Complete Women's Care - Your Guide to a Healthy Pregnancy

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A HEALTHY PREGNANCY Your Guide to

A Division of Mid-Atlantic Women’s Care, PLC

W elcome...

...and thank you for choosing Complete Women’s Care for your maternity care. We are honored that you have chosen us. We believe that you will receive the best healthcare through a partnership with us. We encourage you to ask questions. We have prepared this booklet to explain how our practice works and to introduce you to the various procedures and tests you may encounter in the months ahead. We believe that the birth of your child should be a family experience and we encourage your family to participate fully by attending your prenatal visits, prepared childbirth classes and labor and delivery. At Complete Women’s Care we work together as a team. Our doctors, nurses and staff provide you with coverage 24 hours a day, 7 days a week. To be able to achieve this goal our doctors share our “On Call” schedule. (Please refer to the back cover of this booklet for information regarding after-hours telephone calls.) During your prenatal care, you may choose to see all of our doctors and our nurse practitioners or you may select whom you see. We request that you meet at least two of our doctors. This system affords a healthy check and balance system with automatic consultation among physicians. Your labor and delivery will be attended by the Complete Women’s Care physician who is on call that day. After your delivery you may choose one physician to provide your gynecology care. At your first office visit, we will obtain a complete medical history and perform a complete physical exam including bloodwork and pap smear. We will develop a plan for your pregnancy and answer all of your questions. Generally, your visits will be every four to six weeks until the seventh month of pregnancy, every two to three weeks until the ninth month, and weekly until delivery. We will monitor your health and the health of the baby. More frequent visits may be required if you develop complications. Once again, we are honored that you have placed your trust in us at this most special time. We will strive to provide you with the highest level of maternity care as your family grows.

A Division of Mid-Atlantic Women’s Care, PLC

Melody R. Adler, M.D., F.A.C.O.G. Melissa J. Buchberg, M.D., F.A.C.O.G. Monique S. Crabb, M.D., F.A.C.O.G. Maria Crippen, M.S.N., W.H.N.P.-B.C. Patricia Dudley, M.S.N., F.N.P.-B.C. Deidre Fish, M.D., F.A.C.O.G.

Jennifer George Ward, M.D., F.A.C.O.G. Amour M. Johnson, M.D., F.A.C.O.G. Ashley Moan, M.S.N., W.H.N.P.-B.C. J. Julie Rekant, M.S.N., F.N.P.-B.C. Tracy B. Wright, M.D., F.A.C.O.G.

YOUR GUIDE TO A HEALTHY PREGNANCY

CCI Scan + Play App

videos and more

Looking for a fun way to learn new things? The “CCI Scan + Play” app makes it fast and easy to watch helpful videos on several interesting topics in this book. Follow the instructions below to get started.

1. DOWNLOAD Visit customizedinc.com/ScanAndPlay and download the “CCI Scan + Play” app.

2. FIND Look for the purple “Scan + Play” icons throughout this book.

3. SCAN Use the “CCI Scan + Play” app to scan the purple icons.

4. PLAY Sit back, get comfortable and enjoy your video!

BREATHING EXERCISES

STICKER BOOK

You can also use the app to access interactive features throughout your pregnancy. For example, breathing exercises that can help you feel calm and relaxed. Plus, stickers you can add to photos to mark special milestones during pregnancy. Creating lifetime memories to share with your family and friends has never been easier!

3Min Exercise

Breathing Exercises

Hold breath for 7 seconds

VIDEOS INCLUDED

DUE DATE

Table of Contents

Page 7

Prenatal Care Overview . . . . . . . . 5 Your First Visit . . . . . . . . . . . 6 Follow-up Visits . . . . . . . . . . . 7 Prenatal Testing . . . . . . . . . . . 8 Genetic Testing 11 Planning and Preparation . . . . . . . 15 How Your Body Changes . . . . . . . 17 Making Good Choices . . . . . . . . 24 Partners and Families . . . . . . . . 30 Six Steps to a Healthy Pregnancy . . . . 31 Easy Exercises . . . . . . . . . . . 36 How Babies Grow and Change . . . . . 38 Disease and Infection . . . . . . . . 40 Possible Complications . . . . . . . 44 High-Risk Pregnancy 48 The Final Weeks . . . . . . . . . . 49 Labor and Birth 51 Labor Induction 53 Pain Management . . . . . . . . . 54 Cesarean Birth . . . . . . . . . . . 56 VBAC . . . . . . . . . . . . . . 56 After the Birth . . . . . . . . . . . 57 Breastfeeding 59 Home at Last . . . . . . . . . . . 62 Glossary 64

SONOGRAM

Page 8

PREGNANCY ACHES AND PAINS

Page 17

EXERCISING DURING PREGNANCY

Page 35

MILESTONES (1-10 MONTHS)

Page 38

AND... SKIN-TO-SKIN MILK PRODUCTION FEEDING CUES LATCH

57 59 60 61

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CONGRATULATIONS!

You’re going to have a baby. Now what? Over the next few months your body will

experience many physical changes. You may also face some unexpected challenges and emotions. At every stage of your pregnancy, you will have lots of questions. Is this normal? What happens next? We want to help. Whether this is your first pregnancy or you’ve had other children, you’ll find practical answers to many common questions about pregnancy in this book. If you can, read through the entire book early on. The more you know about what is happening—and what to expect next—the more confidently you can move through your pregnancy. See a word in blue text ? You’ll find it defined in the Glossary section at the back of the book. A final thought. Having a trusted support system around you while you’re pregnant can make a big difference. There will be ups and downs. There will be milestones to celebrate. Sharing this exciting experience with the people who know and love you lets everyone be part of the joy of bringing a new baby into the world.

