Abortion Abortion is an issue that evokes, on all sides, very strong feelings and judgments and very heated

recriminations. The most radical formulation of the anti-abortion or "pro-life" side of the debate views abortion as the murder of unborn children, and so as the equivalent of out and out infanticide, making the legal use of abortion since Roe v. Wade, at a rate of around 1.5 million a year in the United States, into a holocaust of the innocent fully comparable to the Nazi genocide against the Jews. Radical "pro-life" activists who blockade abortion clinics (or who even commit terrorist acts of vandalism, arson, and murder) see what they do as what "good Germans" didn't do in the face of Hitler's atrocities, or what John Brown did do in his attempt at Harper's Ferry to free the slaves through mass rebellion. While John Brown was regarded as a dangerous and treasonous fanatic during his lifetime, Union armies later marched through the South singing the song "John Brown's Body," whose tune Julia Ward Howe borrowed for the great "Battle Hymn of the Republic." Antiabortionists thus feel that they would be similarly vindicated and honored by history [note]. On the other hand, the most radical formulation of the pro-abortion or "pro-choice" side views opposition to abortion as opposition to the freedom of women, as hatred of women, and as part of a historical effort to "subjugate" women as nothing more than baby-making machines or, failing that, to see that they die in botched abortions as part of, indeed, something comparable to the Nazi genocide of the Jews. They sometimes interpret the anti-abortion cause as so heinous that even non-violent anti-abortion protests are regarded as "hate crimes" which should be suppressed using the most draconian federal anti-racketeering and anti-terrorist laws [note]. In general, "pro-choice" activists believe that the availability of abortion is absolutely necessary for the general alleviation of poverty and for the possibility of better and fulfilling lives for both women and children. My concern in this essay is to examine the extent to which arguments used by both sides of this debate are poor to untenable. The common acceptance of bad reasoning as self-evidently true always serves to demonize the opposition and to further radicalize and irrationalize the whole debate, to the benefit of every kind of extremist. While I am personally in the "pro-choice" camp, I am embarrassed to find that many common pro-choice arguments are based on appallingly bad reasoning. And if I seem particularly harsh about pro-choice arguments, it is obviously because I am concerned that the cause I favor be honored with the more sensible and cogent arguments. I also do not believe that the heated rhetoric that accompanies and is exacerbated by the bad arguments is any help in reaching a political modus vivendi on the issue. One of the most often repeated of such arguments is that abortion should be legal just because it would continue being practiced even if it were illegal again. The trouble with such reasoning is that it could just as easily give us an argument for legalizing theft or murder or rape. These things have been illegal for a long time, but they just continue happening anyway. So we may as well legalize them, since they are going to just continue happening anyway. Of course, no one is going to accept such reasoning in those matters. The fact that something is happening or will continue to happen cannot be an argument for whether it is acceptable or moral or just. A similarly bad argument says that abortion should be legal because women will get maimed or killed getting illegal abortions. That could just as easily be an argument for legalizing armed robbery or any other crime, since armed robbers and other criminals can get shot or killed in doing what they do. If something is genuinely wrong, then the fact that someone engaging in that wrong action might be hurt or killed is irrelevant. And if the argument is that abortion is too trivial a thing for women to die because of, that begs the question, since it is precisely the issue whether abortion is murder or not; and if it is, then it is not any kind of trivial matter. A pro-choice bumper-sticker occasionally seen says, "If you can't trust me with a choice, how can you trust me with a child?" However, although everyone is trusted with a "choice" whether or not to commit murder, this does not mean that they can choose whether murder is right or wrong. Just because mothers (and fathers) have a right to raise their children, they do not have a right to decide that murder, if it is murder, is OK. If abortion is murder, then the moral and legal issue is the same whether a mother and a father are thinking about murdering each other rather than aborting a fetus. Similarly, conservative firebrand and Republican sometime Presidential candidate Alan Keyes says: ...if your daughter comes and says "Dad, I want to kill grandma for the inheritance," you wouldn't say "well, this is not a good idea, but it's your choice."

