410 ‒ The biology of pregnancy: physiologic adaptation, childbirth, and long-term maternal health
In a Nutshell
Pregnancy functions as a comprehensive physiologic stress test that unmasks underlying predispositions to diabetes, hypertension, and cardiovascular disease, with gestational diabetes and preeclampsia serving as early warning signals for future metabolic and cardiac problems. The biological mechanisms driving labor onset, preeclampsia, and preterm birth remain poorly understood despite their clinical importance, reflecting chronic underinvestment in pregnancy research at the NIH and elsewhere. Delivery mode, microbiome transfer, and breastfeeding capacity have been oversold in popular discourse relative to their actual impact on long-term maternal and infant health outcomes.
These notes were generated by AI and may contain inaccuracies.
Katie is a physician scientist with an MD PhD. During her undergraduate studies at the University of Wisconsin, a required advisory meeting with a professor led her to pursue both medical school and a PhD. The professor mentioned his daughter had gone to medical school but would have been happier also completing a PhD, prompting Katie to investigate this path further.
Katie's PhD was technically in immunology but focused on a benzoazipene compound identified from a drug screen. Previous lab work had shown this compound helped treat autoimmune lupus disease, but the mechanism was unknown. Her research involved understanding the molecular mechanism of this novel benzoazipene, specifically where it bound and how it induced apoptosis in cells. She isolated mitochondria from cow hearts and performed biochemical assays showing the compound acted on the mitochondrial ATPase.
The original drug was not very soluble, making it difficult to develop into a readily absorbed medication. However, a derivative of the compound has entered clinical trials for inflammatory bowel disease because it can act specifically in the gut.
Katie had always been interested in women's health. During her third-year clinical rotations, she found she liked both medicine and surgery, but was particularly drawn to pregnant patients and deliveries. She was fascinated by the unique motivation pregnant patients showed regarding their health, which differed from other areas of medicine.
From a research perspective, she was drawn to obstetrics and gynecology because fundamental questions remained unanswered: why people go into labor, why people have preterm labor, and why people develop preeclampsia. The lack of understanding in these areas made it an attractive field for investigation.
Pregnancy places tremendous demands on a woman's body. An adult becomes pregnant and immediately faces increased demands to support a developing fetus. There is great expansion of blood volume, alterations in endocrine function and metabolism, all of which are dramatic and persist throughout pregnancy.
Pregnancy functions as a cardiovascular stress test due to massive plasma volume expansion. It also serves as a metabolic stress test because of increased insulin resistance, particularly in the second half of pregnancy, which can cause gestational diabetes in some women and often unmasks future disease predisposition.
For women with regular periods, the missed period is typically the first sign of pregnancy before actual symptoms appear. Shortly after conception, implantation occurs and the placenta begins to grow.
In the initial phase, the ovary provides endocrine support for pregnancy development through production of estradiol (the dominant estrogen) and progesterone. Between 8-10 weeks of pregnancy, there is a transition where the placenta begins secreting hormones to support the pregnancy. This is why IVF patients receive supplementary hormones for the first several weeks, as their natural hormone production has been shut down.
hCG levels rise dramatically from zero during early pregnancy. The purpose of this rise is not entirely clear, though hCG is essentially luteinizing hormone.
For a long time, hCG was thought to drive morning sickness, but genetics research has identified the GDF-15 gene as important in driving hyperemesis gravidarum (extreme nausea and vomiting of pregnancy). This has become a developing target for therapeutics. The condition is not well understood, and it is not necessarily correlated with motion sickness susceptibility.
Women who experience hyperemesis in their first pregnancy often have it in all subsequent pregnancies. The biggest risk is maternal dehydration and lack of nutrition, as the fetus takes what it needs from the mother.
Standard antiemetics like Zofran can be used during pregnancy. However, they are often not sufficient for severe cases, and some women require hospitalization for IV hydration and even IV nutrition. The prevalence of such interventions is less than 1% of pregnancies overall, though it is very severe for those affected.
Plasma volume expansion starts immediately after conception and increases by 50% by 28 weeks. This expansion is pretty linear initially but accelerates in the second part of the second trimester before leveling off.
