Changes During Pregnancy

Read articles on staying healthy and what to expect during your nine months of pregnancy.

1. Caring For Yourself In Each Trimester

First Trimester: Business as Usual (More or Less)

For most of your first month of pregnancy, you're unlikely to notice much of a change in your body or your feelings. In fact, many women (especially women who have somewhat irregular periods) don't begin to suspect they're pregnant until close to the end of that first month. Soon enough, however, the physical changes make themselves felt. This can be a time of wonder and excitement—but it's also the time of your most raging hormone-based symptoms (particularly morning sickness).

The Second Trimester's Activity Spurt

The second trimester, which runs from the fourth to the sixth month of pregnancy, is always a time of increased energy. This is when you run the risk of boredom if you have nothing to do—and is a great time to have some fun before nature stops you in your tracks.

Third Trimester—Time Out

For most of the third trimester you usually can keep pretty active, but you really do slow down in the last few weeks before delivery. You could do worse than to treat yourself like a cat during this time before delivery: Have you ever noticed how cats do nothing they do not want to do. They luxuriate in their laziness and always seem to know something we humans have yet to figure out.

Here are a few cat-like self-indulgences that can make the final weeks more comfortable:

Take baths with wonderful-smelling oils. Just watch the water temperature—you don't want to get overheated.
Get plenty of rest and insist that your partner support your need to be pampered.
Avoid frustration. If you really want to test your partner's supportiveness, insist that you be in control of the TV remote at all times. After all, his channel surfing could disturb your equanimity.
Lighten up on yourself about housework. Now's the time for your partner to pitch in and take over some—if not all—of the daily chores. This is, after all, the last chance you're going to have—for a long time to come—to just put your feet up and relax.

That last point is really true: If you think you will have the luxury to do what you want when you want after the baby is born, think again. Once you have a baby, you realize that for the next 18 years—and well beyond—you will never again have the luxury of thinking only of yourself. This is not the same as suggesting that you lose your personal identity—it's just a recognition that, in ways different from any other relationship you've ever had, the mother-child tie is lifelong and profound.

2. First Trimester Basics

by Dr. Peter J. D'Adamo with Catherine Whitney

The first trimester is the most critical time in your pregnancy. Although the fetus at the end of three months is only about 4 inches long and weighs less than 1 ounce, all of its functions have begun to form — major organs and nervous system, heartbeat, arms, fingers, legs, toes, hair, and buds for future teeth.

This is not a time to skimp on food or count calories. You're not quite eating for two people, but you do need extra nutrients for your growing fetus. The general recommendation is to eat about 300 extra calories a day. You'll need to gain 25 to 35 pounds during your pregnancy. This will allow you to nourish your fetus and store nutrients for breast-feeding. Expect to gain at least 3 to 4 pounds during the first trimester.

For many women, the first trimester is also the period when you experience the most profound changes. Although you may not appear pregnant, you'll certainly feel all of the differences.

Common First Trimester Conditions
Morning Sickness and Nausea
The nausea — "morning sickness" — that many women experience during the first trimester of pregnancy is the result of hormonal changes. Morning sickness (which isn't necessarily limited to mornings) may actually be a positive thing — though you may not feel particularly grateful. Some scientists believe that morning sickness evolved as a natural way of protecting women against foods that might contain dangerous microorganisms or parasites, or foods whose chemical compositions might prove harmful to a developing fetus, by expelling those foods. Also, increasing levels of the hormone beta-hcg have been linked to nausea. Since high levels of beta-hcg tend to protect against miscarriage, look on the bright side: Your morning sickness may well be an early sign that your pregnancy is off to a good start. Morning sickness usually disappears after the first trimester.

Mood Swings
Women are often surprised that they don't feel more buoyant at the start of pregnancy — especially when it is a long-awaited result. The stresses of the first trimester can produce many emotional ups and downs. Although you may be delighted that you're pregnant, the hormonal adjustments you're experiencing can make you feel anything but joyous. You may experience mood swings, fatigue and insomnia, anxiety about your ability to experience a successful pregnancy, and fear about what will happen.

Constipation
Constipation is a fact of life for most pregnant women. Hormonal changes are largely responsible, signaling food to move more slowly through your system as it nourishes your fetus.

Fatigue
Your entire system is fully engaged in creating a healthy environment for your fetus — producing the placenta, a process that is completed at the end of the third month, as well as providing sufficient nutrients. Every organ is engaged in a vast reorganization. No wonder you're tired.

Food Aversions and Cravings
The food cravings and aversions that many women experience during pregnancy are something of a mystery. While you may crave what's good for you and be repelled by foods that are harmful, it doesn't always work that way. Your best strategy is to eat what's right for you and try to find replacements within your diet for the harmful foods you may crave.

Prenatal Supplements
Vitamins are very important to the developing fetus. However, you should be aware that overdoing supplements can cause grave problems in the baby, so consult your physician before taking any vitamins or supplements.

Virtually any of the commercial prenatal multivitamins will be effective. But many are made with synthetic components rather than the preferred whole food ingredients. Choose a blend of the B vitamins, along with antioxidants. Look for quality, not quantity. Not all formulations release the specified amount of nutrients on the label. When researchers at the University of Maryland tested nine prescription prenatal vitamin tablets to see whether the folate contained would dissolve, only three passed the muster. Two failed so miserably that they released less than 25 percent of the folate specified on the label. That means that if swallowed by someone, more than 75 percent of the folate in those pills could possibly travel right through the body with very little chance of being absorbed by the blood and transported to various tissues, including tissues belonging to the fetus. If possible, use powder-in-capsule versus compacted pills: Evidence suggests that dissolvability is a big problem with many prenatals. Encapsulated ingredients do not need to dissolve.

Your daily prenatal vitamin/mineral supplement probably doesn't give you enough calcium. Most of the daily prenatal formulas only contain about 200 to 300 milligrams of calcium — about 1,000 milligrams less than you and your baby need every day. So check the label on your bottle or talk to your doctor. You'll want to make sure that you are getting at least 1,200 milligrams of calcium every day from natural food sources and supplements.

If you wish to take a prenatal supplement specifically formulated for your blood type, see appendix B for information about "Healthy Start ABO."

Special Note: DHA Supplementation
A natural nutrient for humans of all ages, DHA, an omega-3 long-chain polyunsaturated fatty acid, is one of the essential building blocks of human brain tissue. Found naturally in breast milk, DHA is also present in egg yolk and oily fish, such as salmon and sardines. What does having enough DHA mean for you and your baby? Whether you're a baby or an adult, DHA is important for signal transmission in the brain, eye, and nervous system. Your developing baby receives the DHA through the blood, via the placenta and umbilical cord. Seventy percent of the brain cells are formed before birth. These cells are mainly composed of essential fatty acids, with DHA being the most important because it gives great flexibility to the cell membranes. Flexibility is essential for fast and accurate message transfer in the brain. During pregnancy, the recommended intake of DHA is 300 milligrams per day, in food and supplements. Studies have shown that mothers' diets deficient in DHA are often linked with low head circumference, low placental weight, and low birth weight in their babies.

Exercise Guidelines
There are tremendous benefits to maintaining your exercise program throughout your pregnancy. Regular exercise improves your condition and reduces the risk factors associated with pregnancy. It can also alleviate many of the uncomfortable side effects of early pregnancy, such as fatigue and morning sickness.

One of the most important functions of exercise is its ability to reduce stress and improve your mental condition. Pregnancy itself can be stressful. Throughout your pregnancy, you are also grappling with the effects this new reality will have on your relationship to the world. Your feelings, fears, and expectations about yourself, your family, and the impending arrival of your baby are important, too. To make matters a bit more complicated, your emotions can be affected by the dramatic hormonal changes you're experiencing. This is especially true during the first trimester.

Exercising three to four times a week, according to the blood type recommendations contained in chapters 3 to 6, will help you reduce stress, fight fatigue, and stabilize your emotions.

Exercise is good for your baby, too. Studies show that babies born to moms who exercise during pregnancy may benefit from better stress tolerance and advanced neurobehavioral maturity. These children are leaner at five years of age and have better early neurodevelopment. The new findings are added to the already-known benefits of exercise during pregnancy, including improved cardiovascular function, improved attitude and mood, easier and less complicated labor, quicker recovery, and improved fitness.

In addition to individual blood type guidelines, all blood types should bear in mind the following:

All aerobic exercise is not of equal value. If your regular workout involves contact sports or in-line skating, I'd suggest you forgo them during pregnancy, to avoid any potential injury to the abdominal area.
Make your aerobic exercises the low-impact variety. If you are taking dance or movement classes, keep your feet on the floor. No jumping or bouncing. Or choose exercises such as cycling, swimming, or brisk walking that have little or no impact risks.
Take extra time to warm up and properly stretch your muscles before exercising.
Wear a good support bra to protect your breasts and limit discomfort, especially if they are feeling tender.
Drink plenty of water throughout the workout.
Don't exercise on an empty stomach. Eat a snack 30 minutes before exercising.

