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Week 33
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How Big Is Your Baby?

Your baby weighs about 4.4 pounds (2000g) by this week. Its crown-to-rump length is about 12 inches (30cm) and total length is 19.4 inches (43cm).

How Big Are You?

Measuring from the pubic symphysis, it is now about 13.2 inches (33cm) to the top of the uterus. Measurement from your bellybutton to the top of your uterus is about 5.2 inches (13cm). Your weight gain should be between 22 and 28 pounds (9.9 and 12.6kg).

How Your Baby Is Growing and Developing

Placental Abruption

The illustration on page 275 shows placental abruption, which is separation of the placenta from the wall of the uterus. Normally, the placenta does not separate from the uterus until after the baby is delivered. Separation before delivery can be very serious.

The frequency of placental abruption is estimated to be about 1 in every 80 deliveries. We do not have a more-exact statistic because time of separation varies, altering risk to the fetus. If the placenta separates at the time of delivery and the infant is delivered without incident, it is not as significant as a placenta separating during pregnancy.

The cause of placental abruption is unknown. Certain conditions may increase its chance of occurring. Factors include:

ò physical injury to the mother, as from a car accident

ò a short umbilical cord

ò very sudden change in the size of the uterus (from delivery or rupture of membranes)

ò hypertension

ò dietary deficiency

ò a uterine abnormality, such as a band of tissue in the uterus where the placenta cannot attach properly

Separation of the placenta may involve partial or total separation from the uterine wall. The situation is most severe when the placenta totally separates from the uterine wall. The fetus relies entirely on circulation from the placenta. With separation, it cannot receive blood from the umbilical cord, which is attached to the placenta.

Studies indicate that folic-acid deficiency can play a role in causing placental abruption. Others suggest maternal smoking and alcohol consumption may make a woman more likely to have placental abruption.

A woman who has had placental abruption in the past is at increased risk of having it recur. Rate of recurrence has been

estimated to be as high as 10%. This can make a pregnancy following placental abruption a high-risk pregnancy.

Symptoms of Placental Abruption

Symptoms of placental abruption can vary a great deal. There may be heavy bleeding from the vagina, or you may experience no bleeding at all. The illustration above shows bleeding behind the placenta with complete separation. There is no

apparent bleeding from the cervix and vagina. Other symptoms can include lower-back pain, tenderness of the uterus or abdomen, and contractions or tightening of the uterus.

Ultrasound may be helpful in diagnosing this problem, although it does not always provide an exact diagnosis. This is particularly true if the placenta is located on the back surface of the uterus where it cannot be seen easily with ultrasound examination.

Serious problems, such as shock, may occur with separation of the placenta. Shock occurs because of the rapid loss of large quantities of blood. Intravascular coagulation, in which a large blood clot develops, can also be a problem. Factors that clot the blood may be used up, which can make bleeding a problem.

Of the various symptoms associated with placental abruption, vaginal bleeding occurs in about 75% of all cases. Tenderness of the uterus occurs about 60% of the time, as does fetal distress or problems with the fetal heart rate. Tightening or contraction of the uterus occurs about 34% of the time. Premature labor occurs in about 20% of the cases. Fetal death, while uncommon, occurs about 15% of the time.

Can Placental Abruption Be Treated?

Treatment of placental abruption varies, based on the ability to diagnose the problem and the status of the mother and baby. With very heavy bleeding, delivery of the baby may be necessary.

When bleeding is not heavy, the problem may be treated with a more conservative approach. This depends on whether the fetus is in distress and if it appears to be in immediate danger.

Placental abruption is one of the most serious problems related to the second and third trimesters of pregnancy. If you have any symptoms, call your doctor immediately!

Changes in You

How Will You Know Your Membranes Have Ruptured?

Caroline was unsure of how she would know when her water broke, so she asked me what she needed to look for. I told her, ôWhen your bag of waters breaks, it isn't usually just one gush of water, with no further leakage. There is often a gush of amniotic fluid, usually followed by a leaking of small amounts of fluid. Women describe it as a constant wetness or water running down their leg when they stand. Continual leakage of water is a good clue your water has broken.ö

Amniotic fluid is usually clear and watery. Occasionally it may have a bloody appearance, or it may be yellow or green.

It isn't uncommon to have an increase in vaginal discharge or to lose urine in small amounts as your baby puts pressure on your bladder. But there are ways for your doctor to tell if your water has broken. Two tests can be done on the amniotic fluid.

One is a nitrazine test. When amniotic fluid is placed on a small strip of paper, it changes the color of the paper. This test is based on the acidity or pH of the amniotic fluid. However, blood can also change the color of nitrazine paper, even if your water hasn't broken.

Another test that may be done is a ferning test. Amniotic fluid or fluid from the back of the vagina is taken with a swab and placed on a slide for examination under a microscope. Dried amniotic fluid has the appearance of a fern or branches of a pine tree. Ferning is often more helpful in diagnosing ruptured membranes than looking at color changes on nitrazine paper.

What Do You Do When Your Water Breaks?

Your membranes may rupture at any point in pregnancy. Don't assume it will only happen around the time of labor.

If you think your water has broken, notify your doctor. Avoid sexual intercourse at this time. Intercourse increases the possibility of introducing an infection into your uterus and thus to your baby.

How Your Actions Affect Your Baby's Development

Weight Gain

You are continuing to gain weight as your pregnancy progresses. You may be gaining weight faster than at any other time during pregnancy. This is because your baby is going through a period of increased growth. It may be gaining as much as 8 ounces (224g) or more every week!

Continue to eat the right foods for you. Heartburn may be more of a problem now because your growing baby may not allow your stomach much room. You may find eating several small meals, rather than three large meals, makes you feel more comfortable. Follow the guidelines in Week 7, and listen to your doctor's advice.

You Should also Know

Will Your Doctor Perform an Episiotomy?

You may be wondering whether you will need an episiotomy. An episiotomy is an incision made from the vagina toward the rectum during delivery to avoid undue tearing as the baby's head passes through the birth canal. It may be a cut directly in the midline toward the rectum, or it may be a cut to the side.

There is little you can do if you need an episiotomy. Some people practice, teach and believe in stretching the birth canal during labor and at the time of delivery to try to avoid an episiotomy. It may work for some, but it doesn't work for every woman. Others suggest an episiotomy to avoid stretching the vagina, bladder and rectum. Stretching the vagina can change sensations experienced during sexual intercourse.

The reason for an episiotomy usually becomes clear at delivery when the baby's head is in the vagina. The episiotomy substitutes a controlled, straight, clean cut for a tear or rip that could go in many directions. This may include tearing or ripping into the bladder, into large blood vessels or into the rectum. An episiotomy heals better than a ragged tear.

Ask your doctor if he or she thinks you may need an episiotomy. Discuss why an episiotomy is necessary. Find out whether it might be a cut in the middle or to the side of the vagina. You might also ask if there is anything you can do to prepare for the possibility of an episiotomy, such as an enema or stretching the vagina.

If a vacuum extractor or forceps are used for delivery, an episiotomy may be done before the device is placed on the baby's head.

Description of an episiotomy also includes a description of the depth of the incision:

ò a first-degree episiotomy cuts only the skin

ò a second-degree episiotomy cuts the skin and

underlying tissue

ò a third-degree episiotomy cuts the skin, underlying tissue

and rectal sphincter, which is the muscle that goes around the anus

ò a fourth-degree episiotomy goes through the three layers and through the rectal mucosa

After the baby is delivered, layers are closed separately with absorbable sutures that do not require removal after they heal.

After your baby is born, the most painful part of the entire birth experience might be the episiotomy. It may continue to cause some discomfort as it heals. Don't be afraid to ask for medication to ease any pain. You can take many safe medications, even if you are breastfeeding your baby, including acetaminophen (Tylenol). Tylenol with Codeine« or other medications may also be prescribed for pain.

Delivery of the Placenta

In most instances, the placenta is delivered within 30 minutes after the birth of your baby and is a routine part of the delivery. However, complications can arise if the placenta adheres to the lining of the uterus. With a retained placenta, the placenta does not deliver spontaneously. (See Week 38 for further information.) Women who have had a previous retained placenta, Cesarean delivery or a D&C for miscarriage or heavy bleeding are more likely to have a retained placenta.

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From Your Pregnancy Week by Week by Glade B. Curtis, M.D., OB/GYN. Copyright by Fisher Books. Electronic rights by Medical Data Exchange.

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