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Chapter 8: Reproduction: Conception, Pregnancy, and Childbirth Learning Objectives Parenting and Reproductive Decisions • Define pronatalism and describe its impact on the decision to have children. Ensuring a Healthy Pregnancy • Understand how to prepare the body for a healthy pregnancy. Conception and Pregnancy • Describe the stages of pregnancy and the processes of prenatal development. • Understand how pregnancy affects both pregnant women and their partners in biological, social, and interpersonal ways. Birth and the Postpartum Period: What to Expect • Identify the available birthing options in the United States. • Identify the features of postpartum depression and available treatment options. • Know when it is healthy to resume sex after birth. Infertility and Options • Identify the options available for those who face infertility and for those who desire alternative methods of becoming parents. Abortion • Describe the medical techniques of abortion available in the United States. • Understand how the decision to have an abortion involves the holistic issues of body, individuality, and community participation. Sexual Well-Being and Reproductive Rights • Identify how changes in policies and laws have affected reproductive decisions. Chapter Outline Chapter 8: Reproduction: Conception, Pregnancy, and Childbirth Learning Objectives 8.1 Discussion Topic 8.1 Discussion Topic 8.2 Discussion Topic 8.3 Learning Objectives 8.2 Discussion Topic 8.4 Discussion Topic 8.5 Learning Objectives 8.3 Discussion Topic 8.6 Discussion Topic 8.7 Learning Objectives 8.4 Discussion Topic 8.8 Discussion Topic 8.9 Learning Objectives 8.5 Discussion Topic 8.10 Learning Objectives 8.6 Discussion Topic 8.11 I. Parenting and Reproductive Decisions • The processes of conception and fetal development result in physical and hormonal changes for the pregnant woman. Additionally, the experiences she has in the time after pregnancy and birth all produce enormous changes within her body and possibly her mind. • Many psychological changes occur for those who choose to become parents. One such change impacts an individual’s identity. o Additionally, parents often find that experiencing pregnancy and the birth of their child brings about emotions and thoughts they had never considered before. • Society and cultural norms also influence the decision-making processes when considering parenthood. For example, in the United States, it is more common for women today to bear children in their late 20s and early 30s than it was in the 1950s and 1960s, when women were more likely to have children in their late teens and early 20s. o Today the average age at the birth of a first child for U.S. women is 25 years. A. Pronatalism • Becoming a parent is one of society’s most pervasive social expectations. This is partly due to the fact that in the United States we have a cultural bias called pronatalism, which is the belief system that promotes childbearing. o This set of beliefs, attitudes, and practices is so ingrained that many individuals do not recognize it much less question it. We simply accept that all typical adults want to and should have children. o The whole notion of motherhood is part of this. • In traditional societies throughout much of history as well, parenting and having children was regarded as natural and even required to be a member of the group. Motherhood is held in such high esteem in some societies that women who did not bear children were viewed as not having achieved the meaning and full power of their lives. • There is some debate about the origin of this belief system: Some see it as stemming from biological and natural drives and others view it as a learned expectation. • Today, in the United States, women experience the cultural tension between valuing motherhood and valuing career success. People tend to think that this tension is about competing passions or commitments between family and career, and this may contribute to an idea that women must choose between family and career, and this may contribute to an idea that women must choose between the two. • Some men shrug off the duality by thinking that their wives or partners will do the domestic work, leaving them to pursue their careers. That traditional attitude is breaking down. • More and more men are making critical decisions regarding career and family that favor more time and commitment to their families and children. The number of men who are stay-at-home dads continues to rise. o Approximately 2.7% of stay-at-home parents in the United States are fathers (Shaver, 2007). The estimate is almost triple the number compared to the 1990s. o Some experts believe this number should be much higher as this data did not include single fathers or those with children over 15 years of age. • It is unfortunate that many in our society believe that, for women especially, career and family cannot coexist. Clearly, people can devote time and attention to both of these huge areas of life. B. Family Leave • Having a family these days can have tremendous effects on finances and income. For this reason, family leave—the amount of paid or unpaid leave allowed for the parents—is an important issue for those who are considering parenthood. • In fact, the United States is one of the few industrialized nations that do not provide paid family leave for new parents. The Netherlands, by contrast, provides 16 weeks paid leave for the mother, 8 weeks for the father, and a total of 26 additional weeks unpaid leave. • In the United States, parents are covered only by the Family and Medical Leave Act of 1993, which guarantees that employees in companies or organizations with more than 50 employees can take 12 weeks of unpaid leave to care for a newborn, adopted child, or family member with an illness. C. Considering Parenthood • One study has shown that husbands and wives, in particular, who become parents within the first 5 years of marriage, were more satisfied with their marital relationships when they were newlyweds than when they became parents. In the same study, people associated a decline in marital satisfaction with the transition to parenthood as compared to couples that were not parents. o This suggests that transition to parenthood does affect the quality of a couple’s relationship. II. Ensuring a Healthy Pregnancy • A healthy pregnancy begins long before a woman gets pregnant. Good nutrition, exercise, and regular prenatal care are critical factors for a healthy pregnancy. A. Preparing the Body for Pregnancy • Because so much parental development occurs even before a woman knows she is pregnant, it is important that she prepares her body before getting pregnant. The CDC offers the following five steps to aid in the preparation of a healthy pregnancy: o Take 400 micrograms (mcg) of folic acid every day for at least 3 months before getting pregnant to help prevent birth defects. o Stop smoking and drinking alcohol. o Make sure that any preexisting medical conditions are under control. Ensure that your vaccinations are up-to-date. o Talk with your health care provider about any over-the-counter medication or prescription medication you are taking. o Avoid toxic substances or material that can cause infection. • Some factors can have serious negative effects before and during pregnancy, including legal and illegal drugs, alcohol, and nicotine. Many medications can have a negative impact on a pregnancy. • Table 8.1 summarizes the possible effects of prescription and over-the-counter drugs on fetal development. For example, if a woman ingests high levels of alcohol during pregnancy, her infant may be born with fetal alcohol syndrome (FAS). • Figure 8.1 depicts some physical characteristics of children born with FAS. Note that FAS represents one of the fetal alcohol spectrum disorders (FASDs), which form a group of conditions that can occur in a person whose mother ingested alcohol during pregnancy. o In addition to a variety of physical characteristics, children with FAS can have problems with learning, memory, attention span, communication, vision, or hearing. Children with FAS may also display behavioral difficulties, thus making social interaction difficult. • Sexually transmitted infections (STIs) can also have a negative impact on pregnancy and the developing fetus. Untreated genital herpes, for example, can lead to spontaneous abortion, preterm birth, or birth defects. o Chlamydia can also lead to premature birth as well as neonatal eye infections. • Some pregnancy-related problems or complications women cannot prevent from occurring, such as chromosomal disorders. Many of these issues are related to maternal age. Healthy Sexuality Getting Pregnant Later in Life • While it is common today for a woman to conceive after 35, some fertility risks are associated with conception later in life: o A decrease in the number of eggs to be ovulated makes it harder to conceive. o Changes in the hormone production can alter timing and regularity of ovulation. o Possible presence of other gynecological issues such as endometriosis, a condition in which tissue similar to the uterine lining grows outside of the uterus, makes conception difficult. • If an older woman does get pregnant, she is at higher risk for miscarriage, increased labor time, and cesarean birth. o She may also give birth to a newborn that is under typical weight. B. Nutrition and Exercise • Although pregnant women do require an increase in calories, it is excessive to double the amount of calories eaten unless they were undereating prior to becoming pregnant. • A balanced and nutritious diet is key to a healthy pregnancy. A balance of carbohydrates, fat, and protein is vital to help support the development of the fetus. o Folate, vitamin D, and calcium are important as they help to ensure healthy development of the fetus’s neural and skeletal structure. • A pregnant woman also needs a healthy level of exercise. Research shows that regular exercise contributes to a healthier pregnancy. • Following are some guidelines for engaging in healthy exercise during pregnancy (American Pregnancy Association, 2009): o Be aware of any signs that it is time to reduce your level of exercise. o Never exercise to the point of exhaustion or breathlessness. o Wear comfortable exercise footwear with strong ankle and arch support. o Take frequent breaks, and drink plenty of fluids during exercise. o Avoid exercise in extremely hot weather. C. Sex during Pregnancy • Individuals often wonder if it is safe to engage in sexual behavior and/or have sex while pregnant. The reality is pregnancy can coexist with passionate sexual relationships and pleasure, and it can be an exciting time to feel intimate with your partner. • Biologically, changes during pregnancy may cause an increase in the desire for sexual interaction. Interestingly, some pregnant women report a decrease in libido. • Every woman’s body reacts somewhat differently to the hormone increase and to bodily changes that pregnancy brings. Regarding sexual activity, an increase in hormones may create a new kind of connection between the partner and the pregnant woman. • Unless a health care provider advises against it, sex to orgasm is a healthy activity for a pregnant woman, at least until the start of labor. • Despite the benefits of an active sex life during pregnancy, women and their partners often worry about whether intercourse can harm the developing baby. One of the fears most often stated, particularly in popular culture, is that the penis will invade the baby’s space during intercourse and cause subsequent physical or emotional trauma. o In reality, a penis cannot invade the space of a developing fetus because the cervix acts as a barrier between the fetus and the vagina. The cervix remains tightly closed throughout pregnancy and only opens during labor and delivery when the baby is on the way down the birth canal. III. Conception and Pregnancy A. Cross Cultural Ideas about Conception • Beliefs about conception are often at the heart of a culture’s vision of life and death, the afterworld, and family formation. These beliefs help shape a culture’s understanding of society. • For example, the people of the Trobriand Islands in Papua New Guinea have a matrilineal society, meaning that descent and inheritance come through the mother’s kinship line. They believe that a spirit causes conception. o While bathing in a lagoon, a woman may become pregnant when a spirit enters her womb. Because the resulting pregnancy apparently has no connection to her husband, it connects her to her mother’s people rather than to her husband’s. • For many years, Asian cultures have believed that either a pregnant woman or some other close family member will have a conception dream for each of their children before the baby is born. This belief originated in China and has influenced Korea, Japan, Vietnam, and other Asian countries. • More commonly, however, attitudes about conception and birth focus on the social and psychological states of the parents, and whether they are being properly moral in their conduct toward each other and toward their society. As such, they believe that immoral acts, especially extramarital relationships, may cause birth defects. o In patriarchal societies, where men assume primary responsibilities for families and community, infertility may be blamed on women. Some societies deny the possibility that men could be infertile because that possibility would undermine the patriarchy that governs inheritance and power. Healthy Sexuality The Developing Fetus’s Chances for Survival • Only 31% of all conceptions survive prenatal development to become living newborn babies: o During the germinal period, from the moment of conception through the fourteenth day, 58% of all fertilized ova will not survive due to gross abnormalities in one or more areas of physical development. o During the embryonic period, from day 14 through day 56, approximately 20% of all embryos are spontaneously aborted, most often due to chromosomal abnormalities. o During the fetal period, from the ninth week through birth, approximately 5% of fetuses are either spontaneously aborted before 20 weeks or are stillborn after 20 weeks of gestation. Gestation is the period of time between conception and birth; it is usually referred to in terms of weeks. B. Trimesters: The Developing Fetus and Changes for Women and Partners • Pregnancy is divided into 3-month blocks of time, commonly known as trimesters. Each of these trimesters includes significant development to the fertilized ovum, embryo, or fetus as well as accompanying changes for the pregnant woman and for nonpregnant partners. • Conception and the first trimester—The first trimester of pregnancy includes weeks 0–12 and begins after the first day of the last menstrual period. Fertilization takes place about 2 weeks after the first day of the last menstrual period. During ovulation, a woman’s body releases an ovum, which is fertilized when one sperm cell breaks through the zona pellucida, the thick, protective layer on the outer part of the ovum. o Fertilization happens typically in the upper third of one of the fallopian tubes. From there, the fertilized ovum, known as a zygote, begins to divide as it moves down the fallopian tube toward the uterus where, about 6 to 7 days after fertilization, it implants into the endometrium, the lining of the uterus. We call this attached mass of cells a blastocyst. o Once attached, significant changes begin to occur in the tissue surrounding the blastocyst, which continues to develop into an embryo. In humans, an embryo is the product of conception from the time of implantation until the eighth week of development at which time it is considered a fetus. A developing baby is called a fetus from the eight week of pregnancy until birth. o Figure 8.3 illustrates the process of cell division and implantation of the fertilized ovum. o The embryo begins to release human chorionic gonadotropin (hCG), the hormone that signals the corpus luteum to release progesterone, a hormone that helps to sustain the pregnancy. This hormone release continues throughout the first trimester. o The embryo cells are quickly differentiated into outside and internal cells. The outside cells develop into membranes that nourish and protect the embryo. These membranes include the amniotic sac or amnion, the chorion, the placenta, and the umbilical cord (Figure 8.4). o The internal cells of the embryo actually become the embryo itself. These cells develop into three distinct cellular layers and separate into the major organ systems in the body. The ectoderm becomes the nervous system, skin, endocrine glands, and sensory receptors; the endoderm becomes the respiratory and digestive system; and the mesoderm becomes the reproductive, circulatory, and skeletal systems. o Month 1—By the end of week 4, the embryo is approximately 1/100 of an inch long. The ectoderm, endoderm, and mesoderm have developed and the embryo has developed a spinal cord. o Month 2—By the end of this month, all of the major body organs and systems have begun to develop. The limb buds of arms and legs are beginning to develop. o Month 3—The embryo is now considered a fetus. By the end of the month, all major organ systems and human characteristics are fully formed though highly immature. o Figure 8.5 summarizes the stages of prenatal growth from conception through birth. o Changes in pregnant women—By the time a woman finds out that she is pregnant, usually because she has missed her regular menstrual period, she may have experienced some symptoms of pregnancy. These may include sensitive or swollen breasts or both, nausea, fatigue, backaches, headaches, frequent urination, darkening of the areolas, and food cravings and aversions. The due date is typically calculated based on the first day of the mother’s last menstrual period (LMP). If women do not remember the exact date of their LMP or when they might have conceived, doctors are able to pinpoint fetal development through the use of an ultrasound. Ultrasound is a very common form of screening and is used often to monitor the development of the fetus throughout the pregnancy. The main physical changes during the first trimester are to the breasts. They increase in size and the nipples and areolas darken. Cognitively, women may begin to notice changes. For example, 50–80% of women report lapses in their memories and thinking during the first trimester. Researchers have called this the “baby brain phenomenon.” Interestingly, the female brain actually shrinks a bit during pregnancy. This research suggests that on a biological and cognitive level, pregnancy and a short period after the baby’s birth are “downtimes” for women. Emotionally, women can experience a vast array of feelings during the first trimester. The rapid increase in hormone production at unparalleled levels may contribute to women being irritable or tearful. o Changes in nonpregnant partners—Partners also experience similar hopes, anxieties, fears, and questions as their pregnant partner. Finding out that their partner is pregnant may trigger feelings of responsibility, excitement, relief, and even some irrational fears. Partners also experience a connection with the growing child inhabiting their partner’s body. Studies show that pregnant women “connect” with their pregnancies sooner than the partners. • Second trimester—The second trimester, between weeks 13 and 24, brings a whole host of new experiences. Because they often feel better and more energized with the lessening of morning sickness, pregnant women may find this the most exciting time during pregnancy. o Month 4—Facial development continues as the outer ear begins to take shape. The fetus moves a lot, which women begin to feel. o Month 5—During this time of rapid growth, the fetus develops muscle, grows fat under its skin, and grows hair on top of it. Internal organs continue to develop with the exception of the lungs, which fully develop in the last month of the pregnancy. o Month 6—Brain development continues during this month. Eggs will develop in the ovaries of female fetuses and the fetus’s skin will be covered with a fine, soft hair called lanugo as well as a protective, waxy substance called vernix. o For a summary of the changes that occur during the second trimester, refer to Figure 8.5. o Changes in pregnant women—Women begin to “feel” pregnant at this time because their regular clothes no longer fit. They begin to feel the fetus’s movements and often report that the pregnancy feels more real, which is perhaps a psychological sign that they are accepting this new presence as separate from themselves. Physical symptoms of the second trimester vary. Some women experience little or no physical symptoms; others experience changes in skin coloration, swelling in the extremities, clumsiness, backaches, nosebleeds, heartburn, and hemorrhoids. Figure 8.6 shows how the woman’s body adapts to the presence of the growing fetus during pregnancy. o Changes in nonpregnant partners—The pregnancy may begin to feel more real or concrete for partners, too. As the pregnant woman’s bodily changes become more obvious, nonpregnant partners may begin to feel more “left out.” Some cultures have a ceremonial practice that allows the fathers-to-be to act out their own pregnancy. In native North and South American tribes, some husbands experience a sympathetic pregnancy during their wife’s pregnancy, labor, and delivery. These symptomatic experiences are referred to as couvade. • Third trimester—The exciting third trimester, weeks 25 to 40, is a time of rapid fetal growth and great emotion for the partners as they prepare for the day a new life will enter their world. Finalizing aptly describes the activities of the woman, her partner, and her family, as well as those of the developing fetus. o Month 7—The fetus may begin to feel cramped in the uterus as it gains length and weight. Despite this restricted area, it kicks and moves often. o Month 8—The fetus gains a lot of weight during this month, as it gets ready to enter the world. The skeletal system gains strength and the brain begins to differentiate the various regions that are synonymous with adult brain structure. o Month 9— Lung development finalizes during this month, preparing the fetus to breathe when it is born. In addition, the fetus gains approximately 0.5 pound per week. The fetus turns to a head-down position to prepare for birth. A fetus that does not turn is in a breech position. If health care providers cannot get the fetus to rotate into the head-down position, they may schedule a cesarean (or C-section) birth, a surgical birth of the baby via incision in the mother’s abdomen. Figure 8.7 illustrates a fetus in the breech position and a fetus with its head down ready for a vaginal birth. o Changes in pregnant women—By the end of the third trimester, most women are ready to birth their babies. Many second trimester symptoms continue into the third. Additionally, women begin to feel achy or tired because of the pressure and weight of the growing fetus. Pressure symptoms include varicose veins, hemorrhoids, swelling in the legs and ankles, leg cramps, backaches, and shortness of the breath as the large fetus pushes against women’s diaphragm. Many women experience Braxton-Hicks contractions, which are likened to a dress rehearsal for the big day. These contractions can be quite uncomfortable but rarely do anything to enhance the labor process. Emotionally, women begin to feel tired of being pregnant. As their due date approaches, they become more anxious and apprehensive about the baby’s health and the processes of labor and delivery. Typical weight gain in the third trimester is about 1 pound per week. Total weight gain for a pregnancy should be approximately 25 to 35 pounds depending on a woman’s prepregnancy weight. o Changes in nonpregnant partners—Partners experience thoughts and questions similar to pregnant women. Social and identity shifts can occur at this time, and partners begin to notice other parents in their own social circles and environments. C. Potential Problems during Pregnancy • Ectopic pregnancy—If a fertilized ovum implants outside of the uterus, usually in a fallopian tube, it is called an ectopic pregnancy. A variety of factors may cause this complication to occur, including previous STIs or other conditions that may have caused scar tissue to develop, which then prevents a fertilized ovum to move through a fallopian tube to the uterus. • Miscarriage—A miscarriage, also known as a spontaneous abortion, is the premature end of pregnancy usually before 20 weeks of gestation. When a miscarriage occurs, especially in the early part of pregnancy, it is difficult if not impossible to discern the cause. Many factors can cause miscarriage, including the following: o Chromosomal abnormalities o Structural problems with the uterus o Chronic maternal health conditions o High fever early in the pregnancy o Unusual infections o Substance use o Trauma from an accident or major surgery The loss of a viable pregnancy after 20 weeks of gestation is called a stillbirth. No matter when it occurs, the loss of a pregnancy can be devastating for the mother and her partner. • Preterm birth—A baby born before 37 weeks of gestation is considered to be preterm. Many often refer to these babies as “preemies.” Another term often used in this context is premature, although premature birth most often describes infants whose lungs are immature at the time of birth. Some risk factors for preterm birth are as follows: o Having experienced preterm labor or delivery, or both, in a previous pregnancy o Using chemical substances, specifically cigarettes and cocaine o Carrying twins or multiple fetuses o Having a cervix or uterus that is structurally abnormal o Experiencing increased levels of estriol, a chemical found in women’s saliva Treatment of premature labor often requires partial or continuous bed rest and some medications. Nearly 1 million women are prescribed bed rest every year due to complications in their pregnancies. • Gestational diabetes—Gestational diabetes, intolerance of glucose during pregnancy, is a fairly common complication of pregnancy. It occurs when a woman’s body does not produce enough insulin or when her pregnant body does not use insulin properly. The biological reasons for gestational diabetes are largely still a mystery. One hypothesis is that the hormones involved in pregnancy interfere with how the body uses insulin, often leading to insulin resistance. Risk factors for developing gestational diabetes include the following: o Age 30 or older o Obesity o A family history of type I or II diabetes o Gestational diabetes in a previous pregnancy o A previous baby weighing over 9.5 pounds D. Detecting Problems in Pregnancy • Pregnant women may receive a variety of tests to monitor both their health and the development of the fetus. Historically, health care professionals checked the pregnant woman’s blood pressure, weight, and urine throughout the pregnancy. • Urine tests can reveal gestational diabetes, a kidney problem, or a poor diet. Now a multitude of prenatal tests are routinely used—a practice that is debatable. o Part of the debate surrounds tests that might return a false-positive result, meaning that the test seems to show an abnormality that does not actually exist. • Amniocentesis—An amniocentesis is a procedure done usually between 16 and 20 weeks of gestation. A doctor removes a small amount of amniotic fluid via a needle in the mother’s abdomen (Figure 8.8). Genetic studies are done on the cells contained on the fluid to test for conditions such as Down syndrome and cystic fibrosis. Amniotic fluid can also give doctors information regarding the presence of defects such as spina bifida. o Due to the higher rates of genetic abnormalities more common among older mothers, doctors recommend this test for women over the age of 35. • Chorionic villus sampling—Chorionic villus sampling (CVS) is another screening procedure in which a doctor obtains a small amount of tissue from the placenta by inserting a thin, hollow tube into the vagina and through the cervix to reach the placenta (Figure 8.8). The tissue is analyzed for chromosomal disorders and specific genetic diseases. This procedure can be performed as early as 10 weeks of gestation. • Ultrasound—Ultrasound is a very common form of screening and is used often to monitor the development of the fetus throughout the pregnancy. In an ultrasound procedure, a device known as a transducer is placed on the abdomen. An ultrasound can detect several different kinds of birth defects and is the primary way parents find out the sex of their fetus. An amniocentesis and CVS can provide this information as well. Other information parents and doctors can detect from an ultrasound includes: o Number of fetuses present o Fetal growth o Confirmation of due date o Position of placenta • A three-dimensional ultrasound provides a more detailed picture of the fetus. Figure 8.9 shows examples of both a traditional and a three-dimensional ultrasound. IV. Birth and the Postpartum Period: What to Expect • The average length of a pregnancy is 40 weeks, but a normal birth can occur anywhere from 37 to 42 weeks. • Labor and childbirth occur in three distinct stages (Figure 8.10). • Stage 1 prepares the cervix for delivery of the baby. Propelled by intense contractions of the uterine walls, the cervix will undergo a process of dilation, which expands the cervical opening to approximately 10 cm in diameter. Effacement, the thinning of the cervical tissue to a paperlike thickness, allows for dilation and the passage of the fetus into the vaginal canal. o Women begin to feel pain of childbirth as contractions do their job. These contractions cause the upper part of the uterus (fundus) to tighten and thicken while the cervix and lower portion of the uterus stretch and relax, helping the baby pass from inside the uterus and into the birth canal for delivery. • Stage 2 involves the actual birth of the fetus. As contractions get closer together and more intense, the laboring woman will begin to feel the urge to push as the fetus moves down through the birth canal to the vaginal opening. The end result of stage 2 is the birth of the child. • Stage 3 involves the birth of the placenta. Once the child is born, the woman will continue to feel contractions as her uterus releases the placenta. o In the United States, the placenta is usually seen as nothing more than medical waste—a by-product of childbirth that is most often simply discarded. Consequently, most people don’t spend much time contemplating its life-sustaining powers. o The placenta is an incredible, life-sustaining organ that is treated with respect in many cultures. A. Options for Giving Birth • Over the years in the United States, childbirth has become a medical procedure that takes place in a hospital. In contrast, many other countries combine indigenous childbirth practices with holistic medicine and, when needed, with hospital delivery. • Learning about all the options for childbirth allows women to make decisions that reflect their desires for pain management, movement while laboring, birthing environment, partner involvement, and medical interventions if they are needed. Knowing about the options helps women and their partners take an active, authoritative role in their birthing experience or in helping someone else. B. Birth Assistance and Interventions • Preparing for the birth of a child requires that parents make many important decisions. Some decisions revolve around what kind of birth assistance might be helpful in the labor process. • Some women and their partners have found one type of birth assistance, the Lamaze method, helpful during labor. • Midwives and Doulas—While some women prefer the presence of a physician at the birth of their child, others prefer the more involved and hands-on orientation of a midwife, doula, or trained labor coach. Prior to the 1920s, in the United States, midwives attended and assisted in births but were not considered to be trained medical practitioners. Today, midwives are typically registered nurses with additional training and certification in nurse-midwifery. o Doulas are trained labor coaches that have extensive training to assist a pregnant woman and her partner in the labor and delivery process. In fact, many of them are certified through educational programs as childbirth assistants. They often assist midwives or doctors in birth-related activities and provide a constant presence during labor. • Pain Management: Hydrotherapy and Pain Medication—Labor can be painful for the birthing mother. Different ways to help ease the pain include hydrotherapy and pain medication. Hydrotherapy, immersion in a tub of warm water, may help the mother relax her muscles. This method of delivery may create a better transition from the warm, insulated environment of the womb to the cold, harsh environment of the outside world. o Pain medication is an option for women who want to ease the pain of childbirth. Sedatives and a variety of anesthesia may help relieve labor pains. The epidural is a common form of pain management. With an epidural a doctor inserts a small tube at the base of woman’s spine. A woman can then receive pain medication through this tube as needed throughout the labor and delivery process. • Interventions—The medical field has many available interventions should they be needed to assist in the birth of a child. For example, fetal monitoring during labor can solely dictate the need for a C-section birth if the monitor indicates fetal distress. o Forceps and vacuum extraction—Forceps are metal instruments placed around the baby’s head inside the birth canal to aid in the birth of the child. These instruments, which look like large salad tongs, are placed on either side of the baby’s head. Slight force is then applied to pull the infant further down into the birth canal. Figure 8.11a depicts the position of forceps around the baby’s head. The rate of forceps delivery has fallen dramatically over the years for at least three reasons: adverse complications for both the baby and mother, and women’s hesitation to allow their use. Complications for the baby include: Temporary, though possible permanent, facial marking, bruising, and lacerations Injuries to infant facial nerves Skull fractures or intracranial hemorrhage Increased correlation with higher incidences of cerebral palsy, mental retardation, or later behavioral problems because of a prolonged episode of fetal oxygen deprivation Increased need for assisted and mechanical ventilation in infants Complications for the mother include: Increased likelihood of tears in the vaginal opening, perineum, and surrounding tissues Injury to the bladder Possible blood transfusion from loss of blood caused by significant perineal tears In vacuum extraction, a plastic or metal suction cup is placed on the baby’s head. The doctor uses suction to deliver the baby’s head and body. Complications associated with vacuum extraction are similar to those associated with forceps delivery. Figure 8.11b illustrates how vacuum extraction helps deliver a baby. • Episiotomy—The intervention of episiotomy is a surgical incision to the perineum, which is the tissue between the vagina and the rectum. It is used during delivery to avoid having the vaginal opening tear and to provide a larger opening to birth the infant. • C-section—Cesarean birth, or C-section, is generally performed when the doctor decides it’s in the best interest of the mother and infant. In case of a breech birth, a cesarean is routine in the United States. C. Making a Birth Plan • Women and their partners need to be educated about possible interventions and feel empowered to assert their desires and wishes for the birth of a child. One of the best ways is to create a birth plan that states their needs, goals, and desires, so there is little confusion surrounding what may well be one of the most important events in the life of a woman, her partner, and their family. • With so many options available, pregnant women and partners can plan an active, authoritative, safe childbirth experience. They can ask their health care providers about their views on labor and delivery. • Because most health care providers and hospitals follow a set of policies and procedures, birth plan should be discussed with all individuals who will be involved during the birth and the care of the baby at the hospital. Women and their partners should try to match their desires with the policies of the doctors, nurses, and staff at the hospital. D. After the Birth: The Postpartum Period • The changes of the postpartum period after birth last for about 6 weeks and create flux for the entire family as everyone gets used to new routines, including older siblings. These changes require patience, understanding, and sensitivity from parents, family, friends, and the surrounding community. • As parents adjust to life with their newest family member, they may need to deal with two major issues in this postpartum period: depression and resumption of sexual activity. It is important to have accurate information about both issues because opinions abound. • Depression—Following the birth of a child, many women experience postpartum depression, also called postpartum blues. This is a critical issue in women’s health care, because studies show that high levels of maternal depression are associated with compromised parenting, unhealthy infant attachment, poorer infant cognitive development, and higher rates of infant behavior problems. o Many factors cause postpartum depression. Medical doctors cite the vast decrease in hormone production as the most likely cause of postpartum depression. o Symptoms of postpartum depression include the following: Feelings of sadness, doubt, guilt, hopelessness, or anger that get worse with each passing week and cause disruptions in one’s daily life Inability to sleep even when tired Sleeping most of the time even when the baby is awake Constant worry and anxiety about the baby Lack of interest in or feelings for the baby and family Several methods of coping are available for new mothers. Support groups, therapy, and medications are some of the approaches that may lessen the symptoms. • Resuming sexual activities—Many women are excited at the thought of resuming sexual activity because they want to reclaim their own personal space and to reconnect on a physically intimate level with a partner. Other women may be hesitant to engage in sexual activity due to fears of pain or injury. o The consensus is that women can resume having vaginal intercourse approximately 6 weeks after giving birth. By this time the uterus has shrunk back to its prepregnancy size and the lochia, the menstrual period like fluid that is expelled following birth has stopped flowing. At this time, women should also begin doing regular Kegel exercises, which involve the contraction and relaxation of pelvic floor muscles, to strengthen this area. Stronger pelvic floor muscles help to prevent urinary incontinence and uterine prolapse, and may increase pleasure during sex. If a woman had a cesarean, episiotomy, or other invasive intervention, physicians may recommend postponing vaginal intercourse for a longer period. o In many cultures, postpartum taboos are among the most important ways to regulate marital sex and the establishment of family units. The Sambia of Papua New Guinea, for example, prohibit the resumption of vaginal sex for up to 2 years, fearing that the baby will be harmed if the mother’s milk dries up. V. Infertility and Options • Those who want to raise children but either have been unsuccessful conceiving, do not have a partner, or are in a same sex-relationship, can explore other options such as assisted reproductive techniques, surrogacy, and adoption. • Many factors can cause infertility, including problems with the woman, the man, or both. Possible causes of infertility among women age 35 years and younger include the following problems: o Fallopian tube blockage or abnormality—Endometriosis or scar tissue from STIs, pelvic inflammatory disease (PID), or a second trimester abortion may cause the blockage. The blockage may not allow sperm to reach the egg or may not allow the fertilized ovum to reach the uterus, which may lead to an ectopic pregnancy. o Ovulatory disruptions—Many factors may cause these disruptions, including hormone imbalances, benign pituitary growths, amenorrhea due to a lower or higher than normal body weight, or conditions such as polycystic ovarian syndrome, a disorder in which numerous small cysts develop on the ovaries and prevent ovulation of mature ova. o Endometriosis • Women are not the only ones with conditions leading to infertility. Main issues for male infertility are abnormally low sperm count and low movement of sperm. o Causes of low sperm count can be either biological or environmental. Evidence shows that toxic substances, alcohol, tobacco, and certain prescription medications can affect the volume of sperm. o Low sperm movement, or motility, means that sperm do not move through the female reproductive tract quickly enough and die before they reach the ovum as it moves down the fallopian tube. Men can also have high levels of malformed sperm, which are sperm with structural abnormalities or deficiencies, that do not live very long and have difficulty reaching and penetrating the ovum. Causes of sperm malformation may be biological or environmental. A. Assisted Reproductive Techniques • A variety of fertility technologies, called assisted reproductive techniques, have been developed to assist people in their efforts to conceive. Some of the sociological implications about these techniques are: o Not everyone may have access to them, including single women, lesbians, poor women, women with disabilities, and older women. o Individuals may not be covered by health insurance, which makes them more available to the more affluent people in society. o Physicians who perform these techniques may impose their own biases and may discriminate based on age, socioeconomic status, or marital status. • Egg donors—To donate her eggs, a woman must be in the age range of 18 to early 30s and pass a variety of medical and psychological exams. Once they are chosen to donate, donors begin taking hormone shots that boost their egg production for about 30 days. Ten to 15 eggs are extracted via needle from the sedated donor. These eggs are then combined with sperm to create embryos, which may later be inserted into the uterus of a would-be mother to possibly become a child. o With in-vitro fertilization (IVF), mature eggs are removed from a woman’s ovaries and are fertilized by sperm in a laboratory dish. Once the eggs appear to be fertilized, a doctor inserts them in the woman’s uterus, where they may implant. o Gamete intrafallopian transfer (GIFT) is a procedure in which a doctor places the sperm and egg directly into the fallopian tube in the hope that their proximity will aid in the process of fertilization. The possible benefit of GIFT over IVF and ZIFT is that it more closely follows the journey of a typical fertilized ovum as it travels from the fallopian tubes into the uterus where it will hopefully implant. o Zygote intrafallopian transfer (ZIFT) is similar to GIFT, but in this case the ovum is fertilized in a laboratory dish and then a doctor places the fertilized egg in the fallopian tube for it to travel to the uterus for possible implantation. o Artificial insemination (AI) is the deliberate introduction of semen into a female for the purpose of fertilization, by means other than ejaculation directly into the vagina or uterus. Usually sperm is taken from a partner or donor and placed either in the vagina or deeper into the uterus during the time at which a woman is thought to be ovulating. • In the United States, there are many sperm banks where men have donated sperm for use in assisting a woman in conceiving a child. Sperm banks are a good source for lesbian couples looking to conceive a child, single women wishing to conceive a child without a partner, and heterosexual couples where the man has challenges with fertility. B. Other Options for Creating a Family • Parenthood through surrogacy—For women who are unable to carry children, or for gay men who want to raise children, parenthood through surrogacy is an option. With surrogacy, a woman outside of the pair bond carries the fetus to term, delivers the baby, and then turns it over to the parents to adopt and raise. • Adoption—Adoptions can be done privately where the biological mother chooses the people whom she wishes to parent her unborn child. Some agencies specialize in open adoption, which means that the adoptive parents will update the birth parents on how their child is doing. Adoptions can also occur when parents adopt children whose biological parents have had their parental rights legally removed. Often referred to as foster adoption, the child in this situation is placed in a foster home and may be eventually adopted by that family once the biological parents have had their rights legally terminated. Kinship adoption is also a possibility whereby adoptive parents adopt children who are biologically related to them in some form. o Private adoption is expensive as adoptive families often cover the cost of the biological mother’s prenatal care and hospitalization for the birth of the child. In addition, adoptive parents must assume the expensive court and attorney costs that are necessary to finalize the adoption. o Public adoption is a much more cost-effective way to start a family. Some states and counties in the United States cover the legal costs of adoption and even subsidize the cost of caring for the child until age 18 years. VI. Abortion A. Defining Abortion • Abortion, the elective termination of a pregnancy, is one of the most difficult topics when it comes to reproductive and family life, and sexual health and well-being; and it has become an important social question in the United States today. • Women may seek an abortion for many reasons, but chief among them are that they feel too young or unprepared to have children or that they are pregnant because of sexual violence, such as rape or incest. • Those who consider abortion may want to think about the following issues: o Do you have any reason to be concerned about your safety during this procedure? o How far along in the pregnancy are you and what abortion options are available? o Is a partner involved in the decision and will you consult with that person? o How will your decision fit with your faith or cultural traditions? o Do you anticipate any emotional reactions to an abortion that you should investigate or be prepared for in advance? • Women choose to have an abortion for many different reasons. One study by Jones and colleagues (2008) reported that some women choose abortion because the cost of raising a child and providing an education is beyond them. o Other women cite parenting characteristics such as the desire to create a “good home,” which means wanting the child to grow up in a stable family environment with financial security. One quarter of the women claimed they had considered the option of adoption, but felt that the emotional consequences would be too distressing. • Research shows that women do much better after an abortion when they have good social support—especially when the support comes from their partners. Evidence also shows that women who make this decision independently, versus feeling coerced or pressured into the decision by a partner or family, tend to cope better. B. Safe Methods of Abortion • When a woman chooses to terminate a pregnancy in the United States, it is done before she has reached 24 weeks of gestation. If an abortion is performed after 24 weeks, it is usually only done for serious threats to the mother’s health or life or the discovery of a serious fetal anomaly. • Women may opt to have an in-clinic abortion or to take an abortion pill. The most common form of in-clinic abortion is aspiration. Doctors often use the aspiration method until 16 weeks after a woman’s last menstrual period. A health care provider inserts a speculum into the vagina to gain access to the cervix. The opening of the cervix is stretched with dilators. o A tube is then inserted through the cervix into the uterus. A suction device is used to empty the uterus. Illustrated in Figure 8.12, this procedure usually takes 5 to 10 minutes, but more time may be necessary to prepare the cervix. • Less than 10% of in-clinic abortions in the United States are performed using the method of dilation and evacuation (D&E). This procedure is usually performed once a woman has past the first 16 weeks after her last menstrual period, but before 24 weeks as mentioned earlier. It is similar to aspiration, except that in this procedure, a medication is given through the abdomen to ensure that the fetus dies and the doctor may use forceps to assist in the abortion procedure. o This procedure usually takes between 10 and 20 minutes and is normally done under general anesthesia in a hospital setting. • Other options for a medical abortion in the United States are abortion pills. These pills are known as abortifacients. They can be used up to 9 weeks after a woman’s last menstrual period. Mifepristone, also known as RU486, is most common in the United States and in Europe. Using mifepristone is a two-step process. o First, a woman takes it to block progesterone, the hormone that maintains a pregnancy. Without progesterone, the endometrium breaks down and a pregnancy cannot continue. o Then a woman takes a second medication, misoprostol, which causes severe cramping and bleeding. It is reported that more than 50% of women abort within 4 to 5 hours after taking the second medication. C. After an Abortion • Women experience a variety of emotions after they elect to terminate a pregnancy. Most women experience relief but others also report feeling anger, regret, guilt, or sadness for a period of time. • Do women who are minors experience emotional problems after an abortion than older women do not? Studies show that minors are not at higher risk for depression or adverse consequences as compared to older women. o Specifically, research shows that at 1 month after an abortion, minors were somewhat less satisfied with their decision than adult women. This dissatisfaction was primarily because the coping skills of adolescents are underdeveloped or less mature than adults. o Regardless of age, making the decision to terminate a pregnancy is difficult. If a woman is having trouble coping with her decision to have an abortion, professional counseling may help to ensure her emotional health and well-being. VII. Sexual Well-Being and Reproductive Rights • The pursuit of sexual well-being in the context of reproductive rights and justice in the United States has been difficult, political, and hard. Poverty is a large factor, because people in rural areas tend to be poorer and have less access to quality health care compared to urban areas, including good sexual health and maternal or reproductive health care. • There is political opposition to reproductive rights, and some states prohibit any abortion supported by public or private funds, which has a negative effect on poor women and women of color. The reasons for this political opposition, especially among conservative males, are complex but they tend to be reinforced by traditional gender role attitudes. • In addition to gender roles, some people think that women should just not have abortions, they should stay at home and not work, and they may believe that women who have abortions are sexually promiscuous. • Some of this attitude may also influence people’s reaction to the 1973 Supreme Court decision in the case of Roe v. Wade. With this decision, the United States affirmed the right of a woman to have an abortion under certain conditions. Key Terms Pronatalism—a belief system that promotes childbearing Family leave—an absence from work, either paid or unpaid, granted so that an employee can give care to a family member, such as a new baby Fetal alcohol syndrome (FAS)—a pattern of mental and physical defects that can develop in a fetus in association with high levels of alcohol consumption during pregnancy Fetal alcohol spectrum disorders (FASDs)—a group of conditions (including FAS) that can occur in a person whose mother ingested alcohol during pregnancy Endometriosis—a potentially painful and dangerous medical condition caused when endometrial cells grow outside of the uterus into the abdominal cavity Matrilineal society—a society in which descent and inheritance come through the mother’s kinship line Patriarchal society—a society in which descent and inheritance come through the father’s kinship line Trimester—one of three periods of approximately 3 months each that make up full-term pregnancy Germinal period—the first phase of prenatal development, from conception through day 14 Embryonic period—the second phase of prenatal development, from day 14 through day 56 after conception Fetal period—the third phase of prenatal development, from the ninth week through birth Gestation—the period of time between conception and birth Zona pellucida—the thick, protective layer on the outer part of the ovum Zygote—the product of the fusion of an egg and a sperm Blastocyst—the developing zygote prior to implantation in the uterine wall Embryo—a blastocyst that has implanted in the uterine wall Fetus—a developing baby from the eighth week of pregnancy until birth Amniotic sac (amnion)—the sac in which the fetus develops Chorion—a membrane that separates the fetus from the mother Placenta—an organ attached to the uterine wall that joins the embryo to the mother’s bodily systems to transfer nutrients, oxygen, and waste products between the fetus and the mother Umbilical cord—a structure that transports oxygen, waste, and nutrients between the fetus and the placenta Ultrasound—a form of screening used to monitor development of the fetus throughout a pregnancy Lanugo—a fine, soft hair that covers a fetus’s body Vernix—a protective waxy substance on a fetus’s body Couvade—a syndrome in which male partners experience pregnancy symptoms similar to those of their pregnant partners Breech—position of a fetus that is emerging with buttocks or legs first rather than head first Cesarean (C-section) birth—surgical removal of a fetus from the mother’s uterus through an incision in the abdomen Ectopic pregnancy—a complication in which a fertilized ovum grows outside the uterus, most commonly in the fallopian tubes Miscarriage (spontaneous abortion)—the unintentional loss of an embryo or fetus during the first 20 weeks of pregnancy Stillbirth—the unintentional loss of a pregnancy after 20 weeks of gestation Preterm (premature)—birth of an infant less than 37 weeks after conception Estriol—a chemical found in women’s saliva that may indicate preterm birth Gestational diabetes—a condition of glucose intolerance that may occur during pregnancy Amniocentesis—a procedure done between 16 and 20 weeks of gestation in which a doctor removes a small amount of amniotic fluid via a needle in the abdomen to test for genetic abnormalities Chorionic villus sampling (CVS)—a procedure in which a small amount of tissue from the placenta is analyzed for genetic abnormalities Dilation—the expansion of the cervical opening (to approximately 10 cm) in preparation for birth Effacement—thinning of cervical tissue that occurs in preparation for birth Contractions—muscular movement that causes the upper part of the uterus to tighten and thicken while the cervix and lower portion of the uterus stretch and relax, helping the baby pass from the uterus into the birth canal for delivery Midwife—a person who has been trained in most aspects of pregnancy, labor, and delivery but who is not a physician Doula—a person trained in the process of labor and delivery and assists a midwife in childbirth Hydrotherapy—the use of a warm tub of water in the birth process to encourage relaxation Epidural—a form of pain management in which a doctor passes pain medication through a small tube that has been inserted at the base of a woman’s spine Forceps—metal instruments placed around the baby’s head inside the birth canal to aid in the birth of the child Vacuum extraction—the use of suction to assist in delivering the baby Episiotomy—an incision made in the perineum to create a larger space to deliver a baby Postpartum period—literally meaning “following birth,” this term refers to the months or first year following the birth of a child Postpartum depression—a psychological depressive disorder that may occur within 4 weeks following the birth of a child Lochia—fluid that is expelled following the birth of a child Kegel exercises—the voluntary contraction and relaxation of pelvic floor muscles to help prevent urinary incontinence and slippage of the uterus following childbirth Motility—ability of sperm to move when ejaculated Malformed sperm—sperm that are abnormally formed Assisted reproductive techniques—fertility technologies that assist people in their efforts to conceive In-vitro fertilization (IVF)—fertilization of eggs by sperm in a lab dish for implantation in a woman’s uterus Gamete intrafallopian transfer (GIFT)—procedure in which sperm and egg are placed directly into the fallopian tube to aid in fertilization Zygote intrafallopian transfer (ZIFT)—implantation of a fertilized ovum in the mother’s fallopian tube Artificial insemination (AI)—a procedure that artificially introduces semen into a female for the purpose of fertilization Surrogacy—a woman becomes pregnant for another individual or couple and then gives the child to them to raise Open adoption—a form of adoption in which birth parents remain connected to the adoptive family through periodic updates and other communication Abortion—elective termination of a pregnancy Aspiration—an abortion procedure using suction to remove an embryo or fetus from the uterus Dilation and evacuation (D&E)—an abortion procedure used after the first trimester in which medication is administered to ensure fetal death prior to removing it from the uterus Abortifacients—medications used to prevent the progression of pregnancy and induce uterine contractions to remove embryonic or fetal tissue Instructor Manual for Human Sexuality: Self, Society, and Culture Gilbert Herdt, Nicole Polen-Petit 9780073532165, 9780077817527