The 50% plasma volume increase creates a relative anemia as hemoglobin concentration does not expand proportionally. Women with severe enough cardiac or pulmonary disease cannot tolerate this expansion, and pregnancy is not recommended in such cases. Since 50% of pregnancies are unplanned, some women may not know they have such high-risk conditions until becoming pregnant.
Progesterone has important functions in pregnancy, particularly in maintaining uterine quiescence (preventing contractions) and supporting placental development. Estrogen levels rise dramatically, and symptoms like breast tenderness are common early in pregnancy, though these often abate as the body adjusts.
Increased nutrient demands occur particularly in the second half of pregnancy when fetal growth is greatest. Prenatal vitamins are recommended, including iron to support blood volume expansion.
Folic acid is critical to have adequate levels prior to conception. Folic acid deficiency increases the risk of neural tube defects in the baby, and by the time pregnancy is recognized, it may be too late to correct deficiencies. This is why prenatal vitamins are recommended even before conception, and why all women of childbearing age should consider them or maintain a healthy diet with supplemented foods.
Neural tube defects occur when the neural tube does not form correctly. The most common type is myelomeningocele, where at the base of the spine the spinal cord is exposed due to improper skin formation. In utero surgery can be performed in eligible cases to improve long-term ambulatory function, bowel and bladder function.
Without intervention, neural tube defects can cause variable effects including problems with walking, lower extremity strength and function, bowel and bladder function, and accumulation of fluid in the brain requiring lifelong shunting.
Anencephaly is the most severe neural tube defect where the brain and cranium do not form at all. Cases still occur today, with two cases noted in one practice in a single year. The relationship between folate deficiency severity and defect type (anencephaly versus milder spinal defects) is not understood - some cases are associated with genetic syndromes while others appear sporadic.
By the end of the first trimester, formation of all fetal organs is complete. The heart has four chambers, and all major developmental processes have occurred. The fetus is approximately 1.5-2 inches long but perfectly formed. Maternal weight gain during this period is typically 0-10 pounds.
The second trimester involves significant fetal growth. Plasma volume expansion accelerates in the latter part of this trimester. Metabolism shifts from insulin sensitive to more insulin resistant, driven by placental growth. Maternal weight gain increases compared to the first trimester, and pregnancy becomes visibly apparent.
The insulin resistance that develops is meant to be adaptive, providing enough fuel for fetal growth. However, in some women glucose production exceeds needs, resulting in persistently high glucose levels and a diagnosis of gestational diabetes. This is more similar to type 2 diabetes than type 1 diabetes.
Routine screening for gestational diabetes became standard because risk factor-based screening missed half of cases. Women cannot be reliably predicted to develop gestational diabetes based on risk factors alone. Women may present with glucose in urine and symptoms like polyuria and polydipsia from high blood sugar.
Uncontrolled high glucose levels during pregnancy pose significant risks primarily to the fetus rather than the mother in the short term. When the fetus experiences elevated glucose levels, it can result in excessive growth known as fetal macrosomia. This increases the risk of pregnancy complications including preeclampsia, characterized by high blood pressure and protein in the urine, particularly when gestational diabetes is not well treated. Delivery complications include increased risk of C-section and shoulder dystocia. The newborn faces elevated risk of hypoglycemia as it ramps up its own insulin production to manage glucose levels, then becomes detached from the mother and placenta while still producing excess insulin.
There is evidence that babies exposed to gestational diabetes have higher long-term risk of metabolic issues, though the mechanisms are not fully understood. This risk may involve epigenetic factors, though complete understanding remains elusive.
Screening for gestational diabetes occurs between 24 and 28 weeks gestation, chosen because earlier screening might miss cases that develop later. Data indicates that diagnosing gestational diabetes earlier may not improve outcomes, making this window optimal for both identification and treatment impact.
The initial screening uses a one-hour glucose test with 50 grams of glucose that does not require fasting. Patients drink the glucose solution and have blood drawn one hour later. If glucose exceeds 130 or 140 mg/dL depending on the cutoff used, a follow-up three-hour glucose tolerance test is performed. This requires fasting, uses 75 grams of glucose, and involves testing at one, two, and three hours post-ingestion.
