Caring for You and Your Baby ABOUT PRENATAL CARE, DELIVERY, AND POSTPARTUM CARE CARILIONCLINIC.ORG
J2557 OB Booklet for Expecting Mothers Updated.indd 1
1/8/15 1:48 PM
WELCOME
PRENATAL CHECKLIST
We would like to take this opportunity to congratulate you on your pregnancy and welcome you to our practice. We are honored to be participating in your care during such a wonderful time in your life.
Fill this in following your appointments. Ask your doctor or nurse for help with the information.
When you are pregnant, there is a lot of information you need to know about the course of a normal pregnancy, things to do to help assure a healthy pregnancy, and what you can expect from your prenatal care. The providers and nurses have created this information booklet to help answer some common questions that many women have.
My estimated due date
Our goal is to provide you with the highest level of care. Our providers want you to have a happy and healthy pregnancy and birth. We encourage you to communicate with us, so that we can help answer your questions and address your concerns. Please let us know if there is anything we can do to enhance your experience. We look forward to working with you and your family during this exciting time in your life.
Thank you for choosing our practice!
(based on
LMP
ultrasound
My last menstrual period
both)
My prenatal labs (date drawn
)
Blood type Antibody screen Hepatitis B Hepatitis C HIV Rubella Hemoglobin
TABLE OF CONTENTS Prenatal Visits ............................................................................................................................................ 3 Prenatal Tests ............................................................................................................................................. 4 Tracking Your Visits ............................................................................................................................... 4-5 Nutrition, Weight Gain, and Healthy Diet ............................................................................................ 6-7 Exercise, Activity, and Travel .................................................................................................................... 8
Pap smear Chlamydia Gonorrhea Syphilis screen Cystic fibrosis Hemoglobin electrophoresis
Employment ............................................................................................................................................ 8-9
My 28-week labs (date drawn
Ultrasound and Fetal Movement .............................................................................................................. 9
Glucose test
Medications During Pregnancy ......................................................................................................... 10-11
Hemoglobin
Common Discomforts and Problems ................................................................................................ 11-15
RhoGam or Rhophylac (if Rh negative) (date given
When and How to Contact Us ................................................................................................................. 15
Repeat HIV test
Prenatal Classes ....................................................................................................................................... 16
Antibody screen
)
)
Preparing for Delivery ............................................................................................................................. 16 After Your Baby is Born ..................................................................................................................... 16-18
My 35- to 37-week lab
After Your Go Home .......................................................................................................................... 18-19
Vaccinations given
Birth Control ...................................................................................................................................... 19-22
Flu shot
1
J2557 OB Booklet for Expecting Mothers Updated.indd 1-2
(date collected
Tdap
)
Group beta strep
Hepatitis B 2
1/8/15 1:48 PM
PRENATAL VISITS Your “estimated due date” (EDD) is based on a 40-week gestational period, starting with the first day of your last menstrual period. The EDD is either confirmed or changed based on your first ultrasound. Your prenatal visits are scheduled according to your due date and gestational age. During your pregnancy, diagnostic studies (such as lab work, cultures, and pap smears) are done to check your health and for any potential risks to the baby. If the test results are normal, we will discuss them with you at your next visit. If the tests come back abnormal, we will notify you of the results and discuss any additional testing or followup, if needed. HIV testing is recommended and will be performed unless you notify your provider that you want to decline this testing. Please keep your phone number and contact information up to date, so that we can reach you easily. If you have worries about a test result and don’t want to wait until the next visit, please feel free to call our office nurse. He or she will be happy to share your results with you. In an uncomplicated pregnancy, your prenatal care visits will typically follow the schedule in the table below. We will check your urine, weight, and blood pressure at each visit. INITIAL VISIT
Review your medical, surgical, family medical history, and your genetic history. You will also have a physical exam and lab work.
12-WEEK VISIT
Listen to the baby’s heart and review your initial prenatal labs. We will also schedule a screening test for Down syndrome, if desired (see the “Prenatal Tests” section in this booklet for more information).
16-WEEK VISIT
Check your uterus size and baby’s heart rate, and offer the “quad screen” to check for Down syndrome and spina bifida, if desired (see the “Prenatal Tests” section for more information). We will also order an 18- to 20-week ultrasound to check the baby’s development. The ultrasound will not be performed in the office but will be scheduled with radiology.
20-WEEK VISIT
Check uterine size and baby’s heart rate.
24-WEEK VISIT
Measure your uterine size, check baby’s heart rate, and review ultrasound results.
28-WEEK VISIT
Measure uterine size, check baby’s heart rate, and draw blood work to check for gestational diabetes and anemia (see the “Prenatal Tests” section for instructions). If you are Rh negative, you will receive your RhoGam injection. Depending on the office where you receive your care, the blood for the lab work may be drawn in the office or you may be sent to the laboratory.
30-WEEK VISIT
Measure uterine size, check baby’s heart, and review your 28-week labs. Get your tdap vaccination.
32-WEEK VISIT
Measure uterine size and check baby’s heart rate. If you would like permanent sterilization, this is a great time to discuss that method of birth control with your provider if you have not already done so (Patients on Medicaid will need to have paperwork signed at least 30 days before the procedure can be performed).
34-WEEK VISIT
Measure uterine size and check baby’s heart rate.
36-WEEK VISIT
Measure uterine size and check baby’s heart rate. Today, we will collect a vaginal swab to check for group beta strep (GBS) (see the “Prenatal Tests” section for more information).
37-WEEK AND WEEKLY UNTIL DELIVERY
Measure uterine size and check baby’s heart rate. If you would like us to check your cervix, please tell the nurse (although this does not have to be done routinely).
3
J2557 OB Booklet for Expecting Mothers Updated.indd 3-4
We recommend that you see different providers during the course of your pregnancy, so you get to know us and we get to know you.
