CONFIRMATION OF PREGNANCY: 5-12 weeks.
Introduction, Transvaginal Ultrasound , Dating the Pregnancy
Review for urgent problems and special risks
1 WEEK LATER-NEW OBSTETRIC PATIENT VISIT: Baseline History, Physical, Lab tests, Risk assessment, discussion. Introduction to Website
12 WEEK VISIT: Check for Problems/Questions/Vital Signs, Weight, Urine check.
Uterine Size, Fetal Heart Beat… This will be repeated at each visit. Discussion of
special genetic counseling and testing.
16-17 WEEK VISIT: Problems or Questions? Check baby’s size and heartbeat,
AFP or Maternal Serum Multiple Marker Screen and Provide Ultrasound Consent Info
20 WEEK ULTRASOUND: Wednesday Evening Morphology scans
21-22 WEEK VISIT: Problems or Questions? Ultrasound discussion.
26-28 WEEK VISIT: Problems or Questions? If Rh (-) receive Rhogam
Screen for Gestational Diabetes, Recheck Labs. Give important info: Pediatrician List , Birthing Plan, Birthing (and other) Classes, When Labor Begins, Recommend Pertussis (Tdap) Vaccine
30-32 WEEK VISIT: Problems or Questions? Pre-register at Center for Birth, Visit Hospital for Familiarity, Circumcision Information.
35 WEEK VISIT: Problems or Questions? Group B Strep Vaginal Culture, Recovery From Pregnancy Info, Birth Control after Baby is born
37 WEEK VISIT: Problems or Questions? Start internal examinations, Cervical ripeness / Fetal Position
38 WEEK VISIT: Problems or Questions?, Cervical ripeness / Fetal Position
39 WEEK VISIT: Problems or Questions? Cervical ripeness / Fetal Position
40 WEEK VISIT: Problems or Questions? Cervical ripeness / Fetal Position
41 WEEKS AND BEYOND
POSTDATES VISITS: Problems or Questions? Cervical ripeness / Fetal Position
Non-Stress Testing, Biophysical Profile, 2x/week visits hereafter
We will give you a Due Date which is the AVERAGE time of birth.
About 10% of women will deliver prematurely (before 37 weeks)
About 10% of women will go “post dates” (over 10 days past due date).
Most women deliver at “Term” of between 37 and 41 1/2 weeks)
No one can RELIABLY predict a natural delivery date.
After 36 weeks we can start giving you a better rough estimate once we check your cervix.
NEW OB VISIT: (one week after confirmation of pregnancy) we will check a Blood Count, Blood Group and Rh type, Antibody screen, Rubella, Hepatitis, HIV, Pap smear, GC, Chlamydia testing. Hemoglobin electrophoresis based on ethnicity. Additional testing may be ordered depending on personal history, physical exam, family history and risk factors.
16 WEEKS: it is common for us to do a Multiple Marker screen for a refined risk assessment for Chromosomal abnormalities.
26-30 WEEKS: Diabetes Screening (that sweet sugar drink) and repeat a blood count.
35 WEEKS: Vaginal/Genital Area culture for Group B strep carrier status. This bacterium is found in 20-30% of all women and usually causes no problems. HOWEVER, it is a risk factor for uncommonly causing serious even fatal infection in newborns. If your culture is positive, the rate of the baby being attacked is about 1 in 200. Therefore, you will receive antibiotics when you go into labor. This approach has been found to cut the risk in half or more.
SPECIAL TESTING: For Chromosomal and Genetic conditions. If based on age, family history, previously affected child you are at increased risk, then we would refer you to EVMS for genetic counseling.
TWO NEW TESTS; deserve your attention:
NIPT: Non invasive prenatal testing – a maternal blood test to look at the baby’s Chromosomal makeup.
COUNSYL TEST: Looks for up to 100 single gene defects – Including Cystic Fibrosis.
CYSTIC FIBROSIS TESTING: determines if you are a carrier of a CF gene mutation. This condition can cause severe lung disease and death in children if BOTH parents are carriers. The adult carrier rate is 1/22 but both parents must be carriers for the child to be affected. If the mother is negative, we stop there.
