BabyontheWay Healthresourceguide 0

Baby on the way!
Your pregnancy and postpartum health resource guide
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All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest.
500 NE Multnomah St., Suite 100, Portland, OR 97232.
congratulations
youre pregnant!
Whether its your first child or your next, each pregnancy and birth is a brand-new
experience. Welcome to parenthood!
If youre like most new moms, you have lots of questions. Throughout pregnancy, you
will notice changes in your body, emotions, and activities. Your Kaiser Permanente
medical team is here to support you through it all.
We created this guide especially for you. Its contents provide answers, information,
and resources so you know what to expect during pregnancy and the first few weeks
of your babys life. Use this valuable road map to navigate your way and stay healthy.
Youll see some sections organized by trimester, so you can keep track of whats
happening, and when. Youll learn about your babys development week by week, how
to care for yourself, tests you might need, getting ready for your newborn, and more.
Read the right chapter before each medical appointment. Use the prenatal visit
records to log your babys progress and make notes. Skip ahead to the labor, delivery,
and postpartum section to prepare ahead of time. Theres a bounty of insights here,
covering the spectrum of prenatal and postpartum needs.
When you come in for a visit and to the hospital, bring this guide with you. Together
well review the contents that match your needs and answer questions.
Weve all heard about that healthy glow in pregnant moms-to-be. Now its your turn to
shine. Use the information in this guide to help you and your baby thrive. We are here
for you, every step of the way.
We look forward to meeting you and sharing this special time in your life!
Best wishes,
Kaiser Permanente Northwest
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table of contents
Your care team............................................... 4
First trimester............................................... 56
Finding providers and services....................... 5
Overview...................................................... 57
My Health Manager........................................ 6
Weeks 1 to 4................................................. 58
Pregnancy resources...................................... 7
Weeks 5 to 8................................................. 59
Prenatal visits................................................10
Weeks 9 to 12............................................... 60
Prenatal visit schedule................................... 12
Second trimester......................................... 64
Overview...................................................... 65
Prenatal visit records..................................... 13
Weeks 13 to 16............................................. 66
Classes and education...............................18
Weeks 17 to 20............................................. 70
Pregnancy and childbirth classes.................. 19
Weeks 21 to 24............................................. 72
Why take a childbirth class?......................... 20

Genetic testing............................................ 22
Weeks 25 to 28............................................. 74
Down syndrome and other

chromosomal problems................................ 23
Third trimester............................................. 78
Genetic diseases.......................................... 26
Weeks 29 to 32............................................. 80
Cystic fibrosis................................................ 30
Weeks 33 to 36............................................. 82
Health and wellness.................................. 34
Weeks 37 to 40............................................. 84
Your health and wellness.............................. 35
Home and nursery....................................... 86
Staying fit...................................................... 36
Getting ready for baby................................. 87
Eating well.................................................... 40
A safe nursery............................................... 90
Medications and natural remedies............... 44
Preparing for birth..................................... 92
Managing emotions ..................................... 46
Your birth plan.............................................. 93
Body changes and discomfort..................... 48
Birthing options............................................ 97
Risks and safety........................................... 52
Preparing for labor...................................... 100
Things to avoid............................................. 53
What to bring to the hospital...................... 103
Overview...................................................... 79
When to call for help.................................... 54
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Labor, delivery, and postpartum........... 104
Appendix: Navigating complications...146
Timing contractions..................................... 105
Asthma........................................................148
Timing contraction chart............................. 106
Bacterial vaginosis....................................... 150
Early labor.................................................... 108
Deep vein thrombosis................................. 152
Active labor: First stage...............................110
Depression..................................................154
Active labor: Second stage..........................111
Diabetes...................................................... 156
Third stage: After your baby is born............112
Domestic abuse........................................... 161
Postpartum recovery and coping.................114
Ectopic pregnancy (tubal pregnancy)......... 162
Infant care....................................................116
Fifth disease................................................164
Infant care overview.....................................117
Genital herpes............................................. 165
Newborn experience....................................118
High-risk pregnancy....................................166
Newborn appearance.................................. 124
Iron deficiency anemia................................ 170
Newborn behavior....................................... 126
Molar pregnancy......................................... 172
Baby care..................................................... 128
Multiple pregnancy..................................... 174
Feeding your baby...................................... 130
Obesity........................................................ 178
Multiples...................................................... 135
Placenta abruptio........................................180
Preterm infants............................................ 136
Placenta previa............................................182
Keep your baby healthy............................... 138
Preeclampsia and high blood pressure.......184
Keep your baby safe.................................... 140
Preterm labor...............................................188
Common newborn problems...................... 142
Preterm premature rupture of membranes.190

Rh sensitization............................................ 192
Toxoplasmosis............................................. 196
Urinary tract infection.................................. 198
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Your care team
Your care team

When youre pregnant, you want the best possible care for you and your baby. Your Kaiser Permanente
team is dedicated to providing just that.
Each year, more than 90,000 pregnant women receive the care they need at Kaiser Permanente clinics.
We help them bring their babies into the world at our own Kaiser Permanente or affiliated hospitals.
In the Oregon/Washington region, youll have access to a team of doctors, nurses, midwives, and
other health professionals who partner with you to keep you and your baby healthy. Its an integrated
approach that puts you at the center.
Finding providers
and services
You can find Kaiser Permanente providers and
medical offices online.
Visit kp.org and click the Locate our services
tab. Scroll down and select Find doctors &
locations. On the next page, follow the prompts
to narrow your search.
Obstetric and gynecological care is available at
most Kaiser Permanente medical offices in Oregon
and Southwest Washington. Our obstetrics advice
line and the Mother-Baby Program offer additional
resources, classes, and tips.
When the time comes, Labor & Delivery
and birthing services at Kaiser Permanente
Sunnyside Medical Center and our affiliated
hospitals have you covered.
Contact a member of your medical team anytime.
They can help you make decisions that support
you and your growing family.
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Appointments and urgent care

If you or your baby requires care during regular
medical office hours, you can call to request a
same-day appointment (as available) from 8 a.m.
to 6 p.m. weekdays.
To make an appointment, call 1-800-813-2000
from all areas. For TTY, call 1-800-735-2900.
For language interpretation services, call
1-800-324-8010.
Outside regular medical office or urgent care
hours, you can call the regional advice nurse.
Our advice nurse can direct you to the most
appropriate place for treatment or discuss your
health concern. Call 1-800-813-2000 from all
areas. For TTY, call 1-800-735-2900. For language
interpretation services, call 1-800-324-8010.
My Health Manager
Use My Health Manager to manage your health
online. This robust online tool lets you email your
doctor, view lab results, refill prescriptions, make/
cancel appointments, and more. See page 6 to
learn how to get started.
my health manager
Anytime. anywhere.
Manage your health online with My Health Manager.
Register today.
To start using My Health Manager,
just go to kp.org/register. Well
ask you a few questions to verify
your identity. Once registered,
you can sign on with your unique
user ID and password. You can rest
assured knowing we keep your
information safe using the highest
standards of online security. And
if you cant or dont wish to
complete registration online, you
can finish the process by mail.
*The secure features of My Health

Manager are available when you
receive care and/or fill prescriptions
at Kaiser Permanente facilities.
kp.org/myhealthmanager
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My Health Manager is your one-stop online resource for timesaving features.* Use it 24 hours a day, seven days a week, to:
Email your doctors office

Send secure, routine messages to your doctors office, saving time,
gas, and a copayment. (If you have urgent questions, call your
providers office.)
View most lab test results
Get most lab test results as soon as theyre available many on the
same day.
Refill prescriptions

Order your prescription refills. Enjoy the convenience of home
delivery for most refills at no extra charge.
Schedule, cancel, or review routine appointments

Request appointments and check past office visit information for
recommended follow-up steps.
View recent immunizations, allergies, and more

Review the names and dates of your immunizations, a list of your
allergies, and your eligibility and benefit information.
Act for a family member

Access your family members health information and email their
doctors offices using our secure online features.
pregnancy resources
Have a question about your pregnancy? You
can get assistance from these medical offices,
hospitals, our Mother-Baby Program, and more.
Obstetrics advice.............................. 503-571-4210
KAISER PERMANENTE
Appointment cancellations............... 503-813-2000
Portland....................................... 503-813-2000
All other areas..........................1-800-813-2000
For obstetrics advice past 20 weeks pregnancy:
During office hours, call Obstetrics &
Gynecology Advice at your medical office.
After office hours and on weekends and
holidays, call Kaiser Permanente Sunnyside
Medical Center.
Portland....................................... 503-571-9850
Washington.................................360-256-0556
Beaverton Medical Office
Obstetrics advice..............................503-520-4906
Appointments................................... 503-350-2450
Mother-Baby Program.......................503-626-5502
Cascade Park Medical Office
Appointments................................... 360-571-4267
Mt. Talbert Medical Office

Appointments................................... 503-571-2946
Mother-Baby Program,
Kaiser Permanente Sunnyside Medical Center
.......................................................... 503-571-4636
Rockwood Medical Office
Appointments................................... 503-571-2946
.......................................................... 503-571-4636
Salmon Creek Medical Office
Appointments................................... 360-571-4267
Mother-Baby Program........................360-571-3017
Skyline Medical Office
Appointments...................................503-370-4854
Salmon Creek Medical Office............360-571-3017
Interstate Medical Office East
Obstetrics advice..............................503-520-4906
Appointments................................... 503-249-0550
Vancouver area............................ 360-694-1577
Mother-Baby Program....................... 503-331-6479
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pregnancy resources
Mother-Baby Program....................... 503-361-5400
* Please register for a hospital tour by your 32nd week.
HOSPITALS
reference materials

.......................................................... 503-652-2880
You can find some of the following resources

for sale, reference, or loan online or at your
favorite bookstore, local library, or the Kaiser
Permanente Northwest Regional Library at
Kaiser Permanente Sunnyside Medical Center.
Vancouver area............................360-256-0556
Labor & Delivery................................503-571-4217
Tour appointments (Portland)*.......... 503-286-6816
Tour appointments (other areas)*
....................................... 1-866-301-3866 (toll free)
Providence St. Vincent
Medical Center...................................503-216-1234
All other areas................................ 1-800-677-6752
Labor & Delivery................................503-216-7391
....................................... 1-866-301-3866 (toll free)
Salem Hospital.................................. 503-561-5200
All other areas in Oregon................1-800-876-1718
Southwest Washington
Medical Center..................................360-256-2000
Portland area............................... 503-972-3000
Family Birth Center/
Labor & Delivery...............................360-514-4000
....................................... 1-866-301-3866 (toll free)
Books
Your Pregnancy Week by Week, 6th edition.
Glade B. Curtis, MD, and Judith Schuler, MS,
Da Capo Lifelong Books, 2008.
The Whole Pregnancy Handbook: An
Obstetricians Guide to Integrating
Conventional and Alternative Medicine Before,
During, and After Pregnancy. Joel Evans, MD,
OB/GYN, Gotham, 2005.
Your 9-Month Breakfast, Lunch, and Dinner
Date! A Guide to Healthful Eating During
Pregnancy. Maggie McHugh, MS, RD, CDN,
and Ellen Burggraf, MS, Eating for You (and
baby too), Inc., 2007.
Guide to a Healthy Pregnancy. Mayo Clinic,
Collins Living, 2004.
Hey! Whos Having This Baby Anyway?:
How to take charge and create a safe
environment for your babys birth, including
essential information about medications and
interventions. Breck Hawk, RN, Metropolis Ink/
End Table Books, 2005.
The Official Lamaze Guide: Giving Birth With
Confidence. Judith Lothian and Charlotte
DeVries, Meadowbrook, 2005.
The Birth Partner: A Complete Guide to
Childbirth for Dads, Doulas, and All Other
Labor Companions. Penny Simkin, Harvard
Common Press, 2007.
Breastfeeding Made Simple: Seven Natural
Laws for Nursing Mothers. Nancy Mohrbacher,
New Harbinger Publications, 2005.
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The Nursing Mothers Companion.

Kathleen Huggins, RN, MS, Harvard Common
Press, 2005.
The Ultimate Breastfeeding Book of Answers:
The Most Comprehensive Problem Solving
Guide to Breastfeeding From the Foremost
Expert in North America. Jack Newman, MD,
and Teresa Pitman, Three Rivers Press, 2006.
My Baby Can Talk Sharing Signs. Baby

Hands Productions, 2005.
Websites
Pregnancy and childbirth information
childbirth.org
Baby Center
babycenter.com
Connection Parenting: Parenting Through

Connection Instead of Coercion, Through Love
Instead of Fear. Pam Leo, Wyatt-MacKenzie
Publishing, 2007.
Breastfeeding.com, Inc.
breastfeeding.com
Bright From the Start: The Simple, ScienceBacked Way to Nurture Your Childs
Developing Mind from Birth to Age 3. Jill
Stamm, PhD, Gotham, 2007.
Child Safety Seat Resource Center

actsoregon.org
American Academy of Pediatrics

aap.org/parents.html
Baby Hearts: A Guide to Giving Your Child an

Emotional Head Start. Susan Goodwin, PhD,
and Linda Acredolo PhD, Bantam, 2005.
The Happiest Baby on the Block: The New
Way to Calm Crying and Help Your Newborn
Baby Sleep Longer. Harvey Karp, MD,
Bantam, 2005.
Videos and DVDs
Laugh and Learn About Childbirth. Expect
This LLC, 2007.
Pregnancy for Dummies. Wiley Publishing,
Inc., 2002.
National Geographic In the Womb.
National Geographic Video, 2006.
Denise Austin: Fit & Firm Pregnancy. Lions
Gate, 2006.
Prenatal Yoga With Shiva Rea. Living Arts, 2005.
Having Your Baby! A Complete Lamaze
Prepared Childbirth Class. Parent
Productions, 2004.
Baby Massage Therapy: Newborns, Infants
and Toddlers Version 2.0. Television School
of Massage Therapy, 2003.
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Prenatal visits
prenatal visits
prenatal visits
You and your baby are undergoing a lot of
changes. Week by week, your pregnancy reaches
new milestones and turning points. Its critical to
ensure you both stay healthy through it all.
Thats why one of the most important steps you
can take during pregnancy is to attend all your
prenatal visits.
During these checkups, youll discuss your babys
development, how to care for yourself, tests
you might need, preparations for your newborn,
and more. These visits help you keep tabs on
your health and your babys progress along the
way. You review current priorities and things to
consider. Each visit brings something new.
As soon as you know youre pregnant, make

an appointment with your doctor or certified
midwife. The schedule on page 12 outlines how
often you should come in and what to expect
during examinations.
Prenatal visit records

At each visit, you can use the prenatal visit
records to log your progress. Bring this guide
with you and enter the information with your
care team.
Beginning around week 28, you can take time

to talk with your doctor about your labor and
delivery options. As you identify your preferences,
you may want to write them down as a birth plan.
See page 93 for more information about this
important step.
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11
Prenatal
visit schedule
Regular prenatal examinations are a priority during any pregnancy. Heres the visit schedule for a lowrisk term pregnancy. If you have a pre-existing medical condition, develop complications, or are a teen,
you may require more frequent visits.
Week 6 8

Confirm pregnancy.
Lab tests.
First visit with your provider.
Genetic testing options.
Educational and diet information.
Physical exam.
Week 10 12

Fetal heart tones.

Confirm genetic testing decision.
Review lab results.
Influenza vaccine (November 1 March 31).
Week 15 16
Blood screening tests.

Schedule ultrasound.
Week 20

Tdap/Td vaccination.
Discuss ultrasound results.
Due date confirmation.
Hospital registration.
Week 24
View preterm labor video.

Schedule childbirth class.
Week 28
Learn to count fetal kicks.

Diabetes and blood count test; RhoGAM if
RH negative.
Start birth plan discussion.
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Week 32
Discuss birth control plans; sign tubal ligation

consent form if desired.
Schedule hospital tour.
Discuss breastfeeding.
Discuss circumcision.
Week 34
Optional visit, per provider and patient.
Week 36
Group B strep test.

Confirm babys position.
Discuss signs and symptoms of labor and
preeclampsia.
Confirm birth plan.
Week 37
Week 38
Discuss readiness for labor and delivery.
Week 39
Week 40 41
Discuss postdate plan.

Schedule postpartum visit.
After delivery: 4 6 weeks
Routine postpartum visit (sooner if needed).

Physical exam.
Discuss birth control, feeding, depression,
return to work.
12
Prenatal
visit records
Due date
First trimester
6 8 weeks
Time
Appointment date
Moms weight
Tummy measurement
Tests
Questions to ask
Provider instructions
10 12 weeks
Time
Appointment date
Moms weight
Tummy measurement
Tests
Questions to ask
First-trimester notes
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13
Prenatal
visit records
Second trimester
15 16 weeks
Time
Appointment date
Moms weight
Tummy measurement
Tests
Questions to ask
20 weeks
Time
Appointment date
Moms weight
Tummy measurement
Babys heart rate
Tests
Questions to ask
24 weeks
Time
Appointment date
Moms weight
Tummy measurement
Babys heart rate
Tests
Questions to ask
28 weeks
Time
Appointment date
Moms weight
Tummy measurement
Tests
Questions to ask
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14
Babys heart rate
Second-trimester notes
Third trimester
32 weeks
Time
Appointment date
Moms weight
Tummy measurement
Babys heart rate
Tests
Questions to ask
34 weeks (optional visit)
Time
Appointment date
Moms weight
Tummy measurement
Babys heart rate
Tests
Questions to ask
36 weeks
Time
Appointment date
Moms weight
Tummy measurement
Tests
Questions to ask
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15
Babys heart rate
Prenatal
visit records
Time
Appointment date
Moms weight
Tummy measurement
Babys heart rate
Tests
Questions to ask
Third trimester
38 weeks
Time
Appointment date
Moms weight
Tummy measurement
Babys heart rate
Tests
Questions to ask
Time
Appointment date
Moms weight
Tummy measurement
Tests
Questions to ask
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Babys heart rate
40 weeks
Time
Appointment date
Moms weight
Tummy measurement
Tests
Questions to ask
third-trimester notes
Prenatal visit tests and lab results

Ultrasound results
Lab results
Other
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17
Babys heart rate
classes
and education
classes
and education
Pregnancy and
childbirth classes
Your journey through pregnancy will teach
you many new things. Prepare yourself for the
healthiest experience possible by learning what
you need to know.
Kaiser Permanente Northwest offers a variety of
classes and programs designed just for expectant
and new parents.
To find details on products and classes near you,
visit kp.org and click the Health & wellness tab.
Then search for pregnancy programs and classes
in the Oregon/Washington region.
Newborn care products

For your convenience, Kaiser Permanente sells
some maternity and nursing products, such as
pillows and pumps. Visit kp.org to read details
about these items:
Medela breast pump.
Theraline maternity and nursing pillow.
To learn more and to order items, call
Health Education Services at 503-286-6816 or
1-866-301-3866 (toll free).
For more information and to sign up, call

Health Education Services at 503-286-6816, or
1-866-301-3866 (toll free).
Types of classes offered

There are a variety of classes to choose from to
support you in your journey to motherhood. To
find class locations and times, visit kp.org and
look for these topics:
Hospital birth tour. One-time session.
Preparation for birth. Two or five
class sessions.
Preparation for birth. Online class
sessions vary.
Life with baby. Nine online class sessions.
Tool kit for new parents. One-time session.
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19
Why take a
childbirth class?
By now, youve probably surrounded yourself with
articles on childbirth and heard countless labor
stories from friends and loved ones. But do you
really know what to expect during labor and birth
at Kaiser Permanente? A childbirth education
class can make a real difference in this experience.
Why should I take a childbirth

education class?
Whether youre a first-time mom or a delivery
room veteran, a childbirth education class can
help you prepare to meet the challenges of labor
and birth. You can:
Learn things about pregnancy, labor, birth,
and postpartum that you cant get in books
or DVDs. Find out what happens to you and
your baby during the birth process as well as
what you can do during the last months of
pregnancy to make the birth a more positive
experience for you, your partner, and your
baby. Youll also have the opportunity to
have your questions answered by a certified
childbirth educator.
Discuss options for handling pain. You can

practice breathing, relaxation, visualization,
and other methods for coping with
contractions. Our classes also cover commonly
used birth medications, such as narcotic
analgesics and epidural blocks, including their
advantages and effects on you and your baby.
Learn about cesarean birth. Learn why an
abdominal birth may be needed and
what typically happens if your baby is
delivered surgically.
Get more information on newborns and
postpartum at home. In addition to labor and
birth, you can discuss newborn appearance
and procedures, breastfeeding, comforting
baby, and postpartum issues.
Gain a sense of empowerment. Knowledge
is power. Learning more about the birth
process and your options allows you to more
confidently make decisions.
For more information, or to register for a class,
call 503-286-6816 or 1-866-301-3866 (toll free).
Address concerns. Talk and share ideas and

resources with other pregnant women and
their partners.
Connect with your partner or labor coach.
A childbirth education class offers your
partner or labor support person the chance
to learn about childbirth, too, as well as how
to support you during labor. The class will
give you an opportunity to practice relaxation
techniques together techniques that are life
skills, not just for labor and birth.
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20
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21
Genetic testing
Genetic diseases and chromosomal problems bring their own challenges. For many women, the chance
of having a child with one of these conditions is quite low about 3 to 4 percent. However, if you or
your partner is a genetic carrier of a disease, then the risk of having a child with that disease may be
higher. Chromosomal problems are less predictable, although chances increase with your age.
There are tests that can tell you if your baby has one of these problems or is at risk. The following pages
explain more about each condition and the screening tests available.
For more information
To learn more, contact Genetics at:

Interstate Medical Office West
3325 N Interstate Ave.
Portland, OR 97227
503-331-6593 or 1-800-813-2000, ext 16-6593
Genetic testing
If you have questions, you can talk to your health practitioner. The Genetics department offers evening
classes for Kaiser Permanente members. These sessions offer more detailed information about prenatal
testing options and can help support decision-making.

chromosomal problems
Abnormal chromosomes can cause some
pregnancies and babies to have problems.
Tests can show if your baby has a chromosomal
problem or is at high risk for one. These tests can
be helpful for some people, but they also have
drawbacks. It is always your choice to have testing
or not.
What are chromosomal problems?

Chromosomes are tiny structures in our cells that
contain genetic information. This information is
important in how a baby grows and develops.
Most people have 46 chromosomes in each of
their cells. The chromosomes come in pairs,
numbered from 1 to 23. The 23rd pair contains
the sex chromosomes and determines whether
a baby is a boy or a girl. If there is an extra
chromosome or a missing chromosome, this can
cause problems in a babys development.
Down syndrome is a common chromosomal
problem. People with Down syndrome have an
extra chromosome 21. This extra chromosome
causes people with Down syndrome to have
developmental disabilities and unusual facial
features. For most people with Down syndrome,
the developmental disabilities are mild, although
sometimes they can be more severe. Most
people with Down syndrome are able to lead
fulfilling lives.
There are many other types of chromosomal
problems. One severe chromosomal problem
is called trisomy 18. Babies with trisomy 18 have
an extra chromosome 18, and this seriously
impairs growth and development. Most babies
with trisomy 18 will miscarry, and few survive
for long. Trisomy 18 is much less common than
Down syndrome.
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More about Down syndrome

This genetic condition is caused by abnormal
cell division in the egg, sperm, or fertilized egg.
This results in an extra or irregular chromosome
in some or all of the bodys cells, causing
varying levels of intellectual disability and
physical problems.
Down syndrome is also called trisomy 21, for
the chromosome that has the abnormality. A
person with Down syndrome has three copies of
chromosome 21. Most people have two copies.
Down syndrome usually can be detected during
pregnancy or soon after birth. Chromosome
(karyotype) tests and how a baby looks can help
with a diagnosis.
Babies with Down syndrome usually have
distinctive facial characteristics, such as upwardsloping eyes and a flattened nose. People with
Down syndrome have an increased risk of health
problems. For example, some babies with Down
syndrome are born with heart, intestinal, ear, or
respiratory defects.
These health conditions often lead to other
problems, such as respiratory infections, sleep
apnea, or hearing problems. Other health issues,
such as vision trouble or thyroid problems, can
also develop.
Children with Down syndrome grow and develop
more slowly than other children. But most are
able to attend school, play sports, socialize, and
enjoy active lifestyles. Unless their disabilities are
severe, adults with Down syndrome can care for
most of their own needs. Many people with Down
syndrome survive into their 50s and some into
their 60s or older.
23

chromosomal problems
More about trisomy 18
Trisomy 18 is the second most common trisomy
condition after Down syndrome.
Chance for
chance
Mothers
chromosomal for down
age
problems
syndrome
A fetus with trisomy 18 has three copies of

chromosome 18. The extra chromosome causes
the fetus to develop abnormally, with a number
of physical and mental problems. Trisomy 18 can
be identified during pregnancy. Doctors can do
prenatal tests and fetal ultrasounds to screen for
problems, and they can do chromosome tests to
diagnose trisomy 18.
Most fetuses with trisomy 18 do not survive to
birth. Those who do generally live for a couple
of months to a couple of years. Babies born with
trisomy 18 can have many physical problems,
including heart and kidney problems, a small
head with low-set ears, a chest with an unusual
shape, and crossed legs. They also have severe
intellectual disability.
Who is at risk for having a baby with a
chromosomal problem?
Everyone has some chance of having a baby with
a chromosomal problem, although the chances
increase with maternal age (see chart).
Most problems with chromosomes are caused
by accidents in how the egg or sperm is formed
and have nothing to do with the parents
chromosomes or family history. Chromosomal
problems are not caused by anything that the
parents have done.
20
1 in 530
1 in 1,660
25
1 in 480
1 in 1,250
30
1 in 400
1 in 700
35
1 in 200
1 in 370
40
1 in 70
1 in 110
45
1 in 23
1 in 32
50
1 in 8
1 in 11
If I find out my baby has a chromosomal

problem, can anything be done?
There is no cure for chromosomal problems.
Some people want to know this information to
prepare for the birth of a child with special needs.
Others might choose to end their pregnancy
if they find out there is a serious chromosomal
problem. This is an extremely personal decision.
Chromosome screening tests

Screening tests can give you a better idea of the
chances for certain chromosomal problems like
Down syndrome, but they cannot tell for sure if
there is a problem. These are noninvasive tests,
so there is no risk of miscarriage.
There are two types of screening tests
stepwise screening and quad screening.
1. Stepwise screening can predict the chances
for Down syndrome. This screening starts
with a blood test at 9 to 12 weeks. The result
will tell if the chance for Down syndrome is
medium or very low. If the chance is medium,
the next step is a special type of ultrasound
called nuchal translucency.
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24
Nuchal translucency measures the fluid at

the back of the babys neck and is helpful
for figuring the chances for Down syndrome.
If the risk is very high, a woman can consider
amniocentesis or chorionic villus sampling
(CVS). If the risk is medium, the next step is
another blood test called the quad screen.
If the chance for Down syndrome is high
after these steps, a woman can choose to
have an amniocentesis.
2. Quad screening by itself is another way to
predict the chances for Down syndrome,
trisomy 18, and spina bifida. If this test shows
a high chance for one of these problems, a
woman might want to consider other tests like
an amniocentesis or ultrasound.
What are the benefits and drawbacks of having
amniocentesis or CVS?
These tests will tell you for certain whether the
baby has a chromosomal problem. This can be
helpful if:
You might consider ending the pregnancy if
there is a serious chromosomal problem.
You think it would be helpful to know
before delivery if there is a problem with
the babys chromosomes.
You are particularly worried and want to
know for certain whether the chromosomes
are normal.
The biggest drawback to amniocentesis and CVS
is the risk of miscarriage. Also, amniocentesis and
CVS cannot predict all types of problems a baby
might have.
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What are possible benefits of the screening

tests for chromosomal problems?
The screening tests provide more personal
information about the chances for some
chromosomal problems.
There is no risk of miscarriage.
If the screening test shows a low risk, this can
be reassuring information.
Some people would want to know if there is a
higher risk, particularly if they would consider
having amniocentesis or CVS.
What are the drawbacks to the screening tests?
These tests can never tell for certain whether
there is a chromosomal problem.
Even if the test shows a low risk, there is still
a small possibility the baby has a
chromosomal problem.
Even if the test shows a high risk, most of the
time the baby is perfectly fine.
If the screening test shows a high risk for
chromosomal problems, this information can
cause a lot of stress and anxiety.
Whether to have any prenatal testing is
completely up to you. Some people feel
that having information about the babys
chromosomes is very important. Others decide
not to have testing because of the risk of
miscarriage, or because they feel the information
would not be helpful to them. Only you can
decide whats best for you.
If you would like to have any of these tests, let
your Ob-Gyn provider know.
25
genetic diseases
Genetic diseases are caused by genes that do
not work properly. Genes are the basic units of
inheritance that determine many characteristics
of a baby, such as eye color, height, and blood
type. Genes are also important in determining a
babys health.
What does it mean to be a carrier?
Genes that do not work correctly are responsible

for genetic diseases such as thalassemia, sickle
cell disease, and Canavan disease (see table on
pages 28 and 29).
A child will have one of these diseases only if he

or she receives the same nonworking gene from
each carrier parent.
Being a carrier does not cause any health

problems. However, if both parents carry genes
for the same genetic disease, there is a chance
their child will have the disease.
All of our genes come in pairs; we get one from

each parent. To have one of the above disorders,
a baby must receive two nonworking genes for
the same disease, one from each parent. A person
who has only one nonworking gene for one of
these diseases is called a carrier.
When both parents are carriers, there is a 1 in 4

(25 percent) chance in each pregnancy that the
baby will have the disease. There is also a 3 in 4 (75
percent) chance that the baby will not inherit the
disease. If only one parent passes a nonworking
gene on to a baby, the baby will not have the
disease but will be a carrier like the parents.
Who carries genetic diseases?
How can I know if I am a carrier?
We all have some genes that do not work

properly, so everyone is a carrier for some genetic
disease. However, some genetic diseases, such
as the ones mentioned here, occur more often
in certain ethnic and racial groups than in the
general population. You dont have to have a
family member with one of these diseases to be a
carrier. Usually, there is no family history, so most
people do not know if they are carriers.
Although carrier testing is not available for most

genetic diseases, simple blood tests can tell
you if you are a carrier for thalassemia, sickle
cell disease, cystic fibrosis, Tay-Sachs disease,
Canavan disease, or familial dysautonomia.
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26
You can be tested for one or more of these

diseases if you or your babys father has an ethnic
background that is associated with a higher
chance of being a carrier. The test results are
most accurate in the higher risk groups listed
in the table and may be less accurate in other
groups. Most of these genetic carrier blood tests
are optional.
What does a negative result mean?
A negative test result means you are most likely not
a carrier for that particular disease. Therefore, no
further testing is generally needed. These tests are
very accurate, but they will not identify all carriers.
What does a positive result mean?
If the father of the baby is also found to be a

carrier, a genetic counselor will meet with you to
discuss the option of testing the baby before birth
(prenatal diagnosis).
Prenatal diagnosis can tell you whether or not
the baby will have the disease. Some people
who learn that their baby will have one of these
diseases may choose not to continue their
pregnancy. Others may use this information to
help them prepare for taking care of a child with
special needs.
If you choose not to have prenatal testing, your
baby can be tested shortly after birth. A genetic
counselor can help you make these decisions and
give you ongoing support.
A positive test result means that you are a carrier

for that particular disease. A health care provider
will tell you of your positive test result, and the
father of the baby will be offered testing. If his
test is negative, there is only a small chance that
your baby will have the disease, and no more
testing will be done.
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27
Genetic diseases risk and carrier screening chart

Disease
Higher-risk populations
Chance of being a carrier
Thalassemia
Asian.
Varies; 1 in 30 or higher.
Mediterranean (from Italy, Greece, Turkey,

Cyprus, and so on).
African-American, black.
Sickle cell disease
African-American, black.
About 1 in 12.
Cystic fibrosis
Caucasian, white (non-Hispanic).
About 1 in 25.
Tay-Sachs disease
Jewish (Ashkenazi/Eastern European).
About 1 in 30.
French Canadian.
Cajun.
Canavan disease
About 1 in 40.
Familial
dysautonomia
1 in 30.
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28
Symptoms and treatment
Carrier
screening
Blood disorders; two major types: alpha thalassemia, beta thalassemia.
Routine blood test.
Alpha thalassemia usually causes babies to die during pregnancy or shortly after birth.
During pregnancy, mother of an affected baby may develop serious health problems.
Very accurate, but will

not identify all carriers.
Beta thalassemia usually causes severe anemia and poor growth, beginning in infancy/
early childhood.
There may be a shortened life span.
Treatment may include lifelong blood transfusions, medications, frequent hospital stays.
Severity varies. Some people lead productive lives without serious illness.
Generally cannot be cured.
Blood disorders beginning in infancy/early childhood that cause anemia, bone pain, and
frequent serious infections. There may be a shortened life span.
Optional blood test.
Treatment may include frequent hospital stays, medications, blood transfusions.
Very accurate.
Generally cannot be cured.
Disease of the lungs and digestive system, developing in early childhood.
Thick mucus clogs the lungs, causing difficulty breathing and frequent lung infections.
Lung disease worsens over time. Problems with digesting food, resulting in poor weight
gain. Most people do not live beyond early adulthood.
Treatment may include daily chest physical therapy, medications, frequent hospital stays.
Detects about 90
percent of all carriers
in the Caucasian (nonHispanic) population.
Currently no cure.
Disease of the brain and nerves, developing in infancy.
Causes muscle weakness, developmental disabilities, and blindness. Greatly worsens

over time.
Death generally occurs by about 3 to 5 years.
No treatment or cure.
Detects about 95
in the Ashkenazi
Jewish population;
fewer in French
Canadians and Cajuns.
Disease of the brain and nerves, developing in infancy.
Causes muscle weakness, developmental disabilities, and seizures. Worsens over time.
Death generally occurs by 10 years.
No treatment or cure.
Detects about 97
in the Ashkenazi
Jewish population.
Disease of the nervous system, developing in infancy.
Causes problems with growth, balance, muscle tone, and lung infections. Also problems
with regulation of blood pressure, temperature, breathing, and digestion. Affects
perception of heat, pain, and taste.
Average life expectancy is 30 years.
Detects about 99
in the Ashkenazi
Jewish population.
No cure is available.
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29
Cystic fibrosis
Cystic fibrosis (CF) is a genetic disorder that
causes problems with frequent lung infections
and digestion. Without testing, a person would
ordinarily not know if he or she were a CF carrier
since being a carrier does not affect health in
any way.
Some people who are pregnant or planning
a pregnancy might like to know if they are CF
carriers. Others prefer not to know. Whether or
not to have CF carrier testing is completely up
to you.
How does CF affect a person?
CF causes a persons mucus to thicken and be
stickier than usual. This makes it more likely that
a person with CF will develop lung infections.
It can also cause problems with the digestive
enzymes usually produced by the pancreas, so
there can be problems with properly digesting
food. Sometimes babies with CF are born with
blockages in the intestines. Most men with CF are
infertile, and women with CF may have difficulties
becoming pregnant. CF does not affect a
persons intelligence or appearance.
The average life span for a person with CF is
currently about 30 years. Symptoms can range
from mild to severe. It is not always possible to
predict how severe the disease will be. Some
individuals with CF die in childhood, while others
may live into their 40s, 50s, or beyond. Many
people with CF are able to lead fulfilling lives.
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Can CF be treated?
At this time, there is no cure for CF. Some things
can be done to help treat CF. Medication can help
with the digestive problems. Respiratory therapy
(pounding or vibrating the chest) on a daily basis
is recommended for people with CF this helps
remove mucus from the lungs.
When lung infections do happen, they are treated
with antibiotics. However, the lung infections
typically worsen over time and become more
difficult to treat.
How is CF inherited?
CF is a genetic disorder. Our genes come in
pairs. In each gene pair, we get one gene from
our mother and the other from our father.
Sometimes there can be changes in genes that
cause them not to work properly. CF is a recessive
genetic disorder.
For CF and other recessive disorders, both genes
in the pair must be altered for the person to have
the disease. If a person has only one altered
gene for CF and the other gene in the pair works
correctly, then the person is a CF carrier and is
not affected by CF. CF carriers do not have any
health problems because the normal gene makes
up for the gene with the harmful alteration.
For a child to have CF, both parents must be CF
carriers. If both parents are carriers, there is a 1
in 4 chance that a child will inherit an altered CF
gene from each parent, and have CF.
30
What are my chances of being a CF carrier?

