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Congressional OB GYN Proudly Presents

“Expecting”

PREGNANCY RESOURCE BOOKLET FREQUENTLY ASKED QUESTIONS

Congressional OB GYN

Your Comprehensive Guide to Pregnancy

Welcome to Congressional OB GYN

Contents Expecting the Unexpected

Morning Sickness

Screening for Birth Defects

Exercise and Pregnancy

Nutrition During Pregnancy

Travel in Pregnancy

Screening For Genetic Disorders

We are privileged to have the opportunity to care for you during this pregnancy. We hope you find this resource useful during your pregnancy. It is not a substitute, however, for individualized advice from your provider. Please contact us if you have any questions. Thank you for choosing Congressional OB GYN.

Our Providers

Steve Behram, MD, FACOG

Testing for Group B Streptococcus

Special Tests and Monitoring

Induction of Labor

Vaginal Birth After C-Section

Circumcision

Signs and Symptoms of Labor

Postpartum Depression

Getting in Shape Postpartum

Nancy Behram, MD, FACOG

Danni Ibarra, NP

Jinkal P. Saini, PA-C

Kathryn O’Reilly, CNM http://congressionalobgyn.com (301) 294-8525

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Expecting the

Unexpected Congratulations on your pregnancy! We are honored that you have selected our practice for your prenatal care. We take this responsibility very seriously. We look forward to the opportunity to provide you with world-class care during this amazing journey.

Our Team We have four providers, with years of training and expertise, here to guide you through your pregnancy journey. Drs. Steve & Nancy Behram, together with Dr. Genesis Millan Serrano and Ms. Jinkal Saini, will make ourselves available to you throughout your pregnancy. Our physicians divide the call coverage. For emergencies that occur after hours, you would just call the main number for our office. This line is answered by our staff during work hours, and forwarded to the answering service after hours. Our physicians have privileges at Holy Cross Hospital at Germantown. After Hours Call Policy Patients are encouraged to make a scheduled appointment at the office for any problems or questions that arise during the pregnancy.

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This will ensure that you’re seen by the provider who would know most about your situation and can provide you the best of continuity of care. Most problem visits that occur after hours, can safely be handled the next business day. For urgent problems that cannot wait until the next day, it is appropriate for the patient to contact the healthcare provider through the answering service. This is done by calling our regular telephone number which is (301) 294-8525. In the event of a problem with our main phone line, you can call the answering service directly at (301) 446-2634. Patients should never proceed to the hospital without first talking to

the provider, as there are occasions when we do not recommend that the patient go to the hospital. Again, your provider can help you with this decision and may be able to help you avoid a hospitalization. Finally, for less critical communication, patients can always use the portal to message their provider at no cost after hours. As a general rule, we will not call-in prescriptions after hours without seeing and evaluating the patient in the office. This includes all refill requests, and self-diagnosed conditions such as yeast or urinary tract infections.

In the event of a life and death emergency, you should call 911 to be transported to the closest hospital.

Patient Pre--Registration Patients should pre-register at the Holy Cross website prior to delivery. The web-form for pre-registration is located here. Once you submit the information, the hospital will have all they need to expedite your admission when it’s time for you to go to the hospital. You should not expect to receive any other confirmation with your pre-registration. Pregnancy Testing and Imaging Every patient and every pregnancy is unique, and there are many tests and imaging studies that are typically ordered as part of your prenatal care. The following is a partial list of available tests and imaging studies. Not all patients receive every test or study. If you have any questions

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or if you would like to have additional information, please take a few minutes to discuss this with your provider. During your first visit, the provider will help confirm the pregnancy and begin to work to establish your Estimated Date of Delivery (EDC). Even with a positive home pregnancy test, your provider will have to determine that your pregnancy is within the uterus and growing according to expectations. Once this has been established, your provider will order additional tests for blood type, rubella, anemia, varicella, sexually transmitted infections, thyroid disease, and Pap smear. All patients are encouraged to get the flu vaccine when it becomes available for the season irrespective of the gestational age. During each subsequent visit, your provider will check your weight, your vitals, your baby’s heart sounds and your urinalysis. Typically between 16-21 weeks, your provider will check your alpha-fetoprotein (AFP) for neural tube defects in the fetus. Even families with no prior history of spina bifida are screened. A positive test result does not necessarily mean that the baby has spina bifida, but only that there is additional risk and more testing may be required. At the same time a morphology ultrasound of the baby is usually performed.

recommended to all of our expectant moms. For our high risk patients, nonstress tests (NSTs) and biophysical profiles (BPPs) are obtained beginning usually at 32 weeks. Please review the portion about additional testing found in this guide. Typically between 36-37 weeks, you will be screened for Group B Streptococcus or GBS. You may learn more about GBS by reading the section in this guide.

After 28 weeks, the Tdap vaccine is

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• Supplements In addition to taking prenatal vitamins, we recommend that patients consider additional supplements based on their health and status of their pregnancy. •

Between 37-41 weeks, and based on what’s going on with both mother & baby, we begin to make plans for delivery. During this period, your provider may also perform pelvic exams including cervical checks to assess the likelihood of labor.

•

OTC Medications We get asked a lot of questions about over-the-counter medications during pregnancy. These are our most common recommendations for some of the most common maladies.

•

• • • • •

Typically between 24-28 weeks, your provider will order a glucola test and also check you for syphilis and anemia. If you’re Rh negative, you will be given a prescription for a rhogam injection.

•

• • •

•

Colds & Congestion: Cepacol, Cepastat, Robitussin DM, Tylenol, Theraflu, Vicks Rub Constipation: Colace, Dulcolax, Miralax, Senekot, Fiber Diarrhea: Imodium Gas: Gas X, Mylicon Hemorrhoids: Tucks Pads, Preparation H Indigestion: Tums, Maalox, Mylanta, Prilosec, Pepcid-AC Insomnia: Chamomille Tea, Benadryl, Unisom Pain or Fever: Tylenol Prenatals: All are fine to take, but we recommend Theranatal One. Seasonal Allergies: Benadryl,

Zyrtec, Claritin Sore Throat: Chloroseptic, Cepacol

Calcium & Vitamin D: We recommend Theracal 2000 if your vitamin D was normal or Theracal 4000 if you were deficient prior to the pregnancy. Folic Acid: You will need 400 mcg of folic acid daily. This should already be included with your prenatal vitamin. If you’ve had a prior baby with a neural tube defect, you may need additional folic acid supplementation. Ferrous Sulfate: Your body will need 27 mg of elemental iron daily. If you’re anemic, you will need to supplement with additional iron daily. Ask your provider to see what dose is right for you.

• If you’ve had bariatric surgery, your requirements may be different. Please discuss this with your provider. Smoking, Alcohol & Drugs There is absolutely no safe level of tobacco, alcohol or drug use during the pregnancy. Patients are encouraged to discontinue these items immediately upon learning that they are pregnant. We believe that prior exposure to these substances occurs frequently, but if stopped immediately and for the duration of the pregnancy, that it is of little consequence to the pregnancy.

On the other hand, the continued use of tobacco, alcohol and other drugs, including marijuana, can substantially harm, permanently damage, or possibly even kill the fetus. Many hospitals have very strict rules governing the release of the baby to a mother who tests positive for alcohol or drugs while pregnant. If you think you might have a problem, please discuss it with your healthcare provider who will help you devise a strategy immediately to assist you in having a safe pregnancy. Lactation Breast feeding is always best for a newborn infant. The nurses at the hospital, along with lactation consultants at the hospital, will help and assist you if so desired. All newborns are expected to lose approximately 15% of their birthweight in the first couple of days. This should not dissuade you from breastfeeding. Our providers will also be available to you to guide you even after you go home from the hospital. Most insurance companies will provide you with a breast pump at no cost to you. If you are breast feeding and you develop redness of the breast, pain and fever, please remember that these may be a sign of mastitis. Please contact us during regular business hours and we will evaluate you and prescribe appropriate treatment if indicated. Selecting a Pediatrician You will need to select a pediatrician. If you already have a pediatrician, great! Just inform them that you’re expecting and make certain that they’re accepting new babies

in their practice. If you don’t have a pediatrician, this is a good time to ask neighbors, colleagues and family members for their advice and recommendations. For over two decades, we’ve worked with a number of pediatricians that we love. We would be happy to make a referral to you if you so wish. Most pediatricians will schedule a complimentary “meet & greet” appointment for expectant parents. This gives you an opportunity to check out the office and find a provider that will be a good match for your growing family. Laboratory We provide our patients with access to a full-service laboratory in our office. This means that you will have most of your lab work done in our office without the inconvenience of having to travel to another facility or the need of having to make a separate appointment. Your laboratory test results will appear in one of two portals. Please ask a staff member to assist you in establishing your access to both our practice portal as well as to the laboratory portal. You will receive notification when your results are available and you could view those results at your own convenience. Ultrasound Imaging We have our own sonography suite and access to technology enabling us to perform sophisticated real-time imaging of the fetus. Because ultrasound uses sound waves, it is a perfectly safe and effective way of imaging the pregnancy. Our coordinating staff will work hard to coordinate your visits to maximize the efficiency of each visit.

Maternal-Fetal Medicine For our high-risk patients, we work with a number of the finest maternal-fetal medicine experts in our area. We are able to consult and coordinate care with these experts, bringing you a seamless and integrated plan of care. Postpartum Care Pregnancy used to be divided into three “trimesters.” Today, we think of postpartum as the forth trimester. This means that your team of doctors, nurses, and health care professionals will continue to be available to you for 12 weeks after you deliver. This enables us to better care for our patients. We can make resources available to parents as needs evolve during this period. We can give advice about contraception and birth control. We can help with postpartum mental health services. We could even help patients lose their pregnancy weight. Our patient-centered care focuses on you at every stage of your life, not just pregnancy. We love meeting patients that we delivered decades ago, including their kids who have grown so much since we saw them last! We love it when patients send family members, co-workers, neighbors and friends to be a part of our growing family. We also love it when patients stay connected with us through social media, sending us updates and sharing with us their stories and adventures. In short, we love what we do and we hope we have the opportunity to show you.

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NAUSEA & VOMITING MORE THAN JUST A NUISANCE Nausea and vomiting are common during pregnancy, especially during the first part of pregnancy. Although it is often called “morning sickness,” it can occur at any time of the day. Most cases of nausea and vomiting are not harmful, but these symptoms can have a serious effect on your life. Causes of Morning Sickness Although no one is certain what causes morning sickness, increasing levels of hormones during pregnancy may play a role. In most women, symptoms of nausea and vomiting are mild and go away after the middle of pregnancy. In a small number of women, nausea and vomiting can be severe. This condition is called hyperemesis gravidarum. It can lead to loss of weight and body fluids. Effects on Pregnancy Most mild cases of nausea and vomiting do not harm you or your baby’s health. Morning sickness does not mean

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your baby is sick. It can become more of a problem if you cannot keep any food or fluids down and begin to lose weight. If your nausea and vomiting are severe, or if you have symptoms caused by loss of body fluids, call our office during regular business hours. What You Can Do There is no cure for morning sickness. Some research suggests that women who are taking a multivitamin supplement regularly at the time they become pregnant are less likely to have severe cases of morning sickness. If you experience morning sickness, there are several things you can do that might help you feel better. You may need to try

more than one of these remedies: • Get plenty of rest. • Avoid smells that bother you. • Eat five or six small meals each day instead of three large meals. • Eat a few crackers before you get out of bed in the morning to help settle your stomach. • Eat small snacks high in protein (such as a glass of milk or a cup of yogurt) throughout the day. • Avoid spicy foods and fatty foods. Ginger has been shown to be helpful for some women. Taking three 250-milligram capsules of ginger a day plus another capsule right before bed may help relieve nausea.

Remember to talk with your health care provider before taking any herbal medication or supplement or trying any treatment. You also can try ginger ale or ginger tea made with real ginger. Medical Treatment In severe cases of nausea & vomiting, your provider may recommend medications given orally or by a pump attached to the skin. This is done in cases of severe dehydration which, if left untreated, may jeopardize the health and well-being of both mother and baby. Most cases can be treated without the need for hospitalization.

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SCREENING TESTS FOR BIRTH DEFECTS

Screening tests can give information about a pregnant woman’s risk of having a baby with certain birth defects or genetic conditions. Some pregnant women may have other tests, depending on their medical histories, previous pregnancies, family or ethnic backgrounds, or exam results.

