BABY ON THE WAY!
Your pregnancy and postpartum health resource guide
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All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest. 500 NE Multnomah St., Suite 100, Portland, OR 97232.
CONGRATULATIONS — YOU’RE PREGNANT! Whether it’s your first child or your next, each pregnancy and birth is a brand-new experience. Welcome to parenthood! If you’re like most new moms, you have lots of questions. Throughout pregnancy, you will notice changes in your body, emotions, and activities. Your Kaiser Permanente health care team is here to support you through it all. We created this guide especially for you. It has answers, information, and resources so you know what to expect during pregnancy and the first few weeks of your baby’s life. You’ll see some sections organized by trimester so you can keep track of what’s happening and when. You’ll learn about your baby’s development, how to care for yourself, tests you might need, getting ready for your newborn, and more. When you come in for a visit, bring this guide with you. Together we’ll review the contents that match your needs and answer questions. We’ve all heard about that healthy glow in pregnant moms-to-be. Now it’s your turn to shine. Use the information in this guide to help you and your baby thrive. We are here for you, every step of the way. We look forward to meeting you and sharing this special time in your life!
Best wishes, Kaiser Permanente Northwest
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TABLE OF CONTENTS YOUR CARE TEAM............................................... 5
HEALTHY SMILES DURING PREGNANCY......... 53
Your care team................................................ 7
Healthy smiles during pregnancy................. 55
Finding clinicians and services....................... 8
RISKS AND SAFETY........................................... 57
PRENATAL VISITS................................................ 11
Risks and safety............................................ 59 Things to avoid............................................. 60
Prenatal visits................................................. 13 Prenatal visit schedule................................... 14 Prenatal visit records.....................................15 CLASSES AND EDUCATION...............................21 Childbirth and parenting classes...................23 GENETIC TESTING............................................ 25 Genetic testing............................................. 27 HEALTH AND WELLNESS.................................. 29 Your health and wellness.............................. 31
When to call for help.................................... 62 FIRST TRIMESTER............................................... 65 First trimester............................................... 67 SECOND TRIMESTER......................................... 71 Second trimester.......................................... 73 THIRD TRIMESTER............................................. 79 Third trimester.............................................. 81 HOME AND NURSERY....................................... 85 Getting ready for baby................................. 87
Staying fit...................................................... 32 Healthy eating during pregnancy................. 34 What if I get sick?......................................... 40
A safe nursery............................................... 88 PREPARING FOR BIRTH..................................... 91 Your birth preferences.................................. 93
Managing emotions .................................... 42
Birthing options............................................ 98
Body changes and discomfort..................... 45
Preparing for labor...................................... 100 What to bring to the hospital...................... 101
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LABOR, DELIVERY, AND POSTPARTUM........... 103
NAVIGATING COMPLICATIONS....................... 149
Timing contractions..................................... 105
Overview..................................................... 151
Timing contraction chart............................. 106
Asthma........................................................ 152
Early labor................................................... 108
Diabetes......................................................154
Active labor: First stage.............................. 110
Domestic abuse...........................................158
Active labor: Second stage..........................111
Fifth disease................................................ 159
Third stage: After your baby is born............112
High-risk pregnancy....................................160
Postpartum recovery and coping.................114
Obesity........................................................164
INFANT CARE....................................................117
Preeclampsia and high blood pressure.......166
Infant care overview.....................................119
Preterm labor...............................................168
Newborn experience................................... 120
Toxoplasmosis............................................. 170
Newborn appearance.................................. 126
Urinary tract infection.................................. 172
Newborn behavior....................................... 128 Baby care..................................................... 130 Feeding your baby...................................... 132 Multiples...................................................... 138 Keep your baby healthy............................... 140 Infant oral care............................................. 142 Keep your baby safe.................................... 144 Common newborn problems...................... 146
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YOUR CARE TEAM
YOUR CARE TEAM
YOUR CARE TEAM When you’re pregnant, you want the best possible care for you and your baby. Your Kaiser Permanente team is dedicated to providing just that. Each year, more than 90,000 pregnant women receive the care they need at Kaiser Permanente clinics. We help them bring their babies into the world at our own Kaiser Permanente or affiliated hospitals.
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In the Oregon/Washington region, you’ll have access to a team of doctors, nurses, midwives, and other health professionals who partner with you to keep you and your baby healthy. It’s an integrated approach that puts you at the center.
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FINDING CLINICIANS AND SERVICES Use kp.org/myhealthmanager to manage your health online. You can: • Email your clinician. • View lab test results. • Refill prescriptions. • Make or cancel routine appointments. • And more! You can also find clinicians and medical offices. Go to kp.org and click the “Locate our services” tab. Scroll down and select “Find doctors & locations.” On the next page, follow the prompts to narrow your search. Obstetric and gynecological care is available at many Kaiser Permanente medical offices in Oregon and Southwest Washington. Our obstetrics advice line and the Mother-Baby Program offer additional resources, classes, and tips.
APPOINTMENTS AND URGENT CARE Do you or your baby need care during regular medical office hours? You can call to request a same-day appointment (as available) from 8 a.m. to 5 p.m. weekdays. Call the regional advice nurse for help outside regular medical office hours or Urgent Care hours. The nurse can discuss your health concern and direct you to the most appropriate place for treatment.
PHONE NUMBERS To contact medical and dental offices, hospitals, the Mother-Baby Program, or an advice nurse, please see the phone number and resource list in pocket of this booklet.
When the time comes, Labor and Delivery and birthing services at Kaiser Permanente Sunnyside Medical Center, Kaiser Permanente Westside Medical Center, and our partner hospitals have you covered. Contact a member of your health care team anytime with questions or concerns. They can help you make decisions that support you and your growing family.
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PRENATAL VISITS PRENATAL VISITS
PRENATAL VISITS You and your baby are undergoing a lot of changes. Week by week, your pregnancy reaches new milestones and turning points. It’s critical to ensure you both stay healthy through it all. That’s why one of the most important steps you can take during pregnancy is to attend all your prenatal visits. As soon as you know you’re pregnant, make an appointment with your physician or certified midwife. The schedule on page 14 outlines how often you should come in and what to expect during examinations.
Beginning around week 28, you can take time to talk with your clinician about your labor and delivery options. As you identify your preferences, you may want to write them down. See pages 93 to 96 for more information about this important step.
PRENATAL VISIT RECORDS At each visit, you can use the prenatal visit records to log your progress. Bring this guide with you and enter the information with your care team.
During these checkups, you’ll discuss your baby’s development, how to care for yourself, tests you might need, preparations for your newborn, and more. These visits help you keep tabs on your health and your baby’s progress along the way. You review current priorities and things to consider. Each visit brings something new.
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PRENATAL VISIT SCHEDULE Regular prenatal exams are a priority during any pregnancy. Here’s the visit schedule for a low-risk term pregnancy. If you have a pre-existing medical condition, develop complications, or are a teen, you may require more frequent visits.
WEEK 6–9 • • • • • •
Confirm pregnancy. Lab tests. First visit with your clinician. Discuss genetic testing options. Educational and diet information. Physical exam.
WEEK 10–12
• Fetal heart tones. • Confirm genetic testing decision. • Review lab results.
WEEK 32
• Discuss birth control plans; sign tubal ligation consent form if desired. • Schedule hospital tour. • Discuss breastfeeding. • Discuss circumcision.
WEEK 34
• Optional visit, per clinician and patient.
WEEK 36
WEEK 15–16
• Blood screening tests. • Schedule ultrasound.
• Group B strep test. • Confirm baby’s position. • Discuss signs and symptoms of labor and preeclampsia. • Confirm birth preferences.
WEEK 20
WEEK 37
• Discuss ultrasound results. • Due date confirmation. • Hospital registration.
WEEK 24
• Optional visit, per clinician and patient.
WEEK 38
• Discuss readiness for labor and delivery.
• View preterm labor video. • Schedule childbirth class.
WEEK 39
WEEK 28
WEEK 40–41
• Learn to count fetal kicks. • Diabetes and blood count test; Rh Immune Globulin if Rh negative. • Start birth plan discussion. • Tdap vaccination.
• Optional visit, per clinician and patient. • Discuss postdates plan. • Schedule postpartum visit.
4–6 WEEKS AFTER DELIVERY
• Routine postpartum visit (sooner if needed). • Physical exam. • Discuss birth control, feeding, depression, return to work.
Note: Kaiser Permanente recommends pregnant women receive an Influeza vaccination (flu shot) at any appointment from October through March. 1899KPCC-15/5-15
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PRENATAL VISIT RECORDS Due date
FIRST TRIMESTER 6–9 weeks Appointment date
Time
Mom’s weight Tests Questions to ask Clinician instructions 10–12 weeks Appointment date
Time
Mom’s weight Tests Questions to ask Clinician instructions
FIRST-TRIMESTER NOTES
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PRENATAL VISIT RECORDS SECOND TRIMESTER 15–16 weeks Appointment date Mom’s weight
Time Baby's heart rate
Tests Questions to ask Clinician instructions 20 weeks Appointment date Mom’s weight
Time Tummy measurement
Baby’s heart rate
Tests Questions to ask Clinician instructions 24 weeks Appointment date Mom’s weight
Time Tummy measurement
Baby’s heart rate
Tests Questions to ask Clinician instructions 28 weeks Appointment date Mom’s weight
Time Tummy measurement
Tests Questions to ask Clinician instructions 1899KPCC-15/5-15
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Baby’s heart rate
SECOND-TRIMESTER NOTES
THIRD TRIMESTER 32 weeks Appointment date Mom’s weight
Time Tummy measurement
Baby’s heart rate
Tests Questions to ask Clinician instructions 34 weeks (optional visit) Appointment date Mom’s weight
Time Tummy measurement
Baby’s heart rate
Tests Questions to ask Clinician instructions 36 weeks Appointment date Mom’s weight
Time Tummy measurement
Tests Questions to ask Clinician instructions
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Baby’s heart rate
PRENATAL VISIT RECORDS 37 weeks (optional visit) Appointment date Mom’s weight
Time Tummy measurement
Baby’s heart rate
Tests Questions to ask Clinician instructions
THIRD TRIMESTER 38 weeks Appointment date Mom’s weight
Time Tummy measurement
Baby’s heart rate
Tests Questions to ask Clinician instructions 39 weeks (optional visit) Appointment date Mom’s weight
Time Tummy measurement
Tests Questions to ask Clinician instructions
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Baby’s heart rate
40 weeks Appointment date Mom’s weight
Time Tummy measurement
Tests Questions to ask Clinician instructions
THIRD-TRIMESTER NOTES
PRENATAL VISIT TESTS AND LAB RESULTS Ultrasound results
Lab results
Other
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Baby’s heart rate
CLASSES AND EDUCATION
CLASSES AND EDUCATION
CHILDBIRTH AND PARENTING CLASSES Your journey through pregnancy will teach you many new things. Prepare yourself for the healthiest experience possible by learning what you need to know.
TALK WITH A HEALTH COACH
Kaiser Permanente Northwest offers a variety of programs designed just for expectant and new parents.
• Your health goals.
To find details on classes and resources, visit kp.org/healthylivingcatalog/nw.
Call 503-286-6816 or 1-866-301-3866 (toll free) and select option 2. This service is free for Kaiser Permanente members. It is available Monday through Friday, 8 a.m. to 5 p.m.
For more information and to sign up, call Health Engagement and Wellness Services at 503286-6816 or 1-866-301-3866 (toll free), option 1.
You can get support and motivation in a brief chat with a coach as you discuss: • The process of change. • Your options for next steps.
TYPES OF PROGRAMS OFFERED There are a variety of programs to choose from to support you in your journey to motherhood. To find information, visit kp.org/classes and look for these topics: • Hospital birth tour. One-time session. • Preparation for birth. Two or five sessions. • Preparation for birth. Online program lets you work at your own pace. • Life with baby. Ongoing online sessions. • Tool kit for new parents. One-time session.
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GENETIC TESTING
GENETIC TESTING
GENETIC TESTING GENETIC DISEASES AND CHROMOSOMAL PROBLEMS For many women, the chance of having a child with a genetic disease or chromosomal problem is quite low (about 3 to 4 percent).
These tests can be helpful for some people, but they also have drawbacks. It is always your choice to have testing or not. If you have questions, talk with your health care clinician.
There are tests that can tell you if your baby has one of these problems or is at risk. They include blood tests, ultrasound, amniocentesis, and CVS (chorionic villus sampling).
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HEALTH AND WELLNESS
HEALTH AND WELLNESS
YOUR HEALTH AND WELLNESS One of the best ways you can care for your baby’s health is to take care of yours. The following pages offer tips on how to exercise, eat, and feel your best during one of the most dynamic times of your life. You’ll learn about: • Staying fit. • Healthy eating during pregnancy. • What if I get sick? • Managing emotions. • Body changes and discomfort.
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STAYING FIT Moderate exercise during pregnancy can help you feel your best and ward off discomforts, such as backache and fatigue. Exercise is a good warm-up for childbirth because physical activity improves your circulation and energy for labor. Also, exercising during pregnancy can help you maintain muscle strength and shed unwanted pounds after your baby is born. If you’re physically active most days, great! If not, this is a good time to start. Begin slowly, build up gradually, and try to exercise at least 30 minutes per day.
TIPS FOR A SAFE WORKOUT • Check with your clinician before starting any exercise routine. • Whatever activity you choose, don’t overdo it. Listen to your body and rest if you feel tired. You should be able to carry on a conversation during any activity. • Drink extra water before, during, and after exercise to avoid dehydration. • Get plenty to eat so that you don’t run low on glucose. • Do not exercise to lose weight. Read about the importance of weight gain during pregnancy. • Avoid overheating. During hot weather, exercise indoors and (ideally) in an airconditioned space.
• Walking. It’s safe and easy for most women from the moment you find out you’re pregnant until the final weeks. Wear a fitness tracker or use an app to motivate you to stay active. Remember to use a handrail when walking up or down stairs. • Swimming or water aerobics. Both are gentle on your joints and provide a feeling of weightlessness (a welcome break in the later months of pregnancy). • Stretching or yoga. Stretching eases back pain and helps you maintain flexibility. Look for classes or DVDs designed for pregnant women. • Low-impact dance or aerobics. Moving to music is fun for both you and your growing baby. Stay balanced by avoiding jumps, kicks, leaps, and bouncing.
EXERCISES TO PREPARE FOR BIRTH The muscles in your lower abdomen, lower back, and around the vagina (birth canal) come under great strain during pregnancy. During delivery, these same muscles must relax and stretch. In the event of a lengthy labor, increased endurance can be a real help. Go to kp.org and search for "exercise during pregnancy" for examples of exercises and stretches.
BEST BETS FOR MOMS-TO-BE During your first trimester, you should be able to continue your same exercise routine if you’re having a healthy pregnancy. Try for a combination of aerobic, strength, and flexibility exercises. In your second and third trimester, you may need to vary your routine slightly.
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KEGELS — THE OTHER EXERCISE
ACTIVITIES TO AVOID
During pregnancy and delivery, the pelvic floor can become stretched and weak. This can lead to urine control problems after your baby is born. Kegel exercises help you strengthen your pelvic floor muscles.
As you enter your second trimester, you may find that your achy joints, growing belly, and changing center of gravity make you unstable on your feet. During this time, you’ll probably need to make adjustments to your normal exercise routine. Here are some activities to avoid:
Start doing Kegel exercises daily as soon as you become pregnant. Kegels can be done anytime, standing or sitting. No one will even know. Here’s how: • Firmly tighten the muscles around your vagina, as you would to stop urinating. (It’s not recommended to practice Kegel exercises while on the toilet because this may strain the pelvic floor muscles.) • Hold tightly for as long as you can (8 to 10 seconds). Remember to keep breathing as you hold the muscles. • Then slowly release the muscles and relax. • Repeat 10 to 15 times, at least 3 times a day. Kegel exercises are effective only when done regularly.
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• Bouncing, jumping, or movements where you could lose your balance, especially in the third trimester. • Contact sports, such as soccer, softball, and basketball. • Scuba diving. • Exercise in high altitudes (above 6,000 feet). • Water or downhill skiing. • Horseback or motorcycle riding. • After your fourth month, avoid anything that requires you to lie flat on your back (such as sit-ups and some yoga poses). • Avoid overheating or extreme sweating.
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HEALTHY EATING DURING PREGNANCY HEALTHY PREGNANCY PLATE Congratulations on your pregnancy. A healthy pregnancy depends on a healthy lifestyle. This includes eating a balanced diet, staying well hydrated, and getting physical activity most days of the week. Strive to build a plate like this at every meal.
Practice mindful eating Choose food that is satisfying and nourishing, sit at the table in a relaxed environment, and tune in to your hunger and fullness levels.
GRAINS & STARCHES Make a little more than 1 ∕4 of your plate whole grains or starches.
FRUITS & VEGETABLES
Stay hydrated Aim for 64 ounces of water per day.
Make ½ your plate fruits and vegetables.
PROTEIN
Move more
Make a little less than ¼ of your plate lean meat or other protein foods.
Exercise daily or most days of the week. The benefits are endless. Choose fruit as your sweet treat Limit foods and beverages with added sugars.
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Select a 9-inch plate and use this guide to help keep your portions in control.
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One serving is:
Fruits and vegetables Choose 6 or more servings per day
• 1 cup raw vegetables • ½ cup cooked vegetables • 1 medium fruit • 1 cup fruit • 3–4 ounces juice
Choose 2–3 fruits and 4 or more vegetables for optimal nutrition and less calories.
One serving is:
Protein-rich foods
HEALTHY FOOD CHOICES
Choose 7–11 servings per day
• ½ cup beans, split peas, or lentils • ½ cup tofu or tempeh • ¼ cup nuts or seeds • 2 tablespoons peanut or almond butter, or tahini • 1 ounce pasteurized cheese (Swiss, mozzarella, queso fresco, cheddar)
• ¼ cup cottage or ricotta cheese • ½ cup Greek yogurt • 1 cup regular yogurt • 1 egg • 1 ounce fish, seafood,* skinless chicken or turkey, or lean cuts of beef or pork
One serving is:
Starches (grains and starchy vegetables) Choose 5–8 servings per day
• ½ cup beans, corn, peas, taro, or potatoes (Yukon gold, red, sweet) • 1 cup winter squash • 1∕3 cup cooked brown rice, quinoa, buckwheat, millet, or pasta/noodles (1 cup cooked = 3 servings)
• 1 slice whole-wheat or sourdough bread • ½ cup cooked cereal (oatmeal) • 4–6 whole grain crackers • 2–3 corn tortillas • 1 whole-wheat tortilla • 3 cups popcorn
One serving is:
Calcium-rich foods Choose 3 servings per day to get the recommended 1,000 milligrams of calcium
• 1 cup (8 ounces) milk • 1 ½ ounces cheese • 8 ounces yogurt • 1 cup calcium-fortified soy, rice, or almond milk • ½ cup calcium-set tofu
• 1 ½ cups cooked kale, bok choy, turnip greens, mustard greens, beet greens, or broccoli • 1∕3 cup soy nuts • 2 cups white beans
One serving is:
Fats Choose 4–7 servings per day
• 2 tablespoons avocado • 1 teaspoon olive, canola, or peanut oil • 5 olives • 1 tablespoon nuts or seeds • 1 teaspoon peanut, almond, or sunflower seed butter, or tahini
• 1 tablespoon salad dressing • 1 teaspoon mayonnaise • 1 teaspoon butter • 2 tablespoons cream, half & half, or sour cream • 1 tablespoon cream cheese
*Seafoods that are rich sources of omega-3 fatty acids include mackerel, salmon, albacore tuna, sardines, and lake trout. For more information on safe and healthy seafood choices, visit seafoodwatch.org 1899KPCC-15/5-15
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HEALTHY EATING DURING PREGNANCY THINKING FOR TWO VERSUS EATING FOR ONE
Examples of mini meals and snacks with approximately 200 to 300 calories:
In general, most women need 1,600 to 2,000 calories per day. During the second and third trimester of pregnancy, your calorie needs go up by only 200 to 300 calories per day. Eating a meal or snack every 3 to 4 hours can help prevent nausea, control appetite, and keep your energy levels up throughout pregnancy, during labor and delivery, and after you have your baby
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1 piece of fruit with 1–2 tablespoons peanut butter
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1 slice whole-grain toast with avocado
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¼ cup nuts or seeds with a piece of fruit
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Carrot sticks with ½ cup hummus
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½ of PB&J or tuna fish sandwich
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Handful of tortilla chips with cottage cheese and salsa
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Smoothie — blend yogurt with ½ cup berries
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4–6 whole-grain crackers with 1 ounce cheese
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Carton of Greek yogurt with ¼ cup granola and berries
HOW MUCH WEIGHT SHOULD I GAIN DURING PREGNANCY This depends on your body mass index (BMI) at the time of conception PRE-PREGNANCY BMI
TOTAL PREGNANCY WEIGHT GAIN
TOTAL FIRST TRIMESTER WEIGHT GAIN
SECOND AND THIRD TRIMESTER WEIGHT
Less than 18.5 (underweight)
28–40 lbs
2.2–6.6 lbs
5 lbs per month
18.5–24.9 (normal weight)
25–35 lbs
2.2–6.6 lbs
4 lbs per month
25–29.9 (overweight)
15–25 lbs
2.2–6.6 lbs
2.6 lbs per month
More than 30 (obese)
11–20 lbs
0.5–4.4 lbs
2 lbs per month
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It doesn't matter if I gain too much weight; I'll just lose it after the baby comes.
• Veggies with lean protein (carrots and hummus, or a salad with beans and dressing).
Gaining too much weight during pregnancy may harm your health and the health of your baby. Gaining too much weight increases the risks for a cesarean birth, early delivery, or a bigger baby, which can make for a complicated birth.
• Lean protein with whole grain (string cheese with whole-grain crackers).
Gaining too much during pregnancy can also affect your children for generations — increasing their risk for diabetes, high blood pressure, and overweight/obesity. Losing pregnancy weight can be difficult. About half of all women retain about 10 pounds of their pregnancy weight gain, and 1 out of every 4 women retain more than 20 pounds. How can I help prevent too much weight gain when I'm so hungry? Try eating a meal or snack every 3 to 4 hours.
• Choose whole foods as often as you’re able. • Choose fruit as your sweet treat. Limit foods and beverages that are high in added sugars or white flours (and other processed grains) — they don’t provide many nutrients or keep you feeling full for very long. • Stay hydrated. Aim for 64 ounces of water per day. • Practice mindful eating. Choose food that is satisfying and nourishing, sit at the table in a relaxed environment, and tune into your hunger and fullness levels. • Move more. Exercise daily or most days of the week. The benefits are endless.
Make meals and snacks more filling by including a combination of foods that contain protein, fiber, and fat each time that you eat. Some examples:
What else can I do?
• Fruit with nuts or seeds (apple slices with peanut butter).
• Try using a calorie and activity tracking system online or on your mobile phone. “Super Tracker” on ChooseMyPlate.gov can be a great place to start.
• Yogurt, fruit, nuts (plain Greek yogurt, blueberries, and almonds). • Whole-grain bread, lean protein, and fat (turkey on whole-wheat bread with avocado). • Whole grains, protein, fruit, and nuts (oatmeal, milk, peaches, and pecans). • Whole grain, lean protein, and vegetables (brown rice, chicken, and vegetable stir-fry).
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Have a plan for daily physical activity. Check out the ideas on kpmoves.org.
• Plan to breastfeed your baby. Women who breastfeed exclusively for three months tend to lose more weight than those who do not. Also, teens and adults who were breastfed as babies are 15 to 30 percent less likely to be obese as adults.
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HEALTHY EATING DURING PREGNANCY PRENATAL VITAMINS Most women can benefit from prenatal vitamins, even before they start trying to conceive. Taking a prenatal vitamin is especially important for women who are pregnant with multiples or women who have dietary restrictions, certain health issues, or pregnancy complications. Prenatal vitamins are available without a prescription. Take a vitamin supplement or prenatal vitamin with 150 micrograms (0.15 milligrams) iodine and 400 micrograms (0.4 milligrams) of folic acid daily. Folic acid is a B vitamin that can help prevent birth defects. If you have questions, talk to your clinician.
FOODS TO AVOID Although you can enjoy most foods while pregnant, there are some that you should cut back on or eliminate. This list includes: • Alcohol. Drinking alcohol can harm your baby and cause him or her problems later in life. There is no amount of alcohol that has been proven safe in pregnancy, so it’s better not to drink any alcohol. • Raw or undercooked meat, chicken, and fish. Cook raw foods thoroughly and cook ready-to-eat meats — such as hot dogs or deli meats (ham, bologna, salami, and corned beef) — until they’re steaming hot. Wash your hands, knives, cutting boards, and cooking surfaces with warm, soapy water after handling raw or undercooked meat. • Unpasteurized soft cheeses. Avoid brie, feta, fresh mozzarella, and blue cheese because they contain bacteria that could harm your baby. Hard cheese, processed cheeses, cream cheese, and cottage cheese are safe, but look for reduced-fat options.
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• Caffeine. Coffee, tea, soda, hot chocolate, or sports and energy drinks may contain caffeine. It’s a good idea to keep your caffeine intake below 200 milligrams a day, because more caffeine may be connected to higher rates of miscarriage. However, there is not enough evidence to know for sure. In addition, caffeine is a diuretic, meaning it makes you urinate more often, which can cause you to lose important minerals, including calcium. Caffeine may also interfere with sleep for both you and your baby. • Shark, swordfish, king mackerel, tilefish, and albacore tuna. Some fish may have high levels of mercury, which is dangerous to your baby. Eat no more than 12 ounces a week of fish or shellfish with low mercury levels. Check nrdc.org/health/effects/mercury/guide.asp for the latest information on contaminated species. • Raw eggs and foods containing raw egg. Lightly cooked eggs (such as soft-scrambled eggs), Caesar dressing, or hollandaise sauce can increase your risk of exposure to salmonella. • Liver. This has excessive amounts of vitamin A, and too much vitamin A may cause birth defects. However, fruits and vegetables that contain beta carotene (a precursor to vitamin A) are perfectly safe to eat. • Papaya, especially when unripe. Papaya is sometimes recommended for soothing indigestion, which is a common ailment during pregnancy. Although a fully ripe papaya is not considered dangerous, a papaya that is at all unripe contains a latex substance that triggers uterine contractions. Contractions of the uterus could lead to a miscarriage.
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WHAT IF I GET SICK? If you take any medications or herbal remedies, your developing baby takes them, too. That’s why it’s important to ask before taking any form of medication. In general, follow these guidelines: • If you’re taking prescription medications, continue to take them unless your clinician tells you otherwise. Make sure to follow the directions carefully. • Tell your clinician about all medications (prescription and over-the-counter), vitamins, homeopathic remedies, herbs, or home remedies that you’re taking.
