Prenatal care

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Prenatal care
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A doctor performs a prenatal exam.

Prenatal care, also known as antenatal care, is a type of preventive healthcare. It is provided in the form of medical checkups, consisting of recommendations on managing a healthy lifestyle and the provision of medical information such as maternal physiological changes in pregnancy, biological changes, and prenatal nutrition including prenatal vitamins, which prevents potential health problems throughout the course of the pregnancy and promotes the mother and child's health alike. [1] [2] The availability of routine prenatal care, including prenatal screening and diagnosis, has played a part in reducing the frequency of maternal death, miscarriages, birth defects, low birth weight, neonatal infections and other preventable health problems.

Contents

Traditional prenatal care in high-income countries generally consists of:

The traditional form of antenatal care has developed from the early 1900s and there is very little research to suggest that it is the best way of giving antenatal care. [3] Antenatal care can be costly and uses many staff. The following paragraphs describe research on other forms of antenatal care, which may reduce the burden on maternity services in all countries.

Visits numbers

The WHO recommends that pregnant women should all receive at least eight antenatal visits to spot and treat problems and give immunizations. Although antenatal care is important to improve the health of both mother and baby, many women do not receive eight visits. [4] There is little evidence behind the number of antenatal visits, pregnant women receive and what care and information is given at each visit. [3] It has been suggested that women who have low-risk pregnancies should have fewer antenatal visits. [3] However, when this was tested, women with fewer visits had babies who were much more likely to be admitted to neonatal intensive care and stay there for longer (though this could down to chance results). [3] A 2015 Cochrane Review findings buttresses this notion, with evidence that in settings with limited resources, where the number of visits is already low, programmes of ANC with reduced visits are associated with an increase in perinatal mortality. [3] Therefore, it is doubtful that the reduced visits model is ideal, even in low income countries (LICs), where pregnant women are already attending fewer appointments. [2] Not only is visiting prenatal care early is highly recommended, but also a more flexible pathway allowing more visits, from the time a pregnant woman books for prenatal care, as it potentially enables more attention to those women who come late. [2] Also, women who had fewer antenatal visits were not as satisfied with the care they received compared with women who had the standard number of visits. [3] A new alternative for some of the routine prenatal care visits is Telemedicine. [5]

There are many ways of changing health systems to help women access antenatal care, such as new health policies, educating health workers and health service re-organisation. Community interventions to help people change their behavior can also play a part. Examples of interventions are media campaigns reaching many people, enabling communities to take control of their own health, informative-education-communication interventions and financial incentives. [6] A review looking at these interventions found that one intervention helps improve the number of women receiving antenatal care. [6] However interventions used together may reduce baby deaths in pregnancy and early life, lower numbers of low birth weight babies born and improve numbers of women receiving antenatal care. [6]

The World Health Organization (WHO) reported that in 2015 around 830 women died every day from problems in pregnancy and childbirth. [7] Only 5 lived in high-income countries. The rest lived in low-income countries. [7]

A study examined the differences in early and low-weight birth deliveries between local and immigrant women and saw the difference caused by prenatal care received. The study, between 1997 and 2008, looked at 21,708 women giving birth in a region of Spain. The results indicated that very preterm birth (VPTB) and very low birth weight (VLBW) were much more common for immigrants than locals (Castelló et al., 2012). The study showed the importance of prenatal care and how universal prenatal care would help people of all origins get proper care before pregnancy/birth (Castelló et al., 2012).

Group versus individual care

Group antenatal care has a couple of obvious benefits: it costs less than one-to-one visits and the women have more hours of care as a group than on their own. [8] Only small studies have been conducted looking at group care but they have found that mothers knew more about pregnancy, birth and parenting in the group setting. [8] The mothers reported liking the group care and the review found no difference between how the pregnancies developed between the group and individual settings. [8]

Midwife-led care

Midwife-led care for low-risk women is where a midwife team (and GP if needed) leads the care a woman receives and she does not usually see a specialist doctor in her pregnancy. [9] Women with midwife-led pregnancies are more likely to give birth without being induced but have natural labours. However they are less likely to have their waters broken, an instrumental delivery, episiotomy or preterm birth. [10] Around the same number of women in each group had a caesarean section. [10]

Prenatal examinations

At the initial antenatal care visit and with the aid of a special booking checklist the pregnant women become classified into either normal risk or high risk.

