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Normal Pregnancy

INTRODUCTION

DIAGNOSIS OF PREGNANCY

CHOOSING AN OBSTETRIC CARE PROVIDER

ll continue with that provider. For many other women, options for obstetric care need to be investigated.

Many angles need to be considered when choosing the clinician as well as the delivery setting. Does medical insurance limit choice of provider or hospital? What type of providers are involved in the obstetric care (midwives, physicians, nurse practitioners, etc.)? What type of birth setting is available in your community (free-standing birth center, hospital or home)? What are the options for pain management during the labor in each of the settings you are considering? Do you have any risk factors with your pregnancy that indicate that you should choose a hospital that has the capability to care for premature babies (a Level 2 or 3 Intensive Care Nursery)?

There are many ways to explore the options in your community. Talk with other parents who have recently been through the birth experience. Find out which hospitals in your community have an obstetrical unit where deliveries are done, and take a tour of them with your list of questions. Ask your primary care practitioner for suggestions for obstetric care. Ask your insurance carrier for a list of providers and birth settings covered by your insurance policy. Check out websites for obstetricians (www.acog.org) and for midwives (www.mymidwife.org).

Some clinicians will talk with you on the phone about their practice, and some may even offer a free limited interview so you can get to know them before you make your decision. Alternatively, you can simply make an obstetric appointment with a clinician and see how it goes.

The first prenatal visit should be in the first trimester (each trimester 13-14 weeks of the pregnancy is called a trimester), ideally between 7 - 10 weeks of pregnancy. Questions to ask may include: What is your approach to labor and delivery? If you will not be at the delivery, who might be covering for you? What are the choices for the birth setting? Which childbirth classes do you recommend?

HEALTHY HABITS IN PREGNANCY

Nutrition

ount of weight gain necessary for promoting a healthy pregnancy depends on your pre- pregnancy weight and height.

In general, you'll need to increase your daily calorie intake by about 10 - 15%. For most women this will mean around 300 calories a day, but this can be complicated by nausea and vomiting in the first trimester, which causes many women to either lose weight or gain too much weight (sometimes eating something every two hours can help the nausea to stay away but try to use low calorie foods for this). Try to keep weight gain steady. If you have concerns about your weight, ask your clinician for advice. They may recommend you see a nutritionist if there are serious concerns.

By the end of your pregnancy, your weight will be distributed as below:

Baby = 7-8 pounds

Uterus = 2 pounds

Placenta = 1-2 pounds

Amniotic fluid = 2 pounds

Maternal breast tissue = 2 pounds

Maternal blood = 4 pounds

Fluids in maternal tissue = 4 pounds

Maternal fat and nutrient stores = 7 pounds

How you gain this weight - especially the nutritional quality of the foods you ingest - is important for your overall well-being.

The Food Guide Pyramid is an easy-to-use reference designed to recommend the six food groups you should eat every day. It's updated every five years, and is the basis for most dietary recommendations in the United States. The pyramid emphasizes a diet rich in plants, grains, vegetables and fruits, and is low in fats.

During pregnancy, you can follow the food pyramid as general guide, but increase milk or other calcium rich servings. Remember to avoid alcohol. If you cannot achieve the recommended dairy/calcium intake from your diet, be sure to take calcium supplements, as the fetus needs a tremendous amount of calcium to grow its bones.

The six food groups are:

Breads, cereals, rice: (6-11 servings a day): Choose whole grain varieties like whole-wheat bread or unprocessed brown rice over white. They are great sources of fiber.

Fruit: (2-4 servings a day): Try to eat fresh fruit only. Fresh fruit is a wonderful source of fiber.

Vegetables: (3-5 servings a day): Try eating fresh veggies, which are good sources of fiber, folate, and other important vitamins.

Meat, fish, poultry, nuts, tofu, eggs, and dry beans: (3-4 servings): If you eat meat, try to get your meat from sources that do not use antibiotics or hormones.

Milk, cheese, and yogurt: (2-3 servings a day): Low-fat varieties contain all the nutrients you need. Dairy products are terrific sources of calcium and protein. Be sure all dairy products are pasteurized.