• Don’t take any prescription medications unless they’re prescribed or approved by a clinician who knows you’re pregnant. • Use over-the-counter medications only if you really need them. Stop taking them as soon as you feel better. Try natural remedies for relief, if possible. (See the chart on the right.) Call your clinician if: • You feel worse after you take any medication. • Your symptoms don’t improve.
FLUID INTAKE Drinking plenty of fluids during pregnancy, you will be less likely to become dehydrated, be constipated, get urinary tract infections, or experience preterm (premature) contractions. You’ll also have softer skin and be at less risk of retaining water. Your baby needs fluids for proper growth. To get enough fluids for yourself and your baby: • Drink about 8 to 10 full glasses (64 to 80 ounces) of fluid each day. • Keep a full glass of water with you. • Try a variety of fluids, like milk and soups, in moderate amounts. • Choose caffeine-free, nonalcoholic drinks.
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NATURAL REMEDIES AND SAFE OVER-THE-COUNTER MEDICATIONS PROBLEM
NATURAL REMEDIES
OVER-THE-COUNTER MEDICATIONS
Headache
• Massage. • Rest. • Cool washcloth on forehead.
• Acetaminophen (such as Tylenol). • Do not take aspirin or ibuprofen (such as Motrin, Advil, Nuprin, or Medipren).
Cold and cough • Rest. • Drink plenty of warm liquids. • Use a vaporizer, humidifier, or shower for nasal congestion.
• Acetaminophen (such as Tylenol) for aches and fever. • Pseudoephedrine (such as Sudafed) for stuffy or runny nose, may be used after 13 weeks gestation. • Chlorpheniramine (such as Chlor-trimeton) for allergies. • Saline nasal drops. • Cough drops. • Dextromethorphan or guaifenesin. • Loratidine (Claritin) for allergy symptoms.
Constipation
• Increase fluids and fiber in diet (such as prunes). • Exercise regularly.
• Metamucil (plain), Fiberall, or Colace.
Diarrhea
• Drink clear liquids.
• Imodium.
Indigestion
• Eat smaller meals. • Wear loose-fitting clothing. • Elevate head when lying down.
• Tums (for occasional heartburn relief). • Aluminum hydroxide, Gelusil, Magnesium hydroxide, or Simethicone.
Hemorrhoids
• Use witch hazel pads, Tucks pads, or ice packs. • Take a warm sitz bath.
• Preparation H, Anusol, or 1% hydrocortisone cream.
Nausea and vomiting
• Take vitamin B6 (25 milligrams three times a day). • Eat crackers or dry toast. • Use acupressure on wrist. • Ginger tea or capsules.
Vaginal itch
• Eat yogurt that contains live Lactobacillus organisms. • Wear cotton underwear. • Reduce or eliminate sugar from diet.
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• 7-day treatment Monistat or Gyne‑Lotrimin (for yeast infections).
MANAGING EMOTIONS WHAT TO EXPECT FROM YOUR EMOTIONS Emotions during pregnancy differ for every woman. You may experience highs and lows or feel uncertain — even if your pregnancy was planned. Increased hormones and the fatigue of pregnancy can spur mood swings. At times, you may feel exhausted, forgetful, or moody. You may worry about your body, how to manage symptoms, or how different your life is becoming. Many women fear that their baby will have a problem. Or they may feel anxious about childbirth or that their pregnancy isn’t going well.
• Second trimester. Fatigue, morning sickness, and moodiness usually improve or go away. You may feel more forgetful and disorganized than before. Looking heavier than normal, then looking visibly pregnant and feeling the baby move, can make you feel any number of emotions. • Third trimester. Forgetfulness may continue. As your due date nears, it is common to feel more anxious about the childbirth and how a new baby will change your life. As you feel more tired and uncomfortable, you may be more irritable.
HANDLING UPS AND DOWNS
Other concerns can come up, too. Keeping up with everyday life, finances, and relationships with family and friends are potential sources of confusion or stress.
Feeling waves of emotion during pregnancy is natural. To keep your stress low, try doing relaxation exercises and time management practices at home. Here are a few tips to get started:
As you adjust to your changing world, it’s important to understand why things feel different and how to find relief.
Guided imagery
EMOTIONAL SHIFTS BY TRIMESTER
• Use the free podcasts at kp.org/audio. You can listen online or download for later use.
Each trimester brings new streams of thought and body sensations. Here are general ways your emotional life may shift along the way: • First trimester. Extreme fatigue or morning sickness can color your daily life. Moodiness (as with premenstrual syndrome) is normal. Happiness and anxiety about a new pregnancy, or feeling upset about an unplanned pregnancy, are also common.
It is possible to feel calm just by imagining it. Guided imagery suggestions:
• Work with audio recordings, an instructor, or a script (a set of written instructions) to lead you through the process. • Imagine yourself in a calm, peaceful setting to help you relax and relieve stress. • Use all of your senses (touch, smell, taste, hearing, and sight) in guided imagery. For example, if you want a tropical setting, you can imagine the warm breeze on your skin, the bright blue of the water, the sound of the surf, the sweet scent of tropical flowers, and the taste of coconut so that you actually feel like you are there.
Note: Let your health care team or clinic know about changes to your emotions if they are persistent or severe or if the techniques on this page don't help. 1899KPCC-15/5-15
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Breathing exercises
Massage
Deep breathing can help you feel relaxed, reduce tension, and relieve stress. Try some of these breathing exercises to calm and relax your mind and body:
Gentle massage can help relieve muscle tension and pain and help you relax. It can also be a nice way for you and your partner to bond.
• Belly breathing. Sit in a comfortable position with one hand on your belly just below your ribs and the other hand on your chest. Take a deep breath in through your nose, and let your belly push your hand out. Your chest should not move. Breathe out through pursed lips as if you were whistling. Feel the hand on your belly go in, and use it to push all the air out. Do this breathing 3 to 10 times. Take your time with each breath. • 4-7-8 breathing. Put one hand on your belly and the other on your chest. Take a deep, slow breath from your belly, and silently count to 4 as you breathe in. Hold your breath, and silently count from 1 to 7. Breathe out completely as you silently count from 1 to 8. Try to get all the air out of your lungs by the time you count to 8. Repeat 3 to 7 times or until you feel calm. • Morning breathing. From a standing position, bend forward from the waist with your knees slightly bent, letting your arms dangle close to the floor. As you inhale slowly and deeply, return to a standing position by rolling up slowing, lifting your head last. Hold your breath for just a few seconds in this standing position. Exhale slowly as you return to the original position, bending forward from the waist. These are just a few of the breathing exercises out there. Consult your care team to find out which exercises are the best fit for your specific needs.
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Calming activities Take time every day to relax, even if only for 10 or 15 minutes. Sitting in a quiet room, listening to music, taking a warm (not hot) bath, or taking a walk are simple ways to quiet your mind and feel centered. Progressive relaxation Learning to relax will increase your energy and lower your stress during pregnancy, as well as help you know how to relax during labor. Try this progressive relaxation exercise, in which you tense then relax each muscle group: • To begin, get into a comfortable position, preferably lying on your side or propped up with pillows in a semi-sitting position on a bed or a couch. • Close your eyes and take a deep breath through your nose. Exhale completely through your mouth. Repeat this “cleansing breath.” Now, allow your breathing to become slower and effortless. • Next, you'll tense then relax each muscle group. Start with your forehead and move progressively toward your toes. • Raise your eyebrows toward your hairline and contract your forehead while inhaling. Try not to laugh; it tightens the rest of your face. Now exhale … and release the tension. • Keeping your forehead relaxed, bite down and clench your teeth as you inhale. Now exhale … and release the tension; let your mouth open slightly.
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MANAGING EMOTIONS • Next, raise your shoulders and tense up the neck and upper shoulder as you inhale. This is where many of us carry a lot of tension. Is your face still relaxed? Now exhale … and release the tension. • Extend your right arm as you inhale. Make a fist and tense your right arm all the way to your shoulder. Now exhale … and release the tension; let the arm drop to your lap. Feel the tension and distraction dissolve with every exhalation. Feel the relaxation flood your body with every inhalation. Calm in … tension out. Focus in … distraction out. Continue these steps with your left arm, abdomen, buttocks, left toes (flex toward nose), then right toes. When your whole body is relaxed, take a deep breath and exhale any remaining tension. Visualize that the tension is moving from your head, down your body, and out through your toes. Take another cleansing breath. Notice how relaxed your muscles feel. If there’s one area where you still feel tension, focus on it, breathe in and out 4 or 5 times, and relax it further each time. Move through this exercise at a comfortable pace. If possible, have your partner touch each area that you’re relaxing as you inhale and contract the muscle. Have your partner feel the difference in muscle tone as you exhale and relax the area. If you’re practicing alone, concentrate on tensing each muscle group, relaxing it, feeling the difference between tension and relaxation, and breathing.
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This is an excellent technique to use in your daily life when you feel stressed. At work or at home, find a quiet place and practice this exercise. After 2 or 3 weeks of daily practice, you’ll be able to produce the same relaxed feelings on the spur of the moment. You’ll also get a head start on preparing your mind and body for labor. Time management When you’re pregnant, demands on your time can increase. Medical appointments, classes, and preparing for the new baby — plus all of your normal obligations — add up fast. Finding a system to manage your time, activities, and commitments helps make your life easier, less stressful, and more meaningful. Time management suggestions: • Prioritize tasks. Make a list of all your tasks and activities for the day or week. Then rate these tasks by how important or urgent they are. • Control procrastination. The more stressful or unpleasant a task, the more likely you are to put it off. This only increases your stress. Try this instead: Structure your time, break up large tasks, create short-term deadlines, and avoid perfectionism. • Let go. Liberate yourself from doing it all. Learn what’s important to you, recognize that you have limits, and decide how you want to spend your time. When you do, you’ll breathe a little easier. • Make commitments. Commit first and foremost to your health during the pregnancy. Add other commitments as you can without overloading your schedule. Once you commit, see it through. Commit as fully as you can, don’t back out of obligations, and be open to new ideas and suggestions.
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BODY CHANGES AND DISCOMFORT Your body changes a lot in 9 months with a baby growing inside of you! Although they can range from mild to severe, the following conditions are common during pregnancy.
APPETITE CHANGES You may be very hungry, or you may find it hard to eat much at all. Both are normal. Be sure to choose quality “baby-building” foods (see "Healthy eating during pregnancy"). During your first trimester, a healthy weight gain is about half a pound per week. Ask your clinician for help if you think you’re gaining too much or too little weight.
BACK PAIN AND SCIATICA Most women develop back pain at some point during pregnancy. As the size and weight of your growing belly place more strain on your back, you may notice your posture changing. To protect your back: • Avoid standing with your belly forward and your shoulders back. • When standing, rest one foot on a small box, brick, or stool. Try not to stand for long periods of time. • Sit with a back support or pillow against your lower back. If you must sit for prolonged periods, take a break every hour. • Avoid heavy lifting. Lift only by raising from a squat, keeping your waist and back straight. • Avoid stretching to reach something, such as on a high shelf or across a table.
BREAST CHANGES During of pregnancy, your breasts will become larger and heavier. You may need a larger and more supportive bra. As your breasts become larger, veins become more noticeable under the skin. The nipples and the area around the nipples (areola) darken, and small bumps may appear. You may also notice yellowish discharge (colostrum) from your nipples. Colostrum is what your breasts produce when they are preparing for breastfeeding.
CHANGES IN VAGINAL DISCHARGE A thin, milky-white discharge (leukorrhea) is normal throughout pregnancy. You may also have yeast infections that reoccur or are difficult to get rid of. Review the “What if I get sick?” section for treatment options.
CONSTIPATION Pregnancy hormones cause the digestive tract to relax and function more slowly. Constipation is likely to result, especially as your pregnancy progresses. The following suggestions may decrease constipation: • Drink more fluids (keep a bottle of water near you during the day). • Eat more high-fiber foods like fruits, vegetables, beans, and whole-grain breads and cereals. • Exercise regularly. • Establish a regular time for bowel movements. • Try Metamucil, bran tablets, or Fiberall.
• Sleep on a firm mattress (plywood under a mattress helps). Lie on your side with a pillow between your knees.
• Try an over-the-counter stool softener called Colace (also called docusate sodium) as directed by your clinician.
• Stay active, and do the simple back exercises from the kp.org section on excercise during pregnancy.
• Don’t use laxatives (such as Ex-Lax) without first talking with your clinician.
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BODY CHANGES AND DISCOMFORT DIZZINESS AND FAINTING
FATIGUE
Women often feel dizzy when they’re pregnant, but dizzy spells should lessen or disappear as your blood supply increases to meet your baby’s growing needs. If you feel faint, try these suggestions:
Most women struggle with fatigue during pregnancy, especially during the first and third trimesters. To manage fatigue during pregnancy:
• Sit down immediately and put your head down, as low as possible, between your legs. • If you can’t sit, kneel with your head and hands down, as if you were going to touch your hands and forehead to the floor. • Lie down and keep your legs higher than your head (use pillows to prop your feet up). To reduce the likelihood of dizziness, try: • Standing up slowly. Move slowly, especially when changing from a lying or sitting position. • Eating frequently to help your blood sugar stay constant, and so you don’t feel lightheaded or faint. Eat healthy snacks like fruits, vegetables, bread, or crackers. • Drinking plenty of fluids, especially water. • If you sit in the sun, wearing a hat. • Avoiding closed-in spaces and getting plenty of fresh air. Fainting is rare. Be sure to report fainting. If you fall to the ground or hit an object, you’ll need to be examined right away.
EMOTIONS
• Take frequent rest breaks during the day. If you feel tired, that's your body's way of telling you to slow down. • Reduce nonessential activities and responsibilities. • Exercise regularly — get outside, take walks, keep your blood moving with your favorite workout. If you don’t have your usual energy, don’t push it. • Eat a balanced diet and drink plenty of water.
FREQUENT OR PAINFUL URINATION When you are first pregnant, you may notice that you need to pee frequently. This is because your uterus is in your pelvis and, as it expands, it puts pressure on your bladder. By your second trimester, your growing baby will move the uterus out of the pelvis, putting less pressure on your bladder. Continue to drink plenty of fluids and monitor how you feel. If you ever feel burning or pain when you urinate, call your clinician. These symptoms may indicate a bladder infection, and you will need to be tested. Call immediatley if you have chills and fever or a temperature of 100.4 degrees or greater, with or without backache. These symptoms could be a sign of a more serious infection.
Pregnancy can be an emotional roller coaster for some. You’re not alone if you have mood swings, cry easily, feel easily annoyed, or feel disorganized and have trouble concentrating. Accept your feelings and share them with someone who cares. Talk to your clinician if you need help coping with your feelings.
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HAIR CHANGES During pregnancy, hormonal changes can affect how your hair looks and feels. You may notice that your hair is thicker and healthier looking than usual. But some women find that their hair is more limp and lifeless during pregnancy. It is normal during pregnancy to grow hair on other parts of your body, such as your abdomen, face, or back. After pregnancy, your hair’s growth cycle returns to normal.
HAND PAIN, NUMBNESS, OR WEAKNESS (CARPAL TUNNEL SYNDROME) Tingling, numbness, and pain in the hands are common during pregnancy, especially in the last trimester. These problems are usually caused by carpal tunnel syndrome, and they usually go away after pregnancy. To reduce discomfort, try changing or avoiding activities that may be causing symptoms and take frequent breaks. You can also try using wrist guards, especially when sleeping.
HEADACHES Lie down and relax if possible. Put a cool cloth on your head and neck, and ask your partner to give you a neck and shoulder massage. Don’t take aspirin, ibuprofen (such as Advil and Motrin), or migraine medication while you’re pregnant unless directed by your clinician. Call your clinician if: • You have severe headaches after week 20 of pregnancy. • You have headaches along with muscle weakness, visual disturbance, or fever. • Acetaminophen (such as Tylenol) doesn’t help your headache.
HEARTBURN (A SYMPTOM OF GASTROESOPHAGEAL REFLUX DISEASE, OR GERD) You may experience heartburn along with a sour taste in your mouth. Heartburn is caused when stomach acids bubble back into the esophagus. It’s not cause for concern, but it’s unpleasant and uncomfortable. For relief: • Eat small, frequent meals. • Avoid fatty, fried, or spicy foods. • Avoid beverages that contain caffeine, such as coffee, tea, or soda. • Avoid bending over or lying down after meals. Take a walk instead. • Avoid tight clothes and waistbands. • If heartburn is a problem at night, avoid eating just before bedtime and sleep propped up with pillows. • Take an antacid, such as Tums or Mylanta, for instant relief. If your heartburn does not go away, you may use acid blockers such as cimetidine (Tagamet) or ranitidine (Zantac). • Don’t take high-sodium antacids such as AlkaSeltzer or baking soda.
HEMORRHOIDS Hemorrhoids (dilated, twisted blood vessels in and around the rectum) are common, especially in the last months of pregnancy when the uterus is pushing constantly on the rectal veins. Hemorrhoids can cause pain, itching, and bleeding during a bowel movement. They usually improve without treatment shortly after birth. • Keep your stools soft by increasing your intake of liquids, fruits, vegetables, and fiber. • Avoid sitting for long periods of time. Lie on your side several times a day. • Cleanse the area with soft, moist toilet paper, witch hazel pads, or Tucks pads.
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BODY CHANGES AND DISCOMFORT • Try ice packs to relieve discomfort.
LEG CRAMPS
• Take a sitz bath (a warm-water bath taken in the sitting position where only the hips and buttocks are covered) for 20 minutes, several times a day. • Use Preparation H, Anusol, or 1% hydrocortisone cream to help relieve the pain.
They are common in late pregnancy. Leg cramps usually occur late at night and may wake you up. They may be caused by the pressure of the enlarged uterus on nerves or blood vessels in your legs, from lack of calcium, or occasionally from too much phosphorous in your diet.
LEAKING FROM YOUR NIPPLES
To relieve leg cramps:
During the second or third trimester (any time after 12 weeks), you might notice a yellowish or whitish fluid leaking from your nipples. This fluid is called colostrum, the first breast milk.
• Sit on a firm bed or chair. Straighten your leg and flex your foot slowly toward the knee.
It’s the perfect food for your newborn. It also supplies antibodies to help protect your baby from infections. Although leakage is common for many women, some women don’t have any leakage until after delivery. Colostrum may continue to leak from time to time through the rest of your pregnancy. If your blouse or dress gets wet from leaking: • Use breast pads (all cotton, no plastic liners) inside the cup of your bra. • Keep your breasts clean and dry.
LEAKING URINE As your growing uterus puts pressure on your bladder, you might notice that you leak urine when you laugh or cough. This is common and is called stress incontinence. You can help prevent leaking by doing Kegel exercises (page 23 for instructions). Kegels strengthen your pelvic floor muscles and help reduce.
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• Stand on a flat surface (a cold surface is even better) and lift your toes up, as if to stand on your heels. Then try walking while keeping your toes up. Note: for safety use a counter or chair back for balance. • Use a heating pad or hot water bottle. To prevent leg cramps: • Avoid too much phosphorous in your diet. This is found in highly processed foods, such as lunch meats, packaged foods, and carbonated beverages. • If you have frequent cramps (more than twice a week), increase the amount of calcium in your diet or take calcium supplements that don’t contain phosphorous. • Do leg stretches before bedtime. • Wear leg warmers at night. • Exercise moderately every day. • Take a warm (not hot) bath before bedtime. Although uncommon, a blood clot can form in a deep vein of the leg (deep vein thrombosis, or DVT) during pregnancy. DVT can be lifethreatening and requires medical treatment. Consult your care team if you are concerned you may have a blood clot in your leg.
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MORNING SICKNESS
PAINFUL KICKING
Morning sickness is nausea, sometimes with vomiting, caused by hormones released during pregnancy. Morning sickness occurs most often during the first 3 months of pregnancy.
Your baby may settle into a position that is very uncomfortable for you. Your baby’s kicks and twists can be strong and sometimes painful. When your baby drops into your pelvis (called “lightening”), the kicks will probably be less uncomfortable. If you’re having your first baby, lightening can occur several weeks before delivery. For subsequent babies, it usually doesn’t happen until just before labor. If the baby’s movements are causing you discomfort:
You may find that nausea and vomiting are worse in the morning. But symptoms can occur at any time of the day or night. Most women feel better at the beginning of the second trimester. However, symptoms can continue throughout pregnancy. Review the “What if I get sick” section for treatment options.
NOSEBLEEDS/STUFFY NOSE You may have a stuffy nose, fluid dripping into your throat (post-nasal drip), or frequent sinus headaches. You can even get nosebleeds from blowing your nose too hard. Increased hormones make the mucous membranes inside your nose and sinuses swell. The tiny blood vessels in your nose have more blood while you’re pregnant. They can break with the slightest strain or even no pressure at all. Stuffiness and nosebleeds should get better after your baby is born. In the meantime: • Use saline nose sprays to moisten dry nasal passages. • Dab Vaseline in each nostril and use a cool mist vaporizer. • Avoid nasal decongestant spray, which can actually make stuffiness worse. • Don’t use any drugs without asking your health care team first. Call your clinician if you can’t control the bleeding from a nosebleed or if the bleeding gets too heavy.
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• Change your position and hope your baby changes position, too. • Try taking a deep breath while you raise your arm over your head and then breathe out while you drop your arm. • Try cupping your hands around your baby’s buttocks and gently moving the baby.
PELVIC ACHES AND HIP PAIN As your pregnancy progresses, you may develop aches and pains in your hips and pelvic area. This is a normal sign that your pelvic girdle is preparing for childbirth. Pregnancy hormones are relaxing your ligaments, loosening up your pelvic bones so they can shift and open for childbirth. To help manage pelvic and hip pain at home: • When lying on your back, propped up on your elbows or a pillow, squeeze a pillow between your knees. This can help realign your pelvic bones and may give you temporary pain relief. • Wear a prenatal belt or girdle around your hips, under your abdomen, to help stabilize your hips. • Sleep with a pillow between your knees. • Rest as much as possible, applying heat to painful areas. • Talk to your health professional about whether a safe pain reliever might help. 49
BODY CHANGES AND DISCOMFORT ROUND LIGAMENT PAIN
Pregnancy sleep tips
Round ligaments help support your uterus. As pregnancy progresses, these ligaments can stretch. Any movements that stretch these ligaments can cause pain. It can occur when turning over in bed, walking quickly, or sneezing and coughing. These tips can help you avoid the pain:
• Use extra pillows to support your legs and back. Try sleeping on your side with pillows between your knees and behind your back.
• Change positions slowly. • Use your hands to support your weight when changing positions.
• Have a light snack or a glass of milk before going to bed. • Get regular exercise during the day to help you sleep more soundly at night. • Practice relaxation exercises before going to sleep or if you wake up during the night.
• Rest as much as possible.
• Take a warm (not hot) bath or shower before going to bed.
• A maternity girdle or belt can help lift the weight of the uterus off the pelvic floor.
• Avoid caffeine, including chocolate, especially late in the day.
SLEEP PROBLEMS
• Do not use sleeping pills or drink alcohol because they could harm your baby.
Hormonal changes, plus the discomforts of later pregnancy, may disrupt your sleep cycle. Regular exercise, shorter naps, and relaxation techniques can help you get the best possible sleep during pregnancy. After your first trimester, lying on either side is better for you and the baby. When you lie on your back, the weight of your uterus and your baby rests on the vena cava, the largest vein in your abdomen. When there is pressure on that vein, your blood pressure can go down, and you may feel dizzy or light-headed. After week 16 of pregnancy, avoid exercises that involve lying on your back for longer than 3 minutes. As pregnancy progresses, leg cramps, breathlessness, contractions, the frequent need to urinate, and an active baby may interfere with your sleep. You may not be able to find a comfortable position.
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STRETCH MARKS, ITCHINESS, AND OTHER SKIN CHANGES Stretch marks are most common on the belly, but they can also develop on the breasts and thighs. Other skin changes can also occur: • A dark line known as a linea nigra may appear on the skin between your navel and your pubic area. It generally fades after delivery. • Dark patches may develop on your face. This is known as the “mask of pregnancy,” or chloasma, and it usually fades after delivery. • Blotchy skin and acne may increase or clear up during pregnancy. • Tiny, red elevated areas (vascular spiders, or angiomas) may appear on the face, neck, chest, and arms. These are not serious and usually go away after pregnancy.
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SWOLLEN FEET AND ANKLES
VAGINAL BLEEDING OR SPOTTING
You may notice that your feet, ankles, hands, and fingers become swollen, particularly at the end of the day. It’s normal to have extra fluid in your tissues during pregnancy, but much of the swelling should disappear after a good night’s sleep. If your fingers are puffy, remove your rings. Do not take diuretics (water pills) because they interfere with your normal fluid balance.
Minimal bleeding or spotting may be normal in some pregnancies. But any bleeding during pregnancy needs to be evaluated by your clinician.
To prevent swelling or puffiness: • Avoid high-sodium (salty) foods. (Aim for less than 2,400 milligrams of sodium per day.)
VARICOSE VEINS Enlarged, swollen veins are common during pregnancy, particularly in women with a family history of the problem. Varicose veins typically develop on the legs but can also affect the vulva.
• Drink 8 to 10 glasses of fluids each day.
Your calves may ache or throb, even when the veins aren’t visible. Most varicose veins will shrink or disappear after birth. Until then:
• Keep your feet up on a stool or couch whenever possible.
• Try not to stand for long periods of time.
• Avoid standing for long periods of time. • Don’t wear tight shoes or knee-high stockings. • Wear support stockings, and put them on before you get out of bed in the morning. • Lie on your side to remove fluid from your puffy tissues. • Try sleeping with your feet slightly higher than your heart. Raise the foot of your bed by putting a thick blanket or pillows under the mattress.
• When sitting, avoid crossing your legs at the knees. • Elevate your feet and legs whenever possible. • Avoid tight clothing or stockings that hamper circulation. • Wear compression stockings. You can buy them at the Kaiser Permanente pharmacy after being measured at your ob-gyn appointment. • Exercise regularly to improve your blood circulation. Try walking for at least 30 minutes each day on most days.
To learn more about common body changes and discomforts, visit kp.org/pregnancy and look for “symptoms and discomforts.” Consult with your care team for specific treatment advice.
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HEALTHY SMILES DURING PREGNANCY
HEALTHY SMILES DURING PREGNANCY
HEALTHY SMILES DURING PREGNANCY Good oral health is an important part of overall wellness, which is especially crucial during pregnancy. Pregnant women are susceptible to some very specific oral conditions that can be prevented or treated by a visit to the dentist. Also, mothers’ prenatal oral health is thought to influence the future oral health of their children (based on transmission of oral bacteria from mother to child). It’s important to receive routine cleanings and exams when pregnant, as well as necessary treatments. Your prenatal dental appointments also offer an opportunity to discuss with your dentist how to help your child develop good oral hygiene habits from a young age to ensure a lifetime of healthy smiles. By paying attention to your oral hygiene and eating habits while pregnant, you can go a long way toward keeping your and your baby’s mouths healthy.