Your Guide to a Healthy Pregnancy

Prenatal Care Overview As soon as you think you’re pregnant, schedule your first prenatal appointment with an obstetrician or midwife. Having a healthy pregnancy puts you on the road to a healthy birth. Here are some of the best

reasons to see your health care provider for regular prenatal care : • Better chance of avoiding pregnancy surprises or emergencies • Early identification of any possible health issues or challenges • Practical information about giving your baby a healthy start in life • Building a trusting relationship with your health care provider

PRENATAL APPOINTMENTS How often you see your doctor or midwife will be based on your health, your age, and how your pregnancy is progressing. Your provider will let you know when to schedule your next follow-up visit. These follow-up visits will be shorter than your first appointment, but they are just as important. You may see your provider more often during the last couple of months of your pregnancy. During each of the three trimesters of your pregnancy, your doctor or midwife may order different tests to monitor the health of you and your baby. Tests can include:

Blood and urine tests

Sonography (ultrasound)

Genetic screening tests

Diagnostic testing

Your health care provider will recommend tests based on your health, your medical and family history, your baby’s development, and other important factors. You’ll find more information about why and how you may be tested on the following pages.

CENTERING PREGNANCY PROGRAMS Centering pregnancy is a health care model that combines traditional medical services with longer group sessions with a small group of expectant parents with similar due dates . The group sessions focus on three key components of prenatal care—risk assessment, education and personal support.

How a centering program typically works: • You do your medical history and physical exam in a provider’s office or clinic • You are invited to join a group of 8-12 women or couples with similar due dates

• You continue to see your provider for checkups, followed by a 90-120 minute group session Sessions are often conducted by a midwife or nurse practitioner who leads group discussions and interactive activities. You may also receive printed materials covering subjects like nutrition, common discomforts, stress management, labor and delivery, breastfeeding, baby care and much more. Most groups continue to meet through the postpartum period. For more information about pregnancy centering groups in your area, ask your doctor or midwife or visit www.centeringhealthcare.org

Your Guide to a Healthy Pregnancy

Your First Visit Your first prenatal office visit may take longer than follow-up visits. Your doctor or midwife may do a number of important things at this visit: • Review your complete medical history • Perform a physical examination • Order your first prenatal lab tests • Discuss what to expect during pregnancy MEDICAL HISTORY Your medical history helps your provider learn about your health and how to help you and your baby through your pregnancy. Some providers may ask you to come in early to fill out these forms. Others may let you complete them online or over the phone. Your medical history should include: • Calculate your baby’s due date • Do an ultrasound test if needed • Any past pregnancies or surgeries • Your family and/or genetic history • Medications or supplements you take • Use of tobacco, alcohol or drugs • Immunizations and medication allergies • Anything else that affects your health

LAB TESTING During your pregnancy, your provider will closely monitor the health of you and your baby. Routine blood, urine and other types of tests provide up-to-date information about how you and your unborn baby are doing. At your first prenatal visit, you may have the following routine tests: • Complete blood count (CBC)

• Blood type and Rh status • Urinalysis and urine culture • Rubella immunity • Hepatitis B and hepatitis C

• Sexually transmitted infections (STIs) • Human immunodeficiency virus (HIV)

PHYSICAL EXAM During your first prenatal visit, your provider will check your blood pressure, measure your height and weight, and calculate your body mass index to determine how much weight you should gain for a healthy pregnancy. You will also have a physical exam, including checking your breasts, pelvis, heart, lungs and thyroid. If you haven’t had a recent cervical cancer test, your provider may want to do this. DISCUSSION TOPICS During your first appointment, your doctor or midwife may talk to you about some of the physical changes you’ll experience during pregnancy, including nausea and vomiting (morning sickness), swollen breasts, and other changes. You’ll find more information about common changes during pregnancy in the “How Your Body Changes” section beginning on page 17. Your provider may also talk to you about caring for yourself and making practical, safe choices during your pregnancy. You’ll learn about eating healthy, prenatal vitamins, exercise, preventing infection, substance or psychological issues, and more. You’ll find helpful information and answers to many questions in the “Making Good Choices” section beginning on page 24. You may also discuss some of the signs or symptoms that could indicate a problem with your pregnancy. Look for more information in the “Possible Complications” section beginning on page 44.

Your Guide to a Healthy Pregnancy

YOUR DUE DATE Unless you know the specific date you conceived, your due date is based on your last menstrual cycle. Only one in twenty babies are born exactly on their due date, but most are born within 10 days of that date. Your due date can be calculated based on calendar dates or a sonogram (ultrasound) exam.

How to estimate your due date

Subtract 3 months from the first day of your last menstrual period and add 7 days.