Fats, oils and sugars: Choose wisely. Some fats are better than others. Ice cream, though high in fats, is a good source of calcium.

Visit http:///www.mypryramid.gov for an interactive site that can help you create your own food pyramid, calculate your body mass index, and provide an individualized recommendation for your total weight gain during pregnancy.

Fish and shellfish

Fish and shellfish are great sources of protein and heart-healthy omega-3 fatty acids. However, almost all fish and shellfish contain a harmful chemical called mercury. Mercury gets into your body primarily by ingesting fish, and high levels of mercury can be harmful to the developing baby. The risk of mercury in fish and shellfish depends on the amount and type of fish and shellfish you eat.

Here are a few tips that can assist you in getting healthy protein and omega-3 fatty acids in fish and avoid mercury at the same time:

• AVOID shark, swordfish, king mackerel, or tilefish (also called golden or white snapper). They are large predator fish and contain very high levels of mercury.
• Salmon, shrimp, and catfish are considered low in mercury. Salmon is also a great source of omega-3, which is considered important in fetal brain development.
• Do not eat more than six ounces of "white" or "albacore" tuna or tuna steak each week. Some pregnant women avoid all tuna during the pregnancy.

Foods to avoid

Avoid hot dogs and luncheon meats unless heated thoroughly. These foods may contain listeria, a bacterium that can be very detrimental to the health of the mother and developing fetus.

Avoid unpasteurized dairy foods, including some milk and certain cheeses, such as Brie, feta, Camembert, Roquefort.

Avoid meat spreads, and smoked seafood (such as salmon, trout, whitefish, cod, tuna, or mackerel) as they may contain listeria bacteria.

Avoid unpasteurized juices as they are susceptible to germs, including E. coli. Make sure the juice you consume is pasteurized.

Avoid alcoholic drinks. The effects of alcohol are permanent and there is no known safe level for alcohol consumption in pregnancy.

Exercise

Research and literature extol the health benefits of moderate levels of physical activity during pregnancy. We recommend that you engage in forms of physical activity that are beneficial without compromising your self or the baby, for thirty minutes each day.

How to decide on which activities to include during the pregnancy?

Ask yourself: "What have I been doing for physical exercise? How much time during a day do I spend on physical activity? Do I like the exercise/activities that I do?" The type of exercise you do should depend on your health and how active you were before you became pregnant. If you were active before pregnancy, continue to exercise in moderation. If you are just beginning an exercise program, build up slowly.

A sensible, regular exercise program during your pregnancy should be one that does not negatively impact your health or the well-being of your developing fetus. As you progress in your pregnancy, we suggest that you exclude activities such as contact sports that can cause blunt trauma. These include downhill skiing, snow -boarding, ice skating, bike racing, mountain climbing, soccer, and basketball. There may be more injuries during pregnancy due to the relaxin and progesterone which relax the ligaments. You also may have balance issues as you become more asymmetrical with the growth of the baby. Avoid heavy free weights, but low weights and resistance training are fine.

As your pregnancy advances, you will feel more tired and it may feel uncomfortable to run, jog, and work out the same amount as before. If you are used to an exercise program, do not stop, just adjust and do what feels most comfortable. Swimming, prenatal yoga and exercise workshops are great forms of physical activity to start during your pregnancy. Swimming and walking 30 minutes a day is great. Stretching exercises are excellent to help keep your back in good shape.

Always remember to consult with your clinician about the exercise routines you wish to pursue.

Sex

As long as you do not have any medical complications of pregnancy, such as vaginal bleeding or preterm labor, sex is usually not restricted. The need for intimacy is felt in many ways during pregnancy, and expressing this intimacy sexually is important for most people. Although during the first trimester, many women have symptoms such as nausea and excessive fatigue and may not have the energy for sexual activity, during the second and third trimesters, many of the symptoms have abated, and there may be an enhanced desire for sexual activity. During this time, communication about desire for sexual activity is essential to maintain so that mis-interpretation does not happen when one partner is not feeling up to sexual activity.

