Your Pregnancy Guide

Welcome to Los Olivos Women’s Medical Group. We are pleased that you have ch osen our office for your obstetric care. Our approach toward your care is to educate you and work together with you to make your pregnancy a wonderful and memorable experience. The following information is designed to help you with your pregnancy. You will be given a copy of the guide at your first obstetric visit with your physician.
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Practice Information

Appointments
You may schedule appointments before or after your office visit or by calling our office. If you have been advised about the need for an ultrasound or non-stress test, please tell the receptionist so that this can also be scheduled. Additional appointments may be scheduled as needed.
Visits are typically scheduled as follows for an uncomplicated pregnancy:
First appointment between 8 and 12 weeks
Every 4 weeks until 30 – 34 weeks
Every 2 weeks until 36 weeks
Every week until delivery

Our physicians are dedicated to their patients. Your obstetrician may be called out of the office to deliver a baby or tend to an emergency when you are in for a visit. We ask for your understanding and patience. We would be happy to offer to reschedule your appointment or you may wait for your physician to return.

Office Hours
Our office is open Monday through Friday from 8:00 am to 5:00 pm. We are located at 15151 National Avenue in Los Gatos on the corner of Carlton Avenue and National Avenue, next to the Los Gatos Surgical Center.

After Hours
For urgent concerns that cannot wait until regular office hours you may contact a Los Olivos physician by calling the answering service at (408) 554-2872. When you call, describe your problem and the physician on call will return your call as quickly as possible. Please limit your calls to true emergencies. Unblock your telephone if necessary to receive calls from private numbers. Have your pharmacy number available and please make sure that they are open. Physicians on call are sometimes in surgery or delivering a patient and may not call back immediately. If you need to go to labor and delivery or the emergency room and your call has not been returned, please do so. Do not call the emergency number for routine questions or prescription refills.

Communication
Feel free to ask questions or discuss concerns at scheduled appointments. We welcome and encourage you to call the office if you have any medical problems or additional questions. Please make non-emergency calls during office hours when your records are available. Medical assistants will convey information to and from your physician during the day. If you wish to speak with a physician, your call will be returned at the end of the day, if possible. Please always have your pharmacy phone number available.

Laboratory Testing
Los Olivos is not affiliated with any laboratory. Most patients are required by their insurance to have blood work at Quest Laboratory, Labcorp or Bioreference Laboratory. If your insurance requests that you go to a different lab, please inform your physician. It is your responsibility to determine which lab is covered by your insurance. The policy at Los Olivos is to call patients with abnormal results only. Usually, no news is good news. If you would like to hear that your results are normal, please leave a voice mail message with your doctor’s nurse. To locate your chart more readily, please spell your first and last name, indicate which doctor you see, and your date of birth. Please leave a phone number(s) where you can be reached and the best time for us to contact you. Results will not be left on an answering machine or with anyone other than you without your permission.

Childbirth Education and Hospital Tours
Sign up for a birthing class early in your pregnancy as you may not be able to take it at the time or place of your choice if you wait until the third trimester to register. Los Olivos birthing classes are designed to help both new and experienced parents prepare for childbirth. With adequate knowledge and preparation, expectant parents are encouraged to take an active role towards a healthy and fulfilling pregnancy and childbirth. A cesarean section class is also available. Classes are taught by experienced registered nurses certified in childbirth education. The instructors are committed to providing the most current pertinent and practical birth information.

Register for Los Olivos classes at 356-0431 extension 209, or by email. Good Samaritan Hospital offers childbirth education classes, breast-feeding classes, infant CPR and sibling classes. Register by calling 559-BABY. Tours of Good Samaritan Hospital labor and delivery and the mother and baby suites are included with the birthing classes or can be arranged separately by calling 559-BABY.

Anesthesia Information
Group Anesthesia Services (GAS) offers a free informational monthly meeting to discuss pain control options during labor and delivery. The discussion is led by an anesthesiologist (pain relief MD) and covers many topics including epidurals and narcotics. The meeting is the first Tuesday of every month at 7:00 pm in the Good Samaritan Hospital auditorium. Call 559-BABY for more information. An anesthesiologist is available on the labor and delivery unit for your safety at all times. This service is provided by physicians in Group Anesthesia Services. More information about the group is available at www.groupanesthesia.com.

Hospital Registration
Los Olivos Women’s Medical Group delivers babies at Good Samaritan Hospital. You will be provided with a hospital registration form during the third trimester of your pregnancy or you can download it. After completing the form, FAX it to Good Samaritan Hospital admissions at (408) 559-2675. They will need a copy of your insurance card and driver’s license with the form. The completed form can also be dropped at the admissions desk located in the lobby of Good Samaritan Hospital. You can also register online.

Cesarean Section Scheduling
If you are planning a cesarean section, they are typically scheduled in the week before your due date to avoid going into labor and to be certain the baby’s lungs are mature. A cesarean section in a high risk pregnancy may be scheduled earlier if necessary. Once you and your physician agree on a date, please contact Celeste so that the surgery can be scheduled. Please email or call her (408) 358-4835.

Billing
The global fee for a normal vaginal delivery without complications includes all routine pregnancy related office visits, vaginal delivery and the postpartum visit. The fee does not include laboratory testing, ultrasounds, or additional visits due to complications of pregnancy. These are additional services that are billed to your insurance carrier.

If you require a cesarean section, the surgeon and assistant surgeon have additional fees. Unfortunately, complications during a pregnancy or in delivery can occur. Any charges incurred for complications are not included in the fee for a normal vaginal delivery. Office visits for non-pregnancy related issues such as colds or urinary tract infections are typically not covered by your “global” fee and will be charged as a separate visit outside the global fee. Hospital visits outside of admission for delivery are billed separately as they are not included in the global fee.

Insurance and Financial Agreement
After your first obstetrical appointment, please visit our financial counselor to determine an estimate of your out-of-pocket expenses for an uncomplicated vaginal delivery or repeat cesarean section. We will make every effort to work with you and your insurance company. The counselor will contact the insurance company to determine your level of benefits. Your portion of the estimate, including the deductible, should be paid by the 26th week of your pregnancy. Pre-certification is simply a statement that the insurance carrier has been notified and believes that the admission is medically necessary. It is not a guarantee of benefits.

Please keep in mind that we have no control over hospital charges and that you will receive separate bills from the hospital, laboratory and anesthesiologist. If you have any questions regarding billing, insurance, or the financial arrangement, please email or call Celeste at (408) 358-4835.

Medication Use in Pregnancy pdf

The following medications have been taken during pregnancy and have not been shown to cause birth defects. Even so, we recommend not using any medication unless necessary. If you take a medication routinely for a medical problem and are unsure about the medication, please contact our office before discontinuing that medication. Take all medications according to the manufacturers directions listed on the bottle unless otherwise directed by your physician.
Acne medications (topicals are allowed)
Antacids (Mylanta, Maalox, Pepcid AC, Tums, Zantac)
Antibiotics (Keflex, Macrodantin, Macrobid, Amoxicillin, Penicillin, Zithromax, Clindamycin, Cipro)
Antihistamines (Allegra, Benedryl, Claritin, Chlor-Trimeton, Dimetapp, Tavist, Zyrtec)
Anti-nausea medications (Phenergan, ½ Unisom plus Vitamin B6, Reglan, Scopolamine patch, Ginger, Diclegis)
Antiviral medications (Acyclovir, Valtrex)
Blood pressure medications (Nifedipine, Aldomet, Propanolol, Labetolol)
Cold medications (Airborne, Theraflu)
Cough drops/lozenges/syrups (Cepacol, Herbal cough drops, Robitussen, Vicks)
Decongestants (Actifed, Sudafed, Entex)
Kaopectate, Gas-X
Hemorrhoids (Anusol HC, Preparation H, Tucks, Analpram)
Laxatives (Ducolax, Miralax, Milk of Magnesia)
Pain medications (Codeine, Vicodin, Demerol, Morphine)
Nasal sprays (Afrin, Beclovent, Flonase, Nasonex, Neosynephrine, Saline, Ventolin)
Pepto-Bismol
Sleeping medications (Tylenol PM, Ambien, Sominex, Unisom, Sonata)
Stool softeners (Benefiber, Colace, Citracel, Fibercon, Metamucil)
Thyroid medicine (Synthroid, Thyroxine)
Tocolytics to stop labor (Terbutaline, Ibuprofen, Nifedipine)
Tylenol
Vitamins (Vitamin C, Airborne, Vitamin B6)
Yeast medications (Monistat, Gyne-Lotrimin, Femstat, Terazol, Diflucan)

Medication you should NEVER take during pregnancy includes: Accutane, Lithium, Tetracycline, Vibramycin, Minocycline. Though Ibuprofen (NSAID – anti-inflammatory drugs) or aspirin may be prescribed by your physician for certain medical conditions during your pregnancy, we recommend against routine use without your doctors advice.

Other medications may be safe or have minimal risk but should be discussed with your physician before taking the medication. Most fall into the “unknown category”. This means that there is no documentation of their safety during pregnancy.

Teratogen (Birth defect) Information
OTIS Pregnancy Risk Information -OTIS provides accurate clinical information to patients about exposures during pregnancy and lactation. www.OTISpregnancy.org
or (800) 532-3749
National Pesticide Information Center (800) 858-7378

Frequently Asked Questions in Pregnancy pdf

What can I take for a headache? Tylenol is safe to take for a headache, fever or any general discomfort. Follow the recommended dosage on the bottle.

What can I take for a cold? Sudafed or Actifed is safe to take for a decongestant. Robitussin is safe to take for a cough. Tylenol is safe to take for fever, aches, and pains. Sore throat lozenges are safe to take for a sore throat. You may use Airborne.

What can I do if I have been exposed to chicken pox? There is no danger to your baby if you have previously had chicken pox. If you are not sure, a blood test can be done to determine if you are immune. If you are not immune, please call your physician.

What do I do if I have been exposed to Fifth’s Disease (Parvovirus B19)? It is likely that you have had the disease as a child and are therefore immune. If you are not sure, a blood test can be done to determine your immunity. It is not likely that you will contract the disease with casual contact. Good hand washing and hygiene are important to prevent infection. Please call your physician if you have been exposed. More information is available at the CDC website.

What should I do if I am exposed to Hand, Foot and Mouth Disease? HFMD is a common illness of infants and children and is characterized by fever, sores in the mouth, and a rash with blisters. It is caused by an enterovirus and does not harm a pregnant mother or the fetus. Good hygienic practices will prevent its spread.

How late in my pregnancy can I travel in an airplane? Please discuss with your doctor if you plan to travel during the third trimester, as some physicians do not allow travel after 28 weeks. You should never fly in an airplane after your 34th week of pregnancy. When traveling, it is important to drink plenty of water and to get up and walk about the cabin of the plane every hour. Please check with your insurance company to make sure you are covered outside the San Jose area should an emergency arise. Airport screening will not harm the baby.

Can I sleep on my back or abdomen? You may sleep on your back until the third trimester as long as you are comfortable. When your uterus is large enough to compress your major blood vessels causing hypotension (low blood pressure), you will become nauseous and dizzy. Placing a pillow under one hip should prevent these symptoms. You may sleep on either your left or right side. Sleeping on your abdomen does not harm the baby and can be continued as long as comfortable.

What can I do if I am constipated? Increase oral fluids, dietary fiber (fresh fruits and vegetables), and exercise (walking). You may try Citrucel, Benefiber, or Fibercon. Coffee and herbal teas can also have a laxative effect and alleviate constipation. Miralax is safe and effective. For severe constipation, Ducolax suppositories or Fleet's enema may be used.

When can I expect to feel the baby move? You can expect to begin to feel the baby move at about 20 to 22 weeks of pregnancy. You may not feel daily regular movements until 28 weeks of pregnancy.

Is it normal for my pelvis to ache? Early in pregnancy it is normal to feel cramping as the uterus grows and discomfort as the ligaments stretch. During the second trimester, it is normal to feel pains in the pelvis as the uterus grows, your skin stretches, and the baby moves around. During the third trimester, it is common to have a backache and sciatica. Sciatica causes shooting pains down the back of the leg and buttocks. Toward the end of the third trimester, ligaments in the hips and pelvis loosen causing discomfort. The baby may kick nerves on the inside of the uterus causing shooting pains toward your upper abdomen or vagina. Areas of numbness may also occur on your abdomen. If you are concerned about preterm labor, please call your physician.

