Obstetrics

PRECONCEPTION CONSULTATION

Given that nearly one-half of pregnancies are unintended, preconception care should be considered an integral part of primary care for women of reproductive age. Common issues in preconception care include family planning, achieving a healthy body weight, screening and treatment for infectious diseases, updating appropriate immunizations, and reviewing medications for teratogenic effects. Women who want to become pregnant should take folic acid supplements to reduce the risk of neural tube defects. Control of chronic diseases is essential for optimizing pregnancy outcomes. Family physicians should work with patients to control conditions such as diabetes mellitus, hypertension, and seizure disorders while simultaneously offering family planning services to avoid unintended pregnancies. Bariatric surgery is increasingly common and may improve fertility in many women with previous insulin resistance. Family physicians should counsel women undergoing bariatric surgery to prevent pregnancy during rapid weight loss and provide assistance with contraception. In addition, patients have special nutritional requirements after bariatric surgery.

The Centers for Disease Control and Prevention defines preconception care as a set of interventions aimed at identifying and modifying biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management. The goal is to ensure that the woman is as healthy as possible before conception to promote her health and the health of her future children. Preconception care is integral to primary care for women in their reproductive years. It is not a single medical visit, but rather should be incorporated into every medical decision and treatment recommendation for these women.

Nearly one-half of all pregnancies in the United States are unintended. Family planning is an essential component of preconception care and allows optimal opportunity for health promotion and preventive care. Primary care clinicians should consider asking all patients of reproductive age about intention to become pregnant and providing contraceptive counseling tailored to patients’ intentions.

The Centers for Disease Control and Prevention’s U.S. medical eligibility criteria for contraceptive use can assist clinicians in counseling patients about contraceptive choices, and provides evidence-based guidance on the safety of contraceptive methods for women with specific characteristics and medical conditions. All women and men should be encouraged to develop a reproductive life plan, including individual goals about childbearing and a plan for achieving them.

For primary care physicians, caring for a woman of reproductive age should include identifying health risks to her and her future children, and implementing interventions to reduce these risks. General issues in preconception care are summarized in Screening and treatment for infectious diseases, and providing appropriate immunizations are also important in these patients

Nutritional Considerations

FOLIC ACID

Folic acid supplementation of 400 mcg daily started before pregnancy and continued until six to 12 weeks postconception reduces the rate of neural tube defects by nearly 75%. One study showed that women receiving preconception counseling from their primary care physicians are five times more likely to take folic acid before conception. Women taking folic acid antagonists or who have carried a fetus affected by a neural tube defect or other birth defects linked with folic acid deficiency (e.g., oral facial cleft, structural heart disease, limb defect, urinary tract anomaly, hydrocephalus) should take 4 to 5 mg of folic acid daily starting three months before conception and continuing until 12 weeks postconception. Women with certain health risks (e.g., epilepsy, insulin-dependent diabetes mellitus, obesity with a body mass index [BMI] greater than 35 kg per m2, family history of a neural tube defect) should also take this higher dosage.

OVERWEIGHT

In the United States, 26% of women 20 to 39 years of age are overweight (BMI of 25 to 29.9 kg per m2), and 29% are obese (BMI of 30 kg per m2 or higher). Women who are overweight or obese are at risk of diabetes, gestational diabetes, and hypertension. These conditions are associated with adverse pregnancy outcomes, including macrosomia, shoulder dystocia, operative delivery, congenital anomalies, intrauterine growth restriction, spontaneous abortion, stillbirth, preeclampsia, and eclampsia.

There are numerous effective interventions for women who are overweight or obese. A systematic review found that out of five commercial diets, Weight Watchers was the least costly, and women maintained a 3.2% weight loss two years after intervention. The review noted that medically supervised programs are more expensive and have higher rates of attrition, but are associated with greater weight loss (15% to 25%), compared with other types of programs.

Women who are overweight or obese are more likely to have difficulty with conception because of insulin resistance and oligomenorrhea. Weight loss and medications can improve these symptoms, as well as fertility.

BARIATRIC SURGERY

There were 220,000 bariatric surgeries in 2008; one-half were performed in women of reproductive age. Many women undergoing gastric surgery have a history of oligomenorrhea or amenorrhea from insulin resistance, and they should be advised that fertility may return as they lose weight. Women are generally directed to prevent pregnancy for 12 to 18 months after surgery to stabilize weight loss and optimize nutrition status, but observational studies have shown that the time from surgery to conception does not increase obstetric and neonatal complications. Oral contraceptives may be less effective after malabsorptive bariatric surgery.

There is little evidence-based data to guide preconception care of women who have had bariatric surgery. These patients are at risk of nutrient deficiencies, including vitamins A, D, E, K, C, B1, B6, B12; folic acid; and iron. It is generally recommended that they take at least two multivitamins per day in addition to extra iron (approximately 65 mg), folic acid (400 mcg), vitamin D (400 to 800 IU), and vitamin B12 (350 mcg). Women should be assessed for common nutrient deficiencies before pregnancy with a complete blood count.

UNDERWEIGHT

Low prepregnancy weight (BMI less than 18.5 kg per m2) is associated with preterm birth and low birth weight. Low body weight is also associated with nutrient deficiencies, osteoporosis, amenorrhea, infertility, and arrhythmias. Infants whose mothers had low prepregnancy body weight are at higher risk of gastroschisis. Women with low BMI should be assessed for eating disorders and counseled about how being underweight can affect their health and pregnancy.

DIABETES

Diabetes is the most common serious disease to affect the maternal-fetal dyad. The disease affects nearly 10% of women of reproductive age, and about 1% of pregnancies are complicated by pregestational diabetes. Pregestational diabetes increases the risk of miscarriage, congenital fetal anomalies, and perinatal death.

Glucose is teratogenic at high levels, and rates of congenital fetal anomalies are directly related to glycemic control in the first trimester. Good glycemic control during organogenesis reduces rates of congenital malformations. Preconception A1C levels should approach those considered normal in patients without diabetes; national organizations recommend varying targets of 7% or lower. Pregnancy is associated with higher rates of hypoglycemia, decreased hypoglycemic awareness, increased rates of diabetic ketoacidosis, and the progression of diabetic retinopathy and nephropathy.

Preconception counseling improves pregnancy outcomes in women with diabetes and should be part of diabetes care for reproductive-aged women. Preconception care should include educating women about the impact of diabetes on pregnancy outcomes and the impact of pregnancy on diabetes, optimizing glycemic control, screening for vascular complications of diabetes, evaluating medication use, and encouraging effective family planning.

HYPERTENSION

Chronic hypertension affects 3% of women of reproductive age. Chronic hypertension in pregnancy is associated with higher rates of preterm birth, placental abruption, intrauterine growth restriction, preeclampsia, and fetal death. Women with chronic hypertension are at risk of worsening hypertension and end-organ damage, and 25% of women with hypertension develop superimposed preeclampsia during pregnancy.

Pregnancy outcome is related to the degree of hypertension. There is no evidence that treating mild to moderate hypertension in pregnancy improves perinatal outcomes. Treating severe hypertension (systolic blood pressure of 180 mm Hg or higher, or diastolic blood pressure of 110 mm Hg or higher) improves pregnancy outcomes.

Caring for women of reproductive age with hypertension should include educating them about the risks of hypertension during pregnancy and that their medication regimen may need to be changed before conception. Women with long-standing hypertension who are planning pregnancy should be assessed for retinopathy, renal disease, and ventricular hypertrophy.

THYROID DISEASE

Thyroid disease can significantly impact pregnancy outcomes. Hypothyroidism affects 2.5% of women of reproductive age, and even more have subclinical disease. Many patients with hypothyroidism are inadequately treated. Hypothyroidism in the first trimester is associated with cognitive impairment in children. Hypothyroidism (clinical and subclinical) in pregnant women increases the risk of preterm birth, low birth weight, placental abruption, and fetal death.

Women who are adequately treated before pregnancy and those diagnosed and treated early in pregnancy have no increased risk of perinatal morbidity. It is essential to monitor women on thyroid replacement therapy and educate them about its impact on pregnancy. During pregnancy, thyroid replacement dosages typically need to be increased by four to six weeks’ gestation, possibly by 30% or more. Routine screening for subclinical hypothyroidism is not recommended; however, women with risk factors and symptoms of thyroid diseases should be screened, and subclinical hypothyroidism should be treated.

Hyperthyroidism can result in significant maternal and neonatal morbidity, and outcomes correlate with disease control. Guidelines recommend achieving euthyroidism before pregnancy.

ASTHMA

Women with poorly controlled asthma before pregnancy are more likely to experience worsening symptoms during pregnancy. Poorly controlled asthma poses risks to the fetus, such as neonatal hypoxia, intrauterine growth restriction, preterm birth, low birth weight, and fetal and neonatal death. Preconception care should focus on optimizing asthma control with medications, and identifying and reducing exposure to allergens. Patients should be counseled on smoking cessation and avoidance of secondhand smoke exposure.

THROMBOPHILIA

Women with thrombophilia are more likely to develop venous and arterial clots during pregnancy and are at risk of preeclampsia. Effects on the fetus include placental infarction, intrauterine growth restriction, placental abruption, recurrent miscarriage, fetal stroke, and fetal death. Warfarin (Coumadin), an anticoagulant commonly used in the treatment of thrombophilia, is teratogenic. It is important to educate women with thrombophilia about the risks of pregnancy so that they can make informed decisions about conception. Preconception care allows women to change to a treatment regimen that is safer for the fetus before pregnancy and to consider genetic testing for inherited thrombophilia.

SEIZURE DISORDERS

Seizure disorders are the most common neurologic diseases to affect pregnant women, and both the diseases and its treatments can adversely affect pregnancy. Approximately one-third of women with a seizure disorder will experience more frequent seizures in pregnancy. Seizure disorders are associated with miscarriage, low birth weight, developmental disabilities, microcephaly, and hemorrhagic disease of the newborn (induced by antiepileptic drugs). Seizure disorders increase the risk of congenital anomalies, whether or not the mother is taking medication. Given increased rates of neural tube defects with many antiepileptic drugs, supplementation with 4 mg of folic acid daily should be initiated at least one month before conception and continued in the first trimester.

MATERNAL FETAL MEDICINE

Pregnancy

Labbor And Delivery

POSTNATAL CARE

Although it is recommended that all women undergo a comprehensive visit within the first 6 weeks after birth, as many as 40% of women do not attend a postpartum visit. In order to optimize postpartum care for patients and to promote continuation of care through a woman’s lifespan, today, the American College of Obstetricians and Gynecologists (ACOG) released a new Committee Opinion to guide women’s health care providers on how to best care for new mothers.

“Optimizing Postpartum Care,” states that patient-centered, maternal postpartum care has the potential to improve outcomes for women, infants and families and to support ongoing health and well-being. In the weeks after birth, a woman must adapt to multiple physical, social and psychological changes. She must recover from childbirth, adjust to changing hormones, and learn to feed and care for her newborn. In addition to being a time of joy and excitement, this “fourth trimester” can present major challenges like lack of sleep, pain, depression, lack of sexual desire and urinary incontinence. Postpartum care visits with obstetrician-gynecologists or other obstetric care providers can help women navigate the challenges of motherhood.

While postpartum care visits occur after delivery, obstetric providers can and should begin counseling their patients during pregnancy. The patient and her obstetrician-gynecologist or other obstetric care provider together, should formulate a postpartum care plan and identify the health care professionals who will comprise the postpartum care team for the woman and her infant.

“We encourage providers to partner with women during pregnancy to begin planning for the Fourth Trimester,” said Alison Stuebe, MD, lead author of the Committee Opinion. “Each woman has different postpartum needs, and we recommend that she and her provider identify members of her postpartum care team and develop an individualized postpartum care plan.”

The postpartum care team may include the woman’s family and friends, her maternity provider, her infant’s provider, and community supports, such as home visitors, mothers’ groups and peer counselors. The care plan addresses each woman’s plans for infant feeding, future pregnancy plans, and specific health needs. Dr. Stuebe added, “As ob-gyns, we should leverage our community’s resources to provide patient-centered care for new mothers.”

For some women, such as those with hypertensive disorders of pregnancy or women at high risk of postpartum depression, follow-up one to two weeks after birth is recommended. For all women, a comprehensive postpartum visit should take place within the first 6 weeks after birth and should include a full assessment of physical, social and psychological well-being. This visit is an opportunity for the woman to ask questions about her birth and the implications of any complications for her future health. Providers should discuss reproductive life plans to ensure each woman can receive her desired form of contraception, if immediate postpartum long-acting reversible contraception placement was not done earlier. The visit also should include infant feeding, expressing breast milk if returning to work or school, postpartum weight retention, sexuality, physical activity and nutrition. For women who experience miscarriage or stillbirth, the visit should include emotional support and bereavement counseling.

To maintain the continuity of care during the postpartum period, a single health care practice should assume the responsibility of coordinating a woman’s care. If responsibility is transferred to another primary care provider after the comprehensive postpartum visit, the ob-gyn or other obstetric care provider is responsible for ensuring that there is communication with the primary care provider so that he or she can understand the implications of any pregnancy complications for the women’s future health and maintain continuity of care.

Edinburgh Postnatal Depression Scale: this test can be done in our office to check if you are in risk of postnatal depression or not

MATERNAL FETAL MEDICIN

( Pregnancy , Labor And Delivery )

NUTRITION DURING PREGNANCY

How can I plan healthy meals during pregnancy?

Planning healthy meals during pregnancy is not hard. The United States Department of Agriculture has made it easier by creating www.choosemyplate.gov. This web site helps everyone from dieters and children to pregnant women learn how to make healthy food choices at each mealtime.

How does MyPlate work?

With MyPlate, you can get a personalized nutrition and physical activity plan by using the “SuperTracker” program. This program is based on five food groups and shows you the amounts that you need to eat each day from each group during each trimester of pregnancy. The amounts are calculated according to your height, prepregnancy weight, due date, and how much you exercise during the week. The amounts of food are given in standard sizes that most people are familiar with, such as cups and ounces.

What are the five food groups?

Grains—Bread, pasta, oatmeal, cereal, and tortillas are all grains.
Fruits—Fruits can be fresh, canned, frozen, or dried. Juice that is fruit juice also counts.
Vegetables—Vegetables can be raw or cooked, frozen, canned, dried, or vegetable juice.
Protein foods—Protein foods include meat, poultry, seafood, beans and peas, eggs, processed soy products, nuts, and seeds.
Dairy—Milk and products made from milk, such as cheese, yogurt, and ice cream, make up the dairy group.

Are oils and fats part of healthy eating?

Although they are not a food group, oils and fats do give you important nutrients. During pregnancy, the fats that you eat provide energy and help build many fetal organs and the placenta. Most of the fats and oils in your diet should come from plant sources. Limit solid fats, such as those from animal sources. Solid fats also can be found in processed foods.

Why are vitamins and minerals important in my diet?

Vitamins and minerals play important roles in all of your body functions. During pregnancy, you need more folic acid and iron than a woman who is not pregnant.
How can I get the extra amounts of vitamins and minerals I need during pregnancy?

Taking a prenatal vitamin supplement can ensure that you are getting these extra amounts. A well-rounded diet should supply all of the other vitamins and minerals you need during pregnancy.

What is folic acid and how much do I need daily?

Folic acid, also known as folate, is a B vitamin that is important for pregnant women. Before pregnancy and during pregnancy, you need 400 micrograms of folic acid daily to help prevent major birth defects of the baby’s brain and spine called neural tube defects. Current dietary guidelines recommend that pregnant women get at least 600 micrograms of folic acid daily from all sources. It may be hard to get the recommended amount of folic acid from food alone. For this reason, all pregnant women and all women who may become pregnant should take a daily vitamin supplement that contains folic acid.

Why is iron important during pregnancy and how much do I need daily?

Iron is used by your body to make a substance in red blood cells that carries oxygen to your organs and tissues. During pregnancy, you need extra iron—about double the amount that a nonpregnant woman needs. This extra iron helps your body make more blood to supply oxygen to your baby. The daily recommended dose of iron during pregnancy is 27 mg, which is found in most prenatal vitamin supplements. You also can eat iron-rich foods, including lean red meat, poultry, fish, dried beans and peas, iron-fortified cereals, and prune juice. Iron also can be absorbed more easily if iron-rich foods are eaten with vitamin C-rich foods, such as citrus fruits and tomatoes.

Why is calcium important during pregnancy and how much do I need daily?

Calcium is used to build your baby’s bones and teeth. All women, including pregnant women, aged 19 years and older should get 1,000 mg of calcium daily; those aged 14–18 years should get 1,300 mg daily. Milk and other dairy products, such as cheese and yogurt, are the best sources of calcium. If you have trouble digesting milk products, you can get calcium from other sources, such as broccoli; dark, leafy greens; sardines; or a calcium supplement.

Why is vitamin D important during pregnancy and how much do I need daily?

Vitamin D works with calcium to help the baby’s bones and teeth develop. It also is essential for healthy skin and eyesight. All women, including those who are pregnant, need 600 international units of vitamin D a day. Good sources are milk fortified with vitamin D and fatty fish such as salmon. Exposure to sunlight also converts a chemical in the skin to vitamin D.

How much weight should I gain during pregnancy?

The amount of weight gain that is recommended depends on your health and your body mass index before you were pregnant. If you were a normal weight before pregnancy, you should gain between 25 pounds and 35 pounds during pregnancy. If you were underweight before pregnancy, you should gain more weight than a woman who was a normal weight before pregnancy. If you were overweight or obese before pregnancy, you should gain less weight.

Can being overweight or obese affect my pregnancy?

Overweight and obese women are at an increased risk of several pregnancy problems. These problems include gestational diabetes, high blood pressure, preeclampsia, preterm birth, and cesarean delivery. Babies of overweight and obese mothers also are at greater risk of certain problems, such as birth defects, macrosomia with possible birth injury, and childhood obesity.

Can caffeine in my diet affect my pregnancy?

Although there have been many studies on whether caffeine increases the risk of miscarriage, the results are unclear. Most experts state that consuming fewer than 200 mg of caffeine (one 12-ounce cup of coffee) a day during pregnancy is safe.

What are the benefits of including fish and shellfish in my diet during pregnancy?

Omega-3 fatty acids are a type of fat found naturally in many kinds of fish. They may be important factors in your baby’s brain development both before and after birth. To get the most benefits from omega-3 fatty acids, women should eat at least two servings of fish or shellfish (about 8–12 ounces) per week and while pregnant or breastfeeding.

What should I know about eating fish during pregnancy?

Some types of fish have higher levels of a metal called mercury than others. Mercury has been linked to birth defects. To limit your exposure to mercury, follow a few simple guidelines. Choose fish and shellfish such as shrimp, salmon, catfish, and pollock. Do not eat shark, swordfish, king mackerel, or tilefish. Limit white (albacore) tuna to 6 ounces a week. You also should check advisories about fish caught in local waters.

How can food poisoning affect my pregnancy?

Food poisoning in a pregnant woman can cause serious problems for both her and her baby. Vomiting and diarrhea can cause your body to lose too much water and can disrupt your body’s chemical balance. To prevent food poisoning, follow these general guidelines:

Wash food. Rinse all raw produce thoroughly under running tap water before eating, cutting, or cooking.
Keep your kitchen clean. Wash your hands, knives, countertops, and cutting boards after handling and preparing uncooked foods.
Avoid all raw and undercooked seafood, eggs, and meat. Do not eat sushi made with raw fish (cooked sushi is safe). Food such as beef, pork, or poultry should be cooked to a safe internal temperature.

What is listeriosis and how can it affect my pregnancy?

Listeriosis is a type of food-borne illness caused by bacteria. Pregnant women are 13 times more likely to get listeriosis than the general population. Listeriosis can cause mild, flu-like symptoms such as fever, muscle aches, and diarrhea, but it also may not cause any symptoms. Listeriosis can lead to miscarriage, stillbirth, and premature delivery. Antibiotics can be given to treat the infection and to protect your unborn baby. To help prevent listeriosis, avoid eating the following foods during pregnancy:

  • Unpasteurized milk and foods made with unpasteurized milk
  • Hot dogs, luncheon meats, and cold cuts unless they are heated until steaming hot just before serving
  • Refrigerated pate and meat spreads
  • Refrigerated smoked seafood
  • Raw and undercooked seafood, eggs, and meat

CAR SAFETY FOR PREGNANT WOMEN AND BABIES

Why is it important to wear a seat belt when I travel during pregnancy?

Although the baby is protected inside your body, you should wear a lap and shoulder belt every time you travel while you are pregnant for the best protection—even in the final weeks of pregnancy. You and your baby are much more likely to survive a car crash if you are buckled in.

How should I wear a seat belt while I am pregnant?

When wearing a seat belt, follow these rules:

  • Buckle the lap belt below your belly so that it fits snugly across your hips and pelvic bone.
  • Place the shoulder belt across your chest (between your breasts) and over the mid-portion of your collar bone (away from your neck).
  • Never place the shoulder belt under your arm or behind your back.
  • Pull any slack (looseness) out of the belt.

What should I know about air bags when I travel in a car?

Follow these tips if your car has air bags:

  • Keep 10 inches between the steering wheel and your breastbone.
  • If the car has an air bag “on/off” switch, check to be sure it is turned to “on.”
  • As your belly grows, you may not be able to keep as much space between you and the steering wheel. If the car has a tilt steering wheel, make sure it is angled toward your breastbone, not your belly or head.

If I am pregnant, when should I buy a car seat for my baby?

You cannot take your newborn home from the hospital without a car seat. Plan to have the car seat at least 3 weeks before your due date so you will have time to install it correctly and learn how to buckle the baby in safely.

Where should child car seats be installed in the car?

All car seats for children should be used in the back seat of the car—never in the front seat. Air bags in the front seat can cause serious injury to children. Until they reach age 13 years, children should always ride in the back seat.

What types of car seats are available for infants, toddlers, and school-aged children?