PRACTICE GOOD ORAL HYGIENE • Brush your teeth gently twice daily with a soft-bristled toothbrush and a toothpaste containing fluoride. • Replace your toothbrush every 3 or 4 months, or sooner if the bristles are frayed.
EAT RIGHT Eat a healthful diet with a balanced mix of grains, vegetables, fruits, dairy, protein, and fats and oils. Try to limit your snacking – especially foods high in sugar, since they cause your mouth to release acids that increase your risk of cavities.
VISIT YOUR DENTIST If your last dental visit took place more than six months ago, or if you are experiencing any oral health problems, schedule an appointment. As part of a full examination, your dentist may need to take X-rays. Oral health care, including the use of X-rays, pain medication, and local anesthesia, is safe throughout pregnancy. You may experience some unique oral health problems during your pregnancy. For example, hormonal changes can affect your gums, causing swelling or tenderness. Your gums also may bleed a little when you brush or floss. This condition is called gingivitis. The gum tissue itself can develop red lumps called “pregnancy tumors.” These lumps are not cancerous and typically go away after the baby is born. Contact your dentist if you experience any of these problems or have other concerns. Please see the phone number and resoure list in the pocket of this booklet.
• Floss daily to help remove plaque from the surface of your teeth and food particles from between your teeth and under the gumline.
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RISKS AND SAFETY
RISKS AND SAFETY
RISKS AND SAFETY Pregnancy is a sensitive time in a woman’s life. These guidelines summarize some healthy habits, risks to avoid, and warning signs when you’re expecting.
TRAVEL
HEALTH AND SAFETY
During the middle of your pregnancy, you may feel great, have lots of energy, and be able to enjoy a relaxing vacation — free of strollers and diapers (you’ll have plenty of time for those later). During this period, your risks for miscarriage and early labor are at their lowest. If travel is an option during your pregnancy, the second trimester is typically the best timing.
• Pregnancy over age 35 poses some risks, but most older women have healthy pregnancies. • Some immunizations (also called vaccinations) should be done only before pregnancy. You can get other vaccinations during pregnancy. • Flu vaccine is safe and recommended for all pregnant women. The vaccine also can help prevent H1N1 flu.
If your pregnancy is normal and healthy, it is generally OK for you to travel during your second trimester (weeks 13 to 28).
• Tetanus, diphtheria, and acellular pertussis (Tdap) immunization or booster is recommended for all pregnant women between 27 weeks and 36 weeks of gestation, to maximize passive antibody transfer to the newborn. • Pregnancy after bariatric surgery may mean that you keep seeing the doctor who did your weight-loss surgery, along with seeing the clinician who is caring for you during pregnancy. • Domestic violence can happen more often and/or get worse when women are pregnant. It is dangerous for both mother and baby. See page 158 for more information.
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THINGS TO AVOID Certain substances aren’t good for you any time, but the list grows when you’re pregnant. Make sure you know what to steer clear of. Here are tips about things to avoid and moderate: • Hazardous chemicals, radiation, and certain cosmetic products. Avoid exposure to dangerous substances, such as pesticides, some household cleaners, lead, and mercury during pregnancy and while breastfeeding. These toxins can be harmful to a developing fetus and/or cause birth defects or miscarriage. If you are exposed to chemicals in your work place, consult your Material Safety Data Sheets (MSDS). Another available resource is mothertobaby.org. Artificial nails and hair permanents also contain strong chemicals. It is wise to reduce your exposure to these chemicals and be sure the room is well‑ventilated if you use them.
pregnancy. Keep in mind that your core body temperature remains elevated for some time even after you get out of the hot tub. • Many prescription and over-the-counter medicines (including herbs and other supplements). Some over-the-counter and prescription medicines are not safe to take when you’re pregnant. Tell your clinician about all the drugs and supplements you take. They can help you decide what medicines are best for you. Review the “What if I get sick?” section in this guide for general recommendations. • Smoking during pregnancy. This unhealthy habit increases the risk of problems such as low birth weight, preterm labor, miscarriage, and sudden infant death syndrome (SIDS).
• Hot tubs and saunas. If you use a hot tub or sauna during pregnancy, be conservative. Avoid uncomfortably high temperatures, and limit your exposure. Raising your core body temperature (hyperthermia) can harm your fetus, particularly during the early and later weeks of
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WHEN TO CALL FOR HELP Problems during and after pregnancy have warning signs. To stay as healthy as possible, familiarize yourself with these signs. If anything does go wrong, you will know just what to do and when. Call your clinician with urgent questions. Emails may take a few days for response, and should be used only for routine questions.
• Sharp or continuous pain in your stomach. • Abdominal pain that does not go away. • Severe emotional or social issues. • Your baby has stopped moving or is moving less than 10 times in 2 hours once you are past 28 weeks gestation. A common method of checking your baby’s movement is to count the number of kicks or moves you feel in an hour. Ten movements (such as kicks, flutters, or rolls) in an hour are normal. To count:
DURING PREGNANCY When to call your clinician During your pregnancy, call your health care professional immediately if any of the following occur:
• Pick your baby’s most active time of day. Some clinicians suggest that you count in the morning until you get to 10 movements. Then you can quit for that day and start again the next day.
• Vaginal bleeding. • Vaginal discharge that causes itching, soreness, or bad odor.
• If you do not feel 10 movements in an hour, your baby may be sleeping. Wait for the next hour and count again.
• Signs of preeclampsia: • Severe headache that does not go away with acetaminophen (such as Tylenol). • Visual disturbances, blurred vision, flashes of light, or spots before your eyes. • Sudden, increased swelling of the face, hands, or feet.
• Uterine tenderness, unexplained fever, or general weakness (possible symptoms of infection). • Contractions: • Between 20 and 37 weeks, more than 4 to 6 contractions in an hour could indicate preterm labor.
• Sudden weight gain, 2 to 3 pounds in a week, in your third trimester. • Very bad, continuous headaches.
• After 37 weeks, contractions every 5 minutes for 1 to 2 hours could indicate labor.
• Pain or burning when urinating. • Decreased urine output, despite drinking large amounts of fluid.
• Between 20 and 37 weeks, preterm labor could be indicated by low back pain or pelvic pressure that does not go away, or intestinal cramping with or without diarrhea.
• Continuous vomiting or loose stools. • Fever with a temperature above 100.4 degrees, or feeling chills. • Painful, hard veins in the legs or elsewhere. • A gush or leak of water from the vagina. • An accident, hard fall, or other injury.
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When to call 911 You or someone else should call 911 or other emergency services immediately if you think you may need emergency care. For example, call if you: • Have a seizure. • Pass out (lose consciousness). • Have severe vaginal bleeding. • Have severe pain in your belly or pelvis. • Have had fluid gushing or leaking from your vagina (the amniotic sac has ruptured) AND you know or think the umbilical cord is bulging into your vagina (cord prolapse). This is quite rare, but if it happens, immediately get down on your knees and drop your head and upper body lower than your buttocks to decrease pressure on the cord until help arrives. Cord prolapse can cut off the baby’s blood supply.
AFTER DELIVERY When to call your clinician Watch closely for changes in your health, and be sure to contact your clinician if: • You are not getting better after 2 to 3 days.
• Your breasts are painful or red and you have a fever, which are symptoms of breast engorgement and mastitis. • You have severe vaginal bleeding. You are passing blood clots and soaking through a new sanitary pad each hour for 2 or more hours. • Your vaginal bleeding seems to be getting heavier or is still bright red 4 days after delivery, or you pass blood clots larger than the size of a golf ball. • You feel dizzy or lightheaded, or you feel as if you may faint. • You are vomiting or you cannot keep fluids down. • You have a fever. • You have new or more belly pain. • You pass tissue (not just blood). • You have a severe headache, vision problems, or sudden swelling of your face, hands, or feet. You or someone else should call 911 or other emergency services immediately if you think you may need emergency care.
• You have vaginal discharge that smells bad. • You have signs of postpartum depression, such as: • Feelings of despair or hopelessness for more than a few days. • Troubling or dangerous thoughts or hallucinations.
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FIRST TRIMESTER
FIRST TRIMESTER
FIRST TRIMESTER ABOUT YOUR BABY Your due date or estimated delivery date is based on the first day of your last menstrual period. It is about 40 weeks (280 days) after your last period. However, your baby is considered to be full term between 37 and 40 weeks. During the week after fertilization, the fertilized egg grows into a microscopic ball of cells (blastocyst). It implants on the wall of your uterus. This implantation triggers a series of hormonal and physical changes in your body.
Having reached a little more than 1 inch in length by the ninth week of growth, the embryo is called a fetus. By now, the uterus has grown from about the size of a fist to about the size of a grapefruit. By the end of the first trimester, most of your baby's critical development is complete. The reproductive organs have developed, but an ultrasound won't clearly show whether the fetus is a girl or a boy until later (about week 20). Your baby is now about 2 to 3 inches long and weighs about an ounce.
The third through eighth weeks of growth are called the embryonic stage. At this time the embryo develops most major body organs. Arm and leg buds are visible, and some bones are forming. The head may seem larger than the rest of the body because the brain is developing faster than the other organs.
During the first 3 months, your baby develops quickly and is especially sensitive to toxins and stresses. Avoid harmful substances, such as tobacco, alcohol, recreational drugs, radiation, and infectious diseases. Try to reduce stress and get enough sleep.
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FIRST TRIMESTER ABOUT YOU
TIPS FOR STAYING HEALTHY
Extreme fatigue or morning sickness can color your daily life during the first trimester. Moodiness (as with premenstrual syndrome) is normal. Happiness and anxiety about a new pregnancy, or feeling upset about an unplanned pregnancy, are also common.
• Limit your caffeine intake to less than 200 milligrams daily.
The first trimester can bring insomnia and night waking. Most women feel the need to take naps to battle daytime sleepiness and fatigue. By the second month, you may start to notice early signs of pregnancy: breast tenderness, increased urination, fullness or mild aching in your lower abdomen, nausea with or without vomiting, and food cravings or aversions. A milky vaginal discharge is also common in your first trimester. By the end of your first trimester, you may not have a baby bump, but you probably will feel pregnant. The third month can be hard — you may feel tired and need extra rest, and morning sickness can peak. But fatigue and nausea will lessen, and you'll start to feel normal as you approach your second trimester.
WHAT'S NORMAL • Some cramping as the uterus enlarges and contracts is normal. During this time, your uterus will increase in weight from about an ounce to more than 2 pounds. • Your breasts may feel larger and tender when touched. • Some bleeding in your gums is common, but don’t forget to brush and floss regularly. • Whitish vaginal discharge is normal throughout pregnancy. You may also have yeast infections that recur or are difficult to get rid of.
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• Ask your clinician about the safety of any medications you’re taking. • Eat a healthy, well-balanced diet. • Avoid alcohol. • Eat a variety of foods including those high in iron, calcium, and protein each day. It’s quality, not quantity, that counts. • Exercise in moderation unless your clinician has instructed otherwise. Learn about the benefits of exercise during pregnancy. • Drink plenty of water throughout the day. • If you smoke, your baby smokes, too. See the “Health and wellness” section of this guide. • Cat feces can sometimes cause an infection called toxoplasmosis, which could harm your baby. If you have a cat, ask someone else to change the litter box. If that’s not possible, wear rubber gloves and wash your hands well. • Avoid very hot baths and hot tubs (temperature should be below 101 degrees), saunas, steam rooms, and tanning beds. High temperatures may harm your developing baby. • You should gain about 1 pound a month for the first three months of your pregnancy. Too much weight gain in pregnancy can lead to a variety of health problems for you and your baby. • Pregnant women need 1,200 milligrams of calcium daily. Calcium builds your baby’s bones and teeth. It also prevents osteoporosis later in your life. Good sources include skim milk, yogurt, dark-green leafy vegetables, canned salmon, and tofu.
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Plan for baby expenses by creating a budget.
YOUR TO-DO LIST If you haven’t already done so, use our medical staff directory to help you select a clinician with whom you feel comfortable.
Get plenty of rest. This trimester is an important time for testing. If you are worried about Down syndrome or other chromosomal problems, a blood test (called first trimester screening) is done around 9 to 11 weeks. Talk to your clinician about genetic testing options to screen for chromosomal defects.
Learn as much as you can. This guide has information to guide you through your pregnancy, childbirth, and the challenging first months of parenthood. Go to kp.org and get familiar with the pregnancy health and wellness topics. You’ll find a wealth of material, tools, and calculators. You’ll also find information on pregnancy and childbirth classes offered in this region.
Though some mild cramping is normal, call your clinician if cramping is severe. Practice Kegel exercises to start preparing for childbirth (you can do it any time, anywhere). Refer to page 33 for instructions.
Your first visit is usually scheduled between 9 and 12 weeks. Make sure you schedule your appointment if you haven’t already.
Create your own at-home spa to pamper yourself and relieve stress.
Keep the lines of communication with your partner open. It’s important for you both to share your feelings about your pregnancy and impending parenthood.
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SECOND TRIMESTER
SECOND TRIMESTER
SECOND TRIMESTER Your second trimester officially begins at week 13. This is when your risk of miscarriage drops dramatically. Take this time to enjoy your pregnancy — you’ll probably find the weeks of your second trimester to be the easiest.
ABOUT YOUR BABY The second trimester lasts from weeks 13 to 28 of pregnancy. It’s when your baby’s movement takes off. If this is your first pregnancy, you’ll begin to feel your baby move at about 14 to 28 weeks after your last period. If you’ve been pregnant before, you may notice movement earlier, sometime between weeks 16 and 18. This is a time of rapid growth for your baby. At the start of the second trimester, your baby now has more muscle tissue, and the bones have developed and become harder. Your baby is rolling, kicking, and moving a lot — flexing tiny arms and legs. The skin is beginning to form, but it’s almost transparent at this point. Your baby’s kidneys are functioning and start to pass urine. Most of the amniotic fluid that nourishes and protects your baby comes from the urine. The intestinal tract is starting to work too, producing meconium, which will later be used as your baby’s first bowel movement. As the trimester progresses, your baby is swallowing more amniotic fluid, which is good practice for the digestive system. The umbilical cord that connects you and your baby is thickening and continues to carry blood and nutrients.
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Your baby’s sucking instinct develops, and he or she may have started thumb-sucking. Your baby’s head is no longer so big compared to the rest of the body. Hair is starting to grow on the scalp, and tiny eyelashes and eyebrows are appearing. Your baby also sleeps and wakes regularly. The baby is still small enough to change position frequently — from head-down to feet-down, or even sideways. The eyes are beginning to open and close, and the brain is very active now. Your baby hears sounds outside your womb and responds by kicking or moving. Talk to your baby often so that he or she will recognize your voice and be comforted by it, both now and after birth. By the end of the trimester, your baby can grip firmly with little hands, which now have fingernails and fingerprints. The skin goes from being wrinkled, red, and shiny, to smoother. The hair on the head is getting longer. The lanugo, a soft, fine, downy hair that once covered your baby's body, is beginning to disappear. The vernix caseosa, a white, creamy substance that protects the skin from long exposure to amniotic fluid, still covers your baby’s body. The lungs are maturing, and your baby is starting to practice breathing. At 16 weeks, your baby is about 6 inches long and weighs about 3 to 4 ounces. By the end of this trimester (28 weeks), your baby will be about 11 to 14 inches and weight about 2 to 2.5 pounds.
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SECOND TRIMESTER ABOUT YOU By the start of your second trimester, you'll likely feel better and more energetic. Morning sickness and breast tenderness are easing. It's probably time to break out the maternity clothes because your belly is starting to grow. Your breasts will become larger and heavier in the second trimester. You may need a larger and more supportive bra. As your breasts become larger, the veins become more noticeable. The nipples and the area around the nipples (areola) become darker and larger. Small bumps may appear on the areolae and disappear after delivery. As early as the 16th to 19th week, you may notice a thin, yellowish discharge (colostrum) from your nipples. Colostrum is what your breasts produce when they are preparing for breastfeeding. If this is not your first pregnancy, you might feel your baby move. (It takes a little longer to feel this the first time you are pregnant.) These first flutters you feel are called quickening. Emotional shifts also occur during this trimester. While fatigue and moodiness usually improve or go away, you may feel more forgetful and disorganized than before. Looking heavier than normal, then looking visibly pregnant and feeling the baby move, can make you feel any number of emotions.
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Many pregnant women report an increase in nightmares as their pregnancy progresses. Don’t worry. These vivid dreams are just your mind’s way of helping you process and adapt to the changes in your life. You may also notice that you and your partner are not experiencing your pregnancy in the same way (or at the same pace). It’s important to have frequent conversations about the new baby to reconnect to each other and share in your excitement for the future. You can enjoy a sexual relationship with your partner throughout pregnancy, unless you have been told that you’re at high risk for preterm labor or that your placenta is over your cervix (placenta previa). If you have either of these conditions, talk with your clinician. As your second trimester draws to a close, new symptoms may start to crop up: aching back, leg cramps, minor swelling, and sleep problems, to name a few. Continue to get moderate exercise, which can help prevent and relieve some of these symptoms. Feel as if you can’t catch your breath? It’s your growing uterus pressing up on your diaphragm and crowding your lungs. Relief usually comes when your baby settles into your pelvis.
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WHAT’S NORMAL • You may experience heartburn along with a sour taste in your mouth. It’s not a cause for concern, but it’s uncomfortable. • Pregnancy hormones also cause the digestive tract to relax and work more slowly. As a result, you might feel constipated, especially as your pregnancy progresses. • You may experience round ligament pain. Round ligaments help support your uterus. As pregnancy progresses, these ligaments can stretch. Any movements that stretch these ligaments can cause pain. It can occur when turning over in bed, walking quickly, or sneezing and coughing. • You may begin feeling Braxton Hicks contractions, especially if this isn’t your first pregnancy. This painless tightening of muscles in the uterus is normal as long as it is random and not in a regular pattern. • Notice brown patches on your face? It’s called the “mask of pregnancy” and is due to a temporary increase in estrogen. The brown patches may darken in the sun, so use sunscreen.
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• You may see a narrow, dark line (the linea nigra) running from your belly button to the top of your pubic bone. After birth, the darkened area should lighten and then disappear. • You may notice a rhythmic jerking motion that can last several minutes. This means your baby has the hiccups! You don’t need to do anything about hiccups. They will stop soon and won’t hurt either of you. • You may also notice that your baby kicks and stretches more (and you may even be able to see squirming under your clothes). You will feel more movement or less movement at certain times of the day and night. • Toward the end of the second trimester, your blood pressure may increase slightly, returning to its normal pre-pregnancy state. • Sometimes your baby settles into a position that is very uncomfortable for you. Your unborn baby’s kicks and twists can be strong, very noticeable, and sometimes painful. • You may feel pelvic pressure or pain if your baby’s head is low in your pelvis. Lying on your side may help relieve this discomfort.
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SECOND TRIMESTER TIPS FOR STAYING HEALTHY • Keep weight gain under control by watching your portion sizes. This will make it easier to lose weight after the baby is born. • Make sure you get vitamin C daily, and drink plenty of water to reduce your risk of bladder infections. • We recommended that pregnant women get a flu vaccination. • Even as your belly expands, continue to wear a seat belt any time you are in a car. Wear both the lap belt and the shoulder harness, but place the lap belt low, below the baby (not across your stomach or uterus). • To soothe aching legs and prevent varicose veins, elevate your legs often, don’t cross your legs when sitting down, and slip on support hose made especially for pregnant women. • Keep taking your prenatal vitamin supplement and eating a diet rich in nutrients. • Pump up your daily iron intake (you now need about 30 milligrams) to prevent irondeficiency anemia. • Lying on your side promotes good circulation and improves oxygen flow to your baby. Use pillows for comfort and to help maintain the side position.
• Practice relaxation exercises to increase your energy, reduce your stress, and prepare for a relaxing labor. For ideas, check out our healthy pregnancy and childbirth guided imagery podcasts at kp.org/audio. • If you have one or more children at home, your pregnancy can’t be your central focus. Get tips on parenting while pregnant. • If at any time, even during the last weeks of pregnancy, you detect a lack of fetal movement, call your clinician. • Learn the signs of preterm labor. Read more about preterm labor further in this guide. • You may experience hemorrhoids because of the amount of pressure your uterus is placing on the veins in your rectum. Talk to your clinician about your treatment options. Eat a high-fiber diet, drink water, and avoid sitting or standing for long stretches of time. • Drink plenty of fluids and avoid processed foods and other super-salty snacks to prevent swelling in your legs and fingers. • Make sure to get the nutrients that will fuel your growing baby and keep you healthy: folate, iron, and calcium. (See pages 34 to 36.) • Be aware of the warning signs of preeclampsia.
• Sleep on your side. When you lie on your back, the weight of your uterus and baby rests on a large vein in your abdomen, which can cause your blood pressure to go down and make you feel dizzy or light-headed.
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YOUR TO-DO LIST
RECOMMENDATIONS
Your clinician may recommend prenatal blood tests, such as an alpha-fetoprotein screening (AFP) or a maternal serum quadruple test (also called a quad test or expanded AFP screening), which detect signs of a possible birth defect.
• Between 24 and 28 weeks, you will be given an oral glucose tolerance test to screen for gestational diabetes, a pregnancy complication affecting 4 percent of expectant moms.
Your clinician may also recommend an amniocentesis at 15 to 20 weeks of pregnancy to check for birth defects and genetic problems.
• Prepare for changes in your relationship with your partner. Take a “babymoon,” a weekend away with your partner to relax and enjoy yourselves before the new baby comes (and while you can still travel). Ask a health care professional for tips on traveling while pregnant.
Around 20 weeks, your clinician will recommend an ultrasound to measure your baby’s growth, examine your baby's anatomy, estimate your due date, screen for certain abnormalities, and rule out twins (or more). Check your employer’s maternity leave policy. You may be entitled to 12 weeks of unpaid leave under the Family and Medical Leave Act. Start discussing your maternity leave with your supervisor. Think about how long you’ll take off, and get the terms of your leave in writing. If you plan to return to work after your leave, start to make arrangements for child care. Quality child care providers often have waiting lists. Elastic waistbands will go only so far. Time to start shopping for (or borrowing) maternity clothes.
• Select a pediatrician or family practice clinician to care for your baby. Get recommendations from friends and family. • Keep track of your baby’s movements. • Talk with your spouse or partner about how you’re feeling and your expectations of family. • Take your childbirth preparation class and learn all you can about labor and childbirth, including your pain management options. • Accept your growing body as beautiful. At 20 weeks, you’ve reached the halfway mark of your pregnancy. Your clinician may recommend an ultrasound to check your baby’s anatomy. During the test, you might be able find out if you’re having a boy or a girl (if you want to know).
Check kp.org/healthylivingcatalog/nw for the childbirth education class listings, and call to find out the dates of the classes. Most expecting parents begin classes in the seventh month.
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THIRD TRIMESTER
THIRD TRIMESTER
THIRD TRIMESTER The third trimester lasts from about 29 weeks of pregnancy until birth. On average, women gain about 11 pounds — and babies gain about 5 pounds and grow 5 inches — in the third trimester alone. Take care of yourself and your baby by continuing to exercise and eat well. By the end of the trimester, you may feel a surge of energy, but make sure you're also getting plenty of rest. If you work outside the home, start winding down projects and have plans in place for your leave. Only 5 percent of babies are born on their due date. But don’t worry; your baby will arrive soon.
ABOUT YOUR BABY During the third trimester, the fetus’ size increases and organs mature. As the last weeks go by, your baby's: • Brain and vision are in a major developmental spurt, and eyesight is sharpening. • Bones are fully developed, but still soft and flexible for delivery. • Nervous system is perfecting itself. • Skin is now pink and smooth, and the arms and legs look chubby. • Lungs are maturing, and your baby continues to practice breathing in anticipation of the first breath of air. After week 32, your baby becomes too big to move around easily inside your uterus and may seem to move less. At the end of the third trimester, your baby usually settles into a headdown position in your uterus. You will likely feel some discomfort as you get close to delivery. Your baby will spend the final few weeks putting on weight. At birth, most full-term babies weigh 6 to 9 pounds and measure 19 to 21 inches long. But healthy babies come in many different shapes and sizes. 1899KPCC-15/5-15
ABOUT YOU As you enter the final months of your pregnancy, the fatigue that you felt during the first trimester may return as your body grows and sleep becomes more difficult. You’ve probably noticed how easy it is to get off balance and feel clumsy. This is partly due to your center of gravity moving forward as your baby grows. You also release a pregnancy hormone called relaxin that softens the cartilage in your joints and pelvis. The pubic bone also opens up to make more room for the baby, causing the waddle that most pregnant women have when they walk. In the third trimester, your chest wall may widen because of your growing baby. You may need a larger bra or a bra extender. You may also experience Braxton Hicks contractions. These are “warm‑up” contractions that are usually painless and irregular. They do not lead to labor. The third trimester is a time to expect increasing insomnia and night waking. Most women wake up a few times a night, usually because of such discomforts as back pain, needing to urinate, leg cramps, heartburn, and fetal movement. Strange dreams are also common in the last few weeks of pregnancy. You might need more rest during this time. It is important to listen to your body. Your good health continues to be important because your immunities are passed on to your baby, helping fight off infection after birth. Around 36 weeks, you’ll have a test for Group B streptococcus (GBS), which is harmless in adults but can cause serious complications if you pass it on to your baby during birth. GBS is fairly common; about 25 percent of our members are GBS carriers. Moms who have positive GBS cultures need to be treated with antibiotics during labor to prevent their babies from becoming ill. 81
THIRD TRIMESTER If your GBS culture is positive when you go to Labor and Delivery, you will receive antibiotics in your IV before the baby is born. To make sure there is time to receive the antibiotics, please call Labor and Delivery and go in as soon as your bag of waters breaks. If you are laboring at home and your bag of waters is not broken, call Labor and Delivery to have the nurse help you determine when to come in. Make sure when you call that you tell them you are GBS positive. Try to relax and enjoy these last few weeks and days before your baby comes. Go see a movie. Read. Take walks. At week 37, you’re considered full term, and by week 40, you’ve reached your official due date! Your pregnancy is not post-term or overdue until after 41 weeks (or 1 week after your due date), when risks go up for the baby. Delivery is typically recommended by 42 weeks. Near the end of your pregnancy, your clinician may perform a pelvic exam as part of your prenatal visit to check your cervix and the position of your baby. Your cervix may begin to thin out (efface) and open (dilate) by the time you go into labor. For some women, these changes begin weeks before their due date, as their bodies prepare for labor and birth
WHAT’S NORMAL • Your feet, ankles, hands, and fingers may become swollen, particularly at the end of the day. It’s normal to have extra fluid in your tissues during pregnancy, but much of the swelling should disappear after a good night’s sleep. • As your growing uterus puts pressure on your bladder, you might notice that you leak urine when you laugh or cough. This is common. If you notice any consistent leaking, whether it is a large or small amount, call your clinician’s office to make sure that your water hasn’t broken. • Your growing uterus is also crowding other surrounding organs, leading to all sorts of common discomforts and annoyances, including heartburn, constipation, and hemorrhoids. • Leg cramps, breathlessness, contractions, the frequent need to urinate, and an active baby may interfere with your sleep. If you’re having trouble finding a comfortable position, try some of the tips on page 50. • Feel achiness or numbness in your fingers, wrists, or hands? You may have carpal tunnel syndrome. See page 47 for more information. • By your last month:
EMOTIONAL SHIFTS
• You'll be seeing your clinician every week.
