legs, then in their arms and trunk. The weakness rapidly worsens. Most children die during their second decade, usually as a result of severe weakness of the muscles of respiration. The disease has no cure. Treatment includes physical therapy, braces, and, occasionally, surgery.

Newer techniques and better understanding of the genes involved have made prenatal testing possible. Advances in genetic testing are soon likely to make it possible to detect the recessive trait in carriers as well.

Multifactorial Genetic Diseases

Multifactorial genetic diseases are illnesses that tend to run in families. These diseases are not due simply to the inheritance of a single defective gene. Rather, a cluster of faulty genes is inherited, which predisposes the person to a disease. Given the appropriate environmental factors, the person may actually develop that disease. Examples of illnesses that run in families include such chronic adult diseases as coronary heart disease, high blood pressure, and stomach ulcers, as well as birth defects, such as cleft lip and palate and spina bifida.

Cleft lip and palate: In cleft lip, the upper lip is divided by a vertical fissure. In cleft palate, the roof of the mouth is split by a longitudinal fissure. These two birth defects can occur alone or together. They are the result of incomplete fusion of the components that form the lip and mouth during fetal development.

Spina bifida: Spina bifida is a failure in the closure of the bony vertebral column with or without protrusion of the nerve tissue of the spinal cord. Paralysis below the defect often accompanies spina bifida if the spinal cord does protrude. When the spinal cord does not protrude, the vertebral defect may go unnoticed. Clues to indicate the presence of this form of spina bifida are abnormalities of the skin and tufts of hair overlying the spine in the lower part of the back.

During pregnancy, spina bifida in the fetus can be diagnosed by means of ultrasound study and detection of elevated levels of a substance called alpha-fetoprotein in the mother's blood and in the amniotic fluid that bathes the fetus. Spina bifida can be caused by a folate deficiency in the mother during pregnancy or exposure of the pregnant woman to certain drugs that interfere with folate.

Chromosomal Abnormalities

Sometimes the structure or the number of chromosomes is not normal. The risk of having a child with chromosomal abnormalities increases with increasing maternal age (and to some extent with increasing paternal age as well). If chromosomal abnormalities occur in the sex cells (eggs and sperm), the offspring may have physical and mental disorders.

Down syndrome: Formerly called mongolism, Down syndrome is a condition caused by a chromosomal abnormality. Due to the failure of the chromosomes to divide evenly during cell division, the person with Down syndrome has an extra chromosome (a total of 47). The presence of this extra chromosome causes a characteristic physical appearance and delayed physical and mental development. Other ailments, such as defects in the heart and digestive system, can accompany this syndrome. Despite their disabilities, children with Down syndrome usually have pleasant dispositions and can do quite well if given special therapy.

The cause of the chromosomal abnormality leading to Down syndrome is unknown. A genetic predisposition may exist. The incidence of Down syndrome increases with increasing maternal age. The condition can be diagnosed prenatally with the use of amniocentesis. For these reasons, women who have previously given birth to a baby with a chromosomal abnormality or who are older than 35 years of age are encouraged to undergo amniocentesis.

Genetic Counseling

In recent years, tremendous progress has been made in the development of genetic tests to diagnose heritable diseases. You may wish to consult your physician about genetic counseling if any of the following risk factors apply to you:

You have a family history of a hereditary disease or of mental retardation of unknown origin.

You are a woman older than 35 years of age.

You have had a previous child with a chromosomal or other genetic disorder or any birth defects.

You have had three or more miscarriages or a stillbirth.
If you have any concerns or questions regarding heritable diseases, ask your physician. If you are considered to be at risk for passing on a hereditary disease to your children, you can receive genetic counseling. A genetic counselor asks you about your personal and family medical history. Blood tests may be necessary to help determine whether you are a carrier of a heritable disorder. You are advised about the chances of transmitting hereditary illness to your offspring.

If you are pregnant, the well-being of your fetus can be assessed by several procedures:

Ultrasound: High-frequency sound waves are used to produce images of the placenta and fetus. It can detect gross defects, especially of the heart, bones, brain, and spinal cord.

Amniocentesis: A small amount of amniotic fluid, the liquid that bathes the baby inside the uterus, is withdrawn and analyzed. Many genetic diseases can be diagnosed prenatally with the use of am-niocentesis.

Chorionic Villus Sampling (CVS): A few fetal cells from the chorionic villus, a part of the placenta, are withdrawn and analyzed for the presence of select diseases.

Fetoscopy: The fetus is directly observed within the uterus by means of special lenses. During fetoscopy, fetal blood can be sampled. It is rarely used today.

Radiography: X-ray films are occasionally obtained because they can depict certain skeletal abnormalities in the fetus.
Remember that the diseases described in this section are rare. Most expectant parents can look forward to the arrival of a healthy baby. If you are pregnant or hope to be and have any worries about the well-being of your child, don't hesitate to address them with your doctor.

If your child does have a hereditary disease, however, it's important to confront and accept the realities of this challenge. Keep the lines of communication open within your family, seek out support groups, and avoid bearing all the guilt for your child's disease.

Genetic Predispositions to Diseases

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Happily, most children arrive in this world normal and healthy. By adulthood, children have had their share of colds, coughs, stomachaches, and other minor illnesses. Compared with the usual childhood ailments, hereditary diseases are rare, but they do occur, and all parents should be informed about the more common ones. Genetic counseling is advisable for parents who are in certain high-risk groups.

Central to any discussion of hereditary diseases is an understanding of the basis of heredity -- the gene. Genes are bits of chemical information that determine all of our inborn characteristics. They are carried in structures called chromosomes within the nucleus of all cells.

Genes are composed of varying arrangements of molecules of deoxyribonucleic acid (DNA), which makes up the chromosomes. Each gene, by virtue of its unique DNA sequence, holds the code for a specific trait.

Except for the sex cells (eggs and sperm), each cell in the body contains 46 chromosomes. Forty-four of the chromosomes are called autosomes. The two remaining chromosomes are the sex chromosomes.

The autosomal chromosomes are paired. For each pair, one chromosome comes from an individual's mother, the other from the father. Each gene on one chromosome is matched to a corresponding gene on the other chromosome. Thus, for every genetic trait, there are two genes.

The two genes that provide the code for a trait may not be identical. For example, if a gene pair governs eye color, one gene may code for blue eyes, the other for brown eyes. Because the gene for brown eyes is dominant, the eyes will be brown. The gene for blue eyes is recessive. A person with brown eyes may also have two genes for brown eyes. For a dominant trait to be expressed, however, only one dominant gene is necessary. A person with blue eyes must have two genes for blue eyes. To express any recessive trait, a double dose of recessive genes is necessary. A person with only one copy of a recessive gene exhibits no evidence of the trait.

Like eye color, certain illnesses are genetically determined. In some instances, the defective gene has been passed from generation to generation within a family by carriers who show no symptoms of the illness. Parents may be aware of a family history of hereditary disease. Whether their baby develops that illness depends upon the inheritance of dominant or recessive genes.

The better known genetic disorders include sickle cell anemia, Tay-Sachs disease, and cystic fibrosis, which are more prevalent among certain demographic groups. Other diseases include Phenylketonuria, autosomal dominant disease, hemophilia, muscular dystrophy and may include conditions like cleft lip, spina bifida and Down syndrome

Hereditary Illnesses Overview

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Hereditary illnesses are sometimes passed down from parents to their children in much the same way as gene traits. For instance, blue-eyed parents will also have children with blue eyes. But diseases can prove much more subtle, as children might inherit the abnormal, dysfunctional genes of their parents even though previous generations never suffered from the symptoms of that disease. Even today children can be born with serious, chronic or even fatal illnesses. Parents must accept these challenges when they arise, seek support, and avoid blaming themselves.

Genetic Predispositions to Diseases

Genes are bits of chemical information that determine our characteristics, by carrying hereditary traits from one generation to the next, including everything from eye color to diseases. Each genetic trait has two genes, which might be identical or might include one gene that is dominant and one that is recessive. For instance, the gene for brown eyes dominates the gene for blue eyes. Illnesses can also be passed down within a family, even if the carriers show none of the symptoms.

Genetic Diseases

The risk of a genetic disease increases if both parents carry the dysfunctional, abnormal gene, even if they are nonsymptomatic carriers. The better known genetic disorders include sickle cell anemia, Tay-Sachs disease, and cystic fibrosis, which are more prevalent among certain demographic groups. Other diseases include Phenylketonuria, autosomal dominant disease, hemophilia, muscular dystrophy and may include conditions like cleft lip, spina bifida and Down syndrome.

Coping With a Child Who Has a Hereditary Illness

Despite the security of modern medicine, some children still face serious, chronic and even fatal illnesses. It's important for parents to cope with these challenges. They need to confront and accept the diagnosis, and be honest with themselves and their other children about the realities of hereditary illnesses. They should keep the lines of communication open within the family, seek out support groups, and avoid bearing the guilt upon their own shoulders for the child's situation.

Well-Baby Care

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During your baby's first three years of life, she will see her doctor a number of times. These visits are important to check that she is growing and developing appropriately. Her doctor will ask you a number of questions about how the baby is doing, and he will examine your baby, checking for normal growth and looking for problems.

Routine and regular checkups are particularly important for your baby during her first three years of life. Problems found at this age, if not treated early, may have serious implications for her later in life.

It used to be that your baby's doctor would see her for the first time within 24 hours of her birth. For some babies, this may still be the case. But with changes in insurance and hospitalization coverage, most new babies leave the hospital with their mother 24 to 48 hours after the birth.

So the first time the doctor sees the baby is now commonly at her first visit to the doctor's office. Most doctors like to see the new baby when she's one to two weeks old.

Whenever your baby and her doctor first meet, the doctor will perform a complete physical examination of the baby and talk to you about your pregnancy, labor, and delivery. If you smoked, took any drugs (prescribed or recreational), or drank any alcohol, you need to tell this to the doctor. These factors may affect your baby's health and growth.

When you visit the doctor's office, the doctor's staff will probably ask you some questions before you see the doctor. Here are just a few samples: How is the baby feeding? Is she sleeping well? Does she seem to have any problems with her bowels? Does she have any skin problems? They will also measure your baby's growth, including her weight, length, and head circumference (the distance around her head). The doctor goes over all this information and may ask more questions.

Next comes the examination of your baby. With your baby completely undressed, the doctor will examine your baby's heart, lungs, abdomen, arms and legs, eyes, ears, nose, throat, and everything in between. Essentially, the doctor will examine your baby from head to toe -- though not necessarily in that order.

Rarely are there any surprises found at this visit, although occasionally a congenital abnormality (a birth defect) is found that was not apparent when the baby was in the hospital. At this age, no immunizations are given.

During her first month, the baby changes a lot. You will have many questions and concerns about your new baby, and this visit gives you the opportunity to ask them. Write down your questions ahead of time so you don't forget anything. Never be afraid or ashamed to ask a question; the doctor should take time to address all your concerns. Your doctor can also give you advice on taking care of your new baby, such as feeding and sleeping instructions and safety tips.

Regular Office Visits

Doctors like to see infants at regular intervals to monitor their growth, development, and health. Regular visits are important because they improve the chance of finding any health problem early so appropriate treatment can begin immediately. Although your doctor may have a slightly different schedule of visits, most infants are seen when they are 2, 4, 6, 9, 12, 15, 18, and 24 months old, and then once a year until they are of school age.

In addition to the doctor physically examining your baby, a nurse or the doctor will measure the baby's weight, head circumference, and body length. These measurements are important for monitoring your baby's growth. Each is plotted on a growth chart. These charts are the best way to determine if your baby is growing well. If your baby's rate of growth is abnormal, follow-up is necessary.

The doctor will also ask you questions about your baby's behavior and development. The doctor looks for certain developmental milestones -- features babies usually demonstrate at certain ages. It's important to understand these milestones are only guidelines, but if a baby consistently fails to reach them by certain ages, further investigation is necessary.

After the Second Year

As your baby grows, he does not need to visit the doctor routinely as often as when he was an infant. Yearly visits are for the same reasons as the earlier ones -- to make sure your child is growing and developing as he should and to provide you with an opportunity to ask questions. New topics become important, although you may need to discuss many of the old ones, such as behavior and eating, again.

The Well-Baby Examination

Your doctor's well-baby examination consists of many different parts, each designed to discern certain information. You may have to watch closely to see the doctor perform each part of the exam because the doctor has probably developed tricks and techniques for making the exam as comfortable for your baby as possible.

While the doctor may just seem to be simply talking to your infant, he or she is carefully checking the baby's skin or eyes. Some doctors like to have the baby on the examination table; others prefer that a parent hold the baby. If you prefer to hold your baby during the examination, most doctors will respect your choice; however, the doctor may require your baby to be on the table during some portions of the exam.

Here are some of the major areas your doctor considers and what he or she looks for:

General Appearance: cleanliness, problems associated with poor nutrition, alertness

Skin: good color, rashes, bruises, swelling, condition of hair and nails

Head: shape, softness of the anterior fontanel (soft spot)

Eyes: "lazy eye," good movement, light reflexes, vision (when child is old enough to understand)

Ears: irritation or infection of the ear canals or middle ear

Nose: congestion, discharge

Mouth: condition of gums, tongue, throat, tonsils

Neck: swelling of the thyroid or lymph nodes, mobility

Heart: rate and rhythm, murmurs

Lungs: breathing rate and pattern, abnormal noises, air exchange, movement of the chest wall

Abdomen: bowel sounds (normal stomach gurglings), enlarged organs or tenderness

Genitals: in girls -- normal appearance of external genitals, redness; in boys -- normal appearance of penis (if circumcised, check that it has healed well; if not, check that foreskin is normal), both testicles in scrotum

Arms and Legs: normal movement and color, any swelling and discoloration

Hips: in infants-normal placement in sockets

Pulses: equal femoral pulses-located in the groin region above each leg

Muscles: muscle movement and coordination, tone, strength

Doctor visits will be a commonplace, and sometimes scary, thing as your child gets older. But regular medical care will ensure that your child is always healthy and happy.

Choosing an Infant Healthcare Provider

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If possible, you should try to meet with several doctors before you have your baby. This gives you an opportunity to find out what they are like -- their style, their approach, their fees, and so forth. Most doctors encourage this and usually don't charge for the visit.

Note that if you participate in a managed healthcare organization (HMO, PPO, or others), your choices are limited to those doctors participating in your specific managed care program. You should still meet with a few of them, so you can choose from among those available through your insurance carrier.

If you already know you want to see a particular doctor, be sure he or she participates in your program. Otherwise, you may be responsible for charges which could have been covered under your insurance program.

Questions to Ask

When you go for the get-acquainted visit before your baby is born, you should bring a list of questions. The prenatal interview appointments usually last from 10 to 15 minutes, so you will not have the opportunity to discuss all your questions. Decide on a few areas that interest you the most and discuss those. Take notes, and follow up on any answers you don't understand.

Be aware of the doctor's style and how he or she answers the questions. Do you feel secure picturing this person as your child's health care provider? Are his or her style and philosophy compatible with yours?

Here is a list of some questions you might ask:

What hospitals do you use?

You may want to be sure the doctor uses the hospital you prefer. If he or she prefers a hospital far from your home, find out why. Perhaps that hospital offers special services or has a different approach to taking care of children. You may find the approach or services worth the inconvenience.

What hours is your office open?

With medicine becoming more competitive, doctors are doing more to attract and keep patients. This includes offering evening and Saturday office hours. If a doctor's office hours are inconvenient for your family, you may want to find another doctor.

What services do you provide in your office?

Many doctors now provide a number of services in their offices to make obtaining appropriate health care for your child more convenient for you. For example, they may take blood samples there to save you a separate trip to a hospital laboratory; they may even perform some laboratory tests at the office. Many doctors also perform hearing and vision tests in their offices. The more done in the office, the fewer places you may have to take your child. (Although, if an abnormality is found during a test conducted in the doctor's office, you may have to go to a hospital laboratory for further testing.)

Do you conduct all the examinations or do you use the services of physician assistants or nurse practitioners?

The presence of these physician extenders is really an added bonus. Remember that they often have more time to spend answering any questions you may have about your child's health and development. Unlike doctors, these professionals are not usually called away to handle emergencies, so you may have to spend less time in the waiting room. They refer any questions or problems to the doctor, so your child in no way receives lesser professional care.

What should I do if my child gets sick at night or on the weekend and I can't reach you?

Most doctors arrange to have other physicians cover for them when they are taking some time off or are out of town. Be sure the doctor has such a system. Find out who the covering doctors are because you may have to deal with them. Be wary of a doctor who tells you to take your sick child to the emergency room when he or she is not around.

How do I fit into the care of my child?

Some doctors encourage parental education and awareness and want parents to actively participate in the medical care of their children. They may even provide newsletters, pamphlets, or other educational materials or services to parents. Other doctors want to be completely in charge and make all the decisions without input from parents. You need to know the doctor's feelings in this area. If they conflict with yours, the doctor probably isn't right for you.

What type of training did you receive?

Any doctor should be willing to tell you about his or her training -- medical school, residency, and any special training. It is a good idea to ask if the doctor is board-certified -- that is, if he or she has demonstrated, by completion of certain requirements and passage of an examination, competency in a specialty. You may also want to ask what measures the doctor takes to keep up with the latest information and developments in the specialty. Does he or she attend conferences? Take continuing medical education courses?

What are your fees?

Different doctors may charge different fees for the same services. If you have health insurance, contact your insurance carrier to find out the extent of your coverage. Some insurance carriers reimburse at a higher rate if the doctor or hospital belongs to a specific network or organization. Find out about any such policies before you choose your baby's doctor.

After you have visited with a few physicians, talk to friends and coworkers. Find out what doctors they see and why. If they have a doctor that you visited, ask them the questions you asked the doctor (especially about service and availability), and see if you get the same answers. When you have all this information, you are in a position to make an educated decision.

Once you decide, let the doctor's office know. Find out if the office needs any information about you. If another doctor has any records of your children, arrange for them to be sent.

After all this work, there's still a chance you'll decide, after a few visits, that your new doctor isn't what you expected. You should discuss this with him or her. Try to explain why you aren't satisfied. Maybe a misunderstanding has occurred that is easy to correct.

Your doctor's reaction to what you say is important. If the reaction is anger or rudeness, you should look for another doctor. Don't feel obligated to continue to see a doctor with whom you disagree on some important matter, such as approach, treatment, or fees.

When you change doctors, you should get your child's old medical records. Contact the former doctor's office to ask staff to send the records to the new doctor. Physicians do this as a service to all patients. Most states require doctors to do this: The law says the contents of the records belong to the patient even though the actual records belong to the physician.

Most likely, you will be asked to send your request in writing and, to comply with federal regulations, to fill out a form allowing your child's former doctor to release the records to the new doctor.

Infant Healthcare Providers

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Pediatricians, practitioners, pysician extenders, clinics -- the world of medical care for babies can be confusing. And you'll want to sort it out, because your baby will get sick. The trick is to pick one healthcare professional who serves as the point person for all your baby's needs, and, fortunately, the process boils itself down pretty easily.

Family Practitioners and Pediatricians

Two different physician specialists care for babies -- family practitioners and pediatricians. Both types of physicians have completed a residency (extra training after graduation from medical school).

A family practitioner's training covers all areas of medicine, including adult medicine, pediatrics, obstetrics, and surgery. A pediatrician's residency focuses entirely on pediatrics, and in their practice pediatricians specialize in the care of children and adolescents only.

Pediatricians have more training in childhood illness than any of the other providers. Compared with the family practitioner, the pediatrician has spent more time dealing with very ill children and with children who have special problems. Most pediatricians generally see their patients through the teenage years. Their staff and their waiting rooms are geared for children.

Family practitioners, on the other hand, can care for your entire family -- from the very young to the very old. Most family practitioners encourage this approach. They find it easier to treat an individual if they know the whole family.

Both pediatricians and family practitioners can take care of normal children equally well; however, if your child has special problems, a pediatrician is usually preferred. In addition, a family practitioner would refer any serious illnesses to a physician with more pediatric training.

Other Healthcare Providers

Other healthcare providers are also available for babies and children. These are nurse practitioners and physician assistants -- often collectively referred to as physician extenders.

Nurse practitioners are registered nurses who take one or two years of further training in physical examination, diagnosis, and prescribing medicines. Many work with physicians, although in some areas, they may practice by themselves.

Pediatric nurse practitioners are nurse practitioners who have taken additional training in clinical pediatrics. They specialize in well-child care and the treatment of common illnesses. They tend to be very capable in the areas of children's development and emotional needs and parenting concerns and often conduct classes in these areas. All nurse practitioners refer serious problems to physicians.

Physician assistants graduate from a two-year program in which they learn many of the same skills as the nurse practitioner. Many have a medical background, having worked as a laboratory technician, respiratory therapist, or other health care worker.

In most states, nurse practitioners and physician assistants perform the same functions; however, although a nurse practitioner may prescribe medications, a physician assistant cannot do so without a doctor's approval.

Physician extenders often work in clinics or groups, with physicians available for consultation and referral. Many private physicians also employ physician extenders who see children in the office for routine health care. Physician extenders often can spend more time talking with you, answering your questions, and teaching you what you need to know.

Settings for Child Care

These healthcare professionals work in different settings with their own advantages and disadvantages. Private care, such as from your own physician, tends to be more personalized, more convenient, and more expensive. Children's health clinics cost less to those with low incomes and usually offer good care, although you may experience more waiting and less continuity of care with the same practitioner. Children's health clinics are largely staffed by physicians taking their specialty training in family medicine or pediatrics.

Well-child clinics, such as those sponsored by the public health department, provide free or low-cost checkups and immunizations, but usually little care for the sick child. They are often staffed by physician extenders.

After looking into the types of care, decide which you want to investigate and make appointments to get to know the people involved. Ideally, try to do this at least a few weeks before your baby is due.

Infant Healthcare Overview

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One of the most important decisions you'll make about your baby's health is selecting his or her doctor. It's important to find a doctor you feel comfortable with -- someone whom you can talk to and who is willing to answer your questions. After all, you will turn to this doctor for help often, and even when your baby is healthy you'll be making regular visits. In the following pages you'll learn who the different doctors are, how they care for your baby, and how to pick the one that's right for you.

Infant Healthcare Providers

There are two main types of doctors who specialize in infant care: pediatricians and family practitioners. In addition to choosing between them, you'll also be choosing from among different settings for your child's health care. Find out how these two types differ from each other and from other healthcare professionals.

Choosing an Infant Healthcare Provider

Before you settle on a doctor, you'll want to know about his or her style, if he or she can work on your schedule, and who serves as backup if the doctor can't be reached, among other things. This page gives you many good questions to ask during your interviews with potential doctors for your baby.

Well-Baby Care

Once you've chosen the right person, he or she will want to see your baby often. During the first couple years of life, even visits for regular checkups are frequent. The doctor will want to check your baby's eyes, ears, nose, vital organs, arms and legs, and other things for normal development. On this page, you'll learn how often you can expect to see the doctor, and what to expect at these visits.

Recovery From Diastasis

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Recovery time is very individualized. It depends on what kind of shape you were in before and during pregnancy, in addition to how much effort, time, and planning you are willing to now give to your body. If your abdominals were strong and you exercised them regularly before and throughout pregnancy, one to two months -- at the most, three months -- should see you back to normal.

On the other hand, if your abdominals were not strong and you didn't exercise them regularly, then it may take between 6 and 12 months of regular exercise to get them into good shape. (These time frames assume you perform abdominal exercises four to six days a week.)

What if you took up regular exercise for the first time in your life during pregnancy? This gives you something of a head start for this postpartum period. However, the advancing growth of the baby did not allow as adequate a workout of the abdominals as if you had also exercised before pregnancy. In this case, achieving strong, firm abdominals should take between three and six months (which is still much faster than for someone who did not exercise during pregnancy).

If you never put into action your resolve to re-strengthen your abdominal wall, there is no telling how long the process will take. In fact, some women's abdominals never return to their original shape. The truth is it requires action on your part to improve your figure. But exercise affects more than your appearance. A slack set of abdominals probably means you will experience a lot of backaches and fatigue.

The abdominals do 40 percent of the work involved in supporting the trunk of your body as you move through your daily activities. If they do only 10 percent, the back muscles pick up the load -- or attempt to, anyway. The back muscles are responsible for 60 percent of the work of keeping the body upright and helping to lift, move, and bend. Increase that workload by 10 to 30 percent and the muscles respond by becoming fatigued faster and with the occurrence of painful spasms, especially in the lower back.

Sometimes the lower back muscles become so tight the angle of the normal pelvic tilt changes. These tight muscles squeeze or press on the nerves coming off the spine in the lower back area. These nerves, in turn, divide and branch out to each leg. You may feel pain in the lower back, one or both buttocks, and one or both legs (upper or full length). Don't allow this kind of problem to decrease the joy of those first beautiful months with your new baby.

Other factors to consider in estimating recovery time are how much weight you gained and how much your abdominal wall expanded (partially due to the size of the baby and how you carried the child). Additional factors include your diet, the amount of rest you get, and the types of activities you're involved in.