In many countries, women are given a summary of their case notes including important background information about their pregnancy, such as their medical history, growth charts and any scan reports. [11] If the mother goes to a different hospital for care or to give birth the summary of her case notes can be used by the midwives and doctors until her hospital notes arrive. [11]

A review looking into women keeping their own case notes shows they have more risk of having a caesarean section. [11] However the women reported feeling more in control having their notes and would like to have them again in future pregnancies. [11] 25% of women reported their hospital notes were lost in hospital though none of the women forgot to take their own notes to any appointments. [11]

Prenatal diagnosis or prenatal screening (note that "Prenatal Diagnosis" and "Prenatal Screening" refer to two different types of tests) is testing for diseases or conditions in a fetus or embryo before it is born. Obstetricians and midwives have the ability to monitor mother's health and prenatal development during pregnancy through series of regular check-ups.

Physical examinations generally consist of:

In some countries, such as the UK, the symphysial fundal height (SFH) is measured as part of antenatal appointments from 25 weeks gestation. [12] (The SFH is measured from the woman's pubic bone to the top of the uterus. [13] ) A review into this practice found only one piece of research so there is not enough evidence to say whether measuring the SFH helps to detect small or large babies. [14] As measuring the SFH is not costly and is used in many places, the review recommends carrying on this practice. [14]

Growth charts are a way of detecting small babies by the measuring the SFH. [15] There are two types of growth chart:

  1. Population based chart, which shows a standard growth and size for each baby
  2. Customized growth chart, which is worked out by looking at the mother's height and weight, and the weights of their previous babies. [15]

A review looking into which of these charts detected small babies found that there is no good quality research to show which is best. [15] More research is needed before the customized growth charts are recommended because they cost more money and take more time for the health care workers to make. [15]

Obstetric ultrasounds are most commonly performed during the second trimester at approximately week 20. Ultrasounds are considered relatively safe and have been used for over 35 years for monitoring pregnancy. Among other things, ultrasounds are used to:

Generally an ultrasound is ordered whenever an abnormality is suspected or along a schedule similar to the following:

A review looking at routine ultrasounds past 24 weeks found that there is no evidence to show any benefits to the mother or the baby. [16]

Early scans mean that multiple pregnancies can be detected at an early stage of pregnancy [17] and also gives more accurate due dates so that less women are induced who do not need to be. [17]

Levels of feedback from the ultrasound can differ. High feedback is when the parents can see the screen and are given a detailed description of what they can see. [18] Low feedback is when the findings are discussed at the end and the parents are given a picture of the ultrasound. [18] The different ways of giving feedback affect how much the parents worry and the mother's health behaviour although there is not enough evidence to make clear conclusions. [18] In a small study, mothers receiving high feedback were more likely to stop smoking and drinking alcohol however the quality of the study is low and more research is needed to say for certain which type of feedback is better. [18]

Women experiencing a complicated pregnancy may have a test called a Doppler ultrasound to look at the blood flow to their unborn baby. [19] This is performed to detect signs that the baby is not getting a normal blood flow and therefore is 'at risk'. A review looked at performing Doppler ultrasounds on all women even if they were at 'low risk' of having complications. [19] The review found that routine Doppler ultrasounds may have reduced the number of preventable baby deaths but the evidence was not strong enough to recommend that they should be made routine for all pregnant women. [19]

Exercise intensity and delivery outcomes

Research suggests that physical activity levels during pregnancy can impact delivery outcomes. [20] A study examining the effects of exercise intensity on delivery type and risk of preterm birth found that varying levels of physical activity were linked to different pregnancy outcomes and associated risks.

Very low levels of physical activity are associated with an increased risk of both preterm and instrumental deliveries. [21] Pregnant individuals with minimal activity may experience lower overall fitness and muscle tone, which can impact the body’s ability to manage the physical demands of labor. Another study showed that individuals with higher handgrip strength are more likely to have a vaginal delivery, as greater muscle strength and endurance can support the labor process. In contrast, those who gained more weight during pregnancy or had larger arm and calf circumferences were more likely to undergo cesarean delivery, particularly in cases of nonprogressive labor. [22]

Low levels of physical activity during pregnancy have been linked to a slightly elevated risk of cesarean delivery. [21] Regular moderate exercise may help enhance pelvic muscle tone and cardiovascular fitness, potentially reducing the likelihood of cesarean intervention by supporting the body’s endurance during labor.

