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Stillbirth

Stillbirth

Stillbirth is when pregnancy ends without a live birth due to natural causes, including pregnancy loss, miscarriage, or spontaneous abortion. Some pregnancies do not result in a live birth. Miscarriage is commonly used to describe the loss of a fetus, usually before the age of gestation of 20 weeks. Stillbirth is the delivery of an infant which is dead at birth, regardless of the stage of development. In the United Kingdom, this term is used for an infant delivered showing no signs of life after 24 weeks gestation. If a pregnancy is terminated deliberately, this is termed induced abortion, which may be medical or surgical in nature.

Causes

Stillbirth, or more generically pregnancy loss, may be caused by:
- genetic defects, such as cardiac malformation or chromosomal abnormalities. Chromosomal abnormalities appear to be particularly common in early pregnancy loss.
- infection
- maternal illness, such as diabetes or measles
- placental dysfunction
- unknown causes The cause for any specific stillbirth is not always known, but parents should always be offered investigations, such as an autopsy, in order to try and determine a cause, and also plan care in future pregnancies (Wright and Lee 2004).

Effects

Pregnancy loss is often emotionally devastating to the parents, particularly the mother. The stillbirth of an infant near or at term may be even more difficult to bear than early miscarriage. Parents who have lost a child to stillbirth may experience rage, depression, isolation, marital difficulties, and trouble resuming normal life.

Perinatal Bereavement: Loss at the time of Pregnancy

- Molar pregnancy
- Reproduction
- Maternal death -------- Perinatal death in the U.S. alone can affect as many as 40,000 families. While the causes may be many, the experience of loss is nearly universal. "Perinatal bereavement" is the grief experienced in and around the time of birth, and the initial synthesis of the grieving process may last two years or more. Perinatal death includes miscarriages, stillbirths and neonatal deaths. SIDS is usually considered in a separate category. Loss at abortion may also be considered in this general area. At the death of an infant, parental expectations turn upside down. At a time when plans are made to announce a birth, announcements of the death take place, usually from a hospital. Reactions to the death early on may include shock and numbness and the reality of the event is difficult to assimilate, followed by waves of grief and despondency. Over the first few weeks, these opposite waves of feelings of loss and numbness ebb and flow, often followed by depression and occasionally rage over people or events associated with the timing of the infant's death. Characteristics of all normal grief including perinatal bereavement include appetite and sleep disorders, stress related symptoms and illnesses, a lowering of the immune system's function, depression, nightmares and even having random experiences of the pregnancy in what is termed 'phantom' movement or even cries.

Morbid or Difficult Reactions

Morbid or complicated reactions include the inability to do such activities as taking down a nursery even after a year or more, extreme phantom experiences which cause distress, 'replacement child syndrome' in which the next child is saddled with the expectations of the 'ideal' first child, or 'vulnerable child syndrome' in which all subsequent children are seen as very fragile and prone to harm or illness.

Essential Choices & Facilitation of Grief

While grief cannot be treated or 'cured' as an illness, there are things which aid families experiencing perinatal loss. These include: 1) Choices in making funeral plans, 2) Choices in early hospital arrangements 3) Seeing, holding and saying goodbye to the infant, which is thought to alleviate experiences of phantom crying and bring closure to the death, 4) Crisis intervention and effective listening by health care providers and loved ones, 5) Keeping memorabilia to anchor grief such as clothing, hospital bracelets or footprints/ultrasound photos, and 6) Freedom to allow for individual differences in relinquishment of the infant in the grieving process. There is often a blur between what is normal and not in perinatal bereavement.

Negative Consequences

When the intense grief of perinatal loss is not dealt with, severe familial reactions may occur including loss of intimacy, sexual dysfunction, divorce, alcoholism, juvenile delinquency and other difficulties. Openness and acceptance of the normal process of grief along with careful listening skills may often bring about the greatest effect.

Intervention

Over the past 25 years, radical changes have been made in in-hospital effectiveness in treatment or intervention with perinatal bereavement. International Self-Help Resources include SHARE - for the support of parents experiencing Stillbirth, HAND - for those experiencing a neonatal death, and The MISS Foundation - a volunteer-based organization committed to providing crisis support and long term aid to families after the death of a child from any cause.

Reference

Wright C, and Lee REJ (2004) Investigating perinatal death: a review of the options when autopsy consent is refused. Archives of Disease in Childhood Fetal and Neonatal Edition 2004;89:F285 [http://fn.bmjjournals.com/cgi/content/full/89/4/F285]

External links

- [http://www.angelfire.com/journal2/forgottengrief The Forgotten Grief: Perinatal Death]
- [http://www.missfoundation.org The MISS Foundation]
- [http://www.uk-sands.org/ SANDS] The Stillbirth and Neonatal Death Society (UK)

Pregnancy

:For a broader view of pregnancy in mammals see mammalian pregnancy. For the medicine of pregnancy, see Obstetrics. Obstetrics Pregnancy is the carrying of one or more embryos or foeti by female mammals, including humans, inside their bodies. In a pregnancy there can be multiple gestations (for example, in the case of twins, or triplets). Human pregnancy is the most studied of all mammalian pregnancies. Human pregnancy lasts approximately 40 weeks between the time of the last menstrual cycle and birth (38 weeks from fertilisation). The medical term for a pregnant woman is "genetalian," just as the medical term for the unborn human is an embryo (early weeks) and then "foetus" (until birth). A woman who is pregnant for the first time is known as a primigravidanite or gravida 1: a woman who has never been pregnant is known as a gravida 0; similarly, the terms para 0 and para 1 are used for the number of times a woman has given birth. In many societies' medical and legal definitions, human pregnancy is arbitrarily divided into three trimester periods, as a means to simplify reference to the different stages of fetal development. The first trimester period carries the highest risk of miscarriage (natural death of embryo or fetus), while during the second trimester the development of the fetus can start to be monitored and diagnosed. The third trimester marks the beginning of viability, which means the fetus can survive if an early natural or induced birth occurs. Because of the possible viability of developed fetus, cultural and legal definitions of life often consider a fetus in the third trimester to be a distinct living person. :See also Pregnancy terms and definitions
Detection and dating
Pregnancy terms and definitions The beginning of pregnancy may be detected in a number of ways, including various pregnancy tests which detect hormones generated by the newly-formed placenta. Clinical blood and urine tests can detect pregnancy as early as 6-8 days after date of conception. Home pregnancy tests are personal urine tests, which normally can't detect a pregnancy until at least 12-15 days after conception. Both clinical and home tests can only detect the state of pregnancy, and cannot detect the actual date of conception. Home pregnancy test In practice, for the purpose of giving a date for a conception (i.e. an "age" for an embryo), doctors typically date the pregnancy by "menstrual date," based on the first day of a woman's last menstrual period, as the woman reports it. Unless a woman's recent sexual activity has been limited, the exact date of conception or implantation are unknown. And absent any symptoms of morning sickness, the only visible sign of a pregnancy is often an interruption of her normal monthly menstruation cycle, (i.e. a "late period"). Hence, the "menstrual date" is simply a common educated estimate for the age of a fetus, which is an average of two weeks later than conception, (the margin of error considers 0 to 30 days after last menstruation, hence a 14 day average). The term "conception date" may sometimes be used when that date is more certain, though even medical professionals can be imprecise with their use of the two distinct terms. An unknown date for conception means that in practice the distinction between embryo and fetus is a clinical one only, and not used as to refer to stages of development of a particular pregnancy. margin of error There are likewise finer distinctions between the concepts of fertilization (conception) and the actual state of pregnancy. In a normal pregnancy, the fertilization of the egg usually will have occurred in the Fallopian tubes or in the uterus. (In women with fertility problems, an egg may become fertilized yet fail to become implanted in the uterus.) If the pregnancy is the result of in-vitro fertilization the fertilization will have occurred in a Petri dish, after which "pregnancy" begins when one or more zygotes implants after being transferred by a physician in the woman's uterus. In the context of political debates regarding a proper definition of life, the terminology of pregnancy can be confusing. Because precise assessment of a pregnancy as being at the "embryo" or "fetus" stage is usually undeterminable, the terms (though more clinically precise) are less commonly used than terms like "baby" or "child." The medically and politically neutral term which remains is simply "pregnancy," though this can be problematic as it only refers indirectly to the embryo or fetus. In the context of personal treatment, bedside manner generally dictates that doctors make sparse use of clinical language like "fetus" and "embryo," and instead simply refer to the developing child as a "baby." progesterone
Timeline of a typical pregnancy
Pregnancy is typically broken into three periods, or trimesters, each of about three months. While there are no hard and fast rules, these distinctions are useful in describing the changes that take place over time.
First trimester

