Induction of labour is the planned treatment that stimulates childbirth and delivery prior to its spontaneous onset. Inducing labour can be accomplished with pharmaceutical or non-pharmaceutical methods. Every year, 1 in 5 labours are induced in the UK.
Most women go into labour naturally (spontaneously) by the time they’re 42 weeks pregnant.
Induction is offered to all women who don’t go into labour naturally by 42 weeks, as there’s a higher risk of stillbirth or problems for the baby if pregnancy exceeds 42 weeks.
Other indications for induction include circumstances when there is increased risk to mother or baby, for example high blood pressure, pre-eclampsia or the baby isn’t growing. Once active labour is established, maternal and foetal monitoring should be carried out
Spontaneous rupture of membranes more than 24 hours before labour starts, has an increased risk of infection and is an indication for induction.
There are a number of absolute contraindications to induction including placenta praevia and severe foetal compromise.
It is therefore usually a medical decision to deal with a specific problem. There is however an argument in favour of inducing all women at term or shortly after.
Induction of labour for improving birth outcomes for women at or beyond term Philippa Middleton, Emily Shepherd, Caroline A Crowther
First published: 9 May 2018 Editorial Group: Cochrane Pregnancy and Childbirth Group
To assess the effects of a policy of labour induction at or beyond term compared with a policy of awaiting spontaneous labour, or until an indication for birth induction of labour is identified, on pregnancy outcomes for infant and mother.
A policy of labour induction at or beyond term compared with expectant management is associated with fewer perinatal deaths and fewer caesarean sections; but more operative vaginal births. NICU admissions were lower and fewer babies had low Apgar scores with induction. No important differences were seen for most of the other maternal and infant outcomes.

Methods of Induction
Methods of inducing labour include both pharmacological medication and mechanical or physical approaches.
• Prostaglandin E2 is the most studied compound and with most evidence behind it. A range of different dosage forms are available with a variety of routes possible. Vaginal PGE2 should not be used if there are specific clinical reasons for not using it (in particular the risk of uterine hyper-stimulation).
• Intravenous administration of synthetic oxytocin preparations.
• “Membrane sweep”, also known as membrane stripping, or “stretch and sweep” during an internal examination, the practitioner moves their finger within the cervix to stimulate and/or separate the membranes around the baby from the cervix. This causes a release of prostaglandins which can help to kick-start labour.
• Artificial rupture of the membranes (AROM or ARM) (“breaking the waters”) which is usually done immediately following a membrane sweep.
• Cervical balloons catheters and laminaria tents are not used routinely for induction of labour.

The most recent reviews on the subject of induction and its effect on Caesarean section indicate that there is no increase with induction and in fact there can be a reduction.
Ekaterina Mishanina et al., “Use of labour induction and risk of caesarean delivery: a systematic review and meta-analysis”, April 2014, Canadian Medical Association Journal
Our meta-analysis showed that the risk of caesarean delivery following labour induction was significantly lower than the risk associated with expectant management. This finding supports evidence from systematic reviews but is contrary to prevalent beliefs and information from consumer organizations, guidelines and textbooks. Labour induction was associated with benefits for the fetus and no increased risk of maternal death.

How effective is amniotomy as a means of induction of labour? 2010, 179 (3):381-3 Ir J Med Sci
In total, 26,670 women delivered in the National Maternity Hospital during the study period. Of these 4,928 women required induction of labour and 72.8% of these (n = 3,586) underwent amniotomy only for induction of labour. Spontaneous labour occurred in 90.1% of the women who underwent amniotomy within 24 h. Oxytocin as an induction agent was employed in 9.8% of cases. Overall, 80.5% of the women had a spontaneous delivery, 7.3% had a ventouse delivery, 4.3% had a forceps delivery, and 7.9% underwent a caesarean section. CONCLUSIONS: Amniotomy is a simple, safe and effective method of induction of labour.

If there is a medical indication to induce labour then the decision had been taken to deliver that patient within 24 hours. Induction is an active process and should not be dependent on suitability unless the alternative is immediate caesarean section.