Diastasis after pregnancy is a fairly common occurrence. Though the complications can be severe, the treatment can be easy and fun. Following the advice in this article will help you get your abdominals back in prepregnancy shape in no time.

Exercises for Diastasis

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Your abdominal area may feel week soon after childbirth, but that's OK. Even light exercises will help you get back into shape. And if you do them regularly, you'll find you're ready to increase the intensity in no time. Here are a range of exercises to strengthen your abdominal, pelvic, and buttock muscles.

Pelvic Rock

Perform at least 50 repetitions a day.

Lie on your back with your knees bent. Cross your hands over the abdominal area so you pull the muscles toward the center of the abdomen as you slowly raise your head.

Take a deep breath. As you slowly exhale, lift your head (and later your shoulders, to a 45-degree angle from the bed or floor), at the same time pulling the muscles together with your hands. Return your head (and shoulders) slowly to the bed or floor. Remember to keep your movements slow and controlled, your eyes on the ceiling, your chin straight up.

Continuing the Program

Once you have completed the appropriate exercises for your type of delivery, gradually replace the postdelivery exercises with the ones you did during pregnancy. These exercises also work all the muscle groups that are important during the postpartum period, with no muscle or joint strain.

The "Pelvic Rock," which you can now perform while lying on your back with your knees bent, improves posture and eases back strain. It is wonderful for working buttock, abdominal, and pelvic floor muscles all at the same time, and it provides a great back stretch. Remember to do the exercise slowly with control, and gradually increase the time you hold the tilt.

Be sure to warm up (walk or march in place for three to five minutes) and then stretch for five minutes before beginning any floor exercise. Turn on music with a strong, regular beat. Music helps you move smoothly, makes time pass quickly, and adds an element of fun.

Extra Help

The following exercises are good for a stubborn, protruding abdominal wall (a potbelly). Because the rectus muscles are long, vertical muscles that run from the breastbone to the pubic bone, you need to perform exercises that cause action at both ends of these muscles. To shape and to strengthen these muscles, you must perform at least two exercises: the "Reverse Sit-Up" and "Reverse Trunk Twist." You can alternate the "Reverse Sit-Up" with the "U-Seat," or you can perform all three during each exercise session.

For all these exercises, begin with 5 of each and gradually increase the repetitions as you get stronger. The key to success is controlled movements with no "sling and fling" moves.

Exercises to Develop and Maintain a Flat Abdominal Wall

Reverse Sit-Up

Start with 5 repetitions and increase gradually.

Lie on your back with your knees bent and your arms at your sides, palms down.

Keeping your knees bent, raise your legs until your knees are past the level of your chest or above your face. Raise your buttocks toward your upper body. Keep your head and shoulders flat.

Return to the starting position and repeat.
Note: You may notice a tendency to press down or grip the floor with your hands, or you may feel a strain in your neck or upper shoulders as you attempt to reach the desired height with the knees. This disappears as you become stronger and more relaxed with the movement. (Remember to breathe during this exercise.)

Another hint: Start by getting only the hips off the floor. As you progress, lift more and more of the hips and lower back. Keep the movement controlled. You do not gain height by slinging or throwing your lower legs above the head. The action should be smooth and come from the abdominals.

This exercise works the lower fibers of the rectus muscles as well as the external obliques. To work the horizontal fibers you should also perform the "Reverse Trunk Twist."

Reverse Trunk Twist

Start with 5 repetitions and increase gradually.

Lie on your back with your arms out to your sides, palms down, and your legs raised 90 degrees from the floor. Bend your knees slightly.

Lower your legs to the right and touch the floor with the outside of your right foot. Keep your shoulders and arms on the floor at all times.

Return to the starting position and repeat, alternating sides on each repetition. (After a time, you will notice increased flexibility of your midsection while performing this exercise.)
Advanced action:

Begin with the same starting position but with your legs straight (but loose). Keep your legs straight as you lower them to the side. Be sure to press your back to the floor as you come toward the center each time.

Note: If your shoulders come off the floor as you drop your legs to the side, have someone hold them down. This person should be on all fours with his or her hands on your shoulder joints (not the neck area), arms straight, and shoulders directly above yours. As flexibility and strength increase, you will not need assistance.

If you have difficulty keeping your legs straight when performing the advanced exercise because of tight hamstring muscles, bend your knees slightly but keep your legs together. The more you bend your knees, the easier the exercise is to perform. Doing it in the straight leg position is the most effective, so try to work up to that.

The "Reverse Trunk Twist" works all portions of the internal and external obliques, tightening the front and sides of the abdominal wall much more than any other abdominal exercise. This exercise also strengthens the spine because it uses the small muscles -- both the deep and the surface muscles -- that hold the bony vertebrae together and twist the spine. Strengthening these muscles eases the typical overuse backache and may help prevent injuries that occur when you execute quick, twisting movements.

The U-Seat

Start with 5 repetitions; progress to a maximum of 20.

Lie on your back with your arms behind your head, knees bent, and feet on the floor.

At the same time, slowly raise your head and begin raising your knees toward your chest. Continue the movement, raising your shoulders and buttocks off the floor simultaneously. (Do not push your head and neck forward with your hands -- rest your head in your hands, and let your shoulders do the work.) Continue both actions and try to touch your knees to your chest. At the end of these movements, your pelvis and upper body should be off the floor. Do not lift your lower back from the floor.

Return to the starting position and repeat.
Note: Bring your knees up smoothly, using the abdominals. If you need momentum to make it easier to raise the pelvis, raise your knees relatively quickly, but do not jerk.

Think of the exercise as two steps: 1) raise head and knees, then 2) raise shoulders and buttocks. This timing allows for proper coordination and smooth movement between pelvis and chest.

Performed correctly and smoothly, "The U-Seat" exercise maximally involves both the lower and upper portions of your abdominals.

Diagnosing Diastasis

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After delivery, the abdominal muscles are always loose and soft. The abdomen looks and feels like gelatin, which can be quite a shock. It is important to check the linea alba between the rectus muscles for separation, called diastasis. The opening between the muscles may be slight or so large the uterus or abdominal contents can be felt bulging through the opening.

Since a good balance must exist between back and abdominal muscles, a large diastasis eventually causes backaches (and possibly radiating leg pain) just from moving through the normal day's activities of caring for an infant or managing a full-time job at or away from home. If you make no corrective attempts to close the opening, reestablishing muscle balance and strength, you will have little support for a subsequent pregnancy. Your posture will be poor, and many aches and pains will develop, all from lack of abdominal strength.

Check for diastasis on the third or fourth day after delivery. Until this time, the area will feel too slack for you to get an indication of the state of the abdominals. Also, you will have had a few days' worth of abdominal exercises to help improve your strength.

To check for diastasis:

Lie on your back with your knees bent. Place the fingers of one hand on your abdomen covering your navel (your fingers should point toward your pubic bone). Apply firm pressure.

Inhale deeply. Then exhale slowly and at the same time lift your head and neck slowly. As you lift, you'll feel each of the rectus muscles tighten and pull toward the center (toward your fingers).

Check to see how many fingers fit in the gap. One to two finger-widths is normal and to be expected; this gradually decreases with exercise. Three to four finger-widths require special attention from you to repair and rebalance the muscles.
Don't hesitate to ask for help from your physician if you have difficulty checking your abdominals.

Correcting Diastasis
The following special exercise is very effective for closing a large diastasis. Raising just your head in this exercise ensures you work only the rectus muscles. As they become stronger, you will be able to lift your shoulders, thus working the other abdominal muscles also. It is important to strengthen the rectus muscles first, thus ensuring their stabilization and alignment as the other muscles come into play.

Repeat this special exercise often, at least 50 times a day. To speed progress, do 10 each hour you are awake. Remember to use slow, controlled movements, resting whenever you feel the need. The gap should be back to the normal 1/2-inch within a week or so. If you do fewer repetitions than those recommended above, closing the gap takes longer.

Because the other abdominal muscles are attached to the rectus muscles and because the abdominals in general are weak and out of balance, avoid the following exercises, which serve only to increase the diastasis: 1) those rotating the trunk of the body (waist twists), 2) those twisting the hips, and 3) those that cause the trunk to bend to the side (waist or side stretches).

Be sure to breathe out as you raise your head and shoulders; this prevents an increase in the intra-abdominal pressure. Increased intra-abdominal pressure just increases the diastasis, which defeats the whole purpose of the exercise and adds time to the muscle rehabilitation.

Do not let the abdominal muscles bulge. Tighten your abdomen any time you might strain.

There are many other exercises that can reduce your diastasis.

The Abdominal Wall After Delivery

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When choosing exercises after delivery, most new mothers think of achieving a flat abdomen as their first priority. Actually, the pelvic floor should receive prime attention with the abdominal muscles second. Strong pelvic floor muscles ensure good support of internal organs and sphincter control (urethra, rectum, and vagina). They also ensure pleasurable sensations during sexual intercourse for both the woman and her partner.

After vaginal delivery, the pelvic floor may be bruised, swollen, and tender. After a cesarean section, it may be lax. In either case, the pelvic floor loses tone or elasticity from the weight of the baby and months of sluggish circulation.

You may be surprised at your initial attempts to tighten the muscles of the pelvic floor immediately after delivery -- you feel little or nothing! Your muscles have been torn or cut and nerves, damaged. It's no wonder you have little sensation. Perhaps, too, the structure of the pelvic floor was surgically repaired.

Exercise can improve all these situations by 1) alleviating discomfort (although it is uncomfortable at first to even gently squeeze those muscles) and 2) improving circulation to the area, which increases the oxygen supply, removes waste products, decreases swelling, and promotes the prompt return of urinary control.

If you neglect the pelvic floor area, the muscles remain stretched and loose. They become further weakened as you resume your usual schedule. The sooner you start to exercise the pelvic floor after delivery, the faster the muscles respond. Waiting only results in more time and effort necessary to strengthen these muscles.

The Abdonimal Wall

Right after delivery, you may wonder if your stomach will ever be flat again. If you begin an exercise program early (within 24 hours of giving birth) and are fiercely persistent with frequent repetitions of the appropriate exercises, your stomach will indeed be flat once more.

The abdominal muscles we feel and notice most often are the rectus muscles. They are long, slender muscles located along the center of the abdominal wall. They run vertically from the end of the sternum (breastbone) and the lower ribs to the pubic bone. The right and left rectus muscles are separated by a band of fibrous connective tissue about 1/2-inch wide called the linea alba.

The internal and external oblique muscles lie on the sides of the rectus muscles. They cover the waist -- a hard area to tighten even when you haven't had a baby. The external obliques cover the front and sides of the abdomen from the rectus muscle to the back muscles. The external oblique muscles have a wide area of attachment: The top edges attach to the ribs, and they run from the lower eight ribs to the front surface of the pelvis and on down to the pubic bone.

The internal obliques are directly below the external obliques. Most of their muscle fibers are nearly horizontal, running at almost a 90-degree angle to those of the external obliques. The internal obliques run from approximately the waist area down to the pubic bone.

All this may sound unnecessarily technical when you just want to have a flat belly again, but knowing how your body is put together enables you to understand how the exercises work and what kinds of exercises you need to renovate those muscles after delivery. Learning to listen to your body is also a primary step in getting started.

The lower ends of the rectus muscles go through a slit in the deep abdominal muscles before they attach to the pubic bone. When the rectus muscles are relaxed, as they are when you walk and move around, they follow a curved line; they become straight only when they contract (when you consciously and tightly hold in your stomach).

Hereditary factors come into play in the deposition of fat in the lower abdomen, even when body fat is at an ideal level. Because the rectus muscles are curved and small deposits of fat are stubbornly held in that area, most women find their stomach is still slightly rounded.

The Third and Fourth Stages of Labor

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Your job is not quite finished. The placenta still needs to be expelled. The third stage usually lasts from 5 to 30 minutes. The nurse or caregiver keeps a hand on your abdomen to determine when the placenta separates from the wall of your uterus. Then he or she asks you to push it out. You may feel some cramps, but the discomfort is usually very slight.

The Fourth Stage

Immediately after birth, while you hold and admire your new baby, your doctor or midwife focuses on your well-being. The condition of your uterus and vagina is of major concern. It is important that your uterus remain contracted after birth, which keeps it from bleeding as much as when it is relaxed.

Most women lose about one cup of blood at the time of birth. While this may seem like a lot, remember that among the many other changes of pregnancy, your blood supply greatly increased. That excess blood is no longer needed; you lose some of it at the time of birth and continue to lose some over a period of several weeks (this discharge is called lochia). Your caregiver watches the amount of blood lost immediately after birth and, if necessary, takes measures to reduce the blood loss. These may include massaging your uterus vigorously, asking you to lightly stimulate your nipples, or giving you an injection of a medication such as Methergine (methyl-ergonovine) or Pitocin (oxytocin) that causes your uterus to contract.

Your doctor also checks your vagina to see if you need any stitches. If an episiotomy (an incision to make childbirth easier and to avoid tearing of tissues) was performed, you definitely need stitches. Some tearing of the vagina or perineum may also have occurred when the baby was born. Although the idea of tearing sounds rather unpleasant, be assured the tears (or cuts) are usually not serious and heal rapidly. If necessary, your doctor begins stitching within a few minutes after birth. You will receive a local anesthetic for pain relief if you have not already had one.

Childbirth is a natural process. Although labor may sound frightening and painful, it can be managed without complications and with wonderful results.

The Second Stage of Labor

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The second stage is when the momentous occasion occurs. The feelings of love for your newborn baby -- and of relief -- will be incredible. The second stage ranges in length from 15 minutes to 3 or more hours.

When your cervix is fully dilated, the intense, out-of-control feelings may subside. The contractions often space out somewhat, and you may even get a short break from contractions (this is more likely with first-time mothers). It is always wonderful news when you are told your cervix is fully dilated and you can begin pushing whenever you feel like it.

During the second stage, you may find yourself holding your breath or slowly letting it out, while bearing down (something like, but much more than, what you do when having a bowel movement) and releasing your pelvic floor (relaxing the muscles in the area around your vagina). This last is most important because tensing the pelvic floor actually fights against the birth of your baby -- and it hurts much more than letting go.

A change in your contractions occurs in the second stage. Accompanying most contractions is a reflex need to strain or grunt, called an urge to push, which comes and goes three to five times per contraction. The combination of the uterine contraction and your bearing-down effort pushes the baby closer to the outside. It is hard work and it hurts, but it is also an exciting time, with lots of cheering and praise for your efforts. Most women find they have the strength to keep pushing.

The best way to push is to push only when your body makes it happen -- only when the urge to push comes. That way you won't hold your breath so long that you or the baby gets too little oxygen. The following is a routine many women use during second-stage contractions:

Greet the contraction with a long breath, and curl your body forward whether you are reclining, lying on your side, squatting, or sitting on a birthing chair.

Breathe as you did during first-stage contractions.

When you feel the reflex urge to push (it is unmistakable), follow it by grunting or holding your breath and bearing down. You may need reminders to relax your pelvic floor. The urge to push goes away after a few seconds. Then breathe again until the urge returns. Repeat this routine until the contraction ends.

Unless the baby is coming fast, you have time to change positions. Many childbirth educators encourage women to learn to squat comfortably before labor because this is such a helpful position for the second stage. When you squat, you give the baby more room to come down through your pelvis than in other positions. Sitting on a bedpan may help if you have trouble relaxing your pelvic floor.

Lying on your side is a good position if the baby is coming fast, if you have painful hemorrhoids, or if you must lie down for some reason. Resting on your hands and knees may help if the baby is large or experiencing a slowing of the heartbeat during contractions. Semi-sitting is a good position because you can see your caregiver and the baby as he comes out. This position is also a convenient one for your caregiver.

The lithotomy position, where the woman lies on her back with her legs in stirrups, used to be the way all women gave birth. Most women disliked the position. Their objections to it, plus the fact it sometimes caused slowing of the baby's heartbeat and other problems for the mother, finally led to discontinuation of its use as a routine position during most deliveries. Other caregivers continue to use the position, particularly with anesthetized births and deliveries assisted with forceps or vacuum extraction.

You might use several positions during the second stage, ending with semi-sitting or lying on your side for the actual birth. Discuss positions for the second stage with your caregiver in advance.

The Moment of Birth

You know when the baby's head emerges. You feel a stretching or burning sensation in your vagina. This is an exciting, intense time. You know the baby is almost here and may be tempted to push as hard as you can to help him fully emerge. That would be a mistake, however, because a sudden push could make the baby come out too quickly and damage your perineum (causing tearing). It is important for you not to push hard at this time. Let your uterus do the work alone. You should breathe rapidly and lightly (pant as animals do), so the baby can emerge gradually. Your caregiver gives instructions and helps the baby out slowly. You'll soon be holding your baby.

After the head emerges, the baby turns to one side, and a shoulder and then the whole body are born. And what a sense of relief you feel! Labor is over (or very nearly so). You have a baby. It may take a while for it all to sink in. In the meantime, you may be holding and caressing your baby or watching as a nurse or your doctor or midwife examines him and cares for him.

The First Stage of Labor

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Labor is described as having three stages: the first stage, from the onset of progressing labor contractions until the cervix is completely dilated; the second stage, from complete dilation of the cervix until the baby is born; and the third stage, from the birth of the baby until the placenta is expelled.
A fourth stage, from the delivery of the placenta until the mother's medical condition is stable and safe, is also frequently mentioned.

The first stage is almost always the longest (2 to 24 or more hours), usually starting slowly and then speeding up when the dilation of the cervix reaches about four or five centimeters. Your contractions may not be clear and strong at first, but they will become longer, stronger, and closer together with time.

You may spend much of your time in the first stage trying to figure out if you are in labor or not. If you can be distracted from your contractions, it is unlikely you are in very advanced labor. On rare occasions, women have been unaware of labor until the baby was about to be born! In these cases, there really is no way to prevent a hectic scene unless a woman has had such a birth previously. Then she should watch carefully for any sign of labor -- subtle, preliminary, or absolutely clear.

As labor progresses, you will no longer have any question whether you are in labor. Its pace quickens, and the contractions usually become painful. Once you are certain you are in labor, go to the hospital or birthing center, or if the birth is to be at home, await your caregiver's arrival. Of course, if you have any concerns, feel free to go to the hospital. Be sure to take your bag and have needed items on hand.

You may become serious and quiet, focused on only one thing -- your labor. Jokes are not funny; world events lose their importance. You need support, encouragement, help, and comforting gestures from your partner, caregiver, and nurse. You are likely to have emotional ups and downs throughout labor. You may feel discouraged and may weep from time to time, but if you accept and understand what is happening and what to expect, you can recover from these down periods and go on.

Arrival at the Hospital

On arrival, your first stop is usually the admitting office, where you are asked to read and sign forms and indicate how you will pay for your hospital stay. However, hospital procedures vary considerably, so prior to going into labor, check with your hospital regarding their admitting policies -- especially their procedures for late-night and weekend admissions.

From there you go to the maternity ward, where a nurse greets you, does a quick health check on you, assesses your contractions and the baby's condition, and does a vaginal examination to establish how far along you are in labor.

From then on, hospitals vary widely in their routine care for labor. You may undergo various routines depending on what your doctor feels is best for you. In addition, your nurse periodically takes your temperature and blood pressure, monitors your baby's heartbeat, and feels your abdomen during contractions to determine how labor is progressing. Discuss the procedures in advance with your doctor and express your preferences.

Factors Influencing Labor

Factors you cannot control:

Size and shape of your pelvis

Size and shape of baby's head and shoulders

Baby's station, presentation, and position

The condition of your cervix when contractions begin

The power of your contractions

The amount of rest you have between contractions

Some aspects of your general health and your baby's well-being
Factors you can control, to some extent:

Your emotional state and attitude toward birth (optimism, confidence, and relaxation versus anxiety, fear, and tension)

Presence of helpful, caring partner(s)

Knowledge of what to expect

An environment and a professional staff that help you feel secure and well cared for

Good care of yourself (including good nourishment and good health habits)

Station refers to how low the baby is in the pelvis.

Presentation refers to which part of the baby's body emerges first (usually it is the head, but on occasion it maybe the buttocks, the feet, or even a shoulder).

Position refers to the location -- on the left or the right side of the mother -- and the orientation -- anterior (toward the mother's front), posterior (toward the mother's back), or transverse (lying crosswise) -- of a given part of the baby, specifically, the occiput (back of the head), brow, chin, shoulder, or sacrum (the bone at the lower end of the spinal column). For example, if a baby's position is left occipitoanterior, the back of the head is on the left, pointing toward the mother's front.

Mother's Activities During Labor

Once settled in at the hospital, you will find a routine for handling contractions, perhaps based on what you learned in childbirth classes. Many women learn and use the following routine:

Greet the contraction with a long sigh. As you breathe out, release all bodily tension.

At the same time, focus your attention in some way (for example, focus on your partner's face or on a picture or object of your choice; close your eyes and picture your cervix opening as your uterus contracts; picture a peaceful, relaxing place and picture yourself there; focus on music of your choice or the soothing voice of your partner; or focus on the feel of your partner holding or stroking you).

Breathe slowly and easily.

Maintain relaxation throughout the contraction. Stay limp. It may help if you focus on one part of your body with each breath out. Try to release tension in that part as you breathe out. Then focus on another part with the next breath.
You can follow this routine with every contraction and in any position -- lying down, sitting, standing, on your hands and knees. You can do it in the tub or shower, in bed, in the car, in a chair, in the hospital corridor, or in your room. You can lean on your partner, the wall, or your bed.

These techniques often keep pain within manageable limits for part or all of your labor. Women who use them generally need less pain medication than others. Indeed, some women do not need to use any pain medication when using these techniques.

Some women learn several types, or levels, of breathing to use progressively during labor. Besides the slow pattern just described, they may learn a lighter, faster, but still relaxing pattern and other variations.

Besides using a routine for each contraction, you should try to change position every 20 or 30 minutes, go to the bathroom every hour or so, and sip liquids or suck on ice after every contraction. These measures may be comforting.

You may find hot packs on the lower portion of your abdomen, your groin, and your perineum (external genital-rectal area); cold packs on the lower part of your back; and a cool, moist washcloth rubbed over your face and neck ease some discomfort. Being touched and rubbed, especially in tense, sore areas, such as the shoulders and the lower part of the back, helps a lot. If you feel a bit out of control, it helps when your partner holds you tightly or gently but firmly holds your head in his hands.

During intense periods, such as the transition phase (from about seven to ten centimeters of cervical dilation), you may feel almost out of control. You may feel your body is running away with you, and you are being swept along in a tide of intense sensations. Fighting these sensations is pointless.

You may feel an urge to push but be told that you are not yet fully dilated. It is important that -- for the time being -- you resist the urge to push. Pushing too soon could injure the cervix and perineal tissues and may lead to heavy bleeding. What helps the most is knowing nothing is wrong. Just accept that your body is in charge, and don't try to stay in control. Let your loved ones help you, moan and complain if you want to, and know it will not last too long.

What Is Labor?

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Labor is a different experience for every woman and every birth. Many first-time mothers make the mistake of thinking they have entered labor prematurely, and may end making unnecessary trips to the hospital. To be fully prepared for labor, it's important to understand exactly what happens during this time.

The changes taking place in your body, placenta, and baby during the last three months of pregnancy accelerate at the end, culminating in labor. As the placenta ages and gradually loses its ability to maintain the pregnancy, the baby becomes strong and capable enough to survive outside the mother's body; the uterus begins to let go and expel the baby; and the mother becomes ready to give birth and to feed and nurture her baby.

Labor consists of rhythmic uterine contractions, which open the cervix and press the baby down through the birth canal and out of your body. The uterus is a big, strong, hollow muscle; when it contracts, it tightens and hardens. This may happen anywhere from 25 to 300 times during labor, which may take anywhere from a few hours to more than a day. The process involves not only your uterus but your entire body and mind; all your energy is devoted toward the one goal of giving birth to your baby.

How will you know when you are in labor? As basic as this question is, it is one of the most difficult to answer. It usually takes hours or even days to figure out whether your sensations are labor or something else (prelabor, or false labor). This is because labor does not begin suddenly. It evolves gradually. At some point, you or your doctor will recognize these sensations are true labor, meaning they are accompanied by increasing dilation of the cervix. This section describes the signs and sensations of labor to help you recognize it. It also describes the birth process, the emotions that accompany labor, and how your partner can help you the most.

If you are within a week or two of your due date, you generally may wait until you have an absolutely clear sign of labor before going to the hospital, although your caregiver may ask you to let him or her know if your bag of waters (amniotic sac surrounding the baby) seems to be leaking. If your pregnancy has been complicated by diabetes, high blood pressure, or other medical conditions, or if you have twins, your doctor may advise you to go to the hospital with the onset of preliminary signs. If you are several weeks before your due date, you should notify your doctor if you have any preliminary signs because they could indicate early or premature labor. Premature labor can often be stopped if treatment is begun early enough.