Fertilization
progesterone progesterone Before pregnancy begins, a female oocyte (egg) must be fertilized, by male sperm in a process referred to in medicine as "fertilization," or commonly as "conception." Pregnancy is usually dated as beginning on the first day of a woman's last menstrual period. This date is used to estimate an EDD, or Estimated Date of Delivery. Traditionally (according to Naegele's Rule, which is used to calculate the estimated date of delivery (EDD)), a human pregnancy is considered to last approximately 40 weeks (280 days) from the last menstrual period (LMP), or 37 weeks (259 days) from the date of conception. However, a pregnancy is considered to have reached term between 37 and 43 weeks. Babies born before the 37 week mark are considered premature, while babies born after the 43 week mark are considered postmature. postmature However, the average length of pregnancy depends on ethnic background of the mother (Caucasian women are more likely to have a longer pregnancy than other women) and if it is a first pregnancy (which tend to last longer than subsequent pregnancies). For example, a Caucasian woman's first pregnancy lasts an average 274 days from conception (288 days from the last menstrual period). An accurate date of conception is important, because it is used in calculating the results of various prenatal tests (for example, in the triple screen test). A decision may be made to induce labour if a baby is perceived to be overdue. Due dates are only a rough estimate, and the process of accurately dating a pregnancy is complicated by the fact that not all women have 28 day menstrual cycles, or ovulate on the 14th day following their last menstrual period. Approximately 3.6% of all mothers deliver on the due date predicted by LMP, and only 4.7% give birth on the day predicted by ultrasound.
Implantation
In medicine, pregnancy is defined as beginning when the developing embryo becomes implanted into the endometrial lining of a woman's uterus. The outer layers of the embryo grow and form a placenta, for the purpose of receiving essential nutrients through the uterus wall. The umbilical cord in a newborn child signifies the remnants of the connection to the placenta. The developing baby undergoes tremendous growth and changes during the process of embryonic and fetal development. Morning sickness aflicts about half of all pregnant women, typically only in the first trimester.
Second trimester
Morning sickness Most women feel more energised in this period, and begin to seriously put on weight. The first movement of the baby, often referred to as "quickening", can be felt, as the baby begins to form into a recognisable shape.
Third trimester
Final weight gain takes place, and the baby begins to move regularly. This can be uncomfortable, causing symptoms like weak bladder control and back-ache.
Medical aspects of pregnancy
Diagnostic criteria are: In a woman who has regular menstrual cycles and is sexually active, a period delayed by a few days or weeks is suggestive of pregnancy; elevated B-hcG to around 100,000 mIU/mL by 10 weeks of gestation.
Birth
Morning sickness Childbirth is the process in which the baby is born. It is considered by many to be the beginning of a person's life, where age is defined relative to this event in most cultures. A woman is considered to be in labour when she begins experiencing regular painful uterine contractions, accompanied by changes of her cervix — primarily effacement and dilation. While childbirth is widely experienced as painful, some women do report painless labours.
Postnatal Period
For topics following on from a successful pregnancy and birth, see:
- Breastfeeding
- Child development
Terms and definitions

Technical

- zygote - from fertilization until second cell division
- embryo - conceptus between time of fertilization to 10 weeks of gestation
- fetus - from 10 weeks of gestation to time of birth
- FASD - Fetal Alcohol Spectrum Disorder, a clinical term for the effects alcohol can have on the developing fetus
- gestational age - time from last menstrual period (LMP) up to present
- gravidity (G) - number of times a woman has been pregnant
- infant - time of birth to 1 year of age
- viability - minimum age for fetus survival, ca. third trimester
- previable infant - delivered prior to 24 weeks
- preterm infant - delivered between 24-37 weeks
- term infant - delivered between 37-42 weeks
- first trimester - up to 14 weeks of gestation
- second trimester - 14 to 28 weeks of gestation
- third trimester - 28 weeks to delivery
- parity (P) - number of pregnancies with a birth beyond 20 weeks GA or an infant weighing more than 500 g
- Ga Pw-x-y-z - a = number of pregnancies, w = number of term births, x = number of preterm births, y = number of miscarriages, z = number of living children; for example, G4P1-2-1-3 means the woman had a total of 4 pregnancies, of which 1 is of term, 2 are preterm, 1 miscarriage, and 3 total living children (1 term + 2 preterm).
Colloquial
There are a number of colloquialisms for pregnancy, usually regional. The action of impregnating a woman or girl is called 'knocking (her) up' in Canada and some parts of the U.S., and the state of being pregnant 'knocked-up'. The term 'lady-in-waiting', meaning a pregnant mother, is used broadly in the U.S. The word 'gone' or 'along' is used to represent gestational time, e.g. 'she's really far gone' or 'about 6 weeks gone' or 'six months along'. In the southern U.S. the euphemism of a water well is occasionally used to represent pregnancy (e.g. 'drink out of the well', to become pregnant), and a baby almost ready to be delivered is 'on his/her road'. Eastern Seaboard slang describes the mother as being 'in a fix' or, occasionally, 'preggers'; the Southern U.S. equivalent is 'in the family way'. An alternate term not slang or colloquial is 'with child', now restricted mainly to England. 'Having a bun in the oven' is another frequently used phrase to indicate that a woman is pregnant.
See also

- Abortion
- Lamaze
- Obstetrics
- Contraception
- Twin and Multiple birth
- Teenage pregnancy
- Pregnancy discrimination
- Low birth weight paradox
- Pregnancy in science fiction
- Melasma
- Wrongful abortion
- False pregnancy
- Simulated pregnancy
Reference

- Mittendorf R, Williams MA, Berkey CS, Cotter PF. The length of uncomplicated human gestation. Obstet Gynecol 1990;75:929-32. PMID 2342739.
External links

- [http://www.mayoclinic.com/health/pregnancy/HQ00451 Early pregnancy: Morning sickness, fatigue and other common symptoms, from MayoClinic.com]
- [http://www.visembryo.com/ The visible embryo]
- [http://www.merck.com/mrkshared/mmanual/section18/chapter249/249a.jsp Normal Pregnancy, Labor, And Delivery (Merck Manual)]
- Alan Guttmacher Institute [http://www.agi-usa.org/pubs/tgr/08/2/gr080207.html (2005) The Implications of Defining When a Woman Is Pregnant discussion of the political and legal background.
- [http://www.normalbirth.lamaze.org Lamaze Institute for Normal Birth], an advocacy site for "natural" childbirth.
- [http://www.chabad.org/library/article.asp?AID=72141 Jewish customs for conduct during Pregnancy and Birth] chabad.org Category:Midwifery Category:Obstetrics Category:Women Category:Fertility ko:임신 ja:妊娠

Childbirth

Childbirth (also called labour, birth, partus or parturition) is the culmination of a human pregnancy with the emergence of a newborn infant from its mother's uterus. A woman is considered to be in labour when she begins experiencing regular, strong uterine contractions, accompanied by changes of her cervix — primarily effacement and dilation. While childbirth is widely experienced as painful, some women do report painless labours. When the baby is born its birth weight is determined. birth weight

The normal birth

First stage: contractions

A typical human childbirth will begin with the onset of contractions of the uterus. The frequency and duration of these contractions varies with the individual. The onset of labour may be sudden or gradual. A gradual onset with slow cervical change towards 3 cm (just over 1 inch) dilation is referred to as the "latent phase". A woman is said to be in "active labour" when contractions have become regular in frequency (3-4 in 10 minutes) and about 60 seconds in duration. The now powerful contractions are accompanied by cervical effacement and dilation greater than 3 cm. The labour may begin with a rupture of the amniotic sac, the paired amnion and chorion ("breaking of the water"). The contractions will accelerate in frequency and strengthen. In the "transition phase" from 8 cm–10 cm (3 or 4 inches) of dilation, the contractions often come every two minutes are typically lasting 70–90 seconds. Transition is often regarded as the most challenging and intense for the mother. Some mothers say things like "I give up, I want to stop now. Forget this!" It is also the shortest phase. During a contraction the long muscles of the uterus contract, starting at the top of the uterus and working their way down to the bottom. At the end of the contraction, the muscles relax to a state shorter than at the beginning of the contraction. This draws the cervix up over the baby's head. Each contraction dilates the cervix until it becomes completely dilated, often referred to as 10+ cm (4") in diameter. During this stage, the expectant mother typically goes through several emotional phases. At first, the mother may be excited and nervous. Then, as the contractions become stronger, demanding more energy from the mother, mothers generally become more serious and focused. However, as the cervix finishes its dilation, some mothers experience confusion or bouts of self-doubt or giving up. The duration of labour varies widely, but averages some 13 hours for women giving birth to their first child ("primiparae") and 8 hours for women who have already given birth. If there is a significant medical risk to continuing the pregnancy, induction may be necessary. As this carries some risk, it is only done if the child or the mother are in danger from prolonged pregnancy. 42 weeks gestation without spontaneous labour is often said to be an indication for induction although evidence does not show improved outcomes when labour is induced for post-term pregnancies. Inducing labour increases the risk of cesarean section and uterine rupture in mothers that have had a previous cesarean section.