INSURANCE: In all cases you should DEMAND to know if your insurance will cover testing before blindly accepting. Some of the tests are very expensive.
Center for Birth offers a wide range of classes from Birthing and Breastfeeding to infant CPR.
To speak with a human being regarding classes call:
PERTUSSIS IMMUNIZATION: We are in a Pertussis Epidemic. The newest recommendation if for women to be immunized against pertussis at 28-38 weeks of pregnancy. There are many local facilities offering immunizations called the Tdap vaccine.
INFLUENZA IMMUNIZATION: is recommended during pregnancy. This vaccine helps protect your child inthe first 6 months of life. You may prevent your child from getting very ill.
The new guidelines emphasize being able to carry on a comfortable conversation at all times. If your gasping and can’t talk normally you must slow down.
Second key rule: Avoid Jolts or Concussion. So no more diving for volleyballs at the beach or playing flag football with the guys. Please do NOT expose yourself to sudden shocking jolts like jumping off a chair.
Pregnancy is not the time to start intense new forms of training. Think walking, elliptical, swimming, recumbent biking, normal biking, relaxed pace step training is ok if you don’t over do it. Light hand weights to maintain tone is fine.
My personal pet peeve: Please don’t go bounding (running) on asphault after 20 weeks. For one thing you’ll cause car accidents and… its not good for ankle, knee, hip joints loosened under the influence of hormones of pregnancy.
Heartburn makes MANY pregnant women miserable. Progesterone, the main hormone that rises during pregnancy, relaxes the muscle that helps keep acid out of your esophagus. In addition, the enlarging uterus pushes up on the stomach pushing acid into the esophagus.
GOOD NEWS: There are safe, effective ways to markedly reduce or control heartburn. You really don’t need to suffer with heartburn anymore. Consider the following strategies…
EAT SMALL MEALS: If you’re suffering from nausea, eating small meals is not hard. But if your appetite is strong, be careful to stay away from eating so much that you feel uncomfortably full. A full stomach can cause heartburn. Instead of three larger meals, try five or six smaller ones spread out over time.
EAT SLOWLY: Relax and enjoy your meals slowly, this will also help you avoid overeating. Downing your food quickly can cause heartburn.
DRINK SLOWLY: Rather than a big glass of milk with dinner, try sipping liquids during meals. Get the most of your fluid intake by drinking between, rather than with, meals.
STAY UPRIGHT AFTER A MEAL: take a walk, do some housework, sit and read a book— but don’t just lie down. Also try to avoid bending over – this can help wash acid back up into your esophagus causing heartburn.
DON’T EAT RIGHT BEFORE GOING TO BED: Having a BIG dinner and then going to bed is way to make heartburn likely. Try not to eat for three hours sleeping. The same goes for liquids. (limit intake to reduce heartburn risk).
KEEP YOUR UPPER BODY ELEVATED AT NIGHT: Many people with heartburn benefit from using wedge-shaped pillows that gently angle your upper body so that it is higher than the stomach – helping to keep stomach acid away from the esophagus. These are available from Bed, Bath and Beyond relatively inexpensively. Alternately you may try putting blocks under the legs at the top of your bed.
KNOW THE TRIGGERS: Coffee, chocolate, citrus, fat—pregnant women with heartburn may be helped by avoiding these possible triggers. However, what causes heartburn in one woman may not in another. Try to avoid foods that specifically aggravate YOU! Different women have very different triggers. Some pregnant women can enjoy a particular spicy food that would make another woman miserable.
WEAR LOOSE CLOTHING: snug clothing puts more pressure on your tummy and may worsen acid reflux. Try loose-fitting maternity clothes if you’re trying to manage heartburn.
CONSIDER AN ANTACID: over-the-counter antacids may help your heartburn.
Tums: Chewable, calcium based.
Rolaids Ultra Strength:
Phillips Milk of magnesia: 15 ml by mouth 4 times a day or 2 Magnesium hydroxide tablets with 8oz glass of water.
Antacids containing calcium or magnesium have been shown to be safe during pregnancy.
Stay away from antacids that have aluminum because it contributes to constipation and is unsafe at high doses.