To determine whether your contractions are progressing (that is, becoming longer, stronger, and closer together), you need to time them. On a sheet of paper, list the times contractions begin and how long the contractions last. Time them in this way for an hour or two. If they are not progressing, stop for a while until the contractions seem different, then try timing them again.

You should call your caregiver or your hospital's labor and delivery ward to tell them you are in labor or to ask for advice. Be sure to report the status of your bag of waters; whether you have a bloody discharge (called bloody show, which you continue to pass throughout labor); how long and how many minutes apart your contractions are; and how strong or painful they feel to you.

Labor varies from woman to woman; even in the same woman each labor is different. Some labors are very fast, lasting only a few hours; some are average in length (about 15 or 16 hours for first-time mothers and 7 or 8 hours for women who have had babies before); some are very long, lasting a day or two. Some start slowly and then speed up unexpectedly; others start rapidly and then slow down. The amount of pain and fatigue varies also. It is best not to have definite expectations but to prepare yourself for the wide range of possibilities.

Physical Changes Before Labor

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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 (tenderness, tingling sensations, and feelings of heaviness) very early, even before you knew you were pregnant. These changes indicate your body is beginning to get ready for breast-feeding. By late pregnancy, you may notice more veins in your breasts, indicating the increased blood supply in the area. You may also notice your breasts are somewhat larger than they were 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 substance called colostrum, which enables you to breast-feed as soon as 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 your hips, stiffness in the lower part of your back, or soreness in the front joint of your pelvis (the 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 crowds your stomach and intestines and causes you to burp up acid and have trouble moving your bowels. Despite these discomforts, there are benefits. Your body is able to absorb more nutrients from your digestive tract because of this 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 sensitive. If you sneeze or bump your abdomen, your uterus often contracts immediately afterward. It is very sensitive to sudden pressure. Sometimes, while you rest, your uterus spontaneously contracts 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, called Braxton Hicks contractions, are an indication the uterus has become more sensitive to the circulating oxytocin.

While Braxton Hicks contractions are not labor, they probably cause changes in your cervix that prepare it for labor. These changes include ripening (softening), effacement (thinning or shortening), 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 an unripe, thick cervix. The amount of ripening and thinning can be determined only with a vaginal examination. Effacement is measured as a percentage. For example, if your cervix is 25 percent effaced, it is 25 percent thinner, or shorter, than usual. (The cervix is usually about three to four centimeters long. Twenty-five percent effaced means 21/4 to 3 centimeters remain.) At 100 percent effacement, the cervix is paper thin.

Your cervix opens slightly before you go into labor. Referred to as dilation, this process is measured by feeling the circular rim of the cervix and estimating (in centimeters) the diameter of the opening. Many women are one or two centimeters dilated before they are aware of any signs of labor. During labor your cervix continues 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 in the placenta, the baby, and the mother.

Childbirth Overview

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As you enter the last three months of pregnancy, you may spend a lot of time thinking about the upcoming birth. Your large size and your baby's movements are constant reminders you will become a mother soon. You might be apprehensive about the birth and unsure of what to expect. Fortunately for you, countless mothers have gone through the very same process, and, while every birth is different, there are some basic elements they all have in common. In this article, we will cover the various aspects of childbirth, including:

Physical Changes Before Labor

In the final stages of pregnancy, the physical changes you experience will increase. Your body's behavior may be so different that it is difficult to distinguish when the actual labor process is beginning. We'll start by showing you which symptoms are and are not part of labor.

What Is Labor?

Every labor is a unique experience, and even women who have given birth before might not fully understand what is happening to their bodies. The right time to go to the hospital usually will depend on factors unique to your pregnancy, such as high blood pressure or other complications. We tell you some common symptoms and what they mean.

The First Stage of Labor

The first stage lasts the longest, from several hours to over a day. During this time, the cervix dilates completely so that the baby can come out. In fact, your entire body and mind will focus on the task of pushing the baby down the birth canal. On this page, you learn what you can and cannot control during this time.

The Second Stage of Labor

This is the moment you've been waiting for -- your baby is here! This part can be painful, but the power of becoming a mother pulls women through it. After all, this is what everything that has happened in the last nine months has led to. We tell you step-by-step what will happen in this stage.

The Third and Fourth Stages of Labor

Your baby is here, but your labor isn't quite complete. During the last stages you will expel the placenta and your doctor will take important steps for your well-being. While these stages may sound daunting, most new mothers find them to be much less unpleasant than they were expecting. On this page, you find out what happens immediately after birth.

After the C-Section

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The average hospital stay after a C-section is longer than for a vaginal birth -- four days after a C-section and only two days after a vaginal delivery. Women who give birth vaginally usually have a one- to two-week recovery time, which stretches to six weeks after a C-section. Vaginal delivery might be more painful, but C-section recovery pain is often intense, and the new mother needs a few weeks to gain full mobility.

After a C-section, doctors closely monitor the mother for the first 24 hours and give her pain medication throughout the hospital stay. If surgery went smoothly, after about a day, doctors encourage new moms to walk around to help gas from collecting in the abdomen and blood clots from forming in the legs.

The patient might attempt to breast-feed in the hospital, but babies born via C-section are less likely to be breast-fed than those delivered vaginally. One factor is that the mother will need to sleep and recoup from surgery. So she'll have less time with the baby, especially during the first hour after birth, which is the best time to begin breast-feeding. Also, babies delivered via C-section can be lethargic from the pain medication given to the mother, resulting in a disinterest in learning to breast-feed.

Doctors often remove the new mom's staples or stitches before she leaves the hospital. At discharge, they will give extensive information on how to recognize signs of serious complications, such as infection or hemorrhaging.

So what about the next delivery? We discussed the risks of multiple C-sections, along with the dangers of vaginal delivery after a C-section, so what's a woman to do? Each woman is different, of course, but vaginal delivery can be perfectly safe after a C-section. In fact, according to the American Pregnancy Association, nearly 90 percent of all women who have had C-sections are candidates for vaginal delivery in a subsequent pregnancy. Of those who decide on a vaginal delivery, up to 80 percent will have a normal delivery.

However, of the 80 percent of women who could opt for a vaginal delivery, only about one in 10 actually does. Why is this? Well, as we discussed, there are risks. One is the rupture of the uterus, which can be as high as 1.5 percent [source: APA]. Other risks include the reopening of the previous C-section scar, rehospitalization after birth and infertility (which can result from an emergency hysterectomy or from uterine scarring). To avoid these risks, most doctors will do a "trial labor." This simply means that the mother begins labor expecting a vaginal birth. She is monitored closely for any complications, and a C-section is an immediate option if needed. Of those women who attempt a vaginal delivery after a C-section, approximately four out of every 10 end up having a C-section [source: WebMD]. A C-section is the safest option if the vaginal delivery is not going well, but the risk of infection doubles.

But there are also many benefits to a vaginal delivery. First, no more scars. This is especially important for women who want more children -- the more scars on the uterus, the greater the chance of complications in future pregnancies. Other benefits include less pain during recovery, a shorter recovery, higher chance of successful breast-feeding and a lower risk of infection.

Planned C-Sections

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Planned C-sections are scheduled well before labor begins. There are two subgroups: indication-based and patient-requested.

Indication-based C-sections are usually scheduled at the doctor's request when a patient suffers from, or is at great risk of, a medical problem that could result in labor that would harm her or the baby. When a child is in the breech (feet-down) position, vaginal delivery is dangerous. Large babies (more than 9 pounds) are often delivered by planned C-section. Mothers who suffer from chronic conditions that could be exacerbated by labor, like diabetes or heart disease, often plan C-sections.

Multiple births, which are more common these days because of the increased use of fertility medications, are usually an indication for a C-section. The doctor will opt for a C-section when there are three or more fetuses in the womb, or when twins are conjoined or sharing one amniotic sac. Women who have had previous C-sections will often have a planned C-section.

One of the advantages of a planned C-section is the assurance that you will be at the hospital during peak hours, when a full staff is working. The risks of a planned C-section are also lower than those of an emergency operation.

Patient-requested C-sections (planned, without medical indications) are a growing trend in the United States. The National Institute of Health estimates that, in 2004, 4 to 18 percent of C-sections were performed on maternal request instead of for medical reasons [source: NIH]. While the NIH has admitted that these numbers are difficult to validate, they are sure that this type of C-section is becoming more and more common.

We know that the risks of C-sections are greater than risks of vaginal birth, at least with your first pregnancy. So why are women opting for C-sections, even for their first birth? Some theorize that the combination of improved C-section safety, along with increased maternal age, has lead to women being able to control when and how they are going to give birth. This type of control is attractive to women who are balancing family and career -- they can perfectly plan maternity leave, right down to the date of the last conference call. Another popular theory is that some women, fearing the pain of vaginal delivery and wanting to avoid urinary incontinence, jump at the chance to give birth via C-section.

Whatever the reasoning, doctors are quick to point out that women should not make this decision lightly. One C-section increases the necessity for another with the next child -- and the risk of serious complications increases for subsequent C-sections. The NationaI Institutes of Health has guidelines for patient-requested C-sections. To ensure proper fetal lung maturity, they should not be scheduled before 39 weeks of pregnancy. If a delivery is scheduled before this time the fetus' lung maturity must be verified before delivery.

Unplanned C-Sections

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Most unplanned C-sections are emergency surgeries, which means they are performed after labor has begun, when the health of the mother or child is at risk. This can happen for a number of reasons.

Fetal distress, which is indicated by a dramatic change in the baby's heart rate. This is one of the most common reasons for an emergency C-section.
Placental abruption occurs when the placenta prematurely separates from the uterine wall. This can cause excessive bleeding in the mother and decreased oxygen supply for the baby, both of which can result in death.

During a vaginal delivery, there can be umbilical cord problems. The cord can wrap around the baby's neck and cut off oxygen supply. It can also slip out of the birth canal before the baby, which can result in a lack of blood supply.

A long and difficult labor could also necessitate an unplanned C-section. Labor could stop progressing for several reasons, including cephalopelvic disproportion -- when the infant's head is too large for the mother's pelvic structure.

A maternal health condition could result in a C-section if it could be passed on to the child through vaginal delivery. For example, a mother with genital herpes can deliver vaginally, as long as she's not suffering from an outbreak. But if she is having an outbreak when her water breaks or during delivery, the baby is will be delivered via C-section.

C-sections are unavoidable in some situations, but what would make a doctor or mother choose one if there's no emergency? That's what we'll discuss in the next section.

Self C-Section
This one certainly falls into the "unplanned" category. In 2000, a Mexican woman with no medical training gave herself a C-section. Ines Ramirez came to fame when an article in the International Journal of Gynecology and Obstetrics described her amazing self-performed surgery.

Ramirez was alone at home -- with no phone -- when labor pains started. After nearly 12 hours of labor, she was concerned for the baby’s life, so she found a 6-inch knife, gulped some rubbing alcohol and began to cut through her skin and muscles using a diagonal line across her belly. After about an hour, she was able to reach inside to pull her baby free and remembers cutting the umbilical cord with scissors before passing out. One of the village’s medical assistants managed to close her nearly 7-inch incision, and Ramirez was then loaded into the back of a pickup truck for the eight-hour drive to the nearest hospital. Unlike many women who have C-sections in the hospital, Mrs. Ramirez did not suffer from any infections and left the hospital only four days later.

The Risks of a C-Section

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-sections are relatively safe, but they are major surgery. So, by definition, they are riskier than vaginal deliveries. All surgeries involve the risk of infection, complications from anesthesia, internal injuries, postoperative adhesions and hemorrhaging. Today, maternal deaths in the United States range anywhere from 6 to 22 per every 100,000 births, with the higher rates usually involving emergency C-sectionsHowever, these numbers can be a bit misleading. Many women have C-sections because of medical conditions, and complications from that condition -- not from the surgery -- are more often the cause of the death. About 25 to 50 percent of C-section deaths are directly attributable to the actual operation

After a C-section, the uterine tissues become infected in nearly 40 percent of women. This complication, postpartum endomyometritis, is 20 times more likely after a C-section than after a vaginal delivery. Incision infection occurs in anywhere between 2.5 and 15 percent of women. Urinary tract infections are a common risk, affecting as many as 16 percent of C-section patients. These infections, usually a result of the urinary catheter, can be treated with antibiotics. Decreased or absent bowel function can also occur, which is usually caused by pre- and postsurgery narcotics. Another serious risk is blood clotting. These clots are found in 1 out of every 400 pregnancies, regardless of delivery. However, the risk is as much as five times greater after a C-section

C-sections can also put the mother at risk during subsequent births. Complications include preterm birth, breech presentation and low birth weight, with the major risk being a ruptured uterus. This rupture can involve a small tear (with minimal complications) or a large one that results in the fetus and placenta pouring into the abdominal cavity. This happens when the incision scar expands and tears during pregnancy or labor, and it can cause the mother to need a blood transfusion and possibly a hysterectomy -- and the baby could die from lack of oxygen. It's certainly a serious complication, but the actual risk can be as low as 1 percent when the previous C-section was a low transverse incision. It increases to 4 to 10 percent with a classic C-section. So, doctors often advise women not to opt for vaginal delivery after having had a C-section.

The risks increase with each C-section -- one of the most common is placenta accreta. This happens when the placenta, which provides nourishment to the fetus during pregnancy, is attached too deeply to the uterine wall. The risk gets higher with each C-section because scar tissue can build up in the uterus. Another risk that increases with recurring C-sections is the need for emergency hysterectomies at delivery. The chance of hysterectomy increases five times with the fourth C-section and is nearly 20 times greater in women with six or more C-sections [source: Emedicine]. Placenta previa can also occur with multiple C-sections. This occurs when the placenta develops low in the uterus, blocking the cervix and possibly causing a need for another C-section.

Mom is not the only one who faces risks with C-sections. Babies born by C-section can suffer from neonatal respiratory distress -- breathing problems in the first few days of life that usually call for treatment with oxygen therapy. This occurs in 12 to 35 per 1,000 C-section babies -- compared to 5.3 per 1,000 vaginal births [source: Canadian Medical Association Journal]. When a baby is born vaginally, pressure on the lungs pushes out excess fluid. That doesn't happen in a C-section, so these babies sometimes have trouble breathing.

Doctors use the Apgar scale to quickly assess a baby's health immediately after birth -- they rate the baby's skin color, heart rate, reflexes, muscle tone and respiration on a scale of one to 10. Babies who are delivered by C-section often have low scores, usually because of the breathing problems mentioned above, along with the sedation medication given to the mother (and therefore baby), which can make the child lethargic. These sedatives can also make it hard to breast-feed at first. Finally, a rare but serious risk is injury to the fetus from the surgical incisions.

The C-Section Procedure

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C-sections are now considered routine procedures, with a low chance of mortality for mother and child. Doctors have used several C-section techniques over the years, but there are two that are most widely used today.

The most common type is a low transverse incision, also known as a Monroe-Kerr incision. Doctors usually prefer this method because of its lower incidence of blood loss and other complications like infections. The surgeon makes an incision across the mother's belly, usually about 1 to 2 centimeters above the pre-pregnancy upper border of the bladder, or the top of the bikini line. The doctor will then cut through the tissues that lie above the uterus. After these tissues and the abdominal muscles have been separated, the doctor makes a horizontal incision in the lower section of the uterus. The baby's amniotic fluid is then suctioned off for more room during delivery. After this step, the doctor usually can pull the baby out without complication or use forceps or a vacuum extractor if he needs extra help.

The other type of C-section may sound familiar to an older generation of women. The classic C-section is the procedure that leaves women with a large vertical scar across their belly. The doctor makes a vertical incision and cuts through tissue, fat and muscle to reach the uterus, where he makes another a vertical incision. Doctors used this technique in the past to give more room for delivery. But they later realized that there were less complications (and a better-placed scar) if the delivery space were reduced. Today, this method is reserved for specific cases, such as an extremely premature baby. The classic C-section is the best choice in this scenario because the lower part of the uterus doesn't thin out until later in pregnancy. The upper part of the uterus is thinner, so doctors must access the baby that way. Women who have gone through a classic C-section are usually not able to deliver any future children vaginally due to a high risk of uterine rupture.

Before either procedure, the mother is prepped and given pain medication. This usually comes in the form of an epidural, which numbs the mother from the abdomen down but leaves her awake for the birth of her child. In the operating room, the mother is covered with surgical drapes that block her view of the surgery. She'll probably have a catheter inserted into her bladder. The mother's husband or partner can accompany her in most situations -- after undergoing a quick wardrobe change into surgical attire.

After delivery, doctors remove the placenta and use dissolving stitches to sew up the incision. Some underlying tissue and muscle will be able to reattach on its own within a few days without any scars. Doctors then close the skin with stitches or staples. This entire closing process usually takes about 30 minutes, more with a classic C-section incision.

Infant Feeding and Fathers

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Research has shown that fathers can influence the diets of their families in some very important ways. In one study, 89 percent of mothers served infrequently or eliminated from the family diet entirely the foods the fathers disliked.

In another study, 81 percent of mothers surveyed planned meals based on the food preferences of the fathers. As a result of such studies, nutritionists now urge fathers to recognize the important effect their food tastes have on the nutritional well-being of their families.

Your food preferences and dietary habits are the first important way you are involved in feeding. You have an essential role in achieving a nutritious, age-appropriate diet for your baby.

During pregnancy, you and the baby's mother probably discussed how to feed your baby -- by breast or bottle. If the two of you decided breast-feeding was the best choice, your unswerving support during the time your baby is breast-fed is crucial.

If you chose to bottle-feed, your acquiring knowledge about formula preparation and healthy feeding practices is necessary and valuable. Perhaps you and the baby's mother chose to breast-feed first and bottle-feed later or to combine the two feeding methods. In any case, your support and involvement with feeding your baby will help your baby and give pleasure to you.

If your baby is breast-fed, you obviously cannot directly provide milk for your baby, although you can give him bottles of expressed milk if there are times when it is inconvenient or impossible for your partner to breast-feed. There are other important ways you can be helpful during feedings. You can bring your baby to his mother for night feedings and then tuck him back in bed later. You can burp the baby after feedings and take the opportunity to enjoy the quiet but alert time he has after feeding.

Many breast-feeding mothers experience sore nipples, fatigue, and doubts about milk supply. Your encouragement and nurturing help are important. In fact, one study has demonstrated a relationship between the father's support of breast-feeding and its success or failure.

Another important way you can help is to teach other family members about breast-feeding, so they understand and support this method of feeding. In the past, less was known about the benefits of breast-feeding than is known today, and feeding practices were different.

If your baby is bottle-fed, you can help by actively sharing the feedings with his mother. Make it your responsibility to mix formula in the proper way and to ensure the feeding equipment is clean and functioning well.

Always hold your baby when you feed him. He will begin to trust that you love him and are able to satisfy his needs. To provide for normal eye muscle development, hold him sometimes in your right arm and sometimes in your left. Hold him so his head is slightly elevated. Feeding in a flat position is associated with greater risk of middle ear infections.

Discontinue feeding your baby when he indicates he is through. Burp him during and after feedings. The frequency of burping depends on how much air he seems to swallow.

Whether your baby is breast- or bottle-fed, you can help by keeping feeding times calm. Run interference with the doorbell and the telephone. Anything you do to reduce tension is beneficial.

When your baby is ready for table foods, you can be involved in many ways. You can help by making mealtimes pleasant. Tension during feedings diminishes appetite and disturbs digestion. Make an effort to indicate pleasure with the variety of foods you offer your baby even if the food does not appeal to you. As tempting as it might be, avoid using food as a reward for good behavior or a special accomplishment.

Never offer your baby junk food or alcohol. Neither is part of a nutritious diet, and each replaces the foods your baby does need for growth and health. In addition, even small amounts of alcohol can be toxic to a young child.

Your involvement with your child's mealtimes is important. You can have a significant effect on your baby's health, and your relationship benefits from the time you spend together.

The decision to breast-feed is ultimately a personal choice that the parents will make by themselves. In fact, you might find that you cannot make a final decision until you have tried breast-feeding after the delivery. Hopefully, the information in this article will help you make this choice.

Infant Feeding Schedules and Burping

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No matter how you feed your baby there are additional considerations you will have to take into account. In this section, we will review feeding schedules and burping.

Demand Versus Scheduled Feedings

There is no consensus regarding which feeding method is best -- feeding at the child's demand or according to a schedule. If your schedule is flexible and you are willing to feed your baby frequently, demand-feeding may be best. You feed the baby whenever he seems hungry. A potential problem is that your baby may get used to taking only small amounts of formula or milk frequently, so you spend a lot of time feeding him. Using a regular schedule may be easier -- since you know what times he will eat, you can organize your day around this schedule, and he can become accustomed to the schedule.

Whichever method you use, it's important not to overfeed your baby. Once he loses interest in the bottle or breast, stop. Don't try to coax him into taking more. An infant generally doesn't need more than one quart of formula a day. Most breast-fed babies consume the majority of milk from a feeding in five minutes on each breast. Any sucking after that is usually for comfort.

Burping

Babies generally swallow some air as they feed, although breast-fed babies tend to swallow less air than bottle-fed babies. To minimize the amount a bottle-fed baby swallows, try to always keep the nipple full of formula as you feed. Regardless of the method of feeding, an air bubble may accumulate and make your baby uncomfortable. To prevent that distress, you should burp her at the conclusion of each feeding; you may also want to burp her at the midpoint of the feeding to prevent the buildup of too large a bubble.

There are a number of common positions to burp a baby, and no one of them is the right one. You will eventually find the one that is most effective for your baby, although on some occasions, you may have to run through the whole repertoire of burping positions until you get results.

These positions generally have in common putting some slight pressure on the baby's abdomen -- by placing her against your shoulder so she faces backward; by sitting her on your lap, resting her midsection on your forearm or hand; or by laying her face down across your lap and then gently rubbing or patting the middle of her back. Remember to protect the area beneath her mouth with a cloth because she is quite likely to bring up some milk with the gas bubble; this is usually only a small amount and does not indicate a feeding problem.

Some babies don't accumulate a large bubble or aren't made uncomfortable by one, so if your baby doesn't burp after several minutes of concerted effort, there is no point in exhausting both of you in a marathon burping session.

Of course, you want to spare your baby any discomfort that might result from an air bubble, but if your burping efforts aren't successful, the worst that may happen is your baby noisily lets you know when the bubble is making her uncomfortable, at which point you can renew your burping efforts.

How to Bottle-Feed

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Mothers have fed their babies formulas for years. In the past, evaporated milk was the main component of formula. Doctors would recommend various additions to it in an attempt to make the formula more complete.

Many different types of baby formula are available. Formula manufacturers continually improve their products, trying to make them closer to breast milk. A number of special formulas are also available for babies with certain health problems.

Most formulas use nonfat cow's milk as their base and source of protein. Many different fat sources are used: Soy, coconut, and corn are the most common. Various vitamins, minerals, and trace elements are also added. There is, however, no way to duplicate the antibodies found in breast milk.

For babies with a milk allergy or intolerance, formulas are available with soy protein in place of nonfat cow's milk as the main source of protein.

Babies with digestive problems or acute, severe diarrhea often need formulas that are very easy to digest and absorb. These formulas use casein as their protein source. They are usually used for only a few days, until the baby recovers from the diarrhea.

Selecting a Formula

All the milk-based formulas currently available are similar in composition and nutrient value, with only minor differences between them. Despite this, some babies seem to do better on one milk-based formula than on another. If your baby has gas, vomiting, or bowel problems with one formula, consult your doctor regarding a possible change in formula.

Most formulas are available either with or without supplemental iron. The iron is necessary to prevent iron deficiency. The American Academy of Pediatrics recommends iron-supplemented formulas only.

Through television and print advertising, formula manufacturers encourage use of their brand of formula. The American Academy of Pediatrics opposes this type of advertising because your doctor is best suited to help you decide which formula is best for your baby if you do not breast-feed.

Formulas come in three forms: ready-to-feed, concentrate, and powder. All three forms contain the same protein, fats, and other nutrients. The type you select is a matter of price and convenience. The most convenient, but most expensive, is the ready-to-feed in individual baby bottles or quart cans. The powder and concentrate are less expensive but can be more of a hassle to use.

The only difference between the three forms of formula is the water you need to add to the concentrate and powder forms. If your water contains fluoride, then you may not need to give your infant a fluoride supplement. If you use a ready-to-feed, then your baby may need the additional fluoride.

Bottles, Nipples, and More

Using formula means you need bottles, nipples, and other paraphernalia. There's really little difference between plastic and glass bottles except glass bottles break more easily. The size you select is a matter of convenience. And some parents find special bottle/liner systems handy.

Nipples come in many different sizes and shapes. Some makers of nipples claim theirs are "more like mother" because of their shape. What's really important is not what the nipple looks like in the package but how it works when your baby sucks on it. If you find a nipple that meets your baby's needs, stick with it.

If your water supply is safe and clean, you do not need to sterilize or boil bottles and nipples. Clean them with hot, soapy water and then rinse and thoroughly dry them. Some parents put the bottles in the dishwasher.