For individuals seeking to engage in levels of vigorous or high intensity physical activity, one study did observe a slight increase in instrumental delivery, which involves the use of medical tools like forceps or vacuum devices. [21] More intense physical activity may add extra demands on the body, potentially affecting labor progression and increasing the need for instrumental assistance.

It is important for pregnant individuals to consult with their healthcare provider before beginning or adjusting exercise routines, particularly if they are new to regular physical activity or have any health conditions that may affect pregnancy.

United States

Proper prenatal care affects all women of various social backgrounds. While availability of such services have considerable personal health and social benefits, socioeconomic problems prevent its universal adoption in both developing and developed nations, such as the US. Although women can benefit by utilizing prenatal care services, there exists various levels of health care accessibility between different demographics throughout the United States.

See also

Related Research Articles

<span class="mw-page-title-main">Caesarean section</span> Surgical procedure to deliver a baby through an incision in the mothers abdomen

Caesarean section, also known as C-section, cesarean, or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen. It is often performed because vaginal delivery would put the mother or child at risk. Reasons for the operation include obstructed labor, twin pregnancy, high blood pressure in the mother, breech birth, shoulder presentation, and problems with the placenta or umbilical cord. A caesarean delivery may be performed based upon the shape of the mother's pelvis or history of a previous C-section. A trial of vaginal birth after C-section may be possible. The World Health Organization recommends that caesarean section be performed only when medically necessary.

<span class="mw-page-title-main">Multiple birth</span> End of a multiple pregnancy where two or more offspring are born

A multiple birth is the culmination of one multiple pregnancy, wherein the mother gives birth to two or more babies. A term most applicable to vertebrate species, multiple births occur in most kinds of mammals, with varying frequencies. Such births are often named according to the number of offspring, as in twins and triplets. In non-humans, the whole group may also be referred to as a litter, and multiple births may be more common than single births. Multiple births in humans are the exception and can be exceptionally rare in the largest mammals.

<span class="mw-page-title-main">Childbirth</span> Conclusion of the human pregnancy with the expulsion of a fetus from mothers womb

Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million human births globally. In developed countries, most deliveries occur in hospitals, while in developing countries most are home births.

<span class="mw-page-title-main">Amniocentesis</span> Sampling of amniotic fluid done mainly to detect fetal chromosomal abnormalities

Amniocentesis is a medical procedure used primarily in the prenatal diagnosis of genetic conditions. It has other uses such as in the assessment of infection and fetal lung maturity. Prenatal diagnostic testing, which includes amniocentesis, is necessary to conclusively diagnose the majority of genetic disorders, with amniocentesis being the gold-standard procedure after 15 weeks' gestation.

<span class="mw-page-title-main">Preterm birth</span> Birth at less than a specified gestational age

Preterm birth, also known as premature birth, is the birth of a baby at fewer than 37 weeks gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 weeks, very early preterm birth is between 28 and 32 weeks, early preterm birth occurs between 32 and 34 weeks, late preterm birth is between 34 and 36 weeks' gestation. These babies are also known as premature babies or colloquially preemies or premmies. Symptoms of preterm labor include uterine contractions which occur more often than every ten minutes and/or the leaking of fluid from the vagina before 37 weeks. Premature infants are at greater risk for cerebral palsy, delays in development, hearing problems and problems with their vision. The earlier a baby is born, the greater these risks will be.

<span class="mw-page-title-main">Gestational diabetes</span> Exercise and Obesity Management During Pregnancy

Gestational diabetes is a condition in which a woman without diabetes develops high blood sugar levels during pregnancy. Gestational diabetes generally results in few symptoms; however, obesity increases the rate of pre-eclampsia, cesarean sections, and embryo macrosomia, as well as gestational diabetes. Babies born to individuals with poorly treated gestational diabetes are at increased risk of macrosomia, of having hypoglycemia after birth, and of jaundice. If untreated, diabetes can also result in stillbirth. Long term, children are at higher risk of being overweight and of developing type 2 diabetes.

<span class="mw-page-title-main">External cephalic version</span> Process by which a breech baby can sometimes be turned from buttocks or foot first to head first

External cephalic version (ECV) is a process by which a breech baby can sometimes be turned from buttocks or foot first to head first. It is a manual procedure that is recommended by national guidelines for breech presentation of a pregnancy with a single baby, in order to enable vaginal delivery. It is usually performed late in pregnancy, that is, after 36 gestational weeks, preferably 37 weeks, and can even be performed in the early stages of childbirth.

