Saturday 11 June 2011

Kendo

Kendo, 剣道 kendō?, meaning "Way of The Sword", is a modern Japanese martial art of sword-fighting based on traditional samurai swordsmanship, or kenjutsu. Kendo is a physically and mentally challenging activity that combines strong martial arts values with sport-like physical elements.

History
Since the earliest samurai government in Japan, during the Kamakura period (1185-1333), sword fencing, together with horse riding and archery, were the main martial pursuits of the military clans. In this period kendo developed under the strong influence of Zen Buddhism. The samurai could equate the disregard for his own life in the heat of battle, which was considered necessary for victory in individual combat, to the Buddhist concept of the illusory nature of the distinction between life and death.
Those swordsmen established schools of kenjutsu (the ancestor of kendo) which continued for centuries and which form the basis of kendo practice today.  The names of the schools reflect the essence of the originator's enlightenment. Thus the Ittō-ryū (Single sword school) indicates the founder's illumination that all possible cuts with the sword emanate from and are contained in one original essential cut. The Mutō-ryu (swordless school) expresses the comprehension of the originator Yamaoka Tesshu, that "There is no sword outside the mind". The Munen Musō-ryū (No intent, no preconception) similarly expresses the understanding that the essence of kenjutsu transcends the reflective thought process. The formal kendo exercises known as kata were developed several centuries ago as kenjutsu practice for warriors and are still studied today, albeit in a modified form.
The introduction of bamboo practice swords (shinai) and armour (bōgu) to sword training is attributed to Naganuma Sirōzaemon Kunisato during the Shotoku Era (1711-1715). Naganuma developed the use of bōgu and established a training method using the shinai.
In addition, the inscription on the gravestone of Yamada Heizaemon Mitsunori's (Ippūsai) (山田平左衛門光徳(一風斎)?, 1638 – 1718) third son Naganuma Sirōzaemon Kunisato (長沼 四郎左衛門 国郷?, 1688 - 1767), the 8th headmaster of the Kashima Shinden Jikishinkage-ryū Kenjutsu, states that his exploits included improving the bokuto and shinai, and refining the armour by adding a metal grill to the men (head piece) and thick cotton protective coverings to the kote (gauntlets). Kunisato inherited the tradition from his father Heizaemon in 1708, and the two of them worked hard together to improve the bogu until Heizaemon's death.
This is believed to be the foundation of modern kendo. Kendo began to make its modern appearance during the late 18th century. Use of the shinai and bōgu made it possible to deliver strikes and thrusts with full force but without injuring one's opponent. These advances, along with the development of set practice formats, set the foundations of modern kendo.
Concepts such as mushin (無心?), or "empty mind", are borrowed from Zen Buddhism and are considered essential for the attainment of high-level kendo. Fudōshin (不動心?), or "unmoving mind", is a conceptual attribute of the deity Fudo Myo-O, one of the five "Kings of Light" of Shingon Buddhism. Fudōshin, implies that the kendōka cannot be led astray by delusions of anger, doubt, fear, or surprise arising from the opponent’s actions, collectively called "the four kendo sicknesses" (四戒 shikai?, lit. four admonitions). Thus today it is possible to embark on a similar quest for spiritual enlightenment as followed by the samurai of old.
The Dai Nippon Butoku Kai was established in 1895 to solidify, promote, and standardise all martial disciplines and systems in Japan. The DNBK changed the name of gekiken (Kyūjitai: 擊劍; Shinjitai: 撃剣, "hitting sword") to kendō in 1920. Kendo (along with other martial arts) was banned in Japan in 1946 by the occupying powers. This was part of "the removal and exclusion from public life of militaristic and ultra nationalistic persons" in response to the wartime militarization of martial arts instruction in Japan. Kendo was allowed to return to the curriculum in 1950 (first as "shinai competition" (竹刀競技 shinai kyōgi?) and then as kendo from 1952).
The All Japan Kendo Federation (AJKF or ZNKR) was founded in 1952, immediately following the restoration of Japanese independence and the subsequent lift of the ban on martial arts in Japan.
The International Kendo Federation (FIK) was founded in 1970, it is an international federation of national and regional kendo associations and the world governing body for kendo. The FIK is a non-governmental organization, and its aim is to promote and popularize kendo, iaido and jodo.
The World Kendo Championships are an FIK event and have been held every three years since 1970.

Practitioners
Practitioners of kendo are called kendōka (剣道家?), meaning "someone who practices kendo", or occasionally kenshi (剣士?), meaning "swordsman". and the old term of kendoists sometimes is used,
The "Kodansha Meibo" (a register of dan graded members of the All Japan Kendo Federation) shows that as of September 2007, there were 1.48 million registered dan graded kendōka in Japan. According to the survey conducted by the All Japan Kendo Federation, the number of active kendo practitioners in Japan is 477 thousand in which 290 thousand dan holders are included. From these figures, the All Japan Kendo Federation estimates that the number of "kendōka" in Japan is 1.66 million by adding the number of the registered dan holders and the active kendo practitioners without dan grade.

Concept and purpose
In 1975 the All Japan Kendo Federation (AJKF) developed then published "The Concept and Purpose of Kendo" which is reproduced below.

Concept
Kendo is a way to discipline the human character through the application of the principles of the katana.
Purpose
To mold the mind and body.
To cultivate a vigorous spirit,
And through correct and rigid training,
To strive for improvement in the art of Kendo.
To hold in esteem human courtesy and honor.
To associate with others with sincerity.
And to forever pursue the cultivation of oneself.
Thus will one be able:
To love ones country and society;
To contribute to the development of culture;
And to promote peace and prosperity among all peoples.

Modern practice
Kendo training is quite noisy in comparison to other martial arts or sports. This is because kendōka use a shout, or kiai (気合い?), to express their fighting spirit when striking. Additionally, kendōka execute fumikomi-ashi (踏み込み足?), an action similar to a stamp of the front foot, when making a strike.
Like some other martial arts, kendōka train and fight barefoot. Kendo is ideally practiced in a purpose-built dōjō, though standard sports halls and other venues are often used. An appropriate venue has a clean and well-sprung wooden floor, suitable for fumikomi-ashi.
Modern kendo techniques comprise both strikes and thrusts. Strikes are only made towards specified target areas (打突-部位 datotsu-bui?) on the wrists, head, or body, all of which are protected by armour. The targets are men, sayu-men or yoko-men (upper left or right side of the men), the right kote at any time, the left kote when it is in a raised position, and the left or right side of the dō. Thrusts (突き tsuki?) are only allowed to the throat. However, since an incorrectly performed thrust could cause serious injury to the opponent's neck, thrusting techniques in free practice and competition are often restricted to senior dan graded kendōka.

Once a kendōka begins practice in armour, a practice session may include any or all of the following types of practice.
Kiri-kaeshi (切り返し?)
Striking the left and right men target points in succession, practising centering, distance, and correct technique, while building spirit and stamina.
Waza-geiko (技稽古?)
Waza or technique practice in which the student learns and refines that techniques of Kendo with a receiving partner.
Kakari-geiko (掛稽古?)
Short, intense, attack practice which teaches continuous alertness and readiness to attack, as well as building spirit and stamina.
Ji-geiko (自稽古?)
Undirected practice where the kendōka tries all that has been learnt during practice against an opponent.
Gokaku-geiko (互角稽古?)
Practice between two kendōka of similar skill level.
Hikitate-geiko (引立稽古?)
Practice where a senior kendōka guides a junior through practice.
Shiai-geiko (試合稽古?)
Competition practice which may also be judged.

Competition
A scorable point (有効打突 yūkō-datotsu?) in a kendo competition (tai-kai) is defined as an accurate strike or thrust made onto a datotsu-bui of the opponent's kendo-gu with the shinai making contact at its datotsu-bu, the competitor displaying high spirits, correct posture and followed by zanshin.
Datotsu-bui or point scoring targets in kendo are defined as:
Men-bu, the top or sides of the head protector (sho-men and sayu-men).
Kote-bu, a padded area of the right or left wrist protector (migi-kote and hidari-kote).
Do-bu, an area of the right or left side of the armour that protects the torso (migi-do and hidari-do).
Tsuki-bu, an area of the head protector in front of the throat (tsuki-dare).
Datotsu-bu of the 'shinai' is the forward, or blade side (jin-bu) of the top third (monouchi) of the shinai.
Zanshin (残心?), or continuation of awareness, must be present and shown throughout the execution of the strike, and the kendōka must be mentally and physically ready to attack again.
In competition, there are usually three referees (審判 shinpan?). Each referee holds a red flag and a white flag in opposing hands. To award a point, a referee raises the flag corresponding to the colour of the ribbon worn by the scoring competitor. Usually at least two referees must agree for a point to be awarded. The match continues until a pronouncement of the point that has been scored.
Kendo competitions are usually a three point match. The first competitor to score two points, therefore wins the match. If the time limit is reached and only one competitor has a point, that competitor wins.
In the case of a tie, there are several options:
Hiki-wake (引き分け?): The match is declared a draw.
Enchō (延長?): The match is continued until either competitor scores a point.
Hantei (判定?): The victor is decided by the referees. The three referees vote for victor by each raising one of their respective flags simultaneously.

Advancement
Grades
Technical achievement in kendo is measured by advancement in grade, rank or level. The kyū (級?) and dan (段?) grading system is used to indicate one's proficiency in modern kendo. The dan levels are from first-dan (初段 sho-dan?) to tenth-dan (十段 jū-dan?). There are usually six grades below first-dan, known as kyu. The kyu numbering is in reverse order, with first kyu (一級 ikkyū?) being the grade immediately below first dan, and sixth kyu (六級 rokkyū?) being the lowest grade. There are no visible differences in dress between kendo grades; those below dan-level may dress the same as those above dan-level.
Eighth-dan (八段 hachi-dan?) is the highest dan grade attainable through a test of physical kendo skills. In the AJKF the grades of ninth-dan (九段 kyū-dan?) and tenth-dan are no longer awarded, but ninth-dan kendōka are still active in Japanese kendo. International Kendo Federation grading rules allow national kendo organisations to establish a special committee to consider the award of those grades.
All candidates for examination face a panel of examiners. A larger, more qualified panel is usually assembled to assess the higher dan grades. Kendo examinations typically consist of jitsugi, a demonstration of the skill of the applicants, Nihon Kendo Kata and a written exam. The eighth-dan kendo exam is extremely difficult, with a reported pass rate of less than 1 percent.

Saudi Prince Khalid bin Adbullah dead at 54

RIYADH, Saudi Arabia — Prince Khalid bin Abdullah bin Abdulaziz Al Saud, the eldest child of Saudi Arabia’s King Abdullah, has died, state media reported Saturday. He was 54.

Prince Khalid died Friday and funeral rites were performed in the Saudi capital Riyadh, according to a statement by the Saudi royal court.

Prince Khalid was honorary head of the Jiddah-based football club Al-Ahli and was on the board of trustees at the King Abdullah University of Science and Technology. He was not in line for the throne.

Twin bomb attack kills 34 in Peshawar of Pakistan‎

Peshawar Pakistan‎, June 12 -- At least 34 people were killed and 80 others injured in a twin blast that ripped through a supermarket in Peshawar of northwest Pakistan late Saturday night, reported local Urdu TV channel Samaa quoting local officials.



According to the local media reports, the twin bomb attack took place at about 23:50 p.m. local time Saturday at the Khyber supermarket of the city.

The first bomb, which, according to police, was fixed to a motorbike and was relatively small in intensity, went off at the market at about 23:40 p.m. local time, injuring three people. As the rescue team rushed to the site, the second bomb, which, again according to police, was a remote-control device, but much bigger in intensity, exploded among the large crowd of people gathering at the site.

Over 20 shops near the blast site were reportedly destroyed. A two-stored hotel was completely destroyed and many people were buried under the debris of the collapsed buildings around the blast site.

Some of the local media offices near the blast site were also damaged and at least one journalist was killed and three media personnel were injured in the explosion.

The blasts were just four minutes apart. The first blast was quite small but as people gathered close to the site of the explosion, the second one, which was real big one, went off. The building of super market caught fire after the blasts.

Rescue teams reached the spot soon after the incident and kicked off relief activities. The injured are being rushed to nearby hospitals. Emergency has been declared in the city hospitals.

More than 4,400 people have been killed across Pakistan in attacks blamed on Taliban and other Islamist extremist networks based in the nearby tribal belt since government troops stormed a radical mosque in Islamabad in 2007.
"The first blast was triggered by a timed device planted in the bathroom of the hotel while a suicide bomber riding a motorbike blew himself up near the hotel," bomb disposal chief Shafqat Malik told AFP.
"We have found head and some other body parts of the bomber from the attack site," Malik added.
The latest violence came hours after visiting Afghan President Hamid Karzai called on Pakistan to eradicate militant sanctuaries at "detailed" talks about a peace process with the Taliban that inaugurated a joint peace commission.
Karzai and a raft of top aides held two days of meetings in Islamabad, just weeks after bin Laden's death, heightening calls within the United States for a peaceful settlement in Afghanistan.
CIA chief Leon Panetta held talks Friday with top military and intelligence officials and discussed ways to strengthen future intelligence sharing, the Pakistani military said.
The twin attack also came a week after Pakistan's Al-Qaeda commander Ilyas Kashmiri, one of the network's most feared operational leaders, was likely killed in a US drone strike in South Waziristan tribal region, near the Afghan border.
Peshawar is the gateway to Pakistan's rugged northwest tribal region, which is known as the country's premier stronghold of Taliban and Al-Qaeda linked militants, and bomb attacks are common.

Childbirth

Childbirth, also called labour, birth, partus or parturition  is the culmination of a human pregnancy or gestation period with the birth of one or more newborn infants from a woman's uterus. The process of normal human childbirth is categorized in three stages of labour: the shortening and dilation of the cervix, descent and birth of the infant, and birth of the placenta. In many cases, with increasing frequency, childbirth is achieved through caesarean section, the removal of the neonate through a surgical incision in the abdomen, rather than through vaginal birth. In the U.S. and Canada it represents nearly 1 in 3 (31.8%) and 1 in 4 (22.5%) of all childbirths, respectively.

Signs and symptoms
Natural childbirth at home.
Labour is accompanied by intense and prolonged pain. Pain levels reported by labouring women vary widely. Pain levels appear to be influenced by fear and anxiety levels. Some other factors may include experience with prior childbirth, age, ethnicity, preparation, physical environment and immobility.
Psychological
Childbirth can be an intense event and strong emotions, both positive and negative, can be brought to the surface.
While many women experience joy, relief, and elation upon the birth of their child, some women report symptoms compatible with post-traumatic stress disorder (PTSD) after birth. Between 70 and 80% of mothers in the United States report some feelings of sadness or "baby blues" after childbirth. Postpartum depression may develop in some women; about 10% of mothers in the United States are diagnosed with this condition. Abnormal and persistent fear of childbirth is known as tokophobia.
Preventive group therapy has proven effective as a prophylactic treatment for postpartum depression.
Childbirth is stressful for the infant. In addition to the normal stress of leaving the protected uterine environment, additional stresses associated with breech birth, such as asphyxiation, may affect the infant's brain.

Mechanism of vaginal birth
Because humans are bipedal with an erect stance and have, in relation to the size of the pelvis, the biggest head of any mammalian species, human fetuses and human female pelvises are adapted to make birth possible.
The erect posture causes the weight of the abdominal contents to thrust on the pelvic floor, a complex structure which must not only support this weight but allow three channels to pass through it: the urethra, the vagina and the rectum. The relatively large head and shoulders require a specific sequence of maneuvers to occur for the bony head and shoulders to pass through the bony ring of the pelvis. A failure of these maneuvers results in a longer and more painful labor and can even arrest labor entirely. All changes in the soft tissues of the cervix and the birth canal depend on the successful completion of these six phases:
Engagement of the fetal head in the transverse position. The baby's head is facing across the pelvis at one or other of the mother's hips.
Descent and flexion of the fetal head.
Internal rotation. The fetal head rotates 90 degrees to the occipito-anterior position so that the baby's face is towards the mother's rectum.
Delivery by extension. The fetal head passes out of the birth canal. Its head is tilted backwards so that its forehead leads the way through the vagina.
Restitution. The fetal head turns through 45 degrees to restore its normal relationship with the shoulders, which are still at an angle.
External rotation. The shoulders repeat the corkscrew movements of the head, which can be seen in the final movements of the fetal head.
The fetal head may temporarily change shape substantially (becoming more elongated) as it moves through the birth canal. This change in the shape of the fetal head is called molding and is much more prominent in women having their first vaginal delivery.
Latent phase
The latent phase of labor, also called prodromal labor, may last many days and the contractions are an intensification of the Braxton Hicks contractions that may start around 26 weeks gestation. Cervical effacement occurs during the closing weeks of pregnancy and is usually complete or near complete, by the end of latent phase. Cervical effacement or cervical dilation is the thinning and stretching of the cervix. The degree of cervical effacement may be felt during a vaginal examination. A 'long' cervix implies that not much has been taken into the lower segment, and vice versa for a 'short' cervix. Latent phase ends with the onset of active first stage; when the cervix is about 3 cm dilated.
First stage: dilation
There are several factors that midwives and clinicians use to assess the labouring mother's progress, and these are defined by the Bishop Score. The Bishop score is also used as a means to predict whether the mother is likely to spontaneously progress into second stage (delivery).
The first stage of labor starts classically when the effaced (thinned) cervix is 3 cm dilated. There is variation in this point as some women may have active contractions prior to reaching this point, or they may reach this point without regular contractions. The onset of actual labor is defined when the cervix begins to progressively dilate. Rupture of the membranes, or a blood stained 'show' may or may not occur at or around this stage
Uterine muscles form opposing spirals from the top of the upper segment of the uterus to its junction with the lower segment. During effacement, the cervix becomes incorporated into the lower segment of the uterus. During a contraction, these muscles contract causing shortening of the upper segment and drawing upwards of the lower segment, in a gradual expulsive motion. This draws the cervix up over the baby's head. Full dilatation is reached when the cervix has widened enough to allow passage of the baby's head, around 10 cm dilation for a term baby.
The duration of labour varies widely, but active phase averages some 8 hours for women giving birth to their first child ("primiparae") and 4 hours for women who have already given birth ("multiparae"). Active phase arrest is defined as in a primigravid woman as the failure of the cervix to dilate at a rate of 1.2 cm/hr over a period of at least two hours. This definition is based on Friedman's Curve, which plots an ideal rate of cervical dilation and fetal descent during active labor. Some practitioners may diagnose "Failure to Progress", and consequently, perform an unnecessary Cesarean. However, as is the case with any pre-emptive diagnosis, doing so is severely discouraged due to the extra expense and healing time involved with Cesarean operations.

Second stage: expulsion
This stage begins when the cervix is fully dilated, and ends when the baby is finally born. As pressure on the cervix increases, the Ferguson reflex increases uterine contractions so that the second stage can go ahead. At the beginning of the normal second stage, the head is fully engaged in the pelvis; the widest diameter of the head has successfully passed through the pelvic brim. Ideally it has successfully also passed below the interspinous diameter. This is the narrowest part of the pelvis. If these have been accomplished, what remains is for the fetal head to pass below the pubic arch and out through the introitus. This is assisted by the additional maternal efforts of "bearing down" or pushing. The fetal head is seen to 'crown' as the labia part. At this point, the woman may feel a burning or stinging sensation.
Birth of the fetal head signals the successful completion of the fourth mechanism of labour (delivery by extension), and is followed by the fifth and sixth mechanisms (restitution and external rotation).
The second stage of labour will vary to some extent, depending on how successfully the preceding tasks have been accomplished.

Third stage: placenta
In this stage, the uterus expels the placenta (afterbirth). The placenta is usually birthed within 15–30 minutes of the baby being born. Maternal blood loss is limited by contraction of the uterus following birth of the placenta. Normal blood loss is less than 600 mL.
Breastfeeding during and after the third stage, the placenta is visible in the bowl to the right.
The third stage can be managed either expectantly or actively. Expectant management (also known as physiological management) allows the placenta to be expelled without medical assistance. Breastfeeding soon after birth and massaging of the top of the uterus (the fundus) causes uterine contractions that encourage birth of the placenta. Active management utilizes oxytocic agents and controlled cord traction. The oxytocic agents augment uterine muscular contraction and the cord traction assists with rapid birth of the placenta.
A Cochrane database study suggests that blood loss and the risk of postpartum bleeding will be reduced in women offered active management of the third stage of labour. However, the use of ergometrine for active management was associated with nausea or vomiting and hypertension, and controlled cord traction requires the immediate clamping of the umbilical cord.
Although uncommon, in some cultures the placenta is kept and consumed by the mother over the weeks following the birth. This practice is termed placentophagy.

Station
Refers to the relationship of the fetal presenting part to the level of the ischial spines. When the presenting part is at the ichial spines the station is 0 (synonymous with engagement). If the presenting fetal part is above the spines, the distance is measured and described as minus stations, which range from -1 to -4 cm. If the presenting part is below the ischial spines, the distance is stated as plus stations ( +1 to +4 cm). At +3 and +4 the presenting is at the perineum and can be seen.(Pilliteri, Adele.(2009). Maternal & Child health nursing:care of the childrearing family. Lippencott Williams & Wilkins: New York.)

Fourth stage
The "fourth stage of labor" is a term used in two different senses:
It can refer to the immediate puerperium,or the hours immediately after delivery of the placenta.
It can be used in a more metaphorical sense to describe the weeks following delivery.
Afterwards
Further information: Postnatal
Many cultures feature initiation rites for newborns, such as naming ceremonies, baptism, and others.
Mothers are often allowed a period where they are relieved of their normal duties to recover from childbirth. The length of this period varies. In many countries, taking time off from work to care for a newborn is called "maternity leave" or "parental leave" and can vary from a few days to several months.
Being born in the caul
When the amniotic sac has not ruptured during labour or pushing, the infant can be born with the membranes intact. This is referred to as "being born in the caul." The caul is harmless and its membranes are easily broken and wiped away. In medieval times, and in some cultures still today, a caul was seen as a sign of good fortune for the baby, even giving the child psychic gifts such as clairvoyance, and in some cultures was seen as protection against drowning. The caul was often impressed onto paper and stored away as an heirloom for the child. With the advent of modern interventive obstetrics, artificial rupture of the membranes has become common, so babies are rarely born in the caul.

Management
Pain control
Non pharmaceutical
Some women prefer to avoid analgesic medication during childbirth. They still can try to alleviate labor pain using psychological preparation, education, massage, hypnosis, or water therapy in a tub or shower. Some women like to have someone to support them during labor and birth, such as the father of the baby, the woman's mother, a sister, a close friend, a partner or a doula. Some women deliver in a squatting or crawling position in order to more effectively push during the second stage and so that gravity can aid the descent of the baby through the birth canal.
The human body also has a chemical response to pain, by releasing endorphins. Endorphins are present before, during, and immediately after childbirth. Some homebirth advocates believe that this hormone can induce feelings of pleasure and euphoria during childbirth, reducing the risk of maternal depression some weeks later.
Water birth is an option chosen by some women for pain relief during labor and childbirth, and some studies have shown waterbirth in an uncomplicated pregnancy to reduce the need for analgesia, without evidence of increased risk to mother or newborn. Hot water tubs are available in many hospitals and birthing centres.
Meditation and mind medicine techniques are also used for pain control during labour and delivery. These techniques are used in conjunction with progressive muscle relaxation and many other forms of relaxation for the mind and body to aid in pain control for women during childbirth. One such technique is the use of hypnosis in childbirth.
A new mode of analgesia is sterile water injection placed just underneath the skin in the most painful spots during labor. A control trial in Iran of 0.5mL injections was conducted with normal saline which revealed a statistical superiority with water over saline.

Pharmaceutical
Different measures for pain control have varying degrees of success and side effects to the woman and her baby. In some countries of Europe, doctors commonly prescribe inhaled nitrous oxide gas for pain control, especially as 50% nitrous oxide, 50% oxygen, known as Entonox; in the UK, midwives may use this gas without a doctor's prescription. Pethidine (with or without promethazine) may be used early in labour, as well as other opioids such as fentanyl, but if given too close to birth there is a risk of respiratory depression in the infant.
Popular medical pain control in hospitals include the regional anesthetics epidural blocks, and spinal anaesthesia. Epidural analgesia is a generally safe and effective method of relieving pain in labour, but is associated with longer labour, more operative intervention (particularly instrument delivery), and increases in cost. One study found that the women receiving epidural analgesia had more fear before the administering of the epidural than those who did not receive it, but that they did not necessarily have more pain.Medicine administered via epidural can cross the placenta and enter the bloodstream of the fetus. Epidural analgesia has no statistically significant impact on the risk of caesarean section, and does not appear to have an immediate effect on neonatal status as determined by Apgar scores.

Augmentation
Augmentation is a procedure which attempts to speed up the process of labour. Oxytocin has been used to increase the rate of vaginal delivery in those with a slow progress of labor.
Instrumental delivery
Obstetric forceps or ventouse may be used to facilitate childbirth.
The woman will have her legs supported in stirrups.
If an anaesthetic is not already in place it will be given.
Episiotomy might be needed.
A trial forceps might be performed, which is abandoned in favor of a caesarean section if delivery is not optimal.

Multiple births
Twins can be delivered vaginally. In some cases twin delivery is done in a larger delivery room or in the theatre, just in case complications occur e.g.
Both twins born vaginally - this can occur both presented head first or where one comes head first and the other is breech and/or helped by a forceps/ventouse delivery
One twin born vaginally and the other by caesarean section.
If the twins are joined at any part of the body - called conjoined twins, delivery is mostly by caesarean section.

Support
There is increasing evidence to show that the participation of the woman's partner in the birth leads to better birth and also post-birth outcomes, providing the partner does not exhibit excessive anxiety. Research also shows that when a labouring woman was supported by a female helper such as a family member or doula during labour, she had less need for chemical pain relief, the likelihood of caesarean section was reduced, use of forceps and other instrumental deliveries were reduced, there was a reduction in the length of labour, and the baby had a higher Apgar score (Dellman 2004, Vernon 2006). However, little research has been conducted to date about the conflicts between partners, professionals, and the mother.

Collecting stem cells
It's possible to collect two types of stem cells during childbirth: amniotic stem cells or umbilical cord blood stem cells. To collect amniotic stem cells, it is necessary to do amniocentesis before or during the birth. Amniotic stem cells are multipotent and very active, useful for both autologous or donor use. There are private banks in US; the first is Biocell Center in Boston.
Umbilical cord blood stem cells are also active, but less multipotent than amniotic stem cells. There are a lot of banks of cord blood, both private and public and for autologous or eterologous use.
Complications

Disability-adjusted life year for maternal conditions per 100,000 inhabitants in 2002.
no data
less than 100
100-400
400-800
800-1200
1200-1600
1600-2000
2000-2400
2400-2800
2800-3200
3200-3600
3600-4000
more than 4000


Disability-adjusted life year for perinatal conditions per 100,000 inhabitants in 2002.
no data
less than 100
100-400
400-800
800-1200
1200-1600
1600-2000
2000-2400
2400-2800
2800-3200
3200-3600
3600-4000
more than 4000
Birthing complications may be maternal or fetal, and long term or short term.
Labor complications
The second stage of labor may be delayed or lengthy due to:
malpresentation (breech birth (i.e. buttocks or feet first), face, brow, or other)
failure of descent of the fetal head through the pelvic brim or the interspinous diameter
poor uterine contraction strength
active phase arrest
cephalo-pelvic disproportion (CPD)
shoulder dystocia
Secondary changes may be observed: swelling of the tissues, maternal exhaustion, fetal heart rate abnormalities. Left untreated, severe complications include death of mother and/or baby, and genitovaginal fistula. These are commonly seen in Third World countries where births are often unattended or attended by poorly trained community members.
Maternal complications
Vaginal birth injury with visible tears or episiotomies are common. Internal tissue tearing as well as nerve damage to the pelvic structures lead in a proportion of women to problems with prolapse, incontinence of stool or urine and sexual dysfunction. Fifteen percent of women become incontinent, to some degree, of stool or urine after normal delivery, this number rising considerably after these women reach menopause. Vaginal birth injury is a necessary, but not sufficient, cause of all non hysterectomy related prolapse in later life. Risk factors for significant vaginal birth injury include:
A baby weighing more than 9 pounds.
The use of forceps or vacuum for delivery. These markers are more likely to be signals for other abnormalities as forceps or vacuum are not used in normal deliveries.
The need to repair large tears after delivery.
Pelvic girdle pain. Hormones and enzymes work together to produce ligamentous relaxation and widening of the symphysis pubis during the last trimester of pregnancy. Most girdle pain occurs before birthing, and is known as diastasis of the pubic symphysis. Predisposing factors for girdle pain include maternal obesity.
Infection remains a major cause of maternal mortality and morbidity in the developing world. The work of Ignaz Semmelweis was seminal in the pathophysiology and treatment of puerperal fever and saved many lives.
Hemorrhage, or heavy blood loss, is still the leading cause of death of birthing mothers in the world today, especially in the developing world. Heavy blood loss leads to hypovolemic shock, insufficient perfusion of vital organs and death if not rapidly treated. Blood transfusion may be life saving. Rare sequelae include Hypopituitarism Sheehan's syndrome.
The maternal mortality rate (MMR) varies from 9 per 100,000 live births in the US and Europe to 900 per 100,000 live births in Sub-Saharan Africa. Every year, more than half a million women die in pregnancy or childbirth.

Fetal complications
fetal injury
Risk factors for fetal birth injury include fetal macrosomia (big baby), maternal obesity, the need for instrumental delivery, and an inexperienced attendant. Specific situations that can contribute to birth injury include breech presentation and shoulder dystocia. Most fetal birth injuries resolve without long term harm, but brachial plexus injury may lead to Erb's palsy or Klumpke's paralysis.

Neonatal infection
Disability-adjusted life year for neonatal infections and other (perinatal) conditions per 100,000 inhabitants in 2004. Excludes prematurity and low birth weight, birth asphyxia and birth trauma which have their own maps/data.
no data
less than 150
150-300
300-450
450-600
600-750
750-900
900-1050
1050-1200
1200-1350
1350-1500
1500-1850
more than 1850
Neonates are prone to infection in the first month of life. Some organisms such as S. agalactiae (Group B Streptococcus) or (GBS) are more prone to cause these occasionally fatal infections. Risk factors for GBS infection include:
prematurity (birth prior to 37 weeks gestation)
a sibling who has had a GBS infection
prolonged labour or rupture of membranes
Untreated sexually transmitted infections are associated with congenital and perinatal infections in neonates, particularly in the areas where rates of infection remain high. The overall perinatal mortality rate associated with untreated syphilis, for example, approached 40%.
Neonatal death
Infant deaths (neonatal deaths from birth to 28 days, or perinatal deaths if including fetal deaths at 28 weeks gestation and later) are around 1% in modernized countries. The "natural" mortality rate of childbirth—where nothing is done to avert maternal death—has been estimated as being between 1,000 and 1,500 deaths per 100,000 births. (See main article: neonatal death, maternal death)
The most important factors affecting mortality in childbirth are adequate nutrition and access to quality medical care ("access" is affected both by the cost of available care, and distance from health services). "Medical care" in this context does not refer specifically to treatment in hospitals, but simply routine prenatal care and the presence, at the birth, of an attendant with birthing skills.
A 1983-1989 study by the Texas Department of State Health Services highlighted the differences in neonatal mortality (NMR) between high risk and low risk pregnancies. NMR was 0.57% for doctor-attended high risk births, and 0.19% for low risk births attended by non-nurse midwives. Conversely, some studies demonstrate a higher perinatal mortality rate with assisted home births. Around 80% of pregnancies are low-risk. Factors that may make a birth high risk include prematurity, high blood pressure, gestational diabetes and a previous cesarean section.
Intrapartum asphyxia
Intrapartum asphyxia is the impairment of the delivery of oxygen to the brain and vital tissues during the progress of labour. This may exist in a pregnancy already impaired by maternal or fetal disease, or may rarely arise de novo in labour. This can be termed fetal distress, but this term may be emotive and misleading. True intrapartum asphyxia is not as common as previously believed, and is usually accompanied by multiple other symptoms during the immediate period after delivery. Monitoring might show up problems during birthing, but the interpretation and use of monitoring devices is complex and prone to misinterpretation. Intrapartum asphyxia can cause long-term impairment, particularly when this results in tissue damage through encephalopathy.

Professions associated with childbirth
Model of pelvis used in the beginning of the 20th century to teach technical procedures for a successful childbirth. Museum of the History of Medicine, Porto Alegre, Brazil
Doulas are assistants who support mothers during pregnancy, labour, birth, and postpartum. They are not medical attendants; rather, they provide emotional support and non-medical pain relief for women during labour.
Midwives provide care to low-risk pregnant mothers. Midwives may be licensed and registered, or may be lay practitioners. Jurisdictions with legislated midwives will typically have a registering and disciplinary body, such as a College of Midwifery. Registered midwives are trained to assist a mother with labour and birth, either through direct-entry or nurse-midwifery programs. Lay midwives, who are usually not licensed or registered, typically gain experience through apprenticeship with other lay midwives.
Medical doctors who practice obstetrics include categorically specialized obstetricians; family practitioners and general practitioners whose training, skills and practices include obstetrics; and in some contexts general surgeons. These physicians and surgeons variously provide care across the whole spectrum of normal and abnormal births and pathological labour conditions. Categorically specialized obstetricians are qualified surgeons, so they can undertake surgical procedures relating to childbirth. Some family practitioners or general practitioners are also privileged to perform obstetrical surgery. Obstetrical procedures include cesarean sections, episiotomies, and assisted delivery. Categorical specialists in obstetrics are commonly dually trained in obstetrics and gynecology (OB/GYN), and may provide other medical and surgical gynecological care, and may incorporate more general, well-woman, primary care elements in their practices. Maternal-fetal medicine specialists are obstetrician/gynecologists subspecialized in managing and treating high-risk pregnancy and delivery.
Obstetric nurses assist midwives, doctors, women, and babies prior to, during, and after the birth process, in the hospital system. Some midwives are also obstetric nurses. Obstetric nurses hold various certifications and typically undergo additional obstetric training in addition to standard nursing training.

Society and culture
Childbirth routinely occurs in hospitals in modern Western society, although prior to the 20th century and in some countries to the present day has more typically occurred at home.:110[neutrality is disputed]
In Western and other cultures, age is reckoned from the date of birth, and sometimes the birthday is celebrated annually. East Asian age reckoning starts newborns at "1", incrementing each Lunar New Year.
Some families view the placenta as a special part of birth, since it has been the child's life support for so many months. Some parents like to see and touch this organ. In some cultures, parents plant a tree along with the placenta on the child's first birthday. The placenta may be eaten by the newborn's family, ceremonially or otherwise (for nutrition; the great majority of animals in fact do this naturally).
The exact location in which childbirth takes place is an important factor in determining nationality, in particular for birth aboard aircraft and ships.

Pregnancy

Pregnancy, is the carrying of one or more offspring, known as a fetus or embryo, inside the womb of a female. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets. Human pregnancy is the most studied of all mammalian pregnancies. Childbirth usually occurs about 38 weeks after conception; i.e., approximately 40 weeks from the last normal menstrual period (LNMP) in humans. The World Health Organization defines normal term for delivery as between 37 weeks and 42 weeks.

Terminology
One scientific term for the state of pregnancy is gravid, and a pregnant female is sometimes referred to as a gravida. Neither word is used in common speech. Similarly, the term "parity" (abbreviated as "para") is used for the number of previous successful live births. Medically, a woman who has never been pregnant is referred to as a "nulligravida", a woman who is (or has been only) pregnant for the first time as a "primigravida", and a woman in subsequent pregnancies as a multigravida or "multiparous".Hence, during a second pregnancy a woman would be described as "gravida 2, para 1" and upon live delivery as "gravida 2, para 2". An in-progress pregnancy, as well as abortions, miscarriages, or stillbirths account for parity values being less than the gravida number, whereas a multiple birth will increase the parity value. Women who have never carried a pregnancy achieving more than 20 weeks of gestation age are referred to as "nulliparous".
The term embryo is used to describe the developing offspring during the first 8 weeks following conception, and the term fetus is used from about 2 months of development until birth.
In many societies' medical or legal definitions, human pregnancy is somewhat arbitrarily divided into three trimester periods, as a means to simplify reference to the different stages of prenatal development. The first trimester carries the highest risk of miscarriage (natural death of embryo or fetus). During the second trimester, the development of the fetus can be more easily monitored and diagnosed. The beginning of the third trimester often approximates the point of viability, or the ability of the fetus to survive, with or without medical help, outside of the uterus.

Progression
Pregnancy occurs as the result of the female gamete or oocyte merging with the male gamete, spermatozoon, in a process referred to, in medicine, as "fertilization", or more commonly known as "conception". After the point of fertilization, it is referred to as a zygote or fertilized egg. The fusion of male and female gametes usually occurs through the act of sexual intercourse, resulting in spontaneous pregnancy. However, the advent of artificial insemination and in vitro fertilisation have also made achieving pregnancy possible in cases where sexual intercourse does not result in fertilization (e.g., through choice or male/female infertility).
The process of fertilization occurs in more than a single step, and the interruption of any of these can lead to a failure. Therefore, what is commonly known as "conception" is much more than the fusion between the female gamete and male spermatozoon. Through fertilization, the egg and sperm are saved: the egg is activated to begin its developmental program, and the haploid nuclei of the two gametes come together to form the genome of a new diploid organism
At the very beginning of the process, the sperm undergoes a series of changes which makes pregnancy likely to occur. As freshly ejaculated sperm is unable or poorly able to fertilize , the sperm undergoes the phenomenon called "capacitation". It is estimated that during the ejaculation, 300,000,000 sperma is released, from which only 200 reach the oviduct. Capacitation is the process through which the spermatozoon is prepared for the merging with the egg. Capacitation occurs in 5 to 6 hours and it takes place once the sperm reaches the vagina. This is also the process through which the spermatozoon becomes hyperactivated and prepared for the acrosome reaction. In order to be able to fecundate the egg, the sperm must get through the coat surrounding the egg, the so called "zona pellucida". Once zona pellucida is penetrated, the sperm is able to reach the oocyte. But in order to get through the egg's coat, the sperm undergoes an acrosome reaction that provides it with and enzymatic drill which is able to penetrate zona pellucida. The acrosome itself is a modified lysosome, situated on the anterior part of the head of the sperm.
Once a sperm penetrates the zona pellucida, it binds to and fuses with the plasma membrane of the oocyte. Binding occurs at the posterior (post-acrosomal) region of the sperm head. After binding occurs, the egg must also undergo a series of metabolic and physical changes which may influence the further development of the zygote. These changes are called in medicine egg activation, mainly because prior to fertilization, the egg is in a latent state.
Methods to assist reproduction also include intracytoplasmic sperm injection, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and embryo cryopreservation (frozen fertilized egg and sperm). These techniques are considered as alternatives to get pregnant by women who have tried unsuccessfully for at least one year. It is estimated that only in the United States more than 6 million adults are affected by infertility which makes about 10% of the population of reproductive age in this country.
Prenatal period
Prenatal defines the period occurring "around the time of birth", specifically from 22 completed weeks (154 days) of gestation (the time when birth weight is normally 500 g) to 7 completed days after birth.
Legal regulations in different countries include gestation age beginning from 16 to 22 weeks (5 months) before birth.

Postnatal period
The postnatal period begins immediately after the birth of a child and then extends for about six weeks. During this period, the mother's body returns to prepregnancy conditions as far as uterus size and hormone levels are concerned.

Perinatal period
The perinatal period is immediately before to after birth. Depending on the definition, it starts between the 20th to 28th week of gestation and ends between 1 to 4 weeks after birth (the word "perinatal" is a hybrid of the Greek "peri-" meaning 'around or about' and "natal" from the Latin "natus" meaning "birth.").
Duration
The expected date of delivery (EDD) is 40 weeks counting from the first day of the last menstrual period (LMP), and birth usually occurs between 37 and 42 weeks.The actual pregnancy duration is typically 38 weeks after conception. Though pregnancy begins at conception, it is more convenient to date from the first day of a woman's last menstrual period, or from the date of conception if known. Starting from one of these dates, the expected date of delivery can be calculated. Forty weeks is 9 months and 6 days, which forms the basis of Naegele's rule for estimating date of delivery. More accurate and sophisticated algorithms take into account other variables, such as whether this is the first or subsequent child (i.e., pregnant woman is a primip or a multip, respectively), ethnicity, parental age, length of menstrual cycle, and menstrual regularity.
Pregnancy is considered "at term" when gestation attains 37 complete weeks but is less than 42 (between 259 and 294 days since LMP). Events before completion of 37 weeks (259 days) are considered preterm; from week 42 (294 days) events are considered postterm.When a pregnancy exceeds 42 weeks (294 days), the risk of complications for woman and fetus increases significantly.As such, obstetricians usually prefer to induce labour, in an uncomplicated pregnancy, at some stage between 41 and 42 weeks.
Recent medical literature prefers the terminology preterm and postterm to premature and postmature. Preterm and postterm are unambiguously defined as above, whereas premature and postmature have historical meaning and relate more to the infant's size and state of development rather than to the stage of pregnancy.
Fewer than 5% of births occur on the due date; 50% of births are within a week of the due date, and almost 90% within 2 weeks. It is much more useful and accurate, therefore, to consider a range of due dates, rather than one specific day, with some online due date calculators providing this information.
Accurate dating of pregnancy is important, because it is used in calculating the results of various prenatal tests (for example, in the triple test). A decision may be made to induce labour if a fetus is perceived to be overdue. Furthermore, if LMP and ultrasound dating predict different respective due dates, with the latter being later, this might signify slowed fetal growth and therefore require closer review.
The age of viability has been receding because of continued medical progress. Whereas it used to be 28 weeks, it has been brought back to as early as 23, or even 22 weeks in some countries. Unfortunately, there has been a profound increase in morbidity and mortality associated with the increased survival to the extent it has led some to question the ethics and morality of resuscitating at the edge of viability.

Diagnosis
The beginning of pregnancy may be detected in a number of different ways, either by a pregnant woman without medical testing, or by using medical tests with or without the assistance of a medical professional.
Most pregnant women experience a number of symptoms, which can signify pregnancy. The symptoms can include nausea and vomiting, excessive tiredness and fatigue, craving for certain foods not normally considered a favorite, and frequent urination particularly during the night.
A number of early medical signs are associated with pregnancy. These signs typically appear, if at all, within the first few weeks after conception. Although not all of these signs are universally present, nor are all of them diagnostic by themselves, taken together they make a presumptive diagnosis of pregnancy. These signs include the presence of human chorionic gonadotropin (hCG) in the blood and urine, missed menstrual period, implantation bleeding that occurs at implantation of the embryo in the uterus during the third or fourth week after last menstrual period, increased basal body temperature sustained for over 2 weeks after ovulation, Chadwick's sign (darkening of the cervix, vagina, and vulva), Goodell's sign (softening of the vaginal portion of the cervix), Hegar's sign (softening of the uterus isthmus), and pigmentation of linea alba – Linea nigra, (darkening of the skin in a midline of the abdomen, caused by hyperpigmentation resulting from hormonal changes, usually appearing around the middle of pregnancy).
Pregnancy detection can be accomplished using one or more various pregnancy tests, which detect hormones generated by the newly formed placenta. Clinical blood and urine tests can detect pregnancy 12 days after implantation , which is as early as 6 to 8 days after fertilization. Blood pregnancy tests are more accurate than urine tests. Home pregnancy tests are personal urine tests, which normally cannot detect a pregnancy until at least 12 to 15 days after fertilization. Both clinical and home tests can only detect the state of pregnancy, and cannot detect the date the embryo was conceived.
In the post-implantation phase, the blastocyst secretes a hormone named human chorionic gonadotropin, which in turn stimulates the corpus luteum in the woman's ovary to continue producing progesterone. This acts to maintain the lining of the uterus so that the embryo will continue to be nourished. The glands in the lining of the uterus will swell in response to the blastocyst, and capillaries will be stimulated to grow in that region. This allows the blastocyst to receive vital nutrients from the woman.
Despite all the signs, some women may not realize they are pregnant until they are quite far along in their pregnancy. In some cases, a few woman have not been aware of their pregnancy until they begin labour. This can be caused by many factors, including irregular periods (quite common in teenagers), certain medications (not related to conceiving children), and obese women who disregard their weight gain. Others may be in denial of their situation.
An early sonograph can determine the age of the pregnancy fairly accurately. In practice, doctors typically express the age of a pregnancy (i.e., an "age" for an embryo) in terms of "menstrual date" based on the first day of a woman's last menstrual period, as the woman reports it. Unless a woman's recent sexual activity has been limited, she has been charting her cycles, or the conception is the result of some types of fertility treatment (such as IUI or IVF), the exact date of fertilization is unknown. Without symptoms such as morning sickness, often the only visible sign of a pregnancy is an interruption of the woman's normal monthly menstruation cycle, (i.e., a "late period"). Hence, the "menstrual date" is simply a common educated estimate for the age of a fetus, which is an average of 2 weeks later than the first day of the woman's last menstrual period. The term "conception date" may sometimes be used when that date is more certain, though even medical professionals can be imprecise with their use of the two distinct terms. The due date can be calculated by using Naegele's rule. The expected date of delivery may also be calculated from sonogram measurement of the fetus. This method is slightly more accurate than methods based on LMP.The beginning of labour, which is variously called confinement or childbed, begins on the day predicted by LMP 3.6% of the time and on the day predicted by sonography 4.3% of the time.
Diagnostic criteria are: Women who have menstrual cycles and are sexually active, a period delayed by a few days or weeks is suggestive of pregnancy; elevated B-hcG to around 100,000 mIU/mL by 10 weeks of gestation.

Physiology
Pregnancy is typically broken into three periods, or trimesters, each of about three months. While there are no hard and fast rules, these distinctions are useful in describing the changes that take place over time.
First trimester
Traditionally, doctors have measured pregnancy from a number of convenient points, including the day of last menstruation, ovulation, fertilization, implantation and chemical detection. In medicine, pregnancy is often defined as beginning when the developing embryo becomes implanted into the endometrial lining of a woman's uterus. In some cases where complications may have arisen, the fertilized egg might implant itself in the fallopian tubes or the cervix, causing an ectopic pregnancy. Most pregnant women do not have any specific signs or symptoms of implantation, although it is not uncommon to experience minimal bleeding at implantation. Some women will also experience cramping during their first trimester. This is usually of no concern unless there is spotting or bleeding as well. After implantation the uterine endometrium is called the decidua. The placenta, which is formed partly from the decidua and partly from outer layers of the embryo, is responsible for transport of nutrients and oxygen to, and removal of waste products from the fetus. The umbilical cord is the connecting cord from the embryo or fetus to the placenta. The developing embryo undergoes tremendous growth and changes during the process of fetal development.
Morning sickness occurs in about seventy percent of all pregnant women and typically improves after the first trimester. Although described as "morning sickness", women can experience this nausea during afternoon, evening, and throughout the entire day.
In the first 12 weeks of pregnancy, the nipples and areolas darken due to a temporary increase in hormones.
Most miscarriages occur during this period.
The first 12 weeks of pregnancy are considered to make up the first trimester. The first two weeks from the first trimester are calculated as the first two weeks of pregnancy even though the pregnancy does not actually exist. These two weeks are the two weeks before conception and which include the woman's last period.
The third week is the week in which fertilization occurs and the 4th week is the period when implantation takes place. In the 4th week, the fecundated egg reaches the uterus and burrows into its wall which provides it with the nutrients it needs. At this point, the zygote becomes a blastocyst and placenta starts to form. Moreover, most of the pregnancy tests may detect a pregnancy beginning with this week.
The 5th week marks the start of the embryonic period. This is when the baby's brain, spinal cord, heart and other organs begin to form. The embryo is made at this point from three layers, from which the top one (called ectoderm) will give rise to the baby's outermost layer of skin, central and peripheral nervous systems, eyes, inner ear, and many connective tissues. The heart and the beginning of the circulatory system as well as the bones, muscles and kidneys are made up from the mesoderm (the middle layer). The inner layer of the embryo will serve as the starting point of the development of the baby's lungs, intestine and bladder. This layer is referred to as endoderm. The dimensions of a baby at 5 weeks are normally between 1/16 and 1/8 inch (in length).
In the 6th week, the baby will be developing basic facial features and its arms and legs start to grow. At this point, the embryo is usually not longer than 1/6 to 1/4 inch. In the following week, the brain, face and arms and legs quickly develop. In the 8th week, the baby starts moving and in the next 3 weeks, the baby's toes, neck and genitals develop as well. According to the American Pregnancy Association, by the end of the first trimester, the fetus will be about 3 inches long and will weigh approximately one ounce.
Second trimester
Weeks 13 to 28 of the pregnancy are called the second trimester. Most women feel more energized in this period, and begin to put on weight as the symptoms of morning sickness subside and eventually fade away.
In the 20th week the uterus, the muscular organ that holds the developing fetus, can expand up to 20 times its normal size during pregnancy. Although the fetus begins to move and takes a recognizable human shape during the first trimester, it is not until the second trimester that movement of the fetus, often referred to as "quickening", can be felt. This typically happens in the fourth month, more specifically in the 20th to 21st week, or by the 19th week if the woman has been pregnant before. However, it is not uncommon for some women not to feel the fetus move until much later. The placenta fully functions at this time and the fetus makes insulin and urinates. The reproductive organs distinguish the fetus as male or female.

Third trimester
Final weight gain takes place, which is the most weight gain throughout the pregnancy. The fetus will be growing the most rapidly during this stage, gaining up to 28 g per day. The woman's belly will transform in shape as the belly drops due to the fetus turning in a downward position ready for birth. During the second trimester, the woman's belly would have been very upright, whereas in the third trimester it will drop down quite low, and the woman will be able to lift her belly up and down. The fetus begins to move regularly, and is felt by the woman. Fetal movement can become quite strong and be disruptive to the woman. The woman's navel will sometimes become convex, "popping" out, due to her expanding abdomen. This period of her pregnancy can be uncomfortable, causing symptoms like weak bladder control and backache. Movement of the fetus becomes stronger and more frequent and via improved brain, eye, and muscle function the fetus is prepared for ex utero viability. The woman can feel the fetus "rolling" and it may cause pain or discomfort when it is near the woman's ribs and spine.
There is head engagement in the third trimester, that is, the fetal head descends into the pelvic cavity so that only a small part (or nothing) of it can be felt abdominally.
It is during this time that a baby born prematurely may survive. The use of modern medical intensive care technology has greatly increased the probability of premature babies surviving, and has pushed back the boundary of viability to much earlier dates than would be possible without assistance. In spite of these developments, premature birth remains a major threat to the fetus, and may result in ill-health in later life, even if the baby survives.

Embryonic and fetal development
Prenatal development is divided into two primary biological stages. The first is the embryonic stage, which lasts for about two months. At this point, the fetal stage begins. At the beginning of the fetal stage, the risk of miscarriage decreases sharply,all major structures including hands, feet, head, brain, and other organs are present, and they continue to grow and develop. When the fetal stage commences, a fetus is typically about 30 mm (1.2 inches) in length, and the heart can be seen beating via sonograph; the fetus bends the head, and also makes general movements and startles that involve the whole body.Some fingerprint formation occurs from the beginning of the fetal stage.
Electrical brain activity is first detected between the 5th and 6th week of gestation, though this is still considered primitive neural activity rather than the beginning of conscious thought, something that develops much later in fetation. Synapses begin forming at 17 weeks, and at about week 28 begin multiply at a rapid pace which continues until 3–4 months after birth. It isn't until week 23 that the fetus can survive, albeit with major medical support, outside of the womb. It is not until then that the fetus possesses a sustainable human brain.
One way to observe prenatal development is via ultrasound images. Modern 3D ultrasound images provide greater detail for prenatal diagnosis than the older 2D ultrasound technology.While 3D is popular with parents desiring a prenatal photograph as a keepsake, both 2D and 3D are discouraged by the FDA for non-medical use,but there are no definitive studies linking ultrasound to any adverse medical effects.
Some people are confused about the differences between an ultrasound and a sonogram. An ultrasound is the actual machine that lets you observe pregnancy. A sonogram is the image of the baby that the ultrasound produces. 4D Ultrasounds take 3D sonograms. Some people refer to the procedure as prenatal imaging, 3D imaging, a 3D scan, or 4D scan.

Maternal physiological changes
During pregnancy, the woman undergoes many physiological changes, which are entirely normal, including cardiovascular, hematologic, metabolic, renal and respiratory changes that become very important in the event of complications. The body must change its physiological and homeostatic mechanisms in pregnancy to ensure the fetus is provided for. Increases in blood sugar, breathing and cardiac output are all required. Levels of progesterone and oestrogens rise continually throughout pregnancy, suppressing the hypothalamic axis and subsequently the menstrual cycle. The woman and the placenta also produce many hormones.

Management
Prenatal medical care is the medical and nursing care recommended for women before and during pregnancy. The aim of good prenatal care is to detect any potential problems early, to prevent them if possible (through recommendations on adequate nutrition, exercise, vitamin intake etc), and to direct the woman to appropriate specialists, hospitals, etc. if necessary.

Nutrition
A balanced, nutritious diet is an important aspect of a healthy pregnancy. Eating a healthy diet, balancing carbohydrates, fat, and proteins, and eating a variety of fruits and vegetables, usually ensures good nutrition. Those whose diets are affected by health issues, religious requirements, or ethical beliefs may choose to consult a health professional for specific advice. Eating well is very important both for you and your baby.
Adequate periconceptional folic acid (also called folate or Vitamin B9) intake has been proven to limit fetal neural tube defects, preventing spina bifida, a very serious birth defect. The neural tube develops during the first 28 days of pregnancy, explaining the necessity to guarantee adequate periconceptional folate intake. Folates (from folia, leaf) are abundant in spinach (fresh, frozen, or canned), and are found in green leafy vegetables e.g. salads, beets, broccoli, asparagus, citrus fruits and melons, chickpeas (i.e. in the form of hummus or falafel), and eggs. In the United States and Canada, most wheat products (flour, noodles) are fortified with folic acid. Cosmetically, a deficiency in B vitamins can become apparent through increased pigmentation over areas of the body such as the forehead and cheeks (a condition known as 'pregnancy mask' or melasma).
DHA omega-3 is a major structural fatty acid in the brain and retina, and is naturally found in breast milk. It is important for the woman to consume adequate amounts of DHA during pregnancy and while nursing to support her well-being and the health of her infant. Developing infants cannot produce DHA efficiently, and must receive this vital nutrient from the woman through the placenta during pregnancy and in breast milk after birth.
Several micronutrients are important for the health of the developing fetus, especially in areas of the world where insufficient nutrition is prevalent. In developed areas, such as Western Europe and the United States, certain nutrients such as Vitamin D and calcium, required for bone development, may require supplementation.
Dangerous bacteria or parasites may contaminate foods, particularly Listeria and toxoplasma, toxoplasmosis agent. Careful washing of fruits and raw vegetables may remove these pathogens, as may thoroughly cooking leftovers, meat, or processed meat. Soft cheeses may contain Listeria; if milk is raw, the risk may increase. Cat feces pose a particular risk of toxoplasmosis. Pregnant women are also more prone to Salmonella infections from eggs and poultry, which should be thoroughly cooked. Practicing good hygiene in the kitchen can reduce these risks.

Weight gain
Caloric intake must be increased to ensure proper development of the fetus. The amount of weight gained during a singleton pregnancy varies among women. The Institute of Medicine recommends an overall pregnancy weight gain for women starting pregnancy at a normal weight, with a body mass index of 18.5-24.9, of 25-35 pounds (11.4-15.9 kg). Woman that are underweight, with a BMI of less than 18.5, may need to gain between 28-40 lbs. Overweight woman are be advised to gain between 15-25 lbs, whereas an obese woman may expect to gain between 11-20 lbs. Doctors and dietitians may make different, or more individualized, recommendations for specific patients, based on factors including low maternal age, nutritional status, fetal development, and morbid obesity.
During pregnancy, insufficient or excessive weight gain can compromise the health of the mother and fetus. All women are encouraged to choose a healthy diet regardless of pre-pregnancy weight. Exercise during pregnancy, such as walking and swimming, is recommended for healthy pregnancies. Exercise has notable health benefits for both mother and baby, including preventing excessive weight gain.

Immune tolerance
The fetus inside a pregnant woman may be viewed as an unusually successful allograft, since it genetically differs from the woman. In the same way, many cases of spontaneous abortion may be described in the same way as maternal transplant rejection.

Medication use
Drugs used during pregnancy can have temporary or permanent effects on the fetus. Therefore many physicians would prefer not to prescribe for pregnant women, the major concern being over teratogenicity of the drugs.
Drugs have been classified into categories A,B,C,D and X based on the Food and Drug Administration (FDA) rating system to provide therapeutic guidance based on potential benefits and fetal risks. Drugs like multivitamins that have demonstrated no fetal risks after controlled studies in humans are classified as Category A. On the other hand drugs like thalidomide with proven fetal risks that outweigh all benefits are classified as Category X.
Exposure to toxins
Various toxins pose a significant hazard to fetuses during development:
Alcohol ingestion during pregnancy may cause fetal alcohol syndrome, a permanent and often devastating birth-defect syndrome. A number of studies have shown that light to moderate drinking during pregnancy might not pose a risk to the fetus, although no amount of alcohol during pregnancy can be guaranteed to be absolutely safe.
Women who have suffered mercury poisoning in pregnancy have sometimes given birth to children with serious birth defects, termed Minamata disease.

Sexual activity during pregnancy
Most pregnant women can enjoy sexual activity during pregnancy throughout gravidity. Most research suggests that, during pregnancy, both sexual desire and frequency of sexual relations decrease. In context of this overall decrease in desire, some studies indicate a second-trimester increase, preceding a decrease.However, these decreases are not universal: a significant number of women report greater sexual satisfaction throughout their pregnancies.

Stem cell collection
Two different types of stem cells can be collected before childbirth: amniotic stem cells and umbilical cord blood stem cells. The collection of amniotic stem cells is part of the process of amniocentesis. Umbilical cord blood stem cells can be stored in both public and private banks, such as the Biocell Center in Boston.

Complications and complaints
Each year, according to the WHO, ill-health as a result of pregnancy is experienced (sometimes permanently) by more than 20 million women around the world. Furthermore, the "lives of eight million women are threatened, and more than 500,000 women are estimated to have died in 1995 as a result of causes related to pregnancy and childbirth".
The following are complaints that may occur during pregnancy:
Back pain. A particularly common complaint in the third trimester when the patient's center of gravity has shifted.
Carpal tunnel syndrome in between an estimated 21% to 62% of cases, possibly due to edema.
Constipation. A complaint that is caused by decreased bowel mobility secondary to elevated progesterone (normal in pregnancy), which can lead to greater absorption of water.
Braxton Hicks contractions. Occasional, irregular, and often painless contractions that occur several times per day.
Edema (swelling). Common complaint in advancing pregnancy. Caused by compression of the inferior vena cava (IVC) and pelvic veins by the uterus leads to increased hydrostatic pressure in lower extremities.
Regurgitation, heartburn, and nausea. Common complaints that may be caused by Gastroesophageal Reflux Disease (GERD); this is determined by relaxation of the lower esophageal sphincter (LES) and increased transit time in the stomach (normal in pregnancy), as well as by increased intraabdominal pressure, caused by the enlarging uterus.
Haemorrhoids. Complaint that is often noted in advancing pregnancy. Caused by increased venous stasis and IVC compression leading to congestion in venous system, along with increased abdominal pressure secondary to the pregnant space-occupying uterus and constipation.
Pelvic girdle pain. PGP disorder is complex and multi-factorial and likely to be represented by a series of sub-groups with different underlying pain drivers from peripheral or central nervous system, altered laxity/stiffness of muscles,laxity to injury of tendinous/ligamentous structures to ‘mal-adaptive’ body mechanics. Musculo-Skeletal Mechanics involved in gait and weightbearing activities can be mild to grossly impaired. PGP can begin peri or postpartum. There is pain, instability or dysfunction in the symphysis pubis and/or sacroiliac joints.
Round Ligament Pain. Pain experienced when the ligaments positioned under the uterus stretch and expand to support the woman's growing uterus
Increased urinary frequency. A common complaint referred by the gravida, caused by increased intravascular volume, elevated GFR (glomerular filtration rate), and compression of the bladder by the expanding uterus.
Varicose veins. Common complaint caused by relaxation of the venous smooth muscle and increased intravascular pressure.
PUPPP skin disease that develop around the 32nd week. (Pruritic Urticarial Papules and Plaques of Pregnancy), red plaques, papules, itchiness around the belly button that spread all over the body except for the inside of hands and face.