STARTING OUT RIGHT BE SWADDLED This guide will help you through your pregnancy, labor, birth and any questions you may have about your new bundle of joy! Important phone numbers: Clinic phone number: Baby doctor’s (pediatric) phone number: Pharmacy phone number: Sign up for our weekly pregnancy and parenting e-mail Our e-newsletter offers trusted advice and support from health care professionals tailored to where you are in your pregnancy/new baby journey. Three easy ways to register: > Visit healtheast.org/baby > Text HEMN to 617-580-3050 > or scan the QR code WELCOME! You’re going to have a baby! “What now?” you may be thinking. This book may help by providing you with information about your pregnancy, labor, birth and the early days at home with your newborn. You and your baby are being cared for by a health care team. In addition to your doctor or midwife, prenatal educators, dietitians, social workers, outreach nurses and home care nurses are available to help care for you during your pregnancy. If complications or risk factors occur during your pregnancy, you and your health care team will work together to determine what special needs you have and how those needs can best be met. Education is very important, and we strongly encourage you to begin preparing early in your pregnancy. In addition to reading this book, you may want to keep a list of questions as they occur to discuss with your provider. Ask your provider about early pregnancy classes at your clinic. It is important to prepare for birth, breast-feeding and infant care by attending classes. Register for classes as soon as possible—spaces fill quickly. Visit our HealthEast website at healtheast.org for prenatal class options. If you have any questions or concerns during your pregnancy or in the weeks after birth, call your doctor or midwife. This book was developed in cooperation with: HealthEast® Clinics, Metropolitan OB-GYN, Partners OB-GYN, HealthEast® Maternity Care, East Metro Family Practice, Entira Family Clinics, North Suburban Family Physicians Clinics and HealthEast® Home Care. To the many others who contributed to this book—thank you! HealthEast Care System supports the initiatives of the World Health Organization, Unicef and Baby Friendly USA. All areas of our facilities will promote, protect and support breast-feeding as a healthier choice for women and infants. Our facilities do not receive free infant formula or feeding equipment, free gifts, materials, money or support from manufacturers of breastmilk substitutes. We do not provide samples, marketing materials, or coupons for these items to our patients. For additional information, visit babyfriendlyusa.org © 2017, HealthEast® Care System St. John’s Hospital Maternity Care Center 651-232-7550 Social Service 651-232-7356 Outreach Nurse 651-232-7560 Tours 651-232-7550 Woodwinds Health Campus Maternity Care Center 651-232-0022 Social Service 651-232-0337 Outreach Nurse 651-232-0778 Tours 651-232-0228 Other Resources United Way 2-1-1 (formerly First Call for Help) A comprehensive, multilingual resource for help. Hearing impaired, please access through the Minnesota Relay Service WIC Minnesota 1-800-657-3942 HealthEast Resources Ramsey County 651-266-1300 Outpatient Lactation Clinic 651-232-3147 Washington County 651-430-6658 Dakota County 952-891-7525 Perinatal Home Care 651-232-2895 TABLE OF CONTENTS Table of contents.................................................................1 Labor and birth..................................................................74 Off to a good start............................................................. 2 After birth........................................................................... 78 Physiology of pregnancy.................................................3 Infant security in the hospital.......................................80 Changes in the first eight weeks of pregnancy........4 Minnesota newborn screening program..................80 Growth and development............................................... 6 Your baby’s birth certificate.........................................83 Lifestyle changes............................................................... 9 Mother’s physical changes and adjustments.........84 Weight gain........................................................................ 13 Postpartum depression: Things you should know...............................................89 Drugs and medications.................................................. 14 Domestic violence............................................................ 17 Body mechanics..............................................................20 Exercise..............................................................................22 Body conditioning...........................................................23 The expectant partner...................................................25 Common discomforts of pregnancy..........................28 Strengthening exercises and stretches for low back pain..............................................................31 Warning signs during pregnancy................................36 Miscarriage........................................................................ 37 Your health insurance coverage.................................39 Gestational diabetes follow-up...................................92 Diet and postpartum exercise.....................................93 Your newborn...................................................................95 Baby states........................................................................ 97 General baby care......................................................... 105 Your relationship as a couple.................................... 122 Breast-feeding: What to expect during the first month....................................................124 Resources/Reference materials................................ 132 Birth plan...........................................................................137 Birth control options after delivery.......................... 139 Your prenatal care............................................................ 41 1 OFF TO A GOOD START Be a partner in your care You are beginning a professional relationship with your provider, their clinic staff and the staff at the hospital you have selected for birth. We have responsibilities for your care and safety. We will use proven safe and effective treatments for your care; our staff will be competent in their assigned roles and we will promote safe use of medications, supplies and equipment. If you have questions or concerns, you must speak up. If there is something you don’t understand – ask. It’s your body and you have a right to know. Participate in decisions about your care and treatment. Educate yourself about your condition, diagnosis and your treatment plan. Don’t assume anything, pay attention and ask questions. You are the center of the health care team. 2 PHYSIOLOGY OF PREGNANCY To help you understand the many changes that occur within your body throughout pregnancy, it is important to understand the pregnancy process. Hormonal changes during pregnancy As your baby grows and develops, many changes will occur in your body. You may also experience emotional adjustments that affect you and your partner. Many of the changes that occur are caused by changes in hormone production. Some of these changes are the result of the hormones listed below. Human Chorionic Gonadotropin (hCG) This important hormone is produced by the developing placenta. HCG assures that your ovaries produce progesterone and estrogen until your placenta matures and takes over production of this hormone (approximately 3 to 4 months). Progesterone This hormone helps relax the uterus (womb) to keep it from contracting excessively. It also relaxes the walls of blood vessels which help in maintaining a healthy blood pressure. Progesterone stimulates secretion of an ovarian hormone called “relaxin” which softens ligaments, cartilage and the cervix, helping them stretch during birth. Estrogen Estrogen promotes growth of the uterine lining and blood supply. It increases the production of vaginal mucus and helps in the development of the breast duct system and breast blood supply. Estrogen may influence water retention and skin pigmentation. 3 CHANGES IN THE FIRST EIGHT WEEKS OF PREGNANCY This is a very important time for your baby. This period is often called the “developmental period,” because after the first 12 weeks, all fetal organ systems are formed and functioning. For you and your partner this is a time of physical and emotional adjustment to being pregnant. During this period some important changes will take place. Conception The union of the egg and sperm give the fertilized ovum a full set of 46 chromosomes (23 from the mother and 23 from the father). These chromosomes combine to become the blueprint for the development of your child. Your child’s physical appearance, blood type, some personality and mental traits, sex, body type and more have already been determined. After fertilization, the ovum quickly changes from one cell to many. By the end of two days this cluster of cells is called a “morula.” By the end of the first week it implants itself in the upper part of the uterus and is now called a “blastocyst.” The blastocyst develops root-like projections (chorionic villi) that grow into the uterine lining and receive nourishment from it. 4 Pregnancy During the early weeks of pregnancy, the uterine lining (endometrium) thickens and more blood flows to the area. This provides a rich source of nourishment for the developing blastocyst. At the end of the first month, the chorionic villi becomes a primitive placenta. Fetal blood circulates through this placenta while your blood circulates around the villi. A thin membrane separates the two blood streams and normally they do not mix. As the cells specialize, the fetus, placenta, amniotic sac and fluid are formed. The amniotic sac surrounds the blastocyst; which later also protects the developing fetus. During the next few weeks development continues rapidly. The blastocyst is now called an “embryo.” A primitive nervous system with the brain and spinal column begins to form. Although the embryo is very small (about the size of a pea), the head, with eyes, ears and a mouth is beginning to form. A simple liver, digestive tract, umbilical cord and kidneys develop. The circulatory system develops, and by the end of day 25 the heart is beating. By day 28, arm and leg buds appear. The sex of your baby is determined at conception, and during the seventh week, your baby’s sex organs begin to develop. By the eighth week the embryo is complete. During this period, you may feel tired and require more sleep. You may also experience some nausea and vomiting, which is thought to be caused by hCG (human chorionic gonadotropin), a hormone produced by the placenta. As the levels of estrogen, progesterone and other hormones increase during pregnancy, the breasts change in preparation for providing milk for the baby. 5 GROWTH AND DEVELOPMENT First trimester 1 to 4 weeks Baby’s development 6 5 to 8 weeks 9 to 13 weeks 1/4 inch long. Fertilized egg implants in uterine lining. Heart, brain, spinal cord and digestive tract begin to form. One inch long and weighs 1/30 ounce. Heart pumps blood. Buds for arms and legs appear. Eyes, ears and face begin to shape. Normal maternal changes Nausea, fatigue, breast tenderness. Digestive system slows. Sexual interest may decrease. Same as weeks one through four plus frequent urination. Same as previous weeks plus headaches, increased blood volume and nasal congestion. Comfort tips Small, frequent meals. Avoid spicy and greasy foods. Take time for regular exercise. Wear a supportive bra. Same as weeks one to four plus urinate as often as needed. Same as weeks one to eight plus take time for extra rest. Change positions slowly and eat small snacks. All internal organs are present in various stages. Three inches long and weighs one ounce. Sex characteristics defined. Blood cells and bones form. First movements occur. Organs begin to function. Early breathing and sucking. Buds for teeth, fingernails and toenails. May hear heartbeat with doptone (amplified stethoscope). Second trimester 14 to 18 weeks 19 to 23 weeks 24 to 27 weeks Baby’s development Seven inches long and weighs four ounces. Mature muscles and bones. Some nerve control. Kicking. Pinkish, transparent skin. Kidneys produce urine. Sex organs recognizable. 10 to 12 inches long and weighs 1/2 to 1 lb. Fine hair, eyebrows and eyelashes. Swallows amniotic fluid. Can suck thumb. Glands in skin secrete vernix (protective coating for skin). 11 to 14 inches long and weighs 1-1/2 lb. Eyelids open and close. Grasping. Skin looks wrinkled and red. Skin covered with vernix. Footprints and fingerprints appear. Normal maternal changes Your pregnancy begins to “show.” You will experience increased vaginal discharge. Heart pounding may occur. Sexual interest increased. You will feel fetal movement. You can express colostrum from your nipples. You may feel faint or dizzy. Varicose veins may appear. Skin changes: Darkened nipples, reddened palms. You may experience nosebleeds and your skin may itch. Your gums swell and bleeding may occur. Comfort tips Tub bath in warm water. Cotton underpants. Relaxation techniques and slow breathing. Rest with feet up. Change positions slowly with support. Avoid long periods of standing or sitting upright. Wear support hose. No knee high socks. Place a pillow between your legs when sleeping. Use a humidifier. Apply moisturizer to skin. Maintain good dental hygiene. 7 Third trimester 28 to 31 weeks 8 32 to 36 weeks 37 to 40 weeks Baby’s development 14 to 16 inches long and weighs 2 to 3 lbs. Developing lung maturity. Breathing movements. Will settle into pelvis, head down. Fat begins to form under skin. May hiccup. 16 to 18 inches long and weighs 5 to 6 lbs. Skin wrinkles disappear. Fat thicker under skin. Gain 1/4 to 1/2 lb. per week. 18 to 22 inches long and weighs 7 to 9 lbs. Received transfer of mom’s antibodies against measles, mumps, rubella. Downy hair disappears. Normal maternal changes You may experience muscle cramps. Heartburn may become troublesome as there is a delay in the time it takes to empty the stomach. You may fatigue easily. Pressure on nerves may become apparent. You will experience an increase in breast size and colostrum. Stretch marks on abdomen, breast and thighs may appear. Swelling, constipation and hemorrhoids are common. You may experience shortness of breath. The baby moves lower into the pelvis. Backaches and frequent urination are common. You may experience periods of insomnia and unusual dreams. Comfort tips Change your position often. Rest with your head and legs elevated. Point your toes toward your knees for leg cramps. Eat small, frequent meals and avoid high fat meals. You may use an antacid such as Tums® for heartburn. Rest on left side using two pillows. Increase your protein, fluid and fiber intake. Wear support hose and loose clothing. Exercise. May use a fiber additive for constipation. A warm tub bath is relaxing. Use relaxation techniques. Wear low-heeled shoes. Good posture and doing the “pelvic tilt” can help you feel more comfortable. Alternate lovemaking positions. Warm bath or heating pad can be relaxing and comforting. LIFESTYLE CHANGES You are able to control the environment in which your baby develops. Your lifestyle, the foods you eat, smoking, drinking or any medication you take will make a difference in your health and your baby’s - now and in the future. The following suggestions can help you to create a healthy environment for your baby. Nutrition Your eating habits before and during pregnancy affect your baby’s health. During pregnancy the food you eat supplies all the nutrients for you and your developing baby. Your food choices will make a difference in your baby’s health. The following guidelines will help you to make smart food choices. It is important to include a variety of foods to supply nutrients and to make eating enjoyable. Resources: choosemyplate.gov Academy of Nutrition and Dietetics - eatright.org Food group Daily servings Milk and milk products (calcium rich foods) Adult four to five Protein sources Adult six to seven ounces Teen Teen Fruits and vegetables five to six seven to eight ounces Sources Cheese, custard, milk, pudding, yogurt, ice cream, fortified orange juice Fish, legumes (dried beans, peas, etc.), lean meat, lentils, nuts, peanut butter, poultry, seeds, whole grains, cereal, eggs and tofu Five or more with one high in folate Avocado, green leafy vegetables (chard, parsley, romaine lettuce, spinach) kidney One to two high in vitamin C beans, legumes (dried beans, peas, etc.), lima One high in vitamin A beans, lentils, melons, oranges, peas, squash, cauliflower, wheat germ, nuts and seeds 9 Food group Fruits and vegetables Daily servings Sources Five or more with one high in folate Citrus fruits (grapefruit, kiwi, oranges, papaya) berries, melons, tomatoes, chili peppers, One to two high in vitamin C green vegetables (broccoli, Brussels sprouts, One high in vitamin A kohlrabi), potatoes with skin Green and yellow vegetables (broccoli, acorn squash), apricots, tomatoes, carrots, sweet potatoes (vitamin A is also found in milk and egg yolks) Carbohydrates 2 to 8 ounces Bread and bread products, bulgar cereals, pancakes, pasta, rice Beverages 6 to 8 glasses of water Limit caffeine containing beverages to 2 cups per day; no alcohol (8 to 12 cups total fluid) Sugar substitutes Moderation Aspartame appears safe for use in pregnancy but use in moderation; avoid saccharin Special circumstances Good nutrition in pregnancy is always important, but in some circumstances you need to be even more conscientious about your diet. It may be helpful to have nutrition counseling with a registered dietitian in the following circumstances: Multiple pregnancy – If you are carrying two or more babies, you will require 300 extra calories per baby per day. Adolescent pregnancies – Teenagers are still growing and have greater requirements for most nutrients. It is necessary to eat particularly well when pregnant to maintain your own growth while nourishing your baby. Pregnancies close together – A pregnancy may deplete reserves of nutrients such as calcium and iron. If there is sufficient time between pregnancies those reserves are replenished. Pregnancies close together may require extra calories and nutrients. The length of time needed between pregnancies to correct deficiencies depends on your overall nutritional status and diet. 10 Vegetarian diet If you are a vegetarian, you can still follow a nutritious, well-balanced diet during pregnancy, especially if you include milk and eggs in your diet. Your major concerns are the need to take in sufficient calories and the possible need to supplement vitamin B12, most often found in animal meats. If you choose a vegetarian diet during pregnancy, you may want to consult a registered dietitian. Call 651-232-7101 at St. John’s Hospital or 651-232-0647 at Woodwinds Health Campus. Vitamin D If you do not drink milk or get adequate sun exposure, consult your provider to be sure you are getting sufficient amounts of vitamin D. Safe food handling during pregnancy Occasionally, the food we eat can make us sick. Precautions like hand washing, keeping surfaces clean, not allowing cross contamination between cooked and uncooked foods, cooking foods to proper temperatures and refrigerating foods promptly, are very important. Food contaminated by harmful bacteria can cause serious illness. Lysteria monocytogenes is one type of bacteria that can cause an illness called listeriosis. Listeriosis can be especially harmful to pregnant women and their unborn babies. The symptoms of listeriosis may take several days or weeks to appear. Listeriosis may cause flu-like symptoms like fever, chills, muscle aches and sometimes diarrhea or stomach upset. The severity of symptoms varies. Consult your provider if you have these symptoms. Listeriosis is diagnosed with a blood test. Treatment includes the use of antibiotics. Antibiotics are also given to babies who are born with listeriosis. It is especially important to take food safety precautions during pregnancy. By carefully following food safety precautions, people at risk for listeriosis can greatly reduce their likelihood of becoming ill. The USDA’s Food Safety and Inspection Service and the US Food and Drug Administration offer the following advice: • Do not eat hot dogs, lunch meats or deli meats unless they are reheated until steaming hot. • Do not eat soft cheese like feta, brie, camembert, blue-veined cheeses and Mexican style cheeses unless they are pasteurized. • Do not eat refrigerated pâté or meat spreads. • Do not eat refrigerated smoked seafood unless it is an ingredient in a cooked dish. For more information visit the CDC web site at cdc.gov/foodsafety. 11 Sample daily menu during pregnancy Breakfast One slice of toast with margarine Dinner 3/4 cup cereal with sliced banana 1/2 cup potatoes with margarine, sour cream or yogurt Two eggs 3 ounces of fish 4 ounces of citrus fruit or juice Spinach salad (reduced calorie dressing or oil and vinegar dressing) 8 ounces of milk or water Melon slices Lunch 8 ounces of milk One whole wheat roll with margarine Chef’s salad (2 to 3 ounces meat, 1 to 2 ounces cheese, carrot, tomato, lettuce, reduced calorie or regular dressing) 8 ounces of milk Snack Options (one to two per day): milk shake, bran muffin, apple or celery with peanut butter, carrot sticks, water and juice, cheese and crackers Oatmeal raisin cookie Water Remember to drink water throughout the day. Salt and fluids An adequate intake of salt during pregnancy is important to maintain a sufficient fluid balance. Extra fluid or liquids are necessary during pregnancy to support the increased blood volume and amniotic fluid around the baby. Fluids assist food digestion and absorption of nutrients as well as helping to regulate your body temperature. Drink 8 to 12 glasses of liquid daily (water, milk, fruit juices, non-caffeinated). Do not drink less if you are retaining fluid. Reducing your intake of salt is not necessary unless you are a heavy salt user. Folic acid Folic acid is a B vitamin found mainly in green leafy vegetables, beans, asparagus, citrus fruits, juices and whole grain foods. Taking folic acid is especially important in the three months just before conception and in the early weeks of pregnancy. Folic acid helps to protect your unborn baby from birth defects of the spine and brain, such as spina bifida or “open spine.” The U.S. Public Health Service urges you to consume 0.4 milligrams of folic acid every day but no more than 1 milligram unless instructed by your provider. 12 WEIGHT GAIN One of the best ways to protect your baby’s health is to gain a healthy amount of weight during your pregnancy. “How much weight should I gain?” is a question most mothers ask. How much weight you need to gain depends on whether you are underweight, average weight or overweight before becoming pregnant. There is no single correct answer, but there are guidelines. Approximate weight gain distribution Baby Placenta 7 to 8 lbs. 1 lb. Uterus 2 lbs. Amniotic fluid 2 lbs. Breasts 1 to 2 lbs. Blood volume 3 to 5 lbs. Fat 5 to 7 lbs. Tissue fluid 4 to 6 lbs. TOTAL 2011 March of Dimes guidelines state if your pre-pregnancy weight was: Below average, you should gain more weight (approximately 28 to 40 lbs.) than women who are of average weight. Average weight, you should gain 25 to 35 lbs. For overweight women, with a BMI of 30 or greater, you may gain less weight (approximately 11 to 20 lbs.) and benefit yourself and baby by eating high quality foods. 25 to 33 lbs. Helpful hints When you listen to your hunger cues and eat sensibly, you can trust that the amount of weight you gain is right for you. Don’t diet! Pregnancy is not the time to lose weight. On average, your body needs 200 to 300 additional calories per day to support your growing baby. Low calorie diets simply cannot meet the needs of your body and your growing baby. If there are not enough nutrients for both you and your baby, the nutrients will go to maintain your body first. In the last six months, your baby really begins to grow. For the remainder of your pregnancy, you may gain as much as 1 pound per week. A sudden weight gain during pregnancy can be a sign of high blood pressure. If you gain more than 6 pounds in one week, contact your provider. 13 DRUGS AND MEDICATIONS Smoking: make a plan to quit now! The American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American Lung Association all warn that smoking may complicate pregnancy. Tobacco smoking has been widely studied and the evidence is clear: smoking is harmful to mothers and babies! Smoking during pregnancy can cause: • Increased risk of miscarriage and preterm labor. • Smaller birth weight babies who may have more difficulties eating and keeping warm. • Chronic respiratory problems and ear infections for your baby. • Passive smoking or second-hand smoking (breathing in other people’s smoke) can be harmful to you and potentially harmful to your unborn baby. • The incidence of respiratory illness is higher in children from households where adults smoke. • If anyone around you smokes, ask them to go outside to smoke both during pregnancy and after the baby is born. Liquor (alcohol) and pregnancy don’t mix The Surgeon General of the United States has recommended that pregnant women do not drink any alcohol. If you had an occasional drink – perhaps before you knew you were pregnant – talk with your provider. Here are some facts about alcohol use and its effects: • Alcohol quickly crosses the placenta and enters the baby’s blood in the same concentration as yours. • Babies born to mothers who use alcohol are at risk for suffering from Fetal Alcohol Syndrome (FAS) or Fetal Alcohol Effect (FAE) - disabilities that include mental and physical retardation, tremors and peculiar facial characteristics. FAS and FAE are the only birth defects that are totally preventable. • No one has been able to determine a “safe” dose of liquor. • Beer and wine are not less harmful than hard liquor. • In any situation where you might drink alcohol, substitute fruit juice or mineral water. • If you think you have a problem with drinking, call Alcoholics Anonymous, 651-227-5502 or speak to your health care provider. 14 Caffeine Coffee, tea, colas and other soft drinks (read the label), chocolate and some over-the-counter drugs contain caffeine. Significant caffeine use by pregnant women may be associated with miscarriages in the late first and second trimesters and low birth weight in term infants. The Journal of Obstetrics and Gynecology in an article from July 2010, as well as the March of Dimes, recommend limiting your intake of caffeine to less than 200 milligrams a day. This is the amount of caffeine found in 2 to 8 ounces of brewed coffee or 25 ounces of tea. Remember to include caffeine from all sources in your daily intake. Cocaine, “crack,” amphetamines (speed, ice, crank) and other street drugs NEVER take any street drugs! Most street drugs can seriously harm your baby during pregnancy and have lasting effects. It is important to have an honest conversation with your health care provider about what drugs or medications you use or have used in the past. Drug use throughout pregnancy is associated with miscarriage, low birth weight, placental abruption (separation of the placenta from the uterine wall,) premature birth, birth defects and an increased risk of stillbirth. Your baby may even be born addicted to drugs. Use of any form of cocaine, including crack, during pregnancy decreases the food and oxygen supply to the baby. A lack of oxygen and nutrients can affect the growth or even result in the death of the baby. Newborns who are exposed to drugs during pregnancy are often jittery and irritable, cry at the slightest noise or gentlest touch, appear withdrawn or unresponsive and become difficult to console. Later in life, these children may be permanently impaired: physically, behaviorally and emotionally. Discuss this with your provider and/or contact the Narcotics Anonymous Referral Line at 952-939-3939. You may visit the web site drugabuse.gov for more information. 15 Medications Always check with your provider before using any medication. During pregnancy, over-thecounter medications such as pain relievers, antihistamines and cough suppressants may be safe. Some medications are considered “safe” to take during pregnancy; others can have minor effects and a few may cause serious birth defects. Nutritional supplements, herbs and dietary aids are considered medications. It is important to discuss the use of medications, herbs and supplements with your health care provider before you use them while pregnant or breast-feeding. Your provider will know which prescribed and over-the-counter medications are safe to use during pregnancy. It is preferable to not use medication in the first trimester unless medically necessary. The following medications are considered acceptable for use during pregnancy. This list is not complete, just a guide. Your provider may know of other medications that are safe. Acceptable medications Acetaminophen (such as Tylenol®) - may be used throughout pregnancy; pain reliever. Guaifenesin (such as Robitussin® plain, not DM) - not advised if you have diabetes, including gestational diabetes; expectorant. Diphenhydramine (such as Benadryl®) antihistamine; allergy relief. Chlor-Trimeton® – seasonal allergy relief. Miconazole (such as Monistat® 7, Micatin®) - vaginal creams for treatment of yeast infections. Contact your health care provider for accurate diagnosis before treating. Hydrocortisone cream – minor skin irritations, itching; topical steroid. Maalox®, Mylanta®, Tums®, Riopan – heartburn, indigestion; antacid. Metamucil®, Fibercon®, Citrucel® – fiber laxative, promotes regularity. Anusol®, Anusol HC®, Preparation H® - for temporary relief of pain and itching associated with hemorrhoids. Antibiotics: (penicillin, cephalosporins, erythromycin and others) – to treat bacterial infections. 