Many ethical issues arise around whether the mothers right to  autonomy  may have adverse effects on the fetus. These types of situations have been described as maternal autonomy vs. fetal rights. [ 21 ]  In the case of Angela Carter,  In re A.C. , a court order to perform an emergency cesarean section resulted in the death of the severely premature fetus and the terminally ill mother. In addition, obstetricians and pediatricians face challenges when a pregnant HIV positive woman refuses treatment to prevent transmission from mother to baby. In these cases, mothers have the right to refuse treatments during pregnancy, but may subsequently face custody battles from the government to prevent the transmission of HIV via breastfeeding. [ 22 ]


Another important field of discussion is what types of clinical trials are ethically appropriate for pregnant mothers. When a drug designed to benefit the health of the mother is being tested, the potential benefits of the drug may only be explored if the risk to the fetus is minimal. However, the concern is how severe must a health condition must be to justify exposing the fetus to any sort of risk. Clinical trials on pregnant women are forbidden if the drug is not designed for the benefit of the mother or fetus. [ 23 ]


In  reproductive health ,  obstetric transition  is a concept around the secular trend of countries gradually shifting from a pattern of high  maternal mortality  to low maternal mortality, from direct  obstetric  causes of maternal mortality to indirect causes, aging of maternal population, and moving from the natural history of  pregnancy  and  childbirth  to institutionalization of maternity care,  medicalization  and over medicalization. [ 1 ]  This concept was originally proposed in the  Latin American  Association of  Reproductive Health  Researchers (ALIRH, 2013) in analogy of the  epidemiological ,  demographic  and  nutritional  transitions.


In the last two decades, the world has seen a substantial reduction of maternal mortality.(1) Considering that maternal mortality is vastly determined by  social ,  societal  and  contextual  factors, this reduction is important not only because of the number of lives that have been spared in this period (an estimated 2,000,000 between 1990 and 2010), but because it denotes that the world is making progress towards development and  gender equality .(1,2) However, this progress is still insufficient, unequal and slow: recent estimates suggest that 287,000 women died of causes related to pregnancy and childbirth in 2010. Maternal mortality remains a global tragedy, but the observed progress inspires the  international community  to believe and strive for the elimination of maternal mortality in the decades to come.(3)


The vast majority of maternal deaths is avoidable and takes place in  developing countries . In  developed countries , the maternal mortality ratio can be as low as 10 maternal deaths per 100,000 live births while among the least developed countries it can be as a high as 1,000 maternal deaths or more per 100,000  live births .(4) This disparity is also observed within countries and when the population is disaggregated in  quintiles  of income or education.(5-7) Thus, countries, regions within countries and different population groups within country experience a specific momentum in a dynamic process of reduction of maternal mortality, which may benefit from specific approaches.


In 1929, Thompson described the phenomenon of  demographic transition  characterized by a gradual shift from a pattern of high mortality and high  fertility  to a pattern of low mortality and low fertility.(8) Omram (1971) described the  epidemiologic  transition, with a shift from a pattern of high prevalence of  communicable diseases  to a pattern of high prevalence of  non-communicable diseases .(9) Finally, Poppkin (1993) proposed the  nutritional  transition model, which helps to understand the transformations in  human diets  and the global  epidemic  of  obesity .(10) These transitions and other socioeconomic and cultural changes (e.g.  globalization ,  urbanization ) led us to develop the concept of “obstetric transition” (11).


As a result of the  Millennium Development Goals  Project, improved data related to maternal mortality and severe maternal  morbidity  became available for the period between 1990 and 2010. Altogether, these data reflect a secular trend where countries are gradually shifting from a pattern of high maternal mortality to low maternal mortality, from direct obstetric causes of maternal mortality to indirect causes, moving from the natural history of pregnancy and childbirth to institutionalization of  maternity care ,  medicalization  and over medicalization, and aging of maternal population. This is the “obstetric transition” phenomenon, which has implications for the strategies aimed at reducing maternal mortality.


Figure 1 presents trends of maternal mortality by world region for the period 1990 to 2010 derived from recent estimates (2). Considering that countries and world regions are transitioning in the same pathway towards elimination of maternal deaths, five stages can be devised. Countries are experiencing this transition at different paces, and have started this process in different moments of their history (e.g. most developed countries started their transitions more than a century ago, while some developing countries have started their transition much more recently).


In the  Stage I  (MMR> 1,000 / 100,000) most women are experiencing a situation close to the natural history of pregnancy and childbirth, with very little being done – if anything at all – to reduce the risk of maternal mortality at the  population  level. Considering 2010 data,  Chad  and  Somalia  are countries that could illustrate this stage. Hopefully, as time passes (and progress occurs), no country will remain in this stage. Stage I is characterized by very high maternal mortality, high fertility and the predominance of direct causes of maternal deaths together with a substantial proportion of deaths attributable to communicable diseases such as  malaria .


In the  Stage II  (MMR: 999 – 300) mortality and fertility remain very high, with a similar pattern of causes as compared to the Stage I. However, a greater proportion of women in the population are being able to somewhat detach from the natural history of pregnancy and childbirth. Several countries in the  Sub-Saharan Africa  could illustrate the Stage II. For Stages I and II, the main issue is  access to care . In general, these are countries with a substantial lack of basic  infrastructure  (such as roads, transportation, health facilities), very low education levels (particularly female  literacy ), weak  health systems , severe shortages of skilled  birth attendants  and low capacity to deliver essential life-saving interventions. In this context, poor quality of care functions as deterrent for generating demand for  health services . In countries in these stages, focus should be directed to creating the basic infra-structure and implement maternal-mortality primary prevention measures (e.g.  family planning ,  iron  supplementation,  insecticide  treated nets, intersectorial measures to remove barriers to access the health system). As the minimal infra-structure is created, health services should strive to deliver quality care in order to become a sensible alternative to pregnant women (demand generation). (21)


In the obstetric transition, the tipping point occurs in the  Stage III . In this stage the mortality is still high (MMR 299 – 100 maternal deaths / 100,000 live births), the fertility is variable and direct causes of mortality still predominates. This is a complex stage because access remain an issue for a great deal of the population, but as a large proportion of pregnant women are indeed reaching health facilities, quality of care becomes a major determinant of health outcomes. Not only primary prevention is important, but also secondary and tertiary prevention are critical for improving maternal health outcomes in this stage. In other words, quality of care, with skilled birth attendance and appropriate management of complications and disabilities, is essential to reduce maternal mortality.  India ,  Guatemala  and  South Africa  are countries that could illustrate this stage.


In the  Stage IV  (MMR <50 maternal deaths / 100,000 live births), the maternal mortality is moderate or low, there is low fertility and the indirect causes of maternal mortality, particularly the non-communicable diseases, acquire greater importance. In order to further advance the reduction of maternal mortality, the main issue becomes quality of care and elimination of delays within health systems. Another aspect that emerges in this stage is the growing role of over medicalization as a threat to quality and improved health outcomes. Various  Asian  countries and most Latin American countries have joined developed countries in this stage.


In the  Stage V , all avoidable maternal deaths are indeed avoided. The maternal mortality rate is very low, the fertility is low or very low, and the non-communicable diseases are the main causes of maternal mortality. As this is an aspirational, largely theoretical stage at the moment, the maternal mortality levels remain uncertain, but could be lower than 5 maternal deaths per 100,000 live births. The main issue in this stage would be the sustainability of excellence in quality of care.


It is worth noting that the main purpose of this framework is to illustrate different phases of a dynamic process and offer a rationale for different focus and solutions for reducing mortality according to the stage in the obstetric transition. The ranges of maternal mortality ratio uses to define the proposed stages of obstetric transition are frequently in country stratification, (2, 16) but the boundaries between these stages are somewhat imprecise and one stage tends to fade into another. Progression is not always linear and, largely due to equity issues, different stages often co-exist in the same country.


The  obstetrical dilemma  is a  hypothesis  to explain why humans often require assistance from other humans during  childbirth  to avoid  complications , whereas most non-human primates give birth unassisted with relatively little difficulty. This occurs due to the tight fit of the fetal head to the maternal birth canal, which is additionally convoluted, meaning the head and therefore body of the infant must rotate during childbirth in order to fit, unlike in other, non-upright walking mammals. Consequently, there is an unusually high incidence of  cephalopelvic disproportion  and  obstructed labor  in humans. [ 1 ]


The obstetrical dilemma claims that this difference is due to the biological  trade-off  imposed by two opposing  evolutionary pressures  in the development of the human  pelvis :  smaller  birth canals  in the mothers, and larger brains, and therefore  skulls  in the babies.  Proponents believe  bipedal locomotion  (the ability to walk upright) decreased the size of the bony parts of the birth canal.  They also believe that as hominids' and humans' skull and brain sizes increased over the millennia, that women needed wider hips to give birth, that these wider hips made women inherently less able to walk or run than men, and that babies had to be born earlier to fit through the birth canal, resulting in the so-called fourth trimester period for newborns (being born when the baby seems less developed than in other animals). [ 2 ]  Recent evidence has suggested bipedal locomotion is only a part of the strong evolutionary pressure constraining the expansion of the maternal birth canal. In addition to bipedal locomotion, the reduced strength of the pelvic floor due to a wider maternal pelvis also leads to fitness detriments in the mother pressuring the birth canal to remain relatively narrow. [ 3 ] [ 4 ]


This idea was widely accepted when first published in 1960, but has since been criticized by other scientists. [ 5 ]


The term, obstetrical dilemma, was coined in 1960, by  Sherwood Larned Washburn , a prominent early American  physical anthropologist , in order to describe the evolutionary development of the human pelvis and its relation to childbirth and pregnancy in hominids and non-human primates. [ 6 ]  In the intervening decades, the term has been used broadly among anthropologists, biologists, and other scientists to describe aspects of this hypothesis and related topics.


The obstetrical dilemma hypothesizes that when hominids began to develop bipedal locomotion, the conflict between these two opposing evolutionary pressures became greatly exacerbated. Because humans are currently the only recognized extant obligately bipedal primates, meaning the body shape requires to only use two legs, major evolutionary developments had to occur in order to alter to the shape of the female pelvis. [ 2 ]  Human males evolved narrower hips optimized for locomotion, whereas female hips evolved to be a wider optimization because of childbirthing needs. [ 6 ] [ 7 ] [ 8 ]  Human pelves have no gross distinguishing skeletal markers for sex before puberty. With puberty, hormones alter the shape of the pelvis in females to cater to obstetrical demands. Overall, through evolution of the species, a number of structures in the body have changed size, proportion, or location in order to accommodate bipedal locomotion and allow a person to stand upright and face forward. To help support the upper body, a number of structural changes were made to the pelvis. The ilial pelvic bone shifted forward and broadened, while the ischial pelvic bone shrank, narrowing the pelvic canal. These changes were occurring at the same time as humans were developing larger craniums.


