8-10 Weeks	Nurse visit Routine prenatal labs: Blood type, Rh status, antibody screen, Rubella, Hepatitis B, Syphilis, and HIV Urine culture Discuss options for screening tests for birth defects
12 Weeks	OB visit with physician Physical exam and pap smear if indicated Nuchal translucency if desired
16 Weeks	Check fetal heart tones AFP or Quadruple screen if desired
20 Weeks	Check fetal heart tones, measure fetal growth Anatomy ultrasound
24 Weeks	Check fetal heart tones, measure fetal growth
28 Weeks	Check fetal heart tones, measure fetal growth Glucose tolerance test  Rhogam if Rh negative Discuss signs and symptoms of preterm labor
30-34 Weeks	Visits every two weeks Check fetal heart tones, measure fetal growth
36-40 Weeks	Visits every week Group B strep culture performed at 36 weeks Check fetal heart tones, measure fetal growth Cervical exam

*This is an overview of prenatal visits for a routine pregnancy. If you have a medical condition or a condition of pregnancy this schedule may vary.

1 Hour Glucose Tolerance Test (GTT)

This is a test that screens for gestational diabetes of pregnancy.

• It is performed between 24 and 28 weeks of pregnancy.
• You will be given a small glass of a very sugary drink and then have your blood glucose level checked an hour later
• You can eat a normal diet and do not need to fast prior to the test.

If your blood sugar level is higher than normal then you will be asked to perform a 3 hour glucose tolerance test. This test will diagnose diabetes if you have the condition. For this test you must be fasting (nothing to eat or drink for 8 hours). A fasting blood level will be checked. You will then be given 8 ounces of a glucose solution. Blood sugar levels will then be checked one, two and three hours after you drink the solution. If two or more of the blood sugar levels are abnormal you have gestational diabetes.

Be aware - you must stay seated in the waiting room for the three hours of testing – so bring something to read.

*** If you have high glucose levels in your urine or risk factors for gestational diabetes you may need to be screened for gestational diabetes prior to 24 weeks. If this test is normal you will then be checked again between 24 and 28 weeks.

Group B Streptococcus (GBS)

Group B strep is one of the many bacteria that live on our bodies. In women, it can be found in the vagina and rectum. It is NOT a sexually transmitted disease (or infection). Some women have it while others do not. Most women who test positive for GBS have no symptoms and do not know they have it. You can carry the infection at one point in time and not at another. Approximately 30% of women carry GBS.

How does GBS affect pregnancy?
Women who are colonized with GBS (have no symptoms but test positive for the bacteria) are at risk of developing a urinary tract infection or a uterine infection during labor. Additionally, if a woman is GBS positive there is a risk of passing the infection to the baby when the baby moves through the birth canal during delivery.

What are the risks to the baby if exposed to GBS? 
The baby can develop a lung infection, blood infection and meningitis.

How is GBS tested for? 
To test for GBS a sample from the vagina and rectum is obtained using a Q-tip. This is a quick and painless test that is usually done between the 35th-37th weeks of pregnancy. The results are usually available within 1 week.

What if I test positive for GBS? 
If you test positive for GBS you will receive intravenous antibiotics when you go into labor and this helps prevent GBS infection in the newborn. Penicillin is the antibiotic most commonly used but if you have a penicillin allergy a different antibiotic will be used. The antibiotics only work if given during labor – if given earlier the bacteria can regrow and be present during labor.

Who else should be treated for GBS? 
There are two situations when you will be given antibiotics in labor to prevent newborn infection regardless of your GBS culture results.

• If you have had a previous baby who had a GBS infection.
• If you have had GBS identified in your urine at any time during your pregnancy.
  
  

Prenatal Testing

Prenatal testing includes testing for inherited genetic disorders before or during pregnancy. As well as testing in early pregnancy that evaluates elevated risk of having a child with a chromosomal abnormality or neural tube defect. This testing is optional. There are risks and benefits of performing testing and it is a very individual choice for families.

Genetic Carrier Screening

Genetic disorders include conditions such as sickle cell disease, cystic fibrosis, spinal muscular atrophy, fragile X syndrome, Tay-Sachs disease among others. In these disorders, there is an abnormal gene that gets passed from parents to there children.

With genetic disorders, you may carry one copy of an abnormal gene and not have the disorder. This is termed being a carrier. If you are a carrier you have the potential to pass the abnormal gene onto your child. Often times, people who are carriers have no idea they carry the mutation and there is no family history of a genetic condition.