16 DOMESTIC VIOLENCE The problem of domestic violence is widespread. It happens in families of all races, social, economic and religious backgrounds. Abuse can be emotional or sexual as well as physical or verbal. Abusive behavior includes being verbally harassed, pushed or slapped, being punched, stabbed or having your life threatened. Controlling the amount of time a woman spends with her friends or family and the activities she engages in can also be abuse, as can controlling the amount of money she has to spend. Abuse often occurs (or can escalate) during pregnancy. One study found that 37 percent of pregnant women, regardless of race or other factors, were physically abused during pregnancy. Women often remain in abusive relationships because they are financially or emotionally dependent on their abuser. Sometimes religious or family values keep women with their abuser; other times women feel powerless to change their situation or are simply too frightened to leave. If you are being abused, you have choices. These include: • Stay in the relationship. • File a police report. • Obtain an “Order For Protection” - a temporary restraining order that gives you legal protection from your abuser. (See “Order For Protection” below.) • Attend support groups with people who are in similar situations. • Seek temporary safety with friends, relatives or in a safe home/shelter. • Talk to your provider about your concerns. The information you discuss is confidential. Order For Protection What is an Order For Protection? An Order For Protection (OFP) is a court order that will help to protect you from domestic abuse. An Order For Protection tells the abuser to stop harming or threatening you. If the order is violated, it is easier for the police to arrest the abuser. Orders For Protection do work! Who can get an Order For Protection? Any family or household member may ask the court for an Order For Protection. A family or household member means married or divorced people; parents and their children; persons related by blood (such as brothers, sisters, uncles, aunts or grandparents); and people who live together or have lived together in the past. People who have never lived together may also ask for an Order For Protection if they have a child together or have been involved in a significant romantic or sexual relationship. 17 Victims of abuse who are at least 16 years old may get an Order For Protection against an abuser they are, or were, married to or have a child with. Other victims of abuse under 18 years of age must have another family or household member or an adult (at least 25 years old) get an Order For Protection for them. How do I obtain an Order For Protection? Go to the courthouse (you may want to call first to see if you need an appointment or to get instructions) in the county where you live; in the county where the abuser lives; in the county where the abuse happened; or in the county where you and the abuser had other family court cases. There you will be instructed on how to file an Order For Protection. You do NOT need a lawyer and there is no fee. Your Order For Protection is effective in all 50 states, the District of Columbia, Tribal Lands and United States Territories. If you feel you, or someone you care about, is in immediate danger call 911. Domestic violence referral numbers Minnesota Coalition of Battered Women 651-646-0994 Women of Nations Eagle’s Nest Shelter and Crisis Line 651-251-1601; crisis line 651-222-5836 Latinas Domestic Violence Line Casa de esperanza: 651-772-1611 Domestic Abuse and Crisis Shelter 1-866-223-1111 24-hour domestic violence line for counseling, locating a shelter, advocacy services or legal services. All programs are free and confidential. United Way 2-1-1 (formerly First Call For Help) 651-224-1133 or 211 A free, 24-hour information and referral service to more than 2,200 community organizations whose focus is on preventing violence and/or providing services to victims of violence. Tubman 651-770-8544 Can refer women and children to support groups in Ramsey County and Washington County. 18 People Incorporated - Parent Support Services Ramsey County: 651-641-1300 Greater Minneapolis Crisis Nursery: 763-591-0100 Pillsbury Crisis Nursery: 612-302-3500 Crisis intervention and resource referral for families regarding child abuse prevention. Provides emergency care for children, newborn through 6 years. Domestic Abuse Project 612-874-7063 Provides counseling, crisis intervention and community outreach. St. Paul Intervention Project 651-645-2824 Crisis intervention for women living in the St. Paul area. Community University Health Care Center 612-638-0700 Provides counseling and social services in Southeast Asian languages, as well as other languages Prevent Child Abuse MN 651-523-0099 Provides free support group meetings for parents. 19 BODY MECHANICS Posture Good posture is especially important during pregnancy. As you gain weight and your body changes shape, you will need to adjust your posture. When your posture is poor, your abdominal muscles relax causing the curve of your back to be exaggerated. In turn, the small muscles of your lower back will shorten and tighten to maintain your balance and alignment. This often causes backaches. During pregnancy your center of gravity shifts as your baby and uterus grow larger. It takes effort on your part to maintain good posture. You can improve your posture by: • Standing as tall as possible and by keeping your chin level. • Flat or low-heeled shoes are helpful and recommended during pregnancy. • Exercises to maintain abdominal muscle tone and strength are also helpful. Standing Standing for a long time can slow the return of blood from your legs, back to your heart and brain, causing you to feel light headed. To help the return of blood, tighten your leg muscles occasionally to stimulate flow, rotate your ankles in small circles and rock back and forth from your toes to your heels. To help prevent backaches while standing, place one foot on a low stool, alternating feet. 20 Lying down As your pregnancy advances it will become more difficult to find a comfortable position while lying down. Many women find it helpful to use pillows. When lying on your side, place a pillow between your knees and one under your head. Some women find it comfortable to bend the leg resting on top and support it with a pillow. Side lying is especially important if you have pregnancy-induced hypertension (high blood pressure). It is advised that you lie on your left side, which increases placental circulation. It is also a position in which your heart functions more efficiently. If possible, stay off your back, especially in late pregnancy. Women often find that this position causes them to feel dizzy and short of breath. This is caused by the weight of the uterus pressing on the large abdominal vein, which causes a drop in blood pressure and a feeling of being light headed. Lying on your back for a prolonged period can cause a decrease in blood flow to the placenta and oxygen to the baby. Sitting Avoid sitting for long periods of time, especially in late pregnancy. Sitting slows the return of blood from your legs. To assist your circulation: • Do not cross your legs at the knees for long periods. • Move and rotate your feet at the ankles. • Later in your pregnancy, it is more comfortable to sit in, and get out of, a straight-backed chair. • A small pillow at your lower back and a low stool to rest your feet increase comfort. 21 EXERCISE Regular exercise provides benefits for healthy women with routine pregnancies. What does this mean for you? You will have more energy and feel better about yourself, you will be able to move easier and be less likely to experience the aches and pains often associated with pregnancy. You will likely sleep better at night and it may help your labor to be more efficient. Aerobic (“with oxygen”) exercises are especially helpful. The entire time you exercise you should be able to hold a conversation. If you find yourself out of breath and unable to talk, slow down. Moderate exercise during pregnancy has many benefits: • Some control over your changing shape. • An increase in metabolic rate that enables you to burn more calories. • Stronger respiratory and circulatory systems. • Increased flexibility and muscle strength. General guidelines for exercise in pregnancy • Talk with your provider before beginning an exercise regimen or any time you have questions about exercising. • The American College of Obstetricians and Gynecologists has exercise guidelines at their website: acog.org/Search?Keyword=exercise+pregnancy • Exercise regularly, three to four times a week. Take time to warm up and cool down. • Brisk walking is a wonderful alternative if you did not exercise before becoming pregnant. Swimming, biking on a stationary bike or maternal fitness classes are also good choices. • Wear appropriate, supportive footwear. • Keep track of your pulse rate. It should not exceed 140 beats per minute. • Stop the exercise if you feel pain. You may be straining muscles, joints or ligaments. • Avoid strain and fatigue. Start with the easiest position, and then try others as your muscles strengthen. Start with a few repetitions, gradually increasing the number. • Don’t exercise vigorously in hot, humid weather, or when you are ill or have a fever. • Be sure you have eaten and have had plenty of liquids before you exercise. • If you join a maternal fitness class, check the qualifications of the instructor. The instructor should have a degree in adult fitness and some experience with exercise in pregnancy. • Do not do exercises that require you to lie on your back for long periods of time. 22 BODY CONDITIONING Pelvic tilt (pelvic rock) Partial sit-ups or curls Benefits: Strengthens/tones abdominal muscles, stretches lower back muscles and eases backache. When done on “all fours,” it takes the weight of baby and uterus off the lower back and improves circulation from lower extremities. Benefits: Tones/strengthens abdominal muscles used in pushing and for postpartum waistline recovery. Lie on your back, with your knees bent and feet flat on floor. Flatten the small of your back onto the floor by contracting your abdominal muscles. Hold for five seconds, exhale and relax. Get on your hands and knees. Keep your back straight - not arched or swayed - and your knees comfortably apart. Tighten your abdominal muscles to arch your lower back. Hold for five seconds. Relax and return your back to the starting position. Repeat this exercise and each variation five times a day. Lie on your back with your knees bent and feet flat on the floor. Breathe in, tilt your pelvis and keep your lower back pressed against the floor. While breathing out, raise your head and shoulders from the floor, reaching your outstretched arms toward your knees. Keep your waist on the floor. When your shoulders are raised about eight inches, hold this lift for five seconds. Relax and gently lie back. Repeat about five times a day. Tailor-sitting Benefits: Strengthens pelvic floor muscles and stretches inner and outer thighs. Sit on the floor with your legs pulled in and crossed at the ankles. In this position you can also perform a tailor press. Inhale; lift knees; exhale; press knees towards floor with your hands while exerting upward pressure with your legs. 23 Shoulder circling Breast support Benefit: Help to relieve tension in shoulders, neck and back. Benefits: Tones your upper chest muscles. Stand or sit with your back straight, arms relaxed and chin level. Raise your shoulders towards your ears, then slowly roll them forward, down, back and up again, making large circles with your shoulders. Finish with your shoulders back and down in a relaxed position. Do five rotations, then repeat, reversing the direction. Grasp forearms with hands, elbows flexed at shoulder level. Slowly press hands toward elbows as if pushing up sleeves; hold to count of five and release. Repeat three to four times per day. Kegel Benefits: Helps identify muscles involved in birth. Tones and gives elasticity to pelvic floor. Promotes circulation to pelvic floor. After an episiotomy, kegeling will increase circulation to the episiotomy site to promote healing and reduce swelling. Provides support for pelvic organs. The openings from your bladder, vagina or birth canal and rectum pass through the pelvic floor muscles. Kegel exercises tone your pelvic floor muscles. This, in turn, controls bladder leaks, helps the perineum heal and tightens vaginal muscles. Upper body stretch Benefit: Helps relieve upper body tension and backaches. Tailor-sit. Cross your arms at the elbow. Inhaling, raise your hands toward the ceiling and gradually uncross your arms. Reach upward so you feel the stretch in your entire upper body. Exhale as you lower your arms out to the side and behind you, palms up. Feel the stretch across your chest and upper arms. With your arms down and behind you, stretch further by pressing your arms back. Drop your arms to your sides and relax. Repeat five times. 24 Squeeze the muscles that you use to stop the flow of urine. Hold for up to 10 seconds, then release. Do this 10 to 20 times in a row at least three times a day. Practice this exercise as often as you can during the day. Make it part of your daily routine by setting up signals for yourself. For example, every time you stop at a traffic light, do Kegels. The expectant partner Did you know that your diet, habits, lifestyle and attitude play a part in how healthy your baby will be? As an expectant partner, you can take positive steps to help your partner have a healthy baby. Because both parents aren’t going through the same physical changes as their pregnant partner, they may be treated as though nothing very special is happening to them. Partners are more likely to be asked, “How is she doing?” It is easy to feel left out. Partners get the message that their role is just to be supportive of their partner. Partners do feel protective of their partners, but they are experiencing great changes as well. Some common concerns are: • Will I be able to financially support my partner and child? • Do I really have control over any of these changes? How can I gain control? • How will my relationship with my wife/partner change? Will we be the same? • What if something happens to my wife/partner or the baby? • Will I be a good parent? To help with the changes that are coming, it is important to: Seek out the help you need. Talk to friends who have children, read up on pregnancy, birth and parenting. Ask questions. Your partner’s provider is a good resource – go with her to prenatal visits. At prenatal visits you will be able to hear your baby’s heartbeat and experience the pregnancy with your partner. Attend childbirth classes together. Talk with each other about your upcoming birth and share in the decision making. Discuss fears and concerns, medication use during labor, who will be there to support each of you and how you will support her during labor. Attend a class. Check the HealthEast website for class options. healtheast.org Make a place in your heart and home for your new baby. Prepare a nursery, read about infant car seats and purchase one for your baby. Begin baby-proofing your home. Take good care of your health. It is wise to change unhealthy lifestyle habits. For example, if you smoke, this is a great time to quit for your own health and that of your partner and baby. 25 Practice good communication, patience and support. Be aware, especially during early pregnancy, that significant mood swings are common due to hormonal changes. Be kind to each other and support each other with loving understanding. You may need to take on the more difficult and strenuous household chores. Understand your role during labor and birth. Talk with your partner about how she sees your role. Does she need an active coach, a support person or simply your physical presence? Many women in labor are comforted by the presence of their loving partner – and we know that the presence of a loving partner will make labor better. After your baby is born Birth is usually followed by a sense of relief and accomplishment. You made it through! You will discover a new respect for your partner and wonder in her strength in giving birth to your baby. You may find yourself expecting to feel the same way as you did before the baby was born. In reality, life is not as it used to be. As you face the challenges of parenting, don’t be surprised if you have mixed feelings. You may feel joy and pride along with apprehension and insecurity. You will find your way and learn how to parent your baby. This re-orientation to life will happen each time a baby is born into your family. Take advantage of every opportunity you have for interaction with your baby. Fathers can be very nurturing to newborns. Don’t be afraid to touch, look at, talk to, kiss or hold your baby. It will be easier for you to feel comfortable with your baby if you take an early, active role in your baby’s care. Give yourself permission to make mistakes. Your baby does not recognize imperfections. As the weeks go by, your infant will grow and become more responsive to you. The time you spend learning about your baby in the early weeks will be rewarded with gurgles and smiles intended just for you. Partners have a doubly important job in the newborn period. This involves caring for the baby directly and caring for the mother. Do all you can to lighten the workload and arrange for help from others when you can’t be there. If your job permits, take some time off. A period of uninterrupted “settling in” time with the baby is important. 26 Much attention has been given to new mother’s postpartum depression, but many partners experience postpartum depression too. Many postpartum adjustments may be related to financial and lifestyle changes, as well as emotional and sexual changes. Sleep interruption can also be a source of depression for new fathers. Being aware of the possible causes of father’s baby blues may help you to modify the effects. If depression starts to interfere with your functioning or your relationship with your partner or baby, speak to your family physician or a counselor. As you are building a new relationship with your newborn, you are also building a new relationship with your partner. It is natural for both of you to be completely preoccupied at times with the baby. Purposely set time aside for each other. Patience and understanding are important during this time in which you both may feel vulnerable. The more you understand and share about your feelings, the more you will help each other through this period. The postpartum period is a season of life in which many adjustments occur in a very short period of time. As time goes on, your family life will smooth out a bit, and the postpartum season of life will be followed by other seasons enriched by what you have learned and experienced. It is essential to view pregnancy as something that is happening to both of you. Again, check the HealthEast website for class options for dads and partners. healtheast.org Your positive involvement is very important in the life of your partner and baby. 27 COMMON DISCOMFORTS OF PREGNANCY Common physical changes of pregnancy Pregnancy causes many physical changes in a woman’s body. Not all pregnant women experience the same changes. Some changes may go unnoticed and may not cause any discomfort. For example, many women will develop linea nigra (which is a dark line down the middle of the abdomen), small vascular “spiders” on their skin and localized areas of numbness. Changes in sensory perceptions such as smells and tastes may also occur. This information is not intended to describe all the physical changes you may experience but will provide guidance in self-care activities for these changes. It is unlikely that you will experience all of these. Common changes Suggested self-care activities Backache Proper posture may help reduce or prevent backache. Wear low-heeled shoes. Make sure your bed and chairs give adequate support and use a footstool when reaching overhead. Squat and use your leg muscles when picking up objects or children. Breast tenderness Wear a bra that offers good support. A warm shower may offer temporary relief. Constipation You can often prevent constipation by drinking 6 to 8 glasses of water daily and including whole grains, fruits and raw vegetables in your diet. Daily exercise is helpful. If constipation occurs, begin to add 1/4 to 1/2 cup of bran to your daily diet. You can mix it with foods such as cereal, muffins or hot dishes. As with all medications, do not use laxatives unless advised to by your caregiver. Edema (swelling in feet/ankles) When sitting, try to elevate your feet and legs. When in bed, resting on your left side will increase the return of blood to your heart. Eat salty foods in moderation and try to drink 6 to 8 glasses of water daily. Fatigue Naps can be very helpful. Good nutrition and gentle exercise may help you feel more energetic. 28 Common changes Suggested self-care activities Headaches Headaches are common between 12 to 20 weeks of pregnancy. However, third trimester headaches (those after 26 weeks) should be reported to your caregiver. Eat small but frequent meals throughout the day as hunger can make headaches worse. Noise and fatigue can also cause headaches. Increase fluid intake and use acetaminophen as needed. Heartburn Greasy, spicy and hard to digest foods can often cause heartburn. If they affect you, avoid them. Eat small, frequent meals throughout the day. Eat slowly and sit up for approximately 30 minutes after meals. Sleeping with your head and chest elevated may also help. Chewing gum for 30 minutes after each meal may decrease the need for antacids. For antacids that are safe to use during pregnancy (see “Medications in Pregnancy” on page 16). Leg/calf cramps Wear low-heeled shoes and maternity support hose. Stretching for 20 minutes before going to bed may help prevent leg cramps during the night. Avoid pointing toes as this may encourage leg cramps. Adequate calcium intake may decrease leg cramps. However, use calcium supplements only on the advice of your caregiver. Nose bleeds, nasal congestion During pregnancy, the lining of the nose may bleed or crack more easily. Humidifiers or cool mist vaporizers will keep nasal passages moist. You can coat nasal passages with a small amount of Vaseline to add moisture. Nosebleeds should stop after constant gentle squeezing of the nostrils for several minutes. For managing nasal congestion, consult your caregiver. 29 Common changes Suggested self-care activities Stretch marks These may occur over your abdomen, upper thighs and breasts. There is no way to prevent them. Using moisturizers can help relieve the feeling of tightness and itching that can occur. Nausea This is common in the first trimester and is frequently experienced after waking up. Dry toast or crackers before rising may be helpful to you. Eat small but frequent meals throughout the day. Drink liquids after meals rather than with meals. Get plenty of rest as fatigue may increase nausea. Round ligament pain Usually felt as quick, sharp pains on the right or left side of abdomen, which last a few seconds to several minutes. Caused by the stretching of the ligaments that support the uterus. Avoid sudden twisting, turning or stretching. To reduce pain, lean toward the pain to enable the ligament to relax. Shortness of breath This may occur in the third trimester when the uterus is larger, and your lungs can no longer inflate fully. Use correct posture when sitting or standing and sleep with extra pillows to elevate your head and shoulders. Raising your hands over your head gives space for lungs to expand and may provide some relief. Tips for general physical care Rest! Naps after work, or other times throughout the day, are important. Continue your daily hygiene. Tub baths are fine, but you may experience difficulty getting in and out of the tub. Use rubber safety mats in your tub or shower to reduce the risk of slipping. Try to have help available or install a tub safety grip. Extremely hot baths or showers are not advised. • Do not douche during pregnancy. • Avoid tight clothing such as waistbands, socks or hose that restrict circulation. • Visit your dentist as usual. Be sure to tell the dentist that you are pregnant. 30 Strengthening exercises and stretches for low back pain Developed by HealthEast® Optimum Rehabilitation Partial curl up Shoulder depression Do only if there is no diastisis recti (abdominal muscle separation) present. Reach toward knees and curl trunk upward. Hold three to five seconds. Do five to ten repetitions, two times per day. While sitting in an armchair, press shoulder downward while concentrating on holding shoulder blades stable. Support part of your body weight with legs as needed. Hold five seconds and slowly relax. Do five to ten repetitions, two times per day. Hip abduction isometric 1 and 2 Place hands on sides of knees. Try to spread legs apart, but resist the motion with your hands. Hold five seconds, slowly relax. Do five to ten repetitions, two times per day. Place hands on inside of knees. Squeeze thighs together, but resist the motion with your hands. Hold five seconds, slowly relax. Do five to ten repetitions, two times per day. Back stabilization Begin with your spine straight. Lift one leg up. Hold five seconds, alternate and lift other leg up. Hold five seconds. Do five to ten repetitions, two times per day. 31 Back sidebending Cat/cow Tilt head and shoulder to one side as you tilt hips toward head, making a curved shape with your trunk. Hold five seconds. Do five to ten repetitions, two times per day. Find neutral position. Tighten abdominals and squeeze buttock muscles. Alternate from arched to sagged. Hold five seconds. Do five to ten repetitions, two times per day. Scapular retraction Stand with arms at sides. Pinch shoulder blades together and down. Hold five seconds. Do five to ten repetitions, four times per day. Neck retraction Begin sitting or standing. Tuck your chin in and pull your head straight back. Hold five seconds. Do five to ten repetitions, four times per day. 32 Back extension-sitting Back sidebends Roll a small towel so that it makes a firm roll two to three inches thick. Sit with back against chair as shown. Place rolled towel between chair and the small of your back. Place hands behind neck and lean backward until you feel a stretch. Hold five seconds. Do five to ten repetitions, four times per day. Lean to each side until you feel a stretch. Hold five seconds. Do five to ten repetitions, four times per day. Calf stretch Back extension-standing Place hands firmly against hips as shown. Bend backward until you feel a stretch. Hold five seconds. Do five to ten repetitions, four times per day. Position your body against a wall as shown. Point toes directly toward wall and hold heel down. Lean into wall as shown so that you feel a stretch. Hold 15 seconds, repeat three times each leg. 33 Hamstring stretch Hip rotator stretch Lie on back holding one leg with hands. Straighten the knee as far as you can, keeping your other leg straight on the floor. Hold 15 seconds. Do three repetitions per leg, two times per day. Lie on your back with one knee bent, foot flat on floor and braced against other leg. Use your hands to pull the outside of your knee inward. Hold 15 seconds. Do three repetitions per leg, two times per day. Hip adduction stretch Hip flexor stretch Sit with knees bent, feet together. Press knees downward toward the floor, by leaning forward and pressing with your elbows. Hold 15 seconds. Do three repetitions, two times per day. Assume position shown, with one knee on chair. Bend the opposite knee so that you feel a stretch. Do not allow your low back to arch. Hold 15 seconds. Do three repetitions per leg, two times per day. These exercises are intended to be used only when mild to moderate pain is present during pregnancy. Do each exercise as instructed. If any exercise worsens your pain, discontinue doing it until you discuss your condition with your health care provider or physical therapist. If you are in significant pain that is considerably affecting your daily activities, consult your provider. 34 HealthEast Optimum Rehabilitation HealthEast Optimum Rehabilitation is a network of rehabilitation centers that provide the latest in outpatient occupational, physical and speech therapy. Treatment plans are specifically designed to meet your needs while helping to speed recovery and decrease the chance of recurrence. Specialized treatment programs are also available for women to treat back pain during pregnancy, rehabilitation of pelvic floor weakness/ incontinence, pelvic pain, lymphedema management and osteoporosis. Consult your provider for referral to HealthEast Optimum Rehabilitation at any of the following locations: Maplewood Markham Pond Professional Center 1570 Beam Ave., Suite 200 651-232-7820 Markham Pond Professional Building Spine Center (Maplewood) 1747 Beam Avenue #100 651-326-5569 St. Paul Midway 1690 University Ave., Suite 430 651-232-5412 Oakdale Tessar Professional Bldg. 1099 Helmo Ave., Suite 110 651-232-5075 Spine Center Tessar Professional Building Stillwater University Park Professional Bldg. Woodwinds Oak Center Woodbury Oak Center 1825 Woodwinds Drive, Suite 100 651-232-6767 Stillwater 2900 Curve Crest Blvd. 651-471-5630 35 WARNING SIGNS DURING PREGNANCY When you are pregnant some of the changes your body experiences can feel a little strange. Usually these are normal sensations but sometimes they can be an indication that there may be a problem. Report anything unusual. If you have a concern, a phone call to your provider may be all that is needed to restore peace of mind. Call your provider if you experience any of the following: • Vaginal bleeding (even a small amount) • Abdominal pain or cramping • Constant, or intermittent, painful firmness of the abdomen, with or without vaginal bleeding • Leaking or gushing of fluid from the vagina • Sudden puffiness or swelling of the hands, feet or face • Severe, persistent headache • Disturbance of vision including spots, flashes, blurring or blind spots • Dizziness, light-headedness • Noticeable reduction in fetal activity • Painful, warm, reddened area in the leg • Severe pain in the pubic area and hips with difficulty moving legs • Pain or burning when urinating • Irritating/itching vaginal discharge or genital sores • Persistent nausea or vomiting • Fever - oral temperature more than 100 degrees F You do not have to wait for a scheduled appointment to ask questions! 36 Bleeding in early pregnancy ANY bleeding in pregnancy should be reported to your provider, but not all bleeding means you are having a miscarriage. Nearly 25 percent of all pregnant women experience some spotting or bleeding in early pregnancy. In more than half of these cases, it goes away, and a normal, healthy pregnancy continues. Light bleeding or spotting that is brown or pink in color and not accompanied by cramping can occur at these times: • During implantation, when the fertilized egg attaches itself to the uterine wall. • After sexual intercourse or a pelvic exam, due to the increased blood supply to the cervix. Cramping in early pregnancy As your uterus grows and expands, some cramping may occur. Cramping accompanied by bleeding may be a sign of a miscarriage. Call your provider immediately. MISCARRIAGE One in five confirmed pregnancies will end in miscarriage. This estimate may, in fact, be low. A miscarriage can occur before a woman knows she is pregnant. She may only notice a period that is later and heavier than normal, with stronger than normal cramps and never realize that she is miscarrying. Most miscarriages happen during the first trimester, although a woman can miscarry any time before 20 weeks. Unfortunately, there is little that can be done to prevent a miscarriage once it has started. Though a miscarriage can be emotionally difficult, it is a natural, inevitable process that occurs when the body recognizes that a pregnancy is not progressing normally. Possible signs and symptoms of miscarriage If you experience any of the following signs and symptoms, contact your provider: Heavy bleeding: Bright red vaginal bleeding that is as heavy as or heavier than a menstrual period. Significant cramping: Cramping pain that is stronger than menstrual cramps and may be very intense. Cramping may be constant or intermittent. Passing of large clots or whitish or grayish tissue: This may mean a miscarriage has already begun. If you pass any tissue, place it in a plastic bag, store it in the refrigerator and bring it with when you see your provider. 