Is spotting normal in the third trimester? It is common to have spotting or bleeding during the last month of pregnancy after vaginal exams or intercourse. This is caused by hormonal changes that cause the cervix to soften. It is also common to have slight bleeding in early labor. Call the office for heavy bleeding (like a period), prolonged bleeding, or bleeding associated with pain.

I have asthma (or allergies). Can I continue my regular medications? Yes, you need to be healthy for the baby to be healthy. Use of inhalers such as Ventolin, Asthmacort, Proventil, Advair, Nasonex or Flonase will help to keep the breathing passages open. Claritan, Benadryl, Dimetapp, Zyrtec and Tavist are antihistamines in this category that can be taken safely during pregnancy.

You say I am 20 weeks pregnant. How many months is that? Obstetricians have standardized timing a pregnancy to 40 weeks. The first day of your last menstrual period is used to calculate your due date. Twenty weeks is exactly half way through your pregnancy or about 4 1/2 months along.

My dentist needs to take X-rays. Is that okay? You should continue to care for your teeth in the normal manner. If X-rays are necessary, your dentist will shield the baby. Filling cavities or taking antibiotics if prescribed by your dentist is safe and desirable as pregnancy can increase dental disease and cause preterm labor. Ampicillin is the most commonly prescribed antibiotic and is safe during pregnancy. Lidocaine for pain relief can be used as necessary.

Can I paint or remodel the baby’s room? Many paints, glues and flooring materials can release toxic chemicals long after you complete a project. Ask for VOC-free” and “water-based” materials. Let your husband or someone else do the remodeling and painting. Avoid solvents and oil based paints. Keep the room well ventilated.

My feet are swollen. Is that normal? Mild swelling of the ankles and legs is related to the normal and necessary increase in body fluids during pregnancy. To ease the discomfort, elevate your legs or lie down when you can. Wear comfortable shoes and avoid elastic-top socks or stockings. Drink at least sixty ounces glasses of fluid each day. Support hose may help ease the discomfort.

Is it okay to have my hair colored, highlighted or permed? What about artificial nails? Can I get manicures or pedicures? What about spray tanning and tooth whitening? There is no information that any of these procedures will hurt your baby. Please weigh any benefits against any unknown potential risks.

Will it hurt the baby if I don’t take prenatal vitamins? Taking prenatal vitamins with folic acid or folic acid alone during the first trimester may decrease the incidence of neural tube defects such as spina bifida. There is no data that taking vitamins after the first trimester benefits the baby.

I would like to take a hot bath. Is that okay? Studies show that hot saunas during the first trimester may cause miscarriage. There is no evidence that baths up to 100 degrees Fahrenheit cause any fetal harm.

I have a sinus infection. Can I take antibiotics? Yes, the only antibiotic that you should absolutely not take in pregnancy is tetracycline. Avoid sulfa and quinolone antibiotics like Cipro in the third trimester if possible. Zithromax is frequently prescribed during pregnancy and is safe.

Will higher elevations and altitude be harmful to the baby? No, but if you have any difficulty breathing you should return to a lower elevation. Stay hydrated.

Is it okay to have sexual intercourse during pregnancy? There is no evidence that sex causes miscarriage or premature labor in low risk pregnancies. The baby is inside the uterus surrounded by amniotic fluid and the placenta. You may be sexually active until labor starts unless your physician instructs you otherwise. Lubricants such as Astroglide or KY jelly are not harmful. A small amount of spotting during the 24 hours following intercourse is common. Do not have any sexual activity if you have a placenta previa, preterm labor or your amniotic membranes have ruptured.

It feels as if my heart is racing. Is that normal? Yes, it is common to have palpitations. Notify your physician if you have fainting spells.

What can I use to relieve the discomfort of hemorrhoids? Use Anusol HC cream or Tucks medicated pads to relieve hemorrhoidal discomfort. Increase the fluids and fiber in your diet to decrease constipation.

I have varicose veins. Is there anything I can do to alleviate the discomfort and prevent them from getting worse? Avoid long periods of standing or sitting. When sitting elevate your legs above the level of your hips. Try wearing support panty hose throughout the day. Exercise, such as walking 20 to 30 minutes daily, is also helpful. If you are experiencing uncomfortable vulvar varicosities, wearing maternity or bicycle shorts may help.

Should I get the flu shot? All women who will be pregnant during influenza season (October - May) should be vaccinated, regardless of their stage of pregnancy. The vaccine should be thimerosal (mercury) free. H1N1 vaccination is recommended and included in the flu shot.

Is it safe to exercise? Yes. In an uncomplicated pregnancy, we recommend exercise as it makes labor easier, decreases the incidence of preterm labor as well as cesarean section. If an exercise causes cramping, shortness of breath, or pain, then decrease the intensity or stop exercising and discuss with your doctor. You should be able to carry on a conversation while you exercise. It is not necessary to keep your heart rate below 140. Contact sports such as soccer, ice hockey, skiing, horseback riding, and water skiing are strongly discouraged. Scuba diving is not safe at any time during pregnancy.

When do I have to stop running or riding my bike? You can run and ride your bike as long as you are comfortable doing so. Your ligaments will become softer and stretch after 28 weeks. If you have knee pain, you should discontinue running. Your balance will change during your third trimester, which may limit your ability to run or ride. Please use common sense and stop before it becomes a problem.

I drank wine, beer or alcohol before knowing I was pregnant. Will that harm my baby? The baby has different blood circulation very early in pregnancy. A small amount of alcohol before missing a period is very unlikely to hurt the baby. After you know that you are pregnant, you should avoid all alcohol.

I have a belly piercing. What should I do? Remove the ring before it starts to stretch. If you want to replace it during the pregnancy, see www.pregnancypiercing.com.

I just had an ultrasound and they gave me a different due date. Is my baby due at a different time? If the dates are off by more than 2 weeks, the due date may be changed. The ultrasound machine does not know when you got pregnant. It is giving an estimate based on the size of the baby. If you have a large baby, it may appear that you are further along in your pregnancy. Babies can be smaller than dates and still be healthy. Your doctor will confirm your final due date.

What can I do about leg cramps? Leg cramps are common during pregnancy, especially in the second and third trimester. The cause is unknown. Stay hydrated and try stretching more. There is some evidence that a magnesium supplement may help. Increasing your calcium or potassium intake may also help. When you get a cramp, straighten your leg, and gently flex your toes back toward your shins. Try stretching and muscle massage prior to going to sleep as well.

What changes can happen to my skin in pregnancy? It is common to have more acne during pregnancy. You may also develop a “mask” of pregnancy (darkening of the skin on your face) and a black line or linea nigra on the abdomen under the umbilicus. These changes are due to the increased hormones your body is producing. Other common changes are development of skin tags and more moles. Most of the changes resolve after the pregnancy. If you are concerned about abnormal growth of any moles, please see a dermatologist.

Should I avoid deli meats and hot dogs?
The March of Dimes website lists recommendations for food borne risks in pregnancy.

The FDA Food At-A-Glace
Recommendations for prevention of listeria include:
1. Do not eat hot dogs and luncheon meats — unless they are reheated until steaming hot.
2. Do not eat soft cheese, such as Feta, Brie, Camembert,“blue-veined cheeses,” “queso blanco,” “queso fresco,” and Panela — unless they’re labeled as made with pasteurized milk. Check the label.
Do not eat refrigerated pâtés or meat spreads.
3. Do not eat refrigerated smoked seafood — unless it’s in a cooked dish, such as a casserole. (Refrigerated smoked seafood such as salmon, trout, whitefish, cod, tuna, or mackerel, is most
often labeled as “nova-style,” “lox,” “kippered,” “smoked,” or “jerky.” These types of fish are found in the refrigerator section or sold at deli counters of grocery stores and delicatessens.)
4. Do not drink raw (unpasteurized) milk.

Pregnancy Information – Maternal and Fetal Changes PDF

First Trimester (before 12 weeks)

What to expect at the first doctor visit:
Please complete the genetics questionnaire and the prenatal questionnaire before your appointment and bring them with you. Download these forms or have them sent to you.

Your due date will be determined as well as an estimate of how many weeks pregnant you are. It is helpful if you know the first day of your last menstrual period (LMP) or when you ovulated. A “nine month” pregnancy lasts 40 weeks starting from the first day of your last menstrual period (LMP).

During your appointment, your questionnaires will be reviewed and your questions will be answered. If you have not had a recent examination, a physical exam with a Pap smear will be performed.

Carrier states for some genetic diseases can be diagnosed. Tests are available for cystic fibrosis (CF), spinal muscular atrophy (SMA), fragile X disease and sickle cell disease. If you or the father of the baby is of Jewish descent, you may be screened with an Ashkenazi Jewish Genetic Screening panel which includes Tay-Sachs, Canavan’s and Gaucher’s disease. If you are of African-American descent, you may be screened for the sickle cell genetic trait.

The California Prenatal Screening Program will be discussed and offered. This test is an optional screening test for Down syndrome and some other genetic conditions and is available to all age groups. Please refer to the Prenatal Patient Booklet to help you decide if you would like to choose one of the three available testing options.

We recommend that you take prenatal vitamins or folic acid (.4 mg to 1.0 mg) daily during the first 13 weeks of pregnancy. If you have a preference for a certain brand, please let the nurse know and a prescription can be called to your pharmacy. Most nonprescription (OTC or over-the-counter) vitamins have similar formulations and may be less expensive than prescription vitamins.

After meeting with the doctor, you will have an opportunity to meet with the financial counselor. She will call your insurance company to determine your level of benefits and complete a financial agreement.

Please feel free to ask any questions during any of your visits. We recommend that you write them down so that you do not forget any of your concerns and all of your questions can be answered. Between appointments you may call during office hours and leave non-urgent questions on the voice mail. Your calls will be returned by our office staff the same day in most instances.

Please sign up for birthing classes early in your pregnancy as you may not be able to take them at the time or place of your choice if you wait until the third trimester to register. Los Olivos classes are very popular and fill up quickly. Register at Los Olivos (extension 209), CBEclass@lowmg.com, or at Good Samaritan Hospital (559-BABY). Good Samaritan hospital also offers classes on breast-feeding, infant CPR and sibling classes.

First Trimester

You may be experiencing:     
Missed period      
Fatigue, sleepiness, no energy      
Heartburn, indigestion, bloating, excess gas      
Food aversions and cravings      
Emotional ambivalence, anxiety      
Headaches      
Nausea or vomiting      
Breast tenderness and enlargement      
Frequent urination

Baby changes include:
1st month (0-4 weeks)     
The fertilized egg grows rapidly      
The placenta begins to develop      
The heart and lungs begin to develop      
By the end of this month, the baby is ¼ inch long (smaller than a grain of rice)

2nd month (5-9 weeks)    
The baby's major organs and facial features begin to develop      
Fingers, toes, ears and eyes are forming      
Bones are starting to replace cartilage      
By the end of this month, the baby is about one inch long      
The heart begins to beat

3rd month (10-13 weeks)  
The baby's sexual organs develop by the end of this month      
The baby can also open and close its fists and mouth      
As this month ends, your baby is about four inches long and weighs over one ounce

Warning signs:
Please call our office immediately if you experience active bleeding, significant cramping, or trauma or injury to your abdomen.

Second Trimester (12 - 28 weeks)

16-20 weeks
During the second and subsequent visits, you will be asked to give a urine specimen which is tested for protein (screening for pregnancy-induced hypertension) and glucose (screening for gestational diabetes). Your weight and blood pressure will be recorded. We will listen for fetal heart tones and answer questions. As your pregnancy progresses, the uterine or fundal height will be checked and other tests may be ordered.

If you are participating in the California Prenatal Screening Program, a second trimester blood test should be drawn between 15 and 20 weeks of pregnancy. This screening test will give a Risk Assessment to estimate the chance of your baby having Down syndrome or Trisomy 18.