  1. Rear-facing car seat—In a rear-facing car seat, the baby is turned to face the back windshield of the car. Infants and toddlers should ride in a rear-facing car seat until they are 2 years of age or until they reach the highest weight and height allowed by their car seat’s maker.
  2. Forward-facing car seat—A forward-facing car seat faces the front windshield of the car. Toddlers and preschoolers who have outgrown the height and weight limit of the rear-facing seat should use a forward-facing seat.
  3. Booster seat—A booster seat raises and positions your child so that the vehicle’s lap and shoulder belts fit properly. Your child should use a booster seat until the car seat belts fit properly. This usually occurs when the child is between the ages of 8 years and 12 years and is at least 4 feet 9 inches in height.

What should I keep in mind when choosing a car seat?

  • Know whether your car has the LATCH system. LATCH stands for Lower Anchors and Tethers for Children. Instead of seat belts, special anchors hold the seat in place. If your car and car seat do not have the LATCH system, you will need to use seat belts to install the car seat.
  • Try locking and unlocking the buckle while you are in the store. Try changing the lengths of the straps.
  • Read the labels to find out the seat’s height and weight limits.

What should I know if I am considering buying a used car seat?

Do not buy a used car seat if you know it has been in a car crash. Also, used car seats may be missing parts or instructions. Avoid a used car seat that looks old or worn or is missing labels with the model number and maker’s name. Keep in mind that car seats have expiration dates. You can check the expiration date for any car seat on the maker’s web site.

What is distracted driving?

Distracted driving means doing something else while driving that takes your hands off the steering wheel or your eyes or mind off the road:

  • Using a cell phone
  • Texting
  • Eating
  • Feeding a child or picking up a toy
  • Grooming
  • Using a navigation system or changing a DVD

Parents who are distracted while driving with children in the car are more likely to be in a crash. Wait to send a text or make a call until your car is parked.

THE RH FACTOR: HOW IT CAN AFFECT YOUR PREGNANCY

What is the Rh factor?

Just as there are different major blood groups, such as type A and type B, there also is an Rh factor. The Rh factor is a protein that can be present on the surface of red blood cells. Most people have the Rh factor—they are Rh positive. Others do not have the Rh factor—they are Rh negative.

How does a person get the Rh factor?

The Rh factor is inherited—passed down through parents’ genes to their children. If the mother is Rh negative and the father is Rh positive, the fetus can inherit the Rh gene from the father and could be either Rh positive or Rh negative. If the mother and father are both Rh negative, the baby also will be Rh negative.

Can the Rh factor cause problems during pregnancy?

The Rh factor can cause problems if you are Rh negative and your fetus is Rh positive. This is called Rh incompatibility. These problems usually do not occur in a first pregnancy, but they can occur in a later pregnancy.

What happens if there is Rh incompatibility during pregnancy?

When an Rh-negative mother’s blood comes into contact with blood from her Rh-positive fetus, it causes the Rh-negative mother to make antibodies against the Rh factor. These antibodies attack the Rh factor as if it were a harmful substance. A person with Rh-negative blood who makes Rh antibodies is called “Rh sensitized.”

How does Rh sensitization occur during pregnancy?

During pregnancy, the woman and fetus do not share blood systems. However, a small amount of blood from the fetus can cross the placenta into the woman’s system. This sometimes may happen during pregnancy, labor, and birth. It also can occur if an Rh-negative woman has had any of the following during pregnancy:

Amniocentesis
Chorionic villus sampling (CVS)
Bleeding during pregnancy
Manual rotation of a baby in a breech presentation before labor
Blunt trauma to the abdomen during pregnancy

Do problems usually occur during the pregnancy that causes Rh sensitization?

During an Rh-negative woman’s first pregnancy with an Rh-positive fetus, serious problems usually do not occur because the baby often is born before the woman’s body develops many antibodies. If preventive treatment is not given during the first pregnancy and the woman later becomes pregnant with an Rh-positive fetus, the baby is at risk of Rh disease.

Can I still develop antibodies if my pregnancy is not carried to term?

It also is possible to develop antibodies after a miscarriage, an ectopic pregnancy, or an induced abortion. If an Rh-negative woman becomes pregnant after one of these events, she does not receive treatment, and the fetus is Rh positive, the fetus may be at risk of Rh-related problems.

How does Rh sensitization affect the fetus during pregnancy?

Problems during pregnancy can occur when Rh antibodies from an Rh-sensitized woman cross the placenta and attack the blood of an Rh-positive fetus. The Rh antibodies destroy some of the fetal red blood cells. This causes hemolytic anemia, where red blood cells are destroyed faster than the body can replace them.

Red blood cells carry oxygen to all parts of the body. Without enough red blood cells, the fetus will not get enough oxygen. Hemolytic anemia can lead to serious illness. Severe hemolytic anemia may even be fatal to the fetus.

How can I find out if I have become Rh sensitized?

A blood test, called an antibody screen, can show if you have developed antibodies to Rh-positive blood and how many antibodies have been made. If you are Rh negative and there is a possibility that your baby is Rh positive, your health care provider may request this test during your first trimester and again during week 28 of pregnancy.

Can Rh sensitization be prevented?

Yes. If you are Rh negative, you will be given a shot of Rh immunoglobulin (RhIg). RhIg is made from donated blood. When given to a nonsensitized Rh-negative person, it targets any Rh-positive cells in the bloodstream and prevents the production of Rh antibodies. When given to an Rh-negative woman who has not yet made antibodies against the Rh factor, RhIg can prevent fetal hemolytic anemia in a later pregnancy.

Can RhIg help me if I am already Rh sensitized?

RhIg is not helpful if you are already Rh sensitized.

When is RhIg given?

RhIg is given to Rh-negative women in the following situations:

At around the 28th week of pregnancy to prevent Rh sensitization for the rest of the pregnancy
Within 72 hours after the delivery of an Rh-positive infant
After a miscarriage, abortion, or ectopic pregnancy
After amniocentesis or chorionic villus sampling

What if I am Rh sensitized and my fetus is Rh positive?

If you are Rh sensitized, you will be monitored during pregnancy to check the condition of your fetus. If tests show that your baby has severe anemia, it may be necessary to deliver your baby early (before 37 weeks of pregnancy) or give a blood transfusion while your baby is still in your uterus (through the umbilical cord). If the anemia is mild, your baby may be delivered at the normal time. After delivery, your baby may need a transfusion to replace the blood cells.

A PARTNER’S GUIDE TO PREGNANCY

Why is it important to be supportive during your partner’s pregnancy?

Women who have an involved and supportive partner during pregnancy are more likely to give up harmful behaviors, such as smoking, and lead healthier lives. Babies may be born healthier as well, with lower rates of preterm birth and growth problems. Women who are well supported during pregnancy may be less anxious and have less stress in the weeks after childbirth. You can be supportive by educating yourself about pregnancy, going with your partner to prenatal care appointments, and joining her in making healthy lifestyle choices.

How long does pregnancy last?

A normal pregnancy lasts about 40 weeks from the first day of the woman’s last menstrual period (LMP). Weeks of pregnancy are divided into three trimesters. Each trimester lasts about 3 months.

How is the due date estimated?

The estimated date that the baby will be born is called the estimated due date (EDD). This date is based on the LMP or an ultrasound exam. The LMP and ultrasound dating methods often are used together to estimate the EDD. Keep in mind that only 1 in 20 women actually give birth on their estimated due date.

What happens during the first trimester of pregnancy?

During the first trimester (the first 13 weeks), most women need more rest than usual. They may have symptoms of nausea and vomiting. Although commonly known as “morning sickness,” these symptoms can occur at any time during the day or night. Early pregnancy can be an emotional time for a woman. Mood swings are common. It is not unusual for you to have ups and downs as well. Pregnancy and parenthood are huge life changes, and it can take time for you to adjust. Listen to your partner and offer support.

What happens during the second trimester of pregnancy?

For most women, the second trimester of pregnancy (weeks 14–27) is the time they feel the best. As your partner’s abdomen grows, the pregnancy becomes more obvious. Many women begin to feel better physically. Energy levels improve, and morning sickness usually goes away. Your partner will start to feel the baby move. This typically happens at about 20 weeks of pregnancy, but it can happen earlier or later.

Many couples take childbirth classes at the hospital where they plan to have the baby. Classes are a great way to learn what to expect during labor and delivery and how to support your partner during childbirth. You also can meet and talk with other expecting parents.

What happens during the third trimester of pregnancy?

The last trimester (weeks 28–40) usually is the most uncomfortable for your partner. It also can be a very busy time as you prepare for the baby. Your partner may feel discomfort as the baby grows larger and her body gets ready for the birth. She may have trouble sleeping, walking quickly, and doing routine tasks. It is normal for both of you to feel excited and nervous.

What lifestyle changes do my partner and I need to make during pregnancy?

Your partner needs to make her health a top priority during pregnancy, and you can support her by doing this too. Eat healthy meals together, and make sure that she gets plenty of rest. Exercise during pregnancy also is important. It is especially important for your partner to avoid harmful substances such as smoking, alcohol, and illegal drugs.

No amount of alcohol is considered safe during pregnancy. Illegal drugs, such as heroin, cocaine, methamphetamines, and prescription drugs used for a nonmedical reason, can harm a developing baby. And although marijuana is legal in some states, its use is not recommended during pregnancy. Women who use these substances may have other unhealthy behaviors, such as poor nutrition, that are known to be harmful during pregnancy.

Do I need to quit smoking if my partner is pregnant?

You and your partner should both avoid smoking. Smoking during pregnancy increases the risk of fetal growth problems and preterm birth. Secondhand smoke also is harmful. Pregnant women who breathe in secondhand smoke have an increased risk of having a low-birth-weight baby. Infants and children who are around secondhand smoke have higher rates of asthma attacks, respiratory infections, ear infections, and sudden infant death syndrome (SIDS) than those who are not. For all of these reasons, smoking should not be allowed in your home or car.

Is it safe to have sex during pregnancy?

Unless your partner’s obstetrician or other health care professional has told her otherwise, you can have sex throughout pregnancy. You may need to try new positions as your partner’s belly grows. Also, keep in mind that intercourse may be uncomfortable at times for your partner.

How can I help prepare for labor and delivery?

There is plenty you can do to help make labor and delivery go as smoothly as possible:

Tour the hospital. The tour is a good time to ask about the hospital’s policies on who can be in the room during labor and delivery, whether you can stay overnight in the room, and if you can take pictures or videotape the birth. Also ask about parking areas at the hospital and where to check in.
Install a rear-facing car seat. You cannot take your baby home unless you have an infant car seat. Plan to get a rear-facing car seat well before the due date and make sure it is installed correctly. The “Parents Central” web site at www.safercar.gov offers tips on choosing and installing the car seat that is best for your baby.
Get vaccinated. If it is flu season (October to May), get a flu shot. The Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists recommend that everyone 6 months of age and older get the flu vaccine each year. They also recommend that everyone who will be in contact with the baby receive a dose of the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine at least 2 weeks before.

How can I help my partner during labor and delivery?

During this time, you can

help distract your partner by playing games with her or watching a movie during early labor
take short walks with her, unless she has been told to stay in bed
time her contractions
massage her back and shoulders between contractions
offer comfort and words of support
encourage her during the pushing stage

Some partners decide not to attend the labor and birth. Even if you are not in the room, your partner will get plenty of help during labor and delivery from the hospital staff. Friends or family members can offer support. You also can hire a childbirth assistant called a doula.

When can we take our baby home from the hospital?

After the baby is born, you most likely can take your new family home after 1–2 days. If your partner had a cesarean delivery, she and the baby may need to stay in the hospital longer.

What is postpartum depression?

It is very common for new mothers to feel sad, upset, or anxious after childbirth. Many have mild feelings of sadness called postpartum blues or “baby blues.” When these feelings are more extreme or last longer than a week or two, it may be a sign of a more serious condition known as postpartum depression. Often, women with postpartum depression are not aware they are depressed. It is their partners who first notice the signs and symptoms.

What are the signs and symptoms of postpartum depression?

The following are signs of postpartum depression:

The baby blues do not start to fade after about 1 week, or the feelings get worse.
She has feelings of sadness, doubt, guilt, or helplessness that seem to increase each week and get in the way of her normal routine.
She is not able to care for herself or her baby.
She has trouble doing tasks at home or on the job.
Her appetite changes.
Things that used to bring her pleasure no longer do.
Concern and worry about the baby are too intense, or interest in the baby is lacking.
She feels very panicked or anxious. She may be afraid to be left alone with the baby.
She fears harming the baby. These feelings may lead to guilt, which makes the depression worse.
She has thoughts of self-harm or suicide.

If your partner shows any of these signs, tell her of your concerns. Listen to her and support her. Assist in getting her the professional help she may need.

You also should be aware that all new parents can have postpartum depression. Talk to a health care professional if you have any of the signs.

How can I feel involved when my partner is breastfeeding?

Medical experts agree that breastfeeding provides the greatest health benefits for most women and their babies. Some partners feel left out when watching the closeness of breastfeeding. But if your partner has chosen to breastfeed, there are ways you can share in these moments:

Bring the baby to her for feedings.
Burp and change the baby afterward.
Cuddle and rock the baby to sleep.
Help feed your baby if your partner pumps her breast milk into a bottle.

When is it OK to have sex again after the baby is born?

There is no set “waiting period” before a woman can have sex again after giving birth. Some health care professionals recommend waiting 4–6 weeks. The chances of a problem occurring, like bleeding or infection, are small after about 2 weeks following birth. If your partner has had an episiotomy or a tear during birth, she may be told to not have intercourse until the site has completely healed.

PREECLAMPSIA AND HIGH BLOOD PRESSURE DURING PREGNANCY

What is high blood pressure?

Blood pressure is the pressure of the blood against the blood vessel walls each time the heart contracts (squeezes) to pump the blood through your body (see FAQ123 Managing High Blood Pressure). High blood pressure also is called hypertension. Hypertension can lead to health problems. During pregnancy, severe or uncontrolled hypertension can cause complications for you and your baby.

What is chronic hypertension?

Chronic hypertension is high blood pressure that was present before you became pregnant or that occurs in the first half (before 20 weeks) of your pregnancy. If you took blood pressure medication before you became pregnant—even if your blood pressure is normal—you have chronic hypertension.

What is gestational hypertension?

Gestational hypertension is high blood pressure that first occurs in the second half (after 20 weeks) of pregnancy. Although gestational hypertension usually goes away after childbirth, it may increase the risk of developing hypertension in the future.

What kinds of problems can hypertension cause during pregnancy?

High blood pressure during pregnancy can place extra stress on your heart and kidneys and can increase your risk of heart disease, kidney disease, and stroke. Other possible complications include the following:

Fetal growth restriction—High blood pressure can decrease the flow of nutrients to the baby through the placenta. The baby may have growth problems as a result.
Preeclampsia—This condition is more likely to occur in women with chronic high blood pressure than in women with normal blood pressure.
Preterm delivery—If the placenta is not providing enough nutrients and oxygen to your baby, it may be decided that early delivery is better for your baby than allowing the pregnancy to continue.
Placental abruption—This condition, in which the placenta prematurely detaches from the wall of the uterus, is a medical emergency that requires immediate treatment.
Cesarean delivery—Women with hypertension are more likely to have a cesarean delivery than women with normal blood pressure. A cesarean delivery carries risks of infection, injury to internal organs, and bleeding.

How is chronic hypertension during pregnancy managed?

Your blood pressure will be monitored closely throughout pregnancy. You may need to monitor your blood pressure at home. Ultrasound exams may be done throughout pregnancy to track the growth of your baby. If growth problems are suspected, you may have additional tests that monitor the baby’s health. This testing usually begins in the third trimester of pregnancy.

If your hypertension is mild, your blood pressure may stay that way or even return to normal during pregnancy, and your medication may be stopped or your dosage decreased. If you have severe hypertension or have health problems related to your hypertension, you may need to start or continue taking blood pressure medication during pregnancy.

What is preeclampsia?

Preeclampsia is a serious blood pressure disorder that can affect all of the organs in a woman’s body. A woman has preeclampsia when she has high blood pressure and other signs that her organ systems are not working normally. One of these signs is proteinuria (an abnormal amount of protein in the urine). A woman with preeclampsia whose condition is worsening will develop other signs and symptoms known as “severe features.” These include a low number of platelets in the blood, abnormal kidney or liver function, pain over the upper abdomen, changes in vision, fluid in the lungs, or a severe headache. A very high blood pressure reading also is considered a severe feature.

When does preeclampsia occur?

It usually occurs after 20 weeks of pregnancy, typically in the third trimester. When it occurs before 32 weeks of pregnancy, it is called early-onset preeclampsia. It also can occur in the postpartum period.

What causes preeclampsia?

It is not clear why some women develop preeclampsia, but the risk of developing preeclampsia is increased in women who

are pregnant for the first time
have had preeclampsia in a previous pregnancy or have a family history of preeclampsia
have a history of chronic hypertension, kidney disease, or both
are 40 years or older
are carrying more than one baby
have certain medical conditions such as diabetes mellitus, thrombophilia, or lupus
are obese
had in vitro fertilization

What are the risks for my baby if preeclampsia occurs?

If preeclampsia occurs during pregnancy, your baby may need to be delivered right away, even if he or she is not fully grown. Preterm babies have an increased risk of serious complications. Some preterm complications last a lifetime and require ongoing medical care. Babies born very early also may die.

What are the risks for me if preeclampsia occurs?

Women who have had preeclampsia—especially those whose babies were born preterm—have an increased risk later in life of cardiovascular disease and kidney disease, including heart attack, stroke, and high blood pressure. Having preeclampsia once increases the risk of having it again in a future pregnancy. Preeclampsia also can lead to seizures, a condition called eclampsia. It also can lead to HELLP syndrome.

What is HELLP syndrome?

HELLP stands for hemolysis, elevated liver enzymes, and low platelet count. In this condition, red blood cells are damaged or destroyed, blood clotting is impaired, and the liver can bleed internally, causing chest or abdominal pain. HELLP syndrome is a medical emergency. Women can die from HELLP syndrome or have lifelong health problems as a result.

What are the signs and symptoms of preeclampsia?

Swelling of face or hands
A headache that will not go away
Seeing spots or changes in eyesight
Pain in the upper abdomen or shoulder
Nausea and vomiting (in the second half of pregnancy)
Sudden weight gain
Difficulty breathing

How is mild gestational hypertension or preeclampsia without severe features managed?

Management of mild gestational hypertension or preeclampsia without severe features may take place either in a hospital or on an outpatient basis (you can stay at home with close monitoring by your health care provider). You may be asked to keep track of your baby’s movements by doing a daily kick count and to measure your blood pressure at home. You will need to see your health care provider at least weekly and sometimes twice weekly. Once you reach 37 weeks of pregnancy, it may be recommended that you have your baby. If test results show that the baby is not doing well, you may need to have the baby earlier.

How is preeclampsia with severe features managed?

Preeclampsia with severe features usually is treated in the hospital. If you are at least 34 weeks pregnant, it often is recommended that you have your baby as soon as your condition is stable. If you are less than 34 weeks pregnant and your condition is stable, it may be possible to wait to deliver your baby. Corticosteroids may be given to help the baby’s lungs mature, and you most likely will be given medications to help reduce your blood pressure and to help prevent seizures. If your condition or the baby’s condition worsens, prompt delivery will be needed.

What steps can I take to help prevent preeclampsia?

Prevention involves identifying whether you have risk factors for preeclampsia and taking steps to address these factors. If you have hypertension and are planning a pregnancy, see your health care provider for a prepregnancy check-up to find out whether your hypertension is under control and whether it has affected your health. If you are overweight, weight loss usually is advised before pregnancy. If you have a medical condition, such as diabetes, it usually is recommended that your condition be well controlled before you become pregnant.

BLEEDING DURING PREGNANCY

Does bleeding during pregnancy always mean that there is a problem?

Vaginal bleeding during pregnancy has many causes. Some are serious, whereas others are not. Bleeding can occur early or later in pregnancy. Bleeding in early pregnancy is common. In many cases, it does not signal a major problem. Bleeding later in pregnancy can be more serious. It is best to contact your obstetrician–gynecologist (ob-gyn) or other health care professional if you have any bleeding at any time during pregnancy.

How common is bleeding during early pregnancy?

Bleeding in the first trimester happens to about 15–25% of pregnant women. Light bleeding or spotting can occur 1–2 weeks after fertilization when the fertilized egg implants in the lining of the uterus. The cervix may bleed more easily during pregnancy because more blood vessels are developing in this area. It is not uncommon to have spotting or light bleeding after sexual intercourse or after a Pap test or pelvic exam.

What problems can cause bleeding during early pregnancy?

Problems that can cause bleeding in early pregnancy include infection, early pregnancy loss, and ectopic pregnancy.

What is early pregnancy loss?

Loss of a pregnancy during the first 13 weeks of pregnancy is called early pregnancy loss or miscarriage. It happens in about 10% of known pregnancies. Bleeding and cramping are signs of early pregnancy loss. However, about one half of women who have a miscarriage do not have any bleeding beforehand.

If you have had an early pregnancy loss, some of the pregnancy tissue may be left in the uterus. This tissue needs to be removed. You can allow the tissue to pass naturally, or it can be removed with medication or surgery (see FAQ090 “Early Pregnancy Loss”).

What is an ectopic pregnancy?

An ectopic pregnancy occurs when the fertilized egg does not implant in the uterus but instead implants somewhere else, usually in one of the fallopian tubes. If the fallopian tube ruptures, internal bleeding can occur. Blood loss may cause weakness, fainting, pain, shock, or even death.

Sometimes vaginal bleeding is the only sign of an ectopic pregnancy. Other symptoms may include abdominal, pelvic, or shoulder pain. These symptoms can occur before you even know you are pregnant. If you have these symptoms, call your ob-gyn or other health care professional. The pregnancy will not survive, and it must be removed with medication or surgery (see FAQ155 “Ectopic Pregnancy”).

What can cause bleeding later in pregnancy?

Common problems that may cause light bleeding later in pregnancy include inflammation of or growths on the cervix. Heavy bleeding is a more serious sign. Heavy bleeding may be caused by a problem with the placenta. Any amount of bleeding also may signal preterm labor. If you have any bleeding late in pregnancy, contact your ob-gyn right away or go immediately to the hospital.