Mixing and Storing Formula

With the concentrated and powdered formulas, you must add water before you use them. Except when told otherwise by your doctor, never add more water than the instructions say. Over-diluting formula on a regular basis leads to malnutrition.

Again, if your water supply is clean and safe, you don't need to boil the water before you add it to the formula. As a general rule of thumb, if you can drink the water without problems, so can your baby. If you have concerns regarding water quality, check with your local water or health department, or discuss your concerns with your baby's doctor.

If you mix one bottle of formula at a time, you can just add cold tap water to the powder, mix it well, and feed your baby. In areas with fluoride in the water, you won't need to give your baby supplemental fluoride. Avoid using hot tap water -- any lead in the plumbing is more likely to leach into hot water.

You can safely refrigerate mixed or open formula for 24 hours. When you travel, the most convenient form of formula is the powdered type. You simply add water, and you're ready to feed your baby. You should be extremely cautious, however, if there is any question about water quality.

Bottle-Feeding a Baby

It isn't necessary to warm bottles of formula. Some babies will take the formula straight from the refrigerator. Obviously, giving a cool bottle of formula is a lot quicker and easier than trying to warm up a bottle when your baby is screaming. If you wish to warm the bottle, just hold it under hot running tap water. Then, shake it well to mix the formula, and test the formula to be sure it isn't too hot for the baby. Do not heat your baby's formula in a microwave oven. This method has too many potential dangers.

When you feed your baby, always hold your baby and the bottle -- never prop the bottle. Your baby shouldn't lie down and feed. He should always be semi-upright or sitting up. Bottle propping causes four problems-increased ear infections, increased cavities, feeding longer than necessary, and decreased emotional and physical satisfaction from being held.

The nipple hole should be large enough that the formula drips out at a steady pace of two drops per second. A flow that's too slow may increase the amount of air your baby swallows. If the flow is too fast, he may choke.

Breast-Feeding and Diet

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You need about 500 calories a day more than your prepregnancy intake if you breast-feed your baby. These additional calories, plus the calories available from the three to seven pounds you stored in pregnancy for lactation, supply enough calories to make milk.

Once you reach three to seven pounds above your prepregnancy weight (including two to four pounds for the weight of your lactating breasts), let your weight guide you to the number of calories you should consume each day. Your activity level and the amount of milk you produce for your baby also affect your weight.

In addition to extra calories, include extra protein for milk production, more calcium- and vitamin-rich foods, and more fluids than your normal diet.

Here are some simple guidelines:

Continue to take your prenatal vitamins (unless your doctor tells you otherwise).

Eat a varied, balanced, good-quality diet.

Pay special attention to fluids; drink enough to quench your thirst. Many moms drink a tall glass of milk or water while nursing.

Avoid junk foods and empty calories.
Foods and Drugs to Avoid

Every breast-feeding mother wonders if something she ate caused fussiness, gas, diarrhea, or a rash in her baby. While you can eat most foods without problem, some foods can cause difficulty.

Cow's milk in the mother's diet may cause colicky symptoms in some babies. If this is a problem for your baby, she will draw her legs up toward her body and scream with gas pains after feeding. You can eliminate milk from your diet for four to seven days to see if the symptoms disappear. As your baby grows older, reintroduce milk into your diet because babies often outgrow this reaction to milk. If you eliminate dairy products from your diet, you need to talk with your doctor about a calcium supplement.

Other foods that may cause problems for breast-fed babies include those that contain food additives and dyes, certain gas-producing foods (such as broccoli, cabbage, and beans), eggs, nuts, tomatoes, shellfish, chocolate, corn, strawberries, citrus fruits, onion, garlic, and some spices. To decide if a particular food upsets your baby, eliminate that single food from your diet and see if the symptoms disappear.

If you consume food in very large amounts, this may cause problems for a breast-fed baby. A half gallon of apple juice or orange juice, very large amounts of fruit, a whole jar of peanuts, or any other food consumed in unusually large quantities may cause your baby to have diarrhea or gas.

In the past, breast-feeding mothers were encouraged to drink beer to aid milk production. We now know beer does not increase milk production. We also know beer and other alcoholic beverages readily enter the breast milk in about the same concentration as your blood alcohol level. Since no safe level of alcohol has been established for the breast-fed baby, it is wise to strictly limit your alcohol intake or not drink at all. In addition, alcohol can inhibit letdown (the release of milk from the milk-producing sacs within the breasts to the milk ducts), so your baby does not get the milk he needs.

Cigarette smoking and breast-feeding are not compatible. Heavy cigarette smoking may reduce milk production; increase the incidence of nausea, colicky symptoms, and diarrhea in the baby; and decrease the vitamin C content of the milk. Smoking near the baby increases his risk of many respiratory ailments, including pneumonia, bronchitis, and asthma. As in pregnancy, the best advice is to quit.

Caffeine passes into breast milk and may cause your baby to have an upset stomach and be irritable. If you suspect caffeine affects your baby, eliminate coffee, tea, cola, chocolate, and other caffeine-containing products from your diet (or switch to decaffeinated products) to see if the symptoms disappear.

Do not take any vitamin supplements or herbs other than your prenatal vitamins without consulting your doctor or a registered dietitian first.

Almost every drug or medication makes its way into breast milk. Some medications appear to have no harmful effects on your baby, while others are most certainly not safe. Talk with your pharmacist or your child's doctor before you take any prescribed or over-the-counter medications-be sure the medications pose no problems for your baby.

If you need to take any drugs, particularly on a regular basis, discuss this with your doctor. You may have to stop breast-feeding until all the drug has passed out of your system.

There are some cases where a mother will not be able to breast-feed. Modern formulas have come a long way toward reproducing the benefits of breast milk. In the next section, we will show you how to bottle-feed.

How to Breast-Feed

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You should discuss your decision to breast-feed with those who are important to you. It is much more difficult to succeed if your partner, parents, or children don't understand why you want to breast-feed your new baby. A young child may be concerned that his new brother or sister is actually hurting you. Your other children may become jealous of all the attention you give the new baby. Preparing them makes it easier.

Some men become jealous of a new baby, and breast-feeding may make matters worse. Discuss your decision ahead of time as one way to lessen these feelings. And be sure to make the father a participant in routine baby care.

Many misconceptions still exist about breast-feeding. Many women find it frustrating if they don't breast-feed easily and instinctively -- they don't realize they need to learn the best way to breast-feed. Years ago, women learned breast-feeding techniques from their mothers, older sisters, and older women who breast-fed their children. But chances are your mother did not breast-feed you, so she can't really help you with your own breast-feeding.

Classes in breast-feeding techniques are available. Lactation consultants, breast-feeding clinics, and organizations such as La Leche League offer support and encouragement for women having problems with breast-feeding. If you should experience breast-feeding difficulties, remember that the treatment for most breast-feeding problems is to continue breast-feeding.

Getting Started

Most women now have the opportunity to breast-feed their newborns shortly after giving birth. Unless you are so exhausted from the delivery that you can't stay awake, you should try nursing your new baby as soon as possible. Often this means nursing on the delivery table.

Don't be discouraged if your baby isn't interested -- remember, she's been through a tough and tiring process, too. She may be too worn out to be interested in feeding. Don't take this as a rejection. Some women's breasts don't seem to have colostrum (the substance you feed your baby until your milk comes in) immediately after delivery; don't be discouraged-the colostrum, then the milk, will come in.

Feel free to ask questions of your doctor, obstetrics nurse, or lactation consultant about breast-feeding. Very few new mothers cannot breast-feed. Most who feel they have to discontinue just give up too soon. As mentioned earlier, the best treatment for most breast-feeding problems (for example, blocked ducts or insufficient milk supply) is to continue to breast-feed. When you start, your nipples may be a little sore, especially if you are very fair-skinned. This is natural; they aren't accustomed to this type of work and need some time to toughen up.

Allergies

It is extremely rare for a baby to be allergic to her mother's breast milk. If any family members have allergies, particularly to milk or milk products, your baby is more likely to have problems with formula than with your milk. If you suspect an allergy, consult your child's doctor. Some experts recommend that babies from families with allergies breast-feed, and that the mother avoid eating known or commonly allergenic foods while breast-feeding.

Diapers and Bowel Movements

Many parents of breast-fed babies notice their babies' bowel movements are different from those of bottle-fed babies. The bowel movements are soft and yellowish. Changing the soiled diapers of a breast-fed baby may not be as unpleasant as dealing with the diapers of a bottle-fed infant. Because breast milk is so well absorbed, breast-fed infants are rarely constipated. All of this changes once a baby starts formula or solids.

When You Should Not Breast-Feed
There are very few instances when you should discontinue or avoid breast-feeding. If, for example, you must take a drug that crosses into the breast milk and has the potential for harming your baby, you should elect not to breast-feed. In addition, certain diseases and infections (although few in number) may force you to avoid breast-feeding your baby.

Many doctors use the guideline that if you are too sick to bottle-feed, you should not breast-feed. Ask your doctor if you are unsure.

Breast-Feeding and Working

Some women wonder if they can continue to breast-feed once they return to work. Most women in this situation find they can, with a little planning. Remember that breast-feeding is not an all-or-nothing proposition.

The human breast makes milk on a supply and demand basis. The more milk is taken out of the breast, the more milk is made. And human breast milk production is very adaptable. Many women have no problems with breast-feeding in the morning before work, when they pick up their baby in the afternoon, during the evening, and again at night.

You can also reckon with the missed feedings during the day. You can freeze breast milk for up to two weeks. You also may be able to pump your breasts at work and refrigerate the milk in a clean bottle. This pumped breast milk can be fed to your baby the next day by your babysitter so your child's diet consists solely of breast milk.

If you are to successfully combine work and breast-feeding, you must be flexible. What works for one woman may not work best for you. Experiment with your schedule and the times you feed your baby.

Stopping Breast-Feeding

How long to breast-feed is an individual decision. Most women stop within the first year. Remember, even if you breast-feed for only a few months, you have given your baby that much of a head start in good nutrition and protection from some illnesses.

Sometimes a baby decides on her own when it's time to stop breast-feeding. She may lose interest in the breast or prefer solids and a cup to breast milk.

Some women breast-feed for two or more years. If this is your choice, make sure your older child gets adequate calories and nutrition from solid foods in addition to breast milk.

Because the food you eat affects the content of your breast milk, there are some dietary concerns for when you are breast-feeding. We will tell you the foods you should avoid while nursing in the next section.

How Long Should You Breast-Feed?
Breast milk alone supplies all the nutrition your baby needs for at least her first four to six months of life. Wait until your baby is at least four to six months old before starting solids. Even at that age, she gets most of her nutrients from the breast milk, not from the solids. A good guideline to follow is your baby should be old enough, and sufficiently coordinated enough, to let you know when she is full. If she can't yet do this, she isn't old enough to start eating solid foods. Also, until she is at least one year old, you should offer her breast milk or formula before you give her any solid foods.

The Benefits of Breast-Feeding

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While a new mother should not feel pressure to breast-feed or bottle-feed, there are some benefits that many people commonly associate with breast-feeding.

Nutritional Benefits

One of the most convincing arguments for breast-feeding is that human breast milk is designed for human babies, just as cow's milk is designed for calves. Even though formula companies work hard to duplicate the composition of breast milk, commercial formulas will never be identical to human breast milk.

As we learn about the nutrients in breast milk, it becomes more obvious that breast milk provides just about everything a baby needs for good growth and development. However, at four to six months, breast-fed babies require supplemental iron and vitamin D, and at six months, fluoride should be provided to your breast-fed or bottle-fed baby if there is an insufficient amount in the local water supply.

Immunologic Benefits

Every time you have an illness or receive an immunization, your body develops immunity against that illness. This means some special cells become sensitized to a particular type of virus or bacterium. The next time that particular organism invades your body, your body is prepared to fight it off. If the immunity is strong enough, you may never contract that illness again.

This is the principle behind immunizations for such diseases as mumps, measles, and pertussis (whooping cough). A vaccine contains inactivated bacteria or virus. Your body believes an infection is present, and it develops an immunity against the inactivated virus or bacteria, which also works against the active form.

When you breast-feed your new baby, much of the immunity you have developed passes on to her through the antibodies present in your breast milk. Many studies show that breast-fed babies have fewer and milder illnesses and fewer hospitalizations.

Breast-feeding is no guarantee your infant will never get sick, but it surely lowers the chances. Many mothers note that once they stop breast-feeding, their infants seem to experience more colds, runny noses, and so on. This may be due to loss of the protection the baby received from breast milk.

Benefits for the Mother

Some of the weight you put on during your pregnancy was a special type of high-energy fat. With breast-feeding, you tend to burn this extra fat first. This doesn't mean that by breast-feeding you'll lose all the weight you gained. But it helps. Breast-feeding has also been shown to help protect against breast cancer and osteoporosis.

Many mothers feel they develop a certain closeness with their babies when they breast-feed. It comes from more than just holding and feeding the baby. The feeling seems to stem from the knowledge that they are truly the source of nutrition for their growing infants.

Unfortunately, the father may feel left out when the mother breast-feeds because he does not have an opportunity to feed their new baby. You can offset this problem by occasionally expressing breast milk for the father to bottle-feed the baby.

Breast-feeding is much less expensive than bottle-feeding and much more convenient-fewer bottles to sterilize, no formula to prepare, no midnight trips to the kitchen to warm up the baby's meal.

If you have decided you might want to breast-feed because of the health benefits, you might still be unsure of how the process works.

How Breast Feeding Works

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How Breast Feeding Works Overview
The decision to breast-feed or bottle-feed is yours to make. Since you are the one taking care of your baby, you must feel comfortable with the decision. Feeling you've been pressured into one or the other method only leads to discontent.

More and more mothers are deciding to breast-feed their new babies. In deciding if you will breast-feed, you must consider many facts. The more we learn about breast milk and its composition, the more we realize it is the perfect food for babies. Some research even suggests that breast milk improves a baby's intelligence and can protect a baby against certain forms of cancer. Besides the nutritional benefits, a special closeness often develops between mothers and their breast-fed babies. In this article, we will explore all aspects of breast-feeding, including:

The Benefits of Breast Feeding

The reason why breast-feeding has been such an entrenched method for feeding newborns is that there are some empirical benefits to the process. On this page, we will explain the benefits of breast-feeding so that you can decide if it would be right for you. First, there are the nutritional benefits to consider. Next, there are immunologic factors to consider. Many of the mother's immunities can get passed on to the baby through the breast milk. Finally, there is a benefit to the mother from breast-feeding.

How to Breast-Feed

Breast-feeding might not come as naturally to some young mothers as they would have hoped. In fact, some women have a tremendous amount of trouble learning how to breast-feed. In this section, we will show you how to get the help you need to breast-feed successfully. We will also address the questions of when you should definitely not breast-feed and how long you should breast feed. We will also explore the question of breast-feeding at work. Finally, we will look at when it is time to stop breast-feeding.

Breast-Feeding and Diet

You might be surprised to learn that you will require more calories when you are breast-feeding than you did while you were pregnant. There are many complications to your nutritional needs while you are breast-feeding that might surprise you. Also, whatever the mother takes into her body can be passed on to the baby through the breast milk. Naturally, the nursing mother will want to be just as vigilant about what she takes into her body during this time as she was when she was carrying the baby inside her. On this page, we will help you sort all your diet concerns while nursing.

How to Bottle-Feed

If you opt to bottle-feed for medical or personal reasons, we will offer you some helpful tips on this page. First, we will examine the various baby formulas that are available. With recent advancements, baby formulas are almost as fortified as breast milk. There are also soy-based formulas for babies with milk allergies and formulas with special additives for infants with health problems. Next we will discuss mixing and storing your formula. We will also look at the various bottles and nipples that are on the market. Finally, we will look at the correct way to bottle-feed your baby.

Infant Feeding Schedules and Burping

Whether or not you choose to breast-feed or bottle-feed your baby, you will eventually have to decide what schedule you will feed your baby on and know a thing or two about burping your baby. We will show you the two main strategies in feeding methods -- demand and schedule feedings. We will also teach you the correct way to burp your baby.

Infant Feeding and Fathers

An article on breast-feeding would naturally focus on the mother, but fathers can play a vital role in feeding their baby. Fathers can bottle-feed a baby expressed milk and of course formula, but there are other ways a father can contribute. On this page, we will offer some advice to keep dads actively involved in feeding their child. There's no reason why a father has to miss out on the closeness that can develop while feeding a newborn baby.

Heredity and Inherited Diseases

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Understanding Heridity and Inherited Diseases
To understand how some disorders can be passed from one generation to another, one must first understand the role played by the genes in determining the form and function of each cell in the body.

The genes are the basic units that determine the hereditary characteristics of an organism. Genes, which are composed of molecules of deoxyribonucleic acid (DNA), can be thought of as chemical instructions. Each gene, by virtue of the particular structure of its DNA molecule, contains the code for a specific trait, determining both what a cell is and how it works (as if a computer program not only told the computer what to do but helped to form the machine itself).

Within each cell, thousands of genes are linked in a specific order, like beads on a necklace, to form structures called chromosomes, which are, in effect, continuous strands of DNA. It has been estimated that each cell contains about five feet of coiled DNA strands and that each strand is made of about 100,000 genes.

The particular composition of the genes and their arrangement on the chromosomes are what constitute the genetic blueprint for each individual. Cells that develop into liver tissue, rather than blood cells or nerve fibers, for example, do so because that is what their genetic coding dictates. In this way, the cells of the body are programmed to create a person with a certain color of eyes and hair, as well as the thousands of other characteristics that make each human unique.

Sex Cells

Each cell in the human body contains 46 chromosomes. The only exceptions are the sex cells (the ovum and the sperm), each of which contains only 23 chromosomes. When these sex cells unite in the fertilization of the ovum by a sperm, the result is a full complement of 46 chromosomes, with genes donated by both parents. Since each parent contributes only 23 chromosomes (half the genetic coding that makes each parent a unique individual), the genetic makeup of their offspring is a blend of components of both parents' genetic material.

Dominant and Recessive Traits

The traits that genes give rise to may be either dominant or recessive. A recessive gene produces a certain trait only if its effects are not overridden by those of a dominant gene.

Eye color provides a relatively straightforward illustration of how inheritance of traits works. The gene for brown eyes is dominant; the gene for blue eyes is recessive. The child of a brown-eyed parent who has two brown-eye genes and a blue-eyed parent (who must have two blue-eye genes) will have brown eyes because the brown-eyed parent has only dominant brown-eye genes to contribute to the child's genetic makeup. However, if the brown-eyed parent has a dominant brown-eye gene and a recessive blue-eye gene, the child has a fifty-fifty chance of receiving a blue-eye gene from both parents and thereby having blue eyes. (Actually, inheritance does not always work with such textbook simplicity -- sometimes the child of a brown-eyed parent and a blue-eyed parent will have green or hazel eyes.)

The union of two blue-eyed persons, because it involves only recessive blue-eye genes, will always produce blue-eyed offspring.

The offspring of two brown-eyed persons who each have a recessive blue-eye gene have a one-in-four chance of receiving a blue-eye gene from both parents and, as a result, having blue eyes. (This final combination illustrates how recessive genes can be present but unsuspected, allowing a trait to appear unexpectedly after skipping generations.)

Mutation

Genes are normally transmitted unchanged from one generation to the next. Sometimes, however, mutations occur -- that is, the structure of the gene itself is changed, perhaps due to the effect of a toxic substance, an infection, or exposure to radiation. Offspring that receive a mutated gene will exhibit a characteristic that is not present in either parent.

The discovery of the structure of the DNA molecule opened a new era in medical research. Scientists in the new field of genetic engineering are exploring ways of artificially creating mutations in genes so that someday it may be possible to correct the errors in genetic coding that are responsible for causing various disorders.

Genetic Counseling

As the medical profession has learned more about inherited diseases, it has been able to offer genetic counseling to couples concerned about the possibility of having a child with an inherited disease or abnormality. A genetic counselor or specialist in genetic disorders can estimate the likelihood that a couple's offspring will be afflicted with a problem due to an inherited trait or to the age of the parents. For some genetic disorders, tests can determine whether one or both parents are carriers or can detect whether a defect is present in a fetus.

Gynecomastia

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Gynecomastia is excessive development of the breasts in a male. Breast enlargement is a normal, short-term occurrence in some newborn boys, whose breasts enlarge in response to female hormones they receive from their mother during pregnancy. The condition may also appear at puberty, when a boy's body is undergoing normal hormonal changes.

Causes

In most cases, gynecomastia is the result of too much estrogen (a female sex hormone) in the boy's body. Male breast enlargement at birth and at puberty usually occurs because the estrogen level has not yet adjusted to normal (both sexes have estrogen in their bodies). Abnormal gynecomastia occurs when some condition, such as a tumor of one of the testes or an estrogen-secreting tumor of one of the adrenal glands, results in abnormally high levels of estrogen. Some medications can also cause gynecomastia.

Symptoms

In addition to the obvious enlargement of the breasts, symptoms may include tenderness in the breasts and, in extreme cases, secretion of milk.

Treatment

Gynecomastia should always be brought to the attention of a doctor. It is especially important that tumors of the adrenal or pituitary glands or testes be ruled out or treated. Such tumors are usually removed surgically. In severe or prolonged cases, the excess breast tissue can be removed by plastic surgery, with little visible scarring. In most cases, patients can be reassured that the condition is temporary. Especially in need of such reassurance are teenage boys, who are often embarrassed and fearful that they are abnormal.

Fibroid Tumors

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Fibroid tumors are solid, noncancerous growths composed of smooth muscle fibers and connective tissue that grow in the walls of the uterus or out from the uterus. Only rarely do they appear on the cervix. Occasionally, they fill the entire uterus, push through the cervix, and appear in the vagina. These tumors usually grow slowly and vary in size and shape.

Fibroid tumors are thought to be the most common type of abdominal tumor, found in about 25 percent of all women over the age of 30 (more frequently in black women). Cancer rarely develops in fibroid tumors; however, they do sometimes cause problems. They tend to enlarge during pregnancy, which can cause complications as the fetus grows.

Causes

The cause of fibroid tumors is not known, but their growth seems to be related to the female hormone estrogen, since these tumors rarely appear before puberty and tend to recede by the menopause years. They most commonly appear in the middle to late reproductive years, when the estrogen level is at its peak.

Fibroid tumors may occur along with other disorders, such as endometriosis (the displacement of tissue from the uterine lining to areas elsewhere in the body) or pelvic inflammatory disease.

Symptoms

Common symptoms of fibroid tumors are dysmenorrhea (pain during menstruation) and gushing or flooding of the menstrual flow. Occasionally, there is abdominal pain; however, pain is not usually a symptom unless a complication develops. If fibroid tumors become very large, they may press on surrounding organs, such as the intestines and bladder, which may result in constipation or frequent urination. If they extend into the uterus, heavy and prolonged menstrual periods may result. If the tumor is advanced, the abdomen may be noticeably enlarged. Sometimes, however, these tumors cause no symptoms.

Diagnosis

Diagnostic evaluation begins with a physical examination and may include curettage (scraping the uterus walls) or endometrial biopsy (removal of some tissue from the lining of the uterus) to test for cancer. X rays and ultrasound may also be used to establish the location, size, and nature of the tumor.

Treatment

Fibroid tumors may require no treatment at all, other than regular checkups with the doctor. Fibroid tumors that are causing complications may require one of two types of surgery. Removal of the tumor (called a myomectomy) is usually recommended for women in their early reproductive years whose symptoms are somewhat mild and who desire a future pregnancy.

Removal of the uterus (called a hysterectomy) is usually recommended for older women who have completed their families and for women who do not want to become pregnant in the future.

Fibrocystic Breast Disease

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Fibrocystic disease is a condition in which benign (noncancerous) lumps form in the breast, either temporarily or for the duration of the childbearing years.

This condition is not dangerous in itself, but it has been found that women with certain forms of breast lumps may be two to four times more likely to develop breast cancer than are other women. To complicate matters, the presence of these benign lumps makes it difficult to detect any new, possibly dangerous growths.

Cause

The exact cause of fibrocystic disease is not known. However, the tendency to develop it may be inherited. Also, it is seen more often in women who have never breast-fed a child; the reason for this is not known.

Symptoms

The most noticeable symptom of this disorder is the presence of the lumps, which may take the form of either solid masses or fluid-filled sacs called cysts. Large cystic lumps near the surface can be moved about freely, unlike cancerous lumps, which are usually firmly attached to surrounding tissue. Changes in hormonal secretions during the menstrual period tend to increase the size of the lumps slightly, which causes additional pain, but the size of the cysts decreases after the period. Another symptom of fibrocystic breast disease is persistently heavy and tender breasts, not only before and during menstruation (as is commonly seen in healthy breasts) but all the time.

Diagnosis

Diagnostic evaluation will begin with a physical examination. Mammography (a special X-ray study of the breasts) and ultrasound are often done to determine whether the lumps are fluid-filled cysts or solid masses. If they are found to be solid, a biopsy (the removal of a small piece of tissue for analysis) may be performed to detect the presence of cancerous cells.