CONSIDER ZANTAC: If antacids don’t work for you, consider stronger medications.
You may take two Zantac (2×75=150mg) twice a day (Total daily dose = 300mg). They markedly reduce acid in the stomach. They may be less effective when taken every day. You may develop tolerance to the medicine. Try to take this medicine when you experience “breakthrough symptoms”.
OTHER MEDICINES LIKE ZANTAC: (Tagamet HB, Pepcid AC, Axid AR, and Zantac 75) are available without a prescription and thought to be safe during pregnancy. Please let us know if you are taking this type of over the counter medicine. They do work. You only need 1-2 a day.
CONSIDER PREVACID: If antacids and Zantac don’t help, Prevacid has a more powerful acid-suppressing effect and is available over the counter but previcid can only be used for 14 days in a row. Always try behavioral, dietary, antacid and Zantac first (Before Prevacid) as these other methods have a longer track record of safety.
AVOID PRILOSEC: Although this type of medicine is in general, safe for pregnant women, animal studies have raised concerns that omeprazole (Prilosec) could harm a developing fetus. Other medications are safer during pregnancy.
AVOID ALKA-SELTZER: It contains aspirin.
AVOID BAKING SODA: Its too high in Sodium and causes swelling.
WARNING! Just because antacid or medicine made you feel better, don’t relax and start eating whatever you want. Overloading on the wrong food (fatty or fried) can lead to breakthrough symptoms. So chompiong down a giant meal or eating just before bed can put you back where you started.
Drink 6-8 glasses of water a day
Urine should be light yellow in the toilet
Fruit is good, even canned
Increase your vegetables such asparagus, Brussel Sprouts, cabbage, carrots
Stay as active as possible
Add fiber to your diet to stool soft and mushy
Try cereals such as All Brand or Fiber One
If you add fiber you must drink plenty of water because fiber draws water into the intestines to help move things along.
Milk of magnesia
Start with recommended doses and increase until the stool is soft.
Reserve time for your bowel movement (set aside a regular time).
Used to proper position with your back straight and feet on the floor.
Relax do not hold your breath. Don’t ignore the bodies urge.
DEFINITION: Many individuals feel that they need to have a bowel movement on a daily basis; this is not true. 3-4 times a week is adequate. Less than twice weekly, (or straining with hard stool)is considered constipation. Be careful how you treating your constipation. Over $300 million a year his spent on over-the-counter laxatives.
CONSTIPATION CAUSES: Medications (especially narcotic pain relievers), Lack of fiber, Poor Diet, Pregnancy (hormonal causes) Lack of exercise, pelvic floor dysfunction (slow transit), diabetes, hypothyroidism, neurologic problems.
CONSTIPATION TREATMENTS: (Non-laxative)
Smooth Move Tea.
Fish Oil capsules (Omega 3 Fatty Acid).
CONSTIPATION PUDDING: One cup of applesauce, one cup of oat bran, a quarter cup of prune juice, add spices as desired such as cinnamon, nutmeg etc. Store in your refrigerator or freezer. Begin with 2 tablespoons each evening followed by an 8 ounce glass of water for one week. Then increase to 3 tablespoons each evening for one week. Finally increase to 4 tablespoons daily as maintenance. It tastes pretty good. You should begin to see improvement in your bowel habits in 2 weeks. Make it a part of your daily night time routine. This recipe is high in fiber and may initially cause gas or bloating the patient go away and several weeks.
Hemorrhoids are dilated (varicose) veins of the rectum.
SYMPTOMS: rectal itching, bleeding, pain, mucus discharge after bowel movements. A lump that can be felt in the anus. A sensation that the rectum has not emptied completely.
AVOID CONSTIPATION: Keep your bowel movements soft
DIET: fresh fruit, bran muffins, beans, vegetables and whole-grain cereals.
LIQUIDS: Drink 8-10 glasses of fluid daily.
STOOL SOFTENERS: to keep BM soft using Miralax – follow instructions on jar. Also, consider Colace, Surfak, Docusate Sodium SoftGels (Correctol stool softener) Follow package instructions. Use 1 to 3 SoftGels daily.
