What is a high-risk pregnancy?

A high-risk pregnancy is one that threatens the health or life of the mother or her fetus. It often requires specialized care from specially trained providers.

Some pregnancies become high risk as they progress, while some women are at increased risk for complications even before they get pregnant for a variety of reasons.

Early and regular prenatal care helps many women have healthy pregnancies and deliveries without complications.

Risk factors for a high-risk pregnancy can include:

• Existing health conditions, such as high blood pressure, diabetes, or being HIV-positive
• Overweight and obesity. Obesity increases the risk for high blood pressure, preeclampsia, gestational diabetes, stillbirth, neural tube defects, and cesarean delivery. NICHD researchers have found that obesity can raise infants' risk of heart problems at birth by 15%.
• Multiple births. The risk of complications is higher in women carrying more than one fetus (twins and higher-order multiples). Common complications include preeclampsia, premature labor, and preterm birth. More than one-half of all twins and as many as 93% of triplets are born at less than 37 weeks' gestation.
• Young or old maternal age. Pregnancy in teens and women age 35 or older increases the risk for preeclampsia and gestational high blood pressure.

Painless Normal Delivery

If you are anxious about labour, an understanding of painless delivery can go a long way towards providing peace of mind. You may be wondering if it’s really possible to have a painless normal delivery? Is it safe? What are its pros and cons? As an expectant mother, you deserve to get the guidance and support that will help you approach labour with confidence.

What is Painless Delivery?

Painless delivery refers to the use of an epidural injection for pain relief during labor. An anesthesiologist gives an injection in the lower back and places a plastic tube through which drugs are released around your spinal cord. “Epidural substantially reduces pain and sensations in the lower half of the body, but doesn’t always provide 100% pain relief,”. “Also, the injection is given only once you’re in active labour – that is when you’re having at least 3 contractions in 10 minutes. In early labour, pain can be managed well using natural methods like warm showers, massages and exercises.”

Postpartum care: What to expect after a vaginal delivery

Pregnancy changes your body in more ways than you might expect, and it doesn't stop when the baby is born. Here's what to expect physically and emotionally after a vaginal delivery.

Vaginal soreness

If you had an episiotomy or vaginal tear during delivery, the wound might hurt for a few weeks. Extensive tears might take longer to heal. To ease discomfort while you're recovering:

• Sit on a pillow or padded ring.
• Cool the wound with an ice pack, or place a chilled witch hazel pad between a sanitary napkin and the wound.
• Use a squeeze bottle to pour warm water on your perineum as you're passing urine.
• Sit in a warm bath just deep enough to cover your buttocks and hips for five minutes. Use cold water if you find it more soothing.
• Take an over-the-counter pain reliever. Ask your health care provider about a numbing spray or cream, if needed.
• Talk to your health care provider about using a stool softener or laxative to prevent constipation.

Tell your health care provider if you're experiencing severe, persistent or increasing pain, which could be a sign of infection.

Vaginal discharge

After delivery, you'll begin to shed the superficial mucous membrane that lined your uterus during pregnancy. You'll have vaginal discharge consisting of this membrane and blood (lochia) for weeks. This discharge will be red and heavy for the first few days. Then it will taper, become increasingly watery and change from pinkish brown to yellowish white.

Contact your health care provider if you have heavy vaginal bleeding — soaking a pad in less than an hour — especially if it's accompanied by pelvic pain, fever or uterine tenderness.

Contractions

You might feel occasional contractions, sometimes called afterpains, during the first few days after delivery. These contractions — which often resemble menstrual cramps — help prevent excessive bleeding by compressing the blood vessels in the uterus. Afterpains are common during breast-feeding, due to the release of oxytocin. Your health care provider might recommend an over-the-counter pain reliever.

Incontinence

Pregnancy, labor and a vaginal delivery can stretch or injure your pelvic floor muscles, which support the uterus, bladder, small intestine and rectum. This might cause you to leak a few drops of urine while sneezing, laughing or coughing (stress incontinence). These problems usually improve within weeks but might persist long term.

In the meantime, wear sanitary pads and do Kegel exercises to help tone your pelvic floor muscles. To do Kegels, imagine you are sitting on a marble and tighten your pelvic muscles as if you're lifting the marble. Try it for three seconds at a time, then relax for a count of three. Work up to doing the exercise 10 to 15 times in a row, at least three times a day.

Hemorrhoids and bowel movements

If you notice pain during bowel movements and feel swelling near your anus, you might have hemorrhoids — swollen veins in the anus or lower rectum. To ease discomfort while the hemorrhoids heal:

• Apply an over-the-counter hemorrhoid cream or suppository containing hydrocortisone.
• Use pads containing witch hazel or a numbing agent.
• Soak your anal area in plain warm water for 10 to 15 minutes two to three times a day.

If you find yourself avoiding bowel movements out of fear of hurting your perineum or aggravating the pain of hemorrhoids or your episiotomy wound, take steps to keep your stools soft and regular. Eat foods high in fiber — including fruits, vegetables and whole grains — and drink plenty of water. Ask your health care provider about a stool softener, if needed.

Tender breasts

A few days after birth, your breasts might become full, firm and tender (engorgement). Frequent breast-feeding is recommended to avoid or minimize engorgement. If your breasts — including the dark circles of skin (areolae) around the nipples — are engorged, your baby might have difficulty latching. To help your baby latch, you might manually express or use a breast pump to express a small amount of breast milk before feeding your baby. To ease breast discomfort, apply warm washcloths or take a warm shower before breast-feeding or expressing, which might make milk removal easier. Between feedings, place cold washcloths on your breasts. Over-the-counter pain relievers might help, too.

If you're not breast-feeding, wear a supportive bra, such as a sports bra. Don't pump your breasts or express the milk, which will cause your breasts to produce more milk.

Hair loss and skin changes

During pregnancy, elevated hormone levels increase the ratio of growing hair to resting or shedding hair. The result is often an extra-lush head of hair — but now it's payback time. After delivery, you'll experience hair loss for up to five months.

Stretch marks won't disappear after delivery, but eventually they'll fade from red to silver. Expect any skin that darkened during pregnancy — such as dark patches on your face (chloasma) — to slowly fade as well.

Mood changes

Childbirth triggers a jumble of powerful emotions. Many new moms experience a period of feeling down or anxious, sometimes called the baby blues. Symptoms include mood swings, crying spells, anxiety and difficulty sleeping. The baby blues typically subside within two weeks. In the meantime, take good care of yourself. Share your feelings, and ask your partner, loved ones or friends for help.

If you experience severe mood swings, loss of appetite, overwhelming fatigue and lack of joy in life shortly after childbirth, you might have postpartum depression. Contact your health care provider if you think you might be depressed, especially if your symptoms don't fade on their own, you have trouble caring for your baby or completing daily tasks, or you have thoughts of harming yourself or your baby.

Weight loss

After you give birth, you might look like you're still pregnant. This is normal. Most women lose 13 pounds (6 kilograms) during birth, including the weight of the baby, placenta and amniotic fluid. In the days after delivery, you'll lose additional weight from leftover fluids. After that, a healthy diet and regular exercise can help you gradually return to your pre-pregnancy weight.

The postpartum checkup

The American College of Obstetricians and Gynecologists recommends that postpartum care be an ongoing process rather than just a single visit after your delivery. Have contact with your health care provider within the first 3 weeks after delivery. Within 12 weeks after delivery, see your health care provider for a comprehensive postpartum evaluation. During this appointment your health care provider will check your mood and emotional well-being, discuss contraception and birth spacing, review information about infant care and feeding, talk about your sleep habits and issues related to fatigue and do a physical exam. This might include a check of your abdomen, vagina, cervix and uterus to make sure you're healing well. This is a great time to talk about any concerns you might have, including resuming sexual activity and how you're adjusting to life with a new baby.

VBAC (Vaginal Birth After Cesarean)

If you've delivered a baby by C-section and you're pregnant again, you might be able to choose between scheduling a repeat C-section or a vaginal birth after cesarean (VBAC).

For many women, VBAC is an option. In fact, research on women who attempt a trial of labor after cesarean (TOLAC) shows that about 60 to 80 percent have a successful vaginal delivery.

VBAC isn't right for everyone, though. Certain factors, such as a high-risk uterine scar, can lower your likelihood of VBAC and make the option inappropriate. Some hospitals don't offer VBAC because they don't have the staff or resources to handle emergency C-sections. If you're considering VBAC, your health care provider can help you understand if you're a candidate and what's involved.

Why it's done

Women consider VBAC for various reasons, including:

• Shorter recovery time. You'll have a shorter hospital stay after a VBAC than you would after a repeat C-section. Avoiding surgery will help you resume your normal activities sooner, as well as reduce the expense of childbirth.
• Opportunity for an individualized birth plan. For some women, it's important to experience a vaginal delivery.
• Impact on future pregnancies. If you're planning to have a larger family, VBAC might help you avoid the risks of multiple cesarean deliveries, such as scarring. Scarring might make additional surgery difficult and increase the risk of placental problems in pregnancies.
• Lower risk of surgical complications. Vaginal deliveries have lower rates of bleeding, infection, blood clotting in one or more of the deep veins in the body (deep vein thrombosis), and injury to abdominal organs, such as the bladder or bowel.

You might be a candidate for VBAC if you are:

• Pregnant with one baby, have a history of one or two prior low transverse C-sections, and have no problems that would prevent VBAC
• Pregnant with one baby, have a history of one prior C-section with an unknown type of uterine incision, and have no problems that would prevent VBAC — unless it's suspected that you had a prior high vertical (classical) uterine incision
• Pregnant with twins, have a history of one prior low transverse C-section, and are otherwise a candidate for a twin vaginal delivery

You're not a candidate for VBAC if you have had:

• A prior high vertical (classical) uterine incision
• An unknown type of prior uterine incision and it's suspected that it was a high vertical (classical) incision
• A prior uterine rupture
• Certain types of prior uterine surgery, such as fibroid removal

Some health care providers won't offer VBAC if you've had more than two prior C-sections. VBAC also generally isn't an option if you are pregnant with triplets or higher order multiples.

Factors that decrease the likelihood of VBAC include:

• Stalled labor
• Advanced maternal age
• Pregnancy that continues past 40 weeks
• Body mass index greater than or equal to 40 (severe maternal obesity)
• Excessive weight gain during pregnancy
• Preeclampsia
• Previous delivery within 18 months
• History of two or more prior C-sections and no vaginal deliveries
• A need labor induction

Risks

While VBAC is associated with fewer complications than an elective repeat C-section, a failed trial of labor after cesarean (failed TOLAC) is associated with more complications, including, rarely, a uterine rupture. If your uterus tears open during labor, an emergency C-section is needed to prevent life-threatening complications, such as heavy bleeding for the mother. If the rupture is complex or to stop the bleeding, the uterus might need to be removed (hysterectomy). If your uterus is removed, you won't be able to get pregnant again.

How you prepare

If you've previously had a C-section and you're pregnant, you might begin talking about VBAC at your first prenatal visit. Discuss your concerns and expectations with your health care provider. Make sure he or she has your complete medical history, including records of your previous C-section and any other uterine procedures. Your health care provider might use your medical history to calculate the likelihood that you'll have a successful VBAC. It's important to continue discussing the risks and benefits of VBAC throughout pregnancy, especially if certain risk factors arise.

If you choose a VBAC, boost your odds of a positive experience:

• Learn about VBAC. Take a childbirth class on VBAC.
• Plan to deliver the baby at a well-equipped hospital. Look for a facility that's equipped to handle an emergency C-section.
• Allow labor to begin naturally, if you can. Having labor induced or augmented decreases the likelihood of VBAC.
• Be flexible. Some complications of pregnancy or labor might require a C-section. For example, you might need a C-section if there's a problem with the placenta or umbilical cord, your baby is in an abnormal position, or your labor fails to progress.

What you can expect

If you choose VBAC, when you go into labor you'll follow the same process that's used for any vaginal delivery. Your health care provider will likely recommend continuous monitoring of your baby's heart rate and be prepared to do a repeat C-section if needed.

Cesarean Delivery

Cesarean delivery (C-section) is a surgical procedure used to deliver a baby through incisions in the abdomen and uterus.

A C-section might be planned ahead of time if you develop pregnancy complications or you've had a previous C-section and aren't considering a vaginal birth after cesarean (VBAC). Often, however, the need for a first-time C-section doesn't become obvious until labor is underway.

Why it's done

Sometimes a C-section is safer for you or your baby than is a vaginal delivery. Your health care provider might recommend a C-section if:

Your labor isn't progressing. Stalled labor is one of the most common reasons for a C-section. Stalled labor might occur if your cervix isn't opening enough despite strong contractions over several hours.

Your baby is in distress. If your health care provider is concerned about changes in your baby's heartbeat, a C-section might be the best option.

Your baby or babies are in an abnormal position. A C-section might be the safest way to deliver the baby if his or her feet or buttocks enter the birth canal first (breech) or the baby is positioned side or shoulder first (transverse).

You're carrying multiples. A C-section might be needed if you're carrying twins and the leading baby is in an abnormal position or if you have triplets or more babies.

There's a problem with your placenta. If the placenta covers the opening of your cervix (placenta previa), a C-section is recommended for delivery.

Prolapsed umbilical cord. A C-section might be recommended if a loop of umbilical cord slips through your cervix ahead of your baby.

You have a health concern. A C-section might be recommended if you have a severe health problem, such as a heart or brain condition. A C-section is also recommended if you have an active genital herpes infection at the time of labor.

Mechanical obstruction. You might need a C-section if you have a large fibroid obstructing the birth canal, a severely displaced pelvic fracture or your baby has a condition that can cause the head to be unusually large (severe hydrocephalus).

You've had a previous C-section. Depending on the type of uterine incision and other factors, it's often possible to attempt a VBAC. In some cases, however, your health care provider might recommend a repeat C-section.

Some women request C-sections with their first babies — to avoid labor or the possible complications of vaginal birth or to take advantage of the convenience of a planned delivery. However, this is discouraged if you plan on having several children. Women who have multiple C-sections are at increased risk of placental problems as well as heavy bleeding, which might require surgical removal of the uterus (hysterectomy). If you're considering a planned C-section for your first delivery, work with your health care provider to make the best decision for you and your baby.

Risks

Like other types of major surgery, C-sections also carry risks.

Breathing problems. Babies born by scheduled C-section are more likely to develop transient tachypnea — a breathing problem marked by abnormally fast breathing during the first few days after birth.

Surgical injury. Although rare, accidental nicks to the baby's skin can occur during surgery.

Risks to you include:

Infection. After a C-section, you might be at risk of developing an infection of the lining of the uterus (endometritis).

Postpartum hemorrhage. A C-section might cause heavy bleeding during and after delivery.

Reactions to anesthesia. Adverse reactions to any type of anesthesia are possible.

Blood clots. A C-section might increase your risk of developing a blood clot inside a deep vein, especially in the legs or pelvic organs (deep vein thrombosis). If a blood clot travels to your lungs and blocks blood flow (pulmonary embolism), the damage can be life-threatening.

Wound infection. Depending on your risk factors and whether you needed an emergency C-section, you might be at increased risk of an incision infection.

Surgical injury. Although rare, surgical injuries to the bladder or bowel can occur during a C-section. If there is a surgical injury during your C-section, additional surgery might be needed.

Increased risks during future pregnancies. After a C-section, you face a higher risk of potentially serious complications in a subsequent pregnancy than you would after a vaginal delivery. The more C-sections you have, the higher your risks of placenta previa and a condition in which the placenta becomes abnormally attached to the wall of the uterus (placenta accreta). The risk of your uterus tearing open along the scar line from a prior C-section (uterine rupture) is also higher if you attempt a VBAC.

At the hospital. Your abdomen will be cleansed. A tube (catheter) will likely be placed into your bladder to collect urine. Intravenous (IV) lines will be placed in a vein in your hand or arm to provide fluid and medication.

Anesthesia. Most C-sections are done under regional anesthesia, which numbs only the lower part of your body — allowing you to remain awake during the procedure. Common choices include a spinal block and an epidural block. In an emergency, general anesthesia is sometimes needed. With general anesthesia, you won't be able to see, feel or hear anything during the birth.

During the procedure

Your doctor will use an abdominal incision and a uterine incision to delivery your baby.

Abdominal incision. The doctor will make an incision through your abdominal wall. It's usually done horizontally near the pubic hairline. Alternatively, the doctor might make a vertical incision from just below the navel to just above the pubic bone. Your doctor will then make incisions — layer by layer — through your fatty tissue and connective tissue and separate the abdominal muscle to access your abdominal cavity.

Uterine incision. The uterine incision is then made — usually horizontally across the lower part of the uterus (low transverse incision). Other types of uterine incisions might be used depending on the baby's position within your uterus and whether you have complications, such as placenta previa.

Delivery. The baby will be delivered through the incisions. The doctor will clear your baby's mouth and nose of fluids, then clamp and cut the umbilical cord. The placenta will be removed from your uterus, and the incisions will be closed with sutures.

If you have regional anesthesia, you'll be able to hear and see the baby right after delivery.

After the procedure

After a C-section, you'll probably stay in the hospital for a few days. Your health care provider will discuss pain relief options with you.

Once the effects of your anesthesia begin to fade, you'll be encouraged to drink plenty of fluids and walk. This helps prevent constipation and deep vein thrombosis. Your health care team will monitor your incision for signs of infection. If you had a bladder catheter, it will likely be removed as soon as possible.

You will be able to start breast-feeding as soon as you feel up to it. Ask your nurse or a lactation consultant to teach you how to position yourself and support your baby so that you're comfortable. Your health care team will select medications for your post-surgical pain with breast-feeding in mind.

Before you leave the hospital, talk with your health care provider about any preventive care you might need. Making sure your vaccinations are current can help protect your health and your baby's health.

When you go home

During the C-section recovery process, discomfort and fatigue are common. To promote healing:

Take it easy. Rest when possible. Try to keep everything that you and your baby might need within reach. For the first few weeks, avoid lifting anything heavier than your baby. Also, avoid lifting from a squatting position.

Seek pain relief. To soothe incision soreness, your health care provider might recommend a heating pad, ibuprofen (Advil, Motrin, others), acetaminophen (Tylenol, others) or other medications to relieve pain. Most pain relief medications are safe for women who are breast-feeding.

Avoid sex. To prevent infection, avoid sex for six weeks after your C-section.

You might also consider not driving until you are able to comfortably apply brakes and twist to check blind spots without the help of pain medication. This might take one to two weeks.

Check your C-section incision for signs of infection. Pay attention to any signs or symptoms you experience. Contact your health care provider if:

Your incision is red, swollen or leaking discharge

You have a fever

You have heavy bleeding

You have worsening pain

If you experience severe mood swings, loss of appetite, overwhelming fatigue and lack of joy in life shortly after childbirth, you might have postpartum depression. Contact your health care provider if you think you might be depressed, especially if your signs and symptoms don't fade on their own, you have trouble caring for your baby or completing daily tasks, or you have thoughts of harming yourself or your baby.

The American College of Obstetricians and Gynecologists recommends that postpartum care be an ongoing process rather than just a single visit after your delivery. Have contact with your health care provider within the first three weeks after delivery. Within 12 weeks after delivery, see your health care provider for a comprehensive postpartum evaluation. During this appointment your health care provider will check your mood and emotional well-being, discuss contraception and birth spacing, review information about infant care and feeding, talk about your sleep habits and issues related to fatigue and do a physical exam. This might include a check of your abdomen, vagina, cervix and uterus to make sure you're healing well. In some cases, you might have the checkup earlier so that your health care provider can examine your C-section incision. Use this visit to ask questions about your recovery and caring for your baby.

Prenatal care

Prenatal care, also known as antenatal care, is a type of preventive healthcare. Its goal is to provide regular check-ups that allow doctors or midwives to treat and prevent potential health problems throughout the course of the pregnancy and to promote healthy lifestyles that benefit both mother and child. During check-ups, pregnant women receive medical information over maternal physiological changes in pregnancy, biological changes, and prenatal nutrition including prenatal vitamins. Recommendations on management and healthy lifestyle changes are also made during regular check-ups. The routine prenatal care, including prenatal screening and diagnosis, has played a part in reducing the frequency of maternal death, miscarriages, birth defects, low birth weight, neonatal infections and other preventable health problems.

Traditional prenatal care generally consists of:

• monthly visits during the first two trimesters (from the 1st week to the 28th week)
• fortnightly visits from the 28th week to the 36th week of pregnancy
• weekly visits after 36th week to the delivery, from the 38th week to the 42nd week

Prenatal examinations

At the initial antenatal care visit and with the aid of a special booking checklist the pregnant women become classified into either normal risk or high risk.

Physical examinations generally consist of:

• Collection of (mother's) medical history
• Checking (mother's) blood pressure
• (Mother's) height and weight
• Pelvic exam
• Doppler fetal heart rate monitoring
• (Mother's) blood and urine tests
• Discussion with caregiver

Ultrasound Obstetric ultrasounds are most commonly performed during the second trimester at approximately week 20. Ultrasounds are considered relatively safe and have been used for over 35 years for monitoring pregnancy. Among other things, ultrasounds are used to:

• Diagnose pregnancy (uncommon)
• Check for multiple fetuses
• Assess possible risks to the mother (e.g., miscarriage, blighted ovum, ectopic pregnancy, or a molar pregnancy condition)
• Check for fetal malformation (e.g., club foot, spina bifida, cleft palate, clenched fists)
• Determine if an intrauterine growth retardation condition exists
• Note the development of fetal body parts (e.g., heart, brain, liver, stomach, skull, other bones)
• Check the amniotic fluid and umbilical cord for possible problems
• Determine due date (based on measurements and relative developmental progress)

Generally an ultrasound is ordered whenever an abnormality is suspected or along a schedule similar to the following:

• 7 weeks — confirm pregnancy, ensure that it's neither molar or ectopic, determine due date
• 13–14 weeks (some areas) — evaluate the possibility of Down syndrome
• 18–20 weeks — see the expanded list above
• 34 weeks (some areas) — evaluate size, verify placental position

A review looking at routine ultrasounds past 24 weeks found that there is no evidence to show any benefits to the mother or the baby.