If you are under 35, schedule an ultrasound at Los Olivos between 18 and 20 weeks. The ultrasound will check the baby for size, fetal anatomy and placement of the placenta. The ultrasound creates an image of the fetus from sound waves. Our sonographers in Suite 1 and Suite 5 perform most ultrasounds. It is your decision to find out the gender of your baby. If you wish to know, please let the ultrasound technologist know. Unfortunately, there is no guarantee of the fetal sex based on the ultrasound alone (a genetic amniocentesis would be necessary).

If you are over 35, you may schedule genetic counseling and amniocentesis based on your age alone. This is performed at a Prenatal Diagnosis Center between 16 and 18 weeks. Amniocentesis is also available if your Risk Assessment is less than 1 in 1000.

If you will be 35 years or older on your due date, schedule an ultrasound at a Prenatal Diagnosis Center between 18 and 20 weeks.

Your physician will measure your fundal height (the top of your uterus) every visit after 20 weeks to ensure that your uterus is growing appropriately. The top of the uterus is at the umbilicus (belly button) at 20 weeks. Usually, the fundal height, measured in centimeters, is close to your gestational age in weeks (plus or minus 2 centimeters).

24-28 weeks
You will take a one-hour glucola test to check for gestational diabetes. Gestational diabetes occurs when your placenta makes a hormone that causes your body to become resistant to your own natural insulin. When this occurs, the level of glucose or sugar in your blood stream becomes elevated which can cause problems for your baby. If the one hour test value is above 140, you will be intructed to take a three three hour glucose tolerance test.

If you have gestational diabetes as determined by the test, you will be referred to Sweet Success Diabetes program that educates you about your diet so that your sugar levels remain normal throughout the remainder of your pregnancy.

Your blood count is repeated to check for anemia. It is very common to develop anemia in the third trimester and need iron supplements.

If your blood type is Rh negative and your partner has a Rh positive blood type, you will receive a shot of Rhogam at 28 weeks to protect your baby. This will be discussed in more detail if applicable.

If you decide to do cord blood banking, information and collection kits are available in the financial counselor’s office at Los Olivos.

The TdaP vaccine is recommended for all adults in contact with newborns and toddlers under the age of one to prevent transmission of pertussis, also known as whooping cough. It is recommended that you receive a Tdap booster during each pregnancy. The Tdap is available in the Vaccination Clinic in Suite 2 in the Los Olivos building (phone 356-9500) or at the hospital after the baby is born.

Pay your portion of the estimated delivery charges by 26 weeks.

You may be experiencing:
A linea nigra (a dark line running down your abdomen) forms
At 18-22 weeks, you will usually begin to feel "quickening" or fetal movements
Nasal congestion or nose bleeds or bleeding gums
Increased appetite
Mild swelling of hands and feet and leg cramps
Lower abdominal aches, backaches, and constipation

Baby changes include:
4th month (14-18 weeks)
The baby's heartbeat may now be audible with the use of a doppler (ultrasound)
Eyelids, eyebrows, eyelashes, nails and hair are formed
The baby is developing reflexes, such as sucking and swallowing
Tooth buds appear
The fingers and toes are well-defined
The gender is identifiable
By the end of this month the baby is about 6 inches long

5th month (19-23 weeks)
A soft, downy "lanugo" (fine hair) covers the baby's body
Hair begins to grow on its head
A protective vernix (cheese-like) coating covers the baby
The baby now weighs about one pound and measures nearly 10 inches long

6th month (24-28 weeks)
The baby's essential organs are formed
The baby weighs 1-2 pounds and is about 12 inches long
The eyes begin to open, fingerprints form
The baby grows quickly from now until birth
The organs are developing further
The baby can hiccup
The skin is wrinkled and covered with fine hair
The baby moves, kicks, sleeps and wakes
The baby can swallow and hear
The urinary system is working

Third Trimester (28 weeks - delivery)

After 28 weeks
You should be feeling the baby move daily. Start recording fetal kick counts.

Take a tour of Good Samaritan Hospital and preregister. Register online or download the form. The hospital requires a copy of your driver’s license and insurance card. You can fax the information to GSH (408) 559-2675.

Choose a pediatrician. The community is fortunate to have many excellent pediatricians. Ask your friends or your physician for recommendations. The pediatrician is the physician with whom to discuss nursing, circumcision and the baby’s health after birth. If you wish to interview pediatricians, this should be done early in the third trimester.

Your physician may check your cervix for dilation and/or softening during the last month of your pregnancy. A culture for beta-streptococcus is usually taken at 36-37 weeks of pregnancy.

You will be monitored for pre-eclampsia (Pregnancy Induced Hypertension or PIH) during the third trimester. Signs of pre-eclampsia include increased blood pressure, right upper quadrant abdominal pain, protein in your urine, severe headaches, significant swelling of your hands, feet or face.

You may be experiencing:
Abdominal pains and Braxton-Hicks contractions
Shortness of breath
Stronger fetal activity and larger movements
Difficulty sleeping
Swelling of hands and feet
Itchy abdomen and the navel sticking out
Frequent urination
Colostrum or leaking breasts
Increasing back and leg aches
Hemorrhoids and increased vaginal discharge

Baby changes include:
7th month (29-32 weeks)
This is a period of extreme growth and maturation for the baby
By the end of this month fat begins to deposit on the baby
The baby can suck its thumb, hiccup, cry, and can taste sweet or sour
The baby can respond to stimuli (pain, light and sound)
The placental functions begin to diminish
The volume of amniotic fluid lessens
Your baby is about 14 inches long

8th month (32-36 weeks)
The baby is starting to see and hear as the brain matures
Excluding the lungs, most systems are well-developed
By the end of this month, the baby is about 18 inches long and weighs about 5 pounds

9th month (37-40 weeks)
The lungs are maturing this month
The baby adds about ½ pound per week
The baby may weigh nearly 7 pounds and be about 18-20 inches
The baby kicks and stretches as the baby gets bigger and there is less room
Fine body hair disappears
Bones harden, but bones of the head are soft and flexible for delivery
The baby settles into a position for birth

Prenatal Testing

Many tests will be discussed during your pregnancy. Some tests are routine such as the first trimester panel and the Glucola test later in pregnancy. Prenatal genetic screening tests are available.
The California Prenatal Screening Program for genetic diseases including Down syndrome and Trisomy 18 will be offered. Please make sure that you read the California Prenatal Screening Program booklet.

First Trimester Tests

First Trimester panel - Blood tests include: Hepatitis B, HIV, RPR (syphilis test), Rubella (German measles), Blood type and antibody screen, CBC (complete blood count for anemia), TSH (hypothyroidism), Hemoglobin A1c and Urinalysis.

California Prenatal Screening Program – This optional screening test may include a first trimester blood test, nuchal translucency (NT) ultrasound, and a second trimester blood test to determine your Risk Assessment for some genetic conditions. Please read the California Prenatal Screening Program booklet. The first blood test is drawn between 10 weeks and 13 weeks 6 days.

Cell Free DNA testing (NIPT)- a maternal blood test that tests the baby's DNA from for Down syndrome.

Additional optional tests - Cystic fibrosis testing, Ashkenazi Jewish panel, Sickle cell anemia, Fragile X syndrome, SMA, Hemoglobin electrophoresis, Varicella (Chicken pox) and Toxoplasmosis are available and discussed in the appendix.

Second Trimester Tests

15-20 weeks - As part of the California Prenatal Screening Program, this optional blood test is drawn between 15 and 20 weeks and is used to screen for some genetic conditions (please read the California Prenatal Screening Program booklet for further details). This tests for the Quad Marker Screening (only second trimester test), Serum Integrated Screening (first and second blood test) and or Full Integrated Screening (two blood tests and NT) if you have chosen to participate in the California Prenatal Screening Program.

16-18 weeks - If you will be over 35 at delivery, have a history of a genetic condition, or Screen Positive with the California Prenatal Screening program, we recommend genetic counseling and a detailed (Level II) ultrasound at a Prenatal Diagnosis Center. Patients who screen with a risk of greater than 1/500 chance of Down syndrome or Trisomy 18 are also offered amniocentesis with a Prenatal Diagnosis Center. During genetic counseling, a detailed family history will be obtained and the risks and benefits of amniocentesis will be discussed. Obstetrix Medical Group (408) 371-7111 is the local Prenatal Diagnosis Center. If you are Screen Negative with the Preliminary Risk Assessment, as an alternative to amniocentesis you may schedule the second blood test and a detailed ultrasound at the Prenatal Diagnosis Center at 18 weeks.

24-28 weeks - The two-hour glucola test is obtained between 24 and 28 weeks of your pregnancy as a screening test for gestational diabetes. You must fast for 12 hours prior to the test and be prepared to have three blood draws over a two hour period. Gestational diabetes is defined as one abnormal value. You may take the 2 hour GTT test at any laboratory that is convenient. Both Quest and Hunter have Saturday hours. You will also have a CBC drawn to check for anemia. It is common to need iron sulfate supplementation in the third trimester and you will be notified if this is necessary for you.

For locations, call:
Quest Laboratory: (800) 377-8448. Quest requires an appointment.
Bioreference Laboratory: (800) 762-9722. The Hunter laboratory next to Los Olivos at 15195 National Blvd. Suite 205 is open on Saturdays from 8 AM to 1 PM.

Rhogam - If you are Rh negative, your partner’s blood type becomes important. If he is Rh positive, you will need Rhogam to prevent Rh incompatibility. Rhogam is administered as an injection after amniocentesis, at 28 weeks of your pregnancy and after delivery if the baby is Rh positive.

Third Trimester Tests (after 28 weeks)

Group B streptococcus culture – This is a vaginal and perineal culture that tests for bacteria and is usually performed at 36 weeks if you are planning a vaginal birth. It is not neessary if you are scheduled for a cesarean section.

Ultrasound – Routine ultrasounds are not necessary in an uncomplicated pregnancy. Your physician may recommend additional ultrasounds to check for fetal growth, amniotic fluid quantity and fetal position if there are indications of concern in these areas. It is very difficult to see anatomy in the third trimester.

Ultrasounds
Los Olivos has accreditation by the American Institute for Ultrasound in Medicine. Most patients have a screening ultrasound between 18 and 20 weeks of pregnancy. The ultrasound is an evaluation of the uterus and developing baby. Sound waves are sent from a small hand-held device, which is moved across the abdomen to show pictures of the baby. Measurements of the baby’s size will be taken and the amniotic fluid will be assessed along with the location and size of the placenta. The fetal anatomy is evaluated. Ultrasounds check for placental and fetal abnormalities but cannot detect all problems. Ultrasounds do not evaluate fetal genetic abnormalities. You will receive pictures from the ultrasound (no videotapes). If you will be 35 years or older at delivery, Screen Positive in the California Prenatal Screening program, or are high risk, your doctor may refer you to a Prenatal Diagnosis Center for a detailed ultrasound. There is enough room for two additional adults at the ultrasound appointment. Please come in one car. Children are not allowed.

California Prenatal Screening Program PDF

The California Prenatal Screening Program is a set of screening tests offered to pregnant women to screen for certain genetic defects. A screening test is a method of determining who is at risk for a condition that may warrant further diagnostic testing. This screening test is a noninvasive test and carries no risk to you or the baby. A diagnostic test can tell if the fetus actually has a specific birth defect. The California Prenatal Screening Program tests for Down syndrome, Trisomy 18, anencephaly, open spina bifida, abdominal wall defects and Smith-Lemli-Opitz Syndrome (SLOS). Three different types of Prenatal Screening Tests are available and are detailed in the Prenatal Patient Booklet provided by your physician. A glossary of terms is located in the back of this book. This screening is optional and not all couples choose to have this screening.

What are the three tests that are available?
Quad Marker Screening - The Quad Marker Screening test is a screening test for pregnant women during the second trimester (between 15 and 20 weeks) of pregnancy who choose to do only a second trimester blood test. The detection rates for this test are 80 out of 100 Down syndrome and 67 out of 100 for Trisomy 18.

Serum Integrated Screening – This is a combination of a first and a second trimester blood test that detect 85 out of 100 for Down syndrome and 79 out of 100 for Trisomy 18. This series of two blood tests does not include an ultrasound (NT).