Second stage

induction] In the second stage of labour, the baby is expelled from the womb through the vagina by both the uterine contractions and by the additional maternal efforts of "bearing down". The imminence of this stage can be evaluated by the Malinas score. The baby is most commonly born head-first. In some cases the baby is "breech" meaning either the feet or buttocks are descending first. Babies in the breech position can be delivered vaginally by a midwife, though in some areas finding an experienced willing attendant can be difficult. There are several types of breech presentations, but the most common is where the baby's buttocks are delivered first and the legs are folded onto the baby's body with the knees bent and feet near the buttocks (full or breech). Others include frank breech, much like full breech but the babies legs are extended toward his ears, and footling or incomplete breech, in which one or both legs are extended and the foot or feet are the presenting part. Another rare presentation is a transverse lie. This is where the baby is sideways in the womb and a hand or elbow has entered the birth canal first. While babies who present transverse will often move to a different position, this is not always the case. The length of the second stage varies and is affected by whether a woman has given birth before, the position she is in and mobility. The length of the second stage should be guided by the condition of the fetus and health of the mother. Problems may be encountered at this stage due to reasons such as maternal exhaustion, the front of the baby's head is facing forwards instead of backwards (posterior baby), or extremely rarely, because the baby's head does not fit properly into the mother's pelvis (Cephalo-Pelvic Disproportion (CPD)). True CPD is typically seen in women with rickets and bone deforming illnesses or injuries, as well as arbitrary time limits placed on second stage by caregivers or medical facilities. Immediately after birth, the child undergoes extensive physiological modifications as it acclimatizes to independent breathing. Several cardiovascular structures start regressing soon after birth, such as the ductus arteriosus and the foramen ovale. In some cultures, the father cuts the umbilical cord and the infant is given a lukewarm bath to remove blood and some of the vernix on its skin before being handed back to its parents. The medical condition of the child is assessed with the Apgar score, based on five parameters: heart rate, respiration, muscle tone, skin color, and response to stimuli. Apgar scores are typically assessed at both 1 and 5 minutes after birth.

Third stage: placenta

Apgar score] In this stage, the uterus expels the placenta (afterbirth). Nursing the baby will help to cause this. The mother normally loses less than 500 mL of blood. Blood loss will be greater if the umbilical cord be used to tug on the placenta. It is essential that the placenta be examined to ensure that it was expelled whole. Remaining parts can cause postpartum bleeding or infection.

After the birth

infection Medical professionals typically recommend breastfeeding of the first milk, colostrum, to reduce postpartum bleeding/hemorrhage in the mother, and to pass immunities and other benefits to the baby. Parents usually assign the infant its given names soon after birth. Often people visit and bring a gift for the baby. Many cultures feature initiation rites for newborns, such as naming ceremonies, baptism, and others. Mothers are often allowed a babymoon period where they are relieved of their normal duties to recover from childbirth and establish breastfeeding with their babies. Length of this period varies. In China this is 30 days and is referred to as "doing the month". A birth story may be written, detailing the events of the birth. The story may be posted to a blog or web forum.

Variations

When the amniotic sac has not ruptured during labour or pushing, the infant can be born with the membranes intact. This is referred to as "being born in the caul." The caul is harmless and its membranes are easily broken and wiped away by the doctor or midwife assisting with the childbirth. In medieval times, and in some cultures still today, a caul was seen as a sign of good fortune for the baby, in some cultures was seen as protection against drowning. The caul was often impressed onto paper and stored away as an heirloom for the child. With the advent of modern interventive obstetrics, premature artificial rupture of the membranes has become common, so babies are rarely born in the caul.

Pain

The amounts of pain experienced by women during childbirth vary. For some women, the perceived pain is intense and agonizing; for other women there is little to no perceived pain. Many factors affect pain perception, including cultural ideas of childbirth, fear, number of previous births, fetal presentation, birthing position, and a woman's natural pain threshold. Uterine contractions are always intense during childbirth, but a woman may or may not experience them as pain. Some women sleep through much of the labor. Rarely, mothers experience very pleasurable sensations and muscular contractions which they believe to be orgasms. Pain does serve a purpose. Pain directs a person to change behavior, often to reduce injury. For example, pain may direct a woman to squat or to get on all fours. It may direct her to push or to wait. It may direct her to reach down to adjust the position of an emerging baby. When pain is suppressed, the woman can not respond to this natural signal.

Non-medical pain control

Many women believe that reliance on analgesic medication is unnatural, or worry that it may harm the child, but are still very concerned about labour pain. To alleviate pain, they may undergo psychological preparation, education, massage, hypnosis, water therapy in a tub or shower. Most women also find helpful the emotional support and comfort measures by a friend, husband, partner, or a trained professional doula. Birthing in a squatting or crawling position will usually help, though the position is awkward for observers. These methods present no risk to the mother or baby, and many find them effective.

Medical pain control

In Europe, doctors commonly prescribe inhaled nitrous oxide gas for pain control; in the UK, midwives may use this gas without a doctor's prescription. Pethidine (with or without promethazine) may be used early in labour, as well as other opioids; if given too late, they may cause respiratory depression in the infant. Popular medical pain control in hospitals include regional anesthetics (epidural blocks, or spinal anaesthesia); these anesthetics are often used for pain control, and are a necessity for Cesarean surgery, unless the patient undergoes general anesthetic. Doctors favor the epidural block because medication does not enter the mother's circulatory system, thus it does not cross the placenta and enter the bloodstream of the fetus. Different measures for pain control have varying degrees of success and side effects to mother and baby. Administration must be carefully timed. For example, an epidural block given too early in labour can stop or slow labour, and given too late in labour can hinder maternal efforts to push out the baby. These risks should be balanced against the fact that childbirth can be extremely painful, and anesthetics are an effective and generally safe pain treatment.

Complications and Risks of Birth

Problems that occur during childbirth are called complications. They can affect the mother or the baby. Sometimes they cause injury or even death. Doctors and midwives are trained to deal with these problems should they occur. Infant deaths (neonatal deaths from birth to 28 days, or perinatal deaths if including fetal deaths at 28 weeks gestation and later) are around 1% in modernized countries. The risk of maternal death during childbirth in developed nations is comparatively low; only about 1 in 1800 mothers die in childbirth (only 1 in 3700 in North America). In the third-world, it is a much riskier proposition: on average 1 in 48 women die during childbirth. The "natural" mortality rate of childbirth — where nothing is done to avert maternal death — has been estimated as being between 1,000 and 1,500 deaths per 100,000 births. The most important factors affecting mortality in childbirth are adequate nutrition and access to quality medical care ("access" is affected both by the cost of available care, and distance from health services). "Medical care" in this context does not refer specifically to treatment in hospitals, but simply the presence of an attendant with midwifery skills. A 1983-1989 study by the Texas Department of Health revealed that the infant death rate was 0.57% for doctor-attended births, and 0.19% for births attended by non-nurse midwives. Conversely, some studies demonstrate a higher perinatal mortality rate with assisted home births . It is generally accepted that in developed countries, properly assisted home births carry no greater risks than hospital birth for low-risk pregnancies. Around 80% of pregnancies are low-risk. Factors that may make a birth high risk include prematurity, high blood pressure, diabetes and previous cesarean section. One of the most dangerous risks to the fetus is that of premature birth, and its associated low neonatal weight. The more premature (or underweight) a baby is, the greater the risks for neonatal death and for pulmonary, respiratory, neurological or other sequelae. About 12% of all infants born in the United States are born prematurely. In the past 25 years, medical technology has greatly improved the chances of survival of premature infants in industrialized nations. In the 1950s and 1960s, approximately half of all low birth weight babies in the US died. Today, more than 90% survive. The first hours of life for "premies" are critical, especially the very first hour of life. Rapid access to a Neonatal Intensive Care Unit is of paramount importance. Some of the possible complications are:
- Heavy bleeding during or after childbirth, which is the most common cause of mortality in new mothers, in both developed and undeveloped nations. Heavy blood loss leads to hypovolemic shock, insufficient perfusion of vital organs and death if not rapidly treated by stemming the blood loss (medically with ergometrine and pitocin or surgically) and blood transfusion. Hypopituitarism after obstetric hypovolemic shock is termed Sheehan's syndrome.
- Non-progression of labour (longterm contractions without adequate cervical dilation) is generally treated with intravenous synthetic oxytocin preparations. If this is ineffective, Caesarean section may be necessary. Changes in maternal position is effective in many cases.
- Fetal distress is the development of signs of distress by the child. These may include rising or decreasing heartbeat (monitored on cardiotocography/CTG), shedding of meconium in the amniotic fluid, and other signs.
- Non-progression of expulsion (the head or presenting parts are not delivered despite adequate contractions): this can require interventions such as vacuum extraction, forceps extraction or Caesarean section.
- In the past, a large proportion of women died from infection puerperal fever, but since the introduction of basic hygiene during parturition by Ignaz Semmelweis, this number has fallen precipitously.
- Lacerations can be painful. An episiotomy is occasionally necessary to avoid tears involving the anal sphincter, but its routine use - once normal - has now been shown to be harmful.