Certain genetic disorders tend to occur more
frequently in certain ethnic groups. CF is
seen most often in Caucasians. About 1 in 25
Caucasians are CF carriers. With other ethnic
groups, the chances of being a CF carrier are less.
Ethnicity
Chance of being
a CF carrier
Caucasian
1 in 25
Hispanic
1 in 58
African-American
1 in 61
Asian
1 in 94
If I have a relative with CF, does that change

my chances of being a CF carrier?
Is it possible that I could still be a CF carrier,

even though my results are normal?
Yes. At this time, the CF carrier test cannot find
all the harmful alterations in the CF gene, just the
most common ones. The test will detect about 90
percent of CF carriers in the general Caucasian
population. It is about 98 percent accurate in
people with Ashkenazi Jewish ancestry. It is less
accurate in other ethnic groups.
Ethnicity
Caucasian
88 percent
Ashkenazi Jewish
94 percent
Hispanic
72 percent
African-American
64 percent
Asian
49 percent
Yes, it makes your chances higher. For instance,

if you have a niece or nephew with CF, then you
have a 1 in 2 chance of being a CF carrier.
It is important to keep in mind that even if you
dont have anyone in your family with CF, it is
still possible to be a CF carrier. In fact, most
people who are CF carriers dont have any
relatives with CF.
How is CF carrier testing done?
A simple blood test can look at your CF genes to
see if you carry any of the most common harmful
alterations in the gene. Results usually take about
two weeks. If you choose to be tested and your
results show you are a CF carrier, you will be
contacted by phone.
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Accuracy of test
31
Cystic fibrosis
What if I find out I am a CF carrier?
If you are a CF carrier and you are pregnant or
considering a pregnancy, the next thing to do
is offer CF carrier testing to your partner. If your
partners CF results are negative, then it is unlikely
that your baby would have CF.
Remember, both parents have to be CF carriers
for there to be a chance the baby might have
CF. It would also be a good idea to discuss
these results with your relatives. For instance,
if you are a CF carrier, then your brothers and
sisters would each have a 50 percent chance of
being a CF carrier.
What if both my partner and I are CF carriers?
That means that for each of your children, there
would be a 1 in 4 chance that the child would
have CF. You will have an opportunity to discuss
this in more detail with a genetic counselor and to
discuss the possibility of prenatal testing for CF.
Are there risks associated with prenatal testing?
Yes. Prenatal testing can be done through
amniocentesis or chorionic villus sampling (CVS).
Amniocentesis can be done between 15 and 20
weeks of pregnancy and involves taking a small
sample of amniotic fluid. CVS is done at 10 or 11
weeks and involves taking cells from the placenta.
With amniocentesis, there is a 1 in 500 risk of
miscarriage. CVS has a 1 in 100 risk of miscarriage.
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If I find out my baby has CF, can anything

be done?
There is no cure for CF, and there is no treatment
for unborn babies with CF. Some couples might
choose to terminate a pregnancy if they know the
baby has CF. Others might want to continue with
the pregnancy. This is a very personal decision
and is completely up to the couple.
If I had CF carrier testing once, would I ever
need to have it again?
Probably not. It is possible that the test
will become more accurate in the future as
technology improves. Check with your primary
care provider or your Ob-Gyn provider in the
future if you are planning a pregnancy.
Could my CF carrier results ever cause
problems in getting health or life insurance?
There has been some concern in the medical
community about the possibility of genetic
discrimination. Few cases have been reported, and
some laws are already in place to try to prevent
insurance companies from turning people down
because of genetic test results.
Being a CF carrier does not cause health problems.
CF carrier test results will not change your health
care coverage at Kaiser Permanente in any way.
32
When should I have CF carrier testing?
Possible reasons for not being tested
The ideal time is before you become pregnant.

That way, you are better informed beforehand.
You dont see CF as being a serious disorder.
If you are already pregnant and want to have CF

carrier testing, earlier in pregnancy is better. CF
carrier testing usually takes two weeks to get back
the results and another two weeks to get your
partners results if you are a carrier. By testing
early in pregnancy, there is still time for prenatal
testing if you wish to do so.
Possible reasons for being tested
You see CF as being a serious disorder.
You think your chances of being a CF carrier are
high (for instance, you have relatives with CF).
You would consider prenatal testing if you and
your partner are both CF carriers.
You would consider terminating a pregnancy
with CF.
You feel knowing about CF before delivery
would help you be better prepared.
You think your chances of being a CF carrier

are low (for instance, you are not Caucasian).
You would not consider prenatal testing if you
and your partner are both CF carriers.
You would not consider terminating a
pregnancy with CF.
You think knowing about CF before delivery
would not be helpful.
Finding out you are a CF carrier can cause
stress and anxiety.
You are concerned about the possibility of
genetic discrimination.
The test cannot identify all CF carriers.
If you decide that you would like to have CF
carrier testing, let your Ob-Gyn provider or your
primary care provider know, and he or she can
make arrangements for you to have your blood
drawn. Remember its your choice, so make
the best choice for you.
Test results are usually reassuring.

It is unlikely that you would experience genetic
discrimination based on your test results.
The test can identify most CF carriers,
especially in Caucasians.
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33
health
and wellness
health and wellness
Your health
and wellness
One of the best ways you can care for your babys health is to take care of yours. Knowing youre doing
all you can to stay healthy may give you greater peace of mind.
The following pages offer tips on how to exercise, eat, and feel your best during one of the most
dynamic times of your life. Youll learn about:
Staying fit.
Eating well.
Medications and natural remedies.
Managing emotions.
Body changes and discomfort.
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35
staying fit
Moderate exercise during pregnancy can help you
feel your best and ward off discomforts, such as
backache and fatigue. Exercise is a good warmup for childbirth because the physical activity
improves your circulation and energy for labor.
Also, exercising during pregnancy can help you
maintain muscle strength and shed unwanted
pounds after your baby is born. If youre physically
active most days, great! If not, this is a good time
to start. Begin slowly, build up gradually, and try
to exercise at least 30 minutes per day.
tips for a safe workout

Check with your practitioner before starting
any exercise routine.
Whatever activity you choose, dont overdo it.
Listen to your body and rest if you feel tired.
You should be able to carry on a conversation
during any activity.
Drink extra water before, during, and after
exercise to avoid dehydration.
Get plenty to eat so that you dont run low
on glucose.
Do not exercise to lose weight. Read about the
importance of weight gain during pregnancy.
Avoid overheating. During hot weather,
exercise indoors and (ideally) in an airconditioned space.
Best bets for moms-to-be

During your first trimester, you should be able
to continue your same exercise routine if youre
having a healthy pregnancy. Try for a combination
of aerobic, strength, and flexibility exercises. In
your second and third trimester, you may need to
vary your routine slightly.
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Walking. Its safe and easy for most women

from the moment you find out youre pregnant
until the final weeks. Wear a pedometer to
count your steps and motivate you to stay
active. Remember to use a handrail when
walking up or down stairs.
Swimming or water aerobics. Both are
gentle on your joints and provide a feeling of
weightlessness (a welcome break in the later
months of pregnancy).
Stretching or yoga. Stretching eases back
pain and helps you maintain flexibility. Look for
classes or videos designed for pregnant women.
Low-impact dance or aerobics. Moving to
music is fun for both you and your growing
baby. Stay balanced by avoiding jumps, kicks,
leaps, and bouncing.
Exercises to prepare for birth

The muscles in your lower abdomen, lower back,
and around the vagina (birth canal) come under
great strain during pregnancy. During delivery, these
same muscles must relax and stretch. In the event of
a lengthy labor, increased endurance can be a real
help. Practice the following exercises throughout
your pregnancy to help you during childbirth.
Back press
This exercise strengthens your trunk and thighs,
helping you maintain a healthy lower back posture
during your pregnancy.
1. Stand 10 to 12 inches from a wall, with your
back facing the wall.
2. Rest your back flat against the wall and slide
down the wall until your knees are slightly bent.
3. Press your lower back against the wall by
pulling in your stomach muscles.
36
4. Hold this position for a count of 10, then relax

your stomach muscles and slide back up the wall.
5. Do this exercise 10 times.
Backward stretch
This exercise stretches and strengthens your back,
thigh, and pelvic muscles.
1. Kneel on hands and knees with your knees 8
to 10 inches apart, hands directly under your
shoulders, and arms and back straight.
2. Keeping your arms straight, slowly lower your
buttocks toward your heels and tuck your
head toward your knees. Hold for a count of 5.
3. Slowly return to the kneeling position.
4. Do this exercise 5 times.
3. Hold for a count of 5, then slowly sit up straight.

4. Do this bend 5 times or to your comfort level.
Leg-lift crawl
This exercise strengthens your back and
abdomen muscles.
1. Kneeling on hands and knees, place your
hands directly under your shoulders and
straighten your arms.
2. Lift your left knee and point it toward your
elbow, while lowering your chin toward
your chest.
3. Slowly extend your leg behind you without
completely straightening it, while raising your
head to look in front of you. Avoid arching
your back.
Diagonal curl
4. Do left and right lifts 5 to 10 times each.
This exercise stretches your back, spine, and

upper torso muscles.
Pelvic rocking
1. Sit with your feet out in front, knees bent, and

hands clasped in front of you.
2. Slowly twist your upper torso to the left and
then to the right.
3. Twist to each side 5 times.
Forward bend
This exercise strengthens your back, hip, and

abdomen muscles.
1. Kneeling on hands and knees, place your
hands directly under your shoulders and
your knees under your hips.
2. Inhale deeply.
This exercise stretches and strengthens your

back muscles.
3. While slowly exhaling, pull in your abdomen,

and tighten your buttocks and pelvic floor
muscles. This should curve your spine into a
C shape.
1. Sit comfortably in a chair, with your

arms relaxed.
4. Relax, keeping your back straight (dont

allow it to curve toward the floor).
2. Slowly bend forward, allowing your arms to

hang down in front of you. Lean only as far as
you can without feeling discomfort or pressure
on your abdomen.
5. Do this exercise 8 times or to your

comfort level.
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37
staying fit
Pelvic tilt
Tailor stretching
This exercise strengthens your lower back and

pelvis. It is for use during the first four months of
pregnancy. After this point, lying on your back is
not recommended, because it can cause blood
circulation problems for you and your fetus.
This exercise stretches the back, hamstrings,

and arms.
1. Keep your knees relaxed.

2. Tighten your abdominal and buttock muscles.
3. At the same time, gently shift your pelvis
upward. This should flatten the curve in
your back.
4. Hold for a count of 10 and relax.
5. Gradually increase the number of tilts you do
each day, to your comfort level.
Tailor press
This exercise stretches your hip and thigh muscles
and strengthens your arm and leg muscles.
1. Bring the bottoms of your feet together, then
draw them as close to your body as you can.
2. Cup your hands under your knees.
3. Press your knees toward the floor. At the same
time, resist that force by pulling upward with
your hands. Do this while slowly counting to
3. Relax.
4. Gradually increase the number of presses
you do per day. A good goal is 10 times,
twice daily.
Tailor sitting
This exercise stretches your hip and thigh muscles
as you sit comfortably.
1. Bring your feet close to your body while
crossing your ankles.
2. Hold this position for as long as you are
comfortable.
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1. Sit with your back straight, legs about 12

inches apart, and feet relaxed outward.
2. Stretch your hands forward toward your left
foot, then sit up.
3. Stretch your hands straight forward, then sit up.
4. Stretch your hands forward toward your right
foot, then sit up.
5. Gradually increase the number of stretch
sets you do per day. A good goal is 10 sets,
twice daily.
Trunk twist
This exercise stretches your back, spine, and
upper torso muscles.
1. Sit with your legs crossed.
2. Reach your left hand toward your left foot, and
place your right hand at your side for support.
3. Slowly twist your torso to your right.
4. Switch your hands and twist to your left.
5. Repeat left and right twists 5 to 10 times each.
Upper-body bends
This exercise strengthens your back and
torso muscles.
1. Stand with your hands on your hips, legs apart,
and knees slightly bent.
2. Keeping your upper back straight, bend
forward slowly. You should feel a slight pull
below your buttocks.
3. Bend 10 times.
38
Kegels the other exercise
Activities to avoid
During pregnancy and delivery, the pelvic floor

can become stretched and weak, leading to
urine control problems after your baby is born.
Kegel exercises help you strengthen your pelvic
floor muscles.
As you enter your second trimester, you may find

that your achy joints, growing belly, and changing
center of gravity make you unstable on your feet.
During this time, youll probably need to make
adjustments to your normal exercise routine. Here
are some activities to avoid:
Start doing Kegel exercises daily as soon as you

become pregnant. Kegels can be done anytime,
standing or sitting, and no one will even know.
Heres how:
Firmly tighten the muscles around your
vagina, as you would to stop urinating. (Its
not recommended to practice Kegel exercises
while on the toilet because this may strain the
pelvic floor muscles.)
Hold tightly for as long as you can (8 to 10
seconds). Remember to keep breathing as you
hold the muscles.
Then slowly release the muscles and relax.
Repeat 10 to 15 times, at least 3 times a day.
Kegel exercises are effective only when
done regularly.
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Bouncing, jumping, or movements where

you could lose your balance, especially in the
third trimester.
Contact sports, such as soccer, softball,
and basketball.
Scuba diving.
Exercise in high altitudes (above 6,000 feet).
Water or downhill skiing.
Horseback or motorcycle riding.
After your fourth month, avoid anything that
requires you to lie flat on your back (such as
sit-ups and some yoga poses).
Avoid overheating or extreme sweating.
39
Eating well
While youre pregnant, you supply everything
your baby needs to grow. The best way to do
this is to eat at least three meals and two healthy
snacks every day. Also, drink 8 to 10 full glasses of
fluid every day.
The daily food guide on page 41 will help you
choose foods that give you the nutrition you
and your baby need while youre pregnant. At
the end of the day, you can see if youre getting
enough servings from each of the following five
food groups:
Calcium-rich foods
Aim for 1,200 milligrams of calcium per day. If you
dont get enough calcium, your body will draw
it from your own bones to give to the baby. This
may cause you to develop osteoporosis later in
life. Sources of calcium include:
Low-fat or nonfat dairy products (milk,
cheese, yogurt).
Tofu (calcium fortified).
Almonds.
Bread and other whole grains.
Broccoli.
Vegetables, especially green leafy vegetables.
Canned sardines or canned pink salmon

with bones.
Fruits.
Milk and milk products.
Soy nuts or soybeans.
Meat and beans.
Certain green, leafy vegetables (spinach, kale,

bok choy, collards, turnip greens, and broccoli).
Vitamins and minerals
Scallops.
Three vitamins and minerals are especially

important for you and your growing baby:
calcium, iron, and folate (also called folic acid).
Fortified cereals or oatmeal.
You can get the extra nutrients your baby needs

to be healthy if you eat enough of the right foods.
But even if you have excellent eating habits,
your practitioner may still recommend a daily
multivitamin with folic acid.
Corn tortillas.
Orange juice (calcium fortified).
Folate-rich foods
Its recommended that women take folic acid (400
micrograms per day) before getting pregnant and
through the first three months of pregnancy.
However, dont rely on dietary supplements to

make up for an unhealthy diet. Keep in mind that
taking too much of any supplement can have
a harmful effect on you and your baby. To be
safe, check with your practitioner before taking
vitamins, herbs, or other dietary supplements.
Once you are pregnant, you should eat foods that

contain approximately 0.6 milligrams per day of
folic acid, which is a B vitamin. Thats the same as
eating one bowl of 100 percent fortified cereal,
a half-cup of spinach, and a half-cup of great
northern beans.
The following information lists the foods rich

in nutrients that are most important during
pregnancy. Use this as a general guideline for how
much of each nutrient to take daily and where to
find it naturally.
Getting enough folic acid before and during

pregnancy reduces the chance of certain birth
defects. Folate-rich foods include:
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40
Dark-green, leafy vegetables (kale, Swiss

chard, collard greens, and spinach).
Daily food guide

Recommended
daily amounts
Beans.
Food groups
Broccoli.
Bread and other

whole grains
1 slice bread
1 tortilla
1 cup dry cereal
cup hot cereal
cup cooked rice,
noodles, or pasta
6 whole-grain crackers
6 10 ounces
Vegetables
1 cup raw or cooked vegetables
1 cup green salad
1 cup vegetable juice
2 3 cups
Fruits
1 medium piece fresh fruit
1 cup fresh fruit
1 cup orange juice
or other 100 percent fruit juice
1 2 cups
Milk and milk products

1 cup low-fat or nonfat milk
or yogurt
1 cup low-fat or nonfat
frozen yogurt
1 ounces low-fat cheese
2 cups cottage cheese
1 cup soy milk
(calcium fortified)
3 cups
Meat and beans

1 ounce lean meat, chicken,
turkey, or fish
1 cup cooked beans or lentils
cup tofu
1 egg
1 tablespoon peanut butter
cup nuts and seeds
5 7 ounces
Asparagus.
Cantaloupe, honeydew, oranges.
Orange and grapefruit juices.
Peanuts and almonds (limit to 1 to 2
tablespoons per serving).
Folate-fortified breads and breakfast cereals.
Iron-rich foods
If you need an iron supplement (ferrous sulfate),
your practitioner will tell you which type to take
and recommend when to take it. Generally
women wait until their second trimester of
pregnancy to take iron supplements, which may
worsen morning sickness.
You will need twice as much iron in your second
and third trimesters as you did before pregnancy.
Aim for 30 milligrams per day. Getting enough
iron prevents anemia, which is linked to preterm
birth and low-birth weight.
Try to eat iron-rich foods in combination with
foods or juices high in vitamin C such as
oranges, peppers, broccoli, and strawberries
because vitamin C helps your body absorb iron.
Iron-rich foods include:
Lean beef, lean pork, and chicken or turkey
(skin removed).
Pumpkin seeds.
Lentils and beans.
Iron-fortified cereals.
Mussels, oysters, clams, shrimp, and sardines.
Dark-green, leafy vegetables (kale, Swiss
chard, collard greens, and spinach).
Dried fruits (raisins, prunes, apricots).
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For example:
2 slices of bread from
sandwich = 2 ounces
of bread
For example:
1 cup raw carrots
from snack = 1 cup
of vegetables
For example:
1 cup orange juice
from lunch = 1 cup
of fruit
For example:
1 cup low-fat yogurt
from snack = 1 cup
of milk products
For example:
1 ounce turkey from
sandwich = 1 ounce
of meat and beans
Eating well
prenatal vitamins
Most women can benefit from prenatal vitamins,
even before they start trying to conceive. Taking a
prenatal vitamin is especially important for women
who are pregnant with multiples or women who
have dietary restrictions, certain health issues, or
pregnancy complications.
Prenatal vitamins are available without a
prescription.
If you have questions, talk to your practitioner.
Foods to avoid
Although you can enjoy most foods while
pregnant, there are some that you should cut
back on, or eliminate. This list includes:
Alcohol. Drinking alcohol can harm your baby
and cause him or her problems later in life.
There is no amount of alcohol that has been
proven safe in pregnancy, so its better not to
drink any alcohol.
Raw or undercooked meat, chicken, and
fish. Cook raw foods thoroughly and cook
ready-to-eat meats such as hot dogs
or deli meats (ham, bologna, salami, and
corned beef) until theyre steaming hot.
Wash your hands, knives, cutting boards, and
cooking surfaces with warm, soapy water after
handling raw or undercooked meat.
Caffeine. Coffee, tea, soda, hot chocolate,

or sports and energy drinks may contain
caffeine. Its a good idea to keep your caffeine
intake below 200 milligrams a day (about two
cups of coffee) because more caffeine may
be connected to higher rates of miscarriage.
However, there is not enough evidence
to know for sure. In addition, caffeine is a
diuretic, meaning it makes you urinate more
often, which can cause you to lose important
minerals, including calcium. Caffeine may also
interfere with sleep for both you and your baby.
Shark, swordfish, king mackerel, tilefish,
and albacore tuna. They have high levels of
mercury, which is dangerous to your baby.
Eat no more than 12 ounces a week of fish
or shellfish with low mercury levels. Good
choices include shrimp, canned light tuna,
wild salmon, pollack, trout, and catfish.
Raw eggs and foods containing raw egg.
Lightly cooked eggs (such as soft-scrambled
eggs), Caesar dressing, or hollandaise
sauce can increase your risk of exposure
to salmonella.
Liver. It has excessive amounts of vitamin
A, and too much vitamin A may cause birth
defects. However, fruits and vegetables that
contain beta carotene (a precursor to vitamin
A) are perfectly safe to eat.
Unpasteurized soft cheeses. Avoid brie, feta,

fresh mozzarella, and blue cheese because
they contain bacteria that could harm your
baby. Hard cheese, processed cheeses, cream
cheese, and cottage cheese are safe, but look
for reduced-fat options.
Papaya, especially when unripe. Papaya

is sometimes recommended for soothing
indigestion, which is a common ailment during
pregnancy. Although a fully ripe papaya is not
considered dangerous, a papaya that is at all
unripe contains a latex substance that triggers
uterine contractions. Contractions of the
uterus could lead to a miscarriage.
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43
medications and
natural remedies
If you take any medications or herbal remedies,
your developing baby takes them, too. Thats why
its important to ask before taking any form of
medication. In general, follow these guidelines:
If youre taking prescription medications,
continue to take them unless your practitioner
tells you otherwise. Make sure to follow the
directions carefully.
Tell your practitioner about all medications
(prescription and over-the-counter), vitamins,
homeopathic remedies, herbs, or home
remedies that youre taking.
Dont take any prescription medications

unless theyre prescribed or approved by a
practitioner who knows youre pregnant.
Use over-the-counter medications only if you
really need them. Stop taking them as soon as
you feel better. Try natural remedies for relief,
if possible. (See the chart on the right.)
Call your practitioner if:
You feel worse after you take any medication.
Your symptoms dont improve.
Fluid intake
Drinking plenty of fluids during pregnancy can help you avoid many of these symptoms
naturally. With enough fluid, youre less likely to become dehydrated, be constipated, get
urinary tract infections, or experience preterm (premature) labor. Youll also have softer
skin and be at less risk of retaining water. Your baby needs fluids for proper growth. To get
enough fluids for yourself and your baby:
Drink about 8 to 10 full glasses (64 to 80 ounces) of fluid each day.
Keep a full glass of water with you.
Try a variety of fluids, like milk and soups, in moderate amounts.
Choose caffeine-free, nonalcoholic drinks.
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Natural remedies and safe over-the-counter medications

problem
Natural remedies
Over-the-counter
medications
Headache
Massage.
Rest.
Cool washcloth on forehead.
Acetaminophen (such as Tylenol).

Do not take aspirin or ibuprofen (such
as Motrin, Advil, Nuprin, or Medipren).
Cold and cough Rest.

Drink plenty of warm liquids.
Use a vaporizer, humidifier, or shower for
nasal congestion.
Acetaminophen (such as Tylenol) for

aches and fever.
Pseudoephedrine (such as Sudafed) for
stuffy or runny nose.
Chlorpheniramine (such as
Chlor-trimeton) for allergies.
Saline nasal drops.
Cough drops.
Dextromethorphan or guaifenesin.
Constipation
Increase fluids and fiber in diet (such

as prunes).
Exercise regularly.
Metamucil (plain), Fiberall, or Colace.
Diarrhea
Drink clear liquids.
Imodium.
Indigestion
Eat smaller meals.

Wear loose-fitting clothing.
Elevate head when lying down.
Tums (for occasional heartburn relief).

Maalox, Mylanta, or Riopan.
Hemorrhoids
Use witch hazel pads, Tucks pads, or

ice packs.
Take a warm sitz bath.
Preparation H, Anusol, or 1%
hydrocortisone cream.
Nausea and
vomiting
Take vitamin B6 (25 milligrams three

times a day).
Eat crackers or dry toast.
Use acupressure on wrist.
Ginger tea or capsules.
Emetrol.
Vaginal itch
Eat yogurt that contains live

Lactobacillus organisms.
Wear cotton underwear.
Reduce or eliminate sugar from diet.
7-day treatment Monistat or GyneLotrimin (for yeast infections) or 1%

hydrocortisone cream.
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Managing emotions
What to expect from
your emotions
Emotions during pregnancy differ for every
woman. You may experience highs and lows or feel
uncertain even if your pregnancy was planned.
Increased hormones and the fatigue of pregnancy
can spur mood swings. At times, you may feel
exhausted, forgetful, or moody. You may worry
about your body, how to manage symptoms, or
how different your life is becoming.
Many women fear that their baby will have
a problem. Or they may feel anxious about
childbirth or that their pregnancy isnt going well.
Second trimester. Fatigue, morning sickness,

and moodiness usually improve or go away.
You may feel more forgetful and disorganized
than before. Looking heavier than normal,
then looking visibly pregnant and feeling the
baby move, can make you feel any number
of emotions.
Third trimester. Forgetfulness may continue.
As your due date nears, it is common to feel
more anxious about the childbirth and how
a new baby will change your life. As you feel
more tired and uncomfortable, you may be
more irritable.
Handling ups and downs
Other concerns can come up, too. Keeping up

with everyday life, finances, and relationships
with family and friends are potential sources of
confusion or stress.
Feeling waves of emotion during pregnancy is

natural. To keep your stress low, try doing relaxation
exercises and time management practices at home.
Here are a few tips to get started:
As you adjust to your changing world, its

important to understand why things feel different
and how to find relief.
Guided imagery
Emotional shifts by trimester

Each trimester brings new streams of mind and
body sensations. Here are general ways your
emotional life may shift along the way:
First trimester. Extreme fatigue or
morning sickness can color your daily life.
Moodiness (as with premenstrual syndrome)
is normal. Happiness and anxiety about a
new pregnancy, or feeling upset about an
unplanned pregnancy, are also common.
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It is possible to feel calm just by imagining it.

Guided imagery suggestions:
Work with audio recordings, an instructor, or a
script (a set of written instructions) to lead you
through the process.
Imagine yourself in a calm, peaceful setting to
help you relax and relieve stress.
Use all of your senses (touch, smell, taste,
hearing, and sight) in guided imagery. For
example, if you want a tropical setting, you
can imagine the warm breeze on your skin, the
bright blue of the water, the sound of the surf,
the sweet scent of tropical flowers, and the
taste of coconut so that you actually feel like
you are there.
46
Breathing exercises
Time management
Deep breathing can help you feel relaxed, reduce

tension, and relieve stress. Try some of these
breathing exercises to calm and relax your mind
and body:
When youre pregnant, demands on your time

can increase. Doctor visits, classes, and preparing
for the new baby plus all of your normal
obligations add up fast. Finding a system to
manage your time, activities, and commitments
helps make your life easier, less stressful, and
more meaningful. Time management suggestions:
Belly breathing. Sit in a comfortable position

with one hand on your belly just below your
ribs and the other hand on your chest. Take
a deep breath in through your nose, and let
your belly push your hand out. Your chest
should not move. Breathe out through pursed
lips as if you were whistling. Feel the hand on
your belly go in, and use it to push all the air
out. Do this breathing 3 to 10 times. Take your
time with each breath.
4-7-8 breathing. Put one hand on your belly
and the other on your chest. Take a deep,
slow breath from your belly, and silently count
to 4 as you breathe in. Hold your breath,
and silently count from 1 to 7. Breathe out
completely as you silently count from 1 to 8.
Try to get all the air out of your lungs by the
time you count to 8. Repeat 3 to 7 times or
until you feel calm.
Morning breathing. From a standing position,
bend forward from the waist with your knees
slightly bent, letting your arms dangle close
to the floor. As you inhale slowly and deeply,
return to a standing position by rolling up
slowing, lifting your head last. Hold your breath
for just a few seconds in this standing position.
Exhale slowly as you return to the original
position, bending forward from the waist.
Prioritize tasks. Make a list of all your tasks and

activities for the day or week. Then rate these
tasks by how important or urgent they are.
Control procrastination. The more stressful
or unpleasant a task, the more likely you are
to put it off. This only increases your stress.
Try this instead: Structure your time, break up
large tasks, create short-term deadlines, and
avoid perfectionism.
Let go. Liberate yourself from doing it all.
Learn whats important to you, recognize that
you have limits, and decide how you want to
spend your time. When you do, youll breathe
a little easier.
Make commitments. Once you commit, see
it through. Commit as fully as you can, dont
back out of obligations, and be open to new
ideas and suggestions.
These are just a few of the breathing exercises out

there. Consult your care team to find out which
exercises are the best fit for your specific needs.
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Body changes
and discomfort
Your body changes a lot in nine months with
a baby growing inside of you!
Although they can range from mild to
severe, the following conditions are common
during pregnancy:
Back pain and sciatica

Most women develop back pain at some point
during pregnancy. As the size and weight of your
growing belly place more strain on your back,
you may notice your posture changing. To protect
your back, follow these guidelines:
Avoid standing with your belly forward and
your shoulders back. Do the opposite.
When standing, rest one foot on a small
box, brick, or stool. Try not to stand for long
periods of time.
Sit with a back support or pillow against your
lower back. If you must sit for prolonged
periods, take a break every hour.
Avoid heavy lifting. Lift only by raising from a
squat, keeping your waist and back straight.
Avoid stretching to reach something, such as
on a high shelf or across a table.
Sleep on a firm mattress (plywood under a
mattress helps). Lie on your side, with a pillow
between your knees.
Stay active, and do the simple back exercises
from the Staying fit section.
Breast changes
In the second trimester of pregnancy, your breasts
will become larger and heavier, and you may need
a larger and more supportive bra. As your breasts
become larger, veins become more noticeable
under the skin. The nipples and the area around
the nipples (areola) darken, and small bumps may
appear. You may also notice yellowish discharge
(colostrum) from your nipples. Colostrum is what
your breasts produce when they are preparing
for breastfeeding.
Changes in vaginal discharge

A thin, milky-white discharge (leukorrhea) is
normal throughout pregnancy. You may also have
yeast infections that reoccur or are difficult to
get rid of. Review the Medications and natural
remedies section for treatment options.
Fatigue
Most women struggle with fatigue during
pregnancy, especially during the first and third
trimesters. To manage fatigue during pregnancy:
Take frequent rest breaks during the day.
Reduce nonessential activities and
responsibilities.
Exercise regularly get outside, take walks,
keep your blood moving with your favorite
workout. If you dont have your usual energy,
dont push it.
Eat a balanced diet, and drink plenty of water.
Review the Medications and natural remedies
section for more treatment options.
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Hair changes
Hemorrhoids and constipation
During pregnancy, hormonal changes can affect

how your hair looks and feels. You may notice that
your hair is thicker and healthier-looking than usual.
Hemorrhoids and constipation are common

during pregnancy. Pressure on the large intestine,
slower-moving bowels, and the increase in iron
from prenatal vitamins are often the cause. For
relief, try eating a high-fiber diet, drink plenty of
water, avoid straining during bowel movements,
and get more exercise.
But some women find that their hair is more limp

and lifeless during pregnancy. It is normal during
pregnancy to grow hair on other parts of your
body, such as your abdomen, face, or back.
After pregnancy, your hairs growth cycle returns
to normal.
Hand pain, numbness, or weakness

(carpal tunnel syndrome)
Tingling, numbness, and pain in the hands are
common during pregnancy, especially in the last
trimester. These problems are usually caused
by carpal tunnel syndrome, and they usually go
away after pregnancy. To reduce discomfort, try
changing or avoiding activities that may be causing
symptoms and take frequent breaks. You can also
try using wrist guards, especially when sleeping.
Heartburn (a symptom of
gastroesophageal reflux disease,
or GERD)
Heartburn is common during pregnancy
because hormones cause the digestive system
to slow down. However, heartburn rarely causes
complications, and most of the time, symptoms
improve after your baby is born. Avoiding spicy
foods, eating smaller meals, and waiting two to
three hours after eating before you lie down can
help reduce symptoms.

section for treatment options.
Leg cramps
Leg cramps affect many pregnant women. The
cause of leg cramps during pregnancy is not fully
known, but they may be caused by reduced levels
of calcium or increased levels of phosphorus in
the blood.
If you get a leg cramp, straighten your leg, flex
your foot so that your ankle and toes point up
(toward your head), massage your calf, walk
around to stretch your calf, and avoid pointing
your toes when you stretch your legs.
Although uncommon, a blood clot can
form in a deep vein of the leg (deep vein
thrombosis, or DVT) during pregnancy. DVT
can be life-threatening and requires medical
treatment. Consult you care team for specific
treatment advice.

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Body changes
and discomfort
Morning sickness
Pelvic aches and hip pain
Morning sickness is nausea, sometimes with

vomiting, caused by hormones released during
pregnancy. Morning sickness occurs most often
during the first three months of pregnancy.
As your pregnancy progresses, you may develop

aches and pains in your hips and pelvic area.
This is a normal sign that your pelvic girdle is
preparing for childbirth. Pregnancy hormones are
relaxing your ligaments, loosening up your pelvic
bones so they can shift and open for childbirth.
You may find that nausea and vomiting are

worse in the morning. But symptoms can occur
at any time of the day or night. Most women
feel better at the beginning of the second
trimester. However, symptoms can continue
throughout pregnancy.
Nosebleeds and bleeding gums

Nosebleeds during pregnancy may be caused by
increased blood flow to the tissue lining the inside
of the nasal passages (mucous membranes).
Increased blood flow to the mucous membranes
of the mouth and gums during pregnancy may
also cause bleeding, especially when you brush
your teeth. Your gums may appear more swollen
than usual. Try using a soft-bristled toothbrush.
Inform your dentist and visit regularly during
pregnancy for exams, but avoid X-rays and
anesthesia until after you deliver.
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To help manage pelvic and hip pain at home, try

the following:
When lying on your back, propped up on your
elbows or a pillow, squeeze a pillow between
your knees. This can help realign your pelvic
bones and may give you temporary pain relief.
Wear a prenatal belt or girdle around your
hips, under your abdomen, to help stabilize
your hips.
Sleep with a pillow between your knees.
Rest as much as possible, applying heat to
painful areas.
Talk to your health professional about whether
a safe pain reliever might help.
Sleep problems
Hormonal changes, plus the discomforts of
later pregnancy, may disrupt your sleep cycle.
Regular exercise, shorter naps, relaxation
techniques, comfortable pillows, and avoiding
caffeine can help you get the best possible sleep
during pregnancy.
50
Stretch marks, itchiness, and

other skin changes
Stretch marks are most common on the belly, but
they can also develop on the breasts and thighs.
Other skin changes can also occur:
A dark line known as a linea nigra may appear
on the skin between your navel and your
pubic area. It generally fades after delivery.
Varicose veins
Enlarged, swollen veins are common during
pregnancy, particularly in women with a family
history of the problem. Varicose veins typically
develop on the legs but can also affect the
vulva. There are a few preventive and treatment
measures that are safe during pregnancy:
Avoid prolonged standing and sitting.
Dark patches may develop on your face. This

is known as the mask of pregnancy, or
chloasma, and it usually fades after delivery.
Lie on your side as much as possible. This

takes the pressure off your leg veins, allowing
normal blood flow.
Blotchy skin and acne may increase or clear up

during pregnancy.
Elevate your legs whenever possible. Gravity

helps with blood return from your legs.
Tiny, red elevated areas (vascular spiders,

or angiomas) may appear on the face, neck,
chest, and arms. These are not serious and
usually go away after pregnancy.
Wear compression stockings. You can

buy these at the Kaiser Permanente
pharmacy after being measured at your
Ob/Gyn appointment.
Vaginal bleeding or spotting
Get regular exercise to improve your

blood circulation.
Minimal bleeding or spotting may be normal

in some pregnancies. But any bleeding during
pregnancy needs to be evaluated by your doctor.
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To learn more about common body changes

and discomforts, visit kp.org and search for
pregnancy. Consult with your care team for
specific treatment advice.
51
risks and safety
risks and safety

Pregnancy is a sensitive time in a womans
life. These guidelines summarize some healthy
habits, risks to avoid, and warning signs when
youre expecting.
Health and safety

Pregnancy over age 35 poses some risks, but
most older women have healthy pregnancies.
Some immunizations should be done only
before pregnancy. You can get other vaccines
during pregnancy.
Flu vaccine is safe and recommended for all
pregnant women. The vaccine also can help
prevent H1N1 flu.
Tetanus and diphtheria (Td) immunization or
booster is recommended for pregnant women.
Please review your immunization history with
your provider. Pregnancy after bariatric surgery
may mean that you keep seeing the doctor
who did your weight-loss surgery, along with

seeing the doctor or midwife who is caring for
you during pregnancy.
Domestic violence can happen more often
and/or get worse when women are pregnant.
It is dangerous for both mother and baby. See
page 157 for more information.
Travel
If your pregnancy is normal and healthy, it is
generally OK for you to travel during your second
trimester (weeks 13 to 28).
During the middle of your pregnancy, you may
feel great, have lots of energy, and be able to
enjoy a relaxing vacation free of strollers and
diapers. (Youll have plenty of time for those later.)
During this period, your risks for miscarriage and
early labor are at their lowest. So why not seize
this opportunity to hit the road?
Things to avoid
Certain substances arent good for you any time,
but the list grows when youre pregnant. Make
sure you know what to steer clear of. Here are tips
about things to avoid and moderate:
Hazardous chemicals, radiation, and certain
cosmetic products. Avoid exposure to
dangerous substances, such as pesticides,
some household cleaners, paint, lead,
and mercury during pregnancy and while
breastfeeding. These toxins can be harmful to
a developing fetus and/or cause birth defects
or miscarriage. Nail polish, artificial nails, hair
dyes, and hair permanents also contain strong
chemicals. It is wise to reduce your exposure
to these chemicals and be sure the room is
well-ventilated if you use them.
Many prescription and over-the-counter

medicines (including herbs and other
supplements). Some over-the-counter and
prescription medicines are not safe to take
when youre pregnant. Tell your doctor about
all the drugs and supplements you take. He
or she can help you decide what medicines
are best for you. Review the Medications and
natural remedies section in this guide for
general recommendations.
Smoking during pregnancy. This unhealthy
habit increases the risk of problems such as low
birth weight, preterm labor, and miscarriage.
Hot tubs and saunas. If you use a hot tub

or sauna during pregnancy, be conservative.
Avoid uncomfortably high temperatures, and
limit your exposure. Raising your core body
temperature (hyperthermia) can harm your
fetus, particularly during the early weeks of
organ development.
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53
When to call
for help
Problems during and after pregnancy have
warning signs. To stay as healthy as possible,
familiarize yourself with these signs. If anything
does go wrong, you will know just what to do
and when. Call your doctor with urgent questions.
Emails may take a few days for response and
should be used only for routine questions.
Abdominal pain that does not go away.

Your baby has stopped moving or is
moving less than 10 times in 2 hours.
A common method of checking your babys
movement is to count the number of kicks or
moves you feel in an hour. Ten movements
(such as kicks, flutters, or rolls) in an hour are
normal. To count:
During pregnancy
Pick your babys most active time of day.

