Camelback Women's Health Prenatal Handbook

Congratulations on the news of your pregnancy. In order to promote healthy pregnancies for all of our patients, the physicians and staff of Camelback Women's Health dedicate ourselves to maintaining the highest quality and most up to date prenatal care available today. We are excited that you've chosen our doctors and staff to provide for you and your expectant child's care.

Our philosophy of prenatal care centers around individualized one-on-one care with your doctor. Your physician will oversee the special considerations of your pregnancy personally at each visit. We make a special point to have the doctor that you've chosen, whenever possible, available for your delivery. Continuity of care throughout the pregnancy and with each subsequent pregnancy is as important to us as it is to you.

Our goal is to promote a healthy pregnancy through education, early prenatal counseling, appropriate laboratory testing, proper diet and exercise. Since your unborn baby is entirely dependent on you, your health should be your most important consideration for the duration of the pregnancy. We encourage you take advantage of this exciting time in you and your new baby's life to ask questions, read, and improve your lifestyle wherever possible.

This guide is intended to serve as a reference for expectant parents at Camelback Women's Health and the information is not meant to be a substitute for prenatal care visits. We do encourage you to read available prenatal books and literature throughout your pregnancy and bring questions that may arise to each of your prenatal visits.

About Our Medical Staff
About The Hospitals
Emergencies
Important Phone Numbers
Appointments
Genetic Testing Options
HIV Testing

Cystic Fibrosis Testing

Diet
Exercise

Weight Gain In Pregnancy
When You're Not Feeling Well: Colds, Flus, Etc.
Dealing With Constipation in Pregnancy

Your Ultrasound Appointment

Travel
Prenatal Classes

What Can I Do For the Labor Pain?

What Are My Chances For Having A Cesarean Section?

If I Had A Cesarean Section In the Past, Will I Need Another One?

Are Episiotomies Routinely Done?

Do I Need To Contact My Pediatrician When I Am In Labor?
Labor: When To Go To The Hospital And What To Bring
One Last Thing

Gregory DeSanto M.D.
Originally from Rochester, Minnesota, Dr. DeSanto attended the College of St. Thomas in St. Paul, Minnesota., graduating in 1980. He went on to medical school at the University of Minnesota and later completed an Internal Medicine internship in Tucson, where he came to the decision that he eventually would return to Arizona to live and practice. He switched specialty training in 1986 and completed his Ob/Gyn residency at UCLA/Cedars-Sinai Medical Center in 1990 in Beverly Hills, California. He has special interests in high-risk obstetrics, ultrasound, and endoscopic surgery. He and his wife Kathy have three children, Hannah, Ryan and Julienne. He is board certified by the American Board of Obstetrics and Gynecology.

Steven Nelson, M.D., J.D.
A fifth generation Arizonan, born and raised in Yuma, Arizona, Dr. Nelson attended Brigham Young University before beginning his medical studies at Oxford University in England. He completed his medical studies at the University of Utah, then began his training in Ob/Gyn at the University of Louisville, completing his studies at UCLA/Cedars-Sinai Medical Center in Beverly Hills, California. He graduated from Stanford Law School before coming to Phoenix in 1989. Dr. Nelson's special interests are complex laparoscopic surgery and female incontinence. He and his wife Jane have 4 children. He is board certified by the American Board of Obstetrics and Gynecology and is a member of the Arizona Bar. Dr. Nelson is fluent in Spanish.

Erin O'Sullivan, M.D.
Born and raised in Phoenix, Dr. O'Sullivan attended Arcadia High School before continuing her education at the University of California-Irvine. She received her medical degree from the Medical College of Pennsylvania before moving to Houston to complete her Ob/Gyn residency at the University of Texas. Finally she has returned home to her family and friends to practice in Arizona. Dr. O'Sullivan's interest include high risk obstetrics, pelvic relaxation surgery and caring for spanish speaking patients. She is board certified by the American Board of Obstetrics and Gynecology.

Kathleen Schwartz, M.D.
Born and raised in the snowbelt of western New York, Dr. Schwartz has been migrating toward warmer climates since finishing high school. She graduated from the College of William and Mary in Williamsburg, Virginia with a bachelor of science degree in chemistry. Nashville, Tennessee was then home for seven years. After graduation from Vanderbilt University School of Medicine in 1987, her interest in gynecologic pathology led her to complete a residency in anatomic pathology at the Vanderbilt University Medical Center. Dr. Schwartz then returned to clinical practice and completed her Ob/Gyn training in June 1994 at the University of Florida in Gainsville. Dr Schwartz has special interests in high risk obstetrics, laparoscopic surgery and gynecologic pathology. Dr. Schwartz and her husband Paul have a son named Sean and daughters, Ellen and Louise. She is board certified by the American Board of Pathology and the American Board of Obstetrics and Gynecology.

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About The Hospitals

Scottsdale Healthcare-Shea

7700 E. Shea Blvd; 2 blocks east of Pima and Shea; just off the loop 101

Scottsdale Healthcare-Shea offers a more community oriented experience with LDR rooms which allow for labor and delivery in a private labor room. The post partum unit features all private rooms and a level 3 nursery. Scottsdale Healthcare-Shea is well known for its prenatal classes and encourages family involvement through its Stork Stories program for siblings. The hospitalist program maintains in hospital OB coverage 24 hours a day in case of emergencies. The hospital invites new mothers and their babies back 2-3 days after delivery for follow-up on infant care or post partum questions.