Examination of the pelvis is the most useful method for identifying biological sex through the skeleton. Distinguishing features between the human male and female pelvis stem from the selective pressures of childbearing and birth. Females must be able to carry out the process of childbirth but also be able to move bipedally. The human female pelvis has evolved to be as wide as possible while still being able to allow bipedal locomotion. The compromise between these two necessary functions of the female pelvis can be especially seen through the comparative skeletal anatomy between males and females. [ 9 ]
(Diagram of human pelvis needed here)
The human pelvis is made up of three sections: the hip bones (ilium,  ischium  and pubis), the  sacrum , and the  coccyx . How these three segments articulate and what their dimensions are is key for differentiation between males and females. Females acquired the characteristic of the overall pelvic bone being thinner and denser than the pelvic bones of males. The female pelvis has also evolved to be much wider and allow for greater room in order to safely deliver a child. After sexual maturation, it can be observed that the pubic arch in females is generally an obtuse angle (between 90 and 100 degrees) while males tend to have more of an acute angle (approximately 70 degrees). [ 2 ]  This difference in angles can be attributed to the fact that the overall pelvis for a female is preferred to be wider and more open than a male pelvis. Another key difference can be seen in the sciatic notch. The sciatic notch in females tend to be wider than the sciatic notches of males. The pelvic inlet is also a key difference. The pelvic inlet can be observed as oval-shaped in females and more of a heart-shape in males. [ 2 ]  The difference in inlet shape is related to the distance between the ischium bones of the pelvis. To allow for a wider and more oval-shaped inlet, female ischium bones are further apart from one another than the ischium bones of a male.


Differences in the sacrum between males and females can also be attributed to the needs of child birth. The female sacrum is wider than the male sacrum. The female sacrum can also be observed as being shorter than the sacrum of a male. The difference in width can be explained by the overall wider shape of the female pelvis. The female sacrum is also more curved posteriorly. This could be explained by the need for as much space as possible for a birthing canal. The articulating coccyx in females is also generally observed as being straighter and more flexible than the coccyx of a male for the same reason. [ 2 ] [ 10 ]  Because of the female pelvic bones in general being further apart from one another than those of the male pelvis, the acetabula in a female are positioned more medially and further apart from one another. It is this orientation that allows for the stereotypical swinging motion of a female's hips while walking. [ 2 ]  The acetabula not only differ in distance, but depth as well. It has been found that female  acetabula  have a greater depth than those in males, but also paired with a smaller femoral head. This in turn creates a more stable hip joint(insert). [ 10 ]  One of the last key differences can be seen in the auricular surface of the pelvic bones. The auricular surface where the sacroiliac joint articulates seen in females generally has a rougher texture compared to the surfaces seen in males. [ 11 ]  This difference in the texture of the articulating surface may be due to the differences in shape of the sacrum between males and females. These key differences can be examined and used to determine biological sex between two different sets of pelvic bones; all due to the need for bipedal locomotion while having the need for childbearing and childbirth in females.


Early human ancestors, hominids, originally gave birth in a similar way that non-human primates do because early obligate quadrupedal individuals would have retained similar skeletal structure to great apes. Most non-human primates today have neonatal heads that are close in size to the mother's birth canal, as evidenced by observing female primates who do not need assistance in birthing, often seeking seclusion away from others of their species. [ 9 ]  In modern humans,  parturition  (childbirth) differs greatly from the rest of the primates because of both pelvic shape of the mother and neonatal shape of the infant. Further adaptations evolved to cope with bipedalism and larger craniums were also important such as neonatal rotation of the infant, shorter gestation length, assistance with birth, and a malleable neonatal head.


Neonatal rotation was a solution for humans evolving larger brain sizes. Comparative zoological analysis has shown that the size of the human brain is anomalous, as humans have brains that are significantly larger than other animals of similar proportions. Even among the great apes, humans are distinctive in this regard, having brains three to four times larger than those of chimpanzees, humans' nearest relatives. Although the close correspondence between the neonatal cranium and the maternal pelvis in monkeys is also characteristic of humans, the orientation of the pelvic diameters differs. On average, a human fetus is nearly twice as large in relation to its mother's weight as would be expected for another similarly sized primate. [ 2 ]  The extremely close correspondence between the fetal head and the maternal pelvic dimensions requires that these dimensions line up at all points (inlet, midplane, and outlet) during the birth process. [ 11 ]  During delivery, neonatal rotation occurs when the body gets rotated to align head and shoulders transversely when entering the small pelvis, otherwise known as internal rotation. The fetus then rotates longitudinally to exit the birth canal, which is known as external rotation. In humans, the long axes of the inlet and the outlet of the obstetric canal lie perpendicular to each other. [ 2 ]  This is an important mechanism because growth in the size of the cranium as well as the width of the shoulders makes it more difficult for the infant to fit through the pelvis. [ 2 ]  This enables the largest dimensions of the fetal head to align with the largest dimensions of each plane of the maternal pelvis as labor progresses. [ 2 ]  This differs in non-human primates as there is no need for neonatal rotation in non-human primates because the birth canal is wide enough to accommodate the infant. [ 11 ]  This elaborate mechanism of labor, which requires a constant readjustment of the fetal head in relation to the bony pelvis (and which may vary somewhat depending on the shape of the pelvis in question), is completely different from the obstetrical mechanics of the other higher primates whose infants generally drop through the pelvis without any rotation or realignment. [ 2 ]  In contrast to the narrow shoulders of monkeys and higher primates, which are able to pass through the birth canal without any rotation, modern humans have broad, rigid shoulders, which generally require the same series of rotations that the head undergoes in order to travel through. [ 11 ]


Due to the evolution of bipedalism in humans, the pelvis had evolved to have a shorter, more forward curved ilium and broader sacrum in order to support ambulating on two legs. This caused the birth canal to shrink and form a more oval shape, thus the infant must undergo specific movements to rotate itself in a certain position to be able to pass through the pelvis. These movements are referred as the  seven cardinal movements , which the infant rotates itself at the widest diameter of the pelvis to allow for the narrowest aspect of the fetal body to align with the narrowest diameter of the pelvic. [ 12 ]  These movements include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion.


While the seven cardinal movements is considered the normal mechanism for labor and delivery of human babies, [ 12 ]  pelvic sizes and shapes can vary among female humans which can increase the risk of errors in rotations and delivery, especially since these movements are done completely by the baby. One of the biggest issues with the pelvic shape for childbirth is the  Ischial spine . Since the ischial spines support the pelvic floor, if the spines are too far apart it can lead to a weakened pelvic floor muscles. This can cause issues as pregnancy progresses, such as difficulty carrying the fetus to full term. Another complication that can occur during human childbirth is shoulder dystocia, where the shoulder is stuck in the birth canal. [ 13 ]  This can lead to fractured humerus and clavicle of the fetus and hemorrhaging of the mother postpartum. [ 13 ]  Thus, these neonatal rotations are important in allowing the baby to safely pass through the pelvic and ensure the health of the mother as well.


Gestation length in humans is believed to be shorter than most other primates of comparable size. The gestation length for humans is 266 days, or eight days short of nine months, which is counted from the first day of the woman's last menstrual period. During gestation, mothers must support the metabolic cost of tissue growth, both of the fetus and the mother, as well as the ever-increasing metabolic rate of the growing fetus. [ 14 ]  Comparative data from across mammals and primates suggest that there is a metabolic constraint on how large and energetically expensive a fetus can grow before it must leave the mother's body. [ 14 ]  It is thought that this shorter gestation period is an adaptation to ensure the survival of mother and child because it leads to  altriciality . Neonatal brain and body size have increased in the hominin lineage, and human maternal investment is greater than expected for a primate of similar body mass. [ 14 ]  The obstetrical dilemma hypothesis suggests that in order to successfully undergo childbirth, the infant must be born earlier and earlier, thereby making the child increasingly developmentally premature. [ 14 ]  The concept of the infant being born underdeveloped is called  altriciality . Humans are born with an underdeveloped brain; only 25% of their brains fully developed at birth as opposed to non-human primates where the infant is born with 45–50% brain development. [ 15 ]  Scientists have believed that the shorter gestation period can be attributed to the narrower pelvis, as the baby must be born before its head reaches a volume that cannot be accommodated by the obstetric canal.


Human infants are also almost always born with assistance from other humans because of the way that the pelvis is shaped. Since the pelvis and opening of birth canal face backwards, humans have difficulty giving birth themselves because they cannot guide the baby out of the canal. Non-human primates seek seclusion when giving birth because they do not need any help due to the pelvis and opening being more forward. [ 11 ]  There is no evidence to ascertain at what point in human evolution birth assistance arose, but some researchers have suggested  Homo habilis . [ 16 ]  Human infants depend on their parents much more and for much longer than other primates. [ 7 ] [ 14 ]  Humans spend a lot of their time caring for their children as they develop whereas other species stand on their own from when they are born. The faster an infant develops, the higher the reproductive output of a female can be. [ 17 ]  So in humans, the cost of slow development of their infants is that humans reproduce relatively slowly. This phenomenon is also known as  cooperative breeding .


Humans are born with a very malleable fetal head which is not fully developed when the infant exits the womb. [ 2 ]  This soft spot on the crown of the infant allows for the head to be compressed in order to better fit through the birth canal without obstructing it. [ 7 ]  This allows for the head to develop more after birth and for the cranium to continue growing without affecting the birthing process.


The obstetrical dilemma hypothesis has had several challenges to it, as more data is collected and analyzed. Several different fields of study have taken an interest in understanding more about the human birth process and that of human ancestor species.


Some studies have shown that higher brain growth rates happen earlier on in  ontogeny  than previously thought, [ 18 ]  which challenges the idea that the explanation of the obstetrical dilemma is that humans are born with underdeveloped brains. This is because if brain growth rates were largest in early development, that is when the brain size would increase the most. Premature birth would not allow for a much larger head size if most of the growth had already happened. Also, it has been suggested that maternal pelvic dimensions are sensitive to some ecological factors.