SLOW: Do NOT hurry or strain with bowel movements.
CLEANSE: After BM, use soft tissue paper normally, then gently clean anal area with Tucks Medicated Pads.
SITZ BATHS: Sit in 8-10 inches of warm water for 10-20 minutes several times a day.
USE HEMORRHOIDAL CREAM: after each BM and at bedtime use one of the following:.
- PREPARATION H: (With 1 % Hydrocortisone). Apply to affected area 3-4x/day
- ANUSOL (with 2.5% Hydrocortisone). Apply to affected area 3-4x/day
IF MARKEDLY WORSENING PAIN: stay in bed for 1 day, apply ice packs to the anal area, Surgery may be required in stubborn cases.
POSSIBLE CAUSES: As you become more and more pregnant (bigger and bigger!) your enlarging uterus shifts your posture and tends to weaken your abdominal muscles putting strain on your back. also, the expanding uterus may press on nerves in your pelvis causing back pain. Furthermore the extra weight you’re carrying in pregnancy means more work for your muscles and more stress on your joints. All this adds up which is why back ache affects 75% of pregnant women and is usually worse at the end of pregnancy. It may persist after the baby arrives, but usually goes away in a few months.
HORMONE CHANGES during pregnancy loosen joints and ligaments that connect your spine to your pelvic bones contributing to discomfort and making you feel less stable. This discomfort may be worse when you walk, stand, sit for long periods, change position in bed, rise from a chair or the tub, bend over, or lift things.
ACTIVITIES THAT WORSEN: Sitting or standing for long periods of time and lifting usually make it worse, and it tends to be more intense at the end of the day. It may be triggered by activities such as walking, climbing stairs, getting in and out of a tub or a low chair, rolling over in bed, or twisting and lifting. High heels worsen the pain (please switch to running shoes) . Positions in which you’re bent at the waist – such as sitting in a chair and leaning forward while working at a desk – may make back pain worse.
COULD IT BE SCIATICA? True sciatica, which can be caused by a herniated or bulging disk in the lower part of the spine, affects only about 1 percent of pregnant women. If you have sciatica, your leg pain will usually be more severe than your back pain. You’re likely to feel it below the knee as well, and it may even radiate to your foot and toes. And you’ll probably feel a tingling, pins-and-needles sensation in your legs or possibly some numbness. With severe sciatica, you may have numbness in your groin or genital area as well. You may even find that it’s hard to urinate or have a bowel movement. If you think you have sciatica, call us immediately if you feel a loss of sensation or weakness in one or both legs or a loss of sensation in your groin, bladder, or anus (which may make it hard to pee or have a bowel movement, or – alternatively – cause incontinence). We would refer you elsewhere for appropriate treatment (this is outside our training or competence).
WHO IS MOST LIKELY TO BE HAVE BACK PAIN: Not surprisingly, you are fare more likely to have low back pain if you’ve had it before, either before pregnancy or with a prior pregnancy. You are at clearly higher risk if you’ve lead a very sedentary lifestyle (sit alot) and have poor flexibility and weak muscles in your back and abdomen. Carrying twins markedly increases your chances of sufferring with an aching back. Being markedly overweight is another factor contributing to low back pain during pregnancy, but research results do not all agree on this.
WHAT TO DO?
Exercise – You may feel more like curling up in bed than exercising if your back hurts, but don’t take to your bed for long periods. Bed rest is generally not helpful in the long run for low back pain and may even make you feel worse. In fact, exercise may be just what you need.
Check with your caregiver before beginning an exercise program, though, because there are some situations in which you may have to limit exercise or forgo it altogether. Then, consider:
Strengthening exercises to help build the muscles that support your back and legs, including your abdominal muscles.
Stretching exercises to help the muscles that support the back and legs become more flexible. Be careful to stretch gently, because stretching too quickly or too much can put further strain on your joints, which have been made looser by pregnancy. Prenatal yoga is one good way to stay limber, and it can help improve your balance, too.
Swimming is a great exercise option for pregnant women because it strengthens your abdominal and lower back muscles, and the buoyancy of the water takes the strain off your joints and ligaments. Consider signing up for a prenatal water exercise class, if one is available in your community. These can be very relaxing, and there’s research suggesting that water exercise may decrease the intensity of back pain during pregnancy.
