Pregnancy and Birth Source Book
Pregnancy and Birth Source Book
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Basic Consumer Health Information about Pregnancy and Fetal Development, Including Facts about Fertility and Conception, Physical and Emotional Changes during Pregnancy, Prenatal Care and Diagnostic Tests, High-Risk Pregnancies and Complications, Labor, Delivery, and the Postpartum Period Along with Tips on Maintaining Health and Wellness during Pregnancy and Caring for Newborn Infants, a Glossary of Related Terms, and a Directory of Resources for Additional Help and Information
Edited by
Amy L. Sutton
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_________________________ _____________________ _________________________ _____________________ _________________________ _____________________ _________________________ _____________________ _________________________ _____________________ _________________________ _____________________ Basic Consumer Health Information about Pregnancy __________________________ _____________________ __________________________ _____________________ and Fetal Development, Including Facts about Fertility _________________________ _____________________ _________________________ _____________________ and Conception, Physical and Emotional Changes during _________________________ _____________________ Pregnancy, Prenatal Care and Diagnostic Tests, High-Risk _________________________ _____________________ _________________________ _____________________ Pregnancies and Complications, Labor, Delivery, and the _________________________ _____________________ _________________________ _____________________ Postpartum Period _________________________ ____________________ _________________________ _____________________ _________________________ _____________________ Along with Tips on Maintaining Health and Wellness _________________________ _____________________ during Pregnancy and Caring for Newborn Infants, a _________________________ _____________________ _________________________ _____________________ Glossary of Related Terms, and a Directory of Resources _________________________ _____________________ _________________________ _____________________ for Additional Help and Information _________________________ _____________________ _________________________ _____________________ ________________________ ____________________ _________________________ _____________________ _________________________ _____________________ _________________________ _____________________ _________________________ _____________________ Edited by ______________________________ ___________________________ 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SOURCEBOOK
Amy L. Sutton
Bibliographic Note Because this page cannot legibly accommodate all the copyright notices, the Bibliographic Note portion of the Preface constitutes an extension of the copyright notice. Edited by Amy L. Sutton Health Reference Series Karen Bellenir, Managing Editor David A. Cooke, MD, FACP, Medical Consultant Elizabeth Collins, Research and Permissions Coordinator Cherry Edwards, Permissions Assistant EdIndex, Services for Publishers, Indexers *** Omnigraphics, Inc. Matthew P. Barbour, Senior Vice President Kevin M. Hayes, Operations Manager *** Peter E. Ruffner, Publisher Copyright 2009 Omnigraphics, Inc. ISBN 978-0-7808-1074-7
Library of Congress Cataloging-in-Publication Data Pregnancy and birth sourcebook : basic consumer health information about pregnancy and fetal development ... / edited by Amy L. Sutton. -- 3rd ed. p. cm. Summary: "Provides basic consumer health information about the reproductive process from preconception through the postpartum period, with facts about fertility, maintaining health during pregnancy, coping with high risk pregnancies and complications, and newborn care. Includes index, glossary of related terms and directory of resources"--Provided by publisher. Includes bibliographical references and index. ISBN 978-0-7808-1074-7 (hardcover : alk. paper) 1. Pregnancy--Popular works. 2. Childbirth--Popular works. 3. Pregnancy--Complications--Popular works. I. Sutton, Amy L. RG525.P676 2009 618.2--dc22 2009029246
Electronic or mechanical reproduction, including photography, recording, or any other information storage and retrieval system for the purpose of resale is strictly prohibited without permission in writing from the publisher. The information in this publication was compiled from the sources cited and from other sources considered reliable. While every possible effort has been made to ensure reliability, the publisher will not assume liability for damages caused by inaccuracies in the data, and makes no warranty, express or implied, on the accuracy of the information contained herein.
This book is printed on acid-free paper meeting the ANSI Z39.48 Standard. The infinity symbol that appears above indicates that the paper in this book meets that standard. Printed in the United States
Table of Contents
Visit www.healthreferenceseries.com to view A Contents Guide to the Health Reference Series, a listing of more than 15,000 topics and the volumes in which they are covered.
Preface ............................................................................................ xv
Chapter 3Questions and Answers about Preconception Care ................................................. 13 Chapter 4Factors That Affect Fertility .................................... 19
Section 4.1Age and Fertility .......................... 20 Section 4.2Stress and Fertility ..................... 21 Section 4.3Sperm Shape: Does It Affect Fertility? ....................................... 23 Section 4.4Paternal Exposures to Toxins ....................................... 25
Chapter 6Frequently Asked Questions about Infertility ..... 45 Chapter 7Preventing Unintended Pregnancies .................... 49
Section 7.1Contraception (Birth Control) ........................... 50 Section 7.2Mifepristone (The Morning-After Pill) ........... 58 Section 7.3Facts about Abortion in the United States .................. 60
vi
Chapter 11Pregnancy and Bone Health .................................. 99 Chapter 12Carpal Tunnel Syndrome More Common during Pregnancy .................................................. 103 Chapter 13Vision and Oral Changes ...................................... 107
Section 13.1Pregnancy and Your Vision ........................................ 108 Section 13.2Pregnancy and Oral Health ....................................... 110
Chapter 15The Three Trimesters of Pregnancy: You and Your Baby ............................................... 125
Chapter 17Prenatal Medical Tests and Care during Pregnancy .................................................. 141 Chapter 18Immunization Issues for Pregnant Women ........ 159 Chapter 19Taking Medicines during Pregnancy .................. 167
Section 19.1Is It Safe to Use Medicines during Pregnancy? ................... 168 Section 19.2Aspirin and Pregnancy ............ 173
Chapter 22Exercise during Pregnancy .................................. 197 Chapter 23Weight Gain during Pregnancy ........................... 201
Section 23.1How Much Weight Should You Gain? .................... 202 Section 23.2Gestational Weight Gain Warnings ......................... 205
Chapter 24Sleep during Pregnancy ....................................... 209 Chapter 25Sex during Pregnancy ........................................... 213 Chapter 26Working and Traveling during Pregnancy ......... 217
Section 26.1Work and Travel Considerations for Pregnant Women ..................... 218 Section 26.2International Travel during Pregnancy .................... 221
Chapter 27Nicotine, Alcohol, and Drug Use during Pregnancy .................................................. 225
Section 27.1Smoking and Pregnancy ......... 226 Section 27.2Alcohol Use and Pregnancy ................................. 227 Section 27.3Fetal Alcohol Spectrum Disorders .................................. 230 Section 27.4Drug Use during Pregnancy ................................. 235
viii
Chapter 31Allergies, Asthma, and Pregnancy ...................... 281 Chapter 32Cancer and Pregnancy .......................................... 289
Section 32.1Breast Cancer and Pregnancy ................................. 290 Section 32.2Gestational Trophoblastic Tumors ...................................... 293
Chapter 33For Women with Diabetes: Your Guide to Pregnancy ..................................... 295
ix
Chapter 34Epilepsy and Pregnancy ....................................... 303 Chapter 35Lupus and Pregnancy ........................................... 307 Chapter 36Sickle Cell Disease and Pregnancy ..................... 311 Chapter 37Thyroid Disease and Pregnancy .......................... 315 Chapter 38Eating Disorders during Pregnancy .................... 319
Section 38.1How Do Eating Disorders Impact Pregnancy? .................. 320 Section 38.2Pica ........................................... 323
Chapter 44Cholestasis of Pregnancy ...................................... 371 Chapter 45Gestational Diabetes ............................................ 375 Chapter 46Gestational Hypertension .................................... 381 Chapter 47Hyperemesis Gravidarum (Severe Nausea and Vomiting) ............................ 385 Chapter 48Placental Complications ....................................... 391 Chapter 49Rh Incompatibility ................................................ 399 Chapter 50Umbilical Cord Abnormalities ............................. 403 Chapter 51Overview of Sexually Transmitted Diseases (STDs) during Pregnancy ..................... 409 Chapter 52Hepatitis B and Pregnancy .................................. 413
Section 52.1What Is Hepatitis? ................... 414 Section 52.2Frequently Asked Questions about Pregnancy and Hepatitis B ............................... 416
Chapter 53Human Immunodeficiency Virus (HIV) during Pregnancy, Labor and Delivery, and Birth ................................................................ 419 Chapter 54Group B Streptococcus (GBS) .............................. 425 Chapter 55Pregnancy Loss: Ectopic Pregnancy, Miscarriage, and Stillbirth ................................... 429
Section 55.1Ectopic Pregnancy ................... 430 Section 55.2Blighted Ovum ......................... 431 Section 55.3What Is a Miscarriage? ........... 433
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Section 55.4Incompetent Cervix Can Lead to Miscarriage ................. 435 Section 55.5Drug Offers Alternative to Surgical Treatment after Miscarriage ..................... 437 Section 55.6What Is a Stillbirth? ................ 439 Section 55.7Research on Miscarriage and Stillbirth ............................ 441 Section 55.8Coping with Pregnancy Loss ........................................... 443
Chapter 60Birth Plans............................................................. 485 Chapter 61Banking Your Newborns Cord Blood ................. 493 Chapter 62Natural Childbirth ................................................ 497 Chapter 63Pain Relief during Labor ...................................... 503
xii
Chapter 65Inducing Labor ...................................................... 515 Chapter 66Vaginal and Cesarean Childbirth ........................ 519
Section 66.1The Stages of Vaginal Childbirth ................................. 520 Section 66.2Vaginal Birth after a Previous Cesarean Delivery or Repeat Cesarean Section ..... 526 Section 66.3Cesarean Sections .................... 536
Chapter 73Bonding with Your Baby ...................................... 581 Chapter 74Working after Birth: Parental Leave Considerations ....................................................... 587
Section 74.1Maternity Leave in the United States ..................... 588
xiii
xiv
Preface
a birth partner or doula, and preparing a birth plan. This part also provides details on the stages of labor, pain relief during labor, vaginal and cesarean births, and emergency situations that may occur during childbirth. Part VII: Postpartum and Newborn Care discusses common postpartum concerns, including recovery expectations for new mothers, newborn care and screening tests, breastfeeding and formula-feeding tips, strategies for bonding with a new baby, and considerations for working after a childs birth. Part VIII: Additional Help and Information includes a glossary of important terms and a directory of organizations that provide help, information, and assistance to low-income pregnant women and their partners.
Bibliographic Note
This volume contains documents and excerpts from publications issued by the following U.S. government agencies: Agency for Healthcare Research and Quality (AHRQ); AIDSinfo; Center for Devices and Radiological Health (CDRH); Center for the Evaluation of Risks to Human Reproduction (CERHR); Centers for Disease Control and Prevention (CDC); Environmental Protection Agency (EPA); National Cancer Institute (NCI); National Heart, Lung, and Blood Institute (NHLBI); National Human Genome Research Institute (NHGRI); National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS); National Institute of Child Health and Human Development (NICHD); National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); National Institute of Environmental Health Sciences (NIEHS); National Institute of Mental Health (NIMH); National Institute of Neurological Disorders and Stroke (NINDS); National Institute on Alcohol Abuse and Alcoholism (NIAAA); National Institutes of Health (NIH); Office of Womens Health; U.S. Department of Health and Human Services (HHS); U.S. Department of Labor (DOL); and the U.S. Food and Drug Administration (FDA). In addition, this volume contains copyrighted documents from the following organizations: Academy of General Dentistry; A.D.A.M., Inc.; American Academy of Family Physicians; American College of Allergy, Asthma and Immunology; American College of Nurse-Midwives; American Pregnancy Association; American Society for Reproductive Medicine; American Society of Anesthesiologists; BabyCenter LLC; Childbirth Connection; Childrens Hospital of Pittsburgh; DONA xvii
International; Hepatitis B Foundation; Hyperemesis Education and Research Foundation; Institute for Womens Policy Research; Henry J. Kaiser Family Foundation; Lamaze International; March of Dimes Birth Defects Foundation; National Campaign to Prevent Teen and Unplanned Pregnancy; National Network for Immunization Information; The Nemours Foundation; Obesity Action Coalition; Organization of Teratology Information Services (OTIS); Prevent Blindness America; and the University of Pittsburgh Medical Center. Full citation information is provided on the first page of each chapter or section. Every effort has been made to secure all necessary rights to reprint the copyrighted material. If any omissions have been made, please contact Omnigraphics to make corrections for future editions.
Acknowledgements
Thanks go to the many organizations, agencies, and individuals who have contributed materials for this Sourcebook and to medical consultant Dr. David Cooke and document engineer Bruce Bellenir. Special thanks go to managing editor Karen Bellenir and research and permissions coordinator Liz Collins for their help and support.
and the Chicago Manual of Style for questions related to grammatical structures, punctuation, and other editorial concerns. Consistent adherence is not always possible, however, because the individual volumes within the Series include many documents from a wide variety of different producers and copyright holders, and the editors primary goal is to present material from each source as accurately as is possible following the terms specified by each documents producer. This sometimes means that information in different chapters or sections may follow other guidelines and alternate spelling authorities. For example, occasionally a copyright holder may require that eponymous terms be shown in possessive forms (Crohns disease vs. Crohn disease) or that British spelling norms be retained (leukaemia vs. leukemia).
Medical Consultant
Medical consultation services are provided to the Health Reference Series editors by David A. Cooke, MD, FACP. Dr. Cooke is a graduate of Brandeis University, and he received his M.D. degree from the University of Michigan. He completed residency training at the University of Wisconsin Hospital and Clinics. He is board-certified in Internal Medicine. Dr. Cooke currently works as part of the University of Michigan Health System and practices in Ann Arbor, MI. In his free time, he enjoys writing, science fiction, and spending time with his family. xix
xx
Chapter 1
What is pregnancy?
Pregnancy is the term used to describe when a woman has a growing fetus inside of her. In most cases, the fetus grows in the uterus. Human pregnancy lasts about 40 weeks, or just more than 9 months, from the start of the last menstrual period to childbirth.
What are prenatal and preconception care and why are they important?
Prenatal care is the care woman gets during a pregnancy. Getting early and regular prenatal care is important for the health of both mother and the developing baby. In addition, health care providers are now recommending a woman see a health care provider for preconception care, even before she considers becoming pregnant or in between pregnancies. Both preconception care and prenatal care help to promote the best health outcomes for mother and baby.
What is infertility?
Infertility is the term health care providers use for women who are unable to get pregnant, and for men who are unable to impregnate a woman, after at least one year of trying. In women, the term is used to describe those who are of normal childbearing age, not those who cant get pregnant because they are near or past menopause. Women who are able to get pregnant but who cannot carry a pregnancy to term (birth) may also be considered infertile. Infertility is a complex problemit does not have a single cause because getting pregnant is a multi-step chain of events. The cause of infertility can rest in the women or the man, or can be from unknown factors or a combination of factors.
What is contraception?
Contraception, also known as birth control, is designed to prevent pregnancy. Some types of birth control include (but are not limited to): 4
Chapter 2
Preconception Considerations
Chapter Contents
Section 2.1What to Do before You Conceive .............................. 8 Section 2.2Understanding Genetic Counseling and Evaluation: Is It Right for You? ............................. 11
Section 2.1
Some foods, habits, and medicines can harm your babyeven before he is conceived. Find out what to do and what to avoid when youre trying to get pregnant.
Before Pregnancy
If youre thinking about getting pregnant, or are already pregnant, taking care of your health is more important than ever. Follow these tips for a healthy pregnancy: Get 400 micrograms (or 0.4 mg) of folic acid daily. Eat foods fortified with folic acid, take a multivitamin, or take a folic acid pill to get your daily dose. Taking folic acid in a pill is the best way to be sure youre getting enough. Including 0.4 mg of folic acid (or folate) in your diet before you get pregnant and in the first three months of pregnancy can help prevent some birth defects. If you dont get enough folic acid, your babys spine may not form right. This is called spina bifida. Also, your baby needs folic acid to develop a healthy brain. Many doctors will prescribe a vitamin with folic acid. But you also can buy vitamins or folic acid pills at drug and grocery stores. Some foods rich in folate include: leafy green vegetables, kidney beans, orange juice and other citrus fruits, peanuts, broccoli, asparagus, peas, lentils, and whole-grain products. Folic acid is also added to some foods like enriched breads, pastas, rice, and cereals. Start watching what you eat. Load up on fruits, vegetables, and whole-grains (such as whole-wheat breads or crackers). Eat plenty of calcium-rich foods such as non-fat or low-fat yogurt, milk, and broccoli. Your baby needs calcium for strong bones and teeth. When fruits and vegetables arent in season, 8
Preconception Considerations
frozen vegetables are a good option. Avoid eating a lot of fatty foods (such as butter and fatty meats). Choose leaner foods when you can (such as skim milk, chicken and turkey without the skin, and fish). Tell your doctor if you smoke or use alcohol or drugs. Quitting is hard, but you can do it. Ask your doctor for help. Get enough sleep. Try to get seven to nine hours every night. Take steps to control the stress in your life. When it comes to work and family, figure out what you can and can not do. Set limits with yourself and others. Dont be afraid to say no to requests for your time and energy. Move your body. Once you get pregnant, you cant increase your exercise routine by much. So its best to start before the baby is on the way. Get any health problems under control. Talk to your doctor about how your health problems might affect you and your baby. If you have diabetes, monitor your blood sugar levels. If you have high blood pressure, monitor these levels as well. If you are overweight, talk to your doctor about how to reach a healthy weight. Ask your mother, aunts, grandmother or sisters about their pregnancies. Did they have morning sickness? Problems with labor? How did they cope? Find out what health problems run in your family. Tell these to your doctor. You can get tested for health problems that run in families before getting pregnant (genetic testing). Make sure you have had all of your immunizations (shots), especially for rubella (German measles). If you havent had chickenpox or rubella, get the shots at least three months before getting pregnant. Get checked for hepatitis B and C, sexually transmitted diseases (STDs), and HIV [human immunodeficiency virus]. These infections can harm you and your baby. Tell your doctor if you or your sex partners have ever had an STD or HIV. Go over all of the medicines you take (prescription, overthe-counter, and herbals) with your doctor. Make sure they are safe to take while youre trying to get pregnant or are pregnant. 9
Planning Conception
While trying to conceive, you can use natural planning methods such as the ovulation method (have intercourse just before or after ovulation) or the symptothermal method (evaluating fertility based on your daily temperature). Remember: women are more likely to become pregnant if intercourse takes place just before or just after ovulation. This is because the unfertilized egg can live for only 1224 hours in your body. If youve been trying for a few months with no results, dont get discouraged. Only 20% of women trying to get pregnant are successful on the first attempt. So dont lose hope or assume something is wrong.
10
Preconception Considerations
Section 2.2
12
Chapter 3
13
How long before becoming pregnant should a woman start preparing for pregnancy? What are the five most important things she should do before pregnancy for her and her babys health?
Every man and woman should prepare for pregnancy before becoming sexually active, or at least three months before conception. Women should begin some of the recommendations even sooner such as quitting smoking, reaching healthy weight, and adjusting medications. Planning for pregnancy is also a good time to talk about other concerns. Issues such as intimate partner domestic violence, mental health, and previous pregnancy problems need to be discussed. Although men and women can do much on their own, a health care provider is necessary for finding and treating existing health problems. They can also help a woman improve her health before pregnancy. The five most important things a woman can do for preconception health are: 15
4.
5.
The new recommendations say that everyone should have a reproductive life plan. What does this really mean?
A reproductive life plan is a set of personal goals about having (or not having) children. It also states how to achieve those goals. Everyone needs to make a reproductive plan based on personal values and resources. Here are some examples: Im not ready to have children now. Ill make sure I dont get pregnant. Either I wont have heterosexual sex, or Ill correctly use effective contraception. Ill want to have children when my relationship feels secure and Ive saved enough money. I wont become pregnant until then. After that, Ill visit my doctor to discuss preconception health. Ill try to get pregnant when Im in good health. Id like to be a father after I finish school and have a job to support a family. While I work toward those goals, Ill talk to my wife about her goals for starting a family. Ill make sure we correctly use an effective method of contraception every time we have sex until were ready to have a baby. Id like to have two children, and space my pregnancies by at least two years. Ill visit my certified nurse midwife to discuss preconception health now. Ill start trying to get pregnant as soon as Im healthy. Once I have a baby, Ill get advice from a 16
What can men do to support the preconception health of their female partners and their future babies?
Men can make a big difference in promoting good preconception health. As boyfriends, husbands, fathers-to-be, partners, and family members, they can learn how their loved ones can achieve optimal preconception health. They can encourage and support women in every aspect of preparing for pregnancy. There are other ways men can help. Men who work with chemicals or other toxins need to be careful that they dont expose women to them. For example, men who use fertilizers or pesticides in agricultural jobs should change out of dirty work clothes before coming near their female partners. They should handle and wash soiled clothes separately. The family health histories of men are also important when planning a pregnancy. Understanding genetic risks from both sides enables providers to give more accurate advice. Screening for and treating STIs (sexually transmitted infections) in men can help make sure that the infections are not passed to female partners. Men can improve their own reproductive health by reducing stress, eating right, avoiding excessive alcohol use, not smoking, and talking to their health care providers about their own medications. It is also important for men who smoke to stop smoking around their partners to avoid the harmful effects of secondhand smoke.
What should my health care provider be doing about preconception care at my regular visits?
Health care providers have a lot to cover during an appointment, so its always a good idea to make a list and bring up any issues on your mind. Do this even if the health care provider doesnt ask about 17
18
Chapter 4
Chapter Contents
Section 4.1Age and Fertility ...................................................... 20 Section 4.2Stress and Fertility ................................................. 21 Section 4.3Sperm Shape: Does It Affect Fertility? .................. 23 Section 4.4Paternal Exposures to Toxins ................................ 25
19
Section 4.1
In 2005, the general fertility rate rose slightly to 66.7 births per 1,000 women aged 1544 years. The birth rate among teenagers aged 1519 years continued to decline, reaching another record low (40.5 births per 1,000 women aged 1519). This rate was 35 percent lower than the most recent peak reported in 1991 (61.8 births per 1,000). The highest birth rate was among women aged 2529 (115.5 per 1,000), followed by women aged 2024 years (102.2 per 1,000). There was a 2.0 percent increase in birth rates among women aged 3539 years and 4044 years, since 2004, to 46.3 and 9.1 per 1,000, respectively. In 2005, 10.2 percent of births were to women aged 19 years and younger, and 52.5 percent of births were to women in their twenties; more than one-third of births were to women in their thirties, and 2.7 percent were to women aged 4054 years. The average age at first birth was 25.2 years; this is an increase of almost 4 years since 1970. Among non-Hispanic Black and Hispanic women, more than 56 percent of births were to women in their twenties, while just over half of births to non-Hispanic White women occurred in the same age group. The proportion of births to teenagers was higher among nonHispanic Black and Hispanic women (17.0 and 14.1 percent, respectively) than to non-Hispanic White women (7.3 percent). Non-Hispanic White women giving birth were more likely to be in the 30- to 54-yearold age range than were either non-Hispanic Black or Hispanic women.
20
Section 4.2
Stress can come from just about anything that you feel is threatening or harmful. A single event (or your worry about it) can produce stress. So can the little things that worry you all day long. Acute stress, caused by a single event (or your fear of it), makes your heart beat faster and your blood pressure go up. You breathe harder, your hands get sweaty, and your skin feels cool and clammy. Chronic stress, which is when you are always stressed, can cause depression and changes in your sleep habits. It can also decrease your chances of fighting off common illnesses. Stress makes many body organs work harder than normal and increases the production of some important chemicals in your body, including hormones.
Section 4.3
How do doctors decide if a man might have a fertility problem? For many years, experts have focused on semen analysis, but research studies show that the number of sperm (count) and the movement of sperm (motility) do not always predict fertility very well by themselves. It may also be useful to look at the shape of the sperm (morphology), which is also one of the important parts of the semen evaluation. An updated way of determining sperm shape is called the Krugers strict morphology method. Kruger morphology is a useful system that helps doctors determine if a sperm is normally shaped or not. It was originally used to predict the success of in vitro fertilization (IVF), a fertility treatment in which the sperm are mixed with the womans egg in a laboratory. More recently, it has been used to tell if intracytoplasmic sperm injection (ICSI) is a necessary treatment. ICSI is a procedure that helps a sperm fertilize an egg by injecting a single sperm directly into the center of the egg. Even though it is used for these purposes, not all physicians and scientists are sure that strict morphology method alone predicts success with IVF or whether it indicates the need for ICSI. Characteristics of normal sperm. A normal sperm has: a smooth, oval shaped head that is 56 micrometers long and 2.53.5 micrometers around (less than the size of a needle point); a well defined cap (acrosome) that covers 40% to 70% of the sperm head; no visible defect of neck, midpiece, or tail; 23
Are there any substances that I can reduce or eliminate exposure to (e.g., alcohol, tobacco, caffeine) in order to improve the shape of my sperm?
Studies havent shown a clear link between abnormal sperm shape and these factors, but its a good idea to try to eliminate use of tobacco and recreational drugs and limit your consumption of alcohol. These substances reduce sperm production and function in several ways. They may hurt sperm DNA (material that carries your genes) quality. Studies have not shown a clear link between caffeine consumption and changes in sperm shape.
Are there any dietary supplements or vitamins that I can take to improve morphology?
Dietary supplements or vitamins have not been clearly shown to improve sperm morphology. Some specialists do recommend that you 24
Section 4.4
This text talks about the risks that paternal exposures can have during pregnancy. With each pregnancy, all women have a 3% to 5% chance of having a baby with a birth defect. This information should not take the place of medical care and advice from your health care provider.
Can alcohol use by the father affect my chances of getting pregnant or affect the baby during pregnancy?
Heavy alcohol use in males may affect sperm formation and function, or may cause impotence. Whether a fathers alcohol use increases the risks for birth defects is still being investigated. A recent study suggested that paternal alcohol use may be associated with an increased risk for certain rare heart defects in newborns. More information is needed in this area before a conclusion can be made.
Can chemotherapy or radiation for cancer treatments given to the father affect my pregnancy?
Sperm production is frequently affected during cancer treatment. Sometimes, sperm production may return to normal after certain chemotherapy or radiation treatments, but it is not guaranteed. 26
References
Brent R, et al. 1993. Ionizing and nonionizing radiations. In: Occupational and Environmental Reproductive Hazards: A Guide for Clinicians, Ed.: Maureen Paul, Williams, and Wilkin. Baltimore, MD. 27
29
Chapter 5
Trying to Conceive
Chapter Contents
Section 5.1Tips for Trying to Conceive..................................... 32 Section 5.2Do Sexual Positions Affect Conception? ................ 41 Section 5.3Using Ovulation Predictor Kits .............................. 42
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Section 5.1
Fertility Awareness
The Menstrual Cycle
Being aware of your menstrual cycle and the changes in your body that happen during this time can be key to helping you plan a pregnancy, or avoid pregnancy. During the menstrual cycle (a total average of 28 days), there are two parts: before ovulation and after ovulation. Day 1 starts with the first day of your period. Usually by Day 7, a womans eggs start to prepare to be fertilized by sperm. Between Day 7 and 11, the lining of the uterus (womb) starts to thicken, waiting for a fertilized egg to implant there. Around Day 14 (in a 28-day cycle), hormones cause the egg that is most ripe to be released, a process called ovulation. The egg travels down the fallopian tube towards the uterus. If a sperm unites with the egg here, the egg will attach to the lining of the uterus, and pregnancy occurs. If the egg is not fertilized, it will break apart. Around Day 25 when hormone levels drop, it will be shed from the body with the lining of the uterus as a menstrual period. The first part of the menstrual cycle is different in every woman, and even can be different from month-to-month in the same woman, varying from 13 to 20 days long. This is the most important part of the cycle to learn about, since this is when ovulation and pregnancy 32
Trying to Conceive
can occur. After ovulation, every woman (unless she has a health problem that affects her periods) will have a period within 14 to 16 days.
Trying to Conceive
To most accurately track your fertility, use a combination of all three methods. This is called the symptothermal method.
Infertility
It is not uncommon to have trouble becoming pregnant or to experience infertility. Infertility is defined as not being able to become pregnant, despite trying for one year, in women under age 35, or after six months in women 35 and over. Pregnancy is the result of a chain of events. As described in the Fertility Awareness section, a woman must release an egg from one of her ovaries (ovulation). The egg must travel through a fallopian tube toward her uterus. A mans sperm must join with (fertilize) the egg along the way. The fertilized egg must then become attached to the inside of the uterus. While this may seem simple, in fact many things can happen to prevent pregnancy.
Health Problems
Couples also can have fertility problems because of health problems, in either the woman or the man. Common problems with a womans reproductive organs, like uterine fibroids, endometriosis, and pelvic inflammatory disease can worsen with age and also affect fertility. These conditions might cause the fallopian tubes to be blocked, so the egg cant travel through the tubes into the uterus. Some people also have diseases or conditions that affect their hormone levels, which can cause infertility in women and impotence and infertility in men. Polycystic ovarian syndrome (PCOS) is one such hormonal condition that affects many women, and is the most common cause of anovulation, or when a woman rarely or never ovulates. Another hormonal condition that is a common cause of infertility is when a woman has a luteal phase defect (LPD). A luteal phase is the time in the menstrual cycle between ovulation and the start of the next menstrual period. LPD is a failure of the uterine lining to be fully prepared for a fertilized egg to implant there. This happens either because a womans body is not producing enough progesterone, or the uterine lining isnt responding to progesterone levels at some point in the menstrual cycle. Since pregnancy depends on a fertilized egg implanting in the uterine lining, LPD can interfere with a woman getting pregnant and with carrying a pregnancy successfully. Certain lifestyle choices also can have a negative effect on a womans fertility, such as smoking, alcohol use, weighing much more or much less than an ideal body weight, a lot of strenuous exercise, and having an eating disorder. Unlike women, some men remain fertile into their 60s and 70s. But as men age, they might begin to have problems with the shape and movement of their sperm, and have a slightly higher risk of sperm gene defects. They also might produce no sperm, or too few sperm. Lifestyle choices also can affect the number and quality of a mans 36
Trying to Conceive
sperm. Alcohol and drugs can temporarily reduce sperm quality. And researchers are looking at whether environmental toxins, such as pesticides and lead, also may be to blame for some cases of infertility. Men also can have health problems that affect their sexual and reproductive function. These can include sexually transmitted diseases (STDs), diabetes, surgery on the prostate gland, or a severe testicle injury or problem. If you or your partner has a problem with sexual function or libido, dont delay seeing your doctor for help.
Treating Infertility
You should talk to your doctor about your fertility if you: are under age 35 and, after a year of frequent sex without birth control, you are having problems getting pregnant; or are age 35 or over and, after six months of frequent sex without birth control, you are having problems getting pregnant; or believe you or your partner might have fertility problems in the future (even before you begin trying to get pregnant). Your doctor can refer you to a fertility specialist, a doctor who focuses in treating infertility. This doctor can recommend treatments such as drugs, surgery, or assisted reproductive technology. Dont delay seeing your doctor because age also affects the success rates of these treatments. There are many ways to treat infertility.
Tests
The first step to treat infertility is to see a doctor for a fertility evaluation. He or she will test both the woman and the man to find out where the problem is. Testing on the man focuses on the number and health of his sperm. The lab will look at a sample of his sperm under a microscope to check sperm number, shape, and movement. Blood tests also can be done to check hormone levels. More tests might be needed to look for infection or problems with hormones. These tests can include: an x-ray (to look at his reproductive organs); a mucus penetrance test (to see if sperm can swim through mucus); or 37
Trying to Conceive
needed, surgery can be done to repair damage to a womans ovaries, fallopian tubes, or uterus. Sometimes a man has an infertility problem that can be corrected by surgery.
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Trying to Conceive
Section 5.2
Section 5.3
What is LH?
Luteinizing hormone (LH) is a hormone produced by your pituitary gland. Your body always makes a small amount of LH, but just before you ovulate, you make much more LH. This test can detect this LH surge, which usually happens 1 to 1 days before you ovulate.
What is E3G?
E3G is produced when estrogen breaks down in your body. It accumulates in your urine around the time of ovulation and causes your cervical mucus to become thin and slippery. Sperm may swim more easily in your thin and slippery cervical mucus, increasing your chances of getting pregnant.
Trying to Conceive
test can be used to help you plan to become pregnant. You should not use this test to help prevent pregnancy, because it is not reliable for that purpose.
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Chapter 6
What is infertility?
Most experts define infertility as not being able to get pregnant after at least one year of trying. Women who are able to get pregnant but then have repeat miscarriages are also said to be infertile. Pregnancy is the result of a complex chain of events. In order to get pregnant: a woman must release an egg from one of her ovaries (ovulation); the egg must go through a fallopian tube toward the uterus (womb); a mans sperm must join with (fertilize) the egg along the way; the fertilized egg must attach to the inside of the uterus (implantation). Infertility can result from problems that interfere with any of these steps.
Excerpted from Infertility: Frequently Asked Questions, Office of Womens Health (www.womenshealth.gov), part of the U.S. Department of Health and Human Services, May 1, 2006.
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How long should women try to get pregnant before calling their doctors?