What problems with the placenta can cause bleeding during pregnancy?

Several problems with the placenta later in pregnancy can cause bleeding:

Placental abruption—In placental abruption, the placenta detaches from the wall of the uterus before or during birth. The most common signs and symptoms are vaginal bleeding and abdominal or back pain. Placental abruption can cause serious complications if it is not found early. The baby may not get enough oxygen, and the pregnant woman can lose a large amount of blood.
Placenta previa—When the placenta lies low in the uterus, it may partly or completely cover the cervix. This is called placenta previa. It may cause vaginal bleeding. This type of bleeding often occurs without pain. Some types of placenta previa resolve on their own by 32–35 weeks of pregnancy as the lower part of the uterus stretches and thins out. Labor and delivery then can happen normally. If placenta previa does not resolve, you may need to have the baby early by cesarean delivery.
Placenta accreta—When the placenta (or part of the placenta) invades and is inseparable from the uterine wall, it is called placenta accreta. Placenta accreta can cause bleeding during the third trimester and severe blood loss during delivery. Most cases can be found during pregnancy with a routine ultrasound exam. Sometimes, though, it is not discovered until after the baby is born. If you have placenta accreta, you are at risk of life-threatening blood loss during delivery. Your ob-gyn will plan your delivery carefully and make sure that all needed resources are available. You may need to have your baby at a hospital that specializes in this complication. Hysterectomy often needs to be done right after delivery to prevent life-threatening blood loss.

Can bleeding be a sign of preterm labor?

Late in pregnancy, vaginal bleeding may be a sign of labor. If labor starts before 37 completed weeks of pregnancy, it is called preterm labor. Other signs of preterm labor include the following:

Change in vaginal discharge (it becomes watery, mucus-like, or bloody) or increase in amount of vaginal discharge
Pelvic or lower abdominal pressure
Constant, low, dull backache
Mild abdominal cramps, with or without diarrhea
Regular or frequent contractions or uterine tightening, often painless (four times every 20 minutes or eight times an hour for more than 1 hour)
Ruptured membranes (your water breaks—either a gush or a trickle)

How preterm labor is managed is based on what is thought to be best for your health and your baby’s health. In some cases, medications may be given. When preterm labor is too far along to be stopped or there are reasons that the baby should be born early, it may be necessary to deliver the baby.

TRAVEL DURING PREGNANCY

When is the best time to travel during pregnancy?

The best time to travel is probably the middle of your pregnancy—between weeks 14 and 28. Most common pregnancy emergencies usually happen in the first and third trimesters. After 28 weeks, it may be harder for you to move around or sit for a long time.

What should I know about planning long car trips during pregnancy?

During a car trip, make each day’s drive brief. Try to limit driving to no more than 5 or 6 hours each day. Be sure to wear your seat belt every time you ride in a motor vehicle, even if your car has an air bag (see FAQ018 “Car Safety for Pregnant Women, Babies, and Children”). Plan to make frequent stops to move around and stretch your legs.

What should I know about airplane travel while pregnant?

Some domestic airlines restrict travel during the last month of pregnancy or require a medical certificate; others discourage travel after 36 weeks of pregnancy. If you are planning an international flight, the cutoff point for traveling with international airlines is often earlier.

When traveling by air, you can take the following steps to help make your trip as comfortable as possible:

If you can, book an aisle seat, so that it is easy to get up and stretch your legs during a long flight.
Avoid gas-producing foods and carbonated drinks before your flight.
Wear your seatbelt at all times. The seatbelt should be belted low on the hipbones, below your belly.
If you are prone to nausea, your health care provider may be able to prescribe anti-nausea medication.

What should I know when planning a trip on a ship during pregnancy?

It may be a good idea, just in case, to ask your health care provider about which medications are safe for you to carry along to calm seasickness. Seasickness bands are useful for some people, although there is little scientific evidence that they work. These bands use acupressure to help ward off an upset stomach.

Another concern for cruise ship passengers is norovirus infection. Noroviruses are a group of viruses that can cause severe nausea and vomiting for 1 or 2 days. They are very contagious and can spread rapidly throughout cruise ships. People can become infected by eating food, drinking liquids, or touching surfaces that are contaminated with the virus. Before you book a cruise, you may want to check whether your ship has passed a health and safety inspection conducted by the Centers for Disease Control and Prevention (CDC).

How can I prepare for a trip out of the country while pregnant?

If you are planning a trip out of the country, your health care provider can help you decide if travel outside the United States is safe for you and advise you about what steps to take before your trip. The CDC also is a good resource for travel alerts, safety tips, and up-to-date vaccination facts for many countries. While you are pregnant, you should not travel to areas where there is risk of malaria, including Africa, Central and South America, and Asia.

What should I be aware of when traveling out of the country?

When travelling out of the country, make sure to follow these tips:

The safest water to drink is tap water that has been boiled for 1 minute (3 minutes at altitudes higher than 6,000 feet). Bottled water is safer than unboiled tap water, but because there are no standards for bottled water, there is no guarantee that it is free of germs that can cause illness. Carbonated beverages and drinks made with boiled water are safe to drink.
Do not put ice made from unboiled water in your drinks. Do not drink out of glasses that may have been washed in unboiled water.
Avoid fresh fruits and vegetables unless they have been cooked or if you have peeled them yourself.
Do not eat raw or undercooked meat or fish.

What health care preparations should I make before traveling while pregnant?

If you are traveling in the United States, locate the nearest hospital or medical clinic in the place you are visiting. If you are traveling internationally, the International Association for Medical Assistance to Travelers (IAMAT) has a worldwide directory of doctors. The doctors in the country you are visiting may not speak English, so bring a dictionary of the language spoken with you. Another tip is to register with an American embassy or consulate after you arrive at your destination. These agencies may be helpful if you need to leave the country because of an emergency.

HAVING A BABY AFTER AGE 35

Why is there a concern about having a child later in life?

Becoming pregnant after age 35 years can present a challenge. Also, having a child later in life has certain risks. These risks may affect a woman’s health as well as her baby’s health.

How does age affect fertility?

Fertility in women starts to decrease at age 32 years and becomes more rapid after age 37 years. Women become less fertile as they age because they begin life with a fixed number of eggs in their ovaries. This number decreases as they grow older. Eggs also are not as easily fertilized in older women as they are in younger women. Problems that can affect fertility, such as endometriosis and uterine fibroids, become more common with increasing age as well.

What specific health concerns are there for later childbearing?

Older women are more likely to have preexisting health problems than younger women. For example, high blood pressure is a condition that is more common in older women (see FAQ034 “Preeclampsia and High Blood Pressure During Pregnancy”). If you are older than 35 years, you also are more likely to develop high blood pressure and related disorders for the first time during pregnancy. The risk of developing diabetes or gestational diabetes increases with age as well (see FAQ177 “Gestational Diabetes”).

How can high blood pressure affect pregnancy?

High blood pressure poses risks that include problems with the placenta and the growth of the fetus.

How can diabetes affect pregnancy?

If you have diabetes, you are at greater risk of having a child with birth defects. The risks of high blood pressure, miscarriage, and macrosomia, a condition in which the fetus grows too large, are increased as well.

Do older women have an increased risk of having a child with a birth defect?

The overall risk of having a child with a birth defect is small. However, the risk of having a child with a birth defect caused by missing, damaged, or extra chromosomes is increased in older women.

What types of testing can be done during pregnancy to screen for or detect certain birth defects in the fetus?

Screening tests assess the risk that a baby will be born with certain disorders. All pregnant women should be offered screening tests for birth defects. Diagnostic tests show whether the baby actually has a certain disorder. Diagnostic tests are available for some, but not all, inherited defects and many chromosomal disorders. They include a targeted ultrasound exam, amniocentesis, and chorionic villus sampling.

Are older women at greater risk of having a multiple pregnancy?

Older women have a higher risk of multiple pregnancy than younger women. In addition, some fertility treatments carry an increased risk of multiple pregnancy.

What risks are associated with multiple pregnancy?

Multiple pregnancy can cause serious problems, including preterm birth, preeclampsia, fetal growth problems, and gestational diabetes. The risk and severity of these problems increase with the number of babies.

What are the possible complications during labor and delivery for older women?

Older women are at increased risk of preterm labor and preterm birth (see FAQ087 “Preterm [Premature] Labor and Birth” and FAQ173 “Extremely Preterm Birth”). Babies born preterm can have serious short-term and long-term health problems. The risk of stillbirth also is greater in women who are older than 35 years.

Women who are in their 30s are more likely to need a cesarean delivery than women who are in their 20s. Like any major surgery, cesarean delivery involves risks. Risks include infection, injury to organs such as the bowel or bladder, and reactions to the anesthesia used. These problems occur in a small number of women and usually are easily treated (see FAQ006 “Cesarean Birth [C-section]”).

What can I do before pregnancy to increase my chances of having a healthy baby?

See your health care provider for a preconception care checkup (see FAQ056 “Good Health Before Pregnancy: Preconception Care”).
Eat a healthy diet.
Take 400 micrograms (0.4 mg) of folic acid daily for at least 1 month before pregnancy and during pregnancy to help reduce the risk of having a baby with a neural tube defect.
Exercise regularly.
Lose weight if you are overweight or obese.
Stop smoking, drinking alcohol, and taking illegal drugs.
Avoid contact with substances in your home or workplace that could be harmful during pregnancy.

What can I do during pregnancy to increase my chances of having a healthy baby?

Continue to take good care of yourself during pregnancy, and get early and regular prenatal care. At each prenatal care visit, your health care provider will monitor your health and your baby’s health and manage any problems should they arise.

WHAT TO EXPECT AFTER YOUR DUE DATE

What is the due date and what does it mean?

Your due date is used as a guide for checking your pregnancy’s progress and the baby’s growth and age. Health care providers often use more than one method to set the due date. Ultrasound performed between 18 weeks and 20 weeks of pregnancy often is used to help confirm the age of a fetus.

What is postterm pregnancy?

A postterm pregnancy is one that lasts 42 weeks or longer. Women who are having a baby for the first time or who have had postterm pregnancies before may give birth later than expected. However, the most common cause of postterm pregnancy is an error in calculating the due date. When a postterm pregnancy truly exists, the cause usually is unknown.

What are the risks associated with postterm pregnancy?

After 42 weeks, the placenta may not work as well as it did earlier in pregnancy. Also, as the baby grows, the amount of amniotic fluid may begin to decrease. Less fluid may cause the umbilical cord to become pinched as the baby moves or as the uterus contracts.

If pregnancy goes past 42 weeks, a baby has an increased risk of certain problems, such as dysmaturity syndrome, macrosomia, or meconium aspiration. There also is an increased chance of cesarean delivery.

What tests can be performed in cases of postterm pregnancy?

When a baby is not born by the due date, tests can help the health care provider check on the baby’s health. Some tests, such as a kick count, can be done on your own at home. A kick count is a record of how often you feel your baby move. Others are done in the health care provider’s office or in the hospital. These tests involve electronic fetal monitoring and include the nonstress test, biophysical profile, and contraction stress test.

What is electronic fetal monitoring?

Electronic fetal monitoring uses two belts placed around the mother’s abdomen to hold instruments that measure fetal heart rate and the strength of uterine contractions. This method is used to perform the following tests for fetal well-being:

Nonstress test—The mother pushes a button each time she feels the baby move. This causes a mark to be made on a paper recording of the fetal heart rate.
Biophysical profile—This test combines the results of electronic fetal monitoring and an ultrasound exam. It checks the baby’s heart rate (using the nonstress test) and estimates the amount of amniotic fluid. The baby’s breathing, movement, and muscle tone also may be checked.
Contraction stress test—The baby’s heart rate is measured when the mother’s uterus contracts. The contractions are induced, and changes in the fetus’s heart rate are noted.

What is labor induction?

Labor induction is the use of medication or other methods to bring on labor. Labor is induced to cause a pregnant woman’s cervix to open and to prepare for vaginal birth. Most health care providers wait 1–2 weeks after a woman’s due date before considering inducing labor.

How is labor induced?

Methods used to induce labor include:

Ripening or dilating the cervix—Prostaglandins may be used to soften the cervix and to cause the uterus to contract. Special devices can be used to dilate the cervix.
Stripping or sweeping the amniotic membranes—Your health care provider sweeps a finger over the thin membranes that connect the amniotic sac to the wall of your uterus. Women who have this procedure are more likely to have contractions and may go into labor within 48 hours.
Rupturing the amniotic sac—Your health care provider makes a small hole in the amniotic sac to release the fluid (“breaking the water”). Most women go into labor within hours of their water breaking
Using oxytocin—This hormone, given through an intravenous (IV) tube in your arm, causes the uterus to contract.

IF YOUR BABY IS BREECH

What does it mean when a baby is breech?

In the last weeks of pregnancy, babies usually move so that their heads are positioned to come out of the vagina first during birth. This is called a vertex presentation. A breech presentation occurs when the baby’s buttocks, feet, or both are in place to come out first during birth. This happens in 3–4% of full-term births.

What factors are related to breech presentation?

It is not always known why a baby is breech. Some factors that may contribute to a baby being in a breech presentation include the following:

You have been pregnant before.
There is more than one fetus in the uterus (twins or more).
There is too much or too little amniotic fluid.
The uterus is not normal in shape or has abnormal growths such as fibroids.
The placenta covers all or part of the opening of the uterus (placenta previa).
The baby is preterm.

Occasionally babies with certain birth defects will not turn into the head-down position before birth. However, most babies in a breech presentation are otherwise normal.

How can your health care provider tell if your baby is breech?

Your health care provider may be able to tell which way your baby is facing by placing his or her hands at certain points on your abdomen. By feeling where the baby’s head, back, and buttocks are, it may be possible to find out what part of the baby is presenting first. An ultrasound exam or pelvic exam may be used to confirm it.

What is external cephalic version (ECV)?

External cephalic version (ECV) is an attempt to turn the baby so that he or she is head down. It can improve your chance of having a vaginal birth. If the baby is breech and you are between 36 weeks and 38 weeks of pregnancy, your health care provider may suggest ECV.

When will ECV not be attempted?

ECV will not be tried if you are carrying more than one baby, there are concerns about the health of the baby, you have certain abnormalities of the reproductive system, or the placenta is in the wrong place or has detached from the wall of the uterus (placental abruption).

How is ECV performed?

The health care provider performs ECV by placing his or her hands on your abdomen. Firm pressure is applied to the abdomen so that the baby rolls into a head-down position. Two people may be needed to perform ECV. Ultrasound also may be used to help guide the turning.

The baby’s heart rate is checked with fetal monitoring before and after ECV. If any problems arise with you or the baby, ECV will be stopped right away. ECV usually is done near a delivery room. If a problem occurs, a cesarean delivery can be performed quickly, if necessary.

What complications can occur with ECV?

Complications may include the following:

Premature rupture of membranes
Changes in the baby’s heart rate
Placental abruption
Preterm labor

How successful are attempts at ECV?

More than one half of attempts at ECV succeed. However, some babies who are successfully turned with ECV move back into a breech presentation. If this happens, ECV may be tried again. ECV tends to be harder to do as the time for birth gets closer. As the baby grows bigger, there is less room for him or her to move.

What are the options for birth if my baby is breech?

Today, most breech babies are born by planned cesarean delivery. A planned vaginal birth of a single breech baby may be considered in some situations. Both vaginal birth and cesarean birth carry certain risks when a baby is breech. However, the risk of complications is higher with a planned vaginal delivery than with a planned cesarean delivery.

What complications can occur during a vaginal birth of a breech baby?

In a breech presentation, the body comes out first, leaving the baby’s head to be delivered last. The baby’s body may not stretch the cervix enough to allow room for the baby’s head to come out easily. There is a risk that the baby’s head or shoulders may become wedged against the bones of the mother’s pelvis. Another problem that can happen during a vaginal breech birth is a prolapsed umbilical cord. It can slip into the vagina before the baby is delivered. If there is pressure put on the cord or it becomes pinched, it can decrease the flow of blood and oxygen through the cord to the baby.

What complications can occur during a cesarean delivery?

A cesarean delivery is major surgery. Like any major surgery, cesarean delivery may be complicated by infection, bleeding, or injury to internal organs. The type of anesthesia used sometimes causes problems. Having a cesarean delivery also can lead to serious problems in future pregnancies, such as rupture of the uterus and complications involving the placenta. With each cesarean delivery, these risks increase.

What things do I need to consider if I want to have a vaginal birth and my baby is breech?

If you are thinking about having a vaginal birth and your baby is breech, your health care provider will review the risks and benefits of vaginal birth and cesarean birth in detail. You usually need to meet certain guidelines specific to your hospital. The experience of your health care provider in delivering breech babies vaginally also is an important factor.

EARLY PREGNANCY LOSS

What is early pregnancy loss?

The loss of a pregnancy during the first 13 weeks of pregnancy (the first trimester) is called early pregnancy loss, miscarriage, or spontaneous abortion.

How common is early pregnancy loss?

Early pregnancy loss is common. It happens in about 10% of known pregnancies.

What causes early pregnancy loss?

About one half of cases of early pregnancy loss are caused by a random event in which the embryo receives an abnormal number of chromosomes. Chromosomes are the structures inside cells that carry genes. Most cells have 23 pairs of chromosomes for a total of 46 chromosomes. Sperm and egg cells each have 23 chromosomes. During fertilization, when the egg and sperm join, the two sets of chromosomes come together. If an egg or sperm has an abnormal number of chromosomes, the embryo also will have an abnormal number. Development will not occur normally, sometimes resulting in loss of the pregnancy.

Are there certain activities that cause early pregnancy loss?

Some women worry that they have done something to cause their pregnancy loss. Working, exercising, having sex, or having used birth control pills before getting pregnant do not cause early pregnancy loss. Morning sickness does not cause early pregnancy loss. Some women who have had an early pregnancy loss believe that it was caused by a recent fall, blow, or even a fright. In most cases, this is not true.

Smoking, alcohol, and caffeine also have been studied as causes of early pregnancy loss. Some research suggests that smoking increases the risk, while other research suggests that it does not. Alcohol use in the first trimester may slightly increase the risk of early pregnancy loss, but the research is not clear. In any case, it is best to avoid smoking and drinking alcohol during pregnancy. Consuming 200 mg or less of caffeine a day (the amount in two cups of coffee) does not appear to increase the risk of early pregnancy loss.

Are some women at higher risk of early pregnancy loss than others?

The likelihood of early pregnancy loss occurring increases as a woman gets older. Early pregnancy loss occurs in more than one third of pregnancies in women older than 40 years.

What are the signs and symptoms of early pregnancy loss?

Bleeding and cramping are the most common symptoms of early pregnancy loss. A small amount of bleeding and cramping in early pregnancy is relatively common. Bleeding often stops on its own, and the pregnancy continues normally. Bleeding and cramping also can be signs of other pregnancy problems, such as ectopic pregnancy. If you have any of these signs or symptoms, contact your obstetrician–gynecologist (ob-gyn) or other member of your health care team.

How is early pregnancy loss diagnosed?

If you have signs and symptoms of early pregnancy loss, you most likely will have a physical exam. Your obstetrician will ask you questions about when the bleeding started, how much you are bleeding, and whether you have pain or cramping. An ultrasound exam may be done to check whether the embryo is still growing in the uterus or to detect the presence of a heartbeat. You may have a test to measure the level of human chorionic gonadotropin (hCG) in your blood. This substance is made by the developing placenta. A low or decreasing level of hCG can mean loss of the pregnancy. Several ultrasound exams and hCG tests may be necessary to confirm that pregnancy loss has occurred.

If I experience early pregnancy loss, will I have to get treatment?

When a pregnancy is lost, some of the pregnancy tissue may remain in the uterus. This tissue needs to be removed. There are several ways this can be done. If the situation is not an emergency, you can help choose the type of treatment. The available options have similar risks, which include infection and heavy bleeding. The risk of serious complications, regardless of the type of treatment, is very small.

If your blood type is Rh negative, you also likely will receive a shot of Rh immunoglobulin after an early pregnancy loss. Problems can arise in a future pregnancy if you are Rh negative and the fetus is Rh positive. These problems can be prevented by giving Rh immunoglobulin after a pregnancy loss.

What nonsurgical options are available to treat early pregnancy loss?

If you do not show any signs of an infection, one option is to wait and let the tissue pass naturally. This usually takes up to 2 weeks, but it may take longer in some cases. Another option is to take medication that helps expel the tissue.

What can I expect if I have nonsurgical treatment?

You will have bleeding. The bleeding usually is heavier than a menstrual period and lasts for a longer time. Cramping pain, diarrhea, and nausea also can occur. Your ob-gyn may prescribe pain medication. You may pass tissue in addition to bleeding. With an early pregnancy loss, the pregnancy tissue resembles a blood clot. It does not look like a baby. An ultrasound exam or blood tests for hCG usually are done afterward to confirm that all of the tissue has been expelled. If it has not, you may need to have surgical treatment.

What surgical options are available to treat early pregnancy loss?

Surgery is recommended if you have signs of an infection, heavy bleeding, or other medical conditions. One surgical option is called vacuum aspiration. In this procedure, a thin tube attached to a suction device is inserted into the uterus to remove the tissue. The procedure may be performed in your doctor’s office. Local anesthesia is used. You also may be given medication to help you relax. Another option is called dilation and curettage (D&C). In a D&C, the cervix is dilated (opened), and an instrument is used to remove the pregnancy tissue. A D&C usually is done in an operating room or surgical center. General anesthesia or regional anesthesia may be used.

What can I expect during recovery from early pregnancy loss?

You may be advised not to put anything into your vagina (such as using tampons or having sexual intercourse) for 1–2 weeks after an early pregnancy loss. This is to help prevent infection. Call your ob-gyn right away if you have any of the following symptoms:

Heavy bleeding (soaking more than two maxi pads per hour for more than 2 hours in a row)
Fever
Chills
Severe pain

Is there anything that can help my partner and me cope with early pregnancy loss?