People are trusted with freedom because they are generally trusted not to do wrong as autonomous moral agents. When they do wrongs, like murder, robbery, rape, etc., we do not "trust" them by saying that an action is all right just because it was all right with them. The basis of the "pro-life" position, in turn, is that human life starts with conception. The view is that there is no natural point of division in the life of a person between the fertilization of the egg and the point of the "viability" of a fetus to survive outside the womb, let alone birth. Furthermore, an embryo develops quickly, and by the time artificial abortions are likely to be performed, heart, brain, circulation, and other recognizable organs and organic functions already exist. Thus, in the 2007 movie Juno, Ellen Page (as Juno) is dissuaded from having an abortion in part because her classmate tells her that the fetus already has fingernails. As it happens, her classmate, protesting at the abortion clinic, is a sweet Chinese girl -- not the stereotype of a screaming male redneck fundamentalist that pro-choice advocates might prefer to have seen represented. While simple and coherent, the principal difficulty with the "starts with conception" view, however, is that the views of a very large number of "pro-life" people are inconsistent with it, if indeed they believe that abortion should be allowed in cases of rape and incest. If the "starts with conception" view of human life is to be applied consistently, a child of rape or incest is completely innocent of those acts and does not deserve to be killed because of the crime of its father [note]. Since the number of "pro-life" advocates who would be willing to force victims of incest or rape to endure a pregnancy as the result of those crimes is small enough that it wouldn't matter politically all by itself, our attention should turn to "prolife" advocates who would allow abortions in case of rape or incest. They make the difference politically, but since their views are inconsistent with the "starts from conception" view, we must ask if there is any other justification for an antiabortion stance that would make for a coherent perspective for such people. That will leave the "starts from conception" view of human life unanswered (for the moment), but I think that the revulsion most people would feel at making a woman bear the child of a rapist can be taken as a sufficient clue that most pro-life sentiment actually does not come from the "starts from conception" formulation. A more reasonable basis for "pro-life" sentiment centers on the issue of responsibility. "Pro-life" people actually deny that they represent an "anti-choice" view of abortion or that they wish to prevent a woman from having control over her body. Their view is that the choice and the control come at the moment of sex, not at the moment of conception. For instance, the conservative Jewish columnist Mona Charen says in a January 1997 column: Sure a woman has the right to choose whether or not to become pregnant. She makes that choice before engaging in sex. To make that 'choice' after a pregnancy is underway, merely as a matter of birth control, is an immoral act. Michelman [Kate Michelman of the National Abortion Rights Action League] and her allies feel an sense of entitlement to risk-free sex. The "pro-life" argument then is that the act of choosing to have sex is the act of choosing to accept responsibility for the possible consequences, i.e. conception. To them it is no longer a question of a woman's control over her own body when it involves killing someone else, even if that is "merely" an embryo or fetus. If this sentiment is found together with a belief that abortion is acceptable in cases of rape and incest, then the view can only be consistent if the "unborn child" does not have an absolute "right to life." Abortion would be acceptable if the mother did not have a choice in the conception. But the "unborn child" has enough of a "right to life" that a woman must reckon on her responsibility for it in her own free actions. The responsibility issue turns up in related debates about welfare. In the early '90's, the State of New Jersey decided not to increase welfare payments if women had additional children while already on welfare. One side of the debate regarded this as an attack on the children, with the assumption that women have the right to have children even when they know that they can support them only with public money or that, whether the women have that right or not, the children must be given public support regardless, just because they having nothing to do with their origin and are helpless. The other side of the debate held the children to be their parents' responsibility, regardless of their condition, not the public's, and refused to concede that the public has an open-ended obligation to unquestioningly provide the funds that promote the irresponsibility of parents by defusing the consequences of their imprudent behavior. As economists would say, protecting people from the consequences of their actions creates a "moral hazard," which effectively subsidizes and promotes imprudent behavior, even while imposing undeserved costs on others.