During the last part of pregnancy, sexual positions may need to be adjusted for the changing body of the pregnant woman. Some women and men worry that vaginal penetration might hurt the baby somehow, but the vagina expands during sexual activity. However, if there is bleeding after penetration, or if there are prolonged contractions after orgasm for the pregnant woman, it is important to check with your clinician before continuing sexual activity. During the last part of the pregnancy, unless the membranes have ruptured (bag of waters has broken), there is usually no sexual activity restriction.

Travel

Travel is usually safe until about a month before the due date. Some airlines prefer that you not fly after 32 weeks. If you do decide to travel during the last trimester, you need to plan where to go if you have an emergency. If you deliver early, be prepared to stay in that location for a few months. You should ask your clinician about your specific travels plans during your pregnancy. If you are flying for several hours, it is recommended to wear maternity support hose, as pregnant women have more clotting in their blood vessels than when they are not pregnant, and in combination with a long plane flight, have an increased risk of blood clots in their legs. You might consider taking an abbreviated copy of your obstetric record with you if you are traveling in the second or third trimester.

It is also very important to wear your seatbelt while pregnant, even if it is tight against your pregnant belly.

If you are traveling internationally, check the Center for Disease Control website for advice, as certain medications for malaria prevention - as well as certain antibiotics to prevent traveler's diarrhea - should not be used during pregnancy (www.cdc.gov).

THE FIRST TRIMESTER (WEEKS 1 - 13)

Symptoms in the First Trimester

ixth week of pregnancy, improve by the twelfth week and usually stop by the fourteenth to sixteenth week. However, there are about 5% of pregnant women who continue having these symptoms past 16 weeks.

Your clinician will often refer to your nausea and vomiting as a good sign, because women with nausea have lower rates of miscarriage. However, if nausea and vomiting are accompanied by fever, diarrhea, headache, dehydration or abdominal pain, your clinician needs to do further evaluation.

The management of nausea and vomiting during pregnancy is dependent upon the severity of the symptoms. We start with changing dietary intake and progress to medical interventions if needed. There is no fast cure for nausea during pregnancy.

• Sometimes your prenatal vitamins can exacerbate the nausea and vomiting. Change the time of day in which you take your vitamin (consider taking it at night to sleep through any side effects) or
• Consider switching from your prenatal vitamin to folic acid 800 micrograms to 1 mg. until your nausea resolves later in the pregnancy. The folic acid tablets are small and do not seem to upset the gastric system. Be sure to switch back to your vitamins after your nausea has abated.
• Keep food with you at all times so you can snack frequently. You do not want your stomach to get empty because the nausea canget worse.
• Eat small frequent meals as the first step in the treatment of nausea and vomiting.
• When you wake up in the morning, consider eating a small piece of unbuttered toast or saltine crackers before getting out of bed.
• Avoid fatty, greasy and spicy foods. It takes longer for fats to be digested during pregnancy.
• Ginger is a popular treatment for morning sickness throughout the world. However, the safety in pregnancy has not been determined. We suggest taking ginger as a soda, tea, or candy.

Here is a list of suggested foods that might help relieve your nausea:

• Crunchy: celery sticks, apple slices
• Bland: mashed potatoes
• Fruity: fruity popsicles, watermelon
• Salty: chips, pretzels
• Dry: toast, crackers

Keeping hydrated is very important throughout your pregnancy. Try to drink small amounts of fluid throughout the day. Experiment wtih fluid intake: can you manage the fluids better before or after a meal? Suggested liquikds: juices, sparkling waters, ginger ale.

If you are dehydrated from not being able to keep liquids in your stomach due to nausea and vomiting, you may need intravenous fluids in a hospital setting. One way to determine if you are dehydrated, is to noticing how many times per day you are urinating. If you are only urinating 2 to three time per day, and you keep vomiting, it is time to call your obstetric provider. Sometimes the dehydration is severe enough that intravenous fluids in a hospital setting are needed.