Forgetfulness may continue. As your due date nears, it is common to feel more anxious about childbirth and how a new baby will change your life. As you feel more tired and uncomfortable, you may be more irritable.
• Your baby does not have much room to move around, so you will probably notice less big movement than before.
Note: It is recommended to get a Tdap booster at 27–36 weeks of pregnancy.
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• Labor could begin at any time. Review the signs and stages of labor.
If your pregnancy extends beyond 41 weeks, your clinician will conduct tests to determine whether to induce labor or continue to wait for your baby to come on his or her own.
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TIPS FOR STAYING HEALTHY
YOUR TO-DO LIST
• Keep exercising. Moderate, gentle exercise can help with common pregnancy discomforts and prepare you for the rigors of labor.
Start thinking about your childbirth preferences. Discussing these preferences with your health care team beforehand can be helpful.
• Your gums might be more sensitive and may swell and bleed. Check with your dentist if you experience pain or discomfort. Continue to practice good dental hygiene.
Take a free hospital birth tour. To register, call Health Engagement and Wellness Services (see phone list).
• To help avoid varicose veins, wear maternity support hose and prop your feet up when you sit.
Splurge on a new pair of comfortable shoes. The bones in your feet spread when you’re pregnant, and some women find their shoe size goes up.
• Get enough omega-3 fatty acids (found in fish, flaxseed, and walnuts) each day.
Pamper yourself. Get a manicure and haircut (pregnancy hormones make your hair and nails grow faster).
• Prevent or ease leg cramps by elevating your legs or getting a massage.
Start to look into health care benefits for your baby.
• Eat, even if you’re not especially hungry. • Practice squatting to keep your leg muscles strong.
Make a note in your calendar to add your newborn to your health plan within 31 days of birth.
• Do your Kegel exercises. • Get lots of rest. When labor starts, you’ll need all your energy (and you may not sleep for a while).
Practice the breathing and relaxation techniques you learned in your childbirth preparation classes.
• Cook and freeze meals ahead of time and have a stock of groceries on hand. Check out the restaurants in your neighborhood that offer takeout. Find out if there are any grocery delivery services in your area.
Listen to our healthy pregnancy and successful childbirth podcast at kp.org/audio. Know the signs of labor. Keep track of your baby’s movements.
• Arrange for a friend or family member to help with housework, errands, watching older children, and so on. Let people know what you need, and take them up on their offers to help.
Start thinking about names for your baby. Find out the popularity of names and how they have changed over time on the Social Security Administration website, ssa.gov. Try to tie up loose ends at work or home. Pack your bags for the hospital. See the checklist on page 101.
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HOME AND NURSERY
HOME AND NURSERY
GETTING READY FOR BABY ORGANIZING YOUR HOME
CAR SEAT
As your pregnancy enters its final weeks, actually having a new baby and bringing this tiny person home becomes a reality. When you first find out that you’re pregnant, 9 months may seem like a long time, but with so much to do and think about, it’s not too early to plan ahead.
Car seat (the law requires that you have a car seat to safely transport your child in a car). Since most car seats are not installed properly, consider scheduling a car seat safety inspection. Visit seatcheck.org to find an inspection site near you.
You’re preparing for labor and delivery, adjusting to the idea of becoming a parent, and getting your home ready for your newborn. If you can get your household in order before delivery, you’ll be able to focus on caring for and enjoying your new baby.
The impact of a car crash can pull an infant from an adult's arms with a force exceeding 300 pounds. To make travel as safe as possible for your child, please remember:
Have these supplies on hand:
• The law requires that you use a child safety seat for your baby's first ride home from the hospital — and for all trips thereafter.
• A box of large sanitary pads. It’s normal to have vaginal bleeding for a few weeks following delivery, and you may have some blood-tinged discharge for up to 6 weeks. Don’t use tampons during this time.
• Your baby is safest when the child safety seat is secured in the middle of the back seat.
• Digital thermometer. • Acetaminophen (such as Tylenol) for pain. • Diapers or diaper service. • Basic layette of baby clothes and hats, crib sheets, receiving blankets, and washcloths. • A box of nursing pads and 3 nursing bras for breastfeeding mothers.
• Never place a child safety seat in the front seat of a vehicle. If the air bag deploys, it could injure or kill your child.
• The law says babies must ride rear-facing until they reach both 1 year of age and 20 pounds, and child passengers must use a safety seat until they weigh 40 pounds. Kaiser Permanente best practices recommend that children under age 2 remain rear-facing within their safety seat's height and weight limits.
• Crib or bassinet for baby to sleep in. • Waterproof matress pads. Although there are many cute and convenient baby items on the market today, babies need very few things to keep them happy and healthy in the first few weeks.
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A SAFE NURSERY The nursery is your baby’s home — a place where your baby should be safe and protected. A variety of nursery equipment is available, but some pieces are safer than others. Here are some guidelines that you should use when selecting equipment.
CRIBS More infants die every year in accidents involving cribs than with any other nursery product. If you already have a crib or are buying a used one, make sure that:
BABY GATES Don’t use baby gates with a V-shaped, accordionstyle opening, which can trap a child’s head. Safe gates have vertical slats that are no more than 2³/8 inches apart.
DIAPER PAILS Diaper pails are dangerous targets for curious babies. Choose pails with protective lids, and keep the pails out of reach.
• Crib slats are no more than 2³/8 inches apart. • Corner posts don’t extend above the end panel. • Plastic bags aren’t used as a mattress protector. • There are no dangling curtain cords within your child’s reach if the crib is near the window. • Toys, laundry bags, or other objects with strings aren’t hanging near the crib. • All nuts, bolts, and screws are tightened periodically. • Your baby is always placed on his or her back to sleep.
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PACIFIERS
TOYS
Pacifiers must be strong enough so that they won’t tear into pieces and cause your baby to choke or suffocate. Pacifier guards or shields must have holes that allow breathing and must be large enough to prevent the pacifier from entering the baby’s throat. Pacifiers cannot be sold with ribbon, string, yarn, or a cord attached. Don’t put a pacifier on a string around your baby’s neck.
An infant’s mouth is extremely flexible and can stretch to hold larger items than you might expect. Remove all toys and other small objects from the crib when your baby sleeps. If a toy has a part smaller than 15/8 inch, throw it away. Teethers, such as pacifiers, should never be fastened around a baby’s neck.
The American Academy of Pediatrics recommends that pacifiers not be introduced until 2 to 4 weeks postpartum for full-term, breastfeeding babies, since early use of pacifiers may interfere with breastfeeding.
CHANGING TABLES If you get a changing table, buy one with safety straps — and always use them. More than 1,300 children are injured every year from falling off a changing table. Keep one hand on your baby at all times while he or she is on the changing table.
HIGH CHAIRS More than 800 children are treated in emergency departments every year because of accidents involving high chairs. Most of these injuries are due to falls because adults are not watching, or because the baby is not strapped into the chair. Restraining straps should be strong, and the high chair should have a wide base for stability.
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PREPARING FOR BIRTH
PREPARING FOR BIRTH
YOUR BIRTH PREFERENCES Over the months of pregnancy, you’ve likely been imagining what your birth experience will be like. As you prepare for the big day, take some time to finalize or review your birth preferences. A list of birth preferences is an ideal picture of what you would like to happen. Creating one helps you think through the choices you may have during labor and the exciting moments right after your baby is born. It also allows you to communicate your preferences to the staff who will care for you and your baby.
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Since no labor and delivery can be predicted or planned in advance, be flexible. As you think about how you’d handle possible complications, give yourself permission to change your mind at any time. And be prepared for your childbirth to be different from what you planned. We would like to work with you to ensure the safety of you and your baby. We will continue to attempt to honor your birth preferences keeping in mind that you and your baby's health are most important to us. We will continue to keep you informed of an issues that come up so that we can work together to formulate a plan for delivery.
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YOUR BIRTH PREFERENCES A healthy mom, a healthy baby, and a positive birth experience — that’s our goal at Kaiser Permanente. As your baby’s birth gets closer, you may be thinking about what labor will be like and how you can have a good experience. Making a birth preference list is a good way to share what you want with your hospital caregivers. We cannot know exactly what the birth of your baby will be like before it happens, so we cannot guarantee that all of your preferences will be appropriate for your labor. But we will work with you to keep your birth experience as close to what you want as possible, while keeping the safety of you and your baby our most important priority.
KAISER PERMANENTE'S PHILOSOPHY It is our intention that every woman be treated with respect for who she is and what she prefers. We: • Support women who would like a birth that is unmedicated. You’re encouraged to have people present to help support this decision. • Support women who prefer a birth that is as pain free as possible by using medicine for pain or epidural anesthesia at a suitable time in labor.
In addition to creating a birth preference list, there are a few things that you can do to feel more at home while you are in labor. This includes bringing: • Photographs or familiar objects that might be comforting to you. These can include a special blanket, pillow, or something that might serve as a focal point while you breathe through your contractions. Your labor room is for your comfort; make it cozy! • Music (check with your birth hospital as to what kind of player is offered). • Food and drink for your birth partner and other support people with you (some hospital cafeterias may be closed at night). You may also bring clear liquid drinks for yourself. Your preferred drink may not be available at the hospital. Above all, Kaiser Permanente is committed to help all mothers, babies, and families have a healthy and safe birth experience.
• Strongly recommend childbirth preparation classes. Even for women planning on using pain medication, childbirth classes help develop the skills necessary to deal with early labor. • Support movement while in labor, as appropriate. • Do not order routine enemas, shaves (except for cesarean births), or episiotomies. • Recommend that you take a tour of the hospital where you plan to give birth to familiarize yourself with that hospital’s policies.
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We are committed to working with you to make your childbirth experienc, the best it can be. Your individuality and personal preferences are important to us. This is your birth experience, and we want you to tell your health care team about any preferences that you have for your birth. We will strive to meet your expectations while keeping you and your baby’s health and safety our top priority. In keeping with this philosophy, we will: • Respect your wishes about pain management and breastfeeding. • Keep you informed at all stages of your labor. • Be committed to listening to and communicating with you in a compassionate manner.
MY BIRTH PREFERENCE LIST
Birth
Labor
Is there anything your caregivers should know that will help you to create the atmosphere or the memories that will make this birth exerience everything you would like it to be?
Birth support:
Others attending the birth and their role: Your baby
I would like to limit the number of guests and phone calls while I am in labor to the people listed above.
Soon after birth, we will give you special bonding time with your familiy that will include direct skinto-skin contact with mom and baby. Are there any requests you have for this bonding time?
Special concerns during labor:
Cultural/family traditions Do you have any cultural or family traditions you will observe while in the hospital?
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YOUR BIRTH PREFERENCES Comfort measures/pain relief
Delivery
I wish to try:
I would like:
Relaxation techniques.
To choose my birthing position.
Breathing techniques.
A mirror available to view the birth.
Visualization techniques.
To touch my baby's head as it crowns.
Movement, walking, position changes.
That my baby be "lightly" dried off.
Warm shower.
To have ________________________ (name) cut the cord if possible.
Jacuzzi tub. Dim lights. Massage. Birthing ball. Narcotic medicine. Epidural analgesia.
Postpartum I wish to exclusively breastfeed my baby. I, or a support person, plan to participate in my baby's first bath. I need more information about routine procedures such as vitamin K, erythromycin ointment, and hepatitis B vaccine.
Music. Other. The following statement best describes how I feel about pain medicine/epidural:
If I have a boy, I plan to have him circumcised. Other comments or requests:
I want pain medicine/epidural to be given as soon as medically safe to do so. I want to go as far as I can but may choose to have medicine/epidural if I really need it. I wish to avoid pain medicine/epidural and do not want to be offered these unless I ask.
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BIRTHING OPTIONS When you create your birth preferences list, you’ll address many factors. The location of your delivery, who will deliver your baby, and whether you want continuous labor support from a designated health professional, doula, friend, or family member are important details to consider. After you’ve set the stage, think through your preferences for comfort measures, pain relief, medical procedures, and fetal monitoring. Also, think about how you’d like to handle your first hours with your newborn. The following information can help you weigh these options.
COMFORT MEASURES There are many ways to reduce the stresses of labor and delivery. Consider: • Continuous labor support from early labor until after childbirth, which has a proven, positive effect on childbirth. Women who have continuous one-on-one support (for example, from a mother’s support person, or doula; nurse; midwife; or childbirth educator) are more likely to give birth without pain medicine and are less likely to describe their birthing experience negatively. Although there is not a proven direct connection between continuous support and less labor pain, having a support person does help you feel more control and less fear, which are strong elements of mental pain control.
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• Use of a birthing ball, or exercise ball. • Walking during labor, including whether you prefer continuous electronic fetal heart monitoring or occasional monitoring. • Nonmedication pain management (“natural” childbirth), such as continuous labor support, focused breathing, distraction, massage, and imagery. This can reduce pain and help you feel a sense of control during labor. • Laboring in water, which helps with pain, stress, and sometimes slow, difficult labor (dystocia). • Playing music during labor. • Acupuncture and hypnosis, which are low-risk ways of managing pain that work for some women.
PAIN RELIEF WITH MEDICINE Your options for pain relief with medicine may include: • Opioids (narcotics), which are used to reduce anxiety and partially relieve pain. Sometimes opioids can affect a newborn’s breathing, so they are usually not administered close to delivery. • Epidural anesthesia, which is an ongoing injection of pain medicine into the epidural space around the spinal cord. Some women prefer to use epidural anesthesia for pain relief during labor.
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Some pain-relief medicines are not the type that you would request during labor. Rather, they are used as part of another procedure or for an emergency delivery. But it’s a good idea to know about them. • Local anesthesia is the injection of numbing pain medicine into the skin. This is done before inserting an epidural or before making an incision (episiotomy) that widens the vaginal opening for the birth. Local anesthesia may be used before the midwife or doctor places stitches if the woman has a laceration during the birth. • Spinal block is an injection of pain medicine into the spinal fluid that rapidly and fully numbs the pelvic area for assisted births, such as a forceps or cesarean delivery (no pushing is possible). • General anesthesia is the use of inhaled or intravenous (IV) medicine, which makes you unconscious. It has more risks, yet it takes effect much faster than epidural or spinal anesthesia. General anesthesia is used only for some emergencies that require a rapid surgical delivery, such as when an epidural line (catheter) has not been installed in advance or is not working well or when medical reasons prevent you from having a spinal block or epidural anesthesia.
BIRTHING POSITIONS Birthing positions for pushing include sitting; squatting; reclining; hands and knees; or using a birthing chair, stool, or bed.
MEDICAL PROCEDURES FOR LABOR AND DELIVERY Fetal heart monitoring is a standard practice during labor, but other procedures are used as needed. • Labor induction and augmentation includes a simple “sweeping of the membranes” just inside the cervix, rupturing the amniotic sac, using medicine to soften (ripen) the cervix, and using medicine to stimulate contractions. This is not always, but can be, a medically necessary decision — such as when a mother is about two weeks past her due date or when the mother or baby has a condition that requires immediate delivery. • Antibiotics if you tested positive for Group B strep during your pregnancy. • Electronic fetal heart monitoring may be either continuous or periodic depending on pregnancy or baby risk factors or medications being administered. • Episiotomy (not a routine procedure) widens the perineum with an incision. This is used to prevent further tearing when visible tearing is noticed or to create more space when needed for delivery. (Perineal massage and controlled pushing can also prevent or reduce tearing.) • Forceps delivery is used to assist a vaginal delivery, when a little assistance is needed. • The need for a cesarean birth during labor is primarily based on the baby’s and mother’s conditions. If you have had a cesarean delivery before, you may have a choice between a TOLAC and a planned cesarean birth. You and your clinician can review your history to decide if you are a candidate for a trial of labor after cesarean (TOLAC).
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PREPARING FOR LABOR MIND AND BODY READINESS
OTHER WAYS TO FEEL PREPARED
Later in your pregnancy, you and your partner are probably focused on checking off your list of things to do before the baby arrives. But it’s important that you set aside time and energy to prepare your mind and body for labor.
Some of the following suggestions can help you feel more mentally organized leading up to the birth of your baby.
Stretches, exercises, and deep breaths can help you feel more relaxed and ready for the extraordinary act of childbirth.
• Know what to expect. Review the signs and stages of labor and familiarize yourself with the warning signs for preterm labor. Also, learn the difference between false labor (Braxton Hicks contractions) and the real thing so you know when it’s time to grab your bag and go to the hospital. Use a chart to help time and record your contractions.
EXERCISE The muscles in your lower abdomen, lower back, and around the vagina (birth canal) come under great strain during pregnancy. During delivery, these same muscles must relax and stretch. Simple exercises such as the pelvic tilt and tailor stretch will help you strengthen the muscles that support your growing uterus. See page 32 and 33 of this guide and visit kp.org/pregnancy to learn more about these and other exercises.
BREATHING, IMAGERY, AND RELAXATION Learning to relax your muscles, control your breathing, and focus your mind are skills you will need to call upon during labor and delivery. And they take some practice to master. Check the "Managing Emotions" section on page 42 to 44 for a refresher on different practices.
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• Take a childbirth class. If you haven’t done so already, sign up for a childbirth preparation class.
• Stop smoking. If you’ve been smoking during your pregnancy, try to quit now. Women who smoke are more likely to have problems in pregnancy and childbirth. Get help quitting with the free online program at kp.org/breathe or by talking with a health coach (see page 17). • Pack your bags. Make sure you have everything to make your hospital stay comfortable. Review the next page of this guide for a checklist. Add to it any special items you want to bring from home, such as music or photographs, that may help you during labor and delivery. • Get ready for baby. Make sure you have the necessary items to bring your baby home safely and set up a comfortable environment.
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WHAT TO BRING TO THE HOSPITAL Don’t wait until your first labor pains to get ready to go to the hospital. Pack your bag at least three weeks before your due date with these items.
FOR BABY Infant safety seat (required by law to be in the car when you leave the hospital).
LABOR KIT
Outfit for going home (undershirt, outer garment, and hat, depending on the weather).
Kaiser Permanente ID card.
One or two receiving blankets.
Toiletries (toothbrush, toothpaste, lip balm, brush, hair clip or band, lotion, cosmetics). Nightgown, robe, or loose-fitting T-shirt (if you prefer to wear your own; front-opening if you plan to breastfeed). Nonskid slippers. Cotton socks.
Mittens (many babies have long fingernails and can scratch their faces).
PLEASE DO NOT BRING • Electrical devices (curling iron, hair dryer). • Valuables, jewelry, or cash.
Hand fan or spray mist bottle. Underwear (and your favorite brand of sanitary pad if desired). Supportive bra or nursing bra (for breastfeeding mothers). Comfortable, loose-fitting clothing to wear home. MP3 player or CDs and CD player to play relaxing music or audio programs. Camera for photos or videos. Cellphone and numbers of friends and relatives you plan to contact. Eyeglasses and contact lens supplies. Snacks, a change of clothes, and toiletries for your partner. Beverage of your choice not carried by the hospital (such as Gatorade).
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LABOR, DELIVERY, AND POSTPARTUM
LABOR, DELIVERY, AND POSTPARTUM
TIMING CONTRACTIONS A contraction is a tightening of the uterine muscle that becomes frequent or regular as labor begins. It might feel like cramping or pressure in the uterus.
HOW TO COUNT CONTRACTIONS You should count contractions around the time your baby is due. Place your hands on your abdomen and feel for a tightening and then a relaxing (softening) of your uterus. The tightening sensation should be felt over the entire abdomen.
If this is your first baby and your contractions are every 3 to 5 minutes for at least an hour and are uncomfortable, you may be in labor. If this is not your first baby and your contractions are every 5 to 7 minutes for at least an hour and are uncomfortable, you may be in labor. Talk to your clinican about when you should notify Labor and Delivery and go to the hospital. The following are some general guidelines about when to call.
Use a watch or a clock with a second hand and answer these 2 questions:
WHEN TO NOTIFY THE HOSPITAL
• How long do the contractions last (duration)? Time the length of each contraction from the moment it starts until it subsides.
• You can no longer walk or talk through contractions.
• How far apart are the contractions (frequency)? Time each contraction from the beginning of one to the beginning of the next. You’re having a contraction if your uterus stays tight for 30 seconds or more and then repeats. It’s normal for most women to have Braxton Hicks contractions throughout pregnancy. Braxton Hicks contractions don’t usually come in a rhythmic pattern and don’t continue for more than an hour. They often disappear if you change your activity. Call your clinician or advice line if you are not due and experience contractions or cramping that you do not think are Braxton Hicks.
If you’re a first-time mother, call when:
• Contractions are regular, usually every 3 to 5 minutes over an hour-long period. Count from the start of a contraction to the beginning of the next. • Contractions last at least 45 to 60 seconds. Contractions that last 30 seconds are probably very early labor or Braxton Hicks contractions. • Contractions become much stronger when you’re walking. • Your water breaks. If you’re not a first-time mother, call when: • Contractions are every 5 to 7 minutes for at least one hour. • Contractions last at least 45 to 60 seconds. • Contractions become stronger when walking. • Your water breaks.
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TIMING CONTRACTION CHART Use this chart to help you track the duration and frequency of your contractions. You also can use a contraction calculator app, such as the one on thebump.com. TIME
DURATION
FREQUENCY
(Example)
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11 a.m.
60 sec.
11:10
75 sec.
10 min.
11:18
80 sec.
8 min.
TIME
DURATION
FREQUENCY
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EARLY LABOR The birthing process is known as labor and delivery. No one can predict when labor will start. One woman can have all the signs that her body is ready to deliver, yet she may not have the baby for weeks. Another woman may have no advance signs before she goes into active labor. First-time deliveries are more difficult to predict.
SIGNS OF APPROACHING EARLY LABOR Signs that early labor is not far off include the following: • The baby settles into your pelvis. Although this is called dropping, or lightening, you may not feel it. • Your cervix begins to thin and open (cervical effacement and dilation). Your clinician checks for this during your prenatal exams. • Braxton Hicks contractions become more frequent and stronger, perhaps a little painful. You may also feel cramping in the groin or rectum or a persistent ache low in your back. • Your amniotic sac may break (rupture of the membranes). In most cases, rupture of the membranes occurs after labor has already started. In some women, this happens before labor starts. Call your clinician immediately or go to the hospital if you think your membranes have ruptured.
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EARLY LABOR (LATENT PHASE OF LABOR) Early labor is often the longest part of the birthing process, sometimes lasting 2 to 3 days. Uterine contractions: • Are mild to moderate (you can talk while they are happening) and last about 30 to 45 seconds. • May be irregular (5 to 20 minutes apart) and may even stop for a while. • Open (dilate) the cervix to about 3 centimeters. First-time mothers can experience many hours of early labor without the cervix dilating. It’s common for women to go to the hospital during early labor and be sent home again until they progress to active labor or until their water breaks (rupture of the membranes). This phase of labor can be long and uncomfortable. Walking, watching TV, listening to music, or taking a warm shower may help you through early labor.
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EARLY LABOR THAT IS PROGRESSING If you arrive at the hospital or birthing center in early labor that is dilating and effacing the cervix or is progressing quickly, you can expect some or all of the following: • In the birthing room, you will change into a hospital gown. • Your blood pressure, pulse, and temperature will be checked. • Your previous health, pregnancy, and labor history will be reviewed. • You will be asked about the timing and strength of your contractions and whether your membranes have ruptured. • Electronic fetal heart monitoring will be used to record the fetal heart rate in response to your uterine contractions. Fetal heart rate shows how your baby is doing.
Unless you have a cesarean birth, you will labor, deliver, and recover in the same room. In the hospital, you may be: • Encouraged to walk. Walking helps many women feel more comfortable during early labor. Walking is thought to help labor progress, but recent research suggests that walking doesn’t actually speed or slow labor. • Either intermittently or continuously monitored for your baby’s well-being and contractions, depending on your or your baby’s risk factors or medications administered. • Allowed visitors. As your labor progresses and you become more uncomfortable, you may want to limit visitors to your partner and/ or labor coach. • Offered a birthing ball that can be used for different positions during labor.
• You will have vaginal exams to check whether your cervix is thinning and opening (effacing and dilating). • Depending on your physical needs and your clinician’s recommendations, you may have an intravenous (IV) catheter inserted in case you need extra fluids or medicine later.
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ACTIVE LABOR: FIRST STAGE The first stage of active labor starts when the cervix is dilated about 3 to 4 centimeters. This stage is complete when the cervix is fully dilated and effaced and the baby is ready to be pushed out. During the last part of this stage (transition), labor becomes particularly intense. Compared with early labor, the contractions during the first stage of active labor are more intense and more frequent (every 2 to 3 minutes) and longer-lasting (50 to 70 seconds). Now is the time to be at or go to the hospital. If your amniotic sac hasn’t broken before this, it may now. As your contractions intensify, you may: • Feel restless or excited. • Find it difficult to stand. • Have food and fluid restrictions. Some hospitals allow you to drink clear liquids. Others may only allow you to suck on ice chips or hard candy. Solid food is often restricted, because the stomach digests food more slowly during labor. An empty stomach is also best in the rare event that you may need general anesthesia.
TRANSITION PHASE The end of the first stage of active labor is called the transition phase. As the baby moves down, your contractions become more intense and longer and come even closer together than before. During transition, you will be focused on yourself, concentrating on what your body is doing. You may be annoyed or distracted by others’ attempts to help you but still feel you need them nearby as a support. You may feel increasingly anxious, nauseated, exhausted, irritable, or frightened. A mother in first-time labor will take up to three hours in transition, and a mother who has vaginally delivered before will usually take no more than an hour. Some women have a very short, intense, transition phase.
• Want to try breathing techniques, laboring in water, acupuncture, hypnosis, or other calming measures that you’ve chosen to manage pain and anxiety. • Feel the need to shift positions often. This is good for you, because it improves your circulation. • Want pain medicine, such as epidural anesthesia. • Be given intravenous (IV) fluids.
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ACTIVE LABOR: SECOND STAGE The second stage of active labor is the actual birth, when the baby is pushed out by the tightening uterine muscles (contractions). During the second stage: • Uterine contractions will feel different. Though they are usually regular, they may slow down to every 2 to 5 minutes, lasting 60 to 90 seconds. If your labor stalls, changing positions may help. If not, your clinician may recommend using medicine to stimulate (augment) uterine contractions. • You may have a strong urge to push or bear down with each contraction. • The baby’s head is likely to create great pressure on your rectum. • You may need to change position several times to find the right birthing position. • You can have a mirror positioned so you can watch your baby crown and emerge from the birth canal.