Some doctors suggest that you count in the
morning until you get to 10 movements.
Then you can quit for that day and start
again the next day.
When to call your doctor

During your pregnancy, call your health care
provider if any of the following occur:
Vaginal bleeding.
If you do not feel 10 movements in an hour,

your baby may be sleeping. Wait for the
next hour and count again.
Vaginal discharge that causes itching,

soreness, or bad odor.
Signs of preeclampsia:
Severe headache that does not go away
with acetaminophen (such as Tylenol).
Uterine tenderness, unexplained fever,

or general weakness (possible symptoms
of infection).
Visual disturbances, blurred vision, flashes

of light, or spots before your eyes.
Contractions:
Between 20 and 37 weeks, more than
four to six contractions in one hour could
indicate preterm labor.
Sudden, increased swelling of the face,

hands, or feet.
Sudden weight gain, 2 to 3 pounds in a
week, in your third trimester.
After 37 weeks, contractions every five

minutes for one to two hours could
indicate labor.
Very bad, continuous headaches.
Between 20 and 37 weeks, preterm

labor could be indicated by low back
pain or pelvic pressure that does not
go away, or intestinal cramping with or
without diarrhea.
Pain or burning when urinating.

Decreased urine output, despite drinking large
amounts of fluid.
Continuous vomiting or loose stools.
Fever with a temperature above 100.4
degrees, or feeling chills.
Painful, hard veins in the legs or elsewhere.
A gush or leak of water from the vagina.
An accident, hard fall, or other injury.
Sharp or continuous pain in your stomach.
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When to call 911

You or someone else should call 911 or other
emergency services immediately if you think you
may need emergency care. For example, call if you:
Have a seizure.
Pass out (lose consciousness).
54
Have severe vaginal bleeding.

Have severe pain in your belly or pelvis.
Have had fluid gushing or leaking from your
vagina (the amniotic sac has ruptured) AND
you know or think the umbilical cord is bulging
into your vagina (cord prolapse). This is quite
rare, but if it happens, immediately get down
on your knees and drop your head and upper
body lower than your buttocks to decrease
pressure on the cord until help arrives. Cord
prolapse can cut off the babys blood supply.
After delivery
When to call your doctor
Your vaginal bleeding seems to be getting

heavier or is still bright red four days after
delivery, or you pass blood clots larger than
the size of a golf ball.
You feel dizzy or lightheaded, or you feel as
if you may faint.
You are vomiting or you cannot keep
fluids down.
You have a fever.
You have new or more belly pain.
You pass tissue (not just blood).
You have a severe headache, visual problems,
or sudden swelling of your face, hands, or feet.
Watch closely for changes in your health, and be

sure to contact your doctor if:
You are not getting better after two to
three days.
You have vaginal discharge that smells bad.
You have signs of postpartum depression,
such as:
Feelings of despair or hopelessness for
more than a few days.
Troubling or dangerous thoughts
or hallucinations.
Your breasts are painful or red and you
have a fever, which are symptoms of breast
engorgement and mastitis.
When to call 911
These situations after delivery warrant emergency
help, so call 911 if:
You have severe vaginal bleeding. You are
passing blood clots and soaking through
a new sanitary pad each hour for two or
more hours.
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first trimester
first trimester
first-trimester
overview
Your due date or estimated delivery date is based
on the first day of your last menstrual period
and is about 40 weeks (280 days) after your last
period. However, you baby is considered to be
full term between 37 and 40 weeks.
During the week after fertilization, the fertilized
egg grows into a microscopic ball of cells
(blastocyst), which implants on the wall of your
uterus. This implantation triggers a series of
hormonal and physical changes in your body.
The third through eighth weeks of growth are
called the embryonic stage, during which the
embryo develops most major body organs.
During this process, the embryo is especially
vulnerable to damaging substances, such as
alcohol, radiation, and infectious diseases.
Your body and emotions

Extreme fatigue or morning sickness can color
your daily life during the first trimester. Moodiness
(as with premenstrual syndrome) is normal.
Happiness and anxiety about a new pregnancy, or
feeling upset about an unplanned pregnancy, are
also common.
The first trimester can bring insomnia and night
waking. Most women feel the need to take naps
to battle daytime sleepiness and fatigue. You
may also experience breast tenderness, increased
urination, fullness, or mild aching in your lower
abdomen, and nausea with or without vomiting.
Having reached a little more than 1 inch in

length by the ninth week of growth, the embryo
is called a fetus. By now, the uterus has grown
from about the size of a fist to about the size of
a grapefruit.
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First Trimester:
Weeks 1 to 4
About your baby
Your to-do list
Your baby starts as a tiny fertilized egg. The

fertilized egg divides rapidly, forming clusters of
cells as it travels down the fallopian tube.
If you havent already done so, use our medical

staff directory to help you select a practitioner
with whom you feel comfortable.
At about three weeks, the egg burrows into the

uterine wall, where it will make its home for the
next nine months.
Learn as much as you can. Our pregnancy

center has information to guide you through
your pregnancy, childbirth, and the challenging
first months of parenthood.
At four weeks, the heart, brain, and lungs are

forming and the structures of the eyes and ears
are beginning to develop. Arm and leg buds are
visible, and some bones are forming.
Go to kp.org and get familiar with the

pregnancy health and wellness topics.
Youll find a wealth of material, tools, and
calculators. Youll also find information on
pregnancy and childbirth classes offered in
this region.
Tips for staying healthy

During the first three months, your baby develops
quickly and is especially sensitive to toxins and
stresses. Avoid harmful substances, such as
tobacco, alcohol, and other drugs. Try to minimize
stress and get enough sleep.
Take a vitamin supplement or prenatal vitamin
with 400 micrograms (0.4 milligrams) of folic
acid daily. Folic acid is a B vitamin that can
help prevent birth defects.
Take a vitamin D supplement (1,000
milligrams) and omega-3 fatty acid
capsule daily.
Eliminate or cut back on caffeine.
Ask your doctor about the safety of any
medications youre taking.
Eat a healthy, well-balanced diet.
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First trimester:
Weeks 5 to 8
The second month of pregnancy is a time of
amazing development. Your fertilized egg is now
an embryo.
Your to-do list

Your first prenatal visit is coming up. You will
have a complete physical exam, assessment of
pregnancy symptoms, a variety of tests, and a
review of your medical history. Your first visit
is usually scheduled between 8 and 12 weeks.
Make sure you schedule your appointment if
you havent already.
About your baby

At five weeks, your baby resembles a tadpole. At
six weeks, your babys nose, mouth, and ears are
beginning to form, and his or her little heart has
started to beat (almost twice as fast as yours). By
eight weeks, your baby is about 1 inch long.
Fill out and return the questionnaire that was

mailed to you.
Your baby is also starting to look human. The

arms, legs, muscles, and skin are growing. And
the head may seem larger than the rest of the
body because the brain is developing faster than
the other organs.
Keep the lines of communication with your

partner open. Its important for you both to
share your feelings about your pregnancy and
impending parenthood.
About you
Get plenty of rest.
Plan for baby expenses by creating a budget.
You may soon start to notice early signs of

pregnancy: exhaustion, tender breasts, nausea,
and food cravings or aversions. A milky, vaginal
discharge is also common in your first trimester.
Feeling moody? Hormonal changes are partly to
blame. You may also feel emotional about all the
change thats going on in your life.
Eat a variety of foods including those high in
iron, calcium, and protein each day. Its quality,
not quantity, that counts. Keep taking prenatal
vitamins.
Exercise in moderation unless your doctor has
instructed otherwise. Learn about the benefits
of exercise during pregnancy.
Drink plenty of water throughout the day.
If you smoke, your baby smokes, too. See the
Health and wellness section of this guide.
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First Trimester:
Weeks 9 to 12
A fast or slow heart rate does not mean that your
baby is a girl or a boy. The babys heart rate is
faster when the baby moves and slower when the
baby rests.
About your baby

At nine weeks, your baby is moving around,
although you cant quite feel it. Most of your
babys critical development is complete. The
reproductive organs have developed, but an
ultrasound wont show clearly whether the fetus is
a girl or a boy until later (about week 20).
At 10 weeks, your baby is growing more and
more each day. Fingers and toes are emerging
from the growing arms and legs. Your baby also
has soft nails and eyelids. By the end of week 12,
your baby is about 2 to 3 inches long and weighs
about an ounce.
About you
You may not have a baby bump yet, but you
probably feel pregnant by now. This can be
one of the hardest months of pregnancy. Youre
probably tired and needing extra rest. For some,
morning sickness is at its peak. Fatigue and
nausea will lessen, and youll start to feel normal
again as you approach your second trimester.
Whats normal
Some cramping as the uterus enlarges and
contracts. During this time, your uterus will
increase in weight from about an ounce to
more than 2 pounds.

Cat feces can sometimes cause an infection
called toxoplasmosis, which could harm your
baby. If you have a cat, ask someone else to
change the litter box. If thats not possible,
wear rubber gloves and wash your hands well.
Avoid very hot baths and hot tubs (temperature
should be below 101 degrees), saunas, steam
rooms, and tanning beds. High temperatures
may harm your developing baby.
You should gain about one pound a month
for the first three months of your pregnancy.
Too much weight gain in pregnancy can lead
to a variety of health problems for you and
your baby.
Pregnant women need 1,200 milligrams of
calcium daily. Calcium builds your babys
bones and teeth. It also prevents osteoporosis
later in your life. Good sources include skim
milk; yogurt; dark-green, leafy vegetables;
canned salmon; and tofu.
Relieving discomfort
Appetite changes
You may be very hungry, or you may find it hard
to eat much at all; both are normal. Be sure to
choose quality baby-building foods. Cut down
on sweets like candy, cakes, doughnuts, and other
high-fat, empty-calorie foods. At this point, a
healthy weight gain is about pound per week.
Ask your practitioner for help if you think youre
gaining too much or too little weight.
Your breasts may feel larger and tender

when touched.
Some bleeding in your gums is common, but
dont forget to brush and floss regularly.
Whitish vaginal discharge is normal throughout
pregnancy. You may also have yeast infections
that reoccur or are difficult to get rid of.
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Feeling tired
Drink plenty of fluids, especially water.
Your body is working hard throughout your

pregnancy. If you feel tired, thats your bodys
way of telling you to slow down. Dont ignore
your need for extra rest and sleep. Youll find your
energy returning during the middle months of
pregnancy (the second trimester).
If you sit in the sun, wear a hat.
Roller-coaster emotions
Headaches
Pregnancy can be an emotional roller-coaster for

some. Youre not alone if you have mood swings,
cry easily, feel easily annoyed, or feel disorganized
and have trouble concentrating.
Lie down and relax if possible. Put a cool cloth on

your head and neck, and ask your partner to give
you a neck and shoulder massage.
Accept your feelings and share them with

someone who cares. Talk to your practitioner if
you need help coping with your feelings.
Dizziness and fainting
Women often feel dizzy when theyre
pregnant, but dizzy spells should lessen
ordisappear as your blood supply increases to
meet your babys growing needs. If you feel
faint, try these suggestions:
Sit down immediately and put your head
down, as low as possible, between your legs.
If you cant sit, kneel and bend your
head down, as if you were going to tie
your shoelace.
Lie down and keep your legs higher than your
head (use pillows to prop your feet up).
To reduce the likelihood of dizziness, try
these suggestions:
Stand up slowly. Move slowly, especially when
changing from a lying or sitting position.
Eat frequently to ensure that your blood sugar
stays constant and you dont feel lightheaded
or faint. Eat healthy snacks like fruits,
vegetables, bread, or crackers.
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Avoid closed-in spaces and get plenty of

fresh air.
Fainting is rare. Be sure to report fainting. If
you fall to the ground or hit an object, youll
need to be examined right away.
Dont take aspirin, ibuprofen (such as Advil and

Motrin), or migraine medication while youre
pregnant unless directed by your practitioner.
Call your practitioner if:
You have severe headaches after week 20
of pregnancy.
You have headaches along with muscle
weakness, visual disturbance, or fever.
Acetaminophen (such as Tylenol) doesnt help
your headache.
Stuffy nose and nosebleeds
You may have a stuffy nose, fluid dripping into
your throat (post-nasal drip), or frequent sinus
headaches. You can even get nosebleeds from
blowing your nose too hard. Increased hormones
make the mucous membranes inside your nose
and sinuses swell.
The tiny blood vessels in your nose have more
blood while youre pregnant. They can break
with the slightest strain or no pressure at all.
This will get better after your baby is born. In
the meantime:
61
First Trimester:
Weeks 9 to 12
Use saline nose sprays to moisten dry
nasal passages.
Dab Vaseline in each nostril and use a cool
mist vaporizer.
Avoid nasal decongestant spray, which can
actually make stuffiness worse.
Dont use any drugs without asking your
practitioner first.
Call your practitioner if you cant control the
bleeding from a nosebleed or if the bleeding gets
too heavy.
Bleeding gums
Tips for dealing with vaginal discharge include:

Wear cotton underwear and keep it clean
and dry.
Wash thoroughly during baths or showers, but
avoid strong soaps.
Remember that baths should be warm but not
too hot.
Dont douche while youre pregnant.
Avoid sweets and sodas. They encourage
yeast to grow.
Your to-do list

Your first visit is usually scheduled between 8
and 12 weeks. Make sure you schedule your
appointment if you havent already.
Bleeding gums are common during pregnancy.

If you experience this side effect, try switching
to a soft toothbrush, flossing gently, and using
mild toothpaste.
This is an important time for testing. If you

are worried about Down syndrome or other
chromosomal problems, you may be able
to have a special ultrasound and a blood
test (called first trimester screening) around
11 weeks.
See a dentist for a checkup early in pregnancy

and report any painful or swollen gums. Most
dental care can be safely performed during
pregnancy, but be sure to tell your dentist youre
pregnant. Getting your teeth cleaned can help if
youre experiencing bleeding gums.
Talk to your doctor about genetic testing

options to screen for chromosomal defects.
Though some mild cramping is normal, call
your doctor if cramping is severe.
Vaginal discharge
Whitish vaginal discharge is normal throughout
pregnancy. You can also get yeast infections that
come back (or dont go away easily).
Practice Kegel exercises to start preparing for

childbirth (you can do it anytime, anywhere).
Refer to page 39 for instructions.
You can treat yeast infections and itching with

over-the-counter drugs that dont require a
prescription, such as Monistat or Gyne-Lotrimin
(7-day treatment). Make sure to follow the
instructions. You can use 1% hydrocortisone
cream to calm vaginal itching or burning. (Dont
use the cream inside the vagina.)
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Create your own at-home spa to pamper

yourself and relieve stress.
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second trimester
second
trimester
second-trimester
overview
By the end of the first trimester (about week
12 of pregnancy), the fetus has a recognizable
human form.
The second trimester lasts from weeks 13 to 28 of
pregnancy. Its when your babys movement takes
off. If this is your first pregnancy, youll begin to
feel your fetus move at about 18 to 22 weeks after
your last menstrual period.
Although your fetus has been moving for several
weeks, the movements have not been strong
enough for you to notice until now. At first, fetal
movements can be so gentle that you may not be
sure what you are feeling.
If youve been pregnant before, you may notice
movement earlier, sometime between weeks 16
and 18.
Your body
Your breasts will become larger and heavier in
the second trimester. You may need a larger
and more supportive bra. The tenderness and
tingling sensation from early pregnancy will
probably decrease.
As your breasts become larger, the veins become
more noticeable. The nipples and the area around
the nipples (areola) become darker and larger.
Small bumps may appear on the areolae and
disappear after delivery.
You may also experience:

Leg cramps.
Back pain.
Pelvic aches and hip pain.
Stretch marks and other skin changes.
Hemorrhoids and constipation.
Heartburn (also a symptom of
gastroesophageal reflux disease, or GERD).
Nosebleeds and bleeding gums.
Hand pain, numbness, or weakness (carpal
tunnel syndrome).
Braxton Hicks contractions, which are warmup contractions that do not thin and open
the cervix (and do not lead to labor).
Emotional shifts
Fatigue, morning sickness, and moodiness usually
improve or go away. You may feel more forgetful
and disorganized than before. Looking heavier
than normal, then looking visibly pregnant and
feeling the baby move, can make you feel any
number of emotions.
The second trimester tends to feel more normal
for many women. This is often a period of
improved daytime energy and less need for naps.
As early as the 16th to 19th week, you may notice

a thin, yellowish discharge (colostrum) from your
nipples. Colostrum is what your breasts produce
when they are preparing for breastfeeding.
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second Trimester:
Weeks 13 to 16
Your second trimester officially began at week
13. This is when your risk of miscarriage drops
dramatically. Take this time to enjoy your
pregnancy youll probably find the weeks of
your second trimester to be the easiest.
About your baby

This is a time of rapid growth for your baby. Your
baby now has more muscle tissue, and the bones
have developed and become harder. Your baby
is rolling, kicking, and moving a lot flexing tiny
arms and legs. The skin is beginning to form, but
its almost transparent at this point.
Your babys kidneys are functioning and start
to pass urine. Most of the amniotic fluid that
nourishes and protects your baby comes from the
urine. The intestinal tract is starting to work too,
producing meconium, which will later be used as
your babys first bowel movement.
You might now be able to hear the heartbeat
with a Doppler heart monitor. By 16 weeks, your
baby is about 6 inches long and weighs about
3 to 4 ounces.
About you
By week 13, youll likely feel better and more
energetic. Morning sickness and breast
tenderness are easing. Its probably time to break
out the maternity clothes because your belly is
starting to grow.
Whats normal
You may experience heartburn along with a
sour taste in your mouth. Its not a cause for
concern, but its uncomfortable.
Pregnancy hormones also cause the digestive
tract to relax and work more slowly. As a
result, you might feel constipated, especially
as your pregnancy progresses.
You may experience round ligament pain.
Round ligaments help support your uterus.
As pregnancy progresses, these ligaments
can stretch. Any movements that stretch
these ligaments can cause pain. It can occur
when turning over in bed, walking quickly, or
sneezing and coughing.

Keep weight gain under control by watching
your portion sizes. This will make it easier to
lose weight after the baby is born.
Make sure you get vitamin C daily, and
drink plenty of water to reduce your risk of
bladder infections.
We recommended that pregnant women get a
flu vaccine.
Even as your belly expands, continue to wear a
seat belt any time you are in a car. Wear both
the lap belt and the shoulder harness, but
place the lap belt low, below the baby (not
across your stomach or uterus).
If this is not your first pregnancy, you might feel

your baby move. (It takes a little longer to feel this
the first time you are pregnant.) These first flutters
you feel are called quickening.
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Exercise regularly.
Heartburn
Establish a regular time for bowel movements.
You may experience heartburn along with a sour

taste in your mouth. Heartburn is caused when
stomach acids bubble back into the esophagus.
Its not cause for concern, but its unpleasant and
uncomfortable. Follow these suggestions for relief:
Eat small, frequent meals.
Try Metamucil, bran tablets, or Fiberall.

Try an over-the-counter stool softener called
Colace (also called docusate sodium) as
directed by your practitioner.
Dont use laxatives (such as Ex-Lax) without
first talking with your practitioner.
Avoid fatty, fried, or spicy foods.
Hemorrhoids
Avoid beverages that contain caffeine, such as

coffee, tea, or soda.
Hemorrhoids (dilated, twisted blood vessels in

and around the rectum) are common, especially
in the last months of pregnancy when the
uterus is pushing constantly on the rectal veins.
Hemorrhoids can cause pain, itching, and
bleeding during a bowel movement, but usually
improve without treatment shortly after birth.
Here are some tips that might help:
Avoid bending over or lying down after meals.

Take a walk instead.
Avoid tight clothes and waistbands.
If heartburn is a problem at night, avoid eating
just before bedtime, and sleep propped up
with pillows.
Take an antacid, such as Tums or Mylanta,
for instant relief. If your heartburn does not
go away, you may use acid blockers such as
cimetidine (Tagamet) or ranitidine (Zantac).
Dont take high-sodium antacids such as AlkaSeltzer or baking soda.
Constipation
Pregnancy hormones cause the digestive tract
to relax and function more slowly. Constipation
is likely to result, especially as your pregnancy
progresses. The following suggestions may
decrease constipation:
Keep your stools soft by increasing your intake

of liquids, fruits, vegetables, and fiber.
Avoid sitting for long periods of time. Lie on
your side several times a day.
Cleanse the area with soft, moist toilet paper,
witch hazel pads, or Tucks pads.
Try ice packs to relieve discomfort.
Take a sitz bath (a warm-water bath taken in
the sitting position where only the hips and
buttocks are covered) for 20 minutes, several
times a day.
Use Preparation H, Anusol, or 1%
hydrocortisone cream to help relieve the pain.
Drink more fluids (keep a bottle of water near

you during the day).
Eat more high-fiber foods like fruits,
vegetables, whole-grain breads, cereals,
and beans.
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second Trimester:
Weeks 13 to 16
Frequent or painful urination
Round ligament pain
You may notice that you do not need to urinate

as frequently as you did when you were first
pregnant because your uterus is well out of your
pelvis, putting less pressure on your bladder.
Continue to drink plenty of fluids and monitor
how you feel.
Round ligaments help support your uterus. As

pregnancy progresses, these ligaments can
stretch. Any movements that stretch these
ligaments can cause pain. It can occur when
turning over in bed, walking quickly, or sneezing
and coughing. The following tips can help you
avoid the pain:
If you ever feel burning or pain when you urinate,

call your practitioner. These symptoms may
indicate a bladder infection, and you will need to
be tested.
Call now if you have chills and fever or a
temperature of 100.4 degrees or greater, with or
without backache. These symptoms could be a
sign of a more serious infection.
Resting and sleeping positions
Change positions slowly.

Use your hands to support your weight when
changing positions.
Rest as much as possible.
A maternity girdle or belt can help lift the
weight of the uterus off the pelvic floor.
Your to-do list

Your doctor may recommend prenatal blood
tests, such as a maternal serum quadruple
test (also called a quad test or expanded
AFP screening) or an alpha-fetoprotein
screening (AFP), which detect signs of a
possible birth defect.
Lying on your side is better for you and the baby

now. When you lie on your back, the weight of
your uterus and your baby rests on the vena cava,
the largest vein in your abdomen. When there is
pressure on that vein, your blood pressure can go
down, and you may feel dizzy or light-headed.
Your doctor may also recommend an

amniocentesis at 15 to 20 weeks of
pregnancy to check for birth defects and
genetic problems.
Follow these tips for a good nights sleep:

Sleep on your side with a pillow between
your legs.
Announce the news at work. Check your

employers maternity leave policy. In addition
to any state or employer-sponsored leave,
if your company has 50 or more employees,
youre entitled to 12 weeks of unpaid leave
under the Family and Medical Leave Act.
If you find you have turned over onto your

back, just roll back onto your side.
After week 16 of pregnancy, avoid exercises
that involve lying on your back for longer than
three minutes.
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second Trimester:
Weeks 17 to 20
At 20 weeks, youve reached the halfway mark of
your pregnancy. Your practitioner may recommend
an ultrasound to check your babys health. During
the test, you might be able find out if youre having
a boy or a girl (if you want to know).
About your baby

Your baby is swallowing more amniotic fluid,
which is good practice for his or her digestive
system. The umbilical cord that connects you and
your baby is thickening and continues to carry
blood and nutrients.
Its about now that your babys sucking instinct
develops, and he or she may have started thumbsucking. Your babys head is no longer so big
compared to the rest of the body. Hair is starting
to grow on the scalp, and tiny eyelashes and
eyebrows are appearing. Your baby also sleeps
and wakes regularly.
By week 20, your baby is starting to build up body
fat. He or she is about 8 to 10 inches long and
weighs about 10 ounces. Your doctor may be able
to hear your babys heartbeat with a stethoscope.
About you
If this is your first pregnancy, you will start to
feel your baby move between 18 and 22 weeks.
These first flutters are called quickening, and
some women say they feel like gas bubbles. Its
probably time to break out the maternity clothes
because your belly is starting to grow.
Many pregnant women report an increase in
nightmares as their pregnancy progresses. Dont
worry. These vivid dreams are just your minds
way of helping you process and adapt to the
changes in your life.
You may also notice that you and your partner
are not experiencing your pregnancy in the same
way (or at the same pace). Its important to have
frequent conversations about the new baby
to reconnect to each other and share in your
excitement for the future.
Whats normal
You may begin feeling Braxton Hicks
contractions, especially if this isnt your first
pregnancy. This painless tightening of muscles
in the uterus is normal.
Notice brown patches on your face? Its
called the mask of pregnancy and is due
to a temporary increase in estrogen. The
brown patches may darken in the sun, so
use sunscreen.
You may see a narrow, dark line (the linea nigra)
running from your belly button to the top of
your pubic bone. After birth, the darkened area
should lighten and then disappear.
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Your to-do list
To soothe aching legs and prevent varicose

veins, elevate your legs often, dont cross your
legs when sitting down, and slip on support
hose made especially for pregnant women.
Your practitioner may recommend an

ultrasound to measure your babys growth,
estimate your due date, screen for certain
abnormalities, and rule out twins (or more).
Keep taking your prenatal vitamin supplement

and eating a diet rich in nutrients.
Elastic waistbands will go only so far. Time

to start shopping for (or borrowing)
maternity clothes.
Pump up your daily iron intake (you now

need about 30 milligrams) to prevent iron
deficiency anemia.
Ask your doctor and friends to recommend a

childbirth education class and call to find out
the dates of the classes. Most couples begin
classes in the seventh month.
Sleep on your side. When you lie on your

back, the weight of your uterus and baby rests
on a large vein in your abdomen, which can
cause your blood pressure to go down and
make you feel dizzy or light-headed.
Start discussing your maternity leave with your

supervisor. Think about how long youll take
off, and get the terms of your leave in writing.
Practice relaxation exercises to increase your

energy, reduce your stress, and prepare for a
relaxing labor. For ideas, check out our healthy
pregnancy and childbirth guided imagery
podcasts at kp.org/listen.
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If you plan to return to work after your leave,

start to make arrangements for child care.
Quality child care providers often have
waiting lists.
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second Trimester:
Weeks 21 to 24
Your baby hears sounds outside your womb and
responds by kicking or moving. Talk to your baby
often so that he or she will recognize your voice
and be comforted by it, both now and after birth.
About your baby
If at any time, even during the last weeks

of pregnancy, you detect a lack of fetal
movement, call your doctor.
The fetus is still small enough to change position

frequently from head-down to feet-down, or
even sideways. The eyes are beginning to open
and close, and the brain is very active now.
Your baby can grip firmly with little hands, which
now have fingernails and fingerprints. The skin is
wrinkled, red, and shiny, and your baby is starting
to grow real hair.
The fetus is still building up body fat and starting
to put on a lot of weight. At the end of week 24,
your baby will weigh in at around 1 to 1.5 pounds
and measure 11 to 12 inches long.
About you
Pregnancy is a time when gaining the right amount
of weight is essential to you and your babys health.
Its important not to skip meals or restrict eating to
lose weight. Follow your practitioners advice on
healthy eating and weight gain.
Whats normal
You may notice a rhythmic jerking motion that
can last several minutes. This means your baby
has the hiccups! You dont need to do anything
about hiccups. They will stop soon and wont
hurt either of you.
You may also notice that your baby kicks and
stretches more (and you may even be able to
see squirming under your clothes). You will feel
more movement or less movement at certain
times of the day and night.
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If you have one or more children at home, your

pregnancy cant be your central focus. Get tips
on parenting while pregnant.
Learn the signs of preterm labor. Read more

about preterm labor further into this guide.
Difficulty sleeping
As pregnancy progresses, leg cramps,
breathlessness, contractions, the frequent need
to urinate, and an active baby may interfere
with your sleep. You may not be able to find a
comfortable position.
Use extra pillows to support your legs and
back. Try sleeping on your side with pillows
between your knees and behind your back.
Have a light snack or a glass of milk before
going to bed.
Get regular exercise during the day to help you
sleep more soundly at night.
Practice relaxation exercises before going to
sleep or if you wake up during the night.
Take a warm (not hot) bath or shower before
going to bed.
Avoid caffeine, including chocolate, especially
late in the day.
Do not use sleeping pills or drink alcohol
because they could harm your baby.
72
Leg cramps
Leaking from your nipples
Leg cramps are common in late pregnancy. They

usually occur late at night and may wake you
up. They may be caused by the pressure of the
enlarged uterus on nerves or blood vessels in your
legs, from lack of calcium, or occasionally from too
much phosphorous in your diet.
During the second or third trimester (anytime after

12 weeks), you might notice a yellowish or whitish
fluid leaking from your nipples. This fluid is called
colostrum, the first breast milk.
To relieve leg cramps:

Sit on a firm bed or chair. Straighten your leg
and flex your foot slowly toward the knee.
Stand on a flat surface (a cold surface is even
better) and lift your toes up, as if to stand on
your heels. Then try walking while keeping your
toes up.
Use a heating pad or hot water bottle.
To prevent leg cramps:
Avoid too much phosphorous in your diet.
This is found in highly processed foods,
such as lunch meats, packaged foods, and
carbonated beverages.
Its the perfect food for your newborn and also

supplies antibodies to help protect your baby from
infections. Although leakage is common for many
women, some women dont have any leakage until
after delivery. Colostrum may continue to leak from
time to time through the rest of your pregnancy. If
your blouse or dress gets wet from leaking:
Use breast pads (all cotton, no plastic liners)
inside the cup of your bra.
Keep your breasts clean and dry.
Wear a supportive bra.
Your to-do list

Enroll in a childbirth education class.
Look into baby care and breastfeeding classes.
Ask your practitioner for recommendations.
If you have frequent cramps (more than twice a

week), increase the amount of calcium in your
diet or take calcium supplements that dont
contain phosphorous.
Between now and 28 weeks, you will be given

an oral glucose tolerance test to screen for
gestational diabetes, a pregnancy complication
affecting 4 percent of expectant moms.
Do leg stretches before bedtime.
Keep track of fetal movement.
Wear leg warmers at night.
Prepare for changes in your relationship with

your partner. Take a babymoon, a weekend
away with your partner to relax and enjoy
yourselves before the new baby comes (and
while you can still travel). Get tips on traveling
while pregnant.
Exercise moderately every day.

Take a warm (not hot) bath before bedtime.
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second Trimester:
Weeks 25 to 28
You can enjoy a sexual relationship with your
partner throughout pregnancy, unless you have
been told that youre at high risk for preterm labor
or that your placenta is over your cervix (placenta
previa). If you have either of these conditions, talk
with your practitioner.
About your baby

Your babys eyes are able to open and close, skin
is becoming smooth, and the hair on the head is
getting longer. The lanugo, a soft, fine, downy
hair that once covered your baby, is beginning to
disappear. The vernix caseosa, a white, creamy
substance that protects the skin from long
exposure to amniotic fluid, still covers your babys
body. The lungs are maturing, and your baby is
starting to practice breathing.
Feel as if you cant catch your breath? Its your

growing uterus pressing up on your diaphragm
and crowding your lungs. Relief usually comes
when your baby settles into your pelvis.
Whats normal
Your blood pressure may increase slightly,
returning to its normal pre-pregnancy state.
Sometimes your baby settles into a position
that is very uncomfortable for you. Your
unborn babys kicks and twists can be strong,
very noticeable, and sometimes painful.
You may feel pelvic pressure or pain if your
babys head is low in your pelvis. Lying on
your side may help relieve this discomfort.
Your baby could probably survive if he or she

was born now but will be healthier when born at
full term (between 37 and 42 weeks). Your baby
is probably in the head-down position, so you
may feel less rolling over and more kicking under
your ribs.
You may be plagued by hemorrhoids because

of the amount of pressure your uterus is placing
on the veins in your rectum. Talk to your
practitioner about your treatment options. Eat
a high-fiber diet, drink water, and avoid sitting
or standing for long stretches of time.
Throughout your seventh month, your baby

continues to put on a lot of weight. By the end
of week 28, he or she will weigh about 2 to 2.5
pounds and measure about 11 to 14 inches.
Drink plenty of fluids and avoid processed

foods and other super-salty snacks to prevent
swelling in your legs and fingers.
About you
As your second trimester draws to a close, new
symptoms may start to crop up: aching back,
leg cramps, minor swelling, and sleep problems,
to name a few. Continue to get moderate
exercise, which can help prevent and relieve
some of these symptoms.
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Make sure to get the nutrients that will fuel your

growing baby and keep you healthy: folate,
iron, and calcium. (See pages 40 and 41.)
Be aware of the warning signs of preeclampsia.
Lying on your side (especially your left side)
promotes good circulation and improves
oxygen flow to your baby. Use pillows for
comfort and to help maintain the side position.
74
Leaking urine
Painful kicking
As your growing uterus puts pressure on your

bladder, you might notice that you leak urine
when you laugh or cough. This is common and is
called stress incontinence.
Your baby may settle into a position that is very

uncomfortable for you. Your babys kicks and
twists can be strong and sometimes painful.
When your baby drops into your pelvis (called
lightening), the kicks will probably be less
uncomfortable. If youre having your first baby,
lightening can occur several weeks before
delivery. For subsequent babies, it usually doesnt
happen until just before labor. If the babys
movements are causing you discomfort:
Change your position and hope your baby
changes position, too.
Try taking a deep breath while you raise your
arm over your head and then breathe out
while you drop your arm.
Try cupping your hands around your babys
buttocks and gently moving the baby.
Pelvic pressure or pain
Sharp, lower, midline pain is sometimes caused
when the symphysis pubis, a joint at the front
of the pelvis, relaxes in response to pregnancy
hormones. You may feel pelvic pressure or pain
if your babys head is low in the pelvis (after
lightening occurs).
You can help prevent leaking by doing Kegel

exercises (page 39 for instructions). Kegels
strengthen your pelvic floor muscles and help
reduce leaking.
Dont drink less fluid to keep urine from leaking; it
wont work! You still need fluids to keep yourself
and your baby healthy. Not drinking enough fluids
may lead to preterm labor. Also, reducing fluids
will not keep you from needing to get up at night
to empty your bladder. Call your practitioner now
if you need a pad to keep your underwear dry.
This could mean that you have a leak in your bag
of waters.
Swollen feet and ankles
You may notice that your feet, ankles, hands,
and fingers become swollen, particularly at the
end of the day. Its normal to have extra fluid in
your tissues during pregnancy, but much of the
swelling should disappear after a good nights
sleep. If your fingers are puffy, remove your rings.
Do not take diuretics (water pills) because they
interfere with your normal fluid balance.
Lying on your side may help relieve this

discomfort. You might have groin discomfort
as the round ligaments that support the uterus
continue to stretch. Again, resting on your side
might help. Also, be sure to get up slowly from a
sitting or lying position.
Slowly roll onto your side when getting up from a
lying position, and use your arms to get up. This
helps prevent straining your round ligament and
causing ligament pain.
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second Trimester:
Weeks 25 to 28
Tips to prevent swelling or puffiness:
Your to-do list
Avoid high-sodium (salty) foods. (Aim for less

than 2,400 milligrams of sodium per day.)
Select a pediatrician for your baby. Get

recommendations from friends and family.
Drink 8 to 10 glasses of water each day.
Keep track of your babys movements.
Keep your feet up on a stool or couch

whenever possible.
Talk with your spouse or partner about how

youre feeling and your expectations of family.
Avoid standing for long periods of time.
Take your childbirth preparation class and

learn all you can about labor and childbirth,
including your pain management options.
Dont wear tight shoes or knee-high stockings.

Wear support stockings, and put them on
before you get out of bed in the morning.
Accept your growing body as beautiful.
Lie on your side to remove fluid from your

puffy tissues.
Try sleeping with your feet slightly higher
than your heart. Raise the foot of your bed
by putting a thick blanket or pillows under
the mattress.
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77
third trimester
third trimester
third-trimester
overview
The third trimester lasts from about 29 weeks of
pregnancy until birth.
By the end of the second trimester (about week
27 to 28 of pregnancy), all the vital organs of the
fetus have developed. Also, you will begin to
feel the fetus move (quickening), usually starting
between weeks 16 and 20.
During the third trimester, the fetus size increases
and organs mature.
After week 32, your baby becomes too big
to move around easily inside your uterus and
may seem to move less. At the end of the third
trimester, your baby usually settles into a headdown position in your uterus. You will likely feel
some discomfort as you get close to delivery.
Your body
In the third trimester, your chest wall may
widen because of your growing baby. You may
need a larger bra or a bra extender. You may
also experience:
Braxton Hicks contractions, which are warmup contractions that do not thin and open
the cervix (and do not lead to labor).
Fatigue.
Back pain.
Pelvic aches and hip pain.
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Hemorrhoids and constipation.

Heartburn (a symptom of gastroesophageal
reflux disease, or GERD).
Hand pain, numbness, or weakness (carpal
tunnel syndrome).
Breathing difficulty, since your uterus is now
just below your rib cage, and your lungs have
less room to expand.
Mild swelling of your feet and ankles (edema).
Pregnancy causes more fluid to build up in
your body. This, plus the extra pressure that
your uterus places on your legs, can lead to
swelling in your feet and ankles.
Difficulty sleeping.
The third trimester is a time to expect increasing
insomnia and night waking. Most women wake up
three to five times a night, usually because of such
discomforts as back pain, needing to urinate, leg
cramps, heartburn, and fetal movement. Strange
dreams are also common in the last few weeks of
pregnancy. The need to take daily naps returns as
your due date approaches.
Emotional shifts
Forgetfulness may continue. As your due date
nears, it is common to feel more anxious about
childbirth and how a new baby will change your
life. As you feel more tired and uncomfortable, you
may be more irritable.
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third Trimester:
Weeks 29 to 32
On average, women gain about 11 pounds and
babies gain about 5 pounds and grow 5 inches
in the third trimester alone.
Your good health continues to be important

because your immunities are passed on to your
baby, helping fight off infection after birth.
About your baby
Whats normal
Your babys brain and vision are in a major

developmental spurt, and eyesight is sharpening.
The bones are fully developed, but still soft and
flexible for delivery.
Your feet, ankles, hands, and fingers may

become swollen, particularly at the end of
the day. Its normal to have extra fluid in your
tissues during pregnancy, but much of the
swelling should disappear after a good
nights sleep.
The fingernails and toenails are growing, lungs are

maturing, and the nervous system is perfecting
itself. Your baby is also starting to develop taste
buds and can taste sweet and sour.
By week 32, your baby is probably in the headdown position and is taking up more and more
space in your uterus. Your baby is weighing about
3 to 5 pounds and measuring about 16 to 18
inches long.
About you
As you enter the final months of your pregnancy,
the fatigue that you felt during the first trimester
may return as your body grows and sleep
becomes more difficult.
Youve probably noticed how easy it is to get off
balance and feel clumsy. This is partly due to your
center of gravity moving forward as your baby
grows. You also release a pregnancy hormone
called relaxin that softens the cartilage in your
joints and pelvis. The pubic bone also opens up
to make more room for the baby, causing the
waddle that most pregnant women have when
they walk.
As your growing uterus puts pressure on

your bladder, you might notice that you
leak urine when you laugh or cough. This is
common. If you notice any consistent leaking,
whether it is a large or small amount, call your
doctors office to make sure that your water
hasnt broken.
Your growing uterus is also crowding other
surrounding organs, leading to all sorts of
common discomforts and annoyances, including
heartburn, constipation, and hemorrhoids.