Acupressure has been suggested as a treatment for nausea. Although there are no studies that have demonstrated that there is a benefit to acupressure, there are no known adverse side effects either. If you are considering acupuncture, consult your healthcare professional and look for an experienced and licensed acupuncturist. Be sure that the needles they use are sterile.

Commercial wrist bands for relieving motion sickness act on acupressure points and can help relieve the nausea associated with pregnancy for some women. They are over-the-counter that you can get at your local pharmacy.

Sometimes medication or supplements to alleviate the nausea are suggested by your obstetric care provider. These might include:

• Pyridoxine (Vitamin B6): One small study demonstrated that 25 milligrams of vitamin B6 taken every eight hours was more effective than a placebo (pill without the B6) for controlling nausea and vomiting in pregnant women.
• Prescription medications: These therapies are called anti-emetics and include medications such as promethazine (Phenergan), prochlorperazine (Compazine), and ondansetron (Zofran).

Breast Tenderness and Growth

Beginning in the first trimester, your breasts will go through enormous changes. Increases in hormonal production start within the first weeks of pregnancy as part of the process of preparing the breasts to produce milk. Hormones cause growth in milk-producing ducts and cells. An increase in blood flow to the breast can make them very sensitive.

Breast tenderness is so common that it is one of the first signs of pregnancy.

• The breasts may become tender to touch and movement; they might feel swollen, and sensitive. You may experience a throbbing or tingling in the nipples, and/or heaviness in the breasts.
• Some women may develop a darkening of their nipples and areolas due to hormones that cause pigmentation in pregnancy. This change in pigmentation becomes more obvious in the second trimester.
• A crisscrossing pattern of veins on the surface of the breasts might develop, specifically in the third trimester.
• Leakage from the nipples of a yellowish substance, colostrum, may begin in the last trimester.

Overall growth in the breasts continues throughout the pregnancy and these changes are all very normal.

• Remember you breasts will change sizes throughout your pregnancy.
• Wear a supportive bra that fits properly.
• Try to buy cotton bras, and avoid under under-wire bras because they can cut into your breasts.
• Wear a soft bra for sleeping.

Frequent Urination

The urge to urinate is more frequent in pregnancy and it becomes apparent during the first trimester. It is due to pressure from a growing uterus on the bladder, which triggers the urge to urinate. Sometimes it might take a longer time to urinate. If you suspect that you might have a bladder infection, call your clinician. Signs of a bladder infection include an increase in frequency, painful urination, inability to empty the bladder completely, blood in the urine and, occasionally, a fever.

Constipation, Gas, and Bloating

Constipation throughout pregnancy is very common. In the first trimester, the increase in hormones produces a relaxing effect on the intestines and movement of food through your intestines slows down. Stools become firmer and when combined with the reduction in intestinal motility, produce constipation. In the second and mostly in the third trimester of pregnancy, the pressure of your enlarging uterus on the large intestine further impinges the passage of stools.

You can try to prevent constipation from developing by the following approaches:

• Limit apples; they contain pectin, which serves to bind food.
• Drink an additional six to eight glasses of water a day.
• Eat foods low in fat and prepared with little grease. High fat foods are hard to digest and can stay in the intestines for a longer time.
• Avoid fatty foods in the evening because they promote gastric heartburn.
• Eat foods rich in fiber.

o Fiber and fluids can make your stools softer and cause them to pass through your intestines faster

o Eat fruits such as prunes, pears, figs, mangos and apricots.

Eat vegetables, especially crunchy vegetables such as carrots, zucchini, cucumbers, and celery.

• Eat whole grains, such as bran and multi-grain breads.
• If you drink juices, consider nectars (prune, pear, apricot), which are higher in fiber than plain juice.

• Avoid common gas-producing foods: broccoli, cauliflower, brussel sprouts, beans, peppers, and carbonated beverages.
• Eat frequent, small meals throughout the day..
• Regular exercise can help keep your intestines moving efficiently during the pregnancy.