Professions associated with childbirth

Midwives are experts in normal birth. Midwives believe that childbirth is a normal process that is best accomplished with as little interference as possible. Midwives are trained to assist at births, either through direct-entry or nurse-midwifery programs. Lay midwives typically train in apprenticeship programs with experienced midwives. Obstetricians are experts in dealing with normal births as well as abnormal births and pathological labour conditions. Obstetricians in most countries are also trained as surgeons, so they can undertake surgical procedures relating to childbirth. Such procedures include caesarean sections, episiotomies, or emergency hysterectomies. Obstetricians' tendency to intervene surgically to overcome complications has led to criticism that they perform surgery too readily. In the United States, obstetric malpractice settlements are typically very large, so obstetricians argue that they are forced to intervene aggressively to limit their liability. In the United States, a doctor who specializes in caring for women with pregnancy complications is often referred to as a maternal-fetal medicine sub-specialist. Obstetric nurses assist doctors, mothers, and babies prior to, during, and after the birth process. Some midwives are also obstetric nurses. Obstetric nurses hold various certifications, and typically undergo additional obstetric training in addition to standard nursing training.

Social aspects

In some cultures, childbirth is considered to be the beginning of a person's life, and a person's age is defined relative to it. Many families view the placenta as a special part of birth, since it has been the child's life support for so many months. Many parents like to see and touch this mysterious organ. In some cultures, parents plant a tree along with the placenta on the child's first birthday. The placenta may be eaten by the newborn's family, ceremonially or otherwise. The oldest American woman known to give birth was Arceli Keh, aged 63. In November 2004 Aleta St. James, a 56 year old single mother gave birth to twins conceived through in vitro fertilization. In 2005, a 67 year old Romanian woman gave birth by cesarean to one surviving twin.

Legal aspects

In some legal jurisdictions, the place of childbirth decides the nationality of a child (under the doctrine of Jus soli)

Psychological aspects

Childbirth is a stressful event. As with any stressful event, strong emotions can be brought to the surface. Some women report symptoms compatible with post-traumatic stress disorder (PTSD) after birth. Between 70 and 80% of mothers in the United States report some feelings of sadness or "baby blues" after childbirth. Postpartum depression may develop in some women; about 10% of mothers in the United States are diagnosed with PPD. Preventative group therapy has proven effective as a prophylactic treatment for postpartum depression. Childbirth is also stressful for the infant. Stresses associated with breech birth, such as asphyxiation, may affect the infants brain. Medicating the mother against her labor pain is a widespread practice in hospitals. Intravenously-administered drugs — although not, as discussed above, epidurals — may reach the infant's bloodstream through the umbilical cord, with uncertain effects. It is not known how the birth experience affects the development of personality in the infant. It was once thought that newborns do not have the capacity to feel pain or fear, but now some parents are choosing alternative birth settings (other than the hospital) in an attempt to create a more comfortable environment for the newborn.

References

# # Van Lerberghe W, De Brouwere V. Of blind alleys and things that have worked: history’s lessons on reducing maternal mortality. In: De Brouwere V, Van Lerberghe W, eds. Safe motherhood strategies: a review of the evidence. Antwerp, ITG Press, 2001 (Studies in Health Services Organisation and Policy, 17:7–33). # [http://www.safemotherhood.org/facts_and_figures/maternal_mortality.htm Safer Motherhood Fact Sheet: Maternal Mortality ] # [http://www.who.int/whr/2005/chapter4/en/index1.html World Health Organization 2005 World Health Report, Chapter 4: Risking Death To Give Life.] # Zlotnick C, Johnson SL, Miller IW, Pearlstein T, Howard M. Postpartum depression in women receiving public assistance: pilot study of an interpersonal-therapy-oriented group intervention, Am J Psychiatry. 2001 Apr;158(4):638-40. [PMID 11282702]

External links

- [http://www.med-help.net/Emergency%2DChild%2DBirth.htm Emergency Child Birth] - Provides video clip and colour photos (real) of child birth, and also emergency measures
- [http://www.nvsh.nl/Website_Engels/Texts/Sexual_Information/Basics/FOL_1.htm How you came into the world and grew inside a womb: from cells and embryo to baby] - Has colour photos (real) and explanations
- [http://www.cnn.com/2004/HEALTH/parenting/11/12/pregnant.59.ap/index.html AP story on pregnancies in the elderly]
- [http://www.naturalchildbirth.org NaturalChildbirth.org] - Information and discussion forums about natural childbirth options
- [http://www.lamaze.org Lamaze International]
- [http://www.chabad.org/library/article.asp?AID=72141 Jewish customs for conduct during Pregnancy and Birth] chabad.org Category:Human development Category:Midwifery Category:Obstetrics ja:出産

Live birth

A live birth of a human being occurs when a fetus is expelled and separated from the mother's body and subsequently shows some sign of life, such as voluntary movement, heartbeat, or pulsation of the umbilical cord, but for however brief thistime. In the absence of such sign, the event is considered a stillbirth. This definition was created by the World Health Organization in 1950 and is chiefly used for public health and statistical purposes. Whether the birth is vaginal or by Caesarean section, and whether the baby is ultimately viable, is not relevant to this statistical definition. Category:Obstetrics

Gestation

Gestation is the carrying of an embryo or fetus inside a female viviparous animal. In mammals that undergo a pregnancy, they can have one or more gestations at the same time, resulting in multiple gestations. In the case of multiple gestations, the organisms gestated by the mother are called twins. For example, female dogs usually have multiple ovulations in a single estrus cycle, and, when the ova get fertilized, the animal gestates multiple offspring in one single pregnancy. The time interval of a gestation is called gestation period, and the length of time the offspring have spent developing in the uterus is called gestational age. In humans, parturition normally occurs at a gestational age of 37 to 42 weeks. Childbirth occurring before 37 weeks of gestation is considered preterm and has been associated with 70% of neonatal mortality and 75% of morbidity. A preterm fetus is considered viable only if it is delivered after the 28th week of gestation; before this age, that major developmental events that would allow the fetus to survive outside the womb have not occurred. Category:Biological reproduction Category:Mammals

Death

:For other uses, see Death (disambiguation) or Dead (disambiguation). Death is the cessation of physical life in a living organism or the state of the organism after that event.

Interpretations of "death"

In almost all societies, death has one or several symbols associated with it. Common symbols of death in Western cultures include the grim reaper and the color black; conversely, in certain Eastern cultures, the color white is considered symbolic of death. The grave is a metonym for death. Biologically, death can occur to wholes, to parts of wholes, or to both. For example, it is possible for individual cells and even organs to die, and yet for the organism as a whole to continue to live; many individual cells can live for only a short time, and so most of an organism's cells are continually dying and being replaced by new ones. Conversely, when organisms die their cells can live for some time afterward. Organs, for instance, can be removed for transplantation. They must be removed and transplanted quickly, or they too will soon die without the support of their host. Rarely, cell cultures can be "immortal" as in the case of Henrietta Lacks' HeLa cell line. Fingernails and hair appear to grow after a person's death, as, due to bodily dehydration, the flesh pulls away from the hair and nails. In ancient times, this led to confusion about whether a body was actually dead, and added to the myth of vampires. Irreversibility is often cited as a key feature of death. By definition, a dead organism cannot be brought back to life; if it were to be, that would indicate that it had never been dead. Nonetheless, many people do not believe that death is necessarily irreversible; thus some have a religious belief in bodily or spiritual resurrection, while others have hope for the eventual prospects of cryonics or other technological means of reversing what is currently thought of as death. It has been hypothesized that a limited lifespan is a consequence of evolution not selecting for extreme longevity in most species, as evolutionary selection only need apply to the organism up to the point of reproduction; after that, except for caring for kin, the continued existence of an individual can have little effect on the survival of its gene line. A common assumption is that the Second Law of Thermodynamics dictates that all complex systems must eventually deteriorate, so it is not likely that any species could ever be immortal. However, this aspect of the Second Law of Thermodynamics only applies to closed systems, which organisms are not.

Ways of defining human death: medical, religious, and legal

Human death can be defined by three dramatically different but overlapping domains: medical, religious, and legal. These different domains and their importance have evolved over time and can vary from person to person. So when talking about death, it is important to differentiate which domain we are speaking of and to have a general understanding of how each defines death. There are various ways of defining medical death. Early in western culture, death was connected to the heart first and then later the lungs. When these stopped working, a person was dead. It was sometime later that the brain came into the definition. In 1963 a device called an electroencephalogram (EEG) was invented that could very accurately measure the electrical output of the brain. The test showed that when the machine registered zero electrical output from a person's brain (also known as a flat EEG) for 36 hours, the patient could be considered dead. We now know that a person can continue to be medically alive until their brain stem dies. Patients in a persistent vegetative state still have an active brain stem. Legally, a person can be pronounced dead in three different ways. By far the most common is pronouncement by a medical doctor. The second most common is pronouncement by a coroner or a state medical examiner. The third way a person can be pronounced legally dead is by the courts; after a person has disappeared for some time, the courts will pronounce them dead so that their property can be distributed appropriately. A death certificate is a legal document which states how and when a person died, and who pronounced them dead. In religous terms, death is believed to refer to the departure from the body of the soul, or essence.