Exercise Caution
Though exercise in pregnancy is generally safe, moms-to-be embarking on an exercise program should be aware of warning signs. If any of these symptoms occur, stop exercising and contact your practitioner: sudden and severe abdominal pain; uterine contractions lasting 30 minutes once exercising stops; dizziness; and vaginal bleeding. Other signs to watch for are decreased fetal activity, visual disturbances, or numbness in any part of the body.

For some women, such as those with heart disease, blood clots, recent pulmonary embolism, or for those who have a "high-risk" pregnancy, exercise may not be recommended. In taking the complete medical history, your practitioner will determine if maternal conditions limit, or exclude, an exercise program.

3. Second Trimester Basics

by Dr. Peter J. D'Adamo with Catherine Whitney

As you enter your second trimester, your pregnancy begins to show. The chance of miscarriage is substantially lessened, and you may begin to relax as some of the more uncomfortable symptoms — morning sickness, constipation, fatigue — begin to disappear.

During the second trimester you should gain about 1 pound a week — for a total of 12 to 14 pounds. You may experience a greater appetite, especially if you no longer suffer from nausea. Monitor your weight, and, if needed, increase your calorie intake by 100 to 300 calories a day.

Fetal growth is rapid during the second trimester, and you'll experience a number of physiological changes related to that growth. As your blood volume increases to pump more nutrients to your fetus, you may find yourself more susceptible to nosebleeds and bleeding gums due to extra pressure on these sensitive membranes. You'll also be more vulnerable to conditions that can be dangerous to the health of your fetus if they are not kept in check.

Common Second Trimester Conditions
Allergies
If you are susceptible to allergies, they may be exacerbated during this time by hyperimmunity — the increased vigilance of your immune system designed to protect your fetus.

Bleeding Gums/Nosebleeds
High levels of reproductive hormones circulating in your body increase blood flow to the delicate mucus membranes of the nose and mouth. This can bring easy bleeding when you stress these areas — by brushing your teeth too vigorously or by blowing your nose too hard. If you have allergies, a runny nose can make the problem worse.

Blood Sugar Imbalance
Most pregnant women have more sugar (glucose) in their blood during the second trimester. This is normal, since your fetus requires more nourishment. However, elevated blood sugar can lead to a dangerous condition called gestational diabetes, which can cause premature birth and even birth defects.

Hemorrhoids and Varicose Veins
These are inflammatory conditions. Hemorrhoids are actually varicose veins of the anus.

Exercise Guidelines
As your pregnancy progresses, the extra weight and its unwieldy distribution place stress on your joints and muscles, especially in the lower back and pelvis. You might also have problems with circulation, causing leg cramps and dizziness. Adapt your exercise regimen accordingly. If you are still engaging in rigorous workouts, such as cycling or step exercises, this would be a good time to shift to less strenuous activities — and those that don't require careful balance. As your fetus has grown, your center of gravity has shifted. You also may have less oxygen available, so reduce the pace of your routines, or stop altogether if you become breathless.

After the first trimester, avoid exercises that require lying flat on your back. The weight of your expanding uterus can compress major blood vessels and restrict circulation. Do your abdominal exercises in a standing position, and other floor exercises lying on your side.

Overheating during exercise can be dangerous. Keep your body temperature at a moderate level. An increase of more than one degree of body heat can be dangerous. If you're not sure, wear a monitor.

When Not To Exercise
You have pregnancy-induced high blood pressure

You have asthma
You experience bleeding during the second trimester
You have a history of late miscarriage

Do Your Kegels
Kegel exercises should be a part of your daily routine, beginning in the second trimester. During the last months of pregnancy the growing fetus puts pressure on your bladder, which makes you feel the need to urinate frequently. Sometimes women limit their fluids when this happens, but it's absolutely essential that you keep your fluid intake high to stay hydrated. A better solution: Kegel exercises to strengthen the muscles around your urethra. Here's how: Contract the muscles in your vagina, urethra, and anus — as if you were trying to hold back urine. Hold for 5 to 7 seconds, then release. Repeat 10 to 20 times a day.

4. Third Trimester Basics

by Dr. Peter J. D'Adamo with Catherine Whitney

The third trimester is dedicated to intensive fetal growth. Your fetus will gain fully half its weight during this period. In the final months there will be further essential lung and brain development. The food you eat during the final three months is directly utilized in increasing your baby's birth weight. The quality of the food you eat continues to be of primary importance.

As you approach the birth of your baby, typically after some forty weeks, it's normal to feel equal measures of excitement and apprehension. If this is your first pregnancy, you're entering the great unknown. You may find your thoughts filled with worries about whether your baby is all right, and dread about what you'll experience during labor.

If you've participated in childbirth classes and have a strong partnership with your doctor or midwife, some of that anxiety will be alleviated. And if you've adhered to your blood type plan, you can have some degree of confidence that you've done the best you can to assure a healthy baby.

The key now, as you prepare for labor, is to be as physically and mentally prepared as possible. Continue to gain about 1 pound per week during the seventh and eighth months. Your weight may stabilize — and you may even drop a pound or two during the ninth month.

Common Third Trimester Conditions
Lack of Appetite
Many women find they have far less appetite later in pregnancy. One reason is the pressure of the growing fetus on your abdomen. There's simply less room for food. The best way to combat this is to eat something, even a small snack, every 3 to 4 hours. Don't drink water or juice with a meal. Liquid fills your stomach quickly, leaving less room for solid food.

Constipation
Constipation, which afflicts many women in the first trimester, often reappears in the final months of pregnancy.

Edema
Sluggish metabolism, often triggered by eating the wrong foods for your blood type, leads to an accumulation of extracellular water, which, in turn, causes edema. Mild swelling, especially in your legs and feet, is to be expected during pregnancy.

Shortness of Breath/Fatigue
By the third trimester, you'll be carrying a heavy and awkward load. The pressure of the expanding uterus on your respiratory system can cause shortness of breath even with mild exertion. Fatigue can also be caused by sleeplessness. Many women have trouble sleeping in the final months because they can't get comfortable.

Indigestion and Heartburn
You may find that the pressure from your growing fetus constricts your digestive tract, forcing stomach contents back up through the esophagus. You can minimize acid reflux or heartburn by eating small, regular meals, chewing food thoroughly, and eating slowly. Don't lie down for at least an hour after eating.

High Blood Pressure
If your edema is more serious, it could be a sign of preeclampsia. Eclampsia is a severe condition associated with elevated blood pressure. Even women who are not normally at risk for high blood pressure sometimes develop a pregnancy-induced hypertension. High blood pressure can restrict blood flow to the placenta and rob your fetus of oxygen and vital nutrients. If you have hypertension, you'll need to get more rest and even stay off your feet.

Urinary Tract Infections
UTIs are very common during pregnancy. In the third trimester they are more serious because of the potential for developing a kidney infection. Kidney infections can provoke preterm labor.

Exercise Guidelines
Keep in mind that exercise is not only tolerated, it can prevent potentially serious complications, such as high blood pressure that can lead to preeclampsia. Exercise during pregnancy may also prevent some of the aches and pains associated with carrying extra weight and the changes in gait. However, pregnancy is such a different experience for each individual that, according to your own level of fitness and your needs at this time, it is best to approach your exercise program with great care and scrupulous attention to both form and function. Don't hesitate to adapt your daily workout according to your needs. It is common for women in the final months to feel short of breath, especially when exercising. Awkwardness, leg cramps, and pelvic aching can all hinder your ability to exercise as fully as you once did. Care should be taken to rise gradually from the floor to avoid dizziness.

Dads Take Note: Stress and Weight Gain
As your wife's pregnancy progresses, be aware of your own stress triggers. A recent study showed that men gained an average of 3 to 4 pounds during their wives' pregnancies. First-time fathers tended to eat and drink too much in response to stress.

Advice from the Naturopath Midwife Cathy Rogers, N.D.: Perineal Massage
Your body is making lots of new hormones that enhance the relaxation and elasticity of your muscles. This elasticity allows your abdomen and pelvis to accommodate the rapidly growing fetus. You can use this to your benefit by beginning to stretch the vaginal opening to ease the delivery of your infant's head and minimize the need for an episiotomy.

Recline comfortably, either on your bed or the floor. Place a small amount of warm almond or olive oil on your thumb. Insert your thumb into the vaginal tract, and gradually apply light pressure downward toward your feet. Do this for a count of 10, then allow another count of 10 for relaxation. Repeat five to six times. Practice this stretching routine daily in the third trimester — and invite your partner to participate.

5. Side Effects Of Pregnancy

Diet And Morning Sickness
Pregnancy is not without very real—and sometimes very annoying—symptoms. Particularly during a first pregnancy, your hormones will very likely treat you to such wonderful experiences as the legendary morning sickness. Your body is preparing itself for the process of gestation. Each person has a different threshold for tolerating nausea but for some it can be quite debilitating. It usually settles down after a few weeks but sometimes can plague you throughout the entire pregnancy.

And by the way, although it's commonly called morning sickness, you can experience nausea at any time of day or night. A good way to ward off the queasies is to stick to bland foods like soda crackers or dry toast. Fluids also help. If you are actually vomiting, make sure you replace your fluids and electrolytes with drinks designed for that purpose. Gatorade or other sports drinks can help.

