Understanding the baby’s journey in the first trimester
and why it might end “early”
This is the second part of a blog exploring what happens to the fertilised egg and why only 40 to 60% of fertilised eggs make it to being born at term. It also explores what happens during pregnancy loss. In the first part I explored why many women and therapists are wary about bodywork in the first trimester.
The third part will explore thoughts and ideas on how we can support the first trimester with bodywork including how we can support women who are losing their baby.
Implantation – both mother and baby need to say “Yes”
The fertilised egg, in natural conception, spends a week spiralling down the fallopian tube to the womb. During this time her cells are increasing in number, but the egg doesn’t increase in size. She is completely self-nourishing, but eventually needs to take in nourishment from outside. In order to do this she needs to implant in the lining of the womb, where she can receive blood. Where the egg implants the placenta will start to from.
Implantation is a perilous process. Sometimes the egg doesn’t even make to the tube and ends up outside the womb, where miraculously it may even continue developing for a while (ectopic pregnancy). The mother’s body has to accept a “foreign body.” Her immune system might reject it. She may have blood clotting disorders, autoimmune diseases, brain tumours or hormonal imbalances which make it difficult for the egg to implant. Her soul may not be ready.
The fertilised egg has to develop properly, with some cells specialising to form the baby’s body and other cells specialising to form the baby’s support structures: the placenta and membranes. There may be one off or recurring genetic issues with the fertilised egg. The baby also has to say “yes” to becoming completely dependent on their mother’s body to support it during the 9 months of pregnancy and beyond. Their soul may decide it’s not the right time. They may simply want to test the feeling of being contained within a fertilised egg the size of a grain of sand, but then return to the infiniteness of the universe.
It’s hard to know how many fertilised eggs don’t make it to implantation, but best estimates ( Jarvis 2016) are from 10 -40%. These figures seem high but the IVF rate is even higher. Around 30-50% of fertilised eggs don’t make it to the stage when they would be ready to implant in the womb (blastocyst).
Forming the physical body along with its support structures is a miracle
The next weeks are also challenging because not only does a baby have to develop all of its organs and systems in immature form but also their support structures, the placenta and amniotic sac. The first organ to develop during the fourth week is the heart, a primitive pump to circulate the blood. This is another tentative phase and many babies don’t make it through. So many things could go wrong in this process that it is a miracle that things end up in the right place! And of course sometimes they don’t. These reasons can be one off genetic issues with the compatibility of the sperm and the egg or family genetic conditions. Other reasons are mostly due to extremely toxic substances entering the womb. Each organ has its peak sensitivity and we see this clearly in what happened to children in the early 1960’s whose mothers took the drug thalidomide for morning sickness. These babies limbs didn’t fully develop.
If the baby makes it to 9 weeks after fertilisation when their organs have been created, they are fairly likely to survive the rest of the pregnancy. It generally accepted that after implantation around 15-25% pregnancies will end, although 98 -99% of these will be in the first trimester (12 weeks). Early pregnancy loss is before 23 weeks and often called “miscarriage” . The medical term “spontaneous abortion” is rarely used because of its associations with termination of pregnancy.
Later pregnancy loss is after 24 weeks, because a baby may be able to survive outside the womb. This is often called “ stillbirth” – a challenging term. The rate is around 1 in every 200 births in England. Total pregnancy loss from fertilisation to birth is estimated between 40 and 60%. (Jarvis 2016).
The reasons for these losses are usually because of issues with the development of either the baby or the placenta (genetic issues) or with the mother’s body. Maintaining the pregnancy, with its increase in her circulating blood (up to 30 to 40% more than normal), may become too much for her heart or kidneys, or her womb may not be strong enough to carry the weight of the baby (e.g a weak cervix).
Birth itself is a challenging process for both mother and baby, and a very small number of babies and mother’s don’t make it through, although this is extremely rare.
Around 25% of women experience one early pregnancy loss but only around 1% of women experience 3 or more. For some of these women, there is nothing “wrong” – it is chance. For other women there may be an underlying factor. Now there is more diagnosis and conditions can be recognised which cause this –autoimmune disease or blood disorders are the most common.
I have worked with women who have had more than 3 early pregnancy losses who have gone on to conceive naturally as well as carry one or more babies to term. I have also worked with women who have had many failed IVF cycles who have then gone on to conceive naturally and then carry their baby to term.
However, whatever stage there is pregnancy loss, there is always grief. A baby has died.
What happens in early pregnancy loss and how to support it?
A woman’s body recognises that the baby is no longer alive and, in most cases, lets it go. However this can take time, even several weeks. Nothing may happen for a while. Our emotions are strong and we may not want to let go of the baby. This can be part of grieving. Some women like to ask the baby to help them in the letting go process.
If the body is starting to “birth” her baby, early signs are vaginal bleeding and/or mild lower abdominal pain. However there can be some bleeding but the process stops because the baby and placenta are developing properly. If they are not then the process continues. It is a little like having a heavy late period. As in birth at term: the cervix starts to dilate, and the muscles of the womb start to contract. The bleeding becomes more severe and the amniotic sac breaks releasing waters. Then the baby is “born”. Depending on the week of pregnancy some women can recognise the sac or their baby in the blood clots and tissue.
Large clots may come out or it may be prolonged heavy bleeding. The hormonal shifts are similar to menstruation and birth in that the progesterone and oestrogen and relaxin levels drop suddenly, but, since the levels are higher the emotional shifts are more sudden. This process is not so dissimilar to given birth at term, but less intense.
Do I need medical intervention or can I do birth my baby naturally?
If the baby stops growing, the mother’s body in most cases can “birth” the baby naturally during the first trimester. Some midwives and doctors feel it is important to give women time to process this naturally as it is a rite of passage. Passing through it may help a woman to heal physically and emotionally. There haven’t been that many studies on “expectant” (waiting) vs medical but there can be complications with both, and the prevailing view seems to be to let women chose what is best for them, unless there is an infection.
Infection can happen after an incomplete loss or after surgery (D and C). An incomplete loss is when the body has not been able to fully birth the baby’s support structures (e.g. developing placenta, amniotic sac). If this is the case you may have some of the following symptoms: fever, chills, pain in your lower abdomen, foul smelling vaginal discharge or bleeding.
Some doctors and midwives offer drugs like misoprostol (synthetic prostaglandin) to speed up the process. Some women want this so that they can get on with their lives. However I find that working with these women later, they may wish they had taken the time to process their loss because its memory is still held in their body, many years later.
Women may be offered a dilation and curettage (D and C), as is done in the cases of termination/ abortion. The cervix is dilated with metal rods and then the curette (small spoon) is inserted and the womb is scraped clean. I have found that D and C may be traumatising to a woman and may trigger memories of earlier terminations.
After 14 weeks, women are often advised to have their labour induced with synthetic hormones. However, depending on the mother’s and baby’s health, it may also be possible to wait for the mother to naturally birth her baby.
I love Sara Wickham's book "In our own time" which is about allowing women to give birth without inducing labour unless there are clear medical reasons. I feel it should be the same for early births too.
The need for support during loss
During this process that women can need a lot of support. The grieving can be intense. I will explore this more in the next blog.
You might also want to watch the class I ran recently on why it is important to support women in the first trimester of pregnancy.
References and further reading:
In our own time: Sarah Wickham,
Early embryo mortality in natural human reproduction: What the data say:
Gavin E. Jarvis 2016
Windows to the womb: David Chamberlain
Beyond Grief: Navigating the Journey of Pregnancy and Baby Loss: Pippa Vosper