Mount Auburn Hospital - Great Expectations

A GUIDE FOR PRENATAL CARE Great Expectations

THE BAIN BIRTHING CENTER

Congratulations

ON YOUR PREGNANCY!

W e are delighted you have chosen us to help guide you through this very exciting life event! Our goal is to provide you and your baby with the highest quality medical care in a personal and supportive, family centered environment. Mount Auburn Hospital has a full range of services including experienced nursing staff, lactation consultants, anesthesiologists available twenty-four hours a day, and a level II nursery with neonatology and pediatric coverage at all times. In high risk pregnancies we collaborate closely with maternal-fetal medicine specialists as needed. This booklet is designed to provide you with general information about the normal course of pregnancy. Additional information about a variety of specific topics will be given to you as you get further along. We encourage you to take the time to read it and keep it for reference over the coming months. If you have questions specific to your care or pregnancy, please discuss them with us at your prenatal visits. Our staff is happy to help you with any concerns you have. Congratulations again! We look forward to providing you, your baby and your family a healthy and happy birth experience.

YOUR GUIDE TO A HEALTHY PREGNANCY

Reviewed and recognized by AWHONN as a valued patient education resource.

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Prenatal Care Overview.....................................................5 Your First Visit..........................................................................6 Follow-up Visits .....................................................................7 Prenatal Testing ....................................................................8 Genetic Testing ....................................................................10 Emotional Challenges During Pregnancy.........14 Planning and Preparation .............................................16 How Your Body Changes ..............................................18 Making Good Choices ....................................................24 Partners and Families ....................................................28 6 Steps to a Healthy Pregnancy ...............................29 Easy Exercises.......................................................................34 How Babies Grow and Change .................................36 Disease and Infection ....................................................38 Possible Complications .................................................42 High-Risk Pregnancy ......................................................46 The Final Weeks .................................................................47 Labor and Birth ..................................................................49 Labor Induction ...................................................................52 Pain Management .............................................................53 Cesarean Birth ......................................................................55 After the Birth ...................................................................…56 Breastfeeding ......................................................................58 Postpartum Emotions .....................................................61 Glossary ....................................................................................64 Table of Contents

Videos in This Book Due Date Dilemma..............................................................7 Pregnancy Ultrasound.......................................................8 Genetic Testing.....................................................................10 Pregnancy Aches and Pains........................................18 Exercising During Pregnancy....................................34 Your Baby: Month 1.............................................................36 Your Baby: Month 2............................................................36 Your Baby: Month 3............................................................36 Your Baby: Month 4...........................................................36 Your Baby: Month 5............................................................36 Your Baby: Month 6............................................................37 Your Baby: Month 7............................................................37 Your Baby: Month 8............................................................37 Your Baby: Month 9............................................................37 Your Baby: Month 10..........................................................37 Preeclampsia Warning Signs.....................................44 Preterm Labor......................................................................45 Skin-to-Skin.............................................................................56 Milk Production...................................................................58 Feeding Cues.........................................................................59 Breastfeeding Latch.........................................................60

Your Guide to A Healthy Pregnancy is for general reference purposes only and cannot be relied upon as a substitute for medical care. You and your baby should have regular checkups with your health care provider. You should also consult with your health care provider about any special questions or concerns.

Copyright 2000, 2019 by Customized Communications, Inc. All Rights Reserved Updated: 3/2018, 9/2019, 1/2022, 11/2022, 11/2023

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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 purple text ? You’ll find it defined in the Glossary 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 experience with the people who know and love you lets everyone be part of the joy of bringing a new baby into the world.

PRENATAL CARE OVERVIEW

As soon as you think you’re pregnant, schedule your first prenatal appointment with a physician, midwife or other prenatal care provider. 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 • Ongoing assessment of you and your baby • Psychological assessment and support for you PRENATAL APPOINTMENTS How often you see your health care provider 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 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 3 trimesters of your pregnancy, your health care provider 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 tests

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.

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YOUR FIRST VISIT

Your first prenatal office visit may take longer than follow-up visits.