Treatment

Fibrocystic disease often requires no treatment. In some cases, the lumps disappear in a few months. Cysts that are unusually large or particularly bothersome may be drained of their fluid by the insertion of a hollow needle in a procedure called aspiration. If there are many small lumps or if there is continuous development of new ones, other forms of treatment may be necessary to prevent the formation of cysts. Birth control pills may be prescribed, since they act to equalize the concentration of hormones in the body throughout the monthly cycle; however, birth control pills have also been found to cause cysts in some women. Large doses of vitamin E (taken under a doctor's supervision) have reportedly been effective in treating fibrocystic disease.

Prevention

Relieving or preventing fibrocystic disease may be promoted by discontinuing or drastically limiting the intake of nicotine and a chemical called methylxanthine, found most commonly in coffee, tea, cola, chocolate, and some cold medications. Because certain forms of breast lumps carry a greater risk of breast cancer, women with lumps should have a physical examination regularly. They should also report any new growths or enlargements of existing lumps, and they should perform self-examination of their breasts each month after menstruation.

Endometriosis

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Endometriosis is a condition in which tissue from the endometrial lining of the uterus becomes detached and grows in the abdominal cavity outside the uterus. It occurs only in women of childbearing age, especially in women between the ages of 30 and 40 years.

Cause

During each menstrual cycle, the endometrium normally thickens and swells in preparation for possible pregnancy. If no pregnancy occurs, portions of endometrial tissue break down and pass out of the uterus as part of the menstrual flow. When endometriosis develops, displaced endometrial tissue continues to swell and bleed each month in an abnormal location, but the blood has no outlet. The body responds to the presence of this accumulated blood by surrounding it with scar tissue, which builds up month after month, until blood-filled pockets, or cysts, are formed on the affected organs.

The exact cause of endometriosis is not known, but several conditions are thought to lead to its development: Menstrual blood may flow backward through the fallopian tubes and into the abdominal cavity; the cervix or vagina may be blocked, so that the menstrual blood cannot flow out normally; or surgery or another condition may lead to the displacement of some tissue from the uterus.

Symptoms

The symptoms of endometriosis are pain immediately before, during, or immediately after the menstrual period; pain during intercourse; discomfort in the lower urinary tract or intestine; irregular or excessively heavy menstrual flow; bleeding from the rectum; blood in the urine; and infertility. Some women may experience all of these symptoms, while others may experience only one or two.

Diagnosis

Diagnostic evaluation begins with a complete medical and menstrual history. A pelvic examination may be performed -- once during menstruation and once between periods -- to investigate the changes in the reproductive organs during the cycle. The doctor may also perform a laparoscopy, in which a lighted, tubelike instrument is inserted into the lower abdomen through a tiny incision, which will allow a view of displaced tissues.

Treatment

Treatment of this disorder consists of halting the condition, reducing the pain, and restoring normal menstruation and fertility. The best way to halt endometriosis is to modify the body's natural hormonal secretions with drugs in order to stop menstruation and ovulation for some time, thus allowing the endometrial tissue to shrink. Naturally, the patient will be unable to become pregnant during this type of drug therapy, but since endometriosis often causes infertility, many patients are already unable to conceive.

Three types of drugs are usually used in this treatment. Birth control pills, as well as several other medications that modify female hormonal secretions, are sometimes prescribed in doses high enough to stop menstruation and ovulation. However, an excessive dosage often brings with it undesirable side effects, such as nausea, fluid retention, and blood clotting.

A synthetic hormone called danazol creates a condition similar to menopause, causing menstruation and ovulation to stop and the endometrial tissue to shrink almost immediately. Danazol does not have some of the side effects associated with other hormonal drugs. However, it is relatively expensive and is not effective in all cases.

The newest form of treatment is a nasal spray that causes the brain to stop producing hormones that cause ovulation and menstruation. As with the use of danazol, the nasal spray causes endometrial tissue to shrink almost immediately.

If drug therapy is unsuccessful, surgery may be necessary, involving either the removal of scar tissue and endometrial tissue or, in advanced cases, the removal of the uterus and ovaries, rendering the patient sterile. Endometriosis may be destroyed by using very precise medical lasers. This form of therapy has been used to dissolve areas of endometriosis while leaving surrounding normal tissue unharmed.

Dyspareunia

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Dyspareunia is difficulty or pain experienced by a woman during intercourse.

Causes

Dyspareunia may be caused by a resistant hymen (the membrane that usually covers the opening to the vagina in virgins) or by inflammation of or injury to the vagina, the urethra (the tube that carries urine from the bladder to the outside), the vulva (the structures around the opening to the vagina), or the anus. It can be the result of formation of scar tissue around an episiotomy (a surgical cut to enlarge the opening of the vagina immediately before childbirth) or surgery to repair the vagina.

Other physical causes include tight muscles in the area around the vagina, an "hourglass" contraction of the vagina, a divided vagina, inflammation of the cervix, prolapsed (fallen) uterus, infected fallopian tubes, and endometriosis.

Inadequate lubrication of the vagina is a common cause of dyspareunia. This deficiency may be due to inadequate arousal of the woman before insertion of the penis or to menopause, which is accompanied by a decrease in vaginal secretions and thinning of the vaginal lining. Unconscious tightening of the vaginal muscles, called vaginismus, is another possible cause -- perhaps the result of fear, unreadiness or unwillingness to perform the sex act, or other psychological reasons. Improperly fitted or improperly lubricated birth control devices (condoms or diaphragms) and an allergy to spermicides are other causes.

Symptoms

Pain during or after sexual intercourse is the primary symptom of dyspareunia.

Diagnosis

Diagnosis is made on the basis of both a physical and an emotional evaluation. In some cases, physical abnormalities can be detected during the physical examination. In other cases, careful inquiry into the patient's emotional state and sexual history may reveal factors that account for the discomfort.

Treatment

Treatment for dyspareunia is correction of any underlying disease, injury, or structural defect, if such a problem exists. For some couples, counseling by a psychiatrist or sex therapist may be helpful.

Water-soluble lubricating jelly (not petroleum jelly), obtainable in any drugstore, provides a good vaginal lubricant. Estrogen creams can be used along with water-soluble jelly to restore lubrication to a dry vagina after menopause. Soothing creams and temporary avoidance of intercourse can relieve the soreness of dyspareunia.

Dysmenorrhea

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Dysmenorrhea is the term for painful menstruation. It occurs most commonly in teenagers and in women who have never been pregnant.

There are two types of dysmenorrhea. Primary dysmenorrhea is a recurring condition, usually beginning shortly after the onset of menstruation in a young girl. Secondary dysmenorrhea develops later in life, after a woman has been menstruating for some time.

Dysmenorrhea is not a serious condition, but it can be annoying, uncomfortable, and even incapacitating. Since secondary dysmenorrhea usually indicates that another disorder is present, treatment should always be sought for this condition.

Causes

The cause of primary dysmenorrhea is thought to be the release of excess prostaglandins from the lining of the uterus shortly before the beginning of a menstrual period. (Prostaglandins are substances that, among other functions, stimulate uterine contractions.) The resulting contractions constrict blood vessels in the uterus, causing pain in the same way that a decrease in blood supply to the heart causes chest pain. The reason for this excessive production of prostaglandins is not known. Secondary dysmenorrhea is usually a result of another reproductive problem, such as fibroid tumors, a narrow cervix, or endometriosis (the displacement of tissue from the uterine lining to areas elsewhere in the body).

Symptoms

The major symptoms of dysmenorrhea are cramps and pain in the lower abdomen, possibly extending around to the back. Nausea, vomiting, diarrhea, headache, fatigue, and nervousness are mainly associated with primary dysmenorrhea. These symptoms usually appear at the beginning of, or slightly before, the menstrual period, and may last several hours or several days.

Diagnosis

Diagnostic evaluation will include a complete physical examination as well as medical and menstrual histories. If the symptoms have been present from the onset of menstruation at puberty, primary dysmenorrhea is usually the diagnosis. If the symptoms appeared suddenly in a woman who has been menstruating for some years, secondary dysmenorrhea can be assumed. In that case, further diagnostic evaluation of the reproductive organs will then be necessary to identify the underlying disorder. Ultrasound examinations (in which the echoes of sound waves are used to create images of internal structures) or X-ray studies often prove useful.

Treatment

Primary dysmenorrhea has been successfully treated with non-steroidal anti-inflammatory drugs (such as ibuprofen, naproxen, meclofenamate, diflunisal, and mefenamic acid), which, when taken just before a period is to begin, act to suppress the production of prostaglandins and thereby reduce the intensity of the contractions that cause pain.

Secondary dysmenorrhea is treated by correcting the problem that is causing it. For instance, if endometriosis is the underlying problem, it may be treated with hormone therapy or surgery, thereby relieving the dysmenorrhea as well.

Home remedies often help to ease menstrual pain and relieve pressure. These include placing a hot-water bottle or heating pad on the abdomen, taking hot baths, and lying on the back with the knees bent. A woman who experienced dysmenorrhea before pregnancy may find that the problem is lessened after childbirth, possibly because of enlargement of the cervix or destruction of some nerve fibers in the uterus.

Down Syndrome

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Down syndrome is a congenital (present at birth) disorder characterized by varying degrees of mental retardation and a variety of physical abnormalities.

Cause

Normally, each cell in the human body has 46 chromosomes; the cells in someone with Down syndrome, however, have 47. In ways not yet known, the presence of the extra chromosome causes all of the unusual characteristics of Down syndrome. In 95 percent of cases, the condition is called trisomy 21 (because the extra chromosome is attached to the 21st pair of chromosomes), and the mistake in genetic coding is one that apparently could happen to anyone.

Symptoms

Down syndrome is marked by a number of physical characteristics: somewhat slanted eyes in small sockets (which is why it used to be called mongolism); a small, short head, flattened in back and front; a nose flattened at the bridge; a thick tongue; short hands, feet, neck, trunk, arms, and legs; a single, rather than a double, crease across the top of the palm; flabby arms and legs with poor muscle tone; a wide gap between the first and second toes; and generally retarded physical development.

A child with Down syndrome may have a poorly functioning thyroid gland (which regulates metabolism, the rate at which the body uses energy) and pituitary gland (which regulates other glands, including those responsible for growth, maturation, and reproduction). Children with Down syndrome are at much higher risk of developing leukemia, and approximately one-third of them are also especially susceptible to infection.

Education

Characteristically slower than other children to walk, talk, and learn, youngsters with Down syndrome benefit from "early intervention" programs designed to help them develop their abilities as much as possible. Such programs are frequently available from the time the mother and baby leave the hospital after the birth. A number of organizations exist to promote such programs and assist parents in developing their child's potential.

The degree of retardation that accompanies Down syndrome ranges from mild to severe (the average IQ is about 50), and the extent to which a person will be affected cannot be predicted at birth. Some children with the syndrome attend special education classes in public schools; others attend special schools for the mentally retarded. As adults, some may be able to live independently and work in the community. Depending on the degree of retardation that is present, others will require more supervised living arrangements and may be able to hold simple, routine jobs.

Prevention

Prospective parents can reduce their chances of having a child with Down syndrome by starting their families early. At age 20 a woman's risk of giving birth to a child with Down syndrome is only 1 in 2,000 live births, but at age 35 the risk is 1 in 300, at age 40 it is 1 in 100, and at age 45 it is 1 in 40 live births. The age of the father also has some bearing on the risk, but not as much as the age of the mother. Diagnosis of Down syndrome can be made between weeks 16 and 18 of pregnancy through a procedure called amniocentesis. During amniocentesis, the doctor will insert a needle through the mother's abdominal wall and into the uterus. A sample of the amniotic fluid is then drawn into a syringe, grown on a special culture plate, and analyzed to see if there are abnormal chromosomes.

A technique used to check the chromosomes of the growing fetus is called chorionic villus sampling. This procedure, performed during the eighth or ninth week of pregnancy, involves the removal of a small portion of the placenta by a small instrument that is inserted through the woman's cervix. Tissue that is obtained can be immediately evaluated for the presence of chromosome abnormalities.

Dilation and Curettage

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Dilation and curettage, also called a D&C, is a surgical procedure in which the cervix of the uterus is dilated (expanded) and the endometrial lining of the uterus is scraped with a curette (a loop-, ring-, or scoop-shaped instrument with a long handle).

Purpose

This procedure is often used in the diagnosis of diseases of the uterus (such as cancer) and to halt excessive bleeding. It is also used to perform an abortion and may be employed after a miscarriage (involuntary expulsion of a fetus before it is able to live on its own) to remove any remains of tissue and thereby lower the risk of hemorrhage and infection.

Dilation alone may be performed to enlarge the passageway out of the uterus. This might be done if a severely narrowed cervix is causing painful menstruation because of restricted flow of menstrual fluid. For treatment of this problem, multiple dilations may be necessary since the cervix will often become narrow again after several months.

The Procedure

A D&C is a relatively minor procedure, seldom requiring hospital admission. Because the rectum should be empty before the procedure, an enema may be given; the urinary bladder should also be emptied.

The procedure is performed in an operating room under sterile conditions. Anesthesia may be general (the patient is put to sleep) or local. The patient rests on her back with her feet in stirrups. The surgeon inserts metal dilators of progressively larger sizes into the cervix until it is open enough to permit the insertion of the surgical instruments.

A curette is used to remove endometrial tissue. Special forceps may also be used to remove tissue. When the operation is finished, an absorbent pad is placed over the entrance to the vagina. The pad is checked every 15 minutes for two hours, and excessive bleeding is reported to the physician.

Mild painkillers should be enough to control discomfort from the operation. If there is pain in the abdomen that cannot be relieved in this way or that is continuous or sharp, it should be reported immediately. Some difficulty in urinating is to be expected immediately after the procedure.

In most cases, the patient stays in bed for one to two hours after surgery. Most women return home several hours after the procedure or the next day. A return to many daily activities is possible immediately, and in a week all normal physical activities may be resumed. Sexual intercourse and use of tampons are not recommended, however, until after the follow-up visit to the doctor (usually about two weeks after the procedure).

Risks

The principal risks of a D&C are hemorrhage, infection, and perforation (puncture) of the uterus. The latter is more likely during pregnancy, when the uterine walls are especially soft and thin.

Psychosomatic Conditions

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Couvade syndrome is currently not a recognized medical condition, although the St. George's University study gave credibility to its existence. It seems logical that the syndrome can be explained as a reaction by the body to an emotional state in the mind. The next step is to find this link between mind and body, but so far, this link has proven rather elusive.

It wasn't until the 18th century that the investigation into the mind's effects on physical illness began in earnest. European physicians looking into female hysteria (which had previously been thought to originate in the uterus), came to believe that it was a medical condition that could be explained as a reaction to a highly charged emotional state. Since then, the intensity of the investigation into psychosomatic conditions has waxed and waned, although it has never been abandoned.

Psychosomatic conditions may manifest in different ways. For example, it may be looked upon as strictly a mental disorder, as in the case of a patient with Munchausen syndrome, in which a person is convinced that he or she is sick in order to gain attention. While the symptoms are strictly in the patient's mind, they may feel quite real to him or her. It can also manifest as the result of fear or anxiety, as in conversion disorder, a mental condition in which emotional distress manifests itself physically, as in a dancer who is afraid to go on stage developing paralysis [source: Mayo Clinic].

But there is also another way of looking at psychosomatic conditions that don't infer a type of mental illness. It is becoming widely accepted in medicine that the mind has a large influence on the health of an individual.

In this sense, psychosomatic conditions can be as simple as stress causing a headache or as complex as an introverted personality contributing to the development of cancer. Voluminous studies have shown a correlation between illness and emotion. One study found that people diagnosed with panic disorder display a higher likelihood for abnormal electrical activity in their heart function. Others have shown that people who suffer from depression following major surgery are more likely to die than those with a positive attitude following the same types of surgery.

But as the research on the correlation between emotional states and physical illness accumulates, the actual links are still being investigated. Like Couvade syndrome, it's evident: The mind affects the body. But science has never been a discipline to be satisfied with mere correlation.

Endocrinology may be the best contender in providing the link between body and mind. Scientists have known for a long time that hormones play a role in both mood and physiology. For example, emotional distress has been shown to have a correlation to the release of the hormone 17-OHCS by the adrenal gland. The possible connection here may be that emotional stress, like anxiety, acts on the central nervous system -- which can influence the functioning of the endocrine system.

As science delves more deeply into the influence of emotion over physiology, the connection between mind and body is becoming increasingly apparent. This connection seems to go both ways: Like the effect emotion can have on glands, other studies have found that electrolytes -- elements such as potassium that create the electrical impulses need for body function -- are correlated to mental illnesses, like depression. Perhaps eventually research like this will yield an explanation for sympathetic pregnancy.

Can I feel pregnant when my wife is?

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Men are usually somewhat peripheral during pregnancy. After all, women are the ones who carry the child and endure the process of labor and childbirth. Most men will take advantage of any opportunity to help, and getting up in the middle of the night to head to a drive-thru for french fries and a chocolate shake is often their greatest expression of sympathy for their wives' condition. But for some men, doting is just the beginning.

Imagine your stomach bloating as your wife's grows, or the two of you ill at the same time with morning sickness. Up until recently, the medical establishment has ignored reports of fathers-to-be suffering everything from strange food cravings to backaches and weight gain. But a study in the summer of 2007 went a long way to proving the existence of Couvade syndrome -- or sympathetic pregnancy.

The study conducted at St. George's Hospital, a part of St. George's University in London, England, examined 282 men ages 19 to 55 whose wives were pregnant. A group of 281 men whose wives were not pregnant was used as a control in the study. Researchers found that the majority of the men with pregnant wives displayed a variety of pregnancy-associated symptoms like mood swings and morning sickness.

Stomach cramps were the most commonly reported; one man reported his own labor pains that rivaled his wife's while she was delivering their baby. A few of the men who showed signs of sympathetic pregnancy developed pseudocyesis -- a phantom swollen stomach.

The study found that the symptoms generally followed a similar pattern to the men's wives' pregnancies. The symptoms came on during the early stages of the pregnancy, reached their worst point within the third trimester and cleared up after the wives had given birth. Even more strangely, 11 of the men who sought medical help for their symptoms found that doctors could offer no physical explanation.

Cases of Couvade syndrome (which comes from the French "couver," meaning "to hatch") have been widely documented in different parts of the world. One 1994 study showed that some Thai men also exhibited symptoms of sympathetic pregnancy. Another study, conducted in Italy the following year, says that reports of the incidence of sympathetic pregnancy ranges from 11 to 65 percent [source: Klein]. What's more, a person needn't be a man with a pregnant wife to experience Couvade syndrome. In at least one case documented in the United States, a woman began to show sympathetic symptoms similar to her pregnant twin sister who lived in another city [source: Budur, et al].

But why does it happen? Researchers aren't sure. There are, however, a wide variety of suggestions. It may be a man's anxiety over the impending birth of his child that could cause him to show signs of sympathetic pregnancy. Another theory is that Couvade syndrome may be a man's "statement of paternity" or even a sign of envy toward his wife or feelings of rivalry with the baby

Hypnosis and Infertility

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There haven't been many studies on hypnosis as a successful treatment for infertility. However, more and more are coming out, some with astonishing results. One even suggests that hypnosis can double a woman's chance of getting pregnant when used in conjunction with in vitro fertilization (IVF) [source: Fertility and Sterility Journal]. Like acupuncture, hypnosis has a long history -- and it's actually been included in Western medicine since the late 1800s, when doctors used it to help sedate surgery patients.

The process of hypnosis usually begins when a trained therapist asks a person to focus his or her attention on a specific point or idea. This results in a sleep- or trancelike state in which the patient is more receptive to suggestions. When hypnosis is used to treat diseases, addictions or symptoms, we call it hypnotherapy.

Hypnotherapy is believed to be a successful treatment for a variety of ailments, including anxiety, insomnia, pain management and stress-related illnesses. Some women use it to relieve labor pains. The success of hypnotherapy is thought to be caused by many of the same factors seen in acupuncture. Patients undergoing hypnotherapy may be able to lower their blood pressure or increase their immune-system function, both of which would be beneficial for a woman trying to get pregnant. Women may also be able to balance their hormone levels, which, as we discussed, could increase chances of pregnancy. Another benefit includes reducing unhealthy lifestyle patterns -- like smoking and obesity -- that could decrease fertility in both men and women.

However, in the case of infertility, hypnotherapy's effect on anxiety and stress may be the most important factor. As we saw above, hypnotherapy does seem to be effective on its own, but many studies focus on it in conjunction with the stress of IVF.

In 2006, a team from Soroka University in Israel followed women who were undergoing IVF. Some of the women were hypnotized during the embryo transfer stage, a stressful process that can be impeded by uterine contractions. The study showed that 28 percent of the hypnotized women got pregnant, as compared to 14 percent of the women who didn't receive hypnotherapy. The researchers attributed the success of hypnotherapy to relaxation, which may have reduced uterine contractions [source: Our Jerusalem].

But critics aren't convinced. Many of them point to research flaws that could negate the findings. But the study has made an impact by encouraging further studies on the effects of hypnotherapy on infertility.

Acupuncture and In Vitro Fertilization

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If structural issues are the cause of infertility, acupuncture alone is generally not effective. (Structural problems include scar tissue in a woman's uterus or abdomen as a result of previous surgeries, and obstructed sperm ducts in men.) However, there is evidence that acupuncture works well in conjunction with medical treatments like in vitro fertilization (IVF).

Patients who suffer from damaged fallopian tubes or restricted sperm ducts often turn to IVF. Some studies have shown that the use of acupuncture along with IVF can increase pregnancy rates and decrease miscarriage rates. A 2006 study showed that women who received acupuncture immediately before and after embryo transfer had a pregnancy rate of 39 percent. Ninety-seven percent of these women carried their babies to term. Of the women who didn't receive acupuncture, 26 percent got pregnant and 96 percent of them carried to term [source: Dieterle et al].

Another study found that three acupuncture sessions both before and after embryo transfer improved fertilization rates. One study of 258 women found a 10 percent increase in pregnancy rate when they used acupuncture in conjunction with IVF [source: New Trends in Infertility]. Even more impressive results were obtained in a study in which pregnancy rates hit more than 42 percent with acupuncture treatments during fertility treatments. This is nearly twice as much as the group of women who did not receive acupuncture, in which only 26 percent got pregnant [source: Simon].
Researchers have conducted several studies in an attempt to scientifically explain the benefits of acupuncture. One concluded that acupuncture may improve IVF success rates in four possible ways.

Neuroendocrinological modulations. Acupuncture could change the way a woman's nervous system and endocrine glands interact. This is important because the endocrine glands are in charge of hormone secretion, and infertility studies have proven that hormone imbalances can be a cause of infertility.
Increased blood flow to the uterus and ovaries
Cytokine balance. Acupuncture could help balance the body's level of cytokines, which are involved in immunity. Imbalance of certain cytokines has been attributed to infertility, including infertility due to endometriosis.
Reduction of stress, anxiety and depression. The elimination of one or all of these has been shown to increase the chances of pregnancy.

However, a study presented in August 2007 to the European Society for Human Reproduction and Embryology (ESHRE) found that the use of complementary medicine with IVF actually decreased a woman's chance for pregnancy. The study included several different types of alternative therapy, so it isn't clear if one specific therapy could have a negative impact on fertility or if a combination is to blame. In this study, 50 percent of the women used herbal medicine, 19 percent used acupuncture and 40 percent used a combination of alternative therapies. The study concluded that the pregnancy rate for women using complementary therapy was 45 percent. Sixty-six percent of women using IVF without complementary medicine got pregnant

Acupuncture and Infertility

2008-02-12T16:36:00.000-08:00

Acupuncture is an ancient medical technique that uses stimulation of pressure points in an effort to rebalance a patient's body to a state of health. The most common stimulation method is the insertion of needles into specific sites in the skin. The practice has been popular in China and other Asian countries for more than 3,000 years -- it's used to treat chronic pain, nicotine addiction, thyroid problems, migraines and hundreds of other ailments [source: Pregnancy-Info]. Asian cultures have been using acupuncture as an infertility treatment for thousands of years. Several recent studies have shown the benefits of using acupuncture as, or in conjunction with, an infertility treatment.

The basic concept of acupuncture involves an energy force, or chi, that travels through the body on meridians (channels). The chi affects every aspect of life -- emotional, spiritual, physical and mental. Yin and yang, the opposing forces that exist in the chi, must be balanced in a healthy body. In the event of an imbalance that causes health problems, acupuncturists place needles in specific points on the meridians to unblock the passage of chi. Acupuncture points vary according to the ailment.

Traditional Chinese medicine identifies several patterns of disharmony with infertility in women, including lack of energy, unregulated menstrual cycles and excessive stress. So, acupuncture for infertile women targets the meridians for the kidneys, heart and liver. The kidneys are thought to provide the body with energy, so treating this area would give a woman more energy to offer to a baby. Treatment of the liver meridian regulates menstrual flow and reduces the psychological effects of PMS, depression and anxiety. Finally, the heart system is believed to be related to a person's emotional state, so acupuncture that targets this meridian helps to reduce stress and allows relaxation and health throughout the conception process. When all three areas are treated, egg quality will improve, the uterine lining will be healthier, menstrual cycles will regulate and hormones will balance throughout the body.