As it happened, the outcome of this policy in New Jersey produced curious alliances, for one effect of it was to increase the number of abortions as welfare mothers limited births, not through abstinence or birth control, but by abortion. Consequently, some who were opposed to abortion turned against the welfare policy because they saw it as promoting abortions. What the "pro-lifers" often wanted, however, was the same welfare policy and a ban on abortions. Opponents then liked to accuse them of hypocrisy in that respect, as though banning abortion while limiting welfare payments was inconsistent, but of course it was not: they wanted to ban abortion because they believed it was murder, but they might simultaneously want to limit welfare payments in order to make parents accountable for their sexual behavior -- both abstinence and multiple forms of birth control would still be available to avoid the imprudent responsibility of additional children. A troubling assumption that often seems to be made on the pro-welfare, "pro-choice" side in such debates is that sexuality is uncontrollable and that people cannot be held accountable for the consequences of their sexual behavior. The public then can only try and limit the damage by supporting the children after the fact. This is a most extraordinary assumption, whose most troubling aspect is that in application it is certain to be a self-fulfilling prophecy. It is also a convenient assumption for a very contrary kind of conclusion: stripping away individual liberties, after the manner of Communitarians, and perhaps even sterilizing welfare mothers. After all, if imprudent behavior, like riding without a motorcycle helmet or seat belt, can be forbidden because of the public liability incurred, then certainly the public would be justified in reducing its liability by rendering irresponsible mothers unable to burden the public any further. Even as the issue of responsibility may separate unconditional abortion foes from conditional abortion foes in the "prolife" camp, it also marks a separation in the "pro-choice" camp: many people who believe that abortion should be available for many reasons besides rape and incest nevertheless do not like the idea of "abortion on demand" being used merely as a substitute for birth control. They also do not believe that minors are competent either to appreciate the consequences of having sex or to appreciate the consequences of deciding whether or not to have an abortion. This division produces some of the paradoxes found in polling data about American public opinion. A majority of Americans are "pro-choice" in the sense of believing that abortion should be legal far beyond cases of rape and incest; but a majority also regards abortion as in some sense "wrong" and endorses various obstacles to abortion, including waiting periods, counseling, parental consent, etc. Indeed, a New York Times/CBS News poll, reported in the January 16, 1998, Los Angeles Daily News, reports that 50% of Americans actually believe that abortion is murder, though only 22% believe that abortion should not be permitted. This division is only possible if a substantial number of people see responsibility, not "right to life," as the decisive issue. From the poll, we might say that the 45% who believe in abortion with "stricter limits" reflect this view. The obstacles to abortion in that sense serve, not to prohibit abortion, but to make it difficult enough to drive home its seriousness. Of course, to them it is serious, and responsibility is an issue, because of a sense that an embryo or a fetus is a living thing, and a potential human being, so that abortion, even if it is not murder, is a morally serious form of killing. As the fetus approaches viability in the second and third trimesters, and abortion approaches the palpable practice of infanticide, support for abortion drops off dramatically [note]. An attempt to turn the responsibility argument around in favor of abortion on demand could be made by arguing that since a woman gets stuck with the responsibility for caring for the child, should the pregnancy be unwanted and the father irresponsible and unavailable, then no one else, who does not assume that burden of responsibility, has the right to tell her that she must assume it. This, again, is a poor argument, for two reasons: First, because by the same token the disinterested third party would not have the right to tell the father that he should assume his responsibility for the pregnancy; but if a third party can identify the moral responsibility of the father, then there is nothing paradoxical or inappropriate about identifying the mother's moral responsibility. Second, because if this is not to be a good argument for infanticide, it cannot be a good argument for abortion; for a mother may be just as personally responsible for a newborn, which few would regard as not having the moral and legal status of a person, as for a fetus in the womb, whose status as a person is precisely the issue. To say that only the mother is affected by burden of the pregnancy is to beg the question, for the responsibility for care is predicated on the presence of a living being whose very existence hangs in the balance. The issue of the rights, or absence thereof, of that being cannot be ignored because they reciprocally impose duties on specific individuals. The "pro-life" response can still be: If you don't want to assume the duties, then do not engage in the behavior that is liable to subject you to them. In general, the "pro-choice" argument for abortion that is hostile to putting any obstacles in the way of abortion on demand is that a woman has a right to control over her body at any time and that she has just as much right to choose an abortion as to choose sex. Although it is not a view that is voiced, this argument sometimes seems to imply that a woman