To find out if you are a carrier for a genetic condition we can perform a blood test. This blood test can be done at any time, but if you are considering carrier screening, a good time to perform the test is before you start trying to conceive. Please speak with your doctor to discuss your risks for various genetic disorders and if carrier screening is right for you.

Screening tests for birth defects

Previously, we offered prenatal genetic screening only to women over the age of 35. This is no longer true and the American College of Obstetrics and Gynecology recommends all women be offered genetic testing before 20 weeks regardless of the mother’s age. We offer testing to everyone, however, it is important to clarify that this is optional testing. Performing this testing is a very personal choice and we support your decision to opt for or against testing.

Genetic testing is testing that is done during pregnancy to determine if you are at elevated risk for having a baby with conditions including Trisomy 13, 18 and 21 (Down syndrome) as well as open neural tube defects like spina bifida. The options include combined first-trimester screening, non-invasive prenatal testing, the quadruple screen and the fetal anatomy survey.

• The most frequently performed test is the combined first-trimester screening.
• Non-invasive prenatal testing is typically performed if you will be over 35 at time of delivery or if you have an increased risk of a child with a chromosomal abnormality.
• Alpha-fetoprotein screens for neural tube defects and is offered if you choose first-trimester screening or NIPT.
• The quadruple test is performed if you desire genetic screening and you are already in your second trimester.
• The anatomy ultrasound is recommended for all women. This screening test evaluates your baby for a variety of birth defects.

   

If you have a positive screening test that means you are at elevated risk for having a child with a trisomy or neural tube defect. You will be offered genetic counseling and additional testing that will help diagnosis if the child does, in fact, have one of these conditions.

Diagnostic testing includes chorionic villus sampling (CVS) or amniocentesis. These tests are more accurate and provide a diagnosis. However, both are invasive procedures – meaning cells from the placenta or fetal cells from the amniotic fluid are obtained and there is a risk of miscarriage.

Screening for inherited genetic disorders can alert you to potential disorders you carry. If one is found prior to pregnancy you may choose to meet with a genetic counselor and consider in vitro fertilization with pre-implantation genetic testing. However, if you carry a genetic disorder you may face tough decisions regarding future pregnancies as well as if and how you disperse this family information.

Prenatal screening can provide reassurance or alert you to a potential medical condition. This allows you time for preparation, optimal medical care or termination of pregnancy. If you have an abnormal screening test and then decline a diagnostic test because of risks it may lead to additional worry.

This is a very personal choice. If you have questions talk with your doctor and we will be happy to further discuss your option.

If you are considering any genetic testing – you should check with your insurance company ahead of time to confirm coverage. Additionally, both the nuchal translucency and the anatomy scan require a separate ultrasound appointment. Talk with the scheduler to make sure your appointments are scheduled correctly.

• It is recommended you get the vaccine between 27 and 36 weeks of pregnancy. We typically give it at your 28-week visit.
• It is recommended you get the vaccine with each pregnancy.
• If you decline the vaccine in pregnancy it is recommended that you get vaccinated postpartum.
• Also, it is important that all family members and caregivers of the infant are up-to-date with their pertussis vaccines (DTaP or Tdap depending on the age).
  
  

Influenza Vaccination

The flu season in the US is generally between October and May and it is recommended that all pregnant women receive the flu vaccination as soon as it is available.

There are two reasons pregnant women should get the flu shot. First, being pregnant changes your body’s immune response. You do not fight infections as well. Pregnant women who get the flu often get a more serious illness that can lead to hospitalization, pneumonia, preterm labor and other complications. Second, when mom gets vaccinated it helps protect the baby. The baby cannot get vaccinated until 6 months of age. Some of the antibodies mom produces cross the placenta and this helps keep the baby protected.

The flu shot is safe in pregnancy and as explained above recommended. However, if you get your flu vaccine at a location other then our office make sure you avoid the intranasal spray. This is a live attenuated version of the flu vaccine and is not safe in pregnancy

What activities are safe? A good rule of thumb is to maintain the activities you have been doing. If you were a runner before you became pregnant – you may often keep running at that same level. However, if you did not run prior to becoming pregnant you don’t want to start training for a marathon. Other activities that are safe include walking, swimming, cycling and aerobics. If it has been awhile since you last exercised it is a good idea to start with walking as little as 5 minutes a day and add 5 minutes each week until you are active for 30 minutes a day.

What activities should be avoided? Any activity that places you at high risk of falling or involves contact should be avoided. Also, avoid activities that involve jumping, jarring motions or quick changes in direction. Activities include but are not limited to those listed below.

