CareMount Maternity Kit by caremountmedical

From Pre-Conception to Motherhood

As part of Optum, CareMount Medical joins a nationwide family of dedicated physicians and care teams working together to help people live their healthiest lives. As part of a regional team of over 2,100 providers who serve more than 1.6 million patients, our doctors have access to the latest medical information and technology, which lets them spend more time with patients, provide better care and realize better outcomes. CareMount Medical’s board-certified OB/GYN specialists serve patients throughout New York City, Westchester, Putnam, Dutchess, Columbia and Ulster counties.

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Pre-Conception

First Trimester

Welcome Pre-Conception Checklist

First Trimester Checklist

Life Style Modifications

Influenza Vaccine Ultrasound Exam Approved Medications Medications to Avoid

Table of Contents

Midwifery

Second Trimester

Third Trimester

Fourth Trimester

Second Trimester Checklist Local Childbirth Classes Pediatricians at CareMount

Third Trimester Checklist When to Call a Doctor

Fourth Trimester Checklist

Vaccines

What to Expect Postpartum Postpartum Depression

Birth Control Local Support Services Forms

PreConception Welcome Pre-Pregnancy Checklist Ovulation & Pregnancy Lifestyle Modifications Genetic Carrier Screenings

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WELCOME TO CAREMOUNT MEDICAL. Pregnancy is an exciting, but sometimes overwhelming time in your life. There is so much to learn, keep track of, and many decisions to make. That’s why we are firmly committed to providing soon-to-be parents with the education and support they need to have healthy, happy pregnancies and the best possible birth experiences. We’ve designed our online maternity guide to serve as an informational resource for the journey you are about to take. The kit is divided into the five sections: pre-conception, first trimester, second trimester, third trimester and fourth trimester (postpartum). We cover topics from genetic screening to birth control options to breastfeeding and so much more. We hope you will enjoy flipping through the pages and visit here often. All of us at CareMount Medical look forward to caring for you and your family.

Get a complete physical. In addition, make sure to have a pap smear as well as a breast check. Have a dental check-up and cleaning. Complete recommended dental care.

PreConception Checklist

Have a discussion with your doctor about chronic medical conditions that may impact pregnancy. Review current medications including OTC medications you are taking and ask whether there should be changes made. Get a blood test to determine your immunity to childhood diseases. Vaccinate accordingly. Review your job duties with your doctor, as we may need this information to evaluate risks in pregnancy. Take a prenatal multivitamin each day that provides 400 micrograms of folic acid. Assess your eating habits and try to limit sugar and fats. Maintain a healthy diet. Drink plenty of liquids, at least 64 ounces of water each day. Cut back on caffeine; limit caffeine intake to one cup per day; avoid alcohol; stop smoking. Review with your doctor your exercise program. Talk to your doctor about proper weight maintenance, what is a healthy weight for you to conceive and carry a pregnancy. Review your health insurance policy regarding prenatal care.

Ovulation & Pregnancy

Source: americanpregnancy.org WHAT IS OVULATION? Ovulation is a part of your menstrual cycle. It occurs when an egg is released from your ovary. When the egg is released, it may or may not be fertilized by sperm. If fertilized, the egg may travel to the uterus and implant to develop into a pregnancy. If left unfertilized, the egg disintegrates and the uterine lining is shed during your period. Understanding how ovulation happens and when it takes place can help you achieve or prevent pregnancy. It can also help you diagnose certain medical conditions. Ovulation typically happens around day 14 of a 28-day menstrual cycle. However, not everyone has a textbook 28-day cycle, so the exact timing can vary. In general, ovulation occurs in the four days before or four days after your cycle’s midpoint. The process of ovulation begins with your body’s release of follicle-stimulating hormone (FSH), typically between days 6 and 14 of your menstrual cycle. This hormone helps the egg inside your ovary to mature in preparation to release the egg later. Once the egg is mature, your body releases a surge of luteinizing hormone (LH), triggering the egg’s release. Ovulation may happen in the 28 to 36 hours after the LH surge. Impending ovulation can cause an uptick in vaginal discharge. This discharge is often clear and stretchy — it may even resemble raw egg whites. After ovulation, your discharge may decrease in volume and appear thicker or cloudier.

Ovulation may also cause: • • • •

light bleeding or spotting breast tenderness increased sexual drive ovary pain characterized by discomfort or pain on one side of the abdomen

Not everyone experiences symptoms with ovulation, so these signs are considered secondary in tracking your fertility. Your menstrual cycle resets the day that your menstrual flow begins. This is the start of the follicular phase, where the egg matures and is later released during ovulation, around day 14. After ovulation comes the luteal phase. If pregnancy occurs during this phase, hormones will keep the lining from shedding with a menstrual period. Otherwise, a flow will start around day 28 of the cycle, beginning the next cycle. In short: Ovulation generally occurs in the middle of the menstrual cycle. WHAT’S THE “FERTILE WINDOW”? The six days leading up to and including ovulation make up what’s called the “fertile window.” Again, this is the period of time when sexual intercourse may lead to pregnancy. The sperm may wait around for several days in the fallopian tubes after sex, ready to fertilize the egg once it’s finally released. Once the egg is in the fallopian tubes, it lives for around 24 hours before it can no longer be fertilized, thus ending the fertile window. CAN YOU TRACK YOUR OVULATION? There are many ways to track ovulation at home. • Basal body temperature (BBT) charting. This involves taking your temperature with a basal thermometer each morning throughout your cycle to record its changes. Ovulation is confirmed after your temperature has stayed elevated from your baseline for three days. • Ovulation predictor kits (OPK). These are generally available over-the-counter (OTC) at your corner drugstore. They detect the presence of LH in your urine. Ovulation may happen within the next couple of days after the result line is as dark or darker than the control. • Fertility monitors. These are also available OTC. They’re a more expensive option, with some products coming in at around $100. They track two hormones — estrogen and LH — to help identify the six days of your fertile window. You only need to have sex once during your fertile window to achieve pregnancy. Couples who are actively trying to conceive may up their chances by having sex every day or every other day during the fertile window. The best time to get pregnant is in the two days leading up to ovulation and the day of ovulation itself.

If you are trying to have a baby or are just thinking about it, it is not too early to start getting ready for pregnancy. Preconception health and health care focuses on things you can do before and between pregnancies to increase the chances of having a healthy baby. For some women, getting their body ready for pregnancy takes a few months. For other women, it might take longer. Whether this is your first, second, or sixth baby, the following are important steps to help you get ready for the healthiest pregnancy possible.

Lifestyle Modifications

1. Make a Plan and Take Action Whether or not you’ve written them down, you’ve probably thought about your goals for having or not having children, and how to achieve those goals. For example, when you didn’t want to have a baby, you used effective birth control methods to achieve your goals. Now that you’re thinking about getting pregnant, it’s really important to take steps to achieve your goal—getting pregnant, being healthy, and having a healthy baby! 2. See Your Doctor Before getting pregnant, talk to your doctor about preconception health care. Your doctor will want to discuss your health history and any medical conditions you currently have that could affect a pregnancy. He or she also will discuss any previous pregnancy problems, medications that you currently are taking, vaccinations that you might need, and steps you can take before pregnancy to prevent certain birth defects. If your doctor has not talked with you about this type of care, ask about it! Take a list of talking points so you don’t forget anything! Be sure to talk to your doctor about: MEDICAL CONDITIONS If you currently have any medical conditions, be sure they are under control and being treated. Some of these conditions include: sexually transmitted diseases (STDs), diabetes, thyroid disease, phenylketonuria (PKU), seizure disorders, high blood pressure, arthritis, eating disorders, and chronic diseases. LIFESTYLE AND BEHAVIORS Talk with your doctor or another health professional if you smoke, drink alcohol, or use “street” drugs; live in a stressful or abusive environment; or work with or live around toxic substances. Health care professionals can help you with counseling, treatment, and other support services.

MEDICATIONS Taking certain medicines during pregnancy can cause serious birth defects. These include some prescription and over-the-counter medications and dietary or herbal supplements. If you are planning a pregnancy, you should discuss the need for any medication with your doctor before becoming pregnant and make sure you are taking only those medications that are necessary. VACCINATIONS (SHOTS) Some vaccinations are recommended before you become pregnant, during pregnancy, or right after delivery. Having the right vaccinations at the right time can help keep you healthy and help keep your baby from getting very sick or having lifelong health problems. TAKE 400 MICROGRAMS OF FOLIC ACID EVERY DAY Folic acid is a B vitamin. If a woman has enough folic acid in her body at least 1 month before and during pregnancy, it can help prevent major birth defects of the baby’s brain and spine. STOP DRINKING ALCOHOL, SMOKING, AND USING STREET DRUGS Smoking, drinking alcohol, and using street drugs can cause many problems during pregnancy for a woman and her baby, such as premature birth, birth defects, and infant death. If you are trying to get pregnant and cannot stop drinking, smoking, or using drugs, get help! Contact your doctor or local treatment center. AVOID TOXIC SUBSTANCES AND ENVIRONMENTAL CONTAMINANTS Avoid toxic substances and other environmental contaminants at work or at home, such as synthetic chemicals, metals, fertilizer, bug spray, and cat or rodent feces. These substances can hurt the reproductive systems of men and women. They can make it more difficult to get pregnant. Exposure to even small amounts during pregnancy, infancy, childhood, or puberty can lead to diseases. Learn how to protect yourself and your loved ones from toxic substances at work and at home. REACH AND MAINTAIN A HEALTHY WEIGHT People who are overweight or obese have a higher risk for many serious conditions, including complications during pregnancy, heart disease, type 2 diabetes, and certain cancers (endometrial, breast, and colon). People who are underweight are also at risk for serious health problems. The key to achieving and maintaining a healthy weight isn’t about short-term dietary changes. It’s about a lifestyle that includes healthy eating and regular physical activity. If you are underweight, overweight, or obese, talk with your doctor about ways to reach and maintain a healthy weight before you get pregnant.

