There is usually no one sure sign that tells a woman she is pregnant. Rather, there may be a number of signs, especially during the first few weeks. A missed period is probably the first reason to suspect pregnancy. If a woman has regular periods, had sexual intercourse recently without using contraception, and has not had her period on time, she is probably pregnant.
Other signs include swelling or a feeling of tenderness in the breasts, or a tingling feeling in the nipples. One-third to one-half of all pregnant women feel sick to their stomachs and may vomit. This is often called "morning sickness", although it can happen any time of day. Many women need to pass urine more frequently. A few women tire more easily or feel dizzy, particularly during the first three months of pregnancy. Sometimes women have strong desires or cravings for particular foods.
There can be other explanations besides pregnancy for any of the signs mentioned above; for example, a woman with anaemia may feel tired and dizzy. Generally, however, women know when they are pregnant, especially if they have had babies before. Some hospitals or clinics can confirm the pregnancy; they may be able to test for certain chemicals that are found in the urine of pregnant women. Sometimes a midwife, nurse, or doctor can determine if a woman is pregnant by performing a vaginal examination.
Once a woman knows that she is pregnant, especially if this is the first time, many questions come to mind. When is the baby due? Will it be a normal pregnancy and will the labour be normal or difficult? When should she go for medical care? What should she do to make sure her pregnancy is as healthy as possible? What are the danger signs? The next few chapters of this book will answer these and other questions on how to help women go through the experience of pregnancy, labour, and birth safely, and end up with a healthy baby in their arms. Pregnancy is a very special period in a woman's life, and she has special needs. She and her family are responsible for making sure that she receives the care and attention she needs.
Box 6.1: Early Signs of Pregnancy
THINGS A WOMAN MAY NOTICE HERSELF:
· A missed period
THINGS THE DOCTOR, NURSE, MIDWIFE, OR TRAINED BIRTH ATTENDANT CAN DO:
· Examine the vagina to look for changes in the neck of the womb
· Test the urine or blood to look for chemicals that indicate pregnancy (only in a properly-equipped health facility)
A woman undergoes many physical and emotional changes during pregnancy. Many of the changes occur because her body has to be prepared to meet the needs of the baby during pregnancy, and also for the actual birth and breastfeeding.
CHANGES IN THE WOMB
By the sixth week of pregnancy, the womb is already enlarged. It will continue to grow to accommodate the baby, its bag of water, and the placenta. At 13 weeks, the womb and the baby have grown large enough to be felt by a health worker. From this time until the 36th week, the womb grows at the rate of about one finger width every week. By the 36th week the top of the womb has nearly reached the level of the rib cage. Sometimes it will drop a little around the 38th week when the baby's head begins to descend into the birth canal.
CHANGES IN THE BLOOD
During pregnancy the amount of blood in a woman's body increases by about 30% in order to meet the rapidly in- creasing needs of the baby. To move all this blood around inside the body, the woman's heart grows a little bigger and works harder. This is a normal condition, and is not a sign that complications are developing.
CHANGES IN THE BREASTS
Some of the earliest changes caused by pregnancy are in the breasts, which must be prepared to feed the newborn. More blood flows to the breasts, making them tender. A tingling sensation can also be felt, and the breasts actually grow bigger and feel heavier. The dark skin around the nipples becomes darker, and the nipples themselves stick out more. Very early in pregnancy milk is already being produced. Many women may see a yellowish liquid come from their breasts during pregnancy. This is the first milk, called colostrum, and is quite normal.
Feelings and moods may change during pregnancy, partly because of changes in a woman's body chemicals (hormones) and partly in response to the prospect of having and raising a child. A woman may be happy one minute and tearful the next. Many women are anxious and fearful about whether their children will be normal, whether they will be able to cope with labour, and whether they will be able to look after the new baby. It may help the woman to talk about her feelings, either with a health worker, her husband, or with another woman - a sister, mother, or friend - who has been pregnant. Some women may feel sad for a brief period after delivery, but most women feel better and happier.
In some areas, people believe that the baby will be harmed if the mother feels strong emotions, especially anger, during the pregnancy. For example, they believe anger might cause a miscarriage or put a knot in the umbilical cord. While it is better for a woman's own health and happiness if she is not under stress during pregnancy, there is no evidence that anger or sadness can cause problems for the baby's health.
Pregnancy normally lasts 40 weeks from the date the last normal menstrual period started. The length of the pregnancy is the same for both boy and girl babies. A pregnancy that has lasted 37 weeks or more is said to have "reached term", and labour can be expected to start any time.
To calculate the expected date of delivery, add seven days to the first day of the last menstrual period, then count forward nine months. For example, if the last period started on 15 January, add seven days to arrive at 22 January. Now count forward nine months to October. The expected date of delivery is 22 October. Table 6.1 can be used to calculate the expected date of delivery. The expected date of delivery is not an exact date. The baby may actually be born as much as two weeks before or after that calculated date.
One of the most important things a woman can do as soon as she thinks she is pregnant is visit a health facility for antenatal care, ideally by the fourth month of pregnancy and sooner if possible. An early visit can detect complications such as anaemia or a sexually transmitted disease. These complications can then be treated before the pregnancy advances and the problem becomes serious. It is also important to make sure the woman has a. tetanus injection. Chapter 7 describes what happens during antenatal visits.
Table 6.1: How to Calculate the Estimated Date of Delivery
The calculation is made from the first day of the last menstrual period. In each row, the top line of figures represents the first day of the menstrual period; the bottom line of figures represents the corresponding expected date of delivery.
EXAMPLE: If the first day of the woman's last menstrual period was 1 January, the expected date of delivery would be 8 October. Or if the first day was 18 April, the expected date of delivery would be 23 January
There are a number of reasons why a woman might not attend antenatal care early or often enough, or not go at all. She may not understand the benefits of antenatal care, so she sees no reason to go. Her husband or family may not think it is important, and may discourage her from going or refuse to give her money for transport or fees. Some women believe it is bad luck to talk about the pregnancy before the fifth or sixth month because they think it may attract witches or evil people who will harm the baby.
It is important for health workers and others who are providing health education to understand why a woman might not be attending antenatal care. These beliefs can then be addressed directly. In addition, the benefits of early and regular antenatal attendance should be clearly explained to the woman and her family. They should know that antenatal care gives a trained health worker a chance to make sure that the woman is healthy, and find out if there is something wrong that needs special care. If found early and properly treated, many problems do not become dangerous to the mother or baby.
Other things women should know to improve their health and make them more comfortable during pregnancy include:
WORKLOAD, REST, AND SLEEP
Most women work very hard - in the home, on the farm, or in the office. Many continue to work just as hard or even harder when they are pregnant. Too much physically demanding work during pregnancy can contribute to problems with the pregnancy, such as miscarriage, premature labour, or underweight infants, especially if a woman is not eating enough (see section on Diet and Nutrition later on in this chapter).
Pregnancy is hard work in itself; the body is trying to feed a growing baby, and as the pregnancy advances a woman carries about 25 pounds (11 kilos) more weight than usual. This is like carrying a bucket of water all the time. Too much hard work, especially gathering firewood, carrying water, and working in the fields, can strain a woman's body and make her too weak to withstand the physical demands of pregnancy and childbirth.
Women should, therefore, be encouraged to avoid heavy physical labour during pregnancy, especially work such as lifting and carrying heavy loads, walking for many hours, and digging or weeding for long periods. Other members of the family should help with these tasks. If they cannot be given up completely, women should make sure they rest as much as possible between tasks. Regular work and chores may be continued as long as they are not too tiring.
A pregnant woman should also get as much rest as possible; she should lie down for an hour or so during the day, and sleep between six and ten hours every night. Near the end of her pregnancy it may be difficult for her to get a good night's sleep because of the size and movements of the baby. Lying on the side is often the most comfortable position and improves the blood supply to the baby.
EXERCISE AND RECREATION
Women need regular exercise when pregnant but, as in most things, moderation is best. If their daily activities do not require much physical exercise, taking a walk every day helps women stay healthy and feel good. Special exercises can help women prepare for delivery and a speedy recovery after the baby is born, improve muscle tone, aid digestion, prevent constipation, and assure restful sleep. Some of these exercises are shown in Figures 6.1-6.4.
Some women avoid their normal social activities when they are pregnant. There is no need for this, since pregnancy is a natural and normal event; women can continue their usual recreational and social activities for as long as they want to.
Getting sick during pregnancy is especially uncomfortable and unpleasant, partly because of the pregnancy itself and partly because some medicines need to be avoided during pregnancy (see below). In addition, some diseases such as malaria can cause serious problems during pregnancy. For these reasons, women need to be especially careful to avoid diseases and infections when they are pregnant. For example, they should use mosquito nets on their beds when they sleep, and avoid water that is known to carry diseases like schistosomiasis.
Bathing every day, or every other day, is refreshing for most pregnant women; it also reduces the chance of getting an infection or illness. It is especially important to take care of the breasts and the genital area by washing often with clean water; harsh chemicals or strong detergents are not necessary, and can even be harmful.
In the often hot and humid climates of most African countries, loose clothes made of light cotton material are ideal. Well-fitting brassieres can help support the breasts as they get bigger and more tender. Comfortable shoes with flat or low heels can relieve aches in the feet, legs, and back.
It is perfectly safe to travel during pregnancy, although pregnant women should avoid discomfort and exhaustion. If a woman must make a long journey by road, she should be encouraged to stop frequently to stretch her legs, drink plenty of liquids, and empty her bladder. If she has to walk for some distance, she should stop often to rest, and she should not carry a heavy load. Families and communities can help by organising other means of transport (bicycle, motorcycle, or car) when a pregnant woman has to go to a health centre or somewhere else.
ALCOHOL AND SMOKING
Alcohol in the mother's blood passes through the placenta to the baby. Women who drink heavily risk having babies with serious problems, including mental retardation and physical deformities. Since it is not known exactly how much alcohol is dangerous to a baby, women should be counselled to avoid it completely.
Smoking during pregnancy is unquestionably harmful as it interferes with the blood flow from the mother to the baby. Babies born to women who smoke during pregnancy are often smaller than babies of non-smoking mothers; smaller babies are more likely to be sick. It is best if women who smoke can stop before pregnancy, or as soon as possible during the pregnancy. Women who are unable to stop may at least be able to cut back the number of cigarettes they smoke each day if they know it will help their baby to be healthy.
Exercises to Strengthen Muscles Used During Pregnancy and Delivery
Figure 6.1: Pelvic Rock (helps relieve backache and pressure in abdomen and strengthens stomach muscles)
1. Get down on hands and knees, as shown in top figure.
2. Pull in abdomen and lift buttocks, as shown in bottom figure. Hold for a count of five.
3. Gently relax abdomen and buttocks, allowing the curve of the back to return.
4. Repeat 5-6 times.
Exercises to Strengthen Muscles Used During Pregnancy and Delivery
Figure 6.2: Head and Shoulder Lift (strengthens muscles in abdomen)
1. Lie on back with knees bent, feet flat on the floor, and arms at sides as shown.
2. Raise head and shoulders and tighten abdominal muscles. Hold for a count of five. Do not hold breath.
3. Lie back and relax.
4. Repeat 5-10 times.
Exercises to Strengthen Muscles Used During Pregnancy and Delivery
Figure 6.3: Squat (strengthens leg muscles)
1. Stand while holding onto something to help keep balance. Keep feet apart.
2. Slowly bend knees, keeping back straight and keeping knees and feet apart.
3. Rise slowly, keeping hold of the object for balance.
4. Repeat 3-5 times.
NOTE: Do not do this exercise if knees hurt.
Exercises to Strengthen Muscles Used During Pregnancy and Delivery
Figure 6.4: Rib Cage Lift (strengthens leg muscles and makes it easier to breathe)
1. Sit with legs crossed as shown.
2. Curve arm over head, hold it, and return to the original position.
3. Repeat 4-5 times, then do the same with the other arm.
Kegel Exercise (strengthens muscles that help make delivery easier, and reduces the chance of complications during delivery)
1. Tighten the muscles around the anal opening and in the vagina (as if holding back urine). Hold for a count of three, then relax.
2. Repeat 5-10 times. This exercise can be done anytime during the day when sitting down.
NOTE: There is no illustration for the Kegel exercise.
MEDICINES, HERBS, AND X-RAYS
Medicines taken during pregnancy pass through the placenta to the baby. Because no medicine is completely free of side-effects, and because the baby is more likely to suffer from these side-effects, medicines should be avoided during pregnancy. This is particularly true for medicines purchased from drug peddlers or chemists that are not prescribed by a doctor. It is especially important to avoid medicines during the first three months of pregnancy when the fertilised egg is undergoing the most rapid process of growth and development. Medicines taken at this particular time may cause abnormalities in the baby.
Mothers who are addicted to drugs have babies who are also addicted. In addition to going through withdrawal during their first few days, these babies are often smaller or are born too early, and they may develop much more slowly.
There are some exceptions to the "no medicines" rule. They include medicines prescribed by a trained health worker to prevent malaria, and tablets to supplement the diet with iron and vitamins. Other medications may be prescribed by a doctor for specific problems related to pregnancy, such as high blood pressure. If a woman is taking a prescribed medication before pregnancy, she should continue to take it until she has discussed the matter with a doctor as early as possible in the pregnancy.
Herbs or herbal potions that women sometimes take may also contain drugs. For example, some herbs can be addictive; others can cause the womb to contract, which can be very dangerous. If possible, it is best to find out what kinds of herbs a woman is taking during pregnancy, if any, and try to determine whether they have any harmful effect. Most teas, for example, are fine. If an herb could be dangerous, the woman should be discouraged from taking it, and other, harmless herbs should be encouraged instead.
X-rays should be avoided during pregnancy, especially during the early weeks. If an X-ray is absolutely necessary, the woman's abdomen should be well shielded from the rays.
Some chemicals can cause serious problems in a baby, as well as the mother, if she is exposed to them during pregnancy. For example, some hair dyes can be absorbed through the skin and can cause birth defects. Pesticides (chemicals used to kill insects) can also be absorbed by the body and can damage the unborn baby. Herbicides (chemicals used to kill weeds) can cause miscarriages. It is best if pregnant women avoid breathing the fumes of such chemicals and avoid having skin contact with them.
Women, as well as men, often have questions about the effects of sexual intercourse during pregnancy, although they may be reluctant to ask. Traditional beliefs regarding this topic are common. For example, some people believe that intercourse is necessary during pregnancy because they think the man's semen helps the baby grow. While this is not true, couples should know that they can continue to have normal sexual relations during pregnancy as long as they want to. It will not hurt the baby or mother unless there is bleeding from the vagina, signs of premature labour, or the bag of water has broken. Some women feel no desire for sex during pregnancy; others do, and may even feel increased desire. As pregnancy advances, however, sex may be uncomfortable. Women should be encouraged to discuss their feelings, try different positions during sexual intercourse, and find other ways to be close to their husbands or partners.
Pregnancy makes many demands on a woman's body, especially in terms of nutritional status. During pregnancy the fertilised egg grows from a cell not bigger than the tip of a fine needle to a human being weighing 6-7 pounds (3 kilos) at birth. All the food required by the egg to form the baby's body must be provided by the mother during the nine months of pregnancy.
During pregnancy, the baby's needs will be met before those of the woman. For example, if a woman does not get enough food or enough of a particular vitamin, her body will give the baby what it needs first, and then use whatever is left over - which may not be enough. Lack of some vitamins or minerals in the diet can cause illness. For example, anaemia is caused by lack of iron, and goiter is caused by lack of iodine. Therefore, it is critically important that a woman gains enough weight during pregnancy and eats the right foods in order to meet her own energy and nutritional needs, as well as those of her baby.
After pregnancy, breastfeeding places even greater nutritional demands on a woman's body, especially during the first 4-6 months. Depending on how long breastfeeding continues, it can take two or more years for a woman's body to recover fully. Thus women who have many children close together (less than two years apart) do not have a chance to recover from one pregnancy to the next. Their nutritional reserves get used up, and they tend to become sick often and tire easily. Women will enjoy pregnancy more and feel healthier if they are able to plan to have their next pregnancy when their other children are at least two years old or more, and when they are in good health and well nourished.
On average, women should gain about 20-30 pounds (9-13 kilos) during pregnancy, although many women - especially if they are underweight to begin with -gain less than this. This includes the 6-7 pounds of the baby itself, as well as the placenta, the growth in the womb, the increase in the size of the breasts, fat deposits, and increases in the blood and body fluids. Often there is very little weight gain during the first few months, and many women even lose several pounds. After the fourth month, however, a pregnant woman usually gains about four pounds (two kilos) each month.
If there is not enough weight gain and the woman is very thin to begin with, there is a chance the baby may weigh too little - less than 5½ pounds (2½ kilos). Underweight babies are five times more likely to die during their first year of life. They are also more likely to have illnesses such as diarrhoea, anaemia, and colic. If they survive, they are more likely to be mentally retarded. Underweight women are also more likely to suffer from problems during pregnancy and delivery, since their bodies may not be as strong as they need to be.
Some women intentionally try to avoid gaining too much weight during pregnancy, because they believe the baby will be smaller and easier to deliver if they do not eat too much. This custom, often called "eating down", can be very harmful; both the woman and the baby may suffer from problems caused by a poor diet, and both face a higher risk of illness and death. The custom is also unnecessary for a healthy woman of normal size, who is not likely to develop problems with obstructed labour. If she is very short or very young, a woman may need to be advised to deliver in a health facility where medical help is available.
TYPES OF FOODS
Pregnant women should follow a normal, healthy diet. The most important rule is for them to eat enough of the different types of foods to meet their needs and those of the developing baby. Some women have strong desires for certain types of foods, or develop strong dislikes for other foods that they previously enjoyed. Both reactions are normal, and women should be encouraged to eat what they want and avoid what they don't want as long as they eat what is healthy. The following are some of the different types of food that must be included in a daily diet (see Figure 6.5).
Energy-giving foods: These include the so-called starchy foods like maize or corn, potatoes, yams, plantains, cassava, rice, millet bread, etc. Fats are also an important source of energy. They include the oils used for cooking, such as palm kernel oil, coconut oil, and groundnut oil, as well as fat from animal sources, such as butter. A pregnant woman should eat four servings of food from this group every day.
Body-building foods: These include both meats and vegetables that provide the necessary materials, called proteins, for building the many types of tissues that form the human body. Good sources of animal protein include meat, fish, milk, and eggs. Vegetable sources include beans (which are healthiest if they are eaten with a starchy food such as rice or yams), groundnuts, and the leaves of some plants. A pregnant or breastfeeding woman should eat three servings of food from the body-building group each day.
Protective foods: Vitamins are special substances present in many types of food. The body needs small amounts of different vitamins for normal growth and development. Lack of vitamins gives rise to illness. Good sources of essential vitamins are liver, yeast, fish, and eggs. These foods can also provide many of the minerals (such as calcium, iron, iodine, and copper) needed for normal body functions and the growth of the baby. Other good sources of vitamins include fruits and vegetables such as oranges, bananas, pineapples, mangoes, pawpaw, tomatoes, okra, garden eggs, and carrots. They also provide roughage, which helps to keep the bowels moving regularly. A pregnant woman should eat three servings of food from the protective group, especially fruits and vegetables, each day.
A normal, healthy diet contains adequate amounts of vitamins and minerals. Only iron and folic acid, which are essential for preventing anaemia and nourishing both mother and baby, usually need to be taken regularly in addition to the normal diet during pregnancy. Antenatal clinics should provide these, and encourage women to take them by explaining their benefits.
Most of the foods mentioned above are available in local markets, depending sometimes on the season. Imported foods are not only expensive, they are often not readily available.
Women should also drink plenty of liquids, especially clean water, during pregnancy. This helps prevent constipation and urinary tract infections.
Figure 6.5: Food Groups and Proper Nutrition During Pregnancy
During pregnancy and breastfeeding, a woman's daily diet should include foods from all three groups
HOW MUCH FOOD IS ENOUGH?
A woman's energy and nutritional needs increase by about 15% during pregnancy and by about 25% while breastfeeding. This means that if the average non-pregnant woman needs about 2,000 calories of energy each day, she needs 2,300 calories during pregnancy, and 2,500 calories while breastfeeding.
TRADITIONAL ATTITUDES AND TABOOS ABOUT FOOD
Depending on where a woman lives, there may be certain rules and traditions about what may and may not be eaten during pregnancy. Most of these traditions are harmless.
Much harm can be done, however, if a woman is prevented from eating what she needs during pregnancy. In many countries, for example, pregnant women are told they are not supposed to eat eggs, milk, or other foods that are excellent sources of vitamins and protein. When it comes to deciding what to eat and what not to eat, women and their families should remember two rules. First, if it is all right for a woman to eat it when she is not pregnant, it is all right to eat it when she is pregnant. Second, if it does not hurt men to eat it, it is not likely to harm a woman or her baby.
Summary: Early Pregnancy and Self-Care
PREGNANT WOMEN SHOULD:
· Go for antenatal care as soon as they know they are pregnant and at least three or four times during pregnancy
PREGNANT WOMEN SHOULD NOT:
· Lift or carry heavy loads
· Be exposed to chemicals such as hair dyes, pesticides to kill insects, or herbicides to destroy weeds