If you or your partner is having trouble handling the feelings that go along with this loss, talk to your ob-gyn or other member of your health care team. You also may find it helpful to talk with a counselor. Support groups—either online or in person—can be helpful. SHARE: Pregnancy and Infant Loss Support, Inc. (www.nationalshare.org) lists local support groups and offers online resources to help with grief and healing.

Is it possible for me to have another baby after an early pregnancy loss?

Pregnancy loss in the first trimester usually is a one-time event. Most women go on to have successful pregnancies. Repeated pregnancy losses are rare. Testing and evaluation can be done to try to find a cause if you have several pregnancy losses. Even if no cause is found, most couples will go on to have successful pregnancies.

How long after early pregnancy loss will it take for me to be able to become pregnant again?

You can ovulate and become pregnant as soon as 2 weeks after an early pregnancy loss. If you do not wish to become pregnant again right away, be sure to use a birth control method. You can use any contraceptive method, including having an intrauterine device inserted, immediately after an early pregnancy loss. If you do wish to become pregnant, there is no medical reason to wait to begin trying again. You may want to wait until after you have had a menstrual period so that calculating the due date of your next pregnancy is easier.

HEPATITIS B AND HEPATITIS C IN PREGNANCY

What are hepatitis B and hepatitis C infections?

Hepatitis B and hepatitis C are serious infections that affect the liver. Both diseases are contagious and caused by viruses. Both can lead to serious, long-term illness.

What extra risks are caused by hepatitis B and hepatitis C infections during pregnancy?

Not only does a pregnant woman face the risks of hepatitis herself, she also can pass the viruses to her baby. Many pregnant women may not even know that they are infected because infection sometimes causes no signs or symptoms.

How is hepatitis B virus infection spread?

Hepatitis B virus is spread by direct contact with the body fluids (such as blood, semen, or vaginal fluids) of an infected person. This can happen during unprotected sex or while sharing needles used to inject (“shoot”) drugs. A baby can be infected during birth if the mother has hepatitis B. Hepatitis B virus also can be spread if you live with an infected person and share household items that may come into contact with body fluids, such as toothbrushes or razors. Hepatitis B is not spread by casual contact with people and objects. Hepatitis B is not spread by breastfeeding.

What is acute hepatitis B virus infection?

Infection with hepatitis B virus can be acute or chronic. Acute infection is a short-term illness that happens in the first 6 months after a person is infected. Symptoms may include the following:

Tiredness
Loss of appetite
Nausea and vomiting
Jaundice (yellowing of the skin and eyes)
Stomach pain
Pain in the muscles and joints

The infection can clear up completely in a few weeks without treatment. Those who do get rid of the hepatitis B virus become immune to it. They cannot get the virus again.

What is chronic hepatitis B virus infection?

A small number of adults and many children younger than 5 years who are infected never get rid of the hepatitis B virus. This is called chronic infection. These people keep the virus for the rest of their lives. They are known as carriers. Most carriers do not have any symptoms. In a small number of carriers, chronic infection can lead to serious complications, such as cirrhosis of the liver, liver cancer, and early death.

Can hepatitis B virus infection be cured?

There is no cure for hepatitis B virus infection, but symptoms can be managed. There also is a vaccine that prevents hepatitis B virus infection. People who have had recent contact with the hepatitis B virus and are not vaccinated can be given a shot called hepatitis B immune globulin (HBIG) along with the vaccine. HBIG contains antibodies to the virus. It can give additional protection against infection in certain situations.

If I am pregnant and infected with the hepatitis B virus, how likely is it that I will pass the virus to my baby?

About 90% of pregnant women with acute hepatitis B virus infection will pass the virus to their babies. Between 10% and 20% of women with chronic infection will do so.

How does hepatitis B virus infection affect babies?

Hepatitis B virus infection can be severe in babies. It can threaten their lives. Infected newborns have a high risk (up to 90%) of becoming carriers. They, too, can pass the virus to others. When they become adults, they have a 25% risk of dying of cirrhosis of the liver or liver cancer.

How can I find out if I am infected with the hepatitis B virus?

All pregnant women are tested for hepatitis B. There are different blood tests for hepatitis B virus infection. They can tell whether you have been infected recently or whether you are a carrier. They also can tell whether you have had the hepatitis B virus in the past and are now immune to it or whether you have had the hepatitis B vaccine.

What if my test result is positive for hepatitis B virus infection?

If your test result shows that you are infected with the hepatitis B virus, you may have additional tests to check the function of your liver and your general health. Your other children, your sexual partners, and others living in your household are at risk of infection. They should be told about testing and vaccination.

Will having the hepatitis B virus affect how I will give birth?

Having hepatitis B infection does not affect how you will give birth. You still can have a vaginal delivery if you are infected with the hepatitis B virus.

If I am infected with the hepatitis B virus, can I breastfeed?

Yes. You still can breastfeed your baby if you are infected with the hepatitis B virus.

If I am infected with the hepatitis B virus, what can be done to prevent my baby from becoming infected?

Within a few hours of birth, your baby will receive the first dose of the hepatitis B vaccine. A shot of HBIG is given as well. Two more doses of the vaccine are given over the next 6 months. After the vaccine series is complete, your baby will be tested for hepatitis B virus infection.

What if my baby tests positive for hepatitis B virus infection?

If test results show that the baby is infected with the hepatitis B virus, he or she will need to have ongoing medical care. Regular visits with a health care provider will be needed to assess the baby’s health and how well the liver is working.

If I am not infected with the hepatitis B virus, when should my baby be vaccinated?

All babies are vaccinated against the hepatitis B virus. If you are not infected with the hepatitis B virus, your baby should get the first dose of vaccine before you leave the hospital. If it cannot be given by then, it should be given within 2 months of birth. The remaining doses are given within the next 6–18 months.

Can I be vaccinated against hepatitis C virus infection?

There is no vaccine to protect against the hepatitis C virus. Avoiding certain types of behavior is the only way to prevent infection. Hepatitis C is most common in people born between 1945 and 1965. For this reason, all people in this age group should be tested for hepatitis C infection.

How is hepatitis C virus infection spread?

The hepatitis C virus is spread by direct contact with infected blood. This can happen while sharing needles or sharing household items that come into contact with blood. A baby can be infected during birth if the mother has hepatitis C infection. It also can be spread during unprotected sex, but it is harder to spread the virus this way. It is not spread by casual contact or breastfeeding.

What are signs and symptoms of hepatitis C virus infection?

Hepatitis C virus infection causes signs and symptoms similar to those of hepatitis B virus infection. It also can cause no symptoms. Unlike hepatitis B virus infection, most adults infected with the hepatitis C virus—75% to 85%—become carriers. Most carriers develop long-term liver disease. A smaller number will develop cirrhosis of the liver and other serious, life-threatening liver problems.

If I am infected with the hepatitis C virus, how likely is it that I will pass the virus to my baby?

About 4% of women who are infected with the hepatitis C virus will pass it to their babies. The risk is related to how much of the virus a woman has and whether she also is infected with HIV.

If I am infected with the hepatitis C virus, how soon after I give birth will my baby be tested?

If you are infected with the hepatitis C virus, your baby usually will be tested when he or she is at least 18 months of age.

If I am infected with the hepatitis C virus, can I breastfeed?

Yes. You still can breastfeed your baby if you are infected with the hepatitis C virus.

GENETIC DISORDERS

What are genes?

A gene is a small piece of hereditary material called DNA that controls some aspect of a person’s physical makeup or a process in the body. Genes come in pairs.

What are chromosomes?

Chromosomes are the structures inside cells that carry genes. Chromosomes also come in pairs. Most cells have 23 pairs
of chromosomes for a total of 46 chromosomes. Sperm and egg cells each have 23 chromosomes. During fertilization,
when the egg and sperm join, the two sets of chromosomes come together. In this way, one half of a baby’s genes come
from the baby’s mother and one half come from the baby’s father.

What determines my baby’s sex?

Your baby’s sex is determined by sex chromosomes. There are two sex chromosomes: X and Y. Egg cells only contain an X chromosome. Sperm cells can carry an X or a Y. A combination of XX results in a girl and XY results in a boy.

What causes genetic disorders?

Genetic disorders may be caused by problems with either chromosomes or genes.

What causes chromosome disorders?

A chromosome disorder is caused by problems with chromosomes. Most children with chromosome disorders have physical defects and some have intellectual disabilities.

What is aneuploidy?

Having missing or extra chromosomes is a condition called aneuploidy. The risk of having a child with an aneuploidy increases as a woman ages.

Trisomy is the most common aneuploidy. In trisomy, there is an extra chromosome. A common trisomy is trisomy 21 (Down syndrome). Other trisomies include trisomy 13 (Patau syndrome) and trisomy 18 (Edwards syndrome). Monosomy is another type of aneuploidy in which there is a missing chromosome. A common monosomy is Turner syndrome, in which a female has a missing or damaged X chromosome.

What is an inherited disorder?

An inherited disorder is caused by defective genes that can be passed down by parents to their children. Defective genes can occur on any of the chromosomes. A genetic disorder can be autosomal dominant, autosomal recessive, or sex linked.

What is an autosomal dominant disorder?

An autosomal dominant disorder is caused by just one defective gene from either parent. “Autosomal” means that the defective gene is located on any of the chromosomes that are not the sex chromosomes (X or Y). If one parent has the gene, each child of the couple has a 50% chance of inheriting the disorder. An example of an autosomal dominant disorder is Huntington disease.

What is an autosomal recessive disorder?

Autosomal recessive disorders only happen when both parents carry the gene. An example of an autosomal recessive disorder is cystic fibrosis.

What is a carrier?

A carrier of a recessive disorder is a person who carries one copy of a gene that works incorrectly and one that works normally. A carrier may not have symptoms of the disorder or may have only mild symptoms. If both parents are carriers of an abnormal gene, there is a 25% chance that the child will get the abnormal gene from each parent and will have the disorder. There is a 50% chance that the child will be a carrier of the disorder—just like the carrier parents. If only one parent is a carrier, there is a 50% chance that the child will be a carrier of the disorder.

What are sex-linked disorders?

Sex-linked disorders are caused by defective genes on the sex chromosomes. An example of a sex-linked disorder is hemophilia. This disease is caused by a defective gene on the X chromosome.

What are multifactorial disorders?

Multifactorial disorders are caused by a combination of factors. Some factors are genetic, while some are nongenetic. A few of these disorders can be detected during pregnancy.

Do certain people have an increased risk of having a child with a birth defect compared with others?

Most babies with birth defects are born to couples without risk factors. However, the risk of birth defects is higher when certain factors are present. Screening for birth defects begins by assessing your risk factors, such as whether you have a genetic disorder, whether you have a child with a genetic disorder, or whether there is a family history of a genetic disorder.

Some genetic disorders are more common in certain ethnic groups.

What is genetic counseling?

In some situations, you may be referred to a genetic counselor. A genetic counselor has special training in genetics. In addition to studying your family health history, he or she may refer you for physical exams and tests. Using this information, the counselor will assess your baby’s risk of having a problem, discuss your options, and talk about any concerns you may have.
What types of prenatal tests are available to address concerns about genetic disorders?
Screening tests assess the risk that a baby will be born with a specific birth defect or genetic disorder. Diagnostic tests can detect if a specific birth defect or genetic disorder is present in the fetus.

When are screening tests offered during pregnancy and what kinds of disorders do they assess?

Screening tests often are part of routine prenatal care and are done at different times during the first and second trimesters of pregnancy. Screening tests include blood tests that measure the level of certain substances in the mother’s blood combined with an ultrasound exam. These tests assess the risk that a baby will have Down syndrome and other trisomies, as well as neural tube defects. Prenatal screening tests are discussed in detail in FAQ165 Screening Tests for Birth Defects.

What are carrier tests?

Carrier tests are a type of screening test that can show if a person carries a gene for an inherited disorder.

For whom is carrier testing recommended?

Carrier testing often is recommended for people with a family history of a genetic disorder or people from certain races or ethnic groups who are at increased risk of having a child with a specific genetic disorder. Cystic fibrosis carrier screening is offered to all women of reproductive age because it is one of the most common genetic disorders.

When is carrier testing done?

Carrier tests can be done before (preconception) or during pregnancy. Preconception carrier testing is discussed in detail in FAQ179 Preconception Carrier Screening.

When are diagnostic tests offered during pregnancy and what kinds of disorders do they detect?

Diagnostic tests may be recommended if a screening test shows an increased risk of a birth defect. Diagnostic testing also is offered as a first choice to all pregnant women, even those who do not have risk factors. Diagnostic tests can detect if a specific birth defect or genetic disorder is present.

How are diagnostic tests done?

Diagnostic tests are done on cells from the fetus obtained through amniocentesis, chorionic villus sampling, or, rarely, fetal blood sampling. The chromosomes and genes in the cells then can be analyzed using different techniques to diagnose certain inherited defects and many chromosomal defects. Diagnostic tests are discussed in detail in FAQ164 Diagnostic Tests for Birth Defects.

Are there risks associated with diagnostic tests?

Diagnostic tests carry risks, including an increased risk of pregnancy loss.

How do I know which tests to have?

Your health care provider or a genetic counselor can discuss all of the testing options with you and help you decide based on your individual risk factors.

Do I have to have these tests?

Whether you want to be tested is a personal choice. Some couples would rather not know if they are at risk or whether their child will have a disorder, but others want to know in advance. Knowing beforehand gives you time to prepare for having a child with a particular disorder and to organize the medical care that your child may need. You also may have the option of not continuing the pregnancy.

SPECIAL TESTS FOR MONITORING FETAL HEALTH

Why may special tests be needed during pregnancy?

Special testing during pregnancy most often is done when the fetus is at increased risk of problems that could result in pregnancy complications or lead to stillbirth. This can occur in the following situations:

High-risk pregnancy (a woman has had complications in a previous pregnancy or has a preexisting health condition such as diabetes or heart disease)
Problems during pregnancy, such as fetal growth problems, Rh sensitization, or high blood pressure
Decreased movement of the fetus
Pregnancy that goes past 42 weeks (postterm pregnancy)
Multiple pregnancy with certain complications

When during pregnancy are special tests performed?

Special testing usually is started between week 32 and week 34 of pregnancy. Testing may be started earlier if problems are particularly serious or there are multiple risk factors.

How often are special tests done?

How often the tests are done depends on the condition that prompted the testing, whether the condition remains stable, and results of the testing. Some tests are repeated weekly. In certain situations, tests may be done twice weekly.

What are the types of special tests?

The tests used to monitor fetal health include fetal movement counts, the nonstress test, biophysical profile, modified biophysical profile, contraction stress test, and Doppler ultrasound of the umbilical artery.

What are fetal movement counts?

If you have felt fetal movement less often than what you think is normal, your health care provider may ask you to keep track of the fetus’s movements. Fetal movement counting (also called “kick counts”) is a test that you can do at home. There are different ways kick counts can be done. Your health care provider will tell you how often to do it and when to notify him or her.

What is a nonstress test?

The nonstress test measures the fetal heart rate in response to fetal movement over time. The term “nonstress” means that during the test, nothing is done to place stress on the fetus.

How is the nonstress test performed?

This test may be done in the health care provider’s office or in a hospital. The test is done while you are reclining or lying down and usually takes at least 20 minutes. A belt with a sensor that measures the fetal heart rate is placed around your abdomen. The fetal heart rate is recorded by a machine.

What do the results of a nonstress test mean?

If two or more accelerations occur within a 20-minute period, the result is considered reactive or “reassuring.” A reactive result means that for now, it does not appear that there are any problems. A nonreactive result is one in which not enough accelerations are detected in a 40-minute period. It can mean several things. It may mean that the baby was asleep during the test. If this happens, the test may last 40 more minutes, or the baby may be stimulated to move with sound projected over the mother’s abdomen. A nonreactive result can occur if the woman has taken certain medications. It also can mean that the fetus is not getting enough oxygen.

What is a biophysical profile?

A biophysical profile (BPP) may be done when results of other tests are nonreassuring. It uses a scoring system to evaluate fetal well-being in these five areas:

1. Fetal heart rate

2. Fetal breathing movements

3. Fetal body movements

4. Fetal muscle tone

5. Amount of amniotic fluid

Each of the five areas is given a score of 0 or 2 points, for a possible total of 10 points.

How is the BPP performed?

A BPP involves monitoring the fetal heart rate (the same way it is done in a nonstress test) as well as an ultrasound exam. During an ultrasound exam, a device called a transducer is rolled gently over your abdomen while you are reclining or lying down. The transducer creates sound waves that bounce off of the internal structures of the body. The transducer receives these echoes, which are converted into images displayed on a computer screen for the technician to view.

What do the results of a BPP mean?

A score of 8–10 is reassuring. A score of 6 is equivocal (neither reassuring nor nonreassuring). If you have an equivocal score, depending on how far along you are in your pregnancy, you may have another BPP within the next 12–24 hours, or it may be decided to deliver the baby. A score of 4 or less means that further testing is needed. Sometimes, it means that the baby should be delivered early or right away.

No matter what the score is, not enough amniotic fluid means that more frequent testing should be done or delivery may need to be considered.

What is a modified BPP?

A modified BPP is done for the same reasons that a BPP is done. The modified BPP combines a nonstress test with an amniotic fluid assessment that is performed using ultrasound. It is less cumbersome but can be just as useful as the BPP in predicting fetal well-being.

How is the modified BPP performed?

The fetal heart rate is monitored in the same way it is done for the nonstress test. Ultrasound is used to measure how much amniotic fluid there is in four areas of your uterus.

What do the results of a modified BPP mean?

If test results are nonreactive, it could mean that the fetus is having trouble getting enough oxygen. Results of the amniotic fluid measurement give an idea of how well the placenta is working. If the amniotic fluid level is low, it could mean that there is a problem with blood flow in the placenta. A full BPP or contraction stress test may be needed to confirm results.

What is a contraction stress test?

The contraction stress test helps your health care provider see how the fetal heart rate reacts when the uterus contracts. The contraction stress test sometimes is used if other test results are positive or unclear.

How is the contraction stress test performed?

In this test, belts with sensors that detect the fetal heart rate and uterine contractions are placed across your abdomen. To make your uterus contract mildly, you may be asked to rub your nipples through your clothing or you may be given oxytocin.

What do the results of a contraction stress test mean?

If the fetal heart rate does not decrease after a contraction, the result is normal (negative). A decrease in heart rate after most contractions is a positive result (the results are concerning to the health care provider). Results also can be equivocal (the results are not clear) or unsatisfactory (there were not enough contractions to produce a meaningful result).

What is a Doppler ultrasound exam of the umbilical artery?

Doppler ultrasound is used to check the blood flow in the umbilical artery, a blood vessel located in the umbilical cord. Doppler ultrasound is used with other tests when the fetus shows signs of not growing well.

How is the Doppler ultrasound exam performed?

You will be reclining or lying down for this test. A transducer is rolled gently over your abdomen to project sound waves. An image of the artery that is being examined is shown on a computer screen.

What do the results of a Doppler ultrasound exam mean?

A normal test result is one that shows normal blood flow in the umbilical artery. If the test shows problems with the blood flow in the placenta, it can mean that there is a decrease in the amount of oxygen being delivered to the fetus.

GROUP B STREP AND PREGNANCY

What is group B streptococcus (GBS)?

Group B streptococcus is one of the many types of bacteria that live in the body and usually do not cause serious illness. It is found in the digestive, urinary, and reproductive tracts of men and women. In women, it can be found in the vagina and rectum. GBS is not a sexually transmitted infection. Also, although the names are similar, GBS is different from group A streptococcus, the bacteria that causes “strep throat.”

What does it mean to be colonized with GBS?

A person who has the bacteria but shows no symptoms is said to be colonized. The number of bacteria that a person has may change over time. A person colonized with a large number of bacteria may have low levels of bacteria months or years later. It also is possible for the number of bacteria to decrease to levels that cannot be detected.

Why is GBS a concern for pregnant women?

Most pregnant women who are colonized with GBS have no symptoms or health effects. In a small number of women, GBS can cause infections of the uterus and urinary tract. A woman who is colonized with GBS late in her pregnancy can pass it to her baby.

What are the types of GBS infection in newborns?

There are two types of GBS infections in newborns: 1) early-onset infections and 2) late-onset infections. Both types of infections can be serious.

What are early-onset GBS infections?

Early-onset infections occur during the first week of life, generally within the first 24–48 hours after birth. These infections can occur as the baby moves through the birth canal of a woman who is colonized with GBS. Only a few babies who are exposed to GBS develop an infection. Certain factors, such as preterm birth, may increase the risk of a baby becoming infected. The most common problems caused by early-onset GBS infections are lung infections, blood infections, and meningitis.

What are late-onset GBS infections?

These infections occur after the first 6 days of life. Late-onset infections may be passed from the mother to the baby during birth or they may be caused by contact with other people who are colonized with GBS. Late-onset infection can lead to meningitis and other diseases, such as pneumonia.

Can these infections be prevented in newborns?

GBS testing late in pregnancy and treatment during labor can help prevent early-onset infections. However, it does not prevent late-onset infections. It is important to recognize the signs and symptoms of late-onset GBS infection in your baby:

Slowness or inactivity
Irritability
Poor feeding
Vomiting
High fever

If your baby has any of these signs or symptoms, contact your pediatrician right away.

When are pregnant women tested for GBS?

To help prevent early-onset GBS infection, women are tested for GBS late in pregnancy, between weeks 35 and 37. The test is called a culture. In this test, a swab is used to take a sample from the woman’s vagina and rectum. This procedure is quick and not painful. The sample is sent to a lab where it is grown in a special substance.

What if the test results are positive?

If results of the culture test are positive, showing that GBS is present, you most likely will receive treatment with antibiotics during labor to help prevent GBS from being passed to your baby. Antibiotics help get rid of some of the bacteria that can harm the baby during birth. The antibiotics work only if they are given during labor. If treatment is given earlier in pregnancy, the bacteria may regrow and be present during labor. Penicillin is the antibiotic that is most often given to prevent early-onset GBS infection in newborns.

What if I am allergic to penicillin?