When is a person dead?

Identifying the exact moment of death is important for a number of reasons. It allows for the correct time on death certificates, and helps ensure that a person's will is enacted only after they are truly deceased. In particular, identifying the moment of death is important in cases of transplantation, as organs must be harvested as quickly as possible after death. Historically, attempts to define the exact moment of death have been problematic. Death was once defined as the cessation of heartbeat (cardiac arrest) and of breathing, for example, but the development of CPR and early defibrillation posed a challenge: either the definition of death was incorrect, or techniques had been discovered that really allowed one to reverse death (because, in some cases, breathing and heartbeat can be restarted). Generally, the first option was chosen. (Today this definition of death is known as "clinical death".) Today, where a definition of the moment of death is required, doctors and coroners usually turn to "brain death" or "biological death": people are considered dead when the electrical activity in their brain ceases (cf. persistent vegetative state). It is presumed that a stoppage of electrical activity indicates the end of consciousness. Brain activity is a necessary condition to legal personhood, and, perhaps with the exception of the fetus, it is a sufficient condition for legal personhood. "It appears that once brain death has been determined … no criminal or civil liability will result from disconnecting the life-support devices." Dority v. Superior Court of San Bernardino County, 193 Cal.Rptr. 288, 291 (1983) However, those maintaining that only the neo-cortex of the brain is necessary for consciousness sometimes argue that only electrical activity there should be considered when defining death. In most places the more conservative definition of death (cessation of electrical activity in the whole brain, as opposed to just in the neo-cortex) has been adopted (for example the Uniform Determination Of Death Act in the United States). In 2005, the case of Terri Schiavo brought the question of brain-death and artificial sustainment to the front of American politics. However, in all cases the common cause of death is anoxia. Even in these cases, the determination of death can be difficult. EEGs can detect spurious electrical impulses when none exists, while there have been cases in which electrical activity in a living brain has been too low for EEGs to detect. Because of this, hospitals often have elaborate protocols for determining death involving EEGs at widely separated intervals. Medical history contains many anecdotal references to people being declared dead by physicians and coming back to life, sometimes days later in their own coffin or when embalming procedures are about to get underway. Stories of people actually being buried alive (which must assume embalming has not occurred) led at least one inventor in the early 20th century to design an alarm system that could be activated from within the coffin. Because of the difficulties in determining death, under most emergency protocols, a first responder is not authorized to pronounce a patient dead; some EMT training manuals, for example, specifically state that a person is not to be assumed dead unless there are clear and obvious indications that death has occurred, such as mortal decapitation, rigor mortis (the stiffening of the body), livor mortis (blood pooling in the lowest part of the body), decomposition, or incineration. If there is any possibility of life and in the absence of a do not resuscitate order, emergency workers must begin rescue and not end it until a patient has been brought to a hospital to be examined by a physician. This frequently leads to situation of a patient being pronounced dead on arrival.

The process of dying

Cell death

A. Normal cellular function :1. Production of energy required for vital cellular processes :2. Production of enzymatic and structural protein :3. Maintenance of chemical and osmotic homeostasis of cell :4. Cell reproduction B. Needs of cell :1. Oxygen, phosphate, calcium :2. Nutritional substrates :3. ADP - needed to produce ATP :4. Intact cell membranes :5. Steady state of activity enhances 02 consumption

Physiological changes during the process of dying

A. Events leading to death: :1. Brain ceases to supply information vital for controlling ventilation, heart rhythm, and/or vasodilation :2. Lungs unable to supply 0₂ exchange with blood stream :3. Heart and blood vessels unable to maintain adequate circulation of blood to vital tissues B. Cerebrovascular system: :1. Hemorrhage :2. Pump failure :3. Decreased CO₂ leads to decreased PCO2 leads to Cheyne-Stokes respiration C. CNS problems: :1. Infection :2. Blood vessel disruption :3. Malignant tumors :4. Metabolic changes ::a. Renal failure ::b. Hepatic failure ::c. Pancreatic failure D. CNS decompensation: :1. Early signs: ::a. Sluggish pupils :::(1) Non reactive :::(2) Dilated and fixed - drugs also affect this ::b. Confusion ::c. Inability to orient :2. Later signs: ::a. Lethargy ::b. Decreased ability to perform simple cognitive functions ::c. Attention only by tactile, auditory or visual stimuli :3. Late signs: ::a. Stupor, sleep ::b. Withdrawal of purposeless involvement to stimuli without wakefulness or arousal :4. Semicomatose - movement only with pain :5. Deep coma - no response E. Respiratory system: :1. CBF :2. COPD :3. Infections :4. Cancer metutasis :Changes after death: :A. Body cools 1.5 degrees/hr :B. Rigor mortis begins prior to decomposition and liver mortis begins with death :C. Rigor mortis: ::1. Muscles gradually become hard due to decreased ATP and lactic acidosis within muscle febrils ::2. Begins 2-4 hours after death but may be sooner ::3. May disappear 9-12 hours in hot climate :D. Liver mortis: ::1. Body becomes distended ::2. Skin color changes from green to purple to black ::3. Dependent areas fust due to pooling of blood ::4. Seen within 2 hours of death, maximum at 8-12 hours

Signs of approaching death

When death is imminent

• Physical death is a progressive process, during which there are some signs that usually indicate that death is imminent. Not all of the following changes occur, nor do they necessarily occur in any particular order, as the body shuts down during the dying process. In general, the following information may help anticipate and understand changes that appear as an individual approaches death and is “actively dying.” • The dying individual may become increasingly tired and sleepy, and may be difficult to arouse. • The dying individual may become confused much of the time and may no longer recognize familiar persons, places, or objects. • Hearing and vision may become impaired, and speech may be slurred, difficult to understand, or nonsensical. • A few patients become restless or very anxious and move about frequently in the bed, pull at the bed clothes or bedding (linen clutch), and reach out. • The person may hallucinate, seeing things or people which may not appear to anyone else. • Less nourishment will be required, and the person’s intake of food and water will diminish. Difficulty in swallowing (dysphagia) may also occur. • The person may sweat profusely. • The dying individual may lose control of his/her urine or bowels ( incontinence), necessitating that the dying individual be kept especially clean and dry in order to prevent bed sores (decubitis ulcers). • Urination may become darker and diminish or stop. • The mouth of the dying individual may become dry, and then secretions may accumulate in the back of the throat. Breathing may become noisy because of the gurgling or rattling of the secretions in the mouth or chest (“death rattle”). • The pattern of breathing may change; become slower or faster, deeper or shallower, or irregular. Often the patient will have periods of rapid breathing followed by periods in which breathing is very slow or is even absent for as long as 15 seconds. • The legs, and then arms, may become cold and nonreflexive as the circulation slows down. • The skin may be pale or mottled, and some parts, particularly the underside of the body, may become a dark color as the blood pools, usually a deep blue or purple.

When death occurs

• Breathing ceases entirely. • Heartbeat and pulse stop. • The person is entirely unresponsive to stimulus. • The eyes may be fixed in directions. The pupils are dilated and fixed to light. The eyelids may be open or closed. • A loss of control of urine and/or bowels may occur. • The person becomes progressively mottled and cold and stiff (known as rigor mortis) • The skin may become pale; there may be signs of blood buildup on the side the person is laying on.

Cause of death in the United States

The cause of death varies by area and age group. In 2002 in the U.S. the top 10 causes of death were:
- Heart Disease: 696,947
- Cancer: 557,271
- Stroke: 162,672
- Chronic lower respiratory diseases: 124,816
- Accidents (unintentional injuries): 106,742
- Diabetes: 73,249
- Influenza/Pneumonia: 65,681
- Alzheimer's disease: 58,866
- Nephritis, nephrotic syndrome, and nephrosis: 40,974
- Septicemia: 33,865

Other notable causes of death in the United States (2002)

- Murder: 16,110
- Execution: 71
- Intentional Abortion: 1,293,000
- Note that there is much debate as to when a fetus should be considered "human." The death of a human zygote — a one-celled combination of a sperm and an egg — is counted by some as the death of a human, and by others as simply the death of a cell. The above number would apparently include abortions to save the life of the mother, abortions of obviously highly defective fetuses, and abortions of fetuses unlikely to reach term. Statistical data from [http://www.cdc.gov/nchs/fastats/lcod.htm U.S. Department of Health & Human Services] [http://www.deathpenaltyinfo.org/ Death Penalty Information Center] [http://www.nrlc.org/abortion/facts/abortionstats.html National Right To Life], and [http://www.agi-usa.org/media/presskits/2005/06/28/abortionoverview.html The Alan Guttmacher Institute]

What happens to humans after death?