PRENATAL TESTS GENETIC SCREENING TESTS These screenings include the first trimester nuchal translucency test (an ultrasound done between 10 and 13 weeks of pregnancy), first trimester screening, sequential screening, and the quad screen test (done between 15 and 20 weeks of pregnancy). These are screening tests, not diagnostic tests, which means they cannot diagnose a genetic problem, only identify babies who might be at higher risk for genetic problems. If you have an abnormal genetic screening test, we will offer an amniocentesis to diagnose a problem. Amniocentesis involves taking some amniotic fluid out of your uterus, and does have a one in 300 risk for miscarriage or complication, even in a healthy fetus. OTHER TESTS WE RECOMMEND: Test for gestational diabetes (GDM) (high blood sugar during pregnancy) This test is done at about 28 weeks of pregnancy (sometimes we ask women at higher risk for pregnancy-related diabetes to do an earlier test and then repeat the test at about 28 weeks). On the day of your test, you will be given a very concentrated sweet drink. You will then have your blood drawn at one hour after finishing the drink. You do not need to fast for this test. If the test is elevated, we will schedule you for a three-hour glucose test. You will fast for this test and have blood drawn every hour. Please note that this appointment will be three hours in length. If you do have gestational diabetes, we will schedule you to see the diabetic educator. Group beta strep (GBS) test About 25 percent of women are carriers for GBS. There are rarely any symptoms and women who are carriers don’t need any special treatment. However, a few infants who are exposed to GBS during labor can get sick, so we test all women for GBS between 35 to 37 weeks of pregnancy. Using a small cotton swab, we will gently swab just inside your vagina, down your perineum, and barely into your anus. If you are found to be GBS positive, we plan to give you intravenous antibiotics during labor, which helps to prevent the infant from becoming ill.
TRACKING YOUR VISITS You may use the table on the next page to keep track of your appointments. In general, we will plan to see you about every four weeks during the first part of your pregnancy, then every two weeks from 28 to 36 weeks gestation. We will see you weekly during the last month of pregnancy (36 weeks until delivery). During the visits, we will measure your uterus, listen to the baby’s heartbeat, and review any lab work with you. We also encourage you to bring any questions you might have with you (some women actually find it helpful to make a list of questions to ask, as forgetfulness is common during pregnancy!). 4
1/8/15 1:48 PM
PRENATAL VISITS
NUTRITION, WEIGHT GAIN, AND HEALTHY DIET DURING PREGNANCY
(for your personal records, in case you would like to keep track of your visits)
Healthy nutrition is an important part of a successful pregnancy. Everything you eat helps to nourish your body and helps your growing baby. If you started at a normal pre-pregnant weight, we would like you to gain between 25 and 35 pounds during pregnancy. Most women gain about a pound a week, on average, during the second half of pregnancy. If you started out your pregnancy overweight we would like you to gain about 15 pounds. If you started out underweight, we would like you to gain about 40 pounds. This ensures your baby gets enough calories and nutrition to thrive. Please discuss your prepregnant weight and recommended weight gain with your provider.
DATE
WEEKS GESTATION
WEIGHT
BP
TOTAL WEIGHT GAIN
FUNDAL HEIGHT (CM)
FETAL HEART RATE
COMMENTS
HEALTHY DIET: Try to eat mostly fresh, unprocessed foods, including fruits, vegetables, whole grains, beans, nuts, legumes, low-fat dairy (good source of calcium), and unprocessed lean meats. We encourage women to drink mostly water and low-fat milk. Limit or avoid over-packaged, high-fat, fried “junk” food and fast food, and try to limit your soda intake. CAFFEINE AND WATER: You should only drink small amounts of caffeinated drinks (one to two a day), as high caffeine consumption can cause problems during pregnancy. Most women feel better if they drink enough water every day. Drinking plenty of water helps prevent constipation, urinary tract infections, and swelling in your legs and feet. Your urine should be pale yellow (sometimes bright yellow after taking your prenatal vitamin). If your urine is very dark yellow to tea-colored or concentrated, you probably need to drink more water. Please let us know if you have pain with urination or other problems. LISTERIA: Listeria is bacteria found in unpasteurized milk, some luncheon meats, and smoked seafood. Foods to avoid during pregnancy include soft, unprocessed or unpasteurized cheeses, such as Brie, feta, Camembert, blue-veined cheeses, and Mexican-style cheeses such as queso fresco, queso blanco, and panela. Also be cautious when eating hot dogs, luncheon meats, or deli meats, unless they are heated to steaming (at least 160 degrees F). Do not eat refrigerated smoked salmon unless it is in a cooked dish, such as a casserole, and avoid cold paté or meat spreads. Heating the foods listed above to steaming hot will kill any dangerous bacteria, making them safe to eat. Wash all raw foods well before eating. Semi-soft and hard cheeses, including mozzarella, are safe. You can safely enjoy any cheese that has been pasteurized, including processed soft cheeses, such as cream cheese and cottage cheese. FISH DURING PREGNANCY: You may have questions about which fish are safe to eat during pregnancy. We recommend you eat no more than two servings of fish per week. Fish and shellfish do contain omega3 fatty acids and other important nutrients. While pregnant, avoid eating shark, grouper, marlin, orange roughy, king mackerel, swordfish, and tilefish, as these are known to contain high levels of mercury. Also eat only three 6-ounce servings a month or less of the following: saltwater bass, croaker, canned white albacore tuna, fresh bluefin or ahi tuna, sea trout, bluefish, and American lobster (Maine lobster). You can eat a serving of chunk light canned tuna once or twice a week. You can safely enjoy other fish in moderation, once or twice a week. Avoid raw fish, such as found in sushi. 5
J2557 OB Booklet for Expecting Mothers Updated.indd 5-6