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• When the baby’s head passes through the vagina (crowns), you will feel a burning pain. The head is the largest part of the baby and the hardest part to deliver. If this is happening quickly, your clinician may advise you not to push every time, which may give the perineum, or area between the vulva and the anus, a chance to stretch without tearing. Or he or she may make an incision in the perineum (episiotomy). This is not recommended unless there is a medical need. • Your medical staff will be ready to handle anything unexpected. If an urgent problem comes up, people will move quickly. You may suddenly have more people and equipment in the room than before. This pushing stage can be as short as a few minutes or as long as several hours. You are more likely to have a fast labor if you have given birth before.
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THIRD STAGE: AFTER YOUR BABY IS BORN After your baby is born, your body still has some work to do. This is the third stage of labor, when the placenta is delivered. You will still have contractions. These contractions make the placenta separate from the inside of the uterus, and they push the placenta out. Your health care team will help you with this. They will also watch for any problems, such as heavy bleeding, especially if you have had it before.
The third stage can be as quick as 5 minutes. With a preterm birth, it tends to take longer. But in most cases, the placenta is delivered within 30 minutes. If the placenta does not fully detach, your clinician will probably reach inside the uterus to remove by hand what is left. Your contractions will continue until after the placenta is delivered, so you may have to concentrate and breathe until this process is complete.
Your clinician's goal is for the third stage to proceed normally and for all of the placenta to leave the uterus. This is what keeps your bleeding down. You may be given medicine to help the uterus contract firmly. Oxytocin or Pitocin may be given as a shot or in a vein (intravenously) after the placenta is delivered. Oxytocin is given to make your uterus shrink and bleed less (this is the same medicine that is sometimes used to make contractions more regular and frequent during labor). Breastfeeding right away can also help the uterus shrink and bleed less.
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POSTPARTUM RECOVERY AND COPING PHYSICAL CHANGES AFTER CHILDBIRTH After childbirth (postpartum period), your body goes through numerous changes, some of which continue for several weeks during your postpartum period. Like pregnancy, postpartum changes are different for every woman.
• Breast engorgement is common 3 or 4 days after delivery when the breasts begin to fill with milk. This can cause breast discomfort and swelling. Placing ice packs on your breasts, taking a hot shower, or using warm compresses may relieve the discomfort of engorgement.
• Shrinking of the uterus to its pre-pregnancy size (uterine involution) starts when the placenta is delivered and continues for about two months. Within 24 hours, the uterus is about the size it was at 20 weeks of pregnancy, and after a week, it is half the size it was when you went into labor. By 6 weeks after delivery, the uterus is nearly as small as it was before pregnancy.
• Recovery from pelvic bone problems, such as separated pubic bones (pubic symphysis) or a fractured tailbone (coccyx), can take several months. Treatment includes ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and sometimes physical therapy.
• Contractions called afterpains shrink the uterus for several days after childbirth. These sharp pains are usually not as problematic after a first childbirth as they are after later deliveries. Afterpains typically improve by the third day postpartum.
COPING DURING THE POSTPARTUM PERIOD
• Sore muscles (especially in the arms, neck, or jaw) are common after childbirth. This is a result of the hard work of labor and should go away in a few days. You may also have bloodshot eyes or facial bruising from vigorous pushing. • Difficulty with urination and bowel movements (elimination problems) can occur for several days after childbirth. Drink plenty of fluids and use stool softeners if needed. • Postpartum bleeding (lochia) may last for 2 to 4 weeks and can come and go for about 2 months. • Recovery from an episiotomy or perineal tear in the area between the vagina and anus can take several weeks. You can ease the pain with home treatment, including ice, pain medicine, and sitz baths. Pain, discomfort, and numbness around the vagina are common after any vaginal birth. 1899KPCC-15/5-15
Call your clinician if you are concerned about any of your postpartum symptoms.
When you have returned home, you may find it a challenge to meet the increased demands on your limited energy and time. Take it easy on yourself. Pause for a moment and think of what you need. Tips for coping during the postpartum period include accepting help from others, eating well and drinking plenty of fluids, getting rest whenever you can, limiting visitors, getting some time to yourself, and seeking the company of other women who have new babies.
POSTPARTUM DEPRESSION Depression is common during pregnancy and in the postpartum period. If you have symptoms of depression during pregnancy or are depressed and learn you are pregnant, make a treatment plan with your clinician right away. If you are being treated for depression and are planning a pregnancy, talk to your clinician ahead of time. You may be able to taper off your antidepressant medicine before your pregnancy, to see how you feel during your first trimester. It’s best to be medicine-free, especially during the first trimester. But if you are severely depressed, 114
your clinician will probably want you to stay on your medicine. Don’t ever suddenly stop taking antidepressants. This can cause difficult emotional and physical symptoms, and may also affect your fetus. Your clinician can tell you the best way to taper off your medicine.
DEPRESSION TREATMENT CHOICES DURING PREGNANCY If you are not severely depressed, interpersonal counseling or cognitive-behavioral therapy may be all that you need. • Interpersonal counseling focuses on your relationship and life adjustments, giving you emotional support and help with problemsolving and goal-setting. • Cognitive-behavioral therapy helps you take charge of the way you think and feel, while giving you a supportive relationship. If counseling alone isn’t enough, or if your symptoms are severe and disabling, talk to your clinician about other possible treatments: • Light therapy uses regular doses of bright light (not full-spectrum light, which includes ultraviolet light). Typically, a person having light therapy will sit in front of a high-intensity (2,500- to 10,000-lux) fluorescent lamp, slowly building up to 1 to 2 hours each morning. (Possible side effects include eye strain, headache, feeling “wired,” and trouble falling asleep when light therapy is used later in the day.)
There is a small chance that your baby will have minor, temporary symptoms (such as poor feeding and irritability) related to SSRI exposure during pregnancy. But not treating depression can also cause problems during pregnancy and birth. If you become pregnant again, you and your clinician must weigh the risks of taking an SSRI against the risks of not treating depression.
FDA ADVISORY The U.S. Food and Drug Administration (FDA) has issued an advisory on antidepressant medicines and the risk of suicide. The FDA does not recommend that people stop using these medicines. Instead, a person taking antidepressants should be watched for warning signs of suicide. This is especially important at the beginning of treatment or when the doses are changed.
ADDITIONAL MEASURES YOU CAN TAKE AGAINST DEPRESSION Whether you use counseling, medicine, light therapy, or a combination, be sure to also get regular exercise, healthy food, fresh air, and time with people who care about you. These are important parts of preventing and treating depression and having a healthy pregnancy.
POSTPARTUM APPOINTMENT It is important to have a routine postpartum visit with your clinician 4 to 6 weeks after delivery. This appointment will include a physical exam and will give you a chance to discuss birth control, feeding, depression, and your return to work.
• Antidepressant medicine, most often a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine (Prozac) or sertraline (Zoloft), is also an option. Zoloft is the most commonly prescribed antidepressant during pregnancy. If you are planning to breastfeed and are taking an antidepressant, talk about this with your clinician. 1899KPCC-15/5-15
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INFANT CARE
INFANT CARE
INFANT CARE OVERVIEW Congratulations on your new baby! The day you’ve been waiting for is finally here — your baby is home with you. Like pregnancy, the postpartum period can be a time of mixed emotions. You may feel excitement and joy as well as concern and exhaustion. Your new family member has a unique personality and needs, which may take some adjustment. Remember to enroll your newborn in a health insurance plan within 30 days after birth. Check with your employer’s human resources department or a Kaiser Permanente Member Services representative to learn about coverage for your baby.
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NEWBORN EXPERIENCE The time after birth is usually a mix of emotions. We want you to feel supported while also ensuring the safety and health of your infant. The following information should help give you ideas about what to expect while you are in the hospital after the birth of your child. You’ll spend most of the time bonding as a new family and practicing breastfeeding.
BONDING The time immediately following delivery is not only joyous but also very important for establishing a good connection with your new arrival. As long as it is safe, we encourage placing your infant on your chest, skin to skin, and to begin breastfeeding as soon as possible. This also provides warmth for your baby. Partners are encouraged to get involved in this period as well. If your clinician determines that your baby needs additional help to breathe or to be checked just after delivery, we have pediatric clinicians nearby. If this occurs, we try to respect the bonding time for your family as soon as we determine the health and safety of your newborn.
FIRST BATH The timing of your baby's first bath will be determined between you and your clinician based on your baby's needs.
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NEWBORN SCREENING TESTS Screening tests help your clinician diagnose and treat certain potentially serious diseases or conditions before symptoms appear. All states require newborn screening, although the required tests vary from state to state. They may include testing for galactosemia and phenylketonuria (metabolic disorders), sickle cell disease, thyroid hormone, and others. When your baby is at least 24 hours old, we take a few drops of blood from a heel for testing. If the tests results are abnormal, further testing may be needed. Your baby will also have other screening tests, including hearing, oxygen level, and jaundice tests. Often a baby may not pass the hearing test for simple reasons like the presence of fluid in the ear canal. We then repeat the test before or after you go home depending on when you are discharged. The oxygen test helps determine if there is a problem with your baby’s heart. If you have any questions about these, please talk to your clinician.
CIRCUMCISION If you want your newborn son circumcised, Kaiser Permanente Sunnyside Medical Center, Kaiser Permanente Westside Medical Center, and our partner hospitals have health care professionals who can perform the procedure. We also have an outpatient clinic available after your discharge from the hospital. Health plans charge differently for the procedure. You may want to find out what your costs related to the procedure will be.
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MEDICATIONS There are state and national requirements regarding medications for newborns, including the hepatitis B vaccine, an antibiotic eye ointment to prevent infection, and a vitamin K shot to prevent bleeding. These are administered in the first couple of hours following delivery. Some infants may require other medications based on your health history. For instance, if you test positive for hepatitis B, your baby needs an additional injection of immune globulin at birth to help prevent transmission. Or if you had an infection during labor or delivery, your baby may need additional medications, such as antibiotics. We also recommend that families and caregivers be vaccinated against pertussis (whooping cough) and influenza. ERYTHROMYCIN OINTMENT Erythromycin is an antibiotic that kills certain germs in mom and baby. It is applied to your newborn’s eyes within 1 to 2 hours of delivery to prevent infection. This treatment has proved effective and rarely has side effects. Past therapies caused some discomfort or irritation, but this ointment has proved to be safe. Why do we give erythromycin ointment? Eye infections were a significant cause of blindness in newborns before this treatment was started. Chlamydia and/or gonorrhea bacteria, as well as other less common bacteria, can cause eye infections in newborns. The bacteria cause red, irritated eyes with profuse white drainage, and can lead to blindness if left untreated.
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How are chlamydia and gonorrhea transmitted? Chlamydia and gonorrhea are sexually transmitted infections and are routinely screened for early in pregnancy because many women do not have symptoms and may not know they have the infection. Treatment of these infections helps decrease the chance of infection in newborns. A newborn can get infected regardless of the method of delivery. There is also a chance of contracting the infection after this screening. How safe is erythromycin ointment? It is very safe, and side effects are rare. Occasionally mild eye irritation may be noticed, but it is usually not bothersome to the newborn. What happens if my infant does not get the ointment? One study showed that in infants who were not at high risk (mothers tested negative for gonorrhea, had good prenatal care, had stable social situations, and had only one sexual partner), the rate of newborn eye infection was about 1 in 5 newborns with no ointment. There were smaller rates of eye infections in infants treated with erythromycin ointment. If you have active gonorrhea infection, your newborn should also be treated with additional antibiotics to help prevent the disease. Warning signs of eye infection Signs of potential eye infection include, but are not limited to: • Thick white eye discharge. • Eyelid swelling. • Eye redness.
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NEWBORN EXPERIENCE HEPATITIS B The first vaccination in a series of 3 is given to your baby shortly after birth to provide immunization against hepatitis B. Hepatitis B is caused by a virus that can cause liver damage, leading to a transplant or even death. When babies get infected, the virus usually remains in the body for life (this is called chronic hepatitis B). About 1 out of 4 infected babies will die of liver failure or liver cancer as adults. Hepatitis B is a deadly disease, but it’s preventable with vaccination. The vaccine is safe and, when given as recommended, very effective. How is hepatitis B virus spread? Anyone can become infected with hepatitis B virus at any time during their lives. Hepatitis B virus is spread by contact with an infected person’s blood or other body fluids. For example, babies can get hepatitis B virus from their infected mothers at birth. Children can get it if they live with or are cared for by an infected person or if they share personal care items (such as a toothbrush) with an infected person. About 1 out of 20 people in the United States have been infected with the hepatitis B virus. How many people have hepatitis B? In the United States, tens of thousands of people get infected with the hepatitis B virus each year. About 1 out of 20 people in the United States have been infected with the hepatitus B virus. Every year, about 3,000 Americans die from liver failure or liver cancer caused by hepatitis B. Worldwide, 350 million people are infected.
Is there a cure for hepatitis B? No. Although there are several medicines to help people who have lifelong hepatitis B virus infection, there is no medicine that cures it. The good news is that hepatitis B can be prevented by vaccination. Who recommends that all babies get a hepatitis B vaccination at birth? Medical groups such as the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention recommend that every baby get a hepatitis B vaccination at birth, before leaving the hospital. Why does my baby need a hepatitis B vaccination at birth? It is important to vaccinate babies at birth so they will be protected as early as possible from any exposure to the hepatitis B virus. A child who gets infected with the hepatitis B virus during the first 5 years of life has a 15 to 25 percent risk for premature death from liver disease, including liver failure or liver cancer. Hepatitis B vaccine is your baby’s “insurance policy” against being infected with the virus. Won’t my baby just recover from hepatitis B? Babies are not able to fight off hepatitis B as well as adults. About 9 out of 10 babies who get infected in the first year of life will stay infected for life.
It is impossible to know if a person is infected with the hepatitis B virus by looking at them. Most people have no symptoms, do not feel sick, and don’t know they are infected. As a result, they can spread the virus to others without knowing it. The only way to know if a person is infected is through a blood test.
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How many doses of hepatitis B vaccine will my baby receive? The basic series is 3 or 4 doses. The first dose should be given in the hospital (at birth), the second dose 1 to 2 months later, and the third dose at age 6 months or later. Because many health care professionals choose to use certain combination vaccinations during well-baby checkups, some infants will receive 4 doses of hepatitis B vaccine. Either alternative is considered routine and acceptable. How effective is hepatitis B vaccine? Very. More than 95 percent of infants, children, and adolescents develop immunity to the hepatitis B virus after 3 doses of properly spaced vaccine. Is hepatitis B vaccine safe? Yes. Hepatitis B vaccine has been shown to be very safe when given to people of all ages. In the United States, more than 120 million people have received hepatitis B vaccine. The most common side effects from hepatitis B vaccine are soreness at the injection site or slight fever. Serious side effects are rare. Some parents worry that their baby’s immune system is immature and cannot handle vaccination at such a young age. But as soon as they are born, babies start effectively dealing with trillions of bacteria and viruses. In comparison, the challenge to their immune systems from vaccine is tiny.
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Why does my baby need so many vaccinations? It’s true that babies get lots of vaccinations, which can cause temporary discomfort. The good news is that more vaccinations mean more protection from serious diseases than in the past. Like hepatitis B, many of these diseases, such as rotavirus, whooping cough, and meningitis, can result in severe illness, hospitalization, and even death. Make sure your baby gets all his or her vaccinations at the recommended ages. It’s the safest and surest way to protect children from deadly infectious diseases. Your baby is counting on you! VITAMIN K INJECTIONS Vitamin K helps our blood clot. It is given to infants as an injection. Babies have little or no vitamin K stored up when they are born, and they do not absorb or make it adequately in the first few weeks of life. If they become deficient, they may have serious bleeding, even leading to brain damage or death. Why do we give vitamin K? Newborns have low vitamin K at birth and are at risk of low levels for several reasons. First, vitamin K does not move across the placenta well during pregnancy. Second, vitamin K is made by bacteria in the intestines, and babies have sterile intestines when they are born. Third, breast milk is low in vitamin K. While formula has some, it may not be enough. Infants whose mothers are on certain seizure medications are at an even higher risk of low vitamin K. Low vitamin K in newborns may result in vitamin K deficiency bleeding (VKDB).
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NEWBORN EXPERIENCE What is VKDB? Vitamin K deficiency bleeding is a potentially devastating and sometimes fatal disease that can show up days to months after birth. VKDB is easily prevented, and both the American Academy of Pediatrics and Oregon law support giving a vitamin K injection to all newborns. VKDB shows up any time from the first day of life, typically in infants whose mothers were exposed to antiseizure medications or certain tuberculosis drugs, to about 4 months of age. These infants are almost always primarily breastfed and did not receive the vitamin K injection at birth. Some of them have liver disease or other diseases that make it difficult to absorb the vitamin. Some infants will have no signs of a problem until it is too late.
Additional information about vitamin K Vitamin K can be given as an injection or taken orally. The oral version involves giving multiple doses (usually at birth, 1 week, 4 weeks, and 8 weeks of age), and though it may decrease the risk for VKDB, it is not nearly as effective as the injection. Some European countries that switched from the injection to the oral form have seen an increase in VKDB. In 1997, a review of 4 countries that made this change showed that oral vitamin K led to VKDB in 1.2 to 1.8 per 100,000 births, compared with no cases from the injection. Incomplete oral administration resulted in failure in 2 to 4 per 100,000 births. Part of the reasons for these findings was that oral vitamin K tastes bad, and its effectiveness depends on parental compliance for all of the doses.
How common is VKDB? It is a rare disease, but in infants who do not receive vitamin K at birth, about 4 to 7 per 100,000 will be affected. Even though it is rare, it is nearly 100 percent preventable by giving the vitamin K injection at birth.
In the early 1990s, two small studies suggested a link between vitamin K and childhood leukemia. Since then, two large studies in the United States (54,000 infants) and Sweden (1.3 million infants) have found no correlation between childhood leukemia and the vitamin K shot at birth. Go to pediatrics.aapublications.org/ content/112/1/191.full.pdf+html.
How safe is vitamin K? There are no known serious side effects associated with vitamin K. Any injection may cause mild redness, soreness, or swelling at the site; a small amount of blood; or infection, though this is rare since we clean the skin before giving the medicine.
Signs of VKDB Some infants do not have warning signs of serious bleeding. Others may have bleeding, bruising, or change in alertness including, but not limited to: • Blood in feces, urine, vomit, or spit-up. • Black, sticky feces after the immediate newborn period. • Bloody nose, belly button, or circumcision site. • Bruising anywhere. • Not acting right, not eating well, seizures, lethargy. If you have more questions, please discuss them with your pediatrician or family practice clinician.
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TDAP BOOSTER AND FLU VACCINATION Pertussis (whooping cough) and influenza can cause serious and sometimes fatal illness, especially in newborns. Newborns are too young to be vaccinated for these diseases, but family and caregivers are strongly recommended to get the Tetanus, Diptheria, and Pertussis (Tdap) booster and annual flu vaccinations to help prevent passing these diseases onto newborns.
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OTHER THINGS TO REMEMBER •
Group B strep. When you have a positive Group B strep test during your pregnancy, we give antibiotics during labor to prevent transmission of the bacteria to the baby. Antibiotics are most effective when given at least 4 hours before birth. If your baby arrives before the antibiotic is given, we generally observe your infant for 48 hours in the hospital to make sure he or she is safe and healthy when we send you home. Sometimes we need to do blood work on your baby to check for infection. This is done in the first few hours after delivery.
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Diabetes and small or large babies. When babies are born to women with diabetes, or they are smaller or larger than average, we routinely check sugar levels in the baby. If levels are low, frequent and effective feeding can almost always prevent the need for significant interventions.
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Infection. If your clinician is worried about an infection you may have, your pediatrician or family practice clinician will talk to you about making sure the infection is not passed to your baby. This typically involves blood work and antibiotics for your baby until we can be sure.
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Preterm infants. A baby born 3 or more weeks early is considered premature. Premature infants can have problems that range from serious to mild and most often relate to how early they are born. Common problems include difficulty feeding or breathing, temperature regulation, jaundice, and sugar-level control. More serious problems can include infections, brain injury, and cerebral palsy, and may require a blood transfusion or breathing machine. Premature infants need closer monitoring, and some need specialized care in the neonatal intensive care unit (NICU).
DISCHARGE FROM THE HOSPITAL All infants must meet certain criteria to go home healthy. They have to be eating within expected norms, passing urine and stool, have the appropriate screening tests, and be able to maintain normal temperature and other vital signs. Kaiser Permanente’s Mother-Baby Program provides a lactation nurse who sees recently discharged mothers and infants and can assess any concerns that arise after discharge. You will see the lactation nurse 1 to 3 days after being discharged. This, along with your baby’s first clinician appointment, will be made before you leave the hospital.
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NEWBORN APPEARANCE HEAD
SKIN
Your baby’s head may seem large and out of shape. It makes up about 25 percent of total length (compared with about 10 percent for an adult). Your baby’s head may look drawn out and come to a point in the back. During labor, your baby’s head molded itself into this shape to safely pass through your pelvic bones. It will not be long before the head takes on a smoother shape. Sometimes there are rounded bumps on the back and side or the top of the head. These are harmless swellings that will disappear eventually. Your baby’s head has two soft spots — both in the middle of the head, one in front and a small one in the back. These areas may be touched and washed like any other area of the head.
Your baby’s skin may be dry or moist. Some babies have scaly skin that may peel in a few weeks. This is normal. We do not recommend using oils or lotion because they may clog the pores and result in rashes. If the skin cracks at the wrists or ankles, apply Eucerin cream on those areas 3 or 4 times a day.
BREASTS
Your baby’s skin is very sensitive. Things that will not hurt your skin can cause a variety of rashes on your baby. A heat rash looks like many tiny red pimples, usually on the face, neck, chest, or abdomen. This rash does not need treatment. Baby oil or lotion often make it worse.
Your baby’s breasts may be swollen. The same hormones that make your breasts larger during pregnancy can affect your baby’s breast tissue. It may take several months for the swelling to disappear naturally. This can occur even for boys. Your baby’s breasts may produce a milk-like substance.
Your baby may have red blemishes on the eyelids, bridge of the nose, forehead, or nape of the neck. These frequently disappear before your child is a year old. Your baby may have a blue-gray pigmented area above the buttocks (sometimes called a Mongolian Spot) that is normal and is not a bruise.
Your infant may have milia — white, slightly raised pimples. They most often are tiny and numerous on the nose, but may be anywhere, especially the face. If your baby has a peculiar rash that doesn’t fit the description of those above, call your clinician.
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WEIGHT If your pregnancy was full term, your baby probably weighed 5½ to 10 pounds at birth. In the first 3 days, babies will lose 5 to 10 percent of their weight. Small babies lose the least but take the longest to gain it back. Large babies lose the most but usually gain rapidly, often within 1 to 2 weeks. This weight loss will happen no matter what or how much your baby eats. Your baby will gain back the weight, at his or her own rate.
GENITALS If you have a girl, you may notice that her genitals appear swollen. This is caused by the same hormones that make the breasts larger. She may have blood on her diaper at the end of the first week for 3 to 4 days. Infant girls also may have a white vaginal discharge beginning on the second day that may last until the 10th or 12th day. If you have a boy, you may choose to have him circumcised. There is no medical indication for routine circumcision. If you are uncertain about circumcision, discuss it with your clinician. After circumcision, your son may be fussy. When you look at the circumcision area during the first 3 or 4 days after the procedure, it will look red. There also may be a yellow-greenish discharge. This is normal healing and not a sign of infection.
If your clinician uses a plastic ring for circumcision, do not try to remove it. It will drop off on its own in 4 to 10 days. You may notice a few drops of blood on the diaper the first day or two after circumcision. You should report any bleeding after 3 days to your baby’s clinician, even if a ring was not used. For circumcision not using a plastic ring, the site should be kept clean and covered with petroleum jelly for 5 to 7 days or until the site appears pink and healed. For circumcision with a plastic ring, keep the area clean, but do not use petroleum jelly. When your son is 2 weeks old, the site should be healed.
EYES The birth process may cause your baby’s eyelids to look puffy. Sometimes there is a difference from side to side. This should improve within a few days. Your baby’s eyes may be red immediately after delivery, especially if it was a fast or difficult delivery. This is caused by broken blood vessels in the whites of the eyes and will resolve on its own. Your baby may frequently become cross-eyed because of undeveloped muscles. As the muscles strengthen, the eyes will begin to track symmetrically.
HANDS AND FEET Often a newborn’s hands and feet are bluish or spotted. This is normal and will go away on its own.
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NEWBORN BEHAVIOR BREATHING
CRYING
During the first month, your baby may breathe irregularly. He or she may breathe rapidly and shallowly. At other times, breathing may be deep and sighing. You will notice that the abdominal muscles do more of the work than the chest muscles do. Noisy breathing, when the noise seems to come from the back of the nose, is normal. Coughing, sneezing, and hiccupping are common. Feeding may or may not help stop hiccups, which are not harmful.
Your baby will cry. This is how your baby communicates needs. Comforting and holding your baby will not spoil your baby. Babies will cry when hungry, cold, and uncomfortable. They may cry because they need to be cuddled and loved. Some babies cry more than others. For inconsolable crying, call the advice nurse.
SLEEPING Your baby will probably sleep a lot during the first 24 hours but may sleep less and less, even in the hospital, before you go home. Babies vary in their need for sleep. Whether your baby sleeps a lot or hardly at all, you will learn what is normal for your baby. Health care professionals recommend that infants, when being put down to sleep, be placed on their back. Co-sleeping is not recommended because of the risk of suffocation.
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FUSSINESS By 2 weeks of age, many infants will have established a fussy time, usually around the same time each day and frequently in the late afternoon or early evening. This fussiness should begin to ease by 4 months of age. Often rocking or walking will help calm a fussy baby.
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ELIMINATION
PREVENTING SHAKEN BABY SYNDROME
Your baby may not urinate frequently during the first 3 days — and possibly only once or twice during the first 24 to 28 hours. When babies are getting adequate milk, they should have 6 to 10 wet diapers a day.
Make a plan for what you will do when your baby cries for longer than usual. It is normal to feel frustrated. It is important to have a plan to help with these feelings so you don’t hurt your baby. Try one of these ideas:
The first 2 days, your baby will pass a sticky, black substance called meconium. Gradually baby’s bowels will move more frequently, and a loose, greenish stool will replace the meconium. Your baby may have a bowel movement after each feeding or 1 or 2 stools a day. Within the first week, the stool will transition to a loose, yellow, seedy texture. Breastfed babies tend to have more frequent stools. If your baby develops hard stools, contact the advice nurse for information/ treatment. If your baby develops foul-smelling liquid stools, call the advice nurse.