The second question is of what, apart from the cessation of metabolism and the onset of physiological processes of decay, happens, especially to humans, during and after death (or "once dead", thinking of death as a permanent state). In particular, there is the question of what becomes of consciousness or the soul. Such questions are of long standing, and belief in an afterlife (such as an underworld), or in reincarnation, are common and ancient. The belief that any and all consciousness ceases to exist at death, and that death ("after-life") itself is ultimately the exact same experience as prior to conception ("before life"), is common in atheism/agnosticism. Conversely, religious belief in and information about an afterlife is a consolation in connection with the death of a beloved one or the prospect of one's own death. On the other hand, fear of hell or other negative consequences may make death worse. Human contemplation about death is an important motivation for the development of organized religion. Traditions exist across most cultures to mourn the death of loved ones. Many archaeologists feel that the careful burials among Homo neanderthalensis, where ochre ornamented bodies were laid in carefully dug graves, is evidence of ritualised burial. This may indicate early religious belief which, furthermore, might include a concept of an afterlife.

Physiological consequences of human death

For the human body, the physiological consequences of death follow a recognized sequence through early changes into bloating, then decay to changes after decay and finally skeletal remains. The changes in the immediate post-death stage have received the most attention for two reasons—firstly it is the stage mostly likely to be seen by the living and secondly because of the research of forensics in potential crimes. Soon after death (15–120 minutes depending on various factors), the body begins to cool (algor mortis), becomes pallid (pallor mortis), and internal sphincter muscles relax, leading to the release of urine, feces, and stomach contents if the body is moved. The blood moves to pool in the lowest parts of the body, livor mortis (dependent lividity), within 30 minutes and then begins to coagulate. The body experiences muscle stiffening (rigor mortis) which peaks at around 12 hours after death and is gone in another 24, depending on temperature. Within a day, the body starts to show signs of decomposition (decay), both autolytic changes and from 'attacking' organisms—bacteria, fungi, insects, mammalian scavengers, etc. Internally, the body structures begin to collapse, the skin loses integration with the underlying tissues, and bacterial action creates gases which cause bloating and swelling. The rate of decay is enormously variable; a body can be reduced to skeletal remains in days, or remain largely intact for thousands of years.

Settlement of dead human bodies

In most cultures, before the onset of significant decay, the body undergoes some type of ritual disposal, usually either cremation or deposition in a tomb that is often a hole in the ground called a grave, but may also be a sarcophagus, crypt, sepulchre, or ossuary, a mound or barrow, or a monumental surface structure such as a mausoleum (exemplified by the Taj Mahal). In Tibet, one method of corpse disposal is sky burial, which involves placing the body of the deceased on high ground (a mountain) and leaving it for birds of prey to dispose of. Sometimes this is because in some religious views, birds of prey are carriers of the soul to the heavens, but at other times this simply reflects the fact that when terrain (as in Tibet) makes the ground too hard to dig, there are few trees around to burn and the local religion (Buddhism) believes that the body after death is only an empty shell, there are more practical ways of disposing of a body, such as leaving it for animals to consume. On the other hand, in certain cultures, efforts are made to retard the decay processes before burial (resulting even in the retardation of decay processes after the burial), as in mummification or embalming. This happens during or after a funeral ceremony. Many funeral customs exist in different cultures. In some fishing or navy communities, the body is sent into the water aquatic burial. Several mountain villages have a tradition of hanging the coffin in woods. A new alternative is ecological burial. This is a sequence of deep-freezing, pulverisation by vibration, freeze-drying, removing metals, and burying the resulting powder, which has 30% of the body mass. Space burial is also talked about, using rocket to launch part of the cremated body. Graves are usually grouped together in a plot of land called a cemetery or graveyard, and burials can be arranged by a funeral home, mortuary , undertaker or by a religious body such as a church or (for some Jews) the community's Burial Society, a charitable or voluntary body charged with these duties.

Personification of death

Main article: Death (personification) Death is also a mythological figure who has existed in popular culture since the earliest days of storytelling. The traditional Western image of Death, known as the Grim Reaper - usually resembling a skeleton, wearing black robes and carrying a scythe - is employed on a tarot card and in various television shows and films. Some examples:
- Death is a major character in the Discworld series by Terry Pratchett.
- Humorous depictions of Death, often with a Grim Reaper-esque feel, are common during the Día de los Muertos in Mexico, especially in the state of Michoacán.
- An unusual personification of Death appears in Neil Gaiman's Sandman graphic novels.
- In Ingmar Bergman's The Seventh Seal, a knight plays a game of chess against Death.
- Death is also portrayed as a Grim Reaper-esque character in TV shows such as Family Guy and video and computer games such as The Sims.
- In the film, Meet Joe Black, a remake of Death Takes a Holiday, Death inhabits the body of a young man to experience life firsthand.
- In the film, Bill & Ted's Bogus Journey, Death is the bassist for Wyld Stallyns.
- In the TV series Dead Like Me, the main characters are all Grim Reapers as part of a post-life bureaucracy.
- The series Touched by an Angel featured the Angel of Death as a regular character, depicted as a kindly, soft-spoken man in his mid-30s.
- The Angel of Death also appeared in the show Charmed as a man that appeared before those who had died to take them to the afterlife. He was neither good nor evil.
- Death is also a recurring character in the Castlevania video games. He is usually described as Dracula's servant, and is therefore evil. He is almost always a boss, and appears usually near the end of the game. He uses the scythe, and often transforms into more hideous forms.
- Death 'stalks' people who avoided their demise in the Final Destination series.
- Death appears as a character in a sketch in the Monty Python film The Meaning of Life.
- In the cartoon Futurama, Death is represented by the "Sunset Squad", a group of robots who take people away to an unknown destination when they reach the age of 160.
- In the book On a Pale Horse the main character becomes Death himself after killing the previous Death.

External links

- [http://www.disastercenter.com/cdc/111riska.html Deaths and death rates for the 10 leading causes of death in specified age groups: United States, preliminary 1996]
- [http://www.nsc.org/lrs/statinfo/odds.htm Odds of dying due to various injuries or accidents] Source: National Safety Council, United States, 2001
- [http://www.veda.harekrsna.cz/encyclopedia/dying.htm Dying, Yamaraja and Yamadutas + terminal restlessness] (Vedic/Hindu view)
- [http://www.quranichealing.com/bp.asp?caid=65 Death & Dying in Islam]What does a man feel at the time of death? and Is death something to be feared?
- [http://www.zyworld.com/jamus/LifeCycle.htm The Cycle of Life] In context of the page New Age of Aquarius.
- [http://samvak.tripod.com/death.html Death, life, and personal identity] In regard to memetics.
- [http://www.quotesandpoem.com/poems/SelectedPoetryTopic/Death Poems on Death and Dying]
- [http://www.answersingenesis.org/docs2002/death_suffering.asp Why is there death and suffering?] From a creationist point of view.
- [http://www.ogrish.com Deaths and death scenes. WARNING: very explicit]
- [http://www.elijahwald.com/origin.html George Wald: The Origin of Death] A biologist explains life and death in different kinds of organisms in relation to evolution.
- [http://plato.stanford.edu/entries/death/ Stanford Encyclopedia of Philosophy entry on death]
- [http://www.deathclock.com Death Clock] A little joke telling how much time remains for your death
- [http://www.autopsyvideo.com www.autopsyvideo.com] - This site offers documentaries about autopsy, one produced with the cooperation of the Los Angeles County Coroner's Office.
- [http://www.chabad.org/article.asp?AID=281541 The Jewish Way in Death and Mourning] By Maurice Lamm Category:Biology
- ms:Ajal ja:死 simple:Death

Abortion

An abortion is the termination of a pregnancy associated with the death of an embryo or a fetus. In medicine, the following terms are used to define an abortion:
- Spontaneous abortion: An abortion due to accidental trauma or natural causes, this is commonly termed a miscarriage.
- Induced abortion: Induced abortions are further subcategorized into therapeutic abortions and elective abortions.
- Therapeutic abortion: An abortion performed because the pregnancy poses physical or mental health risk to the pregnant woman.
- Elective abortion: An abortion performed for any other reason. In common parlance, the term "abortion" is synonymous with induced abortion. A pregnancy that terminates early, but where the fetus survives to become a live infant, is instead termed a premature birth. A pregnancy that ends with an infant dead upon birth, due to causes such as spontaneous abortion or complications during delivery, is termed a stillbirth. Certain forms of birth control are used to prevent implantation before the pregnancy occurs. These acts of emergency contraception are not classified as abortion by medicine. The ethics and morality of induced abortion have become the subject of an intense debate in the past 50 years in various areas of the world, particularly in the United States of America, but also to a lesser extent in Canada and a number of countries in Europe. Any female mammal can experience abortion, however this article focuses exclusively on abortion in women.