1. Allahyar, J. & Galan, H. “Premature Rupture of the Membranes.”American College of Obstetrics and Gynecologists.
2. Mishanina, E; Rogozinska, E; Thatthi, T; Uddin-Khan, R; Khan, KS; Meads, C (Jun 10, 2014). “Use of labour induction and risk of caesarean delivery: a systematic review and meta-analysis”. CMAJ : Canadian Medical Association Journal. 186 (9): 665–73.
3. Li XM, Wan J, Xu CF, Zhang Y, Fang L, Shi ZJ, Li K (March 2004). “Misoprostol in labor induction of term pregnancy: a meta-analysis”. Chin Med J (Engl). 117 (3): 449–52.
4. Budden, A; Chen, LJ; Henry, A (Oct 9, 2014). “High-dose versus low-dose oxytocin infusion regimens for induction of labour at term”. The Cochrane Database of Systematic Reviews. 10: CD009701.
5. Clark K, Ji H, Feltovich H, Janowski J, Carroll C, Chien EK (May 2006). “Mifepristone-induced cervical ripening: structural, biomechanical, and molecular events”. Am. J. Obstet. Gynecol. 194 (5): 1391–8.
6. Kelly AJ, Kavanagh J, Thomas J (2001). “Relaxin for cervical ripening and induction of labor”. Cochrane Database Syst Rev (2): CD003103.
7. Guinn, D. A.; Davies, J. K.; Jones, R. O.; Sullivan, L.; Wolf, D. (2004). “Labour induction in women with an unfavourable Bishop score: Randomized controlled trial of intrauterine Foley catheter with concurrent oxytocin infusion versus Foley catheter with extra-amniotic saline infusion with concurrent oxytocin infusion”. American Journal of Obstetrics and Gynecology. 191 (1): 225–229
8. ACOG Committee on Practice Bulletins (2009). “ACOG Practice Bulletin No. 107: Induction of Labor”. Obstetrics & Gynecology. 114 (2, Part 1): 386–397.
9. Ekaterina Mishanina et al., “Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis”, April 2014, Canadian Medical Association Journal,
10. Heinberg EM, Wood RA, Chambers RB. Elective induction of labor in multiparous women. Does it increase the risk of cesarean section? 2002. J Reprod Med. 47(5):399–403.
11. Tim A. Bruckner et al, Increased neonatal mortality among normal-weight births beyond 41 weeks of gestation in California, October 2008, American Journal of Obstetrics and Gynecology, [2]
12. Caughey, AB; Sundaram, V; Kaimal, AJ; Gienger, A; Cheng, YW; McDonald, KM; Shaffer, BL; Owens, DK; Bravata, DM (Aug 18, 2009). “Systematic review: elective induction of labor versus expectant management of pregnancy”. Annals of Internal Medicine. 151 (4): 252–63, W53–63.
13. Caughey, AB; Sundaram, V; Kaimal, AJ; Gienger, A; Cheng, YW; McDonald, KM; Shaffer, BL; Owens, DK; Bravata, DM (Aug 18, 2009). “Systematic review: elective induction of labor versus expectant management of pregnancy”. Annals of Internal Medicine. 151 (4): 252–63,
14. National Institute for Health and Clinical Excellence, “CG70 Induction of labour: NICE guideline”,
15. Vernon, David, Having a Great Birth in Australia, Australian College of Midwives, 2005,
16. Roberts Christine L; Tracy Sally; Peat Brian (2000). “Rates for obstetric intervention among private and public patients in Australia: population based descriptive study”. British Medical Journal. 321: 140.
17. Yeast John D (1999). “Induction of labor and the relationship to caesarean delivery: A review of 7001 consecutive inductions”. American Journal of Obstetrics and Gynecology
18. Simpson Kathleen R.; Thorman Kathleen E. (2005). “Obstetric ‘Conveniences’ Elective Induction of Labor, Cesarean Birth on Demand, and Other Potentially Unnecessary Interventions”. Journal of Perinatal and Neonatal Nursing. 19 (2): 134–44.
19. Caughey AB, Nicholson JM, Cheng YW, Lyell DJ, Washington E (2006). “Induction of labor and caesarean delivery by gestational age”. Am Journal of Obstetrics and Gynecology. 195: 700–5.
20. J Caughey A. (8 May 2013). “Induction of labour: does it increase the risk of cesarean delivery?”. BJOG. 121 (6): 658–661.
21. The Institute for Safe Medication Practices Results Of ISMP Survey On High-Alert Medications: Differences Between Nursing, Pharmacy, And Risk/Quality/Safety Perspectives
22. Gülmezoglu AM, Crowther CA, Middleton P, et al Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev 2012;(6):CD004945.
23. Wennerholm UB, Hagberg H, Brorsson B, et al Induction of labor versus expectant management for post-date pregnancy: Is there sufficient evidence for a change in clinical practice? Acta Obstet Gynecol Scand 2009;88:6–17.
24. Wood S, Cooper S, Ross S. Does induction of labour increase the risk of caesarean section? A systematic review and meta-analysis of trials in women with intact membranes. BJOG 2014;121:674–85.
25. Willacy H Labour — active management and induction.; 2009.
26. Caesarean section [clinical guideline 132]. London (UK): National Institute for Health and Clinical Excellence; 2004.
27. Warren R, Arulkumaran S Best practice in labour and delivery. Cambridge (UK): Cambridge University Press; 2009

Do you need an enema in labour?

An enema is the injection of fluid into the lower bowel by way of the rectum. The most frequent use of an enema is to relieve constipation or for bowel cleansing before a medical examination or procedure.

Giving women enemas during labour has been routine practice in delivery wards of many countries and settings. Occasionally women leak from their back passage whilst giving birth and it was thought an enema in early labour would reduce this soiling and the consequent embarrassment for women. It was also thought that emptying the back passage would give more room for the baby to be born, would reduce the length of labour and would reduce the chance of infection for both the mother and the baby. It was also suggested it would reduce bowel movements after birth which often cause women concern.