If you are allergic to penicillin, tell your health care provider before you are tested for GBS. Women with mild allergic reactions can take an antibiotic called cefazolin. If you have had a severe reaction to penicillin, such as hives or anaphylaxis, the bacteria in the sample need to be tested to determine the choice of antibiotic.

What if I already had a baby who had a GBS infection?

If you had a previous baby with GBS infection or if your urine has GBS bacteria during this pregnancy, you are at high risk of passing GBS on to your baby during labor and delivery. You will receive treatment during labor to protect your baby from infection. You will not need to be tested between weeks 35 and 37 of pregnancy.

What if I am having a planned cesarean birth?

If you are having a planned cesarean birth, you do not need to receive antibiotics for GBS during delivery if your labor has not begun or the amniotic sac has not ruptured (your water has not broken). However, you should still be tested for GBS because labor may occur before the planned cesarean birth. If your test result is positive, your baby may need to be monitored for GBS infection after birth.

HIV AND PREGNANCY

What is human immunodeficiency virus (HIV)?

Human immunodeficiency virus (HIV) is the virus that causes acquired immunodeficiency syndrome (AIDS).

How do you get HIV?

HIV enters the bloodstream by way of body fluids, such as blood or semen. Once in the blood, the virus invades and kills CD4 cells. CD4 cells are key cells of the immune system. When these cells are destroyed, the body is less able to fight disease.

How do you get AIDS?

AIDS occurs when the number of CD4 cells decreases below a certain level and the person gets sick with diseases that the immune system would normally fight off. These diseases include pneumonia, certain types of cancer, and harmful infections.

How long does it take for HIV to develop into AIDS?

It can take months or years before HIV infection might develop into AIDS. Unless a woman gets tested, she may never know she is infected with HIV until she gets sick.

Can HIV be treated?

HIV infection can be treated, but not cured. Taking anti-HIV drugs can help people with HIV infection stay healthy for a long time and can decrease the chance of passing the virus to others. There is no vaccine to prevent HIV infection.

If I am infected with HIV and pregnant, can I pass HIV to my baby?

It is possible to pass HIV to your baby in the following ways:

During pregnancy, HIV can pass through the placenta and infect the baby.
During labor and delivery, the baby may be exposed to the virus in the mother’s blood and other fluids. When a woman goes into labor, the amniotic sac breaks (her water breaks). Once this occurs, the risk of transmitting HIV to the baby increases. Most babies who get HIV from their mothers become infected around the time of delivery.
Breastfeeding also can transmit the virus to the baby.

What can I do to reduce the risk of passing HIV on to my baby?

You and your health care provider will discuss things you can do to reduce the risk of passing HIV on to your baby. They include the following:

Take a combination of anti-HIV drugs during your pregnancy as prescribed.
Have your baby by cesarean delivery if lab tests show that your level of HIV is high.
Take anti-HIV drugs during labor and delivery as needed.
Give anti-HIV drugs to your baby after birth.
Do not breastfeed.

By following these guidelines, 99% of HIV-infected women will not pass HIV to their babies.

Why is HIV treatment recommended during pregnancy?

Treatment during pregnancy has two goals: 1) to protect your own health, and 2) to help prevent passing HIV to your baby. Many combinations of drugs are used to manage HIV infection. This is called a “drug regimen.” Anti-HIV drugs decrease the amount of HIV in the body.

Are there any side effects of HIV drugs?

Drugs used to treat HIV infection may cause side effects. Common side effects include nausea, diarrhea, headaches, and muscle aches. Less common side effects include anemia, liver damage, and bone problems such as osteoporosis. While unusual, drugs used to treat HIV may affect the development of the fetus. However, not taking medication greatly increases the chances of passing the virus to your baby.

What is my viral load?

Your viral load is the amount of HIV that you have in your body.

Why is it important for my viral load and CD4 cell count to be monitored?

Both a high viral load and a low number of CD4 cells mean there is a greater risk of passing HIV to your baby and a greater risk of you becoming sick. However, even if you have a low viral load, it is still possible to pass HIV to the baby.
Should I still use condoms during sex even though I am pregnant?

If your partner also is infected with HIV, condoms help protect you and your partner from other infections. If your partner is not infected with HIV, in addition to using condoms, there are some drugs that partners can take that may decrease their risk of becoming infected.
Are there extra risks for me if I am HIV positive and I have a cesarean delivery?

Having a cesarean delivery may carry extra risks if you are HIV positive. Women with low CD4 cell counts have weak immune systems, so they are at greater risk of infection after surgery. The incision may heal more slowly. Drugs to prevent infection are given during cesarean delivery.
After I give birth, how will I know if my baby is infected with HIV?

Babies who are born to HIV-positive mothers are tested for HIV several times in the first few months. The test looks for the presence of the virus in the baby’s blood. The baby has HIV infection if two of these test results are positive. The baby does not have HIV infection if two of these test results are negative. Another type of HIV test is done when the baby is 12–18 months old.

BACK PAIN DURING PREGNANCY

What causes back pain during pregnancy?

The following changes during pregnancy can lead to back pain:

Strain on your back muscles
Abdominal muscle weakness
Pregnancy hormones

How do my back muscles become strained during pregnancy?

The main cause of back pain during pregnancy is strain on your back muscles. As your pregnancy progresses, your uterus becomes heavier. Because this increased weight is carried in the front of your body, you naturally bend forward. To keep your balance, your posture changes. You may find yourself leaning backward, which can make the back muscles work harder. This extra strain can lead to pain, soreness, and stiffness.

How can weakened abdominal muscles affect my back during pregnancy?

Your abdominal muscles support the spine and play an important role in the health of the back. During pregnancy, these muscles become stretched and may weaken. These changes also can increase your risk of hurting your back when you exercise.

How can pregnancy hormones contribute to back pain?

To prepare for the passage of the baby through the birth canal, a hormone relaxes the ligaments in the joints of your pelvis. This loosening allows the joints to become more flexible, but it also can cause back pain if the joints become too mobile.

What can I do to prevent back pain during pregnancy?

To help prevent back pain, be aware of how you stand, sit, and move. Here are some tips that may help:

Wear shoes with good arch support. Flat shoes usually provide little support unless they have arch supports built in. High heels can further shift your balance forward and make you more likely to fall.
Consider investing in a firm mattress. A firm mattress may provide more support for your back during pregnancy.
Do not bend over from the waist to pick things up—squat down, bend your knees, and keep your back straight.
Sit in chairs with good back support, or use a small pillow behind the low part of your back. Special devices called lumbar supports are available at office- and medical-supply stores.
Try to sleep on your side with one or two pillows between your legs or under your abdomen for support.

What can I do to ease back pain?

Get regular exercise. Exercises for the back strengthen and stretch muscles that support your back and legs and promote good posture. They not only ease back pain but also help prepare you for labor and childbirth (see FAQ119 Exercise During Pregnancy). You also can try applying heat or cold to the painful area.

When should I contact my health care professional about back pain during pregnancy?

If you have severe pain, or if pain persists for more than 2 weeks, you should contact your obstetrician or other member of your health care team. Back pain is a symptom of preterm labor, and it also can be a sign of a urinary tract infection. Contact your health care professional right away if you have a fever, burning during urination, or vaginal bleeding in addition to back pain.

EXERCISE DURING PREGNANCY

Is it safe to exercise during pregnancy?

If you are healthy and your pregnancy is normal, it is safe to continue or start most types of exercise, but you may need to make a few changes. Physical activity does not increase your risk of miscarriage, low birth weight, or early delivery. However, it is important to discuss exercise with your obstetrician or other member of your health care team during your early prenatal visits. If your health care professional gives you the OK to exercise, you can decide together on an exercise routine that fits your needs and is safe during pregnancy.
Are there certain conditions that make exercise during pregnancy unsafe?

Women with the following conditions or pregnancy complications should not exercise during pregnancy:

Certain types of heart and lung diseases
Cervical insufficiency or cerclage
Being pregnant with twins or triplets (or more) with risk factors for preterm labor
Placenta previa after 26 weeks of pregnancy
Preterm labor or ruptured membranes (your water has broken) during this pregnancy
Preeclampsia or pregnancy-induced high blood pressure
Severe anemia

What are the benefits of exercise during pregnancy?

Regular exercise during pregnancy benefits you and your baby in these key ways:

Reduces back pain
Eases constipation
May decrease your risk of gestational diabetes, preeclampsia, and cesarean delivery
Promotes healthy weight gain during pregnancy
Improves your overall general fitness and strengthens your heart and blood vessels
Helps you to lose the baby weight after your baby is born

How much should I exercise during pregnancy?

The Centers for Disease Control and Prevention recommend that pregnant women get at least 150 minutes of moderate-intensity aerobic activity every week. An aerobic activity is one in which you move large muscles of the body (like those in the legs and arms) in a rhythmic way. Moderate intensity means you are moving enough to raise your heart rate and start sweating. You still can talk normally, but you cannot sing.

Examples of moderate-intensity aerobic activity include brisk walking and general gardening (raking, weeding, or digging). You can divide the 150 minutes into 30-minute workouts on 5 days of the week or into smaller 10-minute workouts throughout each day.

If you are new to exercise, start out slowly and gradually increase your activity. Begin with as little as 5 minutes a day. Add 5 minutes each week until you can stay active for 30 minutes a day.

If you were very active before pregnancy, you can keep doing the same workouts with your health care professional’s approval. However, if you start to lose weight, you may need to increase the number of calories that you eat.

What changes occur in the body during pregnancy that can affect my exercise routine?

Your body goes through many changes during pregnancy. It is important to choose exercises that take these changes into account:

Joints—The hormones made during pregnancy cause the ligaments that support your joints to become relaxed. This makes the joints more mobile and at risk of injury. Avoid jerky, bouncy, or high-impact motions that can increase your risk of being hurt.
Balance—During pregnancy, the extra weight in the front of your body shifts your center of gravity. This places stress on joints and muscles, especially those in your pelvis and low back. Because you are less stable and more likely to lose your balance, you are at greater risk of falling.
Breathing—When you exercise, oxygen and blood flow are directed to your muscles and away from other areas of your body. While you are pregnant, your need for oxygen increases. As your belly grows, you may become short of breath more easily because of increased pressure of the uterus on the diaphragm (a muscle that aids in breathing). These changes may affect your ability to do strenuous exercise, especially if you are overweight or obese.

What precautions should I take when exercising during pregnancy?

There are a few precautions that pregnant women should keep in mind during exercise:

Drink plenty of water before, during, and after your workout. Signs of dehydration include dizziness, a racing or pounding heart, and urinating only small amounts or having urine that is dark yellow.
Wear a sports bra that gives lots of support to help protect your breasts. Later in pregnancy, a belly support belt may reduce discomfort while walking or running.
Avoid becoming overheated, especially in the first trimester. Drink plenty of water, wear loose-fitting clothing, and exercise in a temperature-controlled room. Do not exercise outside when it is very hot or humid.
Avoid standing still or lying flat on your back as much as possible. When you lie on your back, your uterus presses on a large vein that returns blood to the heart. Standing motionless can cause blood to pool in your legs and feet. Both of these positions can decrease the amount of blood returning to your heart and may cause your blood pressure to decrease for a short time.

What are some safe exercises I can do during pregnancy?

Whether you are new to exercise or it already is part of your weekly routine, choose activities that experts agree are safest for pregnant women:

Walking—Brisk walking gives a total body workout and is easy on the joints and muscles.
Swimming and water workouts—Water workouts use many of the body’s muscles. The water supports your weight so you avoid injury and muscle strain. If you find brisk walking difficult because of low back pain, water exercise is a good way to stay active.
Stationary bicycling—Because your growing belly can affect your balance and make you more prone to falls, riding a standard bicycle during pregnancy can be risky. Cycling on a stationary bike is a better choice.
Modified yoga and modified Pilates—Yoga reduces stress, improves flexibility, and encourages stretching and focused breathing. There are even prenatal yoga and Pilates classes designed for pregnant women. These classes often teach modified poses that accommodate a pregnant woman’s shifting balance. You also should avoid poses that require you to be still or lie on your back for long periods.

If you are an experienced runner, jogger, or racquet-sports player, you may be able to keep doing these activities during pregnancy. Discuss these activities with your health care professional.

What exercises should I avoid during pregnancy?

While pregnant, avoid activities that put you at increased risk of injury, such as the following:

Contact sports and sports that put you at risk of getting hit in the abdomen, including ice hockey, boxing, soccer, and basketball
Skydiving
Activities that may result in a fall, such as downhill snow skiing, water skiing, surfing, off-road cycling, gymnastics, and horseback riding
“Hot yoga” or “hot Pilates,” which may cause you to become overheated
Scuba diving
Activities performed above 6,000 feet (if you do not already live at a high altitude)

What are warning signs that I should stop exercising?

Stop exercising and call your obstetrician or other member of your health care team if you have any of these signs or symptoms:

Bleeding from the vagina
Feeling dizzy or faint
Shortness of breath before starting exercise
Chest pain
Headache
Muscle weakness
Calf pain or swelling
Regular, painful contractions of the uterus
Fluid leaking from the vagina

Why is it important to keep exercising after my baby is born?

Exercising after your baby is born may help improve mood and decreases the risk of deep vein thrombosis, a condition that can occur more frequently in women in the weeks after childbirth. In addition to these health benefits, exercise after pregnancy can help you lose the extra pounds that you may have gained during pregnancy.

SEIZURE DISORDERS IN PREGNANCY

What is a seizure?

A seizure occurs when the activity of nerve cells in the brain becomes abnormal. A seizure can cause a change in mood, emotions, consciousness, or movement.

What is epilepsy?

Epilepsy is one kind of seizure disorder. It is diagnosed when a person has two or more seizures that have no clear cause.

Can seizures be controlled?

People who have repeated seizures usually need to take antiepileptic drugs (AEDs) or “antiseizure” drugs. These drugs do not cure the disorder, but they can prevent seizures all or most of the time. There are more than 20 different AEDs. The choice of drug is based on a patient’s age, the type of seizure, and the side effects of the drug. If one drug does not work, another can be tried. More than one drug may be needed to control seizures.

If I have a seizure disorder, can it cause problems during pregnancy?

Seizure disorders can affect pregnancy in several ways:

Women with seizure disorders have a higher risk of having a child with a birth defect than women who do not have seizure disorders. This increased risk may be related to the seizure disorder itself or to some of the AEDs used to treat it.
Having a seizure during pregnancy can cause injury to you and your baby.
Pregnancy can change the frequency of seizures. Most women will have no changes in seizure frequency or will have seizures less often. One third will have seizures more often.

Many of these problems can be minimized or avoided by getting good medical care before and during pregnancy.

What risks are associated with having a seizure during pregnancy?

Seizures can harm not only the woman, but also her baby. Seizures that cause a loss of consciousness and violent, jerking movements, called grand mal seizures, are especially hazardous during pregnancy. The risks associated with seizures during pregnancy include injury from falls, decreased oxygen to the baby during the seizure, preterm labor, and preterm birth.

Can taking antiseizure medications during pregnancy harm my baby?

Some AEDs have been associated with a small increased risk of birth defects, including cleft lip or palate (the lip or roof of the mouth is not completely closed), heart defects, and neural tube defects. One reason why AEDs may be related to an increased risk of birth defects is that many of these drugs affect the way the body uses folic acid. Folic acid is a B vitamin. Not having enough folic acid before pregnancy and during the first weeks of pregnancy can increase the risk of having a child with a neural tube defect. If you take an AED, your health care provider may recommend that you take extra folic acid before pregnancy and for the first 3 months of pregnancy.

Should I stop taking my antiseizure medications during pregnancy?

Because there are serious risks associated with having a seizure during pregnancy and because the potential risk of harm to your baby from taking AEDs is small, experts recommend that seizures be controlled with AEDs, if necessary, during pregnancy. However, the type, amount, or number of AEDs that you take may need to change. Ideally, any changes in medication should be made before pregnancy. This allows you and your health care provider to see how the medication changes affect you without putting the fetus at risk.

What extra steps may my health care provider take when monitoring my pregnancy?

Blood tests may be done regularly to be sure that medication levels are constant. Levels that are too high can lead to side effects. Levels that are too low can lead to seizures. Blood tests also can be used to screen for certain birth defects. Diagnostic testing, including a targeted ultrasound exam, amniocentesis, or chorionic villus sampling, can be done to determine if certain birth defects are present.

If I have a seizure disorder, will it affect how I have my baby?

Having a seizure disorder does not affect how you will have your baby. Like most women, women with a seizure disorder are able to give birth to their babies vaginally unless a problem arises during labor or delivery. In these cases, a cesarean delivery may be needed.

What do I need to know about using birth control after the baby is born?

AEDs can decrease the effectiveness of some hormonal methods of birth control. These include birth control pills, the vaginal ring, the skin patch, and the implant. Methods that are not affected by AEDs are both types of the intrauterine device, the birth control injection, and barrier methods (such as the diaphragm, spermicide, or condoms). Some women choose to use a barrier method along with a hormonal method. Sterilization is an option if you have completed your family.

Can I breastfeed my baby?

Most women with seizure disorders can breastfeed their babies. AEDs are found in small amounts in breast milk, but in most cases it is not enough to affect the baby.

ROUTINE TESTS DURING PREGNANCY

Why are tests done during pregnancy?

A number of lab tests are suggested for all women as part of routine prenatal care. These tests can help find conditions that can increase the risk of complications for you and your fetus.
What tests are done early in pregnancy?

The following lab tests are done early in pregnancy:

Complete blood count (CBC)
Blood type
Urinalysis
Urine culture
Rubella
Hepatitis B and hepatitis C
Sexually transmitted infections (STIs)
Human immunodeficiency virus (HIV)
Tuberculosis (TB)

What is a CBC and what can the results show?

A CBC counts the numbers of different types of cells that make up your blood. The number of red blood cells can show whether you have a certain type of anemia. The number of white blood cells shows how many disease-fighting cells are in your blood, and the number of platelets can reveal whether you have a problem with blood clotting.

What is blood typing and what can the results show?

Results from a blood type test can show if you have the Rh factor. The Rh factor is a protein that can be present on the surface of red blood cells. Most people have the Rh factor—they are Rh positive. Others do not have the Rh factor—they are Rh negative. If your fetus is Rh positive and you are Rh negative, your body can make antibodies against the Rh factor. In a future pregnancy, these antibodies can damage the fetus’s red blood cells.

What is a urinalysis and what can the results show?

Your urine may be tested for red blood cells (to see if you have urinary tract disease), white blood cells (to see if you have a urinary tract infection), and glucose (high levels may be a sign of diabetes mellitus). The amount of protein also is measured. The protein level early in pregnancy can be compared with levels later in pregnancy. High protein levels in the urine may be a sign of preeclampsia, a serious complication that usually occurs later in pregnancy or after the baby is born.

What is a urine culture test and what can the results show?

A urine culture tests your urine for bacteria, which can be a sign of a urinary tract infection.

What is rubella and what do test results for this disease show?

Rubella (sometimes called German measles) can cause birth defects if a woman is infected during pregnancy. Your blood is tested to check whether you have had a past infection with rubella or if you have been vaccinated against this disease. If you have not had rubella previously or if you have not been vaccinated, you should avoid anyone who has the disease while you are pregnant because it is highly contagious. If you have not had the vaccine, you should get it after the baby is born, even if you are breastfeeding. You should not be vaccinated against rubella during pregnancy.

What are hepatitis B and hepatitis C and what do test results for these infections show?

Hepatitis B and hepatitis C viruses infect the liver. Pregnant women who are infected with hepatitis B or hepatitis C virus can pass the virus to their babies. All pregnant women are tested for hepatitis B virus infection. If you have risk factors, you also may be tested for the hepatitis C virus.

Which STI tests are done in pregnant women?

All pregnant women are tested for syphilis and chlamydia early in pregnancy. Syphilis and chlamydia can cause complications for you and your baby. If you have either of these STIs, you will be treated during pregnancy and tested again to see if the treatment has worked. If you have risk factors for gonorrhea (you are aged 25 years or younger or you live in an area where gonorrhea is common), you also will be tested for this STI.

Why are all pregnant women tested for HIV?

If a pregnant woman is infected with HIV, there is a chance she can pass the virus to her baby. HIV attacks cells of the body’s immune system and causes acquired immunodeficiency syndrome (AIDS). If you are pregnant and infected with HIV, you can be given medication and take other steps that can greatly reduce the risk of passing it to your baby.

Which pregnant women should be tested for TB?

Women at high risk of TB (for example, women who are infected with HIV or who live in close contact with someone who has TB) should be tested for this infection.

What tests are done later in pregnancy?

The following tests are done later in pregnancy:

A repeat CBC
Rh antibody test
Glucose screening test
Group B streptococci (GBS)

When will I be tested for Rh antibodies?

If you are Rh negative, your blood will be tested for Rh antibodies between 28 weeks and 29 weeks of pregnancy. If you do not have Rh antibodies, you will receive Rh immunoglobulin. This shot prevents you from making antibodies during the rest of your pregnancy. If you have Rh antibodies, you may need special care.

What is a glucose screening test and what can the results show?

This screening test measures the level of glucose (sugar) in your blood. A high glucose level may be a sign of gestational diabetes. This test usually is done between 24 weeks and 28 weeks of pregnancy. If you have risk factors for diabetes or had gestational diabetes in a previous pregnancy, screening may be done in the first trimester of pregnancy.

What is GBS and why are pregnant women tested for it?

GBS is a type of bacteria that lives in the vagina and rectum. Many women carry GBS and do not have any symptoms. GBS can be passed to a baby during birth. Most babies who get GBS from their mothers do not have any problems. A few, however, become sick. This illness can cause serious health problems and even death in newborn babies. GBS usually can be detected with a routine screening test that is given between 35 weeks and 37 weeks of pregnancy. For this test, a swab is used to take samples from the vagina and rectum.

What happens if my GBS screening test result is positive?

If your GBS test result is positive, antibiotics can be given during labor to help prevent the baby from becoming infected.

What is the difference between screening tests and diagnostic tests for birth defects?