Full Integrated Screening - This includes the Serum Integrated Screening with nuchal translucency (NT) ultrasound and detects 90 out of 100 for Down syndrome and 81 of 100 for Trisomy 18.

All three screening tests detect 97 out of 100 for anencephaly, 80 out of 100 for open spina bifida, 85 out of 100 for abdominal wall defects and 60 out of 100 for SLOS.

What is the Nuchal Translucency (NT)?
An ultrasound is performed between 11 weeks 2 days and 14 weeks at a Prenatal Diagnosis Center to measure the clear (“translucent”) space in the tissue at the back of the developing baby’s neck. This measurement assesses the baby’s risk for Down syndrome (DS) and other chromosomal abnormalities. Babies with abnormalities tend to have more fluid accumulated at the back of their necks during the first trimester, causing this clear space to be larger. Based on statistical probability, the measurements are used along with the maternal age to calculate the baby’s chances of having a chromosomal abnormality. Along with the ultrasound, an accompanying blood test increases the accuracy of the risk assessment.

What is a Preliminary Risk Assessment?
Results are delivered as a ratio to express your baby’s chances of having a chromosomal problem (based on your age, the baby’s age, and the nuchal fold measurement). For example, a patient who is 35 years of age at delivery has an average risk for a baby with a chromosomal abnormality of 1 in 178. This risk gets higher as you get older. If your baby’s nuchal fold measurement is found to be average for its gestation, the baby’s risk stays the same: 1 in 178. A thicker than average NT increases the risk for an abnormality. If the nuchal fold is thinner than average, then the baby’s risk of a chromosomal abnormality decreases.

This test does not directly test for chromosomal problems. It only gives a better indication of the baby’s statistical risk of having a problem. A normal result (sometimes called “screen negative”) is not a guarantee that your baby is normal, but it suggests that a chromosomal problem is unlikely. Nor does an abnormal result (sometimes called “screen positive”) mean that the baby has a chromosomal problem—just that it has an increased risk of one. (Even so, most “screen positive” babies still end up being normal.)

Based on the screening risk, you will decide if you want to have diagnostic testing done. Individual parents-to-be have different feelings on what is an “acceptable” risk for them. The California State test considers a risk of 1 in 200 for Down syndrome as a “negative” test. Obstetrix Medical Group offers genetic counseling and the option of a diagnostic test if the risk is greater than 1 in 500. It is your choice to have further testing or not and it is up to you to decide what your comfort level is for further testing. A detailed ultrasound can provide additional information, but definitive tests that can diagnose a chromosomal defect are chorionic villus sampling (CVS) and amniocentesis.

What does it mean that the Full Integrated Screening test is “90% accurate?
You may have read that the results of this test are 90% accurate in detecting your risk of having a baby with Down syndrome. That means that if your baby has Down syndrome, there’s a 90% chance that the test will pick that up and give a “screen positive” result that indicates further testing is recommended. It also means there is a 10% chance that the test will miss the Down syndrome and give a “screen negative” result and diagnostic testing will not be recommended. This does NOT mean that a “screen positive” baby has a 90% chance of having DS. It just means that 90% of babies who have DS will have screening results that are suspicious enough to recommend diagnostic testing. And 10% of babies who have DS will be shown to be at normal risk—that is, the results will be falsely reassuring. This screening test also has up to a 5% false positive rate. (A “false positive” result is when a test suggests there may be a problem when, in fact, there is no problem.) In this case, a 5% false positive rate means that 5% of all the babies with normal chromosomes who are tested will be “screen positive” meaning that the test will show them to be at an increased risk even though they are normal. Considering this “false positive” result, their mothers may opt for invasive diagnostic testing that they otherwise might not have done.

What are the advantages of the Full Integrated Screening?
The advantage to these screening tests is that they can give you a better estimate of your baby’s risk for chromosomal problems at an early date without subjecting you to the small risk of miscarriage from a more invasive diagnostic test like CVS. If the risk is low, you can find out as soon as possible and may be relieved. If the risk is high you can decide whether to have CVS (done between 10 and 12 weeks), or amniocentesis at about 16 weeks. These tests give a definitive answer while still early in the pregnancy. The NT is noninvasive and carries no more risk than an ordinary ultrasound. Even if you forgo diagnostic testing (CVS or amniocentesis), you can get more information about your baby’s health and development by following up with a routine second trimester ultrasound at 18 to 20 weeks that looks for “soft markers” of chromosome disorders, such as short limbs, a bright dot in the heart, bright intestines, cysts in a portion of the baby’s brain, and certain problems in the kidneys.

What’s the downside of these screening tests?
Like any screening test, they are not diagnostic—that is, they cannot tell you definitively if your baby has normal chromosomes. In some cases they will lead the patient towards additional intervention. In other cases the tests will be incorrectly reassuring. The NT does not detect neural tube defects, such as spina bifida and other anomalies that may be indicated by the Quad Marker Screening (done at 15 to 20 weeks) and the second trimester ultrasound.

What is the cost of the various components of these tests, and what if my insurance does not pay?
Because this procedure is separate and additional from your global obstetric services, it may not be a covered benefit. Because the California Prenatal Screening Program offers these tests, they are usually covered by insurance – but not always, so it is important to check with your insurance company. If you screen positive, the initial fee covers additional diagnostic testing. The nuchal translucency ultrasound for the Full Integrated Screening is not included in the California Prenatal Screening Program fee.

Non-Invasive Prenatal Testing (NIPT) pdf

NIPT is a non-invasive maternal blood test offered to test for the most common fetal chromosome abnormalities. Indications include 35 years or older at delivery, ultrasound abnormalities, positive California Prenatal Screening, and/or family history. The test is available to patients under 35 but may not be covered by insurance. This test takes maternal blood and looks for fetal DNA - it reports on Down syndrome (>99% sensitivity), Trisomy 18 (97% sensitivity) and Trisomy 13 (87% sensitivity) and fetal sex chromosomes. With the results you can find out if you are having a boy or a girl. This test does not screen for all chromosomes and is not a replacement for CVS or amniocentesis.

What is the Non-Invasive Prenatal Test and how does it differ than the California Screening Program?
This test is a new blood test conducted on the mother as early as 9 weeks. It analyzes the amount of cell-free fetal DNA picked up from the maternal blood sample. It can detect an increased amount of chromosomes 21, 13 and 18, which are associated with Trisomy 21 (Down syndrome), Trisomy 13 and Trisomy 18. It can also detect the sex chromosomes. For a woman 35 and over, the detection rates of chromosome 21, 13 and 18 abnormalities are significantly higher than the California Screening Program. It is important to remember it is still a screening test and not a diagnostic test.

Who should be tested?
This test was developed and tested for pregnant women with one or more of the following: Advanced maternal age (35 or older) Fetal ultrasound abnormality suggestive of chromosomal abnormality Positive 1st or 2nd trimester California Screening Test Personal or family history of Down syndrome.

When can I have this test?
This test can be done as early as 9 weeks gestation. Results are available in about two weeks. Genetic counseling is recommended to further discuss the risks, benefits and alternatives of the various prenatal screening methods in this group of high risk women for whom this testing may be considered.

How are the test results given?
The test results are given as positive or negative. The test has a sensitivity of 99.1% and a specificity of 99.9%. The false positive rate is 0.2% for Down syndrome and trisomy 18 and 1% for trisomy 13, both of which are lower than the California Screening Program. For this reason, CVS or amniocentesis should be considered for any positive result.

How do I interpret a positive California NT Screening test and a negative NIPT?
Multiply the result by 72. If you have a 1 in 80 risk of Trisomy 21 with the California Prenatal screening test, the new risk becomes 1 in 5760. With a risk of 1 in 80 (1.25% chance of Down syndrome), there is a 98.75% chance the baby does not have Trisomy 21. With the addition of a negative NIPT, the risk decreases to .01% chance of Down syndrome.

What if I have a positive result?
A diagnostic test (CVS or amniocentesis) is recommended to confirm this blood test.

Does the NIPT test for other conditions?
Right now, this blood test is only approved to test for Chromosome 21, 18, and 13. It also reports on the sex chromosomes and some labs are reporting on abnormalities of the sex chromosomes. This test does not detect all of the types of chromosome problems that genetic amniocentesis or CVS can detect.

Can it detect the sex of twins?
The test is not available for twin pregnancy or egg donor pregnancy.

How much does it cost?
You should check with your insurance regarding coverage prior to selecting this test. This test is a new blood test conducted on the mother. It analyzes the amount of chromosome 21 in fetal DNA picked up from the maternal blood sample. It can detect an increased amount of chromosome 21 material which is associated with trisomy 21 (Down syndrome). It is completely non-invasive as it only involves a blood sample from the mother.

Diagnostic Chromosomal Testing

Risk Table for Chromosomal Abnormalities by Maternal Age

Diagnostic Testing for Down syndrome and chromosomal abnormalities

The only way to be certain whether your baby has Down syndrome (Trisomy 21) or not is by doing an invasive diagnostic test – an amniocentesis or chorionic villus sampling (CVS). Both tests provide a sample that contains tissue that has the same genetic make-up as the baby, which allows the baby’s chromosomes to be examined. Because of the small increased risk of miscarriage associated with these two tests, they are not generally recommended unless the fetus is at increased risk. Traditionally, this is a mother over 35 years old. Many patients elect to do NIPT test as a screening test. Genetic counseling is recommended for women over 35 and those with a nuchal screen showing 1/500 chance of having a baby with Trisomy 13 or 18 or with a positive NIPT.

Amniocentesis

What is an amniocentesis?
An amniocentesis is a procedure where a small amount of amniotic fluid (fluid surrounding the developing baby) is removed from the uterus through a thin needle, using ultrasound guidance. This procedure is typically performed during 16 to 20 weeks of pregnancy. It can be done as early as 12 to 14 weeks and as late as near term. Some women say amniocentesis does not hurt, while others say they feel pressure or a cramp.

What tests can be performed on amniotic fluid specimen?
Different tests can be done on amniotic fluid; the most common tests are listed below.
Chromosome analysis to detect chromosome abnormalities such as Down syndrome or Trisomy 18.
AFP (alpha-fetoprotein) and AChE (acetylcholinesterase) measurements to detect neural tube defects such as spina bifida and anencephaly. In spina bifida there is an opening in the back or spinal cord, usually requiring multiple surgeries, and may be associated with physical disabilities. In anencephaly the brain development is incomplete, usually resulting in death.

Genetic diseases that can be diagnosed prenatally, including Cystic fibrosis, Fragile X syndrome, Hemophilia, Sickle cell disease, Thalassemia, Tay-Sachs disease, Canavan disease and Gaucher’s disease.

Who should consider having an amniocentesis?
1. Women who will be 35 years or older at the time of delivery. The risk of having a child with Down syndrome or other chromosome abnormalities increases with increasing maternal age.
2. Women with an abnormal nuchal translucency screening test.
Either parent can be a carrier of a chromosome rearrangement. Some individuals have chromosome rearrangements, in which some of the genetic materials on a chromosome may be moved from their normal location. These individuals are healthy, but they may have a child with a chromosome imbalance that can be associated with developmental and physical defects.
3. Previous child with chromosome abnormality. These couples have an increased risk of having another child with a chromosome abnormality.
4. Parents who are carriers of a prenatally diagnosable genetic disorder. These couples have an increased risk of having a child with the genetic disorder. If diagnosis for the disorder is available, amniocentesis can be performed for this purpose. Carrier screening is available for a number of disorders.
5. Women with abnormal ultrasound findings. When ultrasound examination shows abnormalities, amniocentesis for diagnostic testing of the amniotic fluid may be recommended.
6. Women with abnormal California Prenatal Screening test results. This may indicate an increased risk for chromosome abnormalities or neural tube defects.
7. Family history of neural tube defects. The risk of having a child with a neural tube defect, such as spina bifida, is increased when a close relative has the disorder.
8. Certain seizure medications may increase the risk for neural defects and amniocentesis should be considered.