Restricting your diet to accommodate your morning sickness can be tough—especially if old favorites of your prepregnancy days are now triggering the nausea response. Just keep in mind that this, too, shall pass. And promise yourself a great post-pregnancy reward of all the foods you're denying yourself now.

Sleepy-Time Gal

So many physical changes happen when you are pregnant that it sometimes feels as though you're only renting your body and are at the mercy of an absentee landlord. During your first trimester you will very likely feel greater fatigue than you have ever felt before.

Listen to what your body is telling you. When you are tired do your best to catch a nap. If you're working during your pregnancy, even a few minutes with your head down on your desk can make a big difference—you might want to put a co-worker on “snore alert,” just in case. Don't try to overcome the drowsiness with caffeine; it is not good for you or your baby.

Food Fancies

Even if you're one of the many lucky ones who don't have to deal with morning sickness, you'll probably still find your food preferences changing. For some reason, foods you might not have been crazy about before can start to taste incredibly delicious. (For me it was Japanese food, but you should skip the sushi—it's not recommended during pregnancy.)

You may even experience that old stereotype of pregnancy: food cravings. Don't feel guilty! Although there's no hard-and-fast scientific proof, many doctors believe that some cravings are actually your body's way of telling you what you need. For example, a craving for very salty foods may indicate that your body is in a stage of doubling the volume of blood in your uterus to accommodate the needs of the baby—a process that depletes your system of its normal complement of salt.

6. Feeling Your Babies First Movemens

Let the games begin. Sometime in the fifth month, your baby will give you a hello kick. (It's been moving since the ninth week, but you haven't been able to feel it.) This is an absolutely thrilling moment, which you can easily miss if you aren't paying attention. Women describe these first movements as a feeling of butterfly wings flapping inside them; others feel a faint twitch or a punch. You might even think you are feeling hunger pains or gas.

After a while, you might be able to tune into your baby's sleep/wake schedule. Often she'll wake and move around as soon as you lie down to rest. Although your baby's activity at this time might seem like an intentional plan to get you used to staying up all night, it probably means that you're simply more focused and aware of her movements than you are when you're active yourself. Also, babies like motion; it lulls them to sleep.

If you don't feel any kicking this month, tell your doctor—but don't panic. If the heartbeat is strong and all other vital signs are stable, there's no reason to worry. It might simply be that you're due later than you thought (making your baby a few weeks younger).

7. Dressing For Two - Maternity Clothes

Your pregnancy is one crazy fashion opportunity. Your size changes day by day, so it's a real challenge to find clothing that looks good now and will still do the job next week. Your needs in this department depend, of course, on your lifestyle. If you are working, you'll need to build a wardrobe that can cover your expanding body and still look professional. If you spend more time at home than in public, you can get away with large shirts, leggings, and sweat suits for quite a long time.

When it's time to shop to cover the bulge, you might be tempted to run to the nearest maternity clothing shop. The problem with this is that maternity clothes are expensive. You're talking about a whole new wardrobe that you'll wear for a maximum of four months. That's a lot of money. Before you refinance your house to support this fashion spree, consider a few alternatives that can get you through the fifth month without great expense:

Visit your partner's closet. Your partner has shirts, shorts, sweatpants, and sweaters that might fit you just fine in the first four or five months.
Revisit your own closet. During the first five months you might be able to wear a few of your favorite belted dresses, if you remove the belts. You might be able to create outfits by wearing blouses on the outside and by doing some camouflage work with tunic tops, large button-down blouses, large denim shirts, classic A-line or empire dresses, large vests, and boxy blazers.
In the beginning of your pregnancy, you can buy a great nonmaternity outfit on sale in a size or two larger than your prepregnancy size.

When it's time to hit the maternity shops (usually sometime in the fifth or sixth month) you'll find that maternity clothes are made differently than your nonpregnancy clothes—at least they should be. When you shop, look for…

A dress hem line that is longer in the front. This hem pulls up as your belly expands. (That's why buying nonmaternity dresses in large sizes won't work.)
Extra room in the upper arm and bust. You will need it.
No lining. Your body temperature is higher during pregnancy and lining can be very warm and uncomfortable.
Clothing that can be layered to adjust to your changing body temperature.
Clothing that can be mixed and matched to give you a varied selection without spending a fortune.
Easy care, durable material. Maternity clothes are washed and worn about four times as often as nonmaternity clothes.

Looking good during your pregnancy is one way to bolster your self-image. Do yourself a favor and borrow and buy a wardrobe that is stylish and flattering. Today's maternity fashions can make even the largest pregnant woman look fabulous.

8. Psychological Development During Pregnancy

The Work of Pregnancy
The nine months of pregnancy offer parents-to-be the opportunity for psychological as well as physical preparation. The psychological preparation, unconscious as well as conscious, is closely interlocked with the physical stages of a woman's pregnancy. After nine months, most parents feel a sense of completion and of readiness. When this time is cut short, as it is in premature labor, parents feel raw and incomplete. When there are physical complications, they endanger the psychological adjustment.

The psychological work of pregnancy may surface as turmoil or anxiety. Emotional withdrawal or regression to a more dependent role in other relationships within the family is common in this period. The prospect of responsibility for a new baby lends a sense of urgency. A parent-to-be needs to withdraw or regress in order to reorganize. The anxiety within both parents may carry them back to the struggles and ambivalent feelings of earlier adjustments. This mobilization of old and new feelings provides the energy necessary in the huge job of adjusting to a new baby.

Both expectant parents and those who care for them must understand the power and ambivalence of the feelings that accompany pregnancy. Prenatal visits, whether with obstetricians, nurses, pediatricians, or, in certain cases, psychiatrists, must allow for the expression of a wide range of positive and negative feelings. In the authors' experience, pregnancy - like many other critical phases of life - is perceived differently by psychiatrists and pediatricians. The former are consulted in cases of crisis and troubled outcome, and thus are alert to the potential for neurotic or psychotic problems in pregnancy. The latter are more likely to be impressed by a mother's amazing capacity to rearrange her whole life toward the welfare of her child. By looking at the stages of pregnancy from our dual point of view, we hope to illuminate this remarkable period and also to trace within it the birth of parental attachment.

The work of pregnancy can be seen as three separate tasks, each associated with a stage in the physical development of the fetus. In the first stage, the parents adjust to the "news" of pregnancy, which is accompanied by changes in the mother's body, but not yet by evidence of the actual existence of the fetus. In the second stage, the parents begin to recognize the fetus as a being who will eventually be separate from the mother. This recognition is confirmed at the moment of "quickening," when the fetus first announces its physical presence. Finally, in the third and final stage, the parents begin to experience the coming child as an individual, and the fetus contributes to its own individuation by distinctive motions, rhythms, and levels of activity.

Stage One: Accepting the News
"I'm having a baby!"

In the past, a mother waited after a missed period for further confirmation of pregnancy from her own body. Changes in the color and sensation of the nipple, "morning sickness," or weariness made the fact of conception gradually more certain. Nowadays, parents are likely to receive the "news" from a physician after a pregnancy test, or even from a chemical reaction in a home pregnancy test.

However and whenever the news comes, parents will know that they have stepped into a new phase of their lives. Their feelings of dependence on their own parents must give way to responsibility. Their one-to-one relationship with each other must evolve into a triangle.

Initially, both parents are often euphoric. But almost at once the euphoria is replaced with a dawning awareness of future responsibility. When conception is planned, this awareness may have been faced already to some extent, but the reality of pregnancy requires a new level of adjustment; soon there will be no turning back.

The "work" of pregnancy now begins in earnest. The prospect of parenthood throws adults back to their own childhood. No adult looks back on childhood as unmitigated pleasure. The struggles of growing up are mobilized each time an adolescent or young adult faces a crisis and, in pregnancy, these struggles are raw once again. The first fantasy of most parents-to-be is one of avoiding the struggles of their own childhood and of becoming perfect parents. "Not one like my mother." "My father tried, but he got everything wrong." "I certainly hope I can do better than they did!" What is it that parents wish to do better? Is it to protect their child from an imperfect world, or from the perceived negative sides of themselves? The latter is the more likely. As we mentioned earlier, all parents hope that they will be able to shield the new infant from their own feelings of inadequacy, or from the perceived failures of their own lives. With this magical wish that their own inadequacies can be conquered, parents-to-be see themselves as completely nurturant, completely positive - ready to create the perfect child.

Behind this fantasy is also ambivalence. At some point, all parents-to-be begin to wonder why they ever let themselves in for such an adjustment. "Do I really want to be a mother, a father? If I don't, have I hurt this baby already? Can I hurt an unborn baby with my fears, my negative feelings?" Especially for a pregnant woman, the depth of the caring involved in this adjustment makes her so vulnerable that her magical thinking about hurting her fetus becomes very real. All pregnant women dream about the possibility of having a defective child. Not only do they dream of all possible aberrations, but in waking, they rehearse what they would do if their child were born handicapped. Any danger to the fetus that they may have read or heard about will be called up at some time during pregnancy. The barrage of information now available about the effects of drugs, food, tobacco, alcohol, or pollution on the developing fetus only exacerbates the fears that universally haunt pregnant women.