Spontaneous abortion

Spontaneous abortions, generally referred to as miscarriages, occur when an embryo or fetus is lost due to natural causes. A miscarriage is spontaneous loss of the embryo or fetus before the 20th week of development. Spontaneous abortions after the 20th week are generally considered preterm deliveries. Up to 78% of all conceptions may fail, in most cases even before pregnancy is confirmed. 15% of all confirmed pregnancies end in a miscarriage. Most miscarriages occur very early in a pregnancy. Early embryonic development is an error prone process, and the body may spontaneously abort if a fetus is not viable (i.e., due to genetic deformities, such as most cases of trisomy), or when the womb is unable to support the development of the fetus. Other causes can be infection (of either the mother or the fetus), immune responses, or serious systemic diseases of the mother. The risk for spontaneous abortion is greater in women over age 35, those with a history of more than three previous (known) spontaneous abortions, and those with systemic diseases. A spontaneous abortion can also be caused by accidental trauma; intentional trauma to cause miscarriage is considered an induced abortion. Some states have laws increasing the criminal liability of a person who causes a miscarriage during an assault or other violent crime.

Induced abortions

The term "abortion" is usually used by lay people to refer to induced abortion. Women from 27 nations reported the following reasons for seeking an induced abortion:
- 25.5% – Want to postpone childbearing
- 21.3% – Cannot afford a baby
- 14.1% – Has relationship problem or partner does not want pregnancy
- 12.2% – Too young; parent(s) or other(s) object to pregnancy
- 10.8% – Having a child will disrupt education or job
-   7.9% – Want no (more) children
-   3.3% – Risk to fetal health
-   2.8% – Risk to mother's health
-   2.1% – Rape, incest, other In many areas of the world, especially the developing nations or where induced abortions are illegal, many women choose or are pushed to perform abortions on themselves. These self-induced abortions are commonly unsafe abortions as described by the World Health Organization. Furthermore, some abortions are induced because of societal pressures, such as stigma of disabled persons and similar eugenic ideals, societal and religious disapproval of single motherhood, insufficient economic support for families, or laws such as under China's one-child policy. These policies and societal pressures can lead to sex-selective abortion and infanticide, which is illegal in most countries, but difficult to stop.

Methods of inducing abortion

Depending on the gestational age of the embryo or fetus, different methods of abortion can be performed to remove the embryo or fetus from the womb.

Medical Abortion

Effective in the first trimester of pregnancy, medical, or non-surgical abortions comprise 10% of all abortions in the United States and Europe. The process begins with the administration of either methotrexate or mifepristone, followed by misoprostol. While misoprostol may also be used alone to induce abortion, the need for surgical intervention is slightly elevated to about 10%, compared to the 8% when medications are combined. When surgical intervention is necessary, primarily vacuum uterine aspiration is used.

Surgical abortion

In the first fifteen weeks, suction-aspiration or vacuum abortion are the most common methods, replacing the more risky dilation and curettage (D & C). Manual vacuum aspiration, or MVA abortion, consists of removing the fetus or embryo by suction using a manual syringe, while the Electric vacuum aspiration or EVA abortion method uses suction produced by an electric pump to remove the fetus or embryo. From the fifteenth week up until around the eighteenth week, a surgical dilation and evacuation (D & E) is used. D & E consists of opening the cervix of the uterus and emptying it using surgical instruments and suction. Dilation and suction curettage consists of emptying the uterus by suction using a different apparatus. Curettage refers to the cleaning of the walls of the uterus with a curette. Dilation and curettage (D & C) is a standard gynaecological procedure performed for a variety of reasons, such as examination. As the fetus grows, other techniques must be used to induce abortion in the third trimester. Premature delivery of the human fetus can be induced with prostaglandin; this can be coupled with injecting the amniotic fluid with caustic solutions containing saline or urea. Very late abortions can be brought about by the controversial intact dilation and extraction (intact D & X) which requires the surgical decompression of the fetus's head before evacuation and is controversially termed "partial-birth abortion". A hysterotomy abortion, similar to a caesarian section but resulting in a terminated fetus, can also be used at late stages of pregnancy. Hysterotomy abortion can be performed vaginally, with an incision just above the cervix, in the late mid-trimester. An attempted abortion which results in the expulsion of a live infant (known medically as a neonate) is termed a failed abortion. A failed abortion is more likely to occur later in pregnancy. Some doctors who have induced a failed abortion have faced the prospect of having to kill the neonate, but are voicing concerns that doing so may be unethical and possibly subject them to criminal sanctions. As a result, recent investigations have been launched in England by the Confidential Enquiry into Maternal and Child Health (CEMACH) and the Royal College of Obstetricians and Gynaecologists in order to determine how widespread the problem is and an ethical response on how to treat the neonate.

Other means of abortion

A number of herbs are effective abortifacients. Using herbs in this way can cause serious side effects, including multiple organ failure and other serious injury, and are not recommended by physicians. Physical trauma to a pregnant woman's womb can cause an abortion. The severity of the impact required to cause an abortion carries high risk of injury, without necessarily inducing a miscarriage. Both accidental and deliberate abortions of this kind carry criminal liability in many countries.

Health effects

As with most surgical procedures, the most common surgical abortion methods carry the risk of potentially serious complications. These risks include: a perforated uterus, perforated bowel or bladder, septic shock, sterility, and death. It is difficult to accurately assess the risks of induced abortion due to a number of factors. These factors include wide variation in the quality of abortion services in different societies and among different socio-economic groups, a lack of uniform definitions of terms, and difficulties in patient follow-up and after-care. Use of other methods (e.g., overdose of various drugs, insertion of various objects into uterus) for abortion is very dangerous, carrying a significantly elevated risk for permanent injury or death compared to abortions done by physicians.

Physical health

Each phase of the abortion carries separate risks, and practitioners are not in agreement as to the best methods of mitigating those risks. The degree of risk depends upon the skill and experience of the practitioner; maternal age, health, and parity; gestational age; pre-existing conditions; methods and instruments used; medications used; the skill and experience of those assisting the practitioner; and the quality of recovery and follow-up care. A highly-skilled practitioner, operating under ideal conditions, will tend to have a very low rate of complications; an inexperienced practitioner in an ill-equipped and ill-staffed facility, on the other hand, will often have a higher incidence of complications. Some practitioners advocate using the minimal possible anesthesia, so that patient pain can alert the practitioner to possible complications. Others recommend general anesthesia in order to prevent patient movement which might cause a perforation. General anesthesia carries its own risks and most public health officials recommend against its routine use in abortion due to an increased risk of death. Dilation of the cervix carries the risk of cervical tears or perforations, including small tears that might not be apparent and might cause cervical incompetence in future pregnancies. Most practitioners recommend using the smallest possible dilators, and using osmotic rather than mechanical dilators after the first trimester of pregnancy. Instruments are placed within the uterus to remove the fetus. These can, on rare occassions, cause perforation or laceration of the uterus, and damage to structures surrounding the uterus. Laceration or perforation of the uterus or cervix can, again on rare occassions, lead to even more serious complications. Incomplete emptying of the uterus can cause hemorrhage, and infection. Use of ultrasound verification of the location and duration of the pregnancy prior to abortion, with immediate follow-up of patients reporting continuing pregnancy symptoms after the procedure, will virtually eliminate this risk. In rare cases, the abortion will be unsuccessful and the pregnancy will continue. Most practitioners recommend a second procedure to terminate the pregnancy due to the possibility that the abortion attempt had caused injury to the fetus. The sooner a complication is noted and properly treated, the lower the risk of permanent injury or death. A specific and undisputed complication that can arise, especially with repeated abortions by a dilatation and curettage, is the development of Asherman syndrome.

Suggested effects

There is controversy over a number of proposed risks and effects of abortion. Evidence, whether in support of or against such claims, might in part be influenced by the political and religious affiliations of the parties behind it.

Breast cancer

The controversial abortion-breast cancer (ABC) hypothesis posits an association between having an abortion and a higher risk of developing breast cancer. The proposed mechanism is based on the increased estrogen levels found during early pregnancy, which initiate cellular differentiation (growth) in the breast in preparation for lactation. The ABC hypothesis states that if the pregnancy is aborted before full differentiation in the third trimester, then more "vulnerable" undifferentiated cells would be left than prior to the pregnancy, resulting in an elevated risk of breast cancer. The majority of interview-based studies have indicated a link, and some have been demonstrated to be statistically significant, but there remains debate as to their reliability because of possible response bias. According to the National Cancer Institute (NCI), it is "well established" that "induced abortion is not associated with an increase in breast cancer risk." Those findings have been disputed by Dr. Joel Brind, a leading scientific advocate of the ABC hypothesis. Nevertheless, gaps and inconsistencies remain in the research as the "ABC link" continues to be a politicized issue.