Labor induction is the process or treatment that stimulates childbirth and delivery. Inducing (starting) labor can be accomplished with pharmaceutical or non-pharmaceutical methods. In Western countries, it is estimated that one-quarter of pregnant women have their labor medically induced with drug treatment. Inductions are most often performed either with prostaglandin drug treatment alone, or with a combination of prostaglandin and intravenous oxytocin treatment.

<span class="mw-page-title-main">Pregnancy</span> Time of offspring development in mothers body

Pregnancy is the time during which one or more offspring develops (gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.

<span class="mw-page-title-main">Large for gestational age</span> Medical condition

Large for gestational age (LGA) is a term used to describe infants that are born with an abnormally high weight, specifically in the 90th percentile or above, compared to other babies of the same developmental age. Macrosomia is a similar term that describes excessive birth weight, but refers to an absolute measurement, regardless of gestational age. Typically the threshold for diagnosing macrosomia is a body weight between 4,000 and 4,500 grams, or more, measured at birth, but there are difficulties reaching a universal agreement of this definition.

<span class="mw-page-title-main">Low birth weight</span> Birth weight of an infant of 2,499 g (5 lb 8.1 oz) or less

Low birth weight (LBW) is defined by the World Health Organization as a birth weight of an infant of 2,499 g or less, regardless of gestational age. Infants born with LBW have added health risks which require close management, often in a neonatal intensive care unit (NICU). They are also at increased risk for long-term health conditions which require follow-up over time.

<span class="mw-page-title-main">Prelabor rupture of membranes</span> Breakage of the amniotic sac before the onset of labour

Prelabor rupture of membranes (PROM), previously known as premature rupture of membranes, is breakage of the amniotic sac before the onset of labour. Women usually experience a painless gush or a steady leakage of fluid from the vagina. Complications in the baby may include premature birth, cord compression, and infection. Complications in the mother may include placental abruption and postpartum endometritis.

Antenatal steroids, also known as antenatal corticosteroids, are medications administered to pregnant women expecting a preterm birth. When administered, these steroids accelerate the maturation of the fetus' lungs, which reduces the likelihood of infant respiratory distress syndrome and infant mortality. The effectiveness of this corticosteroid treatment on humans was first demonstrated in 1972 by Sir Graham Liggins and Ross Howie, during a randomized control trial using betamethasone.

<span class="mw-page-title-main">Nutrition and pregnancy</span> Nutrient intake and dietary planning undertaken before, during and after pregnancy

Nutrition and pregnancy refers to the nutrient intake, and dietary planning that is undertaken before, during and after pregnancy. Nutrition of the fetus begins at conception. For this reason, the nutrition of the mother is important from before conception as well as throughout pregnancy and breastfeeding. An ever-increasing number of studies have shown that the nutrition of the mother will have an effect on the child, up to and including the risk for cancer, cardiovascular disease, hypertension and diabetes throughout life.

<span class="mw-page-title-main">Postpartum bleeding</span> Loss of blood following childbirth

Postpartum bleeding or postpartum hemorrhage (PPH) is often defined as the loss of more than 500 ml or 1,000 ml of blood following childbirth. Some have added the requirement that there also be signs or symptoms of low blood volume for the condition to exist. Signs and symptoms may initially include: an increased heart rate, feeling faint upon standing, and an increased breathing rate. As more blood is lost, the patient may feel cold, blood pressure may drop, and they may become restless or unconscious. In severe cases circulatory collapse, disseminated intravascular coagulation and death can occur. The condition can occur up to twelve weeks following delivery in the secondary form. The most common cause is poor contraction of the uterus following childbirth. Not all of the placenta being delivered, a tear of the uterus, or poor blood clotting are other possible causes. It occurs more commonly in those who already have a low amount of red blood, are Asian, have a larger fetus or more than one fetus, are obese or are older than 40 years of age. It also occurs more commonly following caesarean sections, those in whom medications are used to start labor, those requiring the use of a vacuum or forceps, and those who have an episiotomy.