For the three-hour test, diagnosis requires two elevated values among the fasting, one-hour, two-hour, and three-hour measurements. If the one-hour value exceeds 200 mg/dL, the three-hour test is not performed. The thresholds are generally similar to those used for diagnosing type 2 diabetes outside pregnancy when not relying on A1C alone.
First-line treatment involves dietary modifications and consultation with nutrition, with monitoring of fasting and postprandial glucose levels. Target values include fasting under 95 mg/dL and one-hour postprandial under 140 mg/dL. Medications are initiated when more than half of values exceed target ranges.
Insulin is first-line medication for gestational diabetes, differing from type 2 diabetes management outside pregnancy. This preference stems from limited data on other medications' efficacy and safety in pregnancy, combined with insulin's proven effectiveness and safety profile. While metformin is considered fairly safe in pregnancy, insulin has the best influence on improving neonatal outcomes.
Lifestyle interventions receive close follow-up with frequent communication about glucose values, though the exact duration depends on individual response. If values remain elevated in the first week, treatment escalation occurs rather than continuing lifestyle modifications alone.
Gestational diabetes typically resolves after delivery for most patients, though differentiation from undiagnosed type 2 diabetes is important. A finger stick is checked while still in the hospital, with a two-hour glucose tolerance test recommended at the six-week postpartum visit to screen for type 2 diabetes. Women with gestational diabetes history require closer surveillance for type 2 diabetes development.
Every woman experiences some degree of insulin resistance during pregnancy as an adaptive response to preferentially direct nutrients to the fetus. Genetic factors can amplify this resistance in some women, while environmental factors including stress, sleep, and nutrition can also contribute. This framework explains why gestational diabetes does not always recur in subsequent pregnancies, though having it once increases likelihood of recurrence.
Preeclampsia is defined as new-onset hypertension after 20 weeks gestation, often accompanied by proteinuria and potentially other severe features including right upper quadrant pain, vision changes, and headaches. The condition is screened for during routine prenatal visits because hypertension is typically asymptomatic.
The original prenatal care schedule was designed to detect developing preeclampsia, explaining the accelerating visit frequency toward the end of pregnancy. Diagnostic thresholds include systolic blood pressure of 140 mmHg and diastolic of 105-110 mmHg. Diagnosis can occur with severe-range blood pressures without requiring overt proteinuria.
Preeclampsia incidence affects approximately 5-7% of pregnancies in the US, with highest risk among first pregnancies and women at the extremes of reproductive age (very young or over 40). The increased risk in first pregnancies may relate to immune responses involving exposure to paternal antigens. Women over 40 face increased cardiometabolic disease and reduced tolerance to cardiovascular demands of pregnancy.
The underlying pathophysiology involves angiogenic imbalance. In early pregnancy, placental trophoblasts should invade maternal spiral arteries, creating wider, lower-pressure vessels for adequate placental blood flow. When this invasion is inadequate, the placenta experiences hypoxia and releases anti-angiogenic factors including sFlt-1 into maternal circulation. This molecule sequesters VEGF, affecting endothelial cell function in both maternal vessels and renal glomeruli, explaining the connection between hypertension and proteinuria.
The molecular understanding of preeclampsia emerged from research by Anant Karumanchi at Beth Israel in Boston, who collected placentas from preeclampsia patients and performed microarrays identifying sFlt-1 upregulation. This work, building on Judah Folkman's Harvard research on anti-VEGF for cancer, established the causal pathway.
Untreated preeclampsia historically progressed to severe hypertension, seizures, maternal death, stroke, and organ failure. This represents a fundamentally different hypertension pattern compared to chronic hypertension, with accelerated and extreme progression capable of causing severe outcomes within months.
Antihypertensive treatment with nifedipine and labetalol allows expectant management in many cases, potentially extending pregnancy by weeks when hypertension presents at 30 weeks. However, delivery remains the only cure. Early-onset preeclampsia is defined as presentation before 34 weeks, with 20 weeks being the earliest possible presentation, though very rare.
Delivery timing balances maternal and fetal risks based on disease severity rather than gestational age alone. At term (37 weeks and greater), delivery occurs even with mild hypertension. Decisions consider hypertension severity, lab abnormalities including elevated liver function tests and low platelets, and fetal concerns such as growth restriction or abnormal testing.