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 (BMI) 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 screening, your provider may want to do one. 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: • Urinalysis and urine culture • Complete blood count (CBC) • Blood type and Rh status • Rubella immunity • Hepatitis B and hepatitis C • Sexually transmitted infections (STIs) • Human immunodeficiency virus (HIV) DISCUSSION TOPICS During your first appointment, your health care provider 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” chapter beginning on page 18. 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 misuse, psychological issues, and more. You’ll find helpful information and answers to many questions in the “Making Good Choices” chapter 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” chapter beginning on page 42.

Your health care provider may do a number of important things at this visit: • Review your complete medical history • Perform a physical exam • Order your first prenatal lab tests • Discuss what to expect during pregnancy

• Calculate your baby’s due date • Do an ultrasound test if needed

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 ask you to complete them online or over the phone. Your medical history should include: • Any past pregnancies or surgeries • Medical, including psychiatric, conditions you have now or had in the past • Your family and/or genetic history • Medications or supplements you take • Use of tobacco, alcohol, marijuana, or street drugs • Occupational and environmental risks • Assessment of social support and risks such as interpersonal violence • Immunizations and medications and any other allergies • Anything else that affects your health

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YOUR DUE DATE Unless you know the specific date you conceived, your due date is based on your last menstrual cycle. Only 1 in 20 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.

SCAN + PLAY

How to estimate your due date: Subtract 3 months from the first day of your last menstrual period and add 1 week.

Example: Last Period (First day).October 5 - Minus 3 months..............July 5 + Plus 1 week......................July 12

Estimated due date: July 12

Follow-up visits are usually shorter than your first appointment but are just as important. These checkups help you and your health care provider know if 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.

FOLLOW-UP VISITS

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 your uterus • Ask you about your baby’s movements in your uterus • Ask you to do kick counts to track your baby’s movements (see page 9) • Give you vaccinations as needed (see page 33) • Do a pelvic exam to check your cervix for changes (close to due date)

During your first follow-up visit, your health care provider will have your lab test results. Based on these results and your medical and family history, your provider may discuss testing to screen for possible genetic disorders and birth defects (see page 10). 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)

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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.

PRENATAL TESTING

ULTRASOUND (SONOGRAPHY) Ultrasound testing fits into several different categories. It may be used for monitoring, screening, or diagnosis. Your health care provider may perform an ultrasound at any time during your pregnancy. Some of the most common reasons to have an ultrasound include: • To confirm your due date and if you are carrying more than 1 baby • To detect a problem or monitor the condition of your baby • To make sure the baby is growing and developing properly • To locate the placenta and check the volume of amniotic fluid

These tests help identify many problems while the baby is still in the uterus. 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 later in pregnancy • Screening – Special tests to see if you or your baby are likely to have certain conditions

SCAN + PLAY

• Diagnostic – Done after a positive screening test to see if you or your baby has the condition

What is an ultrasound? It’s a simple, noninvasive 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.

8 Your Guide to A Healthy Pregnancy

ROUTINE TESTS

If you tested Rh negative at your first prenatal visit, you may be tested for antibodies at 24-28 weeks. You may receive an Rh immunoglobulin injection to stop any Rh problems in this and any future pregnancies. (See page 45.) At 24-28 weeks, you’ll be given a blood test to see if you have gestational diabetes brought on by pregnancy. An hour before the test, you drink a sugary solution. Then your blood is drawn and tested to see how well your body uses the sugar. If the test is positive more testing is needed. If your body can’t process the sugar normally and you have a high amount in your blood, you’ll be treated for gestational diabetes (See page 43). At 36-38 weeks, you’ll be screened for Group B Streptococcus (GBS) , a type of bacteria in the birth canal of 1 in every 3 pregnant people. It usually doesn’t cause you 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 43.) If you test positive your provider will recommend you receive antibiotics during labor to prevent your baby from being infected during birth. 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 ( quickening ) between 16 and 20 weeks. 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 changes to your environment. Each baby has its own rhythm, and each pregnant person can recognize their own baby’s movement. The term “kick count” refers to your baby’s random movements in your uterus. The American College of Obstetricians and Gynecologists (ACOG) recommends, in the 3rd trimester, that you time how long it takes to feel 10 kicks, twists, turns, swishes, or rolls. A healthy baby should have at least 10 movements in less than 2 hours. Most babies will do this in less than 30 minutes. If you do not feel 10 movements in a 2-hour period, contact your health care provider. This test is used to monitor your baby’s heartbeat during a 20-minute period while they are kicking or moving. If their heart rate goes up twice during the 20-minute period, the result is called “reactive,” and the baby is doing well. If the baby is sleeping during this time, they’ll try to wake the baby and repeat the test for another 20 minutes. If the results are nonreactive, more testing may be needed. This test shows how the baby’s heart reacts to uterine contractions . Contractions can be induced in 2 ways: 1) You receive oxytocin medication 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. This is created by combining results from an ultrasound exam (fetal movements, breathing motions, muscle tone, and amount of amniotic fluid) with the NST result to give your pregnancy a score from 1 to 10. The total score helps your health care provider evaluate the baby’s well-being and decide how to manage your pregnancy. This is a more detailed study than the NST or CST. MONITORING TESTS