• Take a deep breath. • Turn the lights down and find a quiet place. Hold your baby next to your chest and breathe slowly to calm yourself and your baby. • Try singing or cooing to your baby. • Take your baby for a walk in a stroller. • Take your baby for a ride in the car (always use a car seat). • Call a family member or a friend to chat. • Ask someone you trust to take over for a while, to give you a break. If these tips don’t help, call the advice nurse. Be sure anyone who cares for your baby knows these steps as well.
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BABY CARE ENJOY YOUR BABY This is equal in importance to feeding and protecting your infant. Remember, your baby has been cuddled, comfortable, warm, and safe these past months, leading an easy life inside your womb. As you walked, the baby enjoyed a gentle to-and-fro rocking motion. Now your baby has many jobs to do, such as breathe, suck, swallow, digest, eliminate, and keep warm — all things that, until now, were taken care of in the womb.
It is important to keep the diaper below the belly button until the umbilical cord has fallen off. Use warm water to clean the diaper area during changes and a mild soap as needed. Desitin is often helpful if a diaper rash should develop. If the rash does not go away in 3 to 5 days, or gets worse, consult your baby’s pediatrician or family practice clinician for further advice.
GIRL BABIES Cleaning the labia It is important to wipe your daughter’s bottom from front to back. Gently separate the folds (labia) and wash and rinse. There may be a white coating inside the folds, along with a clear, jelly-like discharge containing streaks of blood. These are normal. Do not try to scrub them off. They will eventually disappear.
TRUST YOURSELF There will be many times when you will wonder if you are doing the “right thing” in the “right way.” This will be especially true if you have a wellmeaning friend or relative who gives you advice whether you need it or not. There are many ways to care for babies, and nearly all of them are right. If you are enjoying your baby and your new role as a parent, it is almost impossible for you to do something wrong — you will most naturally do it right. Trust yourself, but reach out if you need help.
BOY BABIES Cleaning the scrotum and penis It is important to clean around your son’s scrotum, especially the underneath side. Carefully lift the scrotum and wash gently, being sure to rinse well if you use soap.
LIMIT VISITORS It is best to have few visitors during the first few weeks at home while you and your baby recover together and your family adjusts to new roles. Babies can be fussy from overstimulation or too many visitors.
Care of the uncircumcised baby Care of the uncircumcised boy is uncomplicated. Washing and rinsing your son’s genitals daily is all that is needed. Do not pull back the foreskin (the skin covering the tip of the penis) in an infant. Forcing the foreskin back may harm the penis, causing pain, bleeding, and possible scar tissue. The natural separation of the foreskin from the tip of the penis may take several years. When your son is older, he can learn to pull back the foreskin and clean under it on a daily basis.
CHANGING DIAPERS AND CLEANING THE GENITALS The diaper area should be kept clean and dry. If there is no diaper rash and your baby is not uncomfortable, routine changes at feeding time may be all that is necessary.
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The room should be warm and free of drafts. You may use mild soap or baby shampoo, but water is the best daily cleaner. Avoid highly perfumed soaps. Be careful to not get soap or shampoo in your baby’s eyes. Do not use cotton swabs inside your baby’s nose or ear canals. Your baby should have a sponge bath until the umbilical cord and/ or circumcision heals.
Until the cord falls off, keep the navel dry and clean. After the cord falls off, you may gently clean the area with warm water. If there is a little oozing of blood or yellowish-whitish discharge, be sure the diaper or diaper covering is not over the cord, causing it to remain moist. Slight bleeding a few days before and after the cord falls off is normal. Please call your clinician if the skin around the navel becomes red or swollen or has a foul odor.
SKIN CARE
CHECKING YOUR BABY’S WARMTH
BATHING
Do not use baby oil. These products may cause skin rashes. Do not use baby powder or cornstarch. Your baby may breathe in particles of the powder, which may cause lung irritation. Keep your baby’s skin care simple. It is normal for babies to have some dry skin after birth, but in most babies this old skin will flake off during the first weeks of life; you do not have to use baby lotion while this dry skin is flaking off. For mild irritation in the diaper area, use Desitin ointment. To avoid skin irritation, launder cloth diapers and clothing in a mild detergent. Soak cloth diapers after use, and double-rinse after washing.
EYE CARE For a few days after birth, your baby’s eyes may be puffy and have a yellowish discharge from the antibiotic used to prevent infection. Use clear, warm water on a cotton ball to wipe away the discharge. If swelling or redness with a draining, yellowish discharge continues or returns, this may indicate infection, and you should notify your clinician.
UMBILICAL CORD CARE The stump of the cord is firm, rubbery, and moist. Some of the baby’s skin may cover the closest part of it. The cord will become very dry, wrinkled, and dark. It usually falls off between the 6 and 21 days. It is a good idea not to touch the cord or the skin around it unless your hands are freshly washed. 1899KPCC-15/5-15
Touch your baby on the chest or back for proper skin temperature. If your baby feels comfortably warm, he or she is OK, even if the hands and feet feel cool (but not blue). If your baby feels cool, add clothes, including a hat in cold weather. If your baby feels hot, take his or her temperature using a thermometer in the armpit. If your baby has a temperature of 100.4 degrees or higher, call the advice nurse. If your baby feels warm but his or her temperature is below 100.4 degrees, take off some of his or her clothes and recheck the temperature in an hour. You should keep your baby out of direct sunlight. Protect your baby from the sun with an umbrella, shade, hat, and clothing. You should also keep your baby away from drafts.
NAIL CARE It is common for your baby’s fingernails to be long and/or sharp at birth. You can cover your baby’s hands with socks or baby mittens or use a soft emery board to file down the nails. It is sometimes easier to file down the nails when your baby is sleeping.
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FEEDING YOUR BABY BREASTFEEDING
HOW BREASTFEEDING WORKS
Breastfeeding is an enjoyable and natural way of feeding your baby. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for about the first 6 months of a baby's life, followed by breastfeeding in combination with the introduction of complementary foods until at least 12 months of age, and continuation of breastfeeding for as long as mutually desired by mother and baby. Breastfeeding helps keep baby (and mom!) healthy in a variety of ways:
Breastfeeding is a simple system of supply and demand — the more you nurse, the more milk your body will produce for your baby. Your Labor and Delivery nurse will help you initiate the first steps to breastfeeding with skin-to-skin contact the first half hour immediately after birth. At first, your baby gets your first breast milk called colostrum, a rich, yellowish fluid that protects against infection, is high in protein, and serves as a laxative to help clear out his or her digestive system. Colostrum is the perfect food until the mature breast milk comes in. Your milk production depends on the amount of stimulation at your breasts. Therefore, you should start breastfeeding soon after birth and frequently thereafter to support milk production. Mature breast milk can appear thin and bluish or creamy. Your milk is perfectly suited to your baby’s digestive system and nutritional needs.
• Provides all of the necessary nutrients in the proper proportions and is easily digested by baby. • Provides important immune system support and protection against allergies, sickness, and childhood cancers. • Protects against chronic diseases such as diabetes and obesity. • Reduces the risk of SIDS. • Increases the effectiveness of immunizations • Reduces risk of pre-and post-menopausal breast cancer in mothers who breastfeed. Since many misconceptions and myths exist about breastfeeding, we advise that you consult your lactation specialist.
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GETTING STARTED Breastfeed your baby as soon as possible after birth. Some babies are eager to breastfeed immediately after birth, and others take hours to become interested in latching on to the breast. Don’t be concerned if your baby needs time to learn to breastfeed. Remember, every baby is an individual and will respond and breastfeed at his or her own pace. Give your baby lots of skin-to-skin contact while frequently offering the breast; this will help encourage your baby’s natural instinct to suck. You are both new at breastfeeding, so have patience and give yourself and your baby time to establish this skill.
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Get into a comfortable position — sitting up or lying down is fine. Take advantage of the rooting reflex, which is what causes your baby to seek the nipple when the cheek is stimulated. Tickle your baby’s bottom lip with your nipple, and your baby will turn toward that side and open the mouth. Pull your baby close to you and support your breast so that your baby grasps as much of the areola (dark area) as possible and not just the nipple. Your baby will then use the tongue to hold the nipple against the roof of the mouth and begin to suck. Your baby may nurse on one or both sides. If your baby nurses on both sides, start on the same side you ended with last time. If you need to release your baby’s grasp on your breast, you can insert your little finger in the corner of your baby’s mouth to gently break the suction. Allow your newborn to nurse as long and frequently as he or she demands. Most babies will feed a minimum of 8 times in 24 hours or up to 12 to 14 times in 24 hours. Spend a few minutes between sides burping your baby and changing the diaper. Newborns often fall asleep after the first breast, and such activity between sides can stimulate them to nurse on the second breast. Incorrect positioning and latch are primary causes of sore nipples. Proper positioning will help decrease nipple soreness. Ask your nurse for help with positioning before your nipples get sore. Remember, cracking, bleeding, or blistering is not normal — call the advice nurse, your clinician, or the lactation consultants (IBCLCs) at the MotherBaby Program (see the phone list). Barring any medical indications, there should be no need to supplement your baby’s breastfeeding, as this can delay your milk coming in. Many babies lose interest in breastfeeding when a bottle is introduced too early or too often.
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They use the tongue differently on a bottle nipple and may decrease the ability to latch on to the breast. Check with your clinician or lactation consultant if you have concerns or questions. Breast milk digests quickly and easily, so newborns nurse often, at least every 2 to 3 hours during the day and night. Most babies will feed a minimum of 8 times in 24 hours or up to 12 to 14 times in 24 hours. Some babies are quite sleepy and don’t wake up often to be fed in the early days of life. It is advisable to wake and feed your sleepy baby to ensure he or she is getting enough food and to stimulate your milk supply. Babies tend to "cluster" feeds or breastfeed very frequently, on and off the breast, for a few hours in a row. This is normal newborn behavior and should not be seen as a sign that the baby is "not getting enough." Many newborns have their days and nights mixed up at first — be patient and encourage frequent breastfeedings during the day, but expect to be up during the night feeding your baby. Roomingin at the hospital will allow you to notice your baby's early feeding cues such as stirring, mouth opening, turning head, and rooting or brining his or her hand to mouth. This is the time to put your newborn to the breast because the baby is telling you that he or she is hungry. This frequent, cuebased feeding will help your milk come in sooner. You may take medications prescribed by your obstetric or family practice clinician while breastfeeding. If you are subsequently placed on medications, be sure to tell your clinician that you are breastfeeding. Nurses and other clinicians at your medical office can schedule appointments if you have breastfeeding difficulties. Please call your medical office advice nurse, or the lactation consultants at the Mother-Baby Program, if you need additional help with breastfeeding.
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FEEDING YOUR BABY ABOUT BREAST PUMPS
VITAMINS AND MINERALS
Many breastfeeding mothers find the need for a breast pump at some point during breastfeeding. Breast pumps are provided without cost to breastfeeding mothers. Check with your clinician if you need one.
Breastfeeding also requires an increased intake of vitamins and minerals. You can get what you need by eating a well-balanced diet and by taking your prenatal vitamin/mineral supplement as advised by your clinician. Your requirements for vitamin C, calcium, phosphorus, and folic acid increase during breastfeeding. If you are anemic, you may need to include more iron-rich foods in your diet. Calcium and phosphorus are found in milk and other dairy products. If you do not like milk or cannot tolerate it, your clinician may recommend a calcium supplement.
STORING BREASTMILK Freshly pumped breast milk may be safely stored in the refigerator for up to 3 days and up to 6 months when frozen. Thawed breast milk may be stored in the refrigerator up to 24 hours. For additional information regarding storage guidelines refer to La Leche League International, llli.org.
NUTRITION DURING BREASTFEEDING You must feed yourself to be able to feed your baby. While you were pregnant, what you ate and drank provided nourishment to you and your baby. Now that your baby has been born, what you eat and drink is still important. For the first 6 months, your breast milk supplies all the nutrients and calories your baby needs to grow and develop.
Good sources of iron include liver, beef, raisins, oysters, dried fruit, and iron-fortified cereals. Iron is best absorbed in vitamin C. Good sources of vitamin C include citrus fruits, broccoli, melons, berries, tropical fruits, cabbage, and tomatoes. Folic acid is commonly found in green leafy vegetables such as spinach, mustard greens, romaine lettuce, and kale. Some cereals are fortified with folic acid.
CALORIES, PROTEIN, AND FLUIDS You will need extra calories to produce milk. The current recommendation is 500 additional calories per day, as well as an additional 20 grams of protein. You will also want to drink extra water to stay hydrated.
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OTHER CONSIDERATIONS DURING BREASTFEEDING • If you are a vegetarian, be sure to get enough calories, protein, calcium, iron, zinc, vitamin D, and vitamin B12. Because many foods you eat regularly — fruits, vegetables and grains — are low in calories, you need to be sure to eat adequate amounts each day. You may need a vitamin B12 and iron supplement. • Dieting while breastfeeding is not recommended. • Caffeinated products such as coffee, tea, chocolate, and many sodas should be used in moderation. Caffeine acts as a stimulant to your baby in large amounts. • Talk to your clinician about alcohol consumption while breastfeeding. • While medications can pass into breast milk, many medications are compatible with breastfeeding and do not require a cessation of breastfeeding. If a medication is problematic with breastfeeding, alternatives can also be offered. Talk with your clinician and lactation consultant while you are breastfeeding. Please see the reference list in the pocket of this booklet for helpful resources.
SUCKING NEEDS Many babies have a need to suck that often is not satisfied with breastfeeding or bottle-feeding. These babies can be soothed by sucking on your clean finger. It is recommended by the American Academy of Pediatrics to wait until breastfeeding is wellestablished before introducing a pacifier or bottle nipple. Please consult your clinician, or the lactation consultants (IBCLCs) at the Mother-Baby Program, if you are confused or have questions about your baby’s sucking needs.
BURPING YOUR BABY It is important to burp your baby during and after each feeding. Some babies spit up more than others. This loss of milk, if not excessive, does not interfere with weight gain.
• Due to the risk of too-high levels of methylmercury, which can be passed to baby via breastmilk, the U.S. Food and Drug Administration advises breastfeeding women to avoid eating several types of fish such as shark, swordfish, king mackeral, and tilefish. It is also suggested that consumption of other kinds of fish, (shellfish, canned fish, smaller ocean fish, or farm-raised fish) should average no more than 12 ounces per week. Although pregnant women are advised to avoid sushi, the consensus among breastfeeding experts seems to be that eating sushi (with raw fish) does not pose any problem for a breastfeeding baby. 1899KPCC-15/5-15
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FEEDING YOUR BABY BOTTLE-FEEDING
FORMULA
Here are some useful tips if you choose to bottle-feed your baby:
Powdered formula is less expensive and easy to use. Read the label for instructions on preparing the formula to be sure you are mixing it correctly.
• Put the nipple deep in the baby's mouth. If baby nurses on the tip, formula may leak out of the sides of the mouth. Keep the bottle tipped up enough to keep formula in the nipple. • Your baby has a strong, natural desire to suck and will keep on sucking nipples even after they have collapsed. Take the nipple out of the mouth occasionally to keep it from collapsing. After feeding, offer baby a pacifier (if desired) for additional comfort sucking needs. • Your baby needs the security and pleasure of being held at each feeding. This is the time for both of you to relax and enjoy each other. Hold baby close to your chest. The baby likes your heartbeat. You may change arms when you feed baby.
Water that is mixed with formula should be boiled if it is not from a source that is regularly checked for harmful bacteria. It should then be allowed to cool to room temperature before mixing with formula. This applies to all private wells. Do not boil the milk itself, or you will destroy the vitamins. There is a wide variety of prepared milk formulas on the market. Some are available in ready-tofeed bottles or cans. While prepared formula is an expensive way to feed your baby, some parents find this option useful on long trips. The milk mixture will remain sterile as long as the bottle or can is unopened. Prepared cow’s milk formulas are most common.
• Never prop the bottle up and leave your baby to self-feed. The bottle can easily slip into the wrong position and cause choking. Let your baby feed “on cue” or “demand” feed. Babies should not be placed on a “schedule” for feeding. Baby will show you he or she is hungry with feeding cues such as bringing hand to mouth and “rooting.” Your baby’s appetite will vary — let baby tell you how much he or she needs at each feeding. Your clinician will also advise you on the proper amount of formula to feed your baby.
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FORMULA AND FOOD HANDLING
VITAMINS
It is not necessary to sterilize bottles, nipples, formula, or water. However, great care should be taken when preparing formula and foods:
At your baby’s 2-week checkup, the clinician will talk with you about your baby’s need for vitamins or fluoride drops.
• Wash your hands carefully before preparing formula.
SOLID FOODS
• Wash bottles and nipples thoroughly in dishwashing detergent using a nipple brush and a bottle brush. Rinse and drain well. The top rack of a dishwasher is also safe to use for most bottles and nipples.
According to the American Academy of Pediatrics: Exclusive breastfeeding is sufficient to support optimal growth and development for approximately the first 6 months of life and provides continuing protection against diarrhea and respiratory tract infection. Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child. Complementary foods rich in iron should be introduced gradually beginning around 6 months of age. During the first 6 months of age, even in hot climates, water and juice are unnecessary for breastfed infants and may introduce contaminants or allergens.
• If using liquid infant formula, clean the can lid and shake the can well before opening. • Prepare only enough formula for 24 hours. Always store it in a covered container in the refrigerator until ready to use. Do not save formula when a feeding is finished. Formula must be thrown out and not given to baby at the next feeding. Discard any remaining prepared formula after 24 hours. • Formula should be served at room temperature. If the formula has been refrigerated, the bottle can be warmed in a pan of hot water. Never heat your baby’s bottle or food in a microwave oven. The heating may be excessive or uneven and potentially very dangerous to your baby.
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Your pediatrician or family physician will advise you when it is appropriate to introduce solid foods to your baby. Do not put solid foods in your baby’s bottle.
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MULTIPLES If you have 2 or more babies on the way, you may have twice as many questions. Good information is important because women who are pregnant with more than one baby are at higher risk of:
If the babies you’re carrying are identical, they:
• Preterm birth. • Preeclampsia.
• Probably will have the same body type and the same color skin, hair, and eyes. But they won’t always look exactly the same. They also won’t have the same fingerprints.
• Gestational diabetes.
• Require specialized care by a perinatologist.
• Cesarean birth.
Babies who come from different eggs are called fraternal (nonidentical). This happens when 2 or more eggs are fertilized by different sperm (dizygotic). Fraternal babies tend to run in families. This means that if anyone in your family has had fraternal babies, you’re more likely to have them too.
• Low birth weight.
You will need to see your clinician more often than women who are carrying only 1 baby, so you and your babies' health can be monitored. Your clinician will also tell you how much weight to gain, if you need to take extra vitamins, and how much activity is safe. With close monitoring, your babies will have the best chance of being born near term and at a healthy weight. After delivery and once your babies come home, you may feel overwhelmed and exhausted. Ask for help from your partner, family, and friends. Support groups for parents of multiples can also ease the transition.
• Are either all boys or all girls. • All have the same blood type.
If the babies you’re carrying are fraternal, they: • Can be both boys and girls. • Can have different blood types. • May look different from each other or may look the same, as some brothers and sisters do.
TYPES OF MULTIPLE PREGNANCIES
MULTIPLE PREGNANCY?
A multiple pregnancy means that you have 2 or more babies in your uterus. These babies can come from the same egg or from different eggs.
If you take fertility drugs or have in vitro fertilization to help you get pregnant, you’re more likely to have a multiple pregnancy. Fertility drugs help your body make several eggs at a time. This increases the chance that more than one of your eggs will be fertilized.
Babies who come from the same egg are called identical. This happens when 1 egg is fertilized by 1 sperm (monozygotic). The fertilized egg then splits into 2 or more embryos. Experts think that this happens by chance. It isn’t related to your age, race, or family history.
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In vitro fertilization is the most common kind of assisted reproductive technology used to help women get pregnant. Several of your eggs are mixed with sperm in a lab. When the eggs are fertilized, they’re put back inside your uterus. The doctor puts in several fertilized eggs to increase your chances of having a baby. But this also makes a multiple pregnancy more likely.
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You’re also more likely to have more than 1 baby at a time if:
HOW CAN I TELL IF I'M CARRYING MORE THAN ONE BABY?
• You’re 35 or older.
While you may feel like you’re carrying more than 1 baby, only your clinician can say for sure. He or she will do a fetal ultrasound to find out. This test can give your clinician a clear picture of how many babies are in your uterus and how well they’re doing.
• You’re of African descent. • You’ve had fraternal babies before. • Anyone on your mother’s side of the family has had fraternal babies. • You’ve just stopped using birth control pills.
WHAT ARE THE RISKS OF A MULTIPLE PREGNANCY? Any pregnancy has risks. But the chance of having serious problems increases with each baby you carry at the same time. If you’re pregnant with more than 1 baby, you’re more likely to: • Develop preeclampsia. • Develop gestational diabetes. • Deliver your babies early. When babies are born early, their organs haven’t had a chance to fully form. This can cause serious lung, brain, heart, and eye problems. • Have a miscarriage. This means that you may lose 1 or more of your babies. • Have 1 or more babies with a disease that is caused by a bad gene or group of genes. If you or anyone in your family has had a child with a disease that is linked to a gene change, let your clinician know.
If the test shows that you’re carrying more than 1 baby, you’ll need to have more ultrasounds during your pregnancy. Your clinician will use these tests to check for any signs of problems that your babies may have as they grow.
WHAT TYPE OF TREATMENT WILL I NEED? If you’re pregnant with more than one baby, you’ll need to see your clinician more often than you would if you were having just one baby. This is because you and your babies have a greater chance of developing serious health problems.
NOW WHAT? After your babies are born, you may feel overwhelmed and tired. You may wonder how you're going to do it all. This is normal. Most new moms feel this way at one time or another. Ask your family and friends for help, rest as often as you can, and join a support group for moms with multiples.
Keep in mind that these problems may or may not happen to you. Every day, women who are pregnant with more than 1 baby have healthy pregnancies and healthy babies.
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KEEP YOUR BABY HEALTHY You've been thinking about your baby's health a long time — maybe before you even became pregnant. Once your baby arrives, one of the best ways to help him or her be healthy is to stay up-todate with scheduled immunizations and wellchild checkups. Kaiser Permanente recommends vaccinating children — as do an overwhelming majority of other health professionals, researchers, and organizations. These include the American Academy of Pediatrics, American Academy of Family Practice Physicians, and Centers for Disease Control and Prevention.
If you have questions or concerns, please call us before coming into a medical office. Our professional staff can advise you what to do. In many instances, a concern can be handled over the phone. If your baby needs to be seen, we can arrange for a visit. The best time to receive care is during routine office hours. Most appointment center hours are 7 a.m. to 5 p.m. When calling for appointments, be ready to provide your child’s name, birth date, and health record number.
VISIT SCHEDULE • One to three days after discharge from the hospital with the lactation nurse.
Immunizations are vital for keeping children healthy and preventing the spread of disease.
• At about 2 weeks of age with a pediatrician or family clinician.
Outpatient services include routine (well-child) visits, same-day appointments, urgent care visits, and telephone advice:
• At 2, 4, 6, 9, and 12 months of age with your clinician.
• Well-child checks are regularly scheduled appointments to monitor your baby’s growth and development. • Same-day appointments are made when your baby has a condition or illness that cannot wait until a well-child checkup. This appointment is made during regular medical office hours. • Urgent care is provided after regular clinical hours for conditions that cannot wait until morning.
WHAT TO EXPECT AT EACH EARLY VISIT At these visits, your pediatrician or family physician will look at your baby’s growth by measuring his or her height, weight, and head circumference. The clinician will check your baby’s development and ask about any concerns that you may have. Use these opportunities to learn how you can keep your baby as healthy and safe as possible.
• Telephone advice nurses can often assist you with nonurgent problems or advise whether your baby needs to see a health care professional.
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IMMUNIZATIONS
The following symptoms need attention:
To see a list of recommended immunizations, go to kp.org/prevention. Immunizations prevent your child from getting diseases for which there are often no medical treatments. These illnesses can result in serious complications, permanent handicaps, and even death.
• Any fever (armpit temperature of 99.4 degrees or higher) in an infant 4 months or younger requires an immediate exam by a clinician. Temperature under 97 degrees may also indicate serious illness and should be reported to a clinician.
Immunizations are often required by law. In Oregon, immunizations are required for children in attendance at child care facilities, Head Start programs, preschools, and public and private schools. In Washington, the requirement is for children in licensed child care and public and private schools.
• Marked change in feeding pattern (significantly decreased appetite, vomiting, sweating, or shortness of breath with feeding).
You can find the guidelines for each state at oregon.gov/DHS/ph/imm/school/index.shtml and doh.wa.gov/cfh/Immunize/default.htm.
• Breathing problems (more than 60 breaths per minute while sleeping or quiet, struggling or pulling hard to catch breath, pausing longer than 15 seconds between breaths).
WHEN TO CALL FOR HELP Any symptoms should at least be discussed by phone with a clinician or advice nurse as soon as noticed. A baby who appears ill should be seen immediately. To take your baby’s temperature, use a digital thermometer under the armpit. A normal temperature is 97.6 to 99.8 degrees. Do not use a mercury glass thermometer. Ear thermometers are not always accurate and thus not recommended for babies.
• Marked change in behavior (decreased activity, sleeping through 2 or more feedings in a day, unusual irritability, convulsions, or jerking movements of the body).
• Change in color (blueness, paleness, increasing yellowness). • Explosive watery bowel movements. • Feeding poorly, crying excessively, increased frequency of stools, or foul-smelling stools. • Significant decrease in urine (fewer than 3 or 4 wet diapers per 24-hour period). • Bleeding from any place, other than a small amount from the navel, circumcision, or vagina. • Any soft, fluid-filled blister. You should also call your clinician if you are crying a lot, feel sad for no apparent reason, or are concerned that you may hurt your baby.
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INFANT ORAL CARE A lifetime of healthy smiles starts at a very young age. Children should have their first dental visit within 6 months of when the first tooth breaks through the gums, or by age 1. This first visit often takes place on mom’s or dad’s lap, not in a dental chair. It’s an opportunity for the dentist to provide anticipatory guidance on topics such as nutrition, oral hygiene, injury prevention, and nonnutritive habits like pacifiers and thumb-sucking. It may seem like baby teeth don’t matter, since they fall out, but children with decay in their primary teeth are more likely to develop cavities in their permanent teeth. Now is the time to create a healthy oral environment and help your child establish good hygiene habits, because it’s always better to prevent problems than to treat them.
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GETTING OFF TO A GOOD START Starting at birth, clean your child’s gums with a soft infant toothbrush or cloth and water. As soon as the first tooth comes into place, start brushing your child’s teeth with a soft-bristled toothbrush designed for children. Use a smear of fluoridecontaining toothpaste (about the size of a grain of rice). As your child gets older, it’s important to maintain a routine of regular dental cleanings and exams, as well as proper home care. Tooth decay is the most common chronic childhood disease, and it’s a preventable problem. Good oral health is important to your child’s overall health and impacts everything from communication and school readiness to nutrition and self-esteem. Your child can either see a general dentist or a pediatric dentist. However, most will see a pediatric dentist through 3 years of age, as pediatric dentists receive special training to understand kids' needs — particularly very young kids.