GET HELP FOR VIOLENCE Violence can lead to injury and death among women at any stage of life, including during pregnancy. The number of violent deaths experienced by women tells only part of the story. Many more survive violence and are left with lifelong physical and emotional scars. If someone is violent toward you or you are violent toward your loved ones get help. Violence destroys relationships and families. LEARN YOUR FAMILY HISTORY Collecting your family’s health history can be important for your child’s health. You might not realize that your sister’s heart defect or your cousin’s sickle cell disease could affect your child, but sharing this family history information with your doctor can be important. Based on your family history, your doctor might refer you for genetic counseling. Other reasons people go for genetic counseling include having had several miscarriages, infant deaths, or trouble getting pregnant (infertility), or a genetic condition or birth defect that occurred during a previous pregnancy. GET MENTALLY HEALTHY Mental health is how we think, feel, and act as we cope with life. To be at your best, you need to feel good about your life and value yourself. Everyone feels worried, anxious, sad, or stressed sometimes. However, if these feelings do not go away and they interfere with your daily life, get help. Talk with your doctor or another health professional about your feelings and treatment options. HAVE A HEALTHY PREGNANCY! Once you are pregnant, be sure to keep up all of your new healthy habits and see your doctor regularly throughout pregnancy for prenatal care. https://www.cdc.gov/preconception/planning.html

Genetic testing prior to pregnancy is becoming more common. One example of genetic testing is carrier screening, a tool that can help determine if you or your partner is a carrier of an inherited genetic condition that you could pass on to your child. You can be a carrier without having the condition itself; in fact, each of us carries a genetically inherited condition, any one of which we can pass on. CARRIER SCREENING GIVES INSIGHT INTO YOUR PREGNANCY Knowing your carrier status allows you to plan for an increased genetic risk in pregnancy and helps guide pregnancy decisions down the road. It is a vital part of family planning which anyone can utilize. IT GIVES YOU FAMILY PLANNING OPTIONS

Genetic Screening

If you are a carrier, you have options, such as partner testing, preimplantation genetic diagnosis (PGD) to determine if an embryo is affected with the condition(s), taking additional care during pregnancy, and education regarding the diagnosis and treatments available after birth. IT DETECTS UNKNOWN GENETIC CONDITIONS Eighty percent of individuals that are born with a genetic condition have no known family history of the condition; many carriers of genetic disorders don’t show any symptoms and go undetected. SCREENING REDUCES YOUR ANXIETY ABOUT PREGNANCY If you have a family history of a condition, carrier screening prior to pregnancy can provide the assurance that you are not a carrier of the condition or, if you are a carrier, that you have the resources to put a plan into place. IT HELPS YOUR RELATIVES IN THEIR FAMILY PLANNING Discovering your carrier status can benefit the family planning of your relatives too. A carrier is likely to have family members who carry the same condition. Full-siblings have a 50% chance of carrying the same condition and half-siblings have a 25% chance.

First Trimester 17 18 19 22 23 25 29 31 32 33

Congratulations First Trimester Checklist Prenatal Screening The Influenza Vaccine Ultrasound Exam Dos & Don’ts of Pregnancy Approved Medications for Pregnancy Medications to Avoid Emmi Pregnancy Education Fact Sheet Midwifery

Congratulations! We are pleased you have chosen CareMount Medical to help guide you through this exciting time in your life. Below is some helpful information and services you can receive from CareMount during your pregnancy as well as answers to some frequently asked questions you may have. The best time to reach us is during business hours, 8:30 am - 5:00 pm, Monday through Friday. Any calls made when the office is closed are answered by our answering service. If your call is not answered within 30-60 minutes, please call back. Occasionally, transmissions to the pager are not successful, or the provider is unable to answer immediately due to being in surgery or at a delivery. If you are having an emergency and cannot wait for a call back, let the answering service know and they can try to reach the on call provider directly. Calls made after hours are emergencies only. Your due date is 40 weeks from the first day of your last normal period. If this is not reliable, then we may calculate the date based on the sonogram. Routine prenatal visits usually start around 10 weeks and occur every four weeks until about 28 weeks. Your visits will then be every two or three weeks until 36 weeks. After 36 weeks, your visits will be weekly. Additional visits will be scheduled as needed. You will need to provide a urine sample upon arrival and we will record your blood pressure and weight at each meeting. You will be required to meet all the providers. Due to availability, you may need to be flexible and see providers at multiple locations. Nausea, vomiting and food aversions are common in early pregnancy. You may want to avoid spicy or greasy foods during this time period. Dry crackers, breads, other bland foods, and eating regularly can help minimize symptoms. Vitamin B6 in low doses (50 mg twice a day), pressure point bracelets and peppermint tea may be helpful for some patients. Be sure to continue drinking plenty of fluids. If you are unable to keep fluids down for more than one day, call your provider, as you may require IV fluids to stay hydrated. Mild cramping early in the first trimester is not unusual. If bleeding occurs, call your provider.

Book your prenatal visits. The first should be within 6-8 weeks of last known period. We will review your health and pregnancy history, recommending screening tests such as blood tests and ultrasound scans based on your information, age and prior pregnancy history.

First Trimester Checklist

We recommend genetic screening for you and your baby, carrier screenings for you and your partner, as well as fetal assessments for anomalies such as Down Syndrome and open neural tube defects. These options and recommendation will be discussed with you at your first visit. If you are at risk of having a baby with an inherited disorder, consider scheduling a visit with a genetic counselor. Review insurance for pre-certification and pre-authorization for testing and labs especially genetic screenings. Each insurance plan has many inclusions as well as exclusions. Quit smoking and avoid alcohol. Discuss any drug use both recreation and prescribed. Eat healthy, well balanced meals; increase protein; caloric intake should increase by 300 daily. We will advise on foods that should be avoided during pregnancy. Limit caffeine to one cup per day. Exercise regularly; at least 30 minutes of moderate exercise each day, with your doctor’s approval. Claim government and financial benefits. Consider a prenatal yoga class which will help build strength for labor, as well as improve flexibility, agility, balance, and posture.

Prenatal Screening & Diagnostic Procedures

During your pregnancy, prenatal testing may be recommended to check that you’re healthy and that your baby is developing properly. Many of these tests are routinely recommended in all pregnancies. Others are recommended only in certain situations. Your practitioner will talk with you about the risks and benefits of any tests you’re considering.

BLOOD TESTS FOR ANEMIA, DIABETES, RH FACTOR, HEPATITIS B, SYPHILIS, AND HIV If you have anemia, diabetes, certain Rh blood types, hepatitis B, syphilis, or HIV, you may need special treatment to keep you and your baby healthy. • • • • • • •

All pregnant women are tested for anemia (low iron in the blood that can make the anemic woman feel tired). Some women will be tested for diabetes (high sugar level in the blood and urine) during early pregnancy. All women will be tested for diabetes between 24 and 28 weeks. If you have an Rh-negative blood type, you’ll take another test to check your blood for antibodies that could cause problems for you and your baby. If you test positive for hepatitis B and are identified as a hepatitis B carrier, your infant will receive vaccines at birth and in infancy. These vaccines will greatly reduce the chance of passing hepatitis B to your baby. Pregnant women who test positive for syphilis can be treated with antibiotics. If left untreated, syphilis can cause severe problems in the mother, fetus, and newborn. We recommend testing for HIV during your pregnancy. If you test positive for HIV, there are treatments available that reduce the chance of passing HIV to your baby. Also, early detection and treatment can help you stay healthier. Vaccination for Varicella and Rubella is recommended after delivery, if you are not immune.

If additional testing is needed, your practitioner will discuss it with you at future visits.

ULTRASOUND EXAM An ultrasound (sonogram) exam is routinely ordered during pregnancy to: • • • •

Confirm the estimated delivery date (EDD). Find out the position and development of the placenta and baby. Find out more about the placenta and baby. Look for more than one baby.

An ultrasound device is placed on your abdomen or in your vagina. The device sends sound waves to your uterus, which allows a picture of your baby to appear on a video monitor. Ultrasound has been used for more than 25 years and is considered safe for both mother and baby. If you plan on having an abdominal sonogram, a full bladder is required for the test to work. You’ll need to drink 2 to 4 eight-ounce glasses of water starting 1 hour before the exam. You don’t need a full bladder for a vaginal sonogram.