Screening tests are done during pregnancy to assess the risk that the fetus has certain common birth defects. A screening test cannot tell whether the baby actually has a birth defect. There is no risk to the fetus with having screening tests.

Diagnostic tests actually can detect many, but not all, birth defects caused by defects in a gene or chromosomes . Diagnostic testing may be done instead of screening if a couple has a family history of a birth defect, belongs to a certain ethnic group, or if the couple already has a child with a birth defect. Diagnostic tests also are available as a first choice for all pregnant women, including those who do not have risk factors. Some diagnostic tests carry risks, including a small risk of pregnancy loss.

What is the first step in screening for birth defects?

Screening for birth defects begins by assessing your risk factors. Early in your pregnancy, your health care professional may give you a list of questions to find out whether you have risk factors, such as a personal or family history of birth defects, belonging to certain ethnic groups, maternal age of 35 years or older, or having preexisting diabetes. In some situations, you may want to visit a genetic counselor for more detailed information about your risks.

What is a carrier test?

A carrier test can show if you or your partner carry a gene for a certain disorder, such as cystic fibrosis. Carrier tests can be done before or during pregnancy. Carrier testing often is recommended if you or your partner have a genetic disorder, have a child with a genetic disorder, have a family history of a genetic disorder, or belong to an ethnic group that has an increased risk of specific disorders. Also, cystic fibrosis carrier screening is offered to all women of reproductive age because it is one of the most common inherited disorders.

What are other types of screening tests for birth defects that can be done during pregnancy?

Screening tests include an ultrasound exam in combination with blood tests that measure the levels of certain substances in the mother’s blood.

The new NIPT Test checks the fetal cell free DND in maternal blood circulation . although it is more expensive but sensitivity and specificity is more than 95%.

What are the types of diagnostic tests for birth defects that can be done during pregnancy?

Diagnostic tests for birth defects include amniocentesis, chorionic villus sampling, and a targeted ultrasound exam.

Can I choose whether or not to have testing for birth defects?

Whether you want to be tested is a personal choice. Knowing beforehand allows the option of deciding not to continue the pregnancy. If you choose to continue the pregnancy, it can give you time to prepare for having a child with a particular disorder and to organize the medical care that your child may need. Your health care professional or a genetic counselor can discuss the options with you and help you decide.

REDUCING RISKS OF BIRTH DEFECTS

What is a birth defect?

A birth defect is a condition that is present at birth. Some birth defects can be seen right after the baby is born, such as a clubfoot or extra fingers or toes. Special tests may be needed to find others, such as heart defects or hearing loss. Some birth defects are not noticed until later in life.

What causes birth defects?

Some birth defects are caused by genes that can be passed down from parents to children. Others result from a problem with chromosomes. A small number of birth defects are caused by exposure during pregnancy to certain medications, infections, and chemicals. For many birth defects, the cause is not known.

What can I do before or during pregnancy to decrease my risk of having a baby with certain birth defects?

Most birth defects cannot be prevented because their cause is not known. For a few birth defects, you may be able to decrease your risk by taking certain steps:

See your doctor before becoming pregnant.
Know your risk factors.
Take a daily multivitamin before and during pregnancy.
Maintain a healthy weight.
Use medications wisely.
Take care of medical conditions before pregnancy.
Do not use alcohol or illegal drugs.
Prevent infections.
Avoid known harmful agents.

Why should I see a health care professional before becoming pregnant?

Scheduling a health care visit before becoming pregnant is a good idea. Along with getting advice about diet and exercise from your health care professional, you can discuss whether you have any factors that increase the risk of having a child with a birth defect. If you have a medical condition, you also can discuss any special care that you may need before or during pregnancy.

What factors increase the risk of having a baby with a birth defect?

You may be at an increased risk of having a baby with a birth defect if you

are older
have a family or personal history of birth defects
have had a child with a birth defect
use certain medicines around the time you become pregnant
have a medical condition such as diabetes or obesity
use recreational drugs or drink alcohol during pregnancy

If you have any risk factors, your health care professional may recommend special tests or other steps that may help reduce your risk. For example, if you have a personal or family history of birth defects, genetic counseling and testing may be recommended.

Why is taking a multivitamin important before and during pregnancy?

Prenatal vitamin supplements contain the recommended amounts of the vitamins and minerals you will need during your pregnancy, such as vitamins A, C, and D; folic acid; and minerals such as iron. Taking 400 micrograms of folic acid daily for at least 1 month before pregnancy and during pregnancy helps prevent major birth defects of the baby’s brain and spine called neural tube defects. Most prenatal and “women’s formula” multivitamin supplements contain 400–800 micrograms of folic acid.

What do I need to know about taking medications during pregnancy?

A few medications have been linked to birth defects. You should tell anyone who prescribes drugs for you that you are pregnant or thinking of becoming pregnant. This includes doctors you see for nonpregnancy problems, mental health care providers, and your dentist. Also, check with your health care professional before taking any over-the-counter drug, such as pain relievers, laxatives, cold or allergy remedies, vitamins, herbal products, and skin treatments. A good source for information about the safety or risk of specific drugs and other agents during pregnancy is the Organization of Teratology Information Specialists’ web site at www.mothertobaby.org.

How can obesity have an impact on my pregnancy?

Women who are obese (defined as having a body mass index [BMI] of 30 or greater) when they become pregnant have an increased risk of having babies with certain birth defects than women who are a normal weight. Among the most common obesity-related birth defects are neural tube defects, heart defects, and cleft palate. If you are planning a pregnancy, the best way to prevent problems caused by obesity is to be at a normal weight before you become pregnant.

Why is it important to talk to my health care professional if I have certain medical conditions and am thinking of becoming pregnant?

Some medical conditions—such as diabetes mellitus, high blood pressure, and seizure disorders—may increase the risk of having a baby with certain birth defects. If you have a medical condition, see your health care professional to discuss any changes you need to make in your diet, medication, or other areas to bring the condition under control before you try to become pregnant.

Why is it important for me to not drink alcohol during pregnancy?

Alcohol use during pregnancy is a leading cause of birth defects. “Fetal alcohol spectrum disorders” is a term that describes different effects that can occur in the fetus when a woman drinks during pregnancy. These effects may include physical, behavioral, and learning disabilities that can last a lifetime. One of the most serious effects of drinking during pregnancy is fetal alcohol syndrome. Birth defects caused by alcohol are fully preventable by avoiding all alcohol while you are pregnant.

How can recreational drug use affect my pregnancy?

Use of illegal drugs (such as heroin, cocaine, methamphetamines, and marijuana) and prescription drugs used for nonmedical reasons (such as oxycodone) can harm your baby. Some drugs cause growth problems in the baby. Others may cause long-term emotional, behavioral, and learning problems. Many drugs increase the risk of preterm birth and other serious birth problems. You should avoid all use of these drugs during pregnancy.

What infections should I be concerned about and how can I reduce my risk of getting them during pregnancy?

Some infections can increase the risk of birth defects and other problems during pregnancy for you and your growing baby:

Rubella (German measles) is a viral infection that usually causes a mild rash and a low fever. Having rubella during pregnancy can cause miscarriage or result in deafness, intellectual disability, heart defects, and blindness in your newborn. There is a vaccine against rubella, but it is not recommended for pregnant women. If you have not already had the disease or been vaccinated, you should be vaccinated against rubella and wait at least 1 month before becoming pregnant.
Toxoplasmosis is a disease caused by a parasite that lives in soil. You can become infected by eating raw or undercooked meat or unwashed vegetables or by coming into contact with animal feces, especially from cats that go outdoors. If you are infected for the first time while you are pregnant, you can pass the disease on to your baby. Toxoplasmosis can cause birth defects, including hearing loss, vision problems, and intellectual disability. Make sure that you eat well-cooked meat and wear gloves while gardening or handling unwashed vegetables. If you have an outdoor cat that uses a litter box, have someone else empty it. If you must empty the litter box, use gloves and wash your hands well after doing so.
Sexually transmitted infections (STIs) can cause serious birth defects. Treating an STI—preferably before you become pregnant—may prevent or reduce harm to the fetus.
Cytomegalovirus (CMV) is a common viral infection. Most CMV infections cause no significant problems. If you are infected for the first time when you are pregnant, CMV can infect the fetus. In a small number of cases, the infection can cause intellectual disability, hearing loss, and vision problems. CMV can be spread by contact with an infected child’s urine or other body fluids. Pregnant women who work with young children, such as day care workers or health care workers, should take steps to prevent infection, such as wearing gloves when changing diapers. Frequent handwashing also is recommended.

What precautions can I take to limit my exposure to agents that can cause birth defects?

A few precautions that are recommended for all pregnant women include the following:

Limit your exposure to mercury by not eating eat shark, swordfish, king mackerel, or tilefish. Limit eating white (albacore) tuna to 6 ounces a week. You do not have to avoid all fish during pregnancy. In fact, fish and shellfish are nutritious foods with vital nutrients for a pregnant woman and her growing baby. Be sure to eat at least 8–12 ounces of low-mercury fish and shellfish per week.
Avoid exposure to lead. Lead can be found in old paint, construction materials, alternative medicines, and items made in foreign countries, such as jewelry and pottery.
Avoid taking high levels of vitamin A. Very high levels of vitamin A have been linked to severe birth defects. You should consume no more than 10,000 international units of vitamin A a day.

ECTOPIC PREGNANCY

What is an ectopic pregnancy?

An ectopic pregnancy occurs when a fertilized egg grows outside of the uterus. Almost all ectopic pregnancies occur in a fallopian tube. Rarely, it will attach to an ovary or another organ in the abdomen. As the pregnancy grows, it can cause the tube to rupture (burst). If this occurs, it can cause major internal bleeding. This can be life threatening and needs to be treated with surgery.

Who is at risk of ectopic pregnancy?

Women who have abnormal fallopian tubes are at higher risk of ectopic pregnancy. Abnormal tubes may be present in women who have had the following conditions:

Pelvic inflammatory disease (an infection of the uterus, fallopian tubes, and nearby pelvic structures)
Previous ectopic pregnancy
Infertility
Pelvic or abdominal surgery
Endometriosis
Sexually transmitted diseases
Prior tubal surgery (such as tubal sterilization)

Other factors that increase a woman’s risk of ectopic pregnancy include the following:

Cigarette smoking
Exposure to the drug diethylstilbestrol (DES) during her mother’s pregnancy
Increased age

What are the symptoms of ectopic pregnancy?

Ectopic pregnancy may cause the following symptoms:

Abnormal vaginal bleeding—Bleeding that is not at the time of your normal menstrual period is called abnormal vaginal bleeding. It may be light or heavy.
Abdominal or pelvic pain—This can be sudden and sharp and ache without relief or seem to come and go. It may occur on only one side.
Shoulder pain—Blood from the ruptured tube can build up under the diaphragm (the area between your chest and stomach). This can cause pain that is felt in the shoulder.
Weakness, dizziness, or fainting—This can happen because of blood loss.

These symptoms can occur before you even suspect you are pregnant. If you have these symptoms, call your health care provider.

How is ectopic pregnancy diagnosed?

If your health care provider suspects that you may have an ectopic pregnancy, he or she may do the following:

Perform a pelvic exam.
Check your blood pressure (low blood pressure may mean internal bleeding) and pulse.
Perform an ultrasound exam (a test in which sound waves are used to create an image) to see if there are early signs of a pregnancy.
Test your blood to detect the hormone human chorionic gonadotropin (hCG). This hormone is produced when a woman is pregnant. The test may be repeated to check the levels of hCG.

What treatment is available for ectopic pregnancy?

There are two methods used to treat an ectopic pregnancy: medication and surgery. Several weeks of follow-up are required no matter which type of treatment is used.

When is medication used to treat ectopic pregnancy?

If the pregnancy is small and has not ruptured the tube, sometimes drugs can be used instead of surgery to treat ectopic pregnancy. Medication stops the growth of the pregnancy and permits the body to absorb it over time. It allows a woman to keep her fallopian tube.

When is surgery used to treat ectopic pregnancy, and how is it performed?

If the pregnancy is small and the tube is not ruptured, in some cases the pregnancy can be removed through a small cut made in the tube using laparoscopy. In this procedure a slender, light-transmitting telescope is inserted through a small opening in your abdomen. It is done in a hospital with general anesthesia. A larger incision in the abdomen may be needed if the pregnancy is large or the blood loss is thought to be a concern. Some or all of the tube may need to be removed.

Is pregnancy possible after surgery?

If you have had surgery and the fallopian tubes have been left in place, there is a good chance that you can have a normal pregnancy in the future. Once you have had an ectopic pregnancy, however, you are at higher risk of having another one.

PRENATAL GENETIC DIAGNOSTIC TESTS

What is prenatal genetic testing?

Prenatal genetic testing gives parents-to-be information about whether their fetus has certain genetic disorders.

What are genetic disorders?

Genetic disorders are caused by changes in a person’s genes or chromosomes. Aneuploidy is a condition in which there are missing or extra chromosomes. In a trisomy, there is an extra chromosome. In a monosomy, a chromosome is missing. Inherited disorders are caused by changes in genes called mutations. Inherited disorders include sickle cell disease, cystic fibrosis, Tay–Sachs disease, and many others. In most cases, both parents must carry the same gene to have an affected child.

What are the two main types of prenatal genetic tests?

There are two general types of prenatal tests for genetic disorders:

Prenatal screening tests: These tests can tell you the chances that your fetus has an aneuploidy and a few additional disorders. FAQ165 “Prenatal Genetic Screening Tests” focuses on these tests.
Prenatal diagnostic tests: These tests can tell you, with as much certainty as possible, whether your fetus actually has an aneuploidy or specific inherited disorders for which you request testing. These tests are done on cells from the fetus or placenta obtained through amniocentesis or chorionic villus sampling (CVS). This FAQ focuses on these tests.

Both screening and diagnostic testing are offered to all pregnant women.

What is amniocentesis?

Amniocentesis is a diagnostic test. It usually is done between 15 weeks and 20 weeks of pregnancy, but it also can be done up until you give birth. To perform the test, a very thin needle is used to withdraw a small amount of amniotic fluid. Ultrasound is used to guide the procedure. Depending on the way the cells are analyzed and the information that you want, results can take from 1 day to several weeks. There is a very small chance of pregnancy loss with amniocentesis. Leakage of amniotic fluid and slight bleeding can occur after amniocentesis. In most cases, both stop on their own.

What is chorionic villus sampling (CVS)?

CVS is another type of diagnostic test. In CVS, a sample of tissue is taken from the placenta. The two main advantages of having CVS over amniocentesis are that 1) CVS is performed earlier than amniocentesis, between 10 weeks and 13 weeks of pregnancy, and 2) the results are usually ready sooner for standard testing. With an experienced doctor, CVS carries about the same risk of pregnancy loss as amniocentesis.

What is preimplantation genetic diagnosis?

Preimplantation genetic diagnosis may be offered to couples who are using in vitro fertilization to become pregnant and who are at increased risk of having a baby with a genetic or chromosomal disorder. Before an embryo is transferred to a woman’s uterus, it is tested for certain genetic disorders and mutations. Only embryos that do not test positive for the disorders are transferred.

How are the cells analyzed in prenatal diagnostic testing?

A number of technologies are used in prenatal diagnostic testing. Your obstetrician or genetic counselor can assess what information is being sought and help select the tests that are best for your situation:

Karyotype—Missing, extra, or damaged chromosomes can be detected by taking a picture of the chromosomes and arranging them in order from largest to smallest. Karyotyping results are ready in 1–2 weeks after the cells are sampled.
Fluorescence in situ hybridization (FISH)—This technique can be used to detect common aneuploidies involving chromosomes 13, 18, and 21 and the X and Y chromosomes. Results are ready more quickly (usually within 1–2 days) than with traditional karyotyping. Positive test results are confirmed with a karyotype.
Chromosome microarray analysis—This test can look for different kinds of chromosome problems, including aneuploidy, throughout the entire set of chromosomes. It can find some chromosome problems that karyotyping can miss. Results can be ready in about 7 days.
DNA testing—Tests for specific gene mutations can be done by request. For example, if you and your partner are carriers of the cystic fibrosis gene, you may want to request prenatal diagnostic testing for this specific mutation.

What do the different results of prenatal diagnostic tests mean?

Most of the time, the results of a diagnostic test are negative (normal). A negative result does not rule out the possibility that the fetus has a genetic disorder. It only tells you that the fetus does not have the particular disorder that was tested for.

If a diagnostic test result is positive (it shows that the fetus has the disorder tested for), your obstetrician or genetic counselor can explain the results and provide guidance about your choices and options. A specialist in the disorder can help you understand the life expectancy of the disorder, whether treatment is available, and the care that your child will need. Support groups, counselors, and social workers also can listen to your concerns and answer questions. It may be possible to have additional testing, such as a specialized ultrasound exam, to find out more detail about the defect.

What should I consider when deciding whether to have prenatal genetic testing?

It is your choice whether to have prenatal testing. Your personal beliefs and values are important factors in the decision about prenatal testing.

It can be helpful to think about what you would do if a diagnostic test result comes back positive. Some parents want to know beforehand if their child will be born with a genetic disorder. This gives parents time to learn about the disorder and plan for medical care that the child may need. If the disorder is very serious and the life expectancy is short, hospice care for the baby can be planned. Some parents may decide to end the pregnancy in certain situations. Other parents do not want to know this information before the child is born. They may decide not to have any testing at all. There is no right or wrong answer.

Keep in mind that certain tests can be done only at certain times during pregnancy. Tests that are done earlier allow parents more time to make decisions if a test result is positive. If ending the pregnancy is being considered, it is safer to do so within the first 13 weeks of pregnancy.

How do I choose between prenatal screening and diagnostic testing?

Any woman can choose to have diagnostic testing instead of or in addition to screening. The main benefit of having diagnostic testing instead of screening is that it can detect all conditions caused by an extra chromosome and many other disorders in which chromosomes are missing or damaged. Diagnostic tests also are available for many inherited disorders. The main disadvantage is that diagnostic testing carries a very small risk of losing the pregnancy. A genetic counselor or other health care professional with expertise in genetics can study your family health history, recommend specific tests, and interpret test results.

PRENATAL GENETIC SCREENING TESTS

What is prenatal genetic testing?

Prenatal genetic testing gives parents-to-be information about whether their fetus has certain genetic disorders.

What are genetic disorders?

Genetic disorders are caused by changes in a person’s genes or chromosomes. Aneuploidy is a condition in which there are missing or extra chromosomes. In a trisomy, there is an extra chromosome. In a monosomy, a chromosome is missing. Inherited disorders are caused by changes in genes called mutations. Inherited disorders include sickle cell disease, cystic fibrosis, Tay–Sachs disease, and many others. In most cases, both parents must carry the same gene to have an affected child.

What are the two main types of prenatal genetic tests?

There are two general types of prenatal tests for genetic disorders:

Prenatal screening tests: These tests can tell you the chances that your fetus has an aneuploidy and a few additional disorders. This FAQ focuses on these tests.
Prenatal diagnostic tests: These tests can tell you whether your fetus actually has certain disorders. These tests are done on cells from the fetus or placenta obtained through amniocentesis or chorionic villus sampling (CVS). FAQ164 “Prenatal Genetic Diagnostic Tests” focuses on these tests.

Both screening and diagnostic testing are offered to all pregnant women.

What are the different types of prenatal genetic screening tests?

Screening tests can tell you your risk of having a baby with certain disorders. They include carrier screening and prenatal genetic screening tests:

Carrier screening is done on parents (or those just thinking about becoming parents) using a blood sample or tissue sample swabbed from inside the cheek. These tests are used to find out whether a person carries a gene for certain inherited disorders. Carrier screening can be done before or during pregnancy.
Prenatal genetic screening tests of the pregnant woman’s blood and findings from ultrasound exams can screen the fetus for aneuploidy; defects of the brain and spine called neural tube defects; and some defects of the abdomen, heart, and facial features. This FAQ focuses on these tests. They include first-trimester screening, second-trimester screening, combined first- and second-trimester screening, and cell-free DNA testing.

What is first-trimester screening?

First-trimester screening includes a test of the pregnant woman’s blood and an ultrasound exam. Both tests usually are performed together and are done between 10 weeks and 13 weeks of pregnancy:

The blood test measures the level of two substances.
The ultrasound exam, called a nuchal translucency screening, measures the thickness of a space at the back of the fetus’s neck. An abnormal measurement means there is an increased risk that the fetus has Down syndrome or another type of aneuploidy. It also is linked to physical defects of the heart, abdominal wall, and skeleton.

What is second-trimester screening?

Second-trimester screening includes the following tests:

The “quad” or “quadruple” blood test measures the levels of four different substances in your blood. The quad test screens for Down syndrome, trisomy 18, and neural tube defects. It is done between 15 weeks and 22 weeks of pregnancy.
An ultrasound exam done between 18 weeks and 20 weeks of pregnancy checks for major physical defects in the brain and spine, facial features, abdomen, heart, and limbs.

What is combined first- and second-trimester screening?

The results from first- and second-trimester tests can be combined in various ways. Combined test results are more accurate than a single test result. If you choose combined screening, keep in mind that final results often are not available until the second trimester.

What is cell-free DNA testing?

Cell-free DNA is the small amount of DNA that is released from the placenta into a pregnant woman’s bloodstream. The cell-free DNA in a sample of a woman’s blood can be screened for Down syndrome, trisomy 13, trisomy 18, and problems with the number of sex chromosomes. This test can be done starting at 10 weeks of pregnancy. It takes about 1 week to get the results. A positive cell-free DNA test result should be followed by a diagnostic test with amniocentesis or CVS.

The cell-free DNA screening test works best for women who already have an increased risk of having a baby with a chromosome disorder. For a woman at low risk of having a baby with a chromosome disorder, conventional screening remains the most appropriate choice. Cell-free DNA testing is not recommended for a woman carrying more than one fetus.

What do the different results of prenatal screening tests mean?