Example:

Last Period (1st day)

Minus 3 months

Estimated due date

Plus 7 days

October 5

July 5

July 12

Follow-up Visits Follow-up visits are usually shorter than your first appointment but are just as important. These check-ups help your doctor or midwife make sure everything is going well. You’ll also have a chance to ask questions or share any concerns. As you get closer to your due date, you’ll see your health care provider more often. During your first follow-up visit your health care provider will have your lab test results. Based on these results and other factors in your medical and family history, your provider may discuss testing to screen for genetic disorders and birth defects in your baby. (see page 11) During your follow-up appointments, your provider may: • Check your weight and blood pressure • Order blood and urine tests

• Check your baby’s heartbeat (after 10-12 weeks) • Do certain prenatal screening tests (see page 8) Later in your pregnancy, your provider may also: • Measure your belly to check your baby’s growth

• Feel your belly to check your baby’s position in the womb • Ask you about your baby’s movements in your womb • Ask you to do kick counts to track baby’s moves (see page 9) • Give you a Tdap vaccination (27-36 weeks) (see page 35) • Do a pelvic exam to check your cervix for changes (close to due date)

Your Guide to a Healthy Pregnancy

Prenatal Testing During your pregnancy, your provider’s main concern is the health of you and your baby. Thanks to modern technology, providers have advanced tests they can use to carefully monitor your health and the progress of your baby. These tests help identify many problems while the baby is still in the womb. Some issues can be treated before the baby is born. Categories of prenatal tests include: • Routine. Basic tests done to check for any condition that may cause a health problem. • Monitoring. Tests to check the well-being of the baby; usually done late in pregnancy. • Screening. Special tests to see if you or your baby are likely to have certain conditions. • Diagnostic. Done after a positive screening test to see if you or your baby has the condition.

ULTRASOUND (SONOGRAPHY) Ultrasound testing fits into several different categories. It may be used for monitoring, screening, or diagnosis. Your doctor or midwife may perform an ultrasound at any time during your pregnancy. Some of the most common reasons to have an ultrasound include: • To detect a problem or monitor the condition of your baby • To make sure the baby is growing and developing properly • To confirm your due date and if you are carrying more than one baby • To locate the placenta and check the volume of amniotic fluid

What is an ultrasound? It’s a simple, non-invasive test that uses sound waves to create a video image of your baby moving inside your uterus. The image is created using an instrument called a wand that is placed either on your tummy or in your vagina. While your provider is doing the test, you may be able to watch your baby on a special screen.

Your Guide to a Healthy Pregnancy

ROUTINE TESTS

Glucose Challenge Screening Glucose Challenge Screening (24-28 weeks) is a blood test to see if you have gestational diabetes brought on by pregnancy. Before the test, you drink a sugary solution. Then your blood is drawn and tested at certain times to see how well your body uses the sugar. If your body can’t process the sugar normally and you have a high amount of sugar in your blood, you’ll be treated for gestational diabetes. (see page 45)

Group B Strep Testing Group B streptococcus (GBS) (35-37 weeks) is a type of bacteria in the birth canal of one in every three pregnant people. It usually doesn’t cause any disease or symptoms but could infect the baby during a vaginal birth, with serious consequences. Testing is done by swabbing your vagina and rectum. (see page 45)

Rh Immunoglobulin If you tested Rh negative at your first prenatal visit, you will be tested again at 24-28 weeks. You may receive an Rh immunoglobulin injection to stop any Rh problems in this and any future pregnancies. (see page 47)

MONITORING TESTS

Fetal Movement Test (Kick Count) Babies have a sleep-wake cycle that lasts between 20 minutes and 2 hours. This affects your ability to feel your baby move. You will usually feel that first “flutter” of life (called quickening ) between 16-20 weeks. You may feel the baby move a lot during the 2nd trimester, then settle down as you get closer to your due date. How much the baby moves can be affected by the baby’s position, your blood sugar level, working and eating habits, sound, light, and physical input to the uterus. Each baby has its own rhythm of movement and each pregnant person can recognize their own baby’s movement. The term kick count refers to your baby’s random movements in your womb. The American College of Obstetricians and Gynecologists (ACOG) recommends that you time how long it takes to feel 10 kicks, twists, turns, swishes or rolls. A healthy baby should have at least 10 kicks in less than 2 hours. Most babies will do this in less than 30 minutes. If you do not feel 10 kicks in a 2-hour period, contact your health care provider.

Non-Stress Test (NST) Used to look at your baby’s heartbeat while they are resting and again while they are moving. If the heart rate goes up when the baby kicks or moves, they are doing well. This result is called “reactive.” If the results are “non-reactive” more testing may be needed.

Contraction Stress Test (CST) Shows how the baby’s heart reacts to uterine

contractions . Contractions can be induced in two ways: 1) You receive oxytocin medication given through an IV line, or 2) You stimulate your nipples to increase your natural oxytocin. The “stress” created by your contractions can show if the baby is not getting enough blood and oxygen during contractions. Biophysical Profile Combines results from an ultrasound exam (fetal movements, breathing motions, muscle tone, and amount of amniotic fluid) with the non-stress test result to give your pregnancy a score from 1 to 10. The total score helps your health provider evaluate the baby’s well-being and decide how to manage your pregnancy. This is a more detailed study than the non-stress or contraction stress tests.

Your Guide to a Healthy Pregnancy

Delivering before 37 weeks is called a preterm birth.

PRETERM BIRTH ASSESSMENT

Your doctor or midwife will monitor you closely for any signs that you might deliver your baby too early. Delivering before 37 weeks is called a preterm birth. The following tests can help your provider decide if you need additional treatment to prevent preterm birth.