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KEEP YOUR BABY SAFE The greatest danger to your baby is an accident, not disease. You, as the parents of this newborn, are responsible for constantly exercising sound judgment to keep your baby safe. The 4 most common dangers to an infant are drowning, suffocation, falls, and car accidents. Prevention is the key to a baby’s safe environment.
PREVENT DROWNING Your baby should be well-protected at all times from entering areas near spas, jacuzzis, hot tubs, bath tubs, or swimming pools without constant adult supervision. During bathing, never leave your baby alone. Always support your baby with one hand. If you are interrupted during bathing by the phone or doorbell, either let it ring (they will call back), or wrap up your baby and take him or her with you.
PREVENT SUFFOCATION Your baby should not be able to reach or play with plastic bags, telephone cords, ropes, cords from window coverings (such as mini-blinds), electrical cords, harnesses, soft pillows, or wide-slat openings in cribs made before 1976. These all have the potential to smother, strangle, or suffocate your baby. Don’t place necklaces around your baby’s neck. Small objects of any type have the immediate potential for choking a baby.
PREVENT FALLS The only safe place a baby can be left alone for even a few moments is in a safety-approved crib with all sides up or in a playpen. Babies can kick, scoot, and wiggle off high surfaces such as beds, tables, stairs, couches, and chairs. Floors and full-size beds are unsafe if you are not able to constantly watch your infant. Once your infant becomes mobile (e.g., rolling, scooting, crawling), all stairways should be secured (top and bottom) with approved infant safety gates. Install operable window guards on 1899KPCC-15/5-15
all windows above the first floor. Do not use a baby walker — your child may tip it over, fall out of it, or fall down the stairs in it. Baby walkers may allow children to get to places where they can pull hot foods or heavy objects down on themselves.
CAR SAFETY In Washington and Oregon, the law requires that everyone wear seat belts. Children younger than 1 year and less than 20 pounds must be in a rear-facing car seat. The American Academy of Pediatrics recommends a rear-facing car seat until age 2 and more than 20 pounds. A safety seat: • Prevents your child from being thrown. • Absorbs the force of impact. • Distributes the force of impact more evenly over a child’s body. As a responsible parent, keep these points in mind regarding car safety: • Infants should always be transported in an infant/child car safety seat — never in someone’s lap or arms. • A car seat is effective only if installed and used correctly according to manufacturer’s instructions. • Remove or secure all loose objects from your car that could become airborne in an accident. • The safest place for a child is in the center of the back seat securely fastened in a federally approved car seat. • If your car has an airbag, transport your child only in the back seat. • The best safety seat is one you will use each time your child rides in the car, that fits your car securely, and that is comfortable for your child.
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SLEEP SAFETY AND SUDDEN INFANT DEATH SYNDROME (SIDS) Your baby should sleep near you in a safe crib or bassinet but not in the same bed. It is safe to bring your baby into bed to nurse or comfort. But return your baby to his or her crib or bassinet when you are ready to go back to sleep. The cause of SIDS is unknown, but there are several things you can do to help prevent it: • Put your baby on his or her back to sleep, every time. If your baby is old enough to roll and does so on his or her own, there is no need to correct the position. But you should always put your baby down directly on the back for sleep. • Use a firm, flat sleeping surface. • Keep soft toys and loose bedding out of the crib. • Do not use pillows, bumpers, comforters, stuffed toys, or other soft objects. • Make sure your baby’s head remains uncovered during sleep. • Do not string toys across the crib. They can choke your baby. • Some studies have suggested that pacifiers lower the risk of SIDS. • Put your baby to sleep in an area with good ventilation, and consider using a fan in the room (not blowing directly on the baby). • Do not expose your infant to smoke or use sedating medications.
CRIB SAFETY You can help your baby sleep safely in a crib by following these guidelines: • Use a firm, flat mattress that fits tight next to the edge of crib.
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• Make sure that the crib slats are less than 2³/8 inches apart. Your baby’s head can become trapped if the openings are too wide. • Remove corner post knobs if attached to the crib. They can become loose and cause choking. Also, tighten all nuts, bolts, and screws every few months, and check the mattress support hangers and hooks regularly. • Older cribs may not meet current safety standards. Check used cribs especially carefully. For more information on crib safety, visit keepingbabiessafe.org.
PREVENT BURNS Always check the temperature of warmed milk before feeding it to your baby by squirting some on your wrist. Never microwave milk or the bottle directly. Check to make sure your water heater is set to no higher than 120 degrees. Water heaters have a dial on the side that allows for this adjustment. Never carry hot liquids or foods when holding your baby, as a spill can burn your infant.
AVOID SMOKING Keep your baby’s environment smoke free at all times. Smoking increases the risk of infections, asthma, and SIDS.
SUN SAFETY Newborn skin is very sensitive. Newborns do not need to be exposed to sunlight. If you want to take your baby out on a sunny day, keep him or her shaded, with most of the skin covered. It is a good idea to consider putting on sunblock even if your baby will be covered, to prevent any accidental exposure. For babies younger than 6 months: Use sunscreen on small areas of the body, such as the face, if protective clothing and shade are not available; use caution applying around the eyes.
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COMMON NEWBORN PROBLEMS JAUNDICE About 1 in 5 babies will be noticeably jaundiced by the second or third day of life. Jaundice is a result of the normal breakdown of red blood cells that occurs during the newborn period. There can be a relatively high number of excess red blood cells breaking down, and/or the liver is not quite ready to handle the waste load. Before birth, the mother’s liver does this for the baby. Bilirubin is a byproduct of this metabolic process; bilirubin circulates through the bloodstream and gives the skin a yellowish color. The liver filters bilirubin and sends it out with the bowel movement and urine. You should notice that in a few days, your baby’s bowel movement starts to turn yellow. This is the bilirubin leaving your baby’s system. Your baby’s jaundice may gradually increase for up to 7 days and may last as long as 2 weeks. During this time, it is important that your baby gets plenty of fluids. Feeding your baby every 2 to 3 hours, particularly if you are breastfeeding, is important. If your milk is in, your baby should have at least 6 wet diapers a day. If your baby is increasingly sleepy, or the urine output is decreasing, please call the advice nurse. Your baby may need to have a bilirubin level drawn and a feeding evaluation. How do we check for jaundice? Jaundice usually turns the baby’s skin, and sometimes the whites of their eyes, yellow. It is most noticeable in daylight. It usually starts in the face and then continues to the chest, belly, arms, and legs as the bilirubin increases. We also check every baby’s blood for the bilirubin level to measure the level of jaundice. This is usually done when we do the state newborn screen after the first day of life.
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Can jaundice hurt my baby? Most infants have mild jaundice that is harmless, but in unusual situations the bilirubin level can get really high and can cause brain damage. This is why newborns are checked carefully for jaundice and treated to prevent a high bilirubin level. Signs of worsening jaundice Jaundice usually moves from head to toe, so if you think it is worsening, call your pediatrician or family practice clinician. If your baby is jaundiced and is hard to wake, fussy, or not nursing or taking formula well, jaundice may be contributing, so call right away. Does my baby need closer attention for jaundice? Some babies have a greater risk of developing high levels of jaundice and need closer follow-up. These include babies: • With a high bilirubin level before discharge. • Who were born more than two weeks early. • Who had jaundice in the first 24 hours of life. • Who are not breastfeeding well. • With lots of bruising or bleeding from delivery. • With a family member who had high bilirubin and received phototherapy. How is harmful jaundice prevented? Most jaundice requires no treatment. When treatment is necessary, placing your baby under special lights while undressed will help lower the bilirubin level. This method, called phototherapy, can be used in the hospital or at home depending on the jaundice level. Jaundice is treated using this method only at lower levels, when brain damage is not a concern. This treatment can help prevent the harmful effects of jaundice.
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How do the special lights work? They cause a slight chemical change to bilirubin and allow your newborn’s system to more easily expel it. They work only while your infant is exposed to the lights, so the more time your baby is in the lights, the faster it works. It is also important to have as much skin exposed to the light as possible to ensure that enough bilirubin gets changed.
All babies have fussy periods that may last from one feeding to the next. This is not colic. If a baby sleeps for only 1 to 2 hours at a time and fusses after each feeding and passes a lot of gas, drawing up the legs and crying, this may be colic.
Are there risks to phototherapy? Phototherapy is very safe. The biggest complaint is that the baby needs to be left in the lights for extended lengths of time to be most effective. This means your baby will be allowed out only for short periods (20 to 30 minutes) to allow for feeding. Families sometime complain about the fussiness of the infant in lights or that the blue lights in the room are annoying. We use eye protection on infants in the lights, but there is no need for adults to wear eye protection.
• Rock your baby gently.
When does jaundice go away? Jaundice most commonly will go away on its own unless the level is high and needs treatment. In breastfed infants, jaundice often lasts 2 to 3 weeks, and in formula-fed infants, most jaundice goes away by two weeks. If your baby is jaundiced for more than 3 weeks, see his or her clinician.
CRADLE CAP Cradle cap is a yellowish, dry, crusty scale on the scalp. This may extend onto the face as a rash. If this occurs, you may try the following:
If this occurs, you may try any of these suggestions: • Feed your baby more slowly, with frequent burping. • Wrap your baby firmly in a light, soft blanket. • Provide a soft, steady humming noise. • Avoid sudden loud noises, bright lights, or extreme temperature changes. • Take an infant massage class. While the cause is not known, colic is not harmful, and it usually passes by 3 to 4 months of age even without treatment. Contact your clinician if your baby develops fever, vomiting, bloody stools, or any symptoms that do not fit the colicky pattern described.
DIAPER RASH Diaper rash is common. It is caused by wet diapers irritating the skin. To reduce diaper rash problems, change diapers frequently and clean or bathe the diaper area frequently. Keep the area exposed to the air as much as possible. Protective ointments, such as Desitin cream, can help.
• Soften the scales with baby oil and let the oil remain on the scalp for 15 minutes. • Loosen scales with a very soft brush. • Shampoo gently with your usual baby shampoo. Rinse and dry well. Repeat this daily for one week and then as needed.
COLIC
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NAVIGATING COMPLICATIONS
NAVIGATING COMPLICATIONS
OVERVIEW Most women go through pregnancy and childbirth without any medical problems or complications. Early and regular prenatal care can help keep you and your baby safe.
In this section, you’ll find information about:
If you have a suspected or diagnosed problem, you’ll need to take precautions to help your pregnancy go well. Many complications, such as gestational diabetes, are manageable with proper treatment.
• Domestic abuse.
Even in a healthy pregnancy, it is possible to start labor too early. Learn the signs of preterm labor and what to do if contractions begin. This section provides you with the critical information you need to know.
• Asthma. • Diabetes. • Fifth disease. • High-risk pregnancy. • Obesity. • Preeclampsia and high blood pressure. • Preterm labor. • Toxoplasmosis. • Urinary tract infection.
Review these pages to learn about common complications and how to navigate them. If you experience any problems during or after your pregnancy, contact your health care team. The “Risks and safety” section outlines warning signs and when and if to call for help.
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ASTHMA Asthma is a fairly common health problem for pregnant women, including some women who have never had it before. During pregnancy, asthma not only affects you, but it can also cut back on the oxygen your fetus gets from you. But this does not mean that having asthma will make your pregnancy more difficult or dangerous to you or your fetus. Pregnant women with properly controlled asthma generally have a normal pregnancy with little or no increased risk to themselves or the fetus. All asthma treatments are safe to use when you are pregnant. After years of research, experts now say that it is far safer to manage your asthma with medicine than it is to leave asthma untreated during pregnancy. Talk to your clinician about the safest treatment for you.
RISKS OF UNCONTROLLED ASTHMA If you have not previously had asthma, you may not think that shortness of breath or wheezing during your pregnancy is asthma. If you know you have asthma, you may not consider it a concern if you only have mild symptoms. But asthma can affect you and your fetus, and you should act accordingly. If your asthma is not controlled, risks to your baby include: • Death immediately before or after birth (perinatal mortality). • Abnormally slow growth of the fetus (intrauterine growth restriction). When born, the baby appears small. • Birth before the 37th week of pregnancy (preterm birth). • Low birth weight. The more control you have over your asthma, the less risk there is.
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ASTHMA TREATMENT AND PREGNANCY Pregnant women manage asthma the same way nonpregnant women do. Like all people with asthma, pregnant women should have an asthma action plan to help them control inflammation and prevent and control asthma attacks. Part of a pregnant woman’s action plan should also include recording fetal movements. You can do this by noting whether fetal kicks decrease over time. If you notice less fetal activity during an asthma attack, contact your clinician or emergency help immediately to receive instructions. Considerations for treatment of asthma in pregnancy include the following: • If more than one health professional is involved in the pregnancy and asthma care, they must communicate with each other about treatment. The prenatal care clinician must be involved with asthma care. • Monitor lung function carefully throughout your pregnancy to ensure that your growing fetus gets enough oxygen. Because asthma severity changes for about two-thirds of women during pregnancy, you should have monthly checkups to monitor your symptoms and lung function. Your clinician will use either spirometry or a peak flow meter to measure your lung function. • Monitor fetal movements daily after 28 weeks. • Try to do more to avoid and control asthma triggers (such as tobacco smoke or dust mites) so that you can take less medicine if possible. Many women have nasal symptoms, and there may be a link between increased nasal symptoms and asthma attacks. Gastroesophageal reflux disease (GERD), which is common in pregnancy, may also cause symptoms.
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• It is important that you have extra protection against the flu (influenza). Get a flu vaccination as soon as it’s available, whether you are in your first, second, or third trimester at the time. The flu vaccine is effective for one season. The flu vaccine is safe in pregnancy and is recommended for all pregnant women.
ASTHMA AND ALLERGIES Many women also have allergies, such as allergic rhinitis, along with asthma. Treating allergies is an important part of asthma management. • The antihistamines loratadine or cetirizine are recommended.
ASTHMA MEDICINES AND PREGNANCY Albuterol (ProAir) is a fast-acting pulmonary airway muscle relaxer that can help quickly reverse signs and symptoms in some cases of asthma. If you use this inhaler, you should carry it with you at all times. Budesonide is labeled by the U.S. Food and Drug Administration (FDA) as the safest inhaled corticosteroid to use during pregnancy. One study found that low-dose inhaled budesonide in pregnant women seemed to be safe for the mother and the fetus.
• Inhaled corticosteroids at recommended doses are effective and can be used by pregnant women.
Never stop taking or reduce your medicines without talking to your clinician. You might have to wait until after delivery to make changes in your medicine.
• If you are already getting allergy shots, you may continue getting them, but starting allergy shots during pregnancy is not recommended.
Always talk to your clinician before using any medicine when you are pregnant or trying to become pregnant.
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DIABETES Diabetes is a condition that affects the body’s natural way of storing and using energy. It causes a high level of glucose (sugar) in the bloodstream, which may lead to many health problems.
• You are part of an at-risk ethnic group, including African-American, Asian-American, Hispanic/Latina, Native American, Native Alaskan, or Pacific Islander.
In pregnancy, high blood glucose levels can cause the baby to grow too large, making a natural delivery difficult. This could result in cesarean birth (also called a C-section) or lead to injury of the baby at the time of vaginal delivery (such as a broken collarbone or nerve injury in the arm).
• You have prediabetes or glucose intolerance.
The baby may also have problems after delivery (low blood sugar), and may need to be cared for in a special care nursery. This is why it’s so important to control your blood sugar while you are pregnant.
GESTATIONAL DIABETES If your blood sugar becomes too high for the first time while you are pregnant, you have gestational diabetes. Gestational diabetes is the most common form of diabetes in pregnant women. Gestational diabetes usually begins after the first trimester of pregnancy. Most women with this type of diabetes have normal blood sugar in the first part of pregnancy. Because you can have gestational diabetes without knowing it, all women are tested for diabetes during pregnancy. Your chances of having diabetes in pregnancy are higher if any of the following warning signs are true: • You had high blood sugar during a previous pregnancy. • You have had other babies who weighed more than 9 pounds at birth. • You are overweight. • A close relative, such as a parent or sibling, has diabetes.
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Some women who have diabetes during pregnancy will continue to have diabetes after pregnancy. For most women, blood sugar levels return to normal after pregnancy. However, women who have gestational diabetes are at risk for recurrence in subsequent pregnancies and for developing type 2 diabetes several years after delivery.
TYPE 2 DIABETES Type 2 diabetes is the second most common form of diabetes in pregnancy. Type 2 diabetes is usually diagnosed in adulthood. It has become more common in childhood and adolescence due to the increase in childhood obesity. This type of diabetes can be managed with lifestyle changes (diet and exercise) or may need medications such as insulin or oral medication. Women with type 2 diabetes should see their clinician before they become pregnant to discuss steps they can take to ensure a safe pregnancy and a healthy baby. Women with type 2 diabetes should also be seen as soon as they find out they are pregnant, so that blood sugar levels can be monitored carefully.
TYPE 1 DIABETES Type 1 diabetes is less common but more likely to cause problems in pregnancy. Type 1 diabetes is usually diagnosed in children and young adults. In type 1 diabetes, the body does not produce insulin, a hormone that is needed to help your body properly use and store glucose. Type 1 diabetes can be managed with diet, exercise, and insulin to control blood sugar. 154
WHAT SHOULD I DO IF I HAVE DIABETES? By taking steps that will keep your blood sugar levels as close to normal as possible, you will be doing all that you can do to have a healthy and normal pregnancy. These steps include the following: • Make healthy food choices. Healthy eating will give you all the nutrition you need without extra sugars and fats that can cause your diabetes to get out of control. • Exercise. Physical activity will help your body lower blood sugar levels, help you better control your rate of weight gain, and help improve your overall well-being. • Gain the right amount of weight. Proper weight gain is necessary to provide your baby with good nutrition during pregnancy. But gaining too much weight increases insulin resistance in the body, making blood sugar go up and increasing the risk of having a big baby. • Check blood sugar levels. An important part of treating diabetes is checking your blood sugar level at home. You will need to do a home blood sugar test as directed by your clinician. • Take oral medications or insulin shots. The first way to treat gestational diabetes is by changing the way you eat and exercising regularly. If your blood sugar levels are still too high after changing the way you eat and exercising regularly, you may need oral medications or insulin shots. Synthetic insulin or oral medications can help lower your blood sugar level without harming your baby. Special monitoring usually starts between 32 and 34 weeks if you are taking insulin or oral medications. If you are not on medications, then special monitoring usually starts by week 40 of your pregnancy. 1899KPCC-15/5-15
• Monitor fetal growth and well-being. Your clinician will want you to monitor fetal movements called kick counts. You may also have fetal ultrasounds to see how well your baby is growing. If your blood sugar levels are high or your baby is growing larger than normal, you may need to take oral medication or insulin shots. If you take oral medications or insulin, you may have a nonstress test to check how well your baby responds to movement. Even if you do not take insulin, you may have a nonstress test and ultrasound as you get closer to your due date. • Get regular medical checkups. Having gestational diabetes means regular visits to your clinician. At these visits, your clinician will check your blood pressure and test a sample of your urine. You will also discuss your blood sugar levels, what you have been eating, how much you have been exercising, and how much weight you have gained. • Learn the warning signs of preeclampsia. Women who have diabetes during pregnancy may have a greater chance of developing high blood pressure and preeclampsia. Call your clinician right away if you develop any of the symptoms (see pages 166 to 167).
HOW WILL DIABETES AFFECT MY BABY? There are no absolute guarantees, but with careful lifestyle changes, including healthy food choices, physical activity, and good blood sugar control, it is less likely that there will be any problems. If there are problems, your health care team will be there to assist you and your baby. Problems of a baby born to a mother with diabetes may include the following: • Mothers with high blood sugar levels at the beginning of pregnancy are at an increased risk for having a baby with birth defects. However, this risk can be lowered if blood sugars are well-controlled before pregnancy. 155
DIABETES • Babies of some mothers who have diabetes have a slightly increased chance of stillbirth. • Polyhydramnios (excess amniotic fluid) happens in a relatively small number (about 10 percent) of the women with pre-existing diabetes. Excess fluid can cause premature labor or other problems. • Macrosomia (large baby) happens when your baby grows too big from receiving too much blood sugar from you. The growing baby changes the extra blood sugar to fat and may grow too large to fit through the birth canal. To avoid possible injury to your baby during a vaginal delivery, your clinician may recommend a cesarean birth. • Hypoglycemia (low blood sugar) may occur if your blood sugar levels have been consistently high during pregnancy. This causes the fetus to develop high levels of insulin in the blood. After delivery, your baby no longer has the high level of sugar from you but continues to produce high levels of insulin. As a result, your newborn’s blood sugar becomes very low. Immediately after birth, your baby’s blood sugar level will be checked. If it is too low, your baby may need to be fed right away.
DELIVERY OF YOUR BABY When your blood sugar remains normal throughout pregnancy, diabetes should not affect the delivery of your baby. Sometimes a cesarean birth may be necessary to deliver a baby that is too big to fit through the birth canal. Choices about delivery are very individual. You should discuss your concerns with your clinician or other medical professional.
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SHOULD I BREASTFEED? We strongly encourage breastfeeding. The body uses the calories stored during the first part of pregnancy to make breast milk. About 300 to 500 calories per day are used for breastfeeding. By 6 weeks after delivery, women who breastfeed usually have lost an average of 4 pounds more than women who bottle-feed. This can be especially important for women with gestational diabetes, since keeping a normal body weight may reduce the risk of developing diabetes later in life. Breastfeeding is also good for your baby. Breast milk offers health benefits that formula can’t duplicate. If you have had gestational diabetes, you should be able to breastfeed without any complications. The amount and type of milk your body makes is the same as a woman without gestational diabetes. If you took insulin or oral medications before you were pregnant, your insulin or medication needs may be different while breastfeeding. In particular, women with type 1 diabetes should be aware that their blood sugar may drop during or after nursing. You may want to check your blood sugar before and after feedings during the first few weeks of breastfeeding. You may need to eat snacks to prevent low blood sugar, especially during the night. Most likely, you will need to control your blood sugar with healthy food choices, exercise, and possibly with oral medications or insulin while breastfeeding. If you took one of these medications before pregnancy, talk to your clinician before using it again.
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WHAT HAPPENS AFTER PREGNANCY? Once you have delivered your baby, the impact of diabetes often changes dramatically. If you have gestational diabetes, you will probably not need insulin or oral medication after you deliver. But, as many as 60 percent of women with gestational diabetes will develop type 2 diabetes later in life. It is important that you have a blood sugar test in the laboratory 6 weeks after your baby is born to see if you still have diabetes. You may need this test again after you stop breastfeeding. If you do have diabetes, your clinician will let you know if you need to take diabetes medications. You should continue with the dietary changes made during pregnancy and exercise regularly to help prevent the development of type 2 diabetes or recurrent gestational diabetes in the future. If your blood test is normal, it is still important to keep in mind that you have an increased risk of developing diabetes later, especially if you gain weight.
To decrease your risk of diabetes, remember the following: • Try to reach or maintain a healthy weight. Losing the weight you gained during pregnancy will help decrease your risk. • Try to eat plenty of fruits, vegetables, and whole grains. • Aim for at least 30 minutes of physical activity each day. • Have a laboratory test of your blood sugar every 1 to 3 years to see if you have developed diabetes. • Plan your pregnancies and consult with your clinician or other medical professional before getting pregnant again to be sure your blood sugar is normal. Very high blood sugar in early pregnancy may cause miscarriage or birth defects in the developing fetus. If your blood sugar is under control before you get pregnant, you can reduce the risk of miscarriage and birth defects.
If you took insulin or oral medications to treat your diabetes before you were pregnant, there may be dramatic changes in your insulin needs the first few days after delivery. That’s why it is important to check your blood glucose frequently before meals to know when to adjust your medication. If you were on insulin prior to pregnancy, you probably needed to increase your dose frequently during your pregnancy. After delivery, your body’s insulin needs will be closer to what they were prior to pregnancy. If you are breastfeeding, you are encouraged to use oral medications or insulin after talking with your clinician.
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DOMESTIC ABUSE Domestic violence is more common in pregnancy. If someone is hurting you, making you feel afraid, putting you down, making threats, or pushing or hitting you, it is not right, and it is not your fault. Abuse occurs when someone uses their body, words, or objects to hurt you. An abuser is usually trying to control another person through harmful words or actions. • If you are having problems with someone who threatens you or hurts you, tell your clinician or other medical professional. You and your baby can get free and confidential help.
HAVE A SAFETY NET • Talk to someone you trust about what is going on. • Call the police in an emergency. • Keep a set of car keys and money stashed where you can find them. • Keep important papers (birth certificates, photo ID, bank book) in a safe place. The National Domestic Violence Hotline has counselors who speak English, Spanish, and other languages. Please see the phone number and resource list in the pocket of this booklet.
• Remember: It’s not your fault, no matter what anyone tells you. Nobody deserves to be abused. • You need to take care of yourself because if you are hurt, your children are hurt, too. • Please see reference list in the pocket of this booklet. In an emergency call 911. In nonemergency situations you are not alone. Help is available. Call The National Domestic Violence Hotline at 1-800-799-SAFE (7233), local police, or a women's shelter in your community. If someone has hurt you before, it may happen again while you are pregnant or after your baby is born. Sometimes abuse starts when you become pregnant. Bringing a new baby into your home may bring added stress to you and your partner. Remember that stress is never an excuse for someone to hurt you or your baby.
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FIFTH DISEASE Fifth disease is often referred to as “slapped cheek” disease because of the rash some people get on their face. Thirty to 60 percent of all adults are already immune to fifth disease. It is more common for children to contract this virus. The disease is spread by coughing and sneezing. As a rule, people can spread fifth disease only while they have flu-like symptoms and before they get a rash. Some people who have fifth disease, such as those who have certain blood disorders or weak immune systems, may be able to spread the disease for a longer time.
In extremely rare cases, the infection can cause a condition called fetal hydrops, in which the fetus develops life-threatening anemia and severe swelling throughout the body. The mother and fetus should be closely monitored with fetal ultrasounds to detect this condition. When fetal hydrops is detected, the fetus may be treated with blood transfusions while in the uterus, although this is not usually necessary. Some babies born to mothers who were infected with fifth disease during pregnancy may also be treated with blood transfusions.
For women who have not previously had fifth disease, contracting the illness during pregnancy can increase the risk for certain complications. If you are pregnant and have been exposed to the illness, contact your clinician right away. A very small number of pregnant women who get fifth disease will have a miscarriage.