Results of blood screening tests for aneuploidy are reported as the level of risk that the disorder might be present:

A positive screening test result for aneuploidy means that your fetus is at higher risk of having the disorder compared with the general population. It does not mean that your fetus definitely has the disorder.
A negative result means that your fetus is at lower risk of having the disorder compared with the general population. It does not rule out the possibility that your fetus has the disorder.

Diagnostic testing with CVS or amniocentesis that gives a more definite result is an option for all pregnant women. Your obstetrician or other health care professional, such as a genetic counselor, will discuss what your screening test results mean and help you decide the next steps.

How accurate are prenatal genetic screening tests?

With any type of testing, there is a possibility of false-positive results and false-negative results. A screening test result that shows there is a problem when one does not exist is called a false-positive result. A screening test result that shows there is not a problem when one does exist is called a false-negative result. Your health care professional can give you information about the rates of false-positive and false-negative results for each test.

What should I consider when deciding whether to have prenatal genetic testing?

It is your choice whether to have prenatal testing. Your personal beliefs and values are important factors in the decision about prenatal testing.

It can be helpful to think about how you would use the results of prenatal screening tests in your pregnancy care. Remember that a positive screening test tells you only that you are at higher risk of having a baby with Down syndrome or another aneuploidy. A diagnostic test should be done if you want to know a more certain result. Some parents want to know beforehand that their baby will be born with a genetic disorder. This knowledge gives parents time to learn about the disorder and plan for the medical care that the child may need. Some parents may decide to end the pregnancy in certain situations.

Other parents do not want to know this information before the child is born. In this case, you may decide not to have follow-up diagnostic testing if a screening test result is positive. Or you may decide not to have any testing at all. There is no right or wrong answer.

SKIN CONDITIONS DURING PREGNANCY

What are some of the common skin changes that occur during pregnancy?

Many women notice changes to their skin, nails, and hair during pregnancy. Some of the most common changes include the following: Dark spots on the breasts, nipples, or inner thighs
Melasma—brown patches on the face around the cheeks, nose, and forehead
Linea nigra—a dark line that runs from the navel to the pubic hair
Stretch marks
Acne
Spider veins
Varicose veins
Changes in nail and hair growth

What causes these skin changes during pregnancy?

Some are due to changes in hormone levels that occur during pregnancy. For most skin changes, however, health care providers are not sure of the exact cause.

Why do dark spots and patches appear on the skin during pregnancy?

Dark spots and patches are caused by an increase in the body’s melanin—a natural substance that gives color to the skin and hair. Dark spots and melasma usually fade on their own after you have the baby. Some women, however, may have dark patches that last for years. To help prevent melasma from getting worse, wear sunscreen and a wide-brimmed hat every day when you are outside.

What are stretch marks?

As your belly grows during pregnancy, your skin may become marked with reddish lines called stretch marks. By the third trimester, many pregnant women commonly have stretch marks on the abdomen, buttocks, breasts, or thighs. Using a heavy moisturizer may help keep your skin soft, but it will not help get rid of stretch marks. Most stretch marks fade after the baby is born, but they may never disappear completely.

Is acne common during pregnancy?

Many women have acne during pregnancy. Some already have acne and notice that it gets worse during pregnancy. Other women who may always have had clear skin will develop acne while they are pregnant.

How can I treat my skin if I get acne during pregnancy?

If you get acne during pregnancy, take these steps to treat your skin:

Wash your face twice a day with a mild cleanser and lukewarm water.
If you have oily hair, shampoo every day and try to keep your hair off your face.
Avoid picking or squeezing acne sores to lessen possible scarring.
Choose oil-free cosmetics.

Can over-the-counter medications be used during pregnancy to treat acne?

Over-the-counter products containing the following ingredients can be used during pregnancy:

Topical benzoyl peroxide
Azelaic acid
Topical salicylic acid
Glycolic acid

If you want to use an over-the-counter product that contains an ingredient not on this list, contact your health care provider.

Can prescription medications be used during pregnancy to treat acne?

Some prescription acne medications should not be used while you are pregnant:

Hormonal therapy—Several medications that block specific hormones can be used to treat acne. Their use during pregnancy is not recommended due to the risk of birth defects.
Isotretinoin—This drug is a form of vitamin A. It may cause severe birth defects in fetuses, including intellectual disabilities, life-threatening heart and brain defects, and other physical deformities.
Oral tetracyclines—This antibiotic can cause discoloration of the baby’s teeth if it is taken after the fourth month of pregnancy and also can affect the growth of the baby’s bones as long as the medication is taken.
Topical retinoids—These medications are a form of vitamin A and are in the same drug family as isotretinoin. Unlike isotretinoin, topical retinoids are applied to the skin, and the amount of medication absorbed by the body is low. However, it is generally recommended that use of these medications be avoided during pregnancy. Some retinoids are available by prescription. However, other retinoids can be found in some over-the-counter products. Read labels carefully.

What causes spider veins?

Hormonal changes and the higher amounts of blood in your body during pregnancy can cause tiny red veins, known as spider veins, to appear on your face, neck, and arms. The redness should fade after the baby is born.

What causes varicose veins?

The weight and pressure of your uterus can decrease blood flow from your lower body and cause the veins in your legs to become swollen, sore, and blue. These are called varicose veins. Varicose veins also can appear on your vulva and in your vagina and rectum (usually called hemorrhoids). In most cases, varicose veins are a cosmetic problem that will go away after delivery.

Can I prevent varicose veins?

Although you cannot prevent them, there are some things you can do to ease the swelling and soreness and prevent varicose veins from getting worse:

Be sure to move around from time to time if you must sit or stand for long periods.
Do not sit with your legs crossed for long periods.
Prop your legs up on a couch, chair, or footstool as often as you can.
Exercise regularly—walk, swim, or ride an exercise bike.
Wear support hose.
Avoid constipation by eating foods high in fiber and drinking plenty of liquids.

What changes to my hair may occur during pregnancy?

The hormone changes in pregnancy may cause the hair on your head and body to grow or become thicker. Sometimes women grow hair in areas where they do not normally have hair, such as the face, chest, abdomen, and arms. Your hair should return to normal within 6 months after giving birth.

What hair changes may I experience after childbirth?

About 3 months after childbirth, most women begin to notice hair loss from the scalp. This happens because hormones are returning to normal levels, which allows the hair to return to its normal cycle of growing and falling out. Your hair should grow back completely within 3–6 months.
What nail changes can I expect during pregnancy?

Some women find that their nails grow faster during pregnancy. Others notice that their nails split and break more easily. Like the changes to your hair, those that affect your nails will ease after birth.

What are some uncommon skin changes that can occur during pregnancy?

Certain uncommon skin conditions can arise during pregnancy. They can cause signs and symptoms, including bumps and itchy skin.

What is pruritic urticarial papules and plaques of pregnancy (PUPPP)?

In this condition, small, red bumps and hives appear on the skin later in pregnancy. The bumps can form large patches that can be very itchy. These bumps usually first appear on the abdomen and can spread to the thighs, buttocks, and breasts. It is not clear what causes PUPPP. It usually goes away after you give birth.

What is prurigo of pregnancy?

With prurigo of pregnancy, tiny, itchy bumps that look like insect bites can appear almost anywhere on the skin. This condition can occur anytime during pregnancy and usually starts with a few bumps that increase in number each day. It is thought to be caused by changes in the immune system that occur during pregnancy. Prurigo can last for several months and may even continue for some time after the baby is born.

What is pemphigoid gestationis?

Pemphigoid gestationis is a rare skin condition that usually starts during the second and third trimesters of pregnancy or sometimes right after childbirth. With this condition, blisters appear on the abdomen, and in severe cases, the blisters can cover a wide area of the body. It is thought to be an autoimmune disorder. There is a slightly increased risk of pregnancy problems with this condition, including preterm birth and a smaller-than-average baby.

What is intrahepatic cholestasis of pregnancy (ICP)?

Intrahepatic cholestasis of pregnancy (ICP) is the most common liver condition that occurs during pregnancy. The main symptom of ICP is severe itching in the absence of a rash. Itching commonly occurs on the palms of the hands and soles of the feet, but it also can spread to the trunk of the body. Symptoms usually start during the third trimester of pregnancy but often go away a few days after childbirth. ICP may increase the risk of preterm birth and other problems, including, in rare cases, fetal death.

TOBACCO, ALCOHOL, DRUGS, AND PREGNANCY

Why is smoking dangerous during pregnancy?

If you smoke during pregnancy, your baby is exposed to harmful chemicals such as tar, nicotine, and carbon monoxide. Nicotine causes blood vessels to constrict, so less oxygen and nutrients reach the fetus. Carbon monoxide decreases the amount of oxygen the baby receives.

How can smoking during pregnancy put my baby at risk?

The risks of preterm birth and problems with the way the placenta attaches to the uterus are increased in women who smoke during pregnancy. Also, infants born to women who smoke during pregnancy tend to be smaller than those born to nonsmokers. They are more likely to have asthma, colic, and childhood obesity. They also have an increased risk of dying from sudden infant death syndrome (SIDS).

How can secondhand smoke affect my baby during pregnancy?

Breathing secondhand smoke—smoke from cigarettes smoked by other people nearby—can increase the risk of having a low birth weight baby by as much as 20%. Infants who are exposed to secondhand smoke have an increased risk of SIDS and are more likely to have respiratory illnesses than those not exposed to secondhand smoke.

What help is available if I want to quit smoking?

If you are pregnant and you smoke, tell your health care provider. He or she can help you find support and quitting programs in your area. You also can call the national “quit line” at 1-800-Quit-Now.

Can I use nicotine gum or the patch to help me quit smoking when I am pregnant?

Nicotine replacement (such as nicotine gum or the patch) or prescription medications for quitting smoking need to be used with caution during pregnancy. Over-the-counter nicotine replacement products should be used only if other attempts to quit have not worked and you and your health care provider have weighed the known risks of continued smoking against the possible risks of these products. Smokeless tobacco, electronic cigarettes, and nicotine gel strips are not safe substitutes for cigarettes.

Why is drinking during pregnancy dangerous for my baby?

When a pregnant woman drinks alcohol, it quickly reaches the fetus through the placenta. In an adult, the liver breaks down the alcohol. A baby’s liver is not fully developed and is not able to break down alcohol.

What are fetal alcohol spectrum disorders?

“Fetal alcohol spectrum disorders” is a term that describes different effects that can occur in infants when a woman drinks during pregnancy. These effects may include physical, mental, behavioral, and learning disabilities that can last a lifetime.

What is fetal alcohol syndrome?

Fetal alcohol syndrome (FAS) is the most severe alcohol spectrum disorder. FAS can cause growth problems, mental or behavioral problems, and abnormal facial features.

What amounts of alcohol can cause FAS?

FAS is most likely to occur in infants whose mothers drank heavily (3 or more drinks per occasion or more than 7 drinks per week) and continued to drink heavily throughout pregnancy, but it also can occur with lesser amounts of alcohol use. Even moderate alcohol use during pregnancy (defined as one alcoholic drink per day) can cause lifelong learning and behavioral problems in the child.

Is there an amount of alcohol that is safe to drink during pregnancy?

There is no safe level of alcohol use during pregnancy. Alcohol can affect the fetus throughout pregnancy. It is best not to drink at all while you are pregnant. If you did drink alcohol before you knew you were pregnant, you can reduce the risk of further harm to the baby by stopping drinking.

What is illegal drug use?

Illegal drug use includes the use of heroin, cocaine, methamphetamines, and marijuana and use of prescription drugs for a nonmedical reason.

How can my drug use affect my baby during pregnancy?

A drug’s effects on the fetus depend on many things: how much, how often, and when during pregnancy it is used. The early stage of pregnancy is the time when main body parts of the fetus form. Using drugs during this time in pregnancy can cause birth defects and miscarriage. During the remaining weeks of pregnancy, drug use can interfere with the growth of the fetus and cause preterm birth and fetal death.

How can drug use affect my baby after he or she is born?

Drugs used after the baby is born can be passed to the baby through breast milk.

Why is it important to tell my health care provider if I have used drugs during pregnancy?

It is important to be honest so that you get the help you need for yourself and your unborn baby. Drug testing of your hair or urine during pregnancy or during labor may be done if your health care provider suspects that you have used certain substances and if you have a complication during pregnancy or delivery that suggests drug use. The baby also can be tested after birth.

Will the results of my drug tests be kept confidential?

Some states consider drug use during pregnancy to be a form of child abuse. In some states, if a drug test result shows that you have used certain substances, it must be reported to state authorities. You should be informed about this testing and consent to it before it is done. How your consent is obtained also varies from state to state.

What are some of the problems related to substance abuse?

These problems include work, relationship, and family issues; drunk-driving arrests and car crashes; or medical problems caused by the substance. Substance abuse can lead to dependence (addiction).

What is addiction?

Addiction is a disease with three or more of the following signs and symptoms:

Tolerance—Not having the same effect with continued use of the same amount and the need to use greater amounts of the substance to get “high”
Withdrawal symptoms after stopping use of the substance
Using larger amounts of the substance or using it over a longer period
Desire or unsuccessful attempts to cut down or control substance use
Spending a great deal of time using or obtaining the substance or recovering from its use
Reducing or giving up important social, work, or recreational activities because of substance use
Continuing to use the substance despite knowing that you have a problem
Making excuses to continue using the drug instead of meeting your home or work responsibilities

Why is it important for pregnant women who are addicted to certain drugs, including pain medications and narcotics, to seek treatment to quit rather than quit on their own?

Withdrawal from these drugs can cause miscarriage or other harm to the fetus.

Can I take my prescription medication during pregnancy?

Some prescription medications are safe to take during pregnancy. Others have known risks. If you are taking a prescription medication and become pregnant, tell your health care provider. Do not stop taking a medication prescribed for you without first talking to your health care provider.

Can I take over-the-counter medications during pregnancy?

Medicines sold over the counter, including herbal supplements and vitamins, can cause problems during pregnancy. Pain relievers such as aspirin and ibuprofen may be harmful to a fetus. Check with your health care provider before taking any over-the-counter drug.

CORD BLOOD BANKING

What is cord blood?

Cord blood is the blood from the baby that is left in the umbilical cord and placenta after birth. It contains special cells called hematopoietic stem cells that can be used to treat some types of diseases.

What are hematopoietic stem cells?

Most cells can make copies only of themselves. For example, a skin cell only can make another skin cell. Hematopoietic stem cells, however, can mature into different types of blood cells in the body. Hematopoietic stem cells also are found in blood and bone marrow in adults and children.

How can hematopoietic stem cells be used to treat disease?

Hematopoietic stem cells can be used to treat more than 70 types of diseases, including diseases of the immune system, genetic disorders, neurologic disorders, and some forms of cancer, including leukemia and lymphoma. For some of these diseases, stem cells are the primary treatment. For others, treatment with stem cells may be used when other treatments have not worked or in experimental research programs.

What are the advantages of using cord blood to treat disease?

Using the stem cells in cord blood to treat a disease has the following benefits compared with using those in bone marrow:

Stem cells from cord blood can be given to more people than those from bone marrow. More matches are possible when a cord blood transplant is used than when a bone marrow transplant is used. In addition, the stem cells in cord blood are less likely to cause rejection than those in bone marrow.
It is harder to collect bone marrow than it is to collect cord blood. Collecting bone marrow poses some risks and can be painful for the donor.
Cord blood can be frozen and stored. It is ready for anyone who needs it. Bone marrow must be used soon after it is collected.
Stem cells in cord blood can be used to strengthen the immune system during cancer treatments. Bone marrow stem cells do not have this capability.

What are the disadvantages of using cord blood to treat disease?

A disadvantage of cord blood is that it does not contain many stem cells. Units from several donors can be combined to increase the number of stem cells if a transplant is needed for an adult.

What is an autologous transplant?

In an autologous transplant, the cord blood collected at birth is used by that same child. This type of transplant is rare for the following reasons:

A child’s stem cells cannot be used to treat genetic diseases in that child. All of the stem cells have the same genes that cause the disease.
A child’s own stem cells cannot be used to treat that child’s leukemia, a cancer of the blood.

What is an allogenic transplant?

In an allogenic transplant, another person’s stem cells are used to treat a child’s disease. This kind of transplant is more likely to be done than an autologous transplant. In an allogenic transplant, the donor can be a relative or be unrelated to the child. For an allogenic transplant to work, there has to be a good match between donor and recipient. A donor is a good match when certain things about his or her cells and the recipient’s cells are alike. If the match is not good, the recipient’s immune system may reject the donated cells. If the cells are rejected, the transplant does not work.

How is cord blood stored?

Cord blood is kept in one of two types of banks: public or private. They differ in important ways that may affect your choice.

What are public cord blood banks?

Public cord blood banks store cord blood for allogenic transplants. They do not charge to store cord blood. The stem cells in the donated cord blood can be used by anyone who matches. Some public banks will store cord blood for directed donation if you have a family member who has a disease that could potentially be treated with stem cells.

Donors to public banks must be screened for blood or immune system disorders or other problems. With a cord blood donation, the mother’s blood is tested for genetic disorders and infections, and the cord blood also is tested after it is collected. Once it arrives at the blood bank, the cord blood is “typed.” It is tracked by a computer so that it can be found quickly for any person who matches when needed.

What are private cord blood banks?

Private or family banks store cord blood for autologous use or directed donation for a family member. Private banks charge a yearly fee for storage. Blood stored in a private bank must meet the same standards as blood stored in a public bank. If you have a family member with a disorder that may potentially be treated with stem cells, some private banks will store the cord blood free of charge.

What steps need to be done before cord blood is collected?

Certain steps must be done beforehand:

The bank must be notified and a collection kit must be obtained in advance (usually 6 weeks or more) of your due date. Some hospitals have collection kits on hand, whereas others do not.
A family medical history must be provided and the mother’s blood must be tested.
Consent must be given before labor begins.

If you choose a private bank, you will sign a contract and pay a fee before the baby is born.

How is cord blood collected?

Cord blood is collected by your obstetrician or the staff at the hospital where you give birth. Not all hospitals offer this service. Some charge a separate fee that may or may not be covered by insurance.

The process used to collect cord blood is simple and painless. After the baby is born, the umbilical cord is cut and clamped. Blood is drawn from the cord with a needle that has a bag attached. The process takes about 10 minutes.

What problems can occur during cord blood collection?

Sometimes, not enough cord blood can be collected. This problem can occur if the baby is preterm or if it is decided to delay clamping of the umbilical cord. It also can happen for no apparent reason. If an emergency occurs during delivery, priority is given to caring for you and your baby over collecting cord blood.

What else should I think about when deciding whether to donate or store cord blood?

Think about the following points when making your choice:

Donating cord blood to a public bank adds to the supply and can potentially help others. Donating to a public bank is especially important for ethnic minorities, who are not well represented in cord blood banks. Public cord blood donation increases the chance of all groups finding a match.
Only certain hospitals collect cord blood for storage in public banks.
Storing a child’s stem cells in a private bank as “insurance” against future disease is not recommended.
If you already have a child with a medical condition that may be helped by a cord blood transplant, donating a biological sibling’s cord blood for directed donation is encouraged.
If you decide to store cord blood in a private bank, you should find out the total cost, including charges for collecting and processing the cord blood and the annual storage fees.

EXTREMELY PRETERM BIRTH

When is a baby considered “preterm” or “extremely preterm?”

A normal pregnancy with one baby lasts about 40 weeks. Babies born before 37 completed weeks of pregnancy are called “preterm” or “premature.” Babies born before 28 completed weeks of pregnancy are considered extremely preterm. The earlier a baby is born, the less likely he or she is to survive. Those who do survive often have serious, sometimes long-term health problems and disabilities.

What is gestational age?

Gestational age is the “age” of the pregnancy. It often is counted in weeks and days. For example, “24 and 2/7 weeks of pregnancy” refers to 24 completed weeks and the next 2 days of pregnancy.

What are the health outcomes for extremely preterm babies?

Medical advances have helped some preterm babies survive and overcome health challenges. However, the chances that a baby born extremely early will survive without disability are still small. With very rare exceptions, babies born before 23 weeks of pregnancy do not survive. Although survival rates increase for babies born between 23 weeks and 25 weeks of pregnancy, most survivors face serious, often lifelong disabilities. As gestational age increases, the outlook for preterm babies improves.

Is there specialized health care for women and babies at risk of extremely preterm birth?

Extremely preterm birth usually is managed by a team of specialized health care professionals. In addition to your obstetrician or other pregnancy care professional, the team may include a maternal–fetal medicine subspecialist, a neonatologist, and other pediatric subspecialists. You may be transferred to a hospital that offers specialized care for extremely preterm infants. If time allows, this transfer may take place before delivery. High-level neonatal intensive care units (NICUs) provide care for infants with serious health problems. High-level maternal care facilities manage women with high-risk pregnancies.

What will happen if my baby is expected to be born extremely preterm?

You and your health care team will work together to form a plan about the care you and your baby will receive. This involves weighing the risks and benefits of the available treatment options for both you and your baby. Your personal beliefs and values and what your wishes are for your baby also are important in forming the care plan.

It is important to remember that this care plan may change as circumstances change. For instance, care plans may be adjusted after the baby is born when more information is known about the baby’s condition. Care decisions also may change depending on how the baby responds to treatment.

If my baby is born extremely preterm, will he or she need resuscitation?

Extremely preterm infants will not survive without resuscitation. Often this means helping the baby breathe by inserting a tube into his or her airway. Steps may be taken to start the baby’s heart. Even with resuscitation efforts, some babies will not survive. Those who do may have severe disabilities. Babies born before 23 weeks of pregnancy typically do not survive even with resuscitation. In some cases, after discussion with the health care team, a family may decide that resuscitation is not the best option for their baby. In situations like this, medical care will focus on keeping the baby warm, comfortable and free from pain.

What medications can be given to improve an extremely preterm baby’s chance of survival?

If resuscitation of the baby is planned or being considered, medications given to the pregnant woman may improve the baby’s chances of survival and reduce the risk of disability. These medications include the following:

Corticosteroids to help the baby’s lungs and other organs mature
Magnesium sulfate to decrease the risk of cerebral palsy
Tocolytic medications to help prolong pregnancy for a few hours or days to give time for the first two drugs to work
Antibiotics to prevent infection

Recommendations for giving these medications are made on a case-by-case basis. For example, corticosteroids are not recommended when delivery is expected at 22 weeks of pregnancy or earlier because they have not been found to be helpful. At 23 weeks of pregnancy, corticosteroids may be considered, but whether they will help is uncertain.