has a right to have sex that is superior to the right to exist of the being that may accidentally result. The "pro-choice" people who believe in obstacles to abortion, as well as the "pro-life" partisans, respond to that implied view by not wishing the impression to stand that sex should be something that is morally and legally without consequences. Sex without responsibility (Erica Jong's famous "zippless fuck" of the best selling Seventies book, Fear of Flying) is perceived as what the "abortion on demand" pro-choice people are pushing on society. If the pro-choice response is that dead or mutilated women is a lot to pay for a morally edifying lesson in responsibility, the only problem with that is that feminism is perfectly willing to use a "that's just tough" argument of moral responsibility against men when it comes to the very same issue: Since it is entirely the right of a woman to choose abortion or not, the man who may have unintentionally gotten a woman pregnant has no say in the matter at all, once he has donated his sperm. If a man went to court because he wanted a woman to abort a child that she wanted but he didn't, there would be a firestorm of partisans from both Right and Left against him. He chose to have sex, therefore his rights end immediately, and he is absolutely responsible for the rest of his life for that child, regardless of his wishes. If he didn't want the responsibility, he shouldn't have had sex with the woman. So feminists are perfectly willing to use an argument that responsibility begins with sex against men, that their rights end at intercourse, but then they are unwilling to allow that women should be just as responsible about their own sexual choices and held equally responsible for the rest of their lives for the consequences of their choices. This can easily strike both men and women as a "heads I win; tails you lose" approach to sexual responsibility -- a double standard. Much of my interest in presenting these arguments is to consider that persons of good will can be against abortion for substantial moral reasons that do not involve fundamentalist religion or hatred of women or the belief that women are just machines to make babies. The issue of responsibility can be as persuasive to women, from whose ranks many pro-life activists come (including, recently, "Jane Roe" herself, Norma McCorvey, of Roe v. Wade, who just got tired of the seeing the fetuses stacked in the freezer at the abortion clinic where she was working), as to men, and it is no help in addressing their concerns simply to accuse them of betraying the cause of their sex, of hating women and themselves, or of being a despicable "enemy" whose views are unworthy of consideration. But after my presenting these arguments, one might expect me to actually be "pro-life," even if in some diluted sense. So now let me recount why that is not so. The hard "pro-life" argument, that human life begins at conception, is unacceptable to me, not just because the idea of forcing a raped woman to give birth to the rapist's child is repugnant, but because the idea of a fertilized egg being a human being is absurd. A fertilized egg is a protozoan with a human genetic code in the nucleus. There is nothing sacred about the human genetic code; it is in nearly every cell in the human body. That the protozoan grows into a human being is undoubted, but that leaves us with only vague criteria to decide when the line is crossed between animal life and human life. That there are only vague criteria doesn't prove anything. There are vague criteria about lots of things in life. A religious belief that the fertilized egg possesses a soul, and thus is already fully human for that reason, provides a reasonable ground for a hard "pro-life" view; but since it is a religious belief, it cannot form the basis of a public law incumbent on everyone, who may be of various religious, and non-religious, persuasions. In Japan, abortion is common; but religious belief there, in Buddhism, allows that, although this is an evil, which should be atoned for by repentance and religious practices, the child will actually be reborn and is not permanently harmed. On the other hand, even if we accept that the fertilized egg may be a person, this still leaves untouched what I consider to be the principal argument for "choice," which is the argument of Roe v. Wade itself: Privacy. I say that human beings have a natural right, not a Constitutional right, but a natural right, which the courts are obliged to recognize under the Ninth Amendment, to privacy: the privacy of property -- real and personal -- and of person. And nothing is more private than our own bodies. A state with the considerable invasive power to police bodies, in particular women's bodies in this case, is a state that will exercise its power, as it already does in the Income Tax regulations and the despicable war on drugs, to leave nothing else private. That is not the kind of state that we should wish to have. Feminists of a totalitarian and Stalinist bent, like Catharine MacKinnon, do not like the stated grounds of Roe v. Wade because, as good totalitarians, they do not believe in privacy. The "pro-life" response to this can be that crimes on private property are still crimes and that privacy cannot protect murder. That is true, but it is not practical to prosecute even real crimes when it is not in the capacity of the state to prove them, and rights of privacy deny to the state such capacity in many cases. There is even such an example from Islamic Law: there is a Tradition of the Rightly Guided Caliphs (the first four Caliphs), which is one of the bases of Islamic Law, that when a man informed the Caliph Omar that he had seen someone drinking wine, which is forbidden by the Qur'n, Omar asked him how he had seen this. When the man replied that he had looked through a window into the miscreant's