Women with normal baseline kidney function generally recover renal function after pregnancy, though severe preeclampsia increases long-term risk of both kidney disease and cardiovascular disease.
HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) represents either a severe preeclampsia variant or distinct condition with overlapping features. Patients may present with severe hypertension or mild-range pressures with severe lab abnormalities. Management typically involves betamethasone for fetal lung maturity, waiting 48 hours, then delivery without expectant management.
Preeclampsia is heritable with genetic contributions from both fetal/placental and maternal genomes. Recent genome-wide association studies over the past eight years have identified genetic factors contributing to the condition, providing insights into underlying causal biology and potential therapeutic targets.
ACE inhibitors and ARBs are known to be unsafe in pregnancy due to negative impacts on the fetus. These medications are effective postpartum for controlling maternal blood pressure and are often utilized after delivery.
Hypertension associated with preeclampsia does not resolve as quickly as gestational diabetes. Some women experience rapid resolution after delivery, but many require antihypertensive medications for several weeks. Blood pressure normalization can take 6-12 weeks. Some women have persistent hypertension that never resolves, while others develop hypertension within 5-10 years postpartum.
Proteinuria resolves after delivery without specific monitoring because the placenta is removed, eliminating the driving factor. Monitoring occurs only if metabolic labs show evidence of renal dysfunction or elevated creatinine. Most women without underlying kidney disease experience resolution of proteinuria.
Creatinine levels do not typically increase during pregnancy even with significant proteinuria. When creatinine elevation occurs with preeclampsia, it represents a severe feature of the disease. Cystatin C is not routinely checked.
Hypertension during pregnancy, even when resolved, predicts later-life atherosclerotic cardiovascular disease. This association has been known within obstetrics for quite some time but has not translated well into primary care and other medical fields. Obstetric history should be obtained during any patient history and physical.
Genetic studies reveal that preeclampsia and essential hypertension share strong genetic architectures. Genome-wide association studies of preeclampsia show top hits that are also significant in hypertension studies. Women who develop preeclampsia have higher genetic predisposition to hypertension, and pregnancy unmasks this underlying predisposition.
Beyond genetic predisposition, exposure to hypertensive pregnancy may add additional risk for future cardiovascular disease. Research continues to investigate how pregnancy itself might increase long-term risk. Social factors and other health conditions also contribute to multifactorial long-term disease risk.
Fifty percent of patients with gestational diabetes will develop type 2 diabetes. Recommendations include frequent diabetes screening follow-up and aggressive lifestyle interventions. Healthier diet, appropriate body weight, and regular exercise are critical for risk reduction, especially for those with gestational diabetes history.
High-risk obstetricians see patients only for subsequent pregnancies rather than ongoing primary care. The transition to primary care providers with transmitted information about pregnancy complications is essential. Young patients caring for children often do not follow up adequately between pregnancies. Electronic health records have improved some communication, but providers must recognize the importance of obstetric history.
Cesarean sections became feasible in the late 1800s with modern anesthetics. Many parts of the world still lack access to surgical intervention during labor and delivery, leading to increased stillbirths and maternal complications like fistulas from prolonged labor.
Cesarean section rates in the United States have increased dramatically from approximately 10% to 30% in academic medical centers. This increase reflects higher-risk pregnancies, previous cesarean sections, maternal obesity, and continuous fetal monitoring during labor.
Multiple factors contribute to rising cesarean rates: pregnancies are higher risk than historically, previous cesarean increases likelihood of subsequent cesarean, maternal obesity leads to larger fetuses and labor dystocia, and continuous fetal monitoring results in cesarean delivery for non-reassuring tracings.
Multiple prior cesarean sections increase risk for abnormal placentation, specifically placenta accreta spectrum where the placenta invades abnormally into the uterus. This condition prevents normal placental delivery after birth.
Low transverse cesarean sections cut horizontally in the lower uterine segment, which is less muscular and allows safer future labor with less than 1% risk of uterine rupture. Classical cesarean sections involve vertical incisions through the uterine musculature with approximately 10% rupture risk during labor, making vaginal delivery contraindicated.