37 Medical intervention for a miscarriage Your provider may advise you to observe symptoms at home and report back, or you may be asked to come to the clinic. Once a miscarriage is confirmed, a surgical procedure is sometimes required to remove tissue that has not passed. Although a miscarriage is not generally a serious medical condition, it can be very frightening. Keep in contact with your provider as you need to. After you’ve had a miscarriage Some women wonder if they did something to cause the miscarriage. In the overwhelming majority of miscarriages, that is not the case. Sexual intercourse, vigorous exercise, falls or emotional upsets do not cause a miscarriage. Most women who have one or two miscarriages go on to have normal, healthy pregnancies. The likelihood that the next pregnancy will be successful is as high as 85 percent. Generally, further medical tests aren’t considered until three or more losses have occurred. Deep feelings of loss and sadness often occur when a pregnancy ends in miscarriage. The baby who was to be is gone; hopes and plans for the future have been erased. This is a time to share your feelings with your partner, grieve as you need to and ask for support from others. Feel free to call your provider, midwife or the Infant Loss Coordinator facilitator at 651-232-3192. Ectopic or tubal pregnancy This type of pregnancy occurs when the fertilized egg becomes implanted outside the uterus, usually in the fallopian tube. Left untreated, the tube could burst, creating a potentially life threatening condition. Signs and symptoms that should be reported to your provider include sharp pain on the left or right side which is not relieved when you lie down, often associated with spotting or bleeding. Medical intervention is necessary and may include surgery. 38 YOUR HEALTH INSURANCE COVERAGE Maternity care coverage varies with individual health insurance plans. It is your responsibility to know your coverage in advance. The following questions will assist you when you talk to your insurance carrier. Insurance company: Policy number: Phone number for benefits: Person spoken to: 1. Do I need pre-approval for my hospital stay? r Yes Date/time of call: r No If yes, how do I get this approval: 2. If I have an uncomplicated vaginal delivery, what is the normal postpartum hospital stay for which I do not need a provider’s reason to stay longer? 3. If I have an uncomplicated Cesarean birth, what is the normal postpartum hospital stay for which I do not need a provider’s reason to stay longer? 4. Does my authorized hospital stay begin with: r Admission to hospital r Time of birth 5. If I have complications, will additional hospitalization time be authorized? r Yes 6. Will insurance cover a Home Care visit after I leave the hospital? r Yes r No r No 7. What physicians are covered (in network) under my insurance plan for the baby’s care? 39 8. How do I add my new baby to my insurance plan? 9. If I have a boy and want him circumcised, is that a covered procedure? r Yes r No 10. What coverage is provided if my baby requires additional hospitalization? 11. Will my plan cover an outpatient lactation visit if I need breast-feeding help after my baby is born? r Yes r No Who is covered? Myself or my baby? 12. Does my plan cover the cost of a personal use, double electric breast pump? r Yes r No 13. If my insurance plan benefits change, will I be notified? r Yes 14. Other questions you may have 40 r No YOUR PRENATAL CARE Regular, thorough prenatal care helps ensure that your baby will be born healthy. Soon after you become pregnant, it is important to begin seeing your midwife or provider regularly. During these prenatal visits, you will have an opportunity to discuss concerns. You will have routine examinations to monitor your pregnancy. As your pregnancy progresses, routine screening/diagnostic tests are offered or performed to detect any problems with mother or baby. While these tests are reassuring when the results are normal, if a potential problem is discovered, intervention can take place as soon as possible You will also have opportunities to begin to work with your provider in planning your birth experience and making a birth plan. It is helpful to have your partner accompany you to one or more of your prenatal visits. This allows your partner to experience the pregnancy first hand and to discuss their role during labor and birth. It is also helpful to meet the other providers or midwives, since one of them might be on call when you are in labor. Prenatal visit #1 8 to 11 weeks Date of visit Weight Blood pressure Height Estimated due date Physician examination to include: • Head, ears, eyes, nose, throat • Heart and lungs • Lymph nodes • Breasts • Abdomen Pelvic (vaginal) examination to check: • Cervix, vagina, ovaries and fallopian tubes. • Uterus - The uterus is checked to confirm your pregnancy and due date. • Bony pelvis - This is done to assess the pelvic structure for size and shape. • A speculum examination is done to visualize the cervix and to take a pap test to screen for abnormal changes or signs of cervical cancer. A vaginal culture may be needed if there are signs of vaginal infection. Depending on your sexual history, a culture of your cervix may be taken to test for Chlamydia or gonorrhea. 41 Routine tests during pregnancy There are routine lab tests that are done on all pregnant women. These tests may help your provider spot possible problems during your pregnancy. They will provide clues about how your baby is developing. Other tests may be performed depending on your medical history, family background, ethnic background or exam results. Urine Tested for levels of sugar and protein. May be repeated throughout pregnancy and for infections. Blood Tests • Hemoglobin: Test for anemia • Type and Rh factor • RPR: Test for syphilis (an STD) • Rubella: Immunity to German Measles • Hepatitis B antibodies: To determine exposure • HIV: To detect the AIDS virus • Other blood tests may be needed depending on your health history. Risk screening assessment It is very important that your provider is aware of your past history and present lifestyle. This risk assessment includes physical, mental, emotional and genetic factors. Some of the questions will be assessed through a written worksheet and others will be asked by your provider. A risk assessment includes: • Substance abuse (tobacco, drugs and alcohol) • Physical activity • Violence and domestic abuse • Sexual practices • Use of medication • Nutrition • Previous medical, surgical and obstetrical history • Genetic history • Complications from previous pregnancies • Infectious disease • Accurate recording of menstrual dates • Environmental or work concerns Education • Physiology of pregnancy and warning signs of problems • Plan of care and practice policies • Relief measures for common complaints of pregnancy 42 Blood type and Rh factor You will have a blood test to find out your blood type. Just as there are major blood groups, such as A and B type blood, there is also an Rh factor. The Rh factor is a type of protein (antigen) found on red blood cells. If blood lacks the Rh antigen it is called “Rh negative.” If it has the antigen it is called “Rh positive.” The Rh factor does not affect a person’s general health, but problems may arise when the unborn baby’s blood has the Rh factor and mother’s blood does not. During pregnancy, mother and baby do not share blood systems. However, blood from the baby may cross the placenta into the mother’s system. Should this occur, a small number of pregnant women with Rh negative blood who carry an Rh positive baby will react as if they were allergic to the baby’s blood. They become sensitized by making antibodies which go back and enter the baby’s blood. There they break down the red blood cells and produce anemia (iron deficiency). This condition is called hemolytic disease which can be a serious disease for an unborn or newborn baby. Once formed, the antibodies do not go away. There is a drug that may help – rho(D) immune globulin. If a woman with Rh negative blood has not been sensitized, her provider may suggest she receive rho(D) immune globulin around week 28 of pregnancy to prevent sensitization for the remainder of the pregnancy. Shortly after birth, if the baby has Rh positive blood, the mother should receive another dose of rho(D) immune globulin. This treatment is only effective for the pregnancy in which it is given. Each pregnancy and delivery of an Rh positive baby requires repeat doses of rho(D) immune globulin. Prenatal Testing Description: Prenatal testing is part of nearly every pregnancy. Your provider can give you information about testing that may benefit you, however, the choice is yours. 43 Who should be tested: Women who already may be at increased risk of having a baby with one of the birth defects mentioned above or women with the following risk factors: • maternal age of 35 or older when the baby is due • family or personal history of birth defects • previous child with a birth defect • use of certain medicines around the time of conception • insulin-dependent diabetes prior to pregnancy Tests in early pregnancy used to rule out abnormalities: Ultrasound Your provider may use ultrasound information to verify due date, check on the cause of bleeding in pregnancy, detect normal growth and development or to confirm the number of babies in a multiple birth. An ultrasound uses sound waves instead of radiation to create an image of your baby. A special scanning device is placed over the uterus or in the vagina and a picture of your baby is produced on a screen. Amniocentesis This test is most useful between 14 and 18 weeks of pregnancy and is done with the aid of ultrasound. A needle is passed through the abdomen and uterus into the amniotic sac and a small amount of amniotic fluid is withdrawn. The cells from the fluid are examined for genetic birth defects, such as Down syndrome. It is generally offered to women who will be 35 years of age or older at the time of delivery, or with a family history of genetic disorder. Your provider will carefully explain the risks involved with this procedure. Screening tests for fetal well-being Maternal Serum Screening tests use a sample of the pregnant mother’s blood to give information about her chances of having a baby with certain birth defects such as Down syndrome and spina bifida, or “open neural tube defect.” Spina bifida is a condition where the coverings around the fetus’ brain or spinal cord do not form properly. A screening test can only assess your risk of having a baby with certain defects. If your screening test shows a higher than average risk for having a baby with a certain defect, further diagnostic tests may be offered. Most women with abnormal screening tests have normal babies. It is your decision to have the test. While some women find it reassuring, others would rather not have the information. The results of these tests can help women and their partners make decisions about their options. 44 Harmony Prenatal Testing Some providers use the Harmony Prenatal Test. It is a blood test that is available to check for trisomy disorders. A trisomy is a chromosomal condition that occurs when there is three copies of a particular chromosome instead of the expected two. Harmony Prenatal testing can screen for trisomy 13 (Patau syndrome), trisomy 18 (Edwards syndrome) and trisomy 21 (Down syndrome). The test does not rule out all fetal abnormalities. Nuchal Translucency screening This is a non-invasive screening that may be performed in the first trimester. It involves the use of ultrasound and a blood draw from mother. This test can confirm how far along the pregnancy is, and can take a measurement of fluid underneath the skin fold along the back of the baby’s neck. This measurement is called nuchal translucency. The blood sample from mother will be analyzed for chemicals and proteins that are found in all pregnant women’s blood. The combination of these two tests can help identify pregnancies with a high risk of Down syndrome and other chromosomal abnormalities. Alpha-fetoprotein test Alpha-fetoprotein (AFP) is a protein made by your unborn baby. It is present in baby’s blood and the mother’s blood and, in smaller amounts, in amniotic fluid (liquid that surrounds the baby in the mother’s uterus). A small amount of AFP crosses the placenta and enters the mother’s blood. The AFP test is usually done at 15 to 18 weeks of pregnancy. A small amount of blood is taken from a vein in the mother’s arm and tested in a lab. Results are usually available in about a week. AFP levels are higher than normal in the maternal serum of many women (80 percent) carrying fetuses with open neural tube defects. A high level of AFP can signal a risk of neural tube defects (such as spina bifida). A low level can signal a risk of Down syndrome. Positive results don’t always indicate there’s a problem. For this reason, an abnormal screening test result is followed up with other tests. Other causes of high AFP levels may be that the fetus is older than was thought or twins. 45 Multiple marker screening (MMS) tests Combining other tests with the AFP test can give more information about your risk of having a baby with Down syndrome than the AFP test alone. These are called multiple marker screening (MMS) tests. MMS tests are also performed at 15 to 18 weeks of pregnancy. These tests can be done at the same time as the AFP, using the same blood sample. The results come back in one to two weeks. The best combination of tests is not yet known. Most providers who use multiple tests use two or three tests together. Besides measuring AFP, MMS tests measure other levels in the woman’s blood that change with pregnancy. Other levels that might be measured are human chorionic gonadotropin (hCG) and estriol. HCG is a hormone produced by the placenta. Levels of hCG are higher than normal in most pregnancies if the unborn baby has Down syndrome. Estriol is produced mostly in the placenta and in the baby’s liver. Estriol levels are lower than normal in most pregnancies with a baby with Down syndrome. Routine tests can be followed up with other tests if the results raise concerns. Your provider also may suggest special tests if you have certain risk factors. Chorionic villus sampling (CVS) This is used to diagnose genetic birth defects and involves sampling placental tissue. The advantage of CVS is that it can be performed earlier than amniocentesis, between 9 and 11 weeks, and results can be obtained faster. However, the test also poses a higher risk of complications. The perinatologist who would perform the CVS will discuss the risks and benefits of this test. Bacterial vaginosis screening during pregnancy Bacterial vaginosis is a common vaginal infection caused by an imbalance of the bacteria normally found in the vagina. Bacterial vaginosis affects 12 to 22 percent of pregnant women and half of these women will not have symptoms. Bacterial vaginosis significantly increases the risk of preterm birth and low birth weight babies. Women can be screened for bacterial vaginosis with a simple test during a pelvic exam. Rescreening later in pregnancy may be recommended. Antibiotics are used to treat bacterial vaginosis during pregnancy. Treatment with antibiotics can reduce pregnancy complications related to bacterial vaginosis, such as preterm labor and low birth weight babies, by 40 to 50 percent. 46 HIV/AIDS As a routine part of your prenatal care, it is recommended that you have a confidential HIV test. Many women do not know that they have been exposed to HIV because they do not feel they have put themselves at risk. You are at risk for HIV if you have had unprotected sex (without use of a latex condom) even one time with someone who may be infected. You are also at risk if you have shared needles or syringes with someone who is infected with the virus. An HIV test can let you know if you have the virus so you can make the best decisions for yourself and your baby. If you are infected, you will be able to start treatment early, which may help you live a longer, healthier life and may help prevent transmission to your unborn baby. If you are not infected, you should continue to protect yourself. There are three ways to avoid infection and protect yourself and your baby: • Do not have sex at all. • If there is any chance that your sex partner has ever had sex with anyone else or, ever used injected drugs, you should use a latex condom every time you have sex to reduce the chance of transmission. • Do not use injected drugs or share needles and syringes. If you are infected, you might give HIV to your baby during pregnancy, at delivery or by breast-feeding. Early detection allows for early treatment. Without treatment, about one out of every four babies born to HIV infected mothers are born with HIV infection. Prenatal visit #2 12 weeks Date of visit Weight Blood pressure Fundal height Fetal heart tones Height Education • Fetal growth • Decision on genetic screening tests for next visit • Infant feeding 47 Infant Feeding Policy One of the most important choices you will need to make as new parents is how to feed your baby. The American Academy of Pediatrics recommends exclusive breast milk feeding for the first six months of your baby’s life and ideally until baby is one year old. Breast milk feeding has many benefits. If you can only breast-feed for a short time, your baby’s immune system will still benefit. Breast surgery If you have had breast surgery of any kind, inform your provider. Breast surgery may affect your ability to produce milk in an amount that would enable you to exclusively breast-feed your baby. Prenatal visit #3 16 to 18 weeks Prenatal classes fill quickly - register NOW to ensure taking the classes that fit your schedule. Visit healtheast.org for class information. Date of visit Weight Blood pressure Labs and tests: • Genetic screening tests • OB ultrasound 48 Fundal height Fetal heart tones Education – second trimester growth Childbirth education classes Classes provide valuable labor, birth and parenting information. Your clinic will have information about childbirth preparation classes. It is best to register early to ensure that you can attend the classes of your choice. You may want to schedule a tour of the Maternity Care Center. Check the HealthEast website for tour information. Quickening Quickening, the first awareness of fetal movement, may occur around this time. It will first feel like flutters, then gradually over a few weeks become more distinct kicks. Make note of the day you felt the baby three days in a row. For many first time mothers, quickening is not noticed until around 20 weeks. Backache Backache is very common during pregnancy. Activities like vacuuming, leaf raking and shoveling are particularly aggravating and should be done carefully or not at all. Blood volume expansion Blood volume increases by as much as 40 percent while pregnant. Because of that increase, the hemoglobin in the blood is diluted and usually falls slightly during pregnancy. Headaches, varicose veins, hemorrhoids and bleeding from the nose and gums may also occur. Faintness It is common to feel slightly dizzy during pregnancy. Frequent meals, layered clothing, adequate fluid intake and avoiding prolonged standing may be helpful. Tell your provider if you have severe dizziness or fainting episodes to your provider. 49 Prenatal visit #4 22 weeks Date of visit Weight Blood pressure Fundal height Fetal heart tones Education Have you registered for childbirth, breast-feeding or newborn care classes? If not, check on this now. Gestational diabetes screen Your next visit may include a glucose challenge test. What is gestational diabetes? Your body converts the food you eat into glucose, or sugar. As your blood sugar level rises, your pancreas secrets insulin. Insulin helps the body use the glucose for energy. During pregnancy the placenta secretes hormones that are needed for baby’s growth and development. Those hormones can block the action of insulin in the mother. Sometimes too much insulin is blocked (this is called “insulin resistance”) and mother’s blood sugar rises above a normal level. Pregnant women who have never had diabetes before but who have high blood sugar (glucose) levels during pregnancy are said to have gestational diabetes. Gestational diabetes affects about 4-7% of all pregnancies. How gestational diabetes can affect your baby Some mothers ask why testing for gestational diabetes is delayed until early in the 3rd trimester for most women. It’s because gestational diabetes affects the baby most at this time of rapid growth. When mother’s blood sugar is elevated, the extra sugar crosses the placenta and causes the baby to gain excess weight (“macrosomia”.) Some babies are too big to be born vaginally so their mother will have a cesarean birth. 50 Babies of mothers with uncontrolled gestational diabetes may have difficult births that result in injury to the mother and sometimes to the baby. These babies usually have difficulty maintaining their own blood sugar after birth and they may also have trouble adapting to life outside the womb. Recent research indicates that babies of mothers with uncontrolled or undiagnosed gestational diabetes are at risk for obesity and type 2 diabetes. Women who develop gestational diabetes are more likely to develop type 2 diabetes within 15 years after their pregnancy. Testing for Gestational Diabetes in Pregnancy The American Diabetes Association and the American College of Obstetricians and Gynecologists (ACOG) recommend testing all pregnant women for gestational diabetes. Testing occurs between 26-28 weeks of pregnancy. You will be tested earlier in your pregnancy if you have risk factors. The test is called a glucose (sugar) challenge test. How do I prepare for the test? Eat normally on the day of the test; a diet rich in protein, whole grains and vegetables would be best. Avoid simple sugars, white flour products and juices prior to testing. You will be asked to drink a 10 oz glucose beverage (50 gm, about the same as a can of root beer.) The beverage is not carbonated and it needs to be consumed within 5 minutes. During the next hour, you will often have your regular prenatal visit. You will be asked to limit your activity around the clinic. Feel free to bring a book or your computer. Test Results Any blood sugar level less than 140 for this test is considered normal. If your blood sugar level is 140 to 185, a second test will be recommended. If the level is 185 or above, this confirms the diagnosis of gestational diabetes and a referral to a diabetic educator will be made without additional testing. If you require additional testing it is a three hour glucose tolerance test. If two or more readings are abnormal, the diagnosis of gestational diabetes is confirmed and a referral to a diabetic educator will be made. Additional Information You can visit the American Diabetes Association website diabetes.org for additional information and to purchase their book, “Gestational Diabetes: What to Expect”. 51 A brochure from the American College of Obstetrics and Gynecology is available at: acog.org/publications/ patient_education/bp051.cfm rho(D) immune globulin If you are Rh negative, expect a rho(D) immune globulin vaccination at your next visit. This will prevent your body from making antibodies against your baby, in the event your baby is Rh positive. (see “Blood type and Rh Factor” – Visit #1 on page 43) How will you feed your baby? The American Academy of Pediatrics recommends you breast-feed for your baby’s first year of life. If you cannot commit to one year, any amount of breast-feeding is beneficial to your baby. We have listed the advantages of breast-feeding for mom and baby. Advantages to mother • Women who breast-feed have less vaginal bleeding and less risk of hemorrhage (excessive bleeding) after birth. Breast-feeding (infant suckling) causes the release of oxytocin, a hormone produced in the body that makes the uterus contract. This helps return the uterus to its normal size sooner. • Milk production requires an additional 300 calories each day. One half of the calories come from the body fat mothers deposit during pregnancy. The remaining calories come from foods eaten each day. While many mothers lose unwanted pounds easily, high calorie foods with no nutritional value (junk food) should be avoided. • Breast-feeding lowers a woman’s risk of developing: -- breast and ovarian cancer -- cardiovascular disease -- type 2 diabetes -- osteoporosis -- postpartum depression • Breast-feeding requires no mixing, measuring or clean up, making nighttime feedings quick and easy. • Breast milk is inexpensive. It is always available and requires no sterilization or refrigeration. 52 • Breasts and babies are portable, making travel easier. With a little practice, mothers can breast-feed anywhere. • Breast-feeding produces a special relationship between a mother and baby, a closeness that comes with time and touch. The feeding choice you make will be supported by our caring, competent staff. Advantages to baby • Breast milk is nutritionally perfect for nearly all infants. Human milk changes to meet the needs of a growing baby, something formula cannot do. • Healthier Baby / Immune System Benefits • The cells, hormones and antibodies in breast milk protect babies from illness. As a result, breast-fed babies have fewer illnesses, doctor visits and hospitalizations. For parents, this means fewer days away from work to care for a sick infant. • Breast-fed babies immune systems respond better to immunizations. • Stem cells have been discovered in colostrum as well as mature milk. These are the very important cells that heal and repair all over the body. • Breast-feeding lowers the baby’s risk of the following: -- Developing Type 1 and Type 2 Diabetes -- Sudden Infant Death Syndrome (SIDS), the leading cause of death in infants after one month of age • Breast milk contains important nutrients as well as special protective factors. It’s natures way of safeguarding the newborn against infections. • Breast-feeding lowers the risk of asthma, colic, food allergy and eczema in those infants with a family history of allergy. • Breast milk may contain nutrients or other substances that promote nervous system development and affect intelligence. • Breast-feeding gives babies a chance to touch, to smell, to hear, to see, to taste and to know their mother from the first moment of birth. 53 HealthEast Maternity Care Centers are advocates for breast-feeding and are committed to providing accurate, up-to-date information. You will be supported in breast-feeding by: • Competent Maternity Care Center nurses, including lactation specialists and, when needed, lactation consultants. • The Outpatient Lactation Clinic. You can get help after discharge by telephone or by scheduling an appointment (provider order needed) with our lactation consultant. Call 651-232-3147. • Education. It is often helpful to attend a breast-feeding class before your baby is born. Check the HealthEast website for class information. Prenatal visit #5 28 weeks Date of visit Weight Blood pressure Fundal height Fetal heart tones • Cervix check if indicated • rho(D) immune globulin antibody status: (see visit #1 and visit #4). If your blood type is Rh negative, you will receive an injection of rho(D) immune globulin. • Gestational diabetes screen: Gestational diabetes is defined as glucose intolerance during pregnancy. It occurs in approximately 4 to 7 percent of pregnancies and is easily controlled with dietary changes. All pregnant women are screened using the GCT (glucose challenge test). If your blood sugar is too high, another test will be done to determine the presence of gestational diabetes. See information in Prenatal visit #4, page 50. • Flu shot - seasonal. • Re-screen for bacterial vaginosis if indicated. • Preterm labor risk assessment. • Criteria that were previously evaluated are reviewed for any significant changes. 54 Education Being a legal father If you are unmarried, you will be asked if you want to sign a Recognition of Parentage (ROP) form after your baby is born. By signing this form, a father establishes the legal relationship between himself and his child when he is not married to the child’s mother. The staff will discuss this important matter with you, and offer a booklet and video that explains the process and your rights and responsibilities as a parent. The father of the baby will need a picture ID for this process. Baby’s Birth Certificate Minnesota Statutes that affect the birth certificate. First, under Minnesota Statute the baby’s birth certificate must be completed within 5 days of birth, whether the parents have a name for the baby or not. Parents should never leave the hospital without handing in a yellow Birth Certificate Information sheet. Second, parents now have one year from the date of birth to make changes, additions, or corrections to the birth certificate free of charge provided they have not purchased a Certified copy of the birth certificate. Third, “Civil Marriage” will recognize marriage between same sex partners. Because the spouse of a married mother is the legal parent of any child born during the marriage, her spouse (male or female) will be entered on the birth certificate. However for married male partners the mother and biological father must complete an ROP form and the father’s partner must adopt the baby. Work Many women continue to work until the day the baby is born. You need not stop working, except for medical or personal reasons. Check into your employer’s benefit policies both during pregnancy and after birth. For information about your legal rights during pregnancy or for family leave information, call the Minnesota Commission on Economic Status of Women at 651-296-9002 or visit commissions.leg.state.mn.us/lcesw. 