2.

3 • Pregnancy and Prenatal Development 89

University, OpenStax, under CC BY 4.0 license; credit left: modification of work “Sperm-egg” by PD Images/
Wikimedia Commons, Public Domain; credit middle: modification of work “Tubal Pregnancy with embryo” by Ed
Uthman/Wikimedia Commons, Public Domain)

Prenatal Development and Viability

The three major developmental periods of pregnancy are the germinal period, the embryonic period, and the
fetal period. Significant development changes occur during all of these stages, and during the last, the fetus
becomes viable outside the womb. Complications, such as exposure to teratogens and congenital disorders,
may occur during fetal development.

The Germinal Period

As you’ve learned, conception occurs when a sperm cell enters the ovum and the twenty-three chromosomes
in each of the two cells combine, creating a unique new combination of forty-six chromosomes. The single cell
formed at conception is called a zygote.

The first and shortest of the three developmental periods of pregnancy is the germinal period. It starts at
conception and lasts approximately two weeks. The zygote starts to divide within twenty-four hours of forming,
and around five to seven days later it is a small cluster of a few hundred cells called a blastocyst. About a week
after conception, the blastocyst starts to form burrlike projections, which help it implant in the uterus after it
travels down the fallopian tube. Cell differentiation starts during the germinal period as well.

Cell differentiation is the process in which stem cells, guided by genes, start to specialize or take on
characteristics of what they will later become, such as organs, nails, hair, or skin. This is the start of the
blastocyst’s transformation into an embryo. One end of the blastocyst turns into the embryoblast, which will
eventually become the embryo. The rest develops into a life-support system for the embryo consisting of the
placenta, umbilical cord, amnion, and chorion.

The germinal period is also the time during which twins and other multiples are conceived (Figure 2.16).
Fraternal or dizygotic twins develop when two ova are fertilized at the same time. In the case of identical or
monozygotic twins, for reasons still not completely understood, the zygote splits into two clusters of cells,
creating two genetically identical zygotes (Hall, 2021). In pregnancies that are not due to fertility treatments,
there is a 0.4 percent chance of having monozygotic twins (Roberts et al., 2018). That chance increases to a
1.57 to 5.6 percent chance in pregnancies utilizing IVF and other fertility treatments, possibly due to
medications and laboratory procedures employed in the IVF process (Roberts et al., 2018).
90 2 • Genetic, Prenatal, and Perinatal Health

FIGURE 2.16 In the development of identical twins, a zygote splits into two separate but genetically identical
zygotes. In the case of fraternal twins, two eggs are fertilized by two separate sperm at the same time. (credit:
modification of work “Identical twins lg” by National Human Genome Research Institute/Wikimedia Commons,
Public Domain)

By the end of the germinal period, the blastocyst has traveled through the fallopian tube to the uterus, where it
implants into the uterine wall. This process is called implantation. Successful implantation is not guaranteed,
and it’s estimated that 15 percent of pregnancies are lost before or during this process (Jarvis, 2020). It is
difficult to develop methods to correctly assess the success of implantation without knowing the exact date of
conception.

The Embryonic Period

Once implantation has occurred, the blastocyst becomes an embryo, and the embryonic period begins. This
period lasts from the third to the eighth week of pregnancy. An enormous number of changes happen during
this period. After implantation, part of the embryo rapidly forms four major support structures—the amnion,
chorion, placenta, and umbilical cord:

• The amnion or amniotic sac is a watertight sac that protects the embryo and is filled with amniotic fluid.
• The chorion gathers nourishment for the embryo and eventually becomes the lining of the placenta.
• The placenta is a temporary organ connecting the uterus to the umbilical cord that provides respiration
and nourishment for the embryo in addition to eliminating metabolic wastes.
• The umbilical cord is a flexible tube connecting the embryo and the placenta; it contains three types of
blood vessels that carry nutrients and oxygen from the birth mother to the embryo and transport waste
from the embryo to the placenta (Heil & Bordoni, 2022).

Other changes occurring during the embryonic period include organogenesis, or the formation of organs.
Ongoing cell differentiation allows cells to become specialized to do different jobs. For example, liver cells help

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 2.3 • Pregnancy and Prenatal Development 91

filter out toxins, neural cells help process information, and heart cells beat rhythmically to push blood through
the embryonic body. This process begins approximately three weeks after conception, when the embryo starts
to differentiate into three distinct components, the ectoderm, mesoderm, and endoderm. The outer layer of
the embryo becomes the ectoderm, and cell differentiation allows it to start developing the nervous system,
skin, and hair. The middle layer of the embryo, the mesoderm, develops into muscles, bones, and the
circulatory system. The innermost layer of cells within the embryo becomes the endoderm and develops into
the organs of the digestive system, the lungs, and the urinary tract.

LINK TO LEARNING
Watch this TED talk discussing prenatal development (https://openstax.org/r/104EmbryoDevelp) to learn more
about how embryos develop.

The Fetal Period

The last seven months of pregnancy are a period of organ growth and refinement called the fetal period.
During this time, the fetus grows quickly. Around seventeen to twenty weeks after conception, lanugo and
vernix develop (Verhave & Lappin, 2018). Vernix is a white cheese-like substance that helps protect the skin
from chafing in the amniotic fluid. Lanugo is a soft, thin hair that helps vernix stick to the skin of the fetus in
addition to helping protect the skin itself. Both lanugo and vernix usually disappear between the thirty-third
and thirty-sixth weeks of pregnancy (Verhave & Lappin, 2018).

Growth occurs in several directions both prenatally and after birth. Growth that occurs from head to feet is
called cephalocaudal growth, whereas proximodistal growth occurs from the center of body outward.
Cephalocaudal growth allows the fetus to grow longer, whereas proximodistal growth is exemplified by infants
being able to control their arm movements before their fingers. In mass-to-specific growth, large movements
and structures develop before smaller or more specified movements and structures.

The Age of Viability

The more time the fetus spends inside the womb, the greater its chance of survival. The age of viability is the
age at which a fetus born prematurely (before the thirty-seventh week of pregnancy) may have a chance of
survival outside the womb, usually with intensive medical intervention (Jang & Lee, 2022). In the United
States, the earliest age of viability is generally considered to be the twenty-fifth week of pregnancy. However,
the age of viability has changed over the years and is not the same from country to country. Medical systems
and resources vary from place to place. Not all neonatal intensive care units (NICUs) can handle babies born at
or before twenty-five weeks of gestation. Extremely premature babies require extensive medical care to
survive and may also have long-term cognitive and/or physical issues.

The earliest known surviving infant was born at twenty-one weeks’ gestation; others have survived after being
born at twenty-two weeks’ gestation. All required intensive medical treatment to survive because several
important systems were not sufficiently developed, including the lungs (American College of Obstetricians and
Gynecologists, 2023). Babies born near the lower limits of the age of viability have an increased risk of
neurological and other health issues, including heart and lung problems later in life (Jobe, 2022). It is
estimated that approximately 50 percent of babies born before twenty-four weeks’ gestation may survive, but
none without intensive medical intervention (Thomas & Asztalos, 2021).

Complications in Prenatal Development

Sometimes issues develop during a pregnancy that can lead to spontaneous abortion, which is the loss of a
pregnancy during the first twenty weeks. Spontaneous abortion, often called miscarriage, is the most common
pregnancy complication and is estimated to occur in approximately 15 percent of all pregancies (Laisk et al.,
2020). Of those lost pregnancies, about 60 percent terminate during the germinal period due to the embryo's
failure to grow or implant properly. About 20 percent of those miscarriages occur between weeks six and ten of
92 2 • Genetic, Prenatal, and Perinatal Health

gestation, in the embryonic stage. About 60 percent of spontaneous abortions occur during the germinal
period due to failure to grow or implant properly. About 20 percent occur between weeks six and ten of
gestation, in the embryonic stage.

Spontaneous abortions during the germinal and embryonic stages are believed to often be due to
chromosomal abnormalities. During the fetal stage, around 5 percent of pregnancies result in a spontaneous
abortion or stillbirth, the death of the fetus after twenty-eight weeks. Other risk factors include advanced
maternal age, history of past miscarriages, certain chronic diseases, and chronic stress (Alves et al., 2023).

Spontaneous abortion is most likely to occur for reasons outside the birth mother’s control. In the United
States, low socioeconomic status and lack of access to health care are associated with an increased risk of
miscarriage (Oliveira et al., 2020). A much lower risk of fetal loss, approximately 1.39 percent globally, exists
for stillbirths (Hug et al., 2021). Global public health efforts, including by the WHO, have helped reduce this
risk (Hug et al., 2021).

LINK TO LEARNING
Explore the March of Dimes website on miscarriage (https://openstax.org/r/104Miscarriage) that describes
different types of spontaneous abortions, reasons they may occur, and warning signs of possible pregnancy
loss.

Teratogens

Any disease, drug, or other environmental agent that can harm the embryo or the fetus physically or influence
health or behavior after birth is called a teratogen. Generally, the influence of a teratogen on a body part is
strongest when that part is developing, such as during organogenesis (Figure 2.17). After organs have formed,
they are usually less vulnerable to teratogens, except for the nervous system, which always susceptible. Limb
formation and other aspects of prenatal development show varied critical and sensitive periods for risk of
harm from teratogens.

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 2.3 • Pregnancy and Prenatal Development 93

FIGURE 2.17 Prenatal development includes developmental periods during which different features of growth are
sensitive to teratogens. (credit: modification of work “Figure 1. Sensitivity to teratogens during pregnancy” by
Mehmet Semih Demirtaş/IntechOpen, CC BY 3.0)

The potential impact of a teratogen varies based on a range of factors including the specific teratogen, the
length and amount of exposure, genetic susceptibility, and the quality of the prenatal environment. The longer
the exposure or the higher the dose of a teratogen, the greater the likelihood of it doing harm. Some teratogens
can cause a range of developmental issues, and in some cases, different teratogens contribute to s specific
disorder. Embryos and fetuses can be harmed by teratogens to which their biological fathers were exposed, as
well as by those to which they are exposed via the birth mother’s body during gestation (Table 2.5).

The long-term effects of some teratogens often depend on the quality of the postnatal environment. For
instance, maternal exposure to pollution is related to low birth weight, preterm birth, and neurological effects
(Rani & Dhok, 2023). All these put a developing child at increased risk of challenges to overall health and
quality of life.
94 2 • Genetic, Prenatal, and Perinatal Health

Teratogen Possible Consequences of Exposure

Environmental
Toxin

Organ anomalies, slowed growth, or nervous system abnormalities depending on exposure

Radiation
timing

Increased risk for miscarriage, preterm birth, and low birth weight; damage to brain,
Lead
kidneys, nervous system; learning or behavior problems

Mercury Brain damage and hearing and vision problems

Polychlorinated
Low birth weight and premature birth
biphenyls (PCBs)

Infectious
Diseases

Rubella (German
Malformation of organs or miscarriage if exposed during first three months of pregnancy
measles)

Transmission of HIV from the biological mother to infant; antiviral treatment during
HIV
prenatal period drastically reduces transmission to less than 5 percent

Cytomegalovirus
Central nervous system damage and hearing loss
(CSV)

Genital herpes Blindness or death if exposed to active herpes lesions in the birth canal

Toxoplasmosis and
Miscarriage, preterm birth, and fetal death, depending on exposure timing
listeria

Zika virus Microencephaly, hearing and vision loss, and intellectual disability

COVID-19 Preterm birth and neurodevelopmental disorders

Syphilis Premature birth, low birth weight, and fetal death; congenital diseases

Influenza Spina bifida, cleft palate, and defects in the neural tube

Medications

Miscarriage if high doses are taken early in pregnancy; increased risk of bleeding if low
Aspirin
doses are taken

Certain antibiotics
Hearing loss and incomplete development of bones and teeth
(e.g., streptomycin)

TABLE 2.5 Long-Term Impacts of Various Teratogens (sources: CDC, 2024a; CDC, 2024b; Cestonaro et al., 2022;
Dack et al., 2022; Giuliani et al., 2022; Honein et al., 2017; Kaleelullah & Garugula, 2021; Lin et al., 2023; Lusskin et
al., 2018; Mactier & Hamilton, 2020; Manicklal, 2013; March of Dimes, 2021; Nesheim et al., 2012; Orsolini et al.,
2017; Ross et al., 2015)

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 2.3 • Pregnancy and Prenatal Development 95

Teratogen Possible Consequences of Exposure

Very short or missing arms and legs and other congenital birth defects when taken during
Thalidomide
early pregnancy

Certain antiseizure
Developmental delays during infancy
medications

Certain
antipsychotic Increased risk of heart defects
medications

Certain
antidepressant Risk is not clear
medications

Psychoactive
Drugs

Cocaine Low birth weight and placental abruption/separation

Opioids and
Preterm birth, reduced growth, heart issues, cognitive and behavioral issues
amphetamine

Nicotine Low birth weight, premature birth, stillbirth

Alcohol Damage to developing organs; fetal alcohol spectrum disorder

Addiction requiring medical care to overcome withdrawal symptoms; damage to the visual
Heroin
system; long-term behavioral consequences

Decreased growth; deficits in attention and long-term executive function; increased

Cannabis
impulsivity

Deficiencies in short-term memory, attention, and impulse control; other neurobehavioral

Excessive caffeine
and neurological effects

TABLE 2.5 Long-Term Impacts of Various Teratogens (sources: CDC, 2024a; CDC, 2024b; Cestonaro et al., 2022;
Dack et al., 2022; Giuliani et al., 2022; Honein et al., 2017; Kaleelullah & Garugula, 2021; Lin et al., 2023; Lusskin et
al., 2018; Mactier & Hamilton, 2020; Manicklal, 2013; March of Dimes, 2021; Nesheim et al., 2012; Orsolini et al.,
2017; Ross et al., 2015)

However, research shows that other factors associated with the home environment fostered resilience in
preterm infants and had a positive influence on the children’s academic performance in grade school
(Wouldes, 2022). Parents or caregivers who actively engage with their infants, provide stimulating toys, and
spend time teaching skills such as language and counting increase the chances that preterm and normal-
weight infants will do well in school (Vanes et al., 2021; Wouldes, 2022). Interactions including singing to
infants, telling them stories, and playing with them provide cognitive stimulation important to learning
language and learning in general, regardless of culture (Lansford, 2021).

Extreme conditions such as harsh environments or war zones, in which people may face food shortages and
tremendous stress, can have a negative impact on pregnancy. Severe emotional stress during pregnancy,
including job stress, household stress (such as living paycheck-to-paycheck), or relational stress (such as being
96 2 • Genetic, Prenatal, and Perinatal Health

a victim of domestic violence), leads to increased risk for miscarriage, premature birth, low birth weight,
respiratory illnesses, and digestive problems (Zhang et al., 2023). Additionally, climate change may be a
reason for increased exposure to stress for many people around the world, because it is believed to be
increasing weather extremes such as flooding, wildfires, extreme heat, poor air quality, and restricted access
to food and clean water (Ha, 2022; Olson & Metz, 2020). Working to lower stress and improve resilience factors,
such as improving social support and prenatal care resources, can reduce vulnerability to these adverse
effects and improve health outcomes for both the biological mother and the newborn (Zhang et al., 2023; Nolvi
et al., 2022).

Males can also influence the health of the fetus if they have been exposed to certain toxins such as lead,
radiation, or pesticides, or if they regularly use drugs or smoke. These factors can affect the quality and
mobility of their sperm and therefore the health of the fetus during pregnancy (Meng & Groth, 2017).
Secondhand smoke can lead to lower birth weights, particularly with the type of regular exposure that would
occur from someone in the same house as the developing fetus (Khader et al., 2010). Likewise, intimate
partner violence has adverse effects on the pregnant person including depression, anxiety, PTSD, and on the
developing fetus (Agarwal et al., 2023).

Factors other than teratogens may put the health or even the life of the birth mother, the fetus, or both at risk.
The most common causes of such high-risk pregnancies are maternal health problems like high blood
pressure, diabetes, obesity, the presence of multiple fetuses (twins, triplets), and “advanced” maternal and
paternal age (defined as over age thirty-five years).

Congenital Disorders

Genetics and the environment are factors that can contribute to a congenital disorder, or an abnormality
present at birth. Common congenital disorders include heart defects, clubfoot, and cleft palate (CDC, 2024c).
Approximately 3 percent of infants born within the United States have a congenital disorder, and disorders
affecting the heart, lungs, or other vital organs account for nearly 20 percent of infant deaths (CDC, 2024c).
Worldwide, congenital disorders affect approximately 3–6 percent of all pregnancies (World Birth Defects Day
2023: Global Efforts to Raise Awareness and Support Families | CDC, 2024d). The mortality rate due to
congenital disorders worldwide was estimated to be about 7.6 percent in 2020 (Perin et al., 2023). The
difference in rates between the United States and the rest of the world is likely due to differences in reporting
data; infant mortality rates may be underestimated in many countries, especially those with lower incomes
(Perin et al., 2023).

Monitoring Prenatal Development

Physicians use a variety of methods to monitor the development and health of the growing fetus. Not only do
these allow us to observe the development of structures and organs, but some can detect the presence of
chromosomal abnormalities:

• Ultrasounds use high-frequency sound waves to create an image of the embryo’s or fetus’s developing
structures and organs and are a typical feature of prenatal care in the United States. Transvaginal
ultrasounds have helped researchers and physicians learn more about the early stages of pregnancy than
traditional abdominal ultrasound did.
• Maternal serum tests are blood tests typically given between the eleventh and thirteenth weeks of
pregnancy to measures levels of certain proteins (Graves et al., 2002). Abnormal levels of these proteins
suggest a higher chance of the fetus having a chromosomal abnormality.
• A test in which a needle is inserted through the mother’s abdomen to take a sample of the amniotic fluid
surrounding the fetus is amniocentesis; it is done around the sixteenth week of pregnancy. The sample is
then tested for signs of chromosomal disorders (such as Down syndrome), some genetic disorders (like
cystic fibrosis), and birth defects (such as spina bifida). Amniocentesis is typically only done when
medically recommended.

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 2.3 • Pregnancy and Prenatal Development 97

• During the medical procedure chorionic villus sampling (CVS), a small piece of the placenta is removed to
test for chromosomal and genetic abnormalities or defects. If necessary, it is performed in the first
trimester. Like amniocentesis, CVS carries risks, including infection, limb deficiency, and/or miscarriage
(Olney et al., 1995).

LINK TO LEARNING
Watch this short video about the amniocentesis procedure (https://openstax.org/r/104Amniocentisis) to learn
more about its use in assessing a fetus for chromosomal and genetic abnormalities before birth.

Behaviors for a Healthy Pregnancy

A healthy pregnancy is never guaranteed, though certain prenatal behaviors and choices can improve the odds
of having a healthy and safe experience. The person planning to carry the pregnancy should strive to maintain
a healthy diet with sufficient levels of the macronutrients and micronutrients that support a healthy
pregnancy. Macronutrients, including carbohydrates, proteins, and fats, provide the energy, protein, and fatty
acids needed, while micronutrients provide the vitamins and minerals (Mousa et al., 2019). For example, folate
is a B vitamin particularly important to fetal development and readily available in leafy green vegetables.
Finally, the person carrying the pregnancy can make sure they get enough sleep, exercise regularly, stay up to
date on their vaccinations, and mitigate any potential health issues such as diabetes, drinking, and smoking.

Finding a trusted obstetrician/gynecologist and/or midwife is also important, and prenatal care should begin
as soon as the pregnancy is confirmed. Birth mothers who do not receive regular prenatal care are at higher
risk of having a baby with low birth weight (Thorsen et al., 2019). Low birth weight is one major indicator that a
newborn is at risk of a variety of postnatal complications. Regardless of culture, maintaining health while
pregnant and getting regular prenatal care decrease the chances of having a baby with low birth weight (Khan
et al., 2019; Zhou et al., 2019).

During prenatal visits, the obstetrician will check the vital signs of the pregnant person and the fetus to help
assess the health of both; the pregnant person’s weight is also noted to ensure appropriate weight gain during
the pregnancy. This is generally 25 to 35 lb, depending on pre-pregnancy weight. The pregnant person will
also be advised on diet during pregnancy, including which foods to avoid to limit potential exposure to toxins
like Listeria (a bacterial parasite) and the number of extra calories needed to help support the pregnancy
(about 300 calories more per day than before becoming pregnant) (American College of Obstetricians and
Gynecologists, 2023). Getting enough exercise is also important. Someone who was very active before
pregnancy can typically maintain that activity level; however, it’s advisable to consult a health professional if
starting a new exercise routine after becoming pregnant. Avoiding excessive stress matters too, as does
preparing for the home arrival of the baby.

LINK TO LEARNING
Explore this online tool about beneficial food choices for those who are pregnant or breastfeeding
(https://openstax.org/r/104PregEating) from the U.S. Department of Agriculture. This helps ensure proper
nutrition at each stage of the pregnancy.

LINK TO LEARNING
Learn about some of the surprising ways pregnancy affects the body (https://openstax.org/r/104PregBodyEfct)
in this TED Talk.

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2.4 Childbirth and Perinatal Health

LEARNING OBJECTIVES
By the end of this section, you will be able to:
• Describe the stages of labor and birth
• Compare the birthing options available to parents
• Explain the methods for assessing the health of the birth mother and the newborn

Emily and Omar are expecting a baby in a few short months. As their due date approaches, they discuss
options for the birth. Emily has always been drawn to the idea of a quiet birth at home, accompanied by a
midwife. Omar, on the other hand, expresses anxiety about this option and would feel safer with a hospital
birth. After all, what if something goes wrong? Wouldn’t Emily want a doctor in such a situation? The couple
weighs the pros and cons of each option and arrives at a compromise. Emily will plan to give birth at home with
the support of a midwife but will switch to the hospital if any complications arise. Luckily, when the time
comes, Emily’s labor is uncomplicated, and the couple marvel at the beauty of their newborn in the comfort of
their home. They are grateful for the compromise they reached. The birth was a journey that blended the
intimacy of home with the safety net of the hospital, creating a unique and special experience for them.

Pregnancy can be an exciting experience, although the actual birth may not be the first thing on parents’
minds when they discover that they’re expecting. Like Emily and Omar, parents need to consider where the
birth might take place and who may be present (Figure 2.18). Medications to ease labor pain are available, but
natural childbirth (without the use of medication) is also an option. Doctors, midwives, and doulas can all be
present at a birth, along with partners and supportive friends or family members. A baby’s arrival can also be a
more private experience. Regardless, childbirth can cause anxiety or fear. Understanding the birthing process,
the signs that labor has started, and where and how birth can occur can help expectant parents prepare.

FIGURE 2.18 Birth experiences vary, and labor often looks very different from the way it is depicted on TV. Some
options for managing the pain and process of childbirth include (a) using a birthing pool particularly in early stages,
and (b) using certain positions and pressure techniques throughout various stages of labor. (credit a: modification of
work “birth2” by Lindsey Turner/Flickr, CC BY 2.0; credit b: modification of work “Doula” by Agência Senado/Flickr,
CC BY 2.0)

The Birth Process

The process of giving birth starts approximately two weeks before the big event with changes in birth hormone
levels, including oxytocin. The most common observable first sign of labor is contractions. Contractions may
be true contractions or may include Braxton-Hicks contractions, also called “false labor” (Raines & Cooper,
2023). Braxton-Hicks contractions are typically not painful and may help prepare the body for the process of
100 2 • Genetic, Prenatal, and Perinatal Health

labor.

Though it occurs before labor in only a minority of cases, another sign that birth is approaching is the rupture
of the amniotic sac membranes (often called “water breaking”) (American College of Obstetricians and
Gynecologists, 2020). The mucus plug, which serves as a barrier between the developing fetus and the vagina
and prevents bacteria and other contaminants from entering the uterus, may also be dislodged. Once the
cervix starts to dilate, the mucus plug may be released, and amniotic fluid begins to leak out.

Though the exact mechanisms underlying the timing of birth are still not completely understood, the process
includes hormone-mediated physiological changes that ready both the pregnant person and the fetus for the
event (Hutchinson et al., 2023). One such hormone is oxytocin (Walter et al., 2021), which plays a role in many
behaviors including initiating labor and forming bonds with others. In fact, when labor is medically induced
(started early), birth mothers are often given a synthetic form of oxytocin, called Pitocin, which helps start the
contractions that allow the fetus to be born. Birth mothers may also have an amniotomy, in which their water is
broken manually to speed labor and reduce the likelihood of surgical intervention (De Vivo et al., 2019).

Labor may be induced for several reasons, including to avoid an overdue pregnancy. After forty weeks, the
fetus and birth mother both face potential complications, including more difficult and longer labor, injury
during the birth process, and low blood sugar in the newborn (Šimják et al., 2022). Labor may also be induced
if medical issues like problems with the placenta, such as placental separation, arise that don’t require an
emergency cesarean delivery.

Regardless of whether labor begins on its own or is induced, the process of giving birth has three stages:
dilation, active labor, and afterbirth delivery.

Stage 1: Dilation

The first stage of labor is marked by two different types of contractions, both of which allow dilation (opening)
and effacement (thinning) of the cervix to occur (Figure 2.19). Early contractions are irregular and infrequent
and occur before the cervix dilates to 6 cm. Active contractions are more frequent and powerful and last
longer. The cervix dilates to approximately 10 cm during labor to allow the fetus to pass through the birth
canal. Hormones including estrogen, progesterone, relaxin, and prostaglandins are released to soften the
cervix so that it can dilate and efface (Walter et al., 2021).

FIGURE 2.19 The stages of childbirth begin with stage 1, cervical dilation. (attribution: Copyright Rice University,

Access for free at openstax.org

 2.4 • Childbirth and Perinatal Health 101

OpenStax, under CC BY 4.0 license)

The amniotic sac usually ruptures during the first stage, often due to the fetus’s head placing extra pressure on
it. If active labor (the second stage) doesn’t start naturally within the next twenty-four hours, the birth mother
may require a cesarean delivery (through a surgical incision in the abdomen) because the fetus no longer has
enough amniotic fluid surrounding it to survive (Obrowski et al., 2016).

Though the duration of each stage of labor varies, the first is typically the longest. On average, it takes several
hours, and it can be as long as twenty hours before the second stage starts (Hutchinson et al., 2023). The first
stage may be shorter for subsequent births.

Stage 2: Active Labor

The second stage of labor, called active labor, doesn’t start until the cervix is fully effaced (100 percent) and
dilated to 10 cm (Figure 2.20). In this stage, the birth mother will be asked to push downward through the peak
of the contractions to help the baby move through the birth canal quickly and assist with delivery. Contractions
may last up to a minute each and occur less than five minutes apart (Raines & Cooper, 2023).

FIGURE 2.20 The cervix dilates from completely closed to 10 cm over the course of labor. (credit "Grape":
modification of work "Solaris grapes in Chateaux Luna vineyard 24" by "W.carter"/Wikimedia Commons, CC0 1.0;
credit "Kumquat": modification of work "Meiwa ripe fruit at Pali o Waipio Huelo, Maui, Hawaii" by Forest and Kim
Starr/Flickr, CC BY 2.0; credit "Plum": modification of work "Bluebyrd plum" by Keith Weller, U.S. Department of
Agriculture/Wikimedia Commons, Public Domain; credit "Apple": modification of work "Nittany fruit at Hawea Pl
Olinda, Maui, Hawaii" by Forest and Kim Starr/Flickr, CC BY 2.0; credit "Pomegranate": modification of work "Punica
granatum (Pomegranate)" by "Bj.schoenmakers"/Wikimedia Commons, CC0 1.0)

Crowning occurs when the top of the baby’s head appears and is about to come out. Occasionally an incision
called an episiotomy will be made to increase the size of the vaginal opening and help the baby’s head and
shoulders emerge, though many medical professionals avoid this practice (Jiang et al., 2017). Both episiotomy
and tearing often require stiches to repair the vaginal opening after birth. If necessary, doctors may use
forceps or vacuum suction to help hasten the delivery of the baby.

Typically, the head of the fetus passes through the vaginal opening first, followed by the shoulders and then the
rest of the newborn (Figure 2.21). A fetus that has not moved to a headfirst position in the uterus by thirty-six
weeks is at risk for a breech birth (Cluver et al., 2015), in which the feet or buttocks appear first. Because this
position increases the chance of complications during the birth process, a cesarean delivery may be needed if
doctors cannot get the baby into proper birth position using drugs or other maneuvers (Cluver et al., 2015).
102 2 • Genetic, Prenatal, and Perinatal Health

FIGURE 2.21 Stage 2 of the labor process includes full dilation and expulsion of the newborn. (attribution:
Copyright Rice University, OpenStax, under CC BY 4.0 license)

Stage 3: Afterbirth Delivery

Once the fetus has been born, the placenta, the fetus's source of nutrients and oxygen, is no longer needed.
During the last stage of labor, therefore, the placenta is expelled (Figure 2.22). This process may last between
five and thirty minutes and requires a few final contractions that separate the placenta from the uterus and
help eject it (Hutchinson et al., 2023). If the placenta is not fully expelled, medical intervention may be
necessary to remove the placenta, because its retention can cause serious complications, including infection
and excessive blood loss.

FIGURE 2.22 Stage 3 of labor involves the expulsion of the placenta. (attribution: Copyright Rice University,
OpenStax, under CC BY 4.0 license; credit right: modification of work “Human placenta uterine side” by
“Ravedave”/Wikimedia Commons, Public Domain)

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 2.4 • Childbirth and Perinatal Health 103

In many Western countries, hospital staff dispose of the placenta after it has been expelled. However, in some
cultures, it has significant cultural value, and it may be buried, consumed, or turned into memorabilia (Moeti
1
et al., 2023).

LINK TO LEARNING
Watch this video about the stages of labor (https://openstax.org/r/104StagesLabor) from the Eunice Kennedy
Shriver National Institute of Child Health and Human Development.

Childbirth Options
The end goal of labor is to successfully deliver a healthy infant. But there are innumerable combinations of
circumstances and ways in which that can happen. Decisions about how to give birth, where to give birth,
whether it can be scheduled, how much medical intervention will be available or is desired, and how best to
deal with the discomfort associated with childbirth have led to a wide variety of options.

INTERSECTIONS AND CONTEXTS

Birthing Positions around the World

Various birthing positions are popular around the world, including standing upright, sitting, kneeling on all fours,
lying on the side, and the most widely known, lying on the back (called the supine position). Giving birth while
squatting, kneeling, or standing is believed to reduce pain and increase the ease of delivery, because these
positions rely on gravity to help the fetus complete the journey through the birth canal (Berta et al., 2019; Peters
et al. 2021; Satone, 2023). Before the seventeenth century, giving birth in an upright position was the most
2
common method in Western countries (Satone, 2023).

Today, the supine position is most frequently used in the United States, and it is also growing more prevalent in
countries where medicine is becoming Westernized and births are taking place primarily in hospitals. However,
3
this position may extend the pain associated with giving birth and increase complications (Satone, 2023). Most
recently, midwives and other professionals in the United States and other countries have started educating
pregnant people and medical staff about the advantages of alternate childbirth positions.

Alternatives to the supine position tend to be more common in countries like Uganda, Ethiopia, Kenya, Tanzania,
Nepal, and Peru, where more births occur in the home (Beinempaka et al., 2015; Peters et al., 2021; Regassa et
al., 2022). In Nepal, mothers often give birth on their hands and knees (Peters et al., 2021). Though it’s difficult
to stand or squat during a prolonged labor, a labor chair can offer support when in the squatting position.

In parts of Tanzania, the traditional birthing position was upright, though most birth mothers (80 percent) now
4
give birth in the supine position due to the influence of Western medicine (Mselle & Eustace, 2020). This is also
true in parts of Peru. However, the Peruvian government has begun funding birthing centers where traditional
upright positions are used, to decrease the nation’s high maternal mortality rates (Palomino, 2008).

Lack of information about the variability of birthing positions may also be a factor. A study from Nigeria, where
more than 90 percent of birth mothers at birthing centers give birth in the supine position, found that 69 percent
believed this was the only birthing position (Okonta, 2012). Unawareness of the options may inhibit birth
mothers from making informed choices about their labor experience (Okonta, 2012). The WHO updated its
birthing practice recommendations in 2018 to ensure that birthing mothers know their options and understand
research data showing that upright birthing positions may ease delivery and reduce the risk of postdelivery
hemorrhage (WHO, 2018).

1 This study (Moeti et al., 2023) uses the terms “Western” and “indigenous.”
2 This study (Satone, 2023) uses the term “Western.”
3 This study (Satone, 2023) uses the term “Western.”
4 This study (Mselle & Eustace, 2020) uses the term “Western.”
104 2 • Genetic, Prenatal, and Perinatal Health

Vaginal versus Cesarean Delivery

Vaginal deliveries are generally considered to be the safest for the birth mother and for infants born near or at
full term (Desai & Tsukerman, 2023; Gregory et al., 2011). In this process, the fetus passes through the birth
canal and pelvis during delivery. This type of delivery can occur in multiple settings, including in a hospital, a
birthing center, or at home, and depending on the location, in water. Vaginal delivery, when possible, typically
allows faster recovery for the mother and improved immune functioning for the newborn (Desai &
Tsukermann, 2023).

In some circumstances, however, a vaginal delivery isn’t the best or safest option. For example, if a sexually
transmitted infection may be passed to the newborn through the birth canal, the fetus is too large or is in a
breech position, the umbilical cord is tangled around the fetus, or the mother has placenta previa (which
causes excessive bleeding during birth) or certain other medical conditions, a vaginal birth may not be
advisable. In a cesarean birth, or C-section, an incision is made in both the abdomen and the uterus, and the
newborn and placenta are delivered through the resulting opening. Complications for the birth mother such as
bleeding, blood clots, and infections can arise due to the invasive nature of the procedure. Cesareans also
require longer hospital stays and longer recovery times. Having a cesarean also increases the chances of
needing one again for subsequent pregnancies, but many birth mothers are able to give birth vaginally after a
cesarean delivery, commonly referred to as “vaginal birth after cesarian section” (VBAC).

Pain Management Techniques

Regardless of how birth happens, many options are available for dealing with the pain of labor. In the 1960s,
the epidural, an injection of anesthetics into a space in the mother’s spinal cord to block the sensation of pain,
became common. However, nitrous oxide, widely used in the early 1900s, has been making a comeback (Nanji
& Carvalho, 2020). Depending on the drugs used and their concentrations, however, pain medication may
weaken uterine contractions and prolong labor (Halliday et al., 2022).

In contrast, natural childbirth uses nonpharmaceutical techniques to help minimize both pain for the birth
mother and the need for medical intervention (Table 2.6). While only some of these techniques are evidence-
based practices for pain management, they all can support pain management in combination with stretching
and specific childbirth positions.

Childbirth Description
Technique

Classes teach individuals what to expect and introduce specific breathing techniques and
Lamaze
behaviors to support the birth mother during the birthing process.

Classes promote nutrition and exercise to help reduce pain and complications during delivery. The
Bradley
method also teaches breathing and relaxation techniques and includes partners as labor coaches.

Birth or part of labor occurs in clean warm water, which may soothe both birth mother and
Water birth newborn and relieve pain. Being delivered into a warm, wet environment may also be less of a
shock for the newborn, who is leaving the warm, wet environment of the uterus.

Needles are inserted into specific areas of the body to reduce pain and relieve stress. This method
Acupuncture can be used during early labor to help decrease discomfort and may reduce pain during labor as
well as the need for medications.

TABLE 2.6 Natural Childbirth Options (sources: Gallo et al., 2018; Hao & Mittelman, 2014; Madden et al., 2016;
Santana et al., 2022; Sharifipour et al., 2022; Smith et al., 2020; Vanderlaan et al., 2018; Varner, 2015, Wax et al.,
2010)

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 2.4 • Childbirth and Perinatal Health 105

Childbirth Description
Technique

Massage techniques, warm showers, and the use of delivery balls have all been shown to reduce
Massage
pain.

A practitioner lulls the birth mother into a state where they are more open to suggestions and then
Hypnosis suggests relaxation and pain management strategies for pain management. Hypnosis has yet to be
shown to definitively improve the childbirth experience.

TABLE 2.6 Natural Childbirth Options (sources: Gallo et al., 2018; Hao & Mittelman, 2014; Madden et al., 2016;
Santana et al., 2022; Sharifipour et al., 2022; Smith et al., 2020; Vanderlaan et al., 2018; Varner, 2015, Wax et al.,
2010)

LINK TO LEARNING
Use this helpful online birth plan tool (https://openstax.org/r/104BirthPlan) created by the American College of
Obstetricians and Gynecologists to learn more about all the decisions a person might make in a birth plan.

Professional Assistance

Many people choose to give birth under the care of an obstetrician/gynecologist (OB/GYN). In addition, several
types of midwives can support the birthing process. Their duties vary from culture to culture, but generally,
midwives provide help and care over the prenatal period as well as assist parents during the birth of their
child. Some spend substantial time with birth mothers both before and after delivery and may even help with
housework and visitors, depending on cultural norms. Most midwives in the United States have some level of
medical or nursing training and credentials (Table 2.7).

Midwife Type Description

Certified Nurse- A registered nurse who has received extra training (a graduate degree) and
Midwife (CNM) credentialing to become a midwife

Certified Midwife/
A midwife who has earned graduate degrees that include some medical training,
Direct-entry midwife
allowing them to provide pre- and postnatal care, along with birthing a child
(CM)

Certified Professional A midwife who has mastered an apprenticeship or educational program granting
Midwife (CPM) credentials ranging from a certificate to a graduate degree

TABLE 2.7 Types of Midwives in the United States (source: Backes & Scrimshaw, 2020)

Other credentialed individuals who may assist a pregnancy are known as doulas. In the United States, doulas
may take certification courses to become licensed, but they do not receive the same type of training as a
midwife (Backes & Scrimshaw, 2020). Most of their training focuses on ways to support and assist birth
mothers during pregnancy and after giving birth. Doulas may also support breastfeeding success and provide
emotional support, by being a source of support through home visits and advocacy for pregnant women
(Sobczak et al., 2023). They can also be helpful in bridging cultural and language barriers for those giving birth
outside their country of birth (Kathawa et al., 2021).
106 2 • Genetic, Prenatal, and Perinatal Health

Birth Locations

Many factors come in to play in the decision of where to give birth, including health insurance coverage,
economic resources, the availability of nearby options, and existing health conditions or other considerations
that may require special care. The question for the birth mother or future parents is, what is most important to
them about the birth process.

About 98 percent of births in the United States occur in a hospital (Backes & Scrimshaw, 2020). In some parts
of Europe and elsewhere around the world, birth more frequently occurs in a birthing center (Peters et al.,
2021). One of the advantages of delivering in a hospital or birthing center is the ability to have vital signs like
the heart rate and blood pressure continuously monitored. Changes in these can indicate distress or potential
complications during the labor process, and medical interventions can be started quickly to ensure a safe
delivery. More powerful medications are also available to assist with any discomfort during labor. Another
benefit of institutional delivery is the series of automatic health screenings performed on newborns in
hospitals and other medical settings.

Last, if something goes wrong during the birth, hospitals and birthing centers are typically well-equipped to
provide immediate medical interventions, and many have specialized neonatal units that undertake the care
of infants born prematurely or with complications. However, the quality of care available during labor is not
uniform across the globe. In some countries, such as Finland, medical centers are equipped to handle many
common complications while also providing extensive support for new mothers (Wrede et al., 2021). In
contrast, though health care is free in birthing centers in Malawi, these centers are often short-staffed or not
available in rural areas (Wrede et al., 2021). Though most deliveries are free of complications, issues that
necessitate medical intervention include fetal distress, a tangled umbilical cord or problem in the uterus, and
excessive maternal bleeding (Table 2.8).

Location Overview

Hospitals provide a medical and clinical focus, monitoring of baby and mother’s vital signs, and
Hospital medical intervention ready for high-risk births or complications. Hospital birth is common in the United
States.

Centers provide overall “wellness of mother” focus; monitoring of baby and mother’s vital signs; and
Birthing
sometimes birthing rooms with tubs for water-based births, beds, and other means to make families
center
comfortable during the process. Birthing centers are becoming more frequent in India and Indonesia.

Home offers a familiar environment that might include a room set up for birthing where a midwife or
Home
doula may assist. Giving birth at home is common in the Netherlands.

TABLE 2.8 Birthing Locations (sources: Galková et al., 2022; Pomeroy et al., 2014)

LINK TO LEARNING
Watch this TED talk about a Simple Birth Kit for Mothers in the Developing World (https://openstax.org/r/
104BirthKit) that could decrease maternal mortality.

For some with low-risk pregnancies, giving birth at home is an option. This method allows the birth to occur in
a familiar place, and choices regarding the circumstances surrounding the event, such as whether music is
playing, to be made in ways that can’t always be achieved at a hospital or birthing center. Home births are also
associated with a reduction in unnecessary medical interventions (Committee on Obstetric Practice, 2017), but
only about 1 percent of U.S. births occur at home (Backes & Scrimshaw, 2020). Ensuring the safety of both
mother and newborn requires substantial advance planning. Birthing at home typically relies on the help of

Access for free at openstax.org

 2.4 • Childbirth and Perinatal Health 107

midwives or doulas (or both), but a doctor or medical practitioner should be available if there are
complications. Transportation to a medical facility should also be standing by.

Globally, nearly half of all births occur at home. Income seems to be an influential factor, however (Figure
2.23). In most countries, even those whose populations have the lowest socioeconomic status, women with
higher incomes gave birth in a hospital or birthing center (Montagu et al., 2011). In many parts of Africa, and
parts of Asia such as Nepal, birth often occurs at home and the mother may be assisted by a midwife, though
midwives’ training may be more culturally based rather than medically based as it is in the United States and
Europe (Peters et al., 2021).

FIGURE 2.23 Birth locations around the world vary between public facilities like hospitals and birthing centers,
homes, and private hospitals or birthing centers. (credit: modification of work “Figure 1. Place of birth by region” by
Montagu et al./PLOS One, CC BY)

Perinatal Health and Screening

Perinatal health refers to the health of both the pregnant person and fetus from the twenty-fourth week of
gestation to about two to four weeks after birth of the infant. Pregnant individuals at risk of complications or of
advanced maternal age may be offered more frequent ultrasounds after the twenty-eighth week of gestation.
This noninvasive test helps the OB/GYN or others to assess the size of the fetus, whether it is in breech position
or has turned, and whether it is growing at a typical pace. The fetal heart rate will also be measured to ensure
the vital signs are healthy.

Other important aspects of perinatal health and screening involve newborn tests and care for low-birth-weight
108 2 • Genetic, Prenatal, and Perinatal Health

babies. After giving birth, people remain important and valuable outside of any role related to the pregnancy
and the infant. It is essential to care for their emotional and physical wellbeing in the weeks and months
following the arrival of the child.

Caring for People After Giving Birth

Much of the focus after birth is on the newborn and its care. However, birth mothers are still recovering and
need postpartum care as well. In the United States, they will often have a follow-up appointment to assess their
physical recovery, but they also need help coping with the stress of caring for a newborn while healing. In
Ghana, birth mothers often did not realize that they, too, needed care during the postpartum period (Yenupini
et al., 2023). The lack of such care is thought to contribute to high mortality rates for birth mothers (Yenupini
et al., 2023).

According to the American College of Obstetricians and Gynecologists (2018), postpartum care should be
viewed not as a single-visit issue but as a long-term process with consequences for the future health of both
birth mother and infant. The focus should also be on social and emotional health, not just physical health, and
should assess the mother’s emotional well-being, sleep, and any issues related to feeding and caring for the
newborn (American College of Obstetricians and Gynecologists, 2018). Postpartum care is beneficial in
reducing a variety of emotional and physical health risks in both birth mothers and adoptive parents (Lopez-
Gonzalez & Kopparapu, 2022; Mott et al., 2011).

Newborn Tests

In many Western countries, newborns delivered in a medical facility will be screened for various diseases and
conditions, including genetic and metabolic disorders, usually within the first two days of life. For example,
blood tests and hearing tests are often common screenings, as well as screening for congenital heart issues.
The first test administered to a newborn is the Apgar test.

The Apgar test is typically given one minute after birth and then again at five minutes after birth. This test
assesses how stable an infant is after going through the birth process by measuring five aspects of newborn
functioning: reflex irritability (activity), heart rate (pulse), muscle tone (grimace), body color (appearance), and
respiratory effort (Figure 2.24). A total score over seven is considered good, and most newborns score between
seven and nine, with very few achieving ten.

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