Fetal pain

The experience of the fetus during abortion is a matter of consideration among scientists and political activists. Evidence is conflicting, with some authorities claiming that the fetus is capable of feeling pain from the first trimester, while others hold that the neuro-anatomical requirements for such experience do not exist until the second or third trimester. Pain receptors begin to appear in the seventh week of pregnancy. The thalamus, the part of the brain which receives signals from the nervous system and then relays them to the cerebral cortex, starts to form in the fifth week. However, other anatomical structures involved in the nociceptic process are not present until much later in gestation. Links between the thalamus and cerebral cortex aren't forged until around the 23rd week. [http://www.parliament.uk/post/pn094.pdf]. Myelin, an insulation on nerve fibres whichs aids in the conduction of electrical impulses, does not begin to develop until the sixth month. [http://www.pediatrics.emory.edu/neonatology/dpc/brain.htm] Researchers have observed changes in the heart rates and hormonal levels of neonates after circumcision, blood tests, and surgery — effects which were alleviated with the administration of anaesthesia. [http://www.cirp.org/library/pain/anand/#n99] Others suggest that the human experience of pain, being more than just physiological, cannot be measured in such reflexive responses.

Mental health

It is indisputable that some women will experience negative feelings as a result of elective abortion. However, whether this phenomenon is significant enough to warrant a general diagnosis, or even classification as an independent syndrome (see abortion trauma syndrome), is a subject that is debated among members of the medical community. Data on the incidence of clinical depression, mental illness, post-traumatic stress disorder, and suicide in association with abortion remain inconclusive. [http://bmj.bmjjournals.com/cgi/content/abstract/bmj.38623.532384.55v1] A comparative analysis of the suicide rates among postpartum and post-abortive women in Finland found a raw statistical correlation between abortion and suicide. [http://bmj.bmjjournals.com/cgi/content/full/313/7070/1431] Other studies have suggested a link between the elective termination of an unwanted pregnancy and an improvement in reported mental well-being. The majority of evidence would seem to indicate that adverse emotional reactions to the procedure are most strongly influenced by pre-existing psychological conditions and other negative factors. [http://www.apa.org/ppo/issues/womenabortfacts.html] Elective abortion may reduce the occurrence of depression in cases of unwanted pregnancy, as compared to cases in which the pregnancy has been carried to completion, but it is also sometimes reported as an additional stressor. Spontaneous abortion, or miscarriage, presents an increased risk of depression in women. [http://www.medicinenet.com/script/main/art.asp?articlekey=619]

History of abortion

depression The practice of induced abortion, according to some anthropologists, can be traced to ancient times. There is evidence to suggest that, historically, pregnancies were terminated through a number of methods, including the administration of abortifacient herbs, the use of sharpened implements, the application of abdominal pressure, and other techniques. Soranus, a 2nd century Greek physician, suggested in his work Gynaecology that women wishing to abort their pregnancies should engage in violent exercise, energetic jumping, carrying heavy objects, and riding animals. He also prescribed a number of recipes for herbal bathes, pessaries, and bloodletting, but advised against the use of sharp instruments to induce miscarriage due to the risk of organ perforation. [http://www.stoa.org/diotima/anthology/wlgr/wlgr-medicine355.shtml] It is also known that the ancient Greeks relied upon the herb silphium as both a contraceptive and an abortifacient. The plant, as the chief export of Cyrene, was driven to extinction, but it is suggested that it might have possessed the same abortive properties as some of its closest extant relatives in the Apiaceae family. Such folk remedies, however, varied in effectiveness and were not without risk. Tansy and pennyroyal, for example, are two poisonous herbs with serious side effects that have at times been used to terminate pregnancy. 19th-century medicine saw advances in the fields of surgery, anaesthesia, and sanitation, in the same era that doctors with the American Medical Association lobbied for bans on abortion in The United States and the British Parliament passed the Offences Against the Person Act. Demand for the procedure continued, however, as the disguised, but nonetheless open, advertisement of abortion services in Victorian times would seem to suggest. [http://users.telerama.com/~jdehullu/abortion/abhist.htm]

The abortion debate

Throughout the history of abortion, induced abortions have been a source of considerable debate and controversy regarding the morality and legality of this practice. An individual's position on the complex ethical, moral, philosophical, biological, and legal issues have a strong relationship with that individual's value system. A person's position on abortion may be best described as a combination of their personal beliefs on the morality of induced abortion, and that person's beliefs on the ethical scope and responsibility of legitimate governmental and legal authority. Another factor for many individuals is religious doctrine. See religion and abortion for more. Abortion debates, especially pertaining to abortion laws, are often spearheaded by advocacy groups belonging to one of two camps. Most often those in favor of legal prohibition of abortion describe themselves as pro-life while those against legal restrictions on abortion describe themselves as pro-choice. Both are used to indicate the central principles in arguments for and against abortion: "Is the fetus a human being with a fundamental right to life?" for pro-life advocates, and, for those who are pro-choice, "Should the state or the individual have choice on the matter of abortion?" In both public and private debate, arguments presented in favour of or against abortion focus on either the moral permissibility of an induced abortion, or justification of laws permitting or restricting abortion. Arguments on morality and legality tend to collide and combine, complicating the issue at hand.

Public opinion

Political sides have largely been divided into absolutes. The abortion debate, as such, tends to centre around individuals who hold strong positions. However, public opinion varies from poll to poll, country to country, and region to region:
- Australia: In a February 2005 AC Nielsen poll, as reported in the The Age, 56% thought the current abortion laws were "about right," 16% want changes in law to make abortion "more accessible," and 17% want changes to make it "less accessible." [http://www.theage.com.au/news/National/Poll-backs-abortion-laws/2005/02/15/1108230007300.html] A 1998 poll, conducted by Roy Morgan Research, asked, "Do you approve of the termination of unwanted pregnancies through surgical abortion?" 65% of the Australians polled stated that they approved of surgical abortion and 25% stated that they disapproved of it. [http://oldwww.roymorgan.com/polls/1998/3058]
- Ireland: A 1997 Irish Times/MRBI poll of the Republic of Ireland's electorate found that 18% believe that abortion should never be permitted, 35% that one should be allowed in the event that the mother's life is threatened, 18% if her health is at risk, 28% that "an abortion should be provided to those who need it," and 5% were undecided. [http://www.ireland.com/newspaper/front/1997/1211/archive.97121100003.html]
- Canada: A recent poll of Canadians, conducted in April 2005 by Gallup, found that 52% of those polled want abortion laws to "remain the same," 20% want the laws to be "less strict," and 24% would prefer that the laws become "more strict." An earlier Gallup poll, from December 2001, asked, "Do you think abortions should be legal under any circumstances, legal only under certain circumstances or illegal in all circumstances and in what circumstances?" 32% of Canadians responded that they believe abortion should be legal in all circumstance, 52% that it should be legal in certain circumstances, and 14% that it should be legal in no circumstances. See Abortion in Canada.
- The United Kingdom: An online YouGov/Daily Telegraph poll in August 2005 found that 30% of Britons would back a measure to reduce the legal limit for abortion to 20 weeks, 19% support a limit of 12 weeks, 9% support a limit of less than 12 weeks, and 25% support maintaining the current limit of 24 weeks. 6% responded that abortion should never be allowed while 2% said it should be permitted throughout the entirety of pregnancy. [http://www.yougov.com/archives/pdf/TEL050101042_1.pdf]
- The United States: A CNN/USA Today/Gallup poll conducted in November 2005 revealed that 39% believe that abortion should be legal only in "a few circumstances" and another 16% think that it should be legal under "no circumstances", whereas 26% believe it should remain legal in "all circumstances" (the current law under Roe v. Wade) and 16% said it should be legal under "most circumstances". [http://www.cnn.com/2005/US/11/27/abortion.poll] Additional recent U.S. polling data can be found [http://www.pollingreport.com/abortion.htm here.] [http://www.pollingreport.com/abortion.htm]

Abortion law

Roe v. Wade The Soviet Union (1920) and Iceland (1935) were some of the first countries to generally allow abortion. The second half of the twentieth century saw the liberalization of abortion laws in many other countries. In 1973, the U.S. Supreme Court struck down state laws banning abortion, controversially ruling that such laws violated an inferred right to privacy in the U.S. Constitution. The Supreme Court of Canada, similarly, discarded its criminal code regarding abortion in 1988, after ruling that such restrictions violated the security of person guaranteed to women under in the Canadian Charter of Rights and Freedoms. Ireland, on the other hand, added an amendment to its Constitution in 1983 by popular referendum, recognizing "the right to life of the unborn." (see Abortion in Ireland). Current laws pertaining to abortion are diverse. Religious, moral, and cultural sensibilities continue to influence abortion laws throughout the world. The right to life, the right to liberty, and the right to security of person are major issues of human rights that are sometimes used as justification for the existence or the absence of laws controlling abortion. Many countries in which abortion is legal require that certain criteria be met in order for an abortion to be obtained, often, but not always, using a trimester-based system to regulate the window in which abortion is still legal to perform:
- In the United States, some states impose a 24-hour waiting period before the procedure, prescribe the distribution of information on fetal development, or require that parents be contacted if their minor daughter requests an abortion.
- In the United Kingdom, as in some other countries, two doctors must first certify that an abortion is medically or socially necessitated before it can be performed. Other countries, in which abortion is illegal, will allow one to be performed in the case of rape, incest, or danger to the pregnant woman's life or health. A handful of nations ban abortion entirely, such as