Keep exercising. Moderate, gentle exercise
can help with common pregnancy discomforts
and prepare you for the rigors of labor.
Your gums might be more sensitive and may
swell and bleed. Check with your dentist if you
experience pain or discomfort. Continue to
practice good dental hygiene.
To help avoid varicose veins, wear maternity
support hose and prop your feet up when
you sit.
Nap. Its important to rest more often.
Get enough omega-3 fatty acids (found in fish,
flaxseed, and walnuts) each day.
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Your to-do list
Varicose veins
Start thinking about your childbirth

preferences. Discussing these preferences with
your medical team beforehand can help you
decide your birth plan.
Varicose veins are visible, enlarged blood vessels

in your legs. Your calves may ache or throb, even
when the veins arent visible. Most varicose veins
will shrink or disappear after birth. Until then:
Take a tour of your hospitals labor and

delivery ward.
Try not to stand for long periods of time.
Splurge on a new pair of comfortable shoes.

The bones in your feet spread when youre
pregnant, and some women find their shoe size
goes up.
When sitting, avoid crossing your legs at

the knees.
Elevate your feet.
Pamper yourself. Get a manicure and haircut

(pregnancy hormones make your hair and nails
grow faster).
Avoid tight clothing or stockings that

hamper circulation.
Wear support hose; this may help prevent
aching calves.
Start to look into health care benefits for

your baby.
Exercise regularly. Try walking for at least 30

minutes each day on most days.
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third Trimester:
Weeks 33 to 36
About now, you may be feeling a surge of energy,
but make sure youre also getting plenty of rest.
Achiness, cramps, and breathlessness accompany
this period of pregnancy. Take care by continuing
to exercise, eating well, and winding down work.
About your baby

Your baby is busy preparing for life outside the
womb by storing iron in his or her liver. Things
have become crowded inside your uterus, and
theres not as much room for your baby to
move around.
Your babys skin is now pink and smooth, and
the arms and legs look chubby. The bones of the
head are firm but flexible enough to pass through
the birth canal without damage.
The vernix caseosa, a white, creamy substance
that protects the skin, is disappearing. The lanugo
is almost completely gone except for some soft,
fine hairs on your babys back and shoulders.
During this final month, you babys lungs are
almost fully developed. By week 36, your baby
is weighing in at about 5 to 7 pounds and
measuring around 18 to 20 inches from head
to heels.
About you
This month, youll have a test for Group B
streptococcus (GBS), which is usually harmless in
adults but can cause serious complications if you
pass it on to your baby during birth. GBS is fairly
common; about 25 percent of our patients have
positive results. Moms who have positive GBS
cultures need to be treated with antibiotics during
labor to prevent their babies from becoming ill.
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When you go to Labor & Delivery, you will receive

antibiotics in your IV before the baby is born. To
make sure there is time to receive the antibiotics,
please call Labor & Delivery and go in as soon
as your bag of waters breaks. If you are laboring
at home and your bag of waters is not broken,
call Labor & Delivery to have the RN help you
determine when to come in. Make sure when you
call that you tell them you are GBS positive.
Whats normal
You likely make frequent trips to
the bathroom.
Leg cramps, breathlessness, contractions, the
frequent need to urinate, and an active baby
may interfere with your sleep. If youre having
trouble finding a comfortable position, try
some of the tips on pages 68 and 72.
Feel achiness or numbness in your fingers,
wrists, or hands? You may have carpal
tunnel syndrome. See page 49 for more
information.

Prevent or ease leg cramps by elevating your
legs or getting a massage.
Continue walking for exercise.
Eat, even if youre not especially hungry.
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Your to-do list

Discuss labor and delivery options, including
pain management, with your doctor or midwife
and write your birth plan.
Try to tie up loose ends at work or home.
Make a note in your calendar to add your
newborn to your health plan within 31 days
of birth.
Practice the breathing and relaxation
techniques you learned in your childbirth
preparation classes or listen to our healthy
pregnancy and successful childbirth podcast.
Know the signs of labor.
Keep track of your babys movements.
Start thinking about names for your baby. Find
out the popularity of names and how they
have changed over time on the Social Security
Administration website (www.ssa.gov).
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third Trimester:
Weeks 37 to 40
Only 5 percent of babies are born on their due
date. But dont worry; your baby will arrive soon.
About your baby

Your babys basic physical development is now
complete. Your baby starts to descend into the
pelvic cavity around week 38 (a process called
engagement). The lungs are now mature, and
your baby continues to practice breathing in
anticipation of the first breath of air. The umbilical
cord is 20 inches long and will support your baby
through birth until the lungs take over.
Near the end of your pregnancy, your practitioner

may perform a pelvic exam as part of your
prenatal visit to check your cervix and the position
of your baby. Your cervix will begin to thin out
(efface) and open (dilate) by the time you go into
labor. For some women, these changes begin
weeks before their due date, as their bodies
prepare for labor and birth.
Whats normal
Youre now seeing your practitioner
every week.
Your baby will spend the next few weeks putting

on weight. At birth, most full-term babies weigh
6 to 9 pounds and measure 19 to 21 inches long.
But healthy babies come in many different shapes
and sizes.
Labor could begin at any time. Review the

signs and stages of labor.
About you
If your pregnancy extends beyond 42 weeks,

your doctor may conduct tests to determine
whether to induce labor or continue to wait for
your baby to come on his or her own.
Breathing might be a little easier as your baby

drops into your pelvis in preparation for birth
(called lightening).
At this size, your baby does not have much

room to move around, so you will probably
notice less big movement than before.
Try to relax and enjoy these last few weeks and

days before your baby comes. Go see a movie.
Read. Take walks. At week 37, youre considered
full term, and by week 40, youve reached your
official due date! Your pregnancy is not post-term
or overdue until after 42 weeks (or 2 weeks after
your due date), when risks go up for the baby and
delivery is typically recommended.
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Your to-do list
Take a lot of walks if you feel up to it. Review

the tips for exercising during pregnancy in the
Staying fit section.
Pack your bags for the hospital. See the

checklist on page 103.
Order diaper service or buy diapers so you
have them when you and your baby come
home from the hospital.
Practice squatting to keep your leg

muscles strong.
Do your Kegel exercises.
See our Getting ready for baby tips at the

end of this section to make sure youve covered
all the basics.
Get lots of rest. When labor starts, youll

need all your energy (and you may not sleep
for a while).
Learn how to care for yourself and your baby

by reviewing the postpartum recovery and
coping section.
Cook and freeze meals ahead of time and

have a stock of groceries on hand. Check out
the restaurants in your neighborhood that
offer takeout.
Find out if there are any grocery delivery
services in your area.
Arrange for a friend or family member to
help with housework, errands, watching
older children, and so on. Let people know
what you need, and take them up on their
offers to help.
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home
and nursery
home and nursery
Getting ready
for baby
Organizing your home
The basics include:
As your pregnancy enters its final weeks, actually

having a new baby and bringing this tiny person
home becomes a reality. When you first find out
that youre pregnant, nine months may seem like
a long time, but with so much to do and think
about, its not too early to plan ahead.
Car seat (the law requires that you have a

car seat to safely transport your child in a
car). Since most car seats are not installed
properly, consider scheduling a car seat safety
inspection. Visit seatcheck.org to find an
inspection site near you.
Youre preparing for labor and delivery, adjusting

to the idea of becoming a parent, and getting your
home ready for your newborn. If you can get your
household in order before delivery, youll be able
to focus on caring for and enjoying your new baby.
Crib.
Have these supplies on hand:

A box of large sanitary pads. Its normal
to have vaginal bleeding for a few weeks
following delivery, and you may have some
blood-tinged discharge for up to six weeks.
Dont use tampons during this time.
Digital thermometers.
Three to four sheets.

Six receiving blankets.
Four waterproof mattress pads.
Six undershirts or onesies with a snap at
the crotch.
Hats.
Two warm coveralls or blanket sleepers.
Four to six pairs of socks or booties.
Twelve to 24 washcloths.
Diapers or diaper service.
Wash your babys clothing, blankets, and sheets

in mild soap, such as Dreft, before use. The things
youll need to make life easier:
Basic layette (see below).
Stroller.
A box of nursing pads and three nursing

bras for breastfeeding mothers. (Sign up
for a breastfeeding class at your local
Health Education Department to prepare
for breastfeeding.)
Rocking chair.
Six bottles, six nipples, and a bottle brush.
Baby bathtub.
Acetaminophen (such as Tylenol) for pain.
Although there are many cute and convenient

baby items on the market today, babies need very
few things to keep them happy and healthy in the
first few weeks.
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Infant seat (or car seat that doubles as an

infant seat).
Infant carrier (sling or front pack).
Changing table or dresser top (at a
comfortable level to protect your back).
Other items such as swings, wipe warmers,
cute clothes, and monitors are nice but can
come later.
87
Getting ready
for baby
Meal preparation:
Looking for bargains
Cook and freeze meals ahead of time.
Whether youre getting new or used items,

think about safety. With new items, youll be
able to choose exactly what you want. New
baby furniture must meet all of the latest safety
standards. Some used items might not meet
current safety guidelines.
Stock up on supplies like eggs, bread,

drinking water, and canned goods.
Have paper plates and plastic utensils
on hand.
Housework:
Clean the house or have it cleaned thoroughly
before you go into labor.
Arrange in advance to have cleaning
assistance for a few days after you come
home. Your partner or a relative may volunteer
to help. Professional housekeepers are listed
in your phone book.
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You can probably save up to 80 percent on

some items by shopping at garage sales or at
stores that sell used baby gear.
You can also borrow from friends.
Before you get anything secondhand, make
sure that it meets current safety guidelines. If
possible, avoid buying a used car seat.
Contact twin clubs in your area if youre
expecting multiples.
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A safe nursery
The nursery is your babys home a place where
your baby should be safe and protected. A variety
of nursery equipment is available, but some pieces
are safer than others. Here are some guidelines
that you should use when selecting equipment.
Cribs
More infants die every year in accidents involving
cribs than with any other nursery product. If you
already have a crib or are buying a used one,
make sure that:
Baby gates
Dont use baby gates with a V-shaped, accordionstyle opening, which can entrap a childs head.
Safe gates have vertical slats that are no more
than 2/8 inches apart.
Diaper pails
Diaper pails are dangerous targets for curious
babies. Choose pails with protective lids, and
keep the pails out of reach.
Crib slats are no more than 2/8 inches apart.
Pacifiers
Corner posts dont extend above the

end panel.
Pacifiers must be strong enough so that they

wont tear into pieces and cause your baby to
choke or suffocate. Pacifier guards or shields must
have holes that allow breathing and must be large
enough to prevent the pacifier from entering
the babys throat. Pacifiers cannot be sold with
ribbon, string, yarn, or a cord attached. Dont put
a pacifier on a string around your babys neck.
Plastic bags arent used as a mattress protector.

There are no dangling curtain cords within your
childs reach if the crib is near the window.
Toys, laundry bags, or other objects with
strings arent hanging near the crib.
All nuts, bolts, and screws are
tightened periodically.
Your baby is always placed on his or her back
to sleep.
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The American Academy of Pediatrics recommends

that pacifiers not be introduced until two to four
weeks postpartum for full-term, breastfeeding
babies, since early use of pacifiers may interfere
with breastfeeding.
90
High chairs
More than 800 children are treated in emergency
departments every year because of accidents
involving high chairs. Most of these injuries are
due to falls because adults are not watching or
because the baby is not strapped into the chair.
Restraining straps should be strong, and the high
chair should have a wide base for stability.
Toys
An infants mouth is extremely flexible and can
stretch to hold larger items than you might
expect. Remove all toys and other small objects
from the crib when your baby sleeps. If a toy has a
part smaller than 15/8 inch, throw it away. Teethers,
such as pacifiers, should never be fastened
around a babys neck.
Changing tables
Buy a changing table that has safety straps
and always use them. More than 1,300 children
are injured every year from falling off a changing
table. Keep one hand on your baby at all times
while he or she is on the changing table.
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preparing for birth
preparing
for birth
Your birth plan

Over the months of pregnancy, youve likely been
imagining what your birth experience will be like.
As you prepare for the big day, take some time to
finalize or review your birth plan.
If an emergency situation arises, your doctor has a

responsibility to ensure the safety of you and your
baby. You may still be allowed to share in some
decisions, but your choices may be limited.
A birth plan is not so much a plan as it is an ideal

picture of what you would like to happen. Creating
one helps you think through the choices you may
have during labor and the exciting moments right
after your baby is born. A birth plan also allows you
to communicate your preferences to the staff who
will care for you and your baby.
Since no labor and delivery can be predicted or
planned in advance, be flexible. As you think about
how youd handle possible complications, give
yourself permission to change your mind at any
time. And be prepared for your childbirth to be
different from what you planned.
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your birth plan

Kaiser Permanentes philosophy
It is our intention that every woman be treated
with respect for her individuality and personal
preferences. In keeping with this philosophy, we:
Support women who would like a birth
that is unmedicated, and advocate for
having people present to help and support
this decision.
Photographs, flowers, or familiar objects that

might be comforting to you, such as a special
blanket, pillow, or something that might serve
as a focal point while you breathe through
your contractions. Your labor room is your
bedroom; make it cozy!
Music and a battery-powered player (MP3,
CD, tape).
Support women who have a preference for

pain management, including medicine or
epidural anesthesia when appropriate in labor.
A cooler with food and drink for your birth

coach. You may also bring clear liquid drinks
for yourself. Your preferred drink may not be
available at the hospital.
Strongly recommend childbirth preparation

classes. Even for women planning on using pain
medication, childbirth classes help develop the
skills necessary to deal with early labor.
Above all, Kaiser Permanente is committed to

ensuring that all mothers, babies, and families
have a healthy and safe birth experience.
Support movement while in labor, as it often

helps labor progress.
Do not order routine enemas, shaves,
or episiotomies.
Recommend that you check with the hospital
where you will be giving birth to familiarize
yourself with your hospitals labor and delivery
policies and to find out if it offers tours of
labor and delivery areas.
Believe that parents have a right to choose the
feeding method for their baby. While breast
is best for almost all infants, only you can
decide what is right for your family. We will
respect your feeding decision.
In addition to creating a birth plan, there are a few
things that you can do to feel more at home while
you are in labor. This includes bringing:
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94
Instructions
Pain management
Check off your preferences for childbirth. Once

you have completed your birth plan, bring it
to your next prenatal appointment so you can
discuss it with your provider. Your birth plan will
be put in your chart so the medical and hospital
staff can review it when you are admitted.
I plan on using alternative pain relief options

(such as breathing exercises, visualization/
relaxation, massage, shower, position
changes). I will ask for pain medication if I
need it.
I would like to be offered pain medication if
you see I am uncomfortable.
Please realize that certain circumstances that arise

during labor may limit the number and kinds of
choices you will have. Your provider will discuss
them with you during labor.
I would like to have an epidural as soon

as possible.
I am considering having an epidural or using
pain medication, but will decide when I am
actually in labor.
MY DOCTOR, NURSE PRACTITIONER, OR

NURSE-MIDWIFE IS
Delivery
Environment
If possible, I would like the option to be in a

position other than lying on my back when
I give birth (such as semi-sitting, squatting,
lying on my side, or on my hands and knees).
I would like to limit the number of guests

and phone calls while I am in labor by
disconnecting my phone and by having a sign
posted on my door.
I would like a mirror available to view the birth.
I would like the lights in the room to

be lowered.
I would like to touch my babys head as

it crowns.
Labor
I would like to hold my baby skin to skin

immediately after delivery.
I would like to be out of bed as much

as possible during labor (such as
walking, rocking).
I would prefer that my baby be lightly dried

off before being brought to me.
I prefer to have intermittent fetal monitoring.
I would like to have
If I need an IV, I would prefer to have a saline

lock (a plug for the IV catheter).
cut the cord, if possible.
I would prefer that the amniotic membrane

(bag of waters) rupture naturally.
I would like to meet the pediatric provider on
duty if possible.
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95
your birth plan

Postpartum
Other
I would like to delay newborn procedures

(such as bathing, measuring, physical exam,
eye medication, vitamin K injection) during the
first hour so that I have a chance to feed and
bond with my baby.
I want all procedures and medications for my
baby explained to me before they are carried
out by the medical staff.
I would like to have my baby evaluated and
bathed in my presence.
If my baby must be taken from me to receive
medical treatment, I would like
to accompany the baby.
I plan to exclusively breastfeed my baby while
in the hospital.
Patient signature
Date
This information is not intended to diagnose health
problems or to take the place of medical advice or care you
receive from your physician or other medical professional.
If you have persistent health problems, or if you have
additional questions, please consult with your doctor. If
you have questions or need more information about your
medication, please speak to your pharmacist.
2004, The Permanente Medical Group, Inc. All rights
reserved. Regional Health Education.
I would like to meet with a specialist who can

help me learn to breastfeed effectively.
I would like to be consulted before my baby is
given water, formula, sugar water, or a pacifer.
If I have a boy, I do/do not (circle one) plan on
having him circumcised at Kaiser Permanente.
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Birthing options
When you create your birth plan, youll
address many factors. The location
of your delivery, who will deliver your baby,
and whether you want continuous labor support
from a designated health professional, doula,
friend, or family member are important details
to consider.
After youve set the stage, think through your
preferences for comfort measures, pain relief,
medical procedures, and fetal monitoring.
Also, think about how youd like to handle your
first hours with your newborn. The following
information can help you weigh these options.
Comfort measures
There are many ways to reduce the stresses of
labor and delivery. Consider:
Continuous labor support from early labor
until after childbirth, which has a proven,
positive effect on childbirth. Women who have
continuous one-on-one support (for example,
from a mothers support person, or doula;
nurse; midwife; or childbirth educator) are
more likely to give birth without pain medicine
and are less likely to describe their birthing
experience negatively. Although there is not a
proven direct connection between continuous
support and less labor pain, having a support
person does help you feel more control and
less fear, which are strong elements of mental
pain control.
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Walking during labor, including whether

you prefer continuous electronic fetal heart
monitoring or occasional monitoring.
Nonmedication pain management (natural
childbirth), such as continuous labor support,
focused breathing, distraction, massage, and
imagery, which can reduce pain and help you
feel a sense of control during labor.
Early laboring in water, which helps with
pain, stress, and sometimes slow, difficult
labor (dystocia).
Playing music during labor.
Acupuncture and hypnosis, which are
low-risk ways of managing pain that work
for some women.
Pain relief with medicine

Your options for pain relief with medicine
may include:
Opioids (narcotics), which are used to reduce
anxiety and partially relieve pain. Sometimes
opioids can affect a newborns breathing,
so they are usually not administered close
to delivery.
Epidural anesthesia, which is an ongoing
injection of pain medicine into the epidural
space around the spinal cord. Some women
prefer to use epidural anesthesia for pain relief
during labor.
97
Birthing options
Some pain-relief medicines are not the type that
you would request during labor. Rather, they
are used as part of another procedure or for an
emergency delivery. But its a good idea to know
about them.
Local anesthesia is the injection of numbing
pain medicine into the skin. This is done before
inserting an epidural or before making an
incision (episiotomy) that widens the vaginal
opening for the birth.
Spinal block is an injection of pain medicine
into the spinal fluid, which rapidly and fully
numbs the pelvic area for assisted births, such
as a forceps or cesarean delivery (no pushing
is possible).
General anesthesia is the use of inhaled or
intravenous (IV) medicine, which makes you
unconscious. It has more risks, yet it takes
effect much faster than epidural or spinal
anesthesia. General anesthesia is used only
for some emergencies that require a rapid
surgical delivery, such as when an epidural
line (catheter) has not been installed in
advance, is not working well, or medical
reasons prevent you from having a spinal
block or epidural anesthesia.
Birthing positions
Birthing positions for pushing include sitting,
squatting, reclining, leaning on a ball, or using a
birthing chair, stool, or bed.
Medical procedures for labor

and delivery
Fetal heart monitoring is a standard practice
during labor, but other procedures are used
as needed.
Labor induction and augmentation includes
a simple sweeping of the membranes just
inside the cervix, rupturing the amniotic sac,
using medicine to soften (ripen) the cervix, and
using medicine to stimulate contractions. This
is not always, but can be, a medically necessary
decision such as when a mother is about two
weeks past her due date or when the mother or
baby has a condition that requires immediate
delivery.
Antibiotics if you tested positive for Group B
strep during your pregnancy.
Electronic fetal heart monitoring may be
either continuous or periodic depending on
pregnancy or baby risk factors or medications
being administered.
Episiotomy (not a routine procedure) widens
the perineum with an incision. This is used to
prevent further tearing when visible tearing is
noticed or to create more space when needed
for delivery. (Perineal massage and controlled
pushing can also prevent or reduce tearing.)
Forceps delivery is used to assist a vaginal
delivery, when a little assistance is needed.
The need for a cesarean birth during labor
is primarily based on the babys and
mothers conditions.
If you have had a cesarean delivery before, you
may have a choice between a vaginal trial of labor
and a planned cesarean birth.
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98
Newborn care decisions

Things to think about before your baby is born:
Keeping your baby with you for at least one
hour after birth, for bonding. (Many hospitals
allow rooming-in, with no mother-baby
separation during the entire hospital stay. A
rooming-in policy also allows you to request
time alone for rest, if you need it.)
Preventing breastfeeding problems. Kaiser
Permanente Sunnyside Medical Center and our
partner hospitals have lactation consultants
in-house. You can also make sure that hospital
staff know not to give your baby supplemental
formula, unless there is a medical need.
Having skin-to-skin contact with your baby in
the first hour. It has been shown to help with
breastfeeding and bonding.
Whether and when youd like visitors, including
children in your family.
Whether to bank your babys umbilical cord
blood after the birth for possible use as a stem
cell treatment. (This requires advance planning
early in your pregnancy.)
Consider taking a childbirth education class, and
tour the labor and delivery area of your hospital
or birthing center. This will help you feel more
comfortable when the time for delivery comes.
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Preparing for labor

Mind and body readiness
Later in your pregnancy, you and your partner
are probably focused on checking off your list
of things to do before the baby arrives. But its
important that you set aside time and energy to
prepare your mind and body for labor.
Stretches, exercises, and deep breaths can
help you feel more relaxed and ready for the
extraordinary act of childbirth.
Here are some things you can do to prepare:
Exercise
The muscles in your lower abdomen, lower back,
and around the vagina (birth canal) come under
great strain during pregnancy. During delivery,
these same muscles must relax and stretch.
Simple exercises such as the pelvic tilt and tailor
stretch will help you strengthen the muscles that
support your growing uterus.
See page 38 of this guide and visit
kp.org/pregnancy to learn more about these
and other exercises.
Breathing, imagery,
and relaxation
Learning to relax your muscles, control your
breathing, and focus your mind are skills you will
need to call upon during labor and delivery. And
they take some practice to master.
Try them out now you may find they also help
you manage some of the discomforts
of pregnancy.
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Breathing. Taking slow, deep breaths is a

simple way to help you relax and reduce
stress. Try these relaxing breathing exercises.
Rhythmic breathing (sometimes called
Lamaze breathing) can take your focus away
from pain and is often used to manage pain
during contractions.
Imagery. Guided imagery helps you relax,
manage stress, and alleviate pain
by deliberately focusing your mind on a
particular sensory experience. It usually
centers around creating a visual image (such
as picturing a tranquil beach or beautiful
forest) but can also involve smells, sounds,
tastes, and textures. Download or listen
online to our guided imagery for a successful
childbirth program or try other guided
imagery exercises on kp.org/listen.
Progressive relaxation. Learning to relax will
increase your energy and lower your stress
during pregnancy, as well as help you know
how to relax during labor. Try the progressive
relaxation exercise detailed below.
Massage. Gentle massage can help relieve
muscle tension and pain and help you relax.
It can also be a nice way for you and your
partner to bond.
Calming activities. Take time every day
to relax, even if only for 10 or 15 minutes.
Sitting in a quiet room, listening to music,
taking a warm (not hot) bath, or taking a
walk are simple ways to quiet your mind and
feel centered.
100
Progressive Relaxation
To begin, get into a comfortable position,
preferably lying on your side or propped up with
pillows in a semi-sitting position on a bed or a
couch. Close your eyes and take a deep breath
through your nose. Exhale completely through your
mouth. Repeat this cleansing breath. Now, allow
your breathing to become slower and effortless.
Find a comfortable pace. If possible, have your
partner touch each area that youre relaxing as
you inhale and contract the muscle. Have your
partner feel the difference in muscle tone as you
exhale and relax the area. If youre practicing
alone, concentrate on tensing each muscle group,
relaxing it, feeling the difference between tension
and relaxation, and breathing.
Start with your forehead and move progressively
toward your toes.
Raise your eyebrows toward your hairline
and contract your forehead while inhaling.
(Partners, feel the tension.) Try not to laugh; it
tightens the rest of your face.
Now exhale and release the tension.
(Partners, feel the muscle relax.)
Keeping your forehead relaxed, bite down and
clench your teeth as you inhale. (Partners, feel
the muscles on the sides of her jaws.)
Now exhale and release the tension; let
your mouth open slightly. (Partners, feel
the difference.)
Now exhale and release the tension.

(Partners, massage her a little and make sure
shes totally relaxed.)
Extend your right arm as you inhale. Make a
fist and tense your right arm all the way to
your shoulder. (Partners, feel the tension.)
Now exhale and release the tension; let the
arm drop to your lap. Feel the tension and
distraction dissolve with every exhalation.
Feel the relaxation flood your body with every
inhalation. Calm in tension out. Focus in
distraction out.
Continue these steps with your left arm,
abdomen, buttocks, left toes (flex toward nose),
then right toes. When your whole body is relaxed,
take a deep breath and exhale any remaining
tension. Visualize that the tension is moving from
your head, down your body, and out through your
toes. Take another cleansing breath.
Notice how relaxed your muscles feel. If theres
one area where you still feel tension, focus on it,
breathe in and out four or five times, and relax it
further each time.
This is an excellent technique to use in your daily
life when you feel stressed. At work or at home,
find a quiet place and practice this exercise. After
two or three weeks of daily practice, youll be able
to produce the same relaxed feelings on the spur
of the moment. Youll also get a head start on
preparing your mind and body for labor.
Next, raise your shoulders and tense up the

neck and upper shoulder as you inhale. This is
where many of us carry a lot of tension. Is your
face still relaxed? (Partners, check the tension.)
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Preparing for labor

Other ways to feel prepared
Some of the following suggestions can help you
feel more mentally organized leading up to the
birth of your baby.
Take a childbirth class. If you havent done
so already, sign up for a childbirth preparation
class. A class can reduce your stress both
before and during labor and delivery by
preparing you to deal with what might
happen. It can teach you ways to relax and
the best ways for your support person to
help you.
Pack your bags. Make sure you have

everything to make your hospital stay
comfortable. Review the next section of this
guide for a checklist. Add to it any special
items you want to bring from home, such as
music or photographs, that may help you
during labor and delivery.
Get ready for baby. Make sure you have the
necessary items to bring your baby home
safely and set up a comfortable environment.
Know what to expect. Review the signs and

stages of labor and familiarize yourself with
the warning signs for preterm labor. Also,
learn the difference between false labor
(Braxton Hicks contractions) and the real thing
so you know when its time to grab your bag
and go to the hospital. Use a chart to help
time and record your contractions.
Create a birth plan. A birth plan will help
you think through your options for pain
management during labor and how your baby
will be cared for after delivery.
Stop smoking. If youve been smoking during
your pregnancy, try to quit now. Women who
smoke are more likely to have problems in
pregnancy and childbirth. Get help quitting
with the HealthMedia Breathe program (for
Kaiser Permanente members).
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What to bring
to the hospital
Dont wait until your first labor pains to get ready
to go to the hospital. Pack your bag at least three
weeks before your due date with these items.
For baby
Labor kit
Kaiser Permanente ID card.
Outfit for going home (undershirt, outer

garment, and hat, depending on the weather).
Toiletries (toothbrush, toothpaste, lip balm,

brush, hair clip or band, lotion, cosmetics).
One to two receiving blankets.

Hat or hooded garment.
Nightgown, robe, or loose-fitting T-shirt (if you

prefer to wear your own; front-opening if you
plan to breastfeed).
Mittens (many babies have long fingernails and

can scratch their faces).
Nonskid slippers.
Cotton socks.
Hand fan or spray mist bottle.
Infant safety seat (required by law to be in the

car when you leave the hospital).
Do not bring
Electrical appliances (curling iron, hair dryer).
Valuables, jewelry, or cash.
Underwear (and your favorite brand of sanitary

pad if desired).
Supportive bra or nursing bra (for
breastfeeding mothers).
Comfortable, loose-fitting clothing to
wear home.
MP3 player or CDs and CD player to
play relaxing music or audio programs.
Camera for photos or videos.
Cell phone and numbers of friends and
relatives you plan to call.
Eyeglasses and contact lens supplies.
Snacks, a change of clothes, and toiletries
for your partner.
Beverage of your choice not carried by the
hospital (such as Gatorade).
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103
LABOR, DELIVERY,
AND POSTPARTUM
LABOR, DELIVERY,
AND POSTPARTUM
Timing contractions
A contraction is a tightening of the uterine
muscle that becomes frequent or regular as labor
begins. It might feel like cramping or pressure in
the uterus.
Talk to your practitioner about when you should

notify Labor & Delivery and go to the hospital.
The following are some general guidelines about
when to call.
How to count contractions
When to call
You should count contractions around the time

your baby is due. Place your hands on your
uterus and feel for a tightening and then a
relaxing (softening) of your uterus. The tightening
sensation should be felt over the entire uterus.
If youre a first-time mother, call when:

You can no longer walk or talk
through contractions.
Use a watch or a clock with a second hand and

answer these two questions:
Contractions are regular, usually every 3 to 5

minutes over an hourlong period. Count from
the start of a contraction to the beginning of
the next.
1. How long do the contractions last (duration)?

Time the length of each contraction from the
moment it starts until it subsides.
Contractions last at least 45 to 60 seconds.

Contractions that last 30 seconds are probably
very early labor or Braxton Hicks contractions.
2. How far apart are the contractions

(frequency)? Time each contraction from the
beginning of one to the beginning of the next.
Contractions become much stronger when

youre walking.
Youre having a contraction if your uterus stays

tight for 30 seconds or more and then repeats.
Its normal for most women to have Braxton Hicks
contractions throughout pregnancy.
Braxton Hicks contractions dont usually come in
a rhythmic pattern and dont continue for more
than an hour. They often disappear if you change
your activity.
If youre not a first-time mother, call when:

Contractions are every 5 to 7 minutes for at
least one hour.
Contractions last at least 45 to 60 seconds.
Contractions become stronger when walking.
Call your provider or advice line if you are not due

and experience contractions or cramping that you
do not think are Braxton Hicks.
If you have a contraction every 15 minutes or
more often, you may be in labor.
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105
Timing
contraction chart
Use this chart to help you track the duration and frequency of your contractions.
time
duration
frequency
(Example)
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11 a.m.
60 sec.
11:10
75 sec.
10 min.
11:18
80 sec.
8 min.
time
duration
frequency
106
time
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duration
frequency
107
Early labor
The birthing process is known as labor and
delivery. No one can predict when labor will start.
One woman can have all the signs that her body
is ready to deliver, yet she may not have the baby
for weeks. Another woman may have no advance
signs before she goes into active labor. First-time
deliveries are more difficult to predict.
Signs of approaching early labor

Signs that early labor is not far off include
the following:
The baby settles into your pelvis. Although
this is called dropping, or lightening, you may
not feel it.
Your cervix begins to thin and open (cervical
effacement and dilation). Your doctor checks
for this during your prenatal exams.
Braxton Hicks contractions become more
frequent and stronger, perhaps a little painful.
You may also feel cramping in the groin or
rectum or a persistent ache low in your back.
Your amniotic sac may break (rupture of the
membranes). In most cases, rupture of the
membranes occurs after labor has already
started. In some women, this happens before
labor starts. Call your doctor immediately
or go to the hospital if you think your
membranes have ruptured.
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Early labor (latent phase

of labor)
Early labor is often the longest part of the birthing
process, sometimes lasting two to three days.
Uterine contractions:
Are mild to moderate (you can talk while
they are happening) and last about 30 to
45 seconds.
May be irregular (5 to 20 minutes apart) and
may even stop for a while.
Open (dilate) the cervix to about 3
centimeters. First-time mothers can
experience many hours of early labor without
the cervix dilating.
Its common for women to go to the hospital
during early labor and be sent home again until
they progress to active labor or until their water
breaks (rupture of the membranes). This phase of
labor can be long and uncomfortable. Walking,
watching TV, listening to music, or taking a warm
shower may help you through early labor.
108
Early labor that is progressing