In order to overpower such fears and her underlying ambivalence, a mother-to-be must mobilize more and more defenses. She must begin to idealize the infant, to visualize the baby as perfect and as completely wanted. The work of overpowering the negative forces escalates the positive wishes for the baby and for being the perfect parent.

As a pregnant woman struggles through this turmoil of ambivalent emotions, she will be especially available to the support of others. A physician or nurse or friend who is an experienced mother will be accepted readily. An expectant mother often develops a strong transference to any supportive professional at this time. She yearns for understanding of her powerful emotions, for mothering as she prepares to be a mother. Professionals or family members who can accept this temporary dependency on the part of a mother without being overwhelmed will be helping to launch a stronger family.

During this time, many women tend also to withdraw into themselves. The rebalancing of hormones and other physical processes is paralleled by emotional adjustments, and a great deal of time and energy is needed to achieve a new stability. Days may be spent in daydreaming, nights in sorting out strongly ambivalent dreams. When this inner work is successful, a mother can eventually look forward wholeheartedly to her new role. But she may spend a great deal of her own and her family's energy in the attempt. In the process, she will, in all likelihood, withdraw somewhat from her previous relationships. She may even unconsciously blame her husband and others for her condition, even while, simultaneously, feeling a sense of elation. Now and then, she is likely to feel that she has been forced into this role. Such feelings may represent her effort to share or displace responsibility for the overwhelming adjustment, and may also represent a realistic reaction under certain social and economic conditions.

A woman's most immediate task is to accept the "foreign body" now implanted within her. She may experience the embryo as an intrusion by her mate, and may temporarily want to withdraw from the man who has impregnated her. Just as her body lowers its defenses against this "foreign body" and comes to accept and shelter it, the mother, too, must come to experience the child-to-be as a benign part of herself.

Often, in an effort to accept her new condition, a woman will turn to her own mother or her mother-in-law. But here, too, she may feel ambivalent. Morning sickness and other physiological symptoms may serve to express the negative side of her ambivalence, while consciously she may be adapting with enthusiasm to her role. All pregnant women face this ambivalence, which surprises and disappoints them. Feelings of helplessness, of inadequacy, may even express themselves in the wish for a spontaneous abortion. While the disappointment and feelings of guilt that accompany either the bleeding of a threatened abortion or the reality of one belie this ambivalence, they are always there. Only gradually does the drive toward motherhood, with all the powerful components that we saw earlier, transform this ambivalence into fuel for the work of pregnancy, into the positive anticipation and energy of the later months.

Stage Two: First Stirrings of a Separate Being
At some point during the fifth month of pregnancy, a mother will feel the first butterfly motions of her baby-to-be. These delicate, stroking sensations will gradually turn into vigorous activity. After the confirmation of pregnancy, the moment of quickening is the next landmark event for expectant parents. This news, too, will be eagerly shared with husband, family, and friends.

Until this moment, mother and baby-to-be are one. Until this first fluttering of life, a mother can entertain the narcissistic image of total fusion with her child. Now, psychologically speaking, the baby has begun to "hatch." The earliest attachment may be said to begin here, for there is now a separate being, the possibility of a relationship. Quickening is the child-to-be's first contribution to the relationship.

When the mother begins to recognize the life of her fetus, she will unconsciously put herself in its place, identify with it. Her fantasies will be based on her infantile relationship to her own mother. Dinorah Pines reported a vivid instance of this two-layered fantasy. One of her patients had a series of dreams in which she became progressively younger as the pregnancy progressed; shortly before birth, she dreamt of herself as a baby sucking at the breast, "thus combining the representation of herself as the mother and as the newborn child" (Pines, 1981).

The new concreteness of the baby, supplemented by ultrasound images and the now visible body changes in the mother, brings both a new reality and new fantasies to the pregnancy. The mother can identify with the now evident fetus and also replay her own wishes of fusion and symbiosis with her mother. This fantasized "return to the womb" allows for yet another working through of unfulfilled dependency needs and symbiotic wishes. It is as if - through the mediation of her unborn child - the mother can "plug back into" the rewarding aspects of her early relationships with her mother, refueling and revitalizing herself.

Curiously, this resembles the way toddlers dart back to their mothers, finding in that contact new energy to pursue their development toward individuation (Mahler et al., 1975). Pines points out that pregnancy offers mothers a new opportunity for working through separation conflicts, promoting a new phase in their process of disengagement (individuation) from the original symbiotic relationships (Pines, 1981).

This regressive trend can also activate conflict and pathological reactions. It may be experienced as a threat to identity, for it reawakens strong feelings of fusion between the mother and her own mother. If the mother's need for dependency is too great and unfulfilled (in some teenage mothers, for example), she will experience her fetus - and, later, her baby - as a rival, and may treat the infant as an envied sibling. In this case, mothering will seem a heavy burden and even a frustration of her own needs. When things go well, however, this regression to symbiotic identification with the baby will lead to renewed psychic energy and also a source of empathic knowledge of what a baby is all about.

Recognition of a father's role helps a mother see the baby as separate from herself. If she remains aware that her pregnancy resulted from an act on the father's part as well as her own, and, ideally, of the father's wish for a child, she will avoid falling prey to the illusion that she alone produced the baby. When a woman chooses single parenthood, and especially when she chooses artificial insemination, these issues may be clouded. A woman who uses a man simply to fertilize her, or uses a sperm bank, is more likely to entertain the illusion that the baby is the result of her own omnipotent creativity. Her fears and doubts, as well as her hopes, will be heightened.

Acknowledging the father's role not only helps a mother-to-be with the job of separating from the fetus, and of differentiating it from her fantasies, but reassures her that she alone will not be responsible for any successes or failures. This can cushion her fears of inadequacy and her anxiety about her new role. If the relationship with the father has been fraught mainly with resentment and conflict, this may be projected onto the child-to-be. But if the relationship is sound, if the father endorses his responsibility as a co-creator and doesn't flee from his role, the mother will have a better chance of recognizing that the child is a separate being, with a separate potential for growth. As we will see later, the wish for a child also holds many promises for the father, thus bolstering his own attachment to his future offspring.

The beginning of fetal movement and the recognition that the baby is a reality heighten the mother's self-questioning. Periods of depression and elation may come over her unpredictably. Her fantasies about the baby become more specific. During this period, she may begin to dream about the perfect boy or the perfect girl. Her preference for one or the other may begin to surface, or she may repress her real wishes for fear of endangering the fetus. The traditional belief in the "evil eye" and the superstitious rituals surrounding pregnancy are expressions of the universal desire for a perfect baby and the associated fear that the mother will do something to endanger the fetus. So concerned are mothers-to-be with their own struggles, that intelligent women often express surprise and gratification when told that all women worry during pregnancy.

The rehearsal for an abnormal infant continues during this period. By the time the infant is born, a woman will have worried about every possible kind of problem her baby may present. She will have rehearsed in her dreams and fantasies what she must do if she is presented with a Down syndrome baby, or a cerebral palsied infant, or one who embodies any of the abnormalities that she has heard of in either her own or her husband's family. Hence, a premature or an impaired infant comes less as a surprise to a mother than as a disappointment for her lack of success in all the effort she has made during pregnancy. She will have rehearsed and even mobilized forces for helping her deal with the failure, but she must still face her grief at losing the "perfect" baby she dreamed of as a reward for her work.

The experiences of diagnostic amniocentesis and of ultrasound techniques for visualizing the fetus have a complex effect on this work of adjusting to a baby and a new role. Although mothers (and fathers) profess a hunger to know the sex of the baby (which can be determined by amniocentesis), a surprising number (about 40 percent) do not wish to be told. The pregnant woman's curiosity and amazement at seeing her baby visualized on a screen in the third month is accompanied both by awe and by a fear of looking too deeply below the surface. The work of adjusting to her ambivalent feelings and fears about the fetus has just begun. She is not ready to face the baby as a reality yet. Many first-time expectant mothers who watch the screen on which the fetal movements are being visualized express mixed emotions.

They see the fetus as inadequate, fearsome, or incomplete. They turn away from the screen as if it were too frightening or overwhelming. "Is that a real baby?" "He looks so tiny and helpless." They find unbelievable the obstetrician's reassurance that the fetus is normal, and need to hear it over and over. Until they themselves feel the fetus's movement in the fifth month, this poorly visualized, shadowy creature is likely to be seen as unreal, vulnerable, fearsome. Such feelings are a reflection of the mother's struggle with her own ambivalence. She needs more time to get ready for the baby.

Elizabeth Keller, a Child Development Fellow at Boston Children's Hospital Medical Center, compared mothers and fathers who were told the sex of the baby after amniocentesis or ultrasound with parents-to-be who didn't know the sex of their baby until birth (Keller, 1981)³. One might expect attachment to, and early personification of, the newborn baby to be enhanced by foreknowledge of the baby's sex. Not at all. The parents who knew the baby's sex took longer to personify and recognize the individuality of the baby after birth. It seems there may be a protective system at work - protecting the parents and the baby from a too-early attachment. The work of attachment to an individual baby takes time, and early attempts to consolidate it may be rejected. Once again, this points up the problem of adjusting to a premature infant, for whom this work of attachment has been foreshortened.