A study in 1981 suggested that when preparing for normal labour the enema should be reserved for women who have not had their bowels open in the past 24 hours and have an obviously loaded rectum on initial pelvic examination.

In a Cochrane Database Review in 2013, the Selection criteria being randomised controlled trials (RCTs) in which an enema was administered during the first stage of labour and which included assessment of possible neonatal or puerperal morbidity or mortality were reviewed. Following meta‐analysis of two trials the authors’ conclusion was – “These findings speak against the routine use of enemas during labour, therefore, such practice should be discouraged”.

Enema versus no-enema in pregnant women on admission in labour: A randomized controlled trial Journal of the Medical Association of Thailand = 88(12):1763-7 · December 2005 

To compare the maternal and neonatal outcomes between enema and no-enema in pregnant women on admission in labour. One thousand and one hundred term pregnant women with labour pain were selected randomly on admission to be assigned into two groups at Rajavithi Hospital from 1 February 2002 to 15 June 2002. Five -hundred and thirty-nine cases received enema and five-hundred and sixty one cases received no enema. Seventy three women (39 and 34 cases from the enema and no-enema groups, respectively) were excluded because of caesarean section due to obstetric indications. Five hundred cases received enema and five-hundred and twenty -seven cases received no-enema. All cases were delivered vaginally. There was no statistical significant difference between the two groups with regards to maternal age, gestational age, gravidity, parity, mode of delivery, type of episiotomy and degree of perineal tear. Faecal contamination rate during the second stage of labour was significantly higher in the women who received no-enema (34.9%) in comparison with those receiving enema (22.8% (p < 0.001). No neonatal infection occurred in both groups. Duration of labour was significantly longer in the women who received no-enema (459.8 min) compared with those who received enema (409.4 min) (p < 0.001). No-enema methods on admission in labour had significantly more increase in faecal contamination in the second stage of labour and longer duration of labour than the enema method but there was no difference in perineal wound infection and neonatal infection between both groups.

There continues to be advocates both for and against, particularly amongst midwives and nurses involved in daily deliveries but also with women themselves. There are also marked regional differences.

A survey of maternity practices in Croatia in 2015 found that 78 % of women were given an enema in labour.

Reveiz L, Gaitán HG, Cuervo LG. Enemas during labour. Cochrane Database of Systematic Reviews 2013, Issue 7.
Clarke NT, Jenkins TR. Randomized prospective trial of the effects of an enema during labor [abstract]. Obstetrics & Gynecology 2007;109(4 Suppl):7S.
Cuervo LG, Bernal MP, Mendoza N. Effects of high volume saline enemas vs no enema during labour – the N-Ma randomised controlled trial. BMC Pregnancy and Childbirth 2006;6:8.
Br Med J (Clin Res Ed) 1981;282:1269
Kovavisarach E, Sringamvong W. Enema versus no-enema in pregnant women on admission in labor: a randomized controlled trial. Journal of the Medical Association of Thailand 2005;88(12):1763-7.
Lurie S, Baider C, Glickman H, Golan A, Sadan O. Are enemas given before cesarean section useful? A prospective randomized controlled study. European Journal of Obstetrics & Gynecology and Reproductive Biology 2012;163(11):27-9.
Romney ML, Gordon H. Is your enema really necessary?. British Medical Journal 1981;282(6272):1269-71.


Episiotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician during second stage of labour to quickly enlarge the opening for the baby to pass through.
The incision, which can be done at a 90 degree angle from the vulva towards the anus or at an angle from the posterior end of the vulva (medio-lateral episiotomy), is performed under local anaesthetic and is sutured after delivery.

The use of a surgical incision of the perineum during childbirth was first described in 1742. It was introduced into the USA in the mid-19th Century. In 1920, at a meeting of the American Gynaecological Society in Chicago, USA, Joseph DeLee first publicly advocated the routine adoption of Medio lateral episiotomy for all deliveries in nulliparous women.

They became common practice during the 20th century, the main reason being to reduce the risk of severe perineal tears. 85% of women who have a vaginal delivery, will have some degree of perineal trauma, the majority of which will require suturing. By 1979, episiotomy was performed in approximately 63% of all deliveries in the USA, with higher rates among nulliparous women. In the UK in the same era, episiotomy rates ranged from 14 to 96% among nulliparous women and 16–71% among multiparous women. In recent years opposition to the use of episiotomy as a standard procedure has reduced the rate and its routine use is no longer recommended. Despite this, it is one of the most common medical procedures performed on women, though there is now considerable variation between countries. A review was published in JAMA in 2005. By this time the practice had declined in the USA from of over 60% to 30–35% of vaginal deliveries though the rate was as high as 99% in Eastern Europe.

In 2009, a Cochrane meta-analysis based on studies with over 5,000 women concluded that: “Restrictive episiotomy policies appear to have a number of benefits compared to policies based on routine episiotomy. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy”.