If you arrive at the hospital or birthing center in
early labor that is dilating and effacing the cervix
or is progressing quickly, you can expect some or
all of the following:
In the birthing room, you will change into a
hospital gown.
Your blood pressure, pulse, and temperature
will be checked.
Your previous health, pregnancy, and labor
history will be reviewed.
You will be asked about the timing and
strength of your contractions and whether
your membranes have ruptured.
Electronic fetal heart monitoring will be used to
record the fetal heart rate in response to your
uterine contractions. Fetal heart rate shows
how your baby is doing.
Unless you have a cesarean section, you will labor,

deliver, and recover in the same room.
In the hospital, you may be:
Encouraged to walk. Walking helps many
women feel more comfortable during early
labor. Walking is thought to help labor
progress, but recent research suggests that
walking doesnt actually speed or slow labor.
Either intermittenly or continuously monitored
for your babys well-being and contractions,
depending on your or your babys risk factors
or medications administered.
Allowed visitors. As your labor progresses
and you become more uncomfortable, you
may want to limit visitors to your partner or
labor coach.
Offered a birthing ball that can be used for
different positions and used during labor.
You will have vaginal exams to check whether

your cervix is thinning and opening (effacing
and dilating).
Depending on your physical needs and
your doctors preference, you may have an
intravenous (IV) catheter inserted in case you
need extra fluids or medicine later.
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Active labor:
First stage
The first stage of active labor starts when the
cervix is dilated about 3 to 4 centimeters. This
stage is complete when the cervix is fully dilated
and effaced and the baby is ready to be pushed
out. During the last part of this stage (transition),
labor becomes particularly intense.
Compared with early labor, the contractions
during the first stage of active labor are more
intense and more frequent (every two to three
minutes) and longer-lasting (50 to 70 seconds).
Now is the time to be at or go to the hospital.
If your amniotic sac hasnt broken before this, it
may now.
As your contractions intensify, you may:
Feel restless or excited.
Find it difficult to stand.
Transition phase
The end of the first stage of active labor is
called the transition phase. As the baby moves
down, your contractions become more intense
and longer and come even closer together
than before. During transition, you will be selfabsorbed, concentrating on what your body is
doing. You may be annoyed or distracted by
others attempts to help you but still feel you
need them nearby as a support. You may feel
increasingly anxious, nauseated, exhausted,
irritable, or frightened.
A mother in first-time labor will take up to
three hours in transition, and a mother who has
vaginally delivered before will usually take no
more than an hour. Some women have a very
short, if intense, transition phase.
Have food and fluid restrictions. Some

hospitals allow you to drink clear liquids.
Others may only allow you to suck on ice chips
or hard candy. Solid food is often restricted,
because the stomach digests food more
slowly during labor. An empty stomach is
also best in the rare event that you may need
general anesthesia.
Want to try breathing techniques, laboring in
water, acupuncture, hypnosis, or other calming
measures that youve chosen to manage pain
and anxiety.
Feel the need to shift positions often.
This is good for you, because it improves
your circulation.
Want pain medicine, such as epidural
anesthesia.
Be given intravenous (IV) fluids.
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Active labor:
second stage
The second stage of active labor is the actual
birth, when the baby is pushed out by the
tightening uterine muscles (contractions). During
the second stage:
Uterine contractions will feel different. Though
they are usually regular, they may slow down
to every two to five minutes, lasting 60 to
90 seconds. If your labor stalls, changing
positions may help. If not, your doctor may
recommend using medicine to stimulate
(augment) uterine contractions.
You may have a strong urge to push or bear
down with each contraction.
The babys head is likely to create great
pressure on your rectum.
You may need to change position several times
to find the right birthing position.
You can have a mirror positioned so you can
watch your baby crown and emerge from the
birth canal.
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When the babys head passes through the

vagina (crowns), you will feel a burning pain.
The head is the largest part of the baby
and the hardest part to deliver. If this is
happening quickly, your doctor may advise
you not to push every time, which may give
the perineum, or area between the vulva
and the anus, a chance to stretch without
tearing. Or he or she may make an incision
in the perineum (episiotomy). This is not
recommended unless there is a medical need.
Your medical staff will be ready to handle
anything unexpected. If an urgent problem
comes up, people will move quickly. You may
suddenly have more people and equipment in
the room than before. This is a time when your
doctor or nurse-midwife will be deciding what
is best for you and your baby.
This pushing stage can be as short as a few
minutes or as long as several hours. You are
more likely to have a fast labor if you have given
birth before.
111
Third stage: After

your baby is born
After your baby is born, your body still has
some work to do. This is the third stage of labor,
when the placenta is delivered. You will still
have contractions. These contractions make the
placenta separate from the inside of the uterus,
and they push the placenta out. Your medical staff
will help you with this. They will also watch for any
problems, such as heavy bleeding, especially if
you have had it before.
in most cases, the placenta is delivered within 30

minutes. If the placenta does not fully detach, your
doctor or nurse-midwife will probably reach inside
the uterus to remove by hand what is left. Your
contractions will continue until after the placenta
is delivered, so you may have to concentrate and
breathe until this process is complete.
Your providers goal is for the third stage to

proceed normally, and for all of the placenta
to leave the uterus. This is what keeps your
bleeding down.
You may be given medicine to help the uterus
contract firmly. Oxytocin (such as Pitocin) may
be given as a shot or in a vein (intravenously)
after the placenta is delivered. Oxytocin is given
to make your uterus shrink and bleed less. (This
is the same medicine that is sometimes used to
make contractions more regular and frequent
during labor.) Breastfeeding right away can also
help the uterus shrink and bleed less.
The third stage can be as quick as five minutes.
With a preterm birth, it tends to take longer. But
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Postpartum recovery
and coping
Physical changes after childbirth
After childbirth (postpartum period), your body
goes through numerous changes, some of
which continue for several weeks during your
postpartum period. Like pregnancy, postpartum
changes are different for every woman.
Shrinking of the uterus to its pre-pregnancy
size (uterine involution) starts when the
placenta is delivered and continues for
about two months. Within 24 hours, the
uterus is about the size it was at 20 weeks of
pregnancy, and after a week, it is half the size
it was when you went into labor. By six weeks
after delivery, the uterus is nearly as small as it
was before pregnancy.
Contractions called afterpains shrink the
uterus for several days after childbirth. These
sharp pains are usually not as problematic
after a first childbirth as they are after later
deliveries. Afterpains typically improve during
the third day.
Sore muscles (especially in the arms, neck,
or jaw) are common after childbirth. This
is a result of the hard work of labor and
should go away in a few days. You may also
have bloodshot eyes or facial bruising from
vigorous pushing.
Difficulty with urination and bowel movements
(elimination problems) can occur for several
days after childbirth. Drink plenty of fluids and
use stool softeners, if needed.
Postpartum bleeding (lochia) may last for two
to four weeks and can come and go for about
two months.
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Recovery from an episiotomy or perineal tear

in the area between the vagina and anus can
take several weeks. You can ease the pain
with home treatment, including ice, pain
medicine, and sitz baths. Pain, discomfort, and
numbness around the vagina are common
after any vaginal birth.
Breast engorgement is common between the
third and fourth days after delivery, when the
breasts begin to fill with milk. This can cause
breast discomfort and swelling. Placing ice
packs on your breasts, taking a hot shower,
or using warm compresses may relieve the
discomfort of engorgement.
Recovery from pelvic bone problems, such as
separated pubic bones (pubic symphysis) or
a fractured tailbone (coccyx), can take several
months. Treatment includes ice, nonsteroidal
anti-inflammatory drugs (NSAIDs), and
sometimes physical therapy.
Call your doctor if you are concerned about any
of your postpartum symptoms.
Coping during the

postpartum period
When you have returned home, you may find it
a challenge to meet the increased demands on
your limited energy and time. Take it easy on
yourself. Pause for a moment, and think of what
you need. Tips for coping during the postpartum
period include accepting help from others, eating
well and drinking plenty of fluids, getting rest
whenever you can, limiting visitors, getting some
time to yourself, and seeking the company of
other women who have new babies.
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Postpartum depression
If you are having trouble with postpartum blues
that last more than a few days or you think you
may have signs of postpartum depression, call
your doctor or social worker right away.
Postpartum appointment
It is important to have a routine postpartum
visit with your practitioner four to six weeks
after delivery. This appointment will include
a physical exam and will give you a chance to
discuss birth control, feeding, depression, and
your return to work.
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INFANT CARE
INFANT CARE
Infant care overview

Congratulations on your new baby!
The day youve been waiting for is finally here your baby is home with you.
Like pregnancy, the postpartum period can be a time of mixed emotions. You may feel
excitement and joy as well as concern and exhaustion. Your new family member has a
unique personality and needs, which may take some adjustment.
Remember to enroll your newborn in a health insurance plan within 31 days after birth.
Check with your employers human resources department or a Kaiser Permanente
Membership Services representative to learn about coverage for your baby.
Here is some solid advice that may come in handy over the next few months.
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Newborn experience
The time after birth is usually a mix of emotions,
and we want you to feel supported while also
ensuring the safety and health of your infant.
The following information should help give you
ideas about what to expect while you are in the
hospital after the birth of your child. Youll spend
most of the time bonding as a new family and
practicing breastfeeding.
Bonding
The time immediately following delivery is
not only joyous but also very important for
establishing a good connection with your new
arrival. As long as it is safe, we encourage placing
your infant on your chest, skin to skin, and to
begin breastfeeding as soon as possible. This
also provides warmth for your baby. Partners are
encouraged to get involved in this period as well.
If your provider determines that your baby needs
additional help to breathe or to be checked just
after delivery, we have pediatric providers nearby,
if needed. If this occurs, we try to respect the
bonding time for your family as soon as we assure
the health and safety of your newborn.
First bath
When born, infants are covered in a thick, white,
creamy substance called vernix. It protects and
keeps your baby warm during development.
Your baby is given a bath to remove this. The
bath typically takes place in your room, and we
strongly encourage family members to help.
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Newborn screening tests

Screening tests help your doctor diagnose and
treat certain potentially serious diseases or
conditions before symptoms appear. All states
require newborn screening, although the required
tests vary from state to state. They may include
testing for galactosemia and phenylketonuria
(metabolic disorders), sickle cell disease, thyroid
hormone, and others. When your baby is at least
24 hours old, we take a few drops of blood from a
heel for testing. If the tests results are abnormal,
further testing may be needed.
Your baby will also have other screening tests,
including hearing, oxygen level, and jaundice
tests. Often a baby may not pass the hearing test
for simple reasons like the presence of fluid in
the ear canal. We then repeat the test before or
after you go home depending on when you are
discharged. The oxygen test helps determine if
there is a problem with your babys heart. If you
have any questions about these, please talk to
your provider.
Circumcision
If you want your newborn son circumcised,
Kaiser Permanente Sunnyside Medical Center has
providers who can perform the procedure. We
also have an outpatient clinic available after your
discharge from the hospital. Health plans charge
differently for the procedure. You may want to
find out what your costs related to the procedure
will be.
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Medications
There are state and national requirements
regarding medications for newborns, including
the hepatitis B vaccine; an antibiotic eye ointment
to prevent infection; and a vitamin K shot to
prevent bleeding. These are administered in the
first couple of hours following delivery.
Some infants may require other medications
based on your health history. For instance, if you
test positive for hepatitis B, your baby needs an
additional medication at birth to help prevent
transmission. Or if you had an infection during
labor or delivery, your baby may need more
medications, such as antibiotics.
We also recommend that families and caregivers
be vaccinated against pertussis (whooping cough)
and influenza.
Erythromycin ointment
Erythromycin is an antibiotic that kills certain
germs in mom and baby. It is applied to your
newborns eyes within one to two hours of
delivery to prevent infection. This treatment has
proved effective and rarely has side effects. Past
therapies caused some discomfort or irritation,
but this ointment has proved to be safe.
Why do we give erythromycin ointment?
Eye infections were a significant cause of
blindness in newborns before this treatment was
started. Chlamydia and/or gonorrhea bacteria,
as well as other, less common bacteria, can cause
eye infections in newborns. The bacteria cause
red, irritated eyes with profuse white drainage
and can lead to blindness if left untreated.
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How are chlamydia and gonorrhea transmitted?

Chlamydia and gonorrhea are sexually transmitted
infections and are routinely screened for early in
pregnancy because many women do not have
symptoms and may not know they have the
infection. Treatment of these infections helps
decrease the chance of infection in newborns.
A newborn can get infected regardless of the
method of delivery. There is also a chance of
contracting the infection after this screening.
How safe is erythromycin ointment?
It is very safe, and side effects are rare.
Occasionally mild eye irritation may be noticed,
but it is usually not bothersome to the newborn.
What happens if my infant does not get
the ointment?
One study showed that in infants who were
not at high risk (mothers tested negative for
gonorrhea, had good prenatal care, had stable
social situations, and had only one sexual partner),
the rate of newborn eye infection was about
1 in 5 newborns with no ointment. There were
smaller rates of eye infections in infants treated
with erythromycin ointment. If you have active
gonorrhea infection, your newborn should also
get a vaccination of another antibiotic in addition
to the eye ointment to help prevent the disease.
Warning signs of eye infection
Signs of potential eye infection include, but are
not limited to:
Thick white eye discharge.
Eyelid swelling.
Eye redness.
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Newborn experience
Hepatitis B
The first vaccination in a series of three is given
to prevent passing on hepatitis B to your baby.
Hepatitis B is caused by a virus that can cause
liver damage, leading to a transplant or even
death. When babies get infected, the virus
usually remains in the body for life (this is called
chronic hepatitis B). About 1 out of 4 infected
babies will die of liver failure or liver cancer as
adults. Hepatitis B is a deadly disease, but its
preventable with vaccination. The vaccine is safe
and, when given as recommended, very effective.
How is hepatitis B virus spread?
Anyone can become infected with hepatitis B
virus at anytime during their lives. Hepatitis B virus
is spread by contact with an infected persons
blood or other body fluids. For example, babies
can get hepatitis B virus from their infected
mothers at birth. Children can get it if they live
with or are cared for by an infected person
or if they share personal care items (such as a
toothbrush) with an infected person. About 1
out of 20 people in the United States have been
infected with the hepatitis B virus.
How many people have hepatitis B?
In the United States, tens of thousands of people
get infected with the hepatitis B virus each year.
About 1 million people in the U.S. are infected.
Every year, about 3,000 Americans die from
liver failure or liver cancer caused by hepatitis B.
Worldwide, 350 million people are infected.
It is impossible to know if a person is infected
with the hepatitis B virus by looking at them. Most
people have no symptoms, do not feel sick, and
dont know they are infected. As a result, they can
spread the virus to others without knowing it. The
only way to know if a person is infected is through
a blood test.
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Is there a cure for hepatitis B?

No. Although there are several medicines to
help people who have lifelong hepatitis B virus
infection, there is no medicine that cures it. The
good news is that hepatitis B can be prevented by
vaccination.
Who recommends that all babies get hepatitis
B vaccination at birth?
Medical groups such as the American Academy
of Pediatrics, the American Academy of Family
Physicians, the American College of Obstetricians
and Gynecologists, and the Centers for Disease
Control and Prevention recommend that every
baby get hepatitis B vaccine at birth, before
leaving the hospital. These are the same groups
that recommend babies get vaccinated against
whooping cough (pertussis), measles, tetanus,
polio, and other serious diseases.
Why does my baby need a hepatitis B
vaccination at birth?
It is important to vaccinate babies at birth so
they will be protected as early as possible from
any exposure to the hepatitis B virus. Babies and
young children are not able to fight off hepatitis
B virus infection as well as older people. A child
who gets infected with the hepatitis B virus during
the first five years of life has a 15 to 25 percent
risk for premature death from liver disease,
including liver failure or liver cancer. Hepatitis B
vaccine is your babys insurance policy against
being infected with the virus.
Experts recommend vaccination against hepatitis
B as a routine part of a newborns hospital care.
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How could my baby come in contact with the

hepatitis B virus?
In many cases, the hepatitis B virus passes from
mother to baby during birth when the mother
does not know she is infected. In other cases, the
virus is spread to the baby during close contact
with an infected family member, caregiver,
or friend. Most people who are infected with
hepatitis B do not feel sick and have no idea they
carry this virus. They are surprised when they are
told they are infected. Many people have no idea
how they became infected with the virus in the
first place. To protect your baby from infection
with the hepatitis B virus, make sure he or she
receives the first dose of hepatitis B vaccine
before leaving the hospital.
Is hepatitis B vaccine safe?

Yes. Hepatitis B vaccine has been shown to be
very safe when given to people of all ages. More
than 1 billion hepatitis B vaccinations have been
given worldwide. In the United States, more
than 120 million people have received hepatitis
B vaccine. The most common side effects from
hepatitis B vaccine are soreness at the injection
site or slight fever. Serious side effects are rare.
Wont my baby just recover from hepatitis B?

Babies are not able to fight off hepatitis B as
well as adults. About 9 out of 10 babies who get
infected in the first year of life will stay infected
for life.
Why does my baby need so many vaccinations?

Its true that babies get lots of vaccinations, which
can cause temporary discomfort. The good news
is that more vaccines mean more protection from
serious diseases than in the past. Like hepatitis
B, many of these diseases, such as rotavirus,
whooping cough, and meningitis, can result in
severe illness, hospitalization, and even death.
How many doses of hepatitis B vaccine will my

baby receive?
The basic series is three or four doses. The first
dose should be given in the hospital (at birth),
the second dose one to two months later, and
the third dose at age 6 months or later. Because
many health care providers choose to use certain
combination vaccines during well-baby checkups,
some infants will receive four doses of hepatitis
B vaccine. Either alternative is considered routine
and acceptable.
How effective is hepatitis B vaccine?
Very. More than 95 percent of infants, children,
and adolescents develop immunity to the
hepatitis B virus after three doses of properly
spaced vaccine.
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Some parents worry that their babys immune

system is immature and cannot handle vaccination
at such a young age. But as soon as they are born,
babies start effectively dealing with trillions of
bacteria and viruses. In comparison, the challenge
to their immune systems from vaccines is tiny.
Make sure your baby gets all his or her vaccines at

the recommended ages. Its the safest and surest
way to protect children from deadly infectious
diseases. Your baby is counting on you!
Vitamin K Injections
Vitamin K helps our blood clot. It is given to
infants as an injection. Babies have little or no
vitamin K stored up when they are born, and they
do not absorb or make it adequately in the first
few weeks of life. If they become deficient, they
may have serious bleeding, even leading to brain
damage or death.
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Newborn experience
Why do we give vitamin K?
Newborns have low vitamin K at birth and are at
risk of low levels for several reasons. First, vitamin
K does not move across the placenta well during
pregnancy. Second, vitamin K is made by bacteria
in the intestines, and babies have sterile intestines
when they are born. Third, breast milk is low in
vitamin K. While formula has some, it may not be
enough. Infants whose mothers are on certain
seizure medications are at an even higher risk of
low vitamin K. Low vitamin K in newborns may
result in vitamin K deficiency bleeding (VKDB).
What is VKDB?
Vitamin K deficiency bleeding is a potentially
devastating and sometimes fatal disease that can
show up days to months after birth. VKDB is easily
prevented, and both the American Academy
of Pediatrics and Oregon law support giving a
vitamin K injection to all newborns. VKDB shows
up any time from the first day of life, typically
in infants whose mothers were exposed to antiseizure medications or certain tuberculosis drugs,
to about 4 months of age. These infants are
almost always primarily breastfed and did not
receive the vitamin K injection at birth. Some of
them have liver disease or other diseases that
make it difficult to absorb the vitamin. Some
infants will have no signs of a problem until it is
too late.
How common is VKDB?
It is a rare disease, but in infants who do not
receive vitamin K at birth, about 4 to 7 per
100,000 will be affected. Even though it is rare,
it is nearly 100 percent preventable by giving the
vitamin K injection at birth.
How safe is vitamin K?
There are no known serious side effects
associated with vitamin K. Any injection may
cause mild redness, soreness, or swelling at the
sight; a small amount of blood; or infection,
though this is rare since we clean the skin before
giving the medicine.
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Controversies of vitamin K
Vitamin K can be given as an injection or taken
orally. The oral version involves giving multiple
doses (usually at birth, 1 week, 4 weeks, and 8
weeks of age), and though it may decrease the
risk for VKDB, it is not nearly as effective as the
injection. Some European countries that switched
from the injection to the oral form have seen
an increase in VKDB. In 1997, a review of four
countries that made this change showed that oral
vitamin K led to VKDB in 1.2 to 1.8 per 100,000
births, compared with no cases from the injection.
Incomplete oral administration resulted in failure
in 2 to 4 per 100,000 births. Part of the reasons
for these findings was that oral vitamin K tastes
bad, and its effectiveness depends on parental
compliance for all of the doses.
In the early 1990s, two small studies suggested a
link between vitamin K and childhood leukemia.
Since then, two large studies in the U.S. (54,000
infants) and Sweden (1.3 million infants) have
found no correlation between childhood leukemia
and the vitamin K shot at birth.
Signs of VKDB
Some infants do not have warning signs of serious
bleeding. Others may have bleeding, bruising, or
change in alertness including, but not limited to:
Blood in feces, urine, vomit, or spit-up.
Black, sticky feces after the immediate
newborn period.
Bloody nose, belly button, or circumcision site.
Bruising anywhere.
Not acting right, not eating well,
seizures, lethargy.
If you have more questions, please discuss them
with your pediatrician.
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Tdap and flu vaccines

Pertussis (whooping cough) and influenza
can cause serious and sometimes fatal illness,
especially in newborns. Newborns are too young
to be vaccinated for these diseases, but family
and caregivers are strongly recommended to get
the Tdap booster and regular flu vaccinations to
help prevent passing these onto newborns.
Other things to remember
Group B strep. When you have a positive
Group B strep test during your pregnancy,
we give antibiotics during labor to prevent
transmission of the bacteria to the baby.
Antibiotics are most effective when given
at least four hours before birth. If your baby
arrives before the antibiotic is given, we
generally observe your infant for 48 hours in
the hospital to make sure he/she is safe and
healthy when we send you home. Sometimes
we need to do blood work on your baby to
check for infection. This is done in the first few
hours after delivery.
Diabetics and small or large babies. When
babies are born to women with diabetes, or
they are smaller or larger than average, we
routinely check sugar levels in the baby. If
levels are low, frequent and effective feeding
can almost always prevent the need for
significant interventions.
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Infection. If your doctor is worried about

an infection you may have, your pediatric
provider will talk to you about making sure
the infection is not passed to your baby. This
typically involves blood work and antibiotics
for your baby until we can be sure.
Preterm infants. A baby born three or
more weeks early is considered premature.
Premature infants can have problems that
range from serious to mild and most often
relate to how early they are born. Common
problems include difficulty feeding or
breathing, temperature regulation, jaundice,
and sugar-level control. More serious
problems can include infections, brain injury,
and cerebral palsy, and may require a blood
transfusion or breathing machine. Premature
infants need closer monitoring, and some
need specialized care in the neonatal intensive
care unit (NICU). For more details about
preterm infants, please click here.
Discharge
All infants must meet certain criteria to go
home healthy. They have to be eating within
expected norms, passing urine and stool, have
the appropriate screening tests, and be able
to maintain normal temperature and other vital
signs. Kaiser Permanentes Mother-Baby Program
provides a lactation nurse who sees recently
discharged mothers and infants and can assess
any concerns that arise after discharge. You will
see the lactation nurse one to three days after
being discharged. This, along with your babys
first doctor appointment, will be made before you
leave the hospital.
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Newborn appearance
Head
Skin
Your babys head may seem large and out of

shape. It makes up about 25 percent of total length
(compared with about 10 percent for an adult).
Your babys head may look drawn out and come
to a point in the back. During labor, your babys
head molded itself into this shape to safely pass
through your pelvic bones. It will not be long
before the head takes on a smoother, prettier
shape. Sometimes there are rounded bumps on
the back and side or the top of the head. These are
harmless swellings that will disappear eventually.
Your babys head has two soft spots both in the
middle of the head, one in front and a small one in
the back. These areas may be touched and washed
like any other area of the head.
Your babys skin may be dry or moist. Some

babies have scaly skin that may peel in a few
weeks. This is normal. We do not recommend
using oils or lotion because they may clog the
pores and result in rashes. If the skin cracks at the
wrists or ankles, apply Eucerin cream on those
areas three or four times a day.
Breasts
Your babys breasts may be swollen. The same
hormones that make your breasts larger during
pregnancy can affect your babys breast tissue.
It may take several months for the swelling to
disappear naturally. This can occur even for
boys. Your babys breasts may produce a
milk-like substance.
Your baby may have red blemishes on the eyelids,

bridge of the nose, forehead, or nape of the neck.
These frequently disappear before your child is a
year old. Your baby may have a Mongolian spot,
a blue-gray pigmented area above the buttocks
that is normal and is not a bruise.
Your babys skin is very sensitive. Things that will
not hurt your skin can cause a variety of rashes
on your baby. A heat rash looks like many tiny
red pimples, usually on the face, neck, chest, or
abdomen. This rash does not need treatment.
Baby oil or lotion often make it worse.
Your infant may have milia white, slightly
raised pimples. They most often are tiny and
numerous on the nose, but may be anywhere,
especially the face.
If your baby has a peculiar rash that doesnt fit the
description of those above, call your provider.
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Weight
If your pregnancy was full term, your baby
probably weighed 5 to 10 pounds at birth.
In the first three days, babies will lose 5 to 10
percent of their weight. Small babies lose the
least but take the longest to gain it back. Large
babies lose the most but usually gain rapidly,
often within one to two weeks. This weight loss
will happen no matter what or how much your
baby eats. Your baby will gain back the weight, at
his/her own rate.
Genitals
If you have a girl, you may notice that her genitals
appear swollen. This is caused by the same
hormones that make the breasts larger. She may
have blood on her diaper at the end of the first
week for three to four days. Infant girls also may
have a white vaginal discharge beginning on the
second day that may last until the 10th or 12th day.
If you have a boy, you may choose to have him
circumcised. There is no medical indication for
routine circumcision. If you are uncertain about
circumcision, discuss it with your provider. After
circumcision, your son may be fussy. When you
look at the circumcision area during the first three
or four days after the procedure, it will look red.
There also may be a yellow-greenish discharge.
This is normal healing and not a sign of infection.
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If your provider uses a plastic ring for

circumcision, do not try to remove it. It will drop
off on its own in 4 to 10 days. You may notice a
few drops of blood on the diaper the first day
or two after circumcision. You should report any
bleeding after three days to your babys provider,
even if a ring was not used.
For circumcision not using a plastic ring, the site
should be kept clean and covered with petroleum
jelly for five to seven days or until the site
appears pink and healed. For circumcision with a
plastic ring, keep the area clean, but do not use
petroleum jelly. When your son is 2 weeks old, the
site should be healed.
Eyes
The birth process may cause your babys eyelids
to look puffy. Sometimes there is a difference
from side to side. This should improve within
a few days. Your babys eyes may be red
immediately after delivery, especially if it was a
fast or difficult delivery. This is caused by broken
blood vessels in the whites of the eyes and will
resolve on its own. Your baby may frequently
become cross-eyed because of undeveloped
muscles. As the muscles strengthen, the eyes will
begin to look normal.
Hands and feet

Often a newborns hands and feet are bluish
or spotted. This is normal and will go away on
its own.
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Newborn behavior
Breathing
Crying
During the first month, your baby may breathe

irregularly. He/she may breathe rapidly and
shallowly. At other times, breathing may be deep
and sighing. You will notice that the abdominal
muscles do more of the work than the chest
muscles do. Noisy breathing, when the noise
seems to come from the back of the nose, is
normal. Coughing, sneezing, and hiccupping
are common. Feeding may or may not help stop
hiccups, which are not harmful.
Your baby will cry. This is how your baby

communicates needs. Comforting and holding
your baby will not spoil your baby. Babies will
cry when hungry, cold, and uncomfortable. They
may cry because they need to be cuddled and
loved. Some babies cry more than others. For
inconsolable crying, call the advice nurse.
Sleeping
Your baby will probably sleep a lot during the first
24 hours but may sleep less and less, even in the
hospital, before you go home. Babies vary in their
need for sleep. Whether your baby sleeps a lot or
hardly at all, you will learn what is normal for your
baby. Providers recommend that infants, when
being put down to sleep, be placed on their back.
Co-sleeping is not recommended because of the
risk of suffocation.
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Fussiness
By 2 weeks of age, many infants will have
established a fussy time, usually around the same
time each day and frequently in the late afternoon
or early evening. This fussiness should begin
to ease by 4 months of age. Often rocking or
walking will help calm a fussy baby.
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Elimination
Preventing shaken baby

syndrome
Your baby will probably not urinate frequently

during the first three days and possibly only
once or twice during the first 24 to 28 hours.
When babies are getting adequate milk, they
should have 6 to 10 wet diapers a day.
Make a plan for what you will do when your

baby cries for longer than usual. It is normal
to feel frustrated. It is important to have a
plan to help with these feelings so you dont
hurt your baby. Try one of these ideas:
The first two days, your baby will pass a sticky,

black substance called meconium. Gradually
babys bowels will move more frequently, and a
loose, greenish stool will replace the meconium.
Your baby may have a bowel movement after each
feeding or one or two stools a day. Within the first
week, the stool will transition to a loose, yellow,
seedy texture. Breastfed babies tend to have
more frequent stools. If your baby develops hard
stools, contact the advice nurse for information/
treatment. If your baby develops foul-smelling
liquid stools, call the advice nurse.
Take a deep breath.

Turn the lights down and find a quiet
place. Hold your baby next to your chest
and breathe slowly to calm yourself and
your baby.
Try singing or cooing to your baby.
Take your baby for a walk in a stroller.
Take your baby for a ride in the car
(always use a car seat).
Call a family member or a friend to chat.
Ask someone you trust to take over for a
while, to give you a break.
If these tips dont help, call the advice nurse.
Be sure anyone who cares for your baby
knows these steps as well.
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baby care
Enjoy your baby
This is equal in importance to feeding and
protecting your infant. Remember, your baby
has been cuddled, comfortable, warm, and safe
these past months, leading an easy life inside your
womb. As you walked, the baby enjoyed a gentle
to-and-fro rocking motion. Now your baby has
many jobs to do, such as breathe, suck, swallow,
digest, eliminate, and keep warm all things
that, until now, were taken care of in the womb.
changes, and a mild soap as needed. Desitin is

often helpful if a diaper rash should develop. If
the rash does not go away in three to five days,
or gets worse, consult your babys provider for
further advice.
GIRL BABIES
Cleaning the labia
It is important to wipe your daughters bottom
from front to back. Gently separate the folds
(labia) and wash and rinse. There may be a
white coating inside the folds, along with a
clear, jelly-like discharge containing streaks of
blood. These are normal. Do not try to scrub
them off. They will eventually disappear.
Trust yourself
There will be many times when you will wonder if
you are doing the right thing in the right way.
This will be especially true if you have a wellmeaning friend or relative who gives you advice
whether you need it or not. There are many ways
to care for babies, and nearly all of them are right.
If you are enjoying your baby and your new role
as a parent, it is almost impossible for you to do
something wrong you will most naturally do it
right. Trust yourself, but reach out if you need help.
BOY BABIES
Cleaning the scrotum and penis
It is important to clean around your sons
scrotum, especially the underneath side.
Carefully lift the scrotum and wash gently,
being sure to rinse well if you use soap.
Care of the uncircumcised baby
Care of the uncircumcised boy is
uncomplicated. Washing and rinsing your
sons genitals daily is all that is needed. Do
not pull back the foreskin (the skin covering
the tip of the penis) in an infant. Forcing the
foreskin back may harm the penis, causing
pain, bleeding, and possible scar tissue. The
natural separation of the foreskin from the
tip of the penis may take several years. When
your son is older, he can learn to pull back the
foreskin and clean under it on a daily basis.
Limit visitors
It is best to have few visitors during the first few
weeks at home while you and your baby recover
together and your family adjusts to new roles.
Babies can be fussy from overstimulation or too
many visitors.
Changing diapers and cleaning

the genitals
The diaper area should be kept clean and dry.
If there is no diaper rash and your baby is not
uncomfortable, routine changes at feeding time
may be all that is necessary.
It is important to keep the diaper below the belly
button until the umbilical cord has fallen off.
Use warm water to clean the diaper area during
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Bathing
The room should be warm and free of drafts. You
may use mild soap or baby shampoo, but water
is the best daily cleaner. Avoid highly perfumed
soaps. Be careful to not get soap or shampoo in
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your babys eyes. Do not use cotton swabs inside

your babys nose or ear canals. Your baby should
have a sponge bath until the umbilical cord and/
or circumcision heals.
Skin care
Do not use baby lotion or baby oil. These
products may cause skin rashes. Do not use baby
powder or cornstarch. Your baby may breathe in
particles of the powder, which may cause lung
irritation. Keep your babys skin care simple. It
is normal for babies to have some dry skin after
birth, but in most babies this old skin will flake off
during the first weeks of life. For mild irritation in
the diaper area, use Desitin ointment. To avoid
skin irritation, launder cloth diapers and clothing
in a mild detergent. Soak cloth diapers after use,
and double-rinse after washing.
Eye care
For a few days after birth, your babys eyes may
be puffy and have a yellowish discharge from
the antibiotic used to prevent infection. Use
clear, warm water on a cotton ball to wipe away
the discharge. If swelling or redness with a
draining, yellowish discharge continues or returns,
this may indicate infection, and you should notify
your provider.
Umbilical cord care

The stump of the cord is firm, rubbery, and moist.
Some of the babys skin may cover the closest
part of it. The cord will become very dry, wrinkled,
and dark. It usually falls off between the 6th and
the 21st day. It is a good idea not to touch the
cord or the skin around it unless your hands are
freshly washed.
oozing of blood or yellowish-whitish discharge,

be sure the diaper or diaper covering is not
over the cord, causing it to remain moist. Slight
bleeding a few days before and after the cord falls
off is normal. Please call your provider if the skin
around the navel becomes red or swollen or has a
foul odor.
Checking your babys warmth

Touch your baby on the chest or back for proper
skin temperature. If your baby feels comfortably
warm, he/she is OK, even if the hands and feet
feel cool (but not blue). If your baby feels cool,
add clothes, including a hat in cold weather. If
your baby feels hot, take his/her temperature
using a thermometer in the armpit. If your baby
has a temperature of 100.4 degrees, refer to the
checklist of signs and symptoms of illness, and
call the advice nurse after you assess symptoms.
If your baby feels warm but his/her temperature
is below 100.4 degrees, take off some of his/her
clothes and recheck the temperature in an hour.
You should keep your baby out of direct sunlight.
Protect your baby from the sun with an umbrella,
shade, hat, and clothing.
You should also keep your baby away from drafts.
Nail care
It is common for your babys fingernails to be
long and/or sharp at birth. You can cover your
babys hands with socks or baby mittens or use
a soft emery board to file down the nails. It is
sometimes easier to file down the nails when your
baby is sleeping.
Until the cord falls off, keep the navel dry and
clean. After the cord falls off, you may gently
clean the area with warm water. If there is a little
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feeding your baby

Breastfeeding
Breastfeeding is an enjoyable and natural way of
feeding your baby. Since many misconceptions
and myths exist about breastfeeding, we advise
that you consult credible resources.
How breastfeeding works

Breastfeeding is a simple system of supply and
demand the more you nurse, the more milk
your body will produce for your baby. At first,
your baby gets colostrum, a rich, yellowish fluid
that protects against infection, is high in protein,
and serves as a laxative to help clear out his/her
digestive system. Colostrum is the perfect food
until your milk comes in. Your milk production
depends on the amount of stimulation at your
breasts. Therefore, you should start breastfeeding
soon after birth and frequently thereafter to
support milk production. Mature breast milk can
appear thin and bluish or creamy. Your milk is
perfectly suited to your babys digestive system
and nutritional needs.
Getting started
Breastfeed your baby as soon as possible after
birth. Some babies are eager to breastfeed
immediately after birth, and others take hours to
become interested in latching on to the nipple.
Dont be concerned if your baby needs time to
learn to breastfeed. Remember, every baby is
an individual and will respond and breastfeed at
his/her own pace. Give your baby lots of physical
contact while frequently offering the breast; this
will help encourage your babys natural instinct to
suck. You are both new at breastfeeding, so have
patience and give yourself and your baby time to
establish this skill.
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Get into a comfortable position sitting up or

lying down is fine. Take advantage of the rooting
reflex, which is what causes your baby to seek
the nipple when the cheek is stimulated. Tickle
your babys bottom lip with your nipple, and your
baby will turn toward that side and open the
mouth. Pull your baby close to you and support
your breast so that your baby grasps as much of
the areola (dark area) as possible and not just
the nipple. Your baby will then use the tongue to
hold the nipple against the roof of the mouth and
begin to suck.
Your baby may nurse on one or both sides. If your
baby nurses on both sides, start on the same side
you ended with last time. If you need to release
your babys grasp on your breast, you can insert
your little finger in the corner of your babys
mouth to gently break the suction.
Allow your newborn to nurse as long and
frequently as he/she demands. Spend a few
minutes between sides burping your baby and
changing the diaper. Newborns often fall asleep
after the first breast, and such activity between
sides can stimulate them to nurse on the
second breast.
Incorrect positioning and latch are primary causes
of sore nipples. Proper positioning will help
decrease nipple soreness. Ask your nurse for help
with positioning before your nipples get sore.
Remember, cracking, bleeding, or blistering is not
normal call the advice nurse, your provider, or
the Mother-Baby Program.
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Barring any medical indications, there should

be no need to supplement your babys
breastfeeding, as this can delay your milk coming
in. Many babies lose interest in breastfeeding
when a bottle is introduced too early or too often.
They use the tongue differently on a rubber
nipple and therefore lose the ability to latch on
to the breast. Check with your provider or nurse
practitioner if you have doubts or questions.
Breast milk digests quickly and easily, so newborns
nurse often, usually about every two to three
hours during the day and night. Some babies are
quite sleepy and dont wake up often to be fed in
the early days of life. It is advisable to wake and
feed your sleepy baby to ensure he/she is getting
enough food, and to stimulate your milk supply.
About breast pumps

Many breastfeeding mothers find the need for a
breast pump at some point during breastfeeding.
Depending on your need, you may want a manual
or an electric pump, and these range in price.
Pumps can also be rented by the month. Were
happy to help you assess your breast pump needs.
Kaiser Permanente
breastfeeding resources
For breastfeeding questions or concerns, try the
24-hour information line, Mother-Baby Program,
or your medical office advice nurse for over-thephone advice or to make an appointment.
24-hour breastfeeding/newborn care
information line
Portland 503-571-6605
Vancouver 360-992-4162
Salem 503-316-2311
Many newborns have their days and nights mixed

up at first be patient and encourage frequent
breastfeedings during the day. Rooming-in in the
hospital will allow you to put your newborn to the
breast whenever he/she is hungry. This will help
your milk come in sooner.
Mother-Baby Program
Beaverton Medical Office 503-626-5502
Interstate Medical Office East
503-331-6479
Mt. Scott Medical Office 503-571-4636
Salmon Creek Medical Office 360-571-3017
You may take medications prescribed by your

obstetric provider while breastfeeding. If you are
subsequently placed on medications, be sure to
tell your provider that you are breastfeeding.
Preparation for breastfeeding

For classes about breastfeeding and
baby care, see the Health Education
Catalog, available from Health Education
Services. Call 503-286-6816 for a catalog
or more information.
Nurses and other clinicians at your medical

office can schedule appointments if you have
breastfeeding difficulties. Please call your medical
office advice nurse if you need additional help
with breastfeeding.
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feeding your baby

Community
breastfeeding resources
Breast pump resources/rentals
Medela breast pump information line
1-800-TELL-YOU (1-800-835-5968); enter your
ZIP code for the closest rental station.
Apria Healthcare 503-258-2200;
www.apria.com
Support groups/information
La Leche League, Oregon 503-282-9377
La Leche League, Washington 360-892-4212
or 360-574-4866
Nursing Mothers Council 503-293-0661
Healthy Start, Clackamas County 503-655-8601
Nutrition during breastfeeding

You must feed yourself to be able to feed your
baby. While you were pregnant, what you ate
and drank provided nourishment to you and
your baby. Now that your baby has been born,
what you eat and drink is still important. For the
first few months, your breast milk supplies all the
nutrients and calories your baby needs to grow
and develop.
Vitamins and minerals

Breastfeeding also requires an increased intake of
vitamins and minerals. You can get what you need
by eating a well-balanced diet and by taking your
prenatal vitamin/ mineral supplement as advised
by your provider. Your requirements for vitamin
C, calcium, phosphorus, and folic acid increase
during breastfeeding. If you are anemic, you may
need to include more iron-rich foods in your diet.
Calcium and phosphorus are found in milk and
other dairy products. If you do not like milk or
cannot tolerate it, your provider may recommend
a calcium supplement.
Good sources of iron include liver, beef, raisins,
oysters, dried fruit, and iron-fortified cereals. Iron
is best absorbed in vitamin C. Good sources of
vitamin C include citrus fruits, broccoli, melons,
berries, tropical fruits, cabbage, and tomatoes.
Folic acid is commonly found in green, leafy
vegetables such as spinach, mustard greens,
romaine lettuce, and kale. Some cereals are
fortified with folic acid.
Calories, protein, and fluids

You will need extra calories to produce milk. The
current recommendation is 500 additional calories
per day, as well as an additional 20 grams of
protein. You will also want to drink extra fluids to
stay hydrated.
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Other considerations during

breastfeeding
If you are a vegetarian, be sure to get enough
calories, protein, calcium, iron, zinc, vitamin D,
and vitamin B12. Because many foods you eat
regularly fruits, vegetables and grains
are low in calories, you need to be sure to eat
adequate amounts each day. You may need a
vitamin B12 and iron supplement.
Dieting while breastfeeding is not
recommended.
Caffeinated products such as coffee, tea,
chocolate, and many sodas should be used in
moderation (about two to three 8-ounce cups
per day). Caffeine acts as a stimulant to your
baby in large amounts.
Talk to your clinician about alcohol
consumption while breastfeeding.
Consult your provider before taking any
medications while you are breastfeeding, as
many medications can pass through breast
milk to your baby.
Avoid raw fish due to the mercury passing to
the baby. Cooked fish is OK.
Sucking needs
Many babies have a need to suck that often is not
satisfied with breastfeeding or bottle-feeding.
These babies can be soothed by sucking on your
clean finger.
It is recommended by the American Academy
of Pediatrics to wait until breastfeeding is wellestablished before introducing a pacifier or
bottle nipple.
Please consult your provider or nurse if you are
confused or have questions about your babys
sucking needs.
Burping your baby

It is important to burp your baby during and after
each feeding. Some babies spit up more than
others. This loss of milk, if not excessive, does not
interfere with weight gain.
Bottle-feeding
Hold the bottle so that the neck of the bottle and
nipple are always filled with formula. This prevents
your baby from sucking and swallowing air.
Your baby has a strong, natural desire to suck
and will keep on sucking nipples even after they
have collapsed. Take the nipple out of the mouth
occasionally to keep it from collapsing.
Never prop the bottle up and leave your baby to
self-feed. The bottle can easily slip into the wrong
position and cause choking. Your baby needs
the security and pleasure of being held at each
feeding. This is a time for both of you to relax and
enjoy each other.
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feeding your baby

formula and food handling
It is not necessary to sterilize bottles, nipples,
formula, or water. However, great care should be
taken when preparing formula and foods:
Wash your hands carefully before
preparing formula.
Wash bottles and nipples thoroughly in
dishwashing detergent using a nipple brush
and a bottle brush. Rinse and drain well. The
top rack of a dishwasher is also safe to use for
most bottles and nipples.
Water that is mixed with formula should be boiled

if it is not from a source that is regularly checked for
harmful bacteria. It should then be allowed to cool
to room temperature before mixing with formula.
This applies to all private wells. Do not boil the
milk itself, or you will destroy the vitamins.
Powdered formula is less expensive and easy to
use. Read the label when preparing the formula to
be sure you are mixing it correctly.
Vitamins
Wash all lids with detergent and water

before opening.
At your babys 2-week checkup, the provider will

talk with you about your babys need for vitamins
or fluoride drops.
Use a can opener that can be immersed in

water. Wash the opener before and after use.
Solid foods
Prepare only enough formula for 24 hours.