55 Physical discomforts The increasing size of your baby and uterus affects your comfort. Allow yourself extra time to complete tasks and be sure you get enough rest. Daily naps are recommended. Hospital pre-registration To make your admission to the hospital more efficient, ask your clinic for pre-registration forms to complete and mail to your birth hospital. You can also pre-register online at healtheast.org/maternity. Fetal growth Your baby is growing rapidly at this point in the pregnancy. Your baby can open and close its eyes, suck its thumb and cry. It exercises by kicking and stretching and responds to sounds like your voice or music. Your baby is now about 15 inches long and weighs about 3 pounds. Fetal well-being: counting your baby’s movement It is important to be aware of your unborn baby’s movement each day. Counting your baby’s movements is an easy way to check your baby’s health and well-being. Follow these steps: • Choose a time when you have most often felt your baby move. Make sure you choose the same time each day, when you feel calm and relaxed. This is usually after eating a meal. • Lie down on your left side, or place yourself in a reclining position. Call your provider if you: • Feel less than five movements in one hour. • Notice any change in your baby’s usual pattern of movements. Preterm (premature) labor What is premature labor? A full term pregnancy takes about 40 weeks. Premature labor is labor that occurs before week 37. Contractions or tightening of the uterus may cause the cervix to open too early. This could result in the birth of a premature baby who may have problems breathing, eating and keeping warm. 56 Why does it happen? The cause of premature labor is unknown. However, it is known that certain risk factors may increase a woman’s chance of having a premature labor. Some of the more common risk factors include: premature rupture of membranes (water breaking), infection (urinary/uterine), multiple gestations, history of previous preterm labor/birth and drug use. Can we prevent it? No, but often labor can be stopped. Early recognition of preterm labor signs can allow the use of medication and other treatments to stop labor and possibly prevent your baby from arriving too early. Signs of preterm labor While usually not painful, look for these signs to call your provider. It is important to call early as there are medications available that may stop labor! 1. Uterine contractions occurring every 10 minutes or more frequently—six or more contractions in one hour. What is a contraction? When a muscle contracts it becomes tight or hard to the touch. When your uterus contracts you will feel it get tight or hard. When the contraction stops, your uterus becomes soft. It is normal for your uterus to contract at various times in your pregnancy, such as when you first lie down, after sex and when you go up and down stairs. It is not normal to have frequent uterine contractions before your baby’s due date. If you feel a contraction every 10 minutes, or more often, for one hour then your uterus is contracting too much. How to check for contractions: Drink a glass of water. Lie down in a comfortable position on either side. Do not lie on your back; this may cause contractions to occur more often. Put a pillow at your back for support. Place your fingertips on the top of your uterus. If your uterus is contracting, you will actually feel your abdomen get tight or hard and then feel it relax or soften when the contraction is over. 2. Bleeding, spotting or leaking of fluid from your vagina including watery or bloody discharge. 3. Menstrual-like cramps in your lower abdomen or above your pubic bone. 4. Backache or feeling of pressure below waist level. 5. Pelvic pressure—feels like baby is pushing down. Pressure can be felt in your upper thighs, back and lower abdomen. Pressure may come and go or remain constant. 6. Abdominal cramping, with or without diarrhea. 57 Prenatal visit #6 32 weeks Date of visit_________________________________ Weight_____________________________________ Fundal height________________________________ Blood pressure_______________________________ Trust your instincts. If something doesn’t feel right or just feels different, call your provider. Fetal heart tones_____________________________ Education – travel There are no general restrictions on travel during pregnancy. The most comfortable time for most pregnant women to travel is during the second trimester. By this time your body has adjusted to pregnancy, and you probably have more energy. Toward the end of your pregnancy, it may be more difficult to move around or sit comfortably for long periods. You may also not want to travel during the final weeks of your pregnancy so you will be close to your provider for delivery. Although travel is safe in most cases, it is not recommended for women who have serious health problems and need special medical care. Car travel During any car trip, always wear your seat belt. Air bags do not replace seat belts. Plan to make frequent stops to stretch, move around and empty your bladder. If you are traveling a long distance or will be away for a long period of time, you should take a copy of your pregnancy record with you. This information will then be available in case you need medical care while you are away from home. How to wear your seat belt For best protection, wear a lap-shoulder belt every time you travel in a car. If only a lap belt is available, use it. Place the lap belt under your abdomen and across your upper thighs so that it fits as snugly and comfortably as possible. Put the shoulder belt between your breasts and across your shoulder. Adjust your seat if necessary to prevent chafing your neck. Never slip the shoulder belt off your shoulder. Seat belts worn too loosely or too high on the abdomen can cause broken ribs or injure your abdomen. 58 Air bags If you are driving, keep the steering wheel pointed towards your face, not abdomen. Sit about 12 inches from the steering wheel. Airline travel Flights in airplanes with pressurized cabins (such as commercial airlines) are safe, but check with the airlines about their policies on pregnant passengers. Flights in small planes without pressurized cabins are not recommended due to the pressure changes during flight. Metal detectors used for airport security checks are not harmful to the baby. Foreign travel Foreign travel raises unique concerns during pregnancy. Talk to your provider. They can help you decide if foreign travel would be safe for you and offer advice for advance planning. If you do travel, bring a copy of your medical records. The Centers for Disease Control and Prevention has an International Travelers’ Hotline for information on disease and world travel. The number is 1-800-232-4636. There are groups that can help you find a physician or hospital in a foreign country. Contact International Association for Medical Assistance to Travelers (Lewiston, NY), 716-754-4883 or International SOS Assistance (Philadelphia, PA), 215-244-1500. Contact them in advance of your trip for further details. Sexuality Pregnancy, with its many physical and emotional changes, may contribute to great variations in your need and desire for sexual expression. Generally, sexual intercourse is permitted throughout your pregnancy unless your provider advises against it. You may have intercourse UNLESS: • Vaginal or abdominal pain occurs or vaginal bleeding is present. • Amniotic membranes have broken or may be leaking. • There is a possibility of preterm labor. If your provider prohibits intercourse, ask for clear and specific instructions. If the aim is to prevent premature labor, you should avoid all methods of reaching female orgasm, because orgasm causes uterine contractions. 59 In the second and third trimesters, many physical symptoms subside, but a growing baby and enlarging abdomen make other adjustments in intercourse necessary. To avoid physical discomfort, you and your partner may need to try new positions. Side-by-side or rear vaginal entry positions may be more comfortable. Avoid introducing air into your vagina since this can cause problems during pregnancy. Usually, sex is as enjoyable as, or even more so, than any other time. Keep in mind that the need for intimacy, not necessarily intercourse, is important throughout pregnancy. Talking, planning and dreaming about the baby and the future you share is essential. Massage, hugs and other kinds of sexual stimulation are all ways you and your partner can physically express your affection for one another. Let your partner know how you are feeling. Talk openly and share your needs and concerns with each other. Gestational Hypertension—formerly called Pregnancy Induced Hypertension (PIH) Gestational Hypertension is a condition that can develop in late pregnancy. Signs of gestational hypertension are increased blood pressure, excessive edema (fluid retention) and protein in the urine. The causes are unknown and the incidence is relatively rare. However, if you experience the following symptoms, contact your provider: • Severe headache • Blurred vision • Increased facial swelling • Severe abdominal pain Preeclampsia Preeclampsia, a complication of pregnancy, occurs in 5 to 8 percent of pregnancies. Most cases are mild, occur near the end of the pregnancy and have healthy outcomes. But sometimes it can progress and pose a serious threat to mother and baby. Preeclampsia may cause your baby to be small and to be born prematurely. Sometimes women with preeclampsia are put on bed rest. If needed, medication to lower mother’s blood pressure is prescribed. Some risk factors are: • First pregnancy • Preeclampsia in a prior pregnancy • Mother 40 years of age or under 18 • High blood pressure before pregnancy • Diabetes before or during pregnancy • Poly cystic ovarian syndrome Symptoms of preecplampsia include high blood pressure, protein in the urine, headaches, swelling in hands, feet or face, and nausea. 60 Report symptoms to your provider because early diagnosis and careful management will help keep mother and baby safe. Talk with your provider about your concerns or symptoms; you may also find information at preeclampsia.org Tour of Maternity Care Center It often helps you feel prepared for birth if you’ve been able to tour the Maternity Care Center. Check the HealthEast website at healtheast.org for tour information. Labor and birth issues When to go to the hospital (active labor vs. early stages of labor) It is important for you to follow the advice of your provider, but the following guidelines are supported by HealthEast Maternity Care Centers. Active labor contractions generally start in the back, radiate to the front and down the abdomen. They will increase in length and discomfort as the time span between them shortens. Changing positions will not cause contractions to stop. Time your contractions for one hour. If this is your first baby, come to the hospital when contractions occur every three minutes, lasting 45 to 60 seconds. If this is not your first baby, come to the hospital when your contractions are approximately five minutes apart. Please call the hospital when you think you are in labor. Call your provider and go to your hospital’s Maternity Care Center (labor and delivery) if you have any of the following: • Rupture of membranes or leaking of fluid from the vagina. (Note time and color of fluid.) • Vaginal bleeding. • Sharp abdominal pain. • Fever of more than 100 degrees Fahrenheit. • Headache or blurred vision. • Decreased fetal movement. • If you feel something just isn’t right. 61 Premature rupture of membranes In about 15 percent of women, the amniotic sac will break before labor begins and in some of these women, labor will not begin within a short period of time. This is called premature rupture of membranes and is the most common cause of infection. Bacterial infections can be serious for both mom and baby. It is important to contact your provider if you think you are leaking amniotic fluid. Although many women will begin labor on their own after the membranes rupture, induction may become necessary. Induction What is a labor induction? As a woman nears the end of her pregnancy and labor has not started on its own, providers may use medications to start labor. When your care provider suggests a labor induction for your health or the health of your baby, it is called an indicated labor induction. When labor is induced for non-medical reasons, like for your convenience or preference, it is called an elective induction. Elective labor induction is not always a good idea for your baby. Inducing labor before you are at least 39 weeks along in your pregnancy, or before your cervix is ready, has risks. When is elective labor induction okay? You should have an elective labor induction only if it can be determined, with reasonable certainty, that neither you nor your baby would be at an increased risk by doing so. The following guidelines help determine if and when elective labor induction is okay for you and your baby: Your due date When you became pregnant your provider gave you an estimated due date for your baby. This is the date your baby is expected to be full term (40 weeks along) and ready to be born. Your due date is based on: • The date of your last menstrual period. • Results from various lab tests. • The size of your baby based on ultrasound exams. 62 Guidelines from the American Congress of Obstetricis and Gynecologists (ACOG). This is a professional organization for providers who deliver babies. The following guidelines are based on guidelines from this organization. • Your provider must be certain of your due date so labor isn’t started too early, before your baby is fully developed. • You must be at least 39 weeks along in your pregnancy. • Your cervix must be soft and ready to open (dilate). Your provider will know this by examining your cervix. • Your provider must confirm that you do not have a past history of Cesarean section or major surgery on your uterus. • The office record of your pregnancy must be available in the Maternity Care Center. If you do not meet these guidelines, your provider may recommend that the birth of your baby take its natural course. If your provider denies your request for an elective induction, don’t be upset. Be assured that the decision to let your baby come naturally is the best one for both you and your baby. You will want to discuss the situation fully with your care provider. You need to know the risks and benefits of your induction. When labor is electively induced before 39 weeks of pregnancy • Your baby is two to three times more likely to be admitted to intensive care. This will mean a longer and more difficult hospital stay for your baby. It may also make it harder for the two of you to breast feed or bond. • Your baby may have trouble breathing and need to be connected to a breathing machine. • Your baby may have trouble maintaining body temperature and need to spend time in a warming area to keep a stable temperature. When labor is induced and the cervix is not ready • You are more likely to have a longer labor, maybe more than two times as long. A longer labor means increased risks for you and your baby. • You are three to six times more likely to need an unplanned Cesarean birth. This increases the risk of serious problems for you and your baby with your current pregnancy and any future births. 63 Indicated labor induction Common reasons to induce labor are: no onset of labor beyond baby’s due date, membranes that have been ruptured for a long time; gestational hypertension-formerly PIH; problems with the baby’s well being; medical conditions in the mother, or if mom or baby may be harmed by the pregnancy continuing. If labor induction is suggested, be sure to ask why it is necessary and discuss all risks and benefits with your provider. There are several ways to start (induce) labor: • Medication for cervical ripening - The medication is placed in your cervix or your vagina. This is done in the hospital and usually by a nurse. The baby will be monitored afterwards. This medication is primarily used to soften or ripen the cervix before an induction planned for the next day, but occasionally it will also start labor. Depending on which medication you receive, you may go home after one to two hours or you may stay overnight for induction the next day. • Cervical Ripening with a Balloon Catheter / Cooks Catheter. This catheter is inserted into the cervix and the balloon is inflated with sterile saline. This applies pressure to the cervix. The pressure should soften and open the cervix, preparing your body for labor. When the catheter is in place, you will need to stay in hospital but you will be able to move around normally. • AROM (artificial rupture of membranes or amniotomy) - Sometimes labor is started (or augmented, if your labor stalls) simply by breaking your water. Most women start labor a few hours after the water is broken, but this method is not always reliable for starting labor. You may also need Pitocin. • Pitocin - Pitocin is a synthetic form of a woman’s natural hormone, oxytocin, which causes the uterus to contract. Pitocin helps increase the strength of each contraction and makes them more effective. Most commonly, it is given intravenously to stimulate labor. During induction, your baby and your contractions will be monitored. You may still be able to move around and can change positions as needed for comfort. Labor augmentation Prolonged labor increases a woman’s risk of exhaustion, infection and heavy bleeding after delivery. Once you are in labor, if your labor stalls and your cervix changes too slowly (less than 1 centimeter in two hours), your labor may be augmented with Pitocin. Fetal heart rate monitoring during labor and birth St. John’s Hospital and Woodwinds Health Campus require that all women admitted in labor have an admission monitor strip. After you arrive at the hospital in labor, two monitors will be attached to your 64 abdomen with belts in order to assess the baby’s heartbeat and your contraction pattern. Electronic fetal monitoring, or EFM, uses a machine that detects and prints out a graph of fetal heart beats and uterine contractions. The type and amount of monitoring you will have throughout the remainder of your labor will depend upon your provider’s preferences, your labor and the baby. Pain in labor and birth The perception of pain in labor is different for each woman, just as each labor is different and unique. Some factors that may influence your perception of pain are past experiences, cultural background and your expectations for your entire birth experience. When childbirth is normal, the pain is not a sign of injury, rather, it is “pain with a purpose” (Sheila Kitzinger, British Childbirth Educator). Women have different pain tolerance levels and some labors are longer and harder than others. Many factors contribute to what level of pain relief a woman needs. Discuss pain relief options with your partner and provider. Understand your options and you will make the choice that is right for you. Non-medicinal pain relief options A wide variety of methods are used to help women through labor. Some of these include: one-on-one support from your labor partner and/or a certified doula, relaxation and breathing techniques, aromatherapy, massage, acupressure and healing touch, position changes, walking, rhythmic movement or sounds, showers and baths and the use of water to birth in. Aromatherapy Aromatherapy is a natural therapy and healing art, using essential oils extracted from aromatic botanical sources, to balance and treat the mind, body and spirit. The oils can be used by inhalation, in baths, compresses, creams or through massage to the skin. The sense of smell is especially heightened during pregnancy and labor, so use your favorite oils to relax and soothe. This will also make the environment gentler and create a happy place in which to welcome your baby. Make an appointment at the Natural Care Center on the Woodwinds Health Campus to select the essential oils right for you. You can purchase the oils at the Natural Care Center. Some of the common essential oils used for labor and birth are available through the pharmacy at Woodwinds. Nurses may order them for your use during your labor and birth. Some commonly used oils are: tea tree oil, lavender, rosehips, jasmine, sage and chamomile. 65 Hydrotherapy/waterbirth Soaking in a tub of warm water sounds inviting to many women. Women who find water comforting often wish they could labor or birth in water. Laboring in water offers comfort, relaxation and often facilitates the progression of labor. When relaxing in a tub of water, your body is free from the pull of gravity. This reduces sensory stimulation which, in turn, may reduce the production of stress related hormones and a reduction in perceived pain. The Maternity Care Centers at St. John’s Hospital and Woodwinds Health Campus offer the opportunity to experience a waterbirth. Mothers who want a waterbirth should talk with their provider. Contraindications to waterbirth • Active genital herpes. • Presence of any infection that is transmittable by exposure to blood/body fluids (HIV, Hepatitis B and C). • Maternal fever. • Excessive vaginal bleeding. • Prior Cesarean birth. • Intrathecal or epidural analgesia. • Gestation under 37 weeks (unless approved by provider/midwife). • Meconium stained amniotic fluid/fetal distress. • Malpresentations of the baby, such as breech position. • Any condition the provider considers unsafe for mother and/or baby to labor or birth in water. Medicinal pain relief options These include narcotic-like analgesics administered by a nurse or epidural anesthesia administered by an anesthesiologist. It is important to know that narcotic-like analgesics and epidural anesthesia are not without risk. Narcotic analgesics are commonly given into a vein by a nurse. It reduces the pain and can help you relax or sleep between contractions. If given too early in labor, it can slow down your labor. 66 An epidural is anesthesia given through a space in your spine. It is placed and administered by an anesthesiologist. Additional interventions are required. You have an IV, blood pressure monitor, continuous fetal heart rate and contraction monitoring and, sometimes, a tube in your bladder to drain your urine. The epidural numbs you from the waist down, usually providing excellent pain relief, but also prevents you from walking or changing positions easily. Studies show that if you receive an epidural before your cervix is about four centimeters, your chances of having a Cesarean birth increase. Other risks include blood pressure drop and decrease in baby’s heart rate immediately after giving the epidural, spinal headache or infection, difficulty feeling the urge to push or a slowing of labor. Although epidurals are not without risk, there are some situations in which an epidural is appropriate and provides effective pain relief. You need to discuss medication concerns or questions with your provider. A newer method of pain management is intrathecal medication. It is administered by an anesthesiologist in a manner similar to an epidural. It requires accompanying interventions. Pain relief usually lasts about two hours. Episiotomies An episiotomy is the surgical cutting of the perineum to widen the space through which the baby comes. An incision is made into the perineum from the vagina toward the rectum (midline) or off to the side (mediolateral) just before the birth of the baby’s head. Some of the reasons for an episiotomy include to speed delivery of the baby by a few minutes, or to help prevent a tear from occurring. Some care providers do an episiotomy routinely and some do not. Talk to your provider about their philosophy and your wishes. Your baby’s provider Your newborn’s care can be provided by either a pediatrician or a family medicine physician. Decide who you want to take care of your baby before you go to the hospital. Call that clinic to be sure the provider participates in your health insurance plan and is accepting new patients. Call HealthEast Care System at 651-326-CARE (2273) or go to healtheast.org and click on “provider search” for information about providers in your area. 67 Getting ready to bring baby home The postpartum period is the first six to eight weeks after childbirth. It is a time of physical and emotional adjustment as your body returns to its pre-pregnant state and the family incorporates a new person into the home. The way each family adjusts is unique. Some preparation that most families find helpful: • Discuss role expectations and be sure to include other children in the home. • Look into community and family resources which may be needed. • Choose a provider for your baby’s care after birth. Some things to consider are the distance the office is from your home, qualifications and insurance requirements, if applicable. Get referrals from friends with children or your provider. • Pack your bag for the hospital. Include items for labor and postpartum, clothes and a car seat for the baby’s trip home. • Purchase or borrow the necessary clothing, supplies and equipment for the baby. • Buy a supply of diapers or sign up with a diaper service. • Create a convenient baby care area and sleeping area in your home. • Wash borrowed baby clothes. New clothes also need washing to clean and to soften. • Borrow or buy a book on infant care and one on breast-feeding, if appropriate. • Consider planning for two weeks of meals; prepare some meals in advance and freeze them. • Purchase nonperishable items before the baby is born and make a list of perishable items that will need to be purchased. • Clean your house. Discard unwanted piles of papers, magazines and clothing to provide extra space for the baby and baby supplies. • Arrange for help with chores when you are home from the hospital. This will help you to establish successful feedings, care for your baby, get adequate rest and nutrition and to have some time as a family. • If your maternity leave will be less than three months, begin to interview day care providers. • Make a list of important phone numbers that includes your provider, hospital and your baby’s provider. 68 Your baby’s layette Use the following as a guide in getting what you need before coming home from the hospital. Bedding Baby clothing Two to four crib sheets Four to eight undershirts Three to six receiving blankets Three to six gowns with drawstring closure One to two lightweight crib quilts One hat for newborn Two to four waterproof pads for crib and lap Two to four stretch suits with feet Diapers Four dozen cloth diapers, or Four dozen disposable diapers Three to six waterproof pants for use with cloth diapers (newborn size) Two to four small bibs Two blanket sleepers (depends on season) One to three pairs of booties or socks One to two sweaters (depends on season) Baby equipment Diaper ointment (check with baby’s provider) Crib Washcloths or diaper wipes Changing table (optional) Bath Car seat (mandatory) Two to four hooded towels or soft towels Digital thermometer Two to four baby washcloths Blunt-tipped nail scissors or baby nail clippers Baby soap and shampoo Baby bathtub (optional) Large foam pad to place beneath baby in the tub or sink (optional) 69 Prenatal visit #7 36 weeks Date of visit Weight Fundal height Blood pressure Fetal heart tones Cervix check Confirm fetal position Education Postpartum care Care in the hospital will be focused on your physical recovery, learning parenting skills and identifying and solving any problems. It is your opportunity to gain confidence in the care of your baby. Management of late pregnancy/signs and symptoms • Backache - Be particularly careful about lifting and activities like vacuuming, raking and shoveling. Do them carefully, or not at all. • Difficulty sleeping - Use pillows for propping, you may need to find time for naps. • Heartburn Eat small, frequent meals; avoid lying down immediately after eating. May use antacids listed under Medication. • Increased Braxton Hicks - These are often called “rehearsal” or “practice” contractions. These contractions help the uterus prepare for labor. Changing positions or a warm tub bath may help if they interfere with sleep. • Loss of the mucous plug (also called “bloody show”) - Loss of a pink or red streaked piece of mucous; may indicate the cervix is changing; labor may occur within the next few days. Body mechanics It is important to protect your back and joints with proper body mechanics. Good lifting techniques and observing an approximately 25 pound lifting limit will minimize your risk of backache. Pay close attention to good posture and you’ll be more comfortable. 70 Frequent urination This is common during this stage of pregnancy when the uterus puts increased pressure on the bladder. It is important to report any burning, increased odor or blood in your urine because those symptoms may indicate a bladder infection. Group B Streptococcus (GBS) screening in pregnancy GBS is a common bacteria found in the intestine, urinary tract and vagina in many healthy women. The bacteria can come and go without symptoms and antibiotic treatment does not completely eliminate the bacteria. GBS is not a sexually transmitted disease. A baby can be exposed to GBS during birth and this can cause serious newborn illness requiring hospitalization. GBS is the most common cause of newborn infection, affecting one to three babies per 1,000 deliveries in the U.S. Based on the results of the GBS screening, antibiotic treatment may be prescribed during labor. This reduces GBS transmission to the baby and lowers the chance for newborn infection. If you have any concerns, discuss them with your provider. Contraception or birth control Keep in mind that you can get pregnant whether or not menstruation has resumed; breast-feeding is not birth control. It is important to plan about contraception if you want to prevent pregnancy or to space your pregnancies. Talk about options with your provider. Prenatal visits #8-11 38 to 41 weeks Date of visit Weight Blood pressure Fundal height Fetal heart tones Cervix check 71 Education Postpartum vaccination If you are not immune to rubella (German measles), you may be vaccinated postpartum. Infant CPR This is a simple and potentially life saving skill to learn. Anyone responsible for the care of infants or children (parents, grandparents, babysitters, relatives and friends) should take this important class! Classes are offered through community education, the American Red Cross and hospitals. Post dates management (going overdue) The due date you are given is only an approximation of your baby’s birth date. A baby is considered ready to be born anytime between 38 and 42 weeks past the first day of your last menstrual period. Your due date is placed at 40 weeks. There are several tests used to assess your baby’s well-being at about one to one and a half weeks past your due date. If you feel that there has been a significant decrease in your baby’s activity level then you should contact your provider. They may recommend you do a fetal kick count or another form of evaluation. 