home, Omar rebuked him for being in the wrong, for peering into a private home (a very serious offense when we realize that the Arabic word "harem," h.arm, means, not just the women's quarters, but also "sacred" and "forbidden"). Omar, as it were, threw out the case. We now would say this is an early example of the "Exclusionary Rule," which disallows the evidence of crime if it is unlawfully obtained. Assuming that abortion is murder, however, does beg the question about whether abortion is murder. Since reasonable persons disagree on that, what privacy protects is not murder, but the reckoning of conscience about whether abortion is murder or not [note]. Privacy also protects women from suspicion of murder just because of natural spontaneous abortions and miscarriages. These events are common enough and tragic and traumatic enough without adding the gratutious terror of the police showing up, perhaps with a political axe to grind, and starting an inquisition. Thus, as a matter of law rather than morality, the privacy protection of abortion is the best for a free society. A final argument about abortion, such as Communitarians might contribute, could be that it is "society" that must ultimately make a judgment about the constructive or destructive effects of allowing abortion on demand. Such an argument might become more acute once we realize that the typical feminist connection between abortion and poverty is wrong: Their view is that large families create poverty and that an increase in wealth, freedom, and self-fulfillment can only come with the employment of every possible means of birth control, including abortion. Historically this is clearly wrong. It may be easy to associate large populations with poverty today, if we think of places like India, but large and growing populations in the 19th century were clearly associated with booming and powerful European states and the creation of unprecedented levels of wealth for ordinary people. Even today some of the densest concentrations of population in the world are in the most technologically advanced and prosperous places, while some of the worst pockets of poverty and starvation, in Somalia, Ethiopia, etc., are in places with very thin populations. Since independence, India's problem has been its socialist government and socialist economic policies, not its population. Japan, a very mountainous country with a area comparable to California, and a population, heavily concentrated in coastal plains, roughly half that of the whole United States, has produced the second largest economy, and the largest economy per capita, in the world. In American history, we may think of ethnic groups with high fertility rates as poor groups, but one of the highest fertility rates in American history was that of Jews at the beginning of the 20th century: 5.3 children by age 45, identical to Mexican fertility and larger than black (4.2) or Irish (3.3). That fertility rate did not chain the Jews to poverty. On the contrary. The large families created whole new sources of wealth in the American economy. With wealth and success, the fertility rates dropped, even before modern birth control and abortion were available. For things like the social freedom of women, the development of wealth is absolutely necessary, and that has tended to come in countries where booming economies accompany growing population. A Communitarian, consequently, might make "society's" judgment that there is no necessity for abortion as a means of achieving wealth, freedom, and self-fulfillment. Instead, promoting fertility may aid in the growth of a nation's wealth and power, and thus ultimately allow for the freedom of women along with everyone else. The objection to that kind of reasoning, whether in this case or in any case, is that it is not the business of "society," which means government, to make judgments about the good ends to which people's activities should be directed. The state is not an enterprise with a specific purpose -- what has been called a "teleocracy," the rule of some end. The state is merely that which protects the honest enterprise of its citizens, a "nomocracy," a non-purposive Rule of Law. If abortion is an institution that is destructive of some good end, then the affairs of people who practice it will suffer, and the affairs of people who do not practice it will not suffer. We shall know them by their fruits. It is not the business of the state to second-guess such consequences, especially when it can be wrong and thus end up applying the coercive force of government, destroying people's lives, for the sake of a moralistic error.

ESTIMATED DATE OF CONFINEMENT The Estimated Date of Confinement (EDC) is a term describing the estimated delivery date for a pregnant woman.[1] Normal pregnancies last between 37 and 42 weeks.[2]

It is a calculated date (i.e., an estimation), determined by counting forward 280 days (40 weeks) from the first day of the woman's last menstrual period.

The term confinement is a traditional term referring to the period of pregnancy whereby a woman would be confined to bed (in an effort to reduce risk of premature delivery). Except in threatened pregnancies (for example, in pre-eclampsia), this is no longer a part of antenatal care. Estimated date of confinement (EDC): The due date or estimated calendar date when a baby will be born.

Last menstrual period Last menstrual period: By convention, pregnancies are dated in weeks starting from the first day of a woman's last menstrual period (LMP). If her menstrual periods are regular and ovulation occurs on day 14 of her cycle, conception takes place about 2 weeks after her LMP. A woman is therefore considered to be 6 weeks pregnant 2 weeks after her first missed period.  A woman's obstetric date is different from the embryologic date (the age of the embryo). The obstetric date is about 2 weeks longer than the embryologic date

 A pregnancy's duration is marked in weeks, starting from the first day of a woman's last menstrual period, or LMP. If the menstrual cycle is normal, and ovulation occurs on day 14 of the cycle, conception takes place roughly two weeks after the LMP. Therefore, a woman is considered six weeks pregnant, two weeks after she misses her period

Gravidity and Parity Definitions (and their Implications in Risk Assessment) The shorthand system of describing gravidity and parity has evolved based on local obstetric traditions, it may vary slightly between different communities and this can cause confusion.1 Definitions In the UK, gravidity is defined as the number of times that a woman has been pregnant and parity is defined as the number of times that she has given birth to a fetus with a gestational age of 24 weeks or more, regardless of whether the child was born alive or was stillborn. For example, a woman who is described as "gravida 2, para 2" (sometimes abbreviated to G2 P2) has had two pregnancies and two deliveries after 24 weeks, and a woman who is described as "gravida 2, para 0 " (G2 P0) has had two pregnancies, neither of which survived to a gestational age of 24 weeks. If they are both currently pregnant again, these women would have the obstetric resum of G3 P2 and G3 P0 respectively. Sometimes a suffix is added to indicate the number of miscarriages or terminations a woman has had. So if the second woman had had two miscarriages, it could be annotated G3 P0+2.
y y y y