Fetal Fibronectin (fFN) test This is a simple test that collects a small amount of vaginal secretion on a swab. It may be done if you are having labor symptoms between 22-35 weeks to check your risk of giving birth early (before 37 weeks). If you have a positive test result, you are at higher risk of giving birth early. This test is only used for special circumstances related to preterm labor . It may be repeated every one to two weeks. Cervical Length Screening The length of your cervix is closely linked to your risk of having a preterm birth. Cervical length is measured by a very simple, safe transvaginal ultrasound. If your cervix is too short, your health care provider will talk to you about ways to lower the risk of a preterm birth.

Your Guide to a Healthy Pregnancy

Genetic Testing Most babies are born healthy. But some babies may have a problem with their genes or chromosomes. This is called a genetic abnormality. If the baby’s genes are damaged or they don’t have the right number of chromosomes, the baby may develop a serious health condition or birth defect. If a parent or one of their family members has a genetic abnormality, it can be passed to the baby. Genetic abnormalities can also happen randomly, even if there are no risk factors. It’s important that you give your doctor or midwife as much information as you can about your family history and the baby’s father’s family history. If you identify relatives on either side of your baby’s family with a positive history of a certain genetic condition, you can consider undergoing carrier screening for that condition or others. You may also benefit from genetic counseling. It is your decision whether to have any or all of the recommended genetic tests.

GENETIC ABNORMALITIES: QUESTIONS TO ASK

1. Have you, your baby’s father, or anyone in either family had:

• Cystic fibrosis • Down syndrome • Hemophilia • Intellectual disability

• Muscular dystrophy • Neural tube defect • Sickle cell disease • Spina bifida

• Spinal muscular atrophy • Tay-Sachs disease • Thalassemia

2. Have you or your baby’s father had a stillborn child or a child born with a defect not listed above? 3. Have you had three or more miscarriages ? 4. Do you, your baby’s father, or a close relative in either family have any inherited genetic or chromosomal disorders not listed above?

5. Are you, your baby’s father, or a close relative on either side: • Of Jewish ancestry?

• Descended from Eastern European people? • Have ancestors from the Mediterranean?

Your Guide to a Healthy Pregnancy

TYPES OF TESTS Prenatal genetic screening and diagnostic tests can provide valuable information about your baby’s health. There are two main categories of tests: • Screening test. Measures a baby’s risk of developing a disease or medical condition. • Diagnostic test. Determines if a baby actually has the disease or medical condition. Prenatal genetic tests can detect three categories of genetic issues: chromosomal abnormalities , carrier disorders and neural tube defects . You’ll find each of these categories discussed in a separate section below.

The American College of Obstetricians and

Gynecologists (ACOG) now recommends that all pregnant women be offered some type of genetic screening. Check with your insurance company to see that the test chosen is covered. It is your choice whether to have prenatal testing.

CHROMOSOMAL ABNORMALITIES Chromosomal abnormalities can cause specific birth defects. Every person has 23 pairs of chromosomes in their body, one from each parent. Sometimes an extra chromosome will appear on a pair (3 instead of 2) or one chromosome of a pair is lost (1 instead of 2). Either of these issues can cause a birth defect in a baby. The most common condition caused by a problem with the baby’s chromosomes is Down syndrome (trisomy 21, more than one pair) which occurs in approximately 1 in 800 babies.

Screening for Chromosomal Abnormalities Screening tests for chromosomal abnormalities are typically done in the first and second trimesters of pregnancy. Blood samples are taken from the pregnant person to look at certain hormones and proteins (markers). The results of these tests can be used separately or together in sequence to see if the baby is at risk for a chromosomal abnormality. • Cell-free DNA testing (Noninvasive prenatal screening or NIPS). Can be done as early as 10 weeks. This blood test measures fetal DNA levels from certain chromosomes in your blood. • 1st trimester screening. (10-14 weeks) Combined results from an ultrasound and a special blood test. The ultrasound checks how much fluid is under the skin fold along the back of the baby’s neck. This is called nuchal translucency screening. The blood test looks at a specific protein and hormone in your blood. • 2nd trimester screening. (15-22 weeks) A special blood test called a quad screen analyzes four substances produced by the baby and the placenta. A formula is used to determine the probability of a chromosomal abnormality. • Alpha-fetoprotein. If the 1st trimester screening or NIPS test were done, blood can be drawn between 16-18 weeks to measure maternal serum alpha-fetoprotein to screen for neural tube defects.

Integrated test. Uses results from the first and second trimester screenings to provide a single estimate of the risk of neural tube defects and genetic abnormalities.

Sequential screening test. Combines measurements from the first and second trimester blood tests and an ultrasound exam to check for neural tube defects and genetic abnormalities.

If any of these tests show an increased risk of abnormalities you may be offered additional diagnostic testing and genetic counseling.

Your Guide to a Healthy Pregnancy

CARRIER DISORDERS

Carrier disorders are caused by a tiny change (an abnormal gene) in a single chromosome. For a baby to have most carrier disorders, both parents must be carriers (have the same abnormal gene) for the disease. Carrier disorders can run in families, races or ethnic groups. Blood or saliva tests can determine if you or your partner carry the gene for one or several different carrier disorders.

With expanded carrier screening , a single sample is used to screen for a number of different disorders. Companies that offer expanded carrier screening create their own lists of disorders they test for, called screening panels . For more information about expanded carrier screening, ask your health care provider or genetic counselor.