Banner Good Samaritan Medical Center

1111 E. McDowell Rd; 1 mile west of I-51

The Department of Obstetrics and Gynecology at Banner Good Samaritan Medical Center is the regional referral center for high risk pregnancies for most of Arizona and is known for its quality of care and expertise for both high risk and low risk pregnancies throughout the valley. The neonatal unit of Phoenix Children's Hospital is integrated with labor and delivery and is known nationally for its care of premature newborns. The Birthing Centre features newly remodeled, family oriented LDRPN private rooms where labor, delivery and the entire postpartum period can be managed in one comfortable Labor-Delivery-Recovery-Post Natal suite. This allows for rooming in for the newborn baby and the father. Good Samaritan offers 24 hour in-house OB anesthesia services and has a well respected Ob/Gyn graduate medical education program.

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If an emergent situation occurs, please call the office at the telephone number listed below for the office that you normally visit. During business hours, a doctor or nurse practitioner should be available at the office. After hours, the answering service will receive your call, and the on call physician will return your call. Please identify yourself and your physician, the nature of your problem and give a phone number that we can call and stay by your phone. If the on call physician is involved with a delivery or another patients call, he or she will return your call as soon as possible.

We want to know immediately about any heavy or bright red bleeding. Dark red or brown discharges generally do not imply active bleeding, but should be reported when the office opens the next morning. Notify a doctor of any bleeding associated with pain.

During your pregnancy, if contractions ever develop a timeable pattern or involve severe pain, notify a physician. Contractions can occur irregularly throughout the pregnancy and generally do not present a problem, but regular, timeable contractions can suggest preterm labor. Report any large gushes of fluid or continuous leaking of clear liquid immediately. Most other vaginal discharges can be discussed during office hours.

Temperatures for whatever reason over 101 (38 degrees Celsius) should be reported. If you think that you have a fever but you are not sure, please check your temperature with a thermometer before calling. For women past 24 weeks, please report any absence of fetal movement for more than 4 hours. If you are concerned about your baby's level of activity, it is best to monitor movements immediately after a meal while lying down. Movements during the last month of the pregnancy will involve more rolling and turning and therefore will require more attention on your part. Remember, it will be the frequency of movement that is more important, not the type of movement.

If you believe you have an emergency that requires a visit to an emergency room, please call us first. Many insurance plans require preauthorization before a visit, and an unauthorized visit can result in bills becoming your responsibility. Most other problems of a more routine nature can be directed to the office during business hours. On weekends, please call when possible between 8am and 6pm. Many simple questions will be answered in your prenatal books; please look there first or bring them to your next visit. If you call during the business day, please be patient. Calls are returned throughout the day and after the last patients are seen.

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Camelback Women's Health
Paradise Valley 602-494-5050
Biltmore 602-468-3912

Hospitals
Banner Good Samaritan Medical Center
Labor and Delivery: 602-239-2054
OB triage: 602-239-6700
Emergency Room: 602-239-2222
Hospital Information: 602-239-2000
Tour and Prenatal Class Information: 602-239-CARE

Scottsdale Healthcare-Shea
Labor and Delivery: 480-323-3420
Emergency Room: 480-323-3810
Hospital Information: 480-323-3000
Tour and Prenatal Class Information: 480-882-4636

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Appointments are made from 8:30 to 4:40 Monday through Friday at both the Paradise Valley and Biltmore offices. Appointment times may vary from doctor to doctor. Because of the nature of obstetric practices, it is possible that your appointment may need to be rescheduled or delayed due to a delivery or an emergency. As you can understand, the physicians must attend to these cases when they occur, as they will when your special moment arrives. A nurse practitioner is also available to provide routine OB exams. When making future appointments, please leave us a phone number where you think you will reachable just before the visit. The office staff, if necessary, will make every effort to help you reschedule your appointment to suit your needs. We thank you in advance for your patience and understanding.

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Genetic Testing Options

At your first visit your doctor will discuss with you, your family's medical history and previous obstetric history to identify if you are a candidate for early prenatal diagnostic testing or genetic counseling.  You should be able to tell us if any serious birth defects or hereditary diseases affect you,  the baby’s father, close relatives or a previous pregnancy.  Great strides are being  made in science of prenatal diagnosis everyday and these can sometimes be applied to your pregnancy.

Nuchal lucency screening, a careful ultrasound that looks for the thickening of the back of the neck of fetuses between 11 and 13 weeks, is an exciting advance in prenatal diagnosis. Nuchal lucency screening involves an ultrasound done by a qualified radiologist with advanced ultrasound equipment, to measure the thickness in the back of the neck of early pregnancies.  Thickening in the neck or the absence of a nasal bone are features that place the pregnancy at added risk for chromosomal abnormalities such as Down’s Syndrome.

Nuchal luncency testing  is noninvasive and therefore very safe. Because the test can be done without the risks of a needle puncture to remove amniotic fluid with amniocentesis, and because the results can be obtained weeks before amniocentesis (16-17 weeks), many of the fears associated with prenatal genetic testing can be alleviated.
 
Use of the test may lead to less use of amniocentesis for the diagnosis of chromosomal abnormalities. Genetic testing has been traditionally offered only to those patients 35 and over and those patients with abnormal AFP testing or other reasons that put them at high risk for chromosomal problems.  Nuchal lucency testing will be offered to all patients, regardless of age.

When combined with a simple finger stick that measures two blood markers (Genecare screen), the nuchal lucency ultrasound is able to detect 85-91% of affected Downs Syndrome babies in mothers below age 35.  AFP triple screeing at 15 weeks, by comparison detects 65-80% of affected babies.

