Assessments/Interventions: Dry neonate immediately after birth and initiate skin-to-skin contact. Provide warm blankets and a hat. Utilize a radiant warmer if skin-to-skin is not appropriate. Frequently monitor axillary body temperature. Limit neonate's exposure during diaper changes and assessments.


NM_001134 NM_001354717


NP_001125 NP_001341646


Alpha-fetoprotein  ( AFP ,  α-fetoprotein ; also sometimes called  alpha-1-fetoprotein ,  alpha-fetoglobulin , or  alpha fetal protein ) is a  protein [ 5 ] [ 6 ]  that in humans is encoded by the  AFP   gene . [ 7 ] [ 8 ]  The  AFP  gene is located on the  q  arm of  chromosome 4  (4q13.3). [ 9 ]  Maternal AFP serum level is used to screen for  Down syndrome ,  neural tube defects , and other  chromosomal abnormalities . [ 10 ]


AFP is a major  plasma protein  produced by the  yolk sac  and the fetal liver during fetal development. It is thought to be the fetal analog of  serum albumin . AFP  binds to copper ,  nickel ,  fatty acids  and  bilirubin [ 8 ]  and is found in  monomeric ,  dimeric  and  trimeric  forms.


AFP is a  glycoprotein  of 591 amino acids [ 11 ]  and a carbohydrate  moiety . [ 12 ]


The function of AFP in adult humans is unknown. AFP is the most abundant plasma protein found in the human fetus. In the fetus, AFP is produced by both the liver and the yolk sac. It is believed to function as a carrier protein (similar to albumin) that transports materials such as fatty acids to cells. [ 13 ]  Maternal plasma levels peak near the end of the first trimester, and begin decreasing prenatally at that time, then decrease rapidly after birth. Normal adult levels in the newborn are usually reached by the age of 8 to 12 months. While the function in humans is unknown, in rodents it binds  estradiol  to prevent the transport of this hormone across the  placenta  to the fetus. The main function of this is to prevent the  virilization  of female fetuses. As human AFP does not bind estrogen, its function in humans is less clear. [ 14 ]  In human liver cancer, AFP is found to bind glypican-3 (GPC3), another oncofetal antigen. [ 15 ]


The rodent AFP system can be overridden with massive injections of estrogen, which overwhelm the AFP system and will masculinize the fetus. The masculinizing effect of estrogens may seem counter-intuitive since estrogens are critical for the proper development of female secondary characteristics during puberty. However, this is not the case prenatally.  Gonadal hormones  from the testes, such as  testosterone  and  anti-Müllerian hormone , are required to cause development of a phenotypic male. Without these hormones, the fetus will develop into a phenotypic female even if genetically  XY . The conversion of testosterone into estradiol by  aromatase  in many tissues may be an important step in masculinization of that tissue. [ 16 ] [ 17 ]  Masculinization of the brain is thought to occur both by conversion of testosterone into estradiol by aromatase, but also by  de novo synthesis  of estrogens within the brain. [ 18 ] [ 19 ]  Thus, AFP may protect the fetus from maternal estradiol that would otherwise have a masculinizing effect on the fetus, but its exact role is still controversial.


In pregnant women, fetal AFP levels can be monitored in the urine of the pregnant woman. Since AFP is quickly cleared from the mother's serum via her kidneys, maternal urine AFP correlates with fetal serum levels, although the maternal urine level is much lower than the fetal serum level. AFP levels rise until about week 32. Maternal serum alpha-fetoprotein (MSAFP) screening is performed at 16 to 18 weeks of gestation. [ 20 ]  If MSAFP levels indicate an anomaly,  amniocentesis  may be offered to the patient.


The normal range of AFP for adults and children is variously reported as under 50, under 10, or under 5 ng/mL. [ 21 ] [ 22 ]  At birth, normal infants have AFP levels four or more orders of magnitude above this normal range, that decreases to a normal range over the first year of life. [ 23 ] [ 24 ] [ 25 ] [ 26 ] [ 27 ] [ 28 ]


During this time, the normal range of AFP levels spans approximately two orders of magnitude. [ 25 ]  Correct evaluation of  abnormal  AFP levels in infants must take into account these normal patterns. [ 25 ]


Very high AFP levels may be subject to hooking (see  Tumor marker ), which results in the level being reported significantly lower than the actual concentration. [ 29 ]  This is important for analysis of a series of AFP tumor marker tests, e.g. in the context of post-treatment early surveillance of cancer survivors, where the rate of decrease of AFP has diagnostic value.


Measurement of AFP is generally used in two clinical contexts. First, it is measured in pregnant women through the analysis of maternal  blood  or  amniotic fluid  as a  screening test  for certain developmental abnormalities, such as  aneuploidy . Second, serum AFP level is elevated in people with certain tumors, and so it is used as a  biomarker  to follow these diseases. Some of these diseases are listed below:


A peptide derived from AFP that is referred to as  AFPep  is claimed to possess anti-cancer properties. [ 36 ]


In the treatment of  testicular cancer  it is paramount to differentiate  seminomatous  and  nonseminomatous  tumors. This is typically done pathologically after removal of the testicle and confirmed by tumor markers. However, if the pathology is pure  seminoma , if the AFP is elevated, the tumor is treated as a nonseminomatous tumor because it contains yolk sac (nonseminomatous) components. [ 37 ]


This article incorporates text from the  United States National Library of Medicine , which is in the  public domain .


The  amniotic fluid  is the protective liquid contained by the  amniotic sac  of a  gravid   amniote .  This fluid serves as a cushion for the growing  fetus , but also serves to facilitate the exchange of nutrients, water, and biochemical products between mother and fetus.


For humans, the amniotic fluid is commonly called  water  or  waters  (Latin  liquor amnii ).


Amniotic fluid is present from the formation of the  gestational sac . Amniotic fluid is in the  amniotic sac . It is generated from maternal  plasma , and passes through the fetal membranes by osmotic and hydrostatic forces. When fetal kidneys begin to function around week 16, fetal urine also contributes to the fluid. [ 1 ]  In earlier times, it was believed that the amniotic fluid was composed entirely of excreted fetal urine.


The fluid is absorbed through the fetal tissue and skin. [ 2 ]  After 22 to 25 week of pregnancy,  keratinization  of an embryo's skin occurs. When this process completes around the 25th week, [ 2 ]  the fluid is primarily absorbed by the fetal gut for the remainder of gestation. [ 1 ]


At first, amniotic fluid is mainly water with  electrolytes , but by about the 12–14th week the liquid also contains  proteins ,  carbohydrates ,  lipids  and  phospholipids ,  urea , and  extracellular matrix  (ECM) components including collagens and  glycosaminoglycans , including  hyaluronic acid  and  chondroitin sulfate , all of which aid in the growth of the fetus.


The volume of amniotic fluid changes with the growth of fetus. From the tenth to the 20th week it increases from 25 to 400 millilitres (0.88 to 14.08 imp fl oz; 0.85 to 13.53 US fl oz) approximately. [ 3 ]  Approximately in the 10th–11th week, the breathing and swallowing of the fetus slightly decrease the amount of fluid. Neither urination nor swallowing contributes significantly to fluid quantity changes until the 25th week when keratinization of skin is complete; then the relationship between fluid and fetal growth stops. It reaches a plateau of 800 millilitres (28 imp fl oz; 27 US fl oz) by the 28-week  gestational age . The amount of fluid declines to roughly 400 millilitres (14 imp fl oz; 14 US fl oz) at 42 weeks. [ 3 ]  Some sources indicate about 500 to 1,000 millilitres (18 to 35 imp fl oz; 17 to 34 US fl oz) of amniotic fluid is present at birth. [ 1 ] [ 4 ]


The forewaters are released when the amnion  ruptures .  This is commonly known as "water breaking." When this occurs during  labour  at  term , it is known as "spontaneous rupture of membranes". If the rupture precedes labour at term, however, it is referred to as "pre-labour rupture of membranes." Spontaneous rupture of membranes before term is referred to as "premature rupture of membranes." The majority of the hindwaters remain inside the womb until the baby is born. Artificial rupture of membrane (ARM), a manual rupture of the amniotic sac, can also be performed to release the fluid if the amnion has not spontaneously ruptured. [ 5 ]


Swallowed amniotic fluid (in later stages of development) creates urine and contributes to the formation of  meconium . Amniotic fluid protects the developing fetus by cushioning against blows to the mother's abdomen, allowing for easier fetal movement and promoting muscular/skeletal development. Amniotic fluid swallowed by the fetus helps in the formation of the gastrointestinal tract.  It also protects the fetus from mechanical jerks and shocks. The fetus, which develops within a fluid-filled amniotic sac, relies on the  placenta  for respiratory gas exchange rather than the lungs. While not involved in fetal oxygenation,  fetal breathing movements (FBM)  nevertheless have an important role in lung growth and in development of respiratory muscles and neural regulation. FBM are regulated differently in many respects than postnatal respiration, which results from the unique intrauterine environment. At birth, the transition to continuous postnatal respiration involves a fall in temperature, gaseous distention of the lungs, activation of the  Hering-Breuer reflex , and functional connectivity of afferent O2  chemoreceptor  activity with respiratory  motoneurons  and arousal centers. [ 6 ]


Amniotic fluid is removed from the mother by an  amniocentesis  procedure, where a long needle is inserted through the abdomen into the amniotic sac, using ultrasound guidance such that the fetus is not harmed. Amniocentesis is a low risk procedure, with risk of pregnancy loss between 1 in 1,500 – 1 in 700 procedures. Amniocentesis can be performed to obtain diagnostic genetic information, evaluate for intrauterine infection, or rarely, to assess for fetal lung maturity if early delivery is required. If warranted, fluid is collected between 16 and 42 weeks of fetal development. The amount of fluid removed depends on the indication for the procedure and the testing that will be performed on the fluid.


Analysis of amniotic fluid can reveal many aspects of the baby's genetic health as well as the age and viability of the fetus. This is because the fluid contains metabolic wastes and compounds used in assessing fetal age and lung maturity, but amniotic fluid also contains fetal cells, which can be examined for genetic defects.


Amniotic fluid normally has a  pH  of 7.0 to 7.5. [ 7 ]  Because pH in the upper vagina is normally acidic (pH 3.8–4.5), a vaginal pH test showing a pH of more than 4.5 strengthens a suspicion of  rupture of membranes  in case of clear  vaginal discharge  in pregnancy. [ 7 ]  Other tests for detecting amniotic fluid mainly include  nitrazine  paper test and  fern test . [ 8 ]  One main test that is performed on amniotic fluid is the L/S ratio test (lecithin/sphingomyelin). This test is used to determine fetal lung maturity. Both lecithin and sphingomyelin are lung surfactants that are present in increasing amounts in the maturing fetus, though past week 33, sphingomyelin levels remain relatively constant. Measuring a ratio of L/S of 2:1 or greater indicates that the fetus can be safely delivered, with functioning lungs.