According to Western medicine, the most common causes are polycystic ovarian syndrome (PCOS), ovulation irregularities and hormone imbalance. PCOS happens when a woman's ovaries produce high levels of male hormones. This creates an imbalance in all of her hormones, which can impede egg production. Cysts can then form in the ovaries, causing a decrease or stoppage in ovulation. Acupuncture may also help rebalance the body's systems and increase blood flow to the reproductive organs, which restores ovarian function.

An added bonus of increased blood flow to the reproductive organs involves the endometrium, which is the mucus membrane in the uterus. The increased blood flow may make this membrane thicker, which makes the implantation of a fertilized egg in the membrane more likely. In addition, rebalancing the body's forces can help regulate thyroid function and reduce weight, two factors associated with infertility. But when the woman's overall health affects fertility (if she has a thyroid condition, for example), the therapist will use different meridians.

Not Only For the Ladies
Men can get acupuncture for infertility, too -- also in the kidney, heart and liver meridians. This can help infertility caused by stress, low sperm production or poor sperm quality. If the cause is low sperm count or immobile sperm, the treatment must last for at least three months because of the time it takes sperm to mature.

Timing and consistency are also important. Successful treatment usually involves one to two sessions a week for three to six months. A woman's hormones can be adjusted during each week of her menstrual cycle, so therapists recommend a minimum of 12 treatments (or three consecutive cycles). Couples can continue to attempt pregnancy during treatment, but acupuncturists generally believe that body balancing has to happen first. Timing is also an important factor for women who are using acupuncture along with in vitro fertilizaton. Studies have shown that the ideal time for treatment is during the luteal phase of the menstrual cycle (the period after ovulation) and the day of embryo transfer.

Can acupuncture and hypnosis treat infertility

2008-02-12T16:35:00.000-08:00

Infertility is a relatively common condition in the United States, seen in nearly 10 percent of men and women of reproductive age [source: EMedicineHealth]. Doctors can diagnose it after a couple is unable to become pregnant after a full year of unprotected sex. The plethora of treatments for infertile couples includes in vitro fertilization, fertility drugs, hormone therapy, behavioral changes (losing weight or quitting smoking) and surgical repair of fallopian tubes or sperm ducts.

The term complementary and alternative medicine, or CAM, describes any medical practice or product that is not included in the Western world's definition of standard care. Standard care is medicine practiced by doctors, nurses, physical therapists and physician assistants -- it includes the use of modern surgical procedures and prescription drugs.

"Alternative medicine" refers to medical treatments used in place of standard care. "Complementary medicine" is nonstandard treatment that's used along with standard care.

Female Sterilization

2008-02-11T17:21:00.000-08:00

Female surgical sterilization (also called tubal sterilization, tubal ligation, and tubal occlusion) is a low-risk, highly effective one-time procedure that offers lifelong protection against pregnancy. About 700,000 women undergo this procedure each year in the United States.

Basics of Female Sterilization
Female surgical sterilization procedures block the fallopian tubes and thereby prevents sperm from reaching and fertilizing the eggs. The ovaries continue to function normally, but the eggs they release break up and are harmlessly absorbed by the body. Tubal sterilization is performed in a hospital or outpatient clinic under local or general anesthesia.

The uterus is a hollow muscular organ located in the female pelvis between the bladder and rectum. The ovaries produce the eggs that travel through the fallopian tubes. Once the egg has left the ovary it can be fertilized and implant itself in the lining of the uterus. The main function of the uterus is to nourish the developing fetus prior to birth.

Sterilization does not cause menopause. Menstruation continues as before, with usually very little difference in length, regularity, flow, or cramping. (One study suggested that women with a history of Cesarean section may experience slightly heavier bleeding.) Sterilization does not offer protection against sexually transmitted diseases.

Specific Tubal Sterilization Techniques
Laparoscopy. Laparoscopy is the most common surgical approach for tubal sterilization:

The procedure begins with a tiny incision in the abdomen in or near the navel. The surgeon inserts a narrow viewing scope called a laparoscope through the incision.
A second small incision is made just above the pubic hairline, and a probe is inserted.

Once the tubes are found, the surgeon closes them using different methods: clips, tubal rings, or electrocoagulation (using an electric current to cauterize and destroy a portion of the tube).

Laparoscopy usually takes 20 - 30 minutes and causes minimal scarring. The patient is often able to go home the same day and can resume intercourse as soon as she feels ready.

Minilaparotomy. Minilaparotomy does not use a viewing instrument and requires an abdominal incision, but it is small -- about 2 inches long. The tubes are tied and cut. Generally speaking, minilaparotomy is preferred for women who choose to be sterilized right after childbirth, while laparoscopy is preferred at other times. Minilaparotomy usually takes approximately 30 minutes to perform. Women who undergo minilaparotomy typically need a few days to recover and can resume intercourse after consulting their doctor.

Laparotomy. Laparotomy, a less common approach, requires an extensive 2- to 5-inch incision in the abdomen. It is considered major surgery and can require a hospital stay of a few days followed by recovery at home for several weeks. Resumption of intercourse depends on how quickly one is able to recover.

Culdoscopy. Culdoscopy involves inserting a scope through the vagina and into the pelvic cavity. Although it is less invasive than laparoscopy, a major 2002 analysis reported that it has a higher complication rate than either laparoscopy or minilaparotomy.

Essure. Approved in 2002, the Essure method uses a small spiral-like device to block the fallopian tube. Unlike tubal ligation, the Essure procedure does not require incisions or general anesthesia. It can be performed in a doctor’s office and takes about 45 minutes. A specially trained doctor uses a viewing instrument called a hysteroscope to insert the device through the vagina and into the uterus, and then up into the fallopian tube. Once the device is in place, it expands inside the fallopian tubes. During the next 3 months, scar tissue forms around the device and blocks the tubes. This results in permanent sterilization.

Candidacy for Female Sterilization
Before undergoing sterilization, a woman must be sure that she no longer wants to bear children and will not want to bear children in the future, even if the circumstances of her life change drastically. She must also be aware of the many effective contraceptive choices available. Possible reasons for choosing female sterilization procedures over reversible forms of contraception include:

Not wanting children and being unable to use other methods of contraception
Health problems that make pregnancy unsafe

Genetic disorders
If married, both partners should completely agree that they no longer want to have children and should also have ruled out vasectomy for the man. Vasectomy is a simple procedure that has a lower failure rate than female surgical sterilization, carries fewer risks, and is less expensive. [See In-Depth Report #37: Vasectomy.]

Even if all these factors are present, a woman must consider her options carefully before proceeding. Studies report that over time, 14 - 25% of women eventually regret this choice. Women at highest risk for regretting sterilization include:

Women who are younger at the time of sterilization. In one long-term study, over 40% of women who had had tubal ligation between the ages of 18 - 24 regretted their choice. (Only about 4% of women over 35 had these regrets.)

Women who had the procedure immediately after a vaginal delivery.
Women who had the procedure within 7 years of having their youngest child.
Women in lower income groups.

If a woman changes her mind and wants to become pregnant, a reversal procedure is available, but it is very difficult to perform and requires an experienced surgeon. Subsequent pregnancy rates after reversal are between 20 - 84%, depending on the surgical skill, the age of the woman, and, to a lesser degree, her weight and the length of time between the tubal ligation and the reversal procedure. Not all insurance carriers cover the cost of reversal.

Advantages of Female Sterilization
Women who choose sterilization no longer need to worry about pregnancy or cope with the distractions and possible side effects of contraceptives. Sterilization does not impair sexual desire or pleasure, and many people say that it actually enhances sex by removing the fear of unwanted pregnancy. There is some evidence it may help reduce the risk for ovarian cancer.

Disadvantages and Complications of Female Sterilization
Failure is rare, but about 1 in 200 women become pregnant during the first year after sterilization, and failure rate can rise to 5% after 10 years. About a third of these pregnancies are ectopic, which require surgical treatment.

After any of the procedures, a woman may feel tired, dizzy, nauseous, bloated, or gassy, and may have minor abdominal and shoulder pain. In general, there is more postoperative pain with the tubal ring than with electrocoagulation.

Serious complications from female surgical sterilization are rare and are most likely to occur with abdominal procedures. They include bleeding, infection, or reaction to the anesthetic. On rare occasions the bowels or blood vessels are injured and require major surgical repair. The use of electrocoagulation poses a risk for burns in the small intestine and may increase the risk for menstrual disorders afterward.

Emergency Contraception

2008-02-11T17:20:00.002-08:00

Emergency contraception is available to prevent pregnancy:

After sexual assault
After consensual intercourse in which contraception is not used
When contraception is used but fails (for instance, when a condom breaks or a diaphragm dislodges)
Basics of Emergency Contraception

Emergency contraception, also called the “morning after pill,” uses the hormones found in birth control pills to prevent either fertilization or the implantation of a fertilized egg in the uterine lining. It is not the same thing as the "abortion pill" [See Mifepristone, below]. Emergency contraception is usually given as hormone pills within 72 hours of unprotected sex. Some of these pills (such as Plan B) contain only progestin. Other pills (such as Preven) contain a combination of estrogen and progestin. Emergency contraception is also sometimes prescribed as an intrauterine device (IUD), which is inserted within 5 days of unprotected sex.

In 2006, after a long political battle, the FDA approved the Plan B brand as the first over-the-counter emergency contraception. It is available without a prescription at pharmacies and health clinics for women over age 18. Women will need to present proof of age to purchase it. Girls younger than age 18 will still need to get a prescription from their doctors.

Specific Methods
Emergency Oral Contraception. There are two forms of emergency oral contraception:

The Yuzpe method uses two doses of combined oral contraceptives containing estrogen and the progestin levonorgestrel. In the U.S., Preven is the standard brand used for the Yuzpe method. In general, this approach is effective in preventing pregnancies 75% of the time (although some studies report lower success rates).
The other standard approach uses two doses of the progestin levonorgestrel, which includes Plan B. Studies indicate that this method causes less stomach distress and is more effective than the Yuzpe method. In one large study, levonorgestrel prevented pregnancy in 85% of women requiring emergency contraception.
With both methods, the woman takes her first pill or pills within 72 hours of intercourse and a second dose 12 hours later. The earlier they are taken, the more effective they are in preventing pregnancy. Some evidence suggests they may be effective up to 5 days after sex, although effectiveness is greater if used within 72 hours. Although these regimens are popularly called morning-after pills, they are actually the same oral contraceptives that users of OCs take regularly.

Side effects of emergency oral contraception methods include:

Nausea and vomiting are common in both approaches, but particularly with Preven.
Fatigue
Headaches
Dizziness
Diarrhea
Breast tenderness
Fluid retention
Changes in the timing or flow of the woman's next menstrual period. A 2006 study found that emergency contraceptive pills (such as Plan B) that contain levonorgestrel may alter the menstrual cycle and the length of periods.
Immediate side effects typically subside within 1 - 2 days of taking the second dose. Family planning experts warn that emergency pill use should not be treated as a substitute for regular contraception.

Copper-Releasing IUD. An alternative emergency contraception relies on insertion of a copper-releasing IUD within 6 days of intercourse. It can be removed after the woman's next period, or left in place to provide ongoing contraception. The copper IUD reduces the risk of pregnancy by 99.9%.

Mifepristone. Mifepristone is the drug used in Mifeprex (formerly called RU 486). This "abortion pill" blocks progesterone action so that the lining thins and deters implantation of the egg. Unlike emergency oral contraception, the combination of mifepristone and misoprostol can abort an existing pregnancy. A single dose of mifepristone used within 72 hours of unprotected sex can prevent pregnancy.

When used after pregnancy occurs, mifepristone is taken within 49 days of a woman's last period. The woman is given three pills containing mifepristone during her first doctor's visit, and then a second drug (misoprostol) 2 days later. Misoprostol causes uterine contractions that will expel the embryo. A third visit is needed to ensure the abortion is successful. Women who have ectopic or tubal pregnancies cannot take mifepristone. Side effects include pain, and use of the pills may also cause nausea and bleeding.

There have been four reported deaths from infection (sepsis) in women who took mifepristone and misoprostol for medical abortion. In 2005, the manufacturer of Mifeprex revised the drug's prescribing label. The new information advises women to immediately contact their doctors or go to an emergency room if they experience abdominal pain or discomfort, or general malaise (weakness, nausea, vomiting, or diarrhea), with or without fever, more than 24 hours after taking misoprostol.

Natural Family Planning Methods

2008-02-11T17:20:00.001-08:00

Natural family planning contraceptive methods do not use medication, physical devices, or surgery to prevent pregnancy. Instead, these cycle-based fertility awareness methods rely on tracking the changes in the body that signal fertility. A woman is only fertile during part of her menstrual cycle. By monitoring certain changes in her body, a woman can more or less predict the fertile phase and abstain from sexual intercourse during that time. She can also use barrier methods if they are not prohibited by religious beliefs. The Catholic Church, for example, generally approves of most natural family planning methods.

Natural family planning methods include:

Basal body temperature
Cervical mucus
Symptothermal
Lactational amenorrhea
Calendar
Basal Body Temperature Method. To determine the most likely time of ovulation and therefore the time of fertility, a woman is instructed to take her body temperature, called her basal body temperature. This is the body's temperature as it rises and falls in accord with hormonal fluctuations.

Each morning before rising, the woman takes her temperature with a specialized basal body thermometer and marks the result on a graph-paper chart.
She also notes the days of menstruation and sexual activity.
The so-called "fertile window" is 6 days long. It starts 5 days before ovulation and ends the day of ovulation.
The chances for fertility are considered to be highest between days 10 - 17 in the menstrual cycle (with day 1 being the first day of the period and ovulation occurring about 2 weeks later). However, a 2000 study reported that only 30% of women were fertile within that period of time. In the study, women had a 10% chance of ovulating on each day between day 6 and 21. The researchers suggested that each woman track the length of her cycle, which in the general population of women actually runs 19 - 60 days. A long cycle, for example, suggests a delayed ovulation date.
Immediately after ovulation, the body temperature increases sharply in about 80% of cases. (Some women can be ovulating normally yet not show this temperature pattern.)
By studying the temperature patterns over a few months, couples can begin to anticipate ovulation and plan their sexual activity accordingly. To avoid losing spontaneity, couples should try to avoid becoming fixated on the chart in scheduling their sexual activity.

Cervical Mucus Method. The cervical mucus method (also called the ovulation method) requires a woman to take a sample (by hand) of her cervical mucus every day for a least a month and to record its quantity, appearance, feel, and to note other physical signs connected with the reproductive system. Cervical mucus changes in predictable ways over the course of each menstrual cycle:

Six days before ovulation, mucus is affected by estrogen and becomes clear and elastic. Ovulation is likely to occur the last day that mucus has these properties.
Right after ovulation, mucus is affected by progesterone and is thick, sticky, and opaque.
Once a woman's individual pattern is understood, analyzing cervical mucus can provide a highly accurate guide to fertility.

Symptothermal Method. This method uses both the basal body temperature and cervical mucus methods. In addition, the woman tracks symptoms that may identify her fertile period. These symptoms include changes in the shape of the cervix, breast tenderness, and cramping pain.

Prolonged Breastfeeding (The Lactational Amenorrhea Method). Breastfeeding often delays the onset of ovulation and menstruation for about 6 months. A technique called the Lactational Amenorrhea Method (LAM) allows women to rely on breastfeeding for natural family planning. New mothers are candidates for LAM if their periods have not returned after delivery. They must be breastfeeding the baby on demand, day and night, without regularly substituting other liquids or foods in the baby's diet.

The risk for pregnancy with this method is less than 2% in the early months, although by 6 months after birth it increases to over 5%. The return of menstruation indicates the return of fertility. Bleeding or spotting during the first 56 days is not considered menstruation. After that, 2 or more consecutive days of bleeding are usually an indicator that periods have returned. Ovulation can occur before menstruation resumes, although it is less likely within 6 months of delivery (particularly if the mother is intensively breastfeeding).

Calendar Method. The calendar (rhythm method) is considered the least reliable of natural family planning methods, with an effectiveness rate of about 87%. Women who have very irregular periods may have even less success with this method. In the calendar method, the woman first keeps a record of her menstrual periods for about 6 - 12 months. She then subtracts 18 days from the shortest and 11 days from the longest of the previous menstrual cycles. For example, if a woman's shortest cycle was 26 days and her longest cycle was 30 days, she must abstain from intercourse from day 8 through day 19 of each cycle.

Candidacy for Natural Family Planning
Because of the high risk for pregnancy, natural family planning methods are recommended only for those whose strong religious beliefs prohibit standard contraceptive methods. Couples who are not guided by religious authority, but who simply want a more natural sexual life, should use a barrier contraceptive during the fertile phase and no contraception during the rest of the cycle. To be effective against pregnancy, cycle-based methods require not only training, commitment, discipline, and perseverance, but also the cooperation of the male partner. Cycle-based methods are not recommended for women unless they are in a stable, monogamous relationship, and can count on their partner's willing participation.

Advantages of Natural Family Planning
Many couples, especially older ones, who have used these methods for a while and are strongly motivated, are able to successfully incorporate fertility awareness into their lives. For those with strong religious beliefs, natural family planning allows them to have a fulfilling sexual life yet still adhere to the rules of their church.

Disadvantages and Complications of Natural Family Planning
Couples who adopt a cycle-based approach to pregnancy avoidance must often abstain from sex or substitute other kinds of sexual intimacy for vaginal intercourse. Some couples find this self-denial and the need for vigilant tracking of the cycle difficult and stressful for the relationship. Failure rates are high with natural family planning. The risk for sexually transmitted diseases is also of particular concern, because such methods offer no protection against infection and religious beliefs usually preclude barrier protection.

Spermicidal and Barrier Contraception

2008-02-11T17:16:00.000-08:00

Barrier contraceptives are devices that provide a physical barrier between the sperm and the egg. Examples of barrier contraceptives include the male condom, female condom, diaphragm, cervical cap, and sponge. [For a description of the male condom, see Box Male Condom.] Barrier devices are the only contraceptive methods that can help prevent sexually transmitted diseases (STDs).

Spermicides
Spermicides are sperm-killing substances available as foams, creams, or gels, and are often used in female contraception with barrier and other devices. Spermicides are usually available without a prescription or medical examination.

The active ingredient in U.S.-made spermicides is usually nonoxynol-9, which attacks the surface of the sperm cell. Nonoxynol-9, however, does not provide any additional protection against sexually-transmitted diseases. In fact, research indicates that frequent use can cause vaginal irritation and abrasions and actually increase the risk for HIV transmission in women. In addition, use of a spermicide with a barrier device doubles or triples the risk for a urinary tract infection in women, regardless of whether the device is a condom or diaphragm. Spermicides are no longer recommended with male condoms. (Non-spermicidial lubricated condoms are safe to use.) Some experts think they are not necessary for use with diaphragms, but this issue is still under debate.

In general, spermicides may be an appropriate choice for women who have intercourse only once in a while, or need backup protection against pregnancy (for instance, if they forget to take their birth control pills). Spermicides should not be used alone as the primary method of birth control. Nor should they be used to prevent sexually transmitted diseases.

Diaphragm
The diaphragm, which is generally used with a spermicidal cream, foam, or gel, is a small dome-shaped latex cup with a flexible ring that fits over the cervix. The cup acts as a physical barrier against the entry of sperm into the uterus. The spermicide provides added chemical protection but, as stated above, some experts think they are not necessary for use with diaphragms.

The diaphragm is a flexible rubber cup that is filled with spermicide and self-inserted over the cervix prior to intercourse. The device is left in place several hours after intercourse. The diaphragm is a prescribed device fitted by a health care professional and is more expensive than other barrier methods, such as condoms.
There are three basic rim designs:

The Arcing Spring diaphragm applies strong pressure and easily flips into place. It is useful for women with weak vaginal muscles and for new users who are worried about incorrect placement.

The Coil Spring Rim is useful for women with strong vaginal muscles.
The Flat Spring Rim has a delicate rim and a gentle spring, and may be appropriate for women who have not had children.

Diaphragms come in different sizes and require a fitting by a trained health care provider. The health care provider also advises and prescribes the correct size of diaphragm for the user. Some women will need to be refitted with a different-sized diaphragm after pregnancy, abdominal or pelvic surgery, or weight loss or gain of 10 pounds or more. As a general rule, diaphragms should be replaced every 1 - 2 years.

Although the diaphragm has a relatively high failure rate, even with perfect use, it is considered a good choice for women whose health or lifestyle prevents them from using more effective hormonal contraceptives. Certain conditions of the vagina and uterus, a history of toxic shock syndrome, or a history of recurrent urinary tract infections, may disqualify a woman from using the device. The diaphragm should not be used if either partner is allergic to latex or spermicides.

Using and Inserting the Diaphragm. The diaphragm can be placed in the vagina up to 1 hour before intercourse and can be used even when a woman is menstruating. The following are general guidelines for insertion:

Before or after each use, the woman should hold the diaphragm up to the light and fill it with water to check for holes, tears, or leaks.
A small amount of spermicide (about 1 tablespoon) is usually placed inside the cup, and some is smeared around the lip of the cup.

The device is then folded in half and inserted into the vagina by hand or with the assistance of a plastic inserter.

The diaphragm should fit over the cervix, blocking entry to the womb.
If more than 6 hours pass before repeat intercourse occurs, the diaphragm is left in place and extra spermicide is inserted into the vagina using an applicator.
The diaphragm must remain in the vagina for 6 - 8 hours after the final act of intercourse, and can safely stay there up to 24 hours after insertion.

The diaphragm should be washed with soap and warm water after each use and then dried and stored in its original container, which should be kept in a cool dry place.
Advantages of the Diaphragm. The diaphragm can be carried in a purse, can be inserted up to an hour before intercourse begins, and usually cannot be felt by either partner. It may protect against cervical gonorrhea, Chlamydia, and trichomoniasis, although more research is needed to confirm this. It does not provide protection against sexually-transmitted infections in areas other than the cervix.

Disadvantages and Complications of the Diaphragm. Some disadvantages or complications are as follows:

Failure rates are high, about 20% with typical use.
Some women dislike having to insert the device every time intercourse occurs or have trouble mastering the insertion and removal process.

Frequent urinary tract infections are a problem for some women. This difficulty can sometimes be resolved by a refitting, by urinating before inserting the device, or by urinating after intercourse.

Cases of toxic shock syndrome have been reported among diaphragm users, but it is very rare. To be safe, the diaphragm should not stay in place for more than 24 hours. (It is still important for pregnancy protection, however, to retain the diaphragm for 6 - 8 hours after intercourse.)

It provides protection against sexually transmitted disease only in the cervix, and women should not rely on it for protection against HIV.
Cervical Cap
The cervical cap (Prentif, FemCap) is a thimble-shaped latex cup that fits over the cervix. It is always used with a spermicidal cream or gel. It is similar to a diaphragm, but smaller, and is available in only four sizes. The cap is sold by prescription and requires a pelvic examination, Pap test, and fitting by a health care provider.

Insertion and Use of the Cervical Cap. After a small amount of spermicide is placed in the cap, the device is inserted by hand. As in diaphragm use, instruction and practice is required. The cap must be kept in the vagina for 8 hours after the final act of intercourse. Caps wear out and should be replaced every 1 - 2 years. A refitting may also be needed when a woman experiences certain changes in her health or physical status.

Candidacy for the Cervical Cap. Because of the restricted range of available sizes, about 1 in 5 woman will not be able to be fitted for the cap. The cap is not widely used, and some women, particularly those who live in sparsely populated areas, may not have access to health care professionals who are trained in fitting this device. Other conditions that can preclude cap use include:

An abnormal Pap test
A history of toxic shock syndrome
A sexually transmitted or reproductive tract infection
Inflammation of the cervix

The cap has little value for women who have had children, because the stretching of the vagina and cervix makes a proper fit more difficult and failure rates are high.
Advantages of the Cervical Cap. Among women who have never given birth, the cap's failure rate, at least with Prentif cervical cap, is similar to that of the diaphragm. (The FemCap appears to have a higher failure rate.) The cap in general is also similar to the diaphragm in terms of cost, ease of use, protection against STDs, and also the potential for latex or spermicidal allergies. But unlike the diaphragm, the cap can safely remain in the vagina for up to 48 hours (twice the time limit for a diaphragm), so it can be inserted well in advance of intercourse. The cap is rarely associated with urinary tract infections, and no documented cases of toxic shock syndrome have been reported.

Disadvantages of the Cervical Cap. The following are disadvantages of the cervical cap:

Failure rate with any cap is high in women who have given birth (40%). In general, the FemCap has a higher risk for failure than either the diaphragm or the Prentif cap.