There has been a lot of evidence linking body mass to brain mass, leading to the determination of maternal metabolism as a key factor in the growth of the fetus. Maternal constraints could be largely due to thermal stress or energy availability. A larger brain mass in the neonate corresponds to more energy needed to sustain it. It takes much more energy for the mother if the brain fully develops in the womb. If maternal energy is the limiting factor then an infant can only grow as much as the mother can sustain. Also, because fetal size is positively correlated to maternal energy use, thermal stress is an issue because the larger the fetus, the more the mother can suffer heat stress. [ 6 ]


Additional studies suggest that other factors may further complicate the obstetrical dilemma hypothesis. One of these is dietary shifts, possibly due to the emergence of agriculture. This can be both due to change in diet as well as the increase in population density since agriculture was developed; more people leads to more disease. [ 6 ]  Studies have also been done in twins to show that pelvic size may be due more to the environment in which they live than their genetics. [ 19 ]  Another study disproves the thought that narrower hips are optimized for locomotion because it was found that a Late Stone Age population Southern Africa that survived largely on terrestrial mobility had women who had uncharacteristically small body size with large pelvic canals. [ 6 ]


The energetics of gestation and growth (EGG) hypothesis offers a direct challenge to the obstetrical dilemma hypothesis, equating the constraints on gestation and parturition to the energy restrictions of the mother. It has been shown in studies using professional athletes and pregnant women, that there is an upper limitation to the amount of energy a woman can produce before it causes deleterious effects: approximately 2.1x their basal metabolic rate. During pregnancy the growing brain mass and length in the neonate correspond to more energy needed to sustain it. This results in a competing balance between the fetus's demand for energy and the maternal ability to meet that demand. At approximately nine months gestation, the fetus's energy needs surpasses the mother's energy limitation, correlating with the average time of birth. [ 14 ]  The newly born infant can then be sustained on breast milk, which is a more efficient, less energy demanding mechanism of nutrient transfer between mother and child. [ 20 ]  Additionally, this hypothesis demonstrates that, contrary to the obstetrical dilemma, an increased pelvic size would not be deleterious to bipedalism. Studying the running mechanics of males and females, it was shown that an increased pelvic size related to neither an increased metabolic nor structural demand on a woman. [ 21 ]


The obstetrical dilemma hypothesis has also been challenged conceptually based on new studies. The authors argue that the obstetrical dilemma hypothesis assumes that human, and therefore hominid, childbirth has been a painful and dangerous experience through the species' evolution. [ 22 ]  This assumption may be fundamentally false as many early analyses focused on maternal death data from primarily females of European-descent in  Western Europe  and the  United States  during the 19th and 20th century, a limited population. [ 22 ]  In a recent study a covariation between human pelvis shape, stature, and head size is reported. It is said that females with a large head possess a birth canal that can better accommodate large-headed neonates. Mothers with large heads usually give birth to neonates with large heads. Therefore, the detected pattern of covariation contributes to ease childbirth and has likely evolved in response to strong correlational selection. [ 23 ]  A recent study aimed to evaluate the original ideas under the 'obstetrical dilemma' and provide a detailed, more complex explanation for the tight fetopelvic fit observed in humans. They propose the original obstetrical dilemma hypothesis remains valuable as a foundation to explain the complex combination of evolutionary, ecological, and biocultural pressures that constrain maternal pelvic form and fetal size. [ 24 ]


Obstetrical nursing , also called  perinatal nursing , is a nursing specialty that works with patients who are attempting to become pregnant, are currently pregnant, or have recently delivered. Obstetrical nurses help provide prenatal care and testing, care of patients experiencing pregnancy complications, care during labor and delivery, and care of patients following delivery. Obstetrical nurses work closely with  obstetricians ,  midwives , and  nurse practitioners . They also provide supervision of  patient care technicians  and  surgical technologists .


Obstetrical nurses perform a number of tasks, like mammograms, administering medications through IV's, monitoring newborns, stress test evaluations, cardiac monitoring, vascular monitoring, and health assessments. Obstetrical nurses are required to possess specialized skills such as  electronic fetal monitoring ,  nonstress tests ,  neonatal resuscitation , and  medication  administration by continuous  intravenous  drip.


The workload and daily routine of obstetrical nurses requires them to be detailed and organized, possess mental and physical strength and emotional stability, and to possess critical thinking skills. [ 1 ]


Common workplaces for obstetrical nurses are as follows:


In the U.S. and Canada, the professional nursing organization for obstetrical nurses is the  Association of Women's Health, Obstetric and Neonatal Nursing (AWHONN) .


Obstetrical nurses in the U.S. make an average of about US$148,000 annually plus benefits. It can vary depending on location. [ 3 ]


The gender ratio of obstetrical nurses is 3% male and 97% female. Furthermore, ethnicities are the following: White 66.2%, Black 10.5%, Hispanic 9.5%, Asian 9%, unknown 4.3% and American Indian and Alaska Native 0.5%. [ 4 ]


Obstetrical nurses typically start as registered nurses, which means that they first obtain a degree or nursing diploma. An internship in obstetrics suffices in order to start at an entry-level position. [ 5 ]  The  National Certification Corporation  (NCC) offers certifications for obstetrical nurses. These include RNC-OB (Inpatient Obstetrics), a certification that allows graduate nurses who have completed a bachelor's degree in the US or Canada to expand into obstetrics. In order to gain an RNC-OB certificate, an online exam must be taken. [ 6 ]  RNC-MNN (Maternal Newborn Nursing) is another online exam for certified registered nurses, who have completed their bachelor's degrees in Nursing, have gained experience in the area of newborn nursing and want to gain a certification/qualification in the area. They have a 90-day window to complete the actual exam. [ 7 ]  Both tests cost approximately US$325. A third online certification is C-EFM (Electronic Fetal Monitoring). It is open to licensed registered nurses, nurse practitioners, nurse midwives, physicians, physician assistants, and paramedics, according to the US and Canada requirements. [ 8 ]


Bachelor's degrees in either nursing and/or midwifery are required to become an obstetrical or perinatal nurse in Australia. In Australia alone there are 32 different universities that offer nursing as an undergraduate degree, such as Australian Catholic university, Charles Darwin University and the University of Notre Dame in Australia. [ 9 ]  Once completing their degree, they are required to complete their master's degree in nursing. Bachelor's degrees and jobs as licensed nurses/midwives are required in order to be accepted for the master's degree.  There are 24 different universities in Australia that offer a master's degree in nursing, including Edith Cowan University, Monash University, James Cook University and University of Canberra. [ 10 ]


Osmotic dilators , also known as  hygroscopic dilators , are medical implements used to dilate the uterine  cervix  by swelling as they absorb fluid from surrounding tissue. [ 1 ]  They may be composed of natural or synthetic materials. A  laminaria stick  or  tent  is a thin rod made of the stems of dried  Laminaria , a genus of  kelp .  Laminaria sticks can be generated from  Laminaria japonica [ 2 ]  and  Laminaria digitata . [ 3 ]  Second generation dilators such as Dilapan-S are composed of  polyacrylonitrile , a plastic polymer. [ 4 ]  The  hygroscopic  nature of the polymer causes the dilator to absorb fluid and expand.


Osmotic dilators are most commonly used to slowly dilate and soften the cervix prior to surgical abortion, a process referred to as cervical preparation. Adequate cervical preparation is important prior to surgical abortions because it helps to prevent complications of  dilation and evacuation  (D&E), such as laceration of the cervix. [ 5 ]  Cervical preparation can be accomplished with osmotic dilators, with medications such as prostaglandins and/or mifepristone, or with a combination of these. However, there is no consensus as to which cervical preparation method is superior in terms of safety and efficacy. [ 6 ]


At later gestational ages, osmotic dilators, including laminaria, may be used to assist in dilating the cervix. Most abortion providers use laminaria, Dilapan-S, or both for osmotic dilation prior to surgical abortion after 16–18 weeks gestation. [ 7 ]


Osmotic dilators may also be used to achieve cervical dilation prior to gynecology procedures, such as  hysteroscopy  or  dilation and curettage  of the non-pregnant uterus, [ 8 ]  although this is uncommon.


Prior to a planned surgical abortion, osmotic dilator(s) may be inserted into a woman's cervix. A  speculum  is placed in the vagina to allow the provider to see the uterine  cervix . A  tenaculum  may be placed on the anterior lip of the cervix to straighten the cervical canal and hold the cervix steady. Pain medications may be administered via a  paracervical block .  The dilator is then grasped with a ring forceps and is placed into the cervix so that it spans both the internal cervical os and external cervical os. Over time, the osmotic dilator absorbs fluid and swells to 3-4 times the initial diameter. [ 9 ]  Most of the increase in size occurs within 6 hours after the dilator are placed in the cervix, though further expansion will continue over 12–24 hours. [ 7 ]  The number of osmotic dilators placed depends on the degree of cervical dilation that is sought. This may be affected by the gestational age of the pregnancy and history of prior vaginal deliveries. More dilators are generally used with advancing gestational age. [ 10 ]


Laminaria tents are usually left in place overnight. [ 6 ] [ 11 ]


Laminaria function by absorbing fluid from the surrounding tissue and expanding. Thus exerts radial pressure on the cervix. They also cause the release of prostaglandins. [ 12 ]


Laminaria are removed prior to initiating the D&E, after they have started the process of dilating the cervix. They are removed by grasping the strings of the dilator and applying gentle traction. The cervix may be dilated further using rigid cervical dilators which serially increase in diameter. [ 11 ]


There is no evidence regarding the risk of not achieving vaginal delivery within 24 hours with laminaria compared to prostaglandin E2 but there may be a lower risk of uterine hyperstimulation with laminaria. It is not certain whether the risks of caesarian section, perinatal death or maternal death are reduced or increased with laminaria compared with vaginal or cervical prostaglandin E2. [ 13 ]


The incidence of complications related to  osmotic [ 1 ]  dilator use prior to abortion has not been systematically studied and reported, but serious complications appear to be very rare. [ 8 ]  Risks of osmotic dilator insertion include pain, [ 14 ]  rupture of amniotic membranes, initiation of labor, cervical or uterine perforation, retention of the dilator, and infection. [ 8 ] [ 7 ]


Original Dilapan dilators were prone to fracturing under tension during removal which sometimes led to retention of dilator fragments within the uterus. [ 8 ]  Dilapan was subsequently removed from the market and replaced with Dilapan-S which is less prone to fragmentation. [ 8 ]  Dilapan may expand unevenly within the cervix and develop a dumbbell shape which can result in difficult removal.