Walking is another option to consider. It’s low impact and easy to make part of your daily routine.
Low Back Pain – try doing pelvic tilts, which can ease back pain by stretching your muscles and, over time, strengthening them as well. Here’s how: Get on your hands and knees, arms shoulder-width apart and knees hip-width apart. Keep your arms straight, but don’t lock the elbows. Tuck your buttocks under and round your back as you breathe in. Relax your back into a neutral position as you breathe out. Repeat at your own pace.
BE CAREFUL – Whether you’re an athlete or a newcomer to exercise, listen to your body and don’t do anything that hurts. Finally, watch for warning signs that you may be overdoing things or developing a problem that needs medical attention.
BE AWARE OF POSITIONING AND PROPER BODY MECHANICS:
Stand up straight. This gets harder to do as your body changes, but try to keep your bottom tucked in and your shoulders back. Pregnant women tend to slump their shoulders and arch their back as their belly grows, which puts more strain on the spine.
Sit up straight (especially if you sit a lot during the day) Supporting your feet with a footstool can help prevent or reduce low back pain. Consider using a small pillow called a lumbar roll behind your lower back. Take frequent breaks from sitting. Get up and walk around at least every hour or so.
Avoid standing for too long. If you need to stand all day, try to take a midday break and rest lying on your side while supporting your upper leg and abdomen with pillows.
Be aware of anything that makes the pain worse. If you have low back pain, try to avoid or limit activities like stair climbing, for example. Stay away from any exercise that requires extreme movements of your hips or spine.
Wear comfortable shoes and avoid high heels. As your belly grows and your balance shifts, high heels will make your posture even worse and increase your chances of stumbling and falling.
Always bend from your knees and lift things from a crouching position to minimize the stress on your back. Pregnancy is NOT the time to risk throwing your back out. Get someone else lift the heavy things and reach for things high on a shelf. Avoid excessive twisting movements. Skip activities like mopping and vacuuming that make you have to bend and twist at the same time. If there’s no one else to help with these chores, move your whole body at once rather than twisting to get to out-of-the-way spots. Divide up the weight of things you have to carry. Carrying one shopping bag in each hand is better than the uneven stress of carrying one larger, heavier bag.
Get out of bed carefully: Bend your legs at the knees and hips when you roll over to your side. Use use your arms to help push yourself up as you relax your lower legs over the side of the bed.
To get a better night’s rest, try sleeping on your side with a pillow between your knees. Near the end of pregnancy, use another pillow or wedge to support your abdomen.
TREAT YOURSELF WELL: Taking steps to ease soreness and tension and generally taking good care of yourself is wise. At least your likely to feel better temporarily. Take the time to experiment with the following measures:
Learn relaxation techniques to help you cope with the discomfort and may be very useful at bedtime if your back pain makes it hard to get to sleep.
Try heat or cold. There’s some evidence that heat may provide a bit of short-term relief. Try soaking in a warm (not hot) tub, which can also help you relax. Or place a hot water bottle (or hot pack) on your lower back. Although there’s no hard evidence that cold helps, applying a cold pack is easy to do and worth a try if heat doesn’t work for you. Whether you use heat or cold, cover the pack or bottle with a thin cloth to protect your skin.
Treat yourself to a massage by a therapist trained in prenatal massage – it may provide some relief. If your insurance doesn’t cover therapeutic massage, get your partner or a friend to give you a gentle backrub – it will not cure you, but it might help you relax. (Most insurance companies don’t cover massage, though a referral might help. It’s worth looking into.)
Maternity Support Belt – may be helpful (www.bellybandit.com) the bamboo style.
Physical Therapy – may help and they can teach you exercises to do on your own to prevent later episodes of low back pain
Chiropractic care may be helpful – though research that’s specific to pregnancy-related back pain is scant.
Physician (MD) care – specialist referral – often limited by restrictons imposed by pregnancy
Acupuncture may help – reduce the intensity of back pain during pregnancy.