A nulliparous woman (nullip) has not given birth previously (regardless of outcome). A primagravida is in her first pregnancy. A primiparous woman has given birth once. The term 'primip' is often used interchangeably with primagravida, although technically incorrect as a woman does not become primiparous until she has delivered her baby. A multigravida has been pregnant more than once.

y y

y y

A multiparous woman (multip) has given birth more than once. A grand multipara is a woman who has already delivered five or more infants who have achieved a gestational age of 24 weeks or more, and such women are traditionally considered to be at higher risk than the average in subsequent pregnancies. A grand multigravida has been pregnant five times or more. A great grand multipara has delivered seven or more infants beyond 24 weeks' gestation.

Multiple pregnancies present a problem: a multiple gestation counts as a single event and a multiple birth should be interpreted as a single parous event, although this remains contentious.1 In a survey, only 20% British midwives and obstetricians recognised a twin delivery as a single parous event - G1 P1 rather than G1 P2,2 revealing the potential lack of standardisation in our documentation. A more elaborate coding system used elsewhere, including America, is GTPAL (G=gravidity, T=term deliveries, P=preterm deliveries, A=abortions or miscarriages, L=live births). Epidemiology The current total fertility rate (the average number of children a woman would have if she experienced the fertility rate of a particular year for her entire child-bearing years) stands at 1.96 (2008 figures).3 Women are commencing their childbearing later and having fewer children in total. More women remain childless (1 in 5 of women born in 1963 compared to 1 in 8 of those born in 1933). Fewer women have 3 or more children (3 in 10 women born in 1963 compared to 4 in 10 women born in 1933). The number of higher order grand multips has fallen significantly. Relationship of gravidity and parity to risk in pregnancy Obstetric histories should always record parity, gravidity and outcomes of all previous pregnancies as:
y y y

Outcomes of previous pregnancies give some indication of the likely outcome and degree of risk with the current pregnancy. The number of previous pregnancies and deliveries will also influence the risks associated with the current pregnancy. What is considered normal labour varies according to parity: o Normal labour in a primagravida is significantly different to normal labour in multiparous women, as physiologically the uterus is a less efficient organ, contractions may be dyscoordinate or hypotonic. The average first stage in a primagravida is significantly slower than in a multip (primarily due to the rate of cervical dilation)4 - so progress is expected to be slower but delay longer than expected should prompt augmentation in managed labour. o Interestingly, grand multips have a longer latent phase of labour than either nulliparous or lower-parity multiparous women but then begin to dilate more rapidly. After 6 cm dilation, partogram curves for lower parity multips and grand multips are indistinguishable. Progress of labour does not appear to continue to improve with additional child-bearing.5

Risks associated with nulliparity/primagravidae

y Higher risk of developing pre-eclampsia (relative risk 2.91 with confidence interval 1.28-6.61). y Delayed first stage of labour, though this could be considered normal in a primagravida. y Dystocia (or difficult labour) was diagnosed in 37% primagravidae in one Danish study.7
6

Risks associated with grand multiparity8 Increased risk of:

y y y y

Abnormal fetal presentation Precipitate delivery Uterine atony Placenta praevia

y y y y y

Uterine rupture Amniotic fluid embolism Obstetric haemorrhage Stress incontinence and urinary urgency symptoms9 Levator ani dysfunction10

What is a high-risk pregnancy? Risk equates to factors that increase likelihood of harm to mother or baby. There is no universally accepted definition of a 'high-risk' pregnancy and nor can antenatal 'risk' screening identify every pregnancy/labour that will run into complications. Usually risk factors are combined and weighted to try to match an appropriate level of medical care and intervention to a more risky pregnancy to attempt to reduce the chances of a poor outcome. Confounding variables11 Increased parity is often associated with:
y Increasing maternal age y Lower socio-economic and educational status y Poorer prenatal care (more likely to be late bookers and poor attenders) y Smoking and alcohol consumption y Higher BMIs y Higher rates of gestational diabetes