SCREENING TESTS FOR BIRTH DEFECTS Prenatal screening tests can help you find out if you have a higher or lower chance of having a baby with certain birth defects. Screening tests do not look for all types of birth defects or health problems, but can help detect: • • • •

Down Syndrome - a chromosome abnormality that causes intellectual disability and some physical problems. Trisomy 18 - another chromosome-abnormality that causes severe mental and physical problems. Open neural tube defects - openings along the baby’s spine and/or brain. Abdominal wall defects - openings along the baby’s abdomen or belly.

Screening tests do not increase the chance of miscarriage. Your screening test result is based on some or all of the following: • • • • •

Your age at delivery. Your gestational age (the size of your baby). Blood tests measuring pregnancy related hormones and proteins. Blood tests for screening start as early as 10 weeks in pregnancy, but additional blood tests are usually done between 15 and 20 weeks. Nuchal translucency ultrasound (a specialized early ultrasound).

Most women who take a screening test will have a negative result. A negative result does not guarantee that the baby won’t have these birth defects, but it indicates that the risk is low. A small number of women will have a positive screening test result. Usually, this doesn’t mean that the baby has a problem, but a positive result alerts you and your practitioner to take a closer look at the pregnancy. If you have a positive result you’ll be contacted by a genetic counselor. Your result will be explained and you’ll be given the option of further testing to help determine the reason for the positive result. Further testing options might include diagnostic procedure or ultrasound.

DIAGNOSTIC PROCEDURES FOR BIRTH DEFECTS Diagnostic procedures are medical tests that can accurately detect certain birth defects. Amniocentesis and chorionic villus sampling (CVS) are two different diagnostic procedures that can test the baby for: • • •

Chromosome abnormalities (like Down Syndrome and trisomy 18). Certain genetic diseases. Neural tube defects (like spina bifada and anencephaly).

Amniocentesis is generally done between 15 and 20 weeks. CVS is done between 10 and 13 weeks. These diagnostic procedures have a small risk of miscarriage (less than 1 percent). Prenatal testing for both birth defects is optional. You may choose to have a screening test before deciding whether you want a diagnostic procedure. Or you may choose to have a diagnostic procedure without having a screening test first. You can also choose not to have any prenatal testing for birth defects at all.

GENETIC CONDITIONS IN CERTAIN ETHNIC GROUPS Some genetic conditions are more common in certain ethnic groups. • • • • •

Canavan disease - Jewish (Ashkenazi/Easter Europe) Cystic fibrosis - Caucasian/White (non-Hispanic), Jewish (Ashkenazi/Eastern Europe) Familial dysauntonmia - Jewish (Ashkenazi/Eastern Europe) Sickle cell disease - African-American/Black Tay-Sachs disease - Jewish (Ashkenazi), French Canadian and Cajun

Testing is available to see whether you’re at risk of having a baby with any of these conditions.

FAMILY HISTORY OF GENETIC CONDITIONS AND BIRTH DEFECTS Talk to your practitioner if you have any history of an inherited condition or birth defect in your family--especially if you’ve previously given birth to a child with an inherited condition or birth defect.

GROUP B STREPTOCOCCUS Group B streptococcus (GBS) is a common type of bacteria found in many women. It can cause illness in newborn babies if transmitted at the time of delivery. A test can be done between 35 and 37 weeks to check for the presence of this bacteria in the vagina and the rectum. If your test comes back positive, you’ll be treated with antibiotics during labor to reduce chances of GBS from being transmitted to your baby.

The Influenza Vaccine & Pregnancy Influenza (the flu) is an infection of the respiratory tract and is caused by a variety of viruses. Common symptoms include fever, chills, congestion, sore throat, headache, muscle aches, coughing and runny nose. Nausea is rarely seen with influenza. Influenza is contagious. The virus is known to be spread by contact with secretions of the mouth and nose of people who are infected . Time between infection and the development of symptoms is 1 to 3 days. Pregnancy can increase the risk of complications from the flu, and pregnant women are more likely to be hospitalized from complications of the flu than non-pregnant women of the same age. In previous worldwide outbreaks of the flu (pandemics of 1918-19 and 1957-58), deaths among pregnant women were associated with the flu. Pregnancy can change the immune system in the mother, as well as affect her cardiovascular system (heart and lung function). These changes may place pregnant women at risk for complications from the flu. This vaccine is considered safe to administer during pregnancy and will not increase the risk to the fetus. Because the flu shot is made from inactive viruses (the viruses are killed), it is non-infectious and cannot cause influenza. Most of these vaccines contain virus particles from three different stains of influenza (2 type A, 1 type B). Each year the mixture of viruses is updated according to the current type of virus thought to be causing infection. Many experts consider flu shots safe during any stage of pregnancy. However, since miscarriages (spontaneous abortion) most often occur in the first trimester of pregnancy, experts have traditionally not given a flu shot during the first trimester to avoid a coincidental association with miscarriage. 9

The Ultrasound Exam

Your doctor has requested an obstetrical ultrasound examination... although you may have heard about ultrasound before, you may still have some questions. The American Institute of Ultrasound in Medicine (AIUM)–an organization composed of doctors, sonographers, and scientists–has put together this information to answer some of the most commonly asked questions and explain how ultrasound works.

What is ultrasound? Ulstrasound is like ordinary sound except it has a frequency (or pitch) higher than people can hear. Ultrasound is sent into the body from a scanning instrument (transducer) placed on your skin. The sound is reflected off structures inside your body and is analyzed by a computer to make an image of these structures on a monitor, which is similar to a television screen. The moving pictures can be recorded on film and videotape. Diagnostic ultrasound is commonly call sonography or ultrasonography.

Why do patients have an obstetric ultrasound examination? The most common reason for having an obstetrical ultrasound examination is to help your doctor determine when your baby is due or to make sure your baby is growing, as it should. Your doctor may also want an ultrasound examination to determine the baby’s position or to see if you are carrying more than one baby. With an ultrasound examination, the amount of fluid around your baby can be seen. Ultrasonography also may be used to detect some birth defects.

Are there any special preparations needed for the examination? In most cases, no special preparation is needed for the examination. In some cases, your doctor may recommend an endovaginal ultrasound study, which involves the use of a special transducer in your vagina, to improve visualization of your baby or your cervix. A complete obstetric ultrasound examination usually takes between 10 and 60 minutes.

Who will perform the examination? In most cases, a specially trained professional called a sonographer will examine you. In some cases, a doctor may also examine you or perform the ultrasound exam itself. In all cases, the pictures are reviewed and read by a doctor.

Will it hurt? There is no pain from an ultrasound examination. You may feel some pressure from an endovaginal ultrasound examination in which a probe is inserted in your vagina; the probe is the size of a tampon and is smaller than a speculum. You may choose to insert the probe yourself. The ultrasound examination does not affect your pregnancy.

During the scanning procedure, a gel-like material is put on your abdomen and a transducer is placed on your skin. The gel makes it possible for the ultrasound system to see through your skin, into your body. The gel may feel cold and, although the gel wipes off easily and does not usually stain clothing, it is a good idea to wear clothes that can be washed.

Can I see my baby move? Your baby’s heartbeat and movement of his or her body, arms, and legs, can be seen using ultrasound, depending on the age of the baby. Your baby can be seen moving during a ultrasound examination many weeks before you can feel the movement.

Will I learn the sex of my baby? Sometimes it is possible to see the sex of the baby and sometimes it is not possible. If your baby is lying in an inconvenient position, the baby’s sex cannot be determined.

Does an ultrasound examination guarantee a normal baby? No, an ultrasound examination does not guarantee a normal baby. The ability to detect fetal abnormalities depends on many things. For instance, the size and position of your baby may not allow certain abnormalities to be seen. Some types of abnormalities cannot be seen because they are too small or not visible by ultrasound.

Will I need more than one ultrasound examination? In many cases, women need only one ultrasound examination or “scan,” but for a variety of reasons, your doctor may order additional scans during your pregnancy.

What is a Doppler Ultrasound? Doppler ultrasound is a special form of ultrasound. This type of ultrasound is useful in evaluating blood flow to the pelvic organs and fetal vessels. The doctor or sonographer performing the scan can display this information in several ways. An audible sound may be used, or the blood flow may be shown as a graphic or color display. It is not painful. The decision to use Doppler Ultrasound is often not made by the doctor until the time of the exam; for example, for further evaluation of the heart of the fetus. It is not considered harmful to the fetus.

Is ultrasound safe? The AIUM has a bioeffects committee that meets regularly to consider safety issues and evaluate reports dealing with bioefects and the safety of ultrasound. The AIUM has adopted the following official statement: “There are no known harmful effects associated with the medical use of sonography. Widespread clinical use of the diagnostic ultrasound for many years has not revealed any harmful effects. Studies in humans have revealed no direct link between the use of diagnostic ultrasound and any adverse outcomes. Although the possibility exists that biological effects may be identified in the future, current information indicates that the benefits to patients far outweigh the risks, if any.”

The Dos & Don’ts

Prenatal Vitamins Pregnant women should consume the following each day through diet or supplements: • Folic acid 400-800 micrograms (until the end of the first trimester). • Iron 30mg (or be screened for anemia) • Vitamin D 600 international units • Calcium 1,000 mg Prenatal vitamins are unlikely to be harmful. Therefore, they may be used to ensure adequate consumption of several vitamins and minerals in pregnancy However, their necessity for all pregnant women is uncertain, especially for women with well-balanced diets. There is no known ideal formulation for a prenatal vitamin.