Levine EM et al in 2015 noted – The average episiotomy rate steadily declined from 1996-1998, 2003-2005 and 2012-2014. The rate of advanced perineal lacerations coincidentally rose during these time period comparisons. Levine EM, Bannon K, Fernandez CM, Locher S (2015) Impact of Episiotomy at Vaginal Delivery. J Preg Child Health 2:181.

It has been suggested that perineal massage during the second stage of labour can reduce the need for episiotomy.
Infrared lamp therapy is an effective method of treatment on healing of episiotomy wound among post-natal mothers.
In a study by Sabzaligol M et al. Aloe Vera gel not only relieved the pain but also increased the rate of wound healing in episiotomy.

1. Practice Bulletin No. 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery”. Obstetrics and Gynecology. 128 (1): e1–e15. July 2016.
2. Chang,S-R; Chen,K-H; Lin,H-H; Chao,Y-M Y.; Lai,Y-H (April 2011). “Comparison of the effects of episiotomy and no episiotomy on pain, urinary incontinence, and sexual function 3 months postpartum: A prospective follow-up study”. International Journal of Nursing Studies. 48 (4): 409–418.
3. Graham,I.D.; Carroli,G.; Davies,C.; Medves,J.M. (August 2005). “Episiotomy Rates Around the World: An Update”. Birth. 32 (3): 219–223.
4. Carroli, G, Mignini, L. “Episiotomy for vaginal birth”. Cochrane Database Syst Rev. 2009 Jan 21; (1):
5. Jiang, Hong; Qian, Xu; Carroli, Guillermo; Garner, Paul; Jiang, Hong (2017). “Selective versus routine use of episiotomy for vaginal birth”.
6. American College of Obstetricians-Gynecologists (2006). “ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006” Obstetrics & Gynecology. 107 (4): 956–62
7. Levine EM, Bannon K, Fernandez CM, Locher S (2015) Impact of Episiotomy at Vaginal Delivery. J Preg Child Health 2:181.
8. Sabzaligol M, Safari N, Baghcjeghi N, Latifi M, Koohestani H R, Bekhradi R, et al . The effect of Aloevera gel on prineal pain & wound healing after episiotomy. cmja. 2014; 4 (2) :766-775

Nausea and vomiting of pregnancy

Nausea and vomiting of pregnancy is a common condition that affects the health of the pregnant woman and her fetus. It can diminish the woman’s quality of life and also significantly contributes to health care costs and time lost from work. Because “morning sickness” is common in early pregnancy, the presence of nausea and vomiting of pregnancy may be minimized by obstetricians, other obstetric providers, and pregnant women and, thus, undertreated. Furthermore, some women do not seek treatment because of concerns about safety of medications. Once nausea and vomiting of pregnancy progresses, it can become more difficult to control symptoms; treatment in the early stages may prevent more serious complications, including hospitalization. Mild cases of nausea and vomiting of pregnancy may be resolved with lifestyle and dietary changes, and safe and effective treatments are available for more severe cases. The woman’s perception of the severity of her symptoms plays a critical role in the decision of whether, when, and how to treat nausea and vomiting of pregnancy.
American College of Obstet Gynecol 2015;126:e12-24.

Nausea and vomiting is an expectation for the majority of women during the first trimester of pregnancy. In fact, only 25% of pregnancies are unaffected by nausea with or without vomiting. Approximately 35% of all pregnant women are absent from work on at least one occasion through nausea and vomiting. Among affected woman, recurrence in subsequent pregnancies varies. Although the symptoms are often most pronounced in the first trimester, they are by no means confined to it. Despite the usage of the term “morning sickness” in only a minority of cases are symptoms confined to the morning. The severity of symptoms is variable from patient to patient and they typically peak by 9 weeks. With early treatment and dietary counseling, the severity of symptoms diminishes as gestation advances; for most women, symptoms abate or resolve by the end of the first trimester. The etiology is unknown but theories include psychologic predisposition, evolutionary adaptation to protect the woman and fetus from potentially dangerous foods, and the hormonal stimulus of high human chorionic gonadotropin (HCG) and estradiol levels in early pregnancy. Conditions with increased placental mass such as multiple gestations and molar pregnancy are associated with a higher risk for nausea and vomiting.

In some women, the condition is severe and progresses to hyperemesis gravidarum, which occurs in 0.3 to 3% of pregnancies. A high risk of recurrence is observed in women with hyperemesis in the first pregnancy. The risk was reduced by a change in paternity. For women with no previous hyperemesis, a long interval between births slightly increased the risk of hyperemesis in the second pregnancy.
Trogstad LI, Stoltenberg C, Magnus P, Skjaerven R, Irtens LM. Recurrence risk in hyperemesis gravidarum. BJOG 2005;112:1641-5

Treatment of nausea and vomiting depends on the perception of severity. Basic recommendations include avoidance of stimuli that provoke nausea and vomiting such as sensory stimuli to strong odors, and other sensory stimuli such as heat and noises that trigger the labyrinthine areas. Dietary counseling about frequent small meals and avoidance of spicy or fatty foods is appropriate even though the evidence for such recommendation is lacking.
A Cochrane Database review found that the use of ginger products may be helpful to women, but the evidence of effectiveness was limited and not consistent. There was only limited evidence from trials to support the use of pharmacological agents including vitamin B6, and anti-emetic drugs to relieve mild or moderate nausea and vomiting.
Matthews A, Haas DM, O’Mathuna DP, Dowswell T, Doyle M. Interventions for nausea and vomiting in early pregnancy. Cochrane Database of systematic Reviews 2014, Issue 3.

A single blind randomized controlled trial to determine whether acupuncture reduced nausea, dry retching, and vomiting, and improved the health status of women in pregnancy was undertaken at a maternity teaching hospital in Adelaide, Australia. 593 women less than 14 weeks’ pregnant with symptoms of nausea or vomiting were randomized into 4 groups: traditional acupuncture, pericardium 6 (p6) acupuncture, sham acupuncture, or no acupuncture (control). Treatment was administered weekly for 4 weeks. They found that acupuncture was an effective treatment for women who experience nausea and dry retching in early pregnancy.
Birth. 2002 Mar;29(1):1-9.
Acupuncture to treat nausea and vomiting in early pregnancy: a randomized controlled trial.
Smith C, Crowther C, Beilby J.

Simon, Eric & Schwartz, Jennifer. (1999). Medical Hypnosis for Hyperemesis Gravidarum. Birth. 26. 248 – 254. 10.1046/j.1523-536x.1999.00248.x. Hyperemesis gravidarum in pregnancy is a serious condition that is often resistant to conservative treatments. Medical hypnosis is a well-documented alternative treatment. This article reviews the empirical studies of medical hypnosis for treating hyperemesis gravidarum, explains basic concepts, and details the treatment mechanisms. It is suggested that medical hypnosis should be considered as an adjunctive treatment option for those women with hyperemesis gravidarum. It is also stressed that medical hypnosis can be used to treat common morning sickness that is experienced by up to 80 percent of pregnant women. Its use could allow a more comfortable pregnancy and healthier foetal development, and could prevent cases that might otherwise proceed to full-blown hyperemesis gravidarum.

Normal Pregnancy

The first lecture that I presented at McMaster University I gave the title “What is normal?” This was about research and laboratory data. A paper had been published by an English university which I disagreed with. The paper was on infertility in patients with “normal Prolactin levels”. In this study the patients had blood samples taken on one occasion in a morning. Prolactin has a diurnal variation (the level changes from morning to night). We had demonstrated marked variations in the same patient at different times of the day, with levels up to five times higher in the evening. The laboratory reports a level against a normal value. However it is never stated if this is an internationally recognised normal, normal for the equipment used, normal for the assay established by that laboratory or normal for that patient. All laboratories have reference levels for healthy men and women but although it is known that levels for most routine laboratory tests change during pregnancy, many laboratories do not show ranges for pregnant women.
There is no such thing as a normal pregnancy – every mother and baby is unique. There are however some common features.
Symptoms of pregnancy
A missed period is usually the first signal of pregnancy, although women with irregular periods may not recognize this. During this time, many women experience a need to urinate frequently, extreme fatigue, nausea and/or vomiting, and increased breast tenderness. Most over-the-counter pregnancy tests are sensitive 9-12 days after conception. During early pregnancy, most women experience an increased appetite.
Weight gain during pregnancy
Weight gain during pregnancy consists of the products of conception (fetus, placenta, amniotic fluid) increase of maternal organs and tissues (uterus, breasts, blood, extracellular fluid, maternal fat stores). The rate of weight gain varies with the trimester. Although weight should be gained throughout pregnancy, it is most critical in the second trimester. The appropriate gestational weight gain depends upon the pre-pregnancy Body Mass Index (BMI). The Institute of Medicine’s 2009 pregnancy weight gain recommendation guidelines for singleton pregnancies are
Underweight (BMI less than 18.5) – 28-40 lbs
Normal weight (BMI of 18.5-24.9) – 25-35 lbs
Overweight (BMI of 25-29.9) – 15-25 lbs
Obese (BMI that exceeds 30) – 11-20 lbs
Women with a low BMI need to gain more weight to produce babies with birth weights comparable to women with a normal BMI. Women with a high BMI can deliver babies with higher birthweights with lower gestational weight gain.
Fetal movement
Most women start to feel fetal movement by 18 to 20 weeks gestation in a first pregnancy, in following pregnancies it can occur as early as 15-16 weeks’ gestation. Early fetal movement is felt most commonly when the woman is sitting or lying quietly. The time at which a woman first feels the baby move is termed quickening.
Breast changes during pregnancy
Pregnancy-related breast changes include growth and enlargement, tenderness, darkening of the nipples, and darkened veins due to increased blood flow. In addition, small raised bumps (Montgomery tubercles) appear around the areola in mid-pregnancy. Colostrum is a yellowish fluid secreted by the breast that can be expressed as early as the 16th week of pregnancy. It is replaced by milk on the second postpartum day.
Skin changes during pregnancy
Pigmentation changes are directly related to melanocyte-stimulating hormone (MSH) elevations during pregnancy. Increased pigmentation of some form affects 90% of pregnant women but is more obvious in women with darker skin. This is typically evident in the nipples, umbilicus, axillae and perineum, the linea alba darkens to a brown line called the linea nigra on the midline of the abdomen. Pre-existing moles, freckles and recent scars also become darker. Melasma (also known as chloasma or the mask of pregnancy) is a tan or dark skin discoloration. These are seen in 75% of pregnant women and are commonly found on the upper cheek, nose, lips and forehead. Most of these changes regress after delivery but may recur in future pregnancies.
Striae gravidarum (stretch marks) occur in most pregnant women, usually by the end of the second trimester. In Caucasian women the incidence is reported as 90%. Stretch marks usually occur when weight is lost or gained quickly and the degree to which a woman experiences stretch marks is determined genetically. They usually fade and pale with time.
Hair changes in pregnancy are very common both scalp and body hair. Hirsutism (excessive growth of body hair) is seen in many pregnant women. Thickening of scalp hair during pregnancy is usually followed by increased hair shedding one to four months after delivery.
Sebaceous gland activity is increased during the second half of pregnancy causing greasy skin and possibly acne.
Haemorrhoids and varicose veins
As pregnancy progresses the combination of increased blood volume, circulating progesterone effect on blood vessels and pressure of the growing uterus result in haemorrhoids being more common during pregnancy.
Varicose veins may also appear for the first time during pregnancy due to the relaxant effect of progesterone on blood vessel walls and stasis in leg vessels caused by pressure of the uterus.
The onset of labour is regular contractions resulting in progressive cervical changes. A “show” (blood stained mucus discharge) or spontaneous rupture of the membranes (waters breaking) do not of themselves define the onset of labour. Despite the prevalence of “waters breaking” heralding the start of labour in films and TV dramas, this occurs before regular contractions in less than 8% of pregnancies.
The duration of labour varies with different populations and management practices. A general guideline would be that in most first pregnancies labour lasts less than 12 hours and this is reduced to less than 8 hours in subsequent pregnancies.
Most blood loss related to childbirth occurs within the first hour after birth. In vaginal deliveries up to 500ml of blood may be lost from the genital tract within 24 hours after birth, some of which may appear as clots.

Acupuncture during pregnancy

In recent years there has been increased interest in the use of acupuncture in obstetrics, since it offers a drug-free alternative to conventional treatments for common pregnancy-related complaints.
A study to review the effectiveness of needle acupuncture in treating the common and disabling problem of pelvic and back pain in pregnancy was reported in the American journal of obstetrics and gynecology198.3 (Mar 2008): 254-9, although not a large study supported its use.
Other studies on back pain in pregnancy include –
Acupuncture relieves pelvic and low-back pain in late pregnancy
Kvorning, Nina; Holmberg, Catharina; Grennert, Lars; Aberg, AndersView Profile; Akeson, Jonas; et al. Acta obstetricia et gynecologica Scandinavica83.3 (Mar 2004): 246-50.
Conclusion – Acupuncture relieves low-back and pelvic pain without serious adverse effects in late pregnancy.

Acupuncture for low back pain in pregnancy – a prospective, quasi- randomised, controlled study
Bosco Guerreiro da Silva J; Uchiyama, Nakamura M; Cordeiro JA; Kulay, Acupunct Med22.2 (Jun 2004): 60-7.
Conclusion – results indicate that acupuncture seems to alleviate low back and pelvic pain during pregnancy, as well as to increase the capacity for some physical activities and to diminish the need for drugs, which is a great advantage during this period.

Other studies in pregnancy have shown acupuncture to be effective for stress, morning sickness, hip and low back pain, breech position, mild to moderate depression, labour induction, and shortening the length of labour. Acupuncture therapy may offer some advantage over conventional treatment in the management of hyperemesis gravidarum and post caesarean section pain.
Acupuncture for insomnia in pregnancy -da Silva JB; Nakamura, MU; Cordeiro JA; Kulay, L J. Acupunct Med23.2 (Sep 2005): 47-51.
The results of this study suggest that acupuncture alleviates insomnia during pregnancy.

A 2002 study conducted at the Women’s & Children’s Hospital at Adelaide University in Australia on the safety of acupuncture for nausea in early pregnancy verified that there is no increased risk of congenital anomalies, miscarriage, stillbirth, placental abruption, pregnancy-induced hypertension, preeclampsia, premature birth, or normal measures of neonatal health (such as maturity or birth weight) when women receive acupuncture during pregnancy. The study was conducted during the first trimester of pregnancy, when foetal development is most vulnerable.
A systematic review of the safety of acupuncture during pregnancy reported in 2014 reviewed 105 studies. The objective of this review was to identify adverse events associated with acupuncture treatment during pregnancy. Total incidence of adverse events was 1.9%, the most common being needle pain and all were classified as mild to moderate. The conclusion was that acupuncture during pregnancy appears to be associated with few adverse events. The safety of acupuncture during pregnancy: a systematic review. Park, Jimin; Sohn, Youngjoo; White, Adrian R ; Lee, Hyangsook ; NLM. Acupuncture in medicine : journal of the British Medical Acupuncture Society 32.3 (Jun 2014): 257-66.
Acupuncture is safe when it is conducted by a qualified practitioner.
There is no statutory regulation of acupuncture in England though GPs, physiotherapists and nurses, are subject to statutory regulation and many are now trained in acupuncture.

Mild, short-lasting side effects do occur in some cases. These include:
• pain where the needles puncture the skin
• bleeding or bruising where the needles puncture the skin
• drowsiness
Because of the slight risk of bleeding, people with bleeding disorders such as haemophilia, or people taking medication to prevent blood clotting (anticoagulants), may not be able to have acupuncture.
Acupuncture is also not usually advised if you have a metal allergy or an infection in the area where needles may be inserted.
Acupuncture is not a substitute for prenatal medical care. It does however offer complementary care that may have many benefits with very few side effects.

Too Many Caesarian Sections.

Cesarean delivery is the most commonly performed surgical procedure in the United States. Cesarean delivery may be a safe alternative to vaginal delivery but its use in 1 of 3 women giving birth in the US seems too high.
American College of Obstetricians and Gynecologists (ACOG) 2017 Annual Meeting.
“About half the C-sections we do in the United States today are probably avoidable.” “According to our own guidelines, we shouldn’t be doing any C-sections on labor progress alone before 6 centimetres, if we just did that, it’s worth tens of thousands of C-sections per year.”

Rates in American hospitals for low-risk patients range from 2.4% to 36.5% (Health Aff [Millwood]. 2013;32:527-535)
In 2014, 1.3 million women in the United States delivered via cesarean, placing the rate at 32.2%, down just 0.7% from the peak in 2009.
In 2013-14, in the UK; 386,937 (60.9 per cent) of deliveries in NHS hospitals were spontaneous deliveries, while 166,081 (26.2 per cent) were caesarean deliveries.
In the 1950s, 3% of births in England were by CS. By the early 1980s this had risen to 10% and in the 1990s rates started to climb rapidly, from 12% in 1990 to 21% in 2001.
The cesarean rate has risen without improving maternal or neonatal outcomes.
One reason for increasing cesarean rates may be a rise in elective cesarean delivery, also known as cesarean delivery by maternal request (CDMR). estimated at 4% in the United States.
Physicians in one study reported that they were more likely to perform a cesarean if they had been sued recently or if they thought about being sued frequently. (Cheng YW, Snowden JM, Handler SJ, et al. Litigation in obstetrics: does defensive medicine contribute to increases in cesarean delivery? J Matern Fetal Neonatal Med. 2014;27:1668–1675.)
Delayed admission to an active delivery unit in the latent phase of labor may reduce cesarean deliveries. (Tilden EL, Lee VR, Allen AJ, et al. Cost-effectiveness analysis of latent versus active labor hospital admission for medically low-risk, term women. Birth. 2015;42:219–226.)
The effect of cesarean delivery on future pregnancies should be considered when the first cesarean is being performed. Infants born to mothers who have had prior cesareans are at increased risk of stillbirth, and in cases of trial of labor after Caesarian, uterine rupture carries a risk to the neonate. For pregnancies complicated by abnormal placentation, delivery before term may be required.
Solheim KN, Esakoff TF, Little SE, et al. The effect of current cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. J Matern Fetal Neonatal Med. 2011;24:1341–1346.
Smith GC, Pell JP, Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet. 2003;362:1779–1784.
Fetal malpresentation, most commonly breech presentation at term, is seen in approximately 4% of pregnancies. Currently, the vast majority of such pregnancies are delivered via cesarean. When I first went to Canada I was amazed that a consultant obstetrician could not conduct a breech vaginal delivery, which had been common practice in England. Of course morbidity in untrained hands will be higher. The current primary approach to reducing cesareans in breech presentation is the use of external cephalic version (ECV). In general, ECV will be effective in approximately 70% of attempts and the majority of women with a successful ECV will go on to deliver vaginally. Finally, moxibustion (a Chinese medicine approach) has been shown to reduce breech presentation ( Cardini F, Weixin H. Moxibustion for correction of breech presentation: a randomized controlled trial. JAMA. 1998;280:1580–1584.)
A major management issue for patients in the second stage of labor is fetal malposition. Persistent fetal malposition particularly occiput transverse or occiput posterior position occurs in approximately 5% of fetuses and is associated with an increased risk of cesarean delivery and both maternal and neonatal complications. In such cases, rotation of the fetal head is useful. Historically, this was accomplished with forceps, particularly Kielland forceps but fewer Obstetricians are being trained to perform forceps rotations. I always found Kiellands to be a useful instrument but certainly not one for untrained hands, when used correctly and with gentleness they can achieve a controlled, atraumatic delivery.
Kielland’s forceps help to minimise the following risks that can occur with manual rotation:
• the baby rotating back to a malposition following manual rotation
• cord prolapse following disimpaction of the head
• complete disimpaction of the head out of the pelvis – too high for a safe forceps delivery.
(USA) In 1990 slightly more than 9% of livebirths resulted from either forceps delivery (5.11%) or vacuum extraction (3.9%), by 2014 only 3.21% of livebirths resulted from operative vaginal delivery and forceps accounted for less than 20% of these births (0.57% of all live births).
Hamilton BE, Martin JA, Osterman MJ, Curtin SC, Matthews TJ. Births: Final Data for 2014. Natl Vital Stat Rep. 2015 Dec;64(12):1-64.
Twin gestations
Supportive evidence exists for intended vaginal delivery in a twin gestation if the presenting twin is cephalic. A randomized trial found no improvement in neonatal outcomes in planned cesarean for a twin gestation. (Barrett JF, Hannah ME, Hutton EK, et al; Twin Birth Study Collaborative Group. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. N Engl J Med. 2013;369:1295–1305.)
If the second twin is breech it is obvious that the obstetrician needs to be trained in vaginal breech delivery.

Practices that have become standard over decades should be carefully questioned and replaced by standardized, evidence-based practices. This may safely decrease the cesarean rate. Obstetrics is an art as well as a science. Unfortunately much of the art has been lost and abandoned practices should possibly be revisited.

Pregnancy – Basic Facts

Pregnancy has historically been dated from the last menstrual period (LMP) with a duration of 40 weeks to give an estimated date of delivery (EDD) as a specific date. In fact term is usually a range from 37 – 42 weeks and these days pregnancy dates are usually set by ultrasound measurement.
The American College of Obstetricians and Gynecologists, the American Institute of Ultrasound in Medicine, and the Society for Maternal-Fetal Medicine recommend that –
Ultrasound measurement of the embryo or fetus in the first trimester (up to and including 13 6/7 weeks of gestation) is the most accurate method to establish or confirm gestational age.
A new formula for estimating gestational age based on ultrasound examination was reported in – Obstet Gynecol. 2017;130:433-441

Preconception Care
Medical assessment prior to becoming pregnant. The Centers for Disease Control and Prevention (CDC) has defined preconception care as “a set of interventions that aim to identify and modify medical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management.”
Pre-conception care includes –
1. Optimizing the management of chronic maternal health problems.
2. Providing lifestyle advice to avoid behaviours hazardous to a pregnancy, such as smoking, drinking excessive alcohol, or taking drugs.
3. Providing advice to optimize the health of the mother and baby, such as guidance on taking folic acid supplements.
4. Identifying couples who are at increased risk of having a baby with a genetic or chromosomal malformation, and providing them with sufficient knowledge to make informed decisions.

Medical History
A number of factors have to be considered early in pregnancy, if not addressed at the pre-pregnancy stage.
Pre-existing medical conditions in the individual, such as diabetes, renal disease, hypertension, HIV, previous thrombosis and epilepsy, would have to be considered in managing the pregnancy. Congenital abnormalities and genetic problems have to be considered in both parents.
Obesity – a BMI of over 30 carries an increased risk of complications such as hypertension, diabetes, and caesarean delivery also attainment of a normal pre-conception BMI will also likely prevent obesity and related long-term health effects in the developing child.
Antenatal screening is offered for –
• Foetal anomalies by ultrasound
• Down’s syndrome
• Haemoglobinopathies
• Rubella status
• Hepatitis B
• Tay-Sachs disease in high risk individuals

Body Changes
Blood volume increases during pregnancy, beginning at 6-8 weeks gestation, which accounts for part of the weight gain. The increase is mainly in the plasma rather than the cellular constituents of the blood leading to a fall in haemoglobin and the possible need for iron.
As the uterus grows pushing up the diaphragm there may be some breathlessness, light headedness and possible fainting. Palpitations and irregular heartbeats are also not uncommon in pregnancy.

Nutrition in Pregnancy
During early pregnancy, most women experience an increased appetite, with extra caloric needs of approximately 300 kcal/d. Some women have nonfood cravings, known as pica.
Should certain foods be avoided during pregnancy?
Pregnant women are at increased risk of bacterial food poisoning. For the safety of both mother and fetus, it is important to take steps to prevent foodborne illnesses, including the following
• Properly cook food to kill bacteria.
• Cook eggs until they have a firm yolk and are white. Eggnog and hollandaise sauce have raw or partially cooked eggs and are not considered safe.
• Eat liver in moderation. Liver can contain extremely high levels of vitamin A.
• Avoid products containing unpasteurized milk, including soft cheeses like brie, feta, and blue cheese. Also avoid unpasteurized juice.
• Carefully wash all fruits and vegetables to eliminate harmful bacteria.
• Longer-lived and larger fish, such as shark, swordfish, king mackerel, and tilefish, have increased mercury levels and the FDA advises that they should not be eaten by pregnant or nursing women.