New statistical risks of having an affected child are calculated for patients who do these two tests, allowing the parents to make a more informed decision on whether to pursue amniocentesis. 

It’s important to understand that amniocentesis is still the preferred tests for parents who want certainty of the chromosomes and is always recommended to confirm the diagnosis in those patients that have abnormal nuchal lucency/genecare results. Chorionic villus sampling is also available in the the event that the nuchal lucency screen is abnormal. This allows a result by 13 weeks gestation. Because the amniocentesis culture results take 10-14 days to return, many parents are faced with waiting until 16 or 17 weeks gestation before finding out the results of amniocentesis.

Because the test has been endorsed by several scientific groups, it should be a covered benefit under your insurance plan. Be sure to confirm this with your insurance carrier to avoid any unexpected expenses.

In Phoenix, there are only a few radiologists qualified to perform nuchal lucency screening.  Our office will help you make the appropriate appointments. For more information on nuchal lucency screening, please refer to our website.

Alpha-fetoprotein screening is a blood test offered to all pregnant women and is drawn between 15-20 weeks gestation.  The test is intended as a screening study for a group of disorders called neural tube defects.  These include spina bifida, myelomenigoceles and anencephaly,  serious conditions that affect the brain and nervous system.  The test has been improved and refined in recent years using two additional markers (now called the triple screen or AFP+) and can serve also as a screening test for Down’s Syndrome (Trisomy-21) and Trisomy 18.

It is very important to understand that  the AFP triple screen is exactly that, a screening test that has both the risk of being falsely positive or falsely  negative.  An abnormal test does not necessarily mean that there is something wrong with the pregnancy, but gives you and your doctor the chance to more carefully evaluate your situation.  The screen for neural tube defects is based on elevated AFP levels, but a positive screen  results in an affected child in only 3% of cases.

The screen for chromosomal  problems is based on low AFP levels and two other markers, combined with your age. The very important limitation of this test is that it will still miss up to 30% of those pregnancies affected with Down’s Syndrome in patients over 35 and up to 60% in younger patients.  The test is useful as a guide for further evaluation for most patients and can, taking into account your age, give  you a revised risk of your pregnancy being affected with a chromosomal problem.

Genetic amniocentesis is a procedure usually done between 14 1/2 and 16 weeks gestation in patients at risk for chromosomal abnormalities.  The test involves taking a small amount of fluid from around the sac of the baby under ultrasound guidance and sending the fluid for cell culture. The test takes about 7-10 days for reporting since it involves a culture and has a risk of about 1 in 250 of resulting miscarriage or rupture of membranes.  This test is done in our office and is very accurate in evaluating pregnancies at risk for chromosomal problems.

Chorionic villus sampling is a test available for early prenatal diagnosis of chromosomal problems and can be done between 9 and 11 weeks gestation.  It involves sampling the early placental tissue (chorionic villi) and has a  higher risk of miscarriage.  Referral  to  a specialist trained in this procedure is necessary.

There is a Down syndrome detection rate of 90-95% accuracy, with a false positive rate of only 5% for integrated, sequential and contingent screens. These tests offer a high accuracy rate by integrating the information from the combined first trimester and second trimester quad screen to assess the risks for fetal Down syndrome, Trisomy 18 and open neural tube defects. It may be a useful option for some, but not all women. We can discuss these options with you to determine the most appropriate test in your situation.

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The American Medical Association, the American College of Obstetrics and Gynecology, the American Academy of Pediatrics and the National Institute of Health have all passed resolutions to advise all pregnant women to have HIV testing during their pregnancy, since newer medical therapies are able to significantly reduce the transmission rate and subsequent infection rate to babies if the treatment is started before delivery. HIV occurrence rates are relatively low in Arizona.

It had been previously recommended that patients have the HIV test, however patients were consented and given the option to accept or decline the test. Now, it is being recommended that patients sign a consent to opt out of testing, since this decision can theoretically put a new baby at risk. We will therefore have any patient that decides not to test for HIV sign a consent stating they understand the possible consequences of not receiving the test. Insurance covers HIV testing.

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The American College of Obstetrics and Gynecology and the American Academy of Pediatrics are recommending offering cystic fibrosis testing to all pregnant and prospective pregnant women. Newer testing is now able to detect approximately 85% of the carriers of cystic fibrosis. The gene is present in approximately 1 in 40 men and women and requires both parents to carry the gene in order for a child to be affected. Therefore, approximately 1 in 1600 children is affected by cystic fibrosis, a serious and debilitating lung condition. Certain ethnicities have higher carrier rates.

Please read the ACOG bulletin on this subject carefully and let us know if you would like testing. It is recommended that the mother be tested first and, if positive, the father then be tested before genetic counseling is pursued. Since the test detects approximately 85% of the known gene defects for cystic fibrosis, a negative test is not a guarantee that you do not carry the cystic fibrosis gene. It would, however, be exceedingly unlikely that a child would be affected if one parent's test were negative. Insurance should cover the screening tests.

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Your diet during your pregnancy is perhaps the most important element of having a healthy pregnancy and newborn. You are solely responsible for providing the nutrients for your growing baby. This is also the perfect time in your life to begin better eating habits that can carry on with you through your lifetime. During early pregnancy, calorie content is not nearly as important as the quality of your diet. Please spend an extra few minutes to read about how to eat right during your pregnancy in one of your prenatal books.