Most healthy women under the age of 30 shouldnt worry about infertility unless theyve been trying to get pregnant for at least a year. At this point, women should talk to their doctors about a fertility evaluation. Men should also talk to their doctors if this much time has passed. 47
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Chapter 7
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Section 7.1
Contraceptive Sponge
This barrier method is a soft, disk-shaped device with a loop for taking it out. It is made out of polyurethane foam and contains the spermicide nonoxynol-9. Spermicide kills sperm. Before having sex, you wet the sponge and place it, loop side down, inside your vagina to cover the cervix. The sponge is effective for more than one act of intercourse for up to 24 hours. It needs to be left in for at least 6 hours after having sex to prevent pregnancy. It must then be taken out within 30 hours after it is inserted. 51
Female Condom
This condom is worn by the woman inside her vagina. It keeps sperm from getting into her body. It is made of polyurethane and is packaged with a lubricant. It can be inserted up to 8 hours before having sex. Use a new condom each time you have intercourse. And dont use it and a male condom at the same time.
Male Condom
Male condoms are a thin sheath placed over an erect penis to keep sperm from entering a womans body. Condoms can be made of latex, polyurethane, or natural/lambskin. The natural kind do not protect against STIs. Condoms work best when used with a vaginal spermicide, which kills the sperm. And you need to use a new condom with each sex act. 52
The Patch
Also called by its brand name, Ortho Evra, this skin patch is worn on the lower abdomen, buttocks, outer arm, or upper body. It releases the hormones progestin and estrogen into the bloodstream to stop the ovaries from releasing eggs in most women. It also thickens the cervical mucus, which keeps the sperm from joining with the egg. You put on a new patch once a week for 3 weeks. You dont use a patch the fourth week in order to have a period.
Shot/Injection
The birth control shot often is called by its brand name DepoProvera. With this method you get injections, or shots, of the hormone progestin in the buttocks or arm every 3 months. A new type is injected under the skin. The birth control shot stops the ovaries from releasing an egg in most women. It also causes changes in the cervix that keep the sperm from joining with the egg. The shot should not be used more than 2 years in a row because it can cause a temporary loss of bone density. The loss increases the longer this method is used. The bone does start to grow after this method is stopped. But it may increase the risk of fracture and osteoporosis if used for a long time.
Vaginal Ring
This is a thin, flexible ring that releases the hormones progestin and estrogen. It works by stopping the ovaries from releasing eggs. It also thickens the cervical mucus, which keeps the sperm from joining the egg. 54
Implantable Rod
This is a matchstick-size, flexible rod that is put under the skin of the upper arm. It is often called by its brand name, Implanon. The rod releases a progestin, which causes changes in the lining of the uterus and the cervical mucus to keep the sperm from joining an egg. Less often, it stops the ovaries from releasing eggs. It is effective for up to 5 years.
Surgical Sterilization
For women, surgical sterilization closes the fallopian tubes by being cut, tied, or sealed. This stops the eggs from going down to the uterus where they can be fertilized. The surgery can be done a number of ways. Sometimes, a woman having cesarean birth has the procedure done at the same time, so as to avoid having additional surgery later. For men, having a vasectomy keeps sperm from going to his penis, so his ejaculate never has any sperm in it. Sperm stays in the system after surgery for about 3 months. During that time, use a backup form of birth control to prevent pregnancy. A simple test can be done to check if all the sperm is gone; it is called a semen analysis.
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Section 7.2
Mifeprex is used, together with another medication called misoprostol, to end an early pregnancy (within 49 days of the start of a womans last menstrual period). Since its approval in September 2000, the Food and Drug Administration has received reports of serious adverse events, including several deaths, in the United States following medical abortion with mifepristone and misoprostol. Each time FDA receives a report of a serious adverse event or death after medical abortion with these drugs, the agency carefully analyzes the available scientific information to determine whether or not the serious adverse event or death is related to the use of the drugs. As previously reported by the agency, several of the women who died in the United States died from sepsis (severe illness caused by infection of the bloodstream) after medical abortion with mifepristone and misoprostol. Sepsis is a known risk related to any type of abortion. Most of these women were infected with the same type of bacteria, known as Clostridium sordellii. The symptoms in these cases of infection were not the usual symptoms of sepsis. We do not know whether using mifepristone and misoprostol caused these deaths. Patients should contact a healthcare practitioner right away if they have taken these medications for medical abortion and develop stomach pain or discomfort, or have weakness, nausea, vomiting or diarrhea with or without fever, more than 24 hours after taking the misoprostol. These symptoms, even without a fever, may indicate sepsis. Patients should make sure their healthcare practitioner knows they are undergoing a medical abortion. All providers of medical abortion and emergency room healthcare practitioners should investigate the possibility of sepsis in women who are undergoing medical abortion and present with nausea, vomiting, or diarrhea and weakness with or without abdominal pain. These symptoms even without a fever may indicate a hidden infection. Strong consideration should be given to obtaining a complete blood count in 58
Section 7.3
Approximately one-fifth (19%) of the 6.4 million pregnancies occurring annually in the United States end in induced abortion.1 While abortion is one of the most common medical procedures for women,2 access and availability of services has been subject to ethical and political debates. Federal and state policies have a substantial impact on womens access to abortion services. This information provides an overview of the use of abortion services in the United States and reviews state and federal policies that affect womens access.
Methods
Two general types of abortion are available to women in the United States: surgical and medical (non-surgical) abortions. Surgical abortions account for the majority (87%) of abortions performed in the United States.11 The most common surgical methods include vacuum aspiration, dilation and curettage (D&C), and dilation and evacuation (D&E). Surgical abortion is generally not performed until the sixth week of gestation. In September 2000, the U.S. Food and Drug Administration approved mifepristone (also known as RU-486), the first drug specifically designed for use as a method of medical abortion. This drug, in conjunction with misoprostol, is the most commonly used method of medical abortion.12 Methotrexate, usually followed by misoprostol, is also used for medical abortion. Medical abortion can be initiated as soon as a pregnancy is confirmed. In 2005, medical abortions accounted for approximately 13% of all abortions (compared to 6% in 2001) and 22% of abortions before nine weeks gestation.13 Since the 1990s, 31 states have enacted bans on procedures called partial-birth abortions, with 14 state laws (GA, IN, KS, LA, MS, MT, NM, ND, OH, OK, SC, SD, TN, UT) in effect. All include an exception to the ban: four states (GA, KS, NM, OH) include a health exception and the rest of the states include an exception only when a womans life is in danger.14 In 2003, the President signed the Partial-Birth Abortion Ban Act of 2003, which banned partial-birth abortions with no health exception. This legislation was upheld by the Supreme Court in the April 2007 Gonzales v. Carhart decision. The procedure banned 61
Abortion Financing
The cost of an abortion varies depending on factors such as location, facility, timing, and type of procedure. In 2005, a nonhospital abortion at 10 weeks gestation ranged from $90 to $1,800 (average: $430), whereas an abortion at 20 weeks gestation ranged from $350 to $4,520 (average: $1,260).24 Costs are higher for a medical abortion than a first-trimester surgical abortion.25
Medicaid
Federal law requires that states cover abortions under Medicaid in the event of rape, incest, and life endangerment, but bans the use of federal Medicaid funds for any other abortions. Based on these restrictions, 32 states and DC fund abortions through Medicaid only in the cases of rape, incest, or life endangerment.26 SD covers abortions only in the cases of life endangerment, which does not comply with federal requirements under the Hyde Amendment. IN, UT and WI have expanded coverage to women whose physical health is jeopardized, and IA, MS, UT and VA also include fetal abnormality cases. Seventeen states (AK, AZ, CA, CT, HI, IL, MD, MA, MN, MT, NJ, NM, NY, OR, VT, WA, WV) use their own funds to cover all or most medically necessary abortions sought by low-income women under Medicaid.27 62
Endnotes
1. Ventura SJ et al. Estimated pregnancy rates by outcome for the United States, 19902004. CDC National Vital Health Statistics, 2008. Owings MF & Kozak LJ. Ambulatory and inpatient procedures in the United States, 1996. CDC National Vital Health Statistics, 1998. Jones RK et al. Abortion in the United States: Incidence and access to services, 2005. Perspectives on Sexual and Reproductive Health, 40(1), 2008. Finer LB & Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health, 38(2), 2006. Jones RK et al. Abortion in the United States: Incidence and access to services, 2005. Perspectives on Sexual and Reproductive Health, 40(1), 2008. Guttmacher Institute. Henshaw SK adjustments to Strauss LT et al. Abortion surveillanceUnited States, 2004. MMWR, 56(SS-9), 2007. 64
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3.
4.
5.
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8. 9. 10. 11.
12. 13.
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Additional copies of this publication (#3269-02) are available on the Kaiser Family Foundations website at www.kff.org.
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Chapter 8
Chapter Contents
Section 8.1Signs of Pregnancy .................................................. 70 Section 8.2Understanding Home Pregnancy Tests ................. 72 Section 8.3Calculating Your Dates: Gestation, Conception, and Due Date ...................................... 77
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Section 8.1
Signs of Pregnancy
From Pregnancy, by the National Institute of Child Health and Human Development (NICHD, www.nichd.nih.gov), part of the National Institutes of Health, February 5, 2008.
What is pregnancy?
Pregnancy is the term used to describe when a woman has a growing fetus inside of her. In most cases, the fetus grows in the uterus. Human pregnancy lasts about 40 weeks, or just more than 9 months, from the start of the last menstrual period to childbirth.
Section 8.2
How soon after a missed period can I take a home pregnancy test and get an accurate result?
Many home pregnancy tests (HPTs) claim to be 99 percent accurate on the first day of your missed period. But research suggests that 74
My home pregnancy test says that I am not pregnant. Might I still be pregnant?
Yes. Most home pregnancy tests (HPTs) suggest women take the test again in a few days or a week if the result is negative. Each woman ovulates at a different time in her menstrual cycle. Plus, the fertilized egg can implant in a womans uterus at different times. So, the accuracy of HPT results varies from woman to woman. Other things can also affect the accuracy. Sometimes women get false negative results when they test too early in the pregnancy. This means that the test says you are not pregnant when you are. Other times, problems with the pregnancy can affect the amount of hCG in the urine. If your HPT is negative, test yourself again in a few days or one week. If you keep getting a negative result but think you are pregnant, talk with your doctor right away.
American College of Obstetricians and Gynecologists 409 12th Street, SW P.O. Box 96920 Washington, DC 20090-6920 Phone: 202-638-5577 Website: www.acog.org American Pregnancy Association 1425 Greenway Drive Irving, TX 75038 Phone: 972-550-0140 Fax: 972-550-0800 Website: www.americanpregnancy.org E-mail: questions@americanpregnancy.org Planned Parenthood Federation of America 434 West 33rd Street New York, NY 10001 Toll-Free: 800-230-7526 Phone: 212-541-7800 Fax: 212-245-1845 Website: www.plannedparenthood.org U.S. Food and Drug Administration 10903 New Hampshire Avenue Silver Spring, MD 20903 Toll-Free: 888-463-6332 Website: www.fda.gov
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Section 8.3
Gestational age, or the age of the baby, is calculated from the first day of the mothers last menstrual period. Since the exact date of conception is almost never known, the first day of the last menstrual period is used to measure how old the baby is.
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Chapter 9
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Section 9.1
Everyone expects pregnancy to bring an expanding waistline. But many women are surprised by the other body changes that pop up. Get the lowdown on stretch marks, weight gain, heartburn, and other joys of pregnancy. Find out what you can do to feel better.
Body Changes
Aches, Pains, and Backaches
As your uterus expands, pains in the back, abdomen, groin area, and thighs often appear. Many women also have backaches and aching near the pelvic bone due the pressure of the babys head, increased weight, and loosening joints. To ease some of these aches and pains try: lying down; resting; and applying heat. If you are worried or the pains do not get better, call your doctor.
Breast Changes
A womans breasts increase in size and fullness during pregnancy. As the due date approaches, hormone changes will cause your breasts to get even bigger in preparation for breastfeeding. Your breasts may feel full and heavy, and they might be tender or uncomfortable. In the third trimester, some pregnant women begin to leak colostrum from their breasts. Colostrum is the first milk that your breasts 80
Dizziness
Many pregnant women complain of dizziness and lightheadedness throughout their pregnancies. Fainting is rare but does happen even in some healthy pregnant women. There are many reasons for these
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Hemorrhoids
Up to 50% of pregnant women get hemorrhoids. Hemorrhoids are swollen and bulging veins in the rectum. They can cause itching, pain, and bleeding. Hemorrhoids are more common during pregnancy for many reasons. During pregnancy there is a huge increase in the amount of blood in the body. This can cause veins to enlarge. The expanding uterus also puts pressure on the veins in the rectum. Plus, constipation can make hemorrhoids worse. Hemorrhoids usually improve after delivery. Follow these tips to help prevent and relieve hemorrhoids: Drink lots of fluids. Eat plenty of fiber-rich foods like whole grains, raw or cooked leafy green vegetables, and fruits. Try not to strain for bowel movements. Talk with your doctor before taking any laxative. Talk to your doctor about using witch hazel or ice packs to soothe hemorrhoids.
Leg Cramps
At different times during your pregnancy, you might have cramps in your legs or feet. They usually happen at night. This is due to a change in the way your body processes, or metabolizes, calcium. 82
Nasal Problems
Nosebleeds and nasal stuffiness are common during pregnancy. They are caused by the increased amount of blood in your body and hormones acting on the tissues of your nose. To ease nosebleeds blow gently when you blow your nose. Stop nosebleeds by squeezing your nose between your thumb and finger for a few minutes. If you have nosebleeds that do not stop in a few minutes or happen often, see your doctor. Drinking extra water and using a cool mist humidifier in your bedroom may help relieve nasal stuffiness. Talk with your doctor before taking any over-the-counter or prescription medicines for colds or nasal stuffiness.
Shortness of Breath
As the baby grows, your expanding uterus will put pressure on all of your organs, including your lungs. You may notice that you are short of breath or might not be able to catch your breath. Tips to ease breathing include: Take deep, long breaths. Maintain good posture so your lungs have room to expand. Use an extra pillow and try sleeping on your side to breathe easier at night.
Swelling
Most women develop mild swelling in the face, hands, or ankles at some point in their pregnancies. As the due date approaches, swelling 83
Varicose Veins
During pregnancy there is a huge increase in the amount of blood in the body. This can cause veins to enlarge. Plus, pressure on the large veins behind the uterus causes the blood to slow in its return to the heart. For these reasons, varicose veins in the legs and anus (hemorrhoids) are more common in pregnancy. 84
Digestive Difficulties
Constipation
Many pregnant women complain of constipation. High levels of hormones in your pregnant body slow down digestion and relax muscles in the bowels leaving many women constipated. Plus, the pressure of the expanding uterus on the bowels boosts the chances for constipation. Try these tips to stay more regular: Eat fiber-rich foods like fresh or dried fruit, raw vegetables, and whole-grain cereals and breads daily. Drink eight to 10 glasses of water everyday. Avoid caffeinated drinks (coffee, tea, colas, and some other sodas), since caffeine makes your body lose fluid needed for regular bowel movements. Get moving. Mild exercise like walking may also ease constipation.
Sleeping Troubles
During your pregnancy, you might feel tired even after youve had a lot of sleep. Many women find theyre particularly exhausted in the first trimester. Dont worry, this is normal! This is your bodys way of telling you that you need more rest. In the second trimester, tiredness is usually replaced with a feeling of well being and energy. But in the third trimester, exhaustion often sets in again. As you get larger, sleeping may become more difficult. The babys movements, bathroom runs, and an increase in the bodys metabolism might interrupt or disturb your sleep. Leg cramping can also interfere with a good nights sleep. Try these tips to feel and sleep better: When youre tired, get some rest. Try to get about 8 hours of sleep every night, and a short nap during the day. If you feel stressed, try to find ways to relax. Sleep on your left side. This will relieve pressure on blood vessels that supply oxygen and nutrients to the fetus. 87
Weight Gain
The amount of weight you need to gain during pregnancy depends upon how much you weighed before you became pregnant. According to the American College of Obstetricians and Gynecologists (ACOG) women who have a normal weight before getting pregnant should gain 25 to 35 pounds. Women who are underweight before pregnancy should gain 28 to 40 pounds. And women who are overweight should gain 15 to 25 pounds. Research shows that women who gain more than the recommended amount during pregnancy have a higher chance of being obese 10 years later. Ask your doctor how much weight gain during pregnancy is healthy for you.
Section 9.2
Most women have back pain at some point during pregnancy. The pain can be mild or severe, but it can usually be treated. In some cases, it can be prevented.
Figure 9.2. Pelvic tilt start position: Note arch in lower back. Kneel on your hands and knees; youll notice an arch in your lower back. Tilt your pelvis backwards, so you flatten your back, keeping your buttocks relaxed.
Figure 9.3. Pelvic tilt end position: Note absence of arch in lower back.
Figure 9.4. Back stretch: Kneel on your hands and knees, with your legs spread apart, and a small pillow under your belly. Sit back and reach your arms forward to feel a stretch along your spine.
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Figure 9.5. Hamstring stretch: Face a chair and place one foot on it. Keep your back straight as you gently lean forward to stretch the back of the thigh.
What is sciatica?
The sciatic nerve is a large nerve that runs down the back across the buttocks and down the back of your legs. Sciatica is pain in the sciatic nerve which is caused by pressure on the nerve. The symptoms of sciatica that are different from normal back pain in pregnancy are: pain down the buttock and back of your leg past your knee, tingling, numbness, or if you have trouble moving your leg. The treatment for sciatica is the same as the treatment for back pain but your health care provider may also suggest bedrest and physical therapy. Sciatic pain usually goes away in 1 to 2 weeks.
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Chapter 10
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Section 10.1
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Section 10.2
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Chapter 11
Both pregnancy and breastfeeding cause changes and place extra demands on a womans body. Some of these may have an effect on her bones. The good news is that most women do not experience bone problems during pregnancy and breastfeeding. And if their bones are affected during these times, the problem is often easily corrected. Nevertheless, taking care of ones bone health is especially important during pregnancy and when breastfeedingfor the good health of both the mother and her baby.
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Chapter 12
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Chapter 13
Chapter Contents
Section 13.1Pregnancy and Your Vision ................................ 108 Section 13.2Pregnancy and Oral Health ................................ 110
107
Section 13.1
Pregnancy brings an increase in hormones that may cause changes in vision. In most cases, these are temporary eye conditions that will return to normal after delivery. Its important for expectant mothers to be aware of vision changes during pregnancy and know what symptoms indicate a serious problem.
Refractive Changes
During pregnancy, changes in hormone levels can alter the strength you need in your eyeglasses or contact lenses. Though this is usually nothing to worry about, its a good idea to discuss any vision changes with an eye doctor who can help you decide whether or not to change your prescription. The doctor may simply tell you to wait a few weeks after delivery before making a change in your prescription.
Dry Eyes
Some women experience dry eyes during pregnancy. This is usually temporary and goes away after delivery. The good news is that lubricating or rewetting eye drops are perfectly safe to use while you are pregnant or nursing. They can lessen the discomfort of dry eyes. Its also good to know that contact lenses, contact lens solutions, and enzymatic cleaners are safe to use while you are pregnant. To reduce the irritation caused by a combination of dry eyes and contact lenses, try cleaning your contact lenses with an enzymatic cleaner more often. If dry, irritated eyes make wearing contacts too uncomfortable, dont worry. Your eyes will return to normal within a few weeks after delivery. 108
Puffy Eyelids
Puffiness around the eyes is another common side effect of certain hormonal changes women may have while pregnant. Puffy eyelids may interfere with side vision. As a rule of thumb, dont skimp on your water intake and stick to a moderate diet, low in sodium and caffeine. These healthy habits can help limit water retention and boost your overall comfort.
Migraine Headaches
Migraine headaches linked to hormonal changes are very common among pregnant women. In some cases, painful migraine headaches make eyes feel more sensitive to light. If you are pregnant and suffering from migraines, be sure to talk to your doctor before taking any prescription or non-prescription migraine headache medications. Prenatal care helps keep both you and your unborn child healthy. Be sure to tell your doctor if you are having any problems. Keep your eye doctor up-to-date about your overall health. Tell him or her about any pre-existing conditions, and about any prescription and non-prescription medications you are taking.
Diabetes
Women who are diabetic before their pregnancy and those who develop gestational diabetes need to watch their vision closely. Blurred vision in such cases may indicate elevated blood sugar levels.
Glaucoma
Women being treated for glaucoma should tell their eye doctor right away if they are pregnant or intend to become pregnant. While many glaucoma medications are safe to take during pregnancy, certain glaucoma medications such as carbonic anhydrase inhibitors can be harmful to the developing baby. 109
Section 13.2
Its a myth that calcium is lost from a mothers teeth and one tooth is lost with every pregnancy. But you may experience some changes in your oral health during pregnancy. The primary changes are due to a surge in hormonesparticularly an increase in estrogen and progesteronecan exaggerate the way gum tissues react to plaque.
Chapter 14
113
Section 14.1
Hormones, body changes, and new emotions make you vulnerable to emotional ups and downs during and after pregnancy. Learn to spot the signs of depression so you can take care of you and your baby.
What is depression?
Depression can be described as feeling sad, blue, unhappy, miserable, or down in the dumps. Most of us feel this way at one time or another for short periods. But true clinical depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for an extended time. Depression can be mild, moderate, or severe. The degree of depression, which your doctor can determine, influences how you are treated.
Whats the difference between baby blues, postpartum depression, and postpartum psychosis?
The baby blues can happen in the days right after childbirth and normally go away within a few days to a week. A new mother can have sudden mood swings, sadness, crying spells, loss of appetite, sleeping 116
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Section 14.2
Pregnant women who discontinue antidepressant medications may significantly increase their risk of relapse during pregnancy, a new study funded by the National Institute of Healths National Institute of Mental Health found. Women in the study who stopped taking antidepressants while pregnant were five times more likely than those who continued use of these medications to experience episodes of depression during pregnancy, reported Lee Cohen, MD, of Massachusetts General Hospital and colleagues in the February 1 [2006] issue of the Journal of the American Medical Association. Depression is a disabling disorder that has been estimated to affect approximately 10 percent of pregnant women in the United States. Recently there has been concern about the use of antidepressants during pregnancy; however what has not been addressed is the risk of depression recurrence should someone discontinue antidepressant use. This study sheds light on the risk of relapse associated with discontinuing antidepressant therapy during pregnancy. In the study, Cohen and colleagues enrolled pregnant women already taking antidepressants and then noted how many of the women decided to stop taking their medications. They then assessed the risk of relapse for the women who stopped versus maintained antidepressant therapy. Contrary to the belief that hormonal changes shield pregnant women from depression, this study demonstrates that pregnancy itself is not protective. Among the pregnant women who stopped taking antidepressants, 68 percent relapsed during pregnancy compared to 26 percent who relapsed despite continuing their antidepressants. Among the women who discontinued use and relapsed, 50 percent 120
Section 14.3
Abuse during pregnancy is more common than most people think. About one in five women may suffer abuse when they are pregnant. Abuse can start during pregnancy or get worse.
What Is Abuse?
Abuse includes physical hurting, like slapping, hitting, kicking, and punching. But it also can include verbal hurting, like being called names and being accused of doing things you have not done. Abuse can also include being forced to have sex against your wishes or being made to do things sexually you do not want to do. Abuse can include threats and control. The abuser may try to make you behave in a certain way and may say something bad will happen to you if you dont. The abuser may try to keep you from seeing your family and friends. He or she may make you explain in detail what you do each day, where you go, and whom you see and talk to. Women who are abused during pregnancy often feel confused and embarrassed. They ask themselves, How can this be happening to me? There is nothing to be embarrassed about. The abuser is to blame. Abuse is never your fault. 121
Results of Abuse
Abuse affects your mind and body. Here are some of the effects it can have: You may have anemia (too few red blood cells), because you are not eating right or getting enough vitamins and iron. You may have bleeding during the first and second trimesters. You may not gain enough weight during the pregnancy. You may have more infections. Your baby may be too small at birth or may be born too early. Your baby may have problems after birth. You may feel depressed (sad and blue). You may feel anxious, upset, lonely, and worthless. You may not like yourself. You may be at risk for unhealthy behaviors, such as smoking or abusing drugs and alcohol during the pregnancy. You may not receive important regular prenatal care.
Effects on Children
Children who grow up in the midst of violence and abuse often are deeply affected by what they witness. Protect your children, and protect yourself. Keep in mind that a partner who abuses women during pregnancy is more likely to hurt children. Seek help for your children and yourself if you are being abused.
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Chapter 15
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Weeks 3740
By the end of 37 weeks, your baby is considered full term. Your babys organs are ready to function on their own. As you near your due date, your baby may turn into a headdown position for birth. Most babies present head down. At birth, your baby may weigh somewhere between 6 pounds, 2 ounces and 9 pounds, 2 ounces and be 19 to 21 inches long. Most full-term babies fall within these ranges. But healthy babies come in many different sizes.
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Chapter 16
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Section 16.1
Medical checkups and screening tests help keep you and your baby healthy during pregnancy. This is called prenatal care. It also involves education and counseling about how to handle different aspects of your pregnancy. During your visits, your doctor may discuss many issues, such as healthy eating and physical activity, screening tests you might need, and what to expect during labor and delivery.
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Section 16.2
What Is a Midwife?
What Is a Midwife? Journal of Midwifery and Womens Health, September/October 2006. 2006 American College of Nurse-Midwives (www.midwife.org). Reprinted with permission.
Certified nurse-midwives (CNMs) are licensed health care providers educated in nursing and midwifery. Certified midwives (CMs) are licensed health care providers educated in midwifery. CNMs and CMs have graduated from college; they have passed a national examination; and they have a license to practice midwifery from the state they live in. Most of the midwives in the United States are CNMs or CMs.
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Chapter 17
141
X-Linked Disorders
These disorders are determined by genes on the X chromosome. The X and Y chromosomes are the chromosomes that determine sex. These disorders are much more common in boys because the pair of sex chromosomes in males contains only one X chromosome (the other is a Y chromosome). If the disease gene is present on the one X chromosome, the X-linked disease shows up because theres no other paired gene to overrule the disease gene. One such X-linked disorder is hemophilia, which prevents the blood from clotting properly. 143
Multifactorial Disorders
This final category includes disorders that are caused by a mix of genetic and environmental factors. Their frequency varies from location to location, and some can be detected during pregnancy. Multifactorial disorders include neural tube defects, which occur when the tube enclosing the spinal cord doesnt form properly. Neural tube defects, which often can be prevented by taking folic acid (which is in prenatal vitamins) around the time of conception and during pregnancy, include: spina bifida. Also called open spine, this defect happens when the lower part of the neural tube doesnt close during embryo development. The spinal cord and nerves may be covered only by skin, or may be open to the environment, leaving them unprotected. anencephaly. This defect occurs when the brain and head dont develop properly, and parts of the brain are completely absent or malformed. Other multifactorial disorders include: congenital heart defects; obesity; diabetes; cancer.
Other Tests
Here are some other tests that might be performed during pregnancy.
Ultrasound
Why Is This Test Performed? In this test, sound waves are bounced off the babys bones and tissues to construct an image showing the babys shape and position in the uterus. Ultrasounds were once used only in high-risk pregnancies but have become so common that theyre often part of routine prenatal care. Also called a sonogram, sonograph, echogram, or ultrasonogram, an ultrasound is used: to determine whether the fetus is growing at a normal rate; to verify the expected date of delivery; to record fetal heartbeat or breathing movements; to see whether there might be more than one fetus; to identify a variety of abnormalities that might affect the remainder of the pregnancy or delivery; to make sure the amount of amniotic fluid in the uterus is adequate; to indicate the position of the placenta in late pregnancy (which may be blocking the babys way out of the uterus); to detect pregnancies outside the uterus; as a guide during other tests such as amniocentesis. Ultrasounds also are used to detect: 147
Glucose Screening
Why Is This Test Performed? Glucose screening checks for gestational diabetes, a short-term form of diabetes that develops in some women during pregnancy. Gestational diabetes is increasing in frequency in the United States, and may occur in 3 to 8% of pregnancies. Gestational diabetes can cause health problems for the baby, especially if it is not diagnoses or treated. Should I Have This Test? Most women have this test in order to diagnose and treat gestational diabetes, reducing the risk to the baby. When Should I Have This Test? Screening for gestational diabetes usually takes place at 24 to 28 weeks. Testing may be done earlier for women who are at higher risk of having gestational diabetes, such as those who: 149
Amniocentesis
Why Is This Test Performed? This test is most often used to detect: Down syndrome and other chromosome abnormalities; structural defects such as spina bifida and anencephaly; inherited metabolic disorders. Late in the pregnancy, this test can reveal if a babys lungs are strong enough to allow the baby to breathe normally after birth. This can help the health care provider make decisions about inducing labor or trying to prevent labor, depending on the situation. For instance, if a mothers water breaks early, the health care provider may want to try to hold off on delivering the baby as long as possible to allow for the babys lungs to mature. Other common birth defects, such as heart disorders and cleft lip and palate, cant be determined using this test. Should I Have This Test? Your health care provider may recommend this test if you: are older than age 35; have a family history of genetic disorders (or a partner who does); 153
Nonstress Test
Why Is This Test Performed? A nonstress test (NST) can determine if the baby is responding normally to a stimulus. Used mostly in high-risk pregnancies or when a health care provider is uncertain of fetal movement, an NST can be performed at any point in the pregnancy after the 26th to 28th week 154
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Chapter 18
Ideally, women of childbearing age should be immunized before becoming pregnant to protect their babies against serious diseases. For instance, rubella causes serious damage to the unborn fetus and is preventable by rubella vaccine. Varicella (chickenpox) can cause birth defects in the fetus and fatal pneumonia in the mother; it is preventable by varicella vaccine. Tetanus in the newborn, often fatal, is prevented if the mother has been immunized, as is the case with many other vaccine-preventable diseases. Although many medications, including some vaccines, are avoided during pregnancy because of potential harm to the mother or fetus, some vaccines are actually recommended for pregnant women. Certain immunizations during pregnancy will enhance the mothers health and others will protect the child by means of the mothers antibodies that remain in the child for the first 36 months of life. While certain drugs may harm the developing fetus, the risk of a developing fetus being harmed by vaccination of the mother during pregnancy remains only theoretical. Currently, no evidence exists of risk from vaccinating pregnant women with any inactivated viral or bacterial vaccine or toxoid. Live attenuated vaccines, including MMR [measles, mumps, and rubella] and varicella, are of greater theoretical concern, so it is recommended that women avoid pregnancy as a
Immunization Issues: Vaccines for Pregnant Women, 2007 National Network for Immunization Information (www.immunizationinfo.org). Reprinted with permission.
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References
1. Gall, SA 2003. Maternal Immunization. Obstetrics and Gynecology Clinics of North America, 30(4):632636. 165
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Chapter 19
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Section 19.1
How do prescription and over-the-counter (OTC) medicine labels help my doctor choose the right medicine for me when I am pregnant?
Doctors use information from many sources when they choose medicine for a patient, including medicine labels. To help doctors, the U.S. Food and Drug Administration (FDA) created pregnancy letter categories to help explain what is known about using medicine during pregnancy. This system assigns letter categories to all prescription medicines. The letter category is listed in the label of a prescription medicine. The label states whether studies were done in pregnant women or pregnant animals and if so, what happened. Over-thecounter (OTC) medicines do not have a pregnancy letter category. Some OTC medicines were prescription medicines first and used to have a letter category. Talk to your doctor and follow the instructions on the label before taking OTC medicines. The FDA chooses a medicines letter category based on what is known about the medicine when used in pregnant women and animals. The FDA is working hard to gather more knowledge about using medicine during pregnancy. The FDA is also trying to make medicine labels more helpful to doctors. Medicine label information for prescription medicines is now changing, and the pregnancy part of the label will change over the next few years. OTC medicines: All OTC medicines have a Drug Facts label. The Drug Facts label is arranged the same way on all OTC medicines. This makes information about using the medicine easier to find. One section of the Drug Facts label is for pregnant women. With OTC medicines, the label usually tells a pregnant woman to speak with her doctor before using the medicine. Some OTC medicines are known to cause certain problems in pregnancy. The labels for these medicines give pregnant women facts about why and when they should not use the medicine. Here are some examples: Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin (acetylsalicylate), can cause serious blood flow problems in the baby if used 169
Paxil (paroxetine) for depression; Lithium for bipolar disorder; Dilantin (phenytoin) for epileptic seizures; some cancer chemotherapy Accutane (isotretinoin) for cystic acne; Thalomid (thalidomide) for a type of skin disease
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Are herbal remedies, natural products, or dietary supplements safe for me while I am pregnant?
Except for some vitamins, little is known about using dietary supplements while pregnant. Some herbal remedy labels claim they 172
Section 19.2
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Chapter 20
Folic Acid
Why cant I wait until Im pregnant or planning to get pregnant to start taking folic acid?
Birth defects of the brain and spine (spina bifida and anencephaly) happen in the first few weeks of pregnancy; often before you find out youre pregnant. By the time you realize youre pregnant, it might be too late to prevent those birth defects. Also, half of all pregnancies in the United States are unplanned. These are two reasons why it is important for all women who can get pregnant to be sure to get 400 mcg of folic acid every day, even if they arent planning a pregnancy any time soon.
Im planning to get pregnant this month. Is it too late to start taking folic acid?