Unlike the diaphragm, the cap cannot be used during menstruation.
Use of the cervical cap (particularly the Prentif cap) poses a higher risk for abnormal cervical cell growth than with the diaphragm.
Female Condom

The female condom (Reality, Femidom) is a lubricated, loose-fitting pouch that lines the vagina. It is designed to create a physical barrier against sperm and sexually transmitted diseases by surrounding the penis during intercourse. The failure rate for the female condom is about the same as for the diaphragm and cervical cap. It is available without a prescription but may be hard to find.

Use and Insertion of the Female Condom. The female condom is about 3 inches wide and 6 - 7 inches long (larger than a male condom), with a flexible ring at both ends. Current products are made of polyurethane.

The ring at the closed end is used to insert the device into the vagina and hold it in place over the cervix.

The ring at the open end remains outside the vagina and partly covers the labia (lips).

The insertion process may seem difficult at first but becomes much easier with practice:

The female condom is inserted by hand into the vagina up to 8 hours before intercourse. (It should never be used in combination with a male condom.)
Although the female condom is prelubricated, extra lubricant is sometimes needed while inserting the device or during intercourse. (It is not made of latex, so oil lubricants will not harm it.)

During intercourse, the woman checks to be sure that the outer ring is lying flat against her labia and then guides her partner's penis into the ring.
The female condom should be removed in the following circumstances:

If it tears during insertion or use
If the outer ring is pushed inside
If it bunches up inside the vagina
The female condom may be the best option for women at risk for sexually transmitted diseases and who are not certain that their male partner will use a condom. There are virtually no obstacles against its use except a negative psychological perception. It is not completely fail-proof against pregnancy or sexually transmitted diseases.

Advantages of the Female Condom. In one study, 75% of the women preferred the female to the male condom. Many men also find it more appealing than the latex male condom. The female condom has a number of advantages over the male condom:

The female condom is an effective barrier to viruses, including HIV, and other sexually transmitted organism, particularly since it covers a large area, including external genitals. However, there are few clinical studies at this time to determine its protection against sexually transmitted diseases. No contraceptive device is foolproof.

The standard female condom is made of polyurethane, which is thin and soft but at the same time 40% stronger than the latex male condoms. Polyurethane is not damaged by lubricating oils, as latex is and is also less likely to cause an allergic reaction. It transmits body heat better than latex, providing a more "natural" sensation, and possibly enhancing the pleasure of the sexual act.
The man does not have to withdraw his penis immediately after ejaculation, as is the case with the male condom, but can, if he wishes, withdraw after he has lost his erection.

Disadvantages and Complications of the Female Condom. Compliance rates are low for many reasons. About 25% of women have difficulty on the first attempt at self-insertion. Some women are distressed by self-insertion. The inner ring may be uncomfortable for some women (in which case it can be removed). Some couples complain that the female condom is unpleasant to look at and can be noisy during intercourse. Without sufficient lubrication, it can also be pushed out of place by the penis. Using more lubricant can help keep the female condom in place and reduce the noise. Female condoms are also expensive, and some women wash them out and reuse them to save money. (In such cases, they should be disinfected first and then washed carefully.) Repeated washings can increase the risk for damage and holes. It is not known how many rewashings are safe.

The Sponge
The sponge (Today, Protectaid) is a disposable form of barrier contraception. It is made of soft polyurethane, is round in shape, and fits over the cervix like a diaphragm, but is smaller and easily portable. In 1994, the popular OTC contraceptive was taken off the U.S. market because of problems at the company's manufacturing facility. A new company has since acquired the rights to manufacture the sponge, and has been selling it in Canada and online since 2003. In April 2005, the FDA granted re-approval for the Today sponge to return to the U.S. market.

Use and Insertion. To use the sponge, the woman first wets it with water, then inserts it into the vagina with a finger, using a cord loop attachment. It can be inserted up to 6 hours before intercourse and should be left in place for at least 6 hours following intercourse. The sponge provides protection for up to 12 hours. It should not be left in for more than 30 hours from time of insertion.

The sponge should not be used during menstruation, after childbirth, miscarriage, or termination of pregnancy, or by women with a history of toxic shock syndrome.

Advantages. Because the sponge is not felt during intercourse and can be inserted up to 6 hours before intercourse, it encourages spontaneity. It appears to protect against cervical gonorrhea and Chlamydia.

Disadvantages. Failure rates (about 10%) are higher than with the diaphragm. There is a very small risk for toxic shock using the sponge, as there is for other barrier methods of contraception. The sponge may increase the risk for candidiasis (yeast infection). People who are allergic to spermicides should not use the sponge. The sponge does not protect against HIV or sexually transmitted diseases outside the cervix. The Today sponge contains 10 times the amount of the spermicide nonoxynol-9 than other products, and there is some evidence that this spermicide may increase the risk for HIV. The Protectaid sponge, available in Canada, contains a mix of three spermicides (nonoxynol-9, sodium cholate and benzal konium chloride).

Lea Shield
The Lea shield is made of silicone, and its cup-shaped bowl completely surrounds the cervix without resting on it. The shield does not need to be fitted, and is as effective as the diaphragm and cap when used with spermicide. Its advantages are:

One size fits all
Can be left for 48 hours after intercourse
Reusable for 6 months
The Male Condom
The condom is still the only reversible form of male contraception currently available.

Pregnancy Protection. The condom should be put on before intercourse when the penis is erect, long before ejaculation, since the male can discharge sufficient semen to cause pregnancy before ejaculation occurs. The average rate of pregnancy for couples that rely only on condoms for protection is high -- about 12%. In adolescents the risk of pregnancy with condoms is even higher, 18%. Even for those who use a good-quality condom correctly, the annual risk for pregnancy is 3%.

Prevention of Sexually Transmitted Diseases. Condoms are important in the prevention of sexually transmitted disease in both male and female partners, but they have limitations. They are more protective in men against fluid-transmitted infections (gonorrhea, Chlamydia, trichomoniasis, and HIV) than in preventing infections transmitted by skin-to-skin contact (herpes simplex virus, human papilloma virus, syphilis, and chancroid). Male condoms, in fact, offer better protection against herpes for women than they do for men. (Men often shed the virus from the skin of the penis, which is covered by the condom. In women the virus is often shed from areas around their genitals, which can contact male skin outside the condom.)

Some condoms come pre-lubricated with the spermicide nonoxynol-9, which is no longer recommended with condoms because of a higher risk for HIV infection. Its use in male condoms also promotes yeast and urinary tract infections in women. Other condoms come pre-lubricated without spermicide. Lubricants can also be purchased and applied separately. Only water-based lubricants (K-Y Jelly, Astroglide, AquaLube, glycerin) should be used with latex condoms. Do not use petroleum jelly or other oil-based lubricant products as these can damage the condom. In general, it's best to use a pre-lubricated condom or to apply a water-based lubricant. Unlubricated condoms may injure vaginal tissue and make it vulnerable to infections.

Condom Materials.

Latex. Condoms made of latex rubber are the most common types. They are less likely to slip or break than those made of polyurethane, and they are contoured for a better fit that can provide fairly effective protection. Some people are allergic to latex, however, and in some cases the reaction can be very dangerous. The latex smell may also be unpleasant for some people.

Polyurethane. Polyurethane condoms (Avanti, eZ-on) are also available. It is hoped that eventually they will prove to be superior to latex in a number of ways, including strength, sensitivity, and durability. At this point, they have good acceptance by couples but have a higher breakage rate (6 - 7.2%) compared to the latex condom (1.1 - 2%). Other synthetic materials are under investigation.
Animal Membranes. Condoms made from animal membrane (such as lambskin) can prevent pregnancy, but they are permeable and do not protect against sexually transmitted infections.

Intrauterine Devices (IUDs)

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The intrauterine device (IUD) is a small plastic T-shaped device that is inserted into the uterus. An IUD's contraceptive action begins as soon as the device is placed in the uterus and stops as soon as it is removed. Precisely how the IUD prevents pregnancy is a mystery. They may kill sperm or preven them from moving, which prevents fertilization from occurring. They may also stop a fertilized egg from implanting in the uterus. IUDs have an effectiveness rate of close to 100%. They are also a reversible form of contraception. Once the device is removed, a woman regains her fertility.

The intrauterine device shown uses copper as the active contraceptive, others use progesterone in a plastic device. IUDs are very effective at preventing pregnancy (less than 2% chance per year for the progesterone IUD, less than 1% chance per year for the copper IUD). IUDs come with increased risk of ectopic pregnancy and perforation of the uterus and do not protect against sexually transmitted disease. IUDs are prescribed and placed by health care providers.
IUD Forms
Two types of IUDs are available in the United States:

Copper-Releasing (ParaGard) can remain in the uterus for up to 10 years.
Progestin-Releasing (Mirena) can remain in the uterus for up to 5 years. Mirena is also known as a levonorgestrel-releasing intrauterine system, or LNG-IUS. The LNG-IUS is long-acting, safe, very effective in preventing heavy bleeding, and helps reduce cramps. In fact, some experts describe it as a nearly ideal contraceptive. It is also proving beneficial for women with menstrual disorders, (particularly heavy bleeding).

Inserting the IUD
With some exceptions, an IUD can be inserted at any time, except during pregnancy. It is typically inserted in the following manner by a trained health professional:

A plastic tube containing the IUD (the inserter) is slid through the cervical canal into the uterus.

A plunger in the tube pushes the IUD into the uterus.
Attached to the base of the IUD are two thin but strong plastic strings. After the instruments are removed, the health care provider cuts the strings so that about an inch of each dangles outside the cervix within the vagina.
The strings have two purposes:

They enable the user or health care provider to check that the IUD is properly positioned. (Because the IUD has a higher rate of expulsion during menstruation, the woman should also check for the strings after each period, especially if she has heavy cramps.)

They are used for pulling the IUD out of the uterus when removal is warranted.
Candidacy for the IUD

The IUD is often an excellent choice for women who do not anticipate future pregnancies, but who do not wish to be sterilized. Women who are unable to use hormonal contraceptives (for example, those with heart disease, epilepsy, migraines, hypertension, or liver disease) may be good candidates for the copper IUD.

Women with risk factors that preclude hormonal contraceptives should probably avoid progestin-releasing IUDs, although the progestin doses are much lower with LNG-IUS and probably do not pose the same risks. Other women who may be poor candidates for the IUD are those with the following history or conditions:

Current or recent history of pelvic infection
Risk factors for sexually transmitted diseases (such as having multiple sexual partners)

History of menstrual disorders. (Progestin-releasing IUDs may be an option for women with heavy or painful bleeding. They should avoid the copper-releasing IUDs, however.)
Current pregnancy
Abnormal Pap tests
Cervical or uterine cancer
A very large or very small uterus
Advantages of the Intrauterine Device

The IUD is one of the safest, least expensive, and most effective contraceptive devices available. In spite of its clear advantages and current safety record, only 1% of American women currently use the IUD. (Over 10% of European women have chosen the IUD.) This low use in America is mainly due to persisting and now unwarranted fears of serious infection. [See Infection below. ]

IUDs have the following advantages:

The IUD is more effective than OCs at preventing pregnancy and it is reversible. Once it is removed, fertility returns. (In spite of outdated concerns, studies have found no adverse effects on fertility with the current IUDs.)
Unlike the pill, there is no daily routine to follow.

Unlike the barrier methods (spermicides, diaphragm, cervical cap, and the male or female condom), there is no insertion procedure to cope with before or during sex.
Intercourse can resume at any time, and as long as the IUD is properly positioned, neither the user nor her partner typically feels the IUD or its strings during sexual activity.

It is the least expensive form of contraception over the long term.
There are also additional advantages, depending on the specific IUD:

The progestin-releasing LNG-IUS (Mirena) is now considered to be one of the best options for treating menorrhagia (heavy menstrual bleeding). (However, irregular breakthrough bleeding can occur during the first 6 months.) Some studies suggest it might help avoid hysterectomy in 80% of cases. It may even be appropriate and protective for women with uterine fibroids.

The copper-releasing IUDs do not have hormonal side effects and may help protect against endometrial (uterine) cancer.

Disadvantages and Complications of Specific Intrauterine Devices
The insertion procedure can be painful and sometimes causes cramps, but for many women it is painless or only slightly uncomfortable. Patients are often advised to take an over-the-counter painkiller ahead of time. They can also ask for a local anesthetic to be applied to the cervix if they are sensitive to pain in that area. Occasionally a woman will feel dizzy or light-headed during insertion. Some women may have cramps and backaches for 1 - 2 days after insertion, and others may suffer cramps and backaches for weeks or months. Over-the-counter painkillers can usually moderate this discomfort.

Menstrual Bleeding. Both IUD forms have effects on menstruation, although they differ significantly by type:

Copper releasing IUDs can cause cramps, longer and heavier menstrual periods, and spotting between periods. Prescription medications are available to control the bleeding and pain, which, in any event, usually subside after a few months.
Progestin-releasing IUDs produce irregular bleeding and spotting during the first few months. Bleeding may disappear altogether. (This characteristic is a major advantage for women who suffer from heavy menstrual bleeding but may be perceived as a problem for others.)

Menstrual difficulties can be so troublesome with either IUD that, according to one study, they were responsible for a removal rate of 5 - 15% within a year of insertion.

Infection. The current versions of IUD pose a slightly higher risk for pelvic inflammatory disease in the first month following insertion. The risk of PID in women without any symptoms of sexually transmitted infections, however, is the same in both IUD users and nonusers. An early IUD, the Dalkon Shield, which had a braided tail, was banned after reports of several deaths and a very high rate of infection. The newer types of IUDs are much safer and do not pose as high risk for infection. Still, some doctors may prescribe antibiotics as a precaution before insertion.

Ovarian Cysts. The LNG-IUS may increase the risk for ovarian cysts, but such cysts usually do not cause symptoms and resolve on their own.

Expulsion. An estimated 2 - 8% of IUDs are expelled from the uterus within the first year. Expulsion is most likely to occur during the first 3 months after insertion. Expulsion rates may be higher than average if the IUD is inserted immediately after delivery of a child. In 1 in 5 cases, the woman fails to notice that the device is gone, and thus faces the risk of unintended pregnancy. The risk for expulsion is highest during menstruation, so women should be sure to check the strings to make sure the IUD is in place.

Effects on Pregnancy. None of the current IUDs increase the risk for infertility. In the very unlikely event that a woman conceives with an IUD in place, however, there is a higher risk of an ectopic pregnancy or miscarriage.

If the IUD is removed right after conception, the risk for miscarriage is close to average (about 20%). There is no evidence that the IUD in a pregnant woman increases the risk for birth defects in the infant.

Perforation. A potentially serious complication of the IUD is the accidental perforation of the uterus during insertion or later perforation if the IUD shifts position. Such an occurrence is very rare, and the risk is higher or lower depending on the skill of the doctor.

Injected Contraception

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Injected contraceptives are given once every 3 months. Most injectables are progestin-only. In the United States, depo-medroxyprogesterone acetate (Depo-Provera) is the only approved injected contraceptive. Depo-Provera (also called Depo or DMPA) uses a progestin called medroxyprogesterone. Like other progestin contraceptives, Depo-Provera prevents pregnancy by halting ovulation, thickening the cervical mucus, and stopping the implantation of fertilized eggs in the uterine lining.

Depo-Provera is very effective in preventing pregnancies. About 3 in 100 women who use it become pregnant. However, Depo also carries the risk for many mild and serious side effects. The most serious side effect is loss of bone density (see Disadvantages ). Because of this complication, Depo-Provera should not be used for more than 2 years.

Administering Injections:

A physical examination is necessary before beginning the injections.
Depo is injected into a muscle in the patient's arm or buttock. During months between injections, the hormone slowly diffuses out of the muscle into the bloodstream.
Depo requires an injection by the doctor once every 3 months.
If more than 2 weeks pass beyond the regular injection schedules, the woman should have a pregnancy test before receiving the next injection.
Candidacy
Because Depo-Provera does not contain estrogen, it is safe for many women who are not candidates for combination OCs, such as women smokers over age 35.

Depo-Provera should not be given to women who have a history of:

Current or past breast cancer
Stroke or blood clots
Liver disease
Epilepsy, migraine, asthma, heart failure, or kidney disease (due to the fact that the drug causes fluid retention)
Unexplained vaginal bleeding
Risk for osteoporosis
Because of the long lag time between ending treatments and restoration of fertility, Depo-Provera is not recommended for women who are thinking of becoming pregnant within 2 years.

Advantages of Depo-Provera
Provides highly effective reversible protection against pregnancy without placing heavy demands on the user's time or memory
Does not increase risk for breast, ovarian, or cervical cancer. May protect against endometrial cancer.

May be useful for women with painful periods, heavy bleeding (including heavy bleeding caused by fibroids), premenstrual syndrome, and endometriosis
Disadvantages and Complications of Depo-Provera
Weight gain. Most women gain an average of 5 - 8 pounds.

Other common side effects include menstrual irregularities (bleeding or cessation of periods), abdominal pain and discomfort, dizziness, headache, fatigue, nervousness.
Most users of Depo-Provera stop menstruating altogether after a year. Depo can cause persistent infertility for up to 22 months after the last injection, although the average is 10 months.

Long-term (more than 2 years) use of Depo-Provera can cause loss of bone density. In November 2004, the FDA added a “black box” warning to the Depo-Provera label advising of this risk. The warning notes that the decline in bone density increases with duration of use and may not be completely reversible even after the drug is discontinued. Based on this information, the FDA recommends that Depo-Provera should not be used for longer than 2 years unless other birth control methods are inadequate. A 2005 study of young women (age 14 - 18 years) found that adolescents who stop taking Depo-Provera do regain bone density.

The injections do not provide protection against sexually transmitted diseases. According to a 2004 study, women who take Depo-Provera have three times the risk of acquiring chlamydia and gonorrhea as women who do not use a hormonal contraceptive. The reason for this increased risk is unclear. The same study found that oral contraceptive use, in comparison to non-hormonal contraceptives, was not associated with increased risk.

Implant Contraception

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Implant contraception involves inserting a rod under the skin. The rod releases into the bloodstream tiny amounts of the hormone progestin.

The first implant was the Norplant system, which used six rods that contained levonorgestrel. Due in part to serious complications, Norplant was withdrawn from the U.S. market in 2002. The main complication was difficulty inserting and, in particular, removing the rods. (Many women experienced scarring.) In addition, some women who used Norplant experienced heavy irregular bleeding. A two-rod implant called Jadelle is sold in other countries, but not the United States.

In 2006, the FDA approved Implanon, a new implant contraceptive. In contrast to Norplant:

Implanon uses one rod, not six.
It is not inserted as deeply into the skin.
It uses etonogestrel, a different type of progestin than the levonorgestrel used in Norplant.
Only specially trained health care providers are allowed to insert and remove Implanon.
Implanon insertion takes about a minute and is performed with a local anesthetic in a doctor’s office. The rod remains in place for 3 years, although it can be removed at any time. (The removal procedure takes a few minutes longer than insertion.) After the rod is removed, a new one can be inserted.

Studies indicate that Implanon is safe. Irregular bleeding is the main side effect. However, some doctors are concerned that Implanon may have some of the same risks as Norplant.

Oral Contraception

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Oral contraceptives (OCs) are available only by prescription and come in either a combination of estrogen and progestin or progestin alone. Many brands of each form are available. Although both are equally effective with typical use, the combined pill is more effective with perfect use, and most women choose this form.

Some women, however, experience severe headaches or high blood pressure from the estrogen in the combined pill and must take the progestin-only pill. Not all combined pills or progestin-only pills are alike, and brands differ in the amount of estrogen or progestin they contain. Many OC combined brands now use lower estrogen doses than previous brands and are proving to be safe and effective while providing a better quality of life than earlier OCs.

For all OC users, a check-up at least once a year is essential. It is also important for women to have their blood pressure checked 3 months after beginning the pill. Former pill users who want to bear children usually regain fertility in 3 - 6 months, but they may regain it even sooner.

Hormones Used in Contraceptives
Estrogen (Estradiol)

Estrogen is the major female hormone and is responsible for female characteristics. The estrogen compound used in most oral contraceptives is estradiol and is always used with a progestin.

Effects on Reproduction. When used throughout a menstrual cycle with progesterone, it suppresses the actions of other reproductive hormones (luteinizing hormone, or LH, and follicle stimulating hormone, or FSH) and prevents ovulation. Estrogen also changes the cellular structure of the lining of the uterus (the endometrium) and hinders implantation of a fertilized egg.

Side Effects of Estrogen. During the first 2 - 3 months of use of oral contraceptives, side effects from estrogen in the combined pill include:

Nausea and vomiting (can often be controlled by taking the pill during a meal or at bedtime)
Headaches (in women with a history of migraines, they may worsen)
Dizziness
Breast tenderness and enlargement
Progesterone (Progestin)

When used in contraception, progesterone is referred to by one of several names:

Progesterone is the name for the natural hormone
Progestogen is a synthetic form
Progestin is the term for any hormone, natural or synthetic, that causes progesterone effects; it is used as the general term in this report
Progestins may be used alone or with estrogen in oral contraceptives. In addition, certain specific progestins are used in other kinds of contraceptives, such as etonogestrel in the Implanon implant and depo-medroxyprogesterone acetate in the injected Depo-Provera.

Progesterone can prevent pregnancy by itself in several ways:

It blocks luteinizing hormone (LH), one of the reproductive hormones important in ovulation.

It maintains a powerful barrier against the entry of sperm into the uterus by keeping the cervical mucus thick and sticky.
It reduces the mobility of the fallopian tubes, thereby inhibiting sperm transport.
It changes the lining of the uterus and makes it more difficult for the fertilized egg to implant.
Progestins used in contraceptives are referred to as:

Second generation (levonorgestrel, norethisterone).
Third generation (desogestrel, gestodene, norgestimate, drospirenone). The third-generation progestins tend to have fewer male-like side effects. Some studies suggest, however, they may pose a higher risk for blood clots than the older progestins, although the risk is still small.

Side Effects of Progestins. Side effects of progestin occur in both the combination oral contraceptives and any contraceptive that only uses progestin, although they may be less or more severe depending on the form and dosage of the contraceptive. Side effects may include:

Changes in uterine bleeding such as higher amounts during periods, spotting and bleeding between periods (called break-through bleeding), or absence of periods
Unexpected flow of breast milk (check with your doctor if this occurs to be sure other abnormalities are not causing it)
Abdominal pain or cramps
Diarrhea
Fatigue, unusual tiredness, weakness
Hot flashes
Decreased sex drive
Nausea
Trouble sleeping
Acne or skin rash (not all OCs have this side effect; low-dose OCs actually improve acne)

Depression, irritability, or other mood changes (although some OCs are helpful for women with premenstrual dysphoric syndrome)
Swelling in the face, ankles, or feet

Weight gain (however, combination oral contraceptives -- which contain progestins -- do not cause weight gain)

Newer formulations of combination pills that use low-dose estrogen, and newer progestins may reduce and even avoid many of these side effects, including weight gain. Low-dose progestins used in non-oral contraceptives, such as the LNG-IUS IUD, also may not pose as high a risk for these side effects. If side effects persist or are severe, a woman should always talk to her doctor. Many women do not experience these side effects, or for many of those who do, their bodies eventually adjust.

Combination Estrogen-Progestin Contraceptive Pills
Oral contraceptives that contain both estrogen and progestin are the more common type of OC. At least 10 million American women and 100 million women worldwide use combination OCs. When they were first marketed in the early 1960s, OCs contained as much as 5 times the amount of estrogen and up to 10 times the amount of progestins currently used. After reports of severe complications (stroke, heart attack, and pulmonary embolisms) in young women, the hormone amounts were significantly reduced.

The estrogen compound used in most oral contraceptives is ethinyl estradiol (also called estradiol or EE). Fifty micrograms of estradiol is considered to be high dose, 30 - 35 micrograms are considered average dose, and 20 micrograms or less is low-dose. (The high doses found in current OCs are still much lower than earlier forms of the pill.) Experts recommend using the lowest possible progestin and estrogen doses. Estrogen doses should not exceed 50 micrograms as higher doses increase the risk for complications.

Many different types of progestins are used in combination with estradiol. Some common types of progestin, and popular combination oral contraceptive brands, include:

Desogestrel is the progestrin used in Mircette. Approved in 1998, Mircette was the first oral contraceptive to offer a low estrogen dose and a new type of dosing regimen.

Drospirenone is used in Yasmin and Yaz. (Yaz contains a lower dose of estrogen than Yasmin.) Because drospirenone increases blood levels of potassium, women should not use Yasmin or Yaz if they have kidney, liver, or adrenal diseases.
Levonorgestrel is used in Seasonale and Seasonique, as well as many other oral and non-oral contraceptives.

Norethindrone is used in Loestrin and Loestrin 24 Fe (which adds iron supplements to the placebo pills).

Norgestrel is used in various generic and brand contraceptives.
Many types of medications and supplements (Tylenol, anti-seizure drugs, antibiotics, vitamin C, St. John’s wort) can interact with progestin and reduce its effectiveness. Make sure your doctor is aware of any drugs, vitamins, and herbal supplements that you take.