The American College of Obstetricians and Gynecologists (ACOG) now recommends that all pregnant women be offered the following three screening tests: • Cystic fibrosis (CF) carrier test. A simple blood test that can show if you are a carrier of the CF gene. If both parents test positive as CF carriers, chorionic villus sampling (CVS) or amniocentesis testing can be done to see if the baby will be affected. CF is a life-threatening genetic disease that affects breathing and digestion. • Spinal muscular atrophy (SMA) test. A simple blood test that can show if you are a carrier of the SMA gene. Similar to cystic fibrosis testing (above), if both parents test positive, CVS or amniocentesis testing can be done. SMA causes weakness in muscles that eventually makes it hard to sit, walk or stand. It also affects the muscles used to breathe and swallow. • Hemoglobinopathies. A simple blood test for inherited blood disorders called hemoglobinopathies. Hemoglobinopathies is the medical term for a group of blood disorders and diseases that affect red blood cells, including sickle cell disease and thalassemia. Fragile X Syndrome Fragile X syndrome is a carrier disorder that can cause a range of developmental problems in the baby, including learning disabilities or cognitive impairment issues. Only women (about 1 in 250) carry the gene that causes this syndrome. It is found across all ethnic and age groups. A blood test for Fragile X is commonly done on all pregnant women, with or without any history of the disorder. NEURAL TUBE DEFECTS Neural tube defects are serious birth defects of the brain, spine and spinal cord. They are caused by a combination of genetic and environmental factors. The two most common neural tube defects are: • Anencephaly. Babies born with this condition have an underdeveloped head and brain. • Spina Bifida. Babies with this condition have an opening or gap in their backbone.

Your Guide to a Healthy Pregnancy

Screening for Neural Tube Defects An alpha-fetoprotein test (AFP) is a blood test that screens for the risk of a neural tube defect. It may be used by itself or as part of the quad screen test done at 16-18 weeks. Like all prenatal tests, a normal AFP test result does not guarantee a baby without this defect. About one in five babies born with a neural tube defect will have normal alpha-fetoprotein (AFP) levels. Abnormal screening test results will require additional blood tests, ultrasound or amniocentesis to confirm the results.

Only one or two babies in every 1,000 live births will have a neural tube defect. Parents of another child with this abnormality have the highest risk of it happening again.

FETAL ANATOMY SCAN Many health care providers use fetal anatomy scan to look for physical signs that the baby has an obvious birth defect. This is usually done between 18-22 weeks of pregnancy. It’s sometimes called a Level II ultrasound or 20-week ultrasound. If a specific problem is found, your health care provider or a genetic counselor can help you understand what that means. An ultrasound cannot detect all birth defects.

DIAGNOSTIC TEST If a genetic screening test comes back positive or your health care provider needs more detailed information, you may need one of the following diagnostic tests: • Chorionic villus sampling (CVS). Uses a tiny tissue sample taken from the placenta. It is done during the 1st trimester, usually between 10-13 weeks. The main purpose of CVS is to see if the baby has a normal number of chromosomes (46). This test can be done earlier in the pregnancy and provides a diagnosis more quickly than amniocentesis . The risk of miscarriage from the test is very low. • Amniocentesis. Tests fluid taken from the amniotic sac surrounding the baby. When the test is done depends on the reason it is being done. Testing amniotic fluid confirms whether the baby has a normal number of chromosomes (46). Fluid for genetic testing and neural tube issues is usually collected between 16-18 weeks. Testing for fetal maturity and blood incompatibility problems is usually done much later. Amniocentesis is considered 99.5% safe but it is not a routine test. It is only done to detect a highly probable medical problem.

Your Guide to a Healthy Pregnancy

Planning and Preparation It’s never too soon to start planning for the birth of your baby. As your due date gets closer, you will have plenty of questions. It’s also normal to have thoughts and feelings about the birth experience, including some fear of the unknown. The best way to handle your fears is with education. And one of the best places to learn is at a childbirth class.

CHILDBIRTH CLASSES Taking childbirth classes can help prepare you for labor and birth. Led by a trained instructor, classes typically include lectures, discussions and exercises. You’ll also meet other parents who can share their thoughts and experiences. You’ll also want to choose a labor support partner (spouse, partner, friend or relative) to be there for you during labor and birth. You and your support partner can take childbirth classes together, learning exercises and breathing techniques to help your labor experience go as smoothly as possible.

USING A DOULA Doulas are labor coaches with special training in birthing and recovery. They are not licensed medical professionals but can provide helpful emotional and physical support. Doulas do not work in all hospitals or birth centers and their fees are often not covered by insurance plans. Check with your hospital or birth center to see if they have doulas. You can also hire a private doula.

YOUR BIRTH PLAN A written birth plan helps your health care provider and birth facility understand your preferences for labor and birth. It may include who manages your care, who you want in the labor and delivery room with you, and the type of care you want after birth. Your plan should be flexible enough to keep you and your baby safe if something happens during labor and delivery. Talk to your provider or hospital to see if they have their own specific policies. If the provider or hospital doesn’t have a standard birth plan form, you can find them online.