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Each year, about 3 in 100 babies are born with a birth defect. A birth defect is a problem that is present at birth, although it may not be noticed until the child is older. Birth defects may affect any part of the body, including major organs such as the heart, lungs, or brain. The defect may affect the baby’s appearance, body function, or both. There are different types of birth defects. Some birth defects result from aneuploidy, in which there are missing or extra chromosomes. Although any woman at any age can have a child with a chromosome disorder, the risk increases as a woman ages. The most common aneuploidy is called a trisomy, in which there is an extra chromosome. A common trisomy is trisomy 21 (Down syndrome). Other trisomies include trisomy 13

(Patau syndrome) and trisomy 18 (Edwards syndrome). A monosomy is a condition in which there is a missing chromosome. A common monosomy is Turner syndrome, in which a female has a missing or damaged X chromosome. Inherited disorders are caused by defective genes. These disorders are passed down by parents to their children. Some inherited disorders are more common in certain races and ethnic groups, such as sickle cell disease (African American), cystic fibrosis (non- Hispanic white), and Tay-Sachs disease (Ashkenazi Jewish, Cajun, and French Canadian). Defective genes can occur on any of the chromosomes. Disorders caused by genes on the sex chromosomes are called sexlinked disorders. An example of a sex-linked disorder is hemophilia.

This disease is caused by defective gene on the X chromosome. Birth defects also may be caused by exposure to harmful agents, such as medications, chemicals, and infections. Some birth defects may be caused by a combination of factors. For about 70% of babies born with birth defects, the cause is not known. Many birth defects are mild, but some can be severe. Babies with birth defects may need surgery or other medical treatments. For some birth defects, such as chromosome disorders, there is no treatment. Sometimes, symptoms can be managed, such as those of trisomy 21. For other disorders, such as trisomy 13 and trisomy 18, the baby may die. Prenatal Testing for Birth Defects Many types of prenatal tests are

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available to help address concerns about birth defects: Carrier tests Carrier tests are a type of screening test that can show if a person carries a gene for an inherited disorder. Carrier tests can be done before or during pregnancy. Cystic fibrosis carrier screening is offered to all women of reproductive age because it is one of the most common genetic disorders. Screening Tests These tests often are part of routine prenatal care and are done at different times during the first and second trimesters of pregnancy. Screening tests assess the risk that a baby will have Down syndrome and other trisomies, as well as neural tube defects. These tests do not tell whether the fetus actually has these disorders. There are no risks to the unborn baby with having these screening tests. Diagnostic Tests Diagnostic tests can provide information about whether the fetus has a genetic a condition and are done on cells obtained through amniocentesis, chorionic villus sampling, or, rarely, fetal blood sampling. The cells can be analyzed using different techniques. If a screening test shows an increased risk of a birth defect, diagnostic tests may be done to determine if a specific birth defect is present. Diagnostic testing may be done instead of screening if a couple is at increased risk of certain birth defects. Diagnostic testing also is offered as a first choice to all pregnant women, even those who do not have risk factors. Deciding Whether to Be Tested Although screening tests for birth defects are offered to all pregnant women, it is your choice whether to have them done. Knowing

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whether your baby is at risk of or has a birth defect beforehand allows you to prepare for having a child with a particular disorder and to organize the medical care that your child may need. You also may have the option of not continuing the pregnancy. Most babies with birth defects are born to couples without risk factors. However, the risk of birth defects is higher when certain factors are present. Your health care provider or a genetic counselor can help find out if you are at increased risk of passing on a genetic disorder by taking a family health history. You are at increased risk if you have a genetic disorder you already have a child who has a genetic disorder a there is a family history of a genetic disorder you belong to an ethnic group that has a high rate of carriers of certain genetic disorders If you are at increased risk of having a child with a birth defect, you may consider having diagnostic testing instead of screening tests. The main benefit of having diagnostic testing instead of screening is that it tells you whether or not the baby will be born with a chromosome disorder or a specific inherited a disorder. The main disadvantage is that invasive diagnostic tests can pose some risks to the pregnancy, including miscarriage and leakage of amniotic fluid. Your health care provider or a genetic counselor can discuss all of these options with you. You may decide not to have any testing. If you do decide to have testing, you should understand the advantages, disadvantages, and limitations of each test. Understanding Test Results You will not get a “yes” or “no” result with screening test. Screening test results are reported as the risk that a specific defect is present. This risk takes your age into account. For example, a screening test result for Down syndrome of “1 in 872” means

that there is a in 872 chance that your baby will have Down syndrome. This is considered low risk. Results may be described as “negative” if the risk is lower than a certain cutoff point and described as “positive” if the risk is higher than the cutoff point. With any type of testing, it is important to be aware of the possibility of false-positive and false-negative results. A screening test result that shows there is a problem when one does not exist is called a false- positive result. A screening test result that shows there is not a problem when one does exist is called a false- negative result. Your health care provider should have information about the rates of false-positive and false- negative results for each test that is offered. Types of Screening Tests A variety of screening tests are available. The type of screening tests that you will be offered depends on which tests are available in your area, how far along you are in your pregnancy, and your health care provider’s assessment of which tests best fit your needs. First Trimester Screening First trimester screening is a blood test combined with an ultrasound exam. This screening sometimes is called “combined first trimester screening.” It is done between 11

weeks and 14 weeks of pregnancy to detect the risk of Down syndrome and other trisomies. The blood tests measure the level of two substances in the mother’s blood: 1. pregnancy-associated plasma protein-A (PAPP-A) , and, 2. human chorionic gonadotropin (hCG). An ultrasound exam, called nuchal translucency screening, is used to measure the thickness of a space at the back of the neck of the fetus. An increase in the thickness of this space may be a sign of Down syndrome, trisomy 18, or other chromosome problems. Second Trimester Screening If you choose to have only first trimester screening for aneuploidy, a blood test that measures a substance called alpha-fetoprotein (AFP) can be done to test for neural tube defects. This test generally is done in the second trimester between 16 weeks and 18 weeks of pregnancy. A test called “multiple marker screening” is offered to screen for Down syndrome, trisomy 18, and neural tube defects in the second trimester. This test measures the levels of three or four of the following substances in your blood: 1. AFP 2. Estriol 3. hCG

4. Inhibin-A The test using the first three of these substances is called a triple screen. When the fourth substance (inhibin-A) is added, the test is called a quad screen. These tests usually are done around 15-20 weeks of pregnancy. The stage of pregnancy at the time of the test is important because the levels of the substances measured change during pregnancy. First and Second Trimester Screening The results from first and second trimester tests can be used together to increase their ability to detect Down syndrome. The tests can be performed in the following ways: Integrated screening Results of the first-trimester and second-trimester tests are analyzed together. The results are given only after the first-trimester and second-trimester screening tests are completed. Integrated screening is highly accurate and has a low rate of false-positive results. Sequential Screening Results of the first-trimester screening tests are used to determine further testing. If results show that you are at high risk, you can choose to have a diagnostic test. If results show that you are at low or intermediate risk, you can choose to have second-trimester screening or you can choose not to have second-trimester screening. Compared with integrated screening, the chance of a false-positive result with sequential screening is slightly higher and accuracy is slightly lower. Cell Free Fetal DNA Test A screening test called the cell free fetal DNA test is available for certain women. A small amount of fetal DNA circulates in the mother’s

blood. This DNA mainly comes from the placenta. The cell free fetal DNA in a sample of the mother’s blood can be screened for Down syndrome, trisomy 13, trisomy 18, and sex chromosome abnormalities. In women who are at high risk of having a baby with a chromosome disorder, this test is 98% accurate in detecting cases of Down syndrome and has a low rate of false-positive results. This test can be done as early as 10 weeks of pregnancy in some women. Results take about 1 week to process. At this time, the cell free fetal DNA test is recommended only for women who have an increased risk of having a child with a chromosome disorder, such as women who are older than 35 years or who already have a child with a chromosome disorder. It is not recommended for women at low risk of having a baby with a chromosome disorder or women carrying more than one baby because it has not been tested sufficiently in these groups. The cell free fetal DNA test has certain limitations. It does not screen for neural tube defects. An additional screening test needs to be done to check for these disorders. In addition, although it is highly accurate in detecting chromosome problems in high-risk women, it is not as accurate as diagnostic tests. If you have a positive cell free fetal DNA test result, diagnostic testing is recommended. The Next Steps If the results of a screening test or other factors raise concerns about your pregnancy, diagnostic tests or a targeted ultrasound exam can be done to provide more information. Your health care provider or genetic counselor can advise you on which tests may be best for you and explain the results to you.

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Exercise &

Pregnancy Regular exercise builds bones and muses, gives you energy, and keeps you healthy. It is just as important when you are pregnant.

Why Exercise? You’re tired. You’re gaining weight. You may not feel your best. Although most of the time these symptoms are normal during pregnancy, exercise may help provide some relief. Regular activity also helps keep you fit during pregnancy and may improve your ability to cope with the pain of labor. This will make it easier for you to get back in shape after the baby is born. You should not, however, exercise to lose weight while you are pregnant. Changes in Your Body Pregnancy causes

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many changes in your body. Some of these changes will affect your ability to exercise. Joints The hormones produced during pregnancy cause the ligaments that support your joints to become relaxed. This makes the joints more mobile and more at risk of injury. Avoid jerky, bouncy, or high-impact motions that can increase your risk of injury.

worked and away from other parts of your body. So, it’s important not to overdo it. Try to exercise moderately so you don’t get tired quickly. If you are able to talk normally while exercising, your heart rate is at an acceptable level. You should decrease your exercise intensity if your sustained pulse is greater than 140 beats per minute.

Balance Remember that during pregnancy you are carrying extra pounds-as much as 25-40 pounds at the end of pregnancy. The extra weight in the front of your body shifts your center of gravity and places stress on joints and muscles, especially those in the pelvis and lower back. This can make you less stable, cause back pain, and make you more likely to lose your balance and fall, especially in later pregnancy.

Getting Started Before beginning your exercise program, talk with your doctor to make sure you do not have any obstetric or health condition that would limit your activity. Ask about any specific exercises or sports that interest you. Your provider can offer advice about what type of exercise routine is best for you. Women with one of the following conditions may be advised by their doctors not to exercise during pregnancy: • Risk factors for preterm labor • Vaginal bleeding • Premature rupture of membranes Pregnant women with certain other medical conditions, such as high blood pressure, will be advised by their

Heart Rate The extra weight you are carrying will make your body work harder than before you were pregnant. Exercise increases the flow of oxygen and blood to the muscles being

The Healthy Benefits of Exercise Becoming active and exercising at least 30 minutes on most, if not all, days of the week can benefit your health in the following ways: • Helps reduce backaches, constipation, bloating, and swelling • May help prevent or treat gestational diabetes Increases your energy • Improves your mood Improves your posture • Promotes muscle tone, strength, and endurance • Helps you sleep better

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doctors when and if exercise is appropriate. Choosing Safe Exercises Most forms of exercise are safe during pregnancy. However, some types of exercise involve positions and movements that may be uncomfortable, tiring, or harmful for pregnant women. For instance, after the first trimester of pregnancy, women should not do exercises that require them to lie flat on their backs. Standing still for long periods of time also should be avoided as much as possible. Certain sports are safe during pregnancy, even for beginners:

have done them for a while before pregnancy: •

•

• •

•

Walking is good exercise for anyone. Brisk walking gives a total body workout and is easy on the joints and muscles. If you were not active before getting pregnant, walking is a great way to start an exercise program. Swimming is great for your body because it works so many muscles. The water supports your weight so you avoid injury and muscle strain. It also helps you stay cool and helps prevent your legs from swelling. Cycling provides a good aerobic workout. However, your growing belly can affect your balance and make you more prone to falls. You may want to stick with stationary or recumbent biking later in pregnancy. Aerobics is good way to keep your heart and lungs strong. There are even aerobics classes designed just for pregnant women. Low-impact and water aerobics also are good exercise.

Other exercises, if done in moderation, are safe for women who

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Running. If you were runner before you became pregnant, you often can keep running during pregnancy although you may have to modify your routine. Talk to your doctor about whether running during pregnancy is safe for you. Racket sports. In some racket sports, such as badminton, tennis, and racquetball, your changing balance may affect rapid movements. This can increase your risk of falling. You may want to avoid some racket sports. Strength training will make your muscles stronger and may help prevent some of the aches and pains common in pregnancy.

•

Scuba diving should be avoided during pregnancy. The large amounts of pressure from the water put your baby at risk for decompression sickness. With some activities, such as gymnastics, water skiing, and

The following activities should be avoided during pregnancy: •

•

Downhill snow skiing. As with racket sports, your changing center of gravity can cause balance problems. This puts you at risk for severe injuries and falls. Even if you are skilled and careful, some hazards are beyond your control. For instance, exercising at altitudes higher than 6,000 feet can increase your risk of altitude sickness. This makes it harder for you to breathe and may cut down on your baby’s supply of oxygen. Contact sports, such as ice hockey, soccer, and basketball, could result in harm to both you and your baby.

horseback riding, there is an increased risk of falling, which in some cases can cause injury. These activities also should be avoided during pregnancy. With any type of exercise you’d like to try, be sure to discuss it with your doctor ahead of time. If you are an athlete, let your doctor know so you can get any special care

you may need. Your Routine Exercise during pregnancy is most practical during the first 24 weeks. During the last 3 months, it can be difficult to do many exercises that once seemed easy. This is normal. If it has been some time since you’ve exercised, it a is a good idea to start slowly. Begin with as little as 5 minutes of exercise a day and add 5 minutes each week until you can stay active for 30 minutes day. Always begin

each exercise session with a warm-up period for 5-10 minutes. This is light activity, such as slow walking, that prepares your muscles. During the warm up, stretch your muscles to avoid

stiffness and soreness. Hold each stretch for at least 10-20 seconds.

of the warning signs that you may be overdoing it. If you notice any of these symptoms, stop exercising.