• Eat small, frequent meals.
• Avoid foods that commonly cause heartburn: fatty, spicy foods.
• Avoid lying flat immediately after eating.
• Avoid eating late at night.
• Sleep on several pillows.
• Avoid drinking a lot of liquid with meals.
• Use antacids (Tums) as needed, but if you are using 10 per day or more, inform your Clinician. You might need to try a different medication at that point.

Tests for Maternal and Fetal Health in the First Trimester

Your first prenatal visit to your clinician is usually the longest. A full history will be obtained, so it is important to hand-carry any relevant medical records, or to sign a release at the visit so that the records can be requested. A full physical exam is usually done, as well as blood tests. A urine sample is also obtained to rule out any bacteria in the urine.

Screening for birth defects in the fetus can begin in the first trimester. The first step is to decide if you would act on the information that the fetus might have a birth defect. If you would not consider termination of the pregnancy for any reason, you might want to skip the first trimester tests for birth defects, as there are a number of false positive results: you may be told you that your fetus had a positive screening test for a birth defect, when on further invasive testing, the fetus does not actually have that birth defect. However, if you would consider acting on the information from the screening test, you should consider a nuchal lucency test, which is an ultrasound (sonogram) done at 11.5 to 12.5 weeks of pregnancy that measures the thickness of the fetal neck. In most situations, a blood test is also done at 9 -11 weeks from the last period, the results of which are combined with the nuchal lucency measurement to assess the chance of the fetus having a chromosomal abnormality. The combination of the blood test and the nuchal lucency test identifies about 90% of fetuses with Down Syndrome (an extra chromosome #21). Down Syndrome is associated with mild to moderate retardation in the child, as well as an increased risk of heart defects in the newborn.

For example, your result may be a 1 in 10, 000 chance that the fetus has Down Syndrome, which would be a very remote chance. However, if the result indicates a risk of one in 10 chance that your fetus has Down Syndrome, that risk is quite high and a confirmatory test may be considered. However, the confirmatory test is invasive (either a placental biopsy called a Chorionic Villus Sampling [CVS]) or an amniocentesis) with a small risk of miscarriage caused by the test. Therefore, if you would not consider terminating the pregnancy even if Down Syndrome was confirmed, you should not do the invasive test to avoid a potential pregnancy loss. The risk of pregnancy loss with either a CVS or an amniocentesis is about 1/200.

Emotional Changes in the First Trimester

The first trimester can be challenging physically and emotionally. The physical changes of pregnancy can be very difficult to manage for some women and families. It is not uncommon to see symptoms of depression occurring during this time because the exciting expectations of a pregnancy are often overshadowed by the discomforts of pregnancy. It is very common to worry about the health of the fetus and to be concerned about the financial demands of a new family. Family members and your medical providers need to be very supportive during this period. If symptoms of depression last for more than two weeks (crying unexpectedly, inability to sleep especially with early morning waking, sadness) it is important to mention this to your clinician, as depression can be treated effectively during any trimester of pregnancy.

THE SECOND TRIMESTER (weeks 13 - 26)

During the second trimester, most women feel better. Most nausea has abated and there is a growing awareness of the uterus growing. The growth of the uterus is starting to "show", and the excitement of seeing the fetus on ultrasound can contribute to looking forward to the arrival of the newest family member.

Symptoms of the Second Trimester

Although mostly occurring in the third trimester, you might notice uterine contractions earlier. Contractions that do not cause pain and come and go unpredictably are called Braxton-Hicks. These contractions are only worrisome if they come in a regular pattern - more than 4 to 6 times per hour - and do not go away with resting and hydration (drinking fluids). Call your clinician if you are concerned about your contractions.
Gum and Nasal Changes

During this time, there is increased blood circulation in the mucus membranes. The lining of the nasal passages gets congested and sometimes you may experience nose bleeds. If you have trouble stopping the nose bleeds with pressure, or if they are daily, be sure to tell your clinician about them. In addition, your gums might bleed because they become softer in pregnancy. We recommend that you go to your dentist during the pregnancy for routine teeth cleaning and maintain good brushing and flossing at least twice a day.

As your pregnancy progresses, you may experience a shortness of breath. Shortness of breath typically begins before the twentieth week of pregnancy and continues into the third trimester. You may have to rest more frequently during the day, but it should not disrupt your day-to-day activities.

Emotional Changes in the Second Trimester

Psychologically, pregnancy is a dynamic journey. During the early part of the second trimester, anxiety is very common while going through genetic testing. By the middle to the end of this trimester, typically there is a better sense of well-being and relaxation. You can feel fetal movement, and also feel that the fetus is growing with an expanding abdomen. However, stress can occur with the factors such as moving households, changes in relationships, or a heavy work schedule. If stress leads to symptoms of depression, professional help should be sought.

Tests for Maternal and Fetal Health in the Second Trimester

Screening tests in the second trimester include a blood test from the mother to check for birth defects, as well as a sonogram (ultrasound) to detect fetal structural abnormalities. This blood test is done between 15 and 20 weeks from the last period, and usually includes a test for Down Syndrome (identifies about 80% of the fetuses with Down Syndrome), for spina bifida (a defect of the fetal backbone), for Trisomy 18 (an extra #18 chromosome) and for SLOS (a rare birth defect). Sometimes the results also indicate that complications such as high blood pressure might develop in the third trimester, and extra fetal monitoring may need to be done weekly during the last part of the third trimester.

A fetal ultrasound is usually done at 19 to 21 weeks from the last menstrual period, to determine if the fetus has any major structural birth defects. If a woman is 34 years of age or older, a more specialized ultrasound is often ordered, called a Level 2 sonogram or fetal survey, at which time the radiologist looks specifically for birth defects associated with "older" women. However, ultrasound cannot diagnose chromosomal abnormalities of the fetus reliably: the previous genetics tests described above are more suitable for that. An ultrasound done at 19 to 21 weeks of gestation usually reveals the sex of the fetus. If a family prefers not to know the sex of the fetus, please inform the technologist doing the scanning so that this information is not revealed!

Birth defects affect three to five out of every 100 babies. Ten percent of the birth defects are chromosomal such as Down Syndrome; the rest include structural (such as cleft lip/palate), metabolic (PKU) and others. Ultrasound can diagnose many of the major structural birth defects, but not all of them (only about 30% of heart problems of the fetus are diagnosed by ultrasound during pregnancy). If a birth defect is diagnosed, the genetics counselor or the clinician will talk with you and your family about what it means, and will provide you with resources for education and a discussion of options as well as resources such as parent support groups. The March of Dimes is an excellent source of information on birth defects (www.marchofdimes.com)

Childbirth Classes

If this is your first pregnancy, consider taking childbirth classes. Find out what is available in your local community: usually hospitals sponsor such classes, as do other organizations. Some classes teach a specific method of breathing or approach to childbirth philosophically, while other programs may teach an integrated approach to childbirth. The ideal class is held over a series of several weeks, so you can get to know your teacher and other participants in the class, some of whom you may decide to continue a friendship with after the class ends. If you have a difficult schedule to arrange classes, there may be an all-day course. Often there are additional classes for breastfeeding (a very worthwhile investment), infant CPR (which can also be arranged through the local Red Cross Chapter), infant care, and labor anesthesia.

THE THIRD TRIMESTER (weeks 27-40)

The third trimester is hard for most pregnant women due to the discomforts of extra weight, excess fatigue, and just moving slower when so much needs to be done. If you are working outside the home, try to get permission to work from home a couple of days per week if possible, especially if you have a long commute. This will help with your fatigue as you can control the amount of time you are sitting, take an afternoon rest, and do a couple of hours of work in the evening to make up for the afternoon rest.

It is very important to pace yourself carefully for all of the activities of the third trimester. On top of your usual schedule and preparing for the baby's arrival, you also need to integrate into your schedule such things as baby showers (which can be fun but exhausting), childbirth classes, and hospital tours.

You should also consider who is going to help you out for the first few weeks after the birth. Many pregnant women are concerned about asking their parents to help out, especially when they have not been in the role of grandparents before. TAKE ALL THE HELP THAT IS OFFERED! The first two months after childbirth are exhausting and although you will be the primary caretaker of the baby, you need people to take care of YOU!

Many pregnant women like to have a written birth plan to describe their preferences for childbirth. If you have decided to have a written birth plan, it is important compose this and discuss it with your clinician in the office before labor happens so that the communication is clear, and questions can be answered ahead of time. It is useful to keep a copy of your birth plan yourself, as well as to give one to your clinician for your chart. Be sure to bring your copy with you to the birth, in case there is not enough time to locate your chart at that time. Try to have a one-page birth plan rather than a long one; a shorter plan is more likely to be read. Also, be sure to be flexible as unexpected events can arise during labor. It is rare that a birth plan can be followed exactly as written.

Some women decide to employ a doula to help them during birth and postpartum. A doula is a person who supports a woman through labor with her presence, providing encouragement and other skills such as massage. Research shows that women who have a doula in labor are more satisfied with their childbirth experience. If you are considering having a doula accompany you in labor, be sure that your chosen birth setting allows a doula to be present. Also, interview several doulas; they may provide different services and have varying fees. Find out about their back-up plan if they have two clients in labor at the same time. It is a good idea to choose a doula who is familiar with your planned birth setting. Your doula should be part of your birth team working with you and your clinician, rather than working against indicated medical procedures.

By 37 weeks of pregnancy (three weeks before your due date), your suitcase for the hospital should be packed, the car seat placed in the car and checked by the local police or fire station for correct installation unless put in by a professional (if you don't have a car, often hospitals still require you to bring a car seat to the hospital for the ride home), family and friend assistance structured for those first few weeks after the birth, childbirth classes finished, and pediatric care for the newborn identified. If you're having a boy, a pediatric issue to be considered is whether or not to have a circumcision performed. Sometimes a pediatric visit can be arranged before the birth with the clinician who will be caring for the baby, and questions including their approach to circumcision can be discussed. It is also important to remember to notify your insurance company once the baby has been born so that the baby is added to the policy: this usually has to be done within 30 days of the birth.

If you are working outside the home, find out about pregnancy disability leave from your workplace. Some policies allow you to be off two to four weeks before your due date, and others do not give time off before the due date. Usually, women have six weeks of medical leave after a vaginal birth, and eight weeks of leave after a cesarean section, but this can vary (federal employees do not get any maternity leave). Be sure you have talked about your pregnancy leave with your Human Resource representative as well as your direct supervisor well ahead of time, so someone can be trained to replace you during your maternity leave if needed

After the birth, most mothers need two to three months off work to establish breastfeeding, find childcare, and adjust to changing family dynamics. Sometimes vacation and sick leave can be added to medical disability leave for childbirth to lengthen the time off from the workplace. If not, the Family and Medical Leave Act (FEMLA) can be activated. Some states provide a stipend for limited paternity leave.

Symptoms in the Third Trimester

In the third trimester, symptoms are often muscular-skeletal in origin, as getting around is more difficult. Swelling of the lower extremities and sometimes the hands is common. In some cases, the swelling of the hands is severe, resulting in wrist pain (carpal tunnel syndrome) that can be treated with hand splints. Urinating frequently is common, as the bladder sits on top of the uterus as it expands. Sometimes painful uterine contractions come at unexpected times. Too many contractions (more than four to six per hour) can indicate preterm labor if they happen before 37 weeks of pregnancy. If they don't go away with hydration and resting, you should check in with your clinician. Exercising may become more difficult, but should still be 30 minutes every day.

Back Pain

Back pain in pregnancy is very common and affects 50-90% of all pregnant women. Back pain usually develops during third trimester. There are multiple reasons for this discomfort. The growing uterus shifts the center of gravity upward and forward and the abdominal muscles are more lax during pregnancy. Relaxin, a hormone that is secreted during the pregnancy, allows joints and the pubic bones to soften in order to facilitate delivery of the baby. The daily routines that were painless to do before pregnancy now may cause severe discomfort. Back stretches, proper body mechanics, and adequate rest are all important to minimize back pain.

HELPFUL HINTS TO PREVENT BACK PAIN

• Use your leg muscles to lower and raise yourself.
• Avoid standing for long periods and frequently change sitting position.
• When you are get up from a lying position, roll to your side and use your hands to lift your back.
• Wear low heeled and supportive shoes.
• Try a supportive maternity belt.
• Do a pelvic rocking exercise a few times a day.

Back and Pelvic Tilt

• In the hands and knees position, start with your head up, back sunken in by pushing stomach toward floor.
• Tighten buttocks, pull pelvis forward, and straighten back. Tuck chin in.
• Relax to original position. Repeat several times.
  

Screening Tests in the Third Trimester for Maternal and Fetal Health

Screening for maternal anemia (low blood count) and for diabetes is usually done during the third trimester. The blood tests are often done between 24 - 28 weeks, with the drinking of a 50 gram glucose load followed in one hour by a blood draw for the diabetes. An antibody screen is also done in the third trimester for pregnant women who are Rh negative, and if the antibody screen is negative, a Rho(D) Immune Globulin (RhoGAM) shot is given between 28 to 32 weeks to prevent Rh sensitization in a future pregnancy.

During the third trimester, assessment of fetal activity by the mother is an important screening test of fetal health. Many obstetric providers recommend daily kick counts of the fetus starting at about 32 weeks. There are many ways to do the kick counts. One common method is to select the same time every day when the fetus is active (typically after a meal) and to be sure that there are four fetal movements in the hour that follows. If not, the recommendation is usually to eat something sweet, lie down on your left side and check again. If the fetus has still not met the criteria of four movements in the hour, you should call your clinician.

Between 35 to 37 weeks of pregnancy, a Group B strep culture is done from your outer vaginal area, and around your rectal area. About one in three pregnant women has a positive culture for Group B Strep. If the Group B Strep culture is positive, intravenous antibiotics will be administered during labor to decrease the amount of the Group B strep in the vaginal area. This antibiotic administration decreases the risk that the newborn will acquire a Group B Strep infection.

EMOTIONAL CHANGES IN THE THIRD TRIMESTER

It is common in the third trimester to have an increase in anxiety about a month before delivery, often focused on the health of the fetus as well as feelings about the challenge of the upcoming labor and delivery. You may have people coming up to you and telling you about their difficult deliveries, which is the last thing you want to listen to at this time in your life. It is important to let your family and friends know how you are feeling so that they can support you. Take the time for extra rest, meditation, and exercise to keep in shape for the labor. If the anxiety is overwhelming, or you are feeling depressed, you need to talk with your clinician about getting some help. If depression occurs, seek effective treatment before labor starts and the adventure of parenting begins.

Symptoms of Labor

Be sure to discuss and review the symptoms of labor with your clinician to find out when you should call them. Common events that dictate calling your provider include when:

• your bag of water breaks (this can be a small leak or a gush, or maybe you can't figure it out so you be checked in the office or the hospital
• contractions happen every five minutes that hurt (if this is your first baby) or every ten minutes (if you have already had a baby).
• vaginal bleeding (some women pass a brownish mucous plug in their vagina in the weeks before the onset of labor which. does not usually merit a phone call, and does not mean that you will go into labor anytime soon).

Even if none of these symptoms happen, if you are concerned about something, be sure to call your clinician. For instance, if you have been up all night with contractions - even if they are not in a pattern - call and check in with your provider.

CONCLUSION

Pregnancy is an exciting time in the life cycle of women and their families. By doing everything possible to keep healthy yourself, you can maximize the health of your newborn. Unexpected challenges can arise during the pregnancy, but remember that there are many resources to help you navigate these challenges. The first person you should consult is your clinician.

Additional web sites that may be useful to you include:

www.americanpregnancy.org

www.marchofdimes.com

www.revolutionhealth.com/healthy-living/pregnancy/

www.nlm.nih.gov/medlineplus/pregnancy.html

Best wishes in your journey!