The CDC recommends women to take 400 micrograms (mcg) of folic acid every day, starting at least three months before getting pregnant. If you are trying to get pregnant this month, or planning to get pregnant soon, start taking 400 mcg of folic acid today.
From Folic Acid, by the Centers for Disease Control and Prevention (CDC, www.cdc.gov), National Center on Birth Defects and Developmental Disabilities, January 30, 2008.
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I cant swallow large pills. How can I take a vitamin with folic acid?
These days, multivitamins with folic acid come in chewable chocolate or fruit flavors, liquids, and large oval or smaller round pills. A single serving of many breakfast cereals also has the amount of folic acid that a woman needs each day. Check the label. Look for cereals that have 100% daily value (DV) of folic acid in a serving, which is 400 micrograms (mcg).
Vitamins cost too much. How can I get the vitamin with folic acid that I need?
Many stores offer a single folic acid supplement for just pennies a day. Another good choice is a store brand multivitamin, which includes more of the vitamins a woman needs each day. Unless your doctor suggests a special type, you do not have to choose among vitamins for women or active people. A basic multivitamin meets the needs of most women. 176
Folic Acid
How can I remember to take a vitamin with folic acid every day?
Make it easy to remember by taking your vitamin at the same time every day. Try taking your vitamin when you: if you use a cell phone or PDA, program it to give you a daily reminder; brush your teeth; eat breakfast; finish your shower; brush your hair; if you have children, take your vitamin when they take theirs. Seeing the vitamin bottle on the bathroom or kitchen counter can help you remember it, too. Todays woman is busy. You know that you should exercise, eat right, and get enough sleep. You might wonder how you can fit another thing into your day. But it only takes a few seconds to take a vitamin to get all the folic acid you need.
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Chapter 21
Chapter Contents
Section 21.1What to Eat: A Guide for Pregnant Women ..... 180 Section 21.2Vegetarian Diets and Pregnancy ....................... 185 Section 21.3Anemia and Pregnancy ....................................... 188 Section 21.4What You Need to Know about Mercury in Fish and Shellfish ............................................... 190 Section 21.5Caffeine Use during Pregnancy ......................... 191
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Section 21.1
Eat this. Dont eat that. Do this. Dont do that. Pregnant women are bombarded with dos and donts. Heres help to keep it all straight.
Calorie Needs
Your calorie needs will depend on your weight gain goals. Most women need 300 calories a day more during at least the last 6 months of pregnancy than they do prepregnancy. Keep in mind that not all calories are equal. Your baby needs healthy foods that are packed with nutrientsnot empty calories such as those found in soft drinks, candies, and desserts. Although you want to be careful not to eat more than you need for a healthy pregnancy, make sure not to restrict your diet during pregnancy either. If you dont get the calories you need, your baby might not get the right amounts of protein, vitamins, and minerals. Lowcalorie diets can break down a pregnant womans stored fat. This can cause your body to make substances called ketones. Ketones can be found in the mothers blood and urine and are a sign of starvation. Constant production of ketones can result in a child with mental deficiencies. 180
Food Safety
Most foods are safe for pregnant women and their babies. But you will need to use caution or avoid eating certain foods. Follow these guidelines: Clean, handle, cook, and chill food properly to prevent foodborne illness, including listeria and toxoplasmosis. 181
*Note: Women who are sexually active also should take 400 micrograms of folic acid daily.
Alcohol
There is no known safe amount of alcohol a woman can drink while pregnant. When you are pregnant and you drink beer, wine, hard liquor, or other alcoholic beverages, alcohol gets into your blood. The alcohol in your blood gets into your babys body through the umbilical cord. Alcohol can slow down the babys growth, affect the babys brain, and cause birth defects.
Cravings
Many women have strong desires for specific foods during pregnancy. The desire for pickles and ice cream and other cravings might be caused by changes in nutritional needs during pregnancy. The fetus needs nourishment. And a womans body absorbs and processes nutrients differently while pregnant. These changes help ensure normal development of the baby and fill the demands of breastfeeding once the baby is born. Some women crave nonfood items such as clay, ice, laundry starch, or cornstarch. A desire to eat nonfood items is called pica. Eating nonfood items can be harmful to your pregnancy. Talk to your doctor if you have these urges.
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Section 21.2
Are there other nutrients that I should pay attention to if I want to stay healthy on a vegetarian diet?
Other nutrients besides protein that you will want to make sure you get enough of are vitamin B12, vitamin D, calcium, iron, and essential fatty acids. The following text lists good food sources of these nutrients and some guidelines for how much to eat.
Ive been a vegetarian for a while, but I just found out I am pregnant. What can I do to make sure my baby is as healthy as possible?
Most of us slip into habits and lose sight of exactly what we are eating every day. If you are newly pregnant, you might want to do something you probably did when you first became a vegetariankeep a list of everything you eat every day for a while. Check your list against the recommendations to see if you are getting all the nutrients you need. You can grow a healthy baby while eating a vegetarian diet.
What are diet guidelines for a healthy vegetarian diet during pregnancy?
In general, your daily diet should include: one to two servings of dark green vegetables; four to five servings of other vegetables and fruit; three to four servings of bean and soy products; six or more servings of whole-grain products; one to two servings of nuts, seeds, and wheat germ. 186
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Section 21.3
What is anemia?
Anemia means you have low iron in your blood or low blood.1 Iron helps your red blood cells carry oxygen to all parts of your body.
Section 21.4
Fish and shellfish are an important part of a healthy diet. Fish and shellfish contain high-quality protein and other essential nutrients, are low in saturated fat, and contain omega-3 fatty acids. A well-balanced diet that includes a variety of fish and shellfish can contribute to heart health and childrens proper growth and development. So, women and young children in particular should include fish or shellfish in their diets due to the many nutritional benefits. However, nearly all fish and shellfish contain traces of mercury. For most people, the risk from mercury by eating fish and shellfish is not a health concern. Yet, some fish and shellfish contain higher levels of mercury that may harm an unborn baby or young childs developing nervous system. The risks from mercury in fish and shellfish depend on the amount of fish and shellfish eaten and the levels of mercury in the fish and shellfish. Therefore, the Food and Drug Administration (FDA) and the Environmental Protection Agency (EPA) are advising women who may become pregnant, pregnant women, nursing mothers, and young children to avoid some types of fish and eat fish and shellfish that are lower in mercury. By following these three recommendations for selecting and eating fish or shellfish, women and young children will receive the benefits of eating fish and shellfish and be confident that they have reduced their exposure to the harmful effects of mercury. 190
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Follow these same recommendations when feeding fish and shellfish to your young child, but serve smaller portions.
Section 21.5
Numerous studies have examined the effects of caffeine intake on fertility and pregnancy. Most studies found that moderate caffeine intake does not affect fertility or increase the chance of having a miscarriage or a baby with birth defects; some studies did find a relationship between caffeine intake and fertility or miscarriages. However, most of those studies were judged to be inadequate because they did not consider other lifestyle factors that could contribute to infertility or miscarriages. The Organization of Teratology Information Services (OTIS) stated that there is no evidence that caffeine 191
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Chapter 22
Fitness goes hand in hand with eating right to maintain your physical health and well-being during pregnancy. Pregnant or not, physical fitness helps keep the heart, bones, and mind healthy. Healthy pregnant women should get at least 2 hours and 30 minutes of moderateintensity aerobic activity a week. Its best to spread your workouts throughout the week. If you regularly engage in vigorous-intensity aerobic activity or high amounts of activity, you can keep up your activity level as long as your health doesnt change and you talk to your doctor about your activity level throughout your pregnancy. Special benefits of physical activity during pregnancy: Exercise can ease and prevent aches and pains of pregnancy including constipation, varicose veins, backaches, and exhaustion. Active women seem to be better prepared for labor and delivery and recover more quickly. Exercise may lower the risk of preeclampsia and gestational diabetes during pregnancy. Fit women have an easier time getting back to a healthy weight after delivery. Regular exercise may improve sleep during pregnancy.
Excerpted from Staying Healthy and Safe, by the Office of Womens Health (www.womenshealth.gov), March 2009.
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Getting Started
For most healthy moms-to-be who do not have any pregnancyrelated problems, exercise is a safe and valuable habit. Even so, talk to your doctor or midwife before exercising during pregnancy. She or he will be able to suggest a fitness plan that is safe for you. Getting a doctors advice before starting a fitness routine is important for both inactive women and women who exercised before pregnancy. If you have one of these conditions, your doctor will advise you not to exercise: Risk factors for preterm labor Vaginal bleeding Premature rupture of membranes (when your water breaks early, before labor)
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Chapter 23
201
Section 23.1
Healthy weight gain can mean either your overall weight gain, or your weekly rate of weight gain. Some health care providers focus only on overall gain or only on weekly gain, but some keep track of both types of weight gain. First, lets look at overall weight gain. The amount of weight gain that is healthy for you depends on how much you weighed before you were pregnant. Find your prepregnancy weight and height in Table 23.1. Then look at the bottom row of the table to find your overall healthy weight gain goal. If you are expecting twins, an overall weight gain of 35 to 45 pounds is considered healthy. Remember that these goals are only a general range for overall weight gain. Your health care provider will let you know if youre gaining too much or too little weight for a healthy pregnancy. Weight loss can be dangerous during any part of your pregnancy. Report any weight loss to your health care provider right away.
How do I do it?
To maintain a healthy weight gain, eat a healthy diet as outlined by your health care provider, and get regular, moderate physical activity. If you think your weight gain is out-of-control, but you are following a recommended diet and physical activity program, tell your health care provider. He or she will adjust your treatment plan to get your weight gain back into healthy range.
When do I do it?
Its a good idea to keep track of how much weight you gain from the time you learn you are pregnant to the time you have the baby. 202
Table 23.1. Overall Weight Gain Goals by Prepregnancy Height and Weight
Height (Without Shoes) ft. 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 6 in. 9 10 11 0 1 2 3 4 5 6 7 8 9 10 11 0 Weight Status Category (Weight in pounds, in light, indoor clothing) A* 92 or less 94 or less 97 or less 100 or less 103 or less 106 or less 109 or less 113 or less 117 or less 121 or less 124 or less 128 or less 131 or less 135 or less 139 or less 142 or less 3540* B 93-113 95-117 98-120 101123 104127 107131 110134 114140 118144 122149 125153 129157 132162 136166 140171 143175 3035 C 114134 118138 121142 124146 128150 132155 135159 141165 145170 150176 154181 158186 163191 167196 172202 176207 2227 D 135 or more 139 or more 143 or more 147 or more 151 or more 156 or more 160 or more 166 or more 171 or more 177 or more 182 or more 187 or more 192 or more 197 or more 203 or more 208 or more 1520
*The weight gain goal for women in this category may range from 40 to 45 pounds.
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Are there any other ways I can maintain a healthy weight gain?
Some general guidelines that might help you reach your target weekly rate of gain include: Try to get more light or moderate physical activity, if your health care provider says its safe. Use the Nutrition Facts labels on food packages to make lowercalorie food choices that fit into your meal plan. 204
Section 23.2
Nutritional epidemiologist Anna Maria Siega-Riz, Ph.D., had good reason to sound alarmed when she talked about pregnancy and weight gain in February 2008. According to the University of North Carolina at Chapel Hill professor, overweight and obese women, as well as women who gain too much weight during their pregnancies, may be endangering their own health and the health of their children. In her talk, Maternal Obesity: The Number One Problem Facing Prenatal Care Providers in the New Millennium, Siega-Riz presented a preponderance of evidence that these women have a significantly greater risk of suffering from metabolic syndrome-related diseases, of bearing children with birth defects, such as spina bifida, and of giving birth to babies who will experience problems with their own health. 205
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Chapter 24
Women from adolescence to postmenopause are underrepresented in studies of sleep and its disorders. Although sleep complaints are twice as prevalent in women, 75% of sleep research has been conducted in men. More sleep studies in the past five years have included women, but small sample sizes prohibit meaningful sex comparisons. Thus, sex differences in sleep and sleep disorder characteristics, in responses to sleep deprivation, and in sleep-related physiology remain unappreciated. Furthermore, findings from studies based primarily in men are often considered to be representative of normal even when it is recognized that there are important sleep-related physiological differences in women, including timing of nocturnal growth hormone secretion and differential time course of delta activity across the night. Hormonal changes and physical discomfort are common during pregnancy and both can affect sleep. Although nearly all pregnant women will experience disturbed sleep by the third trimester, there have been only two longitudinal sleep studies of subjective and objective sleep measures during pregnancy. There have been no reports of intervention studies to improve sleep quality during pregnancy. Some have assumed that disturbed sleep is a natural consequence of pregnancy, labor, delivery, and postpartum that resolves over time
Excerpted from Sleep, Sex Differences, and Womens Health: National Sleep Disorders Research Plan, by the National Heart, Lung and Blood Institute (NHLBI, www.nhlbi.nih.gov), part of the National Institutes of Health, July 2003. Revised by David A. Cooke, MD, FACP, April 29, 2009.
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Chapter 25
If youre pregnant or even planning a pregnancy, youve probably found an abundance of information about sex before pregnancy (that is, having sex in order to conceive) and sex after childbirth (general consensus: expect a less active sex life when theres a newborn in the house). But theres less talk about the topic of sex during pregnancy, perhaps because of our cultures tendency to dissociate expectant mothers from sexuality. Like many parents-to-be, you may have questions about the safety of sex and whats normal for most couples. Well, whats normal tends to vary widely, but you can count on the fact that there will be changes in your sex life. Open communication will be the key to a satisfying and safe sexual relationship during pregnancy.
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Chapter 26
217
Section 26.1
Generally, women who are pregnant may continue to work during their pregnancy. Some women are able to work right up until they are ready to deliver, while others may need to cut back on their work schedule or stop completely before their due date. Whether you can work during your pregnancy or not depends on your health, the health of the baby, and the type of job that you have. Here are some factors to consider: Heavy lifting: If your job requires heavy lifting, standing, or walking, your doctor may recommend that you work fewer hours a day. This is especially true as you get closer to your delivery date. Exposure to environmental hazards: If you work in a job where you are exposed to hazardous or poisonous agents, you may need to temporarily change positions until after the baby is born. Some agents that may pose a threat to the health of the baby include: chemotherapy medications (may impact health care workers such as nurses and pharmacists); lead (workers in lead smelting, paint manufacturing, printing, ceramics, glass manufacturing, pottery glazing and battery manufacturing; toll booth attendants; and people working on heavily traveled roads); ionizing radiation (X-ray technicians, some physicists and researchers). Get information on possible toxic substances present at your workplace. Find out if these are at toxic levels and if the workplace is adequately ventilated and workers adequately equipped 218
Travel
Traveling is generally considered safe during pregnancy. The key to traveling while pregnant is to make sure you are going to be comfortable and as safe as possible. It is best to notify your doctor of your travel plans and ask for any recommendations specific to your pregnancy. Whether you are traveling by plane, car, or train it is important to do the following: Continue to eat regularly. Drink plenty of fluids to avoid dehydration. Get up and walk around every hour or so to help your circulation and to keep swelling down. Wear comfortable shoes and clothing that doesnt bind. Take crackers and juice with you to prevent nausea. Do not take over the counter medicines or any non-prescribed medications without checking with your doctor. This includes medication for motion sickness or bowel problems related to traveling. Foreign travel: If you are planning a trip out of the country, discuss your trip with your doctor. Plan ahead to allow time for any shots or medications you may need, and be prepared to take a copy of your prenatal record with you. Traveling to high altitudes may cause problems during pregnancy, as your body and your fetus adjust to the lower air pressure and lower levels of oxygen. Its generally best to let your body adjust to moderate 219
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Section 26.2
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Chapter 27
225
Section 27.1
Smoking cigarettes is very harmful to your health and could also affect the health of your baby. Not only does smoking cause cancer and heart disease in people who smoke, a recent large study confirmed that smoking during pregnancy increases the risk of low birth weight. Low-birth-weight babies are at higher risk of health problems shortly after birth. Also, some studies have linked low birth weight with a higher risk of health problems later in life, such as high blood pressure and diabetes. Women who smoke during pregnancy are more likely than other women to have a miscarriage and to have a baby born with cleft lip or palate, types of birth defects. Also, mothers who smoke during or after pregnancy put their babies at greater risk of sudden infant death syndrome (SIDS). Mothers who smoke have many reasons to quit smoking. Take care of your health and your unborn babys health by asking your doctor for help quitting smoking. Quitting smoking is hard, but you can do it with help.
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Section 27.2
Section 27.3
What is FAS?
FAS stands for fetal alcohol syndrome. It is one of the leading known preventable causes of mental retardation and birth defects. FAS represents the severe end of a spectrum of effects that can occur when a woman drinks alcohol during pregnancy. Fetal death is the most extreme outcome. FAS is characterized by abnormal facial features, growth deficiency, and central nervous system (CNS) problems. People with FAS can have problems with learning, memory, attention span, communication, vision, hearing, or a combination of these things. These problems often lead to difficulties in school and problems getting along with others. FAS is a permanent condition. It affects every aspect of an individuals life and the lives of his or her family. However, FAS is 100% preventableif a woman does not drink alcohol while she is pregnant.
How common are fetal alcohol syndrome (FAS) and other prenatal alcohol-related conditions (known collectively as FASDs)?
The reported rates of FAS vary widely. These different rates depend on the population studied and the surveillance methods used. CDC studies show FAS rates ranging from 0.2 to 1.5 cases per 1,000 live births in different areas of the United States. Other prenatal alcohol-related conditions, such as ARND and ARBD, are believed to occur about three times as often as FAS.
If a woman has an FASD, but does not drink during pregnancy, can her child have an FASD? Are FASDs hereditary?
FASDs are not genetic or hereditary. If a woman drinks alcohol during her pregnancy, her baby can be born with an FASD. But if a woman has an FASD, her own child cannot have an FASD, unless she drinks alcohol during pregnancy.
Is there any safe amount of alcohol to drink during pregnancy? Is there a safe time during pregnancy to drink alcohol?
When a pregnant woman drinks alcohol, so does her unborn baby. There is no known safe amount of alcohol that a woman can drink during pregnancy. There is also no safe time during pregnancy to drink alcohol. Alcohol can have negative effects on a fetus in every trimester of pregnancy. Therefore, women should not drink if they are pregnant, planning to become pregnant, or could become pregnant (that is, sexually active and not using an effective form of birth control).
Is there anything I can do now to decrease the chances of having a child with an FASD?
If a woman is drinking during pregnancy, it is never too late for her to stop. The sooner a woman stops drinking, the better it will be for her baby. A woman should use an effective form of birth control until her drinking is under control. If a woman is not able to stop drinking, she should contact her physician, local Alcoholics Anonymous, or local alcohol treatment center, if needed. The Substance Abuse and Mental Health Services Administration has a Substance Abuse Treatment Facility locator. This locator helps people find drug and alcohol treatment programs in their area.
If a woman is sexually active and not using an effective form of birth control, she should not drink alcohol. She could be pregnant and not know it for several weeks or more.
Mothers are not the only ones who can prevent FASDs. Spouses, partners, family members, friends, schools, health and social service organizations, and communities can help prevent FASDs through education and support. 233
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Section 27.4
Drugs use by pregnant women can result in harm to unborn children. The March of Dimes provides information about pregnancy and the use of legal drugs such as tobacco and alcohol and illegal drugs such as cocaine, PCP [phencyclidine], and heroin. Because some prescription and over-the-counter drugs can also harm unborn children, the March of Dimes recommends that pregnant women speak to their doctors before taking any medication.
What is the long-term outlook for babies who were exposed to cocaine before birth?
Some studies suggest that most children who are exposed to cocaine before birth have normal intelligence. This is encouraging, in light of earlier predictions that many of these children would be severely brain damaged. A 2002 study at Harvard Medical School and Boston University found that children up to age 2 who were heavily exposed to cocaine before birth scored just as well on tests of infant development as lightly exposed or unexposed children. However, other studies suggest that cocaine may sometimes affect mental development, possibly lowering IQ [intelligence quotient] levels. A 2002 study at Case Western Reserve University found that cocaine-exposed 2-year-olds were twice as likely as unexposed children from similar low socioeconomic backgrounds to have significant delays in mental development (14 percent and 7 percent, respectively). 236
What is the long-term outlook for babies exposed to marijuana before birth?
There have been a limited number of studies following marijuanaexposed babies through childhood. Some did not find any increased risk of learning or behavioral problems. However, others found that 237
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Section 28.1
Pregnancy is a time to take good care of yourself and your unborn child. Many things are especially important during pregnancy, such as eating right, cutting out cigarettes and alcohol, and being careful about the prescription and over-the-counter drugs you take. Diagnostic x-rays and other medical radiation procedures of the abdominal area also deserve extra attention during pregnancy. This information is to help you understand the issues concerning x-ray exposure during pregnancy. Diagnostic x-rays can give the doctor important and even life-saving information about a persons medical condition. But like many things, diagnostic x-rays have risks as well as benefits. They should be used only when they will give the doctor information needed to treat you. Youll probably never need an abdominal x-ray during pregnancy. But sometimes, because of a particular medical condition, your physician may feel that a diagnostic x-ray of your abdomen or lower torso is needed. If this should happendont be upset. The risk to you and your unborn child is very small, and the benefit of finding out about your medical condition is far greater. In fact, the risk of not having a needed x-ray could be much greater than the risk from the radiation. But even small risks should not be taken if theyre unnecessary. You can reduce those risks by telling your doctor if you are, or think you might be, pregnant whenever an abdominal x-ray is prescribed. If you are pregnant, the doctor may decide that it would be best to cancel the x-ray examination, to postpone it, or to modify it to reduce the amount of radiation. Or, depending on your medical needs, and realizing that the risk is very small, the doctor may feel that it is best to proceed with the x-ray as planned. In any case, you should feel free to discuss the decision with your doctor. 240
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Section 28.2
Pregnant Women Should Avoid Fetal Keepsake Images and Heartbeat Monitors
From Avoid Fetal Keepsake Images, Heartbeat Monitors, by the U.S. Food and Drug Administration (FDA, www.fda.gov), March 24, 2008.
While ultrasonic fetal scanning is generally considered a safe medical procedure, the use of it for unapproved and unintended purposes raises concerns. The use of ultrasound imaging devices for producing fetal keepsake videos is viewed as an unapproved use by the Food and Drug Administration (FDA). Doppler ultrasound heartbeat monitors are not intended for over-the-counter (OTC) use. Both products are approved for use only with a prescription. Although there are no known risks of ultrasound imaging and heartbeat monitors, the radiation associated with them can produce effects on the body, says Robert Phillips, Ph.D., a physicist with FDAs Center for Devices and Radiological Health (CDRH). When ultrasound enters the body, it heats the tissues slightly. In some cases, it can also produce small pockets of gas in body fluids or tissues. Phillips says the long-term effects of tissue heating and of the formation of partial vacuums in a liquid by high-intensity sound waves (cavitation) are not known. Using ultrasound equipment only through a prescription ensures that pregnant women will receive professional care that contributes to their health and to the health of their babies, and that ultrasound will be used when medically indicated.
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Section 28.3
Portable monitors that detect contractions of the uterus do not appear to be useful for identifying women likely to have a preterm delivery, according to a study by the National Institute of Child Health and Human Development (NICHD). Although they are widely prescribed for women at risk of giving birth prematurely, the NICHD study confirms earlier findings that the monitors are not useful for predicting or preventing preterm birth. The study also confirmed that several other methods being assessed as ways to predict preterm labor were of little value. The study found that while women who gave birth prematurely did have slightly more contractions throughout pregnancy than did women who gave birth at term, there was no detectable pattern that would predict premature birth, said Duane Alexander, MD, Director of the NICHD. The study was conducted at the 11 centers participating in the NICHD Network of Maternal-Fetal Medicine Units and appears in the January 25 [2002] New England Journal of Medicine. The study was led by Jay Iams, MD, director of the Division of Maternal-Fetal Medicine at the Ohio State University Medical Center. The portable, or ambulatory, monitors cost up to $100 a day and may be worn for up to 10 weeks. The monitors relay information to a central monitoring office, where any potential signs of early labor can be passed on to a physician. The researchers analyzed 34,908 hours of recordings from 306 women. When the women began the study, they were in their 22nd through 24th week of pregnancy. The authors wrote that the women who gave birth before the 35th week of pregnancy had a slightly greater frequency of contractions than did the women who gave birth 245
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Section 29.1
This information talks about the risks that hyperthermia can have during pregnancy. With each pregnancy, all women have a 3% to 5% chance of having a baby with a birth defect. This information should not take the place of medical care and advice from your health care provider.
What is hyperthermia?
Hyperthermia refers to an abnormally high body temperature. A persons normal body temperature averages about 98.6 degrees Fahrenheit (37 degrees Celsius). In pregnancy, a body temperature of at least 101 degrees Fahrenheit (38.3 degrees Celsius) can be of concern. However, most studies have not shown a concern until your temperature reaches 102 degrees Fahrenheit (38.9 degrees Celsius) or higher for an extended period of time.
I am 5 weeks pregnant and have a high fever. Can this hurt my baby?
There may be an increased risk for a neural tube defect if a woman has a fever of 101 degrees Fahrenheit (38.3 degrees Celsius) or higher for an extended period of time during the first 6 weeks of pregnancy. It is not possible to determine the exact risk. With an illness like the flu, it is often hard to separate the effects of a high temperature from 249
I have a fever of less than 101 degrees Fahrenheit (38.3 degrees Celsius) and am pregnant. Is there a risk to my baby?
A temperature below 101 degrees Fahrenheit (38.3 degrees Celsius) does not appear to increase the risk for birth defects above that seen in any pregnancy. However, you should discuss with your health care provider whether the illness causing your fever poses a risk.
I have been using the hot tub and sauna. Is this a risk during my pregnancy?
Hot tub or sauna use during pregnancy should be limited to less than 10 minutes. This is because it may take only 10 to 20 minutes in a hot tub or sauna to raise your body temperature to 102 degrees Fahrenheit (38.9 degrees Celsius). You may not even feel uncomfortable at this temperature. Although sauna use alone has not been as strongly associated with an increased risk for neural tube defects, the same safety measures are recommended. If you were in a hot tub or sauna for a long period of time early in pregnancy, you may want to talk with your health care provider about ways to detect neural tube defects during pregnancy. After 6 weeks of pregnancy, normal hot tub and sauna use does not appear to increase the risk for birth defects. However, you should still be careful to limit your use to 10 minutes or less and not get overheated or dehydrated. 250
References
Chambers CD, et al. 1998. Maternal fever and birth outcome: a prospective study. Teratology. 58:251257. Edwards MJ, et al. 1995. Hyperthermia and birth defects. Reprod Toxicol 9(5):411. Harvey MAS, et al. 1981. Suggested limits to the use of hot tub and sauna by pregnant women. CMAJ 125:50. Layde PM, et al. 1980. Maternal fever and neural tube defects. Teratology 21:105. Lipson A, et al. 1985. Saunas and birth defects. Teratology 32:147. Lyndberg MC, et al. 1994. Maternal flu, fever, and the risk of neural tube defects: A population based case-control study. Am J Epidemiol 140(3):244. Milunsky A, et al. 1992. Maternal heat exposure and neural tube defects. JAMA 268(7):882. Moretti ME, et al. 2005. Maternal hyperthermia and the risk for neural tube defects in offspring: Systematic review and meta-analysis. Epidemiol 16:216219. NCRP. 1983. National Council on Radiation Protection and Measurements Report No 74, Bethesda, MD, p. 72. 251
Section 29.2
Chiropractic care is health maintenance of the spinal column, disks, related nerves and bone geometry without drugs or surgery. It involves the art and science of adjusting misaligned joints of the body, especially of the spine, which reduces spinal nerve stress and therefore promotes health throughout the body.
Section 29.3
This text talks about the risks that exposure to hair treatments can have during pregnancy. With each pregnancy, all women have a 3% to 5% chance of having a baby with a birth defect. This information should not take the place of medical care and advice from your health care provider.
Before I was pregnant, I had my hair dyed every couple of months. Is this safe now that I am pregnant?
There are very few studies of hair dye use during human pregnancy. In animal studies, at doses 100 times higher than what would normally be used in human application, no significant changes were seen in fetal development. We know that only a small amount of any product applied to your scalp is actually absorbed into your system and therefore, little would be available to get to the developing baby. In addition, many women have dyed their hair during pregnancy with no known reports of negative outcomes. This information, in combination with the minimal absorption through the skin makes hair treatment in pregnancy unlikely to be of concern.
I would like to have my hair permed and am currently in the first trimester of my pregnancy. Is there any risk for birth defects or miscarriage?
Similar to hair dyes, there is limited information available for the safety of hair permanents in pregnancy. The fixation solution used during the application of the permanent may irritate the scalp, but this has not been associated with any other effects in the body. Very 256
I have my hair straightened every two months. Can I continue this into pregnancy?
A study in humans examined the use of hair straighteners during pregnancy. The use of these products was not found to increase the chance of low birth weight or preterm delivery. The study did not address the chance of other abnormal outcomes (such as birth defects). Again, it is likely that only a small amount of hair straightening products are actually absorbed into your system, so the developing baby would only be exposed to small amounts.
I work full time as a cosmetologist and recently became pregnant. Should I stop working until the baby is born?
A large study looked at the risk of miscarriage in cosmetologists. A slightly increased risk of miscarriage was found for cosmetologists who had specific work activities. Activities that seemed to contribute to the slightly increased risk included working more than 40 hours per week, standing more than 8 hours per day, higher numbers of bleaches and permanents applied per week, and working in salons where nail sculpturing was performed. Part time cosmetologists (less than 35 hours per week) did not seem to have an increased risk of miscarriage during pregnancy. In another study, miscarriage rates among hairdressers were reviewed, and newer data was compared to older data. The older data (from 19861988) showed an increased risk of miscarriage, an extended time trying to get pregnant, and low birth weight. The newer data (from 19911993) did not find increased risks. The authors suggest that newer restrictions on some dye formulas and better working conditions have contributed to the better outcomes. Both studies support the importance of proper working conditions. Working in a well ventilated area, wearing protective gloves, taking frequent breaks, and avoiding eating or drinking in the workplace are all important factors that can decrease chemical exposures.
References
Blackmore-Prince C, et al 1999. Chemical hair treatments and adverse pregnancy outcome among Black women in central North Carolina. Am J Epidemiol 149:712716. Burnett C, et al. 1976. Teratology and percutaneous toxicity studies on hair dyes. J Toxicol Environ Health 1:10271040. DiNardo JC, et al. 1985. Teratological assessment of five oxidative hair dyes in the rat. Toxicology and Applied Pharmacology 78:163166. Inouye M. and Murakami U. 1976. Teratogenicity of 2,5-diaminotoluene, a hair dye component, in mice. Teratology 14:241242. John EM, et al. 1994. Spontaneous abortions among cosmetologists. Epidemiol 5:147155. Kersemaekers WM, et al. 1996. Reproductive disorders among hairdressers. Epidemiol 8:396401. Koren G (ed.) 1994. Maternal-Fetal Toxicology: A Clinicians Guide. New York: Marcel Dekker, Inc. Koren G. 1996. Hair care during pregnancy. Can Fam Physician 42:625626. Kramer S, et al. 1987. Medical and drug risk factors associated with neuroblastoma: A case-control study. J Natl Cancer Inst 78:797803. Maibach HI, et al. 1975. Percutaneous penetration following use of hair dyes. Arch Dermatol 111:14441445. Marks TA, et al. 1979. Teratogenicity of 4-nitro-1,2-diaminobenzene (4NDB) and 2-nitro-1,4-diaminobenzene (2NDB) in the mouse. Teratology 19:37A38A. Marks TA, et al. 1981. Teratogenic evaluation of 2-nitro-p-phenylenediamine, 4-nitro-o-phenylenediamine, and 2,5-toluenediamine sulfate in the mouse. Teratology 24:253265. Paul M (ed.) 1993. Occupational and Environmental Reproductive Hazards: A Guide for Clinicians. Baltimore: Williams and Wilkins. Rylander L, et al. 2002. Reproductive outcome among female hairdressers. Occup Environ Med 59:517522. 258
Section 29.4
This text talks about the risks that exposure to self-tanners, tanning pills, and tanning booths can have during pregnancy. With each pregnancy, all women have a 3% to 5% chance of having a baby with a birth defect. This information should not take the place of medical care and advice from your health care provider.
Can using self-tanners, tanning pills, or tanning booths make it more difficult for me to become pregnant?
There is no evidence to suggest that using self-tanners makes it more difficult to become pregnant, as very little of the DHA is absorbed into the bloodstream. Tanning pills are taken orally, so there is a greater chance that a person could ingest a very large amount of canthaxanthin. There are no studies regarding the safety of using tanning pills while trying to become pregnant. Using tanning booths is not expected to make it more difficult to become pregnant.
Is it a problem if the babys father is using self-tanners, tanning pills, or tanning booths while I am trying to become pregnant?
For males, there is no evidence that using any of the self-tanning products or tanning pills will cause birth defects. However, constant spikes in body temperature can decrease sperm production, so a male should be careful not to become overheated in a tanning booth.