Classical cesarean sections are performed when the lower uterine segment is not adequately developed, typically in preterm deliveries where the uterus has not expanded sufficiently. Other indications include surgical complexity from multiple previous cesareans with extensive scar tissue.
Breech deliveries are generally avoided because the largest part of the baby (the head) delivers last, risking head entrapment. External cephalic version can be attempted around 37 weeks with approximately 50% success rate. The procedure can be painful and anesthesia may be provided.
Approximately one-third of deliveries involve the cord wrapped around the neck, usually without causing problems. When complications occur, they may cause variable decelerations in fetal heart rate tracings. Cord complications are sometimes suspected in stillbirths but causation is difficult to confirm.
Stillbirth occurs at a rate of 1 in 160 pregnancies in the United States. Stillbirth is defined as any fetal demise after 20 weeks gestation. After 20 weeks, most lethal chromosomal abnormalities have typically been identified, though some patients choose to continue pregnancies with known anomalies.
The most useful diagnostic tests for determining stillbirth cause include placental pathology, fetal autopsy, and genetic testing. Visual examination during delivery may reveal obvious causes such as placental abruption or tight cord entanglement. Even with comprehensive evaluation, the cause remains unexplained in a substantial percentage of cases.
Growth restriction and placental insufficiency are identified in a substantial fraction of stillbirths but do not fully explain the underlying mechanisms. These findings represent proximal causes rather than explaining why placental problems developed at the end of otherwise normal pregnancies.
Umbilical artery Doppler monitoring is performed only when fetal growth restriction is identified or other specific indications exist. Routine Doppler screening has not been shown to be helpful in low-risk pregnancies.
The physiological triggers for labor onset remain largely unknown. Changes in the HPA axis are thought to shift the uterus from a quiescent progesterone-maintained state to active contraction, but the specific mechanisms are not well understood.
Patients are instructed to monitor fetal movement and report changes, leaking fluid, vaginal bleeding, or contractions. Contractions occurring closer than five minutes apart for more than an hour, increasing in pain and intensity, or accompanied by other warning signs warrant immediate evaluation.
Early contractions may feel similar to severe menstrual cramps. True labor contractions are typically more painful than any previously experienced sensation. Some women with high pain tolerance present quite dilated with minimal pain, though most experience labor as a significantly painful process.
The cervix is monitored during pregnancy for dilation. In early and mid-pregnancy, cervical dilation indicates premature cervical dilation or preterm labor. At term, cervical thinning, softening, and some dilation is common as the body prepares for labor. Digital checks monitor labor progression in the hospital setting.
Dilation alone does not determine labor status. People can remain at 3-4 centimeters dilated for weeks without being in labor, while others at 4 centimeters with painful contractions every three minutes are definitely in labor. The process varies among individuals - in some people the water breaks first, while in others labor begins differently.
When the water breaks, the amniotic sac develops a hole, often in the lower uterine segment or near the cervix, releasing amniotic fluid. The fluid is typically clear, though it may be yellowish, contain meconium (baby's stool) at term, or appear bloody if placental abruption is occurring.
If the water breaks with blood indicating the placenta has started separating, this requires monitoring. If the majority of the placenta remains attached long enough for labor to progress, vaginal delivery may be possible. However, continuous monitoring of the baby's heart rate tracing and bleeding is essential, and nonreassuring findings may necessitate cesarean section.
Once the water breaks, a clock starts due to infection risk. Term patients are recommended to come to the hospital even without contractions. If labor is not induced, infection risk increases. Labor induction with pitocin is recommended, with the goal of delivery within 24 hours, though there is no absolute deadline if the mother and baby remain well and labor progresses without infection.
PROM refers to water breaking at 28 weeks or similar gestational ages. Approximately half of patients with PROM deliver within the next seven days through spontaneous labor. Patients who do not go into labor are monitored in the hospital until 34 weeks if all parameters remain reassuring. Primary concerns include infection, rapid progression into labor, and if the baby is not cephalic (head down), risk of cord prolapse or other body parts emerging through the cervix.
Patients with ruptured membranes often have low amniotic fluid levels but continue producing and leaking fluid. Antibiotics are given at presentation to prolong latency and pregnancy duration, though they do not prevent all infections. Antibiotics are administered initially and not continued.