Always store it in a covered container in the
refrigerator until ready to use. Do not save
formula when a feeding is finished. Discard
remaining prepared formula.
Formula should be served at room
temperature. If the formula has been
refrigerated, the bottle can be warmed in
a pan of hot water. Never heat your babys
bottle or food in a microwave oven. The
heating may be excessive or uneven and
potentially very dangerous to your baby.
Formula
There is a wide variety of prepared milk formulas
on the market. Some are available in ready-to-feed
bottles or cans. While this is an expensive way to
feed your baby, it is useful if you are taking a car
trip with your baby. The milk mixture will remain
sterile as long as the bottle or can is unopened.
Prepared cows milk formulas are most common.
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Your provider will advise you when it is

appropriate to introduce solid foods to your baby.
Do not put solid foods in your babys bottle.
According to the American Academy of
Pediatrics: Exclusive breastfeeding is sufficient
to support optimal growth and development
for approximately the first 6 months of life and
provides continuing protection against diarrhea
and respiratory tract infection. Breastfeeding
should be continued for at least the first year of
life and beyond for as long as mutually desired
by mother and child. Complementary foods rich
in iron should be introduced gradually beginning
around 6 months of age. During the first 6 months
of age, even in hot climates, water and juice
are unnecessary for breastfed infants and may
introduce contaminants or allergens.
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Multiples
Challenges of caring for twins or more
Once a multiple pregnancy is over, new
challenges arise as you care for your babies. Be
aware of signs of stress. Use your family, friends,
and health professional to develop ways of coping
with issues such as:
Premature infants who need to be hospitalized
or have medical problems. See the next
section on preterm infants.
Lack of sleep and exhaustion from meeting
your infants round-the-clock needs.
The needs of other children and
family members.
Lack of time for caring for yourself or
your partner.
The babies may face their own

challenges, including:
Less time spent with a parent. Make time for
each child individually.
Competition for parents attention.
More difficulty developing a separate identity.
Celebrate your childrens differences and
encourage them to make their own choices.
Less likelihood of being breastfed.
Breastfeeding helps with bonding between a
busy mother and child. It also helps increase
an infants immunity against infection and
many diseases in infancy and childhood.
Working closely with a lactation consultant will
help you master the art of breastfeeding more
than one infant.
Possible delays in growth and development.
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preterm infants
What is premature birth?
What causes premature birth?
Pregnancy normally lasts about 40 weeks. A baby

born more than three weeks early is premature.
Babies who are born closer to their due dates
tend to have fewer problems, if any.
Premature birth can be caused by a problem with

the fetus, mother, or both. Often the cause is
never known. The most common causes include:
When a baby is born too early, the major

organs are not fully formed. This can cause
health problems. Any premature baby can have
medical problems. But those who are born
before 32 weeks are more likely to have more
serious problems.
Pregnancy with twins or more.
Babies who are born closer to 32 weeks (just

over 7 months) may not be able to eat, breathe,
or stay warm on their own. But after these babies
have had time to grow, most of them can leave
the hospital.
Babies born earlier than 26 weeks (just under
6 months) are the most likely to have serious
problems. If your baby was born very small or
sick, you may face a hard life-or-death decision
about treatment.
Having a premature baby, often called a
preemie, may be stressful and scary. To get
through it, you and your partner must take
good care of yourselves and each other. It may
help to talk to a spiritual adviser, counselor, or
social worker. You may be able to find a support
group of other parents who are going through
the same thing.
Problems with the placenta.

Infection in the mother.
Problems with the uterus or cervix.
Drug or alcohol use during pregnancy.
What kind of treatments might a

premature infant need?
Premature babies who are moved to the neonatal
intensive care unit (NICU) are watched closely for
infections and changes in breathing and heart
rate. Until they can maintain their body heat, they
are kept warm in special beds called isolettes.
Premature babies are usually tube-fed or fed
through a vein (intravenously), depending on
their condition. Tube-feeding lasts until a baby is
mature enough to breathe, suck, and swallow and
can take all feedings by breast or bottle.
Sick and very premature infants need special
treatment, depending on what medical problems
they have. Those who need help breathing
are aided by an oxygen tube or a ventilator, a
machine that moves air in and out of the lungs.
Some babies need medicine. A few need surgery.
Breast milk can give a baby extra protection from
infection. So your hospital may urge you to pump
your breast milk and bring it in for at least the first
few weeks after birth.
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NICU doctors and nurses are specialists in

premature infant care. If your premature baby is
in the NICU, you can learn a lot from the medical
staff about how to take care of your baby.
Does premature birth cause longterm problems?

Before birth, it is hard to predict how healthy a
premature baby will be. But your doctors can
prepare you for what may lie ahead. They can
base this on your condition and how many weeks
pregnant you will be when you give birth.
Most premature babies do not develop serious
disabilities. But the earlier a baby is born, the
higher the chances of problems.
Most premature babies who are born between
32 and 37 weeks do well after birth. If your baby
does well after birth, his or her risk of disability
is low.
What can i expect when i take my

baby home?
When youre at home, dont be surprised if your
baby sleeps for shorter periods than you expect.
Premature babies are not often awake for more
than brief periods, but they wake up more often
than other babies. Because your baby is awake for
only short periods, it may seem like a long time
before he or she responds to you.
Premature babies get sick more easily than fullterm infants. So its important to keep your baby
away from sick family members and friends. Make
sure your baby gets regular checkups and shots
to protect against serious illness.
Sudden infant death syndrome (SIDS) is more
common among premature babies. So make sure
your baby goes to sleep on his or her back. This
lowers the chances of SIDS.
Babies most likely to have long-term disability

are those who are born before 26 weeks or who
are very small (1.7 pound or less). Long-term
problems may include intellectual disability or
cerebral palsy.
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Keep your
baby healthy
One important way to keep your baby healthy
and happy is to make all necessary appointments
for his or her routine checkups.
Visit schedule
Outpatient services include routine (well-child)

visits, same-day appointments, urgent care visits,
and telephone advice:
At about 2 weeks of age with a pediatrician or

family doctor.
Well-child checks are regularly scheduled

appointments to monitor your babys growth
and development.
Same-day appointments are made when your
baby has a condition or illness that cannot wait
until a well-child checkup. This appointment is
made during regular medical office hours.
Urgent care is provided after regular
clinical hours for conditions that cannot
wait until morning.
Telephone advice nurses can often assist you
with nonurgent problems or advise whether
your baby needs to see a provider.
If you have questions or concerns, please call
us before coming into a medical office. Our
professional staff can advise you what to do. In
many instances, a concern can be handled over
the phone.
If your baby needs to be seen, we can arrange for a
visit. The best time to receive care is during routine
office hours. Most appointment center hours are
8 a.m. to 6 p.m. However, check to see if your
medical office has extended hours. When calling
for appointments, be ready to provide your childs
name, birth date, and health record number.
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One to three days after discharge from the

hospital with the lactation nurse.
At 2, 4, 6, and 12 months of age with

your provider (sometimes there is also a
9-month visit).
What to expect at each early visit

At these visits, your pediatrician will look at your
babys growth by measuring his or her height,
weight, and head circumference. The doctor will
check your babys development and ask about
any concerns that you may have.
Use these opportunities to learn how you can
keep your baby as healthy and safe as possible.
Immunizations
During some visits, your baby may get one or
more shots to protect against childhood
diseases. Ask your pediatrician for a visit and
immunization schedule.
When to call for help

Any symptoms should at least be discussed
by phone with a clinician/advice nurse as soon
as noticed. A baby who appears ill should be
seen immediately.
To take your babys temperature, use a digital
thermometer under the armpit. A normal
temperature is 97.6 to 99.8 degrees. Do not use a
mercury glass thermometer. Ear thermometers are
not always accurate and thus not recommended
for babies.
138
The following need attention:
Whom to call
Any fever (armpit temperature of 100.4

degrees or higher) in an infant 4 months or
younger requires an immediate exam by a
provider. Temperature under 97.6 degrees
may also indicate serious illness and should be
reported to a provider.
If you or your baby requires care during regular

medical office hours, you can call to request a
same-day appointment (as available) from 7 a.m.
to 6 p.m. weekdays.
Marked change in feeding pattern

(significantly decreased appetite, vomiting,
sweating, or shortness of breath with feeding).
Marked change in behavior (decreased
activity, sleeping through two or more
feedings in a day, unusual irritability,
convulsions, or jerking movements of
the body).
Breathing problems (more than 60 breaths per
minute while sleeping or quiet; struggling or
pulling hard to catch breath; pausing longer
than 15 seconds between breaths).
Change in color (blueness, paleness,
increasing yellowness).
To make an appointment or to talk to an advice

nurse, call 1-800-813-2000 from all areas. For TTY,
call 1-800-735-2900. For language interpretation
services, call 1-800-324-8010.
For lactation and breastfeeding questions, call:
Mt. Scott Mother-Baby Program
503-571-4636
East Interstate Mother-Baby Program
503-331-6479
Beaverton Mother-Baby Program
503-626-5502
Salmon Creek Mother-Baby Program
360-571-3017
Explosive watery bowel movements.

Feeding poorly, crying excessively, increased
frequency of stools, or foul-smelling stools.
Significant decrease in urine (fewer than three
or four wet diapers per 24-hour period).
Bleeding from any place, other than a
small amount from the navel or circumcision
or vagina.
Any soft, fluid-filled blister.
You should also call your doctor if you are crying
a lot, feel sad for no apparent reason, or are
concerned that you may hurt your baby.
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keep your baby safe

The greatest danger to your baby is an accident,
not disease. You, as the parents of this newborn,
are responsible for constantly exercising sound
judgment to keep your baby safe. The four most
common dangers to an infant are drowning,
suffocation, falls, and car accidents. Prevention is
the key to a babys safe environment.
Prevent drowning
Your baby should be well-protected at all times
from entering areas near spas, jacuzzis, hot tubs,
bath tubs, or swimming pools without constant
adult supervision.
During bathing, never leave your baby alone.
Always support your baby with one hand. If you
are interrupted during bathing by the phone or
doorbell, either let it ring (they will call back), or
wrap up your baby and take him or her with you.
Prevent suffocation
Your baby should not be able to reach or play
with plastic bags, telephone cords, ropes, cords
from window coverings (such as mini-blinds),
electrical cords, harnesses, soft pillows, or wideslat openings in cribs made before 1976. These
all have the potential to smother, strangulate, or
suffocate your baby. Dont place necklaces around
your babys neck. Small objects of any type have
the immediate potential for choking a baby.
Prevent falls
The only safe place a baby can be left alone for
even a few moments is in a safety-approved crib
with all sides up or in a playpen. Babies can kick,
scoot, and wiggle off high surfaces such as beds,
tables, stairs, couches, and chairs. Floors and
full-size beds are unsafe if you are not able to
constantly watch your infant. All stairways should
be sealed off from creeping babies.
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Car safety
In Washington and Oregon, the law requires
that everyone wear seat belts. Children younger
than 1 year and less than 20 pounds must be in
a rear-facing car seat. The American Academy of
Pediatrics recommends a rear-facing car seat until
age 2 and more than 20 pounds.
To access the safety seat resource center on
the Web:
Go to www.actsoregon.org.
Click on Child Safety Seat Resource Center
for training, education, and information.
A safety seat:
Prevents your child from being thrown.
Absorbs the force of impact.
Distributes the force of impact more evenly
over a childs body.
As responsible parents, keep these points in mind
regarding car safety:
Infants should always be transported in
an infant/child car safety seat never in
someones lap or arms.
A car seat is effective only if installed and
used correctly according to manufacturers
instructions.
Remove or secure all loose objects from your
car that could become airborne in an accident.
The safest place for a child is in the center of
the back seat securely fastened in a federally
approved car seat.
If your car has an airbag, transport your child
only in the back seat.
The best safety seat is one you will use each
time your child rides in the car, that fits your car
securely, and that is comfortable for your child.
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Sleep safety and sudden infant

death syndrome (SIDS)
Your baby should sleep near you in a safe crib
or bassinet but not in the same bed. It is safe to
bring your baby into bed to nurse or comfort. But
return your baby to his/her crib or bassinet when
you are ready to go back to sleep.
The cause of SIDS is unknown, but there are
several things you can do to help prevent it:
Put your baby on his/her back to sleep, every
time. If your baby is old enough to roll and
does so on his/her own, there is no need to
correct the position. But you should always put
your baby down directly on the back for sleep.
Use a firm, flat sleeping surface.
Keep soft toys and loose bedding out of
the crib.
Do not use pillows, bumpers, comforters,
stuffed toys, or other soft objects.
Make sure your babys head remains
uncovered during sleep.
Do not string toys across the crib. They can
choke your baby.
Some studies have suggested that pacifiers
lower the risk of SIDS.
Put your baby to sleep in an area with good
ventilation, and consider using a fan in the
room (not blowing directly on the baby).
Do not expose your infant to smoke or use
sedating medications.
Crib safety
You can help your baby sleep safely in a crib by
following these guidelines:
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Use a firm, flat mattress that fits tight next to

the edge of crib.
Make sure that the crib slats are less than 2/8
inches apart. Your babys head can become
trapped if the openings are too wide.
Remove corner post knobs if attached to
the crib. They can become loose and cause
choking. Also, tighten all nuts, bolts, and
screws every few months, and check the
mattress support hangers and hooks regularly.
Older cribs may not meet current safety
standards. Check used cribs especially
carefully. For more information on crib safety,
visit www.keepingbabiessafe.org.
Prevent burns
Always check the temperature of warmed milk
before feeding it to your baby by squirting some
on your wrist. Never microwave milk or the bottle
directly. Check to make sure your water heater
is set to no higher than 120 degrees. Water
heaters have a dial on the side that allows for this
adjustment. Never carry hot liquids or foods when
holding your baby, as a spill can burn your infant.
Avoid smoking
Keep your babys environment smoke free at all
times. Smoking increases the risk of infections,
asthma, and SIDS.
Sun safety
Newborn skin is very sensitive. Newborns do not
need to be exposed to sunlight. If you want to
take your baby out on a sunny day, keep him/
her shaded, with most of the skin covered. It is
a good idea to consider putting on sunblock
even if your baby will be covered, to prevent any
accidental exposure.
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common
newborn problems
Jaundice
About 1 in 5 babies will be noticeably jaundiced
by the second or third day of life. Jaundice is a
result of the normal breakdown of red blood cells
that occurs during the newborn period. There can
be a relatively high number of excess red blood
cells breaking down, and/or the liver is not quite
ready to handle the waste load. Before birth, the
mothers liver does this for the baby. Bilirubin is
a byproduct of this metabolic process; bilirubin
circulates through the bloodstream and gives the
skin a yellowish color.
The liver filters bilirubin and sends it out with the
bowel movement and urine. You should notice
that in a few days, your babys bowel movement
starts to turn yellow. This is the bilirubin leaving
your babys system.
Your babys jaundice may gradually increase for
up to seven days and may last as long as two
weeks. During this time, it is important that your
baby gets plenty of fluids. Feeding your baby
every two to three hours, particularly if you are
breastfeeding, is important. If your milk is in, your
baby should have at least six wet diapers a day.
If your baby is increasingly sleepy, or the urine
output is decreasing, please call the advice nurse.
Your baby may need to have a bilirubin level
drawn and a feeding evaluation.
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How do we check for jaundice?

Jaundice usually turns the babys skin, and
sometimes the whites of their eyes, yellow. It is
most noticeable in daylight. It usually starts in
the face and then continues to the chest, belly,
arms, and legs as the bilirubin increases. We also
check every babys blood for the bilirubin level to
measure the level of jaundice. This is usually done
when we do the state newborn screen after the
first day of life.
Can jaundice hurt my baby?
Most infants have mild jaundice that is harmless,
but in unusual situations the bilirubin level can get
really high and can cause brain damage. This is
why newborns are checked carefully for jaundice
and treated to prevent a high bilirubin level.
Signs of worsening jaundice
Jaundice usually moves from head to toe, so if
you think it is worsening, call your doctor or tell
your nurse. If your baby is jaundiced and is hard to
wake, fussy, or not nursing or taking formula well,
jaundice may be contributing, so call your doctor
or tell your nurse right away.
Does breastfeeding affect jaundice?
Jaundice is more common in babies who are
breastfed, but usually in babies who are not
nursing well. If you are breastfeeding, you should
nurse your baby at least 8 to 12 times a day in the
first few days to ensure you will produce enough
milk and help keep the babys bilirubin level
down. If you are having difficulty, please contact
your doctor or nurse immediately.
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Does my baby need closer attention

for jaundice?
Some babies have a greater risk of developing
high levels of jaundice and need closer follow-up.
These include babies:
With a high bilirubin level before discharge.
Who were born more than two weeks early.
Who had jaundice in the first 24 hours of life.
Who are not breastfeeding well.
With lots of bruising or bleeding from delivery.
With a family member who had high bilirubin
and received phototherapy.
How is harmful jaundice prevented?
Most jaundice requires no treatment. When
treatment is necessary, placing your baby under
special lights while undressed will help lower the
bilirubin level. This method, called phototherapy,
can be used in the hospital or at home depending
on the jaundice level. Jaundice is treated using
this method only at lower levels, when brain
damage is not a concern. This treatment can help
prevent the harmful effects of jaundice.
Sunlight can help lower levels of jaundice, but
is not recommended as a safe way to treat
jaundice. This cannot be done safely because
your baby may get cold if undressed in your
house, and newborns should never be exposed
to direct sunlight outside because they might get
sunburned. Sometimes giving your newborn more
food by supplementing with formula will help
eliminate the bilirubin by making your baby have a
bowel movement more often. Your doctor will talk
to you about his option if it could help.
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How do the special lights work?

They cause a slight chemical change to bilirubin
and allow your newborns system to more easily
expel it. They work only while your infant is
exposed to the lights, so the more time your
baby is in the lights, the faster it works. It is also
important to have as much skin exposed to the
light as possible to ensure that enough bilirubin
gets changed.
How do we perform phototherapy?
We undress your infant and place him or her next
to a special light blanket. If the bilirubin levels
are higher, we place your baby under bright
blue lights for more effectiveness. The doctor
will recommend a specific phototherapy method
based on many factors, including your infants age
and jaundice level.
Where is jaundice treated?
Most of the time phototherapy can be done
in your room, but it is up to your doctor. Your
provider might want the phototherapy to be done
in the nursery instead of your room if:
You and your family dont want it done in your
room.
There is concern that your infant isnt getting
enough phototherapy (out of lights or off
blanket too much).
Your infant is admitted from home or you have
been discharged from the hospital.
The level of jaundice is too high to be done in
the room.
Your infant is having other problems such as
trouble maintaining body temperature.
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common
newborn problems
Are there risks to phototherapy?
Phototherapy is very safe. The biggest complaint
is that the baby needs to be left in the lights for
extended lengths of time to be most effective.
This means your baby will be allowed out only
for short periods (20 to 30 minutes) to allow for
feeding. Families sometime complain about the
fussiness of the infant in lights or that the blue
lights in the room are annoying. We use eye
protection on infants in the lights, but there is
no need for adults to wear eye protection. A
baby getting too warm or too cold is rare but
may prompt further investigation or require a
different approach to treatment. In babies with
a rare condition called porphyria, phototherapy
may cause the skin to turn bronze-colored. It is
reversible when the phototherapy is stopped,
but if you know of a family history of this disease,
please tell your provider.
Cradle cap
Cradle cap is a yellowish, dry, crusty scale on the
scalp. This may extend onto the face as a rash. If
this occurs, you may try the following:
Soften the scales with baby oil and let the oil
remain on the scalp for 15 minutes.
Loosen scales with a very soft brush.
Shampoo gently with your usual baby
shampoo. Rinse and dry well. Repeat this daily
for one week and then as needed.
Colic
All babies have fussy periods that may last from
one feeding to the next. This is not colic. If a baby
sleeps for only one to two hours at a time and
fusses after each feeding and passes a lot of gas,
drawing up the legs and crying, this may be colic.
Do you have to check any other lab tests?

Every baby being treated for jaundice will
have a repeat bilirubin test at some point. The
frequency of repeat tests will be based on the
doctors recommendations. Often we will check
another bilirubin level after stopping the lights
to ensure that the bilirubin hasnt increased too
fast. Sometimes the doctor will order other tests
like a blood type to ensure that the jaundice is
not more serious.
If this occurs, you may try any of these suggestions:
When does jaundice go away?

Jaundice most commonly will go away on its own,
unless the level is high and needs treatment. In
breastfed infants, jaundice often lasts two to three
weeks, and in formula-fed infants, most jaundice
goes away by two weeks. If your baby is jaundiced
for more than three weeks, see his or her doctor.
Take an infant massage class.
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Feed your baby more slowly, with

frequent burping.
Rock your baby gently.
Wrap your baby firmly in a light, soft blanket.
Provide a soft, steady humming noise.
Avoid sudden loud noises, bright lights, or
extreme temperature changes.
While the cause is not known, colic is not harmful,
and it usually passes by 3 to 4 months of age
even without treatment. Contact your provider if
your baby develops fever, vomiting, bloody stools,
or any symptoms that do not fit the colicky
pattern described.
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Diaper rash
Diaper rash is common and is caused by wet
diapers irritating the skin. To reduce diaper rash
problems, change diapers frequently and clean or
bathe the diaper area frequently. Keep the area
exposed to the air as much as possible. Protective
ointments, such as Desitin cream, can help.
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navigating
complications
navigating
complications
Appendix
Most women go through pregnancy and
childbirth without any medical problems or
complications. Early and regular prenatal care can
help keep you and your baby safe.
If you have a suspected or diagnosed problem,
youll need to take precautions to help your
pregnancy go well. Many complications, such
as gestational diabetes, are manageable with
proper treatment.
Even in a healthy pregnancy, it is possible to start
labor too early. Learn the signs of preterm labor
and what to do if contractions begin. This section
provides you with the critical information you
need to know.
Depression
Diabetes
Domestic abuse
Ectopic pregnancy (tubal pregnancy)
Fifth disease
Genital herpes
High-risk pregnancy
Iron deficiency anemia
Molar pregnancy
Multiple pregnancy
Obesity
Placenta abruptio
Review these pages to learn about common

complications and how to navigate them. If you
experience any problems during or after your
pregnancy, contact your health care provider. The
Risks and safety section outlines warning signs
and when and if to call for help.
Placenta previa
In this section, youll find information about:
Toxoplasmosis
Asthma
Urinary tract infection
Preeclampsia and high blood pressure

Preterm labor
Preterm premature rupture of membranes
Rh sensitization
Bacterial vaginosis
Deep vein thrombosis
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asthma
Asthma is a fairly common health problem for
pregnant women, including some women who
have never had it before.
Risks to your baby include:
During pregnancy, asthma not only affects you,

but it can also cut back on the oxygen your fetus
gets from you. But this does not mean that having
asthma will make your pregnancy more difficult or
dangerous to you or your fetus. Pregnant women
with properly controlled asthma generally have a
normal pregnancy with little or no increased risk
to themselves or the fetus.
Abnormally slow growth of the fetus

(intrauterine growth restriction). When born,
the baby appears small.
Most asthma treatments are safe to use when

you are pregnant. After years of research, experts
now say that it is far safer to manage your asthma
with medicine than it is to leave asthma untreated
during pregnancy. Talk to your doctor about the
safest treatment for you.
Risks of uncontrolled asthma

If you have not previously had asthma, you may
not think that shortness of breath or wheezing
during your pregnancy is asthma. If you know you
have asthma, you may not consider it a concern
if you only have mild symptoms. But asthma can
affect you and your fetus, and you should act
accordingly.
Death immediately before or after birth

(perinatal mortality).
Birth before the 37th week of pregnancy

(preterm birth).
Low birth weight.
The more control you have over your asthma, the
less risk there is.
Asthma treatment and pregnancy

Pregnant women manage asthma the same way
non-pregnant women do. Like all people with
asthma, pregnant women should have an asthma
action plan to help them control inflammation and
prevent and control asthma attacks.
Part of a pregnant womans action plan should
also include recording fetal movements. You can
do this by noting whether fetal kicks decrease
over time. If you notice less fetal activity during an
asthma attack, contact your doctor or emergency
help immediately to receive instructions.
If your asthma is not controlled, risks to your

health include:
Considerations for treatment of asthma in

pregnancy include the following:
High blood pressure.
If more than one health professional is

involved in the pregnancy and asthma care,
they must communicate with each other about
treatment. The obstetrician must be involved
with asthma care.
Preeclampsia, a condition that causes high

blood pressure and can affect the placenta,
kidneys, liver, and brain.
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Monitor lung function carefully throughout

your pregnancy to ensure that your growing
fetus gets enough oxygen. Because asthma
severity changes for about two-thirds of
women during pregnancy, you should have
monthly checkups to monitor your symptoms
and lung function. Your doctor will use either
spirometry or a peak flow meter to measure
your lung function.
Monitor fetal movements daily after 28 weeks.
Asthma and allergies

Many women also have allergies, such as allergic
rhinitis, along with asthma. Treating allergies is an
important part of asthma management.
The antihistamines loratadine or cetirizine
are recommended.
Inhaled corticosteroids at recommended
doses are effective and can be used by
pregnant women.
Consider ultrasounds to monitor fetal growth

if your asthma is not well-controlled or if you
have moderate or severe asthma. Ultrasound
exams can also help your doctor check on the
fetus after you have an asthma attack.
If you are already getting allergy shots, you

may continue getting them, but starting allergy
shots during pregnancy is not recommended.
Try to do more to avoid and control asthma

triggers (such as tobacco smoke or dust
mites) so that you can take less medicine if
possible. Many women have nasal symptoms,
and there may be a link between increased
nasal symptoms and asthma attacks.
Gastroesophageal reflux disease (GERD),
which is common in pregnancy, may also
cause symptoms.
Albuterol (ProAir) is a fast-acting pulmonary

airway muscle relaxer that can help quickly
reverse signs and symptoms in some cases of
asthma. If you use this inhaler, you should carry it
with you at all times.
It is important that you have extra protection

against the flu (influenza). Get a flu vaccination
as soon as its available, whether you are in
your first, second, or third trimester at the
time. The flu vaccine is effective for one
season. The flu vaccine is safe in pregnancy
and is recommended for all pregnant women.
Asthma medicines and pregnancy
Budesonide is labeled by the U.S. Food and

Drug Administration (FDA) as the safest inhaled
corticosteroid to use during pregnancy. One
study found that low-dose inhaled budesonide
in pregnant women seemed to be safe for the
mother and the fetus.
Never stop taking or reduce your medicines
without talking to your doctor. You might have
to wait until after delivery to make changes in
your medicine.
Always talk to your doctor before using any
medicine when you are pregnant or trying to
become pregnant.
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Bacterial vaginosis
Bacterial vaginosis is the most common type of
vaginal infection. Other common types include
yeast infections and trichomoniasis.
What is bacterial vaginosis?

Bacterial vaginosis is a mild infection of the
vagina caused by bacteria. Normally, there are
a lot of good bacteria and some bad
bacteria in the vagina. The good types help
control the growth of the bad types. In women
with bacterial vaginosis, the balance is upset.
There are not enough good bacteria and too
many bad bacteria.
Bacterial vaginosis is usually a mild problem that
may go away on its own in a few days. But since
it can lead to more serious problems, its a good
idea to see your doctor and get treatment.
What causes bacterial vaginosis?

Experts are not sure what causes the bacteria
in the vagina to get out of balance. But certain
things make it more likely to happen. Your risk of
getting bacterial vaginosis is higher if you:
Have more than one sex partner or have a new
sex partner.
Smoke.
Douche.
What are the symptoms?

The most common symptom is a smelly vaginal
discharge. It may look grayish white or yellow.
A sure sign of bacterial vaginosis is a fishy
smell, which may be worse after sex. About half
of women who have bacterial vaginosis do not
notice any symptoms.
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Many things can cause abnormal vaginal

discharge, including some sexually transmitted
diseases (STDs). See your doctor so you can be
tested and get the right treatment.
How is bacterial vaginosis

diagnosed?
Doctors diagnose bacterial vaginosis by asking
about the symptoms, doing a pelvic exam, and
taking a sample of the vaginal discharge. The
sample can be tested to find out if you have
bacterial vaginosis.
What problems can bacterial

vaginosis cause?
Bacterial vaginosis usually does not cause other
health problems. But it can lead to serious
problems in some cases.
If you have it when you are pregnant, it
increases the risk of miscarriage, early
(preterm) delivery, and uterine infection
after pregnancy.
If you have it when you have a pelvic
procedure such as a C-section, abortion, or
hysterectomy, you are more likely to get a
pelvic infection.
If you have it and you are exposed to a
sexually transmitted disease (including HIV),
you are more likely to catch the disease.
Getting treated with antibiotics can help prevent
these problems.
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How is it treated?
Doctors usually prescribe an antibiotic to treat
bacterial vaginosis. Those used most often are
metronidazole (such as Flagyl) and clindamycin
(such as Cleocin). They come as pills you swallow
or as a cream or capsules (called ovules) that you
put in your vagina. During pregnancy, you will
need to take pills.
Bacterial vaginosis usually clears up in two or
three days with antibiotics, but treatment goes on
for seven days. Do not stop using your medicine
just because your symptoms are better. Be sure to
take the full course of antibiotics.
Antibiotics usually work well and have few side
effects. But taking them can lead to a vaginal
yeast infection. A yeast infection can cause
itching, redness, and a lumpy, white discharge.
If you have these symptoms, talk to your doctor
about what to do.
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Deep vein thrombosis

What is deep vein thrombosis?
The known risk factors for blood clots include:
Deep vein thrombosis (DVT) is a blood clot

(thrombus) in a deep vein, usually in the legs.
Pregnancy and the first six weeks after

delivery.
Clots can form in superficial veins and in deep

veins. Blood clots with inflammation in superficial
veins (called superficial thrombophlebitis or
phlebitis) rarely cause serious problems. But clots
in deep veins (deep vein thrombosis) require
immediate medical care.
Personal or family history of blood clots.
These clots are dangerous because they can break

loose, travel through the bloodstream to the lungs,
and block blood flow in the lungs (pulmonary
embolism). A pulmonary embolism is often lifethreatening. DVT can also lead to long-lasting
problems. DVT may damage the vein and cause
the leg to ache, swell, and change color. It can also
lead to leg sores after years of having DVT.
Blood clots most often develop in the calf and
thigh veins, and less often in the arm veins or
pelvic veins. This section focuses on blood
clots in the deep veins of the legs, but diagnosis
and treatment of DVT in other parts of the body
are similar.
What causes deep vein clots

to form?
Blood clots can form in veins when you are
inactive. For example, clots can form if you are
paralyzed or bedridden or must sit while on a
long flight or car trip. Surgery or an injury can
damage your blood vessels and cause a clot to
form. Cancer can also cause deep vein thrombosis.
Some people have blood that clots too easily, a
problem that may run in families (thrombophilia).
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Obesity.
Coagulation disorders, such as factor
V Leiden mutation. This is a genetic
blood-clotting problem.
Inactivity, such as during long-distance travel
in cars or airplanes.