Rh ANTIBODY SCREENING

GLUCOSE CHALLENGE SCREENING

GROUP B STREP TESTING

FETAL MOVEMENT TEST (KICK COUNT)

NON-STRESS TEST (NST)

CONTRACTION STRESS TEST (CST)

BIOPHYSICAL PROFILE

PRETERM BIRTH ASSESSMENT Your health care provider will monitor you closely for any signs that you might give birth too early. Giving birth 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. • Cervical Length Screening – The length of your

• Fetal Fibronectin Test – This simple test collects a small amount of vaginal secretion on a swab. It may be done if you are having labor symptoms between 22 and 35 weeks to check your risk of giving birth early (before 37 weeks). If the result is positive, 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 1-2 weeks.

cervix is closely linked to your risk of having a preterm birth. Cervical length is measured with 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.

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Most babies are born healthy. But some 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.

GENETIC TESTING

If a parent or family member 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 health care provider 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

SCAN + PLAY

Have you had 3 or more miscarriages?

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

3

1

Do you, your baby’s father, or a close relative in either family have any inherited genetic or chromosomal disorders not listed in question 1?

4

?

Are you, your baby’s father, or a close relative on either side: • Of Jewish ancestry? • Descended from Eastern Europeans? • Have ancestors from the Mediterranean?

5

Have you or your baby’s father had a stillborn child or a child born with a defect not listed above?

2

10 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 2 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 a disease or medical condition. Prenatal genetic tests can detect 3 categories of genetic issues: chromosomal abnormalities , carrier disorders , and neural tube defects . You’ll find each of these categories discussed over the next few sections.

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

SCREENINGS FOR CHROMOSOMAL ABNORMALITIES

Screening tests for chromosomal abnormalities are done in the first and second trimesters. Blood samples are taken from the parent to look at certain hormones and proteins (markers). The results of these tests can be used separately or together 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.

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 2 specific proteins in your blood. A special blood test called a quad screen analyzes 4 substances produced by the baby and the placenta. A formula is used to determine the probability of a chromosomal abnormality. If the first trimester screening test was done, blood can be drawn between 15 and 18 weeks to measure maternal serum alpha-fetoprotein to screen for neural tube defects.

FIRST TRIMESTER SCREENING (10-13 WEEKS)

SECOND TRIMESTER SCREENING (15-22 WEEKS)

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

ALPHA FETOPROTEIN

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.

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.

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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 have genes for a number of carrier disorders.

With expanded carrier screening , a single sample is used to screen for 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.

ACOG NOW RECOMMENDS THAT ALL PREGNANT WOMEN BE OFFERED THE FOLLOWING 3 SCREENING TESTS:

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. 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. A simple blood test for inherited blood disorders called hemoglobinopathies, a group of blood disorders and diseases that affect red blood cells, including sickle cell disease and thalassemia.