Stage Three: Learning About the Baby-to-Be
During the last few months of pregnancy, parents see the fetus as increasingly separate and increasingly real. Names are often chosen during this time, houses are rearranged to accommodate the baby, and plans are made for leave from work and for childcare. As parents muse about names, select baby clothes, or paint the nursery, they begin to personify the fetus. During this same time, the fetus is now also playing its role. As fetal motion and levels of activity begin to fall into cycles and patterns, the mother can recognize and start to rely on them. Her response can be seen as a very early form of interaction. She will begin to read into these patterns, giving the baby-to-be a temperament, a personality, sometimes even assigning a sex (Sadovsky, 1981). A mother with older children will compare the behavior of this fetus with that of her earlier ones. She will label these perceived characteristics "quiet," "aggressive," "like a dancer," "like a football player," and so forth, giving meaning to them in the process. It is as if the mother needed to personify the fetus so that he or she will not be a stranger at birth.

Many of the observations of pregnant women over the centuries are being confirmed by modern ultrasound. In order to understand the rich variety of fetal activity to which parents are responding as they endow their unborn baby with an individual personality, we will look briefly at what is now known about fetal development.

Fetal Movements. The full repertoire of movements of the newborn baby can be seen before birth, in the fetus (Milani Comparetti, 1981). A great deal of motor development takes place during pregnancy, preparing for adaptation after birth. For instance, breathing movements are now known to be present as early as 13-14 weeks. These rapid, irregular breathing movements are associated with low-voltage, high-frequency "electrocortical" activity in the brain (Boddy et al., 1974). Fetal movements have been the object of particular attention, because they can be studied by noninvasive methods and because they have diagnostic value. As an extreme example, marked decrease and cessation of fetal movements indicate impending fetal death. Fetal movements are affected by various agents: alcohol, tobacco, sedatives, maternal emotional stress.
Fetal movements evolve in intensity and form during pregnancy.* Around 6-7 weeks, smooth, circular movements of the body are seen. These movements become more complex as time goes on.
Around 13-14 weeks, flexion and extension movements, opening and closing of the hands, swallowing, and breathing movements are present. Mechanical stimuli produce a startle response, and the fetus's ability to habituate to stimuli can be demonstrated.
Around 15 weeks, a fetus will suck on its fingers.

Between 16 and 20 weeks, mothers first perceive fetal movements.
Around 20-21 weeks, one can see isolated segmental movements of fingers, foot, eyelids.
Around 26-28 weeks, a stimulation by sound will induce a startle response or trunk and head rotation, and an increase in heart rate (Janniruberto & Tajani, 1981).
There can be great variations from one fetus to another. While recordings have shown that the mean number of daily fetal movements increases from about 200 in the 20th week to a maximum of 575 in the 32nd week (then to a mean of 282 at delivery), the number in an individual fetus can range from 50 to 956.
Mothers' reports concur with objective measures of fetal movements in 80-90 percent of cases. Fetal movements are affected by various stimuli, increasing after exposure to sound, and also after light stimulation. Ninety percent of fetuses move more during ultrasound exposure. Touch and pressure on the mother's abdomen also trigger an increase.
Cycles of Activity. The states of consciousness observable in the newborn - quiet, alert, sleep, REM sleep, and so on - are observable in the fetus. These states appear to occur in cycles. During maternal sleep, a rhythmic rest-activity cycle of 40-60 minutes was observed over twenty years ago (Sterman, 1967). A rhythmic rest-activity cycle of 40-80 minutes has been noted more recently, in both awake and sleeping mothers (Granat et al., 1979). A marked circadian rhythm of fetal movements has been shown as well (Roberts et al., 1977). This periodicity in fetal activity was not found to be correlated with gestational age, nor with fetal sex, birth weight, or with assessment of newborn behavior such as the Apgar score. Rather, it seems to be connected to intrinsic physiologic properties of the fetus, and may be affected by maternal activity.
In the later months of pregnancy, any woman can tell what times of day her fetus will be active. Most women predict that peaks of fetal movement will occur at times of inactivity for them. Although this association has been attributed to their available awareness during rest periods, there is reason to believe that the observation is correct. The fetus may begin to "adjust" to the mother's rest-activity by reciprocal activity and inactivity. When she is active, it will be quiet. When she is quiet, it will begin to "climb" the uterine walls. The lactic acid of muscular activity, which peaks as the mother rests after activity, has been thought to stimulate fetal movements. A fetus's predictability and adjustment to its mother's rhythms become further evidence for the mother of his or her existence as a person, a person who can "adjust to her," as well as to the pressures of her life.
When asked to keep a record of a fetus's rest and activity, mothers can make extremely accurate predictions after two or three days of conscious attention to these cycles. Such regular, organized cycles dominate fetal behavior. Distinctions between states of activity in the fetus become more and more evident to the mother.
In the last trimester, women can tell when their baby is in (1) deep sleep (quiet and essentially unresponsive to outside stimuli with, at most, an occasional jerk of an extremity), (2) light sleep (quiet, but with bursts of repetitive movements of the extremities, hiccoughs, and, occasionally, slower thrusts of the arms, legs, or trunk), (3) active awake ("climbing" the uterine wall, with bursts of thrusting, vigorous movement), and (4) alert but quiet (apparently waiting and receptive to external stimuli, with smoother, more directed movements, often in response to external events).
Responses to Stimuli. Of the species that are helpless at birth (altricial), humans are the only one in which all the sensory systems are capable of functioning before birth (Gottlieb, 1971). Immature neural tissue functions before nerve-ending receptors are present, before myelinization is complete. Stimulation apparently plays a role in the maturation of sensory organs. This maturation appears to be accelerated or slowed down by increased stimulation or lack of stimulation, respectively.
As early as day 49 after fertilization, the fetus will bend its head away from the site of stimulation when the face is touched lightly near the mouth. Sometime between day 90 and day 120, the so-called "righting reflexes," in which the fetus attempts to keep its head in balance, begin to appear. At about six months, the fetus is capable of responding to auditory stimulation. At this time, fetal heart rate changes in response to sound stimulation have been recorded.
In the last trimester, there are discrete evoked responses of the fetal cortex that can be measured with noninvasive techniques (Rosen & Rosen, 1975). Electrodes applied directly to the fetal scalp after rupture of the membranes demonstrate a rich range of responses to sound, touch, and visual stimuli. Observing whether the fetus is able to habituate to these is one way of measuring fetal well-being; if the fetus keeps on responding with no change, it may be under stress (Hon & Quilligan, 1967). Using maternal reports and confirming them with fetal behavior during ultrasound monitoring, we [TBB] became convinced that the fetus in the last trimester responds reliably to visual, auditory, and kinesthetic stimulation (Brazelton, 1981a).
When a bright light is shone on the mother's abdomen in the fetus's line of vision, it will startle. If a softer light is used in the same position, the infant turns actively but smoothly toward it. A loud noise next to the abdomen will also produce a startle, while if a soft noise is used, the baby will turn toward it. When stimuli are offered while the fetus is in a quiescent state resembling sleep, the responses are less predictable, more subdued, and the fetus habituates to them more rapidly. These differentiated responses to external stimuli can be perceived as signals by the mother. If these signals coincide with her own responses, they may initiate the beginnings of synchrony between mother and child.
While in the womb, the fetus is being preconditioned to maternal sleep-wake rhythms and to the mother's style of reactivity. Not only have newborn babies experienced their mother's rhythms in the womb, but auditory and kinesthetic cues from her are now "familiar." No wonder a newborn already prefers a female to a male voice at birth (Brazelton, 1979). The fetus's reaction patterns are shaped and made ready for "appropriate" cues after birth. Meanwhile, the parents are learning about their baby. Toward the end of pregnancy, mothers report more and more differentiated responses. They say that their babies react one way to a Bach concert - with smooth, rhythmic kicks - and an entirely different way to rock music - sharp, jerky movements. When they announce this, they are proudly stating that the baby is an aware, competent being already. The baby is not only aware of the environment, he or she is demonstrating a readiness to meet it. Parents now begin to see their babies as strong enough to survive in the outside world. The more parents can imagine an unborn child as a competent, interacting individual, the more confident they can be about the baby's ability to survive labor and delivery.
As a mother gets closer to delivery, however, her fears about having damaged her infant once again weigh more heavily. In fact, so raw are these fears that few women can even speak of them in the last month. They must be repressed or they can become overwhelming. To balance these fears, the parents continue to personify their child. The fetus's characteristic movements and responses become of heightened value in demonstrating its integrity. The more a mother can see her unborn baby as a separate person, the more protected she feels from her own imagined inadequacy and incompetence. Mothers who can see their child-to-be as strong and resilient may even perceive the child as an ally in the difficult task of delivery.

The Task at Birth
During the forty weeks of pregnancy, the growth of the fetus is paralleled by a progressive development in the mother's image of the baby. As we have seen, this image is based both on narcissistic needs and yearnings and also on perceptions of the fetus's development: quickening, activity, patterns of response. Thus, when birth occurs, the mother has long been prepared to cope with (1) the shock of the anatomical separation, (2) the adaptation to a particular infant, and (3) a new relationship which will combine her own needs and fantasies and those of a separate being. Not only is pregnancy a period of rehearsal and anticipation, it is also a phase during which old relationships have a chance to be reshuffled, as well as a continuing confrontation between wish fulfillment and the acknowledgement of reality.