After exercising, cool down by slowly reducing your heart rate to return to your activity. This allows normal levels. Cooling down for 5-10 minutes and stretching again also helps you to avoid sore muscles. Things to Watch The changes your body is going through can make certain positions and activities risky for you and your baby. While exercising, try to avoid activities that call for jumping, jarring motions or quick changes in direction that may strain your joints and cause injury. There are some risks from becoming overheated during pregnancy. This may cause loss of fluids and lead to dehydration and problems during pregnancy. When you exercise, follow these general guidelines a for a safe and healthy exercise program: After the first trimester of pregnancy, avoid doing any exercises on your back. Avoid brisk exercise in hot, humid weather or when you have a fever. Wear comfortable clothing that will help you to remain cool. Wear a bra that fits well and gives lots of support to help protect your breasts. Drink plenty of water to help keep you from over- heating and dehydrating. Make sure you consume the daily extra calories you need during pregnancy. While you exercise, pay attention to your body. Do not exercise to the point that you are exhausted. Be aware

After the Baby’s Born Having a baby and taking care of a newborn is hard work. It will take a while to regain your strength after the strain of pregnancy and childbirth. Taking care of yourself physically and allowing your body time to recover is important. If you had a cesarean delivery, difficult childbirth, or complications, your recovery time may be longer. Check with your doctor before starting or resuming an exercise program. Some women may resume their routine within days of giving birth; others may need more time before resuming their pre-pregnancy routine. Walking is good way to get back into exercising. Brisk walks several times a week will prepare you for more strenuous exercise when you feel up to it. Walking has the added advantage of getting both you and the baby out of the house for exercise and fresh air. As you feel stronger, consider more vigorous exercise. You will want to pick an exercise program that meets your own needs. Your provider, nurse, or community center can help. There are also special postpartum exercise classes that you can join. Exercise during pregnancy can help prepare you for labor and childbirth. Exercising afterward can help get you back in shape. Before you begin an exercise program, talk to your doctor. Follow this guide to help maintain a safe and healthy exercise program during pregnancy.

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NUTRITION DURING PREGNANCY Although it may take a little effort, planning and eating healthy meals and snacks during pregnancy will have major benefits for you and your baby. If you have not been eating a healthy diet, pregnancy is a great time to change old habits and start healthy new ones.

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Healthy eating is important during pregnancy. Good nutrition is needed to meet the added demands on your body as well as those of your growing baby.

Although it may take a little effort, planning and eating healthy meals and snacks during pregnancy will have major benefits for you and your baby. If you have not been eating a healthy diet, pregnancy is a great time to change old habits and start healthy new ones. Good Nutrition While you are pregnant, the foods you eat fuel your body’s activities and help your baby grow. Eating a variety of healthy foods is the best way to give you and your growing baby the nutrition you both need. You also can get nutrients from pills containing vitamins and minerals (also called “supplements”). Planning Healthy Meals Planning healthy meals during pregnancy is not hard. The United States Department of Agriculture has made it easier by creating www. choosemyplate.gov. This web site helps everyone from dieters and children to pregnant women learn how to make healthy food choices at each mealtime. Healthy eating benefits not only you and your baby

but also sets up good eating habits for your entire family. With MyPlate, you can get a personalized nutrition and physical activity plan by using the “SuperTracker” program. This program shows you the foods and amounts that you need to eat each day during each trimester of pregnancy. The amounts are calculated according to your height, pre-pregnancy weight, due date, and how much you exercise during the week. The amounts of food are given in standard sizes that most people are familiar with, such as cups and ounces. The Five Food Groups There are five food groups that a pregnant woman of normal weight before pregnancy should eat for each trimester of pregnancy. They include: 1. Grains: Bread, pasta, oatmeal, cereal, and tortillas are all grains. Make one half of them whole grains. Whole grains are those that have not been processed and include the whole grain kernel. They include oats, barley, quinoa, brown rice, and

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bulgur. Products made with these foods also count as whole grains. Look for the words “whole grain” on the product label. 2. Fruits: Fruits can be fresh, canned, frozen, or dried. Juice that is 100% fruit juice also counts. Make one half of your plate fruits and vegetables. 3. Vegetables: Vegetables can be raw or cooked, frozen, canned, dried, or 100% vegetable juice. Use dark, leafy greens to make salads. 4. Protein foods: Protein foods include meat, poultry, seafood, beans and peas, eggs, processed soy products, nuts, and seeds. Include a variety of

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proteins and choose lean or low-fat meat and poultry. 5. Dairy: Milk and products made from milk, such as cheese, yogurt, and ice cream, make up the dairy group. Make sure any dairy foods you eat are pasteurized. Choose fat-free or low-fat (1%) varieties. Oils and fats are another part of healthy eating. Although they are not a food group, they do give you important nutrients. During pregnancy, the fats that you eat provide energy and help build many fetal organs and the placenta. Oils in food come mainly from plant sources, such as olive oil, nut oils, and grapeseed

oil, and can be found in certain foods, such as some fish, avocados, nuts, and olives. Most of the fats and oils in your diet should come from plant sources. Limit solid fats, such as those from animal sources. Solid fats also can be found in processed foods. Key Vitamins and Minerals Vitamins and minerals play important roles in all of your body functions. During pregnancy, you need more folic acid and iron than a woman who is not pregnant. Taking a prenatal vitamin supplement can ensure that you are getting these extra amounts. A well-rounded diet should supply all of the other vitamins and

minerals you need during pregnancy. Folic Acid Folic acid, also known as folate, is a B vitamin that is important for pregnant women. Taking 400 micrograms of folic acid daily for at least 1 month before pregnancy and 600 micrograms of folic acid daily during pregnancy may help prevent major birth defects of the baby’s brain and spine called neural tube defects. Many foods contain folic acid, such as fortified cereal, enriched bread and pasta, peanuts, dark green leafy vegetables, orange juice, and beans. It may be hard to get the recommended amount of folic acid from food alone. For this reason, all pregnant women and all women who may become pregnant should take a daily vitamin supplement that contains the right amount of folic

acid. If you have already had a pregnancy affected by a neural tube defect or if you are taking an anti-seizure medication, you should take a higher daily dose of folic acid (4 milligrams) as a separate supplement beginning one month before trying to become pregnant and during the first 3 months of your pregnancy. Iron Iron is used by your body to make a substance in red blood cells that carries oxygen to your organs and tissues. During pregnancy, you about double the amount that a non-pregnant woman needs. This extra iron helps your body make more blood to supply oxygen to your baby. The daily recommended dose of iron during pregnancy is 27 milligrams, which is found in most prenatal vitamin supplements. You also can eat

foods rich in a certain type of iron called heme iron. Heme iron is absorbed more easily by the body. It is found in animal foods, such as red meat, poultry, and fish. Non-heme iron is found in vegetables and legumes, such as soybeans, spinach, and lentils. Although it is not as easily absorbed as heme iron, non-heme iron is a good way to get extra iron if you do not eat animal foods. Iron also can be absorbed more easily if iron-rich foods are eaten with vitamin C-rich foods, such as citrus fruits and tomatoes. Calcium Calcium is used to build your baby’s bones and teeth. All women, including pregnant women, aged 19 years and older should get 1,000 milligrams of calcium daily; those aged 14-18 years should get 1,300 milligrams daily.

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Milk and other dairy products, such as cheese and yogurt, are the best sources of calcium. If you have trouble digesting milk products, you can get calcium from other sources, such as broccoli; dark, leafy greens; sardines; or a calcium supplement. Vitamin D Vitamin D works with calcium to help the baby’s bones and teeth develop. It also is essential for healthy skin and eyesight. All women, including those who are pregnant, need 600 international units of vitamin D. day, Good sources are milk fortified with vitamin D and fatty fish such as salmon. Exposure to sunlight also converts a chemical in the skin to vitamin D. Many people do not get enough vitamin D. If your health care provider thinks you may have low levels

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of vitamin D, a test can be done to check the level in your blood. If it is below normal, you may need to take a vitamin D supplement. Pregnancy and Weight Gain The amount of weight gain that is recommended depends on your health and your body mass index (BMI) before you were pregnant. If you were underweight before pregnancy, you should gain more weight than a woman who was a normal weight before pregnancy. If you were overweight or obese before pregnancy, you should gain less weight. The amount of weight you should gain differs by trimester. During your first 12 weeks of pregnancy- the first trimester-you may gain only 1-5 pounds or none at all. In your second and third trimesters, if you were a healthy weight before pregnancy,

you should gain between one half pound and 1 pound per week. During this stage, you will need to consume about 300 extra calories per day. That is equal to the amount of calories in glass of skim milk and half of a sandwich. Have healthy snacks on hand, such as yogurt or fresh fruit, which can give you the extra calories you need during the day. Overweight and obese women are at an increased risk of several pregnancy problems. These problems include gestational diabetes, high blood pressure, preeclampsia, preterm birth, and cesarean delivery. Babies of overweight and obese mothers also are at greater risk of certain problems, such as birth defects, macrosomia with possible birth injury, and childhood obesity. If you are overweight or obese, you and your health care provider will work together

to develop nutrition and exercise plan. If you are gaining less than what the guidelines suggest, and if your baby is growing well, gaining less than the recommended guidelines can have benefits, such as decreased risks of needing a cesarean delivery and of having very large baby. If your baby is not growing well, changes may need to be made to your diet and exercise plan. Special Concerns As you plan how you will eat healthfully during your pregnancy, it is important to keep in mind a few special issues. Caffeine Although there have been many studies on whether caffeine increases the risk of miscarriage, the results are unclear. Most experts state that consuming fewer than 200 milligrams of caffeine (one 12-ounce cup of coffee) a day during pregnancy is safe. Remember that caffeine is found not only in coffee, but also in teas, colas, and chocolate. Make sure you count these sources in your total caffeine amount for the day. Special Diets If you have special dietary needs, you need to keep them in mind as you plan your pregnancy diet. For example, if you are a vegetarian, make sure you get enough protein from foods such as soy milk, tofu, and beans and that your intake of iron, vitamin B,2 and vitamin D is sufficient. If you are lactose intolerant, you can get calcium from sources other than dairy products or buy lactose-free products. Talk with your provider about your dietary needs and how you can adapt them to pregnancy. Fish and Shellfish Omega-3 fatty acids are a type of fat found naturally in many kinds of fish. They may be important factors in your baby’s brain development both before and after birth. To get the most benefits

from omega-3 fatty acids, women should eat at least two servings of fish or shellfish (about 8-12 ounces) per week and while pregnant or breastfeeding. Some types of fish have higher levels of a metal called mercury than others. Mercury has been linked to birth defects. To limit your exposure to mercury, follow a few simple guidelines. Choose fish and shellfish such as shrimp, salmon, catfish, and pollock. Do not eat shark, swordfish, king mackerel, or tilefish. Limit white (albacore) tuna to only 6 ounces a week. You also should check advisories about fish caught in local waters. Food Safety Pregnant women can get food poisoning like anyone else. However, food poisoning in a pregnant woman can cause serious problems for both her and her baby. Vomiting and diarrhea can cause your body to lose too much water and can disrupt your body’s chemical balance. Several types of bacteria can cause food poisoning. It is important to contact your health care provider as soon as possible if you have these signs and symptoms. Listeriosis is a type of food-borne illness caused by bacteria. Pregnant women are 13 times more likely to get listeriosis than the general population. Listeriosis can cause mild, flu-like symptoms such as fever, muscle aches, and diarrhea, but it also may not cause any symptoms. However, it can lead to serious complications for your baby, including miscarriage, stillbirth, and premature delivery. If you think you have eaten food contaminated with this bacteria (for instance, if you have eaten food that has been recalled due to a listeriosis outbreak in your area) or if you have any of the symptoms of listeriosis, contact your health care provider. Antibiotics can be given to treat the infection and to protect your unborn baby. To help prevent listeriosis, avoid eating the following foods during

pregnancy: Unpasteurized milk and foods made with unpasteurized milk, including soft cheeses such as feta, queso blanco, queso fresco, Camembert, brie, or blue-veined cheeses unless the label says “made with pasteurized milk.” Hot dogs, luncheon meats, and cold cuts unless they are heated until steaming hot just before serving. Refrigerated Pate and Meat Spreads Refrigerated smoked seafood In addition, follow these general food-safety guidelines: • •

•

• •

Wash food. Rinse all raw produce thoroughly under running tap water before eating, cutting, or cooking. Keep your kitchen clean. Wash your hands, knives, countertops, and cutting boards after handling and preparing uncooked foods. Avoid all raw and undercooked seafood, eggs, and meat. Do not eat sushi made with raw fish (cooked sushi is safe).