CYSTIC FIBROSIS (CF) CARRIER TEST

SPINAL MUSCULAR ATROPHY (SMA) TEST

HEMOGLOBINOPATHIES

FRAGILE X SYNDROME Fragile X syndrome is a carrier disorder that can cause a range of developmental problems in babies. These include learning disabilities or behavioral disabilities, such as autism and attention deficit hyperactivity disorder, that can cause certain intellectual challenges. Fragile X is a common form of inherited learning disabilities and autism worldwide. Fragile X carrier screening is recommended for people with a family history of fragile X-related disorders or an intellectual disability that suggests fragile X syndrome. 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 2 most common neural tube defects are: • Anencephaly – Babies born with this condition are missing major parts of their skull, scalp, and brain. • Spina bifida – Babies with this condition have an opening or gap in their backbone.

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 15-18 weeks. Like all prenatal tests, a normal AFP result does not guarantee that your baby will not have this defect. About 1 in 5 babies born with a neural tube defect will have normal AFP levels. Abnormal results will require additional blood tests, ultrasound, or amniocentesis to confirm the results.

NEED TO KNOW

Only 1 or 2 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.

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FETAL ANATOMY SCAN Many health care providers use a fetal anatomy scan to look for physical signs that the baby has an obvious birth defect. This is usually done between 18 and 22 weeks of pregnancy. It’s sometimes called a Level II 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 TESTS If a genetic screening test comes back positive or your health care provider needs more detailed information, you may be offered one of the following diagnostic tests: • Chorionic Villus Sampling (CVS) – Uses a tiny tissue sample taken from the placenta. It is done during the first trimester, usually 10-13 weeks. Its main purpose is to see if the baby has a normal number of chromosomes (46). It 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 – Fluid taken from the amniotic sac surrounding the baby is tested. When the test is done depends on the reason for it. 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 and 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.

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EMOTIONAL CHALLENGES during PREGNANCY

When you’re pregnant, 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 physical and hormonal changes in your body. The perinatal period lasts through your pregnancy and up to 1 year after the baby is born. Roughly 1 in 5 pregnant people will develop a perinatal mood and anxiety disorder (PMAD) during this period. Fathers, partners, and even adoptive parents may also experience anxiety, depression, and other mood disorders after the baby is born.

14 Your Guide to A Healthy Pregnancy

PREGNANCY CHALLENGES During the perinatal period, there are a number of different mental health issues that could come up anytime. In addition to physical and hormonal changes, you might also face health challenges during your pregnancy or complications with the birth. Becoming a parent is also a time of personal, social, and role changes. Any of these issues can affect your emotions and your mental health, putting you at risk for developing a mood or anxiety disorder. This risk is greater from conception through the first year, because of the hormone changes related to pregnancy, birth, lactation, and resuming menstrual periods. The perinatal period is the most likely time for parents to first make contact with the mental health system.

WHEN TO ASK FOR HELP The good news is that mood and emotional changes are usually temporary and can be treated , often with a combination of self-care, social support, talk therapy, and sometimes medication. One way to start feeling more confident and relaxed when you first know you’re pregnant is to learn as much as you can about pregnancy and child care. Going to childbirth classes, reading books, watching videos, talking to others, and using helpful pregnancy apps can also help. Although mild mood swings are pretty common in the perinatal period, these changes become so powerful for some people that they begin to interfere with everyday life. If you have feelings of depression (sadness or hopelessness) or anxiety (worry or fear) for more than 2 weeks or you have trouble doing daily activities, ask for some help. Perinatal mood and anxiety disorders are treatable with professional help. If you feel you are suffering from any of these illnesses, know that it is not your fault and you are not to blame. Talk to your health care provider right away about what treatment options are right for you. For more information about PMADs, visit Postpartum Support International at www.postpartum.net , or call the helpline at 800-944-4773 . You can also text 503-894-9453 (English) or 971-420-0294 (Español).

CAUSES AND RISK FACTORS Depression and anxiety are the most common perinatal emotional health issues, especially if you already have other things in your life that put you at higher risk for developing a PMAD. These risks can include: • A personal or family history of depression, anxiety, or postpartum depression • A diagnosed premenstrual dysphoric disorder or PMS • Not enough help and support with caring for your baby • Problems with money or personal relationships • Complications with your pregnancy, birth, or breastfeeding • A recent major life event, like a job or personal loss or having to move • You are pregnant with more than 1 baby (multiples) • Your baby is at risk of being in the NICU (neonatal intensive care unit) • You’ve had fertility treatments, a thyroid imbalance, or any type of diabetes

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.