Nutrition and Weight Gain Pregnant women should be advised to eat a healthy, wellbalanced diet and typically should increase their caloric intake by a small amount (350-450 calories/day). Women with higher Pre-Conception BMI do not need to gain the same amount of weight as women with normal or low BMIs.

Alcohol Although current data suggests that consumption of small amounts of alcohol during pregnancy (less than seven to nine drinks/week) does not appear to be harmful to the fetus, the exact threshold between safe and unsafe, if it exists, is unknown. Therefore, alcohol should be avoided in pregnancy.

Artificial Sweeteners Artificial sweeteners can be used in pregnancy. Data regarding saccharin are conflicting. Low (typical) consumption is likely safe.

Caffeine Low-to-moderate caffeine intake in pregnancy does not appear to be associated with any adverse outcomes. Pregnant women may have caffeine but should probably limit it to less than 300 mg/day (a typical 8-ounce cup of brewed coffee has approximately 130 mg of caffeine. An 8-ounce cup of tea or 12-ounce soda has approximately 50 mg of caffeine), but exact amounts vary based on the specific beverage or food.

Fish Consumption Pregnant women should try to consume two to three servings per week of fish with a high DHA and low mercury content. For women who do not achieve this, it is unknown whether DHA and n-3 PUFA supplementation are beneficial, but they are unlikely to be harmful.

Raw and Undercooked Fish In line with current recommendations, pregnant women should generally avoid undercooked fish. However, sushi that is prepared in a clean and reputable establishment is unlikely to pose a risk to the pregnancy.

Other Foods to Avoid • • • • •

Pregnant women should avoid raw and undercooked meat. Pregnant women should wash vegetables and fruit before eating them. Pregnant women should avoid unpasteurized dairy products. Unheated deli meats could also potentially increase the risk of Listeria, but the risk in recent years is uncertain. Pregnant women should avoid foods that are being recalled for possible Listeria contamination.

Smoking, Nicotine & Vaping Women should not smoke cigarettes during pregnancy. If they are unable to quit entirely, they should reduce it as much as possible. Nicotine replacement (with patches or gum) is appropriate as part of a smoking cessation strategy.

Marijuana Marijuana use is not known to be associated with any adverse outcomes in pregnancy. However, data regarding long-term neurodevelopmental outcomes are lacking; therefore, marijuana use is currently not recommended in pregnancy.

Exercise and Bedrest Pregnant women should exercise regularly. There is no known benefit to activity restriction or bedrest for pregnant women.

Oral Health Oral health and dental procedures can continue as scheduled during pregnancy.

Hot Tubs and Swimming Although data are limited, pregnant women should probably avoid hot tub use in the first trimester. Swimming pool use should not be discouraged in pregnancy.

Insect Repellents Topical insect repellents (including DEET) can be used in pregnancy and should be used in areas with high risk for insect-borne illnesses.

Hair Dyes Hair dye is presumed to be safe in pregnancy.

Sexual Intercourse Pregnant women without bleeding, placenta previa at greater than 20 weeks of gestation, or ruptured membranes should not have restrictions regarding sexual intercourse.

Travel Airline travel is safe in pregnancy. Pregnant women should be familiar with the infection exposures and available medical care for each specific destination. There is no exact gestational age at which women must stop travel. Each pregnant woman must balance the benefit of the trip with the potential of a complication at her destination.

Sleeping Position It is currently unknown whether, and at what gestational age, pregnant women should be advised to sleep on their side.

Colds, Cough, and/or Allergies

Approved Medications

Alvert, Allegra, Allergy Shots, Benedryl, Chlortrimetron, Claritan, Deconamane, Entex, Intal, Nasal Medications (Except Neo Synepherine), Robitussin Without Alcohol, Solumedrol, SudafedRegular Strength (Not to be used for an extended period of time.) Tesslon Pearls, Throat Lozenges, Triaminic, Zyrtec.

Constipation Colace, Fibercon, Metamucil, Milk of Magnesia, Senokot.

Diarrhea BRAT Diet (Bananas, Rice, Applesauce, Toast), Imodium, Lomotil (not to be used for extended period of time) and Kaopectate (not be used for extended period of time).

Hemorrhoids Anusol, Hydrocortisone Cream 1%, Ice, Preparation H, Tucks, Witch Hazel.

Morning Sickness Cinnamon Flavored Foods, Dry Crackers, Ginger Snaps, Cinnamon Graham Crackers, Flat Soda (Coke or Ginger Ale), Ginger Tea, Jelly Beans with Pectin, Low Fat Diet.

Heartburn & Nausea Bonine, Compazine, Dramamine, Emetrol, Maalox, Mylanta, Pepcid AC, Pepto Bismol, Phenergen, Reglan, Tagamet, Tigan, Tums, Unisom, Zantac (75 mg two times a day), Zofran.

Antibiotics Ampicillin, Amoxicillin, Ceclor, Ceflzox, Ceftin, Cephalosporin, Erythromycin, Keflex, Penicillin, Zithromax.

Vaccination PPD (Mantoux), Hepatitis, DT (Diphtheria, Tetanus), Flu Vaccine.

Miscellaneous Acyclovir, Aldomet, Aspercreme, BenGay, Codeine, Demerol, Monistat, Nix (For Lice & Eggs), Nystatin, Percocet, Phenobarbitol, Tylenol-Regular Strength.

Dental Visits You may see the dentist when you are pregnant, just follow these guidelines: (1) Inform the dentist that you are pregnant and of any special problems or medical conditions you have (ie: mitral valve prolapse); (2) Abdominal Shield must be used for all X-Rays, (preferably, x-rays should be done past the first trimester); (3) Xyloxiane without epinephrine is preferred, but Xylocaine with epinephrine may be used in small doses. General anesthesia is not advised unless discussed with the OB/GYN physician; (4) If antibiotics are necessary use one from the list on this page provided you are not allergic to it.

Medications to Avoid Asprin (unless prescribed by your physician) Accutane Vitamin A supplements (other than what is contained in standard prenatal vitamins) Certain antibiotics such as tetracycline or ciprofloxacin (Cipro)

Medications to Avoid

NSAIDS such as Ibuprofen and Naproxen (e.g. Advil, Motrin, or Aleve) unless prescribed by your physician. Be careful of combination over-the-counter medications, which may contain “safe” and “unsafe” medications.

We believe that you should be actively involved in all decisions about your pregnancy. CareMount Medical is pleased to offer an educational program called Emmi. Emmi takes complex medical information and makes it easy to understand. Emmi consists of educational modules on a variety of relevant subjects. All modules are web-based and interactive. You can view them at your own pace in the comfort of your home. You can share them with family and friends. Emmi is offered free to our patients. Roughly every 6 weeks, you will receive an e-mail from CareMount Medical with a link and activation code to a different Emmi module. You will have one month to view the module before the activation code expires. If you prefer to receive all the modules at once, please tell your doctor or nurse. The Emmi modules that will be delivered to you automatically are: • • • • •

Morning Sickness Exercise in Pregnancy Work and Travel Childbirth Breastfeeding

Emmi Pregnancy Education

Modules on other subjects are also available. Please ask your doctor or nurse if you have any questions.

At CareMount Medical, our certified nurse-midwives can help you achieve optimal health and wellness by providing you with holistic, personalized care that is attuned to your unique and ever-evolving needs. WHAT IS A CERTIFIED NURSE-MIDWIFE? Many people think midwives only deliver babies, but certified nursemidwives are trained to do so much more. Certified nurse-midwives are advanced practitioners with specialized education in women’s health care and midwifery. Certified nurse-midwives are trained to offer comprehensive gynecological care to women through every phase of their lives, beginning at puberty and continuing well beyond menopause. Our midwives recognize and tailor care to the needs of all based on age, race, sexuality and ethnicity. WHAT DO CERTIFIED NURSE-MIDWIVES DO AT CAREMOUNT MEDICAL?

Midwifery

At CareMount Medical, certified nurse-midwives provide a full range of women’s health services including annual check-ups, health screenings, family planning, obstetrical care, menopause and senior care. For women who are having a low-risk, healthy pregnancy, our certified nurse-midwives provide compassionate care that considers women’s birthing goals, medical needs and personal preferences to help them achieve a satisfying and healthy pregnancy and delivery. We help women prepare their bodies for motherhood, and once pregnant, we help manage any risk factors, make healthy choices, and closely monitor the baby’s development. We help women develop a birth plan that accommodates their personal wishes and preferences during labor, delivery and recovery, including requests for pain relief. Midwives follow a code called “The Midwives Model of Care,” which is based on the perspective that pregnancy and birth are normal life processes. This model includes: • Monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle • Providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support • Minimizing technological interventions • Identifying and referring women who require further medical attention Central to this model is the fact that midwives are trained to recognize an urgent medical situation. They collaborate across disciplines and will always consult with doctors if they feel their patient needs more specialized attention.