Neonatal alloimmune thrombocytopenia is a disease that affects babies in which the platelet count is decreased because the mother's immune system attacks her fetus' or newborn's platelets. A low platelet count increases the risk of bleeding in the fetus and newborn. If the bleeding occurs in the brain, there may be long-term effects.

<span class="mw-page-title-main">High-risk pregnancy</span> Medical condition

A high-risk pregnancy is a pregnancy where the mother or the fetus has an increased risk of adverse outcomes compared to uncomplicated pregnancies. No concrete guidelines currently exist for distinguishing “high-risk” pregnancies from “low-risk” pregnancies; however, there are certain studied conditions that have been shown to put the mother or fetus at a higher risk of poor outcomes. These conditions can be classified into three main categories: health problems in the mother that occur before she becomes pregnant, health problems in the mother that occur during pregnancy, and certain health conditions with the fetus.

Antenatal depression, also known as prenatal or perinatal depression, is a form of clinical depression that can affect a woman during pregnancy, and can be a precursor to postpartum depression if not properly treated. It is estimated that 7% to 20% of pregnant women are affected by this condition. Any form of prenatal stress felt by the mother can have negative effects on various aspects of fetal development, which can cause harm to the mother and child. Even after birth, a child born from a depressed or stressed mother feels the affects. The child is less active and can also experience emotional distress. Antenatal depression can be caused by the stress and worry that pregnancy can bring, but at a more severe level. Other triggers include unplanned pregnancy, difficulty becoming pregnant, history of abuse, and economic or family situations.

<span class="mw-page-title-main">Further research is needed</span> Phrase commonly used in research papers

The phrases "further research is needed" (FRIN), "more research is needed" and other variants are commonly used in research papers. The cliché is so common that it has attracted research, regulation and cultural commentary.

<span class="mw-page-title-main">Operative vaginal delivery</span>

Operative vaginal delivery, also known as assisted or instrumental vaginal delivery, is a vaginal delivery that is assisted by the use of forceps or a vacuum extractor.