Food such as beef, pork, or poultry should be cooked to a safe internal temperature. Eating well during your pregnancy is one of the best things you can do for yourself and your baby. Start now on balancing healthy eating with maintaining a healthy weight to give your baby the best start in life.

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TRAVEL IN PREGNANCY Traveling safely during pregnancy depends on whether you have any problems that need special care, how far along you are in your pregnancy, and your comfort. For most women, traveling is safe during pregnancy.

The Best Time to Travel The best time to travel is probably the middle is of your pregnancy-between weeks 14 and 28. Most common pregnancy emergencies usually happen in the first and third trimesters. After 28 weeks, it may be harder for you to move around or sit for a long time. During mid-pregnancy, your energy has returned, morning sickness is gone, and you are still mobile. Paying attention to the way you feel is the best guide for your activities.

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Getting There When choosing your mode of travel, think about how long it will take to get to your destination. The fastest way is often the best. Whether you go by car, airplane, or ship, there are steps you can take to ensure your comfort and safety. By Car During a car trip, make each day’s drive brief. Spending hours on the road is tiring even when you are not

pregnant. Try to limit driving to no more than 5 or 6 hours each day. Be sure to wear your seat belt every time you ride in a motor vehicle, even if your car has an air bag. If you are involved in a crash- even a minor one- see your health care provider right away. You may need to be monitored to make sure you and your baby are not injured. Plan to make frequent stops. Use these stops to move around and stretch your legs. By Airplane If you have a medical condition that could be made worse by flying or could require emergency medical care, you should avoid flying during your pregnancy. For healthy pregnant women, air travel is almost always safe during pregnancy. Some domestic airlines restrict travel during the last month of pregnancy or require a medical certificate; others discourage travel after 36 weeks of pregnancy. If you are planning an international flight, the cutoff point for traveling with international airlines is often earlier. Always check with your airline to be sure about their rules when planning your trip. If you

are worried about air pressure and cosmic radiation at high altitudes, these issues normally do not cause problems for occasional travelers. Decreased air pressure during flight may slightly reduce the amount of oxygen in your blood, but your body will naturally adjust. Although radiation exposure increases at higher altitudes, the level of exposure for the occasional traveler usually is not a concern. Radiation levels may be a concern for pregnant women whose jobs require them to fly often (such as pilots, flight attendants,

or air marshals). Frequent fliers may exceed the cosmic radiation exposure limits set by the federal government. Most airlines restrict their flight attendants from flying after 20 weeks of pregnancy. Some prohibit pilots from flying once pregnancy is confirmed. If you are a frequent flier, be sure to check with your health care provider about how long it is safe to fly during your pregnancy. When traveling by air, you can take the following steps to help make your trip as comfortable as possible: If you can, book an aisle

seat, so that it is easy to get up and stretch your legs during a long flight. Avoid gas-producing foods and carbonated drinks before your flight. Gas expands in the low air pressure present in airplane cabins and can cause discomfort. Wear your seatbelt at all times. Turbulence can occur without warning during air travel. The seatbelt should be belted low on the hipbones, below your belly. If you are prone to nausea, your health care provider may be able to prescribe anti-nausea medication. By Ship Taking a cruise can be fun, but many travelers on cruise ships have the unpleasant symptoms of seasickness, also called motion sickness. Seasickness is a balance problem. It occurs when conflicting signals about your position from the body, eyes, and inner ear (which controls your sense of balance) are sent to the brain. Seasickness causes nausea and dizziness, and sometimes weakness, headache, and vomiting. If you have never taken a cruise, planning your first one while you are pregnant may not be a good idea. But, if seasickness usually is

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not a problem for you, a traveling by sea during pregnancy may not upset your stomach. Make sure a doctor or nurse is on board the ship and that your scheduled stops are places with modern medical facilities in case there is an emergency. It may be a good idea, just in case, to ask your health care provider about which medications are safe for you to carry along to calm seasickness. Seasickness bands are useful for some people, although there is little scientific evidence that they work. These bands use acupressure to help ward off an upset stomach. For many people, seasickness goes away on its own after a few days as the body adjusts to the boat’s motion. Another concern for cruise ship passengers is norovirus infection. Noroviruses are a group of viruses that can cause severe nausea and vomiting for 1 or 2 days. They are very contagious and can spread

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rapidly throughout cruise ships. People can become infected by eating food, drinking liquids, or touching surfaces that are contaminated with the virus. There is no vaccine or drug that prevents this infection, but you can help protect yourself from it by frequently washing your hands and washing any fruits and vegetables before you eat them. If you are pregnant and get this infection (or any other illness that causes diarrhea and vomiting), see a health care provider. Dehydration can lead to certain pregnancy problems. You may need to receive intravenous (IV) fluids. Before you book cruise, you may want to check whether your ship has passed a health and safety inspection conducted by the Centers for Disease Control and Prevention (CDC). The CDC performs periodic inspections of cruise ships in order to prevent widespread virus outbreaks. The CDC cruise ship

inspection reports can be found here. Traveling Outside the United States If you are planning a trip out of the country, your health care provider can help you decide if travel outside the United States is safe for you and advise you about what steps to take before your trip. The CDC also is a good resource for travel alerts, safety tips, and upto-date vaccination facts for many countries. The CDC web site has a travel page called “Traveler’s Health” that can be accessed here. The CDC can be reached by phone at 1-800-232-4636. Malaria One common health concern about traveling in certain areas is malaria. Malaria is a serious disease carried by mosquitoes that presents a major risk to your pregnancy. While you are

pregnant, you should not travel to areas where there is risk of malaria, including Africa, Central and South America, and Asia. If travel to these areas cannot be avoided, have your health care provider prescribe an antimalarial drug for you, such as chloroquine or mefloquine. Pregnant women should not take the antimalarial drugs atovaquone and proguanil, doxycycline, or primaquine. Food Precautions Traveling to other countries means you may be exposed to other kinds of germs. People who live in the country are used to the organisms in the food and water, but a traveler is not. These organisms can make a traveler very ill. Traveler’s diarrhea may be a minor problem for someone who is not pregnant. It is a greater concern for pregnant women, though. If you do get diarrhea, drink plenty of fluids to combat dehydration. Before taking a diarrhea treatment, check with a health care provider to make sure it is safe. The best way to prevent illness is to avoid unsafe food and water.

Make sure to follow these tips: • The safest water to drink is tap water that has been boiled for 1 minute (3 minutes at altitudes higher than 6,000 feet). • Bottled water is safer than unboiled tap water, but because there are no standards for bottled water, there is no guarantee that it is free of germs that can cause illness. • Carbonated beverages and drinks made with boiled water are safe to drink. • Do not put ice made from unboiled water in your drinks. • Do not drink out of glasses that may have been washed in unboiled water. • Avoid fresh fruits and vegetables unless they have been cooked or if you have peeled them yourself. • Do not eat raw or undercooked meat or fish. Medical Care Even if you are in perfect health before going on a trip, you never know when an emergency will come up. Be sure to get a copy of your health record to take with you.

If you are traveling in the United States, locate the nearest hospital or medical clinic in the place you are visiting. If you need a doctor, visit the American Medical Association’s web site at www. ama-assn. org and search on “Doctor Finder.” The American Congress of Obstetricians and Gynecologists’ web site can help you locate an obstetrician. Go to www.acog.org and click on “Find an Ob-Gyn.” If you are traveling internationally, the International Association for Medical Assistance to Travelers (IAMAT) has a worldwide directory of doctors. To obtain the free directory, call (716) 754-4883, or go to www.iamat.org. The doctors in the country you are visiting may not speak English, so bring a dictionary of the language spoken with you. Another tip is to register with an American embassy or consulate after you arrive at your destination. These agencies may be helpful if you need to leave the country because of an emergency. There is no reason to put off taking trips during your pregnancy if you are not having any complications. Letting your health care provider know about your travel plans and staying alert to your body’s signals can help keep you safe while you are away from home.

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SCREENING FOR GENETIC DISORDERS Problems in the genes or chromosomes of a fetus are called genetic disorders. These disorders may be inherited (passed from parent to child) or they may occur without a family history. Some genetic disorders are more likely if you have a certain ethnic background or if you have a family history of a disorder. Counseling can help predict your risk, and testing may find the disorder.

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Chromosomes and Genes Genetics is the study of how traits--such as blood type-are passed from parent to child through genes and chromosomes. Each cell in your body has pairs of genes and chromosomes. They control your physical makeup. Normally, a man’s sperm and a woman’s egg have 23 chromosomes each. All other cells in the body have 46. When an egg is fertilized by sperm, 23 chromosomes from the mother and 23 chromosomes from the father join to form the 46 chromosomes of the cell that will become the fetus. One pair of these chromosomes--one each from the sperm and the egg-is

the sex chromosomes. There are two types of sex chromosomes: X and Y. A normal sperm has either an X or a Y chromosome. A normal egg always has an X chromosome. The sex chromosome in the sperm determines the sex of the child. If a sperm with Y chromosome joins with an egg, the fetus is male (XY). If the sperm has an X chromosome, the fetus is female (XX). Each chromosome carries many genes. Genes also come in pairs. Half of a fetus’s genes come from the mother. The other half come from the father. Some traits, such as blood type, are determined by a single gene pair. Other traits

including skin color, hair color, and height--are the result of many pairs of genes working together. A gene or a genetic disorder is either dominant or recessive. If one gene in pair is dominant, the trait it carries cancels out the trait carried by the recessive gene. For a recessive trait to appear, the gene that carries it must be inherited from both parents. Types of Genetic Disorders Genetic disorders may be caused by problems with either genes or chromosomes. An inherited disorder is caused by a gene that is passed from parent to child. These

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disorders can be dominant, recessive, or X-linked. Chromosomal disorders can occur even when the parents do not have any risk factors. Some are caused by a mix of factors (multi-factorial). Dominant Disorders Just one gene from either parent can cause a dominant gene disorder. If one parent has the gene, each child of the couple has a 1-in-2 chance of inheriting the disorder. Examples of dominant disorders are: 1. Huntington’s disease--An inherited nerve disorder that causes loss of control of movements and mental function, usually starting between 35-50 years of age. 2. Polydactyly-A condition in which a person has extra fingers or toes. Recessive Disorders For recessive disorders, both parents must carry the gene before the problem can occur in their child. If you have a recessive gene for a certain disorder, you are a carrier for that disorder. Although you may show no signs of the disorder yourself, you can still pass it on to your children. If both parents are carriers of the same recessive disorder, each of their children has a 1-in-4 chance of having the disorder. Some recessive disorders are more common in certain ethnic groups, such as: 1. Sickle cell disease-An inherited disorder in which red blood cells have a crescent shape, causing chronic anemia and episodes of pain. It occurs most often in African Americans. 2. Tay-Sachs disease-An inherited birth defect that causes mental retardation, blindness, seizures, and death, usually by age years. It occurs mostly in people of eastern European Jewish descent (Ashkenazi Jews) and among French Canadians and Cajuns. 3. Cystic fibrosis An inherited disorder that causes problems in digestion

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and breathing that occurs mostly in people of Northern European descent. X-Linked Disorders Disorders that are caused by genes on the X chromosome are called X-linked or sex-linked disorders. In most X-linked disorders, the abnormal gene is recessive. A woman can carry the gene for an X-linked disorder caused by a recessive gene but not have that disorder. This is because even though one of her X chromosomes has the recessive disorder, her other X chromosome has the normal gene, which is dominant. A male baby inherits one X chromosome from his mother. If the X chromosome he inherits has the disorder, he will get the disorder because he doesn’t have another X chromosome with a normal gene to cancel out the abnormal one. Color blindness is a common a X-linked trait. If you are a carrier for an X-linked disorder, there is a 1-in-2 chance a son will have the disorder and a daughter will be a carrier. Very rarely, a daughter has an X-linked recessive disorder. In this case, her father has the disease and her mother is a carrier. If you have a family history of a disorder, carrier testing may be used to show if you are a carrier of an X-linked disorder. Examples of X-linked disorders are: 1. Hemophilia-An inherited sex-linked disorder in which the blood lacks a substance that helps it clot. 2. Duchenne muscular dystrophy-An inherited, sex-linked disease most often affecting males. Symptoms are weakness and muscle wasting, first of the limbs and trunk, but slowly affecting all voluntary muscles, with death usually occurring around age 30 years. 3. Fragile X syndrome-A disorder of the X chromosome that is the most common inherited cause of mental retardation. Chromosomal Disorders Genetic disorders also may be caused by a missing, damaged, or extra

chromosome. Such problems often are caused by an error that occurred when the egg or sperm was forming. Most children with chromosomal disorders have physical defects, and some have mental defects. Two examples of chromosomal disorders are: 1. Down syndrome-A genetic disorder resulting from an extra copy of the 21st chromosome in which mental retardation, abnormal features of the face, and medical problems such as heart defects occur. 2. Trisomy 18-A genetic disorder resulting from an extra copy of the 18th chromosome that causes serious problems with physical and mental development. Most infants with trisomy 18 die within the first year of life. The risk of having a child with a chromosomal disorder increases as a woman ages. For instance, a 35-year-old woman has a 1-in-192 (less than 1%) chance of having a baby with a chromosomal disorder. The chance increases to 1 in 66 (about 1.5%) in a woman aged 40 years. Multi-factorial Disorders Disorders thought to come from a mix of factors are called multi-factorial disorders. This means the actual cause is unknown. A few of these disorders can be detected during pregnancy. Sometimes they can be corrected with surgery. Some examples of multi-factorial disorders are: 1. Abdominal wall defect -The muscle and skin that cover the wall of the abdomen are missing and the bowel is either enclosed in a clear sac (omphalocele) or sticks out through a hole in the abdominal wall (gastroschisis). 2. Cleft palate A gap or space occurs in the roof of the mouth. Clubfoot-The foot is misshaped and twisted out of position.

