Pregnancy
Patient Education

Doctors Who Are Part of the Pregnancy Team

Choosing the person who will deliver your child is a personal decision and there are various types of healthcare workers who can be involved in your delivery. Listed in this patient education guide are the doctors most commonly called on by expecting mothers.

• Obstetrician -A physician specializing in all aspects of pregnancy, labor, delivery and after-care of the pregnant patient. This doctor also diagnoses and treats conditions associated with pregnancies as well as maintaining the diagnosis and treatment of a normal pregnancy.
• Midwife -A healthcare provider who cares for the expectant mother during the pregnancy as well as the labor, delivery and postpartum periods.
• Perinatologist -An obstetrical subspecialist who deals with the care of the expectant mother and fetus in high-risk pregnancies or when associated medical problems exist.
• Nutritionist -A professional who formulates diet plans for both the healthy and compromised individuals as well as advising which vitamins and supplements would promote good health.
• Doula -Professional offering both physical and emotional support as well as information to the pregnant mother-to-be. She is a patient advocate, answering any questions regarding the birthing process and assists in forming a birthing plan. The doula also presents when labor starts to aid in breathing, massage and pain relief methods.
• General Practitioner -A physician who treats both acute and chronic conditions for patients of all ages and also provides preventive care. In some geographical areas, the general practitioner or family doctor can care for the expectant mother and also perform a simple delivery.

How to Prepare for Your Pregnancy

Our pregnancy education guide gives you an overview of what you can expect and how to prepare in each of the trimesters throughout your pregnancy.

How to Prepare for the First Trimester

During the first trimester, preparation focuses on getting you ready to give birth in nine months.

• Diet - Because the baby is forming now, it is crucial to eat properly with balanced meals. Avoid alcoholic beverages and smoking. Eat plenty of vegetables and fruits and take a multivitamin daily.
• Choosing a Healthcare Provider - Have a complete physical examination and consult with an obstetrician or midwife as soon as pregnancy is suspected.
• Exercise - Routine exercise decreases stress, improves mental focus and improves your physical stamina to prepare for labor in the future. Exercising three times a week has been shown to help babies in their neurological development as well. Avoid contact sports or activities that can cause potential risk to bodily harm (e,g. skiing). Dance and low-impact or isometric exercises as well as swimming and brisk walking are great forms of exercise. Tip- wear a good support bra to avoid discomfort.
• Diagnostic tests will be performed at specific time intervals. Sonogram (ultrasound) preparation for the test consists of having a full bladder - 8 glasses of water are consumed. (refer to diagnostic tests in Expect section)

How to Prepare for the Second Trimester

During the second trimester, preparation focuses on the birth and future care of the baby.

• Making the Announcement - Some expectant mothers wait until after the first trimester to share their happy news with family and friends. If you are one of those, it is now time to spread the word and announce your pregnancy. This will help with any support you may need.
• Location of Delivery - If you are planning on having a delivery at a hospital, tour the hospitals that you are considering. Make sure that it is a hospital that meets your requirements or is in alignment with your expectations. Also make sure that the hospital is one that your physician is affiliated with.
  If you are planning on delivery at a birthing center, tour this facility. Find out where you would be transferred if a more specialized delivery becomes warranted. Again, if you are planning a home delivery, consider what facility you would be transferred to in an emergency. Also, it is now time to start amassing items you would need for the home delivery.
• Birthing Plan - Formulate a scheme which addresses pain medication and one in keeping with the program you have chosen (e.g. Lamaze, Bradley)
• Birthing Classes - Can be given in groups or privately and may be located at home or the location where delivery is contemplated. There are several types reflecting particular methods such as Lamaze or Bradley.
• Childcare Purchases - Fun preparation starts too! It's time to purchase the crib and all additional things that the baby will need like the car seat, layette, carriage and stroller. While it is much easier to construct the crib before the third trimester, some may choose to wait. Most stores will allow you to purchase these items and have them sent upon delivery of the baby.
• Doula - Decide whether you would like a doula to assist with birthing plans and the labor process. If so, now is the time to secure one.
• Preparing the Breasts - If you choose to breast?feed the baby after delivery, it is time to prepare the nipples. Each day, rub them for a minute sporadically with a wet washcloth to desensitize them.