Chorionic Villus Sampling (CVS)

What is a CVS?
A CVS is performed between 10 and 12 weeks and involves taking a small amount of tissue from the placenta. Although methods can vary, the procedure involves inserting a small tube called a catheter through the cervix into the uterine cavity. It may be performed after an abnormal nuchal thickness to evaluate the chromosomes of the fetus for abnormalities. CVS chromosomal results are available earlier in pregnancy than amniocentesis results. To complete the testing, AFP only and detailed ultrasound are still recommended. CVS is performed at a Prenatal Diagnosis Center.
NT screen, Amnio and CVS Scheduling at a Prenatal Diagnosis Center

What are the risks and benefits of amniocentesis and CVS?
All invasive procedures have some risks associated with them. These tests are generally recommended when the risk of having the condition is higher than the risk of the procedure. The risks associated with the procedure will be discussed with you before the procedure by the genetic counselor and the physician that performs the procedure. You will have time to have all your questions answered. Generally the risk of an amniocentesis include bleeding, fluid leakage, infection and miscarriage. The physicians at Obstetrix Medical Group estimate a 1 in 1000 risk of miscarriage from an amniocentesis.

NT scheduling and codes

This ultrasound is done at a Prenatal Diagnosis Center between 12 and 13 weeks 6 days. Call your insurance carrier to determine if NT is included in your benefits. The current procedure code for NT is 76813 (singleton) and 76814 (twins). The diagnosis code is 655.83. If you would like to schedule nuchal translucency ultrasound or CVS, you should call before 11 weeks of pregnancy.

Chromosomal testing scheduling

If you are at higher than average risk of a chromosomal abnormality, call a Prenatal Diagnosis Center to schedule your appointment for genetic counseling, CVS or amniocentesis. Amniocentesis is usually performed with a detailed ultrasound between 16 and 18 weeks of pregnancy. If you elect not to have the amniocentesis, you should still consider genetic counseling and a detailed ultrasound at 18-20 weeks. If you are undecided about testing, schedule genetic counseling during the first trimester of your pregnancy.

Prenatal Diagnostic Centers

Please check with your insurance carrier to determine which physician and facility is contracted with your insurance. We recommend the Obstetrix Medical Group at (408) 371-7111 or the Stanford perinatology department at (650) 725-7030.

Third Trimester Tests

Fetal Fibronectin
The fetal fibronectin test is used to help identify patients at risk for preterm delivery. The test is useful in ruling out preterm labor in patients between 24 and 34 weeks of pregnancy with regular uterine contractions. Although a negative test appears to be useful in ruling out imminent preterm delivery (within 2 weeks), the clinical implications of a positive result have not been fully evaluated. The test is not used as a screening test for preterm labor.

Non-stress Test (NST)
This test is based on the premise that the heart rate of a normal healthy fetus will temporarily accelerate with movement. This ability to increase heart rate is a good indicator of healthy fetal function. An electronic fetal monitor is attached to the mother’s abdomen and a report of the baby's heart rate fluctuations is produced. This test can be performed during the last 10 weeks of pregnancy, once or twice per week. It is usually performed at Los Olivos and takes approximately 30 minutes. NSTs are used in high-risk pregnancies such as those with twins, high blood pressure, diabetes, or low amniotic fluid. Your doctor will tell you if this test is necessary for your pregnancy.

Group B Streptococcus (GBS)
Group B strep is a bacteria that is naturally present in the gastrointestinal tract of 15-40% of women. If present in the vagina when the baby delivers, GBS may cause serious infections in a newborn infant. To test for GBS, a culture is obtained between 35-37 weeks of pregnancy. Please ask to know your GBS status before delivery. Patients undergoing elective cesarean section with intact membranes are automatically given prophylactic (preventive) antibiotics and no GBS testing is necessary. If your test comes back positive for GBS, you have a history of group B strep in your urine or vagina, or have had a previous baby infected with GBS, you should get antibiotics when you begin labor or your water breaks. The antibiotics are given through an intravenous line (IV). The antibiotics help during labor only — they are not given before labor because the bacteria recolonize the vagina. More detailed information about GBS can be found at http://www.cdc.gov/groupbstrep/resources/flyer-protect-baby.html

Fetal Kick Counts
Kick counts are a good way to monitor your baby's movements and should be performed daily after 28 weeks. Monitor the baby’s movements at the same time each day. Healthy babies are very active, especially after meals.

The baby normally has sleep and wake cycles or periods of activity and rest. Usually there are at least four noticeable movements or "kicks" most hours of the day. Such activity is reassuring. As the baby grows larger, you may feel fewer "big" movements. When you are busy during the day, you may not notice your baby moving as much as when you are at rest. Kick counts should be done with an empty bladder about one hour after a meal, while resting on your left side to promote circulation.

To perform kick counts, pay attention to any kick or rolling movement of the baby. If four movements occur within 60 minutes, your baby has "passed the test". The best time to do the test is after a meal, the same time each day. If by one hour you have not been aware of four movements, you may have been too busy with other activities. Repeat the test while resting on your left side. If you still have not noted four movements in the next hour, telephone the office (even on weekends and holidays). You may be requested to come into the office or to go to the hospital for further evaluation.

Download a Fetal Kick Count Form

Common Discomforts in Pregnancy PDF

Abdominal cramping - It is common to have cramping as the uterus grows. Pain can occur in the ligaments as the uterus enlarges. Braxton-Hicks are irregular uterine contractions and are common in the second and third trimester. Rx: Use a heating pad, increase fluid intake, rest and try Tylenol to help with discomfort. Call for severe pain, bleeding or regular contractions (more than 4 in one hour).

Acne - It is common for acne to occur during pregnancy due to hormonal changes. Keep your face clean and dry. Benzoyl peroxide, erythromycin and clindamycin can help with acne if prescribed by a dermatologist. Do not use Accutane or Tetracycline while pregnant.

Allergies - Hormonal changes can increase nasal sensitivity resulting in nasal stuffiness and allergies. Rx: Avoid allergens such as mold, dust and pets. Antihistamines such as Claritin or Zyrtec may help. Nasal sprays of saline may help. Prescription nasal steroids such as Flonase or Nasonex will treat allergies. A humidifier is often useful.

Backache - The increasing uterine size causes a shift in the center of gravity and posture. A hormone called relaxin causes the ligaments to soften and elongate. Rx: Practice good posture and keep core muscles strong. Bend at the knees instead of the waist when lifting. Wear low heels and avoid standing for long periods of time. A heating pad, ice or Tylenol may be helpful. Wear a support bra if needed. Try stretching, pelvic rocking, or wearing an external abdominal binder or “Belly band”. Physical therapy or a massage may also help.

Bleeding gums - The high level of estrogen increases gum sensitivity. Rx: Practice good oral hygiene. Use a soft toothbrush & floss regularly. Try warm saline mouthwashes. Increase Vitamin C intake.
Braxton-Hicks contractions - Irregular contractions of the uterus in preparation for labor. Braxton-Hicks do not usually signify labor is going to start. Rx: Rest on your left side and drink lots of fluid. Keep your bladder empty. Call if the contractions become regular (more than 4 in one hour) and intense and you are less than 34 weeks pregnant.

Breast changes - The increased hormone levels thicken the fat layer of the breast and stimulate the development of milk ducts causing breast pain. As the blood supply to the breasts increases, the blood vessels enlarge and bluish veins may appear on the breasts. The areola and nipple darken and Montgomery glands, the small pores around the areola, enlarge. Colostrum may leak during the last part of the pregnancy. Rx: Avoid caffeine, take Vitamin E 800 IU and wear a support bra.

Carpal tunnel syndrome - Fluid retention causes compression of the ulnar nerve in the wrist resulting in numbness and pain in the hands. Rx: Wear a wrist splint while sleeping. The numbness usually disappears about 6-8 weeks postpartum. Remove rings from your fingers before they become too swollen.

Constipation - Progesterone produced in pregnancy relaxes smooth muscle in the colon and decreases peristalsis resulting in constipation. Iron and calcium supplementation, decreased exercise, stress and dehydration can contribute to constipation. Rx: Drink 8 glasses of water daily, eat prunes and a high fiber diet. Increase exercise and use a stool softener such as Colace or Benefiber. Use Miralax if necessary.

Diarrhea - Caused by hormonal changes affecting intestinal motility. This frequently occurs during early labor. Rx: Drink liquids to avoid dehydration. Eat rice, bananas and toast. Avoid dairy products.

Dizziness - The enlarged uterus compresses the vena cava. Dizziness can also be caused by dehydration, nausea, vomiting and blood sugar fluctuations. It may be caused by standing or sitting in the same position for long periods of time causing blood to accumulate in the lower extremities. Rx: Lay on your side (left or right) while sleeping. Eat frequent, small meals, and stay hydrated. Do not get up from sitting too quickly or take very hot showers. Move your legs while standing in place to increase blood circulation.

Fatigue - Caused by a fall in the metabolic rate, hormone level changes and sleep disturbances. Rx: Rest or take naps frequently. Avoid exercise before bed. Avoid caffeine.

Flatulence - Increased progesterone relaxes the anal sphincter. Rx: Avoid gas-producing foods, chewing gum or drinking carbonated drinks. Try Mylicon.

Headaches - Caused by stress, increased blood volume, low blood sugar, or hormone level changes. Rx: Rest, drink fluids, and try relaxation techniques or massage. Use Tylenol.

Heartburn – Increased progesterone relaxes the lower esophageal sphincter and decreases gastric motility. Production of stomach acids increases and the baby puts upward pressure on the stomach. Rx: Avoid acidic foods such as citrus fruits, tomatoes, red peppers and chocolate. Avoid spicy foods. Eat small, frequent meals rather than large meals. Do not lie down after eating. Try Maalox or Milk of Magnesia. Elevate the head of the bed when sleeping. Pepcid and Zantac decrease stomach production of acid. Tums will neutralize the stomach acid and Reglan (prescription) may increase gastrointestinal motility.

Hemorrhoids - Straining during bowel movements and constipation can cause veins in rectum to become inflamed and swollen. Increased blood volume and pressure due to additional weight from the pregnancy can cause varicose veins in the rectal area. Rx: Eat a high fiber diet, bran, whole grains and fruit. Try frequent sitz baths, sitting on a rubber ring, Preparation H, Tucks, or Anusol HC.

Hip pain - Commonly caused by ligaments become softer and looser due to hormonal changes. Keep active by walking and stretching. A heating pad and massage may help.

Insomnia - Caused by hormonal changes and discomfort due to physical changes in pregnancy. Rx: Try a warm bath, relaxation techniques, and a body pillow. Exercise daily, avoid caffeine, and reduce noise while sleeping. Experiment with comfortable sleeping positions. Benadryl causes fatigue and is commonly used to help with insomnia.

Itching - Caused by changing hormone levels. Rx: Increase fluid consumption. An Aveeno bath and moisturizing lotion may help. Use Benadryl cream, calamine lotion or hydrocortisone cream.

Leg cramps - The uterus puts pressure on pelvic blood vessels causing decreased circulation to the lower extremity muscles. Rx: Stretch by straightening the affected leg. Flex the toes forward and away. Try leg elevation and massage. Calcium and magnesium supplements may help. A heating pad, hot water bottle or a warm bath may decrease symptoms.

Mood swings - Occur from constant fluctuation of hormone levels, fatigue and stress. Rx: Make time for yourself, rest, and exercise.

Nasal congestion - The hormone changes increase nasal mucosa sensitivity. Rapid breathing increases the dryness in the nasal passages. Rx: Use a humidifier, drink fluids, and try saline nasal sprays. (See nose bleeds)

Nausea and vomiting - This occurs from changing hormone levels, slowed peristalsis, stretching of the internal organs and the enlarging uterus putting pressure on the stomach. Rx: Avoid spicy or greasy foods. Eat small, frequent meals. Drink tea and liquids between meals. Keep crackers, popcorn, or toast at bedside. Try Vitamin B6 50-100mg with ½ a Unisom tablet. Acupressure wristbands and ginger may help. Several prescription medications are available if symptoms persist and interrupt daily life.

Nose bleeds - Caused by high estrogen levels, which increase nasal sensitivity. Rx: Sit with head tilted forward and pinch your nostrils for 10 - 15 minutes. Avoid overheated, dry air and excessive exertion. Blow your nose gently. Try sleeping with a room humidifier. Use Vaseline on the nasal passages or saline nasal spray to keep the nostrils moist. Try a nasal decongestant (pseudoephedrine) to shrink the swollen vessels.