References
Lapunzina P. 1996. Ultraviolet light-related neural tube defects? Am J Med Genet 67:106. Merck Index, 12th Edition, p. 3225. Meadows M. 2003. Dont Be in the Dark about Tanning. FDA Consumer Magazine 37:6. 261
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Section 30.2
Teen Pregnancy
Teen Pregnancy and Other Health Issues, 2009 National Campaign to Prevent Teen and Unplanned Pregnancy (www.thenationalcampaign.org). Reprinted with permission.
Teen pregnancy can have negative health implications for both the mother and child. Of course, the health and health-related behavior of teen mothers before, during, and after pregnancy affects the health of the baby. Evidence suggests that babies born to teen mothers are at increased risk for specific health problems compared to babies born to older mothers. In addition to these personal costs, there are considerable costs to taxpayers associated with the public health care expenses of teen childbearing. Reducing teen pregnancy will not only improve the health of teens and their future children, it will also reduce some of the costs of public health services. Infants born to teen mothers are at increased risk of being born prematurely and at a low birthweight. This puts newborns at greater risk for infant death, respiratory distress syndrome, bleeding in the brain, vision loss, and serious intestinal problems.1,2 Teen mothers are also more likely than mothers over the age of 25 to smoke during pregnancy, and often teen mothers are not at adequate pre-pregnancy weight and/or do not gain the appropriate amount of weight while pregnant.1 Compared to older pregnant women, pregnant teens are far less likely to receive timely and consistent prenatal care.1 Recent research indicates that while there is little difference in their childs health status as reported by teen mothers or by older mothers, the children of teen mothers are less likely to visit a medical care provider.3 Teen mothers are also slightly more likely than similarly situated older mothers to report that their child has a chronic health condition.3 The children of teen mothers are more likely to depend on publicly provided health care than the children of older mothers. In 268
Sources
1. 2. March of Dimes, Teenage Pregnancy, in Quick Reference and Fact Sheets. 2004. Martin, J.A., Hamilton, B.E., Ventura, S.J., Menacker, F. and Kirmeyer, S., Births: Final Data for 2004. National Vital Statistics Reports, 2006. 55(1). Hoffman, S.D., By the Numbers: The Public Costs of Adolescent Childbearing. 2006, The National Campaign to Prevent Teen Pregnancy Washington, DC. National Campaign analysis of, National Survey of Family Growth, 2002. 2005, National Campaign to Prevent Teen Pregnancy: Washington, DC. Weinstock, H., Berman, S., and Cates, W., Sexually Transmitted Diseases Among American Youth: Incidence and Prevalence Estimates. Perspectives on Sexual and Reproductive Health, 2004. 36(1): p. 610. Centers for Disease Control and Prevention, Sexually Transmitted Disease Surveillance, 2004. 2005, U.S. Department of Health and Human Services: Atlanta, GA. Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, 2005. 2006, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention: Atlanta, GA. Guttmacher Institute, Facts on American Teens Sexual and Reproductive Health in In Brief. 2006, Guttmacher Institute: New York, NY.
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Section 30.3
Today, many women are waiting until their mid-30s or later before having their first child. Women over age 35 can have normal pregnancies and deliver healthy babies. But 35 is the age often used to measure an increased risk of problems with pregnancy. A womans chance of having problems during pregnancy goes up a little each year after a woman is in her early 20s. These problems usually fall into 2 categories: a decrease in fertility (a womans ability to become pregnant) and genetic conditions that may affect the baby.
Decline in Fertility
As you get older, it is harder to become pregnant. This is because your body does not release eggs (ovulate) as often. Even though you may have regular menstrual periods, your body may not be releasing eggs every month. There is less chance that your partners sperm will fertilize the eggs that are released. Fertilized eggs are less likely to attach to your uterus. Some physical conditions, such as a blocked fallopian tube or endometriosis, also may decrease your chance of becoming pregnant. These problems are more common in women over age 35. Also, if you and your partner have been together for a long time, chances are you may be having sex less often. Any of these factors may make it difficult for you to become pregnant. If you and your partner have sex without using birth control for 6 months without your getting pregnant, you should make an appointment with your doctor for a fertility test.
Genetic Conditions
The most common genetic problem in babies born to women older than 35 is Down syndrome. Down syndrome causes birth defects such 271
Other Considerations
If you are over 35 and planning to become pregnant, you also need to consider that chronic health problems, such as diabetes or high blood pressure, often develop with age. Miscarriage and stillbirth (the birth of a baby who has died before delivery) rates also are higher in women over age 35. By staying in good physical health, you can avoid many of these possible problems.
Section 30.4
When a woman is carrying two or more babies (fetuses), it is called a multiple pregnancy. In the past two decades, the number of multiple births in the United States has jumped dramatically. Between 1980 and 2003, the number of twin births increased by two-thirds (66 percent), and the number of higher-order multiples (triplets or more) increased four-fold, according to the National Center for Health Statistics.1 Today, more than 3 percent of babies in this country are born in sets of two, three or more, and about 94 percent of these multiple births are twins.1 The rising number of multiple pregnancies is a concern because women who are expecting more than one baby are at increased risk of certain pregnancy complications, including preterm delivery (before 37 completed weeks of pregnancy). Premature babies are at risk of serious health problems during the newborn period, as well as lasting disabilities and death. Some of the complications associated with multiple pregnancy can be minimized or prevented when they are diagnosed early. There are a number of steps a pregnant woman and her health care provider can take to help improve the chances that her babies will be born healthy.
References
1. 2. Martin, J.A., et al. Births: Final Data for 2003. National Vital Statistics Reports, volume 54, number 2, September 8, 2005. Reddy, U.M., et al. Relationship of Maternal Body Mass Index and Height to Twinning. Obstetrics and Gynecology, volume 105, number 3, March 2005, pages 593597. Wright, V.C., et al. Assisted Reproductive Technology Surveillance2003. Morbidity and Mortality Weekly Report, volume 55 (SS04), May 26, 2006. Practice Committee of the Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine. Fertility and Sterility, volume 82, number 3, September 2004, pages 773774. American Society for Reproductive Medicine. Multiple Pregnancy and Birth: Twins, Triplets, and Higher Order Multiples: A Guide for Patients. Birmingham AL, 2004, accessed 6/8/06. Hoyert, D.L., et al. Annual Summary of Vital Statistics: 2004. Pediatrics, volume 117, number 1, January 2006, pages 168183. Fox, C., et al. Contemporary Treatments for Twin-Twin Transfusion Syndrome. Obstetrics and Gynecology, 2005, volume 105, number 6, pages 14691477. American College of Obstetricians and Gynecologists (ACOG). Multiple Gestation: Complicated Twin, Triplet, and HigherOrder Multifetal Pregnancy. ACOG Practice Bulletin, number 56, October 2004. American College of Obstetricians and Gynecologists (ACOG). Your Pregnancy and Birth, 4th Edition. ACOG, Washington, DC, 2004.
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Chapter 31
Asthma is the most common potentially serious medical condition to complicate pregnancy. In fact, asthma affects approximately 8 percent of women in their childbearing years. Well-controlled asthma is not associated with significant risk to mother or fetus. Uncontrolled asthma can cause serious complications to the mother, including high blood pressure, toxemia, premature delivery and rarely death. For the baby, complications of uncontrolled asthma include increased risk of stillbirth, fetal growth retardation, premature birth, low birth weight and a low APGAR score at birth. Asthma can be controlled by careful medical management and avoidance of known triggers, so asthma need not be a reason for avoiding pregnancy. Most measures used to control asthma are not harmful to the developing fetus and do not appear to contribute to either miscarriage or birth defects. Although the outcome of any pregnancy can never be guaranteed, most women with asthma and allergies do well with proper medical management by physicians familiar with these disorders and the changes that occur during pregnancy.
When Pregnancy Is Complicated by Allergies and Asthma, Copyright 2006 American College of Allergy, Asthma and Immunology (www.acaai.org). Reprinted with permission.
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Summary
It is important to remember that the risks of asthma medications are lower than the risks of uncontrolled asthma, which can be harmful to both mother and child. The use of asthma or allergy medication needs to be discussed with your doctor, ideally before pregnancy. Therefore, the doctor should be notified whenever you are planning to discontinue birth control methods or as soon as you know that you are pregnant. Regular follow up for evaluation of asthma symptoms and medications is necessary throughout the pregnancy to maximize asthma control and to minimize medication risks. This information has been prepared by members of the Pregnancy Committee of the American College of Allergy, Asthma and Immunology, an organization whose members are dedicated to providing optimal care to all patients with asthma, including those who are pregnant.
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Chapter 32
Chapter Contents
Section 32.1Breast Cancer and Pregnancy ............................ 290 Section 32.2Gestational Trophoblastic Tumors .................... 293
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Section 32.1
Every womans hormone levels change throughout her life for a variety of reasons, and hormone changes can lead to changes in the breasts. Hormone changes that occur during pregnancy may influence a womans chances of developing breast cancer later in life. Research continues to help us understand reproductive events and breast cancer risk.
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Section 32.2
Gestational trophoblastic tumor, a rare cancer in women, is a disease in which cancer (malignant) cells grow in the tissues that are formed following conception (the joining of sperm and egg). Gestational trophoblastic tumors start inside the uterus, the hollow, muscular, pear-shaped organ where a baby grows. This type of cancer occurs in women during the years when they are able to have children. There are two types of gestational trophoblastic tumors: hydatidiform mole and choriocarcinoma. If a patient has a hydatidiform mole (also called a molar pregnancy), the sperm and egg cells have joined without the development of a baby in the uterus. Instead, the tissue that is formed resembles grape-like cysts. Hydatidiform mole does not spread outside of the uterus to other parts of the body. If a patient has a choriocarcinoma, the tumor may have started from a hydatidiform mole or from tissue that remains in the uterus following an abortion or delivery of a baby. Choriocarcinoma can spread from the uterus to other parts of the body. A very rare type of gestational trophoblastic tumor starts in the uterus where the placenta was attached. This type of cancer is called placental-site trophoblastic disease. Gestational trophoblastic tumor is not always easy to find. In its early stages, it may look like a normal pregnancy. A doctor should be seen if the there is vaginal bleeding (not menstrual bleeding) and if a woman is pregnant and the baby hasnt moved at the expected time. If there are symptoms, a doctor may use several tests to see if the patient has a gestational trophoblastic tumor. An internal (pelvic) examination is usually the first of these tests. The doctor will feel for any lumps or strange feeling in the shape or size of the uterus. The doctor may then do an ultrasound, a test that uses sound waves to find tumors. A blood test will also be done to look for high levels of a 293
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Chapter 33
You have type 1 or type 2 diabetes and you are pregnant or hoping to get pregnant soon. You can learn what to do to have a healthy baby. You can also learn how to take care of yourself and your diabetes before, during, and after your pregnancy. Pregnancy and new motherhood are times of great excitement, worry, and change for any woman. If you have diabetes and are pregnant, your pregnancy is automatically considered a high-risk pregnancy. Women carrying twinsor moreor who are beyond a certain age are also considered to have high-risk pregnancies. High risk doesnt mean youll have problems. Instead, high risk means you need to pay special attention to your health and you may need to see specialized doctors. Millions of high-risk pregnancies produce perfectly healthy babies without the moms health being affected. Special care and attention are the keys.
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Table 33.1. Blood Glucose Goals for Pregnant Women Recommended by the American Diabetes Association
When Before meals and when you wake up 2 hours after the start of a meal Plasma Blood Glucose (mg/dL) 80 to 110 Below 155
Source: American Diabetes Association. Preconception care of women with diabetes. Diabetes Care. 2004;27(Supplement 1):S7678.
Table 33.2. Blood Glucose Goals Recommended by the American College of Obstetricians and Gynecologists
When Fasting Before meals 1 hour after the start of a meal 2 hours after the start of a meal During the night Plasma Blood Glucose (mg/dL) 105 or less 110 or less 155 or less 135 or less Not less than 65
Source: American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins. ACOG Practice Bulletin Number 60: Pregestational diabetes mellitus. Obstetrics and Gynecology. 2005;105(3):675685.
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Ketone Levels
When your blood glucose is too high or if youre not eating enough, your body might make chemicals called ketones. Ketones are produced when your body doesnt have enough insulin and glucose cant be used for energy. Then the body uses fat instead of glucose for energy. Burning fat instead of glucose can be harmful to your health and your babys health. Harmful ketones can pass from you to your baby. Your 299
Checkups
Pregnancy can make some diabetes-related health problems worse. Your health care provider can talk with you about how pregnancy might affect any problems you had since before pregnancy. If you plan your pregnancy enough in advance, you may want to work with your health care provider to arrange for treatments, such as laser treatment for eye problems, before you get pregnant. Your diabetes-related health conditions can also affect your pregnancy. 300
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Chapter 34
What Is Epilepsy?
Epilepsy is a brain disorder in which clusters of nerve cells, or neurons, in the brain sometimes signal abnormally. Neurons normally generate electrochemical impulses that act on other neurons, glands, and muscles to produce human thoughts, feelings, and actions. In epilepsy, the normal pattern of neuronal activity becomes disturbed, causing strange sensations, emotions, and behavior, or sometimes convulsions, muscle spasms, and loss of consciousness. During a seizure, neurons may fire as many as 500 times a second, much faster than normal. In some people, this happens only occasionally; for others, it may happen up to hundreds of times a day. More than 2 million people in the United Statesabout 1 in 100 have experienced an unprovoked seizure or been diagnosed with epilepsy. For about 80 percent of those diagnosed with epilepsy, seizures can be controlled with modern medicines and surgical techniques. However, about 25 to 30 percent of people with epilepsy will continue to experience seizures even with the best available treatment. Doctors call this situation intractable epilepsy. Having a seizure does not necessarily mean that a person has epilepsy. Only when a person has had two or more seizures is he or she considered to have epilepsy.
From Seizures and Epilepsy: Hope Through Research, by the National Institute of Neurological Disorders and Stroke (NINDS, www.ninds.nih.gov), part of the National Institutes of Health, March 23, 2009.
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Eclampsia
Eclampsia is a life-threatening condition that can develop in pregnant women. Its symptoms include sudden elevations of blood pressure and seizures. Pregnant women who develop unexpected seizures should be rushed to a hospital immediately. Eclampsia can be treated in a hospital setting and usually does not result in additional seizures or epilepsy once the pregnancy is over.
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Chapter 35
Twenty years ago, medical textbooks said that women with lupus should not get pregnant because of the risks to both the mother and unborn child. Today, most women with lupus can safely become pregnant. With proper medical care, you can decrease the risks associated with pregnancy and deliver a normal, healthy baby. To increase the chances of a happy outcome, however, you must carefully plan your pregnancy. Your disease should be under control or in remission before conception takes place. Getting pregnant when your disease is active could result in a miscarriage, a stillbirth, or serious complications for you. It is extremely important that your pregnancy be monitored by an obstetrician who is experienced in managing high-risk pregnancies and who can work closely with your primary doctor. Delivery should be planned at a hospital that can manage a high-risk patient and provide the specialized care you and your baby will need. Be aware that a vaginal birth may not be possible. Very premature babies, babies showing signs of stress, and babies of mothers who are very ill will probably be delivered by cesarean section. One problem that can affect a pregnant woman is the development of a lupus flare. In general, flares are not caused by pregnancy. Flares that do develop often occur during the first or second trimester or
Excerpted from Lupus: A Patient Care Guide for Nurses and Other Health Professionals, 3rd Edition, National Institute of Arthritis and Musculoskeletal and Skin Diseases. NIH Publication No. 06-4262, September 2006.
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Chapter 36
Management of Pregnancy
Prenatal Care
The prenatal assessment visit serves to provide counseling and outline continued care for the duration of the pregnancy. The primary focus is to identify maternal risks for low birth weight, preterm delivery, and genetic risks for fetal abnormalities. At this time, the physician
Excerpted from The Management of Sickle Cell Disease, a publication by the Centers for Disease Control and Prevent (CDC, www.cdc.gov), and the National Heart, Lung and Blood Institute (NHLBI, www.nhlbi.nih.gov), June 2002. Revised by David A. Cooke, MD, FACP, April 29, 2009.
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Chapter 38
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Section 38.1
Eating disorders affect approximately seven million American women each year and tend to peak during child-bearing years. Pregnancy is a time when body image concerns are more prevalent, and for those who are struggling with an eating disorder, the nine months of pregnancy can cause disorders to worsen. Two of the most common types of eating disorders are anorexia and bulimia. Anorexia involves obsessive dieting or starvation to control weight gain. Bulimia involves binge eating and vomiting or using laxatives to rid the body of excess calories. Both types of eating disorders may negatively affect the reproductive process and pregnancy.
Prior to Pregnancy
Achieve and maintain a healthy weight. Avoid purging. Consult your health care provider for a pre-conception appointment. 321
During Pregnancy
Schedule a prenatal visit early in your pregnancy and inform your health care provider that you have been struggling with an eating disorder. Strive for healthy weight gain. Eat well-balanced meals with all the appropriate nutrients. Find a nutritionist who can help you with healthy and appropriate eating. Avoid purging. Seek counseling to address your eating disorder and any underlying concerns; seek both individual and group therapy.
After Pregnancy
Continue counseling to improve physical and mental health. Inform your safe network (health care provider, spouse, and friends) of your eating disorder and the increased risk of postpartum depression; ask them to be available after the birth. Contact a lactation consultant to help with early breastfeeding. Find a nutritionist who can help work with you to stay healthy, manage your weight, and invest in your baby.
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Section 38.2
Pica
Pica, 2009 A.D.A.M., Inc. Reprinted with permission.
Definition
Pica is a pattern of eating non-food materials (such as dirt or paper).
Causes
Pica is seen more in young children than adults. Between 10 and 32% of children ages 16 have these behaviors. Pica can occur during pregnancy. In some cases, a lack of certain nutrients, such as iron deficiency anemia and zinc deficiency, may trigger the unusual cravings. Pica may also occur in adults who crave a certain texture in their mouth.
Symptoms
Children and adults with pica may eat: animal feces; clay; dirt; hairballs; ice; paint; sand. This pattern of eating should last at least 1 month to fit the diagnosis of pica.
Treatment
Treatment should first address any missing nutrients and other medical problems, such as lead exposure. Treatment involves behavior and development, environmental, and family education approaches. Other successful treatments include associating the pica behavior with bad consequences or punishment (mild aversion therapy) followed by positive reinforcement for eating the right foods. Medications may help reduce the abnormal eating behavior, if pica occurs as part of a developmental disorder such as mental retardation.
Outlook (Prognosis)
Treatment success varies. In many cases, the disorder lasts several months, then disappears on its own. In some cases, it may continue into the teen years or adulthood, especially when it occurs with developmental disorders.
Possible Complications
bezoar infection intestinal obstruction lead poisoning malnutrition
Prevention
There is no specific prevention. Getting enough nutrition may help. 324
Chapter 39
325
Section 39.1
If a woman is overweight or obese before pregnancy, she faces special health risks. But she can take steps to protect her own health and the health of her baby. To find out if you are overweight or obese, youll need to know your height and weight. You then can calculate your body mass index (BMI). BMI helps to determine if your weight is appropriate for your height.
Childbirth
An overweight woman is at increased risk of having problems during and after childbirth. The higher her BMI, the more likely she may need a cesarean delivery, which is major surgery. Compared to other pregnant women, very overweight women may have more trouble recovering from a c-section. Also, they may need to stay in the hospital longer.
Section 39.2
A study shows that a childs weight may be influenced by the mother even before the child is actually born. The study, conducted by researchers from Ohio State University (OSU) College of Nursing and School of Public Health, appears in the December 5, 2005 issue of the journal Pediatrics and was supported by the National Institute of Nursing Research (NINR), one of the National Institutes of Health (NIH). The study showed that a child is more likely to be overweight at a very young ageat 2 or 3 years oldif the mother was overweight or obese before she became pregnant. The data also indicate that other prenatal characteristics, particularly race, ethnicity, and maternal smoking during pregnancy, place a child at greater risk of becoming overweight. Specifically, a child is at greater risk of becoming overweight if born to a black or Hispanic mother, or to a mother who smoked during her pregnancy, according to the study. 328
Section 39.3
According to some U.S. statistics 4050 percent of pregnancies are unplanned, so it is difficult to warn obese young women to delay pregnancy until after weight loss. Taking into consideration that obesity causes earlier menarche and is more common among the poor and uneducated, and among African American and Hispanic women, it is obvious that huge educational, cultural, and societal resources are required to limit the growing obesity epidemic. 330
How Does Surgical Treatment of Obesity Fit into the Picture? Or Does It?
Not knowing the dangers of obese pregnancies is only part of the problem. The other part is lacking access to effective means of achieving weight loss, or even maintaining a stable weight among those prone to weight gain. Regardless of reason(s) for undergoing weightloss surgery, the fact is that rapidly increasing numbers of younger and younger women are having weight-loss operations. The majority of them are expected to become pregnant. In fact, obesity is a common cause of infertility, and weight loss by surgery or other means often cures such infertility. What should obese women considering surgery, or having undergone weight-loss surgery, know about its effects on pregnancy outcomes? First, it is important to understand the differences between the two major types of operations. Most operations nowadays are (or should be) performed using a laparoscope and three or four instruments inserted through half-inch cuts in the belly wall, instead of one large cut eight to 12 inches long. One type of operation is purely gastric restrictive, creating a small stomach pouch by placing an adjustable band around the top of the stomach. The inflated band makes a very small opening for the food to pass into the large stomach below the band. This causes small amounts of solid food to stretch the stomach pouch wall creating a sense of fullness as well as slowing the emptying of solid food from the small pouch. Liquids and melting foods (chocolate, cookies, chips) go straight through unless solid food is blocking the opening. The other type of operation combines restriction (a small pouch) with bypass of more than 95 percent of the stomach and the first portions of the small bowel. The restrictive sense of fullness disappears over the first 1018 months because the pouch and the opening between the pouch and the small bowel stretch. The bypass operations work better because the undigested solid food and liquids cause fullness even after the pouch and opening have stretched. Clearly the restrictive action of the operations can cause vomiting, especially if the patient eats quickly and chews poorly. Pills or capsules can similarly cause vomiting if they are sufficiently large. 331
Conclusions
Obese pregnancies are dangerous pregnancies. Pregnancies following weight-loss surgery are safer than obese pregnancies for mother and child. Pregnancies after weight-loss surgery, regardless of weight: a.) should be prevented during the first 18 months after surgery; b.) should be monitored for nutrient deficiencies to guide taking supplements.
Recommendations for Pregnant Women Who Have Undergone Gastric Restrictive Weight-Loss Operations
Eating Behavior
To reduce the risk of vomiting: Eat slowly with minimal stress and distraction. 333
Response to Vomiting
If you vomit or regurgitate: Try to identify the reasons. Do not drink for four hours. Progress your diet slowly, starting with liquids. If nausea or vomiting during progression occurs, consume nothing by mouth for 12 hours. If you continue to vomit, despite above measures, contact your surgeon.
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Chapter 40
337
Section 40.1
Complications of pregnancy are health problems that occur during pregnancy. They can involve the mothers health, the babys health, or both. Some women have health problems before they become pregnant that could lead to complications. Other problems arise during the pregnancy. Keep in mind that whether a complication is common or rare, there are ways to manage problems that come up during pregnancy.
Pregnancy-Related Problems
Sometimes pregnancy problems ariseeven in healthy women. Some prenatal tests done during pregnancy can help prevent these problems or spot them early. Use Table 40.1 to learn about some common pregnancy complications. Call your doctor if you have any of the symptoms on this chart. If a problem is found, make sure to follow your doctors advice about treatment. Doing so will boost your chances of having a safe delivery and a strong, healthy baby.
Symptoms: Feel tired or weak; look pale; feel faint; shortness of breath Treatment: Treating the underlying cause of the anemia will help restore the number of healthy red blood cells. Women with pregnancy related anemia are helped by taking iron and folic acid supplements. Your doctor will check your iron levels throughout pregnancy to be sure anemia does not happen again.
DepressionExtreme sadness during pregnancy or after birth (postpartum)
Symptoms: Intense sadness; helplessness and irritability; appetite changes; thoughts of harming self or baby Treatment: Women who are pregnant might be helped with one or a combination of treatment options, including therapy, support groups, and medicines. A mothers depression can affect her babys development, so getting treatment is important for both mother and baby.
Ectopic pregnancyWhen a fertilized egg implants outside of the uterus, usually in the fallopian tube
Symptoms: Abdominal pain; shoulder pain; vaginal bleeding; feeling dizzy or faint Treatment: With ectopic pregnancy, the egg cannot develop. Drugs or surgery is used to remove the ectopic tissue so your organs are not damaged.
Fetal problemsUnborn baby has a health issue, such as poor growth or heart problems
Symptoms: Baby moving less; baby is smaller than normal for gestational age; fewer than 10 kicks per day after 26 weeks; some problems have no symptoms, but are found with prenatal tests Treatment: Treatment depends on results of tests to monitor babys health. If a test suggests a problem, this does not always mean the baby is in trouble. It may only mean that the mother needs special care until the baby is delivered. This can include a wide variety of things, such as bed rest, depending on the mothers condition. Sometimes, the baby has to be delivered early.
341
Symptoms: Usually, there are no symptoms. Sometimes, extreme thirst, hunger, or fatigue; screening test shows high blood sugar levels Treatment: Most women with pregnancy related diabetes can control their blood sugar levels by a following a healthy meal plan from their doctor. Some women also need insulin to keep blood sugar levels under control. Doing so is important because poorly controlled diabetes increases the risk of preeclampsia; early delivery; cesarean birth; having a big baby, which can complicate delivery; baby born with low blood sugar, breathing problems, and jaundice.
High blood pressure (pregnancy related)High blood pressure that starts after 20 weeks of pregnancy and goes away after birth
Symptoms: High blood pressure without other signs and symptoms of preeclampsia Treatment: The health of the mother and baby are closely watched to make sure high blood pressure is not preeclampsia.
Hyperemesis gravidarum (HG)Severe, persistent nausea and vomiting during pregnancy
Symptoms: More extreme than morning sickness; nausea that does not go away; vomiting several times every day; weight loss; reduced appetite; dehydration; feeling faint or fainting Treatment: Dry, bland foods and fluids is the first line of treatment. Sometimes, medicines are prescribed to help nausea. Many women with HG have to be hospitalized so they can be fed fluids and nutrients through a tube in their veins. Usually, women with HG begin to feel better by the 20th week of pregnancy. But some women vomit and feel nauseated throughout all three trimesters.
MiscarriagePregnancy loss from natural causes before 20 weeks. As many as 20 percent of pregnancies end in miscarriage. Often, miscarriage occurs before a woman even knows she is pregnant
Symptoms: Signs of a miscarriage can include vaginal spotting or bleeding; cramping or abdominal pain; fluid or tissue passing from the vagina Treatment: In most cases, miscarriage cannot be prevented. Sometimes, a woman must undergo treatment to remove pregnancy tissue in the uterus. Counseling can help with emotional healing.
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Symptoms: Painless vaginal bleeding during second or third trimester; for some, no symptoms Treatment: If diagnosed after the 20th week of pregnancy, but with no bleeding, a woman will need to cut back on her activity level and increase bed rest. If bleeding is heavy, hospitalization may be needed until mother and baby are stable. If the bleeding stops or is light, continued bed rest is resumed until baby is ready for delivery. If bleeding doesnt stop or if preterm labor starts, baby will be delivered by cesarean.
Placental abruptionPlacenta separates from uterine wall before delivery, which can mean the fetus doesnt get enough oxygen
Symptoms: Vaginal bleeding; cramping, abdominal pain, and uterine tenderness Treatment: When the separation is minor, bed rest for a few days usually stops the bleeding. Moderate cases may require complete bed rest. Severe cases (when more than half of the placenta separates) can require immediate medical attention and early delivery of the baby.
PreeclampsiaA condition starting after 20 weeks of pregnancy that causes high blood pressure and problems with the kidneys and other organs. Also called toxemia.
Symptoms: High blood pressure; swelling of hands and face; too much protein in urine; stomach pain; blurred vision; dizziness; headaches Treatment: The only cure is delivery, which may not be best for the baby. Labor will probably be induced if condition is mild and the woman is near term (37 to 40 weeks of pregnancy). If it is too early to deliver, the doctor will watch the health of the mother and her baby very closely. She may need medicines and bed rest at home or in the hospital to lower her blood pressure. Medicines also might be used to prevent the mother from having seizures.
Preterm laborGoing into labor before 37 weeks of pregnancy
Symptoms: Increased vaginal discharge; pelvic pressure and cramping; back pain radiating to the abdomen; contractions Treatment: Medicines can stop labor from progressing. Bed rest is often advised. Sometimes, a woman must deliver early. Giving birth before 37 weeks is called preterm birth.
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Section 40.2
Until this point in your pregnancy, youve probably been going about your normal activities of work, chores at home, spending time with family and friends, and exercise. But one day, suddenly or perhaps planned in advance, your doctor tells you that for your health and the health of your baby, youll be restricted to bed rest. Even though your friends and family may envy you for what they see as a mini-vacation, dont be fooledbed rest during pregnancy is no walk in the park. Fortunately, though, there are plenty of ways to make your time in bed more enjoyable and productive, so keep reading and find out how to make the best of bed rest.
Doctors Orders
There are several situations that might cause your doctor to recommend bed rest for some portion of your pregnancy. If your medical history, including previous pregnancies, contains information that might point to a medical complication, your doctor might recommend bed rest. Or, you might experience symptoms, such as bleeding or contractions, that require you to go on bed rest. Even if your medical history is clear and you experience no symptoms, your doctor may require bed rest if the results of a test or procedure indicate a medical complication or if your babys growth is determined to be poor. So what are some common pregnancy complications that often result in bed rest? A few include: high blood pressure (including pregnancyinduced hypertension, preeclampsia, and eclampsia), vaginal bleeding 344
348
Chapter 41
Chapter Contents
Section 41.1Polyhydramnios (Excessive Amniotic Fluid) .... 350 Section 41.2Potter Syndrome and Oligohydramnios (Inadequate Amniotic Fluid) .............................. 351
349
Section 41.1
Definition
Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn infant.
Considerations
Amniotic fluid surrounds and cushions the infant throughout development. There may be too little or too much amniotic fluid due to problems in the fetus. Polyhydramnios can occur if the fetus does not swallow and absorb amniotic fluid in normal amounts. This can happen due to gastrointestinal disorders, brain and nervous system (neurological) problems, or a variety of other causes. Polyhydramnios may also be related to increased fluid production, as is the case with certain fetal lung disorders. Sometimes, no specific cause for polyhydramnios is found.
Causes
Achondroplasia Anencephaly Beckwith-Wiedemann syndrome Diaphragmatic hernia Duodenal atresia Esophageal atresia Gastroschisis Gestational diabetes Hydrops fetalis Multiple gestation (for example, twins or triplets) 350
Section 41.2
Alternative Names
Potter phenotype
Definition
Potter syndrome and Potter phenotype refers to a group of findings associated with a lack of amniotic fluid and kidney failure in an unborn infant.
Causes
In Potter syndrome, the primary problem is kidney failure. The kidneys fail to develop properly as the baby is growing in the womb. The kidneys normally produce the amniotic fluid (as urine). Potter phenotype refers to a typical facial appearance that occurs in a newborn when there is no amniotic fluid. The lack of amniotic fluid is called oligohydramnios. Without amniotic fluid, the infant is not 351
Symptoms
Widely separated eyes with epicanthal folds, broad nasal bridge, low set ears, and receding chin Absence of urine output Difficulty breathing
Treatment
Resuscitation at delivery may be attempted pending the diagnosis. Treatment will be provided for any urinary outlet obstruction.
Outlook (Prognosis)
This is a very serious condition, usually deadly. The short term outcome depends on the severity of lung involvement. Long-term outcome depends on the severity of kidney involvement.
Prevention
There is no known prevention.
References
Behrman RE. Nelson Textbook of Pediatrics. 17th ed. Philadelphia, Pa: WB Saunders; 2004. 352
Chapter 42
Birth Defects
Chapter Contents
Section 42.1Birth Defects That May Be Diagnosed during Pregnancy ................................................ 354 Section 42.2Birth Defects and Developmental Disabilities ........................................................... 358
353
Section 42.1
Birth Defects
chance for a couple to have a child with a birth defect may be higher than the background rate of 3 to 4 percent.
Birth Defects
amniocentesis (another type of prenatal test), CVS does not provide information on neural tube defects such as spina bifida. For this reason, women who undergo CVS also need a follow-up blood test between 16 to 18 weeks of their pregnancy, to screen for neural tube defects. Amniocentesis: a procedure used to obtain a small sample of the amniotic fluid that surrounds the fetus to diagnose chromosomal disorders and open neural tube defects (ONTDs) such as spina bifida. Testing is available for other genetic defects and disorders depending on the family history and availability of laboratory testing at the time of the procedure. The American College of Obstetricians and Gynecologists (ACOG) recommends amniocentesis around 15 weeks to 20 weeks of pregnancy for those women who are at increased risk for chromosome abnormalities, such as women who are over age 35 years of age at delivery, or those who have had an abnormal maternal serum screening test, indicating an increased risk for a chromosomal abnormality or neural tube defect. However, in some situations, amniocentesis may be performed as early as 14 weeks. Ultrasound: a diagnostic technique that uses high-frequency sound waves to create an image of the internal organs. Many birth defects can be detected with ultrasound. Sometimes, birth defects are not diagnosed until physical examination of the baby after birth. To confirm the physical findings, a small blood sample can be taken and the chromosomes can be analyzed. This information is important in determining the risk for that birth defect in future pregnancies.
357
Section 42.2
The March of Dimes Birth Defects Foundation defines birth defects as: an abnormality of structure, function, or metabolism (body chemistry) present at birth that results in physical or mental disability, or is fatal. To date, researchers have identified thousands of different birth defects. Currently, birth defects rank as the leading cause of death for infants during the first year of life. Birth defects can be caused by different factors, such as the following: Genetic problems that result from the failure of one or more genes to work properly Problems with the number or structure of chromosomes, such as extra or missing groups of genes Things that happen to a woman during pregnancy, such as getting rubella or German measles while pregnant, having untreated or uncontrolled diabetes while pregnant, being around or in contact with dangerous chemicals in the environment while pregnant, or using drugs or alcohol during pregnancy These factors can change normal infant growth or development resulting in different types of birth defects, such as the following: Physical problems with body parts or structures: Some physical problems include cleft (has a gap or split) lip or cleft palate, heart defects, and abnormal limbs, such as a club foot Functional problems with how a body part or body system works: These problems are often called developmental disabilities and can include things like these: 358
Birth Defects
Nervous system or brain problems, such as learning disabilities, behavioral disorders, speech or language difficulties, muscle spasms or convulsions, and movement trouble Sensory problems, such as cataracts of the eyes, blindness, hearing loss, or deafness Metabolic disorders involve a body process or chemical pathway or reaction, such as conditions that limit the bodys ability to get rid of waste materials or harmful chemicals. Degenerative disorders are conditions that might not be obvious at birth, but steadily make worse one or more aspects of health. In some cases, birth defects can result from a combination of these factors, or they can affect many parts or processes in the body, which may lead to both physical and functional problems, to different degrees. Some of these types of birth defects and developmental disabilities are described below.
Birth Defects
Hib is also no longer a cause of mental retardation in the United States and other areas. Down syndrome describes a set of mental and physical characteristics related to having an extra copy of a specific chromosome, Chromosome 21. This set of symptoms includes mental retardation. Interventions and treatments for the symptoms of Down syndrome can allow many individuals with this condition to live healthy, productive lives. NICHD-supported work in Down syndrome includes efforts to understand some of the other problems associated with the condition, such as heart defects and early mental decline. Fragile X syndrome is the most common inherited form of mental retardation. Parents with few or no symptoms can pass the condition on to their children through genes. A defect in a specific part of a specific gene, called the Fragile X Mental Retardation 1 gene, or FMR1, causes the body to produce low amounts or none of a certain protein. This protein is vital to normal brain development; without enough of it, the brain doesnt grow properly, leading to the symptoms of Fragile X. In 1991, NICHD-supported researchers were the first to identify that a change in the FMR1 gene caused Fragile X. This and other NICHD-supported research has continued in hopes of finding out what the protein that is lacking or missing does in the brain. In response to the Childrens Health Act of 2000, the NICHD created three centers for Fragile X research, to ensure that this work can continue. In addition, the NICHD is working with other agencies and organizations dedicated to understanding Fragile X to further knowledge about this condition. The Institutes Families and Fragile X Syndrome publication describes what is currently known about and what research is being done to learn more about Fragile X. Autism spectrum disorders: Other developmental disabilities include problems like autism spectrum disorders, a range of problems that can affect a persons ability to communicate, social skills, and intelligence. Because autism is diagnosed on a spectrum, people with this condition can be severely affected, or have only mild symptoms; but they all have a type of autism.
Metabolic Disorders
This group of functional birth defects affects a persons metabolism, which is the way the body builds up, breaks down, and otherwise processes the materials it needs to function. For example, digestion, how your body breaks down food into its smaller parts, is a metabolic process. Two commonly known metabolic disorders include: Phenylketonuria, also called PKU, is a condition in which a problem with a specific enzyme, a protein that speeds up certain chemical reactions, causes mental retardation. NICHD-supported researchers developed a dietary therapy that helps to balance the amount of this enzyme in the body, which has almost eliminated mental retardation in people with PKU. Conclusions from the NIH Consensus Development Conference on PKU: Screening and Management recommend that this dietary therapy continue throughout life. Women known to have PKU should follow the diet while they are pregnant to prevent mental retardation in their children. The NICHD hopes to use its successes with PKU research as a model for efforts on other diseases. Hypothyroidism is a hormonal condition that, if left untreated in a pregnant woman, can cause mental retardation in her baby. The thyroid is a gland in the body that makes a chemical signal called a hormone. Hormones help to regulate certain functions in the body, including puberty and pregnancy. Without enough thyroid hormone in the mothers body, the fetus brain wont develop correctly, resulting in mental retardation. NICHD-supported researchers found that, by identifying women who have this condition early in or before pregnancy, treatments to get the level of thyroid hormone back to normal can prevent mental retardation in some cases. In addition, NICHD research found that children who are born with hypothyroidism could also be treated with thyroid hormone to prevent many of the long-term effects of this condition. 362
Birth Defects
Degenerative Disorders
Some infants born with degenerative disorders appear normal at birth, but then lose abilities or functions due to the condition. In these cases, the defect is usually not detected until an older age, when the child or person starts to show signs of a problem. Degenerative disorder can cause physical, mental, and sensory problems, depending on the specific defect. In one type of degenerative disorder, early onset X-linked adrenoleukodystrophy, also called X-ALD, boys develop normally until between ages 4 and 8. After this point, they begin to lose brain and nervous system function. Eventually, boys with X-ALD lose so much of their brain and neural abilities that they appear to be in a frozen state, unable to move and communicate. X-ALD was the focus of the movie Lorenzos Oil, which described one familys efforts to spur scientific progress. Another type of degenerative birth defect is Rett syndrome. This disorder, which usually affects girls, is caused by a specific genetic abnormality. The NICHDs efforts to understand these types of birth defects focus on screening techniques that allow early detection of these problems, and strategies to treat or relieve some of the symptoms of these conditions. Other work is underway to find the cellular mechanisms or genetic markers for these conditions.
364
Chapter 43
365
Section 43.1
Many women have some bleeding from the vagina in pregnancy. Sometimes the pregnancy continues with no ill effects. But bleeding could be an early sign of miscarriage. If you are pregnant and have bleeding, call your doctor or midwife.
366
Section 43.2
Blood Clots
Excerpted from Deep Vein Thrombosis, by the National Heart, Lung and Blood Institute (NHLBI, www.nhlbi.nih.gov), part of the National Institutes of Health, November 2007.
Pulmonary Embolism
Some people dont know they have DVT until they have signs or symptoms of PE. Symptoms of PE include: unexplained shortness of breath; pain with deep breathing; and coughing up blood. Rapid breathing and a fast heart rate also may be signs of PE.
369
Chapter 44
Cholestasis of Pregnancy
Some women experience a very severe itching in late pregnancy. The most common cause of this is cholestasis, a common liver disease that only happens in pregnancy. Cholestasis of pregnancy is a condition in which the normal flow of bile in the gallbladder is affected by the high amounts of pregnancy hormones. Cholestasis is more common in the last trimester of pregnancy when hormones are at their peak, but it usually goes away within a few days after delivery. According to Cincinnati Childrens Hospital Medical Center, cholestasis occurs in about 1 out of 1,000 pregnancies but is more common in Swedish and Chilean ethnic groups. Cholestasis is sometimes referred to as extrahepatic cholestasis which occurs outside the liver, intrahepatic cholestasis which occurs inside the liver, or obstetric cholestasis.
371
How will the baby be affected if the mother is diagnosed with cholestasis?
Cholestasis may increase the risks for fetal distress, preterm birth, or stillbirth. A developing baby relies on the mothers liver to remove bile acids from the blood; therefore, the elevated levels of maternal bile cause stress on the babys liver. Women with cholestasis should be monitored closely and serious consideration should be given to inducing labor once the babys lungs have reached maturity. 372
Cholestasis of Pregnancy
What is the treatment for cholestasis of pregnancy?
The treatment goals for cholestasis of pregnancy are to relieve itching. Some treatment options include: Topical anti-itch medications or medication with corticosteroids; Medication to decrease the concentration of bile acids such as ursodeoxycholic acid; Cold baths and ice water slow down the flow of blood in the body by decreasing its temperature; Dexamethasone is a steroid that increases the maturity of the babys lungs; Vitamin K supplements administered to the mother before delivery and again once the baby is born to prevent intracranial hemorrhaging; Dandelion root and milk thistle are natural substances that are beneficial to the liver; Bi-weekly non-stress tests which involve fetal heart monitoring and contraction recordings; Regular blood tests monitoring both bile serum levels and liver function. Treatment for cholestasis of pregnancy needs to be determined by your physician who will take the following criteria into consideration: Your pregnancy, overall health, and medical history The extent of the disease Your tolerance of specific medications, procedures, or therapies Expectations for the course of the disease Your opinion or preference Treatments that should not be used for cholestasis include: Antihistamines Aveeno and oatmeal bath There are conflicting views on using the medication cholestyramine for treatment of cholestasis. In the past, this medication was readily used 373
What are the chances of the mother getting cholestasis in another pregnancy?
Whether or not a woman will get cholestasis in future pregnancies is debatable. However, some sources claim that women who have had cholestasis of pregnancy have up to a 90% chance of having this repeat in future pregnancies.
374
Chapter 45
Gestational Diabetes
375
Gestational Diabetes
Fasting blood glucose or random blood glucose test: Your doctor may check your blood glucose level using a test called a fasting blood glucose test. Before this test, your doctor will ask you to fast, which means having nothing to eat or drink except water for at least 8 hours. Or your doctor may check your blood glucose at any time during the day. This is called a random blood glucose test. These tests can find gestational diabetes in some women, but other tests are needed to be sure diabetes is not missed. Your health care provider will check your blood glucose level to see if you have gestational diabetes. Screening glucose challenge test: For this test, you will drink a sugary beverage and have your blood glucose level checked an hour later. This test can be done at any time of the day. If the results are above normal, you may need further tests. Oral glucose tolerance test: If you have this test, your health care provider will give you special instructions to follow. For at least 3 days before the test, you should eat normally. Then you will fast for at least 8 hours before the test. The health care team will check your blood glucose level before the test. Then you will drink a sugary beverage. The staff will check your blood glucose levels 1 hour, 2 hours, and 3 hours later. If your levels are above normal at least twice during the test, you have gestational diabetes.
Table 45.1. Above-Normal Results for the Oral Glucose Tolerance Test
Fasting At 1 hour At 2 hours At 3 hours 95 or higher 180 or higher 155 or higher 140 or higher
Note: Some labs use other numbers for this test. These numbers are for a test using a drink with 100 grams of glucose.
377
Gestational Diabetes
Meal plan: You will talk with a dietitian or a diabetes educator who will design a meal plan to help you choose foods that are healthy for you and your baby. Using a meal plan will help keep your blood glucose in your target range. The plan will provide guidelines on which foods to eat, how much to eat, and when to eat. Choices, amounts, and timing are all important in keeping your blood glucose levels in your target range. You may be advised to: limit sweets; eat three small meals and one to three snacks every day; be careful about when and how much carbohydrate-rich food you eatyour meal plan will tell you when to eat carbohydrates and how much to eat at each meal and snack; and include fiber in your meals in the form of fruits, vegetables, and whole-grain crackers, cereals, and bread. Physical activity: Physical activity, such as walking and swimming, can help you reach your blood glucose targets. Talk with your health care team about the type of activity that is best for you. If you are already active, tell your health care team what you do. Insulin: Some women with gestational diabetes need insulin, in addition to a meal plan and physical activity, to reach their blood glucose targets. If necessary, your health care team will show you how to give yourself insulin. Insulin is not harmful for your baby. It cannot move from your bloodstream to the babys.
Table 45.2. Blood Glucose Targets for Most Women with Gestational Diabetes
On awakening 1 hour after a meal 2 hours after a meal not above 95 not above 140 not above 120
Each time you check your blood glucose, write down the results in a record book. Take the book with you when you visit your health care team. If your results are often out of range, your health care team will suggest ways you can reach your targets.
After I have my baby, how can I find out whether my diabetes is gone?
You will probably have a blood glucose test 6 to 12 weeks after your baby is born to see whether you still have diabetes. For most women, gestational diabetes goes away after pregnancy. You are, however, at risk of having gestational diabetes during future pregnancies or getting type 2 diabetes later. 380
Chapter 46
Gestational Hypertension
381
What is preeclampsia?
Preeclampsia is a condition that typically starts after the 20th week of pregnancy and is related to increased blood pressure and protein in the mothers urine (as a result of kidney problems). Preeclampsia affects the placenta, and it can affect the mothers kidney, liver, and brain. When preeclampsia causes seizures, the condition is known as eclampsiathe second leading cause of maternal death in the United States. Preeclampsia is also a leading cause of fetal complications, which include low birth weight, premature birth, and stillbirth. There is no proven way to prevent preeclampsia. Most women who develop signs of preeclampsia, however, are closely monitored to lessen or avoid related problems. The only way to cure preeclampsia is to deliver the baby.
Gestational Hypertension
Women who developed high blood pressure or preeclampsia during a previous pregnancy, especially if these conditions occurred early in the pregnancy Women who are obese prior to pregnancy Pregnant women under the age of 20 or over the age of 40 Women who are pregnant with more than one baby Women with diabetes, kidney disease, rheumatoid arthritis, lupus, or scleroderma
How can women with high blood pressure prevent problems during pregnancy?
If you are thinking about having a baby and you have high blood pressure, talk first to your doctor or nurse. Taking steps to control your blood pressure before and during pregnancyand getting regular prenatal carego a long way toward ensuring your well-being and your babys health. Before becoming pregnant: Be sure your blood pressure is under control. Lifestyle changes such as limiting your salt intake, participating in regular physical activity, and losing weight if you are overweight can be helpful. Discuss with your doctor how hypertension might affect you and your baby during pregnancy, and what you can do to prevent or lessen problems. If you take medicines for your blood pressure, ask your doctor whether you should change the amount you take or stop taking 383
Does hypertension or preeclampsia during pregnancy cause long-term heart and blood vessel problems?
The effects of high blood pressure during pregnancy vary depending on the disorder and other factors. According to the National High Blood Pressure Education Program (NHBPEP), preeclampsia does not in general increase a womans risk for developing chronic hypertension or other heart-related problems. The NHBPEP also reports that in women with normal blood pressure who develop preeclampsia after the 20th week of their first pregnancy, short-term complications including increased blood pressureusually go away within about 6 weeks after delivery. Some women, however, may be more likely to develop high blood pressure or other heart disease later in life. More research is needed to determine the long-term health effects of hypertensive disorders in pregnancy and to develop better methods for identifying, diagnosing, and treating women at risk for these conditions. Even though high blood pressure and related disorders during pregnancy can be serious, most women with high blood pressure and those who develop preeclampsia have successful pregnancies. Obtaining early and regular prenatal care is the most important thing you can do for you and your baby.
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Chapter 47
Overview
Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting in pregnancy. It is generally described as unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids. If severe and/or inadequately treated, it is typically associated with: loss of greater than 5% of pre-pregnancy body weight (usually over 10%); dehydration and production of ketones; nutritional deficiencies; metabolic imbalances; difficulty with daily activities. HG usually extends beyond the first trimester and may resolve by 21 weeks; however, it can last the entire pregnancy in less than half of these women. Complications of vomiting (e.g. gastric ulcers, esophageal bleeding, malnutrition, etc.) may also contribute to and worsen ongoing nausea.
Understanding Hyperemesis, 2006 Hyperemesis Education & Research Foundation. All Rights Reserved. For additional information, visit the HER Foundation website at www.helpher.org.
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Treatment
Hyperemesis is no doubt a physiological disease. Treating it as anything else is not therapeutic and can be detrimental to the mother 386
Complications
Although numerous depending on ones individual biochemistry, severity of symptoms, and the medical interventions given, many potential complications may result from HG. With an aggressive and proactive approach to treatment, many sequelae can be avoided. If care is inadequate, ineffective, or delayed, cases of morning sickness or mild HG may progress to moderate or severe HG. Women suffer greatly with HG, and effective intervention early in pregnancy can greatly ease the misery and stress associated with this disease. Long term complications (often with vague, chronic symptomology) will likely occur without proper intervention in the early stages. Fortunately, there are usually few immediate, adverse effects of HG on the baby unless weight gain continues to be poor during the second half of pregnancy, or symptoms are severe and prolonged. Acute or chronic complications reported by women to the HER Foundation include gall bladder disease, temporomandibular joint disorders, depression, anxiety, difficulty with weight management, diabetes, motion sickness, and dental caries. Some just say they never have felt the same as before they were pregnant. Women with prolonged HG are also at greater risk for preterm labor, and pre-eclampsia. Emerging research is showing the possibility of potential future health risks to the infant if the mother is malnourished during pregnancy. This should strongly be considered when caring for women with HG, as the care provided affects not only the mother, but also the child for decades to come.
Signs of Severe HG
Debilitating, chronic nausea Frequent vomiting of bile or blood Chronic ketosis and dehydration Muscle weakness and extreme fatigue Medication does not stop vomiting/nausea Inability to care for self (shower, prepare food) Loss of over 510% of your pre-pregnancy weight Weight loss (or little gain) after the first trimester Inability to eat/drink sufficiently by about 14 weeks
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Chapter 48
Placental Complications
The placenta is an unborn babys life support system. It forms from the same cells as the embryo and attaches to the wall of the uterus. The placenta forms connections with the mothers blood supply, from which it supplies oxygen and nutrients to the fetus. The placenta also connects with the fetuss blood supply, from which it removes wastes and returns them to the mothers blood. The mothers kidneys dispose of the waste. The placenta has other important functions in pregnancy. It produces hormones that play a role in triggering labor and delivery. The placenta also helps protect the fetus from infections and potentially harmful substances. After the baby is delivered, the placentas job is done, and it is delivered as the afterbirth. The mature placenta is flat and circular and weighs about 1 pound. But sometimes the placenta: is structured abnormally; is poorly positioned in the uterus; does not function properly. Placental problems are among the most common complications of the second half of pregnancy. Here are some of the most frequent placental problems and how they can affect mother and baby.
Placental Complications, 2007 March of Dimes Birth Defects Foundation. All rights reserved. For additional information, contact the March of Dimes at their website www.marchofdimes.com.
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Placental Complications
A mild abruption usually is not dangerous unless it progresses. If a woman has a mild abruption at term, her health care provider may recommend prompt delivery (either by inducing labor or by c- [Cesarean] section) to avoid any risks associated with a worsening abruption. If a woman has a mild abruption and her fetus would be very premature if delivered immediately, her provider will probably admit her to the hospital for careful monitoring. If tests show that neither mother nor baby is having difficulties, the provider may try to prolong the pregnancy to avoid prematurity-related complications for the baby. If the provider suspects that the abruption is likely to result in premature delivery between 24 and 34 weeks of pregnancy, she will probably recommend treatment with drugs called corticosteroids. These drugs speed maturation of the fetal lungs and significantly reduce the risk of prematurity-related complications and infant deaths. Some women with mild abruptions may be able to go home after the bleeding stops, while others may need to stay in the hospital until delivery.1 If an abruption progresses, a woman is bleeding heavily, or the baby is having difficulties, a prompt delivery, usually by c-section, probably will be necessary.
Placental Complications
What are the symptoms of placenta previa?
The most common symptom of placenta previa is painless uterine bleeding during the second half of pregnancy. Women who experience vaginal bleeding in pregnancy should contact their health care provider.
Placental Complications
uterine muscle or through the entire thickness of the uterus, sometimes extending into nearby structures, such as the bladder.
References
1. Oyelese, Y. and Ananth, C.V. Placental Abruption. Obstetrics and Gynecology, volume 108, number 4, October 2006, pages 10051016. Ananth, C.V., et al. Placental Abruption in Term and Preterm Gestations. Obstetrics and Gynecology, volume 107, number 4, April 2006, pages 785792. Kay, H.H. Placenta Previa and Abruption, in Scott, J.R., et al. (eds.): Danforths Obstetrics and Gynecology, Ninth Edition, Philadelphia, Lippincott Williams & Wilkins, 2003, pages 365 379. Oyelese, Y. and Smulian, J.C. Placenta Previa, Placenta Accreta, and Vasa Previa. Obstetrics and Gynecology, volume 107, number 4, April 2006, pages 927941.
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Chapter 49
Rh Incompatibility
If you just found out youre pregnant, one of the firstand most importanttests you should expect is a blood-type test. This basic test determines your blood type and Rh factor. Your Rh factor may play a role in your babys health, so its important to know this information early in your pregnancy.
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Rh Incompatibility
is severe and the baby is in danger, a series of special blood transfusions (called exchange transfusions) can be performed either while the baby is still in the uterus or after delivery. Exchange transfusions replace the babys blood with RBCs that are Rh-negative. This procedure stabilizes the babys level of red blood cells and minimizes further damage caused by circulating Rh antibodies already present in the babys bloodstream. Because of the success rate of the Rh immune-globulin shots, exchange transfusions are needed in fewer than 1% of Rh-incompatible pregnancies in the United States today.
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Chapter 50
The umbilical cord is a narrow tube-like structure that connects the fetus (developing baby) to the placenta (afterbirth). The cord is sometimes called the babys supply line because it carries the babys blood back and forth, between the baby and the placenta. It delivers nutrients and oxygen to the baby and removes the babys waste products. The umbilical cord begins to form at five weeks after conception. It becomes progressively longer until 28 weeks of pregnancy, reaching an average length of 22 to 24 inches.1 As the cord gets longer, it generally coils around itself. The cord contains three blood vessels: two arteries and one vein. The vein carries oxygen and nutrients from the placenta (which connects to the mothers blood supply) to the baby. The two arteries transport waste from the baby to the placenta (where waste is transferred to the mothers blood and disposed of by her kidneys). A gelatin-like tissue called Whartons jelly cushions and protects these blood vessels. A number of abnormalities can affect the umbilical cord. The cord may be too long or too short. It may connect improperly to the placenta
Umbilical Cord Abnormalities, 2008 March of Dimes Birth Defects Foundation. All rights reserved. For additional information, contact the March of Dimes at their website www.marchofdimes.com.
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References
1. Cruikshank, D.W. Breech, Other Malpresentations, and Umbilical Cord Complications, in: Scott, J.R., et al. (eds.), Danforths Obstetrics and Gynecology, 9th Edition. Philadelphia, Lippincott Williams and Wilkins, 2003, pages 381395. Morgan, B.L.G. and Ross, M.G. Umbilical Cord Complications. emedicine.com, March 1, 2006. Gossett, D.R., et al. Antenatal Diagnosis of Single Umbilical Artery: Is Fetal Echocardiography Warranted? Obstetrics and Gynecology, volume 100, number 5, November 2002, pages 903908. Oyelese, Y. and Smulian, J.C. Placenta Previa, Placenta Accreta, and Vasa Previa. Obstetrics and Gynecology, volume 107, number 4, April 2006, pages 927941.
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Chapter 51
From STDs & Pregnancy, by the Centers for Disease Control and Prevention (CDC, www.cdc.gov), January 4, 2008.
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Chapter 52
Chapter Contents
Section 52.1What Is Hepatitis? .............................................. 414 Section 52.2Frequently Asked Questions about Pregnancy and Hepatitis B................................. 416
413
Section 52.1
What Is Hepatitis?
From Viral Hepatitis, by the Centers for Disease Control and Prevention (CDC, www.cdc.gov), July 22, 2008.
Hepatitis A
Hepatitis A is an acute liver disease caused by the hepatitis A virus (HAV), lasting from a few weeks to several months. It does not lead to chronic infection. Transmission: Ingestion of fecal matter, even in microscopic amounts, from close person-to-person contact or ingestion of contaminated food or drinks. Vaccination: Hepatitis A vaccination is recommended for all children starting at age 1 year, travelers to certain countries, and others at risk.
Hepatitis B
Hepatitis B is a liver disease caused by the hepatitis B virus (HBV). It ranges in severity from a mild illness, lasting a few weeks (acute), to a serious long-term (chronic) illness that can lead to liver disease or liver cancer. Transmission: Contact with infectious blood, semen, and other body fluids from having sex with an infected person, sharing contaminated needles to inject drugs, or from an infected mother to her newborn. Vaccination: Hepatitis B vaccination is recommended for all infants, older children and adolescents who were not vaccinated previously, and adults at risk for HBV infection.
Hepatitis C
Hepatitis C is a liver disease caused by the hepatitis C virus (HCV). HCV infection sometimes results in an acute illness, but most often 414
Hepatitis D
Hepatitis D is a serious liver disease caused by the hepatitis D virus (HDV) and relies on HBV to replicate. It is uncommon in the United States. Transmission: Contact with infectious blood, similar to how HBV is spread. Vaccination: There is no vaccine for hepatitis D.
Hepatitis E
Hepatitis E is a serious liver disease caused by the hepatitis E virus (HEV) that usually results in an acute infection. It does not lead to a chronic infection. While rare in the United States, hepatitis E is common in many parts of the world. Transmission: Ingestion of fecal matter, even in microscopic amounts; outbreaks are usually associated with contaminated water supply in countries with poor sanitation. Vaccination: There is currently no FDA [U.S. Food and Drug Administration]-approved vaccine for hepatitis E.
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Section 52.2
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Chapter 53
Human Immunodeficiency Virus (HIV) during Pregnancy, Labor and Delivery, and Birth
I am pregnant, and I may have human immunodeficiency virus (HIV). Will I be tested for HIV when I visit a doctor?
In most cases, health care providers cannot test you for HIV without your permission. However, the U.S. Public Health Service recommends that all pregnant women be tested. If you are thinking about being tested, it is important to understand the different ways perinatal HIV testing is done. There are two main approaches to HIV testing in pregnant women: opt-in and opt-out testing. In opt-in testing, a woman cannot be given an HIV test unless she specifically requests to be tested. Often, she must put this request in writing. In opt-out testing, health care providers must inform pregnant women that an HIV test will be included in the standard group of tests pregnant women receive. A woman will receive that HIV test unless she specifically refuses. The CDC (Centers for Disease Control and Prevention) currently recommends that health care providers adopt an opt-out approach to perinatal HIV testing.
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How do I find out which HIV treatment regimen is best for me?
Decisions about which HIV treatment regimen you will start should be based on many of the same factors that women who are not pregnant must consider. These factors include: risk that the HIV infection may become worse; risks and benefits of delaying treatment; potential drug toxicities and interactions with other drugs you are taking; 420
What treatment regimen should I follow during my pregnancy if I have never taken anti-HIV medications?
Your best treatment options depend on when you were diagnosed with HIV, when you found out you were pregnant, at what point you sought medical treatment during your pregnancy, and whether you need treatment for your own health. Women who are in the first trimester of pregnancy and who do not have symptoms of HIV disease may consider delaying treatment until after 10 to 12 weeks into their pregnancies. After the first trimester, pregnant women with HIV should receive at least AZT (Retrovir or zidovudine); your doctor may recommend additional medications depending on your CD4 count, viral load, and drug resistance testing.
I am currently taking anti-HIV medications, and I just learned that I am pregnant. Should I stop taking my medications?
Do not stop taking any of your medications without consulting your doctor first. Stopping HIV treatment could lead to problems for you and your baby. If you are taking anti-HIV medications and your pregnancy is identified during the first trimester, talk with your doctor about the risks and benefits of continuing your current regimen. Your doctor may recommend that you change the medications you take. If your pregnancy is identified after the first trimester, it is recommended 421
2. 3.
If you have been taking any other anti-HIV medications during your pregnancy, your doctor will probably recommend that you continue to take them on schedule during labor. Better understanding of HIV transmission has contributed to dramatically reduced rates of mother-to-child transmission of HIV. Discuss the benefits of HIV treatment during pregnancy with your doctor; these benefits should be weighed against the risks to you and to your baby.
I am HIV positive and pregnant. Are there any anti-HIV medications that may be dangerous to me or my baby during my pregnancy?
Yes. Although information on anti-HIV medications in pregnant women is limited, enough is known to make recommendations about medications for you and your baby. However, the long-term effects of babies exposure to anti-HIV medications in utero are unknown. Talk to your doctor about which medications may be harmful during your pregnancy and what medication and dose changes are possible. In general, protease inhibitors (PIs) are associated with increased levels of blood sugar (hyperglycemia), development of diabetes mellitus or worsening of diabetes mellitus symptoms, and diabetic ketoacidosis. Pregnancy is also a risk factor for hyperglycemia, but it is not 422
I am HIV positive and pregnant. What delivery options are available to me when I give birth?
Depending on your health and treatment status, you may plan to have either a cesarean (also called c-section) or a vaginal delivery. The decision of whether to have a cesarean or a vaginal delivery is something that you should discuss with your doctor during your pregnancy.
How do I decide which delivery option is best for my baby and me?
It is important that you discuss your delivery options with your doctor as early as possible in your pregnancy so that he or she can help you decide which delivery method is most appropriate for you. Cesarean delivery is recommended for an HIV positive mother when: 423
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Chapter 55
429
Section 55.1
Ectopic Pregnancy
Ectopic Pregnancy, 2009 University of Pittsburgh Medical Center (www.upmc.com). Reprinted with permission.
Most pregnancies happen in the uterus (womb). An ectopic pregnancy is one that happens outside of the uterus. Often, an ectopic pregnancy happens in one of the fallopian tubes, which run from the ovaries to the uterus. If you have a positive pregnancy test, and the pregnancy cannot be seen on ultrasound, you may have an ectopic pregnancy. You also may have a normal pregnancy, but its too early to see the fetus by ultrasound. You will have a blood test. The test will be repeated in 2 days. The results can help tell if you have an ectopic pregnancy. An ectopic pregnancy is rare, but it is a serious condition. It can be life-threatening if you do not get medical care. An ectopic pregnancy can grow until it breaks through the fallopian tube. This is very painful. It can cause serious bleeding inside your lower belly (abdomen). If this happens, you need to be treated in a hospital right away. An ectopic pregnancy is removed either by taking medicines or by having surgery. Signs that you may have an ectopic pregnancy include: severe lower belly pain; lower belly pain that gets worse; shoulder pain; fainting or dizzy spells; nausea or vomiting; heavy vaginal bleeding. If you have any of these problems, call your doctor or go to an emergency room right away. 430
Losing a Pregnancy
There is no right way to react to losing a pregnancy. Many women are overcome with grief. You and your partner may want to seek a counselor or pregnancy loss support group.
Follow-Up
If you have any concerns about your diagnosis, treatment, or effects of the treatment, or if you have questions about future pregnancies, talk to your doctor.
Section 55.2
Blighted Ovum
Blighted Ovum, 2006 American Pregnancy Association (www.americanpregnancy.org). Reprinted with permission.
Chances are you didnt even know you were pregnant or had just found out you were expecting when you received the shattering news that there is no visible developing embryo on the ultrasound. You are probably feeling sad and confused. As you take time to understand what this means, also take time to grieve as you would for any loss. And remember you are not alone.
Section 55.3
What Is a Miscarriage?
From Miscarriage, by the National Institute of Child Health and Human Development (NICHD, www.nichd.nih.gov), part of the National Institutes of Health, May 24, 2007.
What is a miscarriage?
A miscarriage, sometimes called pregnancy loss, is the loss of pregnancy from natural causes before the 20th week of pregnancy. Most miscarriages occur very early in the pregnancy, often before a woman even knows she is pregnant.
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Section 55.4
During pregnancy, as the baby grows and gets heavier, it presses on the cervix. This pressure may cause the cervix to start to open before the baby is ready to be born. This condition is called incompetent cervix or weakened cervix, and it may lead to a miscarriage or premature delivery. However, an incompetent cervix happens in only about 1 out of 100 pregnancies.
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Section 55.5
A drug first used to reduce the risk of stomach ulcers in people taking certain types of painkillers offers an alternative to surgery after miscarriage, according to a study by researchers at the National Institute of Child Health and Human Development of the National Institutes of Health and other research institutions. The study appeared in the August 18, 2005, New England Journal of Medicine. The drug, misoprostol, has been used to reduce the risk of stomach ulcers that occur in people who take certain pain relievers for arthritis. Misoprostol is now more commonly used to induce labor, as it stimulates contractions of the uterus. In recent years, physicians have begun prescribing misoprostol in place of surgery to women who have experienced a miscarriage. Until the current study, however, no large-scale studies have been undertaken to evaluate the safety and effectiveness of the drug in treating miscarriage. This is the first comprehensive study to show that misoprostol is an effective alternative to surgery in the treatment of miscarriage, said Duane Alexander, MD, Director of the National Institute of Child Health and Human Development (NICHD). Unlike conventional surgery, which is usually conducted in an operating room, treatment with misoprostol can be done on an outpatient basis. The study authors wrote that pregnancy failure, or miscarriage, occurs in 15 percent of pregnancies. With miscarriage, in some cases, a fetus dies in the womb, explained the studys first author, Jun Zhang, MD, PhD, an investigator in the Epidemiology Branch of NICHDs Division of Epidemiology, Statistics, and Prevention Research. In other cases, a fetus may no longer be present, and women may carry a placenta and sac of amniotic fluid. 437
Section 55.6
What Is a Stillbirth?
From Stillbirth, by the National Institute of Child Health and Human Development (NICHD, www.nichd.nih.gov), part of the National Institutes of Health, September 10, 2006.