CALL OR GO TO EMERGENCY ROOM if:
Your back pain is severe, constant, or getting progressively worse, or if it’s caused by trauma or accompanied by a fever.
You’ve lost feeling in one or both legs, or you suddenly feel uncoordinated or weak.
You have a loss of sensation in your buttocks, groin, genital area, or your bladder or anus, which may make it hard to pee or have a bowel movement, or, alternatively, cause incontinence.
You have low back pain in the late second or third trimester. This can be a sign of preterm labor, particularly if you haven’t had back pain before that.
You have pain in your lower back or in your side just under your ribs, on one or both sides. This can be a sign of a kidney infection, especially if you have a fever, nausea, or blood in your urine.
Alright, we are NOT talking about a Starbucks 4 Shot Quad Venti Latte (or God forbid Carmel Macchiato) – if you don’t know what that is DO NOT START. (Please don’t ask how I know)
One or two (normal sized) cups of normal coffee a day appears to have no observable risk – but may cause insomnia. Restricted Moderation is the key. If you have palpitations, high blood pressure, trouble sleeping or simply prefer not to expose your child to In Utero caffeine – Then avoid all caffeine/coffee.
The caffeine based energy drinks or tablets – PLEASE DON”T. Too easy to overdose on caffeine.
HOW MUCH SLEEP: Adults need an average of 8-8 1/2 hours of sleep a night, although it ranges from 6 1/2 to 9 hours. Mortality studies suggest you live longer if you get 7 hours or more of sleep each night.
TIPS FOR BETTER SLEEPING:
AVOID: Caffeine, nicotine, alcohol – for at least four hours before you go to bed. Limit or control other stimulants (Cold, Allergy, Asthma, Decongestants, sudafed), some antidepressants,Thyroid hormone replacement medications may keep you awake.
HELPFUL BEHAVIORS: Be predictable. Go to bed around the same time every night. Don’t toss and turn. If you can’t sleep after 20 minutes, get out of bed and do something else. Save the bedroom for sleep and sex. Avoid bedroom bill paying, TV watching or reading the paper. Take a warm shower or bath this may nudge your bedtime biochemistry along. Face your alarm clock away from the bed. Exercise early. If you exercise, do it before dinner, not after. Get dark. People usually sleep best in a quiet, cool, dark environment. Invest in heavy drapes if city lights glare outside.
PROPER EATING: Grab a snack. It’s hard to sleep hungry, so try a light snack before bedtime. Large meals may keep you awake. Some researchers think tryptophan, a chemical found in milk, naturally induces sleep.
LIMIT NAPS: Cut naps short. If you have trouble falling asleep, avoid naps or limit them to less than an hour before mid-afternoon.
MANAGE STRESS: Deal with stress. If daytime troubles keep you awake, try jotting notes about ways to deal with them. Leave stress at the bedroom door, if you can.
NATIONAL CENTER SLEEP DISORDERS RESEARCH
If behavioral methods fail (see above) the infrequent use of a mild sleeping pill can be safe in pregnancy. I usually use Ambien 5 mg.
Most pregnancy books explain not to lie flat on your back in mid pregnancy and beyond.
However, time motion studies of women asleep show they go to a position of comfort at soon as they fall asleep, and then move all over the bed. (its fun to watch time lapse photography of any adult sleeping)
Whats my point? – Just find a position of comfort and go to sleep, because thats what happens as soon as you are asleep – you go to a position of comfort.
In labor we will often move you to your left side to improve the return of blood to your heart and thereby improve cardiac output and thereby improve oxygenation to the fetus.
If your in an exercise class after 20 weeks pregnancy don’t voluntarily lie flat on your back…. but in bed at night… just go to a position of comfort. If you move to a position that reduces cardiac return it creates a panic sensation with urgency to shift position. You may count on this reflex to protect you.
I live in amazement how much variation there is between different women regarding when they feel the baby first move. I’ve had some “ultrasensitive” women claim they feel the baby move at 15 weeks and some women don’t start feeling movement until 22-24 weeks. I have no way of proving whether it is someone’s imagination or not when they feel the baby early (15 weeks and before).
Generally most women will feel movement around 18-20 weeks gestation.