6
1/8/15 1:48 PM
TOXOPLASMA: This is a harmful parasite that causes toxoplasmosis. It is found in raw/undercooked meat, unwashed fruits and vegetables, soil, and cat litter boxes. Wash all fruit and vegetables, cook meat thoroughly, and avoid changing the litter box. VITAMINS DURING PREGNANCY: We also recommend that you take a daily prenatal vitamin containing iron, folic acid, and DHA. You can buy an over-the-counter brand, or we are happy to prescribe you a prenatal vitamin—just let us know which pharmacy you prefer. If you are too nauseated to take a regular prenatal vitamin in early pregnancy, you can take two chewable Flintstones vitamins or chewable prenatal vitamins (with iron). Sometimes those are easier on your stomach. Also, try to eat plenty of fresh fruit and vegetables of many different colors and types to help nourish your growing baby. Folic acid is a B vitamin that is very important in pregnancy. Prior to pregnancy, and during the first 12 weeks of pregnancy, you need 0.4 milligrams (or 400 micrograms) of folic acid daily in order to decrease the risk of neural tube defects. Women who have had a previous child with a neural tube defect will be recommended to take higher doses (4 milligrams daily). A BRIEF WORD ABOUT IRON SUPPLEMENTS: Usually your prenatal vitamin with iron is all you need to take during pregnancy. However, some women do develop anemia, or low iron, while pregnant. If you develop this condition we will recommend an additional iron supplement. If we recommend you begin an iron supplement, you should take it at a different time than your prenatal vitamin. You can take it about 20 minutes before dinner time with a small glass of orange juice or another source of vitamin C, which helps your body to absorb the iron. Some women report dark stools, constipation, or upset stomach with iron supplements. Be sure to drink plenty of water, eat a diet high in fiber, and walk daily to help your bowels move normally. We recommend women with anemia also increase their dietary sources of iron. Here is a list of foods rich in iron:
EXERCISE AND ACTIVITY Exercise is good for you and your developing baby. If you are already involved in a regular exercise program you may continue as long as you feel comfortable and we haven’t placed you on any specific activity restrictions. We recommend that you avoid contact sports and sports that could be dangerous, including scuba diving, rock climbing, horseback riding, downhill skiing, mountain biking, etc. Lowimpact activities such as walking, biking, and swimming are all highly recommended. You may continue to have sex throughout pregnancy without any fear of harming the baby, unless we advise otherwise. However, if you are actively bleeding or think your water may have broken, please don’t put anything into your vagina and give us a call right away. Generally, if an activity won’t cause you to hit or strike your uterus and does NOT cause bleeding or contractions, it is most likely safe. We are happy to discuss your usual activities with you, if you have concerns. We also want to remind you that it is very important to wear your seat belt every time you are in a car. Wear the lap belt low, across your pelvic bones, just below your pregnant belly. It is also important to use the shoulder belt, which should fit snuggly between your breasts. Wearing a seat belt could save you and your unborn baby’s life!
TRAVEL The best time to travel would be during the middle of your pregnancy, 14 to 28 weeks. During long car trips, remember to make frequent stops to move around and stretch your legs to help prevent blood clots. Airlines may restrict travel in the last month of pregnancy or require a medical certificate.
MASSAGE Prenatal massage is safe during pregnancy. You will have to see a therapist who is comfortable and familiar with performing prenatal massage.
»» Red meat, including beef, pork, lamb, and liver
»» Tofu
»» Chicken and turkey, especially dark meat
»» Egg yolks
»» Oysters, clams, and scallops
»» Blackstrap molasses
EMPLOYMENT
»» Beans, including kidney, lima, navy, black, pinto, soybeans, and lentils
»» Dried fruits, including raisins, prunes, dates, and apricots
»» Iron-fortified whole grains, including cereals, breads, rice, bagels, cream of wheat, and pasta
»» Nuts
If you are employed outside the home, it is your responsibility to take care of yourself and communicate your needs to your employer. While we don’t place any restrictions on healthy pregnant women, we do recommend you consider these sensible tips:
»» Greens, including kale, mustard greens, spinach, and turnip greens
»» Vegetables, including broccoli, artichokes, string beans, sweet potatoes, and asparagus
»» Limiting your work hours to eight hours a day and 40 hours a week, if possible »» Avoiding prolonged standing or sitting (you will feel better if you can take a five minute break at least every two hours) »» Limiting lifting heavy items to 25-35 pounds without additional assistance, unless you were accustomed to this sort of heavy work before pregnancy »» Be sure to have adequate ventilation and try to avoid extreme temperatures
7
J2557 OB Booklet for Expecting Mothers Updated.indd 7-8
8
1/8/15 1:48 PM
If you choose to stop working before your baby is born, it is your responsibility to discuss this with your employer and make the appropriate arrangements. Most Family and Medical Leave Act (FMLA) leave begins when you go into labor. If there is employment associated paperwork you need completed by our office, drop off the forms at our office and give us at least two weeks to complete the paperwork. Pregnancy is not considered an illness. While some women may choose to stop working before the baby is born, the providers can’t write a letter saying it is medically necessary to be off work unless you have an actual medical reason for this.
ULTRASOUND Most patients have an ultrasound ordered by the provider at some time during the pregnancy. The purpose of the ultrasound will be explained to you by the provider who orders it. If the sex of the baby is seen during the ultrasound, the technician will tell you if you want to know. An ultrasound is never ordered just to determine the sex of the baby. Your ultrasound that is performed around 20 weeks gestation is likely the time that you can tell the sex of the baby.