Neural Tube Defect

Incomplete closure of the fetal spine that can result in spina bifida or anencephaly. Risk Factors When you have your pre-pregnancy checkup or start prenatal care, your doctor may give you a list of questions. Your answers to these questions will help your doctor advise you on your risk of having a baby with a genetic defect. He or she also may suggest genetic counseling or testing. If you answer “yes” to any of them, you may be at increased risk for having a baby with a genetic disorder. In most cases, even couples at risk can have healthy children with no genetic disorders. However, genetic disorders can occur even when there is no history of problems in the family. For that reason, some tests to detect genetic disorders are offered to all women. Testing Whether you want to be tested to see if you are at increased risk for birth defects or genetic disorders is a personal choice. Some couples would rather not know if they are at risk for a problem, but others benefit from knowing in advance. Some tests can be done before a woman is pregnant and others are done at various times during pregnancy. Some may need to be done in a special center equipped to perform them. Carrier Testing Carrier testing of both parents will detect if either parent is a carrier of a certain genetic defect. Carrier testing can be done before, during, or after pregnancy. For a carrier test, a sample of blood or saliva is studied in a lab to detect a defective gene for a certain inherited disorder. All women may be offered or informed about carrier testing for cystic fibrosis. Other tests can be done if your family history, ethnic origin, or some other factor raises your risk of being a carrier. Unfortunately, there are no carrier tests for most inherited birth defects. Your doctor or genetic counselor will help you understand the chances that the defect could be passed on to your baby. If the carrier testing is

done before you are pregnant, you can use the results to decide if you want to get pregnant. If you are already pregnant, you may be offered testing to see if the baby has the defect. Screening Tests Screening tests are available to detect some birth defects during pregnancy. However, a screening test only shows if there is an increased risk that a defect will occur. The following screening tests may be offered: •

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Maternal serum screening - These tests measure the level of three or four substances in the mother’s blood. This test is used to find out if a woman a is at increased risk for having a baby with a neural tube defect, abdominal wall defect, Down syndrome, or trisomy 18. These tests usually are done between 15 and 20 weeks of pregnancy. First trimester screening - This screening test combines the results of a special ultrasound test called nuchal translucency screening and blood (serum) tests (PAPP-A and hCG). It is done between 10 and 14 weeks of pregnancy. This test can be done to look for signs of Down syndrome, trisomy 18, and heart defects.

A test result could be positive (showing there is a risk of a problem) even though the baby is healthy. Likewise, a birth defect can occur even if testing doesn’t show a problem. Most tests focus on a certain problem, and not all disorders can be found by testing. If the results of a screening test show an increased risk, further tests may be done to diagnose the problem. Diagnostic Tests If a screening test or other factors raise concerns, diagnostic tests often can show whether certain birth defects are present. The following diagnostic tests may be offered:

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Detailed Ultrasound Exam - This type of ultrasound exam can help explain abnormal screening test results and provide more detailed information. An ultrasound exam can be performed anytime during pregnancy, although a detailed exam is best performed after 18 weeks of pregnancy. Amniocentesis - In this procedure, a needle is used a to withdraw a small amount of amniotic fluid and cells from the sac surrounding the fetus. The amniotic fluid and cells can be tested to detect certain chromosomal problems in the fetus. Amniocentesis usually is done at 1520 weeks of pregnancy. Chorionic Villus Sampling (CVS) - A small sample of cells is taken from the placenta and tested. CVS detects some of the same chromosomal problems as amniocentesis does. This test can be performed earlier than amniocentesis- often at 10-12 weeks of pregnancy. Fetal Blood Sampling - Also known as cordocentesis, this procedure tests for chromosomal defects and other problems. For this test, blood is taken from a vein in the umbilical cord. Fetal blood sampling usually is used when the results of amniocentesis, chorionic villus sampling, or ultrasound are unclear. The test results may take a week or more to complete.

Most babies are born healthy, but for some there is an increased risk of a birth defect. Testing can help detect the risk of a genetic disorder, but no test is 100% accurate. If you are at risk for having a baby with a genetic a disorder, talk to your doctor about counseling and testing. A counselor can give a couple information that can help them decide how to proceed.

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TESTING FOR GROUP B STREPTOCOCCUS Group B streptococcus (G8S) is a type of bacteria that is found in 10-30% of pregnant women. A woman with GBS can pass it to her baby during labor and delivery. Most babies who get GBS from their mothers do not have any problems. A few, however, will become sick. This illness can cause serious health problems and even death in newborn babies. It usually can be prevented with a routine screening test that is given during prenatal care. What Is GBS? GBS is one of the many bacteria that live in the body and usually do not cause serious illness. It is found in the digestive, urinary, and reproductive tracts of men and women. In women, it can be found in the vagina and rectum. GBS is not a sexually transmitted a disease. Also, although the names are similar, GBS is different from group A streptococcus, the bacteria that causes “strep throat.” A person who has the bacteria but shows no symptoms is said to be colonized. The number of bacteria that a person has may change over time. A person colonized with a large number of bacteria may have low levels of bacteria months or years later. It also is possible for the number of bacteria to decrease to levels that cannot be detected. Most pregnant women who are colonized with GBS have no symptoms or health effects. A small number may develop a urinary tract infection or infection of the uterus caused by GBS. The most serious health effect

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is that a woman colonized with GBS late in her pregnancy can pass it to her baby. For this reason, women are tested for GBS late in pregnancy. If GBS is present, a woman will receive treatment during labor. Effects on the Newborn There are two types of GBS infections in newborns. Although both types of infections can be serious, most infants recover with no lasting effects. However, about 5% of babies infected with GBS will die. 1. Early-onset infections -Earlyonset infections occur during the first week of life, generally within the first 24-48 hours after birth. These infections can occur as the baby moves through the birth canal of a woman who is colonized with GBS. Only a few babies who are exposed to GBS develop an infection. Certain factors, such as preterm birth, may increase the risk of a baby becoming infected. The most common

problems caused by early-onset GBS infections are lung infections, blood infections, and meningitis. 2. Late-onset infections -These infections occur after the first 6 days of life. Late-onset infections may be passed from the mother to the baby during birth or they may be caused by contact with other people who are colonized with GBS. Late-onset infection can lead to meningitis and other diseases, such as pneumonia. GBS testing late in pregnancy and treatment during labor can help prevent early-onset infections. However, it does not prevent late-onset infections.

Testing and Treatment To help prevent early-onset GBS infection, women are tested for GBS late in pregnancy, between weeks 36 and 37. The test is called a culture. In this test, swab is used to take a sample from the woman’s vagina and rectum. This procedure is quick and is not painful. The sample is sent to a lab where it is grown in special substance. It may take up to 2 days to get the results. If results of the culture test are positive, showing that GBS is present, you most likely will receive treatment with antibiotics during labor to help prevent GBS from being passed to your baby. Antibiotics help get rid of some of the bacteria that can harm the baby during birth. The antibiotics work only if they are given during labor. If treatment is given earlier in pregnancy, the bacteria may

regrow and be present during labor. Even if you had a negative GBS test result in a previous pregnancy, you still need to be tested during each pregnancy. If you had a positive GBS test result in prior pregnancy, you need to be tested again during each pregnancy. You may no longer have the bacteria. Penicillin-based products are the antibiotics that are most often given to prevent early-onset GBS infection in newborns. If you are allergic to penicillin, tell your health care provider before you are tested for GBS. Women with mild allergic reactions can take an antibiotic called cefazolin. If you have had a severe reaction to penicillin, such as hives or anaphylaxis, the bacteria in the sample need to be tested to determine the choice of antibiotic. If you had a previous baby with GBS infection or if your

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urine has GBS bacteria during this pregnancy, you are at high risk of passing GBS on to your baby during labor and delivery. You will receive treatment during labor to protect your baby from infection. You will not need to be tested between weeks 36 and 37 of pregnancy. Special Situations Women who have planned a cesarean birth do not need to be given antibiotics for GBS during delivery if their labor has not begun or the amniotic sac has not ruptured (their water has not broken). However, these women should still be tested for GBS because labor may occur before the planned cesarean birth. If the test result is positive, the baby may need to be monitored for GBS infection after birth. If woman goes into labor but has not yet been tested for GBS, she may be given antibiotics in certain clinical situations as determined by your provider. Finally. GBS can cause serious health problems in newborns. It is important to know about GBS so that you can protect your baby. Pregnant women are tested for GBS late in pregnancy. If you are GBS positive, treatment during labor and delivery may help prevent earlyonset GBS infection in your baby. Tell your health care provider about your GBS status in past pregnancies, whether you have had a baby infected with GBS, and whether you are allergic to penicillin.

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Special Tests and Monitoring of Fetal Health Special tests may be used to check the well-being of the fetus during pregnancy. These tests can help reassure you and your health care provider that all is going well. If problems arise, tests can help alert your health care provider that special care is needed. Why Special Tests May Be Needed Special testing during pregnancy most often is done when the fetus is at increased risk of problems that could result in pregnancy complications or lead to stillbirth. These tests usually are done for women with high-risk pregnancies. High-risk pregnancies include those in which the woman has had a previous pregnancy in which complications occurred or has a pre-existing health condition, such as heart disease, high blood pressure, diabetes, or advanced maternal age. A woman’s pregnancy can become high risk if certain problems

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arise during the prenatal period. Some examples of these problems include fetal growth problems, Rh sensitization, or high blood pressure that occurs during pregnancy. Testing also may be started if there is decreased movement of the fetus, your pregnancy goes past your due date, or you have a multiple pregnancy with certain complications. A negative test result means that no problems have been found. A positive test result, however, does not necessarily mean that there is a problem. If you have a positive test result, you most likely will have additional tests to find out whether

The Fetal Heart Rate Monitor This fetal heart rate monitor is a critical tool in monitoring the health and well-being of the fetus after 32 weeks. This tool can be used to perform a non-stress test (NST) and also a biophysical profile (BPP). It measures the fetal heart rate continuously and tracks the perceived fetal movements for approximately 20 minutes. It also monitors the uterus for contractions.

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a problem exists. is No test is 100% reliable. Test results may show that there is no problem when one actually exists. This is called a false-negative result. Test results also may show that there is a problem when one does not exist. This is called a false-positive result. It is important to understand the risks associated with both false-positive results and false-negative results when undergoing these tests.

your health care provider may ask you to keep track of the fetus’s movements. When you can feel the same level of movement compared with your previous perceptions of fetal movement, it can be a sign that the fetus is doing well. There are different ways kick counts can be done. Your health care provider will give you instructions. One way to do kick counts is to lie on your side and note how long it takes to feel 10 movements. If it takes fewer than 2 hours, the result

When Tests Are Performed Special testing usually is started around 32 weeks of pregnancy. Testing may be started earlier if problems are particularly serious or there are multiple risk factors. How often the tests are done depends on the condition that prompted the testing, whether the condition remains stable, and results of the testing. Some tests are repeated weekly. In certain situations, such as diabetes in the mother, post-term pregnancy, fetal growth problems, or some chronic health conditions, tests may be done twice weekly. Types of Special Tests The tests used to monitor fetal health include fetal movement counts, non stress test, biophysical profile, contraction stress test, and Doppler ultrasound of the umbilical artery. Fetal Movement Counts Fetal movement counting (also called “kick counts”) is a test that you can do at home. Your health care provider will tell you how often to do it and when to notify him or her. If you have felt fetal movement less often than what you think is normal,

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is considered normal. Once you have felt 10 movements, you can stop counting for that day. This test may be repeated daily. When you first start doing kick counts, you most likely will receive instructions about when to call your health care provider depending on certain results. If you do not feel enough movement, it does not necessarily mean that there is a problem. It could simply mean that the baby is sleeping. Additional tests may be needed to find

out more information. Non Stress Test The non stress test measures the fetal heart rate in response to fetal movement over a period of time. The term “non stress” means that during the test, nothing is done to place stress on the fetus. The fetal heart normally beats faster (called an acceleration) when the fetus moves. During a non stress test, the fetal heart rate is recorded. Your health care provider then notes the number of accelerations that occurred during the test period. This test is usually done in our office. The test is done while you are reclining or lying down and usually takes at least 20 minutes. A belt with a sensor that measures the fetal heart rate is placed around your abdomen. The fetal heart rate is recorded by a machine. If two or more accelerations occur within a 20-minute period, the result is considered reactive or “reassuring.” A reactive result means that for now, it does not appear that there are any problems. Reactive results are slightly different if the gestational age is less than 32 weeks. Sometimes, the baby may be asleep and will not move two times in 20 minutes. If this happens, the test may last 40 more minutes, or the baby may be stimulated to move with sound projected over the mother’s abdomen. A nonreactive result is one in which not enough accelerations are detected in a 40-minute period. It can mean several things. It may mean that the baby was asleep during the test. It can occur if the woman has taken certain medications. Sometimes

a negative result may prompt us to order additional testing to make certain the fetus is doing well. . A biophysical profile or contraction stress test may be needed to give more information. Biophysical Profile A biophysical profile (BPP) may be done when results of other tests are non reassuring. It uses a scoring a system to evaluate fetal well-being. A BPP helps assess fetal well-being in these five areas: 1. 2. 3. 4. 5.