Maternal obesity  refers to  obesity  (often including being  overweight ) of a woman during  pregnancy .   Parental obesity  refers to obesity of either parent during pregnancy.


Maternal obesity has a significant impact on maternal  metabolism  and offspring development. [ 1 ]   Insulin resistance ,  glucose  homeostasis,  fat  oxidation and  amino acid synthesis  are all disrupted by maternal obesity and contribute to adverse outcomes. [ 1 ]   Modification of lifestyle is an effective intervention strategy for improvement of maternal metabolism and the prevention of adverse outcomes. [ 1 ]


Obesity  is defined as having a  Body Mass Index  (BMI) of 30 or greater.  A 5-foot-5-inch tall woman would be considered obese if she weighs 180 pounds or more and a 5-foot-8-inch tall woman would be considered obese if she weighs 200 pounds or more. [ 2 ]  About one third of women of the reproductive ages are overweight with a BMI greater than or equal to twenty-five.  [ 3 ]


Between 18 and 38% of pregnant women in the US are classified as obese. However, little is known about the link between maternal obesity and  diabetic  effects in offspring. Maternal obesity is associated with increased odds of pregnancies affected by  congenital anomalies , including  neural tube defects  and  spina bifida . [ 4 ]  The chances of having neural tube defects in the newborn of an obese woman has been shown to be twice that of a non-obese pregnant female. [ 2 ]  Some other anomalies that were increased among mothers with obesity included  septal  anomalies,  cleft palate , cleft lip and palate,  anorectal atresia ,  hydrocephaly , and limb reduction anomalies. Babies are also more likely to be admitted to  neonatal intensive care units  because of effects from the obese mother. Each year, nearly 2,500 babies are born [ where? ]  with these defects, and many other affected pregnancies end in  miscarriage  and  stillbirth . [ 4 ]


Maternal obesity is linked with elective  preterm delivery ,  neonatal death , and delivery of an extremely low birth weight infant. In follow-up studies of babies whose birth weights were below 1000g, it was shown that 40% to 45% of the survivors had severe neurodevelopmental impairments. [ 5 ]


It has been demonstrated through a study on rats that when a pregnant mother ate a diet rich in fat, sugar, and salt, that mother's offspring was more likely to overeat and have a preference for  junk food . Even when the offspring were not given the option of junk food, their bodies metabolized food differently from offspring whose mother ate healthier. Offspring of mothers who ate badly had higher levels of  cholesterol  and  triglycerides  in their bloodstream and higher risk of heart disease. In addition, these offspring had higher levels of glucose and insulin, which indicate development of  type 2 diabetes . The rats were studied through adulthood and were found to be fatter than the offspring whose mothers ate healthier. This study showed that the diet of mothers not only affects the offspring's chemical physiology but also their likelihood of becoming even more unhealthy through their natural preference to bad habits. [ 6 ]


Fetal macrosomia, maternal obesity and excessive weight gain during pregnancy are associated with later obesity in childhood and adolescence. [ 7 ]  As early as at age 6 years, children of women who were obese before they became pregnant had more often a cardiometabolic risk profile compared to children of normal-weight mothers.  [ 8 ]


Researchers from the  NIH 's  National Institute of Diabetes and Digestive and Kidney Diseases  (NIDDK) conducted a study and found that early-onset paternal obesity is connected with an increased risk of  liver disease  in their kin.  Researchers found that obese fathers had an elevated level of  serum alanine aminotransferase  (ALT), a liver enzyme, compared to fathers who were not obese.  They did a secondary analysis that excluded obese offspring.  Children who were a normal weight but had obese fathers still had elevated ALT levels, which indicated that a child's ALT levels are not dependent upon the child's own BMI. [ 9 ]


Obese women have an increased risk of pregnancy-related complications, including  hypertension ,  gestational diabetes , and  blood clots . Also, the mother is at risk of going into preterm labor. [ 10 ] [ 2 ]   Maternal obesity is also known to be associated with increased rates of complications in late pregnancy such as  cesarean delivery , and  shoulder dystocia . [ 5 ]   A  meta-analysis  estimated that  Cesarean delivery  rates increased with  odds ratios  of 1.5 among overweight, 2 among obese, and 3 among severely obese women, compared with normal weight pregnant women. [ 11 ]  In addition,  morbidly obese  women who have not had children before are at increased risk of  all–cause preterm deliveries .  It is well recognized that obese women are at increased risk of  preeclampsia  and that women who have never been pregnant are at higher risk of preeclampsia than women who have had children in the past. [ 5 ]
Obesity in pregnancy is also known to be associated with hyperinsulinemia, dyslipidemia, impaired endothelial function, and up-regulated markers of inflammation. [ 12 ] [ 13 ] [ 14 ]


Poor  glycemic  control can lead to  neural tube defects .  The usual increase in  insulin resistance  seen in late pregnancy is enhanced in obese mothers, causing a  postprandial  increase in glucose,  lipids , and amino acids, as well as excessive fetal exposure to fuel sources. [ clarification needed ] [ citation needed ]   This, in turn, increases fetal size, fat storage, and potential risk for disease. For mothers, impaired glucose tolerance and  hyperlipidemia  are more common among obese mothers.


There are many options available in treating obesity, such as: altering one's diet and exercising regularly. Regular exercise during pregnancy has been shown to reduce gestational weight gain and reduce the risk of developing obesity related health conditions, such as gestational diabetes, hypertensive disorders, and preeclampsia in the mother. [ 15 ] [ 16 ]   Additionally, regular exercise during pregnancy has been shown to reduce the incidence of adverse fetal health conditions, such as preterm birth, macrosomia, and gestational age discrepancies. [ 15 ]   Some people who are obese turn to  gastric bypass surgery  in order to reduce their appetites.  It is always advised to consult a physician regarding any obesity treatment.


It is recommended that obese women should try to lose weight before becoming pregnant, yet women should not diet during pregnancy because  sufficient nutrition  is important for pregnant women and women planning pregnancy.  Women with gastric banding can have normal pregnancies and better outcomes than women who do not have the surgery, but in most cases, doctors have agreed that pregnancy should wait until surgery-related weight loss has stabilized. Clinicians have been encouraged to talk to women who are pregnant or may become pregnant about getting enough folic acid, quitting smoking, and avoiding alcohol.  Women are also recommended to have appropriate calorie intake and exercise adequately.


Pregnant women who ate more sweets, such as candy and processed juices, in early pregnancy were at higher risk of gaining excessive weight.  A healthy, well-balanced diet during pregnancy can also help to minimize some pregnancy symptoms such as nausea and constipation. [ 17 ]


Pregnant women should be encouraged to follow the gestational weight gain guidelines [ 18 ]  according to their pre-pregnancy BMI, so to best avoid excessive weight gain during their pregnancy, while still providing the nutrients required for healthy fetal development. [ 19 ]


During pregnancy, women should engage in regular physical activity. A large variety of exercise programs and modalities are available and safe for women to perform while pregnant, and should be encouraged for women, regardless of BMI, to include during the duration of their pregnancy. Current exercise recommendation guidelines state that pregnant women should be active for at least 150 minutes a week, most preferably through daily physical activity, at a moderate intensity. Previously sedentary mothers should begin light exercise of a short duration, and progress to longer duration and more intense exercise. [ 19 ]   Doctors state that exercise can help the comfort of the mother and the well-being of the unborn child.  Some benefits include, but are not limited to: reduced  back pain , decrease in  constipation , less likely to gain excess weight, decreased chance of gestational diabetes, easier  labor , quicker recovery, and better physical and emotional health of the baby. [ 20 ]  Exercises performed in the supine position are not recommended after the first trimester, as well as extended periods of standing still. Both positions have been linked to reduced cardiac output. Additionally, prolonged Valsalva maneuvers during isometric exercises, like weight lifting, should be avoided because they may lead to decreased blood flow to the digestive organs and uterus. [ 21 ]


If negative signs and symptoms occur after exercising, pregnant females should stop immediately. Some signs include: dizziness, faintness, headache, shortness of breath, uterine contractions, vaginal bleeding, fluid leaking, or heart palpitations.


A  partogram  or  partograph  is a composite graphical record of key data (maternal and fetal) during  labour  entered against time on a single sheet of paper. Relevant measurements might include statistics such as  cervical dilation ,  fetal heart rate , duration of labour and  vital signs . [ 1 ]


In, 1954  Friedman  prepared the  cervicography . [ 2 ]  In 1972  Philpott  and  Castle , working in  Rhodesia  (now  Zimbabwe ), developed the first partograph, by utilizing Friedman's cervicograph, and adding the relationship of the presenting part to the maternal pelvis. [ 3 ] [ 4 ]


It is intended to provide an accurate record of the progress in labour, so that any delay or deviation from normal may be detected quickly and treated accordingly. However, a  Cochrane review  came to the conclusion that there is insufficient evidence to recommend partographs in standard labour management and care. [ 5 ]


A partograph is contained in the Perinatal Institute's "Birth notes". [ 9 ]


Use of a partograph in established labour is recommended by the National Institute for Clinical Excellence (NICE) in the "Intrapartum Care" guideline. [ 10 ]


A digital partograph is an electronic implementation of the standard paper-based partograph/partogram that can work on a mobile or tablet PC. Partograph is a paper-based tool developed by the  W.H.O.  to monitor labour during pregnancy. The use of the partograph is recommended as an important indicator for monitoring intrapartum care. Partograph includes several labour vitals including cervix dilatation of the mother. Plotting the cervix dilatation against time can help in predicting deviation from the normal progress of labour. In order to overcome the limitations of paper-based partograph, various researchers have suggested the use of digital partograph. Much literature is available regarding the feasibility of a digital partograph.


According to standard W.H.O. protocol different labour vitals needs to monitor at a different interval based on the stage of pregnancy. Electronic partograph can remind the staff nurse to enter labour vital in case they forget the standard protocol. In some cases, such small aid can be life-saving by decreasing the delay in decision making.


Very often the partograph is filled after the delivery [ 11 ]  only for the record keeping purpose. With electronic records, it is impossible to temper the data. Actual time of data entry can be logged easily. This allows obtaining a correct metric of protocol adherence for the labour monitoring process.