It is not always possible to disassociate the various risk factors attributable to each factor. Between 1997 and 1999, the maternal mortality rate was almost 6 times greater in women of parity 4 or more, as compared to that of women in their first pregnancy.12 However, a subsequent report discounted this apparent association between high parity and maternal mortality and the association becomes much harder to characterise as fewer and fewer women in the UK have 4 or more children into the 21st century.13 The lowest maternal mortality rates are observed in women with one previous pregnancy. Management Primigravidae Provide:
y Good antenatal care with particular vigilance to early warning signs of pre-eclamptic toxaemia (PET). NICE

recommends nullips with uncomplicated pregnancies should have 10 routine antenatal appointments (versus 7 in parous women).14 y Good antenatal and parenting education, support during labour and pain control (if desired) are especially important in a first pregnancy as anxiety levels are likely to be high. y Where there is delay in the first stage of labour in a primagravida, active management with artificial rupture of membranes and/or oxytocin to augment labour.15 y The second stage of labour can be allowed to continue for longer than the traditional time associated with multips, as long as fetal monitoring is satisfactory and there is ongoing fetal descent.15 Grand multigravidae It is usually appropriate to book for delivery in a specialist unit. Consider:
y y y y y

Iron and folate prophylaxis. A plan for the care of existing children during admission. Vigilance for abnormal fetal presentations from 36 weeks onward. Plan for possible rapid labour and delivery. Monitor strength of contractions and fetal presentation during delivery.

y Planning for the possibility of postpartum haemorrhage. y Good physiotherapy and postnatal follow-up for urogynaecological problems.

Document references 1. Creinin MD, Simhan HN; Can we communicate gravidity and parity better? Obstet Gynecol. 2009 Mar;113(3):709-11. [abstract] 2. Opara EI, Zaidi J; The interpretation and clinical application of the word 'parity': a survey. BJOG. 2007 Oct;114(10):1295-7. [abstract] 3. National statistics; Total fertility rate 4. Vahratian A, Hoffman MK, Troendle JF, et al; The impact of parity on course of labor in a contemporary population.; Birth. 2006 Mar;33(1):12-7. [abstract] 5. Gurewitsch ED, Diament P, Fong J, et al; The labor curve of the grand multipara: does progress of labor continue to improve with additional childbearing?; Am J Obstet Gynecol. 2002 Jun;186(6):1331-8. [abstract] 6. Duckitt K, Harrington D; Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies.; BMJ. 2005 Mar 12;330(7491):565. Epub 2005 Mar 2. [abstract] 7. Kjaergaard H, Olsen J, Ottesen B, et al; Incidence and outcomes of dystocia in the active phase of labor in term nulliparous women with spontaneous labor onset. Acta Obstet Gynecol Scand. 2009;88(4):402-7. [abstract] 8. Merck Manual; Merck manual of diagnosis and therapy (on-line). Chapter 250 High risk pregnancy 9. Handa VL, Harvey L, Fox HE, et al; Parity and route of delivery: does cesarean delivery reduce bladder symptoms later in life?; Am J Obstet Gynecol. 2004 Aug;191(2):463-9. [abstract] 10. Kisli E, Kisli M, Agargun H, et al; Impaired function of the levator ani muscle in the grand multipara and great Tohoku J Exp Med. 2006 Dec;210(4):365-72. [abstract] 11. Roman H, Robillard PY, Verspyck E, et al; Obstetric and neonatal outcomes in grand multiparity.; Obstet Gynecol. 2004 Jun;103(6):1294-9. [abstract] 12. CEMACH - Why mothers die; Confidential enquiry into maternal deaths in the UK; (1997-1999) 13. CEMACH - Why mothers die; Confidential enquiry into maternal deaths in the UK. Chapter 1 - Introduction and key findings; (2000-2002). 14. Antenatal care: routine care for the healthy pregnant woman, NICE Clinical Guideline (March 2008) 15. Shields SG, Ratcliffe SD, Fontaine P, et al; Dystocia in nulliparous women. Am Fam Physician. 2007 Jun 1;75(11):1671-8. [abstract]

English term or phrase: G, P, T, A, L "Birthing Center" (Maternal Transfer Authorization)

Ann

1- Patient's information: Name ____ Age ________ LMP ______ EDC____ Gestation in Weeks_____ G___ T___ P ____ A_____ L ____ Membranes: Intact______ SROM _______ AROM_______ -* What does each letter of (G, T, P, A, and L) stand for?