Numb spot on the abdomen - Caused by the baby pushing on nerves to the abdomen. It is normal and no treatment is necessary.

Pain with intercourse - Occurs from pelvic and vaginal congestion, uterine enlargement and changing hormone levels. Rx: Try changing positions, more foreplay and using a lubricant.

Palpitations - Heart palpitations (pounding or rapid beats) are a normal response to the extra blood volume and are common in the first trimester. Rx:Take slow, deep breaths and reduce stress and anxiety.

Round ligament pain - The ligaments that support the enlarging uterus are stretching. Rx: Flex your knees to your abdomen. Try warm baths, a heating pad, exercise, or sleeping with a body pillow.
Shortness of breath - The enlarging uterus presses up against the diaphragm causing shortness of breath. Rx: Avoid restrictive clothing. Use pillows to elevate the back while sleeping.

Skin changes - Estrogen and progesterone hormones have melanocyte stimulating effects, causing a dark line on the abdomen (linea nigra) and a facial rash (chloasma). Rx: Avoid sun exposure and wear sunscreen. Be patient, it should resolve by 6 months after delivery.

Stretch marks - There is nothing that prevents stretch marks, although avoiding excessive weight gain in pregnancy may minimize them. The marks occur when the skin’s normal elasticity does not accommodate the growing uterus. Stretch marks can occur on the abdomen, breast, thighs and upper arms. The marks usually fade after delivery. Rx: Moisturizing lotion may help with itching or discomfort.

Swollen hands or feet - Water retention in the extremities occurs from a pressure differential between the blood vessels and the lymphatic system. It occurs more often in the third trimester and can cause discomfort and carpal tunnel syndrome. Rx: Avoid restrictive clothes and long periods of standing. Wear support hose and try elevating the legs. Increase exercise and water intake.

Urinary frequency - Caused by the heavy weight of the uterus putting pressure on the bladder. Rx: Drink fewer fluids before bed. Wear easily removable clothing and do Kegel exercises to prevent urinary leakage.

Urinary tract infection - Due to relaxation of the sphincters in the perineum and slower peristalsis in the urinary system. Rx: Drink more fluids and consider cranberry juice or cranberry tablets. Use Vitamin C tablets. After urination, wipe from front to back. Urinate after intercourse. Call the office if you suspect an infection.

Vaginal discharge - Estrogen causes increased cervical mucus formation. Rx: Wear cotton underwear and panty liners. Call if odor, persistent itch, changes in color or consistency. Avoid pantyhose, girdles, and tight pants. Over the counter yeast medications are safe if symptoms warrent treatment.

Varicosities or varicose veins - Caused by impaired circulation, pressure of the uterus on the circulatory system, and hormonal effects on veins. May be hereditary. Rx: Avoid restrictive clothing, long periods of standing, and crossing legs at the knees. Elevate legs and wear support hose. Continue exercising.

Yeast infection - Caused by a change in vaginal flora due to hormonal fluctuations and pH changes. Rx: Use good hygiene. Wear cotton underwear. Try yeast medication (available without a prescrip

Special Considerations for the Pregnant Woman

Caffeine
The March of Dimes recommends that women who are pregnant consume no more than 200 mg of caffeine per day. This is equivalent to two 8 ounce cups of coffee or four soft drinks per day. The Organization of Teratology Information Specialists www.OTISpregnancy.org states that caffeine has not been shown to cause an increased chance for birth defects. Caffeine crosses the placenta and in large quantities can affect babies in the same way as it does adults.

Alcohol
Fetal Alcohol Syndrome (FAS) is the leading known cause of mental retardation. It is preventable. Please DO NOT drink alcohol during your pregnancy or use any illicit drugs such as amphetamines, cocaine, marijuana, or hallucinogenic drugs. There is no known safe amount of alcohol use in pregnancy.

Herbal Supplements
We do not recommend any herbal supplements during pregnancy. Most have not been studied so no safety record is available. If you are taking a supplement, please bring it to your appointment and discuss its use with your physician.

DHA and Omega-3 Supplements
Docosahexaenoic acid (DHA) is an omega-3 fatty acid. It is found in cold-water fatty fish and fish oil supplements, along with eicosapentaenoic acid (EPA). Vegetarian sources of DHA come from seaweed. Because omega-3 fatty acids are needed for brain development, research is being done to see if DHA may prevent Attention Deficit Hyperactivity Disorder (ADHD) in children. At this time, there is no proven benefit for pregnant women who take fish oil supplements. Supplements can cause a prolonged bleeding time, interaction with other medications and may have side effects (loose stools, abdominal discomfort and belching). Additionally, it is recommended that pregnant women avoid eating fatty fish due to the mercury content in fish.

Smoking
Smoking while pregnant increases the incidence of low birth weight babies, placental abruption, miscarriage, and pre-term labor. It also increases your baby’s risk for future ear infections, frequent colds and SIDS. Please do not smoke during your pregnancy. Call the American Cancer Society for information on quitting (800) 662-8887.

Toxoplasmosis
Toxoplasmosis is a parasite that is sometimes found in birds. If you have a cat that catches and eats birds and uses an indoor litter box, feces from the cat may contain toxoplasmosis. This can be harmful to a developing fetus if inhaled. Please have someone else change the litter box.

Dental Exams
Local anesthesia injections are safe. Use a lead apron if X-rays are necessary. Pain medications and most antibiotics are safe (your dentist will prescribe correctly). Dentists commonly use Lidocaine and Ampicillin for dental procedures which are both safe in pregnancy.

Hot Tubs and Saunas
Studies have shown that there is an increased incidence of miscarriage if a sauna is used during the first three months of pregnancy. We recommend against using the sauna during the entire pregnancy and not using a hot tub during the first three months of pregnancy. After the first three months of pregnancy, limit the hot tub to 100 degrees temperature. The danger to the fetus appears to be from raising the mother's core body temperature. Warm baths and showers are safe throughout pregnancy.

Vaccinations
The Tdap (Tetanus, diphtheria and pertussis) vaccine is recommended for all adults in contact with newborns and toddlers under the age of one to prevent transmission of pertussis, also known as whooping cough. If you have not already received this vaccine, you may receive it during the second or third trimester of pregnancy. If you have not received it during pregnancy, the hospital will offer it after delivery. The Flu shot is recommended for all women who will be pregnant during the flu season (October - May). The H1N1 vaccine is recommended for all pregnant women. The most up-to-date information is available from the CDC. Vaccines are available in the Vaccination Clinic in Suite 2 of the Los Olivos building by appointment (408) 356-9500. Family members can also schedule appointments in the Vaccination Clinic.

Food Handling
Tips for preventing food borne illnesses can be found on the FDA website. Use the same precautions when you are pregnant that you normally use for food preparation and storage. Soft cheeses are safe as long as they are pasteurized. Deli meats should only be consumed if fresh. Cooking food destroys bacteria and parasites.

Processed Foods and Plastic Bottles
Minimize your exposure to processed foods. Ham and bacon contain sodium nitrate, which may be harmful in large quantities. Plastic bottles may contain Bisphenol A (BPA), a synthetic chemical that interferes with the body’s natural hormonal messaging system. Health advocates also recommend not reusing bottles made from plastic #1 (polyethylene terephthalate, also known as PET or PETE), including most disposable water, soda and juice bottles. Such bottles may be safe for one-time use, but reuse should be avoided because studies indicate they may leach DEHP—another probable human carcinogen—when they are in less-than-perfect condition. Use BPA free water bottles. Do not microwave food in plastic containers. Use only glass or ceramic dishes in the microwave oven.

Toxic Substance Exposures
Toxic Substances are chemicals and metals that can harm your health. Minimizing your exposure during pregnancy can protect you and your baby. Here are some tips to prevent or reduce your exposure to these substances.

1. Don’t spray bugs: Pesticides are toxic chemicals for killing insects, rodents, weeds, bacteria and mold. Keep pests out of your home by cleaning up crumbs and spills. Store food in tightly closed containers. Seal cracks around doors and windows. Repair drips and holes and get rid of standing water. Use baits and traps. Don’t use chemical tick and flea collars, flea baths or flea dips.
2. Mop more. Toxic substances like lead, pesticides and flame retardants are present in dust. Sweeping or dusting with a dry cloth can spread the dust in the air instead of removing it. Use a wet mop or wet cloth to clean floors and surfaces.
3. Take off your shoes: Shoes can carry toxic chemicals into your home. Wipe shoes on a sturdy doormat if you want to keep them on.
4. Clean your home with non-toxic products: It is cheap and easy to make effective, non-toxic cleaners. You can use common items like vinegar and baking soda.
5. Avoid dry-cleaning clothes: Most dry-cleaning systems use a chemical called perchloroethylene (PERC). Dry-cleaned clothes release PERC, polluting your home. Use water instead. Most clothes labeled “dry clean only” can be washed with water. Hand wash them yourself or ask the dry-cleaner to “wet clean” them for you.
6. Use non-toxic personal care products: Many products have ingredients that can harm reproductive health.
7. Avoid toxic substances in food and water: Eat organic food when possible to reduce your exposure to pesticides. If you don't buy organic produce, buy the fruits and vegetables with the lowest pesticide levels. Limit foods with a lot of animal fat. Many toxic substances build up in animal fat. Avoid canned foods and beverages as much as possible to avoid exposure to the BPA used in the lining of most cans.
8. Prevent exposure from work: If you are exposed to toxic substances at work, request a change in your duties. If you live with someone who works with toxic substances, that person should shower after work.

Prenatal Nutrition

Healthy Eating During Pregnancy
The following are guidelines for healthy eating in pregnancy. The United States Department of Agriculture has an excellent website for pregnancy: www.mypyramid.gov/mypyramidmoms/index.html. MyPyramid Plan for Moms will show you the foods and amounts that are right for you. Enter your information for a quick estimate of what and how much you need to eat. Go to the MyPyramid Menu Planner For Moms to see how your food choices compare to what you need.

Additional folate or folic acid (400 mcg) is important during the development of the baby’s neural tube, which occurs during the first trimester. Prenatal vitamins contain folic acid. Foods rich in folic acid include beans, lentils, peanuts, sunflower seeds, walnuts, almonds, orange juice, pineapple, cantaloupe, bananas, avocados, broccoli, asparagus, spinach, dark green lettuce and okra. Many cereals and breads may be fortified with folate. The nutrition label on the foods should list any supplements. Patients with a history of a pregnancy complicated by a neural tube defect (NTD) should take 4 mg per day.

Weight Gain During Pregnancy
Pregnant women need about 300 calories a day more than before pregnancy to support growth of the fetus. Before pregnancy, most active women need about 2,200 calories daily. Sedentary women need 1600 calories. If activity levels decline with pregnancy, fewer additional calories are needed.
Weight gain during pregnancy should be gradual with the most weight being gained in the last trimester. If you are a normal weight at the beginning of your pregnancy, you should gain about 2 to 8 pounds during the first three months of pregnancy and then 3 to 4 pounds per month for the rest of your pregnancy. Your BMI can be calculated at www.nhlbisupport.com/bmi/.

Total weight gain for women with a normal Body Mass Index (BMI) should be about 25 to 35 pounds. If you are pregnant with twins, the recommended total weight gain is 35 to 45 pounds. If you start pregnancy underweight, the recommended total weight gain is 28 to 40 pounds. If you start pregnancy overweight, the recommended total weight gain is 15 to 25 pounds.

Obese women should not gain more than 15 pounds during the pregnancy. Obesity is a risk factor for having babies with neural-tube defects and other malformations. They are twice as likely to need a cesarean section for delivery. Babies born from obese mothers are more likely to be overweight later in life.

Suggestions to Avoid Excessive Weight Gain
Do not eat for two. Your metabolism is more efficient during pregnancy and absorbs more nutrients. Eat an additional 300 calories as long as your activity level remains constant.
Limit the amount of fat (butter, mayonnaise, salad dressing, sauces) that you add to your foods.
Avoid fast food.
Drink nonfat or low-fat milk rather than whole milk.
Eat three small meals and three snacks daily at 2-3 hour intervals (graze, rather than eat large meals).
Chose fresh fruit or raw vegetables for snacks rather than sweets.
Read juice labels. Many drinks that seem to be fruit juices are really drinks that have little or no fruit juice. Since fruit-type drinks are mostly sugar, they do not count as a serving. Remember, fresh fruits and dried fruits have more fiber than fruit juice, so they are a better choice.
Incorporate more activity and exercise into your daily routine.
Drink at least 8 to 10 glasses of water per day.