• Downhill skiing
• Gymnastics
• Water skiing
• Hockey
• Basketball
• Soccer
• Scuba diving – places baby at risk of decompression sickness

What are warning signs? You should stop exercising and call your doctor if you experience the symptoms listed below.

• Vaginal bleeding
• Leakage of fluid from your vagina
• Contractions
• Dizziness or shortness of breath
• Headache
• Muscle weakness
• Decreased fetal movement

Other things to consider?

• Wear a bra that provides good support
• Drink plenty of water
• Avoid getting overheated or dehydrated
• Make sure you consume the daily calories you need during pregnancy

Remember – this information pertains to women who are healthy with an uncomplicated pregnancy. If you have any health issues or any complications in your pregnancy talk to your doctor before you begin an exercise routine.

The Coffee Controversy

There is not great evidence regarding the safety of caffeine in pregnancy. The general consensus among most OB/GYN’s is that it is ok to have some caffeine in pregnancy – approximately 1 cup of coffee a day or 200 mg of caffeine. Caffeine does dehydrate you so if you’re drinking a cup of coffee make sure you’re also drinking water and staying hydrated.

Travel During Pregnancy 

The best time to travel is during the middle of your pregnancy – usually between 14 and 28 weeks. Traveling before an ultrasound has confirmed an intrauterine pregnancy is not advised. You are at risk for miscarriage, ectopic pregnancy and spotty bleeding. Your body is adjusting to pregnancy and you may be experiencing nausea, vomiting and significant fatigue. After 28 weeks it can be hard to move around or sit for prolonged periods of time. It is generally advised not to travel after 36 weeks. Some airlines restrict travel in the last month of pregnancy (36 weeks) or require a medical certificate. The cutoff point for traveling internationally is often earlier.

If you are traveling during pregnancy:

• Make an appointment with your doctor a few days before your tri
• Bring a copy of your medical record
• Do NOT stay stationary. You should get up and walk around or get out of the car every few hours.
• If you are traveling out of the country check the CDC for travel alerts, safety tips and recommended vaccinations. Do not travel to areas where there is a risk of Malaria.

*** If you are having any complications in your pregnancy talk with your doctor before you travel.

Weight Gain During Pregnancy

A frequently asked question concerns what is a healthy amount of weight to gain during pregnancy. This is a great question because paying attention to weight gain in pregnancy can have benefits for mom and baby now and in the future.

The amount of weight you should gain during pregnancy is based on your pre-pregnancy body mass index (BMI). Your BMI is based on your height and weight. You can calculate your BMI on the CDC website.

Recommendations for weight gain are described below.

If you are underweight and have poor weight gain you are at risk for having a baby that is small. If you are overweight or obese you are at higher risk of developing gestational diabetes, hypertension, preeclampsia and having a cesarean delivery. Taking the steps to be at a healthy weight when you attempt to get pregnant and watching your weight gain while pregnant can help prevent the above conditions.

We are here to work with you. Please talk to your doctor if you have questions.

Prenatal Vitamins 

Start taking a prenatal vitamin approximately 3 months before you begin trying to conceive or when you find out you're pregnant. Any prenatal vitamin is fine – including the generic brands. It is a good idea to look at the contents and confirm it has 400 mcg of folic acid.

Is it safe to eat fish? Yes! Fish is good for you and your baby's developing brain. However, it is important not to get too much mercury. The MN department of public health has a list of what fish and how much you should consume if you are pregnant or trying to become pregnant.

http://www.health.state.mn.us/divs/eh/fish/eating/kidmom/index.html

What about the prescriptions I’m already taking? Continue your prescription medication – However, you should notify your provider when you find out your pregnant to make sure the medication is safe in pregnancy

Other Things to Avoid

• Smoking – try to quit if you’re a smoker
• Alcohol – even small amounts can affect your baby
• Changing the cat litter if you are pregnant
• Smoked seafood
• Raw seafood or shellfish
• Deli meat unless you reheat it so it is steaming hot
• Unpasteurized cheese and dairy products. Soft cheese can contain Listeria which can cross the placenta and cause an infection in the fetus. Soft cheeses include
• Brie, Feta, Blue cheese, queso blanco and queso fresco as well as others.
  
  

Listeriosis in Pregnancy 

Do you wonder why you can’t eat deli meat? Have you recently watched the news and seen a recall of a food contaminated with Listeria?

Listeria is a bacteria that is found in the environment and frequently transferred through food. Pregnant women are more susceptible to infection by listeria. If they become infected with this bug it can cause an infection called Listeriosis and this can have significant consequences for the baby. This is why we tell pregnant women to avoid foods with a high risk of contamination. These include deli meats, hot dogs, refrigerated smoked seafood, unpasteurized soft cheeses, unpasteurized milk and unwashed raw produce.