How to Prepare for the Third Trimester

As one approaches the home stretch, preparation centers on the actual delivery event and post-delivery actions.

• Pediatrician Selection - The pediatrician is chosen so that medical care can be given to the baby upon birth and securing continued health. The selection process will include interviewing several physicians in this specialty to ensure that it is a provider that you feel comfortable with and one who is in alignment with your preferences or thoughts.
• Address Book - Make note of the address book or directory on your phone including emails. Add any additional people or data so that it is easy to contact those you would like to inform about your happy event. Also add any services to the directory that you may need to contact after delivery as well.
• Childcare - Consider who will be caring for the baby upon delivery. If a baby nurse will be hired for the care upon arriving home, interview and hire this nurse at this point. Also address the issue of who will be watching the baby if you are returning to work outside the home. Discuss care with family members and interview childcare facilities prior to delivery. Don't wait until you are confronted with this issue.
• Names for the Baby - Choosing a name for the baby should not be done hastily. After all, your child will be carrying this name around for a long time. Consider the first with the last name as well as the monogram. Make sure that it is not something that the child will be ridiculed for in the future. (Also consider that while a nickname may seem cute on a baby, it may not be so for an adult.)
• Announcement Cards - If you plan on sending out cards through either the post office or an e-card service, select the ones that you like now. It will be one less item on your task list later when time is at a premium.
• Camera - If you are planning on taking video or photos of the birthing experience and the new baby, make sure that your camera is charged and you have spare batteries.
• CD Player/iPod with Charger - Playing soothing music during labor enhances the birthing experience and makes labor contractions easier to tolerate. Take the music with you.
• Labor and Delivery Bag - Inside this bag, you will have a change of clothes for yourself and an outfit for the baby to wear when you leave the hospital. Include your personal hygiene products, robe, slippers and hair products. Also include items that you may want to use in labor (e.g. tennis ball for back massages, socks during labor, etc.)
• Baby Care Items - Having diapers and bottles on hand are good preparation. If you are not using disposable diapers, and plan on a diaper service, have them lined up. If you plan on breastfeeding, getting a pump is a good idea.

Questions to Ask Your Doctor About Your Pregnancy

From that first moment when you realize you're pregnant up until your delivery, you will have questions about your pregnancy.

Below is a list of helpful questions for each trimester of your pregnancy.

First Trimester

Question About My Diagnosis

• What tests will I need and when should they be done?
• What are the risks for each test?
• What vitamins and supplements should I take?
• Will certain medical conditions interfere with pregnancy?
• What symptoms can I expect and what would be abnormal?
• When should I call you?
• When will I start to feel better?

Questions About My Lifestyle & Family

• What diet should I follow?
• What foods should I avoid?
• How much weight should I gain?
• What exercise can I do? What should I avoid?
• Are there any foods or medications that I should avoid?
• Is it safe to have sex?

Second Trimester

Question About My Diagnosis

• When will I feel the baby moving?
• How can I avoid stretch marks?
• What does bleeding gums mean when I brush my teeth?
• What does the darkening pigment mean?

Questions About My Lifestyle & Family

• What childbirth class do you recommend?
• What can I do about heartburn?
• What can I do about hemorrhoids? How can I avoid them?
• How can I avoid constipation? How do I treat it?
• How can I avoid varicose veins?

Third Trimester

Question About My Diagnosis

• How will I know when I am in labor? What are the signs?
• How will I know if I have broken my "bag of water"?
• When do you believe a pregnancy should be induced?
• Is there anything that I can do to bring on labor?
• Will I have a bloody show? How will I know that it is not abnormal?
• Will I need any further tests?

Questions About My Lifestyle & Family

• Until what week can I fly?
• Can I take road trips? Should I limit the time of the trip?
• When can I work until?
• Are there any activities that would put me in labor?
• Until what week can I have sex?
• When should I notify or get in touch with you?
• If you are not available, who is covering you?
• What level of exercise is safe now?
• When should I go to the hospital?

Common Tests or Labs Throughout Your Pregnancy

During each obstetrical visit throughout the pregnancy, the medical assistant or nurse will measure weight and blood pressure while sitting. The urine is also tested each time for glucose, protein and blood.

The fundal height, or height of the uterus, is measured from the top of the pubic bone to the top of the uterus. At 20 weeks the fundal height will reach the level of the umbilicus and from then until 35 weeks, there is a consistent relationship between the pregnancy length and fundal height (exceptions include multiple gestation i.e. twins or fibroids). Read more about common tests in this patient education guide.

Common Tests in the First Trimester

Test	Why Test?	What Happens?	Normal Result
Blood Type and Rh	If Rh Negative, will test Father for Rh to ensure compatibility with baby	After a tourniquet is applied to the upper arm, the puncture site of skin is swabbed with alcohol and a needle punctures the skin, entering a vein. Blood is drawn into a syringe for analysis. The tourniquet is then removed and a pressure bandage is applied	Rh Positive is less risk
Complete Blood Count	Checks for anemia	After a tourniquet is applied to the upper arm, the puncture site of skin is swabbed with alcohol and a needle punctures the skin, entering a vein. Blood is drawn into a syringe for analysis. The tourniquet is then removed and a pressure bandage is applied	WBC=4.5-11 RBC=4.1-5.1 Hemoglobin Female= 12-16 Hematocrit Female=36-46%
Screen for Rubella,hepatitis B, syphilis and HIV	Checks for immunity	After a tourniquet is applied to the upper arm, the puncture site of skin is swabbed with alcohol and a needle punctures the skin, entering a vein. Blood is drawn into a syringe for analysis. The tourniquet is then removed and a pressure bandage is applied	IgG antibodies <7IU/mL HIV negative, hep.neg. VDRL negative
Tay-Sachs	Checks for risk of the disease	After a tourniquet is applied to the upper arm, the puncture site of skin is swabbed with alcohol and a needle punctures the skin, entering a vein. Blood is drawn into a syringe for analysis. The tourniquet is then removed and a pressure bandage is applied	Hexosaminidase A: 7.2-9.8 U/L Total Hexosaminidase= 9.8-15.9 U/L
Sickle Cell Anemia	Checks for risk of the disease	After a tourniquet is applied to the upper arm, the puncture site of skin is swabbed with alcohol and a needle punctures the skin, entering a vein. Blood is drawn into a syringe for analysis. The tourniquet is then removed and a pressure bandage is applied	Hemoglobin A (not S)
Ultrasound	Confirms age of fetus Visualizes structural abnormalities in uterus and fetus	After lying down on the table, the technician/doctor places clear water-based gel on your tummy and pelvic area. A hand-held probe is then moved back and forth over the area, transmitting sound waves. The echoes of these waves creates an image on a computer monitor Sometimes a transvaginal ultrasound is performed. Here, you lie on the exam table with knees bent and feet in stirrups. A covered probe is lubricated and placed in the vagina. The probe emits sound waves and the echoes create an image on a computer monitor.	Fetal and uterine size matches the date No structural problems seen
Urine	Presence of glucose, protein, blood	Urine is placed in a cup for analysis. The technician dips a special paper into the urine for analysis with color changes	Glucose, protein and blood should be absent in a normal specimen
Chorionic Villus Sampling	Screens baby for genetic defects at 10-12 weeks	An ultrasound locates the uterine position and placental position in the uterus. The vulva, vagina cervix and abdomen are wiped with an antiseptic wash. A thin plastic tube is inserted through the vagina and cervix to reach the placenta, guided with ultrasound and a small sample of tissue is removed. In the transabdominal approach, a needle is inserted through the abdomen and uterus into the placenta. Tissue is withdrawn into a syringe	The DNA of the baby is analyzed. It fails to detect neural tube defect or Rh incompatibility and an amniocentesis is needed if this is a concern. A normal test means there are no genetic defects.

Common Tests in the Second Trimester

Test	Why Test?	What Happens?	Normal Result
Blood for genetic markers (done in 15-18th wk):	Abnormal markers indicate the need for additional testing (usually a sonogram and possibly an amnio-centesis) Abnormal levels suggest: Down syndrome Spina bifida Twins Defect in fetal abdominal wall Wrong due date Other chromosomal abnormalities Abnormal levels are linked to increased risk of chromosomal abnormality	After a tourniquet is applied to the upper arm, the puncture site of skin is swabbed with alcohol and a needle punctures the skin, entering a vein. Blood is drawn into a syringe for analysis. The tourniquet is then removed and a pressure bandage is applied	Alpha-Fetoprotein Screening (AFP) Normal range is .5-2.0 or 2.t MoM Human Chorionic Gonadotropin (hCG) The hCG levels increase during the pregnancy At 13-16 wks=13,300- 254,000 mIU/ml 17-24 wks=4,060- 165,400 mIU/ml Estriol & Inhibin Estriol and inhibin is elevated more than twice the median value in normal pregnancies with genetic problems
Amniocentesis	Done during the 16-18th gestational week to do the following: Rule out any genetic disorder Determine sex of baby Rule out Tay-Sachs in baby	The doctor inserts a needle through the abdomen and into the uterine sac to remove a small amount of amniotic fluid. The needle is withdrawn and pressure is applied to the puncture site The test is usually done with ultrasound guidance to locate the amniotic fluid.	XX for girl XY for boy Hexosaminidase A is absent
Urine Test	Looks for glucose, protein and blood in the urine	Urine is deposited into a cup. The technician then dips a special paper into the urine which changes color for presence of these three substances.	Normal result is when these are absent
One-Hour Glucose Tolerance Test	Rules out Diabetes	You are given a cup of a 50 gm. sugar solution (orange or cola flavored) to drink. After one hour, blood is drawn and analyzed for sugar level.	Less than 140 mg/dL is normal.

Common Tests in the Third Trimester

Test	Why Test?	What Happens?	Normal Result
Group B Streptococcus Screening	B Strep is associated with Mental retardation	Swabs of the vagina and rectum are taken at 35-37 weeks to screen for presence of group B strep.	Negative presence of bacteria
Non-Stress Test	Indicated in high-risk pregnancies as: Twins Diabetes Overdue High blood pressure	Fetal monitor is strapped across the mother's abdomen with the device over the region of the fetal heart and a tracing is obtained of the fetal heart rate over time. Takes about 20 min.	Normal fetal heart rate is 120-140 beats/minute. Dips (decelerations) or accelerations beyond 140 is not seen
Contraction Stress Test	Predicts how the baby will cope to labor stress	The fetal monitor is strapped across the mother's abdomen. She is then asked to stimulate the nipples to stimulate contractions or pitocin is given intravenously to create contractions. The fetal heart rate is then measured in response to the contractions.	Normal fetal heart rate is 120-140 beats/minute. Dips (decelerations) or accelerations beyond 140 is not seen When decelerations are seen in conjunction to the time of the contractions, it can suggest fetal head compressions.
Biophysical Profile	Gives a more accurate assessment of baby wellness	Most often done between 38-42 wks of pregnancy. Combines a non-stress test with an ultrasound	Rating of 0-2 (with 2 normal) is given for each of the following, with a score of ten as the best: Muscle tone Heart rate Body movement Breathing movement Amniotic fluid levels A total score under 6 is abnormal and calls for delivery.
Electronic Fetal Heart Monitoring	Tests fetal heart rate	A fetal doppler is placed on the mother's abdomen over the fetal heart site	Regular pattern with 120-140 beats/min.
Pelvic Digital Examination	Assess any dilatation or thinning of the cervix and where the position of the fetal head is located in conjunction to the birth canal. Performed during the last 4 weeks of pregnancy	The patient bends her knees with her legs abducted and feet on the bed or in "frog-leg" position. The examiner gently parts the vaginal labia and inserts two fingers into the vagina and palpates the cervix to assess effacement (thinning of the cervix) and dilatation, estimated by the number of fingers that would span the opening. (For example, when the cervix is 3-4 cm dilated, 2-3 fingers would span the opening. When 10 cm. occurs, the opening is equivalent to five fingers.)	Effacement is the thinning out of the cervix in labor which goes from uneffaced at 0% to 100% effaced in normal labor. Dilatation goes from closed to 10 centimeters in normal labor

Delivering Your Baby

When it comes to delivery, there are many different variables that can effect the birth. Some methods and treatments are optional, and some will become a necessity as your labor progresses. Read more in this patient education guide.

Delivery Methods

Delivery method	How it Works
Induction	Occasionally an enema is all that is needed to stimulate labor. More commonly evoked by IV infusion of pitocin to bring on regular contractions. After labor has commenced, an internal electrode may be inserted on the fetal head for a more accurate reading by rupturing membranes.
Episiotomy	Incision through vaginal wall and perineum, made when: Birth at hand and perineum is tight Baby is distressed Instrument delivery needed Baby is breech and room is needed After delivery the incision is sutured (which heals better than a ragged tear that needs sewing)
Spontaneous	Natural labor with rhythmic contractions and progression of the baby through the birth canal and delivered without instruments or prompting.
Forceps	Metal instrument with tongs and spoon-shaped edges molded to fit around the baby's head. Forceps are used to: Hasten delivery if distress seen Patient can no longer push Safe delivery of the head during breech birth
Vacuum Extraction	Device with cone-shaped synthetic, pliable suction cup which is placed over the baby's head and attached to a pump, creating vacuum which has measured pressure applied. This enables the physician to hold the baby in place with each push, barring the baby from receding between contractions.
Caesarean Section	This is an operative delivery with an incision (either horizontal or vertical) made between the umbilicus and pubic bone, and carried down to the uterus, which is incised above the lower uterine segment. The baby is delivered within 5 minutes and the placenta is then manually removed. The remainder of the 45-60 minutes entails sewing the various layers to restore normal tissue integrity. Indications include: Fetal distress Large baby size Cord prolapse Preeclampsia Malposition of baby Placenta previa

Anesthesia Options

There are two reasons why one would opt for anesthesia to be given.

In the first scenario, a patient may not be knowledgeable in deep breathing or natural birthing techniques that lessen pain or the patient may find it inadequate for the amount of pain that she is perceiving.

In the second case, anesthesia techniques are induced in order to relax the patient and the muscles so that delivery may be more easily affected.

Type	How it Works
Local Anesthetic	Medication injected subcutaneously to numb a specific area prior to episiotomy or for mending a tissue tear in the perineum. It does not alter contraction pain.
Cervical Block	Local anesthetic injected into the cervix at four quadrants to lessen the pain associated with dilation and effacement of the cervix.
Pudendal Block	Local anesthetic is injected into the vaginal wall to numb the tissue between vagina and anus. Given in advanced labor and is effective in 10-20 minutes
Epidural Block	After lying or sitting on your side with back curved outward, a local anesthetic is injected to numb the lower back at the site of planned epidural needle entry. Medication is injected into the epidural space surrounding the spinal cord and becomes effective in 10 minutes. Sensory function is numbed while often retaining motor skills.
Spinal Block	Used in conjunction with instrument delivery. You sit or lie on your side and medication is injected with a spinal needle into the sac of fluid below the spinal cord, effective within minutes.
General Anesthesia (inhalation gases)	Administered by the anesthesiologist, this is a gas that is passed through a special machine and dosage regulated. Because it can sedate the baby, this is given when immediate sedation is needed as in imminent Caesarean section for fetal distress.

Written by Barbara Hales, M.D.