MEDICATIONS DURING PREGNANCY In general, we prefer women to avoid most medications during pregnancy. However, some medications have a long history of safe use and we are okay with you taking them. If you are on a medication, please discuss it with your provider. There are a few medications that are dangerous during pregnancy so be sure all your healthcare providers, including your dentist, know you are pregnant. We recommend you try to avoid all medications in the first trimester (first three months) of pregnancy unless absolutely needed. The following medications are generally considered safe and you may take them without first contacting our office: FOR SLEEP: Benadryl (diphenhydramine), Tylenol PM, or Unisom (doxylamine)
FOR PAIN, HEADACHE, OR MUSCLE SORENESS:
FETAL MOVEMENT If this is your first baby, you might start feeling the first flutter of movement around 19 weeks gestation. Some women, particularly those who have had a child in the past, will feel the baby move sooner, perhaps around 16 weeks gestation. Some women may feel the baby move later than 20 weeks. Movements can be described as rolling, punching, kicking, or stretching in your uterus. Once you have reached 28 weeks of pregnancy, you should be feeling the baby move every day. Feeling fetal movement is a “low tech” way to tell you that the baby is doing well. Most babies have a certain time of day when they are more active, such as just after dinner, just after you go to bed, or first thing in the morning. Once you reach 28 weeks of pregnancy we would like you to take time each day, during your baby’s active time, to notice his or her movements. If you feel that your baby is not moving normally, please give us a call right away. DAILY FETAL KICK COUNT: Sometimes we ask women to do a fetal kick count. If you have been instructed to do this daily count, we ask that you count the number of times your baby moves during his or her active time of the day. If the baby moves at least 10 times in two hours, no need to call us. If your baby moves less than 10 times in two hours, we would like you to give us a call right away. FETAL MONITORING: Some patients will require fetal monitoring. This is a simple test to listen to the baby’s heartbeat and watch what the heart rate does when the baby moves. You will sit in a comfortable chair with a belt around your abdomen where the monitor is attached. It usually takes about 20 to 40 minutes to complete the test.
9
J2557 OB Booklet for Expecting Mothers Updated.indd 9-10
T ylenol (acetaminophen)—may take two regular strength every four hours or two extra-strength every six hours as needed
FOR MORNING SICKNESS: itamin B6 (25 mg three times a day), works best when also taken with Unisom (Doxylamine) (1/2 a tablet V once or twice a day) See the following section of this booklet for other measures
FOR NAUSEA, UPSET STOMACH, OR GAS: Emetrol, Mylanta (aluminum hydroxide), or Gas X (simethicone)
FOR HEARTBURN: Tums (calcium carbonate), Zantac (ranitidine), Pepcid AC (famotidine), Mylanta, or Maalox
FOR CONSTIPATION: »» Fiber source such as Metamucil or Citrucel or another source of added fiber »» Glycerin suppository, Milk of Magnesia, or Senekot »» Stool softener such as Colace or Surfak (ducosate) »» See the following section of this booklet for other measures
FOR HEMORRHOIDS: Tucks medicated pads, witch hazel compresses, Anusol, or Preparation H
10
1/8/15 1:48 PM
FOR UPPER RESPIRATORY ILLNESSES (COUGH, COLD, SORE THROAT): »» Nasal saline spray, Benadryl (diphenhydramine), Actifed (chlorpheniramine and phenylephrine), Zyrtec (cetirizine hydrochloride), Sudafed (pseudoephedrine), Tylenol Cold & Sinus (acetaminophen and pseudoephedrine) »» Cough: Halls Cough Drops or other cough drops, such as Ricola, Vicks Vapo-Rub, Robitussin DM (dextromethorphan and pseudoephedrine), Dimetapp (brompheniramine and pseudoephedrine) »» Sore throat: Chloraseptic throat spray, Tylenol (acetaminophen), and Luden’s throat drops
FOR DIARRHEA: Imodium AD (loperamide) FOR YEAST INFECTION: »» Monistat or other vaginal yeast creams (insert the applicator carefully, don’t insert too far) »» Please contact our office if you suspect a vaginal infection, especially if it does not respond to the overthe-counter yeast medications, because other infections can cause itching or vaginal discharge
FOR ALLERGIES: Benadryl (diphenhydramine), Claritin (loratadine), or Zyrtec (cetirizine)
FOR RASHES OR SKIN CONDITIONS: »» Benadryl cream or ointment, Calamine lotion, hydrocortisone cream 1 percent, Aveeno oatmeal baths »» Neosporin as a first aid ointment Please AVOID taking Ibuprofen (Motrin or Advil), Pepto Bismol, and aspirin. If you have high blood pressure, do not take over-the-counter medications containing phenylephrine or pseudoephedrine (Sudafed or medications followed by D).
COMMON DISCOMFORTS AND PROBLEMS DURING PREGNANCY VAGINAL SPOTTING Vaginal spotting occurs in half of all pregnancies, especially in the first 12 weeks. Most of the time this spotting will resolve on its own. It sometimes occurs after intercourse or after straining to use the bathroom when constipated and is not always a sign of miscarriage. If the spotting is light, avoid intercourse for a day or two. If the spotting becomes heavy, like a period (with or without cramping), avoid intercourse and please give us a call. VAGINAL DISCHARGE Many women have an increase in vaginal discharge during pregnancy. This discharge is usually white, cloudy or clear, and thin. If the discharge has a fishy or foul odor, causes itching or vaginal pain, or seems to be water instead of mucus, then please give us a call.