Symptoms of DVT include swelling of the affected
leg. Also, the leg may feel warm and look redder
than the other leg. The calf or thigh may ache or
feel tender when you touch or squeeze it or when
you stand or move. Pain may get worse and last
longer or become constant.
If a blood clot is small, it may not cause
symptoms. In some cases, pulmonary embolism is
the first sign that you have DVT.
How is deep vein

thrombosis diagnosed?
If your doctor suspects that you have DVT, you
probably will have an ultrasound to measure
the blood flow through your veins and help find
any clots that might be blocking the flow. Other
tests, such as a venogram, are sometimes used if
ultrasound results are unclear. A venogram is an
X-ray of the blood flow through the veins.
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How is it treated?
Treatment begins right away to reduce the chance
that the blood clot will grow or that a piece of the
clot might break loose and flow to your lungs.
Treatment for DVT usually involves taking blood
thinners (anticoagulants) such as heparin or
enoxaparin (Lovenox). Heparin is given through
a vein (intravenously, or IV) or as an injection.
Enoxaparin is given as an injection.
While there is a risk of taking these medications
(such as bleeding, osteoporosis, or low platelet
count), the risks of more serious complications
from DVT are usually of more concern. These
medications do not cross the placenta, so they
should not affect your baby.
How can deep vein thrombosis

be prevented?
There are things you can do to prevent deep vein
thrombosis. Many doctors recommend that you
wear compression stockings during a journey
longer than eight hours. On long flights, walk up
and down the aisle hourly, flex and point your feet
every 20 minutes while sitting, and drink plenty
of water.
If you have a history of a blood clot in your lung
(pulmonary embolus) or deep vein thrombosis,
please let your provider know.
Your doctor will provide a personalized

treatment plan. You will have blood tests often
to see how well the blood thinners are working.
Most women will continue the blood thinners for
a period after delivery.
Your doctor also may recommend that you prop
up or elevate your leg when possible, take walks,
and wear compression stockings. These measures
may help reduce the pain and swelling that can
happen with DVT.
In rare cases, a vena cava filter may be used. It
is inserted into the vena cava, the large vein that
returns blood to the heart from the abdomen and
legs. A vena cava filter helps prevent blood clots
from traveling to the lungs. This device is usually
used only if you are at high risk for pulmonary
embolism and not able to take blood thinners.
It may also be used if you have DVT that comes
back again or you had a sudden blockage of
blood flow in the lung (pulmonary embolism)
while taking blood thinners.
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Depression
Depression is common during pregnancy and in
the postpartum period. If you have symptoms of
depression during pregnancy or are depressed
and learn you are pregnant, make a treatment
plan with your doctor right away.
If you are being treated for depression and
are planning a pregnancy, talk to your doctor
ahead of time. You may be able to taper off your
antidepressant medicine before your pregnancy,
to see how you feel during your first trimester. Its
best to be medicine-free, especially during the
first trimester. But if you are severely depressed,
your doctor will probably want you to stay on
your medicine.
Dont ever suddenly stop taking an
antidepressant. This can cause difficult emotional
and physical symptoms and may also affect your
fetus. Your doctor can tell you the best way to
taper off your medicine.
Depression treatment choices

during pregnancy
If you are not severely depressed, interpersonal
counseling or cognitive-behavioral therapy may
be all that you need.
Interpersonal counseling focuses on your
relationship and life adjustments, giving you
emotional support and help with problemsolving and goal-setting.
Cognitive-behavioral therapy helps you take
charge of the way you think and feel, while
giving you a supportive relationship.
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If counseling alone isnt enough, or if your

symptoms are severe and disabling, talk to your
doctor about other possible treatments:
Light therapy uses regular doses of bright
light (not full-spectrum light, which includes
ultraviolet light). Typically, a person having
light therapy will sit in front of a high-intensity
(2,500- to 10,000-lux) fluorescent lamp,
slowly building up to one to two hours each
morning. (Possible side effects include eye
strain, headache, feeling wired, and trouble
falling asleep when light therapy is used later
in the day.)
Antidepressant medicine, most often a
selective serotonin reuptake inhibitor (SSRI),
such as fluoxetine (Prozac) or sertraline (Zoloft).
Zoloft is the most commonly prescribed
antidepressant during pregnancy. Fluoxetine
and citalopram (Celexa) are not often used
during breastfeeding, because they can pass
into breast milk in high levels. Fluoxetine is also
linked to side effects in some breastfeeding
babies. If you are planning to breastfeed and
are taking an antidepressant, talk about this
with your doctor.
Women who take an SSRI during pregnancy have
a slightly higher chance of having a baby with birth
defects. There is also a small chance that your baby
will have minor, temporary symptoms (such as poor
feeding and irritability) related to SSRI exposure
during pregnancy. But not treating depression can
also cause problems during pregnancy and birth. If
you become pregnant again, you and your doctor
must weigh the risks of taking an SSRI against the
risks of not treating depression.
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FDA Advisory
The U.S. Food and Drug Administration (FDA)
has issued an advisory on antidepressant
medicines and the risk of suicide. The FDA
does not recommend that people stop using
these medicines. Instead, a person taking
antidepressants should be watched for warning
signs of suicide. This is especially important at
the beginning of treatment or when the doses
are changed.
Additional measures you can take

against depression
Whether you use counseling, medicine, light
therapy, or a combination, be sure to also get
regular exercise, healthy food, fresh air, and
time with people who care about you. These
are important parts of preventing and treating
depression and having a healthy pregnancy.
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Diabetes
Diabetes is a condition that affects the bodys
natural way of storing and using energy. It causes
a high level of glucose (sugar) in the bloodstream,
which may lead to many health problems.
In pregnancy, high blood glucose levels can cause
the baby to grow too large, making a natural
delivery difficult. This could result in cesarean
section (C-section) or lead to injury of the baby
at the time of vaginal delivery (such as a broken
collarbone or nerve injury in the arm).
The baby may also have problems after delivery
(low blood sugar), and may need to be cared
for in a special care nursery. This is why its so
important to control your blood sugar while you
are pregnant.
Gestational diabetes
If your blood sugar becomes too high for the first
time while you are pregnant, you have gestational
diabetes. Gestational diabetes is the most
common form of diabetes in pregnant women.
Gestational diabetes usually begins after the first
trimester of pregnancy. Most women with this
type of diabetes have normal blood sugar in the
first part of pregnancy.
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Because you can have gestational diabetes

without knowing it, all women are tested for
diabetes during pregnancy. Your chances of
having diabetes in pregnancy are higher if any of
the following warning signs are true:
You had high blood sugar during a
previous pregnancy.
You have had other babies who weighed
more than 9 pounds.
You are overweight.
A close relative, such as a parent or sibling,
has diabetes.
You are part of an at-risk ethnic group,
including African-American, Asian-American,
Hispanic/Latina, Native American, Native
Alaskan, or Pacific Islander.
You have prediabetes or glucose intolerance.
Some women who have diabetes during
pregnancy will continue to have diabetes after
pregnancy. For most women, blood sugar levels
return to normal after pregnancy.
However, women who have gestational
diabetes are at risk for recurrence in subsequent
pregnancies and for developing type 2 diabetes
several years after delivery.
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Type 2 diabetes
Type 2 diabetes is the second most common
form of diabetes in pregnancy. Type 2 diabetes
is usually diagnosed in adulthood. It has become
more common in childhood and adolescence due
to the increase in childhood obesity. This type of
diabetes can be managed with lifestyle changes
(diet and exercise) or may need medications such
as insulin or oral medication.
Women with type 2 diabetes should see their
doctor before they become pregnant to discuss
steps they can take to ensure a safe pregnancy
and a healthy baby. Women with type 2 diabetes
should also be seen as soon as they find out they
are pregnant, so that blood sugar levels can be
monitored carefully.
Type 1 diabetes
Type 1 diabetes is less common but more likely to
cause problems in pregnancy. Type 1 diabetes is
usually diagnosed in children and young adults.
In type 1 diabetes, the body does not produce
insulin, a hormone that is needed to help your
body properly use and store glucose. Type 1
diabetes can be managed with diet, exercise, and
insulin to control blood sugar.
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What should I do if I
have diabetes?
By taking steps that will keep your blood sugar
levels as close to normal as possible, you will
be doing all that you can do to have a healthy
and normal pregnancy. These steps include
the following:
Make wise food choices. Healthy eating will
give you all the nutrition you need without
extra sugars and fats that can cause your
diabetes to get out of control.
Exercise. Physical activity will help your body
lower blood sugar levels, help you better
control your rate of weight gain, and help
improve your overall well-being.
Gain the right amount of weight. Proper
weight gain is necessary to provide your
baby with good nutrition during pregnancy.
But gaining too much weight increases insulin
resistance in the body, making blood sugar
go up and increasing the risk of having a
big baby.
Check blood sugar levels. An important
part of treating diabetes is checking your
blood sugar level at home. You will need to
do a home blood sugar test as directed by
your doctor.
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Diabetes
Take oral medications or insulin shots. The
first way to treat gestational diabetes is by
changing the way you eat and exercising
regularly. If your blood sugar levels are still
too high after changing the way you eat
and exercising regularly, you may need oral
medications or insulin shots. Synthetic insulin
or oral medications can help lower your
blood sugar level without harming your baby.
Special monitoring usually starts between 32
and 34 weeks if you are taking insulin or oral
medications. If you are not on medications,
then special monitoring usually starts by week
40 of your pregnancy.
Monitor fetal growth and well-being.
Your doctor may want you to monitor fetal
movements called kick counts. You may also
have fetal ultrasounds to see how well your
baby is growing. If your blood sugar levels
are high or your baby is growing larger than
normal, you may need to take oral medication
or insulin shots. If you take oral medications or
insulin, you may have a nonstress test to check
how well your baby responds to movement.
Even if you do not take insulin, you may have
a nonstress test and ultrasound as you get
closer to your due date.
Get regular medical checkups. Having
gestational diabetes means regular visits to
your doctor. At these visits, your doctor will
check your blood pressure and test a sample
of your urine. You will also discuss your blood
sugar levels, what you have been eating, how
much you have been exercising, and how
much weight you have gained.
How will diabetes affect my baby?

There are no absolute guarantees, but with careful
lifestyle changes, including wise food choices,
physical activity, and good blood sugar control, it
is less likely that there will be any problems.
If there are problems, your health care team will
be there to assist you and your baby. Problems
of a baby born to a mother with diabetes may
include the following:
Mothers with high blood sugar levels at the
beginning of pregnancy are at an increased
risk for having a baby with birth defects.
However, this risk can be lowered if blood
sugars are well-controlled before pregnancy.
Babies of some mothers who have diabetes
before pregnancy have a slightly increased
chance of stillbirth.
Polyhydramnios (excess amniotic fluid)
happens in a relatively small number (about
10 percent) of the women with pre-existing
diabetes. Excess fluid can cause premature
labor or other problems.
Macrosomia (large baby) happens when your
baby grows too big from receiving too much
blood sugar from you. The growing
baby changes the extra blood sugar to fat and
may grow too large to fit through the birth
canal. To avoid possible injury to your baby
during a vaginal delivery, your doctor may
recommend a cesarean section.
Learn the warning signs of preeclampsia.

Women who have diabetes during pregnancy
may have a greater chance of developing
high blood pressure and preeclampsia. Call
your doctor right away if you develop any of
the symptoms.
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Hypoglycemia (low blood sugar) may occur if

your blood sugar levels have been consistently
high during pregnancy. This causes the fetus
to develop high levels of insulin in the blood.
After delivery, your baby no longer has the
high level of sugar from you but continues to
produce high levels of insulin. As a result, your
newborns blood sugar becomes very low.
Immediately after birth, your babys blood
sugar level will be checked. If it is too low,
your baby may need to be fed right away.
Delivery of your baby

When your blood sugar remains normal
throughout pregnancy, diabetes should not affect
the delivery of your baby. Sometimes a cesarean
section may be necessary to deliver a baby that
is too big to fit through the birth canal. Choices
about delivery are very individual. You should
discuss your concerns with your doctor or other
medical professional.
Should I breastfeed?
We strongly encourage breastfeeding. The body
uses the calories stored during the first part of
pregnancy to make breast milk. About 300 to 500
calories per day are used for breastfeeding. By
six weeks after delivery, women who breastfeed
usually have lost an average of 4 pounds more
than women who bottle-feed. This can be
especially important for women with gestational
diabetes, since keeping a normal body weight
may reduce the risk of developing diabetes later
in life.
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Breastfeeding is also good for your baby.

Breast milk offers health benefits that formula
cant duplicate.
If you have had gestational diabetes, you should
be able to breastfeed without any complications.
The amount and type of milk your body makes is
the same as a woman without gestational diabetes.
If you took insulin or oral medications before
you were pregnant, your insulin or medication
needs may be different while breastfeeding. In
particular, women with type 1 diabetes should be
aware that their blood sugar may drop during or
after nursing. You may want to check your blood
sugars before and after feedings during the first
few weeks of breastfeeding. You may need to
eat snacks to prevent low blood sugar, especially
during the night.
Most likely, you will need to control your
blood sugar with wise food choices, exercise,
and possibly with oral medications or insulin
while breastfeeding. If you took one of these
medications before pregnancy, talk to your
doctor or other medical professional before
using it again.
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Diabetes
What happens after pregnancy?
Once you have delivered your baby, the impact of
diabetes often changes dramatically.
If you have gestational diabetes, you will probably
not need insulin or oral medication after you
deliver; however, as many as 60 percent of women
with gestational diabetes will develop type 2
diabetes later in life.
It is important that you have a blood sugar test in
the laboratory six weeks after your baby is born
to see if you still have diabetes. You may need
this test again after you stop breastfeeding. If you
do have diabetes, your doctor or other medical
professional will let you know if you need to take
diabetes medications.
You should continue with the dietary changes
made during pregnancy and exercise regularly
to help prevent the development of type 2
diabetes or recurrent gestational diabetes in
the future. If your blood test is normal, it is
still important to keep in mind that you have
an increased risk of developing diabetes later,
especially if you gain weight.
If you took insulin or oral medications to treat your
diabetes before you were pregnant, there may be
dramatic changes in your insulin needs the first
few days after delivery.
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Thats why it is important to check your blood

glucose frequently before meals to know when to
adjust your medication. If you were on insulin prior
to pregnancy, you probably needed to increase
your dose frequently during your pregnancy.
After delivery, your bodys insulin needs will
be closer to what they were prior to pregnancy.
If you are breastfeeding, you are encouraged to
use oral medications or insulin after talking with
your doctor.
To decrease your risk of diabetes, remember
the following:
Try to reach or maintain a healthy weight.
Losing the weight you gained during
pregnancy will help decrease your risk.
Try to eat plenty of fruits, vegetables, and
whole grains.
Aim for at least 30 minutes of physical activity
each day.
Have a laboratory test of your blood sugar
every one to three years to see if you have
developed diabetes.
Plan your pregnancies and consult with your
doctor or other medical professional before
getting pregnant again to be sure your blood
sugar is normal. Very high blood sugars in
early pregnancy may cause miscarriage or
birth defects in the developing fetus. If your
blood sugar is under control before you
get pregnant, you can reduce the risk of
miscarriage and birth defects.
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Domestic abuse
Domestic violence is more common in pregnancy.
If someone is hurting you, making you feel afraid,
putting you down, making threats, or pushing or
hitting you, it is not right, and it is not your fault.
Abuse occurs when someone uses their body,
words, or objects to hurt you. An abuser is usually
trying to control another person through harmful
words or actions.
If you are having problems with someone who
threatens you or hurts you, tell your doctor or
other medical professional. You and your baby
can get free and confidential help.
Remember: Its not your fault, no matter
what anyone tells you. Nobody deserves to
be abused.
someone to hurt you or your baby.
Have a safety net

Talk to someone you trust about what is
going on.
Call the police in an emergency.
Keep a set of car keys and money stashed
where you can find them.
Keep important papers (birth certificates,
photo ID, bank book) in a safe place.
The National Domestic Violence Hotline has
counselors who speak English, Spanish, and other
languages. They can give you information about
local resources. They are available 24 hours a day,
toll free, at 1-800-799-SAFE (1-800-799-7233).
You need to take care of yourself because if

you are hurt, your children are hurt, too.
If you need help, call the National Domestic
Violence Hotline at 1-800-799-SAFE
(1-800-799-7233).
You are not alone. Help is available. In an
emergency, call the number above, local police,
or a womens shelter in your community.
If someone has hurt you before, it may happen
again while you are pregnant or after your baby is
born. Sometimes abuse starts when you become
pregnant. Bringing a new baby into your home
may bring added stress to you and your partner.
Remember that stress is never an excuse for
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Ectopic pregnancy
(tubal pregnancy)
In a normal pregnancy, a fertilized egg travels
through a fallopian tube to the uterus. The egg
attaches in the uterus and starts to grow. But in
an ectopic pregnancy, the fertilized egg attaches
(or implants) someplace other than the uterus,
most often in the fallopian tube. (This is why it
is sometimes called a tubal pregnancy.) In rare
cases, the egg implants in an ovary, the cervix,
or the belly.
There is no way to save an ectopic pregnancy. It
cannot turn into a normal pregnancy. If the egg
keeps growing in the fallopian tube, it can damage
or burst the tube and cause heavy bleeding that
could be deadly. If you have an ectopic pregnancy,
you will need quick treatment to end it before it
causes dangerous problems.
What causes an
ectopic pregnancy?
An ectopic pregnancy is often caused by damage
to the fallopian tubes. A fertilized egg may have
trouble passing through a damaged tube, causing
the egg to implant and grow in the tube.
You are more likely to have fallopian tube damage
and an ectopic pregnancy if you:
Smoke. The more you smoke, the higher your
risk of an ectopic pregnancy.
Have pelvic inflammatory disease. This is
often the result of an infection such as
chlamydia or gonorrhea.
Have endometriosis, which can cause scar
tissue in or around the fallopian tubes.
Were exposed to the chemical DES before you
were born.
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Some medical treatments can increase your risk of

ectopic pregnancy. These include:
Surgery on the fallopian tubes or in the
pelvic area.
Fertility treatments such as in vitro fertilization.

In the first few weeks, an ectopic pregnancy usually
causes the same symptoms as a normal pregnancy,
such as a missed menstrual period, fatigue, nausea,
and sore breasts.
The key signs of an ectopic pregnancy are:
Pelvic or belly pain. It may be sharp on one side
at first and then spread through your belly. It
may be worse when you move or strain.
Vaginal bleeding.
If you think you are pregnant and you have these
symptoms, see your doctor right away.
How is an ectopic
pregnancy diagnosed?
A urine test can show if you are pregnant. To find
out if you have an ectopic pregnancy, your doctor
will likely do:
A pelvic exam to check the size of your
uterus and feel for growths or tenderness in
your belly.
A blood test that checks the level of the
pregnancy hormone (hCG). This test is
repeated two days later. During early
pregnancy, the level of this hormone doubles
every two days. Low levels suggest a problem,
such as ectopic pregnancy.
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An ultrasound. This test can show

pictures of what is inside your belly. With
ultrasound, a doctor can usually see a
pregnancy in the uterus six weeks after
your last menstrual period.
How is it treated?
The most common treatments are medicine
and surgery. In most cases, a doctor will treat
an ectopic pregnancy right away to prevent
harm to you.
Medicine can be used if the pregnancy is found
early, before the tube is damaged. In most
cases, one or more shots of a medicine called
methotrexate will end the pregnancy. Taking the
shot lets you avoid surgery, but it can cause side
effects. You will need to see your doctor for followup blood tests to make sure the shot worked.
For some patients who are not candidates for
treatment with medication, surgery is safer and
more likely to work. If possible, the surgery will be
laparoscopy. This type of surgery is done through
one or more small cuts (incisions) in your belly.
If you need emergency surgery, you may have a
larger incision.
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What can i expect after an

ectopic pregnancy?
Losing a pregnancy is always hard, no matter how
early it happens. Take time to grieve your loss,
and get the support you need to make it through
this time.
You could be at risk for depression after an
ectopic pregnancy. If you have symptoms of
depression that last for more than a couple of
weeks, be sure to tell your doctor so you can get
the help you need.
It is common to worry about your fertility after an
ectopic pregnancy. Having an ectopic pregnancy
does not mean that you cant have a normal
pregnancy in the future. But it does mean that:
You may have trouble getting pregnant.
You are more likely to have another
ectopic pregnancy.
If you get pregnant again, be sure your doctor
knows that you had an ectopic pregnancy before.
Regular testing in the first weeks of pregnancy
can find a problem early or let you know that the
pregnancy is normal.
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Fifth disease
Commonly referred to as slapped cheek
disease because of the rash some people get
on their face, 30 to 60 percent of all adults
are already immune to fifth disease. It is more
common for children to contract this virus.
The disease is spread by coughing and sneezing.
As a rule, people can spread fifth disease only
while they have flu-like symptoms and before they
get a rash. Some people who have fifth disease,
such as those who have certain blood disorders or
weak immune systems, may be able to spread the
disease for a longer time.
For women who have not previously had fifth
disease, contracting the illness during pregnancy
can increase the risk for certain complications. If
you are pregnant and have been exposed to the
illness, contact your health professional right away.
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A very small number of pregnant women who get

fifth disease will have a miscarriage.
In extremely rare cases, the infection can cause a
condition called fetal hydrops, in which the fetus
develops life-threatening anemia and severe
swelling throughout the body. The mother and
fetus should be closely monitored with fetal
ultrasounds to detect this condition.
When fetal hydrops is detected, the fetus may
be treated with blood transfusions while in the
uterus, although this is not usually necessary.
Some babies born to mothers who were infected
with fifth disease during pregnancy may also be
treated with blood transfusions.
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Genital herpes
Genital herpes is a viral infection caused by
the herpes simplex virus (HSV). It is a sexually
transmitted infection that may cause skin blisters
and sores in the genital area but often causes no
visible symptoms.
It is possible to get genital herpes through sexual
contact with an infected person even if he or
she has no symptoms. After a person is infected
for the first time, HSV stays in the body for life.
Some people may have only a single outbreak
of herpes. Other people will have repeated
outbreaks. Medicine can reduce the number and
severity of herpes outbreaks. But it cannot cure
the infection.
Acyclovir, famciclovir, and valacyclovir are antiviral
medicines used to treat genital herpes. All are
effective, but because valacyclovir and famciclovir
are absorbed better by the stomach, they can be
taken less often than acyclovir.
Antiviral medicines are usually taken by mouth, but
they are sometimes given intravenously in severe
genital herpes outbreaks or herpes in newborns.
The cream (topical) form of acyclovir (Zovirax
ointment) offers little benefit in the treatment of
genital herpes and is not recommended.
Treatment during pregnancy

The Centers for Disease Control and Prevention
has published guidelines about the use of antiviral
medicines in pregnancy:
Oral acyclovir may be given to pregnant
women for a primary HSV infection or for
severe recurrent outbreaks.
Oral acyclovir may be given to pregnant
women at any time during pregnancy,
including the first trimester.
Acyclovir may be given intravenously to
pregnant women with severe HSV infection.
Acyclovir may decrease the frequency of
recurrent outbreaks in pregnant women close
to delivery, thereby reducing the possibility
of needing a cesarean section at the time
of delivery.
If a genital herpes blister or sore is present
at the time of labor and delivery, a cesarean
section is usually done. A cesarean section may
be recommended if a woman suspects she has
symptoms of an impending outbreak, such as
tingling or pain (prodromal symptoms). For women
who have recurrent outbreaks, acyclovir used in the
last four weeks of pregnancy may reduce the need
for a cesarean section by reducing the risk of an
outbreak at the time of delivery.
People with human immunodeficiency virus (HIV)
should talk with their doctors for advice about
these medicines. Depending on the stage of their
illness, they may need higher doses or longer
treatment time with antiviral medicines.
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High-risk pregnancy
Your pregnancy is considered high risk if you or
your baby has an increased chance of a health
problem. Many things can put you at high risk. It
may sound scary, but its just a way for doctors to
make sure that you get special attention during
your pregnancy. Your doctor will watch you closely
during your pregnancy to find any problems early.
You had a problem in a past pregnancy,

such as:
The conditions listed below put you and your

baby at a higher risk for problems, such as slowed
growth for the baby, preterm labor, preeclampsia,
and problems with the placenta. But its important
to remember that being at high risk doesnt mean
that you or your baby will have problems.
You have an infection, such as HIV or hepatitis

C. Other infections that can cause a problem
include cytomegalovirus (CMV), chickenpox,
rubella, toxoplasmosis, and syphilis.
In general, your pregnancy may be high risk if:

You have a health problem, such as:
o Diabetes.
o Cancer.
o High blood pressure.
o Kidney disease.
o Epilepsy.
You use alcohol or illegal drugs, or you smoke.
You are younger than 17 or older than 35.
You are pregnant with more than one baby
(multiple pregnancy).
You have had three or more miscarriages.
Your baby has been found to have a genetic
condition, such as Down syndrome, or a heart,
lung, or kidney problem.
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o Preterm labor.
o Preeclampsia or seizures (eclampsia).
o Having a baby with a genetic problem,
such as Down syndrome.
You are taking certain medicines, such as

lithium, phenytoin (such as Dilantin), valproic
acid (Depakene), or carbamazepine (such
as Tegretol).
Other health problems can make your pregnancy
high risk. These include heart valve problems,
sickle cell disease, asthma, lupus, and rheumatoid
arthritis. Talk to your doctor about any health
problems you have.
How will my doctor care for me

during pregnancy?
You will have more visits to the doctor than a
woman who does not have a high-risk pregnancy.
You may have more ultrasound tests to make sure
that your baby is growing well.
During your third trimester, you may have
additional fetal monitoring (a nonstress test). You
will have regular blood pressure checks, and your
urine will be tested to look for protein (a sign of
preeclampsia) and glucose (sugar, a sign of high
blood sugar).
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Tests for genetic or other problems also may be

done, especially if you are 35 or older or if you
had a genetic problem in a past pregnancy.
Your doctor will prescribe any medicine you
may need, such as for diabetes, asthma, or high
blood pressure.
Talk to your doctor about where he or she
would like you to give birth. Your doctor may
want you to have your baby in a hospital that
offers special care for women and babies who
may have complications.
If your doctor thinks that your health or your
babys health is at risk, you may need to have
the baby early, or you may be hospitalized for
evaluation or treatment.
What type of doctor will I see for

a high-risk pregnancy?
Some women will see a doctor who has
extra training in high-risk pregnancies. These
doctors are called maternal-fetal specialists, or
perinatologists. You may see this doctor and your
regular doctor. Or the specialist may be your
doctor throughout your pregnancy.
What can i do to help have

a healthy pregnancy?
To help yourself and your baby be as healthy
as possible:
Go to all your doctor visits so that you dont
miss tests to catch any new problems.
Eat a healthy diet that includes protein, milk
and milk products, fruits, and vegetables. Talk
to your doctor about any changes you may
need in your diet.
Take any medicines, iron, or vitamins that your
doctor prescribes. Dont take any vitamins
or medicines (including over-the-counter
medicines) without talking to your doctor first.
Take folic acid daily. Experts recommend that
you take 0.4 to 0.8 milligrams (400 to 800
micrograms) of folic acid every day. Folic acid is
a B vitamin. Taking folic acid before and during
early pregnancy reduces your chance of having
a baby with a neural tube defect or other birth
defects. It also helps prevent anemia.
Follow your doctors instructions for activity.
Your doctor will let you know if you can work
and exercise.
Do not smoke. If you need help quitting,
talk to your doctor about stop-smoking
programs and medicines. Avoid other
peoples tobacco smoke.
Do not drink alcohol.
Stay away from people who have colds and
other infections.
Your doctor may ask you to keep track of how
much your baby moves every day. One way to
do this is to note how much time it takes to feel
10 movements.
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High-risk pregnancy
What symptoms should i
watch for?
You have a sudden release of fluid from

your vagina.
Like any pregnant woman, you need to watch for

any signs of problems. This doesnt mean that you
will have any problems. But if you have any of these
symptoms, its important to get care quickly.
You have low back pain or pelvic pressure that

does not go away.
You notice that your baby has stopped moving
or is moving much less than normal.
Call 911 or other emergency services right

away if you think you need emergency care.
For example, call if you:
tests to evaluate fetal health
Have passed out (lost consciousness).

Have severe vaginal bleeding.
Have severe pain in your belly or pelvis.
Have had fluid gushing or leaking from your
vagina and you know or think the umbilical
cord is bulging into your vagina. If this
happens, immediately get down on your
knees so your rear end is higher than your
head. This will decrease the pressure on the
cord until help arrives.
Call your doctor now or seek medical care right
away if:
You have signs of preeclampsia, such as:
o Sudden swelling of your face, hands,
or feet.
o New vision problems (such as dimness
or blurring).
o A severe headache.
You have any vaginal bleeding.
There are many ways to evaluate the health and

well-being of a fetus throughout pregnancy.
If you have a pregnancy that is at higher risk
for complications, certain tests can be done
to check your baby. These tests help to see
if your baby is receiving enough oxygen and
nourishment through the placenta (sometimes
called the afterbirth, the organ that connects
you and your baby). You may be tested to see if
you are having contractions. This is usually done
during the last three months of pregnancy.
Three tests are commonly offered in late
pregnancy if you have a high-risk pregnancy:
Nonstress test.
Contraction stress test.
Biophysical profile.
If you have a high-risk pregnancy, talk with your
doctor or other medical professional about any
prenatal tests you will be given. Testing is also
done in low-risk pregnancies if your babys activity
suddenly decreases. If you notice this occurring,
you should call Labor & Delivery right away.
You have belly pain or cramping.

You have a fever.
You have four to six contractions (with or
without pain) for an hour.
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Nonstress test
A nonstress test (NST) checks your babys heart
rate in response to his/her movements. An NST
takes about 15 to 45 minutes. You dont need to
do anything special to prepare for it.
A device that monitors your baby is attached
by a belt to your abdomen. Another monitoring
device is attached to your abdomen to see if
you are having any uterine contractions. Neither
device poses any risk to you or your baby. Babies
are usually active, and as your baby moves,
the monitor records your babys heart rate in
response to his/her movements.
If your baby is healthy, his/her heart rate will
go up when he/she moves, and will stay steady
when resting, just as ours does. Sometimes, your
baby will not move much because he/she could
be sleeping or resting. A device that makes a
loud buzzing noise may be used to wake up your
baby. Often a brief ultrasound is done at the
same time to check the amount of amniotic fluid
(bag of waters).
Contraction stress test
A contraction stress test (CST) measures the
effect of contractions (stress) on your babys heart
rate. You do not need to do anything special to
prepare for this test.
A monitor records your babys heart rate as your

uterus contracts. If your baby is not receiving
enough oxygen, or is under stress, the heart rate
may slow down when there is a contraction. If the
heart rate stays steady with contractions (or even
goes up), that is generally a sign that your baby is
not under stress.
Biophysical profile
A biophysical profile (BPP) uses ultrasound to
evaluate your babys health. The BPP looks at
your babys breathing pattern, body movements,
muscle tone, and the amount of amniotic fluid
(bag of waters). Often, a nonstress test is
included as part of the BPP. You may have a
biophysical profile done weekly toward the end of
your pregnancy.
Test results
If one or all of these tests are normal, it is very
likely that your baby is healthy. A test may be
repeated in a few days to a week, depending on
risk factors. If the test results are worrisome, your
doctor or other medical professional will talk to
you about what to do next. Additional tests may
be ordered. In some cases, your doctor or other
medical professional may determine that inducing
or starting labor and delivering your baby is the
safest plan.
As with a nonstress test, two monitoring devices

are attached to your abdomen. One measures
your babys heart rate and the other records
uterine contractions. Then, a low dose of a
medicine called Pitocin may be given to you
through a vein to cause your uterus to contract.
Sometimes stimulation of the nipples may be
used to cause uterine contractions.
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Iron deficiency
anemia
What is iron deficiency anemia?
Iron deficiency anemia occurs when your body

doesnt have enough iron.
You may not notice the symptoms of anemia,

because it develops slowly and the symptoms
may be mild. In fact, you may not notice them
until your anemia gets worse. As anemia gets
worse, you may:
Iron is important because it helps you get enough

oxygen throughout your body. Your body uses
iron to make hemoglobin. Hemoglobin is a part of
your red blood cells. Hemoglobin carries oxygen
through your body. If you do not have enough
iron, your body makes fewer and smaller red
blood cells. Then your body has less hemoglobin,
and you cannot get enough oxygen.
Feel weak and tire out more easily.

Feel dizzy.
Be grumpy or cranky.
Have headaches.
Look very pale.
What causes iron

deficiency anemia?
Feel short of breath.
Iron deficiency anemia is caused by low levels of

iron in the body. You might have low iron levels
because you:
Babies and small children who have anemia may:
Have heavy menstrual bleeding.

Are not getting enough iron in food.
Have bleeding inside your body. This bleeding
may be caused by problems such as ulcers,
hemorrhoids, or cancer. This bleeding can
also happen with regular aspirin use. Bleeding
inside the body is the most common cause of
iron deficiency anemia in men and in women
after menopause.
Have trouble concentrating.
Be fussy.
Have a short attention span.
Grow more slowly than normal.
Develop skills, such as walking and talking,
later than normal.
Anemia in children must be treated so
that mental and behavior problems do not
last long.
Cannot absorb iron well in your body. This

problem may occur if you have celiac disease
or if you have had part of your stomach or
small intestine removed.
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How is iron deficiency

anemia diagnosed?
If you think you have anemia, see your doctor.
Your doctor will do a physical exam and ask you
questions about your medical history and your
symptoms. Your doctor will take some of your
blood to run tests. These tests may include a
complete blood count to look at your red blood
cells and an iron test that shows how much iron is
in your blood.
Your doctor may also do tests to find out what is
causing your anemia.
How is it treated?
Your doctor will probably have you take iron
supplement pills to treat your anemia. Most
people begin to feel better after a few days of
taking iron pills. But do not stop taking the pills
even if you feel better. You will need to keep
taking the pills for several months to build up the
iron in your body.
If your doctor finds an exact cause of your anemia,
such as a bleeding ulcer, he or she will also treat
that problem.
If you think you have anemia, do not try to treat
yourself. Do not take iron pills on your own
without seeing your doctor first. If you take iron
pills without talking with your doctor first, the
pills may cause you to have too much iron in
your blood, or even iron poisoning. Your low iron
level may be caused by a serious problem, such
as a bleeding ulcer or colon cancer. These other
problems need different treatment than iron pills.
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You can get the most benefit from iron pills if you
take them with vitamin C or drink orange juice. Do
not take your iron pills with milk, caffeine, foods
with high fiber, or antacids.
Can i prevent iron

deficiency anemia?
You can prevent anemia by eating the right
amount of iron every day. Iron-rich foods include
meats, eggs, and whole-grain or iron-fortified
foods. You can also get iron from many other
foods, including peas, beans, oatmeal, prunes,
and figs. You can often absorb iron better from
food sources than from pills.
You can prevent anemia in babies and children by
feeding them enough iron. To make sure they get
enough iron:
Breastfeed your baby for at least a year or as
long as you and your child desire. Introduce
iron-enriched solid foods at 6 months of age
to complement the breast milk. Iron-fortified
cereals are a good source of iron.
After 6 months of age, give your child two to
three servings of iron-rich foods a day.
For babies who were weaned from the breast
or the bottle before 12 months of age, give
iron-fortified formula, not cows milk or goats
milk. Cow and goat milks are low in iron.
If you are pregnant, you can prevent anemia by
taking prenatal vitamins. Your doctor will give you
prenatal vitamins that include iron. Your doctor will
also test your blood to see if you are anemic. If you
are anemic, you will take a higher-dose iron pill.
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Molar pregnancy
A molar pregnancy happens when tissue that
normally becomes a fetus instead becomes a
growth, called a mole, in your uterus. Even
though it is not an embryo, a mole triggers
symptoms of pregnancy.
A molar pregnancy should be treated right away.
This will make sure that all of the mole tissue is
removed. This tissue can cause serious problems
in some women.
About 1 out of 1,000 women with early pregnancy
symptoms has a molar pregnancy. This means that
999 women out of 1,000 do not have this problem.
What causes a molar pregnancy?

Molar pregnancy is thought to be caused by a
problem with the genetic information of an egg or
sperm. There are two types of molar pregnancy:
Complete molar pregnancy. An egg with no
genetic information is fertilized by a sperm.
The sperm grows, but it can only become a
lump of tissue. It cannot become a fetus. As
this tissue grows, it looks a bit like a cluster of
grapes. This cluster of tissue is called a mole,
and it can fill the uterus.
Partial molar pregnancy. An egg is fertilized
by two sperm. The placenta grows into a
mole. Any fetal tissue that forms is likely to
have severe defects.
Sometimes a pregnancy that seems to be twins
is found to be one fetus and one mole. But this is
very rare.
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Things that may increase your risk of having a

molar pregnancy include:
Age. The risk for complete molar pregnancy
steadily increases after age 35.
A history of molar pregnancy, especially if
youve had two or more.
A history of miscarriage.
A diet low in carotene. Carotene is a form
of vitamin A. Women who dont get enough
of this vitamin have a higher rate of complete
molar pregnancy.

A molar pregnancy causes the same early
symptoms that a normal pregnancy does, such as
a missed period or morning sickness. But a molar
pregnancy usually causes other symptoms too.
These may include:
Bleeding from the vagina.
A uterus that is larger than normal.
Severe nausea and vomiting.
Signs of hyperthyroidism. These include
feeling nervous or tired, having a fast or
irregular heartbeat, and sweating a lot.
An uncomfortable feeling in the pelvis.
Vaginal discharge of tissue that is
shaped like grapes. This is usually a sign
of molar pregnancy.
Most of these symptoms can also occur with
a normal pregnancy, a multiple pregnancy, or
a miscarriage.
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How is a molar
pregnancy diagnosed?
Your doctor can confirm a molar pregnancy with:
A pelvic exam.
A blood test to measure your pregnancy
hormones.
A pelvic ultrasound.
Your doctor can also find a molar pregnancy
during a routine ultrasound in early pregnancy.
Partial molar pregnancies are often found when a
woman is treated for an incomplete miscarriage.
What are the risks of having a

molar pregnancy?
A molar pregnancy can cause heavy bleeding
from the uterus.
Some molar pregnancies lead to gestational
trophoblastic disease, a growth of abnormal
tissue inside the uterus during pregnancy.
Trophoblastic disease can prevent the normal
growth of a fetus.
The abnormal tissue can continue to grow after
a miscarriage.
Sometimes this disease keeps growing after the
mole is removed.
Complete molar pregnancies: Out of
1,000 cases of complete molar pregnancy,
150 to 200 develop trophoblastic disease that
keeps growing after the mole is removed. This
means that in the other 800 to 850 cases, this
doesnt happen.
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Partial molar pregnancies: Out of 1,000 cases

of partial molar pregnancy, about 50 develop
trophoblastic disease. This means that in the
other 950 cases, this doesnt happen.
In a few cases, trophoblastic disease turns into
cancer. Fortunately, almost all women who get
this cancer are cured with treatment.
In rare cases, the abnormal tissue can spread to
other parts of the body.
How is it treated?
When you have a molar pregnancy, you need
treatment right away to remove all the growth
from your uterus. Then you will have regular blood
tests to look for signs of trophoblastic disease.
These blood tests will be done over the next 6 to
12 months.
If you do get trophoblastic disease, theres a small
chance that it will turn into cancer. But your doctor
will likely find it early so it can be cured with
chemotherapy. In the rare case when the cancer
has had time to spread to other parts of the body,
additional chemotherapy is needed, sometimes
combined with radiation treatment.
Trophoblastic disease doesnt keep most women
from becoming pregnant later. However, it may be
recommended that you delay getting pregnant
again for up to one year.
After a molar pregnancy, its normal to feel very
sad and to worry about cancer. It may help to find
a local support group or talk to your friends, a
counselor, or a religious adviser.
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Multiple pregnancy
If you have two or more babies on the way,
you may have twice as many questions. Good
information is important because women who
are pregnant with more than one baby are at
higher risk of:
Preterm birth.
Low birth weight.
Preeclampsia.
Gestational diabetes.
Cesarean birth.
You will need to see your doctor more often
than women who are carrying only one baby
so that your doctor can monitor you and your
babies health. Your doctor will also tell you how
much weight to gain, if you need to take extra
vitamins, and how much activity is safe. With close
monitoring, your babies will have the best chance
of being born near term and at a healthy weight.
After delivery and once your babies come home,
you may feel overwhelmed and exhausted. Ask
for help from your partner, family, and friends.
Support groups for parents or multiples also can
ease the transition.
Types of multiple pregnancies

A multiple pregnancy means that you have two
or more babies in your uterus. These babies can
come from the same egg or from different eggs.
Babies who come from the same egg are called
identical. This happens when one egg is fertilized
by one sperm. The fertilized egg then splits into
two or more embryos. Experts think that this
happens by chance. It isnt related to your age,
race, or family history.
If the babies youre carrying are identical, they:
Are either all boys or all girls.
All have the same blood type.
Probably will have the same body type and
the same color skin, hair, and eyes. But they
wont always look exactly the same. They also
wont have the same fingerprints.
Babies who come from different eggs are called
fraternal (nonidentical). This happens when two
or more eggs are fertilized by different sperm.
Fraternal babies tend to run in families. This means
that if anyone in your family has had fraternal
babies, youre more likely to have them too.
If the babies youre carrying are fraternal, they:
Can be both boys and girls.
Can have different blood types.
May look different from each other or
may look the same, as some brothers and
sisters do.
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What causes a
multiple pregnancy?
What are the risks of a

multiple pregnancy?
If you take fertility drugs or have in vitro

fertilization to help you get pregnant, youre more
likely to have a multiple pregnancy.
Any pregnancy has risks. But the chance of having

serious problems increases with each baby you
carry at the same time.
Fertility drugs help your body make several eggs

at a time. This increases the chance that more
than one of your eggs will be fertilized.
If youre pregnant with more than one baby,

youre more likely to:
In vitro fertilization is the most common kind of

assisted reproductive technology used to help
women get pregnant. Several of your eggs are
mixed with sperm in a lab. When the eggs are
fertilized, theyre put back inside your uterus. The
doctor puts in several fertilized eggs to increase
your chances of having a baby. But this also makes
a multiple pregnancy more likely.
Develop gestational diabetes.
Youre also more likely to have more than one

baby at a time if:
Youre 35 or older.
Youre of African descent.
Youve had fraternal babies before.
Anyone on your mothers side of the family has
had fraternal babies.
Youve just stopped using birth control pills.
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Develop preeclampsia.
Deliver your babies too early. When babies
are born too early, their organs havent had a
chance to fully form. This can cause serious
lung, brain, heart, and eye problems.
Have a miscarriage. This means that you may
lose one or more of your babies.
Have one or more babies with a disease that
is caused by a bad gene or group of genes.
If you or anyone in your family has had a child
with a disease that is linked to a gene change,
let your doctor know.
Keep in mind that these problems may or may
not happen to you. Every day, women who are
pregnant with more than one baby have healthy
pregnancies and healthy babies.
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Multiple pregnancy
How can i tell if im carrying more
than one baby?
While you may feel like youre carrying more
than one baby, only your doctor can say for sure.
He or she will do a fetal ultrasound to find out.
This test can give your doctor a clear picture of
how many babies are in your uterus and how well
theyre doing.
If the test shows that youre carrying more than
one baby, youll need to have more ultrasounds
during your pregnancy. Your doctor will use these
tests to check for any signs of problems that your
babies may have as they grow.
What type of treatment will

i need?
If youre pregnant with more than one baby,
youll need to see your doctor more often than
you would if you were having just one baby. This
is because you and your babies have a greater
chance of developing serious health problems.
Your doctor will do a physical exam at each visit.
Its important that you go to every appointment.
Your doctor may also do a fetal ultrasound, check
your blood pressure, and test your blood and
urine for any signs of problems. Early treatment
can help you and your babies stay healthy.
im having multiples. Now what?