Your Guide to a Healthy Pregnancy

HOSPITAL OR BIRTH CENTER? You’ll want to start looking at hospitals and birth centers during the first few months of your pregnancy. Your choice will most likely depend on your insurance carrier, your medical needs, and where your doctor or midwife has admitting privileges. Most hospitals and birth centers will let you tour their facility. Questions to ask before choosing a facility: • Do they have single LDRs (labor, delivery, recovery rooms) or LDRPs (labor, delivery, recovery and postpartum rooms)? • How many people can be in the room for the birth? • What is their policy on rooming-in ? YOUR BABY’S HEALTH CARE PROVIDER It’s important to choose a health care provider for your baby before you go into labor. This should be a qualified medical professional who specializes in caring for children. Many providers are happy to let you schedule an appointment to visit their office while you are pregnant. If you can, take someone with you to this visit. If you have a health insurance plan with a preferred provider list, check to make sure that the person you choose is on your list of “approved providers.” If you have Medicaid coverage, the Health Department or your caseworker can give you a list of approved health care providers. CORD BLOOD BANKING Collecting leftover blood from the umbilical cord and placenta after birth is called cord blood banking. Cord blood contains stem cells, which may be lifesaving for people with certain cancers, blood disorders and immune diseases. Collected blood can be stored in either a public or a private cord blood bank. If you want your cord blood collected after birth, talk with your health care provider at least two months before your due date. • What are their visiting hours and who can visit? • What are their safety and security procedures?

Baby is born with umbilical cord and placenta attached. After birth, cord is clamped and cut.

Blood drawn from the clamped cord is put into special collection bag.

Collection bag is quickly delivered to the laboratory.

Blood is examined and analyzed.

Blood is stored in special container.

Blood is kept in liquid nitrogen storage tank inside a secure facility.

Your Guide to a Healthy Pregnancy

How Your Body Changes As your pregnancy progresses, you may experience a wide variety of physical and emotional changes. To make it easier for you to find information about specific changes, we’ve listed them in alphabetical order in this section.

BACKACHE

BELLY (ROUND LIGAMENT) PAIN

During the second half of your pregnancy, you may feel sharp or dull pain on one or both sides of your lower belly. This round ligament pain happens when the ligaments supporting your uterus start to stretch or have spasms. You may notice pain when you’re walking or if you quickly roll over in bed. Round ligament stretching early in your pregnancy may feel like menstrual cramps. If the pain is especially strong and does not go away, call your health care provider. Helpful tip: Resting and putting a warm compress or heating pad on the area can help reduce pain.

There are many pregnancy-related causes of back pain. Pregnancy hormones can relax the ligaments that hold your pelvic and weight-bearing bones together to help you prepare for birth. As your uterus grows larger, your belly sticks out further. This can weaken your abdominal and back muscles and cause low back pain. Your enlarged uterus may also push on the sciatic nerve, causing back pain and/or weakness or numbness in your legs. This condition is called sciatica and it usually goes away after pregnancy. Helpful tips: • Wear low-heel, flat-heel or supportive shoes (no high heels) • Take breaks during the day and rest as much as you can • Exercise to strengthen your back and abdominal muscles • A heating pad may help reduce pain; never use it on bare skin • Avoid lifting anything too heavy while you’re pregnant • Never sit straight up after lying on your back; roll sideways first

BREAST CHANGES

You’ll see changes in your breasts very early in your pregnancy: • Breasts become larger, firmer and more tender than usual • Areola (dark area around the nipple) gets larger and darker • Your nipples start to stick out more Halfway through your pregnancy, your breasts may start to leak small amounts of fluid called colostrum . You can buy special pads to protect your clothes if this happens. The veins under the skin of your breasts may also become more visible as your body gets ready to produce milk. Wearing a bra that fits properly can help provide comfort and support.

Your Guide to a Healthy Pregnancy

CONSTIPATION AND BLOATING

CRAVINGS (PICA)

Pica is the medical name for wanting to eat strange things that aren’t nutritious. For example, ice, starch, dirt or clay. Cravings may be a sign that your diet is lacking in some essential nutrients. Helpful tip: No matter what you are craving, keep eating balanced, healthy foods.

Constipation and bloating are common problems during pregnancy. They can be caused by hormone changes, high levels of iron in prenatal vitamins, and pressure from your growing uterus on your lower bowel. NOTE: Certain laxatives may cause contractions and dehydration. Bulk-forming agents or stool softeners are the safest option during pregnancy. Helpful tips: • Drink lots of water; prune juice helps • Eat high-fiber foods vegetables, fruits, and whole grains • Find time to take a walk or do some exercise every day • Eat frequent small meals; these are easier to digest • Avoid processed foods, fatty meats and high-fat dairy • Avoid gassy foods: beans, cabbage, carbonated soda It is normal for the muscles in your uterus to tighten off and on during your pregnancy until labor begins. These are known as Braxton Hicks contractions . Here’s what you need to know: • These contractions are usually painless and happen at random times • You may notice them more after physical or sexual activity • As you get closer to your due date, they may become painful and make you think you’re in labor • They usually go away when you move around or change your activity • Call your health care provider if your contractions come closer and closer together, last longer and/or become more painful CONTRACTIONS

DIZZY SPELLS OR FEELING LIGHT-HEADED

It is normal to feel a little dizzy at times during pregnancy. Hormones can cause your blood pressure to decrease and sometimes low blood sugar is to blame. Helpful tips: • Move slowly when standing or changing positions • Avoid getting too hot or standing for a long time • Lay on your left side when resting and sleeping • Eat frequent small meals or snacks • Stay hydrated by drinking plenty of water

Your Guide to a Healthy Pregnancy

FATIGUE

EMOTIONAL CHANGES

Feeling very tired (fatigue) is a common early sign of pregnancy. Some people feel more energy after their first trimester, then become tired again near the end of pregnancy. Fatigue is caused by hormonal and other types of changes. Your body is now providing nutrients to your growing baby and you may be experiencing emotional changes that can leave you feeling more tired. Helpful tips: Try to rest more often, eat healthy and ask for help if you need it. Even though you might not feel like walking or moving, light exercise can help boost your energy.