Fetal breathing movements Fetal body movements Fetal muscle tone Amount of amniotic fluid Fetal heart rate tracing

Each of the five areas is given a score of 0 or 2 points, for a possible total of 10 points. If the first four areas receive a perfect score, however, the fetal heart rate tracing could be waived as it the results are already reassuring. As such, a BPP involves getting an ultrasound exam and may or may not include a fetal heart rate tracing. During this evaluation, a device called a transducer is rolled gently over your abdomen while you are reclining or lying down. The transducer creates sound waves that bounce off of the internal structures of the body. The transducer receives these echoes, which are converted into images displayed on a computer screen for the technician to view. A score of 8-10 is reassuring. A score of 6 is equivocal (neither reassuring nor non reassuring). If you have an equivocal score, depending on how far along you are in your pregnancy, you may have another BPP within the next 12-24 hours, or it may be decided to deliver the baby. A score of 4 or less means that further testing is needed. Sometimes, it means that the baby should be delivered early or right away. No matter what the score is, not enough amniotic fluid means that more frequent testing should be done or delivery may need to be considered.

Modified Biophysical Profile The modified BPP combines a non stress test with an amniotic fluid assessment that is performed using ultrasound. It is less cumbersome but can be just as useful as the BPP in predicting fetal well-being. This test is done for the same reasons that a BPP is done. The fetal heart rate is monitored in the same way it is done for the non stress test. Ultrasound is used to measure how much amniotic fluid there is in four areas of your uterus. If the non stress test results are nonreactive, it could mean that the fetus is having trouble getting enough oxygen. Results of the amniotic fluid measurement give an idea of how well the placenta is working. If the amniotic fluid level is low, it could mean that there is a problem with blood flow in the placenta. A full BPP or contraction stress test may be needed to confirm results. Contraction Stress Test The contraction stress test helps your health care provider see how the fetal heart rate reacts when the uterus contracts. The contraction stress test sometimes is if used if other test results are positive or unclear. In this test, belts with sensors that detect the fetal heart rate and uterine contractions are placed across your abdomen. To make your uterus contract mildly, you may be asked to rub your nipples through your clothing or you may be given oxytocin. Your uterus may contract on its own, especially if the test is done late in pregnancy. If the fetal heart rate does not decrease after a contraction, the result is normal (negative). A decrease in heart rate after most contractions is positive result (the results are concerning to the provider). Results also can be equivocal (the results are not clear) or unsatisfactory (there were not enough contractions to produce a meaningful result). For some women, this test may increase the risk of some complications. The contractions could cause labor to

start if you are at risk of preterm delivery (although this is rare). However, in some situations, the benefits of having this test may outweigh the risks involved. If results are positive or unclear, your health care provider will use results of previous tests, your condition, and the contraction stress test result to decide on the next steps. More testing may be needed. In some situations, the baby may need to be delivered right away. Doppler Ultrasound Exam Doppler ultrasound is used to check the blood flow in the umbilical artery, a blood vessel located in the umbilical cord. Doppler ultrasound is used with other tests when the fetus shows signs of not growing well. Repeated tests may be done along with other special tests to determine the best time for delivery of the fetus. You will be reclining or lying down for this test. A transducer is rolled gently over your abdomen to project sound waves. An image of the artery that is being examined is shown on a computer screen. A normal test result is one that shows normal blood flow in the umbilical artery. If the test shows problems with the blood flow in the placenta, it can mean that there is a decrease in the amount of oxygen being delivered to the fetus. Although no test is 100% accurate, these tests may play an important role in the early diagnosis and early intervention for high-risk pregnancies. These tests are safe to do and easy to do. The non-stress test (NST) and biophysical profile (BPP) can be very useful in situations where a patient notes decreased fetal movement, but the BPP indicates a healthy intrauterine environment for the baby. A normal BPP means that despite this perception of decreased fetal movement, the chances of a stillbirth occurring over the next week is far less than 1 percent.

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Scheduling Your Delivery Induction of Labor Labor is the process that leads to the birth of a baby. Labor usually starts on its own. Labor induction is the use of medications or other methods to bring on (induce) labor. More than 20% of pregnant women in the United States have labor induced. Labor may be induced for many reasons. Some medications used for induction also can be used to speed up labor that is going too slowly.

Reasons for Labor Induction Labor is induced to stimulate contractions of the uterus in an effort to have a vaginal birth. Labor induction may be recommended if the health of the mother or fetus is at risk. Some of the reasons for inducing labor include the following:

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Before labor is induced, your health care provider will review the baby’s gestational age, how your pregnancy is going, and the possible risks for you and the fetus. With some complications, labor induction may be needed even if it means that the baby will be born early. In these cases, the risks of continuing the pregnancy outweigh the risks associated with the baby being born too early. In certain situations, labor is induced for non- medical reasons,

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Maternal health problems, such as diabetes; high blood pressure; or heart, kidney, or lung conditions Placental problems Fetal problems, such as poor growth or lack of amniotic fluid Pregnancy extending beyond the due date Uterine infection or risk of infection (such as prolonged rupture of membranes) Preeclampsia and eclampsia

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Death of the fetus Risk of a big baby born to a mom with a small pelvis Worsening maternal anxiety, depression or other psychiatric crisis Risk of precipitous delivery outside of health care facility

such as living far away from the hospital. This is called elective induction. Elective inductions should not be done prior to 39 weeks gestation. When Labor Is Not Induced Some conditions may make a vaginal delivery unsafe for the mother or her baby. Some of these conditions include the following: •

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Placenta previa (the placenta covers the opening of the uterus) . Abnormal presentation (the baby is in position that is not favorable for vaginal birth, such as lying sideways in the uterus instead of head down) Prolapsed umbilical cord (the cord has dropped down in the

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vagina ahead of the baby) Active genital herpes infection Some types of previous uterine surgery

How Labor Is Induced There are several ways to start labor. The choice depends on several factors. These factors include your condition and the experience of your health care provider. Several of these methods may be used together. Ripening the Cervix Ripening the cervix is a process that helps the cervix soften and thin out in preparation for labor. Sometimes when labor is going to be induced, the cervix is not yet “ripe” or soft. This means that labor cannot progress. Your health care provider will check to see if your cervix has started this change. Medications or devices may be used to soften the cervix so it will stretch (dilate) for labor. Prostaglandins are drugs that can be used to ripen the cervix. They are forms of chemicals produced naturally by the body. These medications can be inserted into the vagina or taken by mouth. Some of these drugs are not used in women with a previous cesarean delivery or other uterine surgery to avoid increasing the possible risk of uterine rupture (tearing). The cervix also can be widened with special dilators. A catheter (flexible small tube) with an inflatable balloon on the end also can be inserted to widen the cervix. Rupturing the Amniotic Sac The amniotic sac also is called “the bag of waters.” If the sac has not broken already, and your labor has not started on its own, rupturing the amniotic sac can

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start contractions. It also can make them stronger if they have already begun. The health care provider makes a small hole in the amniotic sac a with a special tool. This procedure, called an amniotomy, may cause some discomfort. Amniotomy is done to start labor when the cervix is dilated and thinned and the baby’s head has moved down into the pelvis. Most women go into labor within hours after their water breaks. Oxytocin Oxytocin is a hormone that causes contractions of the uterus. It can be used to start labor or to speed up labor that began on its own. Oxytocin is given through an intravenous (IV) tube in the arm. A pump hooked up to the IV tube controls the amount given. Contractions usually start in about 30 minutes. Your condition, your contractions, and the baby’s heart rate will be monitored when you are given this medication. Risks Problems sometimes can occur with both cervical ripening and labor induction. With some methods, the uterus can be overstimulated, causing it to contract too frequently. Too many contractions may lead to changes in the fetal heart rate, umbilical cord problems, and placental abruption. Other risks of cervical ripening and labor induction include the following: • • •

Infection in the mother or baby Uterine rupture Increased risk of cesarean birth Fetal death

These risks are also present for any patient that spontaneously goes into labor. Medical problems

that were present before pregnancy or occurred during pregnancy may contribute to these complications. To help prevent these complications, the fetal heart rate and force of contractions may be electronically monitored during labor induction. Another risk of labor induction is that sometimes it does not work. A failed attempt at induction may mean that you will need to try another induction or have a cesarean delivery. Some patients who are pregnant with a large fetus, or who themselves have a small pelvis, may end up with a cesarean delivery even if they wait to go into labor. Myths About Induction of Labor There are some myths and incorrect assumptions regarding induction of labor. These include: Myth #1: Inductions are more painful that spontaneous labor - Labor is defined as regular, painful contractions which result in cervical dilation. Labor, by it’s very definition, includes pain. This is true both when a mom naturally goes into labor as well as when labor is induced. When medications are used are used to induced labor, they are titrated to mimic the strength and intensity of contractions that occur naturally. Analgesia (pain relief) is available to expectant mothers to reduce the discomfort of labor, whether it is induced or spontaneous. Myth #2: Inductions are always riskier than waiting for spontaneous labor - Some pregnancies are considered high-risk. This is because there is usually one or more maternal or fetal factors that create a high risk environment for

the pregnancy. This may include advanced maternal age,hypertension, diabetes, large baby, fetal growth restriction, missing the due date or other suspected placental problems, just to name a few. In almost all of these scenarios, the risks of inaction far exceeds the risks of the induction. Myth #3: Inductions always increase your risk of cesarean delivery - The chances of a vaginal delivery depend on multiple factors. A vaginal delivery cannot be guaranteed both when a patient’s labor is induced as well as when the patient goes naturally in labor. At first glance, it may appear that there are more cesarean deliveries in the group of women being induced as compared to the group that goes into labor spontaneously. But careful analysis shows that

this apparent discrepancy is almost completely because the group that is being induced has other high risk characteristics that increase the likelihood of a cesarean delivery. For example, if a mom is suspected of having a 10 1/2 lb fetus and labor is induced, she will have a higher chance of ending up with a cesarean section. This is not necessarily because she was induced, but because her baby was very large. The decision to proceed with induction of labor did not cause her to have a very large fetus. The biggest risk factor for failure of induction of labor is an unripe cervix. This is when the cervix is undilated, thick and firm. As described previously, this is why cervical ripening is such an important part in the process of labor induction. With a “ripe” or favorable cervix, the probability of a vaginal

delivery improves drastically. Labor induction sometimes is necessary to protect the health of both mother and baby. You and your health care provider should weigh the risks and benefits of labor induction compared with the risks and benefits of continuing the pregnancy and waiting for the onset of labor. Understanding the risks and benefits allows you and your health care provider to make the best choice for you and your baby.

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The Debate Over Vaginal Birth After C-Section It was once thought that if a woman had one cesarean delivery, all other babies she had should be born in the same way. Today, it is known that some women can undergo a trial of labor after a cesarean delivery (called TOLAC). After a successful TOLAC, many women will be able to give birth through the vagina (called a vaginal birth after cesarean delivery, or VBAC). TOLAC is not the right choice for every woman, but it is a good choice for some women. It is important to understand the risks and benefits before deciding to attempt TOLAC and VBAC.

Your Choices A woman who has had a previous cesarean delivery has the following choices when planning how to give birth again: • •

She can have a scheduled cesarean delivery. She can try to have a VBAC.

If a woman wants to try VBAC and is considered a good candidate, she will undergo TOLAC. Of women who undergo TOLAC,approximately 60% succeed and are able to give birth vaginally. Unfortunately, 40% of women who try to deliver vaginally will still end up with a cesarean delivery. If problems arise during TOLAC, the baby may need to be born by emergency cesarean delivery. For example, if the baby is not

tolerating labor, or if labor does not progress, an emergency cesarean delivery may be needed. There are more risks, such as a greater risk of infection, with having an emergency cesarean delivery after TOLAC than having a planned cesarean delivery.