If you are having difficulty keeping meals in due to morning sickness, look for ways to maintain hydration, by taking fluids during those portions of the day that you feel better. Morning sickness is thought to be worse when the stomach is empty for prolonged periods of time, hence morning sickness is more troublesome in the morning. If your having difficulties, try keeping your stomach busy with hard candies or gum during the day or try a small snack before bedtime to avoid difficulties the next morning. Many times vitamins during this portion of the pregnancy irritate stomach. Try taking the vitamins with food or just before bed. If this isn't possible, stop the vitamins for week or two before resuming them and look for natural sources of vitamins in fruits and vegetables. Most women who eat a nutritionally sound diet actually do not need additional vitamins. If morning sickness is worsening to the point you cannot keep even liquids in, call your doctor.

Many women, particularly in early pregnancy can feel lightheaded due to low blood sugars, so be sure to eat regularly. In general however, pregnancy tends to be a state when a woman's blood sugar levels run higher than normal, sometimes to the point that diabetes can be a problem. This form of diabetes usually resolves after delivery. Perhaps one the most important goals during your pregnancy therefore should be to reduce or eliminate sugar and processed sugar whenever possible.

Read the labels of prepackaged foods for sugar content. Fruit juices have high fructose concentrations ( translation => sugar) and therefore, although there are beneficial nutrients in fruit juices, limit your daily intake. The sugar substitute Nutrasweet is a very simple protein, and therefore is a safe substitute for sugar, despite what some older prenatal books suggest. Therefore, try diet sodas whenever possible. Avoid saccharin as a sugar substitute. One or two servings of colas or coffee with caffeine should be safe, however it would be best to try decaffeinated products whenever possible.

Calorie requirements go up modestly during pregnancy and weight gain should occur naturally without making special efforts to eat more. One of the easiest ways to gain more weight than is needed is to begin purposely eating for your baby and yourself. If you are near your optimal body weight before your pregnancy, you should gain 22-30 pounds over the course of the pregnancy. If you are overweight before the pregnancy, this weight requirement will be less. Discuss the optimal weight gain for your particular pregnancy and never begin a new diet, particularly weight loss diets, without consulting your doctor.

Emphasis leaner meats, particularly skinless chicken or fish during pregnancy. Reduce the fat in your diet by reading labels whenever possible. Green vegetables are a good source of vitamins, iron and even calcium. Higher fiber foods will help you avoid problems with constipation. Metamucil, citracel and colace, an over the counter stool softener, can be used to naturally supplement fiber content in your diet.

Iron will be important to help increase the blood supply during your pregnancy, but in general iron supplements are not needed if you eat iron-rich foods. Again lean red meats, and green vegetables are good sources of iron. If your doctor suggests an iron supplement, be sure to increase the fiber in your diet as well, since iron supplements can be constipating.

Heartburn can be a problem in pregnancy, particularly as you approach your due date. This is often caused by passage of food back towards the esophagus due to the relaxed nature of the stomach during pregnancy. To avoid this, reduce the portions of food during a single meal. Try smaller meals 4-5 times a day to allow the stomach to empty better. Also try not to lie down for an hour or two after eating, particularly at night. While sleeping, you should try to sleep a bit more upright with a 2nd pillow. Over the counter Prilosec or Tagamet before bedtime will reduce acid secretion while you sleep. Avoid spicy and fatty foods, particularly deep fried foods and stop the use of caffeine, chocolate, and cigarettes. Tums and Rolaids are safe to use and if symptoms persist Maalox or Mylanta may help. Medications are available if more conservative measures fail to relieve the problem. Before using any other over the counter medications, discuss this with your doctor.

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In recent years, there has been more and more information available about the beneficial effects of aerobic exercise in pregnancy. Both the mother and baby benefit directly. Babies of mothers who exercise regularly are generally leaner and more vigorous at birth. Exercise promotes a sense of well being in expectant mothers and labors tend to be better tolerated and faster in well conditioned mothers. The post partum recovery is also generally easier.

Aerobic exercise involves stimulating your heart to a higher heart rate, which results in improved blood flow to organs such as muscles that normally don't require high blood flow. The placenta, which serves as the filter and nutritional bridge between you and your baby also receives improved blood flow during moderate exercise. Essentially, your baby gets a modest workout with you.

Make it a special point to discuss with your doctor what exercises that you normally do and whether these are safe and appropriate for your particular pregnancy. Brisk walks, light jogging, swimming, bicycle riding or low impact aerobics are all good forms or aerobic exercise. Slow walks and working around the house all day do not qualify as aerobic exercise, since your heart rate generally remains low. At the gym, stair steppers, exercise bikes or Nordic Track machines will give you a good workout. Avoid vertical impact movements such as high impact aerobics or horseback riding during your pregnancy.

Your target heart rate should be between 110-120 beats per minute, sustained for 20-30 minutes. Do not exceed 140 beats per minute, as this has been shown to be the heart rate where blood flow begins to drop to the placenta and baby. You should try to do this exercise at least 3 times a week throughout your pregnancy. Start out slowly if you haven't been on an exercise program recently. Particularly in Arizona, its important to stay hydrated both during and after your workout. Bring plenty of fluids with you on walks or hikes.

You may continue using weights in your exercises, but try to work on repetitions and avoid straining movements. Avoid bearing weight over your head. Sit-ups are fine, but you'll obviously note that they become harder and less beneficial as the pregnancy progresses.

Sex is generally healthy and safe during pregnancy. Avoid positions that involve direct impact to the stomach. Report any bright red bleeding. Mild contractions frequently occur for the first hour or so after intercourse and generally are not a problem. If you are at high risk for preterm labor, discuss whether intercourse is advisable during your particular pregnancy.

If you have had any problems with bleeding, preterm contractions or have other medical problems with either this or previous pregnancies, please be sure that you discuss with your doctor what type of exercise is right for you for this pregnancy.

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Weight Gain In Pregnancy

Weight gain in pregnancy is quite important to most patients. Patients are concerned about gaining too much or not enough weight during the pregnancy. Recommendations vary greatly regarding the appropriate amount of weight gain. The general rule is that a weight gain of between 20-30 pounds is appropriate. Women who are slightly overweight at the beginning of the pregnancy should tend to gain less than those who are thinner may gain more.

The amount of weight gain reflects many other factors than the weight of the baby itself. In addition to the birth weight of the baby, there is also the placenta, the fluid around the baby (which is quite dense), additional blood for increased circulation, as well as additional fluid, which is retained in the tissues. The combined weight of all of these represents the total weight gain of a pregnancy. Within 4-8 weeks after delivery, the vast majority of this weight will be lost with no effort on the mother's part.

It is important for a patient not to become overly concerned about weight gain that may occur from visit to visit. The time of day, type of clothing worn, recent meals, and other factors can result in unusual weight gain. Weight gain in pregnancy is not always a smoothly progressive event. A mother may gain a lot of weight in one month then gain much less the next. It is important to look at overall trends and not at the weight gain at any one particular visit.

Thirty to forty years ago, weight gain restrictions were emphasized by obstetricians, and many patients were compelled to limit weight gain to only 10-15 pounds during the course of the pregnancy. We now know that this type of weight gain limitation is not healthy and does not improve the outcome. The truth is that the principle concern of excessive weight gain is cosmetic. Extra weight gain has little impact on the outcome of the pregnancy itself. It is a minor factor for excessive fetal growth (with more important factors being diabetes of pregnancy or heredity). Excessive weight gain may contribute slightly to an increase in Cesarean section rates. Otherwise, excessive weight gain simply means that the patient will have excess fat tissue, which she will need to lose in the usual dieting fashion after the pregnancy has ended.

It is very important that a woman not attempt to lose weight during pregnancy or to severely restrict her calorie intake. The growing fetus needs continual nourishment for growth processes, which occur twenty-four hours a day. The infant is dependent on sugar for energy, and your body will accommodate to provide that sugar. If you skip meals or have periods of fasting, your body will be taxed to maintain adequate sugar levels for the fetus. For this reason, frequent small meals are desirable. This is also helpful because of the pressure of the growing uterus on the stomach. Additionally, the hormones of pregnancy slow down the digestive process and patients may have an uncomfortable full sensation after large meals.

The most important general advice regarding weight gain is to eat wisely. Experience has shown that the patients who gain excessive fat during pregnancy are generally using little restraint and have poor eating habits during the pregnancy. These are the ladies who are eating a pint of ice cream or a bag of potato chips every evening. Patients who eat rich foods in moderation and concentrate on eating fresh fruits and vegetables, salads, simple pasta dishes and cereals will most often have ideal weight gains in their pregnancy and be able to quickly lose the weight after delivery. We have frequently seen patients who have gained as much as 40 pounds in a pregnancy despite excellent eating habits and good exercise. Almost invariably, these same patients will lose the weight very rapidly after the baby delivers.

Don't become overly worried about excessive weight gain, especially on the basis of single visit weigh-ins. Try to concentrate on keeping your activity levels up and eating healthy foods. This will ensure that your weight will not be a problem after you have your baby.

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Perhaps the most common questions that come up during pregnancy relate to colds and flus during your pregnancy. Unfortunately, during pregnancy, your immune system is not as responsive to the troublesome viruses and sometimes bacteria that cause flus and colds.

Its important to do what you can to avoid this problem whenever possible by getting plenty of rest, exercise and eating healthy. Be assured that generally your baby is aided by the antibodies that your immune system makes to ward off these infections, but is also therefore most important that you devote yourself to getting better when your feeling ill.

You should direct any cold medications that you may need to the particular symptoms of your illness at the time, as many times flus over their course migrate from the sinuses, the throat and the chest. If you experience fevers, chills, headaches or muscle aches, 2 Tylenol (regular or extra strength) every 4 hours should help with these symptoms. Avoid ibuprofen (Advil, Motrin, Nuprin) when possible during pregnancy. Aspirin has a role in certain conditions related to pregnancy, but should generally not be used for colds or flus regularly.

If sinus congestion is a problem, try Sudafed or Actifed during daytime hours and Benadryl before bedtime (as this will also help you sleep). Robitussin DM or similar generic cough syrups with dextromethorphan are preferred for coughs. If you begin coughing up excessive sputum or continue to incur fevers, notify your doctor. Antibiotics are only occasionally needed for colds or sore throats.

Although all medications have potential risks, the medications mentioned have been in long-standing use without reported safety concerns and therefore should be safe for pregnancy. Try our recommendations for over the counter medication or other remedies in the chapter below. Oral or nasal inhalers may be needed for more troublesome colds and asthma and are generally quite safe.

Influenza vaccines are available between October and January both through your primary care physician and our department. The vaccines are considered safe in pregnancy and are very useful in protecting you from what are considered to be the most common flu viruses for the coming flu season. Experts suggest you consider getting a flu vaccine either before or during your pregnancy , since women are particularly prone to colds and flus during pregnancy.

Safe Medications To Take During Pregnancy

Some drugs or medications should not be taken during pregnancy. The following medicaions are recommended ONLY as needed and if you have not had an allergic reaction to them in the past.

Please be sure to notify us which medications you have been taking during each office visit.

Headache/Aches/Pains- Extra Strength Tylenol, Tylenol, Acetaminophen

Cough- Robitussin DM

Congestion- Plain Sudafed (white/red box) or Benadryl or Diphenhydramine

Constipation- Metamucil, Milk of Magnesia, Colace, Increace bran, fruit, and clear fluid intake

Diarrhea- Kaopectate, Increase clear fluid intake, and follow bland diet

Indigestion- Tums, Maalox

Gas Pains- Simethacone, GasX, Mylicon

Hemorrhoids- Preparation H, Anusol

Nausea/Vomiting- Vitamin B6 50mg twice daily, Emetrol, follow bland diet, and increase clear fluids

BLAND DIET SUGGESTIONS: Bananas, rice, applesauce, toast, Jello, clear broth, frozen popsicles, hard candies,

CLEAR FLUID SUGGESTIONS: Water, apple juice, Sprite, 7-UP, ginger ale, sports drinks, broth, Jello, frozen popsicles, hard candies or any liquid you can see through.

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Dealing With Constipation in Pregnancy

Constipation is one of the most common complaints of pregnancy. It occurs for a number of reasons. First and foremost, the high progesterone levels, which occur during pregnancy, tend to slow the function of the bowel. The slowdown causes increased absorption of water from the bowel contents, resulting in a hard, dense stool. This process, in combination with diet changes that occur in pregnancy, makes constipation a significant worry for many. In addition, pregnancy has a tendency to worsen problems with hemorrhoids or cause hemorrhoids to appear where they did not previously exist. Constipation and straining at stool aggravate hemorrhoids and correcting the constipation tends to improve the situation.

For this reason, a pregnant woman needs to take special care to avoid constipation. The most effective means of doing so is through diet changes. The first step is to increase the amount of fiber and roughage in the diet. The best way to accomplish this is through increased consumption of raw and cooked fruit and vegetables, as well as whole- wheat grains and cereals. There is a variety of brain-containing breakfast cereals, which are excellent in this regard. You should avoid heavily processed and refined foods. Also, it is often helpful to add additional fiber. This is accomplished by over the counter fiber preparations such as Metamucil, Citrucel, Perdiem, and Senakot. These work extremely well. Generic brands work as well as brand names, and you should find a form that is palatable. Metamucil in the powder form is quite difficult for some to take because of it's glue-like consistency. Tablet and granular forms are sometimes easier to take, as are the new fiber-containing wafers. These products should be taken according to package directions and should also be accompanied by increased fluid intake. They work by capturing and retaining moisture within the bowel, thus maintaining soft stools. They are not at all harmful to the baby.

If severe constipation occurs, one time use of Milk of Magnesia is reasonable. Two tablespoons taken at night will often relieve the problem by morning. Otherwise, we would prefer that you not use Milk of Magnesia or other laxatives such as Ex-Lax or similar products during pregnancy. Many of these other laxatives work by irritating the bowel. This is not desirable during pregnancy.

Constipation can also be a problem after the baby is born. During this time, while the birth canal is healing, it may be painful to go to the bathroom. Under these circumstances, patients may develop constipation. Again, one time use of Milk of Magnesia would be appropriate, but Colace can also be taken for up to a week at a time, two capsules daily of 100mgs each. These are available over the counter without a prescription, available in generic form, and are usually not covered on insurance plans. The high-fiber diet and fiber supplements are also very helpful during this time.

While you are taking fiber supplements, it is important to remember to continue to take your prenatal or multi-vitamins. Fiber can bind some minerals and the multi-vitamins help to ensure that nutrition is adequate.

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Your Ultrasound Appointment

Both Camelback Women's Health offices offer on-site ultrasound, which is advantageous in sorting out problems quickly and conveniently for our patients. In most instances, an ultrasound will be performed by your physician at your first visit to establish that your due date is correct, make sure the pregnancy is progressing normally and confirm that there are not twins, triplets,... etc! Due to the small size of the fetus, this generally is a limited ultrasound that will not identify problems with the baby's anatomy.

A second ultrasound will be obtained at 18-20 weeks gestation to survey fetal anatomy. A normal ultrasound report does not guarantee the baby is anatomically perfect, but it is intended to try to identify potential problems. The spouse or one other close relative is encouraged to attend this ultrasound, but please don't have other family members, friends or children attend. A full bladder will be necessary and therefore if your bladder is not approaching full, drink 32 oz of water an hour prior to the ultrasound.

The ultrasound technician has responsibilities for obtaining accurate film records, and please therefore allow her the time needed to do her work. A short video of the ultrasound can be obtained after the film records are completed if you bring a blank CD/DVD disc with you. It is sometimes possible to identify the sex of the baby, but guarantees are not given.

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Travel

Travel during pregnancy is generally safe, but there are some important guidelines to follow when planning a trip. It is important to check the limitations of your insurance, since many insurance plans have restrictions in coverage for medical costs incurred out of state.

As a general rule, don't schedule trips out of town after 32 weeks gestation (ie. 8 weeks before your due date). If you're planning on flying, check on any restrictions the airlines have on flying and whether a letter will be necessary to board your airplane. Plan ahead by getting to the airport in plenty of time and have someone help with luggage. Airline flight is in itself quite safe in pregnancy, but troubles arise with the stress of travel (chasing luggage, time zone changes, etc). Be sure to get extra rest during your trip.

If you are traveling by car, make plans to get out of the car every 2-3 hours, since pregnancy is a condition that makes women susceptible to blood clots in the legs. Always wear a seat belt and bring extra fluids to keep yourself hydrated during the trip.

If you plan on foreign travel during pregnancy, make every effort to do this early in the pregnancy. Check with your travel agent about illnesses endemic to the countries that your planning on traveling in and what vaccines are necessary. Ideally, vaccines should be given before you become pregnant, however your doctor and you may need to decide whether the risks of a disease are greater than the risk of the vaccine. Particularly when traveling in Mexico, avoid contaminated water by drinking bottled water or soft drinks without ice.

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Prenatal labor classes are offered at all of the local hospitals, usually beginning the first week of the month and lasting three to four weeks. First time mothers and their husbands or significant others are strongly encouraged to attend these classes to learn more about labor and what to expect in the hospital. A single refresher class is also available for mothers who feel that an update on labor would be useful.

These classes provide an excellent opportunity to ask questions and learn more about the process of labor in a comfortable and informal setting. Relaxation and breathing techniques are reviewed and a film is shown both of natural childbirth and cesarean section.

Tours of the hospitals are generally provided with the classes. These can also be arranged separately for those not taking the classes. Classes can be scheduled by calling the phone numbers listed above. Try to have the classes completed before the 36th week of the pregnancy.

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What Can I Do For The Labor Pain?

Modern obstetrics offers ever-improving options for control of labor pain.  We have a common interest in helping you and your baby through labor as safely and as comfortably as possible.

Biofeedback is a very useful concept in approaching labor.  Biofeedback works on the basis that your brain receives pain signals from other parts of the body equally from all other signals, but that these signals can be diverted if other signals are being processed first.  Put simply: keep your mind doing other things, labor pain will be less noticeable.

Walking around, long showers, massage or even mental activities such as playing cards or doing puzzles can help divert your mind from contractions.  Make plans to try these sorts of activities before you go to and when you get to the hospital. Try to keep walking as much as possible after getting to the hospital.

Please don’t self-administer pain medicines at home before you come to the hospital.  The doctors in our group believe in providing whatever options you choose to manage your labor pain, including natural labor without medication.  If you would like medication or an epidural, please just ask. The timing of the medication is most important, in order to avoid complications or slow down your labor.  We have no set dilation requirements for receiving an epidural or a cutoff when you cannot receive one.

Epidurals are extremely safe and do not cause long-term back problems.  Risks of epidural are related to drops in blood pressure, which can be managed with fluids and medication, soreness around the epidural site for up to a week, and the risk of spinal headaches, which also can be managed with medication and added bed rest.  These problems are very rare.We encourage women to get an epidural if the labor is long or difficult.  Frequently epidurals can even hasten delivery by allowing you to relax and get some needed rest.

Once you receive an epidural, you cannot get up or walk and frequently a catheter is placed in your bladder to prevent bladder distension. Your legs and lower stomach will lose sensation and will be difficult to move.  Complete sensation returns 2-3 hours after an epidural is removed.

After delivery, oral medications will be offered.  Ibuprofen or Tylenol are adequate for many patients, but other medications including Tylenol #3, Vicodin, or Percocet are available.  Menstrual cramping usually last 3-5 days and episiotomy discomfort is significantly better within 2 days.

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The statistics both nationally and at our local hospitals is that the risk of a cesarean section in a first time mother is between 15-20%.   This rate goes up to 20-25% if we include patients having repeat cesarean sections.  The risk for cesarean in a patient who has had a previous normal delivery should be closer to 5-10%.

The three most common reasons for a first cesarean section are because the baby cannot get through the mother’s birth canal, breech position (baby’s buttocks is coming first), and because the baby shows signs of not tolerating the labor.  There are numerous less common reasons for cesarean section.  The most common reason overall for a cesarean section is a previous cesarean section.

Cesarean section is the most common surgical procedure in the United States and the risks associated with procedure are quite low.  Nonetheless, there are risks with any type of surgery and the risks of cesarean are no different.  These include bleeding, infection, damage to any internal organs and the risks of anesthesia.  The risk of transfusion is below 3% and only would be done in cases where serious blood loss occurs.  Most often, cesarean sections are done with epidural or spinal anesthesia so that you can be awake.  Your spouse, significant other or family member can be in the room with you.  Rarely, patients are put to sleep for cesarean sections.

After a cesarean section, most patients stay in the hospital 2-4 days.  We allow clear liquids after your surgery and ask that you begin walking in the halls 12 hours after your surgery. The incision used is almost always a bikini-line type of incision that heals very quickly and is cosmetically quite concealed.

Scheduled repeat cesarean sections are generally done with spinal anesthesia, which allows for excellent pain relief for up to 24 hours, although other sensations and the ability to ambulate can return in 2-3 hours.

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If I Have Had A Cesarean Section In The Past, Will I Need Another One?

The American College of Obstetrics and Gynecology has written very strict guidelines that require your obstetrician to be able to perform a repeat cesarean section quickly if you have had a cesarean section in the past.  For this reason, any patient in our practice considering a VBAC (vaginal birth after cesarean section) are delivered at a facility where doctors are in-house (residents or hospitalists) at the hospital 24 hours a day, until which time that we can get to the hospital.

The risk of uterine rupture in patients with a previous cesarean section is quoted to be between 2-5%.  Most often, signs of this occurring can be recognized before serious consequences can occur.  Risks of VBAC can include injury or even death to either the mother or the baby.

If you are considering a VBAC, we will require that you sign an informed consent in the office at 36 weeks and at 36 weeks we will need to review the reasons for your cesarean.  We would like to give you an opinion, based on your baby’s size and cervical exam, of the chances for a successful VBAC.  Neither you nor your doctor want to have you go through labor and then have another cesarean, but this can occur. The most important thing is to make sure you have a healthy baby.

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Are Episiotomies Routinely Done?

No.  Each patient and each labor is different.  The chance of a tear or any episiotomy depends on the number of children a patient has had in the past, the size of the baby and the mother and the length of the labor.  Most of mothers that have had a baby before will not need an episiotomy.  It is possible that tears will occur which may require suturing.

A great deal of controversy surrounds episiotomies in a first labor.  It is not our policy to do routine episiotomies, however it will be quite evident to everyone in the labor room but the mother at the very last moments of pushing that a tear is imminent.   In these circumstances, we all feel that a small clean episiotomy repairs easier, is less uncomfortable after delivery and heals quicker than a tear which frequently can distort anatomy and have a more compromised blood supply.  We make every effort to avoid tears that extend towards the rectum.

Pain after a tear or episiotomy is usually well controlled with Ibuprofen or Tylenol #3.  Topical anesthetic sprays are available and showers and baths can be used immediately after delivery.  Ice is recommended for most mothers for the first 6 hours after delivery.

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Do I Need To Contact My Pediatrician When I Am In Labor?

Most pediatric offices have an office orientation session for new parents once or twice a month in their office.  If they don’t, ask their office what their policy is on meeting a pediatrician before delivery.

If you are first time parents and do not have a pediatrician yet, ask one of our doctors for recommendations of a pediatrician near your home. It will be very helpful for you to bring your insurance booklet so we can help you find a pediatrician who is on your insurance plan.   Frequently, pediatric visits are needed on short notice for colds and flus and it is helpful to have a pediatrician near your home.

Another suggestion would be to ask neighbors with children or nurses in the pediatric wards of local hospitals, who a recommended pediatrician may be. A list of pediatricians that we are familiar with and the office locations is available on our web site.  If you know of a good pediatrician that is not listed, let us know. 

The hospital will take care of all contacts with your pediatrician.  If your pediatrician does not come to the hospital that you are delivering at, let your doctor know after delivery and we will help you find a pediatric group that we are familiar with to take care of your baby while you are in the hospital.  After you go home, these records can be forwarded on to your doctor.

Most babies are able to go home on day 1 or day 2 of delivery. The exception would be for babies of mothers who tested positive for Group B strep and did not receive two doses of antibiotics before delivery.  An extra day in hospital is usually recommended and is only precautionary- this of course, would be at the pediatricians discretion.

If you’re having a boy and considering a circumcision, the pediatrician will usually do this on the day of discharge.  Follow-up with your pediatrician when you go home is usually within 2-7 days.

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Labor: When To Go To The Hospital And What To Bring

The last few weeks prior to your labor can be both the most exciting and yet most anxious time in your pregnancy. Your visits will be weekly with your doctor after 36 weeks, so you should have plenty of opportunity to ask questions or discuss your concerns or feelings at these visits. Despite all the aches, pains and emotions that occur during the last weeks of your pregnancy, try to enjoy this time, since you and your baby will never be this close again.

Your spouse or significant other should plan on attending the visit at 36 weeks where labor will be reviewed. We will discuss when to call us, our approach to labor management and try to accommodate your special requests. We will also discuss pain management options available to you. Our office will generally check for cervical dilation between 37 and 38 weeks, at which point we will be able to give you an idea about how close to delivery you are.

In general, try to approach your labor with a very open mind. Breathing techniques, walking in the halls, showers and other relaxation methods are all intended to keep your focus on the short term goal of remaining as comfortable and in control as possible while keeping in focus the broader objective of a safe and healthy delivery. Friends and relatives like to recount stories of their labors, but remember, every labor and every pregnancy is different. Its far more likely that your labor will be much more different than anyone else's than it will be the same.

When you think that you are in labor, talk first with your spouse or labor coach and then inform our office. You should have plans for a ride to the hospital well in advance of labor. If your contractions are regular, timeable, lasting more than 40 seconds and you are unable to walk or talk through the contractions, call our office. Your doctor should talk with you at your 36 week visit, for your particular pregnancy, about what the frequency of contractions should be before leaving for the hospital. If your water breaks first, which occurs in about 20% of pregnancies, call us first to discuss when you should go to the hospital.

Pack only a small bag of clothing and personal items for your stay and leave jewelry or other valuable items at home. Be sure your camera or camcorder has fresh batteries. In most instances, it will possible to record the first minutes after your child's birth. Bring a comfortable robe and slippers and one set of clothes for your baby. Formula and diapers will be provided by the hospital. A car seat is mandatory before the discharge of your baby. Discuss in advance with your doctor if it will be possible for anyone other than your spouse or labor coach to be able to attend the actual delivery.

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The anticipation of labor can be very exciting, but sometimes frightening. Friends, neighbors and even strangers seem to relate their labor stories to pregnant women- sometimes good and sometimes bad. Please do not let these stories scare you. What is certain is that your labor experience will be unique. There are risks to childbirth and we have chosen to work at hospitals that provide the very best in obstetric care.

Our goal as your doctor will be to guide you through the process as comfortably and safely as possible. Please ask questions both before your labor and at any time during the labor. Both our doctors and your labor nurse are there to take the mystery out of the labor experience. Tell us any special requests at your 36-week visit and let us know of any particular worries. If you know what to expect, labor can be much more tolerable and comfortable.

Try to get to bed early during the last month of your pregnancy, since labors tend to start at night and women that go into their labor tired tend to have more difficulty.

Lastly, this very unique time of your life- having this baby- will soon be over forever. Despite the discomforts of pregnancy, try to relish this experience as much as possible.

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