When the moment of delivery arrives, the mother must be ready to create a new bond, and also to be amazingly available to enter that condition Winnicott described as a form of "normal disease," a state of total involvement in which mothers become able to "step into the shoes of the baby" (Winnicott, 1986).

Among the formidable tasks that face the mother at birth are:

An abrupt ending of the sense of fusion with the fetus, of the fantasies of completeness and omnipotence fostered by pregnancy;
Adapting to a new being who provokes feelings of strangeness. Michel Soule has described these as feelings of unheimlichkeit (Soule & Kreisler, 1983);
Mourning for the imaginary (perfect) child, and adapting to the characteristics of her specific baby;
Coping with fears of harming the helpless child (often experienced in new mothers, for instance, as the fear of drowning the baby in the bath);
Learning to tolerate and enjoy the enormous demands made on her by the total dependency of the baby; in particular, she has to withstand the baby's intense oral cravings, and gratify them with her body.

All this represents a major psychological upheaval. It is as if a new mother must go through a complete "shake-up"; her previously held positions, her attachments, her image of herself are all subject to change. So pervasive is this upheaval, in fact, that it can resemble a transient pathological state. The result is a new maternal identification, a focusing of her affections, and an ability to acknowledge and adjust to an inescapable new reality (Brazelton, 1981b).

During this time, others (husband, family, doctor) can play a vital supportive role. For instance, a prenatal visit with the future pediatrician can be of great help. Young parents are particularly eager to establish a positive relationship with a benevolent figure interested in the future child's welfare (Bibring et al., 1961). Even one short visit will do much to allay parental fears and to prepare for mutual cooperation in later routine visits. One of the unconscious factors often involved here is a desire for the physician to allay a mother's guilt by "allowing" her to have a child, reassuring her that her body is capable of carrying and delivering a healthy fetus.

Apart from her pediatrician or an understanding obstetrician, a mother, of course, has two important allies as she summons her energies to face these tasks. The father of the baby is experiencing many upheavals, some different, some parallel to her own. And their newborn baby will be a powerful force in their new lives, capable from the start of contributing to the growing relationship.

Fetal Movements. The full repertoire of movements of the newborn baby can be seen before birth, in the fetus (Milani Comparetti, 1981). A great deal of motor development takes place during pregnancy, preparing for adaptation after birth. For instance, breathing movements are now known to be present as early as 13-14 weeks. These rapid, irregular breathing movements are associated with low-voltage, high-frequency "electrocortical" activity in the brain (Boddy et al., 1974). Fetal movements have been the object of particular attention, because they can be studied by noninvasive methods and because they have diagnostic value. As an extreme example, marked decrease and cessation of fetal movements indicate impending fetal death. Fetal movements are affected by various agents: alcohol, tobacco, sedatives, maternal emotional stress.
Fetal movements evolve in intensity and form during pregnancy.* Around 6-7 weeks, smooth, circular movements of the body are seen. These movements become more complex as time goes on.
Around 13-14 weeks, flexion and extension movements, opening and closing of the hands, swallowing, and breathing movements are present. Mechanical stimuli produce a startle response, and the fetus's ability to habituate to stimuli can be demonstrated.
Around 15 weeks, a fetus will suck on its fingers.
Between 16 and 20 weeks, mothers first perceive fetal movements.
Around 20-21 weeks, one can see isolated segmental movements of fingers, foot, eyelids.
Around 26-28 weeks, a stimulation by sound will induce a startle response or trunk and head rotation, and an increase in heart rate (Janniruberto & Tajani, 1981).
There can be great variations from one fetus to another. While recordings have shown that the mean number of daily fetal movements increases from about 200 in the 20th week to a maximum of 575 in the 32nd week (then to a mean of 282 at delivery), the number in an individual fetus can range from 50 to 956.
Mothers' reports concur with objective measures of fetal movements in 80-90 percent of cases. Fetal movements are affected by various stimuli, increasing after exposure to sound, and also after light stimulation. Ninety percent of fetuses move more during ultrasound exposure. Touch and pressure on the mother's abdomen also trigger an increase.
Cycles of Activity. The states of consciousness observable in the newborn - quiet, alert, sleep, REM sleep, and so on - are observable in the fetus. These states appear to occur in cycles. During maternal sleep, a rhythmic rest-activity cycle of 40-60 minutes was observed over twenty years ago (Sterman, 1967). A rhythmic rest-activity cycle of 40-80 minutes has been noted more recently, in both awake and sleeping mothers (Granat et al., 1979). A marked circadian rhythm of fetal movements has been shown as well (Roberts et al., 1977). This periodicity in fetal activity was not found to be correlated with gestational age, nor with fetal sex, birth weight, or with assessment of newborn behavior such as the Apgar score. Rather, it seems to be connected to intrinsic physiologic properties of the fetus, and may be affected by maternal activity.
In the later months of pregnancy, any woman can tell what times of day her fetus will be active. Most women predict that peaks of fetal movement will occur at times of inactivity for them. Although this association has been attributed to their available awareness during rest periods, there is reason to believe that the observation is correct. The fetus may begin to "adjust" to the mother's rest-activity by reciprocal activity and inactivity. When she is active, it will be quiet. When she is quiet, it will begin to "climb" the uterine walls. The lactic acid of muscular activity, which peaks as the mother rests after activity, has been thought to stimulate fetal movements. A fetus's predictability and adjustment to its mother's rhythms become further evidence for the mother of his or her existence as a person, a person who can "adjust to her," as well as to the pressures of her life.
When asked to keep a record of a fetus's rest and activity, mothers can make extremely accurate predictions after two or three days of conscious attention to these cycles. Such regular, organized cycles dominate fetal behavior. Distinctions between states of activity in the fetus become more and more evident to the mother. In the last trimester, women can tell when their baby is in (1) deep sleep (quiet and essentially unresponsive to outside stimuli with, at most, an occasional jerk of an extremity), (2) light sleep (quiet, but with bursts of repetitive movements of the extremities, hiccoughs, and, occasionally, slower thrusts of the arms, legs, or trunk), (3) active awake ("climbing" the uterine wall, with bursts of thrusting, vigorous movement), and (4) alert but quiet (apparently waiting and receptive to external stimuli, with smoother, more directed movements, often in response to external events).
Responses to Stimuli. Of the species that are helpless at birth (altricial), humans are the only one in which all the sensory systems are capable of functioning before birth (Gottlieb, 1971). Immature neural tissue functions before nerve-ending receptors are present, before myelinization is complete. Stimulation apparently plays a role in the maturation of sensory organs. This maturation appears to be accelerated or slowed down by increased stimulation or lack of stimulation, respectively.
As early as day 49 after fertilization, the fetus will bend its head away from the site of stimulation when the face is touched lightly near the mouth. Sometime between day 90 and day 120, the so-called "righting reflexes," in which the fetus attempts to keep its head in balance, begin to appear. At about six months, the fetus is capable of responding to auditory stimulation. At this time, fetal heart rate changes in response to sound stimulation have been recorded.
In the last trimester, there are discrete evoked responses of the fetal cortex that can be measured with noninvasive techniques (Rosen & Rosen, 1975). Electrodes applied directly to the fetal scalp after rupture of the membranes demonstrate a rich range of responses to sound, touch, and visual stimuli. Observing whether the fetus is able to habituate to these is one way of measuring fetal well-being; if the fetus keeps on responding with no change, it may be under stress (Hon & Quilligan, 1967). Using maternal reports and confirming them with fetal behavior during ultrasound monitoring, we [TBB] became convinced that the fetus in the last trimester responds reliably to visual, auditory, and kinesthetic stimulation (Brazelton, 1981a).
When a bright light is shone on the mother's abdomen in the fetus's line of vision, it will startle. If a softer light is used in the same position, the infant turns actively but smoothly toward it. A loud noise next to the abdomen will also produce a startle, while if a soft noise is used, the baby will turn toward it. When stimuli are offered while the fetus is in a quiescent state resembling sleep, the responses are less predictable, more subdued, and the fetus habituates to them more rapidly. These differentiated responses to external stimuli can be perceived as signals by the mother. If these signals coincide with her own responses, they may initiate the beginnings of synchrony between mother and child.
While in the womb, the fetus is being preconditioned to maternal sleep-wake rhythms and to the mother's style of reactivity. Not only have newborn babies experienced their mother's rhythms in the womb, but auditory and kinesthetic cues from her are now "familiar." No wonder a newborn already prefers a female to a male voice at birth (Brazelton, 1979). The fetus's reaction patterns are shaped and made ready for "appropriate" cues after birth. Meanwhile, the parents are learning about their baby. Toward the end of pregnancy, mothers report more and more differentiated responses. They say that their babies react one way to a Bach concert - with smooth, rhythmic kicks - and an entirely different way to rock music - sharp, jerky movements. When they announce this, they are proudly stating that the baby is an aware, competent being already. The baby is not only aware of the environment, he or she is demonstrating a readiness to meet it. Parents now begin to see their babies as strong enough to survive in the outside world. The more parents can imagine an unborn child as a competent, interacting individual, the more confident they can be about the baby's ability to survive labor and delivery.
As a mother gets closer to delivery, however, her fears about having damaged her infant once again weigh more heavily. In fact, so raw are these fears that few women can even speak of them in the last month. They must be repressed or they can become overwhelming. To balance these fears, the parents continue to personify their child. The fetus's characteristic movements and responses become of heightened value in demonstrating its integrity. The more a mother can see her unborn baby as a separate person, the more protected she feels from her own imagined inadequacy and incompetence. Mothers who can see their child-to-be as strong and resilient may even perceive the child as an ally in the difficult task of delivery.