The thought of having more than one baby may
be scary, but it doesnt have to be. There are
some simple things you can do to keep you and
your babies healthy.
The best thing you can do is take care of yourself.
The healthier you are, the healthier your babies
will be.
While youre pregnant, be sure to:
Go to every doctors appointment.
Eat a healthy diet. Take in plenty of calories
from foods rich in folic acid, iron, and
calcium. These nutrients are essential for the
healthy growth of your babies. Breads, cereals,
meats, milk, cheeses, fruits, and vegetables
are good choices. If youre not able to eat
enough because of severe morning sickness,
call your doctor.
Dont smoke, drink alcohol, or use illegal drugs.
Avoid caffeine.
Avoid using any medicines, vitamins, or herbs
unless your doctor says its OK.
Talk to your doctor about what activities
are OK.
Get a lot of rest.
After your babies are born, you may feel
overwhelmed and tired. You may wonder how
youre going to do it all. This is normal. Most new
moms feel this way at one time or another.
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Here are some things you can do to ease

the stress:
Ask your family and friends for help.
Rest as often as you can.
Join a support group for moms with multiples.
This is a great place to share your concerns
and hear how other moms cope with the
demands of raising multiples.
If you feel sad or depressed for more than two
weeks, call your doctor.
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obesity
How does my weight affect
my pregnancy?
Should I try to lose weight

during pregnancy?
Most pregnant women have healthy babies and

that includes women who are obese. But being
very heavy does increase the chance of problems.
No. Pregnancy is not the time to lose weight. Your

baby needs you to eat a well-rounded diet. Dont
cut out food groups or go on any type of weightloss diet.
Babies born to mothers who are obese have a

higher risk of:
Birth defects, such as a heart defect or neural
tube defects.
Being too large. This can cause problems
during labor and delivery.
Mothers who are obese have a higher risk of:
Problems during pregnancy, such as
high blood pressure, gestational diabetes,
or preeclampsia.
How much weight should I gain

during pregnancy?
Your doctor will work with you to set a weight
goal thats right for you.
Although pregnant women often joke that theyre
eating for two, you dont need to eat twice as
much food. In general, pregnant women need to
eat about 300 extra calories a day. You can get this
in a sandwich or in an apple and a cup of yogurt.
Cesarean (or C-section) birth and a higher risk

of postoperative complications.
How much can i eat

during pregnancy?
Miscarriage or stillbirth.
How much you can eat depends on:
If youre not pregnant already, being obese can

make it hard to get pregnant.
How much you weigh when you get pregnant.
These are scary problems, and its common to

worry about you and your babys health. But
being obese doesnt mean that you will have
these problems. You can do a lot to improve your
chances of having a healthy pregnancy.
How much you exercise.
Work with your doctor to get the care you need.

Go to all your doctor visits, and follow your
doctors advice about what to do and what to
avoid during pregnancy.
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Your body mass index (BMI).

Like any pregnant woman, you need to eat a
variety of foods from all the food groups. You
especially need to make sure to get enough
calcium and folic acid.
You may want to work with a dietitian to help
you plan healthy meals to get the right amount
of calories.
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How will obesity affect my

prenatal care?
You will have the same number of doctor visits as a
woman of average weight, unless you start to have
problems. Then you would see your doctor more
often. But youll have the same type of tests to look
for problems and make sure your baby is healthy.
What can i do to have a

healthy pregnancy?
The best things you can do to have a healthy
pregnancy are to eat a variety of foods, get
regular exercise, avoid alcohol and smoking, and
go to your doctor visits. If you didnt exercise
much before you got pregnant, talk to your
doctor about how you can slowly get more active.
Pregnancy after bariatric surgery

Bariatric surgery (such as gastric bypass or
banding) helps people lose weight. Its only used
for people who are obese and have not been able
to lose weight with diet and exercise.
This surgery makes the stomach smaller. Some
types of surgery also change how your stomach
connects with your intestines.
How can the surgery affect

my pregnancy?
This surgery may increase your risk of having a

cesarean section. But there is some debate about
why. It may be that past C-sections increase the
risk, rather than the weight-loss surgery. Talk
with your doctor if you have concerns about your
chance of a C-section.
How will my pregnancy

be different after
weight-loss surgery?
In most ways, your prenatal care will be the
same as for other women. But there are a
few differences:
You may need to keep seeing the doctor
who did your surgery. This is to make sure that
you arent having any delayed problems from
the surgery.
A dietitian may work with you to make sure
youre getting the nutrition you need and to
help you plan meals.
You may need to take extra vitamins and
minerals. Weight-loss surgery can make it hard
for your body to absorb some nutrients, such
as folic acid, calcium, vitamin B12, and iron.
Some women may have a hard time with the idea
of gaining weight for pregnancy after losing all
that weight. Talk to your doctor if this bothers you.
Weight-loss surgery before pregnancy can:

Help you get pregnant if obesity was the
reason you had trouble getting pregnant.
Lower your chance of some pregnancy
problems. These include high blood pressure,
gestational diabetes, and preeclampsia.
Reduce how much weight you gain
during pregnancy.
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Placenta abruptio
What is placenta abruptio?
Common risk factors for placenta abruptio include:
Placenta abruptio is a problem with the placenta

during pregnancy. The placenta is a round, flat
organ that forms during pregnancy to give the
baby food and oxygen from the mother. During
a normal pregnancy, the placenta stays firmly
attached to the inside wall of the uterus until the
baby has been born. But with placenta abruptio,
the placenta breaks away, or abrupts, from the
wall of the uterus too early, before the baby is
born. This can cause:
High blood pressure (140/90 or higher). This

is the most common risk factor linked to
placenta abruptio, whether the high blood
pressure is chronic (long term) or is caused by
pregnancy (preeclampsia).
Premature birth.
Low birth weight.
Major blood loss in the mother.
Placenta abruptio can be very harmful for both
the mother and the baby. In rare cases, it can
cause death.
Placenta abruptio is also called abruptio placenta
or placental abruption. It affects about nine out
of 1,000 pregnancies. It usually occurs in the third
trimester, but it can happen at any time after the
20th week of pregnancy.
What causes placenta abruptio,

and how can i lower my risk?
Doctors arent sure what causes placenta
abruptio. But there are risk factors. If you avoid
them, you can lower your risk.
Having a placental abruption in the past.

Smoking during pregnancy.
Less common risk factors for placenta
abruptio include:
Using cocaine.
Having a scar from a past surgery or a uterine
fibroid where the placenta has attached to the
wall of the uterus.
Having an injury to the uterus. This could
happen in a car accident.
Premature rupture of membranes for 24 hours
or more, especially when there is an infection
in the uterus.
What are the common symptoms?

If you have placenta abruptio, you may notice
one or more warning signs. Call your doctor
right away if you are pregnant and have any of
these symptoms:
Light or moderate vaginal bleeding. Bleeding
caused by an abruption depends on where
the abruption is and how long it has taken for
the blood to pass.
A uterus that hurts or is sore. It might also feel
hard or rigid.
Signs of early labor. These include regular
contractions and aches or pains in your lower
back or belly.
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Call 911 or emergency services right away if

you have:
Sudden or severe pain in your belly.
Severe vaginal bleeding.
Any symptoms of shock. These include feeling
lightheaded or like you are going to faint;
feeling confused, restless or weak; feeling sick
to your stomach or vomiting; and having fast,
shallow breathing.
You cant really tell how serious an abruption is
by the amount of vaginal bleeding. There might
be a serious problem even if there is only a little
bleeding. Sometimes the blood can be trapped
between the placenta and the wall of the uterus.
In rare cases, symptoms of shock will be the only
signs that there is a problem.
How is it treated?
The kind of treatment you will have depends on:
How severe the abruption is.
How it is affecting your baby.
How close your due date is.
If you have a mild abruption, it may get better on
its own. You may just be closely watched for the
rest of your pregnancy. You may not have to stay
in the hospital.
A medium to severe abruption means that you
will likely have to stay in the hospital so that
your babys health can be watched closely. In
most cases, your baby will need to be delivered,
sometimes by emergency cesarean section.
How is placenta
abruptio diagnosed?
Your doctor will ask questions about your
symptoms and will check your babys heart rate.
You may have an ultrasound test. Your doctor
might also do a blood test to see if youre anemic
from losing blood.
If your doctor thinks that you have a placental
abruption, youll likely have to stay in the hospital
for at least a few hours. Your doctor will need
to find out how severe the abruption is, if it is
getting worse, and if it is affecting your baby.
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Placenta previa
What is placenta previa?
A history of five or more past pregnancies.
Placenta previa is a problem with the placenta

during pregnancy. The placenta is a round, flat
organ that forms during pregnancy to give the
baby food and oxygen from the mother. The
placenta forms on the inside wall of the uterus
soon after conception.
Being 35 or older.
During a normal pregnancy, the placenta is

attached higher up in the uterus, away from the
cervix. But in rare cases, the placenta forms low
in the uterus. If this happens, it may cover all or
part of the cervix. When the placenta blocks the
cervix, it is called placenta previa.
What causes placenta previa, and

how can i lower my risk?
Doctors arent sure what causes placenta previa.
But there are risk factors. Some risk factors you
can control to lower your risk. Others are things
you cant control.
Risk factors for placenta previa that you can
control include:
Smoking during pregnancy.
Using cocaine during pregnancy.
A history of placenta previa.

If your doctor finds out before your 20th week
of pregnancy that you have a placenta that is
attached low in the uterus, chances are good
that it will get better on its own. In fact, 9 out of
10 cases found before the 20th week go away
on their own by the end of the pregnancy. This is
because as the lower uterus grows, the position
of the placenta can change. So by the end of the
pregnancy, the placenta may no longer block
the cervix.

Some women with placenta previa do not have
any symptoms, but there are a few warning signs.
If you have placenta previa, you may notice one or
more symptoms. These include:
Sudden, painless vaginal bleeding that is light
to heavy. The blood is often bright red.
Symptoms of early labor, such as regular
contractions and aches or pains in your lower
back or belly.
Risk factors that you cant control include:
Call your doctor or go to the nearest emergency

room right away if you have:
Past surgeries or tests that affected the lining

of the uterus, such as uterine surgery, dilation
and curettage (D&C), or myomectomy.
Medium to severe vaginal bleeding during the

first trimester.
Past cesarean delivery (C-section).
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Any vaginal bleeding in the second or

third trimesters.
182
How is placenta previa diagnosed?

Most cases of placenta previa are found during
a routine second-trimester ultrasound. Or it may
be found when a pregnant woman has vaginal
bleeding and gets an ultrasound to find out what
is causing it. Some women find out that they have
placenta previa only when they have bleeding at
the start of labor.
What are the possible problems

from having placenta previa?
Placenta previa can cause problems for both the
mother and the baby. These include:
A condition called placenta abruptio. This
means that the placenta breaks away from
the wall of the uterus before the baby is born.
How the problem is affecting your health and

your babys health.
Severe bleeding in the mother before or during

delivery. This can be very dangerous for both
the mother and the baby. If the placenta has
attached or grown into the wall of the uterus
(known as placenta accreta, placenta increta, or
placenta percreta), the bleeding can be heavy
enough to require a hysterectomy.
How close you are to your due date.
Having to deliver the baby too early.
How is it treated?
The kind of treatment you will have depends on:
How much you are bleeding.
If you have placenta previa and arent bleeding, it

is important to avoid having sex or vaginal exams
and to avoid putting anything else in your vagina.
(But you may have a carefully done vaginal exam
at the hospital.) You should see your doctor if you
have any bleeding.
Birth defects. These occur more often in

pregnancies with placenta previa than in
pregnancies without this problem.
If you are bleeding, you may have to stay in the

hospital. When your baby is mature enough, or
if too much bleeding is putting you or your baby
in danger, your baby will be delivered. Doctors
always do a cesarean section when there is a
placenta previa. This is because the placenta can
be disturbed with a vaginal delivery, and it can
cause severe bleeding.
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Preeclampsia and
high blood pressure
What are high blood pressure
and preeclampsia?
Blood pressure is a measure of how hard your
blood pushes against the walls of your arteries.
If the force is too hard, you have high blood
pressure (also called hypertension). When
high blood pressure starts after 20 weeks of
pregnancy, it may be a sign of a very serious
problem called preeclampsia.
Blood pressure is shown as two numbers. The top
number (systolic) is the pressure when the heart
pumps blood. The bottom number (diastolic) is
the pressure when the heart relaxes and fills with
blood. Blood pressure is high if the top number is
more than 140 millimeters of mercury (mm Hg), or
if the bottom number is more than 90 mm Hg. For
example, blood pressure of 150/85 (say 150 over
85) or 140/95 is high. Or both numbers can be
high, such as 150/95.
You may have high blood pressure before you get
pregnant. Or your blood pressure may start to
go up during pregnancy. If you are being treated
with high blood pressure medications prior to
pregnancy, please discuss this in advance with an
advice nurse or clinician as soon as possible.
If you have high blood pressure during pregnancy,
you need to have checkups more often than
women who do not have this problem, and you
may need some additional lab work. There is no
way to know if you will get preeclampsia. This is
one of the reasons that you are watched closely
during your pregnancy.
High blood pressure

Normally, a womans blood pressure drops during
the second trimester. Then it returns to normal by
the end of pregnancy. But in some women, blood
pressure goes up very high in the second or third
trimester. This is sometimes called gestational
hypertension and can lead to preeclampsia. You
will need to have your blood pressure checked
often, and you may need treatment. Usually, the
problem goes away after your baby is born.
High blood pressure that started before
pregnancy usually doesnt go away after your
baby is born.
A small rise in blood pressure may not be a
problem. But your doctor will watch your pressure
to make sure it does not get too high. The doctor
also will check you for preeclampsia.
Very high blood pressure keeps your placenta
from getting enough blood and oxygen for your
baby. This could limit your babys growth or
cause the placenta to pull away too soon from
the uterus. High blood pressure also can lead to
stillbirth. High blood pressure can be treated.
Preeclampsia
Preeclampsia is a pregnancy-related problem.
The symptoms of preeclampsia include new high
blood pressure after 20 weeks of pregnancy along
with other problems, such as protein in your urine.
Preeclampsia usually goes away after you give
birth. In rare cases, blood pressure can stay high
for up to six weeks after the birth.
High blood pressure and preeclampsia are

related, but they have some differences.
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184
Preeclampsia can be deadly for the mother and

baby. It can keep the baby from getting enough
blood and oxygen. It also can harm the mothers
liver, kidneys, and brain. Women with very bad
preeclampsia can have dangerous seizures. This is
called eclampsia.
What causes preeclampsia and

high blood pressure during
pregnancy?
Experts dont know the exact cause of
preeclampsia and high blood pressure
during pregnancy. But they have some ideas
about preeclampsia:
Preeclampsia seems to start because the
placenta doesnt grow the usual network of
blood vessels deep in the wall of the uterus.
This leads to poor blood flow in the placenta.
Preeclampsia may run in families. If your
mother had preeclampsia while she was
pregnant with you, you have a higher chance
of getting it during pregnancy. You also have
a higher chance of getting it if the mother of
your babys father had preeclampsia.
Your immune system may react to the fathers
sperm, the placenta, or the baby.
Already having high blood pressure when
you get pregnant raises your chance of
getting preeclampsia.
Problems that can lead to high blood
pressure, such as obesity, polycystic ovary
syndrome, and diabetes, could raise your risk
of preeclampsia.
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High blood pressure usually doesnt cause
symptoms. But very high blood pressure
sometimes causes headaches and shortness of
breath or changes in vision.
Mild preeclampsia usually doesnt cause
symptoms, either. But preeclampsia can cause
rapid weight gain and sudden swelling of the
hands and face. Severe preeclampsia causes
symptoms of organ trouble, such as a very bad
headache and trouble seeing and breathing. It
also can cause belly pain and decreased urination.
How are high blood pressure and

preeclampsia diagnosed?
High blood pressure and preeclampsia are usually
found during a prenatal visit. This is one reason
its so important to go to all of your prenatal visits.
You need to have your blood pressure checked
often. During these visits, your blood pressure is
measured with a blood pressure cuff. A sudden
increase in blood pressure often is the first sign of
a problem.
After 20 weeks, you will have a urine test to look
for protein, a sign of preeclampsia.
If you have high blood pressure, tell your doctor
right away if you have a headache or belly pain.
These signs of preeclampsia can occur before
protein shows up in your urine.
185
Preeclampsia and
high blood pressure
How are they treated?
Your doctor may have you take medicine if he or
she thinks your blood pressure is too high.
The only cure for preeclampsia is having the
baby. You may get medicines to lower your blood
pressure and to prevent seizures. You also may
get medicine to help your babys lungs get ready
for birth. Your doctor will try to deliver your baby
when the baby has grown enough to be ready for
birth. But sometimes a baby has to be delivered
early to protect the health of the mother or the
baby. If this happens, your baby will get special
care for premature babies.
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Do preeclampsia and high blood

pressure lead to long-term high
blood pressure?
If you have high blood pressure during pregnancy
but had normal blood pressure before pregnancy,
your pressure is likely to go back to normal after
you have the baby. But if you had high blood
pressure before pregnancy, you probably will still
have it after you give birth.
186
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Preterm labor
What is preterm labor?
Causes of preterm labor include:
Preterm labor is the start of labor between 20 and

37 weeks of pregnancy. A full-term pregnancy lasts
37 to 42 weeks. In labor, the uterus contracts to
open the cervix. This is the first stage of childbirth.
The placenta separating early from the uterus.

This is called placenta abruptio.
Preterm labor is also called premature labor.
What are the risks of preterm

labor and preterm birth?
The earlier the delivery, the greater the risk of
serious problems for the baby. This is because
many of the babys organs especially the
heart and lungs are not fully grown, or
mature. Premature infants born after 32 weeks
of pregnancy tend to have less chance of
problems than those born earlier.
For infants born before 24 weeks of pregnancy,
the chances of survival are extremely slim. Many
who do survive have long-term health problems.
They may also have other problems, such as
trouble with learning and talking and with moving
their body (poor motor skills).
What causes preterm labor?

Preterm labor can be caused by a problem with
the baby, the mother, or both. Often the cause is
not known.
Preterm labor most often occurs naturally.
But sometimes a doctor uses medicine or
other methods to start labor early because of
pregnancy problems that are dangerous to the
mother or baby.
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Elevated blood pressure or preeclampsia.

Being pregnant with more than one baby, such
as twins or triplets.
An infection in the uterus that leads to the
start of labor.
Problems with the uterus or cervix.
Drug or alcohol use during pregnancy.
The amniotic fluid breaking before
contractions start.

It can be hard to tell when labor starts, especially
when it starts early. So watch for these symptoms:
Regular contractions for an hour. This means
about four or more in 20 minutes, or about
eight or more within 60 minutes, even after
you have had a glass of water and are resting.
Leaking or gushing of fluid from your vagina.
You may notice that it is pink or reddish.
Pain that feels like menstrual cramps, with or
without diarrhea.
A feeling of pressure in your pelvis or
lower belly.
A dull ache in your lower back, pelvic area,
lower belly, or thighs that does not go away.
Not feeling well, including having a fever you
cant explain and being overly tired. Your belly
may hurt when you press on it.
188
If your contractions stop, they may have

been Braxton Hicks contractions. These are
a sometimes uncomfortable, but not painful,
tightening of the uterus. They are like practice
contractions. But sometimes it can be hard to tell
the difference.
If preterm labor contractions do not stop, the
cervix begins to open (dilate) or thin (efface).
Before or after contractions begin, the amniotic
sac that holds the baby may break. This is called
a rupture of membranes. It causes a leakage or
a gush of amniotic fluid. Rupture of membranes
before contractions start is called premature
rupture of membranes, or PROM. Before
37 weeks of pregnancy, it is called preterm
premature rupture of membranes, or pPROM.
How is preterm labor diagnosed?

If you think you have symptoms of preterm labor,
call your doctor or certified nurse-midwife. He or
she can check to see if your water has broken, if
you have an infection, or if your cervix is starting
to dilate.
You may also have urine and blood tests to
check for problems that can cause preterm labor.
Checking the babys heartbeat and doing an
ultrasound can give your doctor or midwife a
good picture of how your baby is doing.
Amniotic fluid can be tested for signs that your
babys lungs have grown enough for delivery.
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You may have a painless swab test for a protein

in the vagina called fetal fibronectin. If the test
does not find the protein, then you are unlikely to
deliver soon. But the test cannot tell for certain if
you are about to have a preterm birth.
How is it treated?
If you are in preterm labor, your doctor or
certified nurse-midwife must weigh the risks
of early delivery against the risks of waiting to
deliver. Depending on your situation, your doctor
or midwife may:
Try to delay the birth with medicine. This may
or may not work.
Use antibiotics to treat or prevent infection.
If your amniotic sac has broken early, you
have a high risk of infection and must be
watched closely.
Give you steroid medicine to help prepare
your babys lungs for birth. This treatment
has some risks, but it can improve your
babys chances of surviving a premature birth
between 24 and 34 weeks of pregnancy.
Treat any other medical problems causing
trouble in pregnancy.
Allow the labor to go on because delivery is
safer for you and your baby than letting the
pregnancy go on.
189
Preterm premature
rupture of membranes
Before a baby is born, the amniotic sac breaks
open, causing amniotic fluid to gush out or, less
commonly, to slowly leak. When this happens
before contractions start, it is called premature
rupture of membranes (PROM). PROM can occur
at any time during pregnancy.
When PROM occurs before 37 completed weeks
of pregnancy, it usually leads to preterm labor. You
may hear this early PROM referred to as preterm
premature rupture of membranes, or pPROM.
PROM is often unexpected, and the cause is
often difficult to identify. Known causes of
PROM include:
Uterine infection, which is a common trigger
of pPROM.
Overstretching (distension) of the uterus and
amniotic sac. Multiple fetuses or too much
amniotic fluid (polyhydramnios) are common
causes of distension.
Trauma, as from a motor vehicle accident.
Course of pPROM
Preterm labor can begin shortly after pPROM
occurs. Sometimes, when a slow leak is present
and infection has not developed, contractions
may not start for a few days or longer. In general,
the later in a pregnancy PROM occurs, the sooner
the onset of labor.
Sometimes a leak high up in the amniotic sac may
reseal itself so that preterm labor does not start
or subsides.
In rare cases, a pregnancy can be carried to term
if pPROM occurs in the second trimester.
Treatment for pPROM

Treatment for pPROM includes antenatal
corticosteroid medicines, which are used to
speed up fetal lung maturity at or before
32 to 34 weeks of pregnancy.
Other treatments for pPROM may include:
An observation period or expectant
management.
Antibiotics, given to treat or prevent
amniotic fluid infection.
Amniocentesis, fluid collected from vaginal
pooling, which is sometimes used to check for
infection in the uterus or to see if the fetuss
lungs are mature enough for delivery.
Starting (inducing) labor with medicine if
labor does not start naturally. This is meant
to speed up delivery and reduce the risk of
infection. Labor can be induced if there is
strong evidence that the fetuss lungs are
mature enough, or if you have an infection.
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Alternative treatment for pPROM

Tocolytic medicine (medicine used to relax your
uterus) is sometimes used to delay a preterm
birth long enough for antibiotics and antenatal
corticosteroid medicine to work (24 hours) or
long enough to transport the mother to a hospital
that has a neonatal intensive care unit (NICU).
However, after amniotic membranes rupture,
tocolytic medicine is less effective in slowing or
stopping preterm labor contractions.
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191
Rh sensitization
What is Rh sensitization
during pregnancy?
If you are Rh-negative, your red blood cells do
not have a marker called Rh factor on them.
Rh-positive blood does have this marker. If your
blood mixes with Rh-positive blood, your immune
system will react to the Rh factor by making
antibodies to destroy it. This immune system
response is called Rh sensitization.
What causes Rh sensitization

during pregnancy?
Rh sensitization can occur during pregnancy if you
are Rh-negative and pregnant with a baby who
has Rh-positive blood. In most cases, your blood
will not mix with your babys blood until delivery.
It takes a while to make antibodies that can affect
the baby, so during your first pregnancy, the baby
probably would not be affected.
But if you get pregnant again with an Rh-positive
baby, the antibodies already in your blood could
attack the babys red blood cells. This can cause
the baby to have anemia, jaundice, or more
serious problems. This is called Rh disease. The
problems will tend to get worse with each Rhpositive pregnancy you have.
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During your first pregnancy, your baby could be

at risk for Rh disease if you were sensitized before
or during pregnancy. This can happen if:
You had a previous miscarriage, abortion, or
ectopic pregnancy and you did not receive Rh
immune globulin to prevent sensitization.
You had a serious injury to your belly
during pregnancy.
You had a medical test such as an
amniocentesis or chorionic villus sampling
while you were pregnant, and you did not
receive Rh immune globulin. These tests could
let your blood and your babys blood mix.
Rh sensitization is one reason its important to see
your doctor in the first trimester of pregnancy.
It doesnt cause any warning symptoms, and a
blood test is the only way to know you have it or
are at risk for it.
If you are at risk, Rh sensitization can almost
always be prevented.
If you are already sensitized, treatment can
help protect your baby.
192
Who gets Rh sensitization

during pregnancy?
If you have Rh-negative blood but are

not sensitized:
Rh sensitization during pregnancy can happen

only if a woman has Rh-negative blood and her
baby has Rh-positive blood.
The blood test may be repeated between

24 and 28 weeks of pregnancy. If the test
still shows that you are not sensitized, you
probably will not need another antibody test
until delivery. (You might need to have the
test again if you have an amniocentesis, if your
pregnancy goes beyond 40 weeks, or if you
have a problem such as placenta abruptio,
which could cause bleeding in the uterus.)
If the mother is Rh-negative and the father is

Rh-positive, there is a good chance the baby
will have Rh-positive blood. Rh sensitization
can occur.
If both parents have Rh-negative blood, the
baby will have Rh-negative blood. Since the
mothers blood and the babys blood match,
sensitization will not occur.
If you have Rh-negative blood, your doctor will
probably treat you as though the babys blood
is Rh-positive no matter what the fathers blood
type is, just to be on the safe side.
How is Rh sensitization diagnosed?

All pregnant women get a blood test at their first
prenatal visit during early pregnancy. This test will
show if you have Rh-negative blood and if you are
Rh-sensitized.
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Your baby will have a blood test at birth. If the

newborn has Rh-positive blood, you will have
an antibody test to see if you were sensitized
during late pregnancy or childbirth.
If you are Rh-sensitized, your doctor will watch
your pregnancy carefully. You may have:
Regular blood tests, to check the level of
antibodies in your blood.
Doppler ultrasound, to check blood flow to
your babys brain. This can show anemia and
how severe it is.
Amniocentesis after 15 weeks, to check your
babys blood type and Rh factor and to look
for problems.
193
Rh sensitization
How is Rh sensitization prevented?
How is it treated?
If you have Rh-negative blood but are not Rhsensitized, your doctor will give you one or more
shots of Rh immune globulin (such as RhoGAM).
This prevents Rh sensitization in about 99 out of
100 women.
If you are Rh-sensitized, you will have regular

testing to see how your baby is doing. You may
also need to see a doctor who specializes in highrisk pregnancies (a perinatologist).
You may get a shot of Rh immune globulin:

If you have a test such as an amniocentesis.
Around week 28 of your pregnancy.
After delivery if your newborn is Rh-positive.
If you have any abdominal trauma or
vaginal bleeding.
The shots only work for a short time, so you will
need to repeat this treatment each time you
get pregnant. (To prevent sensitization in future
pregnancies, Rh immune globulin is also given
when an Rh-negative woman has a miscarriage,
abortion, or ectopic pregnancy.)
The shots wont work if you are already
Rh-sensitized.
Treatment of the baby is based on how severe the

loss of red blood cells (anemia) is:
If the babys anemia is mild, you will just
have more testing than usual while you are
pregnant. The baby may not need any special
treatment after birth.
If anemia is getting worse, it may be safest to
deliver the baby early. After delivery, some
babies need a blood transfusion or treatment
for jaundice.
For severe anemia, a baby can have a blood
transfusion while still in the uterus. This can
help keep the baby healthy until he or she is
mature enough to be delivered. You will most
likely have an early C-section, and the baby
may need to have another blood transfusion
right after birth.
In the past, Rh sensitization was often deadly for
the baby. But improved testing and treatment
mean that now most babies with Rh disease
survive and do well after birth.
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195
Toxoplasmosis
What is toxoplasmosis?
Toxoplasmosis is a common infection found in

birds, animals, and people.
If you get toxoplasmosis, you may feel like you

have the flu, or you may not feel sick at all. Most
people who get the infection dont even know
that they have it. Symptoms may include:
For most people, it doesnt cause serious health

problems. But for a pregnant womans growing
baby, it can cause brain damage and vision loss.
Still, the chance of a pregnant woman getting the
infection and passing it on to her baby is low.
If youre pregnant or planning to have a baby and
are worried that you may have toxoplasmosis, ask
your doctor about getting tested. After you have
had the infection, you cant get it again or pass it
on to your baby. Youre immune.
But if you arent immune, youll want to take
special care while youre pregnant. Avoid anything
that may be infected, such as infected meat and
infected cat feces.
What causes toxoplasmosis?

A parasite causes toxoplasmosis. You can get the
infection by:
Eating infected meat that hasnt been fully
cooked or frozen.
Swollen glands.
Muscle aches.
Fatigue.
Fever.
Sore throat.
Skin rash.
How is toxoplasmosis diagnosed?

A blood test can tell whether you have or have
ever had toxoplasmosis. If youre worried about
getting the infection, ask your doctor about
having the test.
If you get the infection while youre pregnant,
youll need to have your baby tested. Your doctor
can take some fluid from the sac that surrounds
your baby and check for the infection.
Changing an infected cats litter box. Cats

infected with the parasite pass it on to others
through their feces.
Digging or gardening in sand or soil where an
infected cat has left feces.
Eating anything that has touched infected cat
feces, including fruits and vegetables that
havent been washed. You can also get the
infection by eating food that has touched
tables and counters your cat has walked on.
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196
How is it treated?
In healthy people, the infection often goes
away on its own. But babies and people whose
bodies cant fight infection well will need to
take medicine to treat the infection and prevent
serious health problems.
If you get toxoplasmosis while youre pregnant,
youll take an antibiotic to treat the infection.
This medicine may:
Keep your baby from getting the infection.
Lower your babys chance of having serious
health problems if he or she does get it.
Your baby has a better chance of being healthy at
birth if you get treatment while youre pregnant.
Most newborns who have been infected with
toxoplasmosis have no symptoms at birth. If your
baby has the infection, he or she will need to take
antibiotics for a year after birth. This lowers the
chance of having problems later on.
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How can i prevent toxoplasmosis

during pregnancy?
There are several things you can do to avoid
getting toxoplasmosis:
If you have a cat or are caring for one, ask
someone to clean or empty the litter box
while youre pregnant. Wash tables and
counters well if a cat may have walked on
them. If you have to clean the cats litter box,
wear gloves and a face mask. Be sure to wash
your hands after youre done.
If you eat meat, make sure it has been fully
cooked or frozen. Avoid dried meats, such as
beef jerky.
Avoid contact with cat feces in your garden.
If you touch soil, be sure to wear gloves and
wash your hands after youre done.
Wash fruits and vegetables before you
eat them.
Wash your hands and anything you use
to prepare raw meat, chicken, fish, fruits,
or vegetables.
197
Urinary tract
infection
What is a urinary tract infection?
Your urinary tract is the system that makes urine
and carries it out of your body. It includes your
bladder and kidneys and the tubes that connect
them. When germs get into this system, they can
cause an infection.
Most urinary tract infections are bladder
infections. A bladder infection usually is not
serious if it is treated right away. If you do not
take care of a bladder infection, it can spread to
your kidneys. A kidney infection is serious and can
cause permanent damage.
What causes urinary

tract infections?
Usually, germs get into your system through your
urethra, the tube that carries urine from your
bladder to the outside of your body. The germs
that usually cause these infections live in your large
intestine and are found in your stool. If these germs
get inside your urethra, they can travel up into your
bladder and kidneys and cause an infection.
Women tend to get more bladder infections
than men. This is probably because women have
shorter urethras, so it is easier for the germs to
move up to their bladders. Having sex can make it
easier for germs to get into your urethra.
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You may be more likely to get an infection if you

do not drink enough fluids, you have diabetes,
or you are pregnant. The chance that you will
get a bladder infection is higher if you have any
problem that blocks the flow of urine from your
bladder, such as kidney stones.
For reasons that are not well-understood, some
women get bladder infections again and again.

You may have an infection if you have any of
these symptoms:
You feel pain or burning when you urinate.
You feel like you have to urinate often, but not
much urine comes out when you do.
Your belly feels tender or heavy.
Your urine is cloudy or smells bad.
You have pain on one side of your back under
your ribs. This is where your kidneys are.
You have fever and chills.
You have nausea and vomiting.
198
Call your doctor right away if you think you have

an infection and:
Can urinary tract infections

be prevented?
You have a fever, nausea and vomiting, or pain

in one side of your back under your ribs.
You can help prevent these infections. Here are

actions that can help:
You have diabetes, kidney problems, or a weak

immune system.
Drink lots of water every day.
How are urinary tract

infections diagnosed?
Urinate often. Do not try to hold it.

Urinate right after having sex.
Your doctor will ask for a sample of your urine.

It is tested to see if it has germs that cause
bladder infections.
If you have infections often, you may need extra
testing to find out why.
How are they treated?

Antibiotics prescribed by your doctor will usually
cure a bladder infection. It may help to drink lots
of water and other fluids and to urinate often,
emptying your bladder each time.
If your doctor prescribes antibiotics, take the pills
exactly as you are told. Do not stop taking them
just because you feel better. You need to finish
taking them all so that you do not get sick again.
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2012 Kaiser Foundation Health Plan of the Northwest

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Baby on the way!

Your pregnancy and postpartum health resource guide

Finding providers and services....................... 5

Prenatal visit schedule................................... 12

Prenatal visit records..................................... 13

Classes and education...............................18

Pregnancy and childbirth classes.................. 19

Why take a childbirth class?......................... 20

Down syndrome and other

Health and wellness.................................. 34

Your health and wellness.............................. 35

Home and nursery....................................... 86

Getting ready for baby................................. 87

Medications and natural remedies............... 44

Preparing for birth..................................... 92

Managing emotions ..................................... 46

Your birth plan.............................................. 93

Body changes and discomfort..................... 48

Risks and safety........................................... 52

Preparing for labor...................................... 100

What to bring to the hospital...................... 103

When to call for help.................................... 54

Labor, delivery, and postpartum........... 104

Appendix: Navigating complications...146

Timing contractions..................................... 105

Timing contraction chart............................. 106

Bacterial vaginosis....................................... 150

Early labor.................................................... 108

Deep vein thrombosis................................. 152

Active labor: First stage...............................110

Active labor: Second stage..........................111

Third stage: After your baby is born............112

Domestic abuse........................................... 161

Postpartum recovery and coping.................114

Ectopic pregnancy (tubal pregnancy)......... 162

Infant care overview.....................................117

Genital herpes............................................. 165

Newborn appearance.................................. 124

Iron deficiency anemia................................ 170

Newborn behavior....................................... 126

Molar pregnancy......................................... 172

Baby care..................................................... 128

Multiple pregnancy..................................... 174

Feeding your baby...................................... 130

Preterm infants............................................ 136

Keep your baby healthy............................... 138

Preeclampsia and high blood pressure.......184

Keep your baby safe.................................... 140

Common newborn problems...................... 142

Preterm premature rupture of membranes.190

Your care team

Your care team

Appointments and urgent care

*The secure features of My Health

Obstetrics advice.............................. 503-571-4210

Appointment cancellations............... 503-813-2000

Mt. Talbert Medical Office

* Please register for a hospital tour by your 32nd week.

Kaiser Permanente Sunnyside Medical Center

You can find some of the following resources

The Nursing Mothers Companion.

My Baby Can Talk Sharing Signs. Baby

Connection Parenting: Parenting Through

*The secure features of My Health