72 These tests are: • Non-stress test (NST) - This involves monitoring the baby’s heartbeat (usually in the office) on a fetal monitor. A good pattern of the baby’s heartbeat usually means the placenta is healthy enough to supply the baby with adequate oxygen. An NST is often planned at about 41 weeks. • Ultrasound - This is usually done at 41-1/2 weeks. There are various indicators of baby well-being, including the amount of amniotic fluid, the muscle tone of the baby and breathing movements. Based on these findings, your baby will get a score and if the score is high, you may safely await the onset of labor. Because labor could occur at any time, it is important to stay well rested, eat well and be sure to drink plenty of fluids. 73 LABOR AND BIRTH During your hospital stay: What to expect for a vaginal birth Admission: Labor and birth First four hours after birth Four to 48 hours after birth Discharge Tests Lab work will be done, requested by your provider. Cord blood is sent to the lab for Rho Immune Globulin Screen if Rh negative. Blood is drawn for hemoglobin test. You may plan to be discharged by noon. Routine Admission interview: Collect medical information, complete admission assessment. You may have an IV to control bleeding, give medication or replace fluids. Take a bath three times a day. You will need to sign a discharge form for yourself and your baby. Nurses will monitor your blood pressure, pulse, temperature and bleeding. You may need an ice pack on your perineum for up to six hours after delivery. Rinse perineum with squeeze bottle during and after emptying bladder. Your IV will be removed. You are encouraged to take a bath. Breast care for breastfeeding: • Apply colostrum to nipple • Wear supportive bra as needed • Feel free to ask questions Diet 74 Light labor diet Regular diet Regular diet Regular diet Meds Activity Admission: Labor and birth First four hours after birth Four to 48 hours after birth Once an active labor pattern is established, you may have IV pain meds as needed if ordered by your provider. Epidural is available per request, if ordered by your provider. Discuss request for pain medication with your nurse. Oral pain pills may be given as needed for discomfort according to provider’s order. Oral pain pills may be given as needed for discomfort according to provider’s order. You will be given rho(D) immune globulin if needed. You are on a fetal monitor for 20 to 30 minutes. The nurse will assist and instruct you with baby care and self-care. The nurse will help you feed your baby. Attend a postpartum discharge class if offered; look over the materials in your patient education folder; ask your nurse questions. You may be up and about as you are able to tolerate it. Your nurse will review your individual needs and assist you with any requests. Teaching is based on your needs. Review education folder and written instructions on self and baby care. The nurse will give you written instructions regarding self-care and baby care. With a fetal monitor strip, you may walk, shower, sit in rocking chair or move about as desired. Teaching Feel free to ask your nurse any questions. Discharge You will be given Rubella and other immunizations if needed. The nurse will give you written instructions regarding resuming intercourse and tampon use. 75 During your hospital stay: What to expect for a Cesarean birth Before surgery Tests Lab tests including hemoglobin and blood type and screen will be done so that blood will be available as needed. Routine Arrive 1-1/2 hours prior to scheduled surgery time. Check in at Maternity Care nurses station. An IV will be started. You will be asked to sign a surgical consent form. The nurse will collect medical information and history. Diet Have nothing to eat or drink. You will drink an antacid called Bicitra to decrease acid in your stomach. 76 Recovery to six hours after delivery Following surgery, you will return to your room to be with your baby. A nurse will monitor your blood pressure, pulse and bleeding. A catheter will drain the urine from your bladder. The next day Discharge Blood is drawn for hemoglobin test. As needed. Your catheter will be removed. You may plan to be discharged by noon. Your dressing on the incision will be removed. You will need to sign a discharge form for yourself and your baby. Your IV will be removed when you are able to take fluids. You will have an IV for fluids and medications. Have nothing to drink for the first hour after surgery. When you return to your patient room, you can drink liquids. Continue to drink clear liquids. As your appetite and bowel function returns, you may have regular foods. Regular diet. Before surgery Meds Activity Recovery to six hours after delivery You will be able to discuss your method of anesthesia, epidural or general, with a provider who specializes in anesthesia. Medication may be added to your IV or you may be given pain pills for pain control after surgery. You may be up in your room as desired. You will be up at bedside within eight hours. The next day Pain pills will be available for discomfort. Rubella immunization if needed. You may shower if desired. You may walk as much as desired. You will be encouraged to walk in the hallway four to six times a day. No lifting anything heavier than your baby for six weeks. Your nurse will instruct you on care of incisions and signs of infection. The nurse will give you written instructions regarding self-care and baby care. You will take deep breaths and try to cough. Your nurse will review the birth with you and answer any questions. Rho(D) immune globulin will be given if needed. You may be given a prescription for pain pills if you need it. You may walk or be taken by wheelchair to Your nurse will assist the operating room. you in turning from side to side or sitting up. Teaching Discharge Your nurse will help you with baby’s first feeding. Your nurse will assist and instruct you with self and baby care. The nurse will give you written instructions regarding resuming intercourse and tampon use. 77 AFTER BIRTH Neonatal Intensive Care Unit (NICU) Most babies are born healthy and never need extra care. But for those who do, it’s reassuring to know that the NICU staff at St. John’s Hospital is there to offer expertise and support. The NICU cares for babies who are premature or need extra medical care after birth. The NICU is a level IIIa nursery. This means we treat babies as premature as 28 weeks gestation and care for sick newborns. The NICU is staffed around the clock by specially trained registered nurses, neonatal nurse practitioners and neonatologists. Our NICU has implemented a holistic developmental model of care. This means we care for baby’s total health – body, mind and spirit. Your baby will receive sensitive, individualized care that focuses on baby’s cues rather than on tasks and schedules. This supportive care enhances family bonding. As a complement to baby’s medical care, infant massage, healing touch, essential oils (prepared especially for newborns) or music therapy may also be used. The amount of light and noise around baby is altered to decrease stress and maintain a calm environment. The nursery at Woodwinds is designed for infants who are born 4-6 weeks prematurely or who need extra care after birth. Babies who require additional care will be transferred to the NICU at St John’s or to another hospital determined by your baby’s provider. Family Centered Care (Rooming in) Our Maternity Care Centers offer family-centered care. This means your baby stays in the room with you and we care for the whole family. We want families to be involved in the care of their baby. There is research that tells us the benefits of rooming in. Some benefits are: • When babies are close to their mom, it is easier for them to get used to life outside the womb. • When babies feel their mom’s warmth, hear her heart beat and smell mom’s smell - they feel safe. • Babies get to know their mom by using their senses. One of the senses babies use is smell. Babies are able to tell the difference between their mother’s smell and that of another woman by the time they are one to two days old. • Bonding and attachment are words that mean “getting to know” or “falling in love with” your baby. The sooner parents and babies spend time together, the sooner this can start. Baby’s attachment instinct is highest during the first days of life. Early attachment has a positive effect on baby’s brain development. It also helps baby feel safe. 78 • Rooming in helps mother to quickly learn baby’s cues. Cues are a baby’s way of telling you what he or she wants. Babies have many cues. There are cues that will tell you when they want to eat. When you know the cue, you will learn how to respond. Mother, baby and the whole family will learn baby’s cues. • Maintaining a good milk supply. When baby shows hunger cues, he or she should be put to breast. Frequent breast-feeding will help mother to produce milk and keep up her milk supply. Babies need to breast-feed eight to 12 times in 24 hours. • Rooming in encourages families to be baby’s main caregivers - before they go home. This will increase parents’ confidence to care for their new baby. • Rooming in helps babies regulate their body rhythms. This includes baby’s heart rate, body temperature and sleep cycle. Nurseries have lights, noise and other distractions. This can interfere with cues regarding the development of baby’s rhythms. • Mothers usually sleep better when their baby is in the room. Mom saves energy by not getting up to go to the nursery. Mom can check on baby and feed baby easily. And, mothers won’t worry about their baby in the nursery. Questions you may have about rooming in What is rooming in? Rooming in is when your new baby stays with you in your Maternity Care room. What if I am unable to care for my baby Talk to our staff and we will create a plan together to meet your needs. If I have a Cesarean birth, should my baby still room in with me? It would help you if a family member stays with you. They can help you care for your baby. You and your baby would still have the benefits of rooming in and spending time together. What if I don’t know how to care for my baby on my own? Teaching is an important part of your stay in the Maternity Care Center. You will not be alone. Our staff will help you learn to care for your baby. 79 Infant security in the hospital It is important to be watchful over your newborn at all times. • You, your partner and baby will be given hospital identification (ID) bands. These bands have the same number. The band numbers are checked by staff every time you receive your baby. Keep your ID band on the whole time you are in the hospital. • Never leave your baby alone. If you want to nap or keep baby with you during the night, place the crib near your bed on the side of the room away from the door. Close the door to your room. You may bring your baby’s crib into the bathroom when you take a bath. • Ask your nurse about daily newborn procedures, feeding, visiting hours and newborn security. • DO NOT give your baby to anyone who is not wearing proper hospital ID. Hospital staff who are approved to care for newborns have a colored stripe on each side of their hospital ID badge. • Know where your baby will be taken for tests or procedures. Ask how long your baby will be away from you. Ask if you are able to go with your baby. • Babies are always transported in their crib – never carried. If anyone tries to take your baby without a crib, immediately use your call light to call a staff person. • Remember the nurses caring for you and your baby. Be careful with unfamiliar people entering your room or asking about your baby – even if they are dressed in hospital clothes. If you have concerns or questions, immediately use your call light to get a staff person to come. Minnesota newborn screening program The Minnesota Newborn Screening Program is a public health screening program for all infants born in Minnesota. This Minnesota Department Health laboratory and follow up program provides high quality, timely, low cost laboratory screening and referral resources in order to prevent or minimize the long term effects of disorders that can lead to death, developmental disability, or other serious medical conditions . Newborn screening Between 24 and 48 hours of age, your baby will be screened for more than 50 rare, metabolic diseases. The screening is important! If any of these diseases are found and treated, serious problems may be prevented. Minnesota state law requires screening on ALL newborns for these diseases. Parents may choose not to have their baby screened. If parents do not want their baby screened, they must complete and sign the “Parental Refusal of Newborn Screening” form. This is a formal and legal way to state that you voluntarily choose not to do the newborn screen. 80 How is your baby screened? A few drops of baby’s blood is sent to the Minnesota Department of Health to test for more than 50 rare, metabolic diseases. The discomfort to your baby is small, and the benefits of testing for these diseases is great. Test results are sent to your baby’s provider. Ask about your newborn screening results at the two week visit. Newborn hearing screen Universal Newborn Hearing Screening (UNHS) / Early Hearing Detection and Intervention (EHDI) The Minnesota EHDI program ensures that all infants and toddlers with hearing loss are identified as early as possible and provided with timely and appropriate audiological, educational and medical intervention. The program includes three basic components: newborn hearing screening, audiological diagnosis and early and ongoing support and services. After birth, while your baby is in the hospital, our staff will give your baby a hearing test. This test is painless and is done while your baby is asleep. You will be given the results of the hearing test right away. If your baby failed the test you will be referred to your baby’s provider or an audiologist for follow up. Failing the test does not necessarily mean your baby has hearing problems. Sometimes babies fail the test because there is amniotic fluid or debris remaining in the ear canals. Your provider or audiologist will know for sure. Information on newborn screening can be found at health.state.mn.us/newbornscreening. Pulse Oximetry Screening for Critical Congenital Heart Disease (CCHD) This is a newborn screen where we look for congenital heart problems. What is Critical Congenital Heart Disease (CCHD)? CCHD is a problem in the structure of the heart or its major blood vessels. It is the most common birth defect. Some forms of CCHD are very serious (critical). These can cause a baby to become sick soon after birth. How do you check for CCHD? Before your baby goes home, we will check for: • A sound in the baby’s heart, called a heart murmur • Abnormal heart rate, breathing or blood pressure Babies with CCHD don’t always have these symptoms right after birth. But if your baby has any of these symptoms, we will need to do more tests. We will also do a pulse oximetry [ox-EH-mah-tree] test to check for low oxygen levels. 81 What is pulse oximetry? Pulse oximetry [ox-EH-mah-tree] is a simple bedside test that measures the amount of oxygen in the blood. The test is done when your baby is between 24 and 48 hours old. The machine we use is called a pulse oximeter. Sensors are placed on the baby’s skin to measure oxygen levels. The test is painless and takes only a few minutes. Why should my baby have pulse oximetry? Low levels of oxygen in the blood can be a sign of a serious CCHD. If your baby has CCHD, this test may tell us before your baby becomes sick. If your baby has low oxygen, we will do more tests to find out if your baby’s heart is normal. Low oxygen may also occur if: • Your baby’s lungs and heart are still adjusting after birth • Your baby has a lung problem Where can I get more information? Your baby’s provider or nurse is a great resource. You may visit: Congenital Heart Defects: cdc.gov/ncbddd/heartdefects/ index.html Screening for Critical Congenital Heart Defects: cdc.gov/ncbddd/pediatricgenetics/ CCHDscreening.html Cord blood banking Cord blood banking allows parents to store stem cells from baby’s umbilical cord. The stem cells would be used in the future if the baby or child develops a disease that may be helped with the use of stem cells. • Families purchase a cord blood collection kit from the Cord Blood Bank. The kit is brought to the hospital when mother is in labor. Mother’s provider or hospital staff is asked to collect the blood. This must be approved in advance by your provider. • The blood is then mailed to the Cord Blood Bank for storage. • Fees for collection and processing in the first year range from $1,000 to $2,000. • There is also a yearly storage fee of about $100. 82 The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists state there are no accurate estimates of the likelihood that children would need their own stored cells. This makes it hard to recommend that parents store their children’s cord blood. There is no guarantee that the cells will ever be used. Banking may be considered if there is a family member with a current or potential need to undergo a stem cell transplant. You may consider donating your cord blood to a public bank, such as the American Red Cross. Questions about cord blood banking should be discussed with your provider. More information may be found at: • American Red Cross of the Twin Cities Area at 612-627-5800 or redcrosstc.org • PharmaStem Therapeutics, Inc. at pharmastem.com • National Institute of Health, search “stem cells” at nih.gov • American Academy of Pediatrics at aap.org • Cord Blood Information at cord-blood.org YOUR BABY’S BIRTH CERTIFICATE Your baby needs a birth certificate. Everyone must have a birth certificate. A birth certificate is your baby’s official birth record. A birth certificate is needed to get a social security number. Later it is needed to get a driver’s license, passport or pension benefits. Birth certificates also: • Give health researchers data. • Help find mothers and babies who may have special health needs. By identifying these needs early, we can help mothers and babies become healthier. In our hospitals you will be given a handout that explains everything you need to know about your baby’s birth certificate. You will be given a form to fill out. You will be asked to complete this before you go home. The birth record will be registered with the Minnesota Department of Health. 83 MOTHER’S PHYSICAL CHANGES AND ADJUSTMENTS Afterpains After birth your uterus will continue to have contractions that facilitate the process of involution – returning the uterus to its pre-pregnant size. These contractions are called afterpains and are much milder than those during labor. Afterpains often occur when breast-feeding and are more common if you’ve had a baby before. Pain medication may be prescribed by your provider, but most women experience adequate relief with over-the-counter medications like ibuprofen (Motrin® or Advil®) and acetaminophen (Tylenol®). Emptying your bladder, warm tub soaks or a heating pad may provide additional comfort. Vaginal bleeding Normal vaginal discharge is heavy and bright red the first few days after your baby’s birth (vaginal or Cesarean) and may contain small clots. When you get out of bed or stand after breast-feeding, you may experience a gush of blood. Usually within 10 days of birth the bleeding decreases in amount and turns pink in color. Within a few weeks it becomes yellow, white or brown. There may be a light or spotty flow for six to eight weeks after birth. When the flow is heavier, change your pad after each voiding or every four hours to prevent the growth of bacteria. Use sanitary pads, not tampons, and delay sexual intercourse until your provider advises. Call your provider if you have excessive bleeding, large clots, unusual tenderness, foul smelling discharge or a fever. Menstruation – when will your periods resume? It is difficult to predict exactly when your periods will resume. If you are not breast-feeding, your period may begin in five to eight weeks. If you are breast-feeding, you may begin your period in two to four months, or it may not begin until you are finished breast-feeding. Breast-feeding is not a means of birth control. Episiotomy – stitches If you have had stitches for an episiotomy or tear, the stitches will dissolve and do not have to be taken out. Initially, this area may feel painful and bruised, but will heal over a period of three to four weeks. The goal is to prevent infection, decrease pain and promote healing. • Ice the perineum as soon after birth as possible. Ice will minimize swelling and decrease pain. Ice can be used for the first 24 hours. • Use a squeeze bottle filled with warm water to rinse your stitches after you urinate. 84 • Pat your bottom dry, from front to back. • Soak in a clean tub of warm water two to four times a day for at least 15 minutes. • Use witch hazel pads (like Tucks®) by holding them in place with a sanitary pad. Change pads frequently during the day. Store Tucks® in the refrigerator for cooling comfort. • To help your stitches from pulling, sit squarely on your bottom and do Kegel exercises. • Rest as much as possible. • Don’t use tampons, douches or have intercourse before advised by your provider. Third or fourth degree laceration The above suggestions will be helpful. Also recommended are the following: • Continue with a high fiber diet. Drink 6 to 8 glasses of water daily. • Use a stool softener as ordered by provider. • Do not use rectal suppositories or enemas. • If you don’t have a bowel movement within three days, or if you have increased tenderness in the perineal area, call your provider. Incision care - Cesarean birth Before you leave the hospital, the staples or long stitches will usually have been removed. There may be strips of tape across your incision called steri-strips; you can leave these on until they become loose and are easy to remove or they simply fall off on their own. It is important to keep the incision clean. Your provider will let you know if you can take a shower or bath. It is normal for the incision to itch as it heals. Report to your provider any drainage, redness or increase in pain in the incision. Deep Vein Thrombosis (DVT) One small, but potential risk during pregnancy and up to six weeks after birth, is that of a venous thrombosis or blood clot. About 1 to 2 women in 1000 will get a blood clot during pregnancy or just after birth. DVT, or deep vein thrombosis, is when a blood clot forms in a deep vein, usually in the leg or pelvis. Anyone can develop a blood clot, but pregnancy and birth place you at greater risk. The symptoms of DVT are pain, tenderness and swelling of the leg. There may be a slight discoloration of the skin on the effected leg. If the clot is in the thigh, the whole leg may be swollen. Call your provider if you have any of these symptoms. 85 DVT is confirmed by an ultrasound exam of the leg. It is treated with a medication called heparin. Heparin is an anticoagulant - it “thins the blood”. It cannot break up the clot, but will keep it from getting bigger. Then your body will be able to dissolve the clot and it will go away. You will also be given compression stockings to wear. These special elastic stockings improve blood flow and decrease swelling of the legs. They should be worn for several months. Your provider will know your risk factors and will advise you on ways to avoid, or minimize your risk of, DVT. Being up and walking about, staying active, can help prevent DVT. Bowel management After birth, you might feel apprehensive about having a bowel movement or you may feel constipated due to tenderness of the perineum, an episiotomy, uncomfortable hemorrhoids or weak abdominal muscles. You may also have some constipation from iron supplements. Drink fluids (especially water) and include plenty of whole grain cereals, fresh vegetables and fruits in your diet. Exercising your abdominal muscles, walking and responding when you feel the urge to have a bowel movement (rather than avoiding it) will assist in the return of your normal function. It may help to support your perineum by gently pressing toilet paper at the episiotomy site during a bowel movement. The relaxation techniques you learned in childbirth class will also help. Vaccination against Pertussis (Whooping Cough) Pertussis or Whooping cough is usually a mild illness for adults, but can be severe, even deadly, for infants less than 1 year of age. Since this disease is still present in the United States, the Centers for Disease Control and Prevention recommends parents have vaccination against Pertussis to protect the newborn until the vaccine the baby receives (which starts at 2 months) is effective. Parents who have not had the Tetanus shot which contains the Pertussis immunization prior to the baby’s birth, should receive ADACEL® or BOOSTRIX®. The vaccine is commonly referred to as the “Tdap”. It is recommended to find out when your last vaccination was received and if it contained the Pertussis part. Prior to May, 2005, the vaccine was only for Tetanus and Diphtheria and provided no protection against whooping cough. Pregnant women should get a dose of Tdap during every pregnancy, to protect the newborn from pertussis. Infants are most at risk for severe, life-threatening complications from pertussis. 86 Mothers can be vaccinated after delivery, before discharge, but partners should seek vaccination anytime before birth from a clinic of their choice or a public health clinic. Other family members who will have close contact with the newborn should be vaccinated, too. The immunization can cause some painful swelling at the injection site, general body aches, tiredness, and/or headache. Have you received the Tdap vaccination? If “yes”, on what date? Insert date Hemorrhoids Allow some time to pass for hemorrhoids to improve. Most go away in two to six weeks. Some specific things you can do to promote healing and reduce discomfort include: • Soak in a warm tub several times a day. • Avoid constipation by eating extra dietary fiber, drink plenty of fluids and use stool softeners as needed. A mild laxative may help. • Use witch hazel pads (like Tucks®). • Talk with your provider for additional suggestions. Breast care for non-breast-feeding mothers Even though you are not breast-feeding, your breasts still experience changes and will need care in the days and weeks after birth. • A supportive bra worn 24 hours a day provides comfort for some women. You decide what feels best. • Your breasts will likely feel full and uncomfortable two to five days after your baby is born. This is due to circulatory changes in your breasts. Ice packs to your breasts (try a package of frozen peas wrapped in a wash cloth and tucked in your bra) will ease the discomfort. • You may experience leaking of breast milk. Express just to the point of comfort. Expressing more will stimulate your breasts to make more milk, which may add to your discomfort. • Tylenol® may be used to ease discomfort. 87 Breast care for breast-feeding mothers Breast changes occur in each woman after giving birth. Breast-feeding mothers may find the following helpful: • A well fitting, supportive bra will offer comfort. • Gently wash your breasts each day and avoid using soap on your nipple area. • Wash your hands before each feeding. • Drink enough fluids. Have a glass of water nearby when you feed your baby. • Nipple tenderness or soreness is common around four to five days as your nipple stretches. Latch on discomfort should be temporary, breast-feeding should not be a painful experience. Apply expressed colostrum or breast milk to your nipples or pure lanolin (PureLan™ or Lansinoh®) to help heal. • Call HealthEast Outpatient Lactation Clinic at 651-232-3147 and talk with our lactation consultant or call your provider if pain is severe or nipples are cracked or bleeding. Rest and activity Getting enough rest is essential to recovery after your baby’s birth. Here are some suggestions: • Rest or sleep when your baby sleeps. Go to bed early if possible, especially if you are getting up for night feedings. • Don’t overtire yourself with every day chores. Avoid too much entertaining when you first get home. Encourage visitors to come for short periods of time. Accept the help of friends and family for basic household tasks and cooking. • Avoid heavy lifting for two weeks after a vaginal delivery and six weeks after a Cesarean birth. When lifting, remember to bend your knees and use your leg muscles. Have older children climb onto your lap. • Exercising can usually be resumed four to six weeks after delivery. Daily walks can be taken as soon as you feel ready. • Overall, gauge your activity by how you feel, follow your provider’s guidelines and take advantage of offers of help. Postpartum warning signs: When to call your provider • Fever or chills with a temperature of 100.4 degrees F or higher • Pain, redness, warmth or swelling in any part of your leg(s), or pain when you point your toes toward your head 88 • Pain or burning when urinating, any change in frequency or not being able to empty your bladder • Hard, red, painful areas in your breast accompanied by a fever or chills • Passing golf-ball sized (or larger) clots, clots containing whitish tissue or bright red bleeding that soaks through a pad in one hour or less • A foul smelling or greenish vaginal discharge • Constant back, abdominal or pelvic pain. Abdomen that is tender to touch – other than usual tenderness around a Cesarean incision • Stitches that have become painful, red or separated – or that have pus-like discharge, with or without a fever • Any difficulty breathing, headache, double or blurred vision • A feeling of extreme sadness or depression that lasts longer than a week; not having enough energy to care for yourself or baby Postpartum depression: Things you should know Women adjust to the role of motherhood in a variety of ways. Most women have a few tough or weepy days, balanced by days that go fairly well. The “baby blues” commonly occur in the first weeks after birth and are usually short-lived and temporary. Often the blues can be decreased by some extra self-care such as a walk without the baby, extra rest, a long bath, improving nutrition or a visit with a good friend. However, if the common symptoms of the baby blues continue or worsen, professional help is needed. Be aware of your feelings and emotional health for the entire year after your baby is born. Postpartum depression is a serious disorder that affects 10 to 20 percent of mothers who have recently given birth. It is commonly confused with the “baby blues,” a less serious problem characterized by sadness and tearfulness that usually begins within a few days after delivery, and lasts from hours to days. In contrast, the symptoms of postpartum depression are more severe and persist for weeks to months. These symptoms do not have to be severe before you seek help. Call your provider for professional help. You may call the Maternity Care outreach nurses for information regarding postpartum support groups. At HealthEast Maternity Care we screen for postpartum depression. Women are given the Postpartum Mood Assessment tool. It is a self assessment. When complete, give the tool to your nurse for scoring. A high score will be referred to a HealthEast social worker for follow up. 89 Symptoms of postpartum depression To diagnose depression, five or more of these symptoms should be present nearly every day for at least two weeks: • Feeling down, depressed • Having decreased interest or pleasure in activities • Having decreased or increased appetite/weight • Sleeping poorly, or wanting to sleep more than usual • Feeling agitated, edgy or slowed down • Being fatigued, having little energy • Feeling worthless or guilty without good reason • Having difficulty thinking or concentrating • Having recurrent thoughts of death or suicide or of harming your baby: If you have this symptom, call your physician immediately. Common myths about depression Myth: ”Depression is caused by a weakness in my personality, or something I did wrong.” This is not true; rather, it is caused by a change in brain chemistry. Women who have recently given birth are more susceptible to such changes, given their dramatic hormonal shifts, the demands of caring for an infant and their frequent lack of sleep. Remember that depression is not your fault. Myth: ”There is nothing I can do to make my depression better. I just have to wait it out.” There are medications and other treatments that are very effective in treating depression. They will usually help to decrease the severity and duration of symptoms. Myth: ”People will look down on me if they find out that I am depressed.” Most of the time, people will respect you for recognizing your symptoms and seeking help. This is true of the health care workers at your clinic and it is also often true of your close friends and family members. If those who are close to you understand the problem, they will be in a better position to help you. Myth: ”I will never be the same again. I will always struggle with this feeling of sadness.” Interestingly, depression itself can produce thought patterns that make you believe you will always be depressed. However, most people who are depressed do get better. It may take awhile - weeks to months - before you are completely back to normal, but medications and other treatments can speed the process. Nearly all those who become depressed recover. 