11
J2557 OB Booklet for Expecting Mothers Updated.indd 11-12
UTERINE CRAMPING Some cramping and uterine contractions are normal during pregnancy, as long as they are mild and don’t occur every 10 minutes or closer. If you notice cramping pain in your lower abdomen or back that lasts for about a minute then relaxes, especially with pelvic pressure and a hard uterus, it is most likely a contraction. If you have a contraction every 10 minutes or closer, drink two big glasses of water and either lie down or take a warm bath. If the contractions do not stop right away, please call us. HEADACHES Headaches are very common during pregnancy due to the hormonal changes. Some measures you can use are increasing your water intake, resting with a cold cloth or ice pack on your head, taking Tylenol as directed, and trying to drink a caffeinated drink (such as cola or coffee). Be sure to eat small, frequent meals and snacks to help maintain your blood sugar, which can help with headaches. If you have a severe headache not relieved by acetaminophen, like Tylenol, please call us. ROUND LIGAMENT PAIN As your uterus grows, the ligaments that help support it also stretch. The ligaments then might spasm briefly. Sometimes women get fairly sharp pains down low in the abdomen, just above the pubic bone or on the sides of the uterus, where the ligaments attach. These pains might increase after being more active, especially after activities involving bending and twisting motions. If the pains are short and go away quickly this is probably normal. Try a warm bath, sleeping with a pillow between your knees, applying a warm pack or ice pack, taking Tylenol, and avoiding twisting motions while you work (turn your entire body versus just twisting your trunk). You can try lying on the side that is cramping and pulling that leg toward your chest. If your pain is severe, does not go away, is rhythmic like contractions (regular pains every 10 minutes, lasting for a minute, then relaxing) or causes you worry, please call us. MORNING SICKNESS OR NAUSEA AND VOMITING This is a common issue during pregnancy and luckily it mostly resolves by about 13 weeks. As long as you are able to keep down some food and fluids it should not cause any long-term problems for you or the baby (except that you might feel miserable). Some measures you can take are to keep well-hydrated (try drinking about 1 ounce of Gatorade, water, or diluted fruit juice every 15 minutes to stay hydrated). Unisom and vitamin B6 together have been shown to be helpful (see the medication section in this booklet). You can also take Tums or Emetrol. Some find that ginger tea, ginger ale, or eating candied ginger may also be helpful. Some women find the scent of a fresh cut lemon (or a cotton ball soaked in lemon extract) provides some relief, as does sucking on sour lemon candies. You can try using “Sea Bands,” which fit over your wrists and put pressure on an acupressure point—this has been shown to help some women. Small frequent meals and snacks are a good idea too. It might also help to eat a high protein bedtime snack and bland foods (bananas, rice, applesauce, and toast). If you should become dehydrated or are losing significant amounts of weight, or are just feeling awful, call us for further instructions. We also want you to call if you are unable to keep down anything for more than 24 hours, if you are unable to urinate, or your urine becomes scant and dark colored. 12
1/8/15 1:48 PM
SWOLLEN FEET AND ANKLES Swelling in the feet and ankles (or hands) is very common during pregnancy. It is caused by fluid retention and it usually gets worse late in the day. Drinking enough water is the number one way you can help decrease swelling. You can also try limiting your intake of salty foods (such as chips, pretzels, processed meats, and canned foods) and elevating your feet periodically during the day. Some women find wearing a maternity support garment can be helpful. When you lie down, try resting on your left side to help promote good circulation. Avoid constricting clothing such as tight socks or knee high hose. We also recommend comfortable shoes and full length support hose. Note: Rapid onset of swelling in the face and hands accompanied by a severe headache unrelieved by Tylenol can be a sign of a complication of pregnancy. Please call us if these symptoms occur. LEG CRAMPS Leg cramps can result from a variety of reasons during pregnancy. In some cases, an imbalance between magnesium and calcium can contribute to the problem, as can the decreased circulation in the lower legs during pregnancy. To relieve a calf cramp, extend your leg out straight and lift your toes toward your knee (like taking your foot off the gas pedal). To prevent leg cramps, you should not point your toes (this can cause a cramp to happen). We recommend you try doing gentle calf stretches several times a day—stand on a stair step with your heel hanging off the edge and gently drop your heel until you feel a non-painful stretch in your calf muscle. You can also try an over-the-counter magnesium supplement. CONSTIPATION The hormones of pregnancy as well as other factors tend to increase constipation in pregnant women. We recommend the following: »» A diet high in fiber (fruits and vegetables), including prune juice and dried plums »» Drink six to eight glasses of water per day (your urine should be pale yellow in color—if there is a strong odor and dark color, you are most likely not drinking enough water) »» Walking every day (this helps your bowels to move and has the added benefit of being good for your pregnancy and baby too) »» Supplemental fiber, such as Metamucil, Citrucel, Fiber One cereal, Uncle Sam cereal, high fiber bars, etc.
HEMORRHOIDS OR VARICOSE VEINS IN THE VULVAR REGION (NEAR YOUR VAGINA) Hemorrhoids are a common problem during pregnancy. Many women notice pain and bleeding after a bowel movement (BM), and tenderness or irritation at the rectum from this condition. Straining while trying to have a BM can also lead to hemorrhoids. To prevent hemorrhoids, eat a diet high in fiber and stay well hydrated. If you suffer from hemorrhoids, you can use a stool softener daily, if needed. One brand is Colace, which is available at the pharmacy without a prescription. You can also buy Tucks pads or witch hazel (make your own compress by soaking a disposable cosmetic pad or small cloth with witch hazel). These can soothe and help shrink hemorrhoids or vulvar varicosities. Some women find that wearing a maternity belt, which lifts the pregnant uterus, can help reduce pelvic varicose veins. This type of garment can be purchased online (“Stork S’port” or “Prenatal Cradle” are popular brands), at many department stores, or at maternity clothing shops. 13
J2557 OB Booklet for Expecting Mothers Updated.indd 13-14