GTPAL (gravida, term, preterm, abortions, living)

Explanation: Good luck from Oso :^) -------------------------------------------------Note added at 2005-06-28 19:11:41 (GMT)

Note added at 2005-06-28 19:12:29 (GMT) -------------------------------------------------G= Gravida T=Term P=Preterm A=Abortions L=Living -------------------------------------------------Note added at 2005-06-28 19:34:39 (GMT) -------------------------------------------------Gravida=number of total pregnancies Term= term deliveries Preterm=preterm deliveries Abortions= abortions (both surgical abortions and miscarriages) Living= living children

Preterm Birth and Abortion

Implications of the Costs to Society Due to Damage from Induced Abortion
Until recently, little has been written about induced abortion as a public health issue.(14,15) The recent publication of two summaries of salient articles raises concerns about induced abortion and preterm birth adding a new dimension to the discussion.(5,15) It should be noted that this study does not include all the excess obstetrical costs, emotional costs to families, and the long term costs of disabled preterm infants. The increase in hospital expenses due to abortion raises the national neonatal hospital expenditure by a total of over $1.2 billion [living ($1.1 billion) and non living ($112 million)] and, theoretically this expense is avoidable. However, this is only the immediate expense for these children and the additional expenses in caring for these children will fall on the families. All women, especially those facing a crisis pregnancy, deserve to be informed of the substantial impact of an induced abortion that the current pregnancy has on the next pregnancy and the entire family. The overwhelming evidence that she may deliver before 32 weeks will substantially impact her cost of raising children, particularly those children who may have conditions such as cerebral palsy and other conditions related to preterm birth. The cost impact for a particular woman, if she does deliver before 32 weeks, varies by the week of delivery, but ranges from $27,000-$145,000. Informed consent prior to elective abortion must include the above information and should stratify the risk of one previous induced abortion and multiple induced abortions.

It should be noted that the risk for cerebral palsy has been reported to increase by some 38 times.(23) This translates into one half of the neurological problems in children that includes severe or significant developmental delay.(23) These problems can be prevented by eliminating abortions. Given that one half of the neurological problems could be prevented, it is astonishing that there is not more call for limitations on abortion. The liability crisis, fueled in part by the brain damaged infant, has become a major issue in obstetrical practice.(24) With the median damage award for medical negligence at birth of over $2 million in the years 1994-2000(25) and the cost for a "brain damaged" infant substantially higher, averaging over $1 million (with one recent case awarded $100 million), should make all obstetricians and abortion providers take notice.(26) A patient may now claim, that if they were not informed of the increased risk of preterm delivery by a physician performing an induced abortion, they may recover monetary damages for such negligence.(27) Even a modest effect attributable to induced abortion leads to significant cost consequences in initial neonatal hospitalizations. Women, the public and public health officials must be made aware of the huge costs (some $1.2 billion a year in the United States) that even an increase of 31.5% of the risk of early preterm birth will have on initial neonatal care. A careful history of induced abortion must be part of every new pregnant patient encounter in any setting. Enhanced surveillance and counseling of increased risk for preterm birth ought to be discussed with women with a history of induced abortion, in preconception visits and/or early prenatal visits. Importantly, these precautions will provide the prudent obstetrical practitioner wish: 1) an opportunity to alter a woman's prenatal care, given their induced abortion history, 2) a malpractice defense for a subsequent preterm birth, since the increased risk came with the induced abortion, not in the obstetrical care, 3) allow for the compilation of national guidelines to manage pregnant women who have had a prior induced abortion, 4) allow for the construction and execution of new studies to improve the perinatal outcome of preterm birth specifically attributable to induced abortion. Using the available information regarding induced abortion and initial hospital costs in the United States, over $1.3 billion in excess initial hospital costs due to preterm delivery are attributable to induced abortion.(1) The calculated initial neonatal hospital costs of over $1.3 billion do not reflect the subsequent significant lifetime costs of the increased morbidity of early preterm birth including: cerebral palsy, blindness, deafness, and learning disabilities. This discussion also does not address other maternal psychological, emotional, or medical costs associated with induced abortion. These costs are beyond the scope of this discussion. Further studies and analysis of the data relative to the attributable risk of preterm birth as a consequence of induced abortion and induced abortion's significant impact on public health costs will be required. Many women and their families, who experienced a previous crisis pregnancy ending in induced abortion, unnecessarily bear the burden for their lifetimes with the birth of a handicapped child. Armed with newer epidemiological studies demonstrating an association between prior induced abortion and preterm birth before 32 weeks, abortion and obstetrical providers necessarily need to carefully re-design informed consent forms (if not already done) for both induced abortion and prenatal care and delivery, and consider the medical and liability consequences of induced abortion more carefully than ever.