90 Some questions about depression treatment and recovery • What types of treatment are available for postpartum depression? The most commonly used treatments are antidepressant medications and counseling, used either separately or together. Other treatments might include group therapy, hormone therapy or even light treatment. • What are some of the side effects of antidepressant medications? Although most people tolerate these medications quite well, they may experience some nuisance effects. Selective serotonin reuptake inhibitors (SSRIs) can produce sleepiness or insomnia, nervousness, nausea, vomiting, diarrhea or sexual difficulties. Tricyclic antidepressants (TCAs) may cause tiredness, dizziness, dry mouth, constipation, weight gain, palpitations, blurred vision and urinary retention. If you are breastfeeding, discuss the risks and benefits of antidepressant medication with your physician. • How long will the treatments last? Antidepressant medication is usually given for several months, and may be continued for a year or longer. If you receive counseling, several visits are usually recommended. • What can I do to help myself recover from postpartum depression? See your physician as soon as possible, and follow through on prescribed treatments and follow-up visits. If a treatment disagrees with you or is not making you feel better, don’t just stop it on your own. Rather, talk to your physician about what to do next. Be sure to eat nutritious foods, get regular exercise (taking your baby for a stroller ride counts), and allow yourself adequate rest and time for fun and relaxation, even if it is for only a few minutes a day. Parents with infants tend to have very heavy work demands that include childcare, household work, and often, employment. Try to find ways to cut back on some of these demands while you are recovering from your depression, by getting help from friends and family members with household chores, childcare and nighttime feedings. You may also want to cut back on your paid work time for awhile. • What should I do if I feel so desperate that I might hurt myself? Call 911, your physician or a crisis line immediately. You may call the Crisis Connection at 612-379-6363 for assistance. For spouses or partners of a depressed person • You are very important to your partner’s recovery. • You can help by being supportive, both emotionally and practically, by being there, listening, helping to care for the baby and any other children during the day and at night, and sharing in the housework. In addition, encourage your partner to keep follow-up appointments with physicians and therapists, and to take prescribed medications. 91 • Having a depressed partner requires extra effort on your part, so make sure you get the support that you need from family and friends, support groups, etc. If you yourself feel depressed, see your physician. • It is common for parents with infants to have decreased sexual activity, sexual enjoyment and partner satisfaction. Although these changes tend to smooth out over time, depression may make them worse. If you are having problems in these areas, please discuss them with your physician. For additional information about postpartum depression, go to postpartum.net. See our other resources listed at the back of this book. If you have a spouse or partner, please share this information with that person. GESTATIONAL DIABETES FOLLOW-UP Most women’s blood sugar will return to normal after delivery. But, gestational diabetes is a warning sign that you are at risk of getting diabetes later in life. You are also more likely to have gestational diabetes with your next pregnancy. Even if your blood sugar is back to normal you still have to take care of yourself. This will help prevent diabetes later in life. How can you lower your risk of diabetes later in life? Maintain a healthy weight Follow simple guidelines, like eating foods that include whole grains, fresh fruits and vegetables, protein found in meat, dairy and eggs. Limit your fat intake to 30% or less of your daily calories. Limit sweet treats and watch portion size. You can find additional information at choosemyplate.gov Exercise Regular exercise helps lower your blood sugar. It also helps you maintain a healthy weight. Breast-feed Breast milk is the best food for most babies. Breast-feeding may help lower your blood sugar. This decreases your risk of getting diabetes later in life. It also decreases your baby’s risk of getting diabetes later in life. Follow Up Care It is recommended to have your blood sugar tested at your postpartum check up. There are different types of tests. Test options include: fasting blood sugar; hemoglobin A1C; 2 hour glucose tolerance test. Your provider will do a fasting blood sugar. 92 If your follow-up test is normal, you should be retested at least every 3 years. More frequent testing is important if you plan to become pregnant again, or if you have other risk factors. Risk factors may be obesity, high blood pressure, high cholesterol or a family history of diabetes. At your postpartum check up, ask your provider if you will need additional testing for diabetes. Resources: The American Diabetes Association diabetes.org DIET AND POSTPARTUM EXERCISE Continue to eat a well-balanced diet. Do not crash diet. Your body needs extra nutrients to heal and to produce milk for your baby if you are breast-feeding. Drink plenty of fluids and if you are breast-feeding, continue taking your prenatal vitamin. Pregnancy greatly affects the abdominal and pelvic floor (perineum) muscles. After birth the abdominal muscles need to be firmed and the pelvic floor muscles need to be toned to provide support for the pelvic organs, to control urination and to promote sexual pleasure. The lower back muscles may need to be stretched if you had a swayed posture during pregnancy. Check with your provider before starting to exercise. Guidelines for exercising • Do fewer repetitions if you need to. • Don’t exercise to the point of pain. • Stop and rest if you feel dizzy. • Split the exercises into groups and do them throughout the day rather than doing them all at once. • Watch your breathing. Exhale during the most difficult part of the exercise; don’t hold your breath. • Walking is an excellent conditioning exercise and can also help lift your spirits. The American College of Obstetricians and Gynecologists has exercise guidelines at their website: acog.org/Search?Keyword=exercise+pregnancy Stretching To help the uterus and other pelvic organs return to good posture and prevent back strain, lie on your stomach with a pillow under your hips and with your arms above your head. Feel the stretch from head to toe as you make yourself as long as possible. Squeeze your buttocks together and tighten your abdomen for more toning. Relax and repeat. Try to lie on your stomach for 10 minutes. 93 Kegel exercise To strengthen and tone pelvic floor muscles and increase circulation, squeeze the muscles that you use to stop the flow of urine. Hold for up to 10 seconds, then release. Knee to chest To relieve backache, lie on your back with your knees bent, feet flat and pelvis tilted. Breathe out as you bring one bent knee toward your chest. Hold the position for three seconds and feel the stretch in your lower back. Repeat with the other knee. Do five repetitions. Partial sit-ups or curls To strengthen abdominal muscles and improve back posture, lie on your back with your knees bent and feet flat on the floor. Breathe in, tilt your pelvis and keep your lower back pressed against the floor. While breathing out, raise your head and shoulders from the floor, reaching your outstretched arms toward your knees. Keep your waist on the floor. When your shoulders are raised about 8 inches, hold this lift for five seconds. Relax and gently lie back. Repeat about five times a day. Heel slides To increase strength and circulation following a Cesarean birth, lie on your back with your legs straight. Slide heels alternately toward and away from your buttocks. Start doing three to five repetitions four or more times per day. Abdominal tightening and breathing To enhance abdominal muscle tone, while lying on your back with bent knees, place your hands on your stomach. Inhale deeply through your nose allowing the abdomen to rise up and keep the ribs as still as possible. Exhale slowly through pursed lips while tightening your abdominals. Imagine that you are touching your abdominals to your spine. Hold for five seconds and relax. Do five repetitions three times a day. Pelvic tilt To strengthen abdominal muscles and release backache, while lying on your back with bent knees, breathe in slowly. Tighten your abdominals and buttocks and tilt or rock your pelvis so you feel the small of your back flatten against the floor or bed. Don’t push with your feet. Hold for five seconds, then relax. Do five repetitions three times a day. 94 YOUR NEWBORN General newborn appearance You may find yourself staring in amazement at your new baby as you take in all of the unique features of your newborn. Although no other baby will look exactly like yours, there are some characteristics common to most newborns. Body Baby’s shoulders are narrow, the abdomen protrudes, the hips are small and the arms and legs are relatively short and flexed. Baby may have fine, downy hair on his or her back, shoulders, ears and cheeks. Head Baby’s head may be misshapen as a result of squeezing through the birth canal. It will become more rounded within the first days of life. Baby’s head may seem large in proportion to the rest of his or her body. There may be some swelling or bruising of the scalp. This is also due to the birth process and will vanish with time. There are two soft spots on baby’s head, called fontanels. These are areas where the skull bones have not completely joined. The smaller fontanel usually closes within two to six months and the large one closes by the time the baby is 18 months old. These areas are covered by a tough membrane so that washing or brushing the scalp will not hurt your baby. There may be puffiness around the eyes or facial bruising. Babies usually display crossed eyes. This disappears at around four months of age when the muscles controlling the eyes become stronger. Skin At the time of birth, baby’s skin is grayish-blue, it’s wet and there may be some streaks of blood and a white creamy coating called vernix. The skin tone will become normal within a minute or two after the baby begins breathing. There may be red areas on the back of the neck, eyelids, nose or forehead. These are collections of superficial blood vessels, not true birthmarks, and usually fade away by 9 months of age. Newborn rash is very common and is characterized by red blotches that come and go. This does not require any treatment. Many babies have peeling skin around their hands, wrists, ankles and feet. If your baby was overdue, you will probably notice this. Using unscented lotions may be helpful. 95 Breasts and genitals Due to the mother’s hormones, both male and female babies may have swollen breasts. This will go away within a few days. Female babies may have swollen labia and there might be milky or blood tinged mucus that comes from the vagina. Male babies may have swelling and redness of the scrotum. These conditions are temporary and do not require any treatment. A red or pink “brick dust” appearance on the diaper suggests your baby may not be getting enough milk. “Brick dust” on the diaper results when uric acid crystals form in concentrated urine. It is not an uncommon occurrence with breast-fed babies during the first day or two, when the quantity of colostrum the baby drinks is low. Once your milk comes in, however, your baby should be able to drink enough milk to produce clear urine. Umbilical cord At delivery, the cord is covered with a white, jelly-like substance. This will dry, turn black, and the entire cord will usually detach within 10 to 21 days. If you notice a protruding belly button, this could be a hernia and should be evaluated by your provider. Breathing Newborns have periods of time when their breathing is irregular. They also make gasping, groaning or snorting noises when they are asleep. They may even pause in their breathing. These can all be frightening to new parents. It may help to know that this is not a concern unless baby’s skin turns blue. These irregularities usually disappear around 2 months of age. 96 BABY STATES Your baby has different levels of sleeping and waking states. Babies behave in certain ways during each state. If you can tell the state your baby is in, you can get to know your baby better. For example, being able to tell when your baby is fully awake will help you know the best time for feeding or playing. When you understand sleep states, you can know the times to let your baby sleep. Your baby cannot be spoiled by being picked up when crying, but will feel secure and loved. Most babies move smoothly between states and may move up and down one or two states at a time. In newborns, this change can happen very quickly. Baby state Sleep – quiet Characteristics • Baby is lying still • May make jerky movements or may startle What it means for you Baby is difficult to awaken. Not a good time to eat. Allow baby to sleep. • Mouth may be making sucking movements Sleep - active • Makes occasional face or body movements • May suck, smile; eyelids flutter Easy to awaken. Wait until baby is fully awake to eat. Do not assume noises mean baby’s fully awake. • Makes brief fussy or crying sounds • Body movements are smooth Sleepy • May gently startle • Eyes open and close because they are heavy, dull and sleepy • Some facial movements This state occurs just before waking; you may think your baby is awake when you see his or her eyes open and close, but wait to see if baby will awaken or wants to sleep. To wake up your baby provide something to look at or listen to. 97 Baby state Alert - quiet Characteristics • Baby’s eyes are open and bright • Moves arms and legs • Face has bright, alert look • Baby will focus on your face, voice or moving objects Alert - active • Baby’s eyes are open, but less bright • Moving arms, legs and head - a lot • Baby is more sensitive to noise and hunger • Not really able to focus What it means for you Baby signals readiness to be with you. Talk in a soothing, gentle tone; provide stimulation in the form of sounds or objects to look at; gently, but firmly, touch or hold your baby - this will keep baby in an alert state. Your baby is telling you it is time for a change. Feed baby if you think he or she may be hungry; you may need to slow the pace a little – stop what you were doing for baby, and try something different. Be calm and reassuring. • May appear to be fussy Crying • Baby is crying • Face is tight - may squeeze eyes shut • Moving arms and legs a lot Crying is a signal that your baby’s had enough; you need to stop what you were doing and help soothe him or her. Try walking, or gently rocking, talk in soothing voice. Repeat a soothing action over and over. Baby behavior Generally, babies have many of the same ways of letting us know what they want and need; but each baby has a unique own way of acting that makes him or her quite unlike every other baby. You will learn your baby’s behavior by looking at what your baby does. Knowing your baby’s behavior will help you care for your baby in a way that is best for him or her. For example, you can learn which things are upsetting and which things are soothing for your baby. Behavior, as well as crying, is baby’s way of communicating with you. The chart describes common ways babies behave and also gives hints to help you learn about your own baby’s behavior. Remember, knowing baby behavior is one way to learn about your baby’s special language. All babies have their own behavior. The state your baby is in will affect how your baby behaves. 98 Behavior Characteristics What it means for you Looking (visual) Babies see best when objects are 7 to 12 inches from their face. They especially like human faces, patterns and contrasting colors like black and white. Babies can follow objects and faces with their eyes and head. When your baby is in an alert state, hold the baby 7 to 12 inches from your face. Slowly move your head side to side, but don’t talk. Watch as your baby follows with his or her eyes or head. Now do the same thing with a bright object and watch baby track the object. Hearing Babies can hear at birth. They will listen to all kinds of sounds - but they enjoy human voices best! When babies listen, they turn their heads toward the sound and search with their eyes to find where the sound is coming from. When your baby is quiet and alert, be near the baby and talk in a steady, soft voice. Watch how your baby reacts. Babies enjoy soothing, repetitive sounds. Holding, cuddling and snuggling Babies cuddle by snuggling into the curve of your arm or neck, your shoulder or chest. They love to snuggle - but some babies like to snuggle more than others. Snuggle often with your baby during the day. Find the way your baby likes to snuggle best. If your baby stiffens when being held close, find other times to snuggle such as when feeding, falling asleep or when baby needs comforting. Remember, all babies have likes and dislikes. Smiling and moving When your baby is very young, his or her smile is a reflex occurring both in sleep and awake states. Your baby may move his or her arms and legs a lot, or a little. Movements may be smooth or appear jerky. Watch for your baby’s smiles. When he or she smiles, smile back, coo and talk. Let the baby know you’re happy. At around 3 to 4 weeks old, your baby will begin to purposefully smile back at you. 99 Behavior Crying as an indicator of pain Characteristics Although babies cry when they are bored, fearful and hungry, the pain cry is high pitched, tense, harsh, nonmelodious, short, sharp and loud. It may be accompanied by an increase in breathing rate, sweaty palms, randomly moving hands and feet, facial grimace with eyes tightly closed and mouth open. What it means for you Because of your excellent observational skills with your baby, you can determine when your baby is in pain. The cry, along with facial expression, body movements and changes in eating/sleeping patterns will help you decide when you need to call baby’s provider. See page 102 for ways to try to soothe your baby. Baby cues What are baby cues? Cues are your baby’s way of telling you what he or she wants. When your baby is very young, most of these cues will be non-verbal. For example, if your baby wants to play he or she will turn toward your voice or look at you. These signals are called engagement cues. The word engage means “to hold or attract.” So, your baby is trying to “hold and attract” you. Cues may or may not be easy to see. Knowing about baby cues will make caring for your baby more enjoyable. Babies can also tell parents when they need a break or a rest period. These are called disengagement cues. The word disengage means “to withdraw.” Your baby needs to withdraw from you for awhile. He or she may turn away from you, grimace or even cry. Usually when your baby is with you, he or she will display a mix of engagement and disengagement cues. Look for the cues that occur most often to decide what your baby is trying to communicate. This helps you decide what to do with your baby. Feeding cues and feeding Parents feel differently about the time spent feeding their baby. Most view feeding time as a special time for feeling close to their baby, and others see feeding as a chore. During the early days and weeks it may be one of the few times your baby is awake. The time you spend feeding your baby gives your a wonderful opportunity to get to know your baby and for your baby to get to know you! 100 Message Feed me Characteristics • Mouthing • Crying • Sucking motions What you should do Feed baby. If baby does not feed, change positions, reposition breast in baby’s mouth. • Hands in or near mouth I need a break • Crying • May spit up • Choking Give baby a rest period. May be full, or just wants a rest period; stop feeding and watch for baby to resume feeding cues. • Looking away • Arching back • Pauses during feeding I’m full • Arches back • Falls asleep • Pushes away Stop feeding baby. If baby just needed a break, feeding cues will resume after a brief rest. • Arms relaxed along side I want you • Smiling • Looking at your face Make sure you allow time during feeding to play and talk to your baby. • Head turned toward you, reaches out to touch you If your baby is a poor eater, does not suck or eat at all, call or see your baby’s provider right away. Babies who do not eat well can become very sick. You may also call: • HealthEast Outpatient Lactation Clinic, talk to a lactation consultant (M – F, 9 a.m. to 2 p.m.) 651-232-3147 101 Baby state variations During a 24-hour period a baby wakes up, goes to sleep and cries many times. The change in sleep, wake and crying is called state variations. Usually babies can wake up, go to sleep and stop crying on their own. They can change their own state. Sometimes babies need help from their parents in order to make these changes. One baby may be sleepy and hard to wake up to feed. Another baby may have greater trouble being soothed and going to sleep. Knowing how to help your baby change sleep/awake states is another way to learn your baby’s special language. Try the hints that follow and see what works best for your baby. To awaken baby An awake baby may eat better. Babies also like hearing your voice and looking at your face. Try these to awaken your baby: • Take baby’s blankets off • Undress your baby, change the diaper • Place baby about 7 to 8 inches from your face and talk gently To soothe baby It may be difficult to calm a tired, fussy and crying baby. Begin with one soothing action at a time. Repeating it over and over seems to work best. If something you’re doing is not working, try something else. • Let baby see your face • Pick up and hold baby close • Alter the pitch of your voice, high or low • Talk to baby in a steady, soft voice • Give your baby something to grasp • Walk, rock or take baby for a stroller ride (car rides often work) • Place baby on your shoulder • Gently rub your baby’s tummy or back • Hum or sing to your baby • Wrap baby snugly in a blanket (swaddling) • Gently hold baby’s arms close to his or her body • Stroke an area of baby’s body like the back, foot or head • Place baby in a baby swing (but do not leave baby unattended) • Try carrying baby in a front pack or sling 102 Crying - Never shake a baby Crying is one of the more obvious ways your baby has of communicating with you, telling you what he or she needs. Cries can indicate your baby is tired, hungry, cold, hot, sick, bored, scared or just wants you. After your baby is born and you are still in the hospital, your baby may cry very little or a lot. We know, based on studies of babies’ behavior, that babies begin to cry more at around 4 to 6 weeks of age. In the first several days at home with your newborn, he or she may be fussy as he or she adjusts to the new rhythm of your family. Also, if you’re breast-feeding, baby may be fussy until your milk comes in. Frequent nursing will stimulate milk production. Crying can be very difficult for parents, especially if it occurs for long periods of time. Babies tend to cry less when you respond quickly to their crying with soothing actions. Try some of the hints listed on the previous page. Sometimes a little change, like moving your baby from the bedroom to a room you are in, can offer comfort to your baby and may stop the crying. Other times a bigger change is needed, like a walk outdoors or a ride in the car. Occasionally, your baby may simply need to cry. Be sensitive to your baby and the need to cry. Do not, however, let your baby cry for long periods of time. If you have ruled out other causes for crying (sick, wet, hungry, tight clothing, need to burp, too hot or too cold) and you feel baby may just need to cry, try this: Allow your baby, safely in her crib, to cry for no more than 10 minutes. Set a timer if you have one. Then pick up your baby. Try to calm your baby for at least 10 minutes. If your baby continues to cry, let him/her cry 10 more minutes. This may allow your baby to handle the tension and give you a break. Get help from family and friends for a “time out” from your baby. Call a relative or friend to come and give you a break from your baby. It is NEVER OK to hit or shake your baby. If you feel you may harm your baby from constant crying – get help immediately! You may call the following: • HealthEast Care Connection (24 hours) 651-326-CARE (2273) • People Incorporated Parent Support Services 651-641-1300 • Greater Minneapolis Crisis Nursery 763-591-0100 103 Crying as an indicator of pain Long periods of crying may mean your baby is sick or in pain. You play an important role in the assessment and management of your baby’s pain. You know what is usual versus unusual behavior for your baby and you know how your baby expresses pain. Consider the following in assessing pain: • Has there been a recent event that would cause or increase your baby’s pain? • Have you done anything to lessen baby’s pain such as rocking, soothing, a favorite toy or given a pain medication? • What is happening when the pain seems to be increased or lessened? • Is baby’s pain lessened or increased when he or she is held in a particular position: lying down or sitting up? • Has there been a change in baby’s usual eating or sleeping patterns? Call or visit your baby’s provider when your baby cries a lot. The information you get from answering the above questions is important information to give to baby’s provider when you call for advice. Colic Colic is another reason babies cry. The exact cause of colic is unknown so it can be difficult to confirm. The diagnosis of colic should only be made by your baby’s provider. You may suspect colic if your baby cries inconsolably at about the same time every day, often between 6 and 10 pm or after most feedings; or if your baby will not stop crying when the usual ways of comforting are tried. Consult your baby’s provider for the advice that is best for your baby and situation. 104 A colicky baby may display How to help your baby Remember • Arched back • Cuddling and snuggling baby • Colic is not your fault. • Clenched fists • Car ride or stroller ride • Flailing arms and legs • Pacifier (extra sucking can be soothing) • Your anger and frustration are normal. • Draws legs up towards abdomen • Your baby is not angry at you. • Tense or bulging abdomen • Play soft music or tapes of heartbeat • Your baby is healthy in spite of excess crying. • Struggling and angry when held • Carry baby in a front pack or sling • Do not feed your baby every time he or she cries. • Screams loudly • Run the vacuum cleaner or washer. (The monotonous sound may be comforting to baby.) • Caution: Never shake your baby – even the slightest shake. Shaking will not stop the crying and could cause serious, permanent brain injury or death. • May pass gas GENERAL BABY CARE Diapering Changing the diaper with each stool and when it is moderately wet will help your baby remain comfortable and prevent diaper rash. Wash the diaper area with each change. Avoid using powder, which can lead to rashes, or cornstarch, which can promote fungal infections. Until the cord falls off, fold the diaper below the cord. Remember, don’t leave your baby unattended. Bathing • Stay with your baby at all times during a bath and when dressing. • It’s best to give baby a bath prior to feeding; baths before bedtime may promote sleep. • Give your baby a complete bath every two to three days. Areas that should be washed every day include head, neck (under chin) and diaper area. • Choose a place that is safe, warm and free from drafts. • If your baby cries when naked, undress and wash one area at a time. • Keep the household water heater set at no more than 130 degrees F. Always test water with your elbow. It should feel lukewarm, not hot. 105 • Have needed bath and dressing items within reach. • Do not use cotton-tip swabs for ears or nose. • Do not use powder. • Do not pull back the foreskin of the penis when bathing an uncircumcised boy. Before you begin, gather all the items you will need for bathing baby: • Soft washcloth • Two towels • Diaper • Clean clothes • Cotton balls • Mild soap (bar or liquid) and baby shampoo • Tub with 3 inches of lukewarm water and a liner to keep baby from slipping Typically, babies are bathed beginning with the cleanest area of the body, and progressing to the dirtiest. The following is the recommended order of washing. To begin either a sponge bath or a tub bath, start by using a soft cloth or cotton ball dipped in cool water. Wipe around the eyes, and wipe the outside of the nose and ears. Wipe the rest of the face with plain, warm water and a washcloth (no soap). Then, for a sponge bath 1. Shampoo the head and squeeze water over it from the washcloth to rinse. If your baby cries when washing his head, wash it last, but use clean water. 