This is true for patients with complex medical histories, and/or those who develop high risk pregnancies. In the latter case, midwives will work with an obstetrician/gynecologist to create a care plan that addresses medical needs, while also making sure that the patient and family have the birth plan they desire. Every stage of a woman’s life, from adolescence to the childbearing years, menopause and beyond, has its own unique health concerns and challenges. The goal of our certified nurse-midwives is to partner with you through the phases of your life and to really get to know you by listening to your questions and concerns with compassion and sensitivity, and respecting your personal preferences and values. To that end, midwives offer counseling, guidance and educational information to help you adapt and cope with your every-changing needs as you pass through the phases of womanhood. The bottom line…our midwives are here to support you, whatever your unique needs may be. OUR GOAL IS TO PROVIDE YOU WITH HOLISTIC, PATIENT-CENTERED CARE.

Second Trimester Second Trimester Checklist 37 Local Childbirth Classes 38 Pediatricians at CareMount 39

Second Trimester Checklist

The provider will discuss with you your second trimester screening tests. This includes a blood test between week 16 and 18, as well as an ultrasound at 20 weeks. Take a tour of your hospital’s maternity ward. Complete pre-registration for the hospital/birthing center. Create a birth plan by discussing your preferences regarding labor and delivery with your doctor and partner. Prepare for breastfeeding as well as resources you’ll need if you decide to do so. Do pelvic exercises to tighten up your muscles and prevent bladder leakage. Consider childcare options in your area if you plan on going back to work after giving birth.

Baby Care Class In just two hours learn about... • • • • • • • •

Local Childbirth Classes

The first few hours Feeding Patterns Bathing Sleep Patterns Safety Issues Vaccinations Picking your Pediatrician Common Concerns of New Patients

Find out about times and locations from your OB/GYN office.

CareMount Pediatricians https://www.caremountmedical. com/care-and-services/pediatrics/

Third Trimester 43 44 45 47 49 50

Third Trimester Checklist When to Call a Doctor Circumcision Facts Newborn Screening Family Vaccines Hospital Packing List

If you are having a boy, consider whether or not you’ll circumcise.

Third Trimester Checklist

Meet with several pediatricians and choose one as your child will need to be checked immediately after birth. Attend childbirth, baby care and breast feeding classes. Collect important contacts for each of these needs. Get your baby’s car seat fitted so that you are ready when it is time to take your baby home. Have your hospital bag packed and ready. It should include the necessary supplies needed for both you and your baby such as a nursing bra, nightgown, baby clothes, etc. Prepare your home and baby’s nursery so that is ready for you and your baby’s arrival. Install some general safeguarding of your home such as putting smoke and carbon monoxide alarms in all rooms. Call your health insurance to inform them of your due date and find out about any requirements they may have about adding a baby to your policy. Consider birth control options post pregnancy. Contact your pet’s vet office for information and recommendations on introducing your newborn baby to your furry friend. Organize a system of friends and family to help out when you’re home with your new baby. Consider cooking and freezing some food for when you’re home with the baby. Relax and enjoy the last weeks of your pregnancy, focusing on rest, fluids and taking care of yourself.

You should call your doctor if you experience the following: • Heavy bleeding or bleeding with cramps • Severe pain in the lower abdomen • Headache, fainting, and dizziness

When to Call the Doctor

• Frequent and painful urination • Moderate to severe bouts of pelvic pain • Bloody diarrhea • Vomiting accompanied by fever or pain • Chills or fever higher than 101 degrees • Steady or heavy vaginal discharge of thin fluid • Sudden swelling of hands, feet, or face • Lack of fetal movement • Thoughts of harming yourself or your baby

What is male circumcision?

Circumcision: Facts to Know

Male circumcision is the surgical removal of the foreskin, which is the layer of skin that covers the head of the penis.

When is circumcision performed? • • •

Circumcision may be performed before or after the mother and baby leave the hospital. It is performed only if the baby is healthy. If the baby has a medical condition, circumcision may be postponed.

How is circumcision performed? • • • •

Circumcision takes only a few minutes. During the procedure, the baby is placed on a special table. Various surgical techniques are used, but they follow the same steps: The penis and foreskin are cleaned. A special clamp is attached to the penis and the foreskin is cut and removed. After the procedure, gauze with petroleum jelly is placed over the wound to protect it from rubbing against the diaper.

What pain medication is used for circumcision? Analgesia is safe and effective in reducing the pain. Before the procedure, you should ask what type of pain relief will be used.

Who performs circumcisions? • •

The procedure may be done by your obstetrician–gynecologist (obgyn) or by a pediatrician. In some cases, a circumcision may be done in a non medical setting for religious or cultural reasons. If this is the case, the person doing the circumcision should be well trained in how to do the procedure, how to relieve pain, and how to prevent infection.

Is circumcision a required procedure? It is your choice whether or not to have your son circumcised. It is not required by law or by hospital policy. Because circumcision is an elective procedure, it may not be covered by your health insurance policy.

What are the health benefits associated with circumcision? • •

Circumcision reduces the bacteria that can live under the foreskin. This includes bacteria that can cause urinary tract infections or, in adults, sexually transmitted infections. Circumcised infants appear to have less risk of urinary tract infections than uncircumcised infants during the first year of life.

Are there risks associated with circumcision? • •

All surgical procedures carry some risk. Complications from a circumcision are rare, but they can occur. When they do occur, they usually are minor. Possible complications include bleeding, infection, or scarring. In rare cases, too much of the foreskin or not enough foreskin is removed.

When should circumcision not be done? • • • •

Circumcision should only be done when the newborn is stable and healthy. Reasons to delay circumcision include the following: The baby is born very early The baby has certain problems with his blood or a family history of bleeding disorders The baby has certain congenital abnormalities

How should I care for my circumcised son? •

•

If you choose to have your baby boy circumcised, you will need to care for his penis as it heals. With each diaper change, the penis should be cleaned and petroleum jelly placed over the wound. The jelly can be placed on a gauze pad and applied directly on the penis or placed on the diaper in the area the penis touches. In most cases, the skin will heal in 7–10 days. You may notice that the tip of the penis is red and there may be a small amount of yellow fluid. This usually is a normal sign of healing.

Newborn screening refers to medical tests, the majority of which are genetic, performed to identify babies with certain disorders. Without intervention, these disorders may permanently impact newborns and their families. Early recognition and treatment of these disorders leads to a better outcome for the newborn. The Newborn Screening Program’s goal is to help affected babies live long, healthy lives by identifying the problem early and intervening.

Newborn Screening & Infant Hearing Test

Facts to know… • A small blood sample is collected by pricking your newborn’s heel usually 1-2 days after birth. • The blood is used to screen for more than 40 different disorders. • There is no charge to you for this service. • Most newborns will not have one of these disorders. • Newborns with one of these disorders may look healthy at birth, which is why the testing must be performed to find those with a disorder. • The earlier treatment is started, the better the outcome is for your newborn. • Screening is designed to identify all newborns with the potential risk for one of these disorders. If screening is positive, further testing is then required to verify whether or not your newborn actually has the disorder. In addition, a hearing test is also performed. For two to three out of every 1,000 babies born each year in the U.S. the sense of hearing is impaired. Since a deficit can affect so many aspects of a child’s development, early diagnosis and treatment are key, which is why the American Academy of Pediatrics (AAP) endorses the test for all newborn babies. This is a noninvasive test performed prior to discharge from the hospital. If a baby does not pass the hearing screen, referral is made for a more complete evaluation with a specialist.

Vaccines for Your Family to Safeguard Baby Newborn babies do not have fully developed immune systems, making them particularly vulnerable to infections. When a baby’s family members and caregivers get vaccinated, they help form a “cocoon” of disease protection around the baby. • • • • • • • •

• •

•

Anyone who is around babies should be up-to-date on all routine vaccines, including the whooping cough vaccine. During flu season, everyone should get a flu vaccine in order to surround the baby with protection. Newborns are most likely to catch whooping cough or flu from someone at home. Parents, brothers and sisters, grandparents, babysitters, and other caregivers can all help prevent the spread of disease by getting vaccinated at least two weeks before meeting the baby. The cocooning strategy provides indirect protection to babies by shielding them from disease. Because cocooning does not provide direct protection and it can be difficult to make sure everyone who is around your baby is vaccinated, it is even more important that women get the whooping cough vaccine while pregnant. Getting the whooping cough vaccine while pregnant allows mothers to pass short-term protection (antibodies) to their babies until they can get their own vaccine. Another way to protect babies from flu is by vaccinating their mothers while they are pregnant. Pregnant women are at increased risk for flu complications and a flu shot will protect them from illness, but it also has been shown to protect their newborn from flu for the first several months after they are born. Complications from the flu during pregnancy may include premature labor, babies who are small for gestational age, hospitalization, or even death. Some people who have the flu do not show any symptoms, but they may still spread the virus to others. Whooping cough can sometimes appear to be nothing more than the common cold, which hides the true danger it poses to babies. When everyone’s vaccinations are up-to-date, parents can feel more secure about the safety of their child.

https://www.cdc.gov/vaccines/pregnancy/family-caregivers/index.html 00

Correct IDs • •

Health insurance card Photo ID or driver’s license

Toiletries • • • • • • • • •

Toothbrush and toothpaste Deodorant Shampoo and conditioner Hair brush Hair band or clip Glasses case or contact lens necessities (the hospital may not allow you to wear contacts during labor) Skin lotion Lip balm Sanitary pads (in case you don’t like the ones at the hospital)