Data is essential in healthcare. One side effect of electronic partograph is that it makes a digital copy of the data available. Partograph itself is a very basic form of AI. But with more data, we can improve the underlying algorithm to predict the complications. It is possible to use nonlinear, multidimensional mathematical models for predicting adverse outcome during pregnancy with such data.


Another common reason for low partograph usage is its availability. This problem can be solved by using a digital medium provided an adequate power supply is available for the new device.


Plotting paper partograph requires training. Digital photographs can be made highly simple to use by taking advantage of recent advances in human-computer interaction. However, the perceived ease of use is highly subjective. Non-tech savvy users might find such shift overwhelming. It is important to pick the correct solution in order to make sure that it is seen as easy to use by its end users.


Perinatal mortality  ( PNM ) is the death of a  fetus  or  neonate  and is the basis to calculate the perinatal  mortality rate . [ 1 ]   Perinatal  means "relating to the period starting a few weeks before birth and including the birth and a few weeks after birth." [ 2 ]


Variations in the precise definition of the perinatal mortality exist, specifically concerning the issue of inclusion or exclusion of early fetal and late neonatal fatalities. The  World Health Organization  defines perinatal mortality as the "number of stillbirths and deaths in the first week of life per 1,000 total births, the perinatal period commences at 22 completed weeks (154 days) of gestation, [ 3 ]  and ends seven completed days after birth", [ 4 ]  but other definitions have been used. [ 5 ]


The UK figure is about 8 per 1,000 and varies markedly by social class with the highest rates seen in Asian women. Globally, an estimated 2.6 million neonates died in 2013 before the first month of age down from 4.5 million in 1990. [ 6 ]


Preterm birth  is the most common cause of perinatal mortality, causing almost 30 percent of neonatal deaths. [ 7 ]   Infant respiratory distress syndrome , in turn, is the leading cause of death in preterm infants, affecting about 1% of newborn infants. [ 8 ]   Birth defects  cause about 21 percent of neonatal death. [ 7 ]


Some major  causes of perinatal mortality  rate is:


Fetal mortality refers to  stillbirths  or fetal death. [ 9 ]  It encompasses any death of a fetus after 20 weeks of gestation or 500 gm. In some definitions of the PNM early fetal mortality (week 20–27 gestation) is not included, and the PNM may only include late fetal death and neonatal death. Fetal death can also be divided into death prior to  labor , antenatal (antepartum) death, and death during labor, intranatal (intrapartum) death.


Neonatal mortality refers to death of a live-born baby within the first 28 days of life. Early neonatal mortality refers to the death of a live-born  baby  within the first seven days of life, while late neonatal mortality refers to death after 7 days until before 28 days. Some definitions of the PNM include only the early neonatal mortality. Neonatal mortality is affected by the quality of in-hospital care for the  neonate . Neonatal mortality and postneonatal mortality (covering the remaining 11 months of the first year of life) are reflected in the  infant mortality rate .


The PNMR refers to the number of perinatal deaths per 1,000 total births. It is usually reported on an annual basis. [ 13 ]  It is a major marker to assess the quality of health care delivery. Comparisons between different rates may be hampered by varying definitions, registration bias, and differences in the underlying risks of the populations.


PNMRs vary widely and may be below 10 for certain developed countries and more than 10 times higher in developing countries. [ 14 ]  The WHO has not published contemporary data.


Probiotic supplementation of preterm and low birthweight babies during their first month of life can reduce the risk of blood infections, bowel sickness and death in low- and middle-income settings.  However, supplementing with Vitamin A does not reduce the risk of death and increases the risk of  bulging fontanelle,  which may cause brain damage. [ 15 ]


Antenatal perineal massage  (APM) or  Birth Canal Widening  (BCW) is the  massage  of a  pregnant  woman's  perineum  – the skin and deep tissues around the opening to the  vagina  (or 'birth canal' – when a baby is in this passage), performed in the 4 to 6 weeks before  childbirth , i.e., 34 weeks or sooner (Reference 7, as more births are occurring at around 28 weeks) and continued weekly until birth. The practice aims to gently mimic the 'massaging' action of a baby's head on the opening to the birth canal (vagina) prior to birth, so works with nature, to achieve the 10 cm diameter opening without using the back of baby's head, i.e., doing some of the hard work of labour (birth) before the start of labour, making birth less stressful on the baby and mother. The intention is also to attempt to: eliminate the need for an  episiotomy  during an instrument ( forceps  and  vacuum extraction ) delivery; to prevent blood loss (risk of  Sheehan's syndrome ) and tearing of the perineum during birth and in this way avoid infection (cellulitis and necrotising fasciitis of the pelvic floor muscles), helping to keep antibiotics working into the future. This technique uses Plastic Surgeons 'skin tissue expansion' principle, to aid a natural birth.


The Oxford Radcliffe NHS Trust Document "Antenatal Perineal Massage" 2011 describes the use of the pregnant mother's thumbs being placed just inside the birth canal, whilst she stands with one foot supported on the toilet. [ 1 ] [ 2 ]  She pulls backwards towards her spine, whilst relaxing her pelvic floor, progressively increasing the pressure under her finger tips until this starts to feel uncomfortable. On the next occasion she uses both thumbs pulling backwards and then sideways, thumbs away from each other, to enlarge the 2 cm diameter opening of the birth canal progressively over time to 10 cm by progressing to use the four fingers of both hands pulling away from each other, painlessly, to avoid causing tearing.  It is not possible to stretch this opening further, because this will be limited by the distance between the bony walls of the pelvis.


If preferred by the mother, a trusted partner can also perform the massage thus avoiding the need for the mother to be standing up and exerting herself. The mother can sit on a floor or in bed with knees bent and slightly apart, and, after applying oil or lubricant, the partner can perform the massage by inserting initially two fingers, pressing down towards the perineum (in the direction of the anus) as far as the pressure is comfortable for the mother. Once this point of maximum pressure is found, hold the position for 30 seconds. Repeat daily, gradually inserting more fingers until able to insert the 4 fingers of both hands i.e. you have stretched to 10 cm.


The goal of APM is to both prevent the baby's head from undergoing excessive strain during the last 30 minutes of labour, by training the mother to relax her pelvic floor to allow the baby's head to pass through the opening and also to prevent excessive blood loss in the mother (post-partum haemorrhage), as haemorrhage in childbirth is one of the five leading causes of deaths of mothers in childbirth ( maternal deaths ) by enabling the mother to completely avoid an  episiotomy . The pelvic floor muscle has a very good blood supply and the blood loss caused by an episiotomy, contributes to the blood loss, which occurs when the placenta separates from the wall of the uterus, tipping mothers, who have a prolonged labour, into shock. APM prevents a prolonged labour by stretching the two fibrous layers within the uro-genital membrane, a triangular shaped muscular shelf at the front half of the opening of the bony pelvis, through which the 2 cm diameter birth canal and urethra pass, and the fibrous coats of the pelvic floor muscles, in this way shortening the pushing stage of birth, and transforms the fat packed rigid skin at the opening to the birth canal into paper thin, stretchy elastic skin, all without using the baby's head, decreasing the risk of tearing. [ 3 ]


If the external skin (perineal skin) opening is stretched before birth, to 10 cm. diameter, the maximal opening in the bony pelvis (pelvic outlet), then there is no reason to perform an episiotomy,as an episiotomy will not increase the diameter of the opening of the birth canal any further i.e. 10 cm. makes episiotomy obsolete. Tearing is less likely as the external skin at the opening has already been stretched and is lax, whilst the underlying muscular pelvic floor has not been damaged, but made more elastic. Episiotomy permanently damages the pelvic floor muscle, as the episiotomy cuts through both the nerve and the arterial blood supply to this muscle, so the larger part of the pelvic floor muscles atrophies and becomes replaced by scar tissue, increasing the mother's chance of developing a prolapse in the future. Antenatal (before birth from 'Anteroir'- meaning before and 'Natal' Latin derived from Nativity meaning birth) perineal massage does not damage the pelvic floor, and so protects against a prolapse of the urinary bladder, through the front wall of the vagina, and the rectum, through the back wall of the vagina, and the uterus through the upper part of the vagina. [ 4 ]


Antenatal perineal massage or pre-birth obstetric massage (birth canal widening) was reportedly used by African tribal people. [ 5 ]  The German obstetrician Mr Welheim Horkel, when visiting a medical mission in the mid-1980s, learned that African tribes used gourds of increasing sizes to stretch the perineum, to avoid tearing during childbirth. [ 5 ]  He replicated this in a hospital setting using an inflatable silicone balloon naming the device 'Epi-no Delphine Plus, from 'Episiotomy -NO!'. [ 5 ]  The Czech have produced an improvement on 'Epi-on Delphine Plus' naming their device 'Aniball'. A new perineal massage device, Perimom Perineal Massager was approved for use in the US and in Europe in late 2021 (FDA-registration and CE approval respectively).


West Berkshire England performed an antenatal massage trial in 1984, and many small trials have been performed worldwide since. Cochrane Collaborate Reports since 2006 have advised that women should be informed that episiotomy is avoidable if they employ digital antenatal perineal massage. [ 6 ]


A recent meta-analysis involving 11 randomized clinical trials and more than 3,000 patients in total clearly demonstrated that antenatal perineal massage is associated with a lower risk of severe perineal trauma and postpartum complications. Women who received antenatal perineal massage had significantly lower incidence of episiotomies (RR = 0.79, 95% CI [0.72, 0.87], p < 0.001) and perineal tears (RR = 0.79, 95% CI [0.67, 0.94], p = 0.007), particularly the risk of third- and fourth-degree perineal tears (p = 0.03). Better wound healing and less perineal pain were evident in the antenatal perineal massage group. Antenatal perineal massage reduced the second stage of labor duration (p = 0.005) and anal incontinence (p = 0.003) with significant improvement in baby's Apgar scores at 1 and 5 minutes (p = 0.01 and p = 0.02). [ 7 ]  Perineal massage by minimising blood loss during birth, decreases the risk of Sheehan's syndrome - the stroke of 'the hormone control centre' on the under surface of the brain, called the pituitary. PubMed.gov 'Sheehan's in modern times: a nationwide retrospective study Iceland 2011'.


Finger tip 'Antenatal Perineal Massage' or 'Birth Canal Widening' to 10 cm diameter, affords mothers worldwide, irrespective of income, the opportunity to shorten the critical last 30 minutes of labour [ 8 ]  and improve APGAR score of baby at birth. [ 9 ]  Mothers with a narrowed opening in their bony pelvis, whether from being born with an abnormally narrow pelvis, from previous fracture or from deformity secondary to infection in the bone (osteomyelitis) or very large baby because of gestational diabetes during the pregnancy, or with conjoint twins, may need surgical intervention, as indicated by a failure to progress either when the baby's head fails to enter the bony pelvis or develops fetal distress.


A  perineal tear  is a laceration of the skin and other soft tissue structures which, in women, separate the vagina from the anus. Perineal tears mainly occur in women as a result of vaginal  childbirth , which strains the  perineum . It is the most common form of  obstetric injury . [ 1 ]  Tears vary widely in severity. The majority are superficial and may require no treatment, but severe tears can cause significant bleeding, long-term pain or dysfunction. A perineal tear is distinct from an  episiotomy , in which the perineum is intentionally incised to facilitate delivery. Episiotomy, a very rapid birth, or large fetal size can lead to more severe tears which may require surgical intervention.


In women, an anatomical area known as the perineum separates the opening of the vagina from that of the anus. Each opening is surrounded by a wall, and the anal wall is separated from the vaginal wall by a mass of soft tissue including:


A perineal tear may involve some or all of these structures, which normally aid in supporting the pelvic organs and maintaining faecal continence. [ 3 ]


Tears are classified into four categories: [ 4 ] [ 5 ]


In humans and some other primates, the head of the term fetus is so large in comparison to the size of the birth canal that  delivery may result in some degree of trauma. [ 7 ]
As the head passes through the pelvis, the soft tissues are stretched and compressed. The risk of severe tear is greatly increased if the fetal head is oriented occiput posterior (face forward), if the mother has not given birth before or if the fetus is large. [ 8 ]


A surgical incision on the perineum skin called an  episiotomy  was historically used routinely in order to reduce perineal tears. [ 9 ]  However, its routine use has declined as there is some evidence it increases the severity of tears when it is not indicated. [ 10 ]  A  Cochrane  review found that routine use of episiotomy increased the incidence of severe perineal tears by 30%. [ 11 ]


Several other techniques are used to reduce the risk of tearing, but with little evidence for efficacy. Antenatal digital perineal massage is often advocated, and may reduce the risk of trauma only in nulliparous women. [ 12 ]  Hands-on techniques employed by midwives, in which the foetal head is guided through the vagina at a controlled rate have been widely advocated, but their efficacy is unclear. [ 13 ]   Water birth  and labouring in water are popular for several reasons, and it has been suggested that by softening the perineum they might reduce the rate of tearing. However, this effect has never been clearly demonstrated. [ 14 ]


Perineal protection is an obstetric measure to prevent the perineal tissue from tearing (perineal tear) during the birth of the baby's head or to keep the extent of the injury as small as possible. The midwife (or obstetrician) supports the perineal tissue with one hand as soon as the head stretches. The other hand rests on the baby's head and regulates its speed of passage (so-called head brake). At the same time, the woman giving birth is guided to push along slowly and in a well-dosed manner. This allows the head to be born slowly over the perineum, which thus has enough time to stretch. [ 16 ]  Warm compresses held against the perineum during the second stage of labor can reduce the risk of tearing. [ 17 ]


Treatment is to either let the tear heal naturally or to surgically repair it. Third- and fourth-degree tears generally require surgical repair. A Cochrane review of comparing surgical treatment with natural healing of first- and second-degree tears found no to little difference between the two treatment options. The review concluded that there was insufficient evidence to recommend either treatment option over the other for first- and second-degree tears. [ 1 ]


A 2008 study found that over 85% of women having a vaginal birth sustain some form of perineal trauma. [ 18 ]  A retrospective study of 8,603 vaginal deliveries in 1994 found a third-degree tear had been clinically diagnosed in only 50 women (0.6%). [ 19 ]  However, when the same authors used anal  endosonography  in a consecutive group of 202 deliveries, there was evidence of third-degree tears in 35% of first-time mothers and 44% of mothers with previous children. [ 20 ]  These numbers are confirmed by other researchers in 1999. [ 21 ]


A study by the Agency for Healthcare Research and Quality (AHRQ) found that in 2011, first- and second-degree perineal tear was the most common complicating condition for vaginal deliveries in the U.S. among women covered by either private insurance or Medicaid. [ 22 ]


Second-degree perineal laceration rates were higher for women covered by private insurance than for women covered by Medicaid. [ 23 ]


First- and second-degree tears rarely cause long-term problems. Among women who experience a third- or fourth-degree tear, 60–80% are asymptomatic after 12 months. [ 24 ]  Faecal incontinence, faecal urgency, chronic perineal pain, pain with sex, and fistula formation occur in a minority of women, but may be permanent. [ 25 ]  The symptoms associated with perineal tear are not always due to the tear itself, since there are often other injuries, such as avulsion of pelvic floor muscles, that are not evident on examination. [ 26 ]


There are claims that sometimes the perineum is excessively repaired after childbirth using a so-called " husband stitch " and that this can increase vaginal tightness or result in pain during intercourse. [ 27 ]


A  Kegel perineometer  or  vaginal manometer  is an instrument for measuring the strength of voluntary contractions of the  pelvic floor muscles .   Arnold Kegel  (1894–1972) was the gynecologist who invented the Kegel perineometer (used for measuring vaginal air pressure) and  Kegel exercises  (squeezing of the muscles of the pelvic floor).  This followed the observation that muscles of the pelvic floor inevitably weakened following the trauma of  childbirth . [ 1 ]   Ascertaining the air pressure inside the  vagina  by insertion of a perineometer, while requesting the woman to squeeze as hard as possible, indicates whether or not she would benefit from strengthening the vaginal muscles using the Kegel exercises.  More modern electromyograph ( EMG ) perineometers, which measure electrical activity in the pelvic floor muscles, may be more effective in this purpose. [ 2 ]   Assessment of pelvic floor strength during gynaecological examination may help to identify women with fascial defects of the  pelvic floor , as well as those at risk of genital  prolapse  or  urinary incontinence .  Both the Kegel perineometer and a digital examination are effective and concordant in their results in this assessment. [ 3 ]


Placental expulsion  (also called  afterbirth ) occurs when the  placenta  comes out of the  birth canal  after  childbirth . The time between the expulsion of the baby and the expulsion of the placenta is called the third stage of labor.


Third stage of labor can be managed actively with several standard procedures, or it can be managed expectantly, also known as physiological management or passive management. The latter allows for the placenta to be expelled without medical assistance.


Although uncommon, in some countries such as the United States, Germany, France, Australia and the United Kingdom, [ 1 ]  the placenta is kept and consumed by the mother over the weeks following the birth. This practice is termed  human placentophagy  and can be harmful. [ 2 ]


As the fetal  hypothalamus  matures, activation of the  hypothalamic–pituitary–adrenal (HPA) axis  initiates labor through two hormonal mechanisms. The end pathway of both mechanisms lead to contractions in the  myometrium , a mechanical cause of placental separation, which is due to the sheer force and contractile and involutive changes that occur within the  uterus , distorting the placentome.


ACTH  increases fetal  cortisol , which acts by two mechanisms:


PTGS in turn produces  prostaglandin E2 , which is a catalyst for  pregnenolone  to C-19 steroids, such as  estrogen . Estrogen increases:


As the HPA axis activates, the  posterior pituitary  of the fetus begins to increase production of oxytocin, which stimulates the maternal  myometrium  to contract.


In the seventh month of pregnancy, the  MHC-I complexes  increase in the interplacentomal arcade reduces the bi- and tri-nucleate cells, a source of immune suppression in pregnancy. By the ninth month, the  endometrial lining  has thinned (due to loss of trophoblast giant cells) which exposes the endometrium directly to the fetal trophoblast epithelium. With this exposure and the increase in maternal MHC-I,  T-helper 1 (Th1) cells , and  macrophages  induce apoptosis of trophoblast cells and endometrial epithelial cells, facilitating placental release. Th1 cells attract an influx of phagocytic leukocytes into the placentome at separation, allowing further degradation of the extracellular matrix.


After delivery, loss of fetal blood return to the placenta allows for shrinkage and collapse of the  cotyledonary  villi with subsequent fetal membrane separation. [ 3 ]


Methods of active management include  umbilical cord clamping , stimulation of uterine contraction and cord traction.


Active management routinely involves clamping of the  umbilical cord , often within seconds or minutes of birth.


Uterine contraction  assists in delivering the placenta. Uterine contraction reduces the placental surface area, often forming a temporary  hematoma  at their former interface. Myometrial contractions can be induced with medication, usually  oxytocin  via intramuscular injection. The use of  ergometrine , on the other hand, is associated with nausea or vomiting and hypertension. [ 4 ]


Breastfeeding  soon after birth stimulates oxytocin which increases uterine tone, and through physical mechanisms uterine massage (targeting the  fundus ) also causes uterine contractions.


Controlled cord traction (CCT) consists of pulling on the umbilical cord while applying counter pressure to help deliver the placenta. [ 5 ]  It may be uncomfortable for the mother. Its performance requires specific training. Premature cord traction can pull the placenta before it has naturally detached from the uterine wall, resulting in hemorrhage. Controlled cord traction requires the immediate clamping of the  umbilical cord .


A  Cochrane review  came to the results that controlled cord traction does not clearly reduce severe postpartum hemorrhage (defined as blood loss >1000 mL) but overall resulted in a small reduction in postpartum hemorrhage (defined as blood loss >500 mL) and mean blood loss. It did reduce the risk of manual placenta removal. The review concluded that use of controlled cord traction should be recommended if the care provider has the skills to administer it safely. [ 5 ]


Manual placenta removal is the evacuation of the placenta from the uterus by hand. [ 6 ]  It is usually carried out under  anesthesia  or more rarely, under  sedation  and  analgesia . A hand is inserted through the  vagina  and  cervix  into the uterine cavity and the placenta is detached from the uterine wall and then removed manually. A placenta that does not separate easily from the uterine surface indicates the presence of  placenta accreta .


A  Cochrane database  study [ 4 ]  suggests that blood loss and the risk of  postpartum bleeding  will be reduced in women offered active management of the third stage of labour. A summary [ 7 ]  of the Cochrane study came to the results that active management of the third stage of labour, consisting of controlled cord traction, early cord clamping plus drainage, and a prophylactic oxytocic agent, reduced postpartum haemorrhage by 500 or 1000 mL or greater, as well as related morbidities including mean blood loss, incidences [ spelling? ]  of postpartum haemoglobin becoming less than 9 g/dL, blood transfusion, need for supplemental iron postpartum, and length of third stage of labour. Although active management increased adverse effects such as nausea, vomiting, and headache, women were less likely to be dissatisfied. [ 7 ]


A  retained placenta  is a placenta that does not undergo expulsion within a normal time limit. Risks of retained placenta include hemorrhage and infection. If the placenta fails to deliver in 30 minutes in a hospital environment, manual extraction may be required if heavy ongoing bleeding occurs. Very rarely, a  curettage  is necessary to ensure that no remnants of the placenta remain (in conditions with very adherent placenta,  placenta accreta ). However, in birth centers and attended home birth environments, it is common for licensed care providers to wait for the placenta's birth up to 2 hours in some instances [ citation needed ]


In most mammalian species, the mother bites through the cord and consumes the placenta, primarily for the benefit of  prostaglandin  on the uterus after birth. [ citation needed ]  This is known as  placentophagy . However, it has been observed in zoology that chimpanzees apply themselves to nurturing their offspring, and keep the fetus, cord, and placenta intact until the cord dries and detaches the next day.


The placenta exists in most mammals and some reptiles. It is likely  polyphyletic , having arisen separately in evolution rather than being inherited from one distant common ancestor. [ citation needed ]


Studies on pigs indicate that the duration of placenta expulsion increases significantly with increased duration of  farrowing . [ 8 ]


In  obstetrics ,  position  is the orientation of the  fetus  in the  womb , identified by the location of the  presenting part  of the fetus relative to the  pelvis  of the mother. Conventionally, it is the position assumed by the fetus before the process of birth, as the fetus assumes various positions and postures during the course of  childbirth .


Depending upon which part of the fetus is expected to be delivered first (fetal presentation), there are many possible positions:


Posterior shoulder  in  obstetrics  refers to the shoulder of the  fetus  other than the  anterior shoulder . Thus, the posterior shoulder faces the  rectum  of the mother during delivery. Whether left or the right shoulder becomes the posterior shoulder is dependent upon the original  position  of the fetus.
It is known as the posterior shoulder as it faces the  posterior  of the mother. This distinction between the anterior and the posterior shoulder is important as the anterior shoulder is delivered first. [ 1 ]


The  postpartum (or postnatal) period  begins after  childbirth  and is typically considered to last for six weeks. [ 1 ]  There are three distinct  phases of the postnatal period; the acute phase, lasting for six to twelve hours after birth; the subacute phase, lasting six weeks; and the delayed phase, lasting up to six months. During the delayed phase, some changes to the  genitourinary  system take much longer to resolve and may result in conditions such as  urinary incontinence .  The  World Health Organization  (WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most  maternal  and  newborn deaths  occur during this period. [ 2 ]


In scientific literature, the term is commonly abbreviated to  P x , where  x  is a number; for example, "day P5" should be read as "the fifth day after birth". This is not to be confused with the medical nomenclature that uses G P to stand for number and outcomes of pregnancy ( gravidity and parity ).


A woman giving birth may leave as soon as she is medically stable, which can be as early as a few hours postpartum, though the average for  a vaginal birth  is one to two days. The average  caesarean section  postnatal stay is three to four days. [ 3 ]  During this time, the mother is monitored for bleeding, bowel and bladder function, and baby care. The infant's health is also monitored. [ 4 ]   Early postnatal hospital discharge  is typically defined as discharge of the mother and newborn from the hospital within 48 hours of birth.


The postpartum period can be divided into three distinct stages; the initial or acute phase, 8–19 hours after childbirth; subacute postpartum period, which lasts two to six weeks, and the delayed postpartum period, which can last up to six months. [ 5 ]  In the subacute postpartum period, 87% to 94% of women report at least one health problem. [ 6 ] [ 7 ]  Long-term health problems (persisting after the delayed postpartum period) are reported by 31% of women. [ 8 ]


Various organizations recommend routine postpartum evaluation at certain time intervals in the postpartum period. [ 9 ]


The first 6 to 12 hours after childbirth is the initial or acute phase of the postpartum period. [ 10 ]  During this time the mother is typically monitored by nurses or midwives as complications can arise.


The greatest health risk in the acute phase is  postpartum bleeding . Following delivery the area where the placenta was attached to the uterine wall bleeds, and the uterus must contract to prevent blood loss. After contraction takes place the fundus (top) of the uterus can be palpated as a firm mass at the level of the navel. It is important that the uterus remains firm and the nurse or midwife will make frequent assessments of both the fundus and the amount of bleeding. Uterine massage is commonly used to help the uterus contract. [ 11 ]


Following delivery if the mother had an  episiotomy [ 12 ]  or tearing at the opening of the vagina, it is stitched.  In the past, an episiotomy was routine. However, more recent research shows that routine episiotomy, when a normal delivery without complications or instrumentation is anticipated, does not offer benefits in terms of reducing perineal or vaginal trauma. Selective use of episiotomy results in less perineal trauma. [ 13 ]  A healthcare professional can recommend comfort measures to help to ease  perineal  pain. [ 11 ]


Within about 10 seconds the infant takes its first breath and the caregiver places the baby on the mother's chest.  The infant's condition is evaluated using the  Apgar scale . [ 14 ]   The Apgar score is determined by evaluating the newborn baby on five criteria which are summarized using words chosen to form an acronym (Appearance, Pulse,  Grimace , Activity, Respiration). Until recently babies were routinely removed from their mothers following birth; however beginning around 2000, some authorities began to suggest that early skin-to-skin contact (placing the naked baby on the mother's chest) is of benefit to both mother and infant. As of 2014, early skin-to-skin contact, also called  kangaroo care , is endorsed by all major organizations that are responsible for the well-being of infants. Thus, to help establish bonding and successful  breastfeeding , the caregiver carries out immediate mother and infant assessments as the infant lies on the mother's chest and removes the infant for further observations only after they have had their first breastfeed, depending on the mother's preference.  The World Health Organization (WHO) also encourages skin-to-skin contact for the first 24 hours after birth to help regulate the baby's temperature. [ 15 ]


The subacute postpartum starts after the acute postpartum period concludes and can last for two to six weeks. [ 10 ]


In the first few days following childbirth, the risk of a  deep vein thrombosis  (DVT) is relatively high as  hypercoagulability increases during pregnancy  and is maximal in the postpartum period, [ 16 ]  particularly for women with C-section with reduced mobility.  Anti-coagulants  or physical methods such as  compression  may be used in the hospital, particularly if the woman has risk factors, such as obesity, prolonged immobility, recent C-section, or first-degree relative with a history of  thrombotic episode . For women with a history of thrombotic event in pregnancy or prior to pregnancy, anticoagulation is generally recommended. [ 17 ]


The increased  vascularity  (blood flow) and  edema  (swelling) of the woman's vagina gradually resolves in about three weeks. [ citation needed ]  The  cervix  gradually narrows and lengths over a few weeks. [ 18 ]   Postpartum infections  can lead to  sepsis  and if untreated, death. [ 19 ]  Postpartum  urinary incontinence  is experienced by about 33% of all women; women who deliver vaginally are about twice as likely to have urinary incontinence as women who give birth via a cesarean. [ 20 ]  Urinary incontinence in this period increases the risk of long term incontinence. [ 10 ]  In the subacute postpartum period, 87% to 94% of women report at least one health problem. [ 6 ] [ 7 ]
 Kegel exercises  are recommended to strengthen the pelvic floor muscles and control urinary incontinence. [ 21 ]


Discharge from the uterus, called  lochia , will gradually decrease and turn from bright red, to brownish, to yellow and cease at around five or six weeks. Women are advised in this period to wear  adult diapers  or nappies, disposable maternity briefs, maternity pads or towels, or  sanitary napkins . The use of  tampons  or  menstrual cups  are contraindicated as they may introduce bacteria and increase the risk of infection. [ 22 ]  An increase in lochia between 7–14 days postpartum may indicate delayed postpartum  hemorrhage . [ 23 ]


Hemorrhoids  and  constipation  in this period are common, and  stool softeners  are routinely given. [ 24 ]  If an episiotomy or perineal tear had to be sutured, the use of a  donut pillow  allows the woman to sit pain-free or at least with reduced pain.


Some women feel uterine contractions, called afterpains, during the first few days after delivery.  They have been described as similar to menstrual cramps and are more common during breastfeeding, due to the release of  oxytocin .  The cramping is the  compressing of the blood vessels in the uterus to prevent bleeding. [ 25 ]


At two to four days postpartum, a woman's  breastmilk  will generally come in. [ 26 ]  Historically, women who were not  breastfeeding  (nursing their babies) were given drugs to  suppress lactation , but this is no longer medically indicated. In this period,  difficulties with breastfeeding  may arise. Maternal sleep is often disturbed as night waking is normal in the newborn, and newborns need to be fed every two to three hours, including during the night. [ 27 ]  The  lactation consultant ,  health visitor ,  monthly nurse , postnatal  doula , or  kraamverzorgster  may be of assistance at this time.