Food Guide Pyramid: Daily Choices for Pregnant Women

Food Group Recommended Servings What Counts as a Serving

Daily Food Plan for Moms and Choose My Plate

Fish and Seafood

Currently the FDA suggests that pregnant women eat 8-12 ounces of fish each week. The nutritional value of fish is important during growth and development of the fetus before birth. Choose fish low in mercury including salmon, shrimp, pollock, light canned tuna, tilapia, catfish, and cod. Albacore has more mercury than light canned tuna so the limit for this fish is six ounces. The FDA has warned that some fish (shark, swordfish, king mackerel, tuna and tilefish) may contain levels of mercury that could lead to brain damage in the developing fetus and should not be consumed. Cooking fish does not decrease the mercury content. For more information on fish consumption advisories, go to the website:www.fda.gov/food/foodborneillnesscontaminants/metals/ucm393070.htm

Calcium and Iron

Dietary Sources of Calcium (PDF)

Pregnant and lactating women need 1200 mg of calcium daily. If your nutritional calcium intake is not adequate, calcium from your bones is used for the baby’s development. This puts you at risk for osteopenia (weak bones) or osteoporosis later in life. Foods are the best source of usable calcium. Food sources of calcium include milk and milk products, cheese, fish, and many vegetables. Other food sources are fortified breads and cereals. High fat dairy products should be taken sparingly. If you are unable to obtain all the necessary calcium from foods, a combination of foods and a moderate amount of supplement may be the best therapy. A list of common foods that contain calcium is available at www.lowmg.com/info/medinfo/general_health/bone_density_information/calcium_sources.pdf.

Calcium Supplements

If you don’t ingest enough calcium in your diet, calcium supplements should be considered. Calcium carbonate provides the largest percentage of usable calcium and should be taken with meals to increase absorption. Calcium absorption is dependent on an adequate level of vitamin D (1000 IU per day). Vitamin D is added to fortified milk and occurs naturally in fish and eggs. Exposure to sunlight for 10 minutes each day also creates Vitamin D in the skin. If you have a history of kidney stones or if calcium carbonate causes gas or constipation, try calcium citrate. Calcium citrate should be taken between meals for best absorption.

Dietary Sources of Iron (PDF)

Iron is a mineral that the body needs to produce red blood cells. When the body does not get enough iron, it cannot produce the number of normal red blood cells. Iron deficiency (iron shortage) is very common in pregnancy and causes anemia. The best dietary source of iron is lean red meat. Chicken, turkey, and fish are also sources of iron, but they contain less than red meat. Dried apricots, molasses, potatoes, raisins, dark leafy greens such as spinach, chard, parsley and strawberries also contain some iron.

Iron Supplements

A blood count will be drawn during your pregnancy at the first visit and again in the third trimester to determine whether you have an iron deficiency anemia. Lack of iron may lead to unusual tiredness, shortness of breath, a decrease in physical performance, and learning problems in children and adults, and may increase your chance of getting an infection. Different preparations include ferrous sulfate, ferrous gluconate or ferrous fumerate. Your body can absorb only a small amount each day, so any of these preparations is adequate for iron supplementation. Some iron preparations contain vitamin C, which increases iron absorption or a stool softener if you have problems with constipation. Nature Made (65mg of iron sulfate) or Slow FE (45 mg) can be taken up to three times daily. If you are taking more than one iron tablet per day, separate the times that you take it and do not take it with your multivitamin. Iron should not be taken with antacids. Stools may turn black in color while taking iron supplementation.

Prenatal Exercise

Exercise Guidelines for Pregnancy
(Adapted from Alton, Exercise guidelines for pregnancy and the ACOG Tech Bulletin 267 and
Exercise Guidelines During Pregnancy March 2012 Obstetrics and Gynecology)

Exercises for Pregnancy and Childbirth PDF
Knee press, abdominal strengthening exercises and pelvic rock information is available on the lowmg.com website. Pilates and prenatal yoga are helpful for maintaining strength and stability during the pregnancy. Exercise and general fitness decrease the incidence of preterm labor. The length of labor and need for pain medication are also decreased in women who exercise on a regular basis.

Benefits of Exercise During Pregnancy
Improved posture and relief of back pain
Improved circulation and flexibility
Increased energy level and less fatigue
Stronger muscles for labor with reduced need for pain medication in labor
Shorter labor
Reduced risk of preterm labor

Physiologic Changes that Occur During Pregnancy Include
Progesterone, relaxin, estrogen and cortisol soften and stretch the connective tissue resulting in laxity and instability of ligaments and joints, thus increasing the risk of musculoskeletal injury.
As the uterus and breasts enlarge, the center of gravity shifts, resulting in balance problems and increasing the risk of falling and of straining the hips and back. Blood volume expansion and increased resting cardiac output decrease the cardiac reserve during exercise. Increased resting oxygen consumption reduces availability of oxygen during aerobic exercise. The effects of progesterone on respiratory function combined with the u-ward displacement of the diaphragm by the enlarging uterus lower the threshold for hyperventilation. Dehydration and hypoglycemia occur more readily. There have been no reports that hyperthermia associated with exercise causes birth defects.

Exercise Precautions
Avoid vigorous exercise during hot, humid weather or if you have a high fever. Avoid use of a sauna, exercising while fatigued or to the point of exhaustion, exercises that strain the lower back, stress ligaments, injure knees, or promote separation of the pubic bone (symphysis pubis). Avoid holding your breath or straining. Avoid exercising while on the back in the third trimester (causes nausea, dizziness and decreased blood pressure).

Exercise Recommendations
Regular, aerobic exercise of mild-to-moderate intensity for 30 minutes daily is preferable to intermittent activity or a sudden increase in exercise level. Intensity should be light enough to allow conversation during exercise (there are no heart rate limitations). Exercise should be preceded by an extended warm-up and followed by a cool-down period and stretching. Ample fluid intake is important before, during and after exercise. Carbohydrates (milk, fruit, juice, grains) should be consumed before and after exercise to prevent hypoglycemia. Caloric intake should be adequate to support exercise and promote optimal weight gain.

Warning Signs to Stop Exercising
Stop exercising if you experience vaginal bleeding, dizziness, headache, chest pain, muscle weakness, calf pain or swelling, preterm labor, decreased fetal movement, amniotic fluid leakage
Exercises Considered Safe During Pregnancy (adapted from Cont OB/Gyn 1995:5:62-90)
Bicycling (stationary balance is difficult to maintain), bowling, dancing, golf, jogging, light weight-training, low-impact aerobics, rowing, running, swimming, tennis, walking, water aerobics

Exercises Not Considered Safe During Pregnancy (adapted from Cont OB/Gyn 1995:5:62-90)
Contact sports, marathon running, diving, downhill skiing, gymnastics, heavy weight-training, high-impact aerobics, horseback riding, ice skating, mountain climbing, racquetball, rollerblading, roller-skating, scuba diving, sky diving, surfing, water skiing

Contraindications to Exercise During Pregnancy (ACOG Tech Bulletin No. 267)
Pregnancy-induced hypertension, severe anemia, cardiac disease, cervical incompetence or cerclage, extreme underweight, hemoglobinopathies, three or more prior miscarriages, intrauterine growth retardation, severe infection, multiple gestation at risk for preterm labor, placenta previa, polyhydramnios, preterm labor, renal disease, preterm rupture of membranes, uncontrolled seizure disorder, uncontrolled diabetes, persistent second or third trimester bleeding, poorly controlled hypertension, poorly controlled hyperthyroidism.

Posture
Good posture can decrease low back and neck pain and fatigue. During pregnancy the weight of the baby causes the center of gravity to move forward. To prevent this, it is important to maintain a pelvic tilt with the pelvis tucked under the spine. It is important to maintain the “core” abdominal muscles and keep the shoulders down to prevent curvature of the spine and back pain. Since traditional crunches and abdominal work are difficult in the third trimester, consider using a yoga ball for crunches. Try doing planks focusing on the side abdominals and keeping the pelvis tilted to support the lower back. Consider wearing a maternity support belt. Avoid high heels late in pregnancy as they can cause the center of gravity to move forward. While sitting, maintain the pelvic tilt and avoid slouching. Sit with knees level to hips. During the third trimester, avoid lying flat as it can compress the vena cava (large blood vessel) and cause decreased blood pressure. This will cause nausea and dizziness in the mother and may cause distress in the baby. To avoid this, place a pillow under your hip to tilt the uterus.

Kegel Pelvic Floor Strengthening Program PDF

What are Kegel Contractions?
Kegel pelvic floor muscle exercises help women improve stress incontinence or the involuntary loss of urine with sudden increases in their abdominal pressure (i.e. sneezing, coughing, running, or exercising). The Kegel exercise is an isometric program designed to strengthen the internal pelvic muscle called the pubococcygeus muscle (the "P.C." muscle). This muscle forms the floor of the pelvis and surrounds the urethra, vagina, and anus, thereby, providing support for all the pelvic organs. It is the muscle used to stop urination, to prevent a bowel movement, or to tighten the vagina during intercourse.

The P.C. muscle contains two types of muscle fibers called "slow-twitch" muscle fibers (70%) and "fast-twitch" muscle fibers (30%). Both muscle fiber types should be exercised to improve the muscle's resting tone (slow-twitch) and its rapid reflex contraction (fast-twitch) during episodes of sudden increases in intra-abdominal pressure (i.e., a cough or sneeze). The muscle can be felt by placing your fingers one to two inches inside your vagina, tightening your PC muscle, and feeling the squeeze.
Incorporate the one-minute series of contractions as a regular part of your normal voiding routine for the rest of your life. You will significantly improve the strength of your pelvic floor muscles and improve your bladder control and vaginal tightness. During a sudden cough or sneeze, the pelvic floor muscles will contract reflexly, thereby stabilizing the position of the bladder neck and decreasing the accidental loss of urine.

How Do You Identify the P.C. Muscle?
Sit on the toilet and begin urinating. When your bladder is nearly empty, attempt to stop the flow of urine WITHOUT contracting your abdominal, buttocks, or inner thigh muscles. This will help you identify the correct muscle. (Contraction of the P.C. muscle is performed by "drawing in" the vaginal muscles and tightening the bladder and anal sphincters as if to stop urination or defecation.) When you can successfully start and stop urinating or feel the vaginal muscle contract, you are using your P.C. muscle.
Performing Kegel exercises: Every time you go to the bathroom (after you finish urinating, but before you stand up) remain sitting on the toilet for one minute and perform either of the following muscle exercises (perform on alternating days):
Slow-Twitch Exercise: Hold the muscle tight for a slow count of three to ten-seconds, relax, and repeat again for a total of five to ten contractions.
Fast-Twitch Exercise: Quickly contract and relax your P.C. muscle ("quick flicks") 20 to 50 times, relax for five-seconds, and repeat again for a total of two to four sets. You may only be able to start out with a total of 40 "quick flicks"; however, over a period of a few weeks you will be able to increase the number up to a total of 200.

High Risk Pregnancy

Bleeding During Pregnancy (PDF)

Bleeding or spotting may occur in 30-40% of pregnancies during the first trimester. Twenty percent of all pregnancies result in miscarriage. The usual cause of a miscarriage is a chromosomal abnormality in the fetus, not something that the pregnant mother has done or could have avoided. Viability can be determined by a vaginal ultrasound. Once a normal heartbeat is visualized, the risk of miscarriage decreases to less than 5% in the first trimester. It is common to have bleeding after a Pap smear or pelvic examination. Bleeding after exercise or intercourse may also occur. Bleeding during labor is also common as the cervix stretches and softens. Most cases of heavy bleeding in the 2nd or 3rd trimester are caused by placental problems. These include a placental previa (the placenta covers part or all the cervix) or a placental abruption (a separation of the placenta from the uterine wall). If you experience heavy bleeding in the second or third trimester, call your physician.