Will I need to have a cesarean delivery if my baby is born extremely preterm?

Not necessarily. Some babies at risk of extremely preterm birth may not be in a good position in the uterus to allow for a safe vaginal delivery. In these cases, a cesarean delivery may be recommended depending on gestational age. Cesarean delivery is rarely recommended before 23–24 weeks of pregnancy because it is unlikely to affect the outcome.

How can extremely preterm delivery affect my health?

A cesarean delivery can increase the risk of complications in future pregnancies. Prolonging pregnancy may worsen some medical conditions, such as preeclampsia, or put you at risk of infection. These health consequences also should be considered in care decisions.

Who can I turn to for support?

Your health care team is trained to give medical guidance and to include your and your family’s wishes and preferences in the decision-making process. Because your culture, values, and religious beliefs are important to consider when making these decisions, you also may want to seek support from family, trusted friends, and clergy. The hospital may offer counseling services and other programs for you and your family.

What will happen if it is decided to withdraw or withhold life-saving care?

If you decide to withdraw or withhold life-saving care, measures will be taken to make sure the baby is kept warm and comfortable. You will be able to spend as much time as you want with your baby. Nurses and other staff can help you create keepsakes, such as taking pictures and making footprints. Your health care team will make sure that you get the help and support you need.

What is involved in caring for an extremely preterm baby after leaving the hospital?

Most extremely preterm babies spend months in the hospital. After they are discharged, many will need ongoing, specialized medical care. There are pediatricians who specialize in the care of preterm babies from birth through childhood. Some clinics focus on follow-up care for preterm babies. The doctor will closely watch how your baby grows and check to see if any other problems develop during childhood.

Many agencies provide help for parents caring for preterm babies. It is a good idea to become as informed as you can so you can give your baby the best care. As your child reaches school age, you may need to find a special school or teachers to help with any learning problems.

HOW TO TELL WHEN LABOR BEGINS

What happens when labor begins?

Signs That You Are Approaching Labor
Sign What It is When It Happens
Feeling as if the baby has dropped lower Lightening. This is known as the “baby dropping.” The baby’s head has settled deep into your pelvis. From a few weeks to a few hours before labor begins
Increase in vaginal discharge (clear, pink, or slightly bloody) Show. A thick mucus plug has accumulated at the cervix during pregnancy. When the cervix begins to dilate, the plug is pushed into the vagina. Several days before labor begins or at the onset of labor

As labor begins, the cervix opens (dilates). The uterus, which contains muscle, contracts at regular intervals. When it contracts, the abdomen becomes hard. Between the contractions, the uterus relaxes and becomes soft. Up to the start of labor and during early labor, the baby will continue to move.

Certain changes also may signal that labor is beginning. You may or may not notice some of them before labor begins:

What is false labor?

Your uterus may contract off and on before “true” labor begins. These irregular contractions are called false labor or Braxton Hicks contractions. They are normal but can be painful at times. You might notice them more at the end of the day.

How can I tell the difference between true labor and false labor?

Differences Between False Labor and True Labor
Type of Change False Labor True Labor
Timing of contractions Often are irregular and do not get closer together (called Braxton Hicks contractions) Come at regular intervals and, as time goes on, get closer together. Each lasts about 30–70 seconds.
Change with movement Contractions may stop when you walk or rest, or may even stop with a change of position Contractions continue, despite movement
Strength of contractions Usually weak and do not get much stronger (may be strong and then weak) Increase in strength steadily
Pain of contractions Usually felt only in the front Usually starts in the back and moves to the front

Usually, false labor contractions are less regular and not as strong as true labor. Sometimes the only way to tell the difference is by having a vaginal exam to look for changes in your cervix that signal the onset of labor.

One good way to tell the difference is to time the contractions. Note how long it is from the start of one contraction to the start of the next one. Keep a record for an hour. It may be hard to time labor pains accurately if the contractions are slight. Listed as follows are some differences between true labor and false labor:

CESAREAN BIRTH (C-SECTION)

What is cesarean birth?

Cesarean birth is the delivery of a baby through incisions made in the mother’s abdomen and uterus.

What are the reasons for cesarean birth?

The following situations are some of the reasons why a cesarean birth is performed:

Multiple pregnancy—If a woman is pregnant with twins, a cesarean birth may be necessary if the babies are being born too early, are not in good positions in the uterus, or if there are other problems. The likelihood of having a cesarean birth increases with the number of babies a woman is carrying.
Failure of labor to progress—Contractions may not open the cervix enough for the baby to move into the vagina.
Concern for the baby—For instance, the umbilical cord may become pinched or compressed or fetal monitoring may detect an abnormal heart rate.
Problems with the placenta
A large baby
Breech presentation
Maternal infections, such as human immunodeficiency virus or herpes
Maternal medical conditions, such as diabetes or high blood pressure

Is a cesarean birth necessary if I have had a previous cesarean birth?

Women who have had a cesarean birth before may be able to give birth vaginally. The decision depends on the type of incision used in the previous cesarean delivery, the number of previous cesarean deliveries, whether you have any conditions that make a vaginal delivery risky, and the type of hospital in which you have your baby, as well as other factors. Talk to your health care provider about your options.

Can I request cesarean birth?

Some women may request a cesarean birth even if a vaginal delivery is an option. This decision should be weighed carefully and discussed with your health care provider. As with any surgery, there are risks and complications to consider. Your hospital stay may be longer than with vaginal birth. Also, the more cesarean births a woman has, the greater her risk for some medical problems and problems with future pregnancies. This may not be a good option for women who want to have more children.

What are the preparations for cesarean birth?

Before you have a cesarean delivery, a nurse will prepare you for the operation. An intravenous line will be put in a vein in your arm or hand. This allows you to get fluids and medications during the surgery. Your abdomen will be washed, and your pubic hair may be clipped or trimmed. You will be given medication to prevent infection.

A catheter (tube) is then placed in your urethra to drain your bladder. Keeping the bladder empty decreases the chance of injuring it during surgery.
cesarean

The incision made in the uterine wall for cesarean birth may be transverse (left) or vertical (right). The type of incision made in the skin may not be the same type of incision made in the uterus.

What type of anesthesia will be used during the procedure?

You will be given either general anesthesia, an epidural block, or a spinal block. If general anesthesia is used, you will not be awake during the delivery. An epidural block numbs the lower half of the body. An injection is made into a space in your spine in your lower back. A small tube may be inserted into this space so that more of the drug can be given through the tube later, if needed. A spinal block also numbs the lower half of your body. You receive it the same way as an epidural block, but the drug is injected directly into the spinal fluid.

How is the procedure performed?

An incision is made through your skin and the wall of the abdomen. The skin incision may be transverse (horizontal or “bikini”) or vertical, near the pubic hairline. The muscles in your abdomen are separated and may not need to be cut. Another incision will be made in the wall of the uterus. The incision in the wall of the uterus also will be either transverse or vertical.

The baby will be delivered through the incisions, the umbilical cord will be cut, and then the placenta will be removed. The uterus will be closed with stitches that will dissolve in the body. Stitches or staples are used to close your abdominal skin.

What are the complications?

Some complications occur in a small number of women and usually are easily treated:

Infection
Blood loss
Blood clots in the legs, pelvic organs, or lungs
Injury to the bowel or bladder
Reaction to medications or to the anesthesia that is used

What should I expect after the procedure?

If you are awake for the surgery, you can probably hold your baby right away. You will be taken to a recovery room or directly to your room. Your blood pressure, pulse rate, breathing rate, amount of bleeding, and abdomen will be checked regularly. If you are planning on breastfeeding, be sure to let your health care provider know. Having a cesarean delivery does not mean you will not be able to breastfeed your baby. You should be able to begin breastfeeding right away.

You may need to stay in bed for a while. The first few times you get out of bed, a nurse or other adult should help you.

Soon after surgery, the catheter is removed from the bladder. The abdominal incision will be sore for the first few days. Your doctor can prescribe pain medication for you to take after the anesthesia wears off. A heating pad may be helpful. There are many different ways to control pain. Talk to your health care provider about your options.

A hospital stay after a cesarean birth usually is 2–4 days. The length of your stay depends on the reason for the cesarean birth and on how long it takes for your body to recover. When you go home, you may need to take special care of yourself and limit your activities.

What should I expect during recovery?

While you recover, the following things may happen:

Mild cramping, especially if you are breastfeeding
Bleeding or discharge for about 4–6 weeks
Bleeding with clots and cramps
Pain in the incision

To prevent infection, for a few weeks after the cesarean birth you should not place anything in your vagina or have sex. Allow time to heal before doing any strenuous activity. Call your health care provider if you have a fever, heavy bleeding, or the pain gets worse.

FETAL HEART RATE MONITORING DURING LABOR

What is fetal heart rate monitoring?

Fetal heart rate monitoring is the process of checking the condition of your baby during labor and delivery by monitoring his or her heart rate with special equipment.

Why is fetal heart rate monitoring done during labor and delivery?

Fetal heart rate monitoring may help detect changes in the normal heart rate pattern during labor. If certain changes are detected, steps can be taken to help treat the underlying problem. Fetal heart rate monitoring also can help prevent treatments that are not needed. A normal fetal heart rate can reassure both you and your health care provider that it is safe to continue labor if no other problems are present.

What are the types of monitoring?

There are two methods of fetal heart rate monitoring in labor. Auscultation is a method of periodically listening to the fetal heartbeat. Electronic fetal monitoring is a procedure in which instruments are used to continuously record the heartbeat of the fetus and the contractions of the mother’s uterus during labor. The method that is used depends on your health care provider’s or hospital’s policy, your risk of problems, and how your labor is going. If you do not have any complications or risk factors for problems during labor, either method is acceptable.

How is auscultation performed?

Auscultation is done with either a special stethoscope or a device called a Doppler transducer. When the transducer is pressed against your abdomen, you can hear your baby’s heartbeat.

When auscultation is used, your health care provider will check the heart rate of the baby at set times during labor. If you have risk factors for problems during labor or if problems appear during labor, the fetal heart rate will be checked and recorded more frequently.

How is electronic fetal monitoring performed?

Electronic fetal monitoring uses special equipment to measure the response of the baby’s heart rate to contractions of the uterus. It provides an ongoing record that can be read by your health care provider. Your health care provider will review the electronic recording of the baby’s heartbeat (called the fetal heart rate tracing) at set times. The tracing may be reviewed more frequently if problems arise.

Electronic fetal monitoring can be external, internal, or both. You may need to stay in bed during both types of electronic monitoring, but you can move around and find a comfortable position.

How is external monitoring performed?

With this method, a pair of belts is wrapped around your abdomen. One belt uses Doppler to detect the fetal heart rate. The other belt measures the length of contractions and the time between them.

How is internal monitoring performed?

With this method, a wire called an electrode is used. It is placed on the part of the baby closest to the cervix, usually the scalp. This device records the heart rate. Uterine contractions also may be monitored with a special tube called an intrauterine pressure catheter that is inserted through the vagina into your uterus. Internal monitoring can be used only after the membranes of the amniotic sac have ruptured (after “your water breaks” or is broken).

What happens if the fetal heart rate pattern is abnormal?

Abnormal fetal heart rate patterns do not always mean there is a problem. Other tests may be done to get a better idea of what is going on with your baby.

If there is an abnormal fetal heart rate pattern, your health care provider will first try to find the cause. Steps can be taken to help the baby get more oxygen, such as having you change position. If these procedures do not work, or if further test results suggest your baby has a problem, your health care provider may decide to deliver the baby right away. In this case, the delivery of the baby is more likely to be by cesarean birth or with forceps or vacuum extraction.

BREASTFEEDING YOUR BABY

How long should I breastfeed my baby?

Exclusive breastfeeding is recommended for the first 6 months of a baby’s life. Breastfeeding should continue up to the baby’s first birthday as new foods are introduced. You can keep breastfeeding after the baby’s first birthday for as long as you and your baby would like.

How does breastfeeding benefit my baby?

Breastfeeding is best for your baby for the following reasons:

Breast milk has the right amount of fat, sugar, water, protein, and minerals needed for a baby’s growth and development. As your baby grows, your breast milk changes to adapt to the baby’s changing nutritional needs.
Breast milk is easier to digest than formula.
Breast milk contains antibodies that protect infants from certain illnesses, such as ear infections, diarrhea, respiratory illnesses, and allergies. The longer your baby breastfeeds, the greater the health benefits.
Breastfed infants have a lower risk of sudden infant death syndrome (SIDS).
Breast milk can help reduce the risk of many of the short-term and long-term health problems that preterm babies face.

How does breastfeeding benefit me?

Breastfeeding is good for you for the following reasons:

Breastfeeding triggers the release of a hormone called oxytocin that causes the uterus to contract. This helps the uterus return to its normal size more quickly and may decrease the amount of bleeding you have after giving birth.
Breastfeeding may make it easier to lose the weight you gained during pregnancy.
Breastfeeding may reduce the risk of breast cancer and ovarian cancer.

How do I get my baby to latch on to my breast?

Holding your baby directly against your bare skin right after birth triggers reflexes that help the baby to attach or “latch on” to your breast. Cup your breast in your hand and stroke your baby’s lower lip with your nipple. The baby will open his or her mouth wide, like a yawn. Pull the baby close to you, aiming the nipple toward the roof of the baby’s mouth. Remember to bring your baby to your breast—not your breast to your baby.

How can I tell if my baby is hungry?

When babies are hungry, they look alert, bend their arms, close their fists, and bring their fingers to their mouths. Offer your baby your breast when he or she first starts bringing fingers to his or her mouth. Crying is a late sign of hunger, and an unhappy baby will find it harder to latch. When full, babies relax their arms and legs and close their eyes.

How often should I breastfeed my baby?

Let your baby set his or her own schedule. During the first weeks of life, most babies feed at least 8–12 times in 24 hours, or at least every 2–3 hours (timed from the start time of one feeding to the start time of the next feeding). Many newborns breastfeed for 10–15 minutes on each breast. But they also can nurse for much longer periods (sometimes 60–120 minutes at a time) or feed very frequently (every 30 minutes, which is called “cluster feeding”). Some babies feed from one breast per feeding, while others feed from both breasts. When your baby releases one breast, offer the other. If your baby is not interested, plan to start on the other side for the next feeding.

What should I do if I am having trouble breastfeeding?

Breastfeeding is a natural process, but it can take some time for you and your baby to learn. Most women are able to breastfeed. A few women cannot breastfeed because of medical conditions or other problems.

Lots of breastfeeding help is available. Peer counselors, nurses, doctors, and certified lactation consultants can teach you what you need to know to get started. They also can give advice if you run into challenges.

What kinds of foods should I eat while breastfeeding?

The following tips will help you meet the nutritional goals needed for breastfeeding:

Your body needs about 450–500 extra calories a day to make breast milk for your baby. If your weight is in the normal range, you need about 2,500 total calories per day.
Eat fish and seafood 2–3 times a week, but avoid eating fish with high mercury levels. Do not eat shark, swordfish, king mackerel, or tilefish, and limit albacore tuna to 6 ounces a week. If you eat fish caught in local waters, check for advisories about mercury or other pollutants. If no information is available, limit your intake of such fish to 6 ounces a week, and do not eat any other fish that week.
Your health care professional may recommend that you continue to take your prenatal multivitamin supplement while you are breastfeeding.
Drink plenty of fluids, and drink more if your urine is dark yellow.

Can I drink caffeine while breastfeeding?

Drinking caffeine in moderate amounts (200 mg a day) most likely will not affect your baby. Newborns and preterm infants are more sensitive to caffeine’s effects. You may want to consume a lower amount of caffeine in the first few days after your baby is born or if your infant is preterm.

Can I drink alcohol while breastfeeding?

If you want to have an occasional alcoholic drink, wait at least 2 hours after a single drink to breastfeed. The alcohol will leave your milk as it leaves your bloodstream—there is no need to express and discard your milk. Drinking more than two drinks per day on a regular basis may be harmful to your baby and may cause drowsiness, weakness, and abnormal weight gain.

How do I know if a medication is safe to take while breastfeeding?

Most medications are safe to take while breastfeeding. Although medications can be passed to your baby in breast milk, levels are usually much lower than the level in your bloodstream. The latest information about medications and their effects on breastfed babies can be found at LactMed, a database of scientific information, at www.toxnet.nlm.nih.gov/newtoxnet/lactmed.htm. If you are breastfeeding and need to take a prescription medication to manage a health condition, discuss this with your health care team and the health care professional caring for your baby.

Why is it important to avoid smoking and drug use while breastfeeding?

Secondhand smoke from cigarettes is harmful to infants and children. It increases the risk of allergies, asthma, and SIDS. Smoking can decrease your milk supply and can make it harder for the baby to gain weight. Be sure not to smoke around the baby.

Using illegal drugs, such as cocaine, heroin, and methamphetamines, and taking prescription drugs for nonmedical reasons can harm your baby if you use them while breastfeeding. And although marijuana is now legal in several states, its use is discouraged during breastfeeding. If you need help stopping drug use, talk with your obstetrician, lactation consultant, or other health care professional.

What birth control methods can I use while breastfeeding?

Many birth control methods are available that can be used while breastfeeding, including nonhormonal methods (copper intrauterine device, condoms, and diaphragms) and hormonal methods. There are some concerns that hormonal methods of birth control can affect milk supply, especially when you first start breastfeeding. If you start using a hormonal method and your milk supply decreases, talk with your obstetrician or other member of your health care team about other options for preventing pregnancy.

NEWBORN CIRCUMCISION

What is circumcision?

Circumcision is the surgical removal of the layer of skin, called the foreskin, that covers the glans (head) of the penis.

When is circumcision performed?

Circumcision on infants may be performed before or after the mother and baby leave the hospital. It only is performed if the baby is healthy. If the baby has a medical condition, circumcision may be postponed. Circumcision also can be performed on older children or adults. However, recovery may take longer when circumcision is done on an older child or adult. The risks of complications also are increased.

Is circumcision a required procedure?

Circumcision is an elective procedure. That means that it is the parents’ choice whether to have their infant sons circumcised. It is not required by law or by hospital policy. Because it is an elective procedure, circumcision may not be covered by your insurance policy. To find out, call your insurance provider or check your policy.

Is circumcision a common practice?

Although many newborn boys in the United States are circumcised, the number of circumcisions has decreased in recent years. It is less common in other parts of the world.

Why do some parents choose to have their sons circumcised?

There are hygienic reasons for circumcision. Smegma is a thick white discharge containing dead cells. It can build up under the foreskin of males who are not circumcised. This can lead to odor or infection. However, a boy who has not been circumcised can be taught to wash his penis to get rid of smegma as a part of his bathing routine.

For some people, circumcision is a part of certain religious practices. Muslims and Jews, for example, have circumcised their male newborns for centuries. Others may choose circumcision so that the child does not look different from his father or other boys.

Why do some parents choose not to have their sons circumcised?

Some parents choose not to circumcise their sons because they are worried about the pain the baby may feel or the risks involved with the surgery. Others believe it is a decision a boy should make himself when he is older.

Are there any health benefits associated with circumcision?

Circumcised infants appear to have less risk of urinary tract infections than uncircumcised infants. The risk of urinary tract infection in both groups is low. It may help prevent cancer of the penis, a rare condition.

Some research suggests that circumcision may decrease the risk of a man getting human immunodeficiency virus (HIV) from an infected female partner. It is possible that circumcision may decrease the risk of passing HIV and other sexually transmitted diseases from an infected man to a female partner. At the present time, there is not enough information to recommend routine newborn circumcision for health reasons.

Are there any risks associated with circumcision?

Possible complications include bleeding, infection, and scarring. In rare cases, too much of the foreskin or not enough foreskin is removed. More surgery sometimes is needed to correct these problems.

How is circumcision performed?

Circumcision takes only a few minutes. During the procedure, the baby is placed on a special table. It is recommended that an anesthetic be used for pain relief. Various surgical techniques are used, but they follow the same steps:

The penis and foreskin are cleaned.
A special clamp is attached to the penis and the foreskin is removed.
After the procedure, a bandage and petroleum jelly are placed over the wound to protect it from rubbing against the diaper.

What should I expect after my baby boy has been circumcised?

If your baby boy has been circumcised, a bandage with petroleum jelly may be placed over the head of the penis after surgery. The bandage typically falls off the next time the baby urinates. Some heath care providers recommend keeping a clean bandage on until the penis is healed, while others recommend leaving it off. In most cases, the skin will heal in 7–10 days. You may notice that the tip of the penis is red and there may be a small amount of yellow fluid. This usually is normal.

How do I keep the circumcised area clean?

Use a mild soap and water to clean off any stool that gets on the penis. Change the diapers often so that urine and stool do not cause infection. Signs of infection include redness that does not go away, swelling, or fluid that looks cloudy and forms a crust.

If I decide not to have my son circumcised, how do I clean his penis and foreskin?

If your baby boy has not been circumcised, washing the baby’s penis and foreskin properly is important. The outside of the penis should be washed with a mild soap and water. Do not attempt to pull back the infant’s foreskin. The foreskin may not be able to pull back completely until the child is about 3–5 years old. This is normal.

As your child gets older, teach your son how to wash his penis. He should pull back the foreskin and clean the area with soap and water. The foreskin then should be pushed back into place.

MEDICATIONS FOR PAIN RELIEF DURING LABOR AND DELIVERY

What are the types of pain-relieving medications that can be used during labor and delivery?

In general, there are two types of pain-relieving drugs: 1) analgesics and 2) anesthetics. Analgesics relieve pain without total loss of feeling or muscle movement. They are used to lessen pain but usually do not stop pain completely. Anesthetics block all feeling, including pain.

What are systemic analgesics?

Systemic analgesics act on the whole nervous system, rather than a specific area, to lessen pain. They will not cause you to lