“Thirty Three Weeks Pregnant” is dedicated to a very special friend: Bette Jeannine Hillock, 53, died Sept. 8, 2005, at Loma Linda University Hospital of cancer. She was an NICU nurse practitioner for 28 years at Loma Linda Hospital in Loma Linda, California.
Your Pregnancy MD
Pregnancy Week Thirty Three
Author James W. Brann, M.D.
Your Body’s Changes at Pregnancy Week Thirty Three
Your uterus now measures roughly 5 inches above your belly button. You may have gained up to 28 pounds or more by this point in your pregnancy. Many women will gain weight more rapidly in the third trimester due to the rapid growth in their baby. Most babies start gaining anywhere from five to nine ounces every week from now on until delivery.
You are probably finding yourself more and more excited at the prospect of meeting your little baby for the first time. You are more than two-thirds of the way there by this point in time. You should consider pre-registering at your hospital if this is allowed. This will help speed the admissions process once you are in labor. The last thing you will have on your mind as you approach delivery is filling out lots of paperwork!
Many women start experiencing mild swelling or edema. This pattern often remains as you continue your pregnancy. Some women find that swelling is worse during warm weather or in hot climates. If you are experiencing your third trimester in the middle of summer more kudos to you! You are probably very warm and quite bloated. Just be sure to drink plenty of water to keep your body as hydrated as possible. This will help with swelling and improve your comfort.
Some women begin experiencing numbness or tingling in their fingers and wrists at this time. This often results from a condition referred to as carpal tunnel syndrome. You may find the tissues supporting your wrists and hands also swell, pinching the nerves running through your wrist. This is often more noticeable for women who work in a job that requires frequent typing. If this is you ask your healthcare provider if wearing a brace will help relieve some of the discomfort you are experiencing in your wrists and hands. Taking frequent rest breaks should help relieve some of the discomfort and swelling you are experiencing.
In the next couple of weeks, as you and your partner gear up for your baby’s birth, you may experience a few false alarms and false runs to the hospital. This is especially true if this is your first pregnancy. False labor pains, also called Braxton-Hicks contractions, can be difficult to tell apart for first-time moms. They are commonly felt in the third trimester, as your body gears up for labor and delivery.
Even if you have familiarized yourself with the signs of Braxton-Hicks contractions, these false labor pains can still confuse you. In the weeks before delivery, these contractions can become more frequent and seem relatively close together. They may even feel painful.
If you are concerned about any contractions that you are feeling, don’t hesitate to contact your doctor or midwife.
Are You At Risk for Preterm Labor
Preterm labor is defined as contractions that begin before 37 weeks of pregnancy and a term pregnancy is defined between 37 to 42 weeks. Your due date is calculated as the 40th week of pregnancy.
Most babies are delivered around their due date, but 12 percent of pregnancies are delivered before 37 weeks, which is considered preterm. Most preterm labor women do not actually go on to deliver their babies early. It is estimated that only 30 to 50 percent of women in preterm labor cannot be stopped and go on to give birth.
A preterm baby is at risk for problems that include a difficult time breathing, difficulty maintain a normal body temperature, feeding problems, as well as more serious problems to the eyes, intestines and central nervous system.
Preterm Labor and Delivery Risk Factors
It is not known exactly why preterm labor starts, but we do know some of the risk factors associated with preterm labor. One of the biggest risk factor is having delivered a previous preterm baby. It is known that 22 percent of women with a previous preterm delivery will go on to have another preterm delivery. Risk factors of preterm delivery include:
- If you are carrying multiples
- A previous cervical conization for abnormal pap smears
- Uterine abnormalities, such as fibroids, polyps or septum
- Bleeding late in your pregnancy
- Illicit drugs usage in pregnancy, such as cocaine
- Abuse of tobacco, smoking cigarettes
- Various infections
- Being underweight before pregnancy, and poor weight gain during pregnancy
- Excessive amount of amniotic fluid
- Anemia in the first part of pregnancy
- Less than 12 months from you last pregnancy
- Young women between 18 to 20 years old
What Causes Preterm Labor
The exact cause of preterm labor in most situations is difficult to identify. But there are four characteristics that may trigger preterm labor.
- Bleeding — from either a placenta previa (when the afterbirth is near the cervix or opening of the uterus) or placental abruption (the separation of the afterbirth from the wall of the uterus) the amniotic sac (the sac the baby is in) can rupture and cause preterm labor.
- Stretching of the uterus greater than normal – If you have twins, or multiples, or have an excessive amount of amniotic fluid your uterus will stretch more than normal. It is believed that this stretching releases substances that lead to preterm contractions and labor.
- Bacterial infection—of the uterus or amniotic sac can produce chemical triggers that start preterm labor contractions.
- Both Physical and/or psychological stress — can trigger the release of hormones that cause contractions and preterm labor.
Are there tests to predict preterm labor?
Two tests are available to help predict if you will have preterm labor, Fetal Fibronectin testing and measuring the cervical length.
- Fetal Fibronectin – Prior to labor a chemical called fetal fibronectin is released. If this substance is not found in vaginal fluid then preterm birth is unlikely. If it is found, there is an increase chance of early delivery, but not always. [Ref]
- Cervical length – By using an ultrasound you can measure the cervical length If it is found to be shorter than normal there is a risk of preterm labor.
What are the signs of preterm labor?
- Increase in watery or bloody vaginal discharge
- Increasing lower abdominal pressure
- Persistent low backache
- Menstrual like cramping associated with or without diarrhea
- Contractions that have become regular and frequent
- Bag of water breaks (ruptured membranes) feels like a gush of water
How is preterm labor treated?
Your physician will either try to stop or slow down your preterm labor by giving you medicines called “tocolytic agents.”
Also, if you are between 23 and 34 weeks pregnant, your physician will administer steroid medications to help with the development of your baby’s lungs.
The most common tocolytic medicines include terbutaline, magnesium sulfate,nifedipine, and indomethacin. You will need to have placed an intravenous line to give these medicines and extra fluids. The baby’s heart beat will be monitored as well as your contractions.
If your labor is stopped you will be monitored in the hospital afterward to make sure your contractions do not restart. When you are finally discharged from the hospital you will be asked to limit your activities and report any contractions to your healthcare provider.
You can monitor yourself at home for contractions by lying down and placing your fingertips on your uterus. The uterus should be soft and relaxed. If you are not having contractions you will be able to easily indent your uterus with your fingertips. With a contraction the uterus forms a hard ball and is difficult to push in.
Steroids for fetal lung maturity
The maturation of your baby’s lungs with steroids will help your baby breathe if born early. The most widely given steroid is betamethasone. An interesting note, the steroids used to develop a baby’s lung are not the same as the steroids athletes use.
Steroids are given by a shot and most be administered several hours before your baby is born. You will receive two doses that are giving 24 hours apart. The best benefit is seen when the shots are given 48 hours before your baby is born.
Preterm labor prevention
It is hard to prevent
preterm labor, but one of the most beneficial things you can do is to stop
habits that could be harmful, like the use of illegal drugs and smoking.
If you have a history of previous preterm labor your physician can give you a progesterone supplement to prevent another early delivery. The progesterone supplement can be given as an injection or a vaginal gel that is administered starting between your 16th to 26th weeks of pregnancy. The progesterone supplement is continued until you reach 36 weeks.
Preterm Rupture of Membranes PROM
My water just broke, but i’m having no contractions
Between 5 and 10% of all pregnancies may involve rupture of fetal membranes before the onset of contractions. It is noteworthy to mention that this condition occurs in no less than 60% of women who are already at term. When your water has broken and the contractions have not started, you are most likely diagnosed with premature rupture of membranes or PROM by your physician.
What is premature rupture of membranes?
PROM occurs when the sac that cushions and protects your baby breaks, causing the fluid within the sac to leak out through your cervix and birth canal
An expecting mother who has manifested signs of rupture of membranes before the start of labor, but at term (greater than 37 weeks), is diagnosed with premature rupture of membranes or PROM. Do not confuse PROM with PPROM or preterm premature rupture of membranes. PPROM is characterized by rupture of membranes before 37 weeks’ gestation.
What are the possible causes of PROM?
The cause of premature rupture of membrane is multifactorial.
One theory is conditions that lead to over distention of the uterus can cause
PROM. Some of the conditions implicated include multiple gestations and
excessive volume of amniotic fluid. Rupture of membranes without contractions
at term has also been associated with cigarette smoking.
Different research groups suggested that membranes that rupture before labor may have different mechanical and chemical properties. One group found that women who had PROM had thinner and less elastic membranes at the site of break when compared to the general population. Another group found that collagen synthesis was also lower in membranes that rupture prematurely. Collagen is a fibrous tissue found in ligaments and tendons. Chorion, the outer membrane of the amniotic sac, is also made up collagen.
What are the signs of PROM at term?
The characteristic sign of premature rupture of membranes at
term is the leaking of amniotic fluid without the occurrence of uterine
contractions. A mother with PROM will most likely note either a large gush of
fluid that wets their sheets or undergarments or a slow trickle of fluid that
constantly moisten their sanitary pads. Diagnosis of rupture of membrane is
established by inserting a speculum into the birth canal for inspection of the
cervix and vaginal cavity. Pooling of amniotic fluid in the vagina is
considered as the most reliable test to verify the diagnosis.
Vaginal discharge, vaginal bleeding, and a sense of pressure in the pelvic area are the other signs of PROM at term.
If the diagnosis is established, what’s next?
After the diagnosis of premature rupture of membrane is made,
the next step is to determine whether to induce labor or to wait for you to
enter spontaneous labor. Research revealed that about 90% of women with PROM
will go into spontaneous labor during the first 24 hours of rupture.
There seems to be a debate as to what to do when PROM takes place. Some physicians suggest that labor should start within 24 hours as the risk of intrauterine infection exceeds the risk of artificial induction of labor. Others believe that the risk for intrauterine infection is low for the next 72 hours and waiting for spontaneous labor to start within 72 hours is fine. The thinking behind waiting is to avoid risks associated with artificial induction of labor, such as fetal distress, increased risk for infection, uterine rupture, and increased risk for a cesarean delivery.
It noteworthy to mention that available evidence suggests that induction of labor decreases the risk of infection, without increasing the risk for a cesarean delivery. Moreover, findings reveal that the risk for infection increases from 10% to 40% after 24 hours of PROM.
The succeeding sections discuss the events you should expect during labor induction and spontaneous delivery.
Induction of labor
If you decide to go through induced labor, your physician will first determine whether or not your cervix is favorable for labor and delivery. If the cervix is favorable (dilated), your physician will administer intravenous oxytocin to stimulate uterine contractions. Prophylactic antibiotics are also administered.
If your cervix is not favorable, your physician may have another approach. Misoprostol, an analogue of prostaglandin E1, is initially administered intravaginally to ripen the cervix.[Ref} Ripening of cervix involves softening, thinning and dilating of the cervix. Oxytocin is also administered if you have not gone into active labor with Misoprostol. You will also receive prophylactic antibiotics to prevent infections that are usually caused by group B Streptococcus.
Expectant management may also be considered. The risk for intrauterine infections at term with premature rupture of membrane is small, as long spontaneous labor occurs for the first 12 to 24 hours. Expectant management is usually not an option after the first 24 hours.
Sometimes, it will take a few hours for contractions to get going. As long as you and your physician have discussed about it and you and your baby are both doing well, waiting for a few hours can be considered. During the wait, you may try simple and effective methods that can stimulate uterine contractions. One of the most commonly used techniques is nipple stimulation. Stimulating your nipples either by hand or breast pump induces your posterior pituitary gland to release oxytocin, a hormone known to stimulate contractions. Walking around in your room or hall with a birth partner may also help
In most cases, the management will mainly depend on your desires. Before labor, it is strongly suggested to discuss your options with your physician, should PROM take place.
Your Baby at 33 Weeks of Pregnancy
By pregnancy week 33 your baby will weigh in over 4.2 pounds and will measure roughly 17.2 inches in length or more!
Your baby is steadily gaining weight now. For the remainder of your pregnancy your baby will continue to put on weight. The amniotic fluid surrounding your baby will reach its highest level at 33 weeks pregnant, then decline somewhat as your baby continues to grow larger.
Your baby’s brain is working hard at maturing. This week your baby’s head will increase in size by as much as 2/8 of an inch due to rapid brain growth and maturity! Your baby’s skin will also start transforming into a more pink color as your baby starts to add fat to his body.
Your little bundle of joy’s fingernails might reach the tip of
his or her fingers. Fortunately, there is no danger of your child accidentally
scratching his or her precious face – his or her nails are very soft, as a
result of their constant immersion in amniotic fluid.
Your baby’s bones continue to harden with the help of the calcium from your diet. (If you don’t have sufficient calcium in your diet, your baby will rob this nutrient from the reservoir in your bones.
At this point in your pregnancy, your baby is swallowing almost a liter of amniotic fluid every day. Amniotic fluid provides your baby with proteins and nutrients, and it also aids in helping his gut development.
Your baby’s nose is almost fully formed. The bridge has formed and your baby no longer has that “button nose” appearance. Your baby’s face is rounding out, and your little one may actually be a bit chubby from here on out.
By 33 weeks pregnant, your baby is often making faces in the womb. He or she may be smiling, sticking out his or her tongue, and making the goofiest expressions.
Neonatal Intensive Care Unit, or NICU
The part of the hospital dedicated to treating babies who were born too early or those who are sick, is called the neonatal intensive care unit, or NICU. It’s also sometimes called the intensive care nursery, newborn intensive care unit or special care nursery. Neonatal refers to a newborn.
Your Baby may end up in the NICU for these reasons:
- Problems during the birth including trouble breathing or infection
- Was born sick or premature (at least 3 weeks before mother’s due date)
- Health problems evident within a few days of birth including problems with intestines, lungs or heart, or also jaundice (skin or white part of the eye turns yellowish)
The doctors and nurses who work in NICU have been specially trained for treating premature and sick newborns. The staff could include:
- One or more nurses assigned to your baby
- Nutritionist (trained to take care of baby’s feedings)
- Neonatologist (doctor trained in newborn medicine and in charge)
- Respiratory therapist (gives treatments to help baby breathe)
- Specialist (trained to treat certain body parts, such as the heart or brain)
What happens in the NICU
To begin with, your child will be placed in a special bed. This could be an incubator, or isolette. This type of bed has clear plastic surrounding it, and keeps your baby warm and safe. Your baby may also be placed in a warmer. This open-type of bed includes an overhead heater.
- Testing – A series of tests will likely be performed to give your child the best care possible. This may include X-rays, urine tests or blood tests.
- Monitoring – Each baby is carefully watched and monitored. Your baby may be connected to a screen with wires stuck on your baby’s skin like stickers. These usually won’t hurt your baby. The screen will track your baby’s vital signs. This includes your baby’s blood pressure, breathing rate, pulse and temperature.
- Medicines – Most babies placed in the NICU will need at least one medicine. This may include infection-fighting antibiotics or medicines that help your baby’s lungs or heart to work. You child may also need an IV placed in a vein to allow doctors to give your baby medicine.
- Additional treatments – Your baby may need other treatments depending on why they are in the NICU. Babies having trouble breathing may need to be attached to a machine called a ventilator to help them breathe. Babies with jaundice may need to be under a special light.
Sometimes, you’ll be able to hold your baby. Use this time to comfort and bond with your baby. Some doctors suggest skin-to-skin contact. In this case, you hold your baby on your bare chest with your baby clothed only in a diaper.
In some situations, it’s not
possible to hold your baby in the NICU. You may still be able to stroke your
baby’s head or hold their hand, though. If you can’t touch your baby, sing or
talk to your child. The nurses and doctors will help you with keeping your baby
Usually other family members can also visit your child, but there will likely be special rules. These rules may include the times they can visit and what they need to do beforehand. This may involve wearing a mask, a special hospital gown and washing their hands. Children may not be allowed to visit, though, since kids are at a greater risk of carrying germs that could harm a sick or small newborn.
Feeding your baby in the NICU
How your baby is fed depends on
how premature your baby is, or how sick your child is. It’s possible your baby
may still be able to nurse, or drink from a bottle. In other cases, though,
your baby may need a feeding tube. This small tube goes in baby’s mouth or
nose, down their throat, and into their stomach. The tube takes formula or
breast milk right to your baby’s stomach. When babies are too sick for a
feeding tube, an IV may be used.
If you want to breastfeed, make sure you speak with the nurses and doctors. Lactation consultants, or rather breastfeeding experts, can help you. If your baby’s not able to suck from your breast, you may want to try a breast pump. This pump takes milk from your breasts, which can then be poured in a bottle or into a feeding tube. If your baby can’t take milk yet, you can store your breast milk for later.
Bring your baby home
How soon you can take your baby
home depends on your baby. With some health issues, babies only need to be in
the NICU for a few days. Some babies, however, are very premature or sick, and
may need to remain in the NICU for weeks or months.
Your child’s nurses and doctors will help you understand your baby’s progress and when you might take your child home. You’ll also get some instructions on caring for your baby at home, and about the follow-up appointments you’ll need in the future.
Having a child in the NICU can be stressful
Having a child in the NICU can be stressful and difficult. There are hospital chaplains, or rather spiritual counselors, as well as social workers that can help you. There are also support groups out there, made up of parents who also have premature or sick babies. It may help you to be able to talk to others going through a similar situation. Try to lean on these sources, as well as friends and relatives. This gives you a support team both at home and in the hospital.