VARICOSE VEINS IN THE LEGS These are also common during pregnancy. Resting frequently with your legs elevated can help reduce the pressure in your leg veins. Consider purchasing support hose and wearing those each time you are up and about. You may find that a maternity support belt also helps. BACK PAIN Sadly, lower back pain is a common problem during pregnancy. As your uterus grows it causes your lower back to become more curved. We become concerned if you have an intermittent and regular cramping pain in your lower back (every 10 minutes or more frequently), which can be a sign of preterm labor. We are also concerned if you have a severe pain on one side of your back over your kidney (especially if accompanied by a fever or urinary tract infection symptoms), which can be a sign of a kidney infection. Some measures that might help lower back pain include taking Tylenol, warm baths, having someone massage your back for you, and being sure to use correct posture. Some women find that wearing a maternity belt, which lifts the pregnant uterus, can help too. This type of garment can usually be purchased online (“Stork S’port” or “Prenatal Cradle” are popular brands), from many department stores, and maternity clothing shops. INSOMNIA It is not uncommon to experience difficulty sleeping at some point during pregnancy, particularly in late pregnancy, as it can be hard to get comfortable. Try a warm bath and glass of milk at bedtime. Try to keep to a regular schedule, going to bed and waking up at the same time each day. Keep your bedroom quiet and dark and use the bedroom only for sex or sleeping (watch TV in another room). Consider some sort of white noise device if you live in a noisy area. If you are tossing and turning, get out of bed, go into another room, and engage in a boring/quiet activity until you feel drowsy again. You may take Benadryl, Tylenol PM, or Unisom as needed, and contact us if the problem is severe. HEARTBURN Heartburn can be reduced by eating smaller, frequent meals, eating slowly, limiting spicy or fatty foods, limiting carbonated beverages, remaining in an upright position for several hours after eating, and trying medications (see medication list). You can also raise the head of the bed 4 inches (using blocks, books or store-bought risers). Tums (calcium carbonate), Zantac (ranitidine), Pepcid AC (famotidine), Mylanta, or Maalox may also help. DIARRHEA OR STOMACH FLU Diarrhea can cause intense cramping and discomfort and can lead to dehydration. Begin treatment by consuming only clear liquids, such as Gatorade, ginger ale, and broth soups for 24 hours, and then gradually introduce a bland diet for the next 24 hours. If your diarrhea is not improving over time, or your urine becomes scant and dark, please call us or your primary care provider for advice. If needed, you can take Imodium AD for diarrhea. COLDS, FLU, SINUS PROBLEMS, AND ALLERGIES During pregnancy, women are more susceptible to respiratory ailments like colds and flu, and these illnesses tend to last longer too. Most over-the-counter medications are safe to use as long as they do not contain aspirin or ibuprofen (see the list in the previous section). If you develop a fever 14
1/8/15 1:48 PM
over 100.6 degrees F, green nasal discharge, or are coughing up bloody or colored sputum, please let us know (or call your primary care provider). We want to remind you that viruses do not respond to antibiotic therapy. During flu season, we do recommend you get the flu vaccine, which we can administer in our office. The flu vaccine is safe and strongly encouraged for pregnant women and new parents, and you need one each year. We also recommend you wash your hands frequently, don’t touch your face unless you have just washed your hands, and try to stay away from people who are coughing and sneezing. See the medication section of the booklet for more information. Allergy medications such as Benadryl, Claritin, and Zyrtec are safe to take during pregnancy.
WHEN AND HOW TO CONTACT US While we prefer you to call the office between 8 a.m. and 4:30 p.m. for regular questions or nonemergency issues, we want you to know that there is a physician on-call for emergency issues around the clock.
PRENATAL CLASSES Carilion offers an assortment of classes, such as breastfeeding, well baby care, prepared childbirth, infant CPR, and a variety of other classes. Please call 800-422-8482 or 540-266-6000 for a schedule of classes and to register. We highly recommend these classes, especially if you are a first-time parent. If you are planning natural childbirth, without the use of epidurals or IV pain medication, we strongly recommend some sort of childbirth preparation class, so that you have the training and mental preparation you and your partner will need to have a positive birth experience. Plan to discuss your birth plan with your provider during one of your visits.
PREPARING FOR DELIVERY As you prepare for delivering your baby, you may want to pack the following items for your comfort: »» Robe and slippers
»» Support bra
For after-hours emergencies or if you think you are in labor, you can always reach the on-call physician by calling the hospital operator at 540-981-7000 and ask for the OB doctor on call for the office where you are a patient.
»» Toiletries
»» Going home outfit and blanket for the baby
»» Medications you are currently taking or a list of the medications
»» Comfortable outfit for mom’s trip home
WARNING SIGNS—CALL US (EVEN AFTER USUAL OFFICE HOURS) IF YOU HAVE THE FOLLOWING:
»» Insurance card
»» Decreased from normal or no fetal movement (if you are far enough along to expect daily movement— see the section on fetal movement in this booklet)
»» Camera (film and batteries if needed)
»» If you have heavy bleeding or bleeding like a period »» Cramping pain or contractions every 10 minutes (if you are less than 36 weeks pregnant) or active labor signs, such as strong contractions that last about a minute and are coming regularly every five minutes for an hour or two »» High fever or severe pain. If you have a fever greater than 101 degrees F, severe pain, injury, or any other reason for which you would go to the ER if you were not pregnant (Note: you may also contact your primary care provider or go to the emergency department if you think it is a non-pregnancy related severe illness). »» Excessive vomiting, particularly if you can’t hold down any fluids or foods for 12-24 hours or you have become dehydrated and cannot urinate »» Premature labor symptoms—If you are less than 36 weeks pregnant and have cramping uterine pains every 10 minutes or closer (your stomach tightens like a fist), you might be in preterm labor. You may also have lower back pain, leaking water, bleeding from your vagina, diarrhea, pain that radiates from your uterus to your thighs/upper legs, cramps that feel like your period, and increased pelvic pressure, like the baby is pushing down. »» If your water has broken (This may be a sudden gush or a slow steady trickle) »» If you have had a C-section before and begin to have labor pains
15
J2557 OB Booklet for Expecting Mothers Updated.indd 15-16
»» Car seat (state law requires a federally approved infant safety seat for transporting your baby in a vehicle)
Remember to choose a pediatrician before delivery. Carilion Clinic offers several offices throughout our region. For more information, please call 800-422-8482 or visit CarilionClinic.org.