Hospital Packing List

Clothes • • • • • • • •

2 sets of comfortable, loose fitting clothes, like T-shirts and sweat pants to wear in the hospital Clothes to wear home -- loose and comfy Pajamas or a nightgown (choose ones that open down the front if you plan on nursing) Socks and slippers Robe 2-3 pairs of underwear At least 2 nursing bras 12 nursing pads

For Your New Baby • • • • •

1 set of clothes 0-3 months for baby to wear home 1 hat, 1 pair of socks, and 1 pair of booties 1 or 2 receiving blankets Newborn diapers (the hospital may provide these) Car seat

Fourth Trimester Fourth Trimester Checklist 53 Caring for Your Episiotomy 54 Recovering after a Cesarian Section 55 What to Expect Postpartum 57 Postpartum Depression 58 Edinburgh Scale 59 Breastfeeding 61 Exercise After Pregnancy 63 Birth Control 66 Local Support Services 71

Fourth Trimester Checklist

Schedule a follow-up visit with your doctor based on your doctor’s recommendation. Limit visitors so you and baby can rest. Get help with cleaning and meals. Follow your doctor’s instructions for recovery. This is an exciting time, but important to rest and recover. Use a Sitz bath if needed for perirectal discomfort. Eat plenty of fruits, vegetables, and whole grains. Drink plenty of fluids, and continue prenatal vitamins. Wear a supportive bra to relieve sore breasts. If breastfeeding, reach out to your lactation consultant for any concerns or issues. Not breastfeeding? Ask your OB about breast care. Talk to your doctor about birth control options. Don’t try to lose baby weight too quickly--go slowly. Take care of yourself so you have more energy. Ask for help when you need it.

Caring for your Episiotomy What is an episiotomy? An episiotomy is a cut (incision) through the area between your vaginal opening and your anus made to enlarge your vaginal opening to aid your healthcare provider in delivering your baby.

Tips for Care: • • • • • • • • • •

Use an ice pack to reduce swelling and pain. Warm or cold shallow baths (sitz baths) to ease soreness and speed healing. Medicated creams or local numbing sprays. Pain reliever as recommended by your doctor. Make sure to keep the incision clean and dry using the method recommended by your healthcare provider, especially after urination and bowl movements. If bowel movements are painful, talk to your doctor about recommended stool softeners. Do not douche, use tampons, or have sex until your provider gives you the OK. Talk to your doctor about limitations on different activities such as exercise or heavy lifting. Go back to your normal diet unless your provider tells you otherwise. Call your doctor if you experience the following: bleeding from the episiotomy site, foul-smelling vaginal drainage, fever or chills, severe perineal pain.

Recovery after a Cesarean Section (C-section)

Recovering after a Cesarean Section

The first 24 hours after your c-section, you may feel nauseated and weak. It may be uncomfortable to cough, sneeze, or even laugh. After a day or so, you’ll be encouraged to get up and start moving around, which is important to prevent fluid from building up in your lungs, boost circulation, and help with digestion. It’ll be hard at first, but the more you move, the better you’ll feel. In addition to the soreness of your abdomen, you may also have gas pains as the intestinal tract begins working again after surgery. Your doctor may also recommend medication for this. Moving around and walking helps relieve gas pains. You may feel some uterine contractions called after-pains for a few days. The uterus continues to contract and get smaller over several weeks. After three or four days, you’ll most likely be able to go home, after your doctor removes your stitches. You’ll get a prescription for pain medication to help you through the next week (if you plan to nurse, make sure your doctor knows so he can prescribe medications that are safe). Once you’re home, resist the temptation to busy yourself with stuff around the house -- just focus on resting, making sure not to lift anything heavier than your baby. Although many c-section mothers report feeling better rather quickly, it’s still important to take it easy -- remember, you just had major surgery. You’ll probably be back to your old self in about a month to six weeks. At Home Care You will need to wear a sanitary pad for bleeding. It is normal to have vaginal bleeding for several days after birth, followed by a discharge that changes from dark red/brown to a lighter color over several weeks. The area around your incision will be tender for the first few weeks and you should watch it closely. If it becomes swollen, red or inflamed, or if you start running a fever, call your doctor, since this could be a sign of infection. Most women notice that their actual scar is numb from the nerves being cut, but this numbness should go away over the next few months. Your scar will continue to get lighter and look better with time -- and eventually it’ll fade to almost the color of your skin. C-section incisions are made very low these days, so they’re easy to conceal -even in bikinis and low-rise jeans. Arrangements will be made for a follow-up visit with your doctor, usually two to three weeks after the surgery.

Intercourse After a C-Section Intercourse will be off limits for the first six weeks after you deliver, which gives your incision time to heal and your cervix time to close and return to normal. When your doctor gives you the green light to get started, know that your first time will actually be much more comfortable than it would have been after having a vaginal delivery. Experiment with Breast-Feeding Positions You can begin breast-feeding almost immediately after the C-section. Breast-feeding positions that work well during C-section recovery include: • Football hold. Hold your baby at your side, with your elbow bent. With your open hand, support your baby’s head and face him or her toward your breast. Your baby’s back will rest on your forearm. Support your breast in a C-shaped hold with your other hand. For comfort, put a pillow along your side and use a chair with broad, low arms. • Side-lying hold. Lie on your side and place your baby on his or her side, facing your breast. Support your baby with one hand. With the other hand, grasp your breast and touch your nipple to your baby’s lips. Once your baby latches on, use one arm to support your own head and the other to help support the baby. For support or breast-feeding information during your C-section recovery, contact a lactation consultant.

Postpartum Care

Right now, you are focused on caring for your new baby. But, new mothers must take special care of their bodies after giving birth and while breastfeeding too. Doing so will help you to regain your energy and strength. When you take care of yourself, you are able to best care for and enjoy your baby. Getting Rest • • • • •

What to Expect After Giving Birth

Take the first few days home as a time for rest and recovery. Focus your energy on yourself and getting to know your baby. Try and limit the number of visitors you have so that you can get as much rest as possible. Try to nap when the baby naps, and do not try to do too much around the house. Don’t be afraid to ask close family and friends to help with cleaning, laundry, meals, or with caring for the baby.

Physical Changes •

• • •

•

You will have vaginal discharge called lochia. It is the tissue and blood that lined your uterus during pregnancy. It is heavy and bright red at first, becoming lighter in flow and color until it goes away after a few weeks. You might also have swelling in your legs and feet. You can reduce swelling by keeping your feet elevated when possible. You might feel constipated. Try to drink plenty of water and eat fresh fruits and vegetables. Menstrual-like cramping is common, especially if you are breastfeeding. Your breast milk will come in within three to six days after your delivery. Even if you are not breastfeeding, you can have milk leaking from your nipples, and your breasts might feel full, tender, or uncomfortable. Follow your doctor’s instructions on how much activity, like climbing stairs or walking, you can do for the next few weeks.

Regaining a Healthy Weight and Shape • • • •

Pregnancy and labor can both affect a woman’s body. You will lose about 10 pounds after giving birth and a little more as body fluid levels decrease. Do not rush to lose weight after giving birth. Gradual weight loss over several months is the safest way, especially if you plan on breastfeeding. Work on maintaining a healthy eating plan along with regular exercise. Keep in mind that nursing mothers should avoid alcohol.

https://www.womenshealth.gov/pregnancy/childbirth -and-beyond/recovering-birth 57

Having a baby is an exciting and wonderful time, with the joy comes exhaustion, as well as new stress for the family. Postpartum depression is the most common complication of childbearing, It can be a time we feel overwhelmed, tired, physically and emotionally drained. While this can be typical we are concerned for the families struggling with undetected postpartum depression, which can start several weeks after the birth of your baby and last for months. Those who have a preexisting history of anxiety and depression can be at a higher risk for PPD. We ask that you complete the postpartum depression scale and take the time to think about your response, as we are here to help. We recognize this affects the whole family and we address this as a family matter, which can be detected early and managed successfully. Symptoms can include: 1. 2. 3. 4. 5. 6.

Weepy, sad and unengaged. Anxious and feeling worried constantly. Loss of appetite Inability to complete daily tasks and activities. Difficulty bonding with newborn. Feelings of helplessness and greatly overwhelmed

Postpartum Depression

Each provider at Caremount has resources ready to offer and activate for support, management and resolution. Please talk to our team for more details and information on this important issue.

Edinburgh Postnatal Depression Scale1 (EPDS) Name: ______________________________

Address: ___________________________

Your Date of Birth: ____________________

___________________________

Baby’s Date of Birth: ___________________

Phone:

_________________________

As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today. Here is an example, already completed. I have felt happy: Yes, all the time Yes, most of the time No, not very often No, not at all

This would mean: “I have felt happy most of the time” during the past week. Please complete the other questions in the same way.

In the past 7 days: 1. I have been able to laugh and see the funny side of things As much as I always could Not quite so much now Definitely not so much now Not at all 2. I have looked forward with enjoyment to things As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all *3. I have blamed myself unnecessarily when things went wrong Yes, most of the time Yes, some of the time Not very often No, never 4.