How to Prevent Infection?

Avoid high-risk foods listed above.

What if I ate something that has been recalled because of listeria contamination?

If you are pregnant and have eaten something that has been recalled you may or may not need testing and treatment. This depends on if you have symptoms. Signs of an infection include fever, headache, body aches, nausea, vomiting and diarrhea.

If you have no symptoms – no testing or treatment is required. Notify your doctor if you develop symptoms within 2 months of exposure.

If you have minor symptoms but no fever – you should notify your doctor.

If you have a fever greater then 38.1°C (100.6°F) and symptoms – you should notify your doctor. You likely will need treatment with antibiotics.

Acne:

• Cetaphil
• Glytone (benzoyl peroxide)

Allergy:

• Cloro-trimeton
• Alavert or Claritin
• Benadryl
• Zyrtec
• Claritin (not Claritin D)
• Sudafed – Avoid in the first trimester of pregnancy

Constipation:

• Add fiber to your diet – Metamucil, Fibrerall, Fibercon, Benefiber
• Milk of magnesia
• Senokot
• Colace (docusate) – 2-3x daily

Gas:

• Mylicon (simethicone)
• Gas-X
• Mylanta

Headache:

• Tylenol (Acetaminophen)

Heartburn:

• Tums
• Maalox
• Mylanta
• Zantac (ranitidine)

Hemorrhoids:

• Preparation H
• Anusol HC
• Tucks
• Cream for external, suppositories for internal

Nausea, vomiting, motion sickness:

• Emetrol (if vomiting)
• Ginger
• Sea-Bands
• Dramamine
• Vitamin B6 25 mg 3 times a day with meals
• Unisom OTC – take ½ of a 25 mg tablet at bedtime

Upper respiratory infection/cold:

• Tylenol
• Sudafed for congestion – Avoid in the first trimester of pregnancy
• Robitussin or Triamninic for cough (plain formulas)
• Throat lozenges – Luden’s, Sucrets, Halls, etc.
• Saline nasal sprays – Ocean, NaSal, Vick’s Vaporub

AMMA Parenting Center

United Hospital

These include St. Joseph’s Hospital, St. John’s Hospital, United Hospital and Woodwinds Health Campus. If you're curious about any of our pregnancy services which include ultrasound, prenatal classes, or infertility, please contact us today. 

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United

Breasts: 

Wear a great support bra. If you notice an area that is tender, reddened or warm this may be an early sign of infection. Call your doctor, hot pack the tender area and continue to breastfeed.

If nursing – adequate rest, good diet and increased fluids (10-12 glasses/day) are essential to establish a good supply of milk. Keep nipples clean and dry. After each feeding you may air dry nipples by using a low setting on your hair dryer. This also helps to “toughen up” the nipple and prevent cracking. Lanolin ointment may also help with minor cracking and sore nipples.

If not nursing – avoid excess fluids. If breasts do become full and engorged, apply cool packs and express enough milk to be comfortable. Wearing a tight fitting sports bra can also be helpful.

Episiotomy or vaginal tears: 

Soak in a warm tub 1-3 times per day. Occasionally, stitches may separate at the skin level. This is not uncommon and will heal by itself. Call the office if you notice any drainage, increased tenderness or inflammation from the stitches. It takes about 1-4 weeks to heal and may be tender for longer.

Constipation: 

Narcotics and pain medication can often cause constipation. Post partum iron supplementation can also cause constipation. To help prevent constipation make sure you drink plenty of fluids and consume foods high in fiber. If you are constipated Colace (stool softener) or Miralax (mild laxative) can be helpful.

Hemorrhoids: 

These are very common after delivery and usually go away within 2 weeks. Soak in a warm tub twice a day. You may use Preparation H, Tucks or Anusol. Also, stool softeners like Colace may help avoid hemorrhoids. Drink plenty of fluids.

Cesarean section instructions:

• You should avoid lifting more than 10 lbs. for 4-6 weeks after delivery
• Avoiding driving for 2 weeks and while taking pain medication
• Continue your prenatal vitamins
• Do not begin exercising until seen by your doctor

Your incision will be closed with either staples or stitches. If you had staples – the staples are typically removed prior to discharge. If you have stitches the suture will dissolve within 4-6 weeks. In both cases you will likely go home with steri strips over your incision. These may fall off on there own. If they are still in place 1 week after your surgery you may remove them. Once your dressing has been removed you should wash your incision with warm soapy water and pat it dry.