During the subacute postpartum period, psychological disorders may emerge. Among these are  postpartum depression ,  posttraumatic stress disorder , and in rare cases,  postpartum psychosis . [ 28 ]  Postpartum mental illness can affect both mothers and fathers, and is not uncommon. [ 29 ]  Early detection and adequate treatment is required. Approximately 70–80% of postpartum women will experience the "baby blues" for a few days. Between 10 and 20 percent may experience clinical depression, with a higher risk among those women with a history of postpartum depression, clinical depression, anxiety, or other mood disorders. [ 30 ]  Prevalence of PTSD following normal childbirth (excluding stillbirth or major complications) is estimated to be between 2.8% and 5.6% at six weeks postpartum. [ 31 ]


Various organizations across the world recommend routine postpartum evaluation in the postpartum period. The  American College of Obstetricians and Gynecologists  (ACOG) recognizes the postpartum period (the "fourth trimester") as critical for women and infants. Instead of the traditional single four- to six-week postpartum visit, ACOG, as of 2018, recommends that  postpartum care  be an ongoing process. They recommend that all women have contact (either in person or by phone) with their obstetric provider within the first three weeks postpartum to address acute issues, with subsequent care as needed.  A more comprehensive postpartum visit should be done at four to twelve weeks postpartum to address the mother's mood and emotional well-being, physical recovery after birth, infant feeding, pregnancy spacing and  contraception , chronic disease management, and  preventive health care  and health maintenance. Results of a 2023 systematic review of the evidence suggests a relationship between having sufficient health insurance and attendance at follow-up postpartum care visits that may prevent additional needs for preventable care. [ 32 ]


Women with  hypertensive disorders  should have a blood pressure check within three to ten days postpartum. A 2023 systematic review of the literature suggests monitoring the blood pressure at home of women in the postpartum period appears to help with overall blood pressure measures and supports overall patient satisfaction. [ 33 ]  More than one half of postpartum  strokes  occur within ten days of discharge after delivery. Women with chronic medical (e.g., hypertensive disorders,  diabetes ,  kidney disease ,  thyroid disease ) and psychiatric conditions should continue to follow with their obstetric or primary care provider for ongoing disease management. Women with pregnancies complicated by hypertension,  gestational diabetes , or  preterm birth  should undergo counseling and evaluation for cardiometabolic disease, as lifetime risk of  cardiovascular disease  is higher in these women. [ 9 ]


Similarly, the  World Health Organization  recommends postpartum evaluation of the mother and infant at three days, one to two weeks, and six weeks postpartum. [ 9 ]


The delayed postpartum period starts after the subacute postpartum period and lasts up to six months. [ 10 ]  During this time, muscles and connective tissue returns to a pre-pregnancy state. Recovery from childbirth complications in this period, such as urinary and  fecal incontinence ,  painful intercourse , and  pelvic prolapse , are typically very slow and in some cases may not resolve. [ 10 ]  Symptoms of PTSD often subside in this period, dropping from 2.8% and 5.6% at six weeks postpartum to 1.5% at six months postpartum. [ 31 ] [ 34 ]   During this period, infant sleep during the night gradually increases and maternal sleep generally improves. [ 27 ]


Approximately three months after giving birth (typically between two and five months),  estrogen  levels drop and large amounts of  hair loss  is common, particularly in the  temple  area (postpartum alopecia). Hair typically grows back normally and treatment is not indicated. [ 35 ] [ 36 ]


Many factors figure into the likelihood of post natal problems including the size of the infant; the method of delivery, such as c-section, or of forceps; perineum trauma from either an  episiotomy  or natural tearing; and the physical condition of the birth mother. Conditions that may result from childbirth include  uterine prolapse ,  cystocele ,  rectocele ,  fecal incontinence , and  urinary incontinence . [ 37 ]   Other conditions that may also arise in this period include  postpartum thyroiditis .  Long-term health problems (persisting after the delayed postpartum period) are reported by 31% of women. [ 8 ]


Ongoing physical and mental health evaluation, risk factor identification, and preventive health care should be provided  (see  § Maternal-infant postpartum evaluation ) .


The  American College of Obstetricians and Gynecologists  (ACOG) recommends women take at least six weeks off work following childbirth.  In the U.S., the only national maternity leave provision is covered by the  Family and Medical Leave Act  (FMLA), which entitles new parents to up to 12 weeks of unpaid leave. However, 60% of new parents are unable to afford taking unpaid leave for six weeks.  According to U.S. Department of Labor statistics, only 17% have access to paid leave. [ 38 ]


The  National Partnership for Women & Families , an organization that works to promote the wellbeing of women and families, says "the benefits of paid family leave in states that have introduced it include improved worker morale, time for parents to bond with their children, increased breastfeeding, more children getting vaccinations on time, cuts in children’s hospital admissions and reduced probabilities of having ADHD and hearing problems." [ 38 ]


The United States is the only country in the  Organisation for Economic Co-operation and Development  (OECD) that does not provide paid maternity, paternity, and parental leave.  Thirteen countries, including eight of the European countries and Colombia, Costa Rica, Chile, Argentina and Mexico offer at least three months of equivalent pay. [ 39 ]


Postpartum confinement refers to a system for recovery following childbirth. It begins immediately after the birth, and lasts for a culturally variable length: typically for one month or 30 days, [ 40 ]  up to 40 days, two months or 100 days. [ 41 ]  This postnatal recuperation can include "traditional health beliefs, taboos, rituals, and proscriptions." [ 42 ]  The practice used to be known as " lying-in ", which, as the term suggests, centres around  bed rest . ( Maternity hospitals  used to use this phrase, as in the  General Lying-in Hospital .) Postpartum confinement customs are well-practiced in China, where it is known as "sitting the month", [ 43 ]  and similar customs manifest all over the world. A modern version of this rest period has evolved, to give maximum support to the new mother. [ 43 ]


Pregnancy  is the time during which one or more  offspring  develops ( gestates ) inside a  woman 's  uterus  (womb). [ 4 ] [ 13 ]  A  multiple pregnancy  involves more than one offspring, such as with  twins . [ 14 ]


Pregnancy usually occurs by  sexual intercourse , but can also occur through  assisted reproductive technology  procedures. [ 6 ]  A pregnancy may end in a  live birth , a  miscarriage , an  induced abortion , or a  stillbirth .  Childbirth  typically occurs around 40 weeks from the start of the  last menstrual period  (LMP), a span known as the  gestational age . [ 4 ] [ 5 ]  This is just over nine months. Counting by  fertilization age , the length is about 38 weeks. [ 5 ] [ 13 ]  Pregnancy is "the presence of an implanted human embryo or fetus in the uterus";  implantation  occurs on average 8–9 days after fertilization. [ 15 ]  An  embryo  is the term for the developing offspring during the first seven weeks following implantation (i.e. ten weeks' gestational age), after which the term  fetus  is used until birth. [ 5 ]


Signs and symptoms of early pregnancy  may include  missed periods , tender breasts,  morning sickness  (nausea and vomiting), hunger,  implantation bleeding , and frequent urination. [ 1 ]  Pregnancy may be confirmed with a  pregnancy test . [ 7 ]  Methods of  birth control —or, more accurately,  contraception —are used to avoid pregnancy.


Pregnancy is divided into three trimesters of approximately three months each. The  first trimester  includes conception, which is when the sperm fertilizes the egg. The  fertilized egg  then travels down the  fallopian tube  and attaches to the inside of the  uterus , where it begins to form the  embryo  and  placenta . During the first trimester, the possibility of miscarriage (natural death of embryo or fetus) is at its highest. Around the middle of the second trimester, movement of the fetus may be felt. At 28 weeks, more than 90% of babies can  survive outside of the uterus  if  provided with high-quality medical care , though babies born at this time will likely experience serious health complications such as heart and respiratory problems and long-term intellectual and developmental disabilities.


Prenatal care  improves pregnancy outcomes. [ 9 ]   Nutrition  during pregnancy is important to ensure healthy growth of the fetus. [ 16 ]   Prenatal care may also include avoiding  recreational drugs  (including  tobacco  and  alcohol ), taking regular exercise, having  blood tests , and regular  physical examinations . [ 9 ]   Complications of pregnancy  may include  disorders of high blood pressure ,  gestational diabetes ,  iron-deficiency anemia , and  severe nausea and vomiting . [ 3 ]  In the ideal childbirth, labor begins on its own "at term". [ 17 ]  Babies born before 37 weeks are " preterm " and at higher risk of health problems such as  cerebral palsy . [ 4 ]  Babies born between weeks 37 and 39 are considered "early term" while those born between weeks 39 and 41 are considered "full term". [ 4 ]  Babies born between weeks 41 and 42 weeks are considered "late-term" while after 42 weeks they are considered " post-term ". [ 4 ]   Delivery  before 39 weeks by  labor induction  or  caesarean section  is not recommended unless required for other medical reasons. [ 18 ]


Associated terms for pregnancy are  gravid  and  parous .  Gravidus  and  gravid  come from the  Latin  word meaning "heavy" and a pregnant female is sometimes referred to as a  gravida . [ 19 ]   Gravidity  refers to the number of times that a female has been pregnant. Similarly, the term  parity  is used for the number of times that a female carries a pregnancy to a  viable stage . [ 20 ]   Twins  and other multiple births are counted as one pregnancy and birth.


A woman who has never been pregnant is referred to as a  nulligravida.  A woman who is (or has been only) pregnant for the first time is referred to as a  primigravida , [ 21 ]  and a woman in subsequent pregnancies as a  multigravida  or as  multiparous. [ 19 ] [ 22 ]  Therefore, during a second pregnancy a woman would be described as  gravida 2, para 1  and upon live delivery as  gravida 2, para 2.  In-progress pregnancies,  abortions ,  miscarriages  and/or  stillbirths  account for parity values being less than the gravida number. Women who have never carried a pregnancy more than 20 weeks are referred to as  nulliparous . [ 23 ]


A pregnancy is considered  term  at 37 weeks of gestation. It is  preterm  if less than 37 weeks and  postterm  at or beyond 42 weeks of gestation. American College of Obstetricians and Gynecologists have recommended further division with  early term  37 weeks up to 39 weeks,  full term  39 weeks up to 41 weeks, and  late term  41 weeks up to 42 weeks. [ 24 ]  The terms  preterm  and  postterm  have largely replaced earlier terms of  premature  and  postmature .  Preterm  and  postterm  are defined above, whereas  premature  and  postmature  have historical meaning and relate more to the infant's size and state of development rather than to the stage of pregnancy. [ 25 ] [ 26 ]


About 213 million pregnancies occurred in 2012, of which, 190 million (89%) were in the  developing world  and 23 million (11%) were in the developed world. [ 11 ]  The number of pregnancies in women aged between 15 and 44 is 133 per 1,000 women. [ 11 ]  About 10% to 15% of recognized pregnancies end in  miscarriage . [ 2 ]  In 2016,  complications of pregnancy  resulted in 230,600  maternal deaths , down from 377,000 deaths in 1990. [ 12 ]  Common causes include  bleeding ,  infections ,  hypertensive diseases of pregnancy ,  obstructed labor , miscarriage, abortion, or  ectopic pregnancy . [ 12 ]  Globally, 44% of pregnancies are  unplanned . [ 27 ]  Over half (56%) of unplanned pregnancies are aborted. [ 27 ]  Among unintended pregnancies in the United States, 60% of the women used  birth control  to some extent during the month pregnancy began. [ 28 ]


The usual  signs and symptoms of pregnancy  do not significantly interfere with  activities of daily living  or pose a health-threat to the  mother  or baby. However,  pregnancy complications  can cause other more severe symptoms, such as those associated with  anemia .


Common signs and symptoms of pregnancy include:


(from the start of the  last menstrual period )