What is a stillbirth?
A stillbirth is the loss of pregnancy due to natural causes after the 20th week of pregnancy. It can occur before delivery or during delivery.
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Section 55.7
Miscarriage
The NICHD supports and conducts research on the causes of miscarriage in hopes of finding ways to prevent women from having them. For instance, NICHD-supported researchers recently found that women with a disorder called polycystic ovary syndrome (PCOS) are three times more likely to miscarry during the early months of pregnancy than women who dont have PCOS. Women with PCOS often have great difficulty getting pregnant naturally. Research has found that women with PCOS also tend to have a condition called insulin resistance, which means their bodies have trouble using the insulin they make to get energy from their cells. Insulin resistance often occurs before someone develops diabetes. To treat this insulin resistance, researchers had been prescribing a drug called metformin. What they found was that metformin not only reduced insulin resistance, but it also brought about changes to the uterine lining that could help women with PCOS get pregnant and reduce the risk of miscarriage during their first trimester (the first three months) of pregnancy. Studies are now underway to confirm the positive effects of the using metformin in women with PCOS, and to evaluate the safety of taking the drug throughout pregnancy. The NICHDs Reproductive Sciences Branch, through its Reproductive Medicine Network (RMN) is currently conducting a clinical trial for the treatment of infertility related to PCOS, using metformin. The RMN website provides more information on this trial and on the RNM itself. Other NICHD-supported research is trying to learn more about repeated miscarriage. Researchers estimate that between 1 percent and 2 percent of women in the United States has more than one miscarriage without a known cause. Women who experience repeated 441
Stillbirth
In spite of how often stillbirth occurs, and how emotionally painful it can be, little research has been done on this type of pregnancy loss. To encourage more research on stillbirth, the NICHD is supporting a new research initiative, Research on the Scope and Causes of Stillbirth in the United States. Through this effort, the NICHD will create a network of research sites whose sole focus will be on understanding stillbirth, its features, its causes, and its effects on a womans uterus. Patients in this network will include women from a variety of ethnic and economic backgrounds to provide a clearer picture of this problem. Through this initiative, the NICHD hopes to support work that may some day be able to predict and prevent stillbirths.
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Section 55.8
Pregnancy loss can happen anytime during a pregnancy. It may be a miscarriage, a tubal (ectopic) pregnancy, a stillbirth, or it may be the death of a baby shortly after birth (neonatal death). When you have a pregnancy loss, you may feel both physical and emotional pain. Every woman reacts differently to the loss. There are no right or wrong feelings. You may have strong feelings of loss no matter how early or how late you were in the pregnancy. At first you may feel a sense of shock and disbelief. Your emotions may range from guilt and sadness, to anger and feeling out of control. You may wonder if you or someone else could have prevented your loss. You may want to be with family and friends or you may want to spend time alone. All of this is normal. The length of time needed to grieve is different for everyone. More important than the length of time is just allowing yourself to grieve.
Support
A pregnancy loss may leave you feeling alone. You may wonder, Are there other women who feel the way I do? or Am I normal? The answer is yes.
Helpful Tips
Be patient and take care of yourself, emotionally and physically. Remember that everyone grieves in his or her own way. You and your loved ones may be at different points in the grief process. Let others know what you need. Family and friends may not know how to help. Remember that you are not alone. Consider attending a support group or ask your nurse, doctor, or midwife to help you find a social worker.
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Chapter 56
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Section 56.1
447
Section 56.2
Section 56.3
Common Treatment to Delay Labor Decreases Preterm Infants Risk for Cerebral Palsy
From the National Institutes of Health (NIH, www.nih.gov), August 27, 2008.
Preterm infants born to mothers receiving intravenous magnesium sulfatea common treatment to delay laborare less likely to develop cerebral palsy than are preterm infants whose mothers do not receive it, report researchers in a large National Institutes of Health research network. The study results appear in the August 28, 2008 New England Journal of Medicine. A third of all cases of cerebral palsy are associated with preterm birth, said National Institutes of Health (NIH) Director Elias A. Zerhouni, MD. This study shows a significant reduction in cerebral palsy among preterm infants whose mothers were given magnesium sulfate. The researchers theorized that magnesium sulfate protects against cerebral palsy because it can stabilize blood vessels, protect against 453
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Section 56.4
Overdue Pregnancy
Reprinted with permission from Pregnancy: What to Expect When Youre Past Your Due Date, April 2008, http://familydoctor.org/online/famdocen/ home/women/pregnancy/labor/143.html. Copyright 2008 American Academy of Family Physicians. All rights reserved.
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Chapter 57
Signs of Labor
Many women, especially with their first babies, think they are in labor when theyre not. This is called false labor. So dont feel embarrassed if you go to the hospital thinking youre in labor, only to be sent home. If you think labor has begun, you should call your doctor or midwife. They can decide if its time to go to the hospital or if you should be seen at the office first. Learn the signs of labor so you will know when the time has come.
From Labor and Birth, by the Office of Womens Health (www.womenshealth .gov), part of the U.S. Department of Health and Human Services, March 2007.
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Hospital
Women with health problems, pregnancy complications, or those who are at risk for problems during labor and delivery should give birth in a hospital. Hospitals offer the most advanced medical equipment and highly trained doctors for pregnant women and their babies. In a hospital, doctors can do a cesarean section if you or your baby is in danger during labor. Women can get epidurals or many other pain relief options. Only certain doctors and midwives have admitting privileges at each hospital. So before you choose your doctor or midwife learn about their affiliated hospital. When choosing a hospital you might consider: Is it close to your home? Is an anesthesiologist at the hospital 24 hours a day? Do you like the feel of the labor and delivery rooms? Are private rooms available? 462
Birth Centers
Healthy women who are at low risk for problems during pregnancy, labor, and delivery may choose to deliver at a birth or birthing center. Birth centers give women a homey environment in which to labor and give birth. They try to make labor and delivery a special, warm, family-focused process. Usually certified nurse-midwives, not obstetricians, deliver babies at birth centers. Birth centers do not do any routine medical procedures. So, you will not automatically be hooked up to an intravenous (IV) line. Likewise, you wont have an electronic fetal monitor around your belly the whole time. Instead, the midwife or nurse will check in on your baby from time to time with a handheld machine. Once the baby is born, all examinations and care will occur in your room. By doing away with most high-tech equipment and routine procedures, labor and birth remain a natural and personal process. Women cannot receive epidurals at a birth center although some pain medicines may be available. If a cesarean section becomes necessary, women must be moved to a hospital for the procedure. Basic emergency care can be done on babies with problems while they are moved to a hospital. Many birthing centers have showers or tubs in their rooms for laboring women. They also tend to have comforts of home like large beds and rocking chairs. In general, birth centers allow more people in the delivery room than do hospitals. Birth centers can be inside of hospitals, affiliated with a hospital, or completely independent, separate facilities. If you are interested in delivering at a birth center, make sure it is accredited by the Commission for the Accreditation of Birth Centers. Accredited birth centers 463
Homebirth
Healthy pregnant women with no risk factors for complications during pregnancy, labor or delivery can consider a planned homebirth. Some certified nurse midwives and physicians will deliver babies at home. If you are considering this choice you should ask your insurance company about their policy on homebirths. Some health insurance companies cover the cost of care for home births and others dont. Homebirths are common in many countries in Europe. But in the United States, planned homebirths are still a controversial issue. The American College of Obstetricians and Gynecologists (ACOG) is against homebirths. ACOG states that hospitals are the safest place to deliver a baby. In case of an emergency, says ACOG, a hospitals equipment and highly trained physicians can provide the best care for a woman and her baby. If you are considering a homebirth, you need to weigh the pros and cons. The main advantage is that you will be able to experience labor and delivery in the privacy and comfort of your own home. Since there will be no routine medical procedures, you will have control of your experience. The main disadvantage of a homebirth is that in case of a problem, you and the baby will not have immediate hospital/medical care. It will have to wait until you are transferred to the hospital. Plus, women who deliver at home have no options for pain relief. To ensure your safety and that of your baby, you must have a highly trained and experienced midwife along with a fail-safe back-up plan. You will need fast, reliable transportation to a hospital. If you live far away from a hospital, homebirth may not be the best choice. Your midwife must be experienced and have the necessary skills and supplies to start emergency care for you and your baby if need be. Your midwife should also have access to a physician 24 hours a day.
Waterbirthing
More and more women in the United States are using water to find comfort during labor and delivery. In waterbirthing, laboring women get into a tub of water that is between 90 and 100 degrees. Some women get out of the tub to give birth. Others remain in the water for delivery. The water helps women feel physically supported. It also keeps them warm and relaxed. This eases the pain of labor and delivery for many women. Plus, it is easier for laboring women to move and find comfortable positions in the water. 465
Pudendal Block
A doctor injects numbing medicine into the vagina and a nearby nerve called the pudendal nerve. This nerve carries sensation to the lower part of your vagina and vulva. This is only used late in labor, usually right before the babys head comes out. With a pudendal block, you have some pain relief but remain awake, alert, and able to push the baby out. The baby is not affected by this medicine and it has very few disadvantages.
Spinal Anesthesia
A doctor injects a medicine into the lower part of your backbone. This medicine numbs the body below where the medicine was injected. Spinal anesthesia gives immediate pain relief. So they are often used for women who need an emergency Cesarean section. Spinal anesthesia uses numbing medicines similar to novocaine combined with opioids like fentanyl. Some disadvantages of spinal anesthesia include: It numbs the body from the chest down to the feet. 467
Cesarean Sections
Most healthy pregnant women with no risk factors for problems during labor or delivery have their babies vaginally. Still, the rate of babies born by cesarean section (c-section) in the United States is on the rise. In 2004, 29.1 percent of babies were born by c-section in this country. This is an increase of more than 40 percent since 1996. Many experts think that up to half of all c-sections are unnecessary. Thus, the U.S. government is trying to reduce the rate. So it is important for pregnant women to get the facts about c-sections before they deliver. Women should find out what c-sections are, why they are performed, and the pros and cons of this surgery.
What Is a C-Section?
During a c-section, the doctor makes a cut in the mothers abdomen and uterus and removes the baby. So, the baby is delivered through surgery instead of coming out of the vagina. Most women get spinal or epidural anesthesia during a c-section. This allows her to stay awake without feeling pain. But sometimes general anesthesia is needed. With general anesthesia the woman is asleep during the procedure. A c-section can save the life of a baby or mother. If health problems come up before or during labor and delivery, a c-section can get the baby out very quickly. Most c-sections result in a healthy mother and baby. Still, a c-section is major surgery. And all surgeries have risks. These include infection, dangerous bleeding, blood transfusions, and blood clots. Women who have c-sections stay at the hospital for longer than women who have vaginal births. Plus, recovery from this surgery takes longer and is often more painful than that after a vaginal birth. So, c-sections should only be done when the health or the mother of baby is in danger.
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Hospitals
Many women fear that a hospital setting will be cold and clinical, but thats not necessarily true. A hospital setting can accommodate a variety of birth experiences. Traditional hospital births (in which the mother-to-be moves from a labor room to a delivery room and then, after the birth, to a semiprivate room) are still the most common option. Doctors manage the delivery with their patients. In many cases, women in labor are not allowed to eat or drink (possibly due to anesthesia or for other medical reasons), and they may be required to deliver in a certain position. Pain medications are available during labor and delivery (if the woman chooses); labor may be induced, if necessary; and the fetus is usually electronically monitored throughout the labor. A birth plan
Birthing Centers and Hospital Maternity Services, December 2008, reprinted with permission from www.kidshealth.org. Copyright 2008 The Nemours Foundation. This information was provided by KidsHealth, one of the largest resources online for medically reviewed health information written for parents, kids, and teens. For more articles like this one, visit www.KidsHealth.org, or www.TeensHealth.org.
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Birth Centers
Women who experience delivery in a birth center are usually those who have already given birth without any problems and whose current pregnancies are considered low risk (meaning they are in good health and are the least likely to develop complications).Women giving birth to multiples, who have certain medical conditions (such as gestational diabetes or high blood pressure), or whose baby is in the breech position are considered higher risk and should not deliver in a birth center. Women are carefully screened early in pregnancy and given prenatal care at the birth center to monitor their health throughout their pregnancy. Natural childbirth is the focus in a birth center. Since epidural anesthesia usually isnt offered, women are free to move around in labor, get in the positions most comfortable to them, spend time in the Jacuzzi, etc. The baby is monitored frequently in labor typically with a handheld Doppler. Comfort measures such as hydrotherapy, massage, warm and cold compresses, and visualization and relaxation techniques are often used. The woman is free to eat and drink as she chooses. A variety of health care professionals operate in the birth center setting. A birth center may employ registered nurses, CNMs, and doulas (professionally trained providers of labor support and/or postpartum care). Although a doctor is seldom present and medical interventions are rarely done, birth centers may work with a variety of obstetric and pediatric consultants. The professionals affiliated with a birth center work closely together as a team, with the nurse-midwives present and the OB/GYN consultants available if a woman develops a complication during pregnancy or labor that puts her into a higher risk category. Birth centers do have medical equipment available, including intravenous (IV) lines and fluids, oxygen for the mother and the infant, infant resuscitators, infant warmers, local anesthesia to repair tears and episiotomies (although these are seldom performed), and oxytocin to control postpartum bleeding. 475
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Chapter 59
Birth Partners
Chapter Contents
Section 59.1Labor Tips for Fathers and Birth Partners ...... 480 Section 59.2Having a Doula: Is It Right for You? ................. 482
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Section 59.1
Uncertain about your role as a birth partner? Follow these nine easy guidelines. 1. Support is a key element to a woman having a positive birth and postpartum experience. As a birth partner, identify the resources you have for informational, emotional, and physical backup early on. As you learn more about the process of birth, you will discover your strengths in offering support, and you can decide how you want to contribute to the birth of this child. Will you be the primary support, work more with the other team members, or be by the mothers side with your full love and support while others do the hands-on work? A birth partner can serve in any manner that helps the laboring woman, so be comfortable, even joyful, in whatever role you both agree upon. Whether you decide to actively work with the mother or just shower her with love, simply being present makes a difference. The birth partner is usually the one member of the team who best knows her desires and can interpret her cues and express her wishes to others. Your personal history with the laboring woman is something the rest of the team doesnt have. In order to care for a mother in labor, you must also care for yourself. Eating and drinking during labor will give you the energy you need. Wear comfortable clothes and let the doula or nurse care for your partner while you take an occasional break. Ask questions. Unless you are birthing at home, you are in an unfamiliar setting surrounded by unfamiliar people. A doula can 480
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3.
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Birth Partners
help you get the attention of the health-care provider so that you are heard. 6. Be prepared to experience some strong emotions. Often, a birth partner is so absorbed in supporting the mother and remaining strong that he or she is surprised by the powerful feelings of love and awe that accompany seeing this incredible woman go through birth. You and the mother may have the most familiar voices to the infant. When you talk to the baby, he experiences a feeling of calmness that has a positive effect on his transition to the outside world. Stroking him will also reduce stress hormones and improve his breathing and temperature regulation. The postpartum period is a mix of joyous and difficult moments. The unpredictability of each day and getting to know your baby can sometimes make for a challenging situation. After the excitement of birth dies down a bit, enjoy quiet time with the mother and baby, and delight in the miracle of birth and the part you played.
7.
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Section 59.2
Birth Partners
reduces the requests for pain medication and epidurals, as well as the incidence of cesareans.
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Birth Plans
In the happy haze of early pregnancy, youre probably already thinking of baby names and planning to shop for baby clothes. The reality of labor and birth may seem extremely far offwhich makes this the perfect time to start planning for the arrival of your baby by creating a birth plan that details your wishes.
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2. How are you hoping for your baby to be treated immediately after and for the first few days after birth?
Do you want the babys cord to be cut by your partner? If possible, do you want your baby placed on your stomach immediately after birth? Do you want to feed the baby immediately? Will you breastfeed or bottle-feed? Where will the baby sleepnext to you or in the nursery? Hospitals have widely varying policies for the care of newborns if you choose to have your baby in a hospital, youll want to know what these are and how they match what youre looking for.
Factors to Consider
Before you make decisions about each of your birthing options, youll want to talk with your health care provider and tour the hospital or birthing center where you plan to have your baby. 486
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You may find that your obstetrician, nurse-midwife, or the facility where they admit patients already has birth-plan forms that you can fill out. If this is the case, you can use the form as a guideline for asking questions about how women in their care are routinely treated. If their responses are not what youre hoping for, you might want to look for a health provider or facility that better matches your goals. And its important to be flexibleif you know one aspect of your birthing plan wont be met, be sure to weigh that aspect against your other wishes. If your options are limited because of insurance, cost, or geography, focus on one or two areas that are really important to you. In the areas where your thinking doesnt agree with that of your doctor or nurse-midwife, ask why he or she usually does things a certain way and listen to the answers before you make up your mind. There may be important reasons why a doctor believes some birth options are better than others. Finally, you should find out if there are things about your pregnancy that might prevent certain choices. For example, if your pregnancy is considered high risk because of your age, health, or problems during previous pregnancies, your health care provider may advise against some of your birthing wishes. Youll want to discuss, and consider, this information when thinking about your options.
Birth Plans
atmosphere in which they give birth. Do you want music and low lighting? How about the freedom to walk around during labor? Is a hot tub something youd like access to? If possible, would you like to eat or drink during labor? You might be able to request things that may make you the most comfortablefrom what clothes youll wear to whether youll have a VCR or DVD player in your room. Procedures during labor: Hospitals used to perform the same procedures on all women in labor, but many now show increased flexibility in how they handle their patients. Some examples include: Enemas: Used to clean out the bowels, enemas used to be routinely administered when women were admitted. Now, you may choose to give yourself an enema or to skip it entirely. Induction of labor: At times, labor may need to be induced or sped up for medical reasons. But sometimes, practitioners will give women the option of getting some help to move things along, or giving labor a little more time to progress on its own. Shaving the pubic area: Once routine, shaving is no longer done unless a woman requests it. Other procedures that you can include in your birth plan are requests about fetal monitoring, extra birthing equipment youd like in the room, and how often you have internal exams during labor. Pain management: This is important for most women and is certainly something you have a lot of control over. Its also something youll want to discuss carefully with your health care provider. Some women change their minds about pain relief during labor only to discover that theyre too far along in their labor to use certain methods, such as an epidural. Youll also want to be aware of the alternative forms of pain relief, including massage, relaxation, breathing, and hot tubs. Know your options and make your wishes known to your health provider. Position during delivery: You can try a variety of positions during labor, including the classic semi-recline with the feet in stirrups that youve seen in the movies. Other choices include lying on your side, squatting, standing, or simply using whatever stance feels right at the time. Episiotomies: When necessary, doctors perform episiotomies (when the perineumthe area of skin between the vagina and the 489
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Make your birth plan read like a list of requests or best-case scenarios, not like a set of demands. Phrases such as I would prefer and if medically necessary will help your health care provider and caregivers know that you understand that they might have to alter the plan. Think about the other personnel wholl be using ithospital staffers might feel more comfortable if you call it your birth preferences rather than your birth plan, which could seem as though youre trying to tell them how to do their jobs. Try to be positive (we hope to) as opposed to negative (under no circumstances). Once youve made your birth plan, schedule a time to go over it with your doctor or nurse-midwife. Find out and discuss where you agree or disagree. During your pregnancy, review the birth plan with your partner periodically to make sure that its still in line with both of your wishes. Strive to keep the plan as simple as possiblepreferably less than two pagesand list them in order of importance. Focusing on your priorities will help ensure that the most important of your wishes are met. You may also want to make several copies of the plan: one for you, one for your chart, one for your doctor or nurse-midwife, and one for your birthing coach or partner. And bringing a few extra copies in your labor bag is a good idea, especially if your doctor ends up not being on call when your baby is born. Although you might not be able to control everything that happens to you during your babys birth, you can play a role in the decisions that are made about your body and your baby. A well thought-out birth plan can help you to do that.
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If my child needs stem cells, can I donate some of mine like donating a kidney?
Stem cells can be taken from the umbilical cord, from embryos, and also from adult tissues and organs, such as bone. There has been a lot of research done on adult stem cells and they are used to treat many diseases. If you or your child needs stem cells to treat a disease, the National Marrow Donor Program will help you find a donor if there is one available.
What is the difference between public and private cord blood banks?
Public cord blood banks like the National Marrow Donor Program offer stored stem cells to anyone who needs them. These banks have stored cord blood donated by parents who want their babys stem cells to be available to anyone who needs them. There is no fee to donate cord blood to a public bank. Private cord blood banks store your babys cord blood for possible future use for your baby or members of your immediate family. Private banks charge between $1000 and $2000 to collect the blood and about $100 a year to keep stem cells frozen in the bank. 494
Is it very likely that your child will need his stem cells in the future?
Some families have illnesses that run in the familyinherited illnesses that can only be cured with stem cells. If you already know that your child is at risk for such an illness, you may want to bank the cord blood stem cells.
Do you have another child who already needs treatment with stem cells?
If you have a child who needs a stem cell treatment but does not have his own stem cells available, you may want to bank cord blood stem cells from your next child. This childs stem cells may be a match for the child who needs them.
Do you want to be sure your babys stem cells will always be available only for her?
Private cord blood banks will store stem cells for future use in your family only. The charges vary from one cord bank to another cord bank. The services provided vary, too. You will want to shop around for the best service and best price.
Are you willing to donate your babys stem cells for someone else?
You can donate your babys cord blood stem cells to one of the public cord blood banks for free if there is one in your area. Another person who matches your baby might use the cells. If your child needs to be 495
Would you like to make your own stem cells available to someone who might need them for treatment of illness?
If you would like to donate your own stem cells to help save someones life, consider signing up as a potential donor with the National Marrow Donor Program. In order to sign up, you will need to get your cells typed. Your type will then be kept in a registry of types. When someone needs a stem cell or bone marrow transplant, his or her type will be checked against the registry. If you are a match, you may be asked to donate. You could save a life!
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Chapter 62
Natural Childbirth
Some women choose to give birth using no medications at all, relying instead on relaxation techniques and controlled breathing for pain. With natural childbirth, the mother is in charge, usually with a labor assistant gently guiding and supporting her through the stages of labor. For many moms-to-be, having a natural childbirth isnt about being brave or a martyrits about treating labor and delivery as a natural event, not a medical problem. Many women find the experience, despite the pain, extremely empowering and rewarding.
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Where is it done?
Many women who opt for natural childbirth choose to deliver in a non-hospital setting such as a birth center, where natural childbirth is the focus. Women are free to move around in labor, get in positions that are most comfortable to them, and spend time in the Jacuzzi. The baby is monitored frequently, typically with a handheld Doppler. Comfort measures such as hydrotherapy, massage, warm and cold compresses, and visualization and relaxation techniques are often used. The woman is free to eat and drink as she chooses. A variety of health care professionals may work in the birth center settingregistered nurses, certified nurse midwives, and doulas (professionally trained providers of labor support and/or postpartum care) that act as labor assistants. Studies indicate that getting continuous support during labor from a trained and experienced woman, such as a midwife or doula, can mean shorter labor, less (or no) medications, less chance of needing a cesarean, and a more positive feeling about the labor when its over. These days, its also possible to have a more natural childbirth in some hospitals. Many have modified their approach for low-risk births. They may have rooms with homelike settings where women can labor, deliver, and recover without being moved. They may take their cues from the laboring woman, allowing labor to proceed more slowly and without intervention if it all seems to be going well. They may use alternative pain medications if requested and welcome the assistance of labor assistants like midwives or doulas. In addition to the father, children, grandparents, and friends may be allowed to attend the births (which is also common practice at birth centers). After birth, babies may remain with the mother longer. In 498
Natural Childbirth
its fullest form, this approach is sometimes called family-centered care. If youre having a high-risk pregnancy, its usually best to give birth in a hospital, where you can receive any necessary medical care (especially in the event of an emergency).
How is it done?
How you choose to work through the pain is up to you. Different women find that different methods work best for them. Many are able to control the pain by channeling their energy and focusing their minds on something else. The two most common childbirth philosophies in the United States are the Lamaze technique and the Bradley method. The Lamaze technique teaches that birth is a normal, natural, and healthy process but takes a neutral position toward pain medication, encouraging women to make an informed decision about whether its right for them. The Bradley method (also called Husband-Coached Birth) emphasizes a natural approach to birth and the active participation of the babys father as birth coach. A major goal of this method is the avoidance of medications unless absolutely necessary. The Bradley method also focuses on good nutrition and exercise during pregnancy and relaxation and deep-breathing techniques as a method of coping with labor. Although the Bradley method advocates a medication-free birth experience, the classes do prepare parents for unexpected complications or situations, like emergency C-sections. Some other ways you can handle pain during labor include: hypnosis (also called hypnobirthing); yoga; meditation; walking; massage or counterpressure; changing position (such as walking around, showering, rocking, or leaning on birthing balls); taking a bath or shower; immersing yourself in warm water or a Jacuzzi; distracting yourself by performing an activity that keeps your mind otherwise occupied; 499
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elated and empoweredyou may feel an overwhelming sense of accomplishment knowing that you did it on your own.
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Systemic Analgesics
Systemic analgesics are often given as injections into a muscle or vein. They lessen pain but will not cause you to lose consciousness. They act on the whole nervous system rather than a specific area. Sometimes other drugs are given with analgesics to relieve the tension or nausea that may be caused by these types of pain relief. Like other types of drugs, this pain medicine can have side effects. Most are minor, such as nausea, feeling drowsy or having trouble concentrating. Systemic analgesics are not given right before delivery because they may slow the babys reflexes and breathing at birth.
Local Anesthesia
Local anesthesia provides numbness or loss of sensation in a small area. It does not, however, lessen the pain of contractions. A procedure called an episiotomy may be done by your doctor before delivery. Local anesthesia is helpful when an episiotomy needs to be done or when any vaginal tears that happened during birth are repaired. Local anesthesia rarely affects the baby. There usually are no side effects after the local anesthetic has worn off.
Regional Analgesia
Regional analgesia tends to be the most effective method of pain relief during labor and causes few side effects. Epidural analgesia, spinal blocks, and combined spinalepidural blocks are all types of regional analgesia that are used to decrease labor pain. Epidural analgesia: Epidural analgesia, sometimes called an epidural block, causes some loss of feeling in the lower areas of your 504
General Anesthesia
General anesthetics are medications that put you to sleep (make you lose consciousness). If you have general anesthesia, you are not awake and you feel no pain. General anesthesia often is used when a regional block anesthetic is not possible or is not the best choice for medical or other reasons. It can be started quickly and causes a rapid loss of consciousness. Therefore, it is often used when an urgent cesarean delivery is needed. 506
Finally
Many women worry that receiving pain relief during labor will somehow make the experience less natural. The fact is, no two labors are the same, and no two women have the same amount of pain. Some women need little or no pain relief, and others find that pain relief gives them better control over their labor and delivery. Talk with your doctor about your options. In some cases, he or she may arrange for you to meet with an anesthesiologist before your labor and delivery. Be prepared to be flexible. Dont be afraid to ask for pain relief if you need it.
Easing Discomforts
Following are some ways to ease discomfort you may feel during labor: Do relaxation and breathing techniques taught in childbirth class. Have your partner massage or firmly press on your lower back. 507
Chapter 64
Is It Labor?
Chapter Contents
Section 64.1True Labor and False Labor ............................... 510 Section 64.2When Does the Bag of Waters Break? ............... 512
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Section 64.1
How will I know when it is real labor? This is a question you may have as you near the end of your pregnancy. Many women have periods of false labor late in their pregnancy. During false labor, you have contractions that seem to come and go. False labor pains are called Braxton Hicks contractions. These contractions help soften and thin your cervix. They tend to happen more often as you get closer to your due date (two to four weeks before birth). Sometimes it is hard to tell the difference between false labor and true labor. Dont be upset or embarrassed if you think labor is beginning when it is actually a false alarm.
Timing of Contractions
False labor: Contractions are often irregular. They dont get closer together over time. True labor: Contractions come regularly and get closer together. Each contraction lasts about 30 to 60 seconds.
Strength of Contractions
False labor: Contractions are often weak and do not get stronger. True labor: Contractions get stronger as time goes on. 510
Is It Labor?
Change with Movement
False labor: Contractions may stop or slow down when you walk, lie down, or change positions. True labor: Contractions continue no matter what you do.
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Section 64.2
Is it a problem if the bag breaks and the labor does not start right away?
If your bag of waters breaks more than three weeks before your due date, your health care provider may try to stop labor if the baby would be too premature. Because the bag of waters protects against infection, you will be checked to make sure there is no infection in your uterus. 512
Is It Labor?
If your bag of waters breaks within three weeks of your due date, your health care provider will recommend either waiting to let your labor start on its own or inducing your labor right away. You can discuss the pros and cons of each of these options with your health care provider. If you have a bacteria, such as Group B strep [streptococcus] in your vagina, your health care provider may want to give you antibiotics or get your labor started (induction). The longer the bag of waters is broken before birth, the more chance there is that infection will get to the baby.
What should I do if I feel wet but am not sure the bag of waters has broken?
Your health care provider can do a simple test using a sterile speculum to see inside your vagina. A sample of the fluid in the vagina will be collected and placed on special paper that turns very dark blue if it touches amniotic fluid.
What if your bag of waters breaks, and you are not in labor yet?
Labor contractions can start any time from right away to many hours or a few days after your water breaks. If you think your bag of waters has broken, call your health care provider. Call your health care provider right away if: your due date is more than three weeks away from today; the water is green, or yellow, or brown, or has a bad smell; you have a history of genital herpes, whether or not you have any herpes sores right now; 513
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Inducing Labor
Its common for many women, especially first-time mothers, to watch their babys due date come and go without so much as a contraction. The farther away from the expected delivery date (called the EDD) you get, the more anxious you may become. You may start to feel like a ticking time bomb. You may wonderis this baby ever going to come? Late pregnancy can be challengingyou may feel large all over, your feet and back may hurt, you might not have the energy to do much of anything, and youre beyond ready to meet the little one youve nurtured all this time. Which is why waiting a little longer than youd expected can be particularly hard. Still, being past your due date doesnt guarantee that your doctor (or other health care provider) will do anything to induce (or artificially start) laborat least not right away.
What is it?
Labor induction is what doctors use to try to help labor along using medications or other medical techniques. Years ago, some doctors routinely induced labor. But now its not usually done unless theres a true
Inducing Labor, July 2006, reprinted with permission from www.kidshealth .org. Copyright 2006 The Nemours Foundation. This information was provided by KidsHealth, one of the largest resources online for medically reviewed health information written for parents, kids, and teens. For more articles like this one, visit www.KidsHealth.org, or www.TeensHealth.org.
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Why is it done?
Your doctor may suggest an induction if: your water broke; your baby still hasnt arrived by 2 weeks after the due date (when youre considered post-termmore than 42 weeks into your pregnancy); you have an infection in the uterus called chorioamnionitis; youre having a pregnancy with certain risks (i.e., if you have gestational diabetes or high blood pressure, or your baby has growth problems). Some doctors will perform elective inductionsin other words, they will induce labor if the mother wants it for nonmedical reasons. However, this isnt always the best option because inductions do come with risks. Doctors try to avoid inducing labor early because the due date may be wrong and/or the womans cervix may not be ready yet.
How is it done?
Some methods of induction are less invasive and carry fewer risks than others. Ways that doctors may try to induce labor by getting contractions started include: Stripping the membranes: The doctor puts on a glove and inserts a finger into your vagina and through your cervix (the opening that connects the vagina to the uterus). He or she moves the finger back and forth to separate the thin membrane connecting the amniotic sac (which houses the baby and amniotic fluid) to the wall of your uterus. When the membranes are stripped, the body releases hormones called prostaglandins, which help prepare the cervix for delivery and may bring on contractions. This method works for some women, but not all. Breaking your water (also called an amniotomy): The doctor ruptures the amniotic sac. During a vaginal exam, he or she uses a little plastic hook to break the membranes. This usually brings on labor in a matter of hours. 516
Inducing Labor
Giving the hormone prostaglandin to help ripen the cervix: A gel or vaginal insert of prostaglandin (often the drug Cervidil) is inserted into the vagina or a tablet is given by mouth. This is typically done overnight in the hospital to make the cervix ripe (soft, thinned out, or dilated) for delivery. Administered alone, prostaglandin may induce labor or may be used before giving oxytocin. Giving the hormone oxytocin to stimulate contractions: Given continuously through an IV [intravenous line], the drug (often Pitocin) is started in a small dose and then increased until labor is progressing well. After its administered, the fetus and uterus need to be closely monitored. Oxytocin is also frequently used to spur labor thats going slowly or has stalled.
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Section 66.1
First Stage
The first stage of labor is the longest and is broken down into three phases: Early labor phase: Starts from the onset of labor until the cervix is dilated to 3 cm. Active labor phase: Continues until the cervix is dilated to 7 cm. Transition phase: Continues until the cervix is fully dilated to 10 cm. Each phase is full of different emotions and physical challenges. It is one big adventure you are about to take and we would like to give you a guide for it. 520
Transition Phase
What to do: During this phase you will rely heavily on your support person. This is the hardest phase but it is also the shortest. Think one contraction at a time. This may be hard to do if the contractions are very close together, but just think about how far you have come. When you feel an urge to push, tell your health care provider. What to expect: Duration will last about 30 minutes2 hours. Your cervix will dilate from 8 cm to 10 cm. Contractions during this phase will last about 6090 seconds with a 30-second2-minute rest in between. Contractions are long, strong, intense, and may overlap. This is the hardest phase but thankfully the shortest. You may experience hot flashes, chills, nausea, vomiting, or gas. Tips for the support person: Offer lots of encouragement and praise. Avoid small talk. Continue breathing with her. Help guide her through her contractions with encouragement. Encourage her to relax in between contractions. Dont feel hurt if she seems to be angry; its just part of transition!
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Section 66.2
This text presents results of recent systematic reviews that can help women compare risks of planned vaginal birth after cesarean (VBAC) and of planned C-section. While more high-quality studies are needed, a large body of research already exists and sheds light on these questions for those who need guidance now. When deciding whether to plan a VBAC or a repeat cesarean, it is important to understand the full range of risks to you and your baby. This means comparing the short- and long-term risks of cesarean surgery and risks of accumulating cesarean surgery scars to mothers and babies on the one hand, to the risk that the uterine scar will give way (uterine rupture) and lead to problems and a few risks that are worse for vaginal birth generally. Even if you do not plan to have more children, you should be aware of risks of multiple cesarean scars to future pregnancies and babies. Many women change their mind and decide to become pregnant again or continue with unplanned pregnancies. 526
What are key messages about VBAC vs. repeat cesarean section?
Despite limitations of the best available research, the following conclusions seem clear: Scar giving way: The scar is more likely to give way during a VBAC labor than in a repeat C-section; for most women (exceptions noted below), the added risk of the scar giving way is about 27 in every 10,000 VBAC labors. In other words, nearly 400 women would need to experience the risks involved with repeat C-section to prevent one uterine rupture during a VBAC labor. Death of baby: While the scar giving way poses a threat to the baby, the added risk that the baby will die from a problem with the scar during a VBAC labor, compared with women planning repeat C-sections, is about 1.4 in every 10,000 VBAC labors. In other words, over 7,100 women would need to experience the risks involved with repeat C-sections to prevent the death of one baby due to uterine rupture. Hysterectomy in mother: If the scar gives way, some women have a hysterectomy (removal of the uterus). The added risk of needing a hysterectomy from this cause is about 3.4 in every 10,000 VBAC labors, when compared with women planning repeat C-sections. However, considering risk for hysterectomy from all causes, women who plan a VBAC are not more likely to experience an unplanned hysterectomy than women planning repeat C-section. 527
What are some concerns about risks of C-section compared with vaginal birth?
When weighing planned VBAC versus planned C-section, the focus is often on potential problems with the uterine scar in labor or 528
What are some concerns about risks of vaginal birth compared with C-section?
C-section offers advantages in a few areas, primarily during the recovery period after birth. (Some practices used with vaginal birth, such as episiotomy, are associated with pelvic floor problems. It is wrong to conclude at this time that vaginal birth itself causes such problems.) A woman who has a vaginal birth is more likely to: have a painful vaginal area in the weeks after birth; leak urine (urinary incontinence) (about 3 women per hundred still have a problem 1 year after birth); leak gas, or more rarely, feces (bowel incontinence) (about 3 women per hundred still have a problem 1 year after birth). Babies born vaginally have been shown to be at higher risk for a nerve injury affecting the shoulder, arm, or hand (brachial plexus injury) (usually temporary).
What are some ways that a planned C-section may differ from an unplanned C-section?
A planned C-section offers some advantages over an unplanned Csection that occurs after labor is under way. For example, there is a lower risk of surgical injuries and of infections. The emotional impact 530
What is the added likelihood that the scar will give way (uterine rupture) during a VBAC labor?
Best research suggests that an extra 27 women experience a ruptured uterus in every 10,000 VBAC labors, compared with planned C-section deliveries. Thus, nearly 400 women would need to experience surgical birth to prevent one instance of uterine rupture during VBAC labors. While the scar giving way usually requires an urgent cesarean, loss of the baby is much less common. Added likelihood for a woman with a known low-transverse (horizontal) scar: moderate for scar rupture compared with planned repeat C-section.
What is the added likelihood that the baby will die as a result of the scar giving way (uterine rupture) during a VBAC labor?
Best research suggests that about 1.4 extra babies die due to problems with the scar in every 10,000 VBAC labors, compared with planned C-section deliveries. Thus, over 7,000 women would need to 531
What is the added likelihood of the scar giving way (uterine rupture) with any of these factors?
Type of uterine scar not known Low vertical uterine incision at prior C-section (may have been used if C-section took place earlier in pregnancy before growth in lower part of the uterus) Baby estimated to be large, weighing over 4,000 grams (8 lb 13 oz) or pregnancy extends past 40 weeks Some caregivers recommend planned repeat C-section with these factors on the grounds that VBAC is riskier, but the research does not support that belief. No added likelihood for scar rupture in a woman with unknown type of uterine scar, prior low vertical uterine incision, baby estimated to weigh more than 4,000 grams, or pregnancy extending past 40 weeks, in comparison with women planning VBAC without these factors.
What is the added likelihood of the scar giving way (uterine rupture) with twin pregnancy or the use of external cephalic version (turning a baby in a buttocks- or feet-first (breech) position to a head-first position by manipulating the womans belly)?
While studies have not found an excess incidence of scar rupture in these situations, not enough women have been studied to rule out an increase. No currently known added likelihood for scar rupture in a woman with a twin pregnancy or a woman experiencing external version, in comparison with women planning VBAC without these factors.
What is the added likelihood that a woman planning VBAC will require a hysterectomy compared with a woman planning repeat C-section?
Most studies find an excess of hysterectomies (surgical removal of the uterus) among women planning repeat C-section. However, this 532
What is the added likelihood that a woman will require a hysterectomy as a result of the scar giving way (uterine rupture) during a VBAC labor?
Best research suggests that about 3.4 extra women have a scarrelated hysterectomy (surgical removal of uterus) occur in every 10,000 VBAC labors, compared with planned C-section deliveries. Thus, nearly 3,000 women would need to experience surgical birth to prevent one instance of hysterectomy due to scar problems during VBAC labors. Added likelihood for a woman with a known low-transverse (horizontal) scar: low for hysterectomy as a result of uterine rupture compared with repeat cesarean.
What is the added likelihood that a woman will develop an infection after a planned cesarean?
Surgery always introduces the risk of infection. Even though some women who plan VBAC will have repeat C-sections, most will not. This puts women planning VBAC at lower risk of having an infection than women planning repeat C-sections. Added likelihood for a woman planning repeat cesarean: moderate for developing a wound or internal infection compared with planned VBAC.
What are some concerns about effects of accumulating uterine scars on future pregnancies and births?
The likelihood of the following problems grows as the number of previous cesareans (and C-section scars) grows: Placenta previa: A woman whose uterus has a cesarean scar is more likely than a woman with an unscarred uterus to have a future placenta attach near or over the opening to her cervix; this increases her risk for serious bleeding, shock, blood transfusion, 533
References
Guise J-M, Berlin M, McDonagh M, Osterweil P, Chan B, Helfand M. Safety of vaginal birth after cesarean: a systematic review. Obstet Gynecol 2004;103:4209. Guise J-M, McDonagh MS, Osterweil P, Nygren P, Chan BKS, Helfand M. Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section. BMJ 2004;329: 15965. Hashima JN, Eden KB, Osterweil P, Nygren P, Guise J-M. Predicting vaginal birth after cesarean delivery: a review of prognostic factors and screening tools. Am J Obstet Gynecol 2004;190:54755. Lieberman E. Risk factors for uterine rupture during a trial of labor after cesarean. Clin Obstet Gynecol 2001;44:60921. [Alone among references, this article is not a systematic review; it is included, however, as a well done review that addresses important questions for women facing the VBAC/repeat c-section decision.] Childbirth Connection. Comparing risks of cesarean and vaginal birth to mothers, babies, and future reproductive capacity: a systematic review. New York: Childbirth Connection, April 2004.
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Section 66.3
Cesarean Sections
Should I Have a Cesarean Section? Journal of Midwifery and Womens Health, March/April 2004. 2004 American College of Nurse-Midwives (www.midwife.org). Reprinted with permission. Reviewed by David A. Cooke, MD, FACP, April 12, 2009. Dr. Cooke is not affiliated with the American College of Nurse-Midwives.
Ive heard that some women have a C-section to avoid problems with leaking urine later in life. Is this a good reason to have a C-section?
There have been many studies trying to find out which is the safest way to have a baby. At this time, there is no proof that having a C-section is safer or protects against future problems with leaking urine or stool, or uterine prolapse. Because there are more medical risks for women who have a C-section compared to women who have a vaginal birth, vaginal birth is safer.
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Chapter 67
Chapter Contents
Section 67.1Cephalopelvic Disproportion .............................. 540 Section 67.2Episiotomy ............................................................ 541 Section 67.3Birth Injuries ....................................................... 543
539
Section 67.1
Cephalopelvic Disproportion
Cephalopelvic Disproportion, 2007 American Pregnancy Association (www.americanpregnancy.org). Reprinted with permission.
The accurate definition of cephalopelvic disproportion (CPD) is when a babys head or body is too large to fit through the mothers pelvis. It is believed that true CPD is rare, but many cases of failure to progress during labor are given a diagnosis of CPD. When an accurate diagnosis of CPD has been made, the safest type of delivery for mother and baby is a cesarean delivery.
Section 67.2
Episiotomy
From What You Need To Know About Episiotomy, by the Agency for Healthcare Research and Quality (AHRQ, www.ahrq.gov), AHRQ Publication No. 06-0005, December 2005.
Research shows that routine use of episiotomies (surgical cuts in the area between the vagina and anus) does not keep the mothers skin from tearing during birth. It does not speed up a normal birth. It does not help avoid the bladder control problems women sometimes get after having a baby.
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Section 67.3
Birth Injuries
Birth Injuries, 2008 Childrens Hospital of Pittsburgh (www.chp.edu). Reprinted with permission.
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Chapter 68
Although most women do not go into labor during emergencies and most of those who do can get to a hospital or birth center, recent events have raised concerns about what to do if travel is not possible. Being prepared can help. The information here includes a list of supplies and directions for managing a normal labor and delivery while taking shelter in place. This is not a do-it-yourself guide for a planned home birth, nor is it all the information you need for every emergency. It is not meant to replace the knowledge and skills of a doctor or midwife. The information is a basic guide for parents-to-be who want to be ready in case they have to give birth before they can get to a hospital or birth center.
547
The Baby
At the time of birth, most babies are blue or dusky. Some cry right away and others do not. Do not spank the baby, but rub up and down her back until you know she is taking deep breaths. Once the baby starts to cry, her color will be more like her mom, but her hands and feet will still be blue. Now is the time to keep the baby warm. Remove the wet towel that is over the baby and put another dry towel and blanket over the mother and baby. Put a hat on the baby. The mother can help keep the baby warm with her body heat. 551
Clean Up
After the mother has delivered the placenta and the bleeding has slowed down, give her a drink of juice, soup, or milk and something to eat like crackers and cheese or a peanut butter and jelly sandwich. Put on gloves to clean up the bed. Roll up the sheet and pads inside the shower curtain and put in a large plastic bag. Have clean under pads ready to cover the sheets and a sanitary pad for the mother. The dirty sheets and towels can be washed in cold water with bleach or ammonia added. Wear gloves when touching items that are bloody. Put a diaper on the baby or you will be sorry.
Breastfeeding
It is important for the mother to breastfeed the baby in the first hour after birth and at least every 2 hours until her milk comes in. Breastfeeding will keep the uterus firm and decrease bleeding. Colostrum, the liquid that is in the breasts right after birth until the milk comes in, will give the baby all of the food she needs and it will help prevent infection. Even if the emergency situation continues for days, weeks, or months, there will always be a ready supply of safe and perfect food for the baby.
What to Avoid
Dont use a pacifier or a bottle to start the baby sucking. It confuses some babies because they do not suck the same on the mothers breast and a bottle or pacifier. Do not separate the mother and baby for very long. The more they stay together, including when they sleep, the sooner breastfeeding will be well established.
Key Points
All parents-to-be should go to: childbirth education classes; infant/child CPR (cardiopulmonary resuscitation) classes; breastfeeding classes. Parents-to-be should keep the family car: in good repair; filled with gas. If you have to labor at home during a terrorist attack or other emergency: Call your midwife or physician. Call for an ambulance. Call a neighbor to help you. Unlock the front door. Keep these instructions and the birth supplies handy. Women in labor need lots of encouragement and need helpers who are calm, positive, and caring. No matter what is happening in the rest of the world, it is important to keep the room peaceful and to focus on 556
Disclaimer
The information provided in this chapter is not a do-it-yourself guide for a planned home birth, nor is it all the information you need for every emergency. Following these directions will not replace the knowledge and skills of a doctor or midwife and cannot ensure a safe outcome. The information is a basic guide for parents-to-be who want to be ready in case they have to give birth before they can get to a hospital or birth center. In all cases, it is critical that you attempt to make contact with a trained health care professional.
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561
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567
Apgar Evaluation
The Apgar test is a quick way for doctors to figure out if the baby is healthy or needs extra medical care. Apgar tests are usually done twice: one minute after birth and again five minutes after birth. Doctors and nurses measure five signs of the babys condition. These are: heart rate; breathing; activity and muscle tone; reflexes; skin color. Apgar scores range from 0 to 10. A baby who scores 7 or more is considered very healthy. But a lower score doesnt always mean there is something wrong. Perfectly healthy babies often have low Apgar scores in the first minute of life. In more than 98 percent of cases, the Apgar score reaches 7 after 5 minutes of life. When it does not, the baby needs medical care and close monitoring. 568
Vitamin K Shot
The American Academy of Pediatrics recommends that all newborns receive a shot of vitamin K in the upper leg. Newborns usually have low levels of vitamin K in their bodies. This vitamin is needed for the blood to clot. Low levels of vitamin K can cause a rare but serious bleeding problem. Research shows that vitamin K shots prevent dangerous bleeding in newborns. Newborns probably feel pain when the shot is given. But afterwards babies dont seem to have any discomfort. Since it may be uncomfortable for the baby, you may want to postpone this shot for a little while.
Hearing Test
Most babies have a hearing screening soon after birth, usually before they leave the hospital. Tiny earphones or microphones are used to see how the baby reacts to sounds. All newborns need a hearing screening because hearing defects are not uncommon and hearing loss can be hard to detect in babies and young children. When problems are found early, children can get the services they need at an early age. This might prevent delays in speech, language, and thinking. Ask your hospital or your babys doctor about newborn hearing screening.
Hepatitis B Vaccine
All newborns should get a vaccine to protect against the hepatitis B virus (HBV) before leaving the hospital. HBV can cause a lifelong infection, serious liver damage, and even death. The hepatitis B vaccine (HepB) is a series of three different shots. The American Academy of Pediatrics and the Centers for Disease Control (CDC) recommend that all newborns get the first HepB shot before leaving the hospital. If the mother has HBV, her baby should also get a HBIG (hepatitis B immune globulin) shot within 12 hours of birth. The second HepB shot should be given 1 to 2 months after birth. The third HepB shot should be given no earlier than 24 weeks of age, but before 18 months of age.
Complete Checkup
Soon after delivery most doctors or nurses also: measure the newborns weight, length, and head; take the babys temperature; measure that babys breathing and heart rate; give the baby a bath and clean the umbilical cord stump.
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What is infancy?
Infancy is generally the period from birth until age two years. It is a time of a lot of growth and change for children and families. This information is provided with full-term infants specifically in mind. It is not meant to provide all the information you need to care for your infant. Preterm infants (those born before the mother has been pregnant about 38 weeks) often have special needs.
What is jaundice?
Jaundice is an illness that can cause a babys skin, eyes, and mouth to turn a yellowish color. The yellow color is caused by a buildup of bilirubin, a substance that is produced in body during the normal process of breaking down old red blood cells and forming new ones.
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Chapter 72
Infant Feeding
Chapter Contents
Section 72.1Breastfeeding ....................................................... 576 Section 72.2Formula Feeding ................................................. 578
575
Section 72.1
Breastfeeding
Excerpted from Breastfeeding: Frequently Asked Questions, by the Office of Womens Health (www.womenshealth.gov), part of the U.S. Department of Health and Human Services, March 2009.
Infant Feeding
How long should I breastfeed?
It is best to give your baby only breast milk for the first six months of life. This means not giving your baby any other food or drinknot even waterduring this time. Drops of liquid vitamins, minerals, and medicines are, of course, fine, as advised by your babys doctor. It is even better if you can breastfeed for your babys first year or longer, for as long as you both wish. Solid iron-rich foods, such as iron-fortified cereals and pureed vegetables and meats, can be started when your baby is around six months old. Before that time, a babys stomach cannot digest them properly. Solids do not replace breastfeeding. Breast milk stays the babys main source of nutrients during the first year. Beyond one year, breast milk can still be an important part of your childs diet.
577
Section 72.2
Formula Feeding
Excerpted from Infant Formula, by the U.S. Food and Drug Administration (FDA, www.fda.gov), April 3, 2006.
Infant Feeding
Do infants fed infant formulas need to take additional vitamins and minerals?
Infants fed infant formulas do not need additional nutrients unless a low-iron formula is fed. If infants are fed a low-iron formula, a health care professional may recommend a supplemental source of iron, particularly after 4 months of age. FDAs nutrient specifications for infant formulas are set at levels to meet the nutritional needs of infants. In addition, manufacturers set nutrient levels for their label claims that are generally above the FDA minimum specifications and they add nutrients at levels that will ensure that their formulas meet their label claims over the entire shelf-life of the product.
Do house brand or generic infant formulas differ nutritionally from name brand formulas?
All infant formulas marketed in the United States must meet the nutrient specifications listed in FDA regulations. Infant formula manufacturers may have their own proprietary formulations but they must contain at least the minimum levels of all nutrients specified in FDA regulations without going over the maximum levels, when maximum levels are specified.
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Bonding is the intense attachment that develops between parents and their baby. It makes parents want to shower their baby with love and affection and to protect and nourish their little one. Bonding gets parents up in the middle of the night to feed their hungry baby and makes them attentive to the babys wide range of cries. Scientists are still learning a lot about bonding. They know that the strong ties between parents and their child provide the babys first model for intimate relationships and foster a sense of security and positive self-esteem. And parents responsiveness to an infants signals can affect the childs social and cognitive development.
581
Making an Attachment
Bonding with your baby is probably one of the most pleasurable aspects of infant care. You can begin by cradling your baby and gently stroking him or her in different patterns. If you and your partner both hold and touch your infant frequently, your little one will soon come to know the difference between your touches. Each of you should also take the opportunity to be skin to skin with your newborn by holding him or her against your own skin when feeding or cradling. 582
Is There a Problem?
If you dont feel that youre bonding by the time you take your baby to the first office visit with your childs doctor, discuss your concerns at that appointment. It may be a sign of postpartum depression. Or bonding can be delayed if your baby has had significant, unexpected health issues. It may just be because you feel exhausted and overwhelmed by your childs arrival. In any event, the sooner a problem is identified, the better. Health care providers are accustomed to dealing with these issues and can help you be better prepared to form a bond with your child. Also, it often helps to share your feelings about bonding with other new parents. Ask your childbirth educator about parenting classes for parents of newborns. Bonding is a complex, personal experience that takes time. Theres no magic formula and it cant be forced. A baby whose basic needs are being met wont suffer if the bond isnt strong at first. As you become more comfortable with your baby and your new routine becomes more predictable, both you and your partner will likely feel more confident about all of the amazing aspects of raising your little one.
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Chapter 74
587
Section 74.1
Paid Parental Leave Is Still Not Standard, Even among the Best U.S. Employers
Nearly one-quarter (24 percent) of the best employers for working mothers provide four or fewer weeks of paid maternity leave, and half (52 percent) provide six weeks or less, according to an Institute for Womens Policy Research analysis of data provided by Working Mother Media, Inc., publisher of Working Mother magazine. Nearly half of the best companies fail to provide any paid leave for paternity or adoption. Each year Working Mother selects the 100 family-friendliest companies in the United States by reviewing employer questionnaires describing their workforce profile, compensation, child care, flexibility, time off and leaves, family-friendly programs and company culture.1 While more than one-quarter of companies (28 percent) provide nine or more weeks of paid maternity leave, many of the winners paid parental leave policies fall far short of families needs. No company provides more than six weeks of paid paternity leave and only 7 of the 100 best companies provide seven weeks or more of paid adoptive leave. An Institute for Womens Policy Research review of the Working Mother 2006 100 Best Companies finds that 7 percent of the highestranked companies offer no paid maternity leave, and another 7 percent provide only one to two weeks, as shown in Table 74.1. Some companies model more adequate standards, however. Goldman, Sachs & Co. offers 16 weeks of paid maternity leave, plus 4 weeks for new fathers and 8 for adoptive parents. Eighteen weeks of paid leave is standard for birth mothers at Pillsbury Winthrop Shaw Pittman LLP. New moms with five years of job tenure at Johnson & Johnson, ranked in the top ten of the 100 winners, receive 26 paid weeks of maternity leave. Half of the 2006 Working Mother 100 Best Companies do not report any paternity leave, and paid leave is much less available for adoptive 588
Note: Years on the job influence the amount of paid maternity leave an individual worker may be entitled to in many establishments. This table shows the longest possible amount of paid leave. *Zero weeks includes companies for which no data are provided on paid maternity leave. Source: Institute for Womens Policy Research analysis of Working Mother Media, Inc.s employment survey for the 2006 Working Mother 100 Best Companies, as presented at http://www.workingmother.com/web?service=vpage/77 (copyright 2007; retrieved 7/12/2007).
parents than for birth mothers (Table 74.2). Thirty-five percent of the 100 Best companies provide only one to two weeks of paternity leave, 8 percent provide three to four paid weeks, and 7 percent provide up to six paid weeks for new fathers. Of the 54 companies that reported paid leave policies for adoptive parents, 17 provide one to two weeks, 13 companies offer three to four weeks, and 16 provide five weeks or more for adoptive parents to bond with their new child.
Table 74.2. Working Mother 100 Best Companies, 2006: Percent Offering Paid Leave for Fathers and Adoptive Parents, by Maximum Leave Length
Number of weeks of paid paternity leave more than 12 weeks 11 to 12 weeks 9 to 10 weeks 7 to 8 weeks 5 to 6 weeks 3 to 4 weeks 1 to 2 weeks 0 weeks* Percent of companies offering paid paternity leave 0% 0% 0% 0% 7% 8% 35% 50% Percent of companies offering paid adoptive leave 1% 3% 0% 3% 9% 13% 17% 46%
Note: Years on the job influence the amount of paid leave an individual worker may be entitled to in many establishments. This table shows the longest possible amount of paid leave. *Zero weeks includes companies for which no data are provided. Source: Institute for Womens Policy Research analysis of Working Mother Media, Inc.s employment survey for the 2006 Working Mother 100 Best Companies, as presented at http://www.workingmother.com/web?service=vpage/77 (copyright 2007; retrieved 7/12/2007).
590
Resources
1. Information collected by Working Mother Media, Inc. from employers and edited by Working Mother Media, Inc. 2007. <http:// www.workingmother.com/web?service=vpage/77> (downloaded July 12, 2007). Patricia McGovern, Bryan Dowd, Dwenda Gjerdingen, Ira Moscovice, Laura Kochevar, and Sarah Murphy, 2000. The Determinants of Time Off Work After Childbirth. Journal of Health Politics, Policy and Law 25 (June 2000): 528564. Ibid. Patricia McGovern, Bryan Dowd, Dwenda Gjerdingen, Cynthia R. Gross, Sally Kenney, Laurie Ukestad, David McCaffrey, and Ulf Lundberg, 2006. Postpartum Health of Employed Mothers 5 Weeks After Childbirth. Annals of Family Medicine. 4 (March/April 2006): 159167. Lawrence M. Berger, Jennifer Hill, and Jane Waldfogel, 2005. Maternity Leave, Early Maternal Employment and Child Health and Development in the U.S., The Economic Journal, 115 (February 2005): F29F47. Roberta M. Spalter-Roth, Claudia Withers, and Sheila R. Gibbs, Improving Employment Opportunities for Women Workers: An Assessment of The Ten Year Economic and Legal Impact of the Pregnancy Discrimination Act of 1978, Publication #A108, Washington, DC: Institute for Womens Policy Research, 1990. According to the Bureau of Labor Statistics, the National Compensation Survey considers paid family leave a paid leave given to an employee to care for a family member. The leave may be available to care for a newborn child, an adopted child, a sick child, or a sick adult relative. Paid family leave is granted 593
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3. 4.
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Section 74.2
The U.S. Department of Labors Employment Standards Administration, Wage and Hour Division, administers and enforces the Family and Medical Leave Act (FMLA) for all private, state and local government employee and some federal employees. Most federal and certain congressional employees are also covered by the law and are subject to the jurisdiction of the U.S. Office of Personnel Management or the Congress. 594
Employer Coverage
FMLA applies to all public agencies, including state, local and federal employers, local education agencies (schools), and private-sector employers who employed 50 or more employees in 20 or more workweeks in the current or preceding calendar year, including joint employers and successors of covered employers.
Employee Eligibility
To be eligible for FMLA benefits, an employee must: work for a covered employer; have worked for the employer for a total of 12 months; have worked at least 1,250 hours over the previous 12 months; and work at a location in the United States or in any territory or possession of the United States where at least 50 employees are employed by the employer within 75 miles. While the 12 months of employment need not be consecutive, employment periods prior to a break in service of seven years or more need not be counted unless the break is occasioned by the employees fulfillment of his or her National Guard or Reserve military obligation (as protected under the Uniformed Services Employment and Reemployment Rights Act [USERRA]), or a written agreement, including a collective bargaining agreement, exists concerning the employers intention to rehire the employee after the break in service. 595
Leave Entitlement
A covered employer must grant an eligible employee up to a total of 12 workweeks of unpaid leave during any 12-month period for one or more of the following reasons: for the birth and care of a newborn child of the employee; for placement with the employee of a son or daughter for adoption or foster care; to care for a spouse, son, daughter, or parent with a serious health condition; to take medical leave when the employee is unable to work because of a serious health condition; or for qualifying exigencies arising out of the fact that the employees spouse, son, daughter, or parent is on active duty or call to active duty status as a member of the National Guard or Reserves in support of a contingency operation. A covered employer also must grant an eligible employee who is a spouse, son, daughter, parent, or next of kin of a current member of the Armed Forces, including a member of the National Guard or Reserves, with a serious injury or illness up to a total of 26 workweeks of unpaid leave during a single 12-month period to care for the service member. Spouses employed by the same employer are limited in the amount of family leave they may take for the birth and care of a newborn child, placement of a child for adoption or foster care, or to care for a parent who has a serious health condition to a combined total of 12 weeks (or 26 weeks if leave to care for a covered service member with a serious injury or illness is also used). Leave for birth and care, or placement for adoption or foster care, must conclude within 12 months of the birth or placement. Under some circumstances, employees may take FMLA leave intermittentlytaking leave in separate blocks of time for a single qualifying reasonor on a reduced leave schedulereducing the employees usual weekly or daily work schedule. When leave is needed for planned medical treatment, the employee must make a reasonable effort to schedule treatment so as not to unduly disrupt the employers operation. If FMLA leave is for birth and care, or placement for adoption or foster care, use of intermittent leave is subject to the employers approval. 596
2. any period of incapacity related to pregnancy or for prenatal care. A visit to the health care provider is not necessary for each absence; or 3. any period of incapacity or treatment for a chronic serious health condition which continues over an extended period of time, requires periodic visits (at least twice a year) to a health care provider, and may involve occasional episodes of incapacity. A visit to a health care provider is not necessary for each absence; or 4. a period of incapacity that is permanent or long-term due to a condition for which treatment may not be effective. Only supervision by a health care provider is required, rather than active treatment; or 597
Job Restoration
Upon return from FMLA leave, an employee must be restored to the employees original job, or to an equivalent job with equivalent pay, benefits, and other terms and conditions of employment. An employees use of FMLA leave cannot result in the loss of any employment benefit that the employee earned or was entitled to before using FMLA leave, nor be counted against the employee under a no fault attendance policy. If a bonus or other payment, however, is based on the achievement of a specified goal such as hours worked, products sold, or perfect attendance, and the employee has not met the goal due to FMLA leave, payment may be denied unless it is paid to an employee on equivalent leave status for a reason that does not qualify as FMLA leave. An employee has no greater right to restoration or to other benefits and conditions of employment than if the employee had been continuously employed.
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amniocentesis: A test performed between 15 and 20 weeks of pregnancy that can indicate chromosomal abnormalities such as Down syndrome, or genetic disorders such as Tay Sachs disease, sickle cell disease, cystic fibrosis, and others. It also can detect the babys sex and risk of spina bifida (a condition in which the brain or spine do not develop properly). amniotic fluid: Clear, slightly yellowish liquid that surrounds the unborn baby (fetus) during pregnancy. It is contained in the amniotic sac. amniotic sac: A sac is formed within the uterus that encloses the fetus. This sac bursts normally during the birthing process, releasing the amniotic fluid. A popular term for the amniotic sac with the amniotic fluid is the bag of waters. anemia: When the amount of red blood cells or hemoglobin (the substance in the blood that carries oxygen to organs) becomes reduced, causing fatigue that can be severe. birth center: A special place for women to give birth. They have all the required equipment for birthing, but are specially designed for a woman, her partner, and family. Birth centers may be free standing (separate from a hospital) or located within a hospital.
This glossary contains terms excerpted from glossaries and documents produced by the National Institute of Child Health and Human Development, Substance Abuse and Mental Health Services Administration, Office of Womens Health, and U.S. Food and Drug Administration.
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Chapter 76
Directory of Organizations That Provide Help and Information about Pregnancy and Birth
Government Agencies That Provide Information about Pregnancy
Agency for Healthcare Research and Quality Office of Communications and Knowledge Transfer 540 Gaither Road, Second Floor Rockville, MD 20850 Phone: 301-427-1364 Fax: 301-427-1873 Website: www.ahrq.gov Center for the Evaluation of Risks to Human Reproduction P.O. Box 12233 Research Triangle Park, NC 27709 Phone: 919-541-3455 Fax: 919-316-4511 Website: cerhr.niehs.nih.gov E-mail: shelby@niehs.nih.gov Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30333 Toll-Free: 800-CDC-INFO (232-4636) Phone: 404-639-3311 Website: www.cdc.gov E-mail: cdcinfo@cdc.gov Healthfinder National Health Information Center P.O. Box 1133 Washington, DC 20013-1133 Toll-Free: 800-336-4797 Phone: 301-565-4167 Fax: 301-984-4256 Website: www.healthfinder.gov E-mail: healthfinder@nhic.org
Resources in this chapter were compiled from several sources deemed reliable; all contact information was verified and updated in May 2009.
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National Advocates for Pregnant Women 15 West 36th Street Suite 901 New York, NY 10018-7910 Phone: 212-255-9252 Fax: 212-255-9253 Website: www.advocatesfor pregnantwomen.org E-mail: info @advocatesfor pregnantwomen.org National Association of Public Hospitals and Health Systems 1301 Pennsylvania Avenue, NW Suite 950 Washington, DC 20004 Phone: 202-585-0100 Fax: 202-585-0101 Website: www.naph.org E-mail: info@naph.org National Coalition on Health Care 1120 G Street, NW Suite 810 Washington, DC 20005 Phone: 202-638-7151 Website: www.nchc.org E-mail: info@nchc.org
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Index
Page numbers followed by n indicate a footnote. Page numbers in italics indicate a table or illustration.
A
A1C test, diabetes mellitus 297 AAFP see American Academy of Family Physicians abortion, overview 6066 see also medical abortion Abortion in the U.S.: Utilization, Financing and Access (Kaiser Family Foundation) 60n abruptio placentae see placental abruption abstinence (sexual activity), contraception 51 abuse, pregnancy 12124 Abuse During Pregnancy (University of Pittsburgh Medical Center) 121n ACAAI see American College of Allergy, Asthma, and Immunology Academy of General Dentistry, oral health, pregnancy publication 110n Accolate (zafirlukast) 286 Accutane (isotretinoin) 170 achondroplasia, screening test 143
active labor phase, described 52223 acute stress, described 21 A.D.A.M., Inc., publications pica 323n polyhydramnios 350n Potter syndrome 351n travel 218n work 218n adolescents, high risk pregnancy 26870 adoption, described 10 Advil (ibuprofen) 169 AeroBid (flunisolide) 286 AFP see alpha-fetoprotein Afrin (oxymetazoline) 287 afterbirth see placenta age factor abortion rates 6061 breast cancer 290 Down syndrome 144 fertility statistics 20 high risk pregnancy 26870, 27173 infertility 3536, 47 Agency for Healthcare Research and Quality (AHRQ) contact information 607 episiotomy publication 541n
619
620
Index
amniocentesis birth defects 357 versus chorionic villus sampling 150 defined 601 described 15354 amniotic fluid abnormalities 35052 defined 601 amniotic sac defined 601 labor 511, 51214 amniotomy, induced labor 516 analgesics labor and delivery 466 pain management 5046 anembryonic pregnancy 431 anemia defined 601 described 341 hypothyroidism 318 pregnancy 18890 screening test 146 sickle cell disease 31213 Anemia and Pregnancy (University of Pittsburgh Medical Center) 188n anencephaly described 249 screening test 144 anesthesia labor and delivery 46768 pain management 475, 504, 5067 anthrax, vaccine 165 antibiotic medications group B streptococcus 42627 mifepristone 59 oral contraceptives 53 pregnancy 170 antidepressant medications, pregnancy 12021 antihistamines, pregnancy 286 anti-inflammatory medications, pregnancy 28586 Apgar test, described 56869 ARBD see alcohol-related birth defects Are You Pregnant? Protect your baby from group B strep! (CDC) 425n ARND see alcohol-related neurodevelopmental disorder ART see assisted reproductive technology Asmanex (mometasone) 286 Aspirin (CERHR) 173n aspirin, pregnancy 16971, 17374 assisted reproductive technology (ART) described 3940 multiple pregnancy 274 see also gamete intrafallopian transfer; in vitro fertilization; zygote intrafallopian transfer Association of Maternal and Child Health Programs, contact information 612 Association of Womens Health, Obstetric and Neonatal Nurses, contact information 612 asthma pregnancy 28188 pregnancy complications 338 atropine 285 Atrovent (ipratropium) 285 autism spectrum disorders, described 361 Avoid Fetal Keepsake Images, Heartbeat Monitors (FDA) 243n Azmacort (triamcinolone) 286 AZT (zidovudine), pregnancy 172, 42122
B
baby blues versus depression 11617 postpartum care 562 BabyCenter LLC, sexual positions, conception publication 41n back pain, pregnancy 80, 8992 Back Pain During Pregnancy (American College of NurseMidwives) 89n bacterial vaginosis, statistics 410 bag of waters see amniotic sac Ball, Eddy 205n
621
622
Index
breastfeeding aspirin 174 asthma medications 288 bone health 99101 breast cancer 291 emergency delivery 55354 epilepsy medications 306 hepatitis B virus 417 maternal obesity 333 oral contraceptives 54 overview 57677 overweight children 330 postpartum care 56364 vaccinations 160 vaginal birth after cesarean 529 Breastfeeding: Frequently Asked Questions (Office of Womens Health) 576n breech delivery birth injuries 543 emergency delivery 55556 bronchodilator medications, pregnancy 285 budesonide 286, 287 Center for Health Care Strategies, Inc., contact information 615 Center for Research on Reproduction and Womens Health, contact information 612 Center for the Evaluation of Risks to Human Reproduction (CERHR) contact information 607 publications aspirin use 173n caffeine 191n drug abuse 235n Centers for Devices and Radiological Health (CDRH), x-rays publication 240n Centers for Disease Control and Prevention (CDC) contact information 607 immunization schedule website 160 publications group B streptococcus 425n hepatitis 414n international travel 221n sexually transmitted diseases 409n sickle cell disease 311n Centers for Medicare and Medicaid Services, contact information 615 cephalohematoma, described 544 Cephalopelvic Disproportion (American Pregnancy Association) 540n cephalopelvic disproportion (CPD) birth injuries 543 described 54041 cerebral palsy, preterm infants 45355 CERHR see Center for the Evaluation of Risks to Human Reproduction certification health care providers 474 certification, chiropractors 25253 certified midwife (CM), described 13639 certified nurse midwife (CNM) birth centers 475 birth plans 488 described 135 hospitals 474
C
Caffeine (CERHR) 191n caffeine use, pregnancy 19195 calcium, pregnancy 99101 Calculating Your Dates: Gestation, Conception and Due Date (American Pregnancy Association) 77n calendar method, fertility pattern 34 canthaxanthin 26061 caput succedaneum, described 54344 carpal tunnel syndrome defined 602 pregnancy 1035 castor oil, induced labor 518 CDC see Centers for Disease Control and Prevention CDRH see Centers for Devices and Radiological Health Center for Devices and Radiological Health, home ovulation tests publication 42n
623
624
Index
continuous abstinence, described 51 contraception breastfeeding 577 described 45 overview 5057 postpartum care 563 contraceptive sponge, described 51 52 contractions see uterine contractions contraction stress test, prenatal care 15556 Cooke, David A. 42n, 96n, 108n, 188n, 209n, 240n, 311n, 366n, 381n, 510n, 512n, 536n cord blood, overview 49396 Cord Blood Banking: Whats It All About? (American College of Nurse-Midwives) 493n corticosteroids nasal spray 287 pregnancy 28586 cosmetics, pregnancy 25961 counseling infertility 40 postpartum depression 11718 preconception health care 14 sickle cell disease 313 CPD see cephalopelvic disproportion CPM see certified professional midwife cramps, pregnancy 8283 cravings, pregnancy 184 cromolyn 28586 c-section see cesarean section CVS see chorionic villus sampling cystic fibrosis, screening test 143, 146 delavirdine 423 delivery see cesarean section; childbirth; labor and delivery; natural childbirth; vaginal delivery dental care, pregnancy 84, 11011 Department of Health and Human Services (DHHS; HHS) see US Department of Health and Human Services Depo-Provera, described 54 depression described 341 hyperemesis gravidarum 387 pregnancy 11419 pregnancy complications 338 see also perinatal depression; peripartum depression; postpartum depression developmental disabilities, birth defects 35864 dexamethasone 373 DHA (dihydroxyacetone) 25960 DHHS see US Department of Health and Human Services diabetes mellitus pregnancy 181 pregnancy complications 33839 pregnancy overview 295301 see also gestational diabetes mellitus diaphragm, described 5, 52 diastolic blood pressure, described 381 diet and nutrition bone health 101 eating guide 18084 folic acid 176 food pyramid 328 gestational diabetes mellitus 37879 hyperemesis gravidarum 388 preconception care 89 vegetarians 18587 weight management 205 dietary supplements bone health 99100 pregnancy 17273 sperm shape 2425
D
D and C see dilation and curettage date calculations overdue pregnancy 45657 pregnancy 7778 Deep Vein Thrombosis (NHLBI) 367n deep vein thrombosis, overview 36769 degenerative disorders, described 363
625
E
Early Head Start, contact information 615 early labor phase, described 52122 early onset X-linked adrenoleukodystrophy, described 363 eating disorders infertility 36 overview 32022 pregnancy complications 339 Eating Disorders and Pregnancy (American Pregnancy Association) 320n eclampsia defined 602 described 304, 382 overweight 32627 ectopic pregnancy coping strategies 44344 defined 602 described 341 overview 43031 Ectopic Pregnancy (University of Pittsburgh Medical Center) 430n efavirenz 423 eggs age factor 3536 assisted reproductive technology 3940 elective induction, described 516 embryo, defined 602 emergency contraception, described 56 emergency delivery, overview 54757 emotional concerns, pregnancy 11424 endometrial biopsy, infertility 38 endometriosis, infertility 36 enfuvirtide 423 Environmental Protection Agency (EPA), fish, mercury content publication 190n EPA see Environmental Protection Agency
626
Index
epidural defined 602 labor and delivery 467 pain management 5046 epilepsy overview 3036 pregnancy complications 339 episiotomy birth plans 48990 defined 602 overview 54142 postpartum care 56162, 564 Essure 5556 estriol birth defects 356 prenatal test 152 estrogen defined 602 oral contraceptives 53 estrone-3-glucuronide (E3G), described 42 exercise bed rest 34546 bone health 1012 gestational diabetes mellitus 37879 infertility 36 postpartum care 564 preconception care 9 pregnancy 197200 exercises back pain treatment 90, 9192 pelvic floor disorders 95 eye care, newborns 569 false negative test results, home pregnancy tests 75 false positive test results, home pregnancy tests 75 Family and Medical Leave Act (FMLA; 1993) defined 603 overview 59192, 59498 FASD see fetal alcohol spectrum disorders FDA see US Food and Drug Administration fecal incontinence postpartum care 562, 565 pregnancy 95 female condoms, described 52 fertility age factor 20, 271 caffeine use 19293 eating disorders 320 overview 3235 stress factor 2122 see also infertility fertility drugs, multiple pregnancy 274 fertility pattern, described 3335 fetal alcohol effects (FAE), described 23031 fetal alcohol spectrum disorders (FASD) defined 603 described 227 overview 23134 Fetal Alcohol Spectrum Disorders (NCBDDD) 230n fetal alcohol syndrome (FAS), overview 23031 fetal keepsake videos, pregnancy 24344 fetal monitoring, asthma 283 fetal problems, described 341 fetus, defined 603 financial considerations abortions 6263 carpal tunnel syndrome 103 home pregnancy tests 73 lupus 309 preterm infants 448 teen pregnancy 269
F
FACE see Freedom of Access to Clinic Entrances Act facial paralysis, described 544 Fact Sheet #28: The Family and Medical Leave Act of 1993 (US Department of Labor) 594n FAE see fetal alcohol effects fallopian tubes contraception 5556 ectopic pregnancy 43031 false labor, described 51011
627
G
gamete intrafallopian transfer (GIFT), described 39 GBS see group B streptococcus genetic counseling blighted ovum 43233 overview 1112 prenatal tests 145 genetic disorders birth defects 355 screening tests 14244 German measles see rubella gestational age, pregnancy 7778 gestational carrier, described 40 gestational diabetes mellitus defined 603 described 342 glucose screening tests 14950 high risk pregnancy 267 multiple pregnancy 27677 overview 37580 overweight 327 screening test 146 vision changes 109 gestational hypertension overview 38184 overweight 326 gestational trophoblastic tumor, described 29394 Gestational Trophoblastic Tumors (NCI) 293n gestational weight management, described 2057 GIFT see gamete intrafallopian transfer gingivitis, pregnancy 11011 Giving Birth In Place: A Guide to Emergency Preparedness for Childbirth (American College of Nurse-Midwives) 547n glaucoma, pregnancy 10910 glucagon, described 299 Glucophage (metformin) 170 glucose screening tests described 14950 gestational diabetes mellitus 37778
628
Index
gonorrhea, statistics 410 Graves disease, described 31617 group B streptococcus (GBS) defined 603 overview 42527 gum problems, pregnancy 84, 11011 Guttmacher Institute, contact information 613 gynecologists defined 604 described 134 hepatitis, pregnancy 41415 hepatitis A virus (HVA), vaccine 16465 Hepatitis B Foundation, hepatitis B publication 416n hepatitis B virus (HBV) described 414 overview 41617 screening test 146 statistics 410 vaccine 163, 570 heredity birth defects 355 deep vein thrombosis 368 epilepsy 3045 twins 274 herpes simplex virus, statistics 410 HHS see US Department of Health and Human Services Hib, birth defects 36061 high blood pressure see gestational hypertension; hypertension High Blood Pressure in Pregnancy (NHLBI) 381n highly active antiretroviral therapy (HAART), described 422 high risk pregnancy described 7172 midwives 13637 overview 26667 High-Risk Pregnancy (NICHD) 266n Hirtz, Deborah 454 HIV (human immunodeficiency virus) high risk pregnancy 267 overview 41924 pregnancy 172 pregnancy complications 339 screening test 146 statistics 410 teen pregnancy 269 HIV During Pregnancy, Labor and Delivery, and After Birth (AIDSinfo) 419n home births birth plans 48788 emergency delivery 54757 labor and delivery 464
H
HAART see highly active antiretroviral therapy hair care, pregnancy 25558 Hair Treatments and Pregnancy (OTIS) 255n hamster-egg penetrance test, infertility 38 HBV see hepatitis B virus hCG see human chorionic gonadotropin health care providers chiropractic 25455 labor and delivery 47475 overview 13439 preconception health care 1718 pregnancy 13738 prenatal tests 15758 Healthfinder, contact information 607 health insurance see insurance coverage Healthy Pregnancy: Before You Start Trying (Office of Womens Health) 8n heartbeat monitors, pregnancy 24344 heart block, described 308 heartburn, pregnancy 8586 hemorrhoids defined 603 postpartum care 562, 564 pregnancy 82
629
I
ibuprofen 169 ICSI see intracytoplasmic sperm injection identical twins, described 27475 Immunization Issues: Vaccines for Pregnant Women (National Network for Immunization Information) 159n immunizations preconception care 9 pregnancy 15966 immunotherapy, pregnancy 28788 Implanon 55
630
Index
implantable rod, contraception 55 incompetent cervix, described 43536 Incompetent Cervix: Weakened Cervix (American Pregnancy Association) 435n incontinence postpartum care 562 pregnancy 95 indigestion, pregnancy 8586 induced abortion see abortion induced labor, described 51518 Inducing Labor (Nemours Foundation) 515n infancy, described 571 Infant Formula (FDA) 578n Infant Health (NICHD) 571n infections mifepristone 5859 screening tests 14647 vaginal birth after cesarean 528 infertility defined 603 described 4 overview 3540, 4548 stress factor 2122 see also fertility Infertility: Frequently Asked Questions (Office of Womens Health) 45n influenza vaccine, pregnancy 16061, 28788 inheritance, birth defects 355 see also heredity inhibin, birth defects 356 inhibin-A, prenatal test 152 injections, contraception 54 Institute for Health Policy Solutions, contact information 615 Institute for Womens Policy Research contact information 613 maternity leave publication 588n insulin diabetes mellitus 301 gestational diabetes mellitus 37879 pregnancy 170 insurance coverage abortions 6263 lupus 309 intact dilation and extraction 62 Intal (cromolyn) 28586 International Childbirth Education Association, contact information 613 International Council on Infertility Information Dissemination, contact information 613 intracytoplasmic sperm injection (ICSI), sperm shape 2324 intrauterine devices (IUD), described 5, 55 in vitro fertilization (IVF) described 39 multiple pregnancy 274 sperm shape 2324 iodine, thyroid hormones 316 ipratropium 285 iron deficiency, pregnancy 18890 Isentress (raltegravir) 423 isotretinoin, pregnancy 170 itching cholestasis of pregnancy 37174 pregnancy 8687 IUD see intrauterine device; intrauterine devices IVF see in vitro fertilization
J
jaundice, described 57172 Robert Wood Johnson Foundation, contact information 616
K
Henry J. Kaiser Family Foundation, abortion publication 60n Kegel exercises pelvic floor disorders 95 pregnancy 200 ketone levels diabetes mellitus 299300 gestational diabetes mellitus 380 Kral, John G. 330n, 334 Kruger morphology, described 23
631
M
male condoms see condoms The Management of Sickle Cell Disease (CDC; NHLBI) 311n Managing Gestational Diabetes: A Patients Guide to a Healthy Pregnancy (NICHD) 202n maraviroc 423 March of Dimes Birth Defects Foundation contact information 613 publications multiple pregnancy 273n overweight 326n placental complications 391n umbilical cord a bnormalities 403n marijuana use, pregnancy 23738 mastitis, defined 604 maternal serum screening, described 152 maternity leave, overview 58898 Maternity Leave in the United States (Institute for Womens Policy Research) 588n meal plans, gestational diabetes mellitus 37879 Medicaid, abortions 62 medical abortion, described 5859 medications allergies 28687 asthma 28486 epilepsy 3036 hepatitis B virus 41617
632
Index
medications, continued HIV infection 42023 home pregnancy tests 75 hyperemesis gravidarum 388 infertility 3839 miscarriage 43739 pain management 46668 paternal exposure 27 postpartum depression 11819 preconception care 9 preconception health care 14, 16 pregnancy 16873 men baby bonding 58384 birth partners 48081, 524 fetal alcohol spectrum disorders 234 infertility 3637, 4647 preconception health care 17 pregnancy loss coping strategies 443 sperm shape 2325 toxin exposure 2529, 46 meningococcal conjugate vaccine (MCV4), pregnancy 164 meningococcal polysaccharide vaccine, pregnancy 164 menstrual cycle defined 604 described 34, 3233 gestational age 7778 pregnancy 70 mental retardation, described 36061 mercury, pregnancy 19091 metabolic disorders described 362 newborn screening 56970 metformin 170 methotrexate 61 methylprednisolone 286 midwives described 135 home births 464 natural childbirth 498 overview 13639 Midwives Alliance of North America, contact information 613 Mifeprex (mifepristone) 5859 Mifeprex (mifepristone) (FDA) 58n mifepristone defined 604 described 5859, 61 migraine headache pregnancy 109 pregnancy complications 339 mini-pill see oral contraceptives Mirena 55 miscarriage age factor 272 blighted ovum 432 coping strategies 44344 defined 604 described 342 hypothyroidism 318 incompetent cervix 43536 infertility 45 overview 43334 research 44142 seizures 305 tobacco use 226 Miscarriage (NICHD) 433n misoprostol described 58, 61, 604 miscarriage 43739 mitochondrial toxicity, described 423 MMR (measles, mumps, rubella) vaccine, pregnancy 15960, 16263 molar pregnancy, described 293 mometasone 286 monozygotic twins, described 27475 montelukast 286 morning-after pill 56, 5859 morning sickness, first trimester 125 Motherisk Program, contact information 614 mother to child transmission, HIV infection 424 Motrin (ibuprofen) 169 mucus penetrance test, infertility 37 multifactorial disorders, screening tests 144
633
N
naproxen 169 nasal problems, pregnancy 83 National Advocates for Pregnant Women, contact information 615 National Association of Public Hospitals and Health Systems, contact information 615 National Campaign to Prevent Teen and Unplanned Pregnancy adolescent pregnancy publication, 268n contact information 614 National Cancer Institute (NCI) contact information 608 publications breast cancer 290n gestational trophoblastic tumors 293n National Center for Complementary and Alternative Medicine (NCCAM), contact information 608 National Center on Birth Defects and Developmental Disabilities (NCBDDD), publications alcohol use 227n fetal alcohol spectrum disorders 230n folic acid 175n preconception care 13n National Coalition on Health Care, contact information 615
634
Index
National Institute of Mental Health (NIMH) antidepressants publication 120n contact information 609 National Institute of Neurological Disorders and Stroke (NINDS) contact information 609 epilepsy publication 303n National Institute on Alcohol Abuse and Alcoholism (NIAAA), alcohol use publication 227n National Institutes of Health (NIH) contact information 609 publications magnesium sulfate 453n misoprostol 437n obesity 328n National Library of Medicine (NLM), contact information 610 National Network for Immunization Information, vaccinations publication 159n National Rural Health Association, contact information 616 National Womens Health Information Center, contact information 609 natural childbirth birth centers 475 overview 497501 pain management 465 see also labor and delivery; vaginal delivery Natural Childbirth (Nemours Foundation) 497n natural family planning conception 10 contraception 51 NCBDDD see National Center on Birth Defects and Developmental Disabilities NCCAM see National Center for Complementary and Alternative Medicine NCI see National Cancer Institute Nemours Foundation contact information 614 publications bed rest 344n birthing centers 473n birth plans 485n bonding with baby 581n delivery recovery 561n inducing labor 515n natural childbirth 497n prenatal tests 141n Rh incompatibility 399n sexual activities 213n neonatal coagulopathy, described 306 neonatal death, coping strategies 44344 neonatal intensive care unit (NICU), preterm infants 447 neonatal lupus, described 308 Neo-Synephrine (oxymetazoline) 287 neural tube defects defined 604 described 359 folic acid 172 maternal body temperature 25051 prenatal tests 15253 screening tests 144 nevirapine 423 newborns, screening tests 56770 NHGRI see National Human Genome Research Institute NHLBI see National Heart, Lung, and Blood Institute NIAAA see National Institute on Alcohol Abuse and Alcoholism NIAMS see National Institute of Arthritis and Musculoskeletal and Skin Diseases NICHD see National Institute of Child Health and Human Development nicotine, pregnancy 171 NICU see neonatal intensive care unit NIDDK see National Institute of Diabetes and Digestive and Kidney Diseases
635
O
obesity pregnancy 32630 pregnancy complications 339 Obesity Before Pregnancy Linked to Childhood Weight Problems (NIH) 328n OB/GYN see gynecologists; obstetricians obstetricians birth plans 488 defined 604 described 134 hospitals 474 Office of Minority Health, contact information 609 Office of Womens Health, publications breastfeeding 576n carpal tunnel syndrome 103n conception attempts 32n contraception methods 50n depression 114n diet and nutrition 180n exercise 197n home pregnancy tests 72n infertility 45n
636
Index
ovulation method conception 10 fertility pattern 3435 ovulation predictor kits, described 4243 ovulation test kits described 38 overview 4243 oxymetazoline 287 oxytocin contraction stress test 155 defined 604 induced labor 457, 517 pelvic inflammatory disease (PID), infertility 36 pelvic organ prolapse, described 9495 percutaneous umbilical blood sampling (PUBS), prenatal care 15657 perinatal depression, defined 605 periodic limb movement disorder, pregnancy 21011 peripartum depression defined 605 described 115 pesticides, infertility 37 phenylephrine 287 phenylketonuria (PKU) described 362 pregnancy 181 phenylpropanolamine 287 phenytoin 170, 305 Phillips, Robert 24344 physical activity gestational diabetes mellitus 37879 pregnancy 197200 weight management 204 see also exercise physical changes, pregnancy 8089, 12527 physicians, prenatal care 134 pica described 184 overview 32324 Pica (A.D.A.M., Inc.) 323n PID see pelvic inflammatory disease the pill see oral contraceptives Pitocin (oxytocin) 155, 457, 517 pituitary gland follicle-stimulating hormone test 38 thyroid hormones 315 placenta childbirth 52526 defined 605 disorders overview 39198 emergency delivery 55253
P
pain management birth centers 476 birth plans 48990 labor and delivery 46468, 5038 midwives 137 Pap tests (Pap smears), prenatal testing 146 ParaGard 55 parental leave, overview 58898 paroxetine 170 partial-birth abortions see late-term abortions the patch see Ortho Evra Paternal Exposures and Pregnancy (OTIS) 25n paternal toxin exposure, infertility 46 Patient Fact Sheet: Sperm Shape (Morphology): Does It Affect Fertility? (American Society for Reproductive Medicine) 23n Patient Fact Sheet: Stress and Infertility (American Society for Reproductive Medicine) 21n Paxil (paroxetine) 170 PCOS see polycystic ovarian syndrome Pelvic Floor Disorders (NICHD) 94n pelvic floor disorders, pregnancy 9495
637
638
Index
Pregnancy and HBV: FAQ (Hepatitis B Foundation) 416n Pregnancy and Medicines: Frequently Asked Questions (Office of Womens Health) 168n Pregnancy and the Overweight Woman (March of Dimes Birth Defects Foundation) 326n Pregnancy and Thyroid Disease (NIDDK) 315n Pregnancy and Your Vision (Prevent Blindness America) 108n Pregnancy Basics (Office of Womens Health) 80n Pregnancy Complications (Office of Womens Health) 338n Pregnancy Discrimination Act (1978) 59091 pregnancy loss see abortion; ectopic pregnancy; miscarriage; stillbirth Pregnancy Loss: How to Cope (University of Pittsburgh Medical Center) 443n pregnancy tumors, gum problems 11011 Pregnancy Tests: Frequently Asked Questions (Office of Womens Health) 72n Pregnancy: What to Expect When Youre Past Your Due Date (AAFP) 456n Pregnant and Depressed? (Office of Womens Health) 114n premature birth see preterm birth premature labor see preterm labor premature rupture of membranes (PROM), described 450 prenatal care described 4, 71 health care providers 13435 screening tests overview 14158 see also preconception health care Prenatal Tests (Nemours Foundation) 141n prescription medications, pregnancy 170 preterm birth (premature birth) cerebral palsy 45355 defined 605 home uterine monitors 24546 multiple pregnancy 273, 27576 prevention 44853 preterm infants cerebral palsy 45355 special needs 574 preterm labor defined 605 described 343, 44647 high risk pregnancy 267 multiple pregnancy 277 prevention 44853 Preterm Labor and Birth (NICHD) 446n Prevent Blindness America, vision changes, pregnancy publication 108n Preventing Preterm Labor and Premature Birth (NICHD) 448n progesterone asthma 28283 defined 605 preterm labor 448 progestin defined 605 oral contraceptives 5355 prolactin, defined 606 PROM see premature rupture of membranes prostaglandin, induced labor 517 protease inhibitors, HIV infection 42223 Protection From Abuse order 123 proteinuria, preeclampsia 383 Prozac (fluoxetine) 170 pseudoephedrine 287 psychotherapy, hyperemesis gravidarum 389 PUBS see percutaneous umbilical blood sampling pudendal block, labor and delivery 467 Pulmicort (budesonide) 286 pulmonary embolism, described 36768
639
R
radiation exposure paternal exposure 2627 prenatal care 24042 raltegravir 423 recessive gene disorders, screening tests 13 Recovering From Delivery (Nemours Foundation) 561n Reproductive Health (NICHD) 3n reproductive health, overview 35 reproductive life plan, described 1617 Rescriptor (delavirdine) 423 Researcher Warns about Gestational Weight Gain (Ball) 205n Research on Miscarriage and Stillbirth (NICHD) 441n RESOLVE: The National Infertility Association, contact information 22, 614 respiratory distress syndrome, preterm infants 452 restless leg syndrome, pregnancy 21011 Retrovir (AZT) 42122 Rett syndrome, described 363 Rh factor defined 606 screening test 146 Rh incompatibility, overview 399401 Rhinocort (budesonide) 287 rhythm method, contraception 51 risk factors birth defects 35859 breast cancer 29092
S
safety considerations domestic abuse 12324 hot tubs 25051 hyperthermia 24849 infants 57274 natural childbirth 500 sexual activity 21316 salmeterol 285 Salsberry, Pamela 32930 saunas, pregnancy 24851 sciatica, described 92 second trimester see trimesters seizure disorders, pregnancy complications 339 see also epilepsy seizures, epilepsy 3036 Seizures and Epilepsy: Hope Through Research (NINDS) 303n Self-Tanners, Tanning Pills, Tanning Booths and Pregnancy (OTIS) 259n Selzentry (maraviroc) 423 semen, defined 606 semen analysis, described 56 sensory deprivation therapy, hyperemesis gravidarum 389 Serevent (salmeterol) 285 sertraline 170 sexual activity postpartum care 563, 56465 pregnancy 88, 21316
640
Index
sexually transmitted diseases (STD) infertility 47 newborns 569 preconception care 9 pregnancy 40912 pregnancy complications 33940 screening tests 146 teen pregnancy 269 sexual position, conception 41 Sexual Positions for Baby-Making (BabyCenter LLC) 41n shortness of breath, pregnancy 83 shots, contraception 54 Should I Have a Cesarean Section? (American College of Nurse-Midwives) 536n sickle cell disease overview 31113 screening test 143, 147 Sidelines National Support Network, contact information 614 SIDS sudden infant death syndrome Siega-Riz, Anna Maria 2056 Singulair (montelukast) 286 skin changes pregnancy 8687, 126 tanning booths 25962 skin patch, contraception 54 Sleep, Sex Differences, and Womens Health: National Sleep Disorders Research Plan (NHLBI) 209n sleep-disordered breathing, pregnancy 21011 sleep problems infants 572 overview 20911 pregnancy 8788, 127 spermicides, condoms 52 sperm shape fertility 2325 infertility 3637 spina bifida described 249, 360 screening test 144 spinal anesthesia, labor and delivery 46768 spinal block, pain management 506 Spong, Catherine Y. 246, 455 sponge see contraceptive sponge Stages of Childbirth: Stage 1 (American Pregnancy Association) 520n Stages of Childbirth: Stage 2 (American Pregnancy Association) 520n Stages of Childbirth: Stage 3 (American Pregnancy Association) 520n Stages of Pregnancy (Office of Womens Health) 125n State Childrens Health Insurance Program (SCHIP), contact information 616 statistics abortion 6064 age, fertility 20 birth defects 35455 carpal tunnel syndrome 103 Down syndrome 144 eating disorders 320 gestational hypertension 382 infertility 46 maternity leave 58889, 589 multiple pregnancy 27374 paternity leave 590 pelvic floor disorders 94 placental abruption 392 placenta previa 394 sexually transmitted diseases 410 teen pregnancies 26869 twin births 382 Staying Healthy and Safe (Office of Womens Health) 180n, 197n Staying Healthy on a Vegetarian Diet During Pregnancy (American College of Nurse-Midwives) 185n STD see sexually transmitted diseases STDs and Pregnancy (CDC) 409n stem cells, cord blood 49396 sterilization contraception 5556 described 5
641
T
talk therapy, postpartum depression 118 tanning booths, pregnancy 25962 Tay-Sachs disease, screening test 143 Td see diphtheria toxoid vaccine Tdap see tetanus diphtheria pertussis vaccine Teen Pregnancy and Other Health Issues (National Campaign to Prevent Teen and Unplanned Pregnancy) 268n teeth problems, pregnancy 84, 11011 temperature see body temperature teratogens, birth defects 355 tests cholestasis of pregnancy 372 diabetes mellitus 29799 Down syndrome 272 ectopic pregnancy 43031 gestational diabetes mellitus 37678 gestational trophoblastic tumor 29394 group B streptococcus 42526 HIV infection 41920 infertility 3738 multiple pregnancy 277 neural tube defects 250 newborns 56770 oligohydramnios 352 ovulation prediction 4243 pica 32324 pregnancy 7076 prenatal care 14158 sickle cell disease 312 tetanus diphtheria pertussis vaccine, pregnancy 161 tetanus vaccine, pregnancy 16061 thalassemia, screening test 143 thalidomide 170
642
Index
theophylline 285 therapeutic abortion, hyperemesis gravidarum 389 thiamine 387 third trimester see trimesters thyroid gland described 362 postpartum depression 115 pregnancy 31518 pregnancy complications 340 thyroid-stimulating hormone (TSH), described 31516 thyroid-stimulating immunoglobulin, described 316 tobacco use infertility 3637, 4647 paternal exposure 26 preconception health care 14, 16 pregnancy 226 sperm production 24 toxoplasmosis, defined 606 transition phase, described 520, 523 travel considerations infants 573 pregnancy 21923 triamcinolone 286 trichomoniasis, statistics 410 triggers, asthma 28384 trimesters defined 606 described 81 multiple pregnancy 277 overview 12530 weight management 204 trimethadione 305 triple screen, described 15253 true labor, described 51011 True Labor or False Labor (University of Pittsburgh Medical Center) 510n Trying to Conceive (Office of Womens Health) 32n TSH see thyroid-stimulating hormone tubal pregnancy see ectopic pregnancy twins overview 27379 statistics 382 twin-twin transfusion syndrome, described 276 typhoid fever vaccine, pregnancy 163
U
ultrasound birth defects 357 body temperature 251 defined 606 gestational diabetes mellitus 378 keepsake images 24344 multiple pregnancy 277 placental abruption 392 placenta previa 395 screening test 14749 umbilical cord blood banking 49396 defined 606 described 4034 emergency delivery 55152 Umbilical Cord Abnormalities (March of Dimes Birth Defects Foundation) 403n umbilical cord cyst, described 4067 umbilical cord knots, described 406 umbilical cord prolapse, described 4045 Understanding Hyperemesis (Hyperemesis Education and Research Foundation) 385n University of Pittsburgh Medical Center, publications abuse 121n age 35, pregnancy 271n anemia 188n bleeding, early pregnancy 366n ectopic pregnancy 430n labor 510n pregnancy loss 443n unprotected sexual activity, emergency contraception 56 Urban Institute, contact information 616
643
V
vagina, defined 606 Vaginal Birth after a Previous Cesarean Delivery or Repeat Cesarean Delivery (Childbirth Connection) 526n vaginal bleeding, early pregnancy 366 vaginal delivery HIV infection 42324 multiple pregnancy 278 overview 52026 see also Cesarean section; childbirth; labor and delivery
W
water births, described 46566 water breaks see amniotic sac water on the brain see hydrocephalus Webster, Larry 254 weight gain, pregnancy 88 weight-loss surgery, pregnancy 33034
644
Index
weight management chart 203 multiple pregnancy 278 postpartum care 562 pregnancy 2025 Wernicke encephalopathy 387 What I Need to Know about Gestational Diabetes (NIDDK) 375n What Is a Midwife? (American College of Nurse-Midwives) 136n What Is Rh Incompatibility? (Nemours Foundation) 399n What You Need To Know About Episiotomy (AHRQ) 541n What You Need to Know about Mercury in Fish and Shellfish (EPA) 190n When Does the Bag of Waters Break? (American College of Nurse-Midwives) 512n When Pregnancy Is Complicated by Allergies and Asthma (ACAAI) 281n When You Are Pregnant Drinking Can Hurt Your Baby (NIAAA) 227n Women, Infants, and Children, contact information 616 workplace maternity leave overview 58898 paternal toxins exposure 27 pregnancy 21819
X
x-linked disorders, screening tests 143 X-Rays, Pregnancy, and You (CDRH) 240n x-rays, prenatal care 24042
Y
yellow fever vaccine, pregnancy 163 Your Babys First Hours of Life (Office of Womens Health) 567n
Z
zafirlukast 286 Zerhouni, Elias A. 453 Zhang, Jun 43739 zidovudine 172, 42122 ZIFT see zygote intrafallopian transfer zileuton 286 Zofran (ondansetron) 170 Zoloft (sertraline) 170 Zyflo (zileuton) 286 zygote intrafallopian transfer (ZIFT), described 39 Zyrtec (cetirizine) 287
645