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HIGH-RISK PREGNANCY Your pregnancy is considered high risk if you or your baby has an increased chance of a health problem. Many things can put you at high risk. It may sound scary, but it’s just a way for your health care team to make sure that you get special attention during your pregnancy. Your clinician will watch you closely during your pregnancy to find any problems early. The conditions listed below put you and your baby at a higher risk for problems, such as slowed growth for the baby, preterm labor, preeclampsia, and problems with the placenta. But it’s important to remember that being at high risk doesn’t mean that you or your baby will have problems. In general, your pregnancy may be high risk if: • You have a health problem, such as: o Diabetes. o Cancer. o High blood pressure. o Kidney disease. o Epilepsy. • You use alcohol or illegal drugs, or you smoke. • You are younger than 17 or older than 35. • You are pregnant with more than one baby (multiple pregnancy). • You have had 3 or more miscarriages. • Your baby has been found to have a genetic condition, such as Down syndrome, or a heart, lung, or kidney problem.
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• You had a problem in a past pregnancy, such as: o Preterm labor. o Preeclampsia or seizures (eclampsia). o Having a baby with a genetic problem, such as Down syndrome. • You have an infection, such as HIV or hepatitis C. Other infections that can cause a problem include cytomegalovirus (CMV), chickenpox, rubella, toxoplasmosis, and syphilis. • You are taking certain medicines, such as lithium, phenytoin (such as Dilantin), valproic acid (Depakene), or carbamazepine (such as Tegretol). Other health problems can make your pregnancy high risk. These include heart valve problems, sickle cell disease, asthma, lupus, and rheumatoid arthritis. Talk to your clinician about any health problems you have.
HOW WILL MY CLINICIAN CARE FOR ME DURING PREGNANCY? You may have more office visits than a woman who does not have a high-risk pregnancy. You may have more ultrasound tests to make sure that your baby is growing well. During your third trimester, you may have additional fetal monitoring (a nonstress test). You will have regular blood pressure checks, and your urine will be tested to look for protein (a sign of preeclampsia) and glucose (sugar, a sign of high blood sugar).
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Tests for genetic or other problems also may be done, especially if you will be 35 or older at the time of delivery, or if you had a genetic problem in a past pregnancy. Your clinician will prescribe any medicine you may need, such as for diabetes, asthma, or high blood pressure. Talk to your clinician about where you will give birth. Your clinician may recommend that you have your baby in a hospital that offers special care for women and babies who may have complications. If your clinician thinks that your health or your baby’s health is at risk, you may need to have the baby early, or you may be hospitalized for evaluation or treatment.
WHAT TYPE OF CLINICIAN WILL I SEE FOR A HIGH-RISK PREGNANCY? Some women will see someone who has extra training in high-risk pregnancies. These clinicians are called maternal-fetal specialists, or perinatologists. You may see this person and your regular clinician. Or the specialist may be your clinician throughout your pregnancy.
WHAT CAN I DO TO HELP HAVE A HEALTHY PREGNANCY? To help yourself and your baby be as healthy as possible: • Go to all your scheduled visits so that you don’t miss tests to catch any new problems. • Eat a healthy diet that includes protein, milk and milk products, fruits, and vegetables. Talk to your clinician about any changes you may need in your diet. • Take any medicines, iron, or vitamins that your clinician prescribes. Don’t take any vitamins or medicines (including over-thecounter medicines) without talking to your clinician first. • Take folic acid daily. Experts recommend that you take 0.4 to 0.8 milligrams (400 to 800 micrograms) of folic acid every day. Folic acid is a B vitamin. Taking folic acid before and during early pregnancy reduces your chance of having a baby with a neural tube defect or other birth defects. It also helps prevent anemia. • Follow your clinician’s instructions for activity. You will discuss if it is safe for you to work or exercise. • Do not smoke. If you need help quitting, talk to your clinician about stop-smoking programs and medicines. Avoid other people’s tobacco smoke. • Do not drink alcohol. • Stay away from people who have colds and other infections. You may be asked to keep track of how much your baby moves every day. One way to do this is to note how much time it takes to feel 10 movements.
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HIGH-RISK PREGNANCY WHAT SYMPTOMS SHOULD I WATCH FOR? Like any pregnant woman, you need to watch for any signs of problems. This doesn’t mean that you will have any problems. But if you have any of these symptoms, it’s important to get care quickly. Call 911 or other emergency services right away if you think you need emergency care. For example, call if you: • Have passed out (lost consciousness). • Have severe vaginal bleeding. • Have severe pain in your belly or pelvis. • Have had fluid gushing or leaking from your vagina and you know or think the umbilical cord is bulging into your vagina. If this happens, immediately get down on your knees so your rear end is higher than your head. This will decrease the pressure on the cord until help arrives. Call your clinician immediately or seek medical care right away if: • You have signs of preeclampsia, such as:
• You have a fever. • You have 4 to 6 contractions (with or without pain) for an hour. • You have a sudden release of fluid from your vagina. • You have low back pain or pelvic pressure that does not go away. • You notice that your baby has stopped moving or is moving much less than normal.
TESTS TO EVALUATE FETAL HEALTH There are many ways to evaluate the health and well-being of a fetus throughout pregnancy. If you have a pregnancy that is at higher risk for complications, certain tests can be done to check your baby. These tests help to see if your baby is receiving enough oxygen and nourishment through the placenta (sometimes called the “afterbirth,” the organ that connects you and your baby). You may be tested to see if you are having contractions. This is usually done during the last three months of pregnancy. Two tests are commonly offered in late pregnancy if you have a high-risk pregnancy:
o Sudden swelling of your face, hands, or feet.
• Nonstress test (NST).
o New vision problems (such as dimness or blurring).
If you have a high-risk pregnancy, talk with your clinician about any prenatal tests you will be given. Testing is also done in low-risk pregnancies if your baby’s activity suddenly decreases. If you notice this occurring, you should call Labor and Delivery right away.
o A severe headache. • You have any vaginal bleeding. • You have belly pain or cramping.
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• Biophysical profile (BPP).
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Nonstress test A nonstress test (NST) checks your baby’s heart rate in response to his or her movements. An NST takes about 20 to 45 minutes. You don’t need to do anything special to prepare for it. A device that monitors your baby is attached by a belt to your abdomen. Another monitoring device is attached to your abdomen to see if you are having any uterine contractions. Neither device poses any risk to you or your baby. Babies are usually active, and as your baby moves, the monitor records your baby’s heart rate in response to his or her movements. If your baby is healthy, his or her heart rate will go up when he or she moves and will stay steady when resting, just as ours does. Sometimes, your baby will not move much because he or she could be sleeping or resting. A device that makes a loud buzzing noise may be used to wake up your baby. Often a brief ultrasound is done at the same time to check the amount of amniotic fluid (“bag of waters”). Contraction stress test A contraction stress test (CST) measures the effect of contractions (stress) on your baby’s heart rate. You do not need to do anything special to prepare for this test. It is typically performed in a hospital setting.
A monitor records your baby’s heart rate as your uterus contracts. If your baby is not receiving enough oxygen, or is under stress, the heart rate may slow down when there is a contraction. If the heart rate stays steady with contractions (or even goes up), that is generally a sign that your baby is not under stress. Biophysical profile A biophysical profile (BPP) uses ultrasound to evaluate your baby’s health. The BPP looks at your baby’s breathing pattern, body movements, muscle tone, and the amount of amniotic fluid (“bag of waters”). Often, a nonstress test is included as part of the BPP. You may have a biophysical profile done weekly toward the end of your pregnancy. Test results It is reassuring if these tests are normal. A test may be repeated in a few days to a week, depending on risk factors. If the test results are worrisome, your clinician or other medical professional will talk to you about what to do next. Additional tests may be ordered. In some cases, it may be decided that inducing or starting labor and delivering your baby is the safest plan.
As with a nonstress test, 2 monitoring devices are attached to your abdomen. One measures your baby’s heart rate and the other records uterine contractions. Then, a low dose of a medicine called Pitocin may be given to you through a vein to cause your uterus to contract. Sometimes stimulation of the nipples may be used to cause uterine contractions.
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OBESITY HOW DOES MY WEIGHT AFFECT MY PREGNANCY?
SHOULD I TRY TO LOSE WEIGHT DURING PREGNANCY?
Most pregnant women have healthy babies — and that includes women who are obese. But being very heavy does increase the chance of problems.
No. Pregnancy is not the time to lose weight. Your baby needs you to eat a well-rounded diet. Don’t cut out food groups or go on any type of weightloss diet.
Babies born to mothers who are obese have a higher risk of: • Birth defects, such as a heart defect or neural tube defects. • Being too large. This can cause problems during labor and delivery. Mothers who are obese have a higher risk of: • Problems during pregnancy, such as high blood pressure, gestational diabetes, or preeclampsia.
HOW MUCH WEIGHT SHOULD I GAIN DURING PREGNANCY? Your clinician will work with you to set a weight goal that’s right for you. Although pregnant women often joke that they’re “eating for 2,” you don’t need to eat twice as much food. In general, pregnant women need to eat only about 300 extra calories a day. You can get this in a sandwich or in an apple and a cup of yogurt.
• Cesarean (or C-section) birth and a higher risk of postoperative complications.
HOW MUCH CAN I EAT DURING PREGNANCY?
• Miscarriage or stillbirth.
How much you can eat depends on:
• Incomplete ultrasound fetal evaluations.
• How much you weigh when you get pregnant.
If you’re not pregnant already, being obese can make it hard to get pregnant.
• Your body mass index (BMI).
These are scary problems, and it’s common to worry about you and your baby’s health. But being obese doesn’t mean that you will have these problems. You can do a lot to improve your chances of having a healthy pregnancy.
Like any pregnant woman, you need to eat a variety of foods from all the food groups. You especially need to make sure to get enough calcium and folic acid.
Work with your clinician to get the care you need. Go to all your appointments, and follow your clinician’s advice about what to do and what to avoid during pregnancy.
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• How much you exercise.
You may want to work with a dietitian to help you plan healthy meals to get the right amount of calories.
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HOW WILL OBESITY AFFECT MY PRENATAL CARE? You will have the same number of office visits as a woman of average weight, unless you start to have problems. Then you would see your clinician more often. But you’ll have the same type of tests to look for problems and make sure your baby is healthy.
WHAT CAN I DO TO HAVE A HEALTHY PREGNANCY? The best things you can do to have a healthy pregnancy are to eat a variety of foods, get regular exercise, avoid alcohol and smoking, and go to your medical appointments. If you didn’t exercise much before you got pregnant, talk to your clinician about how you can slowly get more active.
PREGNANCY AFTER BARIATRIC SURGERY Bariatric surgery (such as gastric bypass or banding) helps people lose weight. It’s only used for people who are obese and have not been able to lose weight with diet and exercise. This surgery makes the stomach smaller. Some types of surgery also change how your stomach connects with your intestines.
HOW CAN THE SURGERY AFFECT MY PREGNANCY?
This surgery may increase your risk of having a cesarean birth. But there is some debate about why. It may be that past C-sections increase the risk, rather than the weight-loss surgery. Talk with your clinician if you have concerns about your chance of a C-section.
HOW WILL MY PREGNANCY BE DIFFERENT AFTER WEIGHT-LOSS SURGERY? In most ways, your prenatal care will be the same as for other women. But there are a few differences: • You may need to keep seeing the clinician who did your surgery. This is to make sure that you aren’t having any delayed problems from the surgery. • A dietitian may work with you to make sure you’re getting the nutrition you need and to help you plan meals. • You may need to take extra vitamins and minerals. Weight-loss surgery can make it hard for your body to absorb some nutrients, such as folic acid, calcium, vitamin B12, and iron. Some women may have a hard time with the idea of gaining weight for pregnancy after losing all that weight. Talk to your clinician if this bothers you.
Weight-loss surgery before pregnancy can: • Help you get pregnant if obesity was the reason you had trouble getting pregnant. • Lower your chance of some pregnancy problems. These include high blood pressure, gestational diabetes, and preeclampsia. • Reduce how much weight you gain during pregnancy.
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PREECLAMPSIA AND HIGH BLOOD PRESSURE WHAT ARE HIGH BLOOD PRESSURE AND PREECLAMPSIA? Blood pressure is a measure of how hard your blood pushes against the walls of your arteries. If the force is too hard, you have high blood pressure (also called hypertension). When high blood pressure starts after 20 weeks of pregnancy, it may be a sign of a very serious problem called preeclampsia. Blood pressure is shown as 2 numbers. The top number (systolic) is the pressure when the heart pumps blood. The bottom number (diastolic) is the pressure when the heart relaxes and fills with blood. Blood pressure is high if the top number is more than 139 millimeters of mercury (mm Hg), or if the bottom number is more than 89 mm Hg. For example, blood pressure of 150/85 (say “150 over 85”) or 140/95 is high. Or both numbers can be high, such as 150/95. You may have high blood pressure (chronic hypertension) before you get pregnant. Or your blood pressure may start to go up during pregnancy (gestational hypertension). If you are being treated with high blood pressure medications prior to pregnancy, please discuss this in advance with an advice nurse or clinician as soon as possible. If you have high blood pressure during pregnancy, you need to have checkups more often than women who do not have this problem, and you may need some additional lab work. There is no way to know if you will get preeclampsia. This is one of the reasons that you are watched closely during your pregnancy. High blood pressure and preeclampsia are related, but they have some differences.
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HIGH BLOOD PRESSURE Normally, a woman’s blood pressure drops during the second trimester. Then it returns to normal by the end of pregnancy. But in some women, blood pressure goes up very high in the second or third trimester. This is sometimes called gestational hypertension and can lead to preeclampsia. You will need to have your blood pressure checked often, and you may need treatment. Usually, the problem goes away after your baby is born. High blood pressure that started before pregnancy usually doesn’t go away after your baby is born. A small rise in blood pressure may not be a problem. But your clinician will watch your pressure to make sure it does not get too high. You'll also be checked for preeclampsia. Very high blood pressure keeps your placenta from getting enough blood and oxygen for your baby. This could limit your baby’s growth or cause the placenta to pull away too soon from the uterus. High blood pressure also can lead to stillbirth. High blood pressure can be treated.
PREECLAMPSIA Preeclampsia is a pregnancy-related problem. The symptoms of preeclampsia include new high blood pressure after 20 weeks of pregnancy along with other problems, such as protein in your urine. Preeclampsia usually goes away after you give birth. In rare cases, blood pressure can stay high for up to 6 weeks after the birth. Preeclampsia can be deadly for the mother and baby. It can keep the baby from getting enough blood and oxygen. It also can harm the mother’s liver, kidneys, and brain. Women with very bad preeclampsia can have dangerous seizures. This is called eclampsia.
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WHAT CAUSES PREECLAMPSIA AND HIGH BLOOD PRESSURE DURING PREGNANCY? Experts don’t know the exact cause of preeclampsia and high blood pressure during pregnancy. But they have some ideas about preeclampsia: • Preeclampsia seems to start because the placenta doesn’t grow the usual network of blood vessels deep in the wall of the uterus. This leads to poor blood flow in the placenta. • Preeclampsia may run in families. If your mother had preeclampsia while she was pregnant with you, you have a higher chance of getting it during pregnancy. You also have a higher chance of getting it if the mother of your baby’s father had preeclampsia. • Your immune system may react to the father’s sperm, the placenta, or the baby. • Already having high blood pressure when you get pregnant raises your chance of getting preeclampsia. • Problems that can lead to high blood pressure, such as obesity, polycystic ovary syndrome, and diabetes, could raise your risk of preeclampsia.
WHAT ARE THE SYMPTOMS? High blood pressure usually doesn’t cause symptoms. But very high blood pressure sometimes causes headaches and shortness of breath or changes in vision. Mild preeclampsia usually doesn’t cause symptoms, either. But preeclampsia can cause rapid weight gain and sudden swelling of the hands and face. Severe preeclampsia causes symptoms of organ trouble, such as a very bad headache and trouble seeing and breathing. It also can cause belly pain and decreased urination.
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HOW ARE HIGH BLOOD PRESSURE AND PREECLAMPSIA DIAGNOSED? High blood pressure and preeclampsia are usually found during a prenatal visit. This is one reason it’s so important to go to all of your prenatal visits. You need to have your blood pressure checked often. During these visits, your blood pressure is measured with a blood pressure cuff. A sudden increase in blood pressure often is the first sign of a problem. In the later weeks of pregnancy, you will have a urine test at every visit to look for protein, a sign of preeclampsia. If you have high blood pressure, tell your clinician right away if you have a headache or belly pain. These signs of preeclampsia can occur before protein shows up in your urine.
HOW ARE THEY TREATED? Your clinician may have you take medicine if your blood pressure is too high. The only cure for preeclampsia is delivering your baby. You may get medicines to lower your blood pressure and to prevent seizures. You also may get medicine to help your baby’s lungs get ready for birth. Your clinician will try to deliver your baby when the baby has grown enough to be ready for birth. But sometimes a baby has to be delivered early to protect the health of the mother or the baby. If this happens, your baby will get special care for premature babies.
DO PREECLAMPSIA AND HIGH BLOOD PRESSURE LEAD TO LONG-TERM HIGH BLOOD PRESSURE? If you have high blood pressure during pregnancy but had normal blood pressure before pregnancy, your pressure is likely to go back to normal after you have the baby. But if you had high blood pressure before pregnancy, you probably will still have it after you give birth. 167
PRETERM LABOR WHAT IS PRETERM LABOR?
Causes of preterm labor include:
Preterm labor is the start of labor between 20 and 37 weeks of pregnancy. A full-term pregnancy lasts 37 to 42 weeks. In labor, the uterus contracts to open the cervix. This is the first stage of childbirth.
• The placenta separating early from the uterus. This is called placenta abruptio.
Preterm labor is also called premature labor.
WHAT ARE THE RISKS OF PRETERM LABOR AND PRETERM BIRTH? The earlier the delivery, the greater the risk of serious problems for the baby. This is because many of the baby’s organs — especially the heart and lungs — are not fully grown, or mature. Premature infants born after 32 weeks of pregnancy tend to have less chance of problems than those born earlier. For infants born before 24 weeks of pregnancy, the chances of survival are extremely slim. Many who do survive have long-term health problems. They may also have other problems, such as trouble with learning and talking and with moving their body (poor motor skills).
WHAT CAUSES PRETERM LABOR? Preterm labor can be caused by a problem with the baby, the mother, or both. Often the cause is not known. Preterm labor most often occurs naturally. But sometimes a clinician uses medicine or other methods to start labor early because of pregnancy problems that are dangerous to the mother or baby.
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• Elevated blood pressure or preeclampsia. • Being pregnant with more than one baby, such as twins or triplets. • An infection in the uterus that leads to the start of labor. • Problems with the uterus or cervix. • Drug or alcohol use during pregnancy. • The amniotic fluid breaking before contractions start.
WHAT ARE THE SYMPTOMS? It can be hard to tell when labor starts, especially when it starts early. So watch for these symptoms: • Regular contractions for an hour. This means more than 4 to 6 contractions an hour, even after you have had a glass of water and are resting. • Leaking or gushing of fluid from your vagina. You may notice that it is pink or reddish. • Pain that feels like menstrual cramps, with or without diarrhea. • A feeling of pressure in your pelvis or lower belly. • A dull ache in your lower back, pelvic area, lower belly, or thighs that does not go away. • Not feeling well, including having a fever you can’t explain and being overly tired. Your belly may hurt when you press on it.
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If your contractions stop, they may have been Braxton Hicks contractions. These are a sometimes uncomfortable, but not painful, tightening of the uterus. They are like practice contractions. But sometimes it can be hard to tell the difference.
HOW IS IT TREATED?
If preterm labor contractions do not stop, the cervix begins to open (dilate) or thin (efface). Before or after contractions begin, the amniotic sac that holds the baby may break. This is called a rupture of membranes. It causes a leakage or a gush of amniotic fluid. Rupture of membranes before contractions start is called premature rupture of membranes, or PROM. Before 37 weeks of pregnancy, it is called preterm premature rupture of membranes, or pPROM.
• Try to delay the birth with medicine. This may or may not work.
HOW IS PRETERM LABOR DIAGNOSED? If you think you have symptoms of preterm labor, call your clinician. He or she can check to see if your water has broken, if you have an infection, or if your cervix is starting to dilate. You may also have urine and blood tests to check for problems that can cause preterm labor. Checking the baby’s heartbeat and doing an ultrasound can give your clinician a good picture of how your baby is doing.
If you are in preterm labor, your clinician must weigh the risks of early delivery against the risks of waiting to deliver. Depending on your situation, your clinician may:
• Use antibiotics to treat or prevent infection. If your amniotic sac has broken early, you have a high risk of infection and must be watched closely. • Give you steroid medicine to help prepare your baby’s lungs for birth. This treatment has some risks, but it can improve your baby’s chances of surviving a premature birth between 24 and 34 weeks of pregnancy. • Give you magnesium for potential reduction in long-term neurologic sequelae. • Treat any other medical problems causing trouble in pregnancy. • Allow the labor to go on because delivery is safer for you and your baby than letting the pregnancy go on.
Amniotic fluid can be tested for signs that your baby’s lungs have grown enough for delivery. You may have a painless swab test for a protein in the vagina called fetal fibronectin. If the test does not find the protein, then you are unlikely to deliver soon. But the test cannot tell for certain if you are about to have a preterm birth.
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TOXOPLASMOSIS WHAT IS TOXOPLASMOSIS?
WHAT ARE THE SYMPTOMS?
Toxoplasmosis is a common infection found in birds, mammals, and people.
If you get toxoplasmosis, you may feel like you have the flu, or you may not feel sick at all. Most people who get the infection don’t even know that they have it. Symptoms may include:
For most people, it doesn’t cause serious health problems. But for a pregnant woman’s growing baby, it can cause brain damage and vision loss. Still, the chance of a pregnant woman getting the infection and passing it on to her baby is low. If you’re pregnant or planning to have a baby and are worried that you may have toxoplasmosis, ask your clinician about getting tested. After you have had the infection, you can’t get it again or pass it on to your baby. You’re immune. But if you aren’t immune, you’ll want to take special care while you’re pregnant. Avoid anything that may be infected, such as infected meat and infected cat feces.
WHAT CAUSES TOXOPLASMOSIS? A parasite causes toxoplasmosis. You can get the infection by: • Eating infected meat that hasn’t been fully cooked or frozen.
• Swollen glands. • Muscle aches. • Fatigue. • Fever. • Sore throat. • Skin rash.
HOW IS TOXOPLASMOSIS DIAGNOSED? A blood test can tell whether you have or have ever had toxoplasmosis. If you’re worried about getting the infection, ask your clinician about having the test. If you get the infection while you’re pregnant, you’ll need to have your baby tested. Your clinician can take some fluid from the sac that surrounds your baby and check for the infection.
• Changing an infected cat’s litter box. Cats infected with the parasite pass it on to others through their feces. • Digging or gardening in sand or soil where an infected cat has left feces. • Eating anything that has touched infected cat feces, including fruits and vegetables that haven’t been washed. You can also get the infection by eating food that has touched tables and counters your cat has walked on.
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HOW IS IT TREATED? In healthy people, the infection often goes away on its own. But babies and people whose bodies can’t fight infection well will need to take medicine to treat the infection and prevent serious health problems. If you get toxoplasmosis while you’re pregnant, you’ll take an antibiotic to treat the infection. This medicine may: • Keep your baby from getting the infection. • Lower your baby’s chance of having serious health problems if he or she does get it. Your baby has a better chance of being healthy at birth if you get treatment while you’re pregnant. Most newborns who have been infected with toxoplasmosis have no symptoms at birth. If your baby has the infection, he or she will need to take antibiotics for a year after birth. This lowers the chance of having problems later on.
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HOW CAN I PREVENT TOXOPLASMOSIS DURING PREGNANCY? There are several things you can do to avoid getting toxoplasmosis: • If you have a cat or are caring for one, ask someone to clean or empty the litter box while you’re pregnant. Wash tables and counters well if a cat may have walked on them. If you have to clean the cat’s litter box, wear gloves and a face mask. Be sure to wash your hands after you’re done. • If you eat meat, make sure it has been fully cooked or frozen. Avoid dried meats, such as beef jerky. • Avoid contact with cat feces in your garden. If you touch soil, be sure to wear gloves and wash your hands after you’re done. • Wash fruits and vegetables before you eat them. • Wash your hands and anything you use to prepare raw meat, chicken, fish, fruits, or vegetables.
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URINARY TRACT INFECTION WHAT IS A URINARY TRACT INFECTION? Your urinary tract is the system that makes urine and carries it out of your body. It includes your bladder and kidneys and the tubes that connect them. When germs get into this system, they can cause an infection. Most urinary tract infections are bladder infections. A bladder infection usually is not serious if it is treated right away. If you do not take care of a bladder infection, it can spread to your kidneys. A kidney infection is serious and can cause permanent damage.
WHAT CAUSES URINARY TRACT INFECTIONS? Usually, germs get into your system through your urethra, the tube that carries urine from your bladder to the outside of your body. The germs that usually cause these infections live in your large intestine and are found in your stool. If these germs get inside your urethra, they can travel up into your bladder and kidneys and cause an infection.
You may be more likely to get an infection if you do not drink enough fluids, you have diabetes, or you are pregnant. The chance that you will get a bladder infection is higher if you have any problem that blocks the flow of urine from your bladder, such as kidney stones. For reasons that are not well-understood, some women get bladder infections again and again.
WHAT ARE THE SYMPTOMS? You may have an infection if you have any of these symptoms: • You feel pain or burning when you urinate. • You feel like you have to urinate often, but not much urine comes out when you do. • Your belly feels tender or heavy. • Your urine is cloudy or smells bad. • You have pain on one side of your back under your ribs. This is where your kidneys are. • You have fever and chills. • You have nausea and vomiting.
Women tend to get more bladder infections than men. This is probably because women have shorter urethras, so it is easier for the germs to move up to their bladders. Having sex can make it easier for germs to get into your urethra.
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Call your clinician right away if you think you have an infection and:
CAN URINARY TRACT INFECTIONS BE PREVENTED?
• You have a fever, nausea and vomiting, or pain in one side of your back under your ribs.
You can help prevent these infections. Here are actions that can help:
• You have diabetes, kidney problems, or a weak immune system.
• Drink lots of water every day.
HOW ARE URINARY TRACT INFECTIONS DIAGNOSED?
• Urinate right after having sex.
Your clinician will ask for a sample of your urine. It is tested to see if it has germs that cause bladder infections.
• Urinate often. Do not try to hold it. • In some cases, your clinician may ask that you take an antibiotic daily.
If you have infections often, you may need extra testing to find out why.
HOW ARE THEY TREATED? Antibiotics will usually cure a bladder infection. It may help to drink lots of water and other fluids and to urinate often, emptying your bladder each time. If your clinician prescribes antibiotics, take the pills exactly as you are told. Do not stop taking them just because you feel better. You need to finish taking them all so that you do not get sick again.
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©2015 Kaiser Foundation Health Plan of the Northwest