2. Wash the front of your baby with your free hand lathered with soap. Go from front to back between the legs. Rinse well with the wet washcloth. 3. Wash the back of your baby with your hand lathered with soap. Rinse well with the wet washcloth. Or, for a tub bath 1. Hold your baby safely. Have your fingers under your baby’s armpit, with your thumb around the shoulder. Your other hand supports your baby’s bottom and legs. 2. Shampoo baby’s head and squeeze water from the washcloth to rinse. Wash the front of your baby. Go from front to back between the legs. Rinse with the wet washcloth. 3. Wash the back of your baby with your free hand lathered with soap. Rinse well with the wet washcloth. 106 Then, after the bath, you’re ready to dry your baby. Gently dry in between baby’s folds of skin to avoid chafing and skin irritation. Lotions and powders are not needed unless recommended by your baby’s provider. Dress your baby in soft, comfortable clothing. Always launder new clothes before allowing your baby to wear them. Dressing Newborns’ ability to regulate their body temperature develops with age. Because their circulation is not fully mature, their hands and feet will often feel cool and are not good indicators about how warm to dress the baby. If babies are overdressed, they may develop a heat rash. Use layers of clothes and blankets that can be added or removed as needed. Nails and hair Newborn nails are very soft. As babies get older, they can easily scratch themselves. You may use a baby nail clipper or baby nail scissors. It works best to trim nails when baby is sleeping. Gently pull back the skin from the nail and carefully trim nail. Even if your baby doesn’t have much hair, brush or comb it every day to stimulate the scalp and prevent a build-up of cells called cradle cap. Taking baby’s temperature The American Academy of Pediatrics does not recommend the use of glass thermometers. Glass thermometers present a potential hazard. The glass can break if dropped or hit on a hard surface. When broken, mercury (the silver line) is released. Mercury is toxic to you and the environment. Use a digital or electronic thermometer. Electronic ear thermometers are not accurate until your baby is more than 6 months old. The methods used for babies are axillary (armpit) or rectal. Many providers and nurse practitioners prefer the rectal temp. Ask your provider which they prefer. Axillary (armpit) Normal range: 97.6 degrees F to 99.6 degrees F 1. Remove baby’s arm from clothing; be sure armpit is dry. 2. Carefully place tip of thermometer high up in baby’s armpit. 3. Hold baby’s arm snug against the body. 4. Thermometer should remain in place until temperature reads out. 5. Remove thermometer and take reading. 107 Rectal (preferred by most providers) Normal range: 98 degrees F to 100.4 degrees F 1. Lubricate the end of the thermometer with a water soluble lubricant (like K-Y®). 2. Lay baby on tummy (across your lap works well) and spread buttocks so anus is easily seen. 3. Hold thermometer between thumb and index finger so that palm can easily rest on the buttocks. Slowly and gently insert thermometer slightly less than 1 inch into the anus. 4. Hold thermometer in place until temperature reads out. Hold baby still with other hand. 5. Remove thermometer and take reading. 6. Clean the thermometer with alcohol after each use. Bulb suctioning Bulb suctioning is used to remove mucus from baby’s mouth and nose. Use the technique taught in the hospital or by your provider. Remember to lightly squeeze bulb before inserting in baby’s mouth or nose and be gentle. When suctioning baby’s mouth, insert the tip of the bulb syringe into the side pockets in the cheeks. Never put the tip of the bulb syringe in the back of the throat. Be very gentle throughout the entire procedure. Empty bulb into tissue and repeat as needed. Clean bulb after each use in warm, soapy (antibacterial) water. Rinse and air dry. Discard bulb when no longer needed. Do not use on other children or family members. Cord care Your baby’s umbilical cord will dry, shrink and darken. Usually it falls off within one to three weeks. It is important to keep the cord clean. Using soap and water on a lightweight washcloth, cleanse around the base of the cord at baby’s bath time. When diapering, fold the diaper away from the cord to allow air to dry it. Do not cover the cord with the diaper. If you notice signs of infection like bleeding, redness, pus-like discharge or foul odor, call your provider. Bowel movements Your newborn’s stool pattern is different from an adult’s. The first bowel movements are large, sticky, black/ green stools called meconium. In the first week following birth, stools will be a mixture of meconium and milk by-products. The stool changes to a yellow/green, soft or even liquid seedy stool (if you are breast-feeding) or a mustard/yellow soft stool (if the baby is on formula) within 10 days. These transitional stools will range in color and be quite soft. 108 Constipation is a hard, dry, formed stool. Call your provider if you think your baby is constipated. Diarrhea stools are mucousy, watery and foul smelling, and occur more frequently than usual. The diaper will show a water ring around the stool. Call your provider for advice. Facial rashes Newborns commonly develop mild facial rashes in the first months of life. These rashes may look like smooth pimples, small red spots or rough red spots. The rashes seem to come and go and rarely require treatment. Jaundice Jaundice is caused by large amounts of bilirubin in the blood. Bilirubin forms normally as red blood cells mature and die. The liver typically clears the bilirubin, but because your baby’s liver is not mature, the bilirubin builds up, causing the skin to look yellow. Sometimes, if not treated in a timely manner, very high levels of bilirubin may become dangerous to the baby and lead to varying degrees of brain damage and/or hearing impairment. Newborn jaundice affects more than half of all newborns in the United States. Jaundice usually appears in the first few days of life (around 72 hours old) and causes your baby’s skin, and sometimes the whites of the eyes, to look yellow. This mild jaundice is considered harmless; however, because a small fraction of infants (about 1:3 in 10,000) is at significant risk of developing very high bilirubin levels, all infants need to be watched for signs of jaundice. It is important for your baby to be feeding well. This will help reduce the risk of jaundice (yellow skin). All jaundice should be reported to your baby’s provider so the cause and treatment can be identified. Newborn Circumcision The American Academy of Pediatrics (AAP) says that circumcision has some medical benefits and some risks. After reviewing research on circumcision, in September of 2012, the AAP determined that the medical benefits outweigh the risks. The AAP believes that the decision to circumcise should be made by the infant’s parents after a discussion with their doctor. It is important to think about medical, religious, cultural traditions and personal beliefs as you make this decision. 109 What is circumcision? The skin that covers the head of the penis is called foreskin. Circumcision is surgery to remove that skin. Removing that skin will expose the tip of the penis. Circumcision is usually performed by a doctor in the first few days of the infant’s life. The infant must be healthy to be safely circumcised. Some insurance will not pay for it. Be sure to call your insurance and ask. Is circumcision painful? Yes. But there are pain medicines that are safe and effective. Medical benefits of circumcision • Greatly reduced risk of getting and transmitting HIV, the virus that causes AIDS. • Lower risk of getting a number of sexually transmitted infections (STIs), including genital herpes (HSV), human papilloma virus (HPV) and syphilis. • A slightly lower risk of urinary tract infections (UTIs). • A lower risk of getting cancer of the penis. This type of cancer is very rare in all males. • Prevents foreskin infections. • Prevents the foreskin from attaching to the penis so it can no longer retract. This condition is called phimosis. • Easier to keep the penis clean. Reasons you may choose to circumcise • The other men in the family are circumcised, and they don’t want their son to feel “different”. • Some groups, such as followers of Jewish or Islamic faiths, practice circumcision for religious or cultural reasons. Reasons you may choose not to circumcise • Fear of the risks of surgery. Complications are rare but may include: bleeding, infection, cutting the foreskin too short or too long, and problems healing. • Some people think: -- the foreskin is needed to protect the tip of the penis; removing the foreskin may irritate the tip of the penis and cause the opening of the penis to become too small. This may cause problems urinating that may need to be corrected with surgery. 110 -- circumcision will make the tip of the penis less sensitive so there will be a decrease in sexual pleasure later in life. -- that personal cleanliness can lower health risks. Boys can be taught how to clean their penis and that can lower their chances of getting infections, cancer of the penis and STIs. What if I choose NOT to have my son circumcised? Talk with your provider about how to keep your son’s penis clean. Use care. The foreskin will not fully retract for several years and should never be forced. When your son is old enough he can learn how to keep his penis clean just as he does other parts of his body. Parents’ Choice • Circumcision is your choice. If you have questions, talk with your doctor or nurse practitioner. Care of the penis after circumcision The glans (or head) of the penis has been exposed now that the foreskin has been removed. The foreskin has been cut and needs to heal. • A small amount of bleeding is normal. • The redness and swelling will go away as healing occurs within a few days after the circumcision. • As part of the normal healing process, a yellow film may form over the area. • Be sure your baby is urinating (peeing). • Until the penis heals, apply a moderate amount of petroleum jelly to the glans each time you change a diaper. This keeps it from sticking to the diaper. As healing progresses, a white film may form over the glans. This is normal. Don’t try to wash this off. • Your baby may be sleepy, irritable and obviously uncomfortable, especially when the penis is handled and cleaned. • Gently clean the penis with clear water as healing occurs. Don’t be too rough, as the area could bleed. • It is OK to give your baby a tub bath. Continue cleaning the genitals with soap and water each day. • If you see a ridge of foreskin after the circumcision is healed, talk to your provider. Call your doctor if you notice signs of infection (persistent redness, pus like drainage) or if your baby is not peeing. 111 Care of the uncircumcised penis The foreskin of an uncircumcised newborn is normally attached to the glans. Do not force it back (retract) over the end of the penis. Gradually it will loosen and between 3 and 5 years of age, most boys’ foreskins are fully retracted. Routine bathing will adequately cleanse the penis during infancy. Premature Infants and RSV (respiratory syncytial virus) RSV (respiratory syncytial virus) is a common virus that causes infections of the lungs and respiratory tract. The peak RSV season begins in the fall and ends in the spring. RSV can infect adults, children and infants. In adults and older, healthy children, the symptoms of respiratory syncytial virus are mild, like the common cold. Infection with respiratory syncytial virus can be severe in some cases, especially in premature babies and infants with other health problems. Babies born at 35 weeks or less are at risk of having health problems. They are at greater risk of having severe lung infections from RSV. Usually these infections must be treated in the hospital. Call your baby’s provider right away if your baby has any of these symptoms: • Persistent coughing • Wheezing (a whistling sound when breathing) • Rapid breathing; problems breathing, or gasping for breath • A bluish color around the mouth or fingernails • A fever. In the first few months, even a fever as low as 100.4 F rectally is a concern. Treating severe cases In cases of severe infection, baby will be hospitalized. This is needed to provide intravenous (IV) fluids and humidified oxygen. Hospitalized infants and children may also be hooked up to mechanical ventilation — a breathing machine — to ease breathing. No vaccine exists for respiratory syncytial virus. But common-sense precautions can help prevent the spread of this infection: • Wash your hands frequently. Do so particularly before touching your baby, and teach your children the importance of hand washing. • Avoid exposure. Limit your infant’s contact with people who have fevers or colds. This is especially important in premature babies and all infants in the first 2 months of life. 112 • Keep things clean. Make sure countertops are clean in the kitchen and bathrooms, especially when someone in your family has a cold. Discard used tissues right away. • Don’t share drinking glasses with others. Use your own glass or disposable cups when you or someone else is sick. Label each person’s cup. • Don’t smoke. Infants who are exposed to tobacco smoke have a higher risk of contracting RSV and potentially more severe symptoms. If you do smoke, never do so inside the house or car. • Wash toys regularly. Do this especially when your child or a playmate is sick. • If your baby was born prematurely and has risk factors for RSV, it may be recommended that s/he receive a vaccine called Synagis. Your provider will tell you if your baby would benefit from Synagis. Safety Your baby will enjoy being in the same room with you. If the baby is in another room, check him or her periodically. Do not leave any baby unattended for long periods of time. Make sure the crib sides are secure. Never leave a baby alone on a high surface; he or she may wriggle and fall off. If you are busy, put baby in a crib or playpen near you. Never hold your baby on your lap when you are riding in the car. In a sudden stop or a crash, your baby can be badly hurt or killed. Car seats Always use an approved baby car seat when traveling with baby (and older children). Read and follow the manufacturer’s directions to properly secure the seat in your car. The seat must be used properly. Babies weighing less than 20 pounds, and younger than 2 years old, should ride in a rear-facing child seat. The seat must be in the back seat and face the rear of the van, car or truck. Do not place your baby in the front seat of your car, especially if your car has a passenger side air bag. Air bags present a life threatening danger to babies and small children. 113 Checklist for car seat safety: • Bring the car seat with you to the hospital for your baby’s first ride home. • Household “baby carriers” and car beds do not provide adequate protection in a crash. • Use the safety harness to secure the baby inside the seat. For very small babies, a small towel rolled up and placed at each side of the baby’s body may make the car seat fit better. • A baby car seat should be placed facing backward until the baby is 2 years old. • Put your baby in the car seat correctly every time you travel. • Wear your seat belt to set a good example. • Remember, your baby depends on you to help keep him or her safe. Baby’s first toys Your baby’s hands and mouth will soon become the center of his or her world of discovery. Use this checklist to help you select safe and appropriate toys for baby. • A toy that is safe for an older child may be dangerous for a baby. Be sure older sibling’s toys are kept away from baby. • Avoid toys with small parts, including stuffed toys with ears or noses that could be pulled off and swallowed. If a toy or toy part can fit through the center of a roll of toilet tissue, your baby could choke on it. • Rattles, teethers and rubber toys in their most compressed size should still be too large to fit through a roll of tissue. If a squeeze toy contains a squeaker, it should not be detachable from the toy. • Crib gyms and mobiles should be securely fastened so they can’t be pulled down. They should be removed when your baby is 5 months old or when he or she can push up on hands and knees. • Avoid attaching or hanging crib toys, rattles, pacifiers, etc. to crib, stroller or playpen with elastic, string or ribbon. They may entangle the baby. • Avoid toys with glass, brittle plastic, sharp edges or parts that could entrap tiny fingers. Toys can be a world of fun and learning for your baby. The best way to keep your baby safe is through careful toy selection and proper supervision. For information about toy safety or toy recalls check the Consumer Product Safety Commission web site at cpsc.gov. 114 Baby walkers Walkers are associated with more injuries than any other baby equipment. Walkers give babies mobility before they or you are ready. Babies in walkers travel at a rate of 3 feet per second, faster than you can react. The most common way a baby is injured is by falling down stairs in the walker. Head injuries can occur as well as broken legs or arms. A walker does not help a baby learn to walk earlier. Babies in walkers may actually be delayed in crawling or sitting. Because the data indicate considerable risk of injury and even death from the use of walkers, and since there is no obvious benefit from their use, the American Academy of Pediatrics recommends a ban on the manufacture and sale of mobile baby walkers. Stationary (without wheels) activity centers are a safer alternative to mobile walkers. Before using, be sure your baby has developed sufficient upper body strength to remain upright in a stationary activity center. Sudden Infant Death Syndrome (SIDS) – babies sleep safest on their backs SIDS is the sudden and unexplained death of a baby under 1 year of age. Sometimes SIDS is called crib death. Providers don’t know what causes SIDS, but they have found some things you can do to make your baby safer. Healthy babies should sleep on their back. Place your baby on his or her back when putting him or her down for a nap or for bed at night. Check with your baby’s provider to be certain this sleep position is right for your baby. Make sure your baby sleeps on a firm mattress or other firm surface. Don’t use fluffy comforters or blankets under your baby. Don’t place your baby on a sheepskin, pillow or waterbed to sleep. Don’t place soft stuffed toys or pillows in the bed with a very young baby. Some babies have been smothered with these soft materials in their crib or bassinet. Babies should be kept warm but comfortable. Keep the room temperature so that it feels comfortable to you. Have baby sleep in light clothing to avoid overheating. If you use a blanket, make sure baby’s feet are at the bottom of the crib, that the blanket comes up no higher than baby’s chest and that it is tucked in on the bottom and two sides of the crib. You may consider using a sleep sack or a wearable blanket instead. Do not allow anyone to smoke around your baby and make sure your baby receives the needed “well baby” check-ups and immunizations. Call your provider or clinic right away if your baby seems sick. Consider breastfeeding your baby. Breast milk helps keep your baby healthy. 115 Back to sleep, tummy to play Tummy time is for babies who are awake and being watched. Your baby needs tummy time to develop strong upper neck and chest muscles. Being placed on their tummies prepares babies for the time when they will be able sit up and crawl. As babies grow older they will need more time on their tummies to build their own strength. Begin tummy time on your first day at home with your baby. Play, sing or talk to your baby while she or he is awake and on the tummy two to three times each day for a short time. You can increase the time as baby shows enjoyment of it. A good time for this may be after a diaper change or when baby wakes from a nap. Some babies may not like tummy time at first. Having you or a toy in easy reach of baby will help tummy time become more pleasant. The majority of babies are born healthy and most stay that way. Don’t let a fear of SIDS keep you from enjoying your baby. If you have questions about SIDS, talk with your baby’s provider. Shaken baby syndrome Parenting a newborn can be a wonderful experience. It can also be very frustrating and overwhelming. Babies cry and sometimes you won’t know exactly why. This can be upsetting, especially when you’re tired from lack of sleep. It’s OK to feel upset, that is normal. But it’s NEVER OK to shake a baby because of how you feel. Shaking babies can cause a number of injuries: • Brain damage • Blindness • Mental retardation • Seizures • Paralysis • Death Shaking a baby is very dangerous. Shaking a baby is child abuse. Everyone who cares for your baby must know this. To soothe your baby, refer to the guidelines in this book. Know your limits. Seek help from friends or relatives if you are feeling frustrated or angry. Take a time out when you feel frustrated or angry. Remember: It is OK to lay your baby safely in a crib for 10 minutes while she is crying until you feel less frustrated and can call for help. Get away before you hurt your baby. Tell your baby’s sitters that if they feel frustrated or angry by your baby’s behavior to call you anytime so you can come and give them a break from your baby. Tell people who care for your baby about shaken baby syndrome. 116 Baby CPR (cardiopulmonary resuscitation) TotSaver is an important class developed by the American Heart Association and is designed for anyone who gives care to babies and children – parents, grandparents, older siblings, uncles, aunts and baby sitters. The program consists of baby and child safety, discusses causes of cardiac and pulmonary arrest, group practice of single rescuer CPR and foreign body airway obstruction or the Heimlich maneuver. The program is taught by trained American Heart Association instructors and the goal is to provide an atmosphere of learning and open discussion. Registration is required and there is a program fee. Visits to your provider You will bring your baby to the provider frequently during the first year of life for well baby visits. During these visits, your provider will monitor your baby’s physical and mental development, give immunizations and answer any questions you may have about your baby’s care and development. These visits are extremely helpful. You will also need to bring your baby in when he or she is sick. Sometimes it is difficult to determine if your baby is sick. You will get to know your baby’s cues and you will be the best person to determine if there is a problem. Trust your instincts. Call if you have any questions or concerns, especially if you are worried that your baby may be sick. Before you call, think about your baby’s symptoms and write them down on paper. This may be helpful when speaking on the phone to the provider. You may want to consider the following when deciding if your baby is sick. 117 Physical symptoms Behavioral symptoms • Fever • Decrease or loss of appetite • Difficulty breathing • Listlessness, sleepier than usual, hard to wake up • Yellow or pale skin; skin that is a different color from what you’ve seen before • Coughing • Vomiting • Diarrhea • Constipation • Unusual fussiness or irritability • Change in usual activity level (example – not able to smile, loss of interest in surroundings) • Continuous crying that cannot be comforted • Fewer wet diapers • Dark urine • Rashes General considerations • How long has baby been sick and what are the signs and symptoms? • What have you done to treat the illness and how has your baby responded? • Have you given your baby any medication? • Has your baby recently been exposed to a known illness? • Have your pharmacy phone number ready if provider prescribes a medication. • Sunken or dry eyes • Sunken look to the soft spots on top of the head When to call your baby’s provider • Breathing difficulties like breathing too fast or too slow, grunting or whistling. A newborn normally breathes about 40 to 60 times a minute. • Blue skin color around the lips and tongue. • A temperature of 100 degrees F (axillary or in the armpit) or 101 degrees F (rectally) or a temperature lower than 97.6 degrees F. • A change in activity level: becoming unusually listless and tired or restless and fussy. • Crying inconsolably for more than two hours. • Yellow or pale skin that is different that what you’ve seen before. Jaundice (yellow skin) that increases or progresses downward on your baby’s body. Also, jaundice shows in the white part of your baby’s eyes. Any jaundice must be reported. • Bleeding of more than a few drops or foul drainage or swelling at the umbilical cord site or from a healing circumcision. Reddened skin on the shaft of the penis. 118 • Unusual skin rashes, especially blisters; drainage from the eyes. • Refusing to eat for two or three feedings. • Recurrent or forceful vomiting. Vomiting differs from spitting up. It is normal for babies to spit up small amounts of some of their feedings. • Frequent liquid stools that contain mucus or blood. More than five liquid stools per day if bottle fed or more than eight liquid stools per day if breast-fed. Breast-fed babies normally have frequent, loose stools but they do not contain blood or mucus. • Fewer than four to six wet diapers in a day. Babies, whether breast or bottle fed, should have six to eight pale yellow, wet diapers per day by 6 days of age. • Dry, hard pebbly stools. The frequency of stooling is not an indicator of constipation, but excessive straining while passing hard stool is. Immunizations Immunizations are shots babies gets to protect them from illnesses like diphtheria, tetanus, pertussis (whooping cough), polio, measles, mumps, rubella (German measles), chicken pox, hepatitis B and Hib (haemophilus influenzae type b). Some of these diseases are much more serious for babies and children than they are for adults. Babies can get these diseases from other children and adults who have not been immunized. Babies will receive most of these shots before the age of 2. Hepatitis Vaccination for baby The American Academy of Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and Prevention recommend the first dose of a series of 3 Hepatitis B vaccines be given to the newborn before discharge from the hospital. HealthEast recommends the immunization be given within the first 12 hours of birth. This vaccination will help protect your baby against the Hepatitis B virus that could cause liver damage, even liver cancer. This virus could be passed through blood and certain body fluids of an infected person. This could occur from birth, if mother was exposed to Hepatitis B and didn’t know it. Exposure may be unknown, for example, the Hepatitis B virus can live in dried blood for 7 days. Protection by vaccination can prevent this disease. Four Hepatitis B shots may be needed if your health care clinic provides combination vaccines. Minor risks of the vaccine are outweighed by the benefits of disease prevention. Talk to your baby’s provider about the Hepatitis B vaccine for further information. 119 It is very important to get baby’s shots at the right ages, when the shots are most effective. They usually do not have to be delayed if your baby has a cold. For questions about immunizations, talk to your baby’s provider. Baby massage Your baby will thrive in your loving care. Babies respond to your gentle touch and are soothed by massage. Massage can be used at bath time, bed time or anytime. There are books on baby massage and classes in the community. Baby massage classes are offered at the Natural Care Center on the Woodwinds Health Campus. Please call the Natural Care Center at 651-232-6830 for more information. Visitors In the first few weeks at home with your baby, it is a good idea to limit the number of visitors, especially children, who handle your baby. People will bring bacteria and viruses to your baby. Since the ability to fight infection is not mature in babies, they may become sick. You may want to avoid large crowds for the same reason. People who are obviously sick should wait until they are healthy before visiting. Request that visitors wash their hands before picking up and holding your baby. Anyone with the following diseases or symptoms should not visit your baby: • Cold or cough • Flu or diarrhea • Cold sores (herpes typeI) • Recent exposure to chicken pox • Rashes • Draining wounds • Fever or other infectious problems such as strep, mumps, measles, scarlet fever Here are some suggestions to help reduce baby’s risk of getting sick: • Limit the number of visitors in the first few weeks at home. • Avoid large crowds. • People who are obviously sick should wait until they are healthy before visiting your baby. • Ask visitors to wash their hands before picking up and holding your baby. • Siblings should be current with their immunizations. 