For women planning to have more children, VBAC may help them avoid problems linked to multiple cesarean deliveries. These problems include hysterectomy, bowel or bladder injury, and certain problems with the placenta.

Reasons to Consider TOLAC There are many reasons why woman may want to consider TOLAC. Compared with a planned cesarean delivery, a VBAC after successful TOLAC is associated with the following benefits:

TOLAC Risks With TOLAC, the risk of most concern is the possible rupture of the cesarean scar on the uterus or the uterus itself. Although rupture of the uterus is between 1%-2%, it is very serious and may harm both mother and baby. If a woman is considered at high risk, TOLAC should not be tried. Some types of uterine incisions are more likely to cause rupture than others. For cesarean birth, one incision is made in the abdomen and another incision is

• • • • •

No abdominal surgery Shorter recovery period Lower risk of infection Less blood loss Cost savings for your insurance

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made in the uterus. There are three types of uterine incisions: 1. Low transverse--A side-to-side cut made across the lower, thinner part of the uterus 2. Low vertical-An up-and-down cut made in the lower, thinner part of the uterus 3. High vertical (also called “classical”) An up-and- down cut made in the upper part of the uterus Low transverse incisions carry the least chance of rupture. They also are the most common type of incision used in cesarean births. The risk of uterine rupture with this type of incision is about 1%. That means that out of every 100 women that try to have a TOLAC, approximately 1 patient will have very serious and potentially life-threatening complications. Some women who have had a C-section with a documented low transverse incision may be candidates for TOLAC in select cases. Women with high vertical incisions

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are not considered to be candidates for TOLAC because their risk of a uterine rupture in labor is increased. TOLAC can be considered if a woman has had a low vertical incision. It is not possible to tell what kind of incision was made in the uterus by looking at the scar on the skin. Medical records from the previous delivery probably include this information. If medical records are not available, a woman should understand the risks associated with all three types of incisions. It is still possible to have a VBAC, but this may be risky if you and your provider are uncertain as to what type of cesarean section you had performed. Other Factors In deciding whether to have a TOLAC, several factors should be considered in addition to the type of incision. These factors include the desire for more children, whether a woman has certain complications, and the hospital where the birth will take place:

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Future deliveries - Multiple cesarean deliveries are associated with additional potential risks. If you know that you want more children, you should think about these risks when making your decision. Even if you currently think you do not want more children, you may change your mind later. Prior uterine rupture - If you had this complication in a previous pregnancy, TOLAC is not advised. Women who have had a previous a uterine rupture should give birth by repeat cesarean delivery before labor starts on its own. An early delivery also may be recommended (before 39 weeks of pregnancy). A pregnancy problem or a medical condition that makes vaginal delivery risky - Vaginal delivery may not be recommended if there is problem with the placenta or problems with the baby or if you have

•

certain medical conditions during pregnancy. Type of hospital - The hospital in which a woman a has a TOLAC should be prepared to deal with emergencies that may arise. Some hospitals may not offer TOLAC because hospital staff do not feel they can provide needed emergency care. You and your health care provider should consider the resources available at the hospital you have chosen and whether these resources are appropriate for TOLAC. If the hospital you have chosen does not have appropriate resources, you often can be referred to one that does.

Is TOLAC Right for You? You should discuss delivery options with your health care provider early in pregnancy. This way, you and your health care provider have the most time to consider all of the options. Many, but not all, of the factors that go into the decision are known early in pregnancy. Also, if the type of incision used in the previous cesarean delivery is not known, an attempt can be made to find this information. Before deciding whether to try VBAC, you need to know the risks and benefits of both TOLAC and planned cesarean delivery. You also should discuss your individual chances of having a successful TOLAC and VBAC and the risks associated with an emergency cesarean delivery. For women considering TOLAC

and VBAC, chances for success should be as high as possible. Be prepared for changes to your delivery plan. If you have chosen TOLAC, things can happen during pregnancy and labor that alter the balance of risks and benefits. For example, you may need to have your labor induced, which can reduce the chances of a successful vaginal delivery and perhaps increase the chance of complications during labor. In the event that circumstances change, you and your health care provider may want to reconsider your decision. If you have chosen a repeat cesarean delivery, in some situations, TOLAC may be advised. For example, if you have planned a cesarean delivery but go into labor before your scheduled surgery, it may be best to consider TOLAC if you are far along in your labor and your baby is healthy. Final Thoughts There is no one-size-fits-all answer when it comes to the decision as to whether or not to attempt a vaginal delivery after having had a

cesarean delivery. For some patients, a small risk for a disastrous complication is considered acceptable. They perceive the 1% complication risk as being a very small number. They are still motivated to attempt to deliver vaginally and understand that there is no guarantee of ending up with a vaginal delivery. For others, the 1% risk of severe complications with TOLAC represents and unacceptable risk. They prefer to have a scheduled cesarean delivery as opposed to trying to deliver vaginally and possibly ending up with an emergency cesarean delivery which carries more risks. TOLAC, VBAC, and repeat cesarean birth have risks and benefits. When considering your options, you need to know the risks and weigh them against the benefits. We can help guide you in making the best decision for you and your baby.

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The Choice of Newborn

Circumcision

Circumcision is the surgical removal of the layer of skin, called the foreskin, that covers the glans (head) of the penis. Whether to have your son circumcised is your decision. If you choose this procedure for your baby, it usually is done at our office one or two weeks after birth. How Circumcision Is Done Circumcision may be performed before or after the mother and baby leave the hospital. It only is performed if the baby is healthy. If the baby has a medical condition, circumcision may be postponed. Circumcision takes only a few minutes. During the procedure, the baby is placed on a special table. Various surgical techniques are used, but they follow the same steps: • The penis and foreskin are cleaned. • A special clamp is attached to the penis and the foreskin is removed. • After the procedure, a bandage and petroleum jelly are placed over the wound to protect it from rub- bing against the diaper. It is recommended that an

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aesthetic be used for pain relief. We typically use lidocaine for this procedure. Making the Decision Circumcision is an elective procedure. That means that it is the parents’ choice whether to have their sons circumcised. It is not required by law or by hospital policy. Because it is an elective procedure, circumcision may not be covered by your insurance policy. To find out, call your insurance provider or check your policy. For some people, circumcision is a part of certain religious practices. Muslims and Jews, for example, have circumcised their male newborns for centuries. Others may choose circumcision so that the child does not look different from his father or other boys. Although many newborn boys in the United States are circumcised,

the number of circumcisions has decreased in recent years. It is less common in other parts of the world. Some parents choose not to circumcise their sons because they are worried about the pain the baby feels or the risks involved with the surgery. Others believe it is a decision a boy should make himself when he is older. However, recovery may take longer when circumcision is done on an older child or adult. The risks of complications also are increased. It is important to have all of the information about the possible benefits and risks of the procedure before making decision. You may want to start thinking about this decision during pregnancy to give yourself enough time to explore all of the facts. Possible Benefits Circumcised infants appear to have

less risk of urinary tract infections than uncircumcised infants. The risk of urinary tract infection in both groups, however, is low. It may help prevent cancer of the penis, a rare condition. Some research suggests that circumcision may decrease the risk of a man getting human immunodeficiency virus (HIV) from an infected female partner. It is possible that circumcision may decrease the risk of passing HIV and other sexually transmitted diseases from an infected man to a female partner. However, at the present time, there is not enough information to recommend routine newborn circumcision for health reasons. There also are hygienic reasons for circumcision. Smegma is a thick white discharge containing dead cells. It can build up under the foreskin of uncircumcised males. This can lead to odor or infection. However, a boy who has not been circumcised can be taught to wash his penis to get rid of smegma as a part of his bathing routine.

falls off the next time the baby urinates. Some heath care providers recommend keeping a clean bandage on until the penis is healed, while others recommend leaving it off. In most cases, the skin will heal in 7-10 days. You may notice that the tip of the penis is red and there may be a small amount of yellow fluid. This usually is normal. Keep the area as clean as possible. Use a mild soap and water to clean off any stool that gets on the penis. Change the diapers often so that urine and stool do not cause infection. Signs of infection include redness that does not go away, swelling, or fluid that looks cloudy and forms a crust. Call your health care provider right away if you notice any of these signs. If your baby boy is not circumcised, washing the baby’s penis and foreskin properly is important. The outside of the penis should be

washed with mild soap and water. Do not attempt to pull back the infant’s foreskin. The foreskin may not be able to pull back completely until the child is about 3-5 years old. This is normal. As your child gets older, teach your son how to wash his penis. He should pull back the foreskin and clean the area with soap and water. The foreskin then should be pushed back into place. Whether to circumcise or not circumcise your newborn boy is an important decision. Remember, circumcision is elective it is your choice whether to have it done. If you have any questions or concerns, talk with your health care provider during your pregnancy so you have enough time to make an informed decision.

Possible Risks All surgical procedures carry some risk. Complications from a circumcision are rare, but they can occur. Possible complications include bleeding, infection, and scarring. In rare cases, too much of the foreskin or not enough foreskin is removed. More surgery sometimes is needed to correct these problems. Caring for Your Newborn If your baby boy is circumcised, a bandage with petroleum jelly may be placed over the head of the penis after surgery. The bandage typically

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SIGNS & SYMPTOMS OF

LABOR

A waiting the birth of a baby is an exciting and anxious time. The average length of pregnancy is 280 days, or 40 weeks. However, there is no way to know exactly when you will go into labor. Most women give birth between 38 weeks and 41 weeks of pregnancy.

Making Plans As you plan for the birth of your baby, you can take steps to help your labor go more smoothly. It is best to discuss your questions about labor with your health care team before the time comes: • When should call my doctor? • How can I reach the doctor or nurse after office hours? • Should | go directly to the hospital or call the office first? • Are there any special steps should

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follow when I think l am in labor? Before it is time to go to the hospital, there are many things to think about. You may not have time to think about them once labor begins, so it is best to consider them ahead of time: • •

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Distance - how far do you live from the hospital? Transportation - is there someone who can take you at any time, or do you have to call and find someone? Time of day - depending on where you live, may it take longer during rush hours than at other times of the day or night? Home arrangements - do you have other children to take to a babysitter’s home, or do you have to make any other special arrangements? Work arrangements - do you have plan for how your workload will be covered and for letting your coworkers know when you have had the baby?

It may be good idea to rehearse going to the hospital to a get a sense of how long it could take. Plan different route you can follow to the hospital if there are delays on the regular route. How Labor Begins No one knows exactly what causes labor to start, although changes in hormones may play role. Most women can tell when they are in labor. Sometimes, it is hard to tell when labor begins. As labor begins, the cervix opens (dilates). The uterus, which is muscle, contracts at regular intervals. When it contracts, the abdomen becomes hard. Between the contractions, the uterus relaxes and becomes

soft. Even up to the start of labor and during early labor, the baby will continue to move. Certain changes, such as bloody show or ruptured membranes, may also signal that labor is beginning. You may or may not notice some of them before labor begins. True Versus False Labor You may have periods of “false” labor, or irregular contractions of your uterus, before “true” labor begins. These are called Braxton Hicks contractions. They are normal but can be painful at times. You might notice them more at the end of the day. It can be hard to tell false labor from true labor. Usually, false contractions are less regular and not as strong as true labor. Sometimes the only way to tell the difference is by having a vaginal exam to find changes in your cervix that signal the onset of labor. One good way to tell the difference is to time the contractions. Note how long it is from the start of one contraction to the start of the next one. Keep a record for an hour. It may be hard to time labor pains accurately if the contractions are slight. If you think you are in labor, call us through the office or the answering service. There also are other signs that should prompt you to call your doctor: •

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Your membranes have ruptured (your “water breaks”), and you are not having contractions. You are bleeding from the vagina (other than bloody mucus). You have constant, severe pain with no relief between contractions. You notice the baby is moving less often.

in pregnancy. Labor pains are not subtle. Typically, the intensity is such that patients have a hard time breathing through the contractions. Most patients do not want to be at the hospital for early labor. This can lead to prolonged hospitalization and patient dissatisfaction. Instead, the usual rule of thumb is that patients should be admitted to the hospital when they’re in active labor. There are many factors that influence the timing of hospitalization, such as: • • • • • • •

Gestational age of the fetus Past pregnancy history Distance to hospital Whether or not membranes have ruptured Last known position of the baby Last cervical exam in the office Other maternal and neonatal risk factors

It is for these reasons that patients are asked to contact someone from our office before proceeding to the hospital. You are nearing a special, exciting time. Although it is not possible to know exactly when labor will begin, you can be ready by knowing what to expect. Being prepared can make it easier for you to relax and focus on the arrival of your baby when the time comes. Remember, we are affiliated with Holy Cross at Germantown. The facility is located at 19801 Observation Drive, Germantown, MD 20876. Labor & Delivery is located on the third floor of the hospital.