During pregnancy, your feelings and moods can change quickly. You may feel happy one minute, then suddenly burst into tears. Up-and-down mood swings are usually caused by hormonal changes in your body. Some people may feel overwhelmed as they worry about the baby’s health, going through labor, even becoming a parent. One of the best ways to feel more confident and relaxed is to learn as much as you can about pregnancy and child care. Going to childbirth classes, reading books, watching videos, and using helpful pregnancy apps can really help. Mild Mood Swings… or More? It’s normal for feelings and emotions to change quickly when you’re pregnant. Scary thoughts or moods that interfere with daily activities may become a problem. Talk to your health care provider and ask about treatment options right away. Mild mood swings are common, but for some people these changes are so powerful that they can interfere with everyday life. If you have feelings of depression (sadness or hopelessness) or anxiety (worry or fear) for more than two weeks or you have trouble doing daily activities, ask for help. Talk to your health care provider right away about what treatment options are right for you.

HEADACHES

You may have headaches during the first few months of your pregnancy. These headaches are caused by blood circulation changes. They usually disappear on their own by the second half of pregnancy. Call your health care provider if your headaches include sensitivity to light, excessive nausea or vomiting, fever, vision problems, weakness, numbness, or speech problems. Certain foods or smells can cause headaches. Try to eat regular meals or snacks and drink plenty of fluids. Getting enough rest and sleep can also help. You can also try applying cold or heat packs to your head and neck area.

Your Guide to a Healthy Pregnancy

HEARTBURN

JOINT PAIN

During pregnancy, your joints may feel achy and loose when you walk. Gaining body weight puts extra pressure on your knees. Swelling can increase stiffness in your hands, feet, hips, knees and ankles. This stiffness makes you feel like you have arthritis. Swelling in your hands can also cause carpal tunnel syndrome or make existing symptoms worse. This condition produces pain and tingling in your fingers, especially at night. Helpful tips: • Wear hand splints to relieve carpal tunnel syndrome • Lie down and rest during the day with your feet up • Reduce the high sodium foods (salt) in your diet • Eat foods rich in Omega 3s (salmon, other oily fish) • Try heat and cold therapy, heating pads/ice packs

Heartburn (indigestion) is another common problem. Heartburn causes a burning pain in your chest and throat and sometimes a hacking cough. It is caused by acid that is forced from your stomach into your throat. Heartburn may get worse in the second half of your pregnancy. Helpful tips: • Eat 4 to 5 small meals during the day • Don’t eat or drink close to bedtime • Avoid fried, acidic (tomatoes, fruit) or spicy foods, caffeine and chocolate • Don’t lie flat on your back; put pillows under your head and shoulders • Try over-the-counter antacids like Mylanta, Rolaids or Tums if your provider approves Hemorrhoids are swollen veins at the opening of the rectum that can become painful, itchy and even bleed. This can happen if constipation causes you to strain during bowel movements. Your growing uterus can also cause fecal movement to slow down. Helpful tips: • Eat healthy (especially high fiber) foods • Drink plenty of water to avoid constipation • Rest on your side • Use ice packs or witch hazel pads on the hemorrhoids • Soak in a warm tub several times a day • Use ointments or creams if approved by your provider HEMORRHOIDS

LEG CRAMPS

Muscle cramps in your lower legs and feet are normal. They can happen at night and wake you up. If you have frequent, painful leg cramps or you notice redness and swelling in your legs or feet, call your provider right away.

Helpful tips:

• Exercise or walk everyday • Wear supportive shoes • Eat foods high in magnesium • Drink lots of water • Take a warm shower or bath • Ice packs may help

Your Guide to a Healthy Pregnancy

NAUSEA

RAPID HEARTBEAT

Morning sickness is the common term for feeling nauseous (sick to your stomach) and/or vomiting when you’re pregnant. It can happen any time of the day and last anywhere from a few minutes to the entire day. Morning sickness usually starts after the first month and goes away after the third month of pregnancy. Some people will experience morning sickness throughout their entire pregnancy. Hyperemesis gravidarum is the most severe form of morning sickness. With this condition, nausea and vomiting can be serious enough to require medical treatment. Call your health care provider if you: • Are losing weight (over 5 pounds over a week or two) • Have a dry mouth, or unpleasant or fruity taste • Are not urinating very often, and your urine is dark and has an odor • Can’t keep food or liquid down for more than 24 hours • Are extremely tired, dizzy or confused Tips to control morning sickness: • Eat bread or crackers before you get out of bed • Eat cold, bland foods—nothing fried, greasy or spicy • Have regular small meals or snacks during the day • Ginger, lemonade and mint tea can help • Chewable prenatal vitamins may cause less nausea

During pregnancy, your blood volume increases by almost 50%. Your heart works harder to pump more blood to your uterus. You may feel that your heart is beating more rapidly because it is. This is common and you might even feel a little lightheaded if you’ve been active. Sometimes a heart irregularity can appear during pregnancy. Call your health care provider if: You feel your heart is racing and you’re lightheaded when you’re resting or feel faint.