You should monitor your incision for signs of infection. These include redness, swelling, tenderness and drainage that may have an odor. If you notice these symptoms or have a fever over 100.4 you should contact your doctor.

Postpartum Checkup

Call the office to schedule an appointment 2 weeks after a cesarean section and 6 weeks after a vaginal delivery.

Contact us immediately if you have:

• Heavy vaginal bleeding with clots – more than 2 pads per hour or large clots
• Fever and chills (temperature greater than 100.4)
• Severe pain
• Foul smelling or purulent vaginal discharge
• Breast problems with fever
• Severe depression

Baby blues and postpartum depression: 

Women frequently may feel sad, afraid, angry or anxious after childbirth. In fact, 70-80% of women experience these feelings at some point after delivery. It is not uncommon to have trouble sleeping, eating or making choices. These feelings usually improve and go away within a few weeks of delivery without treatment.

For other women, these feelings are stronger and persist. If you are having trouble performing your daily tasks because of sadness, anxiety or anger you may have postpartum depression. This most commonly starts 1-3 weeks after delivery and you may benefit from counseling and sometimes medication. Your first visit with your doctor is often not until 6 weeks postpartum. If you are experiencing symptoms of postpartum depression it is important you talk with your doctor and family and seek treatment prior to this 6-week visit. We will help you get the support you need.

Here are some links that may be helpful:

• March of Dimes
• Prairie Care
• United postpartum depression support group

In The News

VBAC: 

If you are pregnant and have previously had a cesarean section you may be facing the decision of undergoing a trial of labor after a cesarean (TOLAC) versus scheduling a repeat cesarean section.

For many women, a TOLAC is an option with a good chance of success. Of women undergoing a TOLAC, 60-80% have a vaginal birth after cesarean (VBAC). However, a TOLAC is not without risk and is not right for everyone. If you are considering a TOLAC it is important to talk to your physician to discuss the risks, benefits and your chances of a successful vaginal delivery.

Benefits of TOLAC/VBAC

• Avoiding abdominal surgery
• Shorter recovery time
• Decreased blood loss
• Lower risk of infection
• Decreased chance of complications in future pregnancies

Risks of failed TOLAC/Repeat cesarean section

• Bleeding
• Infection
• Uterine rupture/uterine scar dehiscence
• Need for emergent surgery
• Fetal complications

While there are many benefits of a VBAC there also is the potential for serious complications. The most significant is a uterine rupture. This is a rare complication (<1%) but if it occurs it can have serious effects on both mom and baby. Chances of complication s are highest if you have a failed trial of labor and a repeat cesarean section. That is why it is important to choose the appropriate situations with a high chance of success for a TOLAC.

Factors that influence your chances of a successful TOLAC include the indication for your prior cesarean section, if you have had prior vaginal deliveries, maternal age, obesity as well as other factors.

At Metro OBGYN we support you and your desires for a vaginal birth after a cesarean section. We’ll work with you to discuss delivery options to ensure a safe delivery. Ultimately, we want a “healthy mom and a healthy baby”.

Cord Blood Banking 

This involves taking blood that is left in the umbilical cord and placenta after the baby is born. The purpose of doing this is that these cells have potential to form different kinds of cells that could then be used to treat some diseases like cancer or diseases of the immune system. Although they have great potential the actual ways to use these cells have limitations. Often, a person who needs stem cells because of a disease cannot get stem cells they have previously donated.

Cord blood is collected at the time of delivery. After the baby is born the umbilical cord is clamped and a needle is placed in the cord to draw what blood is remaining in the cord. This process takes a few minutes and after it is completed the placenta is delivered.

There are some instances when cord blood cannot be collected. A common reason is if there is not enough blood remaining in the cord. Other reasons include if the mom has a medical problem like herpes or genital warts, if mom has an infection during labor, and sometimes if it is an emergency delivery.

To collect cord blood you must select a cord blood bank and request a kit to collect the cord blood. You then bring the kit to the hospital when you go for delivery.

There are two kinds of cord blood banks. A public bank is where you donate the blood and it goes into a pool for anyone to use. A private bank is where you set aside the blood to be used for your baby or family members if needed. There is not currently a public cord blood bank in Minnesota. For private banks, they usually charge a collection fee and a yearly storage fee.

Choosing whether to bank cord blood or not is a personal choice. Although it has potential to help in the future there are some important things to consider. The chance of needing cord blood to treat a child or relative is very low and often you cannot use a person’s own stem cells. Additionally, this can be a very expensive process and we do not know how long stem cells can be stored for.

If you have further questions. Please talk to your doctor.