Among the formidable tasks that face the mother at birth are:

An abrupt ending of the sense of fusion with the fetus, of the fantasies of completeness and omnipotence fostered by pregnancy;
Adapting to a new being who provokes feelings of strangeness. Michel Soule has described these as feelings of unheimlichkeit (Soule & Kreisler, 1983);
Mourning for the imaginary (perfect) child, and adapting to the characteristics of her specific baby;
Coping with fears of harming the helpless child (often experienced in new mothers, for instance, as the fear of drowning the baby in the bath);
Learning to tolerate and enjoy the enormous demands made on her by the total dependency of the baby; in particular, she has to withstand the baby's intense oral cravings, and gratify them with her body.

Fetal Movements. The full repertoire of movements of the newborn baby can be seen before birth, in the fetus (Milani Comparetti, 1981). A great deal of motor development takes place during pregnancy, preparing for adaptation after birth. For instance, breathing movements are now known to be present as early as 13-14 weeks. These rapid, irregular breathing movements are associated with low-voltage, high-frequency "electrocortical" activity in the brain (Boddy et al., 1974). Fetal movements have been the object of particular attention, because they can be studied by noninvasive methods and because they have diagnostic value. As an extreme example, marked decrease and cessation of fetal movements indicate impending fetal death. Fetal movements are affected by various agents: alcohol, tobacco, sedatives, maternal emotional stress.
Fetal movements evolve in intensity and form during pregnancy.* Around 6-7 weeks, smooth, circular movements of the body are seen. These movements become more complex as time goes on.
Around 13-14 weeks, flexion and extension movements, opening and closing of the hands, swallowing, and breathing movements are present. Mechanical stimuli produce a startle response, and the fetus's ability to habituate to stimuli can be demonstrated.
Around 15 weeks, a fetus will suck on its fingers.
Between 16 and 20 weeks, mothers first perceive fetal movements.
Around 20-21 weeks, one can see isolated segmental movements of fingers, foot, eyelids.
Around 26-28 weeks, a stimulation by sound will induce a startle response or trunk and head rotation, and an increase in heart rate (Janniruberto & Tajani, 1981).
There can be great variations from one fetus to another. While recordings have shown that the mean number of daily fetal movements increases from about 200 in the 20th week to a maximum of 575 in the 32nd week (then to a mean of 282 at delivery), the number in an individual fetus can range from 50 to 956.
Mothers' reports concur with objective measures of fetal movements in 80-90 percent of cases. Fetal movements are affected by various stimuli, increasing after exposure to sound, and also after light stimulation. Ninety percent of fetuses move more during ultrasound exposure. Touch and pressure on the mother's abdomen also trigger an increase.
Cycles of Activity. The states of consciousness observable in the newborn - quiet, alert, sleep, REM sleep, and so on - are observable in the fetus. These states appear to occur in cycles. During maternal sleep, a rhythmic rest-activity cycle of 40-60 minutes was observed over twenty years ago (Sterman, 1967). A rhythmic rest-activity cycle of 40-80 minutes has been noted more recently, in both awake and sleeping mothers (Granat et al., 1979). A marked circadian rhythm of fetal movements has been shown as well (Roberts et al., 1977). This periodicity in fetal activity was not found to be correlated with gestational age, nor with fetal sex, birth weight, or with assessment of newborn behavior such as the Apgar score. Rather, it seems to be connected to intrinsic physiologic properties of the fetus, and may be affected by maternal activity.
In the later months of pregnancy, any woman can tell what times of day her fetus will be active. Most women predict that peaks of fetal movement will occur at times of inactivity for them. Although this association has been attributed to their available awareness during rest periods, there is reason to believe that the observation is correct. The fetus may begin to "adjust" to the mother's rest-activity by reciprocal activity and inactivity. When she is active, it will be quiet. When she is quiet, it will begin to "climb" the uterine walls. The lactic acid of muscular activity, which peaks as the mother rests after activity, has been thought to stimulate fetal movements. A fetus's predictability and adjustment to its mother's rhythms become further evidence for the mother of his or her existence as a person, a person who can "adjust to her," as well as to the pressures of her life.
When asked to keep a record of a fetus's rest and activity, mothers can make extremely accurate predictions after two or three days of conscious attention to these cycles. Such regular, organized cycles dominate fetal behavior. Distinctions between states of activity in the fetus become more and more evident to the mother.
In the last trimester, women can tell when their baby is in (1) deep sleep (quiet and essentially unresponsive to outside stimuli with, at most, an occasional jerk of an extremity), (2) light sleep (quiet, but with bursts of repetitive movements of the extremities, hiccoughs, and, occasionally, slower thrusts of the arms, legs, or trunk), (3) active awake ("climbing" the uterine wall, with bursts of thrusting, vigorous movement), and (4) alert but quiet (apparently waiting and receptive to external stimuli, with smoother, more directed movements, often in response to external events).
Responses to Stimuli. Of the species that are helpless at birth (altricial), humans are the only one in which all the sensory systems are capable of functioning before birth (Gottlieb, 1971). Immature neural tissue functions before nerve-ending receptors are present, before myelinization is complete. Stimulation apparently plays a role in the maturation of sensory organs. This maturation appears to be accelerated or slowed down by increased stimulation or lack of stimulation, respectively.
As early as day 49 after fertilization, the fetus will bend its head away from the site of stimulation when the face is touched lightly near the mouth. Sometime between day 90 and day 120, the so-called "righting reflexes," in which the fetus attempts to keep its head in balance, begin to appear. At about six months, the fetus is capable of responding to auditory stimulation. At this time, fetal heart rate changes in response to sound stimulation have been recorded.
In the last trimester, there are discrete evoked responses of the fetal cortex that can be measured with noninvasive techniques (Rosen & Rosen, 1975). Electrodes applied directly to the fetal scalp after rupture of the membranes demonstrate a rich range of responses to sound, touch, and visual stimuli. Observing whether the fetus is able to habituate to these is one way of measuring fetal well-being; if the fetus keeps on responding with no change, it may be under stress (Hon & Quilligan, 1967). Using maternal reports and confirming them with fetal behavior during ultrasound monitoring, we [TBB] became convinced that the fetus in the last trimester responds reliably to visual, auditory, and kinesthetic stimulation (Brazelton, 1981a).
When a bright light is shone on the mother's abdomen in the fetus's line of vision, it will startle. If a softer light is used in the same position, the infant turns actively but smoothly toward it. A loud noise next to the abdomen will also produce a startle, while if a soft noise is used, the baby will turn toward it. When stimuli are offered while the fetus is in a quiescent state resembling sleep, the responses are less predictable, more subdued, and the fetus habituates to them more rapidly. These differentiated responses to external stimuli can be perceived as signals by the mother. If these signals coincide with her own responses, they may initiate the beginnings of synchrony between mother and child.
While in the womb, the fetus is being preconditioned to maternal sleep-wake rhythms and to the mother's style of reactivity. Not only have newborn babies experienced their mother's rhythms in the womb, but auditory and kinesthetic cues from her are now "familiar." No wonder a newborn already prefers a female to a male voice at birth (Brazelton, 1979). The fetus's reaction patterns are shaped and made ready for "appropriate" cues after birth. Meanwhile, the parents are learning about their baby. Toward the end of pregnancy, mothers report more and more differentiated responses. They say that their babies react one way to a Bach concert - with smooth, rhythmic kicks - and an entirely different way to rock music - sharp, jerky movements. When they announce this, they are proudly stating that the baby is an aware, competent being already. The baby is not only aware of the environment, he or she is demonstrating a readiness to meet it. Parents now begin to see their babies as strong enough to survive in the outside world. The more parents can imagine an unborn child as a competent, interacting individual, the more confident they can be about the baby's ability to survive labor and delivery.
As a mother gets closer to delivery, however, her fears about having damaged her infant once again weigh more heavily. In fact, so raw are these fears that few women can even speak of them in the last month. They must be repressed or they can become overwhelming. To balance these fears, the parents continue to personify their child. The fetus's characteristic movements and responses become of heightened value in demonstrating its integrity. The more a mother can see her unborn baby as a separate person, the more protected she feels from her own imagined inadequacy and incompetence. Mothers who can see their child-to-be as strong and resilient may even perceive the child as an ally in the difficult task of delivery.