The bacterial transfer between mother and fetus during vaginal delivery has received significant attention, though the scientific understanding remains limited. While the microbiome is important across medicine, popular press coverage often exceeds the basic medical evidence. There is no epidemiologic data suggesting children born via cesarean section are more or less likely to have gut-related issues. Of all factors determining maternal and infant health, the microbiome transfer from delivery mode is not something to stress about.
Most people without substantial breast surgery or endocrine disruptors have the physiologic capacity to produce breast milk. Breastfeeding represents a maternal-neonatal partnership. For very premature babies unable to latch, mothers must pump, which is less effective than direct breastfeeding for stimulation and ongoing milk production. Breastfeeding requires expressing milk every few hours for many weeks.
Lactation involves complex hormonal interplay. A lactating woman has suppressed estrogen and progesterone levels and typically does not ovulate. However, missing even one feeding can stop cycle suppression, making lactation an unreliable form of birth control.
Exercise is important during pregnancy. Bed rest is detrimental, and people do better with activity. New intensive exercise programs should not be started during pregnancy. Regular activity such as walking or low-weight lifting is acceptable. Patients with established exercise programs can generally continue if the pregnancy is uncomplicated, including resistance training for those accustomed to strenuous lifting.
Exercise restrictions focus on injury risk from changing center of gravity. Downhill skiing is not recommended in the second half of pregnancy. Activities with abdominal trauma risk such as horseback riding should be avoided. For patients with threatened preterm labor or short cervix, heavy lifting and certain activities may be restricted.
Lifelong runners can continue running during pregnancy with mindfulness about the changing center of gravity, avoiding falls, staying hydrated, and potentially moderating intensity. Discomfort at the end of pregnancy may naturally lead to stopping.
At the end of pregnancy when the fetus is large, lying completely flat on the back is not optimal. Some tilt toward the back is advisable due to potential vena cava compression. However, waking up on the back is not cause for panic.
Postpartum blues with dramatic mood changes are common in the first two weeks after delivery due to the collapse of high estrogen and progesterone levels to extremely low levels, along with HPA axis changes. Postpartum depression occurs when baby blues persist beyond this short period, leading to depressive symptoms for weeks afterward.
Standard screening for depression is recommended both during pregnancy and postpartum. Patients at higher risk due to social stressors are identified and connected with resources. Mental health system limitations, time constraints for new mothers, difficulty accessing appointments, hesitancy to seek help, and societal pressure to feel happy with a new baby all contribute to underrecognition and undertreatment.
Cell-free DNA screening from maternal blood has decreased the number of invasive procedures like amniocentesis and chorionic villus sampling. This screening detects fragments of placental DNA and effectively screens for trisomies 21, 18, and fetal sex, though it is less effective for other conditions. Testing can be performed as early as 9-10 weeks of pregnancy and is recommended to be offered to all pregnant patients.
Previous serum screening using three or four protein markers had low positive predictive value - only 5% of positive screens actually indicated a baby with Down syndrome. Cell-free DNA has dramatically improved sensitivity and specificity, though positive screens do not guarantee the condition is present.
Chromosomal disorders currently screened represent only a small percentage of all possible genetic disorders. Cell-free DNA contains the entire genome, but limitations include cost, prenatal implications, distinguishing which conditions should be identified during pregnancy versus later in life, and the large number of genetic variants per condition (such as cystic fibrosis). For many inborn errors of metabolism, there are no prenatal ultrasound features or other signs, making genetic interpretation critical. A significant gap exists between technological capabilities and the framework for deciding what to screen for, along with healthcare system resources needed for counseling.
Delivering devastating diagnoses including underlying genetic conditions, severe fetal anomalies, or stillborn babies represents one of the most difficult aspects of practice. Walking families through implications is emotionally challenging. Resource disparities affecting patients - such as lack of stable housing or complex social situations - also have significant impact on patient outcomes and are difficult for physicians to address.
Midwife care prevalence varies significantly by state, rural versus urban setting, and region of the country. Midwives provide excellent obstetric care throughout the United States.
