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Week 38
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How Big Is Your Baby?

At this time, your baby weighs about 6.8 pounds (3100g). Crown-to-rump length hasn't changed much; it's still about 14 inches (35cm). Total length is 21 inches (47cm).

How Big Are You?

Many women don't grow larger during the last several weeks of pregnancy, but they feel very uncomfortable. The distance between your uterus and the pubic symphysis is 14.4 to 15.2 inches (36 to 38cm). From your bellybutton to the top of your uterus is about 6.4 to 7.2 inches (16 to 18cm).

How Your Baby Is Growing and Developing

Fetal Monitoring during Labor

You may wonder how your doctor can tell your baby is all right, especially during labor. In many hospitals, the baby's heart rate is monitored throughout labor. Being able to detect problems early is important so they can be resolved.

Every time the uterus contracts during labor, less oxygenated blood flows from you to the placenta. Most babies are able to handle this stress without any problem. However, some are affected, and this is called fetal distress.

There are two ways to monitor the baby's heartbeat during labor. External fetal monitoring can be used before your membranes rupture. A belt with a receiver is strapped to your abdomen. It uses a principle similar to ultrasound to detect the baby's heartbeat.

An internal fetal monitor is able to monitor the baby's heartbeat more precisely. This type of monitoring can be very helpful in determining the well-being of your baby. An electrode is placed on the baby's scalp and is connected by wires to a machine that records the fetal heart rate. Only women whose membranes are broken and who are dilated at least 1cm can be attached to an internal fetal monitor.

Evaluating the Results of Fetal Monitoring

In evaluating a fetal heart rate, a doctor looks at a large portion of the fetal monitoring strip, not just a small section. He or she also looks for other information. For example, if you are having contractions, it's important to know how your baby is affected. Fetal monitoring can help determine this.

A contraction stress test (CST) gives an indication of how well the baby will tolerate contractions and labor. If the baby doesn't respond well to contractions, it can be a sign of fetal distress. Some believe this test is more accurate than the nonstress test (discussed in Week 35) in evaluating the baby's well-being. A monitor is placed on your abdomen to monitor the baby. An I.V. is started, and the hormone oxytocin is given in small amounts to make your uterus contract. This test gives an indication of how well the baby will tolerate contractions and labor. If the baby doesn't respond well to the contractions, it can be a sign of fetal distress.

If you've had problem pregnancies before, such as a stillbirth, or medical problems during pregnancy, such as diabetes, your doctor may have you tested as you go through pregnancy. You may be tested weekly or biweekly to determine if the baby is doing well inside your uterus.

Fetal Blood Sampling

Doctors can also test your baby's blood pH to see how well your baby is tolerating the stress of labor. Before this test can be done, your membranes must be ruptured, and you must be dilated at least 2cm.

An instrument is applied to the scalp of the baby to make a small nick in the skin. The baby's blood is collected in a small tube or pipette, and its pH (acidity) is checked. If the baby is having trouble with labor and is under stress, the pH level can help

determine this. This test may be useful in making a decision as to whether labor can continue or if a C-section needs to be done.

Changes in You

Depression during Pregnancy

Antidepressant medication is not generally given during pregnancy because it is not considered safe. If medication is necessary, most physicians prefer to use those that have been in use

for a while, such as tricyclic antidepressants (amitriptyline, desipramine, Sinequan«, Amoxopine«). Recent studies indicate Prozac« is safe to use during pregnancy.

Most evidence indicates there is no rate of increased malformations if these medications must be used during pregnancy. There is little information about the use or safety in pregnancy of some of the newer medications for depression. Without some evidence they are safe, physicians hesitate to prescribe them.

All antidepressant medications pass through the placenta to the baby. There have been isolated case reports of damage to

the embryo from these substances (see Week 9). If these medications must be used during pregnancy, it's best to use the lowest dosage possible.

Treating depression during pregnancy can be a difficult problem and must be done on an individualized basis. Your doctor and possibly a psychologist or psychiatrist may be involved in your treatment. Discuss medications you take for depression with your doctor. An infant born to a mother who takes antidepressants during pregnancy may have withdrawal symptoms.

Postpartum Distress

After your baby is born, you may feel very emotional. You may even wonder if having a baby was a good idea. This is called postpartum distress. Many women experience some degree of postpartum distress; in fact, up to 80% of all women have ôbaby blues.ö It usually appears between 2 days and 2 weeks after the baby is born. It is a temporary situation and usually leaves as quickly as it comes.

Many experts consider some degree of postpartum distress to be normal. Symptoms include:

ò anxiety

ò crying for no reason

ò exhaustion

ò impatience

ò irritability

ò lack of confidence

ò lack of feeling for the baby

ò low self-esteem

ò oversensitivity

ò restlessness

If you believe you may be suffering from some form of postpartum distress, contact your healthcare provider. Every postpartum reaction, whether mild or severe, is usually temporary and treatable.

The mildest form of postpartum distress is baby blues. This situation lasts only a couple of weeks, and symptoms do not worsen.

A more serious version of postpartum distress is called postpartum depression (PPD). It affects about 10% of all new mothers. The difference between baby blues and postpartum depression lies in the frequency, intensity and duration of the symptoms.

PPD can occur from 2 weeks to 1 year after the birth. A mother may have feelings of anger, confusion, panic and hopelessness. She may experience changes in her eating and sleeping patterns. She may fear she will hurt her baby or feel as if she is going crazy. Anxiety is one of the major symptoms of PPD.

The most serious form of postpartum distress is postpartum psychosis. The woman may have hallucinations, think about suicide or try to harm the baby.

We don't really know what causes postpartum distress; not all women experience it. We believe a woman's individual sensitivity to hormonal changes may be the cause, but hormones are only part of it.

One of the most important ways you can help yourself is to have a good support system. Ask family members and friends to help. Have your mother or mother-in-law stay for a while. Ask your husband to take some work leave, or hire someone to come in and help each day.

There is no particular treatment for baby blues, but there are ways you can help relieve the symptoms. Ask for help. Rest when the baby sleeps. Find other mothers who are in the same situation; it helps to share your feelings and experiences. Don't try to be perfect. Pamper yourself. Do some form of moderate exercise every day. Eat nutritiously, and drink plenty of fluids. Go out every day.

With postpartum depression, follow the suggestions above. In addition, you may need medication. About 85% of all women who suffer from postpartum depression require medication for up to 1 year.

How Your Actions Affect Your Baby's Development

Breech Presentation

As I've mentioned already, it's common for your baby to be in the breech presentation early in pregnancy. However, when labor starts, only 3% to 5% of all babies, not including multiple pregnancies, present as a breech. Do your actions determine how your baby presents?

Certain factors make a breech presentation more likely. One of the main causes is the baby's prematurity. Near the end of the second trimester, a baby may be in a breech presentation. By taking care of yourself, you can more easily avoid going into premature labor. That gives your baby the best opportunity to change its position naturally.

Other factors that may result in a breech presentation include relaxation of the uterus because of previous pregnancies and multiple fetuses. Conditions such as polyhydramnios, hydrocephalus and uterine abnormalities or tumors may also increase the chance of a breech presentation.

There are different kinds of breech presentations. A frank breech occurs when the lower legs are flexed at the hips and extended at the knees. This is the most common type of breech found at term or the end of pregnancy; feet are up by the face or head.

With a complete breech presentation, one or both knees are flexed, not extended. See the illustration on page 323.

Delivering a Breech Baby

There is some controversy in obstetrics over the best method of delivering a breech baby. For many years, breech deliveries were performed vaginally. Then it was believed the safest method was to deliver the breech by C-section, especially if it was a first baby.

Many doctors believe a Cesarean section is still the safest method of delivering a breech baby. However, some doctors believe a woman can deliver a breech without difficulty if the situation is right. This usually includes a frank breech in a mature fetus of a woman who has had previous normal deliveries. Most agree a footling breech presentation (one leg extended, one knee flexed) should be delivered by Cesarean section.

Most doctors believe a baby in the breech position can probably be delivered more safely by a Cesarean section performed during early labor or before labor begins. Ask your doctor what he or she normally does in this situation.

Attempts may be made to turn the baby from a breech to a head-down (vertex) presentation. It is more difficult to do this after your water breaks or when you are in labor.

If your baby is breech, it's important to discuss it with your doctor. When you get to the hospital, tell the nurses and hospital personnel you have a breech presentation. If you call with a question about labor and you have a breech presentation, mention this information to the person you talk with.

Other Types of Presentations

Another unusual presentation is a face presentation. The baby's head is hyperextended so the face comes into the birth canal first. This type of presentation is most often delivered by C-section if it does not convert to a regular presentation during labor.

In a shoulder presentation, the shoulder presents first. In a transverse lie, the baby is lying almost as if in a cradle in the pelvis. The baby's head is on one side of your abdomen, and its bottom is on the other side. There is only one way to deliver this type of presentation, and that is by Cesarean section.

You Should also Know

What Is a Retained Placenta?

In most cases, the placenta separates on its own from the implantation site on the uterus in the first few minutes after delivery. It is delivered after the baby. In some cases, a piece of placenta remains inside the uterus. When this happens, the uterus cannot contract adequately, resulting in vaginal bleeding, which can be heavy.

In other cases, the placenta does not separate because it's still attached to the wall of the uterus. This can be a very serious situation. However, this complication is rare.

Bleeding is usually severe after delivery, and surgery may be necessary to stop it. An attempt may be made to remove the placenta by D&C.

Reasons for an abnormally adherent placenta are many. It is believed a placenta may attach over a previous Cesarean-section scar or other previous incisions on the uterus. The placenta may attach over an area that has been scraped, such as with a D&C, or over an area of the uterus that was infected at one time.

Your doctor will pay attention to the delivery of your placenta while you are paying attention to your baby. Some people ask to see the placenta after delivery; you may wish to have your doctor show it to you.

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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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