False alarms are fairly common

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POSTPARTUM DEPRESSION Depression after childbirth also called postpartum depression- is more common than many people realize. About 10-15% of women will experience postpartum depression. This condition is more than just feeling sad or blue for a few days. It is a serious illness that can greatly affect the woman, her baby, and her family. Some women do not realize that they have postpartum depression. Family or friends may be the ones who notice that something is wrong. Once it is diagnosed, postpartum depression can be treated with medication and therapy.

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Postpartum Blues and Postpartum Depression About 2-3 days after childbirth, some women begin to feel depressed, anxious, and upset. They may feel angry with the new baby, their partners, or their other children. They also may cry for no clear reason have trouble sleeping, eating, and making choices question whether they can handle caring for a baby These feelings, often called the postpartum blues, may come and go in the first few days after childbirth. The postpartum blues usually get better within a few days or 1-2 weeks without any treatment. If they do not go away or become more intense, this may be a sign of a more serious condition called postpartum depression. Women with postpartum depression have intense feelings of sadness,

anxiety, or despair that prevent them from being able to do their daily tasks. Postpartum depression can occur up to 1 year after having baby, but it most commonly starts about 1-3 weeks after childbirth. A few new mothers may develop a more severe mental illness called postpartum psychosis. This condition is rare. Women have an increased risk of this condition if they or their family members have history of mental illness. Another mental illness that can appear for the first time after childbirth is bipolar disorder. Women with this disorder have shifts in mood, energy level, and ability to function. Reasons for Postpartum Depression Postpartum depression probably is caused by a combination of body, mind, and lifestyle

factors. No two women have the same physical makeup or life experiences. These differences may be why some women have postpartum depression and others do not. Hormonal Changes The postpartum period is a time of great changes in the body. These changes can affect a woman’s mood and behavior for days, weeks, or months. Changes in hormones may play a role in post-partum depression. Levels of the hormones estrogen and progesterone decrease sharply in the hours after childbirth. These changes may trigger depression in the same way that smaller changes in hormone levels trigger mood swings and tension before menstrual periods. Some women react to these changes while others do not. Those

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who have a history of premenstrual syndrome or premenstrual dysphoric disorder may be more likely to develop postpartum depression than women who do not have these disorders. Thyroid disease could be associated with some cases of postpartum depression. The thyroid gland is located in the neck. It releases hormones that control many processes in the body. Some women develop thyroid problems after having a baby. Symptoms include anxiety, trouble sleeping, and weight loss beginning in the first few months after childbirth. Weight gain and depression may occur in later months.

couple to adjust to the idea of a new baby. Parents of babies who are born too early or with a serious illness or birth defect may have a hard time adjusting. These situations can cause changes in home and work routines that the parents did not expect. Parents also may blame themselves for the baby being sick. Having a baby who must stay in the hospital after birth can cause anger, sadness, and guilt. A woman and her partner may question why they were not able to have the “perfect” baby or feel guilty that the mother did something wrong during pregnancy. Sadness about coming home without the baby is very common and can be profound.

History of Depression Women who have had depression at any time-before, during, or after pregnancy-or who currently are being treated for depression have an increased risk of developing postpartum depression. About in 10 women have some form of depression. Women of reproductive age (between the ages of 25 years and 44 years) have the highest rates. Depression during pregnancy is more common than many people may think. It is estimated that almost 2 out of every 10 pregnant women have signs and symptoms that fit the diagnosis of depression.

Fatigue Fatigue (being very tired) may be a major contributor to postpartum depression. Many women feel very tired after giving birth, and it can take weeks for a woman a to regain her normal strength and energy. For women who have had their babies by cesarean birth, it may take even longer. Also, new mothers seldom get the rest they need. In the hospital, sleep is disturbed by visitors, hospital routine, and the baby’s feedings. At home, the baby’s feedings and care must be done around the clock, along with household tasks and possibly caring for other children. The cycle of fatigue and lack of sleep can go on for months.

Emotional Aspects Emotional factors can affect a woman’s self-esteem and the way she deals with stress during pregnancy and the postpartum period. These factors can add to postpartum depression. For example, feelings of doubt about pregnancy are common. If the pregnancy is not planned or is not wanted, this can affect the way a woman feels about her pregnancy and her unborn baby. Even when a pregnancy is a planned, it still may be hard for a

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Lifestyle Factors A major factor in postpartum depression is lack of support from others. The steady support of a new mother’s partner, other family members, or friends is comfort during pregnancy and after childbirth. It helps when others can assume household chores and share in child care. If a woman lives alone or far away from her family, support may be lacking. Even when family and friends are

present, the mother still may feel overwhelmed or isolated. She may feel unable to reach out for the help she needs. Stressful life events can greatly increase the risk of postpartum depression. Stressful life events can include a recent death of a loved one, a family illness, or moving to a new city. For women who have just had baby, any of these things can cause additional stress and anxiety and may trigger depression. Diagnosis and Treatment If you have the signs and symptoms of postpartum depression, or if your partner or family members are concerned that you do, it is important to see your health care provider as soon as possible. Do not wait until your postpartum checkup. Depression is an illness that affects both you and your baby. It can interfere with your own health as well as your ability to bond with and care for your baby. The sooner you get help, the sooner you will feel better and be able to enjoy your new family. Your health care provider most likely will ask questions to find out if your signs and symptoms match those of postpartum depression. If your health care provider determines you have postpartum depression, you will work together to find the best treatment options to relieve your symptoms. Depression can be treated with medications called antidepressants. Talk therapy also is used to treat depression, often in combination with medications. Antidepressants Antidepressants are medications that work to balance the chemicals in the brain that control moods. There are many types of antidepressants. If one type does not work for you, your health care

provider can prescribe another. Drugs sometimes are combined when needed to get the best results. It may take 3-4 weeks of taking the medication before you start to feel better. Although antidepressants can cause side effects, most are temporary and go away after a short time. If you have severe or unusual side effects that get in the way of your normal daily habits, notify your health care provider. You may need to try another type of antidepressant. If your depression worsens soon after starting medication or if you have thoughts of hurting yourself or others, contact your health care provider or emergency medical services right away. It is important to continue taking antidepressants for as long as your health care provider has prescribed-even if you are feeling better. Do not suddenly stop taking your medication because this can cause withdrawal symptoms or lead to a return of your depression. Some medications need to be stopped gradually to give your body time to adjust. Antidepressants are found in breast milk and can be transferred to babies during breastfeeding. The levels found in breast milk generally are very low. Breastfeeding has many benefits for both you and your baby. Deciding to take an antidepressant while breastfeeding involves weighing these benefits against the potential risks of your baby being exposed to the medication in your breast milk. It is best to discuss this decision with your health care provider. Once the baby is born, be sure to tell your baby’s health care provider that you are taking antidepressant medication while breastfeeding. Therapy In therapy (also called psychotherapy or “talk therapy”), you and a mental health professional talk about your feelings and discuss how to

manage them. Sometimes, therapy is needed for only a few weeks, but it may be needed for months or longer. Although the approaches differ, the goal of therapy for postpartum depression is to learn what works for you to relieve your symptoms. There are different types of therapy for postpartum depression. You may have one-on-one therapy with just you and the therapist or group therapy where you meet with a therapist and other people with problems similar to yours. Another option is family or couples therapy, in which you and your family members or your partner may work with a therapist. Prevention If you have a history of depression at any time in your life or if you are taking an antidepressant, tell your health care provider early in your prenatal care. Ideally, you should tell your health care provider before you become pregnant. Your health care provider may suggest that you begin treatment right after you give birth to prevent postpartum depression. If you were taking antidepressants before pregnancy, your health care provider can assess your situation and help you decide whether to continue taking medication during your pregnancy. If you were taking more than one medication, you may be switched to single medication. Do not stop taking your medication without talking to your health care provider. Stopping medication can cause relapse of your condition. After you have your baby, monitor yourself for signs and symptoms of depression and let your health care provider know right away if you have any. Sometimes people with depression do not realize they are depressed. You may want to ask someone you trust to watch for signs and symptoms and

to help you get the care you need if they occur. Even if you do not have a history of depression, your health care provider may ask you specific questions to assess your risk of this condition early in your prenatal care. Many of the signs and symptoms of depression overlap with those of pregnancy and can be easy to overlook. Coping With Postpartum Depression To get well, women with postpartum depression need realistic goals and support. You may need to learn how to nurture yourself as well as your family. Ask for help with child care or household tasks. It is important to take time for yourself whenever you can so that you can recharge. Asking a friend or family member to babysit so that you can get out of the house at least once day-even if you only go a for a short walk-can be helpful. Sharing your experiences with other women who are dealing with postpartum depression can help you feel better and less alone. Support groups can be found at local hospitals, family planning clinics, or community centers. The Holy Cross Hospital may be able to assist you in finding a support group. Many new mothers feel sadness, fear, anger, and anxiety after having , baby. These feelings, called postpartum blues, are common. If the blues do not improve or your symptoms get worse, you may have postpartum depression. Postpartum depression is an illness that can be treated successfully with medication and therapy. If you think you need help, please do not hesitate to contact us for an immediate consultation.

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GETTING IN SHAPE

POSTPARTUM Having a baby and taking core and taking care of a newborn are hard work. It will take a while to regain your strength after the strain of pregnancy and birth. You should allow your body time to recover. But, as soon as you feel up to it, talk to your doctor about when you can start an exercise program.

Benefits of Exercise Daily exercise can help restore muscle strength and firm up your body. Exercise can make you less tired because it raises your energy level and improves your sense of well-being. During pregnancy, the muscles in your abdomen stretch. It takes time for good muscle tone to return. Exercising helps tighten these muscles. When Can I Start? Check with your provider before starting an exercise program. You should start when you feel up to it and know you will keep it up. Follow the same guidelines as you did when you were pregnant. If you had a cesarean birth, difficult birth, or complications, it may take a little while longer to feel ready to start exercising. If you did not exercise during pregnancy, start with easy exercises and slowly build up to harder ones. If you exercised regularly throughout pregnancy, you a have a head start. You should not try to resume your former pace right away, though.

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Getting Started Walking is a good way to get back in shape. Brisk walks will prepare you for more vigorous exercise when you feel up to it. Walking is a good choice for exercise because the only thing you need is a pair of comfortable shoes. It is free, and you can do it almost any place or time. Walking also is good because your baby can come along. The two of you can get out of the house for exercise and fresh air without needing to find child care. Seeing other people and being outside can help relieve stress and tension. Another way to get started is to try the exercises shown on the reverse side. As you feel stronger, think about trying more vigorous exercise. You will want to decide on exercises that meet your needs. A good program will make your heart and lungs stronger and tone your muscles. There are special postpartum exercise classes that you can join. Your health care provider can help you find some good classes. Resources that may be helpful are local health and fitness clubs, community centers, local colleges,

hospitals, and adult education programs. With any program you get involved in, make sure it is one you will keep doing. Exercise over time is more important than starting right away after birth. Your Exercise Program Your workout should always include time for you to warm up and cool down. This will help reduce the risk of injury or sore muscles. Warm Up Before you begin each exercise session, always warm up for 5-10 minutes. This light activity, such as slow walking, prepares your muscles for exercise. As you warm up, stretch your muscles to avoid injury. Hold each stretch for 10-20 seconds-do not bounce. Target Heart Rate You should exercise so that your heart beats at the level that gives you the best workout. This is called your target heart rate. To check your heart rate, count the beats by feeling the pulse on the inside of your wrist. Count for 10 seconds.

Multiply this count by 6 to get the number of beats per minute. To calculate your maximum heart rate, deduct your age from 220. For example, the maximum heart rate for a 30-year-old would be 190 beats per minute. Your target heart rate will be a fraction of your maximum heart rate. It is about 50-85% of your maximum heart rate (the fastest your heart can beat). When you begin your exercise program,

aim for the lower range of your target heart rate (50%). As you get into better shape, slowly build up to the higher end of your target heart rate. After 6 months of exercise, you should be able to exercise at up to 85% of your target heart rate. But you do not need to exercise at 85% of your target heart rate to stay fit. You should aim to exercise about 20-30 minutes while in your target heart rate.

Cool Down After exercising, cool down by slowing your activity. Cooling down allows your heart rate to return to normal levels. Cooling down for 5-10 minutes, followed by stretching, also helps prevent sore muscles. Keep the following in mind: • Wear comfortable clothing that will help keep you cool. • Wear a bra that fits well and gives plenty of support to help protect your breasts. • Drink plenty of water. Congressional Weight Loss We offer a comprehensive weight loss program for postpartum patients. Whether you choose to use medications to help you lose weight or non-pharmacological remedies, we can help you achieve your goal of returning to your pre-pregnancy weight safely and quickly. Most of our programs are covered by insurance. Please ask your provider for additional information and for a customized plan that suits your needs and your situation.

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Congressional OB GYN 14995 Shady Grove Road, #410 Rockville, MD 20850 T.

Phone: 301.294.8525 Fax: 301.294.5919 www.CongressionalOBGYN.com