Types of Regimens. Combination pills are sold in 21-day or 28-day packs:

Each pill in a 21-day pack contains estrogen and progestin. Women take 1 pill a day for 21 days, and then wait 7 days before starting a new 21-day pack.
28-day packs typically start with 21 hormone pills and add 7 placebo pills that do not contain hormones. After taking hormone pills for 21 days, a woman takes the inactive pills for 7 days. Some newer brands, like Yaz, use 24 days of active pills and 4 days of inactive pills. Mircette uses 21 days of low-dose progestin and estrogen, followed by 2 placebo days, and then 5 days of very low-dose estrogen. Loestrin 24 Fe uses 24 days of active pills followed by 4 days of iron-containing placebo pills.

OCs may be taken in cycles that include pills of the same or different strengths. These are categorized as monophasic (one-phase), biphasic (two-phase), or triphasic (three-phase). Monophasic pills contain the same amount of hormones in each dose. Biphasic and triphasic pills contain different dosages of hormones within the pill packs. Because monophasic pills have a consistent amount of hormones, they tend to cause fewer hormone-fluctuating side effects than biphasic or triphasic pills. Several 2006 reviews found little difference in effectiveness between these three types of oral contraceptives. Many experts recommend monophasic pills as the best first-choice for birth control pills.

Continuous-Dosing Oral Contraceptives. With standard birth control pills, a woman gets her period a few days after completing the active pills in her pack. Continuous dosing, (also called extended use), oral contraceptives aim to reduce -- or even eliminate -- monthly periods. Seasonale, the first continuous use oral contraceptive, was approved in 2003. It contains 84 days of active pills followed by 7 days of inactive pills. Seasonale produces a period about once every 3 months.

In 2006, the FDA approved Seasonique, a follow-up to Seasonale. Seasonique is also a 91-day pill cycle, but it includes 84 days of pills that contain levonorgestrel and estradiol, and 7 days of pills that contain only low-dose estradiol. As with Seasonale, women who take Seasonique have about 4 periods a year. The FDA is also reviewing Lybrel, which supplies a low-dose of hormones for 365 days a year. In clinical trials of Lybrel, some women stopped having periods altogether.

Taking the Pills. A woman usually takes the first pill either on the Sunday after her period starts or during the first 24 hours of her period. (The first pill can be started at any time during the menstrual cycle without affecting the bleeding patterns. Ovulation can occur that month, however.) The remaining pills are taken once a day, ideally at the same time of day, until the pack is used up. If a woman has a 21-day pack, she waits 7 days before starting a new pack. If she is on the 28-day pack, she takes the 7 inactive pills.

If you skip one or more pills, take the following precautions:

Missing the first pill in a new cycle. Take a tablet as soon as you remember and the next one at the usual time. Two tablets can be taken in one day. Use barrier contraception for 7 days after the missed dose. [See Spermicidal and Barrier Contraception.]

Missing a pill 2 days in a row. Take 2 pills as soon as you remember and then 2 more the following day. Also use back-up barrier contraception until the next pill cycle.
Missing more than 2 days. Discard the pack, use a back-up birth control method and begin a new cycle on the following Sunday, even if you have started bleeding. One study found that women who miss 3 pills will probably still not ovulate, but nevertheless, they should take all necessary precautions to prevent pregnancy.
Progestin-Only Oral Contraceptives ("Mini-Pills")
Progestin-only pill brands include:

Levonorgestrel (Plan B)
Norethindrone (Micronor, Avgestin, Norlutin, Nor-QD). (This progestin is made from male hormones, so may cause more male side effects than others.)
Norgestrel (Ovrette)

Progestin-only pills, which only contain progestins, are always sold in 28-day packs and all the pills are active. (An exception is Plan B, which is emergency contraception.) Progestin-only pills must be taken at precisely the same time each day to maintain top effectiveness. If a woman deviates from her pill schedule by even 3 hours, she should call her doctor about using back-up contraception for the next 2 days. Progestin-only pill users will experience even lighter periods than those taking combination pills. Some may not have periods at all. These hormones should not be used by premenopausal women in their 40s, since they pose a higher risk for adverse effects in this group.

Advantages of Oral Contraceptives
Oral contraceptives are the choice of most American women who use birth control, making them the most popular reversible contraceptives in the U.S. OCs are among the most effective contraceptives. Failure rates are very low and are usually due to noncompliance. Some studies have suggested that women who are overweight may have a higher risk for failure. The risk for these women is also still very low, however.

OCs also have the following advantages:

More sexual freedom. OCs do not interfere with intercourse, and in fact, many women report that sex is more pleasurable because they no longer have to worry about pregnancy.

Reduce menorrhagia (heavy bleeding) and, therefore, reduce the risk for anemia.
Reduction in dysmenorrhea (severe pain). High-dose OCs have been especially helpful, but they carry risks. Specific newer low-dose OCs that contain certain progestins, such as Yasmin (with drospirenone) and Mircette (with desogestrel), may reduce menstrual pain.

Possible reduction in premenstrual syndrome with specific OCs, notably Yaz (which was approved for treating premenstrual dysphoric disorder -- premenstrual depression -- in 2006.) Some OCs, however, are associated with worse emotional changes. Monophasic OCs may have a more beneficial effect on mood than triphasic OCs.

Reduction in endometriosis.
Endometriosis is the condition in which the tissue that normally lines the uterus (endometrium) grows on other areas of the body causing pain and irregular bleeding.
Reduction of ovarian cancer. OCs may reduce the risk of ovarian cancer by 30 - 50% (even in women with genetic risk factors). Progestin appears to be the protective factor by suppressing ovulation. Protection occurs after 5 years of use and persists for 10 - 20 years after stopping. Some experts believe that women at particular risk for ovarian cancer might consider oral contraceptives with the highest progestin dose.

Reduction of endometrial (uterine) cancer. According to some studies, older OCs reduced the risk for endometrial cancer by half. More studies are needed on newer formulations, which have lower doses of estrogen, but it is generally believed that they, too, are protective.

Possible protection against colon cancer. Duration of use does not seem to be associated with decreased risk, but protection appears stronger for women who have used oral contraceptives more recently.

Possible protection against multiple sclerosis. Some studies have suggested that women who take oral contraceptives may be less likely to develop multiple sclerosis
Acne improvement with low-dose OCs. (Some low-dose OCs, such as Ortho Tri-Cyclen, have been specifically approved for acne reduction, although most low-dose OCs reduce testosterone levels and so help reduce acne.)
Possible protection against bone loss with low-dose OCs. The effect of OCs on bone density is unclear and may depend on the specific formulas and types of progestins used.

Disadvantages and Complications of Oral Contraceptives
Common Side Effects. Estrogen and progesterone have different side effects. Women on the combined pill may experience different effects from those on the progestin-only pill. Symptoms of serious problems include severe abdominal pain, chest pain, unusual headaches, visual disturbances, or severe pain or swelling in the legs. In spite of some concerns, combination OCs do not generally cause weight gain.

[For specific side effects of estrogen and progestin, See Box Hormones Used in Contraception.]

Serious Effects on Heart and Circulation. Combination birth control pills contain estrogen, which can increase the risk for stroke, heart attack, and blood clots in some women. The risk is highest for women who smoke or have a history of heart disease risk factors (such as high blood pressure) or cardiac events. Women who have certain metabolic disorders, such as polycystic ovary syndrome (PCOS), are also at higher risk for heart-related complications associated with these pills.

When birth control pills were first introduced, heart and circulatory risks were higher than they are now. Current brands of combination oral contraceptives contain much lower dosages of estrogen and are safer than those earlier pills. However, a 2005 review suggested that even low-dose combination birth control pills have some cardiovascular risks. Women should discuss their lifestyle and health history with their doctors to decide if birth control pills are a safe option. For women with heart disease risk factors, progestin-only (“mini-pill”) oral contraceptives may be safer than combination estrogen-progestin oral contraceptives.

Breast Cancer. Studies have been conflicting about whether estrogen in oral contraception increases the chances for breast cancer, and if it does, which women are at risk. Some research supported a higher risk in women with a family history of breast cancer and who also used OCs before 1975, which contained high-dose estrogens and progestins. A reassuring 2002 study supported an earlier major study, with both finding no evidence that current OC use increases the risk for breast cancer. It also reported no higher risk in women who had taken OCs for 15 years of more or had taken them at young ages. Some issues remain unresolved. For example, the risk for women currently taking OCs around menopause (ages 45 - 64) is still unclear. OCs users with a family history of breast cancer or who carry the BRCA1 genetic mutation (although possibly not those with the BRCA2) may be at higher risk. Such women are at higher risk for breast cancer in any case.

Cervical Cancer. Numerous studies report a strong association between cervical cancer and long-term use of oral contraception (OC). The risk is highest (up to four times the risk of nonusers) in women infected with human papillomavirus (HPV) who have taken OCs for 10 years or more. (Women who are not infected with HPV have no significantly higher risk.) The reasons for this risk from OC use are not entirely clear. Some experts have suggested that the hormones in OCs might facilitate entry of the HPV virus into the genetic material of cervical cells. Certainly, women who use OCs are less likely to use a diaphragm, condoms, or other methods that offer some protection against sexually transmitted diseases, including HPV.

Other Complications. Other complications have been associated with the use of oral contraceptives:

Taking oral contraceptives containing certain progestins (desogestrel in one study) may increase the risk for periodontal disease. Other types of progestins do not pose a risk for gum disease.
There has been some debate over whether the progestin-only pill increases the risk for permanent type 2 diabetes in women who develop a temporary form of diabetes during pregnancy (called gestational diabetes). In any case, the low-dose combination pill does not appear to pose such a risk. Women with a history of gestational diabetes should discuss this controversy with their doctor.
Some evidence suggests that oral contraceptives may reduce lung capacity during exercise. In fact, there have been a few reports of worsening of asthma with OCs, but this is an uncommon effect.
The pill can affect the liver and, in rare cases, has been associated with liver tumors, gallstones, or jaundice. Women with a history of liver disease, such as hepatitis, should consider other contraceptive options.
Interactions with Other Medications. Oral contraceptives can interact with many other medications and herbal supplements.

Other Methods for Administering Combination Hormones
New methods of administering the combination of progestin and estrogen are now available. Failure rates with perfect use (0.1 - 0.6%) are similar to those with combined oral contraceptives. The recommendations and side effects are the same as those for OCs. None of these methods protect against sexually transmitted diseases.

Skin Patches. Ortho Evra was approved in 2002 as the first birth control skin patch. It contains a progestin (norelgestromin) and estrogen. The patch is placed on the lower abdomen, buttocks, or upper body (but not on the breasts). Each patch is worn continuously for a week and reapplied on the same day of each week. After three weekly patches, the fourth week is patch-free, which allows menstruation. (The patch remains effective for 9 days, so being slightly late in changing it should not increase the risk for pregnancy.) In 2005, the FDA warned that the Ortho patch exposes women to higher levels of estrogen than most birth control pills, and therefore may increase the risk for blood clots and other serious side effects. Discuss with your doctor whether the patch is appropriate for you.

Vaginal Ring. A 2-inch flexible ring (NuvaRing) is available that contains both estrogen and progestin and is inserted into the vagina. Women can insert the ring by themselves once a month and take it out at the end of the third week to allow menstruation. It appears to be very effective, causing less irregular bleeding than OCs. Some women find it uncomfortable, and a few have reported vaginal irritation and discharge, but such problems rarely cause a woman to discontinue use.

Birth Control Options For Women In-Depth

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Contraceptives are devices or methods for preventing pregnancy, either by preventing the fertilization of the female egg by the male sperm or by preventing implantation of the fertilized egg. Contraceptives are not modern inventions. The first prescription for a contraceptive device described a tampon barrier device and was written on papyrus in 1550 BC.

Contraceptive Options
Choosing the appropriate contraceptive varies from individual to individual. Contraceptive options include:

Hormonal contraceptives (oral contraceptives, skin patch, vaginal ring, implant, injection)
Intrauterine devices (IUDs), which contain either a hormone or copper
Barrier devices with or without spermicides (diaphragm, cervical cap, sponge, condom)
Natural family planning methods (basal body temperature, cervical mucus, symptothermal)
Female sterilization (tubal ligation, Essure)
The pill works in several ways to prevent pregnancy. The pill suppresses ovulation so that an egg is not released from the ovaries, and changes the cervical mucus, causing it to become thicker and making it more difficult for sperm to swim into the womb. The pill also does not allow the lining of the womb to develop enough to receive and nurture a fertilized egg. This method of birth control offers no protection against sexually-transmitted diseases.
Determining Effectiveness
Contraceptive effectiveness is characterized by "typical use" and "perfect use":

Typical use refers to real-life conditions, in which mistakes (such as forgetting to take a birth control pill at the right time) sometimes happen
Perfect use refers to contraceptives that are used correctly each time intercourse occurs

Research has shown that the four most effective standard female contraceptives are surgical sterilization, the IUD, implants, and injections. They all have an estimated failure rate of less than 1% during the first year of normal (typical) use. Vasectomy (male surgical sterilization) is the only male contraceptive that is equally effective. By comparison, the estimated failure rate of the male latex condom used without spermicide is 14% with typical use and 3% with perfect use. To put these rates into perspective, a sexually active woman of reproductive age who does not use contraception faces an 85% likelihood of becoming pregnant in the course of a year.

Access to Contraceptives
Birth control is a controversial subject. In recent years, there has been a growing movement in the United States to restrict a woman's access to contraceptives. In addition to the political battles over non-prescription access to emergency contraception (Plan B), 18 states (as of 2006) are considering legislation that would allow pharmacists to refuse to dispense medications due to moral or religious objections. There have been hundreds of reports of pharmacists refusing to fill birth control prescriptions. In response to this trend, several members of Congress introduced in April 2005 the Access to Legal Pharmaceuticals Act, which would override any state legislation. The bill would require that pharmacies fill birth control prescriptions and would protect women’s legal right to purchase such products.

More Methods of Birth Control

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We continue our treatment of birth-control methods with the intrauterine device (IUD) and others.

Intrauterine Device (IUD)

The intrauterine device (IUD) is a small plastic device inserted into the woman's uterus by a physician. The IUD has a string attached to it that hangs into the cervix, so that the woman can check to be sure that the IUD is still in place. Most researchers believe that the IUD prevents pregnancy by causing changes in the uterine lining that disrupt the normal environment of an egg. For the woman who can use an IUD, the advantages are great, because she does not have to worry about contraception each day. The effectiveness rate is high, with less than a 1 percent chance of pregnancy.

However, there are several disadvantages to the use of an IUD. Severe menstrual cramps and increased menstrual bleeding may follow the insertion of an IUD. Sometimes these side effects lessen after a month or two. In other cases, severe cramps and prolonged bleeding continue, and the physician may advise removal of the IUD. The IUD is also thought to increase the probability of pelvic infections within the first few months following insertion.

Sterilization

A woman may be sterilized by an operation that blocks the fallopian tubes (the structures through which eggs travel from the ovaries to the uterus). A man may be sterilized by a procedure called a vasectomy, in which each vas deferens (one of the two ducts through which the sperm travel from the testes to the urethra) is cut. These procedures may be reversed but only by complicated surgery, which is not always successful. Therefore, physicians recommend sterilization only when a couple has decided, without reservation, that they desire no further pregnancies.

Oral Contraceptives

Oral contraceptives, or birth control pills, are one of the most effective reversible methods of contraception. A woman taking the pill properly has less than a 1 percent chance of getting pregnant.

The pill -- which is available by prescription only -- uses synthetic female hormones (estrogen and progestin) to override the natural hormonal regulation that results in the release of an egg. The pill signals the pituitary gland, which directs hormonal activity in the body, not to release the hormones that would normally stimulate the ovary to release an egg.

Each day the woman takes one pill, at about the same time of day, removing it from a container that has the required number of pills for one cycle (usually 21). One to three days after she takes the last pill for that cycle, her menstrual period begins. Menstrual periods may be lighter in flow, and cramps may be reduced or absent.

If she forgets to take one pill or more, menstrual bleeding may begin. In that case, she should continue taking the pills daily, but she should also use another contraceptive method, such as a condom, until after her next regular period.

Birth control pills are not recommended for women with a history of high blood pressure, blood-clotting problems, hepatitis, or cancer of the uterus or breast. A woman over age 35 who smokes is advised to stop smoking if she wants to take the pill. Birth control pills should not be taken by a woman who suspects she may be pregnant. In addition, women with diabetes, epilepsy, heart disease, or thyroid disease may be advised not to take birth control pills, depending on the nature and severity of the disease.

It is important for a woman taking birth control pills to report to her doctor if any of the following symptoms occur: blurred vision; severe chest pain; sudden shortness of breath; abdominal pain; unusual bleeding or bruising; breakthrough vaginal bleeding (spotting); changes in menstrual flow; pain in the calves; depression; difficult or painful urination; enlarged or tender breasts; hearing changes; increase or decrease in hair growth; migraine headaches; numbness or tingling; rash; skin color changes; swelling of the feet, ankles, or lower legs; vaginal itching; weight changes; or yellowing of the eyes or skin.

Hormonal Implants

The newest form of contraception is the hormonal implant. With this method, six small plastic rods containing the synthetic female hormone progestin are inserted with a needle under the skin of the upper arm or forearm. The hormone is gradually and slowly released from the plastic rods, thus preventing ovulation. This method is effective for about five years from the time the implants are inserted. The major advantage of this method is that the woman does not need to remember to take birth control pills or use a spermicidal agent or diaphragm before each sexual act. Disadvantages include the high cost of the implants, possible infection at the site of insertion, irregular menstruation, and the necessity for surgical incisions on the arm when the implants need to be removed. Hormonal implants are about as effective as oral contraceptives.

Natural Family Planning

Natural family planning is based on calculating when ovulation (release of an egg from one of the woman's ovaries each month) occurs. The couple then abstains from intercourse during the fertile period.

A man's sperm can live in a woman's body for about two days. The egg can live for about 24 hours after ovulation. A few days are added to this fertile period for safety's sake, because it is so difficult to determine just when ovulation occurs. All told, a couple needs to abstain from intercourse seven to ten days a month in order to have the greatest chance of preventing pregnancy.

There are three methods a woman can use to determine when she ovulates. The temperature method is one of the most reliable. Each morning on awakening and before getting out of bed, she takes her temperature with a special basal temperature thermometer (which measures temperatures only between 96°F and 100°F) and records it on graph paper.

Near the middle of the menstrual cycle, the temperature may drop slightly (indicating that ovulation is about to occur) and then rise rapidly and continue to climb for the next three days. The temperature will not return to preovulation levels until the beginning of the menstrual period. The "safe" days to have sexual intercourse are from four days after the sudden rise in temperature until three or four days after the end of the period. It is important to become familiar with the menstrual cycle by recording the temperature levels for several months before relying on this method of birth control.

The mucus method may also help determine the time of ovulation. Each morning the mucus from the vagina and cervix is examined. Cervical mucus undergoes changes as hormone levels vary during the course of the cycle. To detect these changes, the vaginal area is blotted each morning with a facial tissue, and then the mucus is tested between the thumb and forefinger. After the menstrual period, there will be several days with no mucous discharge. This is followed by several days of a thick, sticky yellow or white discharge. There will then be one or two days when the mucus becomes transparent and very slippery, with the consistency of raw egg whites. The mucus will form a string between the thumb and forefinger. This is when ovulation occurs. After ovulation, the mucus again becomes thick and sticky, or there may be no mucus at all.

The fertile period begins with the thick, sticky yellow or white discharge and continues until about three days after the phase when the mucus has the consistency of egg whites. Intercourse should be avoided during this time. In other words, the safe period is from three days after the slippery mucus stage to about three days after the end of the menstrual period. The use of certain medications (such as antihistamines), which alter mucus production throughout the body, will make determination of ovulation by the mucus method difficult, however.

The calendar method is also an option for women. A record of menstrual cycles is kept for one year or more. The doctor will then use the record to figure out the most likely day of ovulation, based on the fact that the average woman menstruates 14 days after she ovulates. However, any individual woman may vary from that average, so the calendar method is not a precise system.

Natural family planning does not require the use of mechanical aids or drugs. The effectiveness rate for this kind of birth control is currently up to about 80 percent, depending on the care with which the techniques are followed. However, even in women with regular cycles, fluctuating factors such as illness, fatigue, stress, and use of certain drugs can delay ovulation or cause the techniques used to determine ovulation to be inaccurate, thereby throwing off the most careful calculations.

We have now covered the many common methods of brith control. You should consult your doctor for more specifics relating to your own case.

Understanding Birth Control

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Birth control, also called contraception, is the voluntary prevention of pregnancy. A variety of methods are available. Couples who use no contraceptive method have an 80 to 90 percent chance of achieving pregnancy over a 12-month period, provided that they have no underlying infertility problem.

In this article, we will cover all the major forms of birth control.

Condom

A condom is a thin rubber or synthetic sheath that a man fits over his erect penis just before sexual intercourse. A condom used alone is about 70 percent to 90 percent effective, depending on the care with which it is used.

Several problems can occur with the use of the condom, however. Tiny holes or tears may develop in the sheath, causing leakage of sperm. Also, when the penis is withdrawn from the vagina after intercourse, the condom sometimes breaks or partially unrolls inside the vagina, releasing sperm.

However, a latex condom used regularly with a spermicide is approximately 95 percent effective in preventing pregnancy. Condoms have the great advantage of being readily available in any drugstore without a prescription. Latex condoms also have the advantage of helping to prevent the spread of many types of sexually transmitted diseases, including acquired immunodeficiency syndrome (AIDS).

Diaphragm

The diaphragm is a molded rubber cap that the woman places inside the vagina to cover the cervix. The diaphragm blocks sperm from entering the uterus. It must be inserted before intercourse and left in place for six hours afterward. Diaphragms are available in different sizes and must be fitted by a physician. When used with spermicides, diaphragms are very effective, with only about a 3 percent chance of pregnancy.

Cervical Cap

The cervical cap is a molded rubber cap that fits over the outside of the cervix. While the diaphragm covers both the cervix and the back of the vagina, the smaller cervical cap fits only over the cervix. Like a diaphragm, the cervical cap blocks sperm from entering the uterus. It must be inserted for each act of intercourse and left in place for six to eight hours afterward. Cervical caps come in different sizes and must be fitted by a physician. Their effectiveness is similar to that of the diaphragm. The cervical cap contains spermicide.

Spermacide

Spermicide is a chemical foam, cream, suppository, or jelly applied to the woman's vagina to kill sperm. A spermicide should be used in conjunction with a condom or diaphragm; used alone, a spermicide is only 75 to 85 percent effective. Some disadvantages of a spermicide are that it must be applied before each individual act of sexual intercourse, it has chemical odors, and it may cause irritation of the vagina. A chief advantage is that spermicides are readily available at drugstores without a prescription.

Contraceptive Sponge

The contraceptive sponge is a disposable, spongelike device saturated with spermicide. The sponge is inserted into the vagina up against the cervix, where the device works by continuously releasing spermicide for up to 24 hours. Additional applications of spermicide are not necessary, even for multiple acts of intercourse. There are other advantages as well: The sponge is available without a prescription; unlike a diaphragm, the sponge does not have to be fitted; and the sponge can be inserted ahead of time, which allows greater spontaneity in sex. The sponge has been found to be about 85 percent effective.

Some side effects are associated with the use of the sponge. Cases of local irritation or allergic reaction have been reported; however, these have been mild and infrequent. There is also concern that the sponge could become a breeding ground for infection, especially if used improperly. You should consult your doctor about the contraceptive sponge and its proper use before trying this method of birth control.

Toys

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Safety is the most important consideration when selecting toys. The fact is, some toys can be accidents waiting to happen.

Make sure that any item -- or any removable part of an item -- is no less than 11/4 inches in any dimension so that it cannot be swallowed or produce gagging.
Avoid anything with sharp corners, jagged edges, or pointy protrusions.

Avoid toys made with straight pins, sharp wires, nails, and other dangerous materials.

Check to make sure that all materials and paints used in the production of any item are safe (not glass or brittle plastic) and labeled nontoxic.

Stuffed toys should be labeled "nonflammable," "flame resistant," or "flame retardant," as well as "washable."

Check for durability and sturdy construction. Don't be shy about removing a toy from its box and giving it a good going-over. If it can be broken into little pieces, if buttons or other decorations can be torn off without too much effort, or if parts can pinch or trap fingers or catch hair, the toy is potentially dangerous.

Regulations go a long way toward protecting your child from unsafe playthings, but they are not an absolute guarantee. It is always possible that a slightly defective item will slip past the safety checks and end up in a store. Moreover, many toys from other countries are not subject to such regulations and many toys that were produced before the regulations went into effect end up on more informal markets, such as garage sales or flea markets. Before purchasing any plaything for your baby, give it a good going-over yourself to make sure that all safety factors are in order.

Check toys periodically to make sure they are in good repair. An item that passes all safety checks at the time of purchase can immediately become a serious hazard as soon as it is broken, chipped, or otherwise damaged