AFTER YOUR BABY IS BORN BREASTFEEDING While we understand that some women may not be comfortable with the idea of breastfeeding, we want to encourage you to consider this method of feeding your new baby. Breastfeeding is nature’s best way to nourish your child and your milk is uniquely suited to your own baby’s nutritional needs and stage of life. Breastfeeding confers many benefits to both you and your baby. Infants who are breastfed have fewer illnesses and are less likely to suffer from allergies and wheezing illnesses. Breastfed babies are less likely to have SIDS (sudden infant death syndrome). Breastfed babies score higher on IQ tests as well as on measures of social and cognitive development. Mothers who breastfeed are less likely to develop certain types of cancer or other illnesses. Mothers who breastfeed also may have an easier time losing the weight they gained during pregnancy. A recent study suggested that there is no difference in the amount of sleep of babies who bottle feed or breastfeed—it is a myth that bottle fed babies sleep better. Most moms also relate how special they found the mother-baby breastfeeding bond to be, and breastfeeding releases beneficial hormones into the mother’s bloodstream. Carilion has certified lactation consultants available to you in the hospital and after you go home (by appointment) to help you with any breastfeeding questions or problems. Please feel free to call Carilion at 540-266-6000 or 800-422-8482 for more information.
16
1/8/15 1:48 PM
KANGAROO CARE: HOLDING YOUR BABY SKIN-TO-SKIN This is a special way to hold your baby skin-to-skin right after the delivery, while you are in the hospital room, and when you are at home. After birth, your baby wears only a diaper and hat, then is placed directly on your chest and covered with a blanket. Sometimes there are medical reasons that keep you from holding your baby in kangaroo right after birth (your caregiver will help you start as soon as possible). You and your baby may kangaroo any time during your hospital stay. Dads can also kangaroo, too, especially while you shower or sleep. Doctors say this is the best care for your baby and all babies benefit from skin-to-skin or kangaroo care.
If you must leave the room to smoke, please have a non-smoking support person or family member take care of your baby while you are out of the room and be sure to change your clothing and wash your hands when you return to prevent exposure of third-hand smoke (chemicals from cigarette smoke that land on any surface such as your hair, skin, fabric items, toys, etc.) to your baby and others.
BENEFITS FOR BABY AND MOM
AFTER YOU GO HOME
Your baby will: »» Transition to the outside world easier »» Be warmer »» Cry less and sleep more »» Hear your voice and heartbeat »» Get important antibodies from your skin »» Breastfeed more easily
You will: »» Have a greater milk supply for breastfeeding »» Feel more confident in caring for your baby
COUPLET CARE Research has shown that a mother/baby couplet care model is the most effective method to provide care for mothers, newborns, and families. At CRMH, we promote couplet care by supporting family participation during the childbearing experience. Couplet care provides individualized, high-touch nursing care, and places the needs of the mother and her family first. We accomplish this by assigning a nurse to care for the mother/baby couple while minimizing the separations or interruptions to the family unit. After a healthy delivery, and when mom and baby are stable, they are moved to a new room on the 12th floor. There, the mother and baby stay in the same room together, day and night. Keeping parents and babies together supports the physical, emotional, and social well-being of the new family members. Procedures such as evaluation, bathing the newborn, and screening for hearing are all completed in the mother’s room. Please understand that if you need to leave your room for personal reasons such as going to the gift shop, making a phone call, or to smoke, you will need to have someone (your support person or family member) take care of your baby. To ensure that we can provide couplet care for all moms, our nurses will not be responsible for watching your baby when you are out of the room unless it is medically necessary.
17
J2557 OB Booklet for Expecting Mothers Updated.indd 17-18
QUIET TIME We understand new moms need quiet time to rest and bond with their baby. Visitors are asked to keep traffic and noise to a minimum during the following quiet time hours: 2 - 4 p.m. and 9 - 11 p.m.
YOUR NEXT APPOINTMENT After you have your baby you might have some more questions. We want you to know that we are still available to you to answer your questions and help you in any way we can. We will see you here in the office at about six weeks after delivery. You can call our office once you get home from the hospital to make your appointment. At that visit, we will do a brief exam to be sure your body is back to normal and will also discuss birth control with you, if you need that information (see page 19). We recommend you continue your prenatal vitamin for at least six weeks (or the entire time you are breastfeeding). POSTPARTUM WARNING SIGNS After you get home and settled in, you should notice you are getting better each day. If you are feeling worse instead, you may want to call and check in with us. Please call us if you have any of the following postpartum warning signs: »» Fever higher than 100.4 degrees F »» Bleeding heavily (soaking a pad in an hour or more frequently) or a foul odor to your bleeding »» Increasing pain not controlled with ibuprofen (Motrin) or acetaminophen (Tylenol) »» Severe headache unrelieved by Tylenol or Motrin »» Feeling an increasing sense of sadness, anxiety, or depression (see below) »» Leaking pus, bleeding, or increased pain at the site of any stitches (either in the vaginal area or on your abdomen if you had a cesarean section)
Note: If you had a vaginal tear that was repaired, it is normal to notice small pieces of the suture material falling off after a week or two as the stitches dissolve. POSTPARTUM DEPRESSION Postpartum depression is surprisingly common and our society doesn’t do that great of a job identifying women who are suffering from it. This disorder can impact the health and well-being of your newborn child and be a very negative experience for you. This type of depression and/or anxiety can affect any woman, regardless of age, income, birth experience, health, or previous history, so all women and families need to be alert for symptoms. Postpartum depression is more common in women with a history of depression or previous postpartum depression. 18
1/8/15 1:48 PM
It is normal in the first week or two after your baby is born to have some ups and downs in your emotions. This is known as the “baby blues.” One moment you may feel happy and the next moment you are sad or crying. This is very normal, as your hormones are changing and you have just been through an emotional and possibly exhausting experience. However, this should resolve within a short time frame and be fairly mild. If after a week or two (or sooner) you notice you are feeling very sad, anxious, overwhelmed, angry, helpless, ashamed, or out of control, you might have postpartum depression. Some women even have thoughts of hurting themselves or their baby. Women who have had a baby are at risk for postpartum depression for a full year after the birth of the child.