Too little amniotic fluid is called  oligohydramnios . In a minority of cases, it can be a cause of problems for the mother and baby. These include contracture of the limbs,  clubbing of the feet and hands , and also a life-threatening condition called  hypoplastic lungs . The  Potter sequence  refers to a constellation of findings related to insufficient amniotic fluid.


On every prenatal visit, the obstetrician, gynaecologist or midwife should measure the patient's  fundal height  with a tape measure. It is important that the fundal height be measured and properly recorded to track proper fetal growth and the increasing development of amniotic fluid. The obstetrician, gynaecologist or midwife should also routinely  ultrasound  the patient—this procedure will also give an indication of proper fetal growth and amniotic fluid development. Oligohydramnios can be caused by infection, kidney dysfunction or malformation (since much of the late amniotic fluid volume is urine), procedures such as  chorionic villus sampling  (CVS), and preterm premature rupture of membranes (PPROM). Oligohydramnios can sometimes be treated with  bed rest , oral and intravenous  hydration ,  antibiotics ,  steroids , and amnioinfusion. [ citation needed ]


The opposite of oligohydramnios is  polyhydramnios , an excess volume of amniotic fluid in the amniotic sac.


Amniotic fluid embolism  is a rare but very often fatal condition for both mother and child.


It is being used in some surgeries of the outside of the eye. [ 9 ]  It is also being studied for some orthopaedic conditions. [ 10 ] [ 11 ]


Recent studies show that amniotic fluid contains a considerable quantity of stem cells. [ 12 ]  These  amniotic stem cells [ 13 ] [ 14 ]  are pluripotent and able to differentiate into various tissues, which may be useful for future human application. [ 15 ] [ 16 ] [ 17 ]  Some researchers have found that amniotic fluid is also a plentiful source of non-embryonic  stem cells . [ 18 ]  These cells have demonstrated the ability to differentiate into a number of different cell-types, including brain, liver and bone.


It is possible to conserve the stem cells extracted from amniotic fluid in private stem cells banks.


The  amniotic sac , also called the  bag of waters [ 1 ] [ 2 ]  or the  membranes , [ 3 ]  is the sac in which the  embryo  and later  fetus  develops in  amniotes . It is a thin but tough transparent pair of  membranes  that hold a developing embryo (and later fetus) until shortly before  birth . The inner of these membranes, the  amnion , encloses the  amniotic cavity , containing the  amniotic fluid  and the embryo. The outer membrane, the  chorion , contains the amnion and is part of the  placenta . On the outer side, the amniotic sac is connected to the  yolk sac , the  allantois , and via the  umbilical cord , the  placenta . [ 4 ]


The yolk sac, amnion, chorion, and allantois are the four  extraembryonic membranes  that lie outside of the embryo and are involved in providing nutrients and protection to the developing embryo. [ 5 ]  They form from the  inner cell mass ; the first to form is the yolk sac followed by the amnion which grows over the developing embryo. The amnion remains an important extraembryonic membrane throughout prenatal development. The third membrane is the allantois, and the fourth is the chorion which surrounds the embryo after about a month and eventually fuses with the amnion. [ 6 ]


Amniocentesis  is a medical procedure where fluid from the sac is sampled during  fetal development , between 15 and 20 weeks of pregnancy, to be used in  prenatal diagnosis  of  chromosomal abnormalities  and fetal infections. [ 7 ]


The amniotic cavity is the closed sac between the embryo and the amnion, containing the amniotic fluid. The amniotic cavity is formed by the fusion of the parts of the amniotic fold, which first makes its appearance at the  cephalic  extremity and subsequently at the  caudal  end and sides of the  embryo . As the amniotic fold rises and fuses over the dorsal aspect of the embryo, the amniotic cavity is formed. [ citation needed ]


At the beginning of the second week, a cavity appears within the  inner cell mass , and when it enlarges, it becomes the amniotic cavity. The floor of the amniotic cavity is formed by the  epiblast . Epiblast migrates between the epiblastic disc and trophoblast. In this way the epiblastic cells migrate between the embryoblast and  trophoblast . The floor is formed by the epiblast which later on transforms to  ectoderm  while the remaining cells which are present between the  embryoblast  and trophoblast are called amnioblasts (flattened cells). These cells are also derived from epiblast which is transformed into ectoderm. [ citation needed ]


The amniotic cavity is surrounded by an  extraembryonic membrane , called the amnion. As the implantation of the blastocyst progresses, a small space appears in the embryoblast, which is the primordium of the amniotic cavity. Soon, amniogenic (amnion-forming cells) called  amnioblasts  separate from the epiblast and line the amnion, which encloses the amniotic cavity. [ 8 ]


The epiblast forms the floor of the amniotic cavity and is continuous peripherally with the amnion. The hypoblast forms the roof of the  exocoelomic cavity  and is continuous with the thin exocoelomic membrane. This membrane along with hypoblast forms the primary yolk sac. The embryonic disc now lies between the amniotic cavity and the primary yolk sac. Cells from the yolk sac  endoderm  form a layer of  connective tissue , the extraembryonic  mesoderm , which surrounds the amnion and yolk sac. [ citation needed ]


If, after birth, the complete amniotic sac or big parts of the membrane remain coating the newborn, this is called a  caul .


When seen in the light, the amniotic sac is shiny and very smooth, but tough.


Once the baby is pushed out of the mother's  uterus , the  umbilical cord ,  placenta , and amniotic sac are pushed out in the afterbirth.


The amniotic sac and its filling provide a liquid that surrounds and cushions the fetus. It is a site of exchange of essential substances, such as oxygen, between the umbilical cord and the fetus. [ 9 ]  It allows the fetus to move freely within the walls of the  uterus . [ citation needed ]   Buoyancy  is also provided.


Chorioamnionitis  is inflammation of the amniotic sac ( chorio-  +  amnion  +  -itis ), usually because of  infection . It is a risk factor for  neonatal sepsis .


During  labor , the amniotic sac must break so that the child can  be born . This is known as  rupture of membranes  (ROM). Normally, it occurs spontaneously at full term either during or at the beginning of labor. A  premature rupture of membranes  (PROM) is a rupture of the amnion that occurs prior to the onset of labor. An  artificial rupture of membranes  (AROM), also known as an amniotomy, may be clinically performed using an amnihook or amnicot in order to induce or to accelerate labour.


The amniotic sac has to be punctured to perform  amniocentesis . [ 10 ] [ 11 ]  This is fairly routine procedure, but can lead to infection of the amniotic sac in a very small number of cases. [ 12 ]  Infection more commonly arises vaginally. [ 12 ] [ 13 ]


Antiphospholipid syndrome , or  antiphospholipid antibody syndrome  ( APS  or  APLS ), is an  autoimmune ,  hypercoagulable  state caused by antiphospholipid  antibodies . APS can lead to  blood clots  ( thrombosis ) in both  arteries  and  veins ,  pregnancy-related complications , and other symptoms like low platelets,  kidney disease ,  heart disease , and  rash . Although the exact  etiology  of APS is still not clear,  genetics  is believed to play a key role in the development of the disease. [ 3 ]


Diagnosis is made based on symptoms and testing, but sometimes research criteria are used to aid in diagnosis. The research criteria for definite APS requires one clinical event (i.e. thrombosis or pregnancy complication) and two positive  blood test  results spaced at least three months apart that detect  lupus anticoagulant ,  anti-apolipoprotein antibodies , and/or  anti-cardiolipin antibodies . [ 4 ]


Antiphospholipid syndrome can be primary or secondary.


• Primary antiphospholipid syndrome occurs in the absence of any other related disease.


• Secondary antiphospholipid syndrome occurs with other  autoimmune diseases , such as  systemic lupus erythematosus .


In rare cases, APS leads to rapid organ failure due to generalized thrombosis; this is termed " catastrophic antiphospholipid syndrome " (CAPS or Asherson syndrome) and is associated with a high risk of death. [ 5 ]


Antiphospholipid syndrome often requires treatment with  anticoagulant  medication to reduce the risk of further episodes of  thrombosis  and improve the prognosis of pregnancy. The anticoagulant medication used for treatment may differ depending on the circumstance, such as pregnancy.


Antiphospholipid syndrome is known for causing  arterial  or  venous   blood clots , in any organ system, and  pregnancy -related complications. While blood clots and pregnancy complications are the most common and diagnostic symptoms associated with APS, other organs and body parts may be affected like platelet levels, heart, kidneys, brain, and skin. [ 4 ] [ 6 ]  Also, people with APS may have symptoms associated with other autoimmune diseases like  lupus erythematosus  that are not caused by APS because APS can occur at the same time as other autoimmune diseases.


In APS patients, the most common venous event is  deep vein thrombosis  of the lower extremities, and the most common arterial event is  stroke . [ 7 ]  People with a blot clot in their extremities may experience swelling, pain, or redness in the affected area. [ 8 ]  People experiencing a  stroke  can experience a variety of symptoms depending on what blood vessel in the brain is affected. Symptoms include but are not limited to trouble speaking, loss of sensation, or weakness in one side of the face or body. [ 9 ]  Blood clots can also occur in the  lungs , which may cause trouble breathing or chest pain, and they can occur in the heart, which could lead to a heart attack. [ 6 ]


Blood clots in patients with APS are often considered unprovoked, which means they occur in the absence of conditions that typically cause blood clots (i.e. prolonged sedentary behavior, immoblization, infection, cancer). However, a person can develop a provoked blood clot while having APS due to APS causing an increased risk of blood clot development. [ 6 ]  Exogenous estrogen therapies, such as estrogen-based contraceptives, significantly increase the risk of developing blood clots for patients with APS. [ 10 ]


In pregnant people affected by APS, there is an increased risk of  recurrent miscarriage ,  preterm birth ,  intrauterine growth restriction ,  pre-eclampsia ,  eclampsia . [ 11 ] [ 12 ]  Recurrent miscarriages associated with APS typically occur prior to 10th week of gestation, but miscarriage associated with APS can also occur after the 10th week of gestation. [ 12 ]  Certain causes must be excluded prior to attributing these complications to APS. Also, in pregnant individuals with lupus and antiphospholipid syndrome, antiphospholipid syndrome is responsible for most of the miscarriages in later trimesters. [ 13 ]


Other common findings that suggest APS are  low platelet count ,  heart valve disease , high blood pressure in the lungs, kidney disease, and a rash called  livedo reticularis . [ 6 ]  There are also associations between antiphospholipid antibodies and different neurologic manifestations [ 14 ]  including  headache , [ 15 ]   migraine , [ 16 ]   epilepsy , [ 17 ]  and  dementia [ 18 ]  although more research is needed to prove that these symptoms are indicative of APS. Cancer is also observed to occur at the same time in some patients with APS. [ 19 ]


Antiphospholipid syndrome is an  autoimmune disease , in which "antiphospholipid antibodies" react against  proteins  that bind to  anionic   phospholipids  on  plasma membranes . Anticardiolipin antibodies, β2glycoprotein 1, and lupus anticoagulant are antiphospholipid antibodies that are thought to clinically cause disease. These antibodies lead to blood clots and vascular disease in the presence (secondary APS) or absence (primary APS) of other diseases. [ 20 ]  While the exact functions of the antibodies are not known, the activation of the coagulation system is evident.