References

  1. ↑ "WHO recommendations on antenatal care for a positive pregnancy experience". www.who.int. Retrieved 2021-12-04.
  2. 1 2 3 David, Rodreck; Evans, Ruth; Fraser, Hamish SF (2021-01-01). "Modelling Prenatal Care Pathways at a Central Hospital in Zimbabwe". Health Services Insights. 14: 11786329211062742. doi:10.1177/11786329211062742. ISSN   1178-6329. PMC   8647229 . PMID   34880627.
  3. 1 2 3 4 5 6 Dowswell, T; Carroli, G; Duley, L; Gates, S; Gülmezoglu, AM; Khan-Neelofur, D; Piaggio, G (16 July 2015). "Alternative versus standard packages of antenatal care for low-risk pregnancy". The Cochrane Database of Systematic Reviews. 2015 (7): CD000934. doi:10.1002/14651858.CD000934.pub3. PMC   7061257 . PMID   26184394.
  4. ↑ "WHO recommendation on antenatal care contact schedules". WHO. World Health Organization. Retrieved July 30, 2020.[ dead link ]
  5. ↑ "Health IT Startup: Doxy.me - Electronic Health Reporter". electronichealthreporter.com. Retrieved 2016-05-11.
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  7. 1 2 "Maternal mortality". WHO. World Health Organization. Retrieved September 23, 2017.
  8. 1 2 3 Catling, CJ; Medley, N; Foureur, M; Ryan, C; Leap, N; Teate, A; Homer, CS (4 February 2015). "Group versus conventional antenatal care for women". The Cochrane Database of Systematic Reviews. 2 (2): CD007622. doi:10.1002/14651858.CD007622.pub3. PMC   6465187 . PMID   25922865.
  9. ↑ "Everything NICE says on a topic in an interactive flowchart". NICE. National Institute for Health Care and Excellemce. Retrieved September 23, 2017.
  10. 1 2 Sandall, J; Soltani, H; Gates, S; Shennan, A; Devane, D (28 April 2016). "Midwife-led continuity models versus other models of care for childbearing women" (PDF). The Cochrane Database of Systematic Reviews. 2016 (4): CD004667. doi:10.1002/14651858.CD004667.pub5. PMC   8663203 . PMID   27121907.
  11. 1 2 3 4 5 Brown, HC; Smith, HJ; Mori, R; Noma, H (14 October 2015). "Giving women their own case notes to carry during pregnancy". The Cochrane Database of Systematic Reviews. 2015 (10): CD002856. doi:10.1002/14651858.CD002856.pub3. PMC   7054050 . PMID   26465209.
  12. ↑ "Antenatal care for uncomplicated pregnancies". NICE. National Institute for Health Care and Excellemce. 26 March 2008. Retrieved September 23, 2017.
  13. ↑ "Fetal Growth - Fundal Height Measurements". Perinatal Institute. Retrieved September 23, 2017.
  14. 1 2 Robert Peter, J; Ho, JJ; Valliapan, J; Sivasangari, S (8 September 2015). "Symphysial fundal height (SFH) measurement in pregnancy for detecting abnormal fetal growth". The Cochrane Database of Systematic Reviews. 2015 (9): CD008136. doi:10.1002/14651858.CD008136.pub3. PMC   6465049 . PMID   26346107.
  15. 1 2 3 4 Carberry, AE; Gordon, A; Bond, DM; Hyett, J; Raynes-Greenow, CH; Jeffery, HE (16 May 2014). "Customised versus population-based growth charts as a screening tool for detecting small for gestational age infants in low-risk pregnant women". The Cochrane Database of Systematic Reviews. 2014 (5): CD008549. doi:10.1002/14651858.CD008549.pub3. PMC   7175785 . PMID   24830409.
  16. ↑ Bricker, L; Medley, N; Pratt, JJ (29 June 2015). "Routine ultrasound in late pregnancy (after 24 weeks' gestation)". The Cochrane Database of Systematic Reviews. 2015 (6): CD001451. doi:10.1002/14651858.CD001451.pub4. PMC   7086401 . PMID   26121659.
  17. 1 2 Whitworth, M; Bricker, L; Mullan, C (14 July 2015). "Ultrasound for fetal assessment in early pregnancy". The Cochrane Database of Systematic Reviews. 2015 (7): CD007058. doi:10.1002/14651858.CD007058.pub3. PMC   4084925 . PMID   26171896.
  18. 1 2 3 4 Nabhan, AF; Aflaifel, N (4 August 2015). "High feedback versus low feedback of prenatal ultrasound for reducing maternal anxiety and improving maternal health behaviour in pregnancy". The Cochrane Database of Systematic Reviews. 2015 (8): CD007208. doi:10.1002/14651858.CD007208.pub3. PMC   6486291 . PMID   26241793.
  19. 1 2 3 Alfirevic, Z; Stampalija, T; Medley, N (15 April 2015). "Fetal and umbilical Doppler ultrasound in normal pregnancy". The Cochrane Database of Systematic Reviews. 4 (4): CD001450. doi:10.1002/14651858.CD001450.pub4. PMC   4171458 . PMID   25874722.
  20. ↑ Hinman, Sally K.; Smith, Kristy B.; Quillen, David M.; Smith, M. Seth (November 2015). "Exercise in Pregnancy: A Clinical Review". Sports Health: A Multidisciplinary Approach. 7 (6): 527–531. doi:10.1177/1941738115599358. ISSN   1941-7381. PMC   4622376 . PMID   26502446.
  21. 1 2 3 Takami, Mio; Tsuchida, Akiko; Takamori, Ayako; Aoki, Shigeru; Ito, Mika; Kigawa, Mika; Kawakami, Chihiro; Hirahara, Fumiki; Hamazaki, Kei; Inadera, Hidekuni; Ito, Shuichi; and the Japan Environment & Children’s Study (JECS) Group (2018-10-29). Rosenfeld, Cheryl S. (ed.). "Effects of physical activity during pregnancy on preterm delivery and mode of delivery: The Japan Environment and Children's Study, birth cohort study". PLOS ONE. 13 (10): e0206160. Bibcode:2018PLoSO..1306160T. doi: 10.1371/journal.pone.0206160 . ISSN   1932-6203. PMC   6205641 . PMID   30372455.
  22. ↑ ErtüRk çEli̇K, GüLsemi̇N; ErtüRk Aksakal, Sezi̇N; Engi̇N üStüN, Yaprak (2024-10-18). "The impact of maternal muscle strength on cesarean delivery outcomes: a comparative study of nulliparous women". Turkish Journal of Medical Sciences. 54 (5): 908–914. doi:10.55730/1300-0144.5867. ISSN   1300-0144. PMC   11518347 . PMID   39473746.

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