SALIVA

You may notice more saliva than usual in your mouth. It’s normal for your salivary glands to make more fluid than usual during pregnancy. This seems to be connected to morning sickness and usually goes away later in pregnancy. Helpful tip: Simply spit out the extra fluid if you need to. Mints, chewing gum, eating frequent small meals, and snacking on crackers may help.

Your Guide to a Healthy Pregnancy

STRETCH MARKS

SEXUAL CHANGES

Your desire for sex may be higher or lower during pregnancy. Many people feel less interested in sex when they are having morning sickness. Others lose interest late in pregnancy when they’re physically more uncomfortable. Explain to your spouse or partner how you’re feeling and why. If you have a history of miscarriages, pregnancy- related vaginal bleeding, or other complications, ask your health provider if it is safe for you to have sex during your pregnancy. With your provider’s permission, you may be able to have sex up until labor begins, but not after your water breaks. Orgasm can cause mild cramping, but that should stop quickly. Some positions may be clumsy late in pregnancy, so you may want to experiment. Having sex does not bother babies since they are protected by fluid, muscle and bone.

As your skin stretches, the elastic tissue below it may break down and cause zig zag lines of stretch marks. You may notice stretch marks on your breasts, buttocks, lower abdomen, hips or thighs. Stretch marks can be pink, red, brown or lighter in color. Moisturizers and lotions can help stop any itching, but they don’t prevent stretch marks from happening. The good news is that they will slowly fade in color after pregnancy.

SHORTNESS OF BREATH

STUFFY NOSE AND NOSE BLEEDS

You may feel like it’s hard to breathe during the last month or two of pregnancy. This happens because your uterus starts to become large enough to be pressing on your breathing muscles. Try moving more slowly, sitting up straight and taking deep breaths from the chest. If you have trouble sleeping due to shortness of breath, prop yourself up with pillows.

A stuffy nose (nasal congestion) is another common problem during pregnancy. This happens because you have more blood in your body, causing your nasal passages to swell, feel very dry and raw, or start to bleed. Helpful tips: • Saline nose drops or a humidifier may help ease the dryness • Talk to your health care provider before you use any nose sprays • Drinking more fluids may help reduce dryness To stop a nosebleed, press your finger firmly against the side that is bleeding for a few minutes. If the bleeding is heavy and/or you can’t stop it by applying pressure, call your health care provider.

SKIN CHANGES

Rising hormone levels during pregnancy can cause some changes to your skin color. These changes usually go completely away or mostly fade after the baby is born and your hormone levels go back to normal. Your skin may just look flushed, like you are blushing. Other common skin changes include blotchy brown markings on your face, a dark line down the middle of your belly, or acne. Staying out of the sun may be helpful.

Your Guide to a Healthy Pregnancy

SWELLING

VAGINAL DISCHARGE

It’s normal to have some swelling in your feet and legs toward the end of pregnancy, especially in hot weather. This happens when your added pregnancy weight slows the circulation rate of fluids to your heart, especially from your feet. At the same time, changing hormone

Hormones can create a clear or white vaginal discharge while you’re pregnant. If you have a discharge that causes soreness or itching (or has a bad odor) see your health care provider. It is common to get yeast or other vaginal infections that need treatment during pregnancy. Vaginal infections can be uncomfortable but are not harmful to the baby. To keep your vagina as free from irritation as possible, use lightweight mini pads if needed, instead of tampons.

levels can cause your body to hold onto water. If you notice excessive leg swelling or swelling in your face and hands, call your health care provider right away. It could be a sign of a blood pressure problem. Tips to reduce swelling: • Rest with your feet and legs elevated • Wear supportive tights or maternity pantyhose • Avoid standing for long periods • Lie on your side when sleeping or resting • Try regular exercise, like walking or swimming • Drink water and avoid salty foods

VARICOSE VEINS

Varicose veins are soft, blue-colored bulges in your legs. They happen when your veins get weak and swell up with blood. They are easier to see when you’re standing up. Pregnancy often makes vein issues worse. As your uterus grows, it can impact the circulation in your legs. This means your veins need to work harder to carry blood back up your legs to your heart. To help blood move more freely through your legs: • Take breaks often and rest with your legs raised • Take short walks or do other exercises several times a day • Wear maternity support pantyhose, not knee-highs or thigh-highs • Don’t sit or stand in one position for a long time without moving • Don’t cross your legs when you sit Some people may develop another type of varicose vein around the vulva (opening of the birth canal). Vulvar varicosities are soft, irregular bulging areas that you can see or feel. To help blood circulation in this area, place a small pillow under your bottom and legs to elevate them when you’re lying down.

URINATION

When your uterus expands, it puts pressure on your bladder. This makes most people feel the need to urinate frequently. Don’t try to control this by drinking less fluid. It’s more important to stay hydrated and drink liquids whenever you are thirsty. Late in pregnancy, you might experience urine leaks when you laugh, cough, sneeze or bend over. Bladder leakage pads or panty liners can help you stay dry. This usually corrects itself after pregnancy.

Your Guide to a Healthy Pregnancy

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