Anti-ApoH and a subset of anti-cardiolipin antibodies bind to ApoH. ApoH inhibits  protein C , a  glycoprotein  with important regulatory function of coagulation (inactivates  Factor Va  and  Factor VIIIa ).  Lupus anticoagulant  antibodies bind to  prothrombin , thus increasing its cleavage to  thrombin , its active form. [ citation needed ]


Other antibodies associated with APS include antibodies against protein S and annexin A5.  Protein S  is a  co-factor  of protein C, which is one of the body's own anti-clotting factors.  Annexin A5  forms a shield around negatively charged phospholipid molecules, which reduces the membrane's ability to participate in clotting. Thus, antibodies against protein S and anti-annexin A5 decrease protein C efficiency and  increase phospholipid-dependent coagulation steps respectively, which leads to increased clotting potential. [ 21 ] [ 22 ]


The lupus anticoagulant antibodies are those that show the closest association with thrombosis; those that target  β 2 glycoprotein 1  have a greater association with thrombosis than those that target prothrombin.
Anticardiolipin antibodies are associated with thrombosis at moderate to high titres (over 40 GPLU or MPLU).
Patients with both lupus anticoagulant antibodies and moderate or high titre anticardiolipin antibodies show a greater risk of thrombosis than with one alone. [ citation needed ]


The increased risks of  recurrent miscarriage ,  intrauterine growth restriction  and  preterm birth  by antiphospholipid antibodies, as supported by  in vitro  studies, include decreased  trophoblast  viability, syncytialization and invasion, deranged production of hormones and signalling molecules by trophoblasts, as well as activation of  coagulation  and  complement pathways . [ 11 ]


Diagnosis of antiphospholipid syndrome is often made through the combination of symptoms and testing. Repeat antibody testing 12 weeks after discovering the presence of antiphospholipid antibodies (aPL) is needed to establish a diagnosis because false positives can occur. [ 4 ] [ 23 ] [ 24 ]


While APS was previously categorized into primary and secondary APS based on the absence or presence of concurrent autoimmune disease respectively, the 16th International Congress on Antiphospholipid Antibodies Task Force categorizes APS into 6 categories: [ 6 ]


In their report, they acknowledge that some individuals may qualify for more than one category based on symptoms. [ 6 ]


Because there are no agreed upon diagnostic criteria for APS, research classification criteria are sometimes used to aid in diagnosis. [ 6 ]  The Sapporo APS classification criteria (1998, published in 1999) [ 25 ]  were replaced by the Sydney criteria in 2006. [ 12 ]  The Sydney criteria requires one clinical (thrombosis or pregnancy related) manifestation and persistent presence of one or more APS antibody. [ 12 ]  In the 2023 American College of Rheumatology and European League Against Rheumatism joint criteria they added heart related symptoms and low platelet levels as clinical criteria and changed some thresholds and specifics for antibody testing. [ 4 ]  However, all previously proposed research criteria are meant to create a standardized group of individuals with APS in order to increase accuracy in statistical analysis, so the criteria are not be representative of all individuals with APS. [ 4 ] [ 6 ]  Thus, people who do not meet all of the criteria could still have APS.


In terms of catastropic APS, the International Consensus Statement is commonly used for diagnosis. Based on this statement, Definite CAPS diagnosis requires: [ 26 ]


Antiphospholipid antibody tests are either liquid-phase coagulation  assays  to detect  lupus anticoagulant  or solid phase  ELISA  (enzyme-linked immunosorbent assay) to detect  anti-cardiolipin antibodies  and  β 2  glycoprotein 1 . [ 24 ]  The use of testing for antibodies specific for individual targets of aPL such as  phosphatidylserine  is currently under debate. [ citation needed ]


This is tested for by using two coagulation tests that are phospholipid-sensitive, due to the heterogeneous nature of the  lupus anticoagulant  antibodies. A patient with lupus anticoagulant antibodies on initial screening will typically have been found to have a prolonged  partial thromboplastin time  (PTT) that does not correct in an 80:20 mixture with normal human  plasma  (50:50 mixes with normal plasma are insensitive to all but the highest antibody levels). The PTT (plus 80:20 mix),  dilute Russell's viper venom time , silica clotting time and  prothrombin time  (using a lupus-sensitive  thromboplastin ) are the principal tests used for the detection of  lupus anticoagulant . The Scientific and Standardization Committee for lupus anticoagulant/antiphospholipid antibodies of the International Society on Thrombosis and Haemostasis no longer recommends the  kaolin clotting time , dilute thromboplastin time, and Taipan/Ecarin snake venom based assays due to implementation issues from a variety of factors. [ 23 ]


Distinguishing a lupus  anticoagulant  antibody from a specific coagulation factor inhibitor (e.g.:  factor VIII ) is normally achieved by differentiating the effects of a lupus anticoagulant on factor assays from the effects of a specific coagulation factor antibody. The lupus anticoagulant will inhibit all the contact activation pathway factors ( factor VIII ,  factor IX ,  factor XI  and  factor XII ). Lupus anticoagulant will also rarely cause a factor assay to give a result lower than 35 iu/dl (35%) whereas a specific factor antibody will rarely give a result higher than 10 iu/dl (10%). Monitoring IV anticoagulant therapy by the PTT ratio is compromised due to the effects of the lupus anticoagulant and in these situations is generally best performed using a chromogenic assay based on the inhibition of  factor Xa  by  antithrombin  in the presence of  heparin . [ citation needed ]


Anti-cardiolipin antibodies  can be detected using an  enzyme-linked immunosorbent assay  (ELISA)  immunological test , which screens for the presence of β 2 glycoprotein 1 dependent anticardiolipin antibodies. A  low platelet count  and positivity for antibodies against  phosphatidylserine  may also be observed in a positive diagnosis. [ citation needed ]


The presence of antiphospholipid antibodies may not indicate APS, which is why considering the symptoms present and retesting antibody levels is essential. People may be transiently positive, incorrectly positive, or incorrectly negative if they are tested when the following is occurring: [ 23 ]


It is recommended to generally re-test people 12 weeks after the first positive test to confirm that it was correct, except for those who test positive during pregnancy. [ 23 ]  For that group, it is recommend to wait 3 months to re-test if possible. Re-testing is more nuanced if the person is taking an anticoagulant, which may require not taking the medication for a certain period of time or specifically timing the test. [ 23 ]


Also, patients who have certain antiphospholipid antibodies may have false positive  VDRL  test, which aims to detect a  syphilis  infection. This occurs because the aPL bind to the lipids in the test and make it come out positive. A more specific test for syphilis,   FTA-Abs , will not have a false-positive result in the presence of aPL. [ citation needed ]


For people with blood clot related APS, other conditions that can cause blood clots should be considered including but not limited to acquired  blood clots , genetic  thrombophilia , and  paroxysmal nocturnal hemoglobinuria . Genetic thrombophilia can coexist in some patients with APS. [ citation needed]  For people with pregnancy related APS, other causes of  recurrent miscarriage  should be considered before the diagnosis of APS, such as genetic, structural, or immune abnormalities.


Treatment depends on a person's APS symptoms. [ 27 ]  Typically a medication that decreases the body's ability to form blood clots is given to prevent future clots. Low dose aspirin can be given to people who have APS antibodies but no symptoms, high risk individuals with  lupus erythematosus  and APS antibodies but no symptoms of APS, and non-pregnant people who had APS during pregnancy. [ 27 ] [ 28 ]  For those people with APS who have had a blood clot (venous or arterial),  anticoagulants  such as  warfarin  are used to prevent future clots. [ 27 ] [ 28 ]  If warfarin is used, the  INR  is kept between 2.0 and 3.0. [ 28 ]   Direct-acting oral anticoagulants  may be used as an alternative to warfarin, but not in people with APS who had a previous arterial blood clot [ 29 ] [ 30 ]  or are "triple positive" with all types of antiphospholipid antibody (lupus anticoagulant, anticardiolipin antibody and anti-β2 glycoprotein I antibody). [ 27 ] [ 28 ] [ 31 ] [ 32 ]  In people with arterial blood clot related APS, using  direct-acting oral anticoagulants  has shown to increase the risk of future arterial blood clots and should not be used. [ 29 ] [ 30 ]


In pregnant women with only pregnancy related APS or only past blood clot related APS,  low molecular weight heparin  and low-dose  aspirin  are used instead of warfarin because of warfarin's  ability to cause birth defects . [ 27 ] [ 28 ]  Heparin and aspirin together appears to make  miscarriage  less likely in pregnant women with APS. [ 28 ]  Women with recurrent miscarriages are often advised to take aspirin and to start low molecular weight heparin treatment after missing a  menstrual cycle . [ citation needed ]  In refractory cases  plasmapheresis  may be used. [ citation needed ]


Factors that increase likelihood of developing APS related future blood clots and pregnancy complications include:


Also, a history of previous blood clots in someone with APS increases the risk for certain pregnancy complications, such as death of the child, smaller sized baby, and blood clots during and after pregnancy. [ 33 ]  Outside of people with APS having an increased risk of blood clots and pregnancy complications, people with APS generally have increased risk of atherosclerotic disease. [ 7 ] [ 34 ]


Other risk stratification criteria for predicting blood clots and pregnancy complications have been proposed, such as the aPL Score and the Global APS score, but further data is needed to validate these tools. [ 6 ]


Factors associated with developing antiphospholipid syndrome include:


In a study of 1000 patients, only 12.7% were diagnosed after the age of 50. [ 37 ]


Antiphospholipid syndrome was described in full in the 1980s, by E. Nigel Harris and Aziz Gharavi. They published the first papers in 1983. [ 38 ] [ 39 ]  The syndrome was  referred to  as "Hughes syndrome" among colleagues after the  rheumatologist   Graham R.V. Hughes  ( St. Thomas' Hospital ,  London ,  UK ), who brought together the team. [ citation needed ]


According to a 2006 Sydney consensus statement, [ 12 ]  it is advisable to classify APS into one of the following categories for research purposes:


An  artificial womb  or  artificial uterus  is a device that would allow for extracorporeal  pregnancy , [ 2 ]  by growing a  fetus  outside the body of an organism that would normally carry the fetus to term. [ 3 ]  An artificial  uterus , as a replacement organ, would have many applications. It could be used to assist male or female couples in the development of a fetus. [ 2 ]  This can potentially be performed as a switch from a natural uterus to an artificial uterus, thereby moving the threshold of  fetal viability  to a much earlier stage of pregnancy. [ 2 ]  In this sense, it can be regarded as a  neonatal incubator  with very extended functions. It could also be used for the initiation of fetal development. [ 2 ]  An artificial uterus could also help make  fetal surgery  procedures at an early stage an option instead of having to postpone them until term of pregnancy. [ 2 ]


In 2016, scientists published two studies regarding human embryos developing for thirteen days within an ecto-uterine environment. [ 4 ] [ 5 ]  In 2017, fetal researchers at the  Children's Hospital of Philadelphia  published a study showing they had grown premature lamb fetuses for four weeks in an extra-uterine life support system. [ 1 ] [ 6 ] [ 7 ]  A 14-day rule prevents human embryos from being kept in artificial wombs longer than 14 days; this rule has been codified into law in twelve countries. [ 8 ]  In 2021,  The Washington Post  reported that "the International Society for Stem Cell Research relaxed a historical '14-day rule' that said researchers could grow natural embryos for only 14 days in the laboratory, allowing researchers to seek approval for longer studies"; but the article nonetheless specified that: "[h]uman embryo models are banned from being implanted into a uterus." [ 9 ]


An artificial uterus, sometimes referred to as an "exowomb", [ 10 ]  would have to provide nutrients and oxygen to nurture a fetus, as well as dispose of waste material. The scope of an artificial uterus, or "artificial uterus system" to emphasize a broader scope, may also include the interface serving the function otherwise provided by the  placenta , an amniotic tank functioning as the  amniotic sac , as well as an  umbilical cord .


A woman may still supply nutrients and dispose of waste products if the artificial uterus is connected to her. [ 2 ]  She may also provide immune protection against diseases by passing of  IgG antibodies  to the embryo or fetus. [ 2 ]


Artificial supply and disposal  have the potential advantage of allowing the fetus to develop in an environment that is not influenced by the presence of disease, environmental pollutants, alcohol, or drugs which a human may have in the circulatory system. [ 2 ]  There is no risk of an immune reaction towards the embryo or fetus that could otherwise arise from insufficient  gestational immune tolerance . [ 2 ]  Some individual functions of an artificial supplier and disposer include:


Theoretically,  animal suppliers and disposers  may be used, but when involving an animal's uterus the technique may rather be in the scope of  interspecific pregnancy . [ original research? ]


In a normal uterus, the  myometrium  of the  uterine wall  functions to expel the fetus at the end of a pregnancy, and the  endometrium  plays a role in forming the placenta. An artificial uterus may include components of equivalent function. Methods have been considered to connect an artificial placenta and other "inner" components directly to an external circulation. [ 2 ]


An interface between the supplier and the embryo or fetus may be entirely artificial, e.g. by using one or more  semipermeable membranes  such as is used in  extracorporeal membrane oxygenation  (ECMO). [ 11 ]


There is also potential to grow a placenta using human  endometrial cells . In 2002, it was announced that tissue samples from cultured endometrial cells removed from a human donor had successfully grown. [ 15 ] [ 16 ]  The tissue sample was then engineered to form the shape of a natural uterus, and human embryos were then implanted into the tissue. The embryos correctly implanted into the artificial uterus' lining and started to grow. However, the experiments were halted after six days to stay within the permitted legal limits of  in vitro fertilisation  (IVF) legislation in the  United States . [ 2 ]


A human placenta may theoretically be transplanted inside an artificial uterus, but the passage of nutrients across this artificial uterus remains an unsolved issue. [ 2 ]


The main function of an  amniotic tank  would be to fill the function of the  amniotic sac  in physically protecting the embryo or fetus, optimally allowing it to move freely. It should also be able to maintain an optimal temperature.  Lactated Ringer's solution  can be used as a substitute for  amniotic fluid . [ 11 ]


Theoretically, in case of premature removal of the fetus from the natural uterus, the natural  umbilical cord  could be used, kept open either by medical inhibition of physiological occlusion, by  anti-coagulation  as well as by  stenting  or creating a  bypass  for sustaining blood flow between the mother and fetus. [ 2 ]


The use of artificial wombs was first termed  ectogenesis  by British-Indian pioneer  JBS Haldane  in 1923. [ 17 ] [ 18 ] [ 19 ] [ 20 ]


Specifying related terminology, one paper determines:


"A potential, though remotely possible, application of the technology is ‘complete ectogenesis’ – complete gestation outside the human body. This will greatly affect the substantiated human involvement during gestation, making it an extracorporeal event and thus completely transforming the conventional notion of pregnancy." [ 21 ]


Emanuel M. Greenberg wrote various papers [ clarification needed ]  on the topic of the artificial womb and its potential use in the future. [ 22 ]


On 22 July 1954 Emanuel M. Greenberg filed a patent on the design for an artificial womb. [ 23 ]  The patent included two images of the design for an artificial womb. The design itself included a tank to place the fetus filled with amniotic fluid, a machine connecting to the umbilical cord, blood pumps, an artificial kidney, and a water heater. He was granted the patent on 15 November 1955. [ 23 ]


In 1996,  Juntendo University  in Tokyo developed the extra-uterine fetal incubation (EUFI). [ 24 ]  The project was led by Yoshinori Kuwabara, who was interested in the development of immature newborns. The system was developed using fourteen goat fetuses that were then placed into artificial amniotic fluid under the same conditions of a mother goat. [ 24 ] [ 25 ]  Kuwabara and his team succeeded in keeping the goat fetuses in the system for three weeks. [ 24 ] [ 25 ]  The system, however, ran into several problems and was not ready for human testing. [ 24 ]  Kuwabara remained hopeful that the system would be improved and would later be used on human fetuses. [ 24 ] [ 25 ]


In 2017, researchers at the  Children's Hospital of Philadelphia  were able to further develop the extra-uterine system. The study uses fetal lambs which are then placed in a plastic bag filled with artificial amniotic fluid. [ 1 ] [ 7 ]  The system consist in 3 main components: a pumpless arteriovenous circuit, a closed sterile fluid environment and an umbilical vascular access. Regarding the  pumpless arteriovenous circuit , the blood flow is driven exclusively by the fetal heart, combined with a very low resistance oxygenator to most closely mimic the normal fetal/placental circulation. The  closed sterile fluid environment  is important to ensure sterility. Scientists developed a technique for  umbilical cord vessel cannulation  that maintains a length of native umbilical cord (5–10 cm) between the cannula tips and the abdominal wall, to minimize decannulation events and the risk of mechanical obstruction. [ 26 ]  The umbilical cord of the lambs are attached to a machine outside of the bag designed to act like a placenta and provide oxygen and nutrients and also remove any waste. [ 1 ] [ 7 ]  The researchers kept the machine "in a dark, warm room where researchers can play the sounds of the mother's heart for the lamb fetus." [ 7 ]  The system succeeded in helping the premature lamb fetuses develop normally for a month. [ 7 ]  Indeed, scientists have run 8 lambs with maintenance of stable levels of circuit flow equivalent to the normal flow to the placenta. Specifically, they have run 5 fetuses from 105 to 108 days of gestation for 25–28 days, and 3 fetuses from 115 to 120 days of gestation for 20–28 days. The longest runs were terminated at 28 days due to animal protocol limitations rather than any instability, suggesting that support of these early gestational animals could be maintained beyond 4 weeks. [ 26 ]  Alan Flake, a fetal surgeon at the Children's Hospital of Philadelphia hopes to move testing to premature human fetuses, but this could take anywhere from three to five years to become a reality. [ 7 ]  Flake, who led the study, calls the possibility of their technology recreating a full pregnancy a "pipe dream at this point" and does not personally intend to create the technology to do so. [ 7 ]


In 2021, a start-up company founded by  Benn Lamm  and  George Church ,  Colossal Biosciences  began research and development of artificial animal wombs to further  de-extinction  and conservation efforts for species such as the  woolly mammoth  and  northern white rhinoceros . [ 27 ]  An artificial womb is also necessary in reviving a species with no suitable living surrogate species such as  Steller's sea cow  or  elephant bird [ 28 ]  Colossal in collaboration with the  University of Melbourne  have also developed artificial  marsupial pouches  as part of their de-extinction project of the  thylacine . [ 29 ]


Since 2016, researchers of  TU/e  and partners aim to develop an artificial womb, which is an adequate substitute for the protective environment of the maternal womb in case of premature birth, preventing health complications. The artificial womb and placenta will provide a natural environment for the baby with the goal to ease the transition to newborn life. The perinatal life support (PLS) system will be developed using breakthrough technology: a manikin will mimic the infant during testing and training, advanced monitoring and computational modeling will provide clinical guidance. [ 30 ]


The consortium of 3 European universities working on the project consists out of Aachen, Milaan and Eindhoven. In 2019 this consortium was granted a subsidy of 3 million euros, and a second grant of 10 million is in progress.
Together, the PLS partners provide joint medical, engineering, and mathematical expertise to develop and validate the Perinatal Life Support system using breakthrough simulation technologies. The interdisciplinary consortium will push the development of these technologies forward and combine them to establish the first ex vivo fetal maturation system for clinical use. This project, coordinated by the Eindhoven University of Technology brings together world-leading experts in obstetrics, neonatology, industrial design, mathematical modelling, ex vivo organ support, and non-invasive fetal monitoring. This consortium is led by professor Frans van de Vosse and Professor and doctor Guid Oei. in 2020 the spin off Juno Perinatal Healthcare has been set up by engineers Jasmijn Kok and Lyla Kok, assuring valorisation of the research done. More information about the spin off can be found here; [ 31 ]


More information about the project of the technical universities and its researchers can be found here: [ 32 ]


In 2021, the  Weizmann Institute of Science  in Israel built a mechanical uterus and grew mouse embryos outside the uterus for several days. [ 33 ]  This device was also used in 2022 to nurture mouse stem cells for over a week and grow synthetic embryos from stem cells. [ 34 ] [ 35 ]


The development of artificial uteri and ectogenesis raises  bioethical  and legal considerations, and also has important implications for  reproductive rights  and the  abortion debate . [ 36 ]  Implementing artificial wombs would require advanced technology and significant costs, potentially limiting access for people in developing countries or with fewer resources.


Artificial uteri may expand the range of  fetal viability , raising questions about the role that fetal viability plays within  abortion law . Within severance theory, for example, abortion rights only include the right to remove the fetus, and do not always extend to the termination of the fetus. If transferring the fetus from a woman's womb to an artificial uterus is possible, the choice to terminate a pregnancy in this way could provide an alternative to aborting the fetus. [ 37 ] [ 38 ]


A 2007 essay theorizes that children who develop in an artificial uterus may lack "some essential bond with their mothers that other children have". [ 39 ]


In the 1970 book  The Dialectic of Sex , feminist  Shulamith Firestone  wrote that differences in biological reproductive roles are a source of  gender inequality . Firestone singled out pregnancy and childbirth, making the argument that an artificial womb would free "women from the tyranny of their reproductive biology." [ 40 ] [ 41 ]


Arathi Prasad argues in her column on  The Guardian  in her article "How artificial wombs will change our ideas of gender, family and equality" that "[i]t will ... give men an essential tool to have a child entirely without a woman, should they choose. It will ask us to question concepts of gender and parenthood." She furthermore argues for the benefits for same-sex couples, saying: "It might also mean that the divide between mother and father can be dispensed with: a womb outside a woman’s body would serve women, trans women and male same-sex couples equally without prejudice." [ 42 ]  It could even be a solution for women with absolute uterine infertility.


In  obstetrics ,  asynclitic birth,  or  asynclitism,  refers to the malposition of the  fetal  head in the  uterus  relative to the  birth canal . [ 1 ]  Many babies enter the  pelvis  in an asynclitic  presentation , but in most cases, the issue is corrected during  labor . [ 2 ]  Asynclitic presentation is not to be confused with a  shoulder presentation , where the shoulder leads first.


Fetal head asynclitism may affect the progression of labor, increase the need for obstetrical intervention, and be associated with difficult instrumental delivery. [ 3 ]  The prevalence of asynclitism at transperineal  ultrasound  was common in  nulliparous  women at the  second stage of labor  and seemed more commonly associated with non occiput anterior position, suggesting an autocorrection occurs in many cases. [ 3 ]


When the self-correction does not occur, obstetrical intervention is necessary to deliver the child. Persistence of asynclitism can cause problems with  dystocia , and has often been associated with  cesarean  births. However, with a skilled  midwife  or  obstetrician  a complication-free  vaginal birth  can sometimes, though not necessarily, be achieved through movement and positioning of the birthing person, and patience and extra time to allow for movement of the baby through the pelvis and moulding of the skull during the birthing process if this is safe in the circumstances. Other options include the use of vacuum-assisted delivery and forceps. [ medical citation needed ] [ 4 ] [ unreliable source? ]  There is no evidence to suggest that people with previous asynclitic presentation are more likely to experience it in subsequent childbirth. [ 5 ] [ better source needed ]


Asynclitism can be digitally diagnosed using intrapartum  ultrasound  through the  transabdominal  cavity and the transperitoneal cavity. Intrapartum ultrasonography is regularly used during  pregnancy  to constantly monitor the fetal position within the mother's belly. [ 6 ]  The  International Society of Ultrasound in Obstetrics and Gynecology  Practice Guidelines recommend the use of intrapartum ultrasound to diagnose asynclitic births during prolonged and obstructed labors. [ 7 ]


Asynclitism is most easily diagnosed during labor when the  cervix  is opened allowing the orientation of the  occiput , the back of the fetal head, to be visually assessed in relation to the mother's pelvis. [ 8 ]  Posterior asynclitism is when the fetal occiput is facing the mother's spine, and anterior asynclitism is when the fetal occiput is facing the mother's belly. The most common and preferred type of asynclitism is the left occiput anterior asynclitism because the baby's head enters the pelvis in such a way that it minimizes the circumference of how the baby exits the body as much as possible. In this type of asynclitism, it allows the fetus to be in the most efficient position. The back of the fetus's head is towards the carrier's left side. Meanwhile, their face is towards the mother's right side at an angle between the hip and the spine of the mother. [ 9 ]  Posterior asynclitism can lengthen the duration of labor and cause complications. [ 10 ]  Asynclitism is most commonly discovered during vaginal exams conducted in labor. During the exam, the healthcare professional may feel the  parietal bone  more distinctly than others. Professionals can also use ultrasound to help identify potential asynclitism. [ 11 ]


Asynclitism can occur at any time during pregnancy. It most commonly occurs near the end of the third trimester or during labor, when the fetus becomes more developed and begins moving down the birth canal. [ 12 ]


The exact cause of asynclitism is unknown. The shape and size of the uterus, the weight of the fetus, pelvic anatomy, and multiparity can contribute to it, [ 13 ]  and the likelihood of asynclitism increases if the mother has rotated hips. Situational factors include a short umbilical cord and unevenness of the pregnant person's pelvic floor during contractions, leading to the baby's head tipping to one side. [ 5 ]


Asynclitism can also begin at the time of birth. This happens when the fetus quickly comes down on the pelvic floor before straightening its head when the water breaks. [ 14 ]  This can be due to the water rushing through the pelvis too quickly and once it occurs, it is difficult to correct.


Signs of asynclitism that may be observed without medical diagnostic equipment include visually asymmetric baby bumps, caused by the baby's head being tilted asymmetrically in relation to the mother's pelvis, or by an abnormal buildup of amniotic fluid. [ 15 ]  The mother may report symptoms of abdominal discomfort, particularly on one side, or pain on one side of the hips. [ 5 ]


Asynclitism is common as the fetus enters through and tilts the maternal pelvis. There are three types: anterior, posterior, and lateral asynclitism. [ 3 ]  Minor asynclitism generally resolves itself and results in uncomplicated births. [ 8 ]  Minor cases present mild molding and the slight deviation of the head from the midline, but are otherwise absent of major fetal head malpositioning. In cases that present with persistent occiput posterior -- in which the head is in a downward position, but facing towards the front of the abdomen -- or shoulder positions, this can result in prolonged and difficult delivery and may warrant surgical intervention. [ 8 ] [ 16 ]


Complications can occur before, during, and after birth that affect both parent and baby. Asynclitism can lead to slower and more difficult labor, increasing stress and fatigue. If the fetus's head is not optimally positioned, this can result in dystocia, necessitating an operative delivery. Complications are associated with procedures such as  operational vaginal deliveries  (OVD), particularly with the use of vacuum extraction, and  caesarean sections  (CS). [ 3 ]  Caesarean sections can increase the risk of maternal complications, which can affect future pregnancies. These include uterine ruptures, chronic pain, hemorrhages, and bladder injury. One of the more severe complications is  placenta accreta , which can lead to a life-threatening hemorrhage and peripartum hysterectomy. [ 3 ]


Complications the baby may face include  cephalohematomas ,  hyperbilirubinemia , and  intracranial hemorrhages . [ 17 ] [ 16 ]  Asynclitic birth can also increase the risk of birth injuries such as  brachial plexus injury , in which the nerves responsible for sending signals to the baby's arm are damaged, resulting in temporary or permanent numbness, weakness, or even paralysis in the affected arm. [ 18 ]  In rare cases, uncorrected asynclitism can lead to  neonatal asphyxia , in which the child does not receive enough oxygen before, during, or just after birth, which can result in temporary or permanent organ damage. [ 19 ]  The mother may experience complications such as vaginal or cervical tears, excessive blood loss, infection of the placental membrane, and  postpartum infections . [ 20 ]  Asynclitism can also affect the development of facial structures and nerves during pregnancy, with lifelong consequences for the child. These complications can include facial malformation,  Bell's palsy ,  deviated septum , and facial asymmetry. [ 21 ]


Various techniques have been tried to resolve an asynclitic position of the fetus.  Vacuum extraction , a delivery assistance method used for prolonged or obstructed labor, has been shown to reverse the position from the less optimal one, known as occiput posterior or occiput transverse, to the more favorable position known as occiput anterior. [ 22 ]  However, it is not the primary treatment for asynclitic births, as the effectiveness rate is not very high and vacuum extraction can lead to additional complications. [ 23 ]  Possible complications include fetal morbidity and fatality, and damage to the derma layer leading to bleeding within the brain and the layer of skin on the skull, known as  cephalohematomas . [ 24 ]  Facial nerve damage and immobility are permanent consequences from intracranial hemorrhage, leading to a diminished quality of life. However, when it is successful, vacuum extraction can change the position from a non-occital anterior position to an occital anterior position, which is more favorable in terms of asynclitic births. [ 25 ]  Following any medical procedure to alter the occiput position or any assisted vaginal delivery, monitoring of the neonate is extremely important as intracranial hemorrhages may be imperceptible.


Non-invasive techniques are typically the first steps when dealing with asynclitic birth. Short and quick breaths synchronized with contractions are commonly suggested by the obstetrician to help with prolonged labor with asynclitism. [ 26 ]  Positioning techniques can also employed to help the baby to rotate or descend. [ 27 ]  Examples of these techniques include the hands-on-knees position, lunging, kneeling lunge, side-lying release, and use of a birth ball. If positioning techniques do not work, healthcare professionals may attempt manual rotation, attempting to adjust the baby's position manually via the vagina. [ 28 ]  If none of these methods are successful, the physician may consider a caesarean section to deliver the baby safely. [ 29 ]


Along with procedural interventions, there are supportive measures that are taken to alleviate the physical and psychological trauma associated with childbirth. Supportive measures come in both non-pharmacological and pharmacological forms. [ 8 ]  For pain management, labor analgesia has been shown to be effective. Depending on the procedure, different types of anesthesia, such as  pudendal block anesthesia , may be used. [ 16 ]


Balloon tamponade  is the use of  balloons  inserted into the  esophagus ,  stomach  or  uterus , and inflated to alleviate or stop  refractory  bleeding.


Examples include:


Balloon tamponade is considered a bridge to more definitive treatment modalities, and is usually administered in the emergency department or in the  intensive-care unit  setting, due to the illness of patients and the complications of the procedure.


In the uterus, balloon tamponade can alleviate or stop  postpartum hemorrhage  (PPH). Inflating a  Sengstaken–Blakemore tube  in the uterus successfully treats atonic postpartum hemorrhage refractory to medical management in approximately 80% of cases. [ 2 ]  Such procedure is relatively simple, inexpensive and has low surgical morbidity. [ 2 ]  A  Bakri balloon [ 3 ]  is a balloon tamponade specifically constructed for uterine postpartum hemorrhage.


The Bakri balloon tamponade (BBT), designed for postpartum hemorrhage, is an effective life-saving balloon. [ 4 ]  A recent study involving 50 cases was carried out by the department of Obstetrics and Gynecology at University Central Hospital in Helsinki, Finland. With an overall success rate of 86%, the authors concluded that the Bakri balloon tamponade is "a simple, readily available, effective and safe procedure" in the management of postpartum hemorrhage. The research also indicates that BBT is able to provide practitioners with "time for other interventions or transportation from local hospital to tertiary centre". The authors of the study recommend BBT be included in the PPH protocol. [ 5 ]


An alternative to the Bakri is the BT-Cath (balloon-tamponade catheter) which has an easy-fill system allowing single person inflation and saving time in the theatre setting. The BT-Cath is more pear-shaped and contours to the uterus more easily than the Bakri.


A low-cost alternative is a condom balloon tamponade, a form of intrauterine tamponade, created from a catheter, a male latex condom, and a string to tie the condom to the catheter. The method was developed in Bangladesh in 2001 by  Sayeba Akhter  and has since been supported by health workers worldwide as an effective method to stop postpartum hemorrhage, particularly in low-resource settings. [ 6 ]


The  Biomedical Research Center  (BRC) is a research center at  Qatar University  focusing on biomedical research. BRC was founded in 2014, and partners with the  Ministry of Public Health (Qatar) , and  Hamad Medical Corporation (HMC) . [ 1 ] [ 2 ] [ 3 ]


The incidence of genetic disorders in  Qatar  is high, [ 4 ]  with the top three causes of death in the country being cancer, heart diseases, and diabetes. [ 5 ] [ 6 ]  The government saw the creation of BRC as a strategy for proactively preventing diseases to help foster public health. [ 7 ] [ 8 ]


BRC labs received the  ISO/IEC - 17025  accreditation from the American Association for Laboratory Accreditation (A2LA). [ 9 ]  This research center focus on  infectious diseases  ( virology  and  microbiology ),  metabolic disorders , and biomedical  omics . [ 10 ]


Since its establishment in 2014, the BRC has published over 530 research papers. [ 11 ] [ 12 ]  The centre's research projects encompass a range of areas, including:


BRC Introduced the use of  zebrafish  as an animal model in biomedical research [ 36 ] [ 37 ] [ 32 ] [ 38 ] [ 39 ] [ 40 ]  and established a facility for it in 2015. [ 41 ] [ 42 ] [ 43 ]  The facility is used as a research unit to study many genetic diseases. [ 32 ]  The Ministry of Public Health articulated an institutional research policy (IRP) on the use of zebrafish in research, [ 44 ]  which Qatar University backed.


The BRC facilities include: [ 41 ]


A  birth attendant , also known as  skilled birth attendant , is a  health professional  who provides basic and emergency care to women and their newborns during  pregnancy ,  childbirth  and the  postpartum period . A birth attendant, who may be a  midwife ,  physician ,  obstetrician , or  nurse , is trained to be present at ("attend") childbirth, whether the delivery takes place in a  health care institution  or  at home , to recognize and respond appropriately to  medical complications , and to implement interventions to help prevent them in the first place, including through  prenatal care . [ 1 ]  Different birth attendants are able to provide different levels of care.


There are five different types of midwives.  There is a certified nurse-midwife who must obtain a high level of education, either bachelors or masters in midwifery, after becoming a nurse. Nurse-midwives can serve in most birthing centers, hospitals, and can have a private home birth practice.


Then there is a Certified Professional Midwife.  This midwife can obtain a license by following an apprenticeship/internship style of learning, along with other certifications.  She must pass a board exam through states/countries that allow for this license and can only be available in a home birth setting.


There are Direct Entry Midwives.  These midwives are trained through an apprenticeship/internship process and are only allowed in home birth settings as well. They do not hold a professional license but rather serve as lay midwives wherever they are needed. [ 2 ]


The next type is a traditional midwife. [ 3 ]  This midwife often has cultural and community based trainings that are passed down through generations. Depending on the location, they can either be formally certified and licensed or not.


The final type of midwife is a lay midwife. A lay midwife are individuals that have learned midwifery through an apprenticeship or a self-directed study rather than a formal training. They are able to provide care and deliver babies outside of a medical setting.


A distinction must be made between "birth attendant" and others who may provide support and care during pregnancy and childbirth, based on professional training and skills,  practice regulations , as well as nature of care delivered. Birth attendants are typically trained to perform clinical functions for basic and emergency obstetric and neonatal care, including administration of  parenteral  antibiotics,  oxytocics  and anticonvulsants; manual removal of  placenta ; removal of retained products of placenta; assisted  vaginal delivery ; and newborn resuscitation. [ 4 ]  Depending on the legal  scope of practice , this may also include performing  cesarean sections .


A birth assistant, also known as a  doula , "birth worker", "labor support person", "labour coach", or "childbirth educator", is someone other than the above who provides emotional support and general care and advice to women and families during pregnancy and childbirth. [ 5 ]   A doula usually offers support services to the family in the weeks following the birth ("postpartum doula", see  Postpartum confinement ) and may also assist during labor and childbirth ("birth doula").


In many developing countries, a  traditional birth attendant , also known as a traditional midwife, is a person who provide basic pregnancy and birthing care and advice based primarily on experience and knowledge acquired informally through the traditions and practices of the communities where they originated. [ 5 ]   They usually have no modern health care training and are not typically subject to professional regulation.


Birth weight  is the  body weight  of a  baby  at their  birth . [ 1 ]  The average birth weight in babies of European and African descent is 3.5 kilograms (7.7 lb), with the normative range between 2.5 and 4.0 kilograms (5.5 and 8.8 lb). [ 2 ]  On average, babies of Asian descent weigh about 3.25 kilograms (7.2 lb). [ 3 ] [ 4 ]  The prevalence of low birth weight has changed over time. Trends show a slight decrease from 7.9% (1970) to 6.8% (1980), then a slight increase to 8.3% (2006), to the current levels of 8.2% (2016). [ 5 ] [ 6 ]  The prevalence of  low birth weights  has trended slightly upward from 2012 to the present. [ 7 ]


Low birth weight is associated with  neonatal infection ,  infant mortality , as well as illness into adulthood. [ 8 ]  Numerous studies have attempted, with varying degrees of success, to show links between birth weight and later-life conditions, including  diabetes ,  obesity ,  tobacco smoking , and  intelligence . [ 9 ]


There are two genetic loci that have been strongly linked to birth weight,  ADCY5  and  CCNL1 , and four that show some evidence ( CDKAL1 ,  HHEX – IDE ,  GCK , and  TCF7L2 ). [ 16 ] [ 17 ] [ 18 ]   The  heritability  of birth weight ranges from 25 to 40%. [ 19 ] [ 20 ]  There is a complex relationship between a baby's genes and the maternal environment that the child is developing in. [ 21 ]   Foetal  genes influence how the fetus grows in  utero , and the maternal genes influence how the environment affects the growing fetus. [ 17 ]


The  health  of the mother during the pregnancy can affect birth weight.  A  pre-existing disease  or acquired disease in pregnancy is sometimes associated with decreased birth weight. For example,  celiac disease  confers an  odds ratio  of low birth weight of approximately 1.8. [ 22 ]  Certain medications (e.g. for high blood pressure or epilepsy) can put a mother at a higher risk for delivering a low birth weight baby. [ 10 ]  Women younger than 15 or older than 35 are at a higher risk to have a low-birth weight baby. [ 10 ] [ 23 ]  Multiple births, where a mother has more than one child at one time, can also be a determinant in birth weight as each baby is likely to be outside the AGA (appropriate for gestational age). Multiple births put children at a higher rate to have low birth weight (56.6%) compared to children born in a single birth (6.2%). [ 5 ]  Low birth weight can also vary by maternal age. In 2008 the rate of low birth weight was the highest in babies born to women younger than 15 years old (12.4%). [ 23 ]  Women aged 40–54 had a rate of low birth weight at 11.8 percent. The lowest rates of low birth weight happened among babies whose mothers were between the ages of 25–29 years (4.4%) and 30–34 years (7.6%). [ 23 ]


Stressful  events have been demonstrated to produce significant effects on birth weight. Those mothers who have stressful events during  pregnancy , especially during the first and second trimester, are at higher risk to deliver low birth weight babies. [ 24 ] [ 25 ]  Researchers furthered this study and found that maternal stressful events that occur prior to conception have a negative impact on birth weight as well, and can result in a higher risk for preterm and lower birth weight babies. [ 26 ] [ 27 ] [ 28 ]  Women who experienced abuse (physical, sexual, or emotional) during pregnancy are also at increased risk of delivering a low birth weight baby. [ 29 ]  For example, in a study completed by Witt et al., those women who experienced a stressful event (i.e. death of close family member, infertility issues, separation from partner) prior to conception had 38% more of a chance to have a very low birth weight baby compared to those who had not experienced a stressful life event. [ 26 ]  Additionally, mothers with diagnosed post-traumatic stress disorder are more likely to give birth to a low birth weight infant. [ 30 ]  The theory is that stress can impact a baby based on two different mechanisms: neuroendocrine pathway or immune/inflammatory pathway. [ 31 ] [ 32 ]  Stress causes the body to produce stress hormones called  glucocorticoids  that can suppress the immune system, as well as raises levels of  placental corticotropin-releasing hormone  (CRH) which can lead to  preterm  labor. [ 33 ] [ 32 ]  These findings can pose evidence for future prevention efforts for low birth weight babies. One way to decrease rates of low birth weight and premature delivery is to focus on the health of women prior to conception through reproductive education, screening and counseling regarding mental health issues and stress, and access to primary care. [ 34 ]


Non-Hispanic Blacks have the highest infant mortality rate in the United States (11.4 deaths per 1,000 live births compared to the national average of 5.9 deaths per 1,000 live births). [ 35 ]  Subsequently,  there has been growing research supporting the idea of  racial discrimination  as a risk factor for low birth weight. In one study by Collins et al., evidence suggested that African American mothers who experienced high levels of racial discrimination were at significantly higher risk of delivering a very low-birth weight baby compared to African American mothers who had not experienced racial discrimination. [ 36 ]


Environmental factors, including exposure of the mother to  secondhand smoke [ 37 ]  can be a factor in determining the birth weight of child. In 2014, 13% of children exposed to smoke were born with low birth weight compared with 7.5% of those children born to nonsmokers. [ 5 ]  Children born to mothers who smoked or were exposed to secondhand smoke are more likely to develop health problems earlier in life such as  neurodevelopmental delays . [ 38 ]  When mothers actively smoke during pregnancy, their child is at a higher risk of being born with a low birth weight. [ 39 ]  Smoking can also be a stress management tool used by expecting mothers. [ 40 ]  There is some support for lower  socioeconomic status  of the parents being a determinant of low birth weight, but there is conflicting evidence, as socioeconomic status is tied to many other factors. [ 41 ] [ 42 ] [ 43 ]


Most babies admitted to the  NICU  are born before 37 weeks of pregnancy or have low birth weight which is less than 5.5 pounds (2.5 kg). [ 44 ]  They could also have a medical condition that requires special care. In the United States nearly half a million babies are born preterm. Because of this, many of these babies also have low birth weights. [ 44 ]  There are four levels of care in the neonatal care units:  intensive care , high dependency care, low dependency, and transitional care: [ 45 ]


Children born with an abnormally low birth weight can have significant problems within the first few years of life. They may have trouble gaining weight, obtaining adequate nutrition, and developing a strong immune system. They also have higher risks for mortality, behavior problems, and mental deficiencies. [ 41 ]  Low birth weight babies are more likely to develop the following conditions compared to normal birth weight babies: [ 10 ]


That said, the effects of low birth weight on a child's first few years of life are often intertwined with other maternal, environmental, and genetic factors and most effects of low birth weight are only slightly negatively significant on a child's life when these factors are controlled for. [ 46 ]  When these factors are taken into account, the only significant effect low birth weight has on a child's development is early physical growth and the likelihood of being underweight, compared to those with a normal birth rate. [ 46 ]


Studies have investigated how a person's birth weight can influence their future life, including potential links with  obesity ,  diabetes  and  intelligence . [ 9 ]


A baby born small or large for gestational age (either of the two extremes) was previously thought to have an increased risk of developing  obesity , [ 48 ] [ 49 ]  but it was later found that both high birth weight and maternal BMI are associated with increased risk of developing obesity in childhood. [ 9 ] [ 50 ]


Growth hormone (GH) therapy  at a certain dose induced catch-up of lean body mass (LBM). However, percentage body fat decreased in the GH-treated subjects.  Bone mineral density  SDS measured by  DEXA  increased significantly in the GH-treated group compared to the untreated subjects, though there is much debate over whether or not SGA (small for gestational age) is significantly adverse to children to warrant inducing catch-up. [ 51 ]
Babies that have a low birth weight are thought to have an increased risk of developing type 2  diabetes  in later life. [ 52 ] [ 53 ] [ 54 ] [ 55 ] [ 56 ]  Low birth weight is linked with increase rates of obesity,  insulin resistance , and type 2 diabetes and it is shown that children with the low birth weights have increased  leptin  levels after they catch up growth during childhood. [ 57 ]   Adiponectin  levels are positively related with birth weight and BMI in babies with an increase of risk of type 2 diabetes. [ 57 ]  The leptin and adiponection mechanisms are still being studied when involving low birth weight. [ 57 ]


There is much variation regarding birth weight within continents, countries, and cities.  Even though over 20 million babies are born each year with low birth weight, it is hard to know the exact number, as more than half of babies born in the world are not weighed at birth. [ 58 ]  The baby's weight is an indicator of the mother and baby's health. In 2013, 22 million newborns had low birth weight, around 16 percent of all babies globally. [ 59 ]  Data on low birth weight is adjusted to account for under reporting. South Asia has the highest rate of babies not weighed at birth with 66 percent, but also have the highest low birth weight, at 28 percent worldwide. [ 59 ]  West and Central Africa and least developed countries are next, with 14 percent low birth weight worldwide. [ 59 ]


More than 96.5% of low birth weight babies are born in developing countries around the world. [ 41 ]  Because low birth weight babies can require more extensive care, it places a financial burden on communities.


The  World Health Organization  (WHO) recently announced an initiative to have a thirty percent reduction in low birth weight worldwide. This is a public health priority, as birth weight can have short- and long-term effects. WHO estimates that worldwide, 15–20 % of all births each year are considered low birth weight, which is about 20 million births. [ 60 ]


The start of prenatal care is very important to help prevent low birth weight and early medical problems. Going to regular doctor's visits is very important for the health of the mother and the baby. At the visits, OB/GYNs check maternal nutrition and weight gain because they are linked to the baby's weight gain. The mother having a healthy diet is essential for the baby. Maintaining good nutrition by taking  folic acid , which can be found in fruits and vegetables, is linked to the prevention of [ 61 ] [ 62 ]  premature births and low birth weight.  Alcohol, cigarettes, and drugs should also be avoided during pregnancy because they can also lead to poor growth and other complications. [ 63 ]  Doctors are also able to monitor pre-existing medical illnesses to make sure they are under control during pregnancy. Mothers with  high blood pressure  and  type 2 diabetes  are more likely to have infants with low birth weights. [ 64 ]  One essential action to increase normal birth weights is to have affordable, accessible, and  culturally sensitive  prenatal care worldwide. This is essential not just for treating low birth weight, but also preventing it.  Other prevention efforts include  smoking cessation  programs, food-distribution systems, stress reduction and social service supports. [ 60 ]


A  birthing center  is a  healthcare facility , staffed by  nurse midwives ,  midwives  and/or  obstetricians , for mothers in  labor , who may be assisted by  doulas  and coaches.  The midwives monitor the labor, and well-being of the mother and the  baby  during birth. Doulas can assist the midwives and make the birth easier.  Should additional medical assistance be required, the mother can be transferred to a hospital. This transfer is more likely if an  epidural  is needed, there is  meconium  staining, it is a prolonged labor, or the newborn needs  intensive care . [ 1 ] [ 2 ]  Some hospitals have birth centers as an alternative to the usual high tech  maternity wards .


A birth center presents a more home-like environment than a  hospital labor ward , typically with more options during labor: food and drink, music, and the attendance of family and friends if desired.  Other characteristics can also include non-institutional furniture such as queen-sized beds, large enough for both mother and father, and perhaps birthing tubs or showers for  water births , an option that can help to reduce birthing pains. [ 3 ]  These centers also offer opioid injections ( Pethidine ) and  Entonox gas  as a way to help alleviate pain. [ 1 ] [ 4 ]  The decor is meant to emphasize the normality of birth.  In a birth center, women are free to act more spontaneously during their birth, such as squatting, walking or performing other  postures that assist in labor .  Active birth is encouraged. The  length of stay  after a birth is shorter at a birth center; sometimes just six hours after birth the mother and infant can go home.


A 2012  Cochrane  review compared traditional hospital births with alternative, home-like settings in or near conventional hospital labor wards. In comparison with traditional hospital wards, home-like settings had a trend towards an increase in  spontaneous vaginal birth , continued  breastfeeding  at six to eight weeks, and a  positive view of care . [ 5 ]  The review also found that having a birth at an alternative birth center decreased the likelihood of  medical intervention  during labor, without increasing risk to mother or child. [ 5 ]  The likelihood of risks during a pregnancy or a mother's preexisting medical conditions may impact the ability for that mother to use a birthing center. [ 6 ]


Like clinics, birth centers arose on the  East  and  West  Coasts in the 1970s, as alternatives to heavily institutionalized health care. Today, use of birthing centers is generally covered by  health insurance . Several of the practices which were innovated in birth centers are beginning to enter the mainstream hospital labor and delivery floors, including:


There are more favourable cases where giving birth at a birth center would be ideal.  First, the mother may have a low-risk, healthy pregnancy,
are pregnant with one baby (i.e. not twins), [ 7 ]  and that the baby is positioned head down ( cephalic presentation ). [ 8 ]


Free-standing birth centers require hospital backup in case complications arise during labor that require more complex care. However, even if a delivery cannot happen at the birth center due to a  high-risk pregnancy , birth center midwives might provide  prenatal care  up to a certain week of gestation.


There also exists birthing centers inside of hospitals. Nearby doctors are very accessible in the case of extreme emergencies (which do not often happen).


The nationwide organization supporting and promoting birth centers is the American Association of Birth Centers (AABC). [ 9 ]  Many birth centers nationwide, like hospitals, chose to become accredited through the Commission for the Accreditation of Birth Centers (CABC). [ 10 ]  Since 1985, CABC has provided this accreditation service, as well as education and support to birth centers and alongside maternity centers. Some birth centers are required to obtain accreditation in order to apply for state licensure, or to become in-network with certain insurance plans. Many birth centers chose voluntarily to undergo accreditation to demonstrate their commitment to safety and continuous quality improvement.


Accreditation depends on a set of measures, called indicators, against which birth centers are evaluated during site visits by CABC Accreditation Specialists. Adherence to these indicators ensures both safety of mother and infant as well as protects the integrity of the birth center model of care as distinct from hospital care. For example, while continuous  fetal monitoring  is typical in hospital labor and delivery units, intermittent monitoring with a handheld electronic device is used in birth centers to protect the birthing woman's freedom of mobility during her labor and birth. CABC Indicators also require a birth center to have a written plan for how to proceed with transfer to a hospital in the event of an emergency that cannot be managed at the birth center.


Birth center applications for accreditation are reviewed by Commissioners on the board of trustees of the CABC. These Commissioners are  Certified Nurse‐Midwives , certified professional midwives, physician specialists in obstetrics and neonatology, nurses, and birth center consumers. The Commissioners meet quarterly to review items of concern relevant to birth center education and development and publish a monthly newsletter for CABC-accredited birth centers for continuing education. The CABC works with policy advocacy organizations to advance and promote birth centers and the midwifery model of care. While CABC works closely alongside the AABC, the organizations are separate and have distinctly separate roles regarding national standards and accreditation of birth centers. CABC is the only accrediting body devoted exclusively to birth centers, whose site visitors are specifically trained to conduct a site visit in a birth center; and whose review panels have first‐hand knowledge of the philosophy, clinical care and operation of birth centers.  AABC on the other hand, is a membership and trade organization for established and developing birth centers and other individuals, agencies and institutions that support the birth center model of care and the national AABC Standards for Birth Centers.


There has been much research in recent years to support out of hospital birth—especially birth center birth—as not just safe but at times safer than hospital birth because of its judicious use of technology, licensed professionals and connection to the health care system.


The  Amish , known for their great respect for tradition, usually have  homebirths  or give birth at birthing centers.  Most Amish women only go to a hospital to give birth when there is a known medical risk for her or the child, but some Amish women choose to go the hospital during labor for  peace of mind .  Two books have been written about Amish medical issues including their birthing practices:  Dr. Frau: A Woman Doctor among the Amish  by Grace Kaiser and  House calls and hitching posts: stories from Dr. Elton Lehman's career among the Amish  by Elton Lehman.  Lehman is known for his work in founding a freestanding Amish birthing center.  The Mount Eaton Care Center, Ohio's first such center, was established in 1984.  In her book,  Kaiser  recounts the private nature of birthing among the Amish.  She points out the practice of Amish women keeping labor a secret to all except their own husbands and midwife or obstetrician, as well as the practice of women waiting until active labor before summoning a midwife or OB.  Due to the latter practice, fathers occasionally end up delivering their own children before the midwife or OB can arrive if a homebirth is selected.  Amish women who choose a home birth often continue with household duties until they are no longer physically able to continue.  If birthing in a birth center, they are free to labor similar to that of home births: eating, drinking, visiting with their family members, etc. [ 11 ] [ 12 ]


In a response to the  National Maternity Action Plan , State and Territory Governments in 2002 started to respond to consumer demand for an increased number of birth centers to be made available to women.   Whilst most birth centers are attached to hospitals, some are being established as free-standing centers much further away from hospital back-up.  As long as they are within 90 minutes of a hospital, they are considered 'safe'.  Most birth centers are now being run solely by  midwives , with  obstetric  back-up only used when there are complications.


Some birth centers in  Australia  are moving away from the 'low-risk' model and are moving to an  All-risk model  where women with medical complications are accepted into the birth center but extra care is provided to them where necessary.


Birthing centers remain controversial. Hospitals do offer this option, and it is available at special clinics.


The Netherlands has seen a growth in the number of locations for giving birth, other than homebirth or hospital maternity wards. In these facilities the birth is overseen by a midwife, typically in a homelike environment. [ 13 ]   Most community midwives work in group practices and only refer patients to hospital obstetric units for labor complications. [ 14 ]  Certification requires a four-year education at a midwifery academy. [ 13 ]


A three-year study focusing on the remote Solukhumbu District explored access to perinatal care and found that 36% of deliveries took place in a health facility. Results from this study noted that access to timely transportation options were a major factor in the lack of accessibility for maternal delivery support. [ 15 ]


Birthing  classes  are classes to help parents to prepare  for the birth of a baby and the first cares of a newborn, and a
 birth plan  is a document created by a  pregnant woman  detailing her decisions and expectations regarding her labor and  childbirth . [ 1 ] [ 2 ] [ 3 ] [ 4 ]


The birth plan may be simple or detailed and complex, depending on individual preferences, and may be revised over the course of pregnancy if desired. [ 4 ]  One may be written at any point during pregnancy, though it is often recommended to do so during the third trimester and after the pregnant woman is provided with information about the physiology of delivery, as well as possible choices and risks. [ 3 ] [ 4 ]  It is recommended that it be created with the support of a  primary care  provider. [ 3 ]  Once created, it is provided to the  obstetrical care  providers, with the intent of facilitating communication and emotional support for the pregnant woman, as well as the humanization of childbirth. [ 3 ]


Birth plans were first introduced in the late 1970s and 1980s, in response to the effects of the medicalization of childbirth in which pregnant women had less and less control over the process and were instead expected to rely on decisions by medical practitioners. [ 1 ] [ 3 ]  It has become increasingly popular in Western countries since then, and has been advocated for by the  World Health Organization  since 1996. [ 3 ]  Because it promotes decision-making by women, it has been considered to advance  female empowerment . [ 3 ]


In addition to preferences related to obstetrical care, a birth plan may include preferences for which individuals should be present at the birth for support, food and water intake, body position, care of the newborn regarding separation and skin-to-skin contact ( Kangaroo care ), breastfeeding, desired interventions if there are complications, pain relief, and cultural preferences. [ 3 ] [ 4 ]


A 2019 review of studies looking at the helpfulness of having a birth plan  concluded that creation and use of a birth plan "positively influences the parturition process and maternal-fetal outcomes", though unrealistic expectations may cause a lack of satisfaction by some pregnant women. It stated that there was a need for greater awareness and support from medical professionals and use of flexible plans to increase maternal satisfaction. [ 3 ]   Another review, done in 2022, concluded that birth plans "were associated with positive outcomes for childbearing women when developed in collaboration with care providers." It found that creation of a collaborative birth plan could improve medical outcomes, increase a sense of control and satisfaction, and promote realistic expectations. [ 1 ]


Birthing classes, also termed antenatal classes, help the parents to  prepare for the baby's birth and care of the newborn.  Individual fears and concerns can be discussed with professionals and others in the class.
Classes  include learning about the process of labor and birth and various medications and other pain management options.  The classes may include information about what area hospitals provide for women in labor, such as facilities for  water births .  Besides water births, pain management may include  aromatherapy , massage, and other plans to help the mother in labor.  Breathing exercises, such as those used in the  Lamaze  method may be introduced. Lamaze method teaches the use of a "birth  ball" (yoga or exercise ball)  and spontaneous pushing. The Lamaze method teaches that labor is best allowed to begin on its own rather than being induced when not medically necessary. [ 5 ] [ 6 ]


A support person, such as a partner, friend, or family member, may attend some or all of the classes.  They can learn how to support the mother and how to help with relaxation techniques.  The  Bradley method of natural childbirth  relies heavily on training partners or other support persons to be labor "coaches".  The role that a  doula  has in supporting and assisting the mother is also discussed.
A large recent study that looked at reports of continuous support for women during labor   found:


Continuous support during labour may improve outcomes for women and infants, including increased spontaneous vaginal birth, shorter duration of labour, and decreased caesarean birth, instrumental vaginal birth, use of any analgesia, use of regional analgesia, low five-minute  Apgar score  and negative feelings about childbirth experiences. [ 7 ]


Some births require medical interventions.  Women learn about the various drugs that may help her to cope with labor pains.  A discussion of the use of  pitocin  or some other drug which may be used to  induce labor  as needed in some instances is discussed. [ 8 ]   Information about different kinds of interventions such as  Caesarean section ,  forceps delivery , or  vacuum delivery  are also explained and discussed with the expectant mother. [ 9 ]


Classes also teach early postpartum needs of the mother and her child.
Some classes teach the importance of early  skin-to-skin  (SSC) care.  It is supported by every major health delivery organization and the  World Health Organization  which states that "the process of childbirth is not finished until the baby has safely transferred from placental to mammary nutrition." WHO has  designated hospitals that fulfill their  Baby Friendly Hospital Initiative  requirements as Baby Friendly.  In the U.S., in 2019 more than 28% of births occurred in Baby Friendly hospitals in all fifty states with a total of 600. [ 10 ]


Some mothers, such as vulnerable, young mothers pregnant with their first child, may have special needs and need more assistance than what they receive in birthing classes.   Nurse-Family Partnership  (NFP) is a non-profit organization operating in the United States and the UK.
Each mother served is partnered with a registered nurse early in her pregnancy and receives ongoing nurse home visits that continue through her child's second birthday. NFP intervention has been associated with improvements in maternal health, child health, and economic security. [ 11 ] [ 12 ]


Bishop score , also  Bishop's score  or  cervix score , is a pre- labor  scoring system to assist in predicting whether  induction of labor  will be required. [ 1 ]  It has also been used to assess the likelihood of spontaneous preterm delivery. [ 2 ]  The Bishop score was developed by Professor Emeritus of Obstetrics and Gynecology, Edward Bishop, and was first published in August 1964. [ 1 ] [ 3 ]


The total score is calculated by assessing the following five components on manual  vaginal examination  by a trained professional:


The Bishop score grades patients who would be most likely to achieve a successful induction. The duration of labor is inversely correlated with the Bishop score;  “A Bishop score of 9 conveys a high likelihood for a successful induction. For research purposes, a Bishop score of 4 or less identifies an unfavorable cervix and may be an indication for cervical ripening.”


Excerpt From
Williams Obstetrics, 25th Edition
F. Gary Cunningham, Kenneth J. Leveno, Steven L. Bloom, Jodi S. Dashe, Barbara L. Hoffman, Brian M. Casey and Catherine Y. Spong
This material may be protected by copyright.


They can be remembered with the mnemonic:  Call PEDS For  Parturition  = Cervical Position, Effacement, Dilation, Softness; Fetal Station.


The examiner assigns a score to each component of 0 to 2 or 0 to 3. The highest possible score is 13 and the lowest possible score is 0.


A score of 5 or less suggests that labour is unlikely to start on its own during the next few days. A score of 9 or more indicates that labour will most likely commence spontaneously in the next few days. [ 4 ]  Scores between 5 and 9 require additional consideration and professional judgement for clinical management.


A Bishop's score 6 or less often indicates that induction (e.g., with controlled-release prostaglandin E2/prostin gel [Cervidil], intravaginal gel [Prostin], intracervical gel [Prepidil]) is unlikely to be successful. [ 5 ]  Some sources indicate that only a score of 8 or greater is reliably predictive of a successful induction.


The score can be recalculated as the pregnancy progresses.


According to the Modified Bishop's pre-induction cervical scoring system, effacement has been replaced by cervical length in cm, with scores as follows: 0 for >3 cm, 1 for >2 cm, 2 for >1 cm, 3 for >0 cm. [ 6 ]  Cervical length may be easier and more accurate to measure and have less inter-examiner variability.


Another modification for the Bishop's score is the modifiers. Points are added or subtracted according to special circumstances as follows:


Bloody show  or  show  is the passage of a small amount of  blood  or blood-tinged  mucus  through the  vagina  near the end of  pregnancy . It is caused by thinning and dilation of the cervix, leading to detachment of the  cervical mucus plug  that seals the cervix during pregnancy and tearing of small cervical blood vessels, [ 1 ]  and is one of the signs that  labor  may be imminent. [ 2 ]  The bloody show may be expelled from the vagina in pieces or altogether [ 3 ]  and often appears as a jelly-like piece of mucus stained with blood. [ 4 ]  Although the bloody show may be alarming at first, it is not a concern of patient health after 37 weeks gestation. [ 5 ]


Bloody show is recognized through the presence of mucus and blood that is combined and discharged from the cervix before labor occurs. [ 6 ]  Bloody show is sometimes used as an indication of active labor, and can occur as a result of the onset of labor. [ 7 ]  Bloody show can also occur with other symptoms of onset of labor, including painful contractions, degree of cervical effacement, and/or spontaneous membrane rupture. [ 8 ]  Severity of symptoms differs from person to person and usually those symptoms are more commonly found than bloody show.


Bloody show may occur before labor, sometimes as early as three days before the actual delivery date. [ 6 ]  When bloody show occurs, pregnant individuals are encouraged to see a midwife or doctor as this may be an indication of active labor. [ 9 ]  Bloody show may occur gradually or all at once, however, it will indicate the pregnant person will go into labor soon. [ 5 ]


Bloody show is the most common cause of bleeding during late pregnancy and often presents as minor bleeding mixed with mucus alongside other signs of labor initiation (contractions, cervical dilation, cervical effacement). [ 10 ]  While not considered as serious bleeding or deadly, the passage of a bloody show signals that labor is beginning or will begin soon. [ 9 ]


The diagnostic examinations and tools used to determine the type of  vaginal bleeding  depend on a combination of gestation age, history of pregnancy and bleeding, past medical history, physical examination, and laboratory work. [ 10 ]


Vaginal bleeding  may occur at any point during pregnancy. [ 14 ]  During late pregnancy, bleeding may be normal but may also indicate a more serious underlying problem such as miscarriage,  placenta previa , or  placental abruption . [ 15 ]   [ 16 ] [ 17 ] [ 18 ]  Bloody show itself is an exclusionary diagnosis, that is, it rules out other causes of vaginal bleeding. [ 10 ]   Other causes of vaginal bleeding in late pregnancy include placental abruption, placenta previa, vasa previa,  uterine rupture , and non-obstetric causes. [ 10 ]