120 Taking care of baby is obviously more than simply staying home Frequently parents underestimate the time they will spend caring for a new baby. You will be feeding, changing diapers and clothes, bathing, comforting and playing with your newborn. Not to mention laundering baby’s diapers and/or clothing, as well as bedding. Baby care is an around-the-clock job. The average time spent on baby tasks is a grand total of nine to 20 hours each day. This does not leave much time for your meal preparation, house cleaning, shopping or time for yourself or time with visitors. Taking care of your baby is a wonderful challenge and yet, to be able to meet that challenge, you must take care of yourself. In the course of your day, be sure to set aside some time just for you. You need time to rest. This helps heal your body and your mind. Sleep when your baby sleeps. Resist the urge to keep your home spotless. Accept offers of help from relatives and friends. For example, they can come and vacuum while you care for your baby, or watch your baby while you shower or nap. Eat nutritious foods. Your body is recovering from your baby’s birth and needs nutrient rich foods to heal. If you are breast-feeding, your body needs nutrients to make breast milk. Drink water and fruit juices to replenish lost fluids in your body. Exercise reduces stress and strengthens your body. Don’t take on too difficult of an exercise routine right away. Go slowly and build up your tolerance for exercise. A walk around the block or at the mall (baby can come, too) may be all you need at first. If you are raising your baby without a partner, try to make contact with others for emotional support and help in emergencies. Neighbors, relatives, friends, parents’ support groups or your church or synagogue can be especially helpful. The group, Parents without Partners may be helpful. Visit their website at parentswithoutpartners.org. 121 YOUR RELATIONSHIP AS A COUPLE You may find it difficult to ensure that while your love for your baby grows, the relationship with your partner doesn’t suffer. It has been said that the greatest thing parents can do for their children is to love each other. Your baby will enjoy the benefits of having two parents who love each other and are committed to each other. While giving your baby as much attention and love as you can, be careful to guard your own time and privacy. Make time to be together. Share as many of the household chores and baby care as possible. Try to see that no one person is responsible for the same chores all the time, unless you have talked and agreed to that arrangement. Keep in touch with your friends. Allow trusted relatives or friends to care for your baby while you get out together. Dinner or a movie can do wonders for the spirit and your relationship. Try to hold conversations that include topics other than your baby. Acknowledge how tiring it is to raise a baby. Help each other during these physically exhausting times. Sexual intercourse may not be a priority for a while. Help your partner understand this is not a rejection. Communicate and express intimacy in other ways. Going home It is often helpful to feed your baby a short time before your discharge. This eliminates some of the stress associated with your homecoming. Enjoy your baby. It is extremely important that your baby is aware of your love and delight. The baby who is talked to and smiled at gains inner security. 122 Baby’s stools and wet diapers The following guidelines can help you know if your baby is getting enough to eat. It is OK for your baby to have more wet or soiled diapers than listed. First day of life Second day of life Third day of life one wet diaper, one stool two wet diapers, two stools three wet diapers, three stools Fourth day of life four wet diapers, three stools Fifth day of life five wet diapers, three stools Sixth day of life six wet diapers, four stools Seventh day of life six wet diapers, four stools If your baby is having less than these numbers of wet diapers and stools, call your baby’s provider. No cow’s milk during baby’s first year Until your baby is a year old, breast milk should be the main food. Cow’s milk is fine for older children, but it is too hard on your baby’s digestive system, and it won’t meet nutritional needs during the first year. Cow’s milk has too much protein Cow’s milk has two to three times the protein of breast milk or baby formula. The type of protein in cow’s milk forms tough, hard to digest curds in the baby’s stomach. Cow’s milk protein is linked to intestinal blood loss and allergies in babies. Cow’s milk has too much sodium Cow’s milk has three to four times the sodium of breast milk or baby formula. Excess sodium can be hard on the baby’s delicate digestive system. Cow’s milk differs from breast milk and baby formula in vitamin, mineral and fat content The levels of vitamin C, copper and zinc in cow’s milk are too low for growing babies. The type of fat in cow’s milk is not absorbed well. Cow’s milk has too little iron Not only is the level of iron low in cow’s milk, but the iron is not absorbed well. Feeding cow’s milk to babies can lead to iron deficiency. This is a common health problem in babies today. 123 BREAST-FEEDING: WHAT TO EXPECT DURING THE FIRST MONTH Day one - birth to eight hours Breast-feed within the first hour after delivery if possible. Early breast-feeding decreases difficulties and helps mothers breast-feed longer. During the first two hours after delivery, you and your baby are in an alert state. However, your baby will soon go to sleep for about eight hours. This is a time when your nipples are maximally everted. Both you and your baby have a heightened sensitivity to each other. Your baby will begin to recognize your smell and taste, which helps him or her more effectively latch on to your breast for feeding. Skin to skin contact is very important as it helps your baby stay warm. Rooting, nuzzling and suckling are a very important part of this first breast-feeding experience and will lead the way to successful breast-feeding. Colostrum is the first breast milk your baby will receive, and it is a warm, thick, sweet fluid which is very easy to swallow. It is also rich in white blood cells, which protect against infections, and has immune properties to help immunizations work better. Colostrum is made in small amounts and is not overwhelming to a newborn, whose stomach holds about 1/2 ounce. Make sure you are comfortable when you breast-feed. Use pillows and sit up as straight as possible. You may also try lying on your side to breast-feed in bed. Hold your baby at the level of your breast and facing you with his or her arms and legs flexed so both of you will be comfortable. Remember that breast-feeding is a learning experience for both of you, so be patient when your baby is latching on to your breast. Being in the same room with your baby and frequent breast-feeding are needed to establish a good milk supply. Prematurity, failure to latch on effectively, excessive sleepiness or separation from your baby for medical reasons interfere with adequate milk production. Start pumping every three hours if there has been no latch on within six hours after birth, due to the above situations. Newborn Stomach Size (approximate) Days 1-2 2-15 ml 124 Days 3-5 15-30 ml Days 5-10 60-80 ml Eight to 24 hours after birth Your baby will become more awake again between eight and 24 hours after birth. With frequent breastfeeding, he or she will start to develop a more coordinated suck and swallow pattern. Breast-fed babies need to feed every one-and-a-half to three hours, and there will be times during the first few weeks when you are not sure when one feeding ends and the next begins. Feeding schedules were designed for formula-fed babies and not breast-fed babies. Do not compare your breast-fed baby to a formula-fed baby as breast milk is digested easier and your baby’s stomach can empty every 90 minutes. Nighttime feedings are very good for your milk supply due to increased levels of prolactin at night. Keep your baby in your room as much as possible so you can learn his or her hunger cues. Hunger cues include rapid eye movements, small muscle movements, hand to mouth movements and rooting. Crying is a late hunger cue, and then you will have to calm your baby before he or she will latch on correctly. Your baby may want to breast-feed 8 to 12 times in 24 hours. You should listen for swallow sounds during much of the feeding. Watch for changes in your baby’s suck pattern from a non-nutritive suck of two sucks per second to nutritive suck or one suck per second as he or she begins receiving milk from your breast. Also, watch your baby and not the clock so you will know when your baby is full. A spontaneous release of the nipple, a relaxed body and open hands are all signs of fullness. Start to record feedings, as well as wet and soiled diapers in a breast-feeding log. Begin in the hospital and continue the log at home for at least one week. Your first night home may be a sleepless one as you and your baby adjust to each other. It will take a few days for him or her to adjust to your day and night schedule. Also remember that baby care is a 24 hour responsibility. 125 Day two Some babies are very alert while others seem disinterested in breast-feeding. Try feeding every 90 minutes to three hours even if your baby is sleepy. Be patient and persistent and make decisions for your baby’s benefit. Breast-feeding needs to be mother-led at this stage. Breast-feeding can be baby led when your baby is more alert and is giving you feeding cues every 90 minutes to 3 hours. How to wake a sleepy baby: • Remove baby’s clothing down to diaper only • Tickle lower lip • Rub baby’s arms, legs and back • Touch your skin to baby’s skin • Tickle feet • Dim any bright lights • Drip milk on lips • Sit baby on your lap holding under chin • Place a cool cloth to baby’s face or chest Signs of adequate milk intake for breast-fed babies: • Moist skin • Slippery, moist oral mucous membranes • Six to eight wet diapers every 24 hours • Two to three stools every 24 hours • Audible swallows • Weight loss should be less than 10 percent • Eight to 12 feedings every 24 hours • Return to birth weight by two weeks • Average weight gain of two-thirds to 1 ounce each day after first week • Yellow, semi-liquid seedy stools after 3 to 4 days old Your breast milk will come in within two to five days and will gradually change in composition from colostrum to mature milk within 14 days. Just before your milk comes in, your baby will want to nurse more frequently, telling you that your milk is coming in. As your baby becomes more efficient at breast-feeding, he or she may decrease the amount of time spent at the breast and may only suckle on one breast each feeding. Keep in mind that 10 to 20 minutes on each breast is sufficient. Empty the first breast before going to the second breast to increase the hindmilk, or richer milk, received by your baby. This increases the amount of fat received and helps your baby grow and sleep better. 126 Days three, four and five Your baby will be alert and awake for longer periods. Milk usually comes in between the third and fourth day. Your breasts will feel full and heavier and you will hear your baby swallow and even gulp with the milk ejection reflex (MER) or “let down.” The yellow color will start to change to pale white and will be more watery and thin instead of thick like colostrum. It will take time for your milk production to match your baby’s needs. Missing feedings or introducing a bottle at this time could cause problems with your milk production and also confuse your baby between the breast and bottle, which is called nipple confusion. Offer your breast frequently or as often as your baby will nurse, every 90 minutes to three hours. One four to five hour sleep cycle is fine, remembering your baby will need to nurse eight to 12 times every 24 hours. You may notice a decrease in your own appetite and fatigue may set in. Eat at least three well-balanced meals, drink plenty of water and nap as much as possible when your baby sleeps. As your milk comes in, you may notice temporary swelling due to increased fluid and blood flow to your breasts. Untreated engorgement of your breasts is an urgent problem and can cause a decrease in your milk supply. Treatment for engorgement • Place warm, moist packs or cold packs on your breasts. • Massage your breasts. • Initiate breast-feeding every 90 minutes to three hours. • You may want to pump your breast milk for comfort. • Call a lactation consultant if engorgement prevents adequate latch on or milk let down. Nipple tenderness or soreness is common around four to five days after delivery as your nipples stretch. Latch-on discomfort should be temporary as breast-feeding should not be a painful experience. Apply expressed breast milk to your nipples or pure lanolin (PureLan™ or Lansinoh®) to help heal. There is no need to clean lanolin off before feeding as it will not hurt your baby and there is no taste or smell. Severe pain, bleeding or cracked nipples are not normal. Call a lactation consultant for help if these conditions occur. Signs of adequate intake on fourth and fifth days • Eight to 12 feedings every 24 hours • Four to five wet diapers every 24 hours • Two to three stools every 24 hours • Yellow, seedy stools • Audible swallows 127 Signs of milk ejection reflex (MER) – Caused by release of oxytocin • Uterine cramping • Increased flow of milk • Tingling sensation • Sleepiness • Leaking on one side while feeding • Rapid sucking pattern changes to slower, on the other breast more rhythmic suck/swallow pattern Red flags – Call lactation consultant for help • No or infrequent stools • Progressive weight loss • Persistent meconium stools • Dehydration, jaundice, sleepiness • Few wet diapers (low output reflects inadequate intake) One week to one month Babies who are taking adequate amounts of breast milk will have many wet diapers and stools every day. Some babies have small yellow liquid stools with every diaper change or feeding. Frequent stools at this age is normal. Stools will decrease in amount around 4 to 6 weeks. Continue with frequent feedings every two to three hours during the day. Try to nap when your baby sleeps. Limit visitors and make visits short. Around 10 days after delivery, you may begin to feel overwhelmed with 24 hour newborn care. This is also the time when your baby will go through his or her first growth spurt. Growth spurts are common at 7 to 10 days and 2 to 4 weeks. Your baby will nurse frequently for 48 to 72 hours, which stimulates your body to increase your milk supply and ensure adequate milk for your baby’s growth. About this same time, between 10 to 14 days, your breasts will suddenly soften and you may be concerned that your milk supply is disappearing. This softening is normal. You will only feel fullness with missed feedings or if the interval between feedings is longer than usual. Your milk supply is stabilizing to match your baby’s needs. Call your provider for a weight check at 10 to 14 days or sooner if needed. Fussiness Fussiness usually peaks at 2 weeks as your baby begins to sleep less. Limit visitors to avoid overstimulating baby. It is very important that you are available to respond to your baby’s needs so he or she will develop 128 trust in you as parents. Bringing your baby’s hands to the middle of his or her body is very consoling for your baby. Walking, rocking, music and even warm baths are very comforting for both of you. You may need to take a break for short periods each day and get away while someone else plays with your baby. Always remember, babies cry for a reason. They may be tired, bored, lonely or uncomfortable as well as hungry. Evening fussiness is also very normal. Decreased prolactin levels towards evening causes a decreased milk supply and frequent feedings are needed. The milk fat content is also at its lowest between 4 and 8 p.m., causing your baby to want to breast-feed more frequently. At 3 months, as the digestive tract becomes more developed, your baby will be less fussy, less gassy and easier to console. Three months is not the optimum time to wean to a bottle as your baby will be changing his or her suck from a reflex action to a conscious suck pattern. Your breast-fed baby may begin to sleep through the night at 8 to 12 weeks old. But remember breast milk is digested in two to three hours, so frequent feedings are still normal. Facts about breast milk Colostrum 17 to 19 calories Breast milk 20 to 21 calories Glucose 6 calories Breast milk is 88 percent water, so additional water is not necessary. Growth spurts typically occur at these intervals and babies may eat more often for two to three days during a growth spurt. Growth spurts normally resolve in 48 to 72 hours. • 7 to 10 days • 3 months • 2 to 3 weeks • 6 months • 6 weeks If you have had breast surgery of any kind, inform your provider. Breast surgery may affect your ability to produce milk in an amount that would enable you to exclusively breast-feed your baby. 129 Pacifiers and nipple confusion happens Babies suck differently on a pacifier or bottle nipple than they do when breast-feeding. A baby’s tongue, jaw and mouth move differently at your breast than when using a pacifier or bottle nipple. When breast-feeding, a baby’s jaw and tongue work together in a coordinated rhythm, and the gums gently compress the areola and massage the milk out of the breast. The baby stretches the nipple to the back of the mouth, and the front part of the tongue goes forward and backward in a wave-like motion. The baby’s lips will be flanged, or spread out, to make a tight seal and hold the nipple in the mouth. When trying to nurse from a bottle, a baby is immediately met with a flow of milk. The baby blocks the flow with his or her tongue to prevent choking. The baby does not need to move the jaw, because gravity increases the milk flow and the baby does not need to compress the nipple to start the milk flowing. The front of the tongue does not move out and in to milk the bottle and the lips are relaxed. Babies do not need to work as hard to obtain their reward. The same sucking pattern occurs when using a pacifier. When pacifiers are used in the first few weeks of life, the baby spends too much time meeting their sucking needs with non-nutritive sucking when they should be getting nutrition. After some babies have had only one bottle or a pacifier, and they return to breast-feeding, they will try to suckle the breast nipple the same way they did the artificial nipple. They will push forward with their tongue as they search for the hard rubber nipple and push the breast nipple out of their mouth, leading to difficulty. This type of incorrect sucking is called flutter suck or tongue thrusting. Artificial nipples lessen the baby’s instinctive efforts to open his or her mouth wide for correct latch on. Babies may become conditioned to wait until they feel the firm artificial nipple in their mouth before they will suck. Babies may also become frustrated when breast-feeding, as the milk does not flow as rapidly as it does from the bottle. This could interfere with their ability to suckle effectively when they are at your breast and may lead to refusal to breast-feed altogether. Kittie Franz, a researcher (1985) estimated that 95 percent of all babies will become nipple confused if given artificial nipples during the first 3 to 4 weeks of life. Are there good uses of pacifiers? After about three to four weeks, when breast-feeding has been wellestablished, moderate cautious use of pacifiers may be all right for short periods of time. Pacifier use can help sooth a fussy baby. You may also find a pacifier convenient when you are in situations where you absolutely cannot breast-feed and your baby needs brief satisfaction. The pacifier should never be used as an easy way out. Determine why your baby is crying/fussy and attempt to meet his/her needs. 130 Breast-feeding resources HealthEast Outpatient Lactation Clinic, 651-232-3147. A lactation consultant is available for telephone counseling, assessment, intervention, support and education Monday through Friday from 8 am to 4 pm, except for holidays. Phone calls are answered between 9 am and 2 pm, Monday through Friday. After hours you may leave a message or be transferred to a HealthEast triage nurse. HealthEast Outpatient Lactation Clinic carries a limited quantity of breast-feeding supplies. Your HealthEast hospital will be able to get you off to a good start with breast-feeding. Some nurses, called lactation specialists, have additional training and are available for assessing and treating problems. • HealthEast Home Care, 651-232-2800 for a home visit if necessary or desired. • LaLeche League of Minnesota and the Dakotas, lllofmndas.org/st-paul-metro.html a breastfeeding advocacy organization. Your local WIC clinic has breast-feeding help. There are breastfeeding peer counselors and nurses who can answer questions and help you succeed. 131 RESOURCES/REFERENCE MATERIALS Parenting resources Day care/nanny services/sitters Child care involves careful planning and investigating and cannot wait until your maternity leave. Request a list of day care providers from the Department of Health located in the county in which you reside. Visit and interview potential day care providers. Nanny services are available in the Twin Cities area (see the yellow pages under “Nanny Services” for local agencies and phone numbers). Ask for and check out references. Also check on the credentials of day care providers. Once you make a selection, make unannounced visits at various times to see firsthand the operation of the center. Teenage sitters require an orientation to your home and an opportunity to meet and play with your baby before they are asked to baby-sit. Ask for references, and observe the teen’s interaction with your baby. Day care resources and referrals Resources for Child Caring (serves the seven county Metro area) 651-641-0332 When you call you will receive a customized list of current openings for the type of care requested and a handbook with information about how to choose child care, including a checklist of interview questions to ask when meeting with potential caregivers. Community resources and referrals Minnesota Poison Control Center 1-800-222-1222 or mnpoison.org National Child Safety Council distributes literature on safety, household dangers, electricity and drug abuse. 1-800-222-1464 or nationalchildsafetycouncil.org Birthright counseling and support for pregnant women St. Paul: 651-646-7033; Minneapolis: 612-338-2353 132 Helpful websites lamaze.org A site for expectant and new parents to increase their knowledge regarding pregnancy, birth and parenting. hypnobirthing.com Provides information on the Mongan Method of hypnobirthing. This method is taught at HealthEast. marchofdimes.org Excellent information on pregnancy, prenatal testing, newborn care and parenting. parentsknow.state.mn.us This site was developed by the MN Department of Education; it contains useful parenting information. gucchd.georgetown.edu A site maintained by Georgetown University Child Development Center for families with children who have special needs. mediafamily.org Sponsored by the National Institute on Media and the Family, this site offers resources on movies, TV and video game ratings. acog.org American Congress of Obstetrics and Gynecology aap.org American Academy of Pediatrics web site dona.org Doulas of North America (DONA); broad information about doulas, listing of DONA certified doulas by state. midwife.org American College of Nurse Midwives, click on “consumer” for midwife overview and resources. 133 familyprovider.org Great source for health information about babies, children and adults. Endorsed by the American Academy of Family Practice. askdrsears.com This web site contains useful information on newborn and child care, as well as information about vaccinations. The site is maintained by respected author Dr. William Sears, a pediatrician, and his three sons, who are also pediatricians. parenting.ivillage.com Parenting information, consumer news safekids.org National Safe Kids campaign cpsc.gov Consumer Products Safety Commission - product recalls breastfeeding.com and lalecheleague.org Breast-feeding information and resources postpartum.net A web site with good information about the signs, symptoms and treatment for postpartum depression, “baby blues” and postpartum psychosis. sparkaction.org A web site with accurate information about product safety alerts and public health initiatives, offers many resources. fatherhood.org Information for dads on fathering and kids nichd.nih.gov/sids National Institute for Child and Human Development Back to Sleep Campaign buckleupkids.state.mn.us/ Car seat safety information - State of Minnesota 134 References Depression, Major, in Adults in Primary Care (Guideline) This guideline is an evidence-based document based on best care, and has also evolved to include information on best practice systems for implementation. ICSI (Institute for Clinical Systems Improvement) Released 05/2008 Postpartum Depression Screening: Importance, Methods, Barriers, and Recommendations for Practice, Dwenda K. Gjerdingen, MD, MS, and Barbara P. Yawn, MD, MSc; JABFM May–June 2007 Vol. 20 No. 3 synagis.com thrombosis-charity.org.uk nlm.nih.gov/medlineplus Institute for Clinical Systems Integration (ICSI) Health Care Guidelines: Routing Prenatal Care, 14th edition July 2010, Bloomington, MN. Williams Obstetrics, 21st Edition, 2001; F. Gary Cunningham, MD, John C. Hauth, MD, Norman Gant, MD, Kenneth Leveno, MD, Larry Gilstrap, III, MD, Catharine D. Wenstrom, MD, Appleton and Lange, Stanford CT. Simpkin, Whalley, Keppler, Pregnancy, Childbirth and the Newborn, 4th edition, 2010. St. Paul, Children’s Health Care, What Happens When You Shake a Baby. Minnesota Safe Kids Buckle Up, Better Safe. Lawrence, R.A., Breast-feeding: A Guide for the Medical Profession, St. Louis, CV Mosby Co., 2011. Kenner, C. & McGrath, J. M. (2004). Developmental care of newborns and infants. St. Louis, MO: Mosby, Inc. Sears, W. (2004). Bonding with your newborn. The Journal of Attachment Parenting International, 1, 1-5. The Nursing Mother’s Companion, Kathleen Huggins, R.N., M.S., 2006. 135 The Breast-feeding Answer Book - 3rd Edition, La Leche League International, 2003, Mohrbacher and Stock Back to Sleep Campaign; National Institute of Health; 2010. American Academy of Pediatrics web site: aap.org. diabetes.org American College of Obstetricians and Gynecologists website: acog.org acog.org/publications/patient_education/bp051.cfm Diabetes and Pregnancy, June 2009 136 BIRTH PLAN A way of communicating your labor and birth preferences to your provider and to the nurses at the Maternity Care Center is to develop a written birth plan. Simply put, a birth plan is a listing of the choices and preferences you and your partner have about labor, birth and your hospital stay. It is easier to make these choices now rather than when you are in labor. Take the time to discuss your options together and talk with your provider about the choices. Give a copy of your birth plan to your provider at a clinic appointment and bring a copy with you to the hospital. The staff will work to with you to follow the plan you’ve drafted. However, your safety and your baby’s safety is their priority. Depending on the course of your labor and your baby’s reaction to it, some of your requests may not be possible. Be flexible as you draft your birth plan and look on it as a list of preferences that may need to be adjusted as labor progresses. Sample birth plan For (mother’s name) Your provider What would you like the environment in your labor room to be like? (calm, quiet, dark, brightly lit, noisy) Who do wish to be present during labor and at your baby’s birth? How can the nurses best help you? Should they stand in the background and let your partner help, offer suggestions, help with comfort measures? 137 What concerns or frightens you most about your labor and birth? (pain, medications, injections, etc.) What relaxation techniques help you most? What do you feel about pain medications during labor and birth? Does your labor partner have any special desires (cutting umbilical cord)? (Circle one) r Yes r No Does your labor partner have any fears or concerns? How are you planning to feed your baby? (Circle one) r Breast r Bottle If breast-feeding, do you want to breast-feed soon after birth? (Circle one) r Yes If bottle feeding, what kind of formula do you prefer? r No What kinds of questions do you have about infant care that we can answer while you are in the hospital? If you have a boy, do you want him to be circumcised? (Circle one) r Yes r No Would you or your partner like to be present at the circumcision? (Circle one) r Yes r No Is there anything else you would like us to know about your preferences, concerns or your wishes for your labor, birth and hospital stay? 138 BIRTH CONTROL OPTIONS AFTER DELIVERY Type Natural family planning - Periodic abstinence based on identifying fertile times utilizing body temperature, vaginal discharge and menstrual calendar. Failure rates (per 1000 women/year) 2 to 10% ideal use 20% typical use Advantage: Inexpensive. Disadvantage: May be difficult to learn and/or use during postpartum and/or breast-feeding. Condom - Latex or animal tissue sheath for penis. 2% ideal use Advantage: Easy to obtain, inexpensive, method of choice by many breast-feeding women. 12% typical use Disadvantage: May interfere with sensation. May break during intercourse (best to use with spermicidal foam for back up). Animal tissue doesn’t prevent HIV transmission. Spermicidal foam, cream, gel - Product to place in vagina prior to intercourse. 3% ideal use 21% typical use Advantage: Easy to obtain, inexpensive, adds lubrication. Disadvantage: High failure rate if used alone, best if used with diaphragm or condom. May be messy. Diaphragm - Latex cup placed in vagina as barrier. 3% ideal use Advantage: Can be used with breast-feeding. 18% typical use Disadvantage: Should not be fit before eight to 12 weeks postpartum. Should be fit by provider after each birth. Needs to be used with spermicide. 139 Type Pill - Tablet taken each day. Contains estrogen and progesterone. Failure rates (per 1000 women/year) 0.1% ideal use 3% typical user Advantage: Excellent protection from pregnancy. Disadvantage: Expensive. Mini pill - Tablet taken each day - contains only progesterone. Slightly higher failure rate than the pill Advantage: May be used by breast-feeding moms. Disadvantage: Expensive. May have spotting and/or weight gain, unpredictable periods. Depo Provera - Injection of a hormone done every three months. 0.3% all users Advantage: Convenient, highly effective, can be used when breast-feeding. Disadvantage: Long acting, frequent spotting, weight gain. IUD - A flexible device placed in the uterus. 1 to 2% ideal use Advantage: Convenient, one time expense. 6% typical user Disadvantage: Inserted at six to eight weeks postpartum by provider, may increase risk of pelvic infection. Sterilization - Surgical altering of sperm (vasectomy) or egg (tubal) carrying tubes. Advantage: Permanent contraception. Disadvantage: Permanent, expensive, surgical risks associated with procedure, especially tubal. 140 0.2% women 0.1% men Type Essure® Procedure – is a non-surgical procedure that makes a woman sterile (unable to have children). There is no cutting of the body. A trained provider inserts spring-like coils through the vagina, cervix and uterus and then into the fallopian tubes. Failure rates (per 1000 women/year) 0% pregnancies in clinical trials About 3 months after the procedure the coil and the body form a tissue barrier. This prevents the egg from passing into the uterus and sperm from reaching the egg. During the first 3 months another form of birth control must be used to prevent pregnancy. Advantage: no hormones, no surgery, procedure performed in provider’s office, very low pregnancy rate Disadvantage: requires additional testing (hysterosalpingogram) At 3 months to determine if coil is in correct location and whether both fallopian tubes are blocked. 141 142 7017-230818 8/17
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