AFTER THE BABY COMES Many of the same risks that contribute to the onset of perinatal mood and anxiety disorders can also cause unexpected negative emotions and mood swings during the postpartum period — defined as the first 6 weeks after you have your baby. The most common postpartum mental health issue is called “ baby blues .” It typically affects about 70 80% of all new parents and starts a few days after they give birth. The baby blues usually last from a few days up to a few weeks. For more information about baby blues and other postpartum emotional changes and challenges, check out the “Postpartum Emotions” chapter beginning on page 61.

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It’s never too soon to start planning for your baby’s birth. 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.

PLANNING AND PREPARATION

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-to-be 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 you want to manage your care, who you want in the labor and birth 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 birth. 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 one online.

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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 health care provider has admitting privileges. Most hospitals and birth centers will let you tour their facility. Questions to ask before choosing a facility: • Does it have single LDRs (labor, delivery, and recovery rooms) or LDRPs (labor, delivery, recovery, and postpartum rooms)? • How many people can be in the room for the birth? • What is its policy on rooming-in ? • What are its visiting hours and who can visit? • What are its safety and security procedures?

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 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 the list. 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 2 months before your due date .

Your baby’s umbilical cord is attached to the placenta 1

The umbilical cord is clamped in 2 places and then cut 2

The blood is drained through a tube into a special collection bag 3

Package the collection kit and ship it to your chosen facility for processing and storage 4

The cord blood stem cells are preserved in a liquid nitrogen storage tank in a secure facility 5

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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.

HOW YOUR BODY CHANGES

SCAN + PLAY

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.

BACKACHE 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 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

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BREAST CHANGES You’ll see changes in your breasts very early in your pregnancy:

CONTRACTIONS It’s 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 • Close 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 CRAVINGS (PICA) Pica is the medical name for wanting to eat strange things that aren’t nutritious— ice, starch, dirt, or clay, for example. Cravings may be a sign that your diet is lacking in some essential nutrients. Helpful tip: No matter what you’re craving, keep eating balanced, healthy foods. 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 • Lie on your side when resting and sleeping • Eat frequent small meals or snacks • Stay hydrated by drinking plenty of water DIZZY SPELLS OR FEELING LIGHT-HEADED

• Breasts become larger, firmer, and more tender • Areola (dark area around the nipple) gets larger and darker • 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.

CONSTIPATION AND BLOATING 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 can also be helpful • Eat high-fiber foods (vegetables, fruits, whole grains) • Find time to take a walk or do some exercise every day • Eat frequent small meals — they’re easier to digest • Avoid processed foods, fatty meats, and high-fat dairy • Avoid gassy foods (beans, cabbage, carbonated soda)

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FATIGUE 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 their pregnancy. Fatigue is caused by hormonal and other 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.

HEARTBURN 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 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 and hormonal changes 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

HEADACHES You may have headaches during the first few months of your pregnancy. They 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.

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JOINT PAIN During pregnancy, your joints may feel achy and loose when you walk. Gaining weight puts extra pressure on your knees. Swelling

NAUSEA “Morning sickness” is the common term for feeling nauseous (sick to your stomach) and/or vomiting when you’re

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 salty foods in your diet • Eat foods rich in omega-3s (salmon, other oily fish) • Try heat and cold therapy (heating pads/ ice packs)

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 • Try ginger, lemonade, or mint tea • Chewable prenatal vitamins may cause less nausea

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

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RAPID HEARTBEAT 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 feeling faint.

SHORTNESS OF BREATH 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

press 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.

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.

SKIN CHANGES Rising hormone levels during pregnancy can cause some changes to your skin color. These changes usually go away

completely or mostly fade after the baby is born and your hormone levels go back to normal. Your skin may just look flushed, like you’re 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 help.

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. 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.

STRETCH MARKS As your skin stretches, the elastic tissue below it may break down and cause zigzag 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 after pregnancy.

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