COMMON METHODS OF BIRTH CONTROL, FROM MOST EFFECTIVE TO LEAST EFFECTIVE (AND A FEW OF THE PROS AND CONS OF EACH METHOD LISTED) METHOD Mirena intrauterine system—contains progesterone
As you approach the end of pregnancy we would like to discuss birth-control methods with you, if you are interested in this information. There are a lot of methods out there and most women can find a method that will suit their life and family. If you have Medicaid for your insurance and plan to have permanent sterilization (your “tubes tied”), let us know at least a couple of months before your due date so that we can complete the necessary paperwork for that type of insurance. Please feel free to discuss birth control methods with us during your pregnancy and again during your postpartum exam. We want to help you find the right method for you. We would suggest you check with your insurance company regarding the coverage of your contraceptive choice.
Skyla intrauterine system— Very reliable method; safe contains progesterone for breastfeeding mothers; lasts up to three years but may be removed before then; causes very light periods in most women, with some women reporting no periods at all
Must be placed by Over 99 percent effective provider in the office; causes irregular spotting and bleeding in most women for the first three to six months of use
Paragard intrauterine device Very reliable method; hormone free; safe for breastfeeding mothers; lasts up to 10 years but can be removed before then
Must be placed by provider in Over 99 percent effective the office; many women report heavier periods and increased cramping pain with menses, particularly in the first year of use
Very reliable method; safe for most people
Permanent, so some might Approximately regret decision; can be 99 percent effective expensive if no insurance; surgical procedure that carries slight risk (particularly the BTL); Medicaid patients must sign a form at least 30 days in advance to be covered (and must be at least 21 years old)
Nexplanon—progesterone Very reliable method; safe containing implanted device for breastfeeding; lasts for three years
Some women have side effects Approximately from the hormone; irregular 99 percent effective bleeding; expensive up-front cost if no insurance
• Essure (Hysteroscopic tubal occlusion) • Vasectomy (for men)
J2557 OB Booklet for Expecting Mothers Updated.indd 19-20
EFFECTIVENESS
Must be placed by provider Over 99 percent effective in the office; causes irregular spotting and bleeding in most women for the first three to six months of use
Permanent sterilization: • Bilateral Tubal Ligation (BTL)
19
CONS
Very reliable method; safe for breastfeeding mothers; lasts up to five years but can be removed before then; causes very light periods in most women, with some women reporting no periods at all
If you think you have any symptoms of postpartum depression, please call us right away. We can help you sort through the emotions you are experiencing, help you with any problems, and make sure you receive treatment for this serious postpartum illness.
BIRTH CONTROL
PROS
20
1/8/15 1:48 PM
METHOD
PROS
CONS
Depo Provera— contains progesterone
Very reliable if you come back in for the injections as scheduled; safe method for most women; many women have very light or no periods on this method
May cause weight gain, acne, decreased sex drive, and depression in some women
Approximately 97 percent effective
Pill—an oral contraceptive pill containing estrogen and progesterone
Reliable method if taken correctly; lighter and more regular periods; welltolerated by most women
Not a good method for breastfeeding mothers as can decrease milk supply; contains hormones (so not best choice for older smokers or women with serious medical problems)
Approximately 92 percent effective
NuvaRing vaginal ring—which contains estrogen and progesterone
Reliable method if used correctly; lighter and more regular periods; welltolerated by most women
Not a good method for breastfeeding mothers as can decrease milk supply; contains hormones (so not the best choice for older smokers or women with serious medical problems)
About 92 percent effective
Not a good method for breastfeeding mothers as can decrease milk supply; contains hormones (so not best choice for older smokers or women with serious medical problems) and does have a slightly higher risk of blood clots than other combined hormone methods
Approximately 92 percent
The Ortho Evra patch—which contains estrogen and progesterone
Reliable method if used correctly; lighter and more regular periods; welltolerated by most women
Mini-pill—an oral contraceptive pill containing progesterone only
Safe for breastfeeding Must take pill at the same time mothers or women who each day can’t take estrogen; reliable if taken correctly
Condoms and spermicidal foam or jelly
Safe for almost all women (except those with allergies to this method); protects against sexually transmitted disease
21
J2557 OB Booklet for Expecting Mothers Updated.indd 21-22
Not the most reliable; must have a partner who is willing to use
EFFECTIVENESS
Effectiveness varies, approximately 92 percent effective. If you are breastfeeding and using this method of birth control, your provider may change your form of birth control when you stop breastfeeding exclusively. Please discuss this with your provider.
METHOD
PROS
CONS
EFFECTIVENESS
Diaphragm and spermicidal Safe for most women jelly (unless latex or other allergy)
Not the most reliable method available; some consider this method to be messy; may cause UTI or irritation; must be fitted in the office and after weight gain/loss; must be placed before any sexual contact and may decrease spontaneity
Approximately 84 percent effective
Fertility awareness method
Safe, as it is hormone free; inexpensive after you have completed the training classes; compatible with certain religious beliefs
Reliability of the method varies greatly; requires training and good follow-up; must have a partner who is willing to respect abstinence days; more difficult to use in women with irregular periods, breastfeeding mothers, or teens
For many couples, about 75 percent effective but can be slightly more effective with perfect use
Vaginal sponge—which contains a spermicidal ingredient
Safe for all women (except those with allergies to the product)
Not the most reliable method available; could be considered messy to use; must be placed before any sexual contact and may decrease spontaneity; expensive
84 percent effective if you have never given birth, 68 percent effective if you have had a child before
ALWAYS ASK We hope this booklet has been helpful. Please ask your provider questions about any area we have not covered. Any question you or a family member has is important and valid. We are here to help you and your baby through this wonderful experience.
Approximately 85 percent effective
22
1/8/15 1:48 PM
© 12/13 CARILION CLINIC SD J2557 TA
J2557 OB Booklet for Expecting Mothers Updated.indd 23
1/8/15 1:48 PM