I have been anxious or worried for no good reason No, not at all Hardly ever Yes, sometimes Yes, very often

I have felt scared or panicky for no very good reason Yes, quite a lot Yes, sometimes No, not much No, not at all

*6. Things have been getting on top of me Yes, most of the time I haven’t been able to cope at all Yes, sometimes I haven’t been coping as well as usual No, most of the time I have coped quite well No, I have been coping as well as ever *7

I have been so unhappy that I have had difficulty sleeping Yes, most of the time Yes, sometimes Not very often No, not at all

I have felt sad or miserable Yes, most of the time Yes, quite often Not very often No, not at all

I have been so unhappy that I have been crying Yes, most of the time Yes, quite often Only occasionally No, never

*10

The thought of harming myself has occurred to me Yes, quite often Sometimes Hardly ever Never

Administered/Reviewed by ________________________________ Date ______________________________ 1

Source: Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786 .

Source: K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199 Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title and the source of the paper in all reproduced copies.

Edinburgh Postnatal Depression Scale1 (EPDS) 2

Postpartum depression is the most common complication of childbearing. The 10-question Edinburgh Postnatal Depression Scale (EPDS) is a valuable and efficient way of identifying patients at risk for “perinatal” depression. The EPDS is easy to administer and has proven to be an effective screening tool. Mothers who score above 13 are likely to be suffering from a depressive illness of varying severity. The EPDS score should not override clinical judgment. A careful clinical assessment should be carried out to confirm the diagnosis. The scale indicates how the mother has felt during the previous week. In doubtful cases it may be useful to repeat the tool after 2 weeks. The scale will not detect mothers with anxiety neuroses, phobias or personality disorders. Women with postpartum depression need not feel alone. They may find useful information on the web sites of the National Women’s Health Information Center <www.4women.gov> and from groups such as Postpartum Support International <www.chss.iup.edu/postpartum> and Depression after Delivery <www.depressionafterdelivery.com>.

SCORING QUESTIONS 1, 2, & 4 (without an *) Are scored 0, 1, 2 or 3 with top box scored as 0 and the bottom box scored as 3. QUESTIONS 3, 510 (marked with an *) Are reverse scored, with the top box scored as a 3 and the bottom box scored as 0. Maximum score: 30 Possible Depression: 10 or greater Always look at item 10 (suicidal thoughts)

Users may reproduce the scale without further permission, providing they respect copyright by quoting the names of the authors, the title, and the source of the paper in all reproduced copies.

Instructions for using the Edinburgh Postnatal Depression Scale: 1. The mother is asked to check the response that comes closest to how she has been feeling in the previous 7 days. 2. All the items must be completed. 3. Care should be taken to avoid the possibility of the mother discussing her answers with others. (Answers come from the mother or pregnant woman.) 4. The mother should complete the scale herself, unless she has limited English or has difficulty with reading. 1

Source: Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786.

Source: K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199

How long should I breastfeed my baby?

Frequently Asked Questions: Breastfeeding

Breastfeeding is recommended if it is going well and your baby is satisfied. Exclusive breastfeeding is recommended for the first 6 months of a baby’s life. Breastfeeding should continue up to the baby’s first birthday as new foods are introduced. You can keep breastfeeding after the baby’s first birthday for as long as you and your baby would like. How does breastfeeding benefit my baby? •

• •

Breast milk has the right amount of fat, sugar, water, protein, and minerals needed for a baby’s growth and development. As your baby grows your breast milk changes to adapt to the baby’s changing nutritional needs. Breast milk is easier to digest than formula. Breast milk contains antibodies that protect infants from certain illnesses, such as ear infections, diarrhea, respiratory illnesses, and allergies. The longer your baby breastfeeds, the greater the health benefits. Breastfed infants have a lower risk of sudden infant death syndrome (SIDS). Breast milk can help reduce the risk of many of the short-term and long-term health problems that preterm babies face.

How does breastfeeding benefit me? •

• •

Breastfeeding triggers the release of a hormone called oxytocin that causes the uterus to contract. This helps the uterus return to its normal size more quickly and may decrease the amount of bleeding you have after giving birth. Breastfeeding may make it easier to lose the weight you gained. Breastfeeding may reduce the risk of breast cancer and ovarian cancer.

How can I tell if my baby is hungry? When babies are hungry, they look alert, bend their arms, close their fists, and bring their fingers to their mouths. Offer your baby your breast when he or she first starts bringing fingers to his or her mouth. Crying is a late sign of hunger, and an unhappy baby will find it harder to latch. When full, babies relax their arms and legs and close their eyes. How often should I breastfeed my baby? Let your baby set his or her own schedule. During the first weeks of life, most babies feed at least 8–12 times in 24 hours, or at least every 2–3 hours (timed from the start time of one feeding to the start time of the next feeding.

What should I do if I am having trouble breastfeeding? Consult with a peer counselor, nurse, doctor, and/or certified lactation consultant. What kinds of foods should I eat while breastfeeding? • • • •

Your body needs about 450–500 extra calories a day to make breast milk for your baby. If your weight is in the normal range, you need about 2,500 total calories per day. Eat fish and seafood 2–3 times a week, but avoid eating fish with high mercury levels. Do not eat shark, swordfish, king mackerel, or tilefish, and limit albacore tuna to 6 ounces a week. Your health care professional may recommend that you continue to take your prenatal multivitamin supplement while you are breastfeeding. Drink plenty of fluids, and drink more if your urine is dark yellow.

Can I drink caffeine while breastfeeding? Drinking caffeine in moderate amounts (200 mg a day) most likely will not affect your baby. You may want to consume a lower amount of caffeine in the first few days after your baby is born or if your infant is preterm. Can I drink alcohol while breastfeeding? If you want to have an occasional alcoholic drink, wait at least 2 hours after a single drink to breastfeed. The alcohol will leave your milk as it leaves your bloodstream—there is no need to express and discard your milk. Drinking more than two drinks per day on a regular basis may be harmful to your baby. How do I know if a medication is safe to take while breastfeeding? If you are breastfeeding and need to take a prescription or over the counter medication to manage a health condition, discuss with a health care professional. Why is it important to avoid smoking and drug use while breastfeeding? Secondhand smoke from cigarettes is harmful to infants and children. It increases the risk of allergies, asthma, and SIDS. Smoking can decrease your milk supply and can make it harder for the baby to gain weight. Be sure not to smoke around the baby. Using illegal drugs, such as cocaine, heroin, and methamphetamines, and taking prescription drugs for nonmedical reasons can harm your baby if you use them while breastfeeding. And although marijuana is now legal in several states, its use is discouraged during breastfeeding. If you need help stopping drug use, talk with your obstetrician, lactation consultant, or other health care professional. What birth control methods can I use while breastfeeding? Many birth control methods are available that can be used while breastfeeding, including non-hormonal methods (copper intrauterine device, condoms, and diaphragms) and hormonal methods. Consult with your Ob/Gyn. https://www.acog.org/Patients/FAQs/Breastfeeding-Your-Baby

If you had a healthy pregnancy and a normal vaginal delivery, you should be able to start exercising again soon after the baby is born. Usually, it is safe to begin exercising a few days after giving birth—or as soon as you feel ready. If you had a cesarean birth or other complications, ask your health care professional when it is safe to begin exercising again. Exercise has many benefits for women postpartum: • • • • •

Exercising Post Pregnancy

It helps strengthen and tone abdominal muscles. It boosts energy. It may be useful in preventing postpartum depression. It promotes better sleep. It relieves stress.

After having a baby, you should get at least 150 minutes of moderateintensity aerobic activity every week. Examples of moderate-intensity aerobic activities include brisk walking and riding a bike on a level surface. You can choose to divide the 150 minutes into 30-minute workouts on 5 days of the week or into smaller 10-minute sessions throughout each day. For example, you could go for three 10-minute walks each day. You may also want to exercise your body’s major muscle groups, such as the legs, arms, and hips. Examples include yoga, Pilates, lifting weights, sit-ups, and push-ups. There also are special exercises (Kegel exercises) that help tone the muscles of the pelvic floor. Muscle-strengthening activities should be done in addition to your aerobic activity on at least 2 days a week. Aim to stay active for 20–30 minutes a day. When you first start exercising after childbirth, try simple postpartum exercises that help strengthen major muscle groups, including abdominal and back muscles. Gradually add moderate-intensity exercise. Remember, even 10 minutes of exercise benefits your body. If you exercised vigorously before pregnancy or you are a competitive athlete, you can work up to vigorousintensity activity. Stop exercising if you feel pain. When you are ready to start exercising, walking is a great way to get back in shape. Walking outside has an added bonus because you can push your baby in a stroller. There are special strollers made for this kind of activity, but using a regular stroller is fine. Another good way to get daily exercise is by joining an exercise class. Working out with a group and socializing with group members can help keep you motivated.

As you get ready for your workout, follow these steps: • Wear loose-fitting clothing that will help keep you cool. • If you are breastfeeding, feed your baby or express your milk before your workout to avoid any discomfort that may come from engorged breasts. • Wear a bra that fits well and gives plenty of support to protect your breasts. • Have a bottle of water handy and take several sips during your workout. Spend 10 minutes warming up to get your muscles ready for exercise. Try stretches for the lower back, pelvis, and thighs. Hold stretches for several seconds and return to the starting position. Walking in place also is a good way to warm up. End your workout with a 5-minute cool-down period that brings your heart rate back to normal. Walk slowly in place and stretch again to help avoid soreness.

Postpartum Birth Control Options and Use: What’s right for me and my family? If you are not using a birth control method, it is possible to become pregnant very soon after having a baby. Using a birth control method in the weeks after you have a baby helps you avoid an unintended pregnancy.

Birth Control Options

When choosing a birth control method to use after you have a baby, think about the following: • •

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Timing—some birth control methods can be started right after childbirth. With other methods, you need to wait a few weeks to start. Breastfeeding—All methods are safe to use while breastfeeding. However, there are a few methods that are not recommended during the first few weeks of breastfeeding because there is a very small risk that they can affect your milk supply. Effectiveness—the method you used before pregnancy may not be the best choice to use after pregnancy. For example, the sponge and cervical cap are much less effective in women who have given birth.

Intrauterine Devices What is an intrauterine device? The intrauterine device (IUD) is a small, T-shaped device that your obstetrician–gynecologist (ob-gyn) or other health care professional inserts into your uterus. IUDs usually can be inserted right after a vaginal delivery or at your first postpartum health care visit. The hormonal IUD releases a small amount of progestin into the uterus and is approved for up to 3-5 years of use, depending on the kind you get. The copper IUD releases a small amount of copper into the uterus and is approved for up to 10 years of use. Both work mainly by stopping the egg and sperm from fertilizing. What are the benefits of an intrauterine device? IUDs do not interfere with sex or daily activities. Once inserted, you do not have to do anything else to prevent pregnancy. The hormonal IUD may decrease menstrual pain and heavy menstrual bleeding.

What are the possible risks and side effects of an intrauterine device? • • •

The IUD may come out of the uterus. This happens in about 5% of users in the first year of using the IUD. Serious complications from using an IUD, such as infection or injury, are rare. The hormonal IUD may cause spotting and irregular bleeding in the first 3–6 months of use. Other side effects include headaches, nausea, depression, and breast tenderness. The copper IUD may increase menstrual pain and bleeding or cause bleeding between periods, mainly in the first few months of use. This usually decreases within one year of use.

Birth Control Implants What is a birth control implant? The birth control implant is a single flexible rod about the size of a matchstick that your ob-gyn or other health care professional inserts under the skin in your upper arm. You can have the implant inserted immediately after a vaginal or cesarean delivery. It releases progestin into the body and is approved for up to 3 years of use. What are the benefits of an implant? The implant does not interfere with sex or daily activities. Once it is inserted, you do not have to do anything else to prevent pregnancy. Almost all women are able to use the implant. What are the possible risks and side effects of an implant? The implant may cause unpredictable bleeding. Your periods may be heavier, lighter, or longer. Some users experience infrequent periods or bleeding in between periods. Other common side effects include mood changes, headaches, acne, and depression.

Birth Control Injections What is a birth control injection? The birth control injection contains a type of progestin called depot medroxyprogesterone acetate (DMPA). It works by preventing ovulation. Your ob-gyn or other health care professional will give you a shot of DMPA in your arm or buttock every 3 months. You can get your first shot right after a vaginal or cesarean delivery. What are the benefits of an injection? An injection does not interfere with sex. Almost all women are able to use the injection. What are the possible risks and side effects of an injection? • • •

Bone loss may occur with use of the injection. When injections are stopped, some, if not all, of the bone that was lost is gained back. An injection should not be used if you have multiple risk factors for cardiovascular disease. An injection may cause irregular bleeding, headaches, or slight weight gain.

Combined Hormonal Methods What are combined hormonal methods? Birth control pills, the vaginal ring, and the patch are birth control methods that contain estrogen and progestin. They work mainly by preventing ovulation. Depending on the method, you need to remember to do one of the following: take a pill each day, insert a vaginal ring every 21 days, or apply a skin patch every week for 3 weeks. What are the benefits of combined hormonal methods? These methods do not interfere with sex. They may make your period more regular, lighter, and shorter. These methods may also reduce cramps, improve acne, reduce menstrual migraine frequency, and reduce unwanted hair growth. What are the possible risks and side effects of combined hormonal methods? •

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During the postpartum period, women have a higher risk of developing blood clots in veins located deep in the body. This condition is called deep vein thrombosis (DVT). Combined hormonal methods increase the risk of DVT even further. If you have no additional risk factors for DVT, you can start using these methods 3 weeks after childbirth. There is a very small risk that the estrogen in these methods can affect your milk supply if you are breastfeeding. You should avoid these methods for the first 4–6 weeks after childbirth, until breastfeeding is established. Combined hormonal methods have been linked to a small risk of stroke and heart attacks. They are not recommended if you are older than 35 years and smoke; have high blood pressure or a history of stroke, heart attack, or DVT; have a history of migraine headaches with aura; have certain medical conditions; or have breast cancer or a history of breast cancer. Side effects may include breakthrough bleeding, headaches, breast tenderness, and nausea.

Progestin-only Pill What is the progestin-only pill? Progestin-only birth control pills contain just progestin. They work mainly by preventing fertilization of the egg by the sperm. They must be taken at the exact same time each day. If you miss a pill by more than 3 hours, you will need to use a back-up method for the next 48 hours. What are the benefits of the progestin-only pill? Progestin-only pills do not interfere with sex. They may reduce menstrual bleeding or stop your period altogether. What are the possible risks and side effects of the progestin-only pill? Side effects include headaches, nausea, and breast tenderness. Progestin-only pills should not be used if you have breast cancer or a history of breast cancer. They are not recommended if you have certain medical conditions.

Barrier Method What is the barrier method? Barrier methods include spermicide, male and female condoms, the diaphragm, the cervical cap, and the sponge. Barrier methods work by preventing the man’s sperm from reaching the woman’s egg. The cervical cap, diaphragm, and sponge can be used starting 6 weeks after childbirth, when the uterus and cervix have returned to normal size. If you used a diaphragm or cervical cap before childbirth, you should be refitted after childbirth. What are the benefits of the barrier method? Condoms are the only birth control method that protect against sexually transmitted infections (STIs). Condoms, spermicide, and the sponge can be bought over the counter. Barrier methods have no effect on a woman’s natural hormones. What are the possible risks and side effects of the barrier method? Spermicides can cause vaginal burning and irritation. Some people are allergic to spermicide and may have a reaction. Frequent use of spermicides (such as every day) can increase the risk of getting human immunodeficiency virus (HIV) from an infected partner.

Lactational Amenorrhea What is the lactational amenorrhea method? Lactational amenorrhea method (LAM) is a temporary method of birth control based on the natural way the body prevents ovulation when a woman is breastfeeding. It requires exclusive, frequent breastfeeding. The time between feedings should not be longer than 4 hours during the day or 6 hours at night. LAM may not be practical for many women. What are the benefits of the lactational amenorrhea method? It is a natural form of birth control. It does not cost anything. What are the possible risks and side effects of the lactational amenorrhea method? There are no health risks or side effects to using LAM. This method can be used for only 6 months after childbirth or until your period returns. It is unclear whether pumping breast milk decreases the effectiveness of LAM.

Sterilization What is sterilization? Sterilization is permanent birth control. In women, sterilization is performed by closing off or removing the fallopian tubes. It can be performed soon after delivery while you are still in the hospital, several weeks after you have your baby, or several months after childbirth. For men, vasectomy is an option. It takes about 2–4 months for the semen to become totally free of sperm after a vasectomy. A couple must use another method of birth control or avoid sexual intercourse until a sperm count confirms that no sperm are present. What are the benefits of sterilization? Sterilization is permanent. Once you have it done, you do not need to use any other birth control method. What are the possible risks and side effects of sterilization? There is a small risk of infection and bleeding with female and male sterilization. You should be sure that you no longer want to become pregnant again in the future. If you change your mind later, attempts to reverse it are not guaranteed to work. Source: www.acog.org

Star Legacy Foundation

Local Support Services

The Star Legacy Foundation is a non-profit organization dedicated to reducing pregnancy loss and neonatal death and improving care for families who experience such tragedies. They are a community of families, health professionals, researchers, policy makers, and individuals dedicated to helping every pregnancy have a happy ending. Their mission: To increase awareness, support research, promote education, and encourage advocacy and family support regarding stillbirth, pregnancy loss, and neonatal death. The Foundation believes there is great hope for the future to prevent many stillbirths and neonatal deaths in the United States and around the world. Through the utilization of technology, education, grassroots efforts, and partnership, the Foundation strives to empower families and health professionals to identify and protect vulnerable babies. What They Do • Provide support groups for bereaved families, bereaved extended families, and couples in a pregnancy after a loss • Promote, support, and conduct research related to stillbirth and perinatal loss • Provide patient education materials • Provide family support materials and companion services to bereaved families • Support and encourage legislation at state and federal levels that provide support for stillbirth prevention efforts and improve care of families experiencing perinatal loss • Host a nationwide telephone support line staffed by certified grief counselors • Raise awareness of issues related to pregnancy and infant loss and stillbirth prevention

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