Among the formidable tasks that face the mother at birth are:

An abrupt ending of the sense of fusion with the fetus, of the fantasies of completeness and omnipotence fostered by pregnancy;
Adapting to a new being who provokes feelings of strangeness. Michel Soule has described these as feelings of unheimlichkeit (Soule & Kreisler, 1983);
Mourning for the imaginary (perfect) child, and adapting to the characteristics of her specific baby;
Coping with fears of harming the helpless child (often experienced in new mothers, for instance, as the fear of drowning the baby in the bath);
Learning to tolerate and enjoy the enormous demands made on her by the total dependency of the baby; in particular, she has to withstand the baby's intense oral cravings, and gratify them with her body.

9. Forgetfulness - The Pregnancy Brain

Are you finding yourself standing around lately wondering what you're supposed to be doing? Do you forget important appointments? Does your mind feel too full to take in any more data? Yep—you're pregnant. This mental fog is a natural result of the body's intense focus on baby-making. Powerful hormonal changes are going on that affect your ability to concentrate and remember. Don't fight it—you'll only get more flustered. Work with it.

If you can't count on your memory anymore, try these memory aids:

Become a list maker. Write down exactly what you're supposed to do each day. Write down what you want to buy at the store. Write down everything, and you won't forget anything.
Ask for help. Tell your partner and your co-workers to remind you of important dates and appointments. Two minds are always better than one—during pregnancy they can be a necessity.
Lighten your load. Pregnant or not, doing too much at one time can muddle the thinking process. Being pregnant makes an overload all the more difficult to manage. Make an effort to drop projects that aren't absolutely necessary. Learn to delegate to others. Practice saying "no."
Get more sleep. If you're burning the midnight oil, you have no hope of being clearheaded the next day. Your mind needs the restorative power of sleep to be sharp, clear, and efficient.

These things will help reduce that scatterbrained feeling—but they won't get rid of it. You can expect to be just a little less efficient for the remainder of your pregnancy. Then, the sleeplessness caused by caring for a newborn will give you a brand-new set of excuses for having a brain that feels like it's turned into mashed bananas.

10. Food Cravings and Aversions During Pregnancy

Feel like eating a jar of pickes? Need a quart of chocolate ice cream at 2 A.M.? These are favorite TV sitcom clichés that get us to laugh at the harried husband, as he combs the streets looking for food to satisfy his pregnant wife's cravings. I doubt there are too many pregnant women out there who really crave pickles or ice cream in the middle of the night, but those wacky hormones that course through the body in the first three months of pregnancy can and do cause both food cravings and aversions. Suddenly, you just have to have a certain food, or, just as suddenly, you can't stand the sight of a food you used to love!

Although hormones are the chief culprit in these cravings and aversions, there is a theory that these are signals from your body telling you what it needs and what you should stay away from. If you suddenly can't stand even the smell of coffee or the thought of a cream doughnut, this aversion could be your body's way of keeping toxins away from your developing baby. If you find yourself craving fruit (as many women do) your body might be low in complexcarbohydrates. If you feel a daily need for an ice cream sundae, your body might actually be calling for more dairy products and calcium. (In this case it's best to skip the sundae and have some yogurt or cottage cheese instead.)

Sometimes there's no explanation at all for a particular food craving or aversion. If you wake up one day and can no longer stand the smell of green vegetables, don't panic. Don't force yourself to eat foods that are "good" for you if they make you sick to your stomach. If an aversion to a nutritious food doesn't disappear in a few days, try something else that will give you the same nutrients. For example, if you can't eat broccoli anymore, make up for this loss of a good source of calcium by eating more dairy products.

If you get a craving for food that is not nutritious for you and your baby, try these two strategies:

Substitute. If you absolutely must have a piece of candy, for example, substitute the craving for something that's sweet but nutritious, such as raisins or dried fruits. If you must have ice cream, switch to a frozen fruit bar or yogurt.
Distraction. When you feel drawn to a food you shouldn't eat, get up and do something else. Take a walk, read a book, call a friend. Keep your mind busy until the craving passes. Or, have a glass of water; some say this often satisfies the urge to eat.
11. Stress During Pregnancy

Don't let worrying about stress add more stress to your day. Stress is a part of life—it has weaseled its way into your schedule before your pregnancy, and it will continue to accompany you throughout your pregnancy. Even when you're pregnant there will still be traffic jams that make you late, inconsiderate and pushy people who drive you nuts, deadlines to meet, and arguments with friends and co-workers. In these kinds of situations, stress will not harm your baby.

On the other hand, stress that is intense or chronic can be a problem for you and your baby. If this is an unplanned pregnancy, for example, or if you have separated from your partner, or if you are grieving over the death of a close friend or family member, or if you have a job that's making you want to jump off a cliff, your body's physical reaction to this kind of stress can be harmful to both you and your baby in many ways:

Extreme stress changes your breathing pattern. When you're upset, you take shorter, shallower breaths that bring in less oxygen. (That's why people who are distraught are always told to take a deep breath.) Your body needs a plentiful supply of oxygen right now, so make a conscious effort to maintain a normal, deep breathing pattern.
Stress can affect your diet. If you lose your appetite, your baby won't get the daily nutrients necessary for healthy growth. If you find yourself bingeing on sweets when you're upset, you'll add fat to your weight gain, raise your blood sugar levels, and give your baby empty calories that can't be used for healthy development.
Stress can affect how well you sleep. Sleep is a restorative time that allows your body to rid itself of toxins, such as free radicals and excess brain chemicals that are released during the day and can zap good health if allowed to build up in your system. Sleep also allows the body to discharge the effects of everyday stress that can build up and cause anxiety. Your body craves sleep (especially in the first trimester) for a good reason.
Stress can weaken the immune system. When your body diverts much of its energy and internal resources to battling the fatiguing effects of intense or chronic stress, your immune system has little left to fight off invading germs. You are much more likely to catch a cold, the flu, or anything else in the air when you're stressed.
Stress can cause physical pain. Tension headaches and backaches, unexplained muscle aches, and even chest pain are all signs of extreme stress.

If you read through these stress-related symptoms and say, "Hey, that's me!" it's time to talk to your health-care provider about finding ways to ease stress. Maybe it's time for an early maternity leave from your job, for example. In the meantime, make relaxation exercises a part of your daily routine.

12. Hair Changes During Pregnancy

Even your hair won't escape the effects of the reproductive hormones that increase blood circulation and metabolism. By the fourth months you'll probably notice that your hair is growing faster and looks thicker and healthier than before. Or you might be one of the few whose hair becomes thinner, oilier, or drier. Either way, there will be noticeable changes in your hair.

Some women see drastic changes when their light hair turns darker, curly hair falls flat, or pencil straight hair turns curly. Most often the change is temporary, occurring during the pregnancy only. But many women claim their hair texture or color changes forever.

The hair on your head is not the only hair on your body that grows longer and gets thicker during pregnancy. Increased amounts of facial hair (particularly on the lips, chin, and cheeks) are the most obvious. But you might also see thicker hair on your arms, legs, back, and belly. Even the area covered by your pubic hair might expand.

Much of this growth disappears within six months after the baby is born.

If your body hair is dark, you might find this unexpected feature of your pregnancy a bit embarrassing. Plucking and shaving are options, but avoid depilatories or bleaching cream. It's possible that they might be absorbed into the bloodstream and circulate into your womb.

13. Skin Changes During Pregnancy

Because skin is the body's largest organ, it's probably no surprise that it can be drastically affected by your pregnancy.

You might be one of the women who wear the "mask of pregnancy." This is a scary sounding name for a change in the pigmentation of the skin on the face, particularly the forehead, nose, upper lip, and cheeks. As a result of the high levels of hormones in your body, patches of darkened skin sometimes appear on the face (light patches might appear on dark-skinned women). Don't get upset—this is most likely a temporary condition that will disappear when the baby is born.

You might also notice that your moles or beauty marks are getting darker and bigger during pregnancy. As if that's not enough, 60 percent of women will get "vascular spiders," which are red blotches on the face, upper chest, and arms. Fortunately, these skin changes disappear when pregnancy ends.

You can try to lighten skin discoloration with cosmetic creams used to lighten birthmarks, but you'll have better luck using makeup to blend the skin colors. You can also keep skin discoloration, such as the mask of pregnancy, from darkening or getting worse, by staying out of the sun and wearing a sunscreen. Whether it's spring, summer, fall, or winter, use a sunscreen with a sun protection factor (SPF) of at least 15 every morning.

14. Stretch Marks From Pregnancy

How do you think you'll look with stretch marks? Well, you might want to convince yourself that you'll look great, because about 50 percent of pregnant women get stretch marks. As the name implies, these pale to dark red or purple streaks occur when the skin stretches to accommodate the growth of your belly. They can occur just about anywhere, but breasts, hips, abdomen, and thighs are the most common spots. If you're dark-skinned and/or have a mother or sister who had stretch marks, it's very likely you will join the club.

Don't get too upset about these badges of motherhood, there's nothing much you can do about them and you probably won't be wearing a bikini anytime soon anyway. Some women rub on special creams made to minimize these marks. The rubbing might make them feel better, but no cream currently on the market has been medically proven to effectively reduce stretch marks. Most stretch marks on light-skinned women fade on their own to a silvery white color .

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