Morning Sickness (Hyperemesis) (PDF)

Changing hormone levels may cause morning sickness or hyperemesis during the first trimester. Increased progesterone causes slowing of intestinal peristalsis causing bloating and increased acid reflux into the esophagus. Nausea and vomiting may result in little or no weight gain during the first trimester. To help alleviate symptoms, stay hydrated and rest. Eat small, frequent meals and avoid spicy and greasy foods. Eating more protein or complex carbohydrates (crackers, popcorn, toast) may help. Antacids and antiemetic (anti-vomiting) medications can be used. Vitamin B6 50-100mg with ½ of a Unisom tablet work well and can be purchased without a prescription. Accupressure wrist bands and ginger may help. Your physician may prescribe Zofran, Reglan, Phenergan or Scopolamine patches. These medications all work differently and can be taken individually or together as needed under the advice of your physician

Rh Negative Mothers and Rhogam (PDF)

If the mother is Rh negative and the baby’s blood type is Rh positive, there is an Rh incompatibility. The baby’s red blood cells have the potential to leak into the maternal blood system causing the mother to produce antibodies against the baby’s blood. The antibodies remain in the maternal system and can cause damage to subsequent babies. Because the baby’s blood type cannot be determined during the pregnancy, all women that are Rh negative should receive Rhogam, unless they are certain the father’s blood type is also Rh negative. Rhogam is a synthetic antibody that will block maternal antibody response. Rhogam is injected at 28 weeks and within 72 hours after a birth, miscarriage, abortion or amniocentesis. If the baby is Rh negative, a second Rhogam injection is not necessary after birth.

Twins (PDF)

There are two types of twins, fraternal and identical. Fraternal twins are more common because each fetus develops from a separate egg and has its own placenta and gestational sac. Mothers of twins are at increased risk of high blood pressure, pre-eclampsia, anemia, gestational diabetes, hyperemesis, preterm labor and postpartum hemorrhage. Babies are more at risk of preterm labor, slowed growth, low birth weight or unequal size (discordance) and birth defects (identical twins). Twin pregnancies are monitored closely with more frequent ultrasounds and non-stress testing. Because of the risk of preterm labor, women carrying twins may stop working sooner than those with a singleton pregnancy.

Preterm Labor (PDF)

Labor that begins before 37 weeks is considered preterm. It occurs more frequently in women with medical health problems such as kidney or heart disease, twin pregnancy, uterine anomalies such as fibroids or an incompetent cervix, previous history of preterm labor, delivery within the last year and maternal age younger than 18 or older than 40. Symptoms of preterm labor include regular uterine contractions that get longer, stronger and closer together. Braxton-Hicks contractions are not regular and are not usually strong. Call if you have more than 5 regular contractions per hour, have abdominal cramps, pain, pressure, bleeding, or think you may have ruptured the membranes. If you are unsure if you are having Braxton-Hicks contractions or preterm labor, go home, rest and drink lots of fluid. If your contractions persist at 5 per hour and are regular, call the office to be seen.

Pregnancy Induced Hypertension or Preeclampsia (PDF)

Preeclampsia is also called Pregnancy Induced Hypertension (PIH) or toxemia and can occur in about 5% of pregnancies. The cause is unknown. PIH is diagnosed by a triad of physical signs that include hypertension (high blood pressure), edema (swelling) and proteinuria (protein in the urine). Symptoms may include severe headache, upper abdominal pain, blurred vision and rapid weight gain. PIH is more common in first pregnancies, multiple gestations, gestational diabetes, teenage pregnancy and pregnancy with hypertension diagnosed before 20 weeks of gestation. The treatment for PIH is delivery. If you develop PIH before your baby can be safely delivered, you may be recommended to start bed rest either at home or in the hospital. In severe cases of PIH, you may be delivered despite the gestational age as the risks of PIH to the mother may outweigh the risks of premature delivery. Severe preeclampsia can result in kidney failure, severe bleeding, stroke and eclampsia (seizures). Magnesium sulfate is frequently used to help prevent seizures during labor.

Gestational Diabetes (PDF)

If you do not pass the two-hour glucola screening test, it means that you have gestational diabetes. If you are diagnosed with gestational diabetes, you will be referred to the Sweet Success Program at Obstetrix Medical Group. The phone number is (408) 371-7111. At Sweet Success, you will meet with a dietician to learn about altering your diet during pregnancy.  A nurse will teach you how to check your blood sugar. Most women are able to control their blood sugar through diet and exercise.  A food pyramid and a preliminary diet for gestational diabetes are available from the American Diabetes Association or the CDC.

What is gestational diabetes?
Approximately 5 percent of expectant mothers develop gestational diabetes. During pregnancy, the placenta can produce a hormone that makes the mother resistant to her own insulin. This results in an elevated glucose level.  Glucose is a small molecule that passes through the placenta and causes the baby to increase its insulin production. This results in complications for the pregnancy as well as the infant. Neonatal (baby) complications from persistent elevated blood sugars may include macrosomia (big baby) and stillbirth.  Macrosomia may lead to a shoulder dystocia (shoulders get stuck resulting in neurologic damage to the baby) with a vaginal delivery or a cesarean section. 

After delivery, the baby may produce too much insulin and may develop hypoglycemia (low blood sugar) which can cause seizures. The baby is also at increased risk for jaundice and polycythemia (high red blood cell count). The baby's glucose is tested at delivery with a heel stick blood test.  If the sugar level is low, the baby may need to be given a sugar water bottle or even an IV glucose solution. Some studies have found a link between severe gestational diabetes and an increased risk for stillbirth in the last two months of pregnancy. Having gestational diabetes makes you about twice as likely to develop pre-eclampsia as other pregnant women.

What factors would put me at risk for gestational diabetes?
All patients are screened with first trimester labs and again between 24 and 28 weeks. You may be at increased risk if you are obese (body mass index over 30), have a history of gestational diabetes in a previous pregnancy, have a strong family history of diabetes, have previously given birth to an unusually large baby, had an unexplained stillbirth, had a baby with a birth defect, or have high blood pressure.

Will my baby be monitored during my pregnancy to avoid complications?
You should begin kick counts after 28 weeks of pregnancy. Most physicians will perform non-stress tests during the last few weeks of your pregnancy.  You will also have an ultrasound to determine a size estimate and make sure the placenta is not overly mature.

How is gestational diabetes managed?
It depends on how serious your condition is. You'll need to keep diligent track of your glucose levels using a home glucose meter or strips. Eating a well-planned diet can help you keep well-controlled glucose levels. The American Diabetes Association recommends getting nutritional counseling from a registered dietician who will help you develop specific meal and snack plans based on your height, weight, and activity level. Once enrolled in the Sweet Success Program, you will be asked to monitor your diet and keep a record of your blood sugars. 

Studies show that moderate exercise also helps improve your body's ability to process glucose, keeping blood sugar levels in check. Most women with gestational diabetes benefit from 30 minutes of aerobic activity, such as walking or swimming, each day.

If you are not able to control your blood sugar well enough with diet and exercise alone, you may have a medication prescribed. You may be a candidate for oral medications (glyburide or metformin). About 15 percent of women with gestational diabetes need insulin.

Third Trimester Information

Cord Blood Banking

California State Disability Information

How do I apply for disability?
Check with your Human Resources Department to determine if you are eligible for private short-term disability insurance or State Disability Insurance. If you are eligible for State Disability Insurance log onto the state disability website to create an account under Claimant Registration. Email the electronic receipt number to the office via the patient portal or bring it to an appointment so that the physician certificate portion can be completed. If you are eligible for Private Short-Term Disability then you will need to get the forms from your Human Resources Department. Please complete the entire patient portion of the forms before bringing it to Los Olivos. The form will then be completed and faxed or mailed to the insurance company.

When do I begin my maternity leave?
The State of California allows maternity leave to begin 4 weeks before your Estimated Due Date for State Disability. Most private insurance companies allow 2 weeks before your due date. You may continue to work until your due date if you are healthy and have no medical reason for stopping work. You cannot add the four weeks before delivery disability to the postpartum disability period.

I feel sore and tired all the time. Can I stop working?
Fatigue, low back pain, nausea and swelling are common symptoms of pregnancy. Although annoying or uncomfortable, these symptoms are not considered disabling conditions for most occupations. To be eligible for disability, your physician must confirm you are disabled from doing your customary work due to a complication of pregnancy.

When does my disability end?
The state allows 6 weeks after a vaginal delivery and 8 weeks for a cesarean section. If you have a complication, you may qualify for an extended disability.

When and where should I bring my forms once I complete the patient section?
The State Disability Office will not accept the forms until you have stopped working, so please do not bring them to the office until one week before your disability date. Private Insurance companies may want the forms earlier. Please return the form when you have decided on your last day of work. Bring a stamped, addressed envelope with the completed form and leave it with your physician’s nurse.

What is the difference between maternity leave and family leave?
Maternity leave is usually a period of paid time off work allowed by your employer for pregnancy. Family leave is unpaid leave that is offered by companies with at least 50 employees. Check with your HR department to determine if you qualify for this type of leave. More information is available on line about the US Family and Medical Leave Act.

How much does disability pay?
For State Disability you can visit their website which has the calculation method based on your quarterly pay periods. You will need to check with your HR department for the percentage that Private Insurance companies pay for short-term disability.

Paid Family Leave Information

What is Paid Family Leave?
Paid Family Leave is unemployment compensation disability insurance paid to workers who suffer a wage loss when they take time off work to care for a seriously ill family member or bond with a new child. An application can be obtained at http://www.paidfamilyleave.org/apply.html

How long may a person receive Paid Family Leave insurance benefits?
Workers may receive up to six (6) weeks of benefits that may be paid over a 12-month period. Employees covered by State Disability Insurance (SDI) will also be covered by Paid Family Leave insurance. If a Voluntary Plan Insurer provides your company's disability insurance coverage, then it must also provide Paid Family Leave insurance coverage.

What is the relationship of Paid Family Leave Insurance to State Disability Insurance?
Paid Family Leave Insurance is a component of the State Disability Insurance (SDI) program. The SDI benefit portion compensates workers who suffer a wage loss when they cannot work because of their own illness or injury. The Paid Family Leave benefit compensates workers who suffer a wage loss due to the need to provide care for a seriously ill family member or to bond with a new child.

What is the relationship between Paid Family Leave insurance and employee leave laws?
The FMLA and CFRA are federal and state leave laws, respectively, that allow workers to take up to 12 work weeks of unpaid leave from their jobs in a 12-month period to care for themselves or family members who are ill, or children who are unable to take care of themselves. Paid Family Leave insurance does not change either law in any way and is completely separate from them. It merely provides up to six (6) weeks of paid benefits to workers who suffer a wage loss when they take time off work to care for others. For more information about FMLA, visit the Department of Labor's Web site at For more information about CFRA contact the California Department of Fair Employment and Housing at (800) 884-1684.

Are employees required to take leave under the federal FMLA and the CFRA at the same time they are receiving Paid Family Leave insurance benefits?
Yes, if your company is subject to the provisions of FMLA and CFRA. For additional information about the CFRA, visit the State Department of Fair Employment and Housing's website.

Is the claimant's job protected?
The Paid Family Leave program does not protect anyone's job. It simply provides partial wage replacement when a person cannot work due to the need to care for a child, parent, spouse, or registered domestic partner, or to bond with a new child. Some persons may have their job protected under other laws, such as the FMLA or the CFRA.

How do I submit a claim for Paid Family Leave insurance benefits?
Women who are receiving State Disability Insurance benefits for their pregnancy and delivery “disability” will automatically receive a special claim form for Paid Family Leave benefits for bonding with their new child. If you do not receive the special claim form, or you want one for the baby’s father, you may request one by calling (877) 238-4273. The Claim For Paid Family Leave Benefits (DE2501F) will not be made available online. When benefits are requested due to a need to provide care for a seriously ill family member, a medical certificate that supports the claim of a serious health condition warranting care is required. The DE 2501F contains a medical certificate that must be completed in the instance noted above. Benefits to bond with a new minor child are limited to the first year after birth, adoption, or foster care placement of a child and a medical certificate is not required.