Midwives provide great access in many places where patients don't have other access. Their training is different, and they can often reach patients who are otherwise skeptical of the medical system or really don't prefer to have a physician taking care of them. Midwives are an important component of obstetric care.
Most practices are set up so that if a surgical procedure is needed, there is a backup. Of anticipated vaginal deliveries, about 20% end up going to C-section. Even for a woman who's been under great care and wants to have a baby at home with a midwife, there's at least a 20% chance they will need to call in for a backup surgical plan.
There are different reasons why people delivering in a birthing center or at home with an attended birth might need to transfer to the hospital. One reason is that a surgical delivery is needed, but another might be that more pain control is needed or that augmentation with oxytocin is needed to help the labor progress.
Midwives are meant to provide access in the outpatient setting. The recommendation is to deliver in a birthing center or a place with access to other types of medication. Patients who choose home births are not being recommended to do so because you can't know when things are going to go wrong. Hemorrhage is a big problem, and things can change in a second when you're very far away from where you need to be to get care. Different obstetrical emergencies can happen, and usually most of them don't, but the risk to the baby and to the mom is higher at home deliveries.
Most of the labor is contractions. The delivery of the head is like a 30-second part of the whole thing. A nurse described it as "like having your balls slammed in a drawer again and again and again" to help a husband understand the pain level. It is described as a very deep visceral pain.
The delivery of the head is very painful. On a third delivery where the epidural medicine was more dilute, there was no coverage right at the perineum, so everything could be felt when the head was about to come out.
Back labor refers to patients who in the first part of labor especially, or even throughout labor, may feel a lot of pain in their back in addition to or instead of feeling pain in the front where the uterus is. Menstrual pain can commonly be both in the front and the back. For patients whose babies might be facing sunny side up, there seems to be more pain in the back during labor.
The most common position is normal delivery with head out first face down.
Women seem to have the pain immediately vanish when the baby is out, and there is a little bit of amnesia where they can't wait to do it again.
Medicine has made so much progress over the last hundred years, and obstetrics has had a greater improvement in mortality than almost any field. Fewer mothers and babies dying during childbirth has had the single biggest impact on a population's longevity.
Despite this progress, the United States still doesn't quite stack up to other OECD nations in this arena. This is a big drag down on overall mortality, survival numbers, and life expectancy numbers.
There are low-hanging fruit that would help. Insurance access is a big deal. For states that expanded Medicaid, patients came into pregnancy with better health and were more willing or able to come to prenatal care because they were able to get insurance through Medicaid. Extended Medicaid postpartum for care is impactful because a lot of mothers die after delivery. Medicaid previously stopped 60 days after leaving the hospital, but states have expanded access with longer postpartum coverage.
One reason health is poor is because insurance access is piecemeal and not guaranteed, and healthcare is expensive even for those who have insurance.
The system is so complicated that most physicians can't actually answer questions about coverage because it is so unpredictable and changes every year with any health plan. There are deductibles and charges that are difficult to understand. It is incredibly frustrating and difficult, and physicians feel very powerless because they would like to provide information but there are so many differences between so many different plans.
It would seem an issue that everyone on both sides of the aisle could agree is bad: that moms and babies not be cared for and nobody should incur bankruptcy-inducing healthcare bills. Everyone is very frustrated with the payers. This is the Achilles heel of the US healthcare system that does not appear in single-payer solutions.
There is still a lack of interventions and treatments in the pregnancy space because of lack of investment in research in this area. Pregnancy has been a neglected area in research and an underfunded area of research, even at the NIH level. The branch of the NIH, the NICHD (National Institutes of Child Health and Development), has nothing in that word about pregnancy, yet that branch has funded the most pregnancy-related research of any branch of the NIH. The title indicates it's about child health, not about the moms.
There is recognition of pregnancy's importance in the whole lifespan that has expanded some funding opportunities, but there is need for continued investment because it still remains understudied and under-resourced.
The American Gynecologic and Obstetric Society has put together a women's health collective to try to advocate for women's health funding, and key players in leading this space across OBGYN are involved in that society. Contacting leaders of these organizations can help direct people to investigators doing the work of interest.
The opportunity during pregnancy provides a window into future health, and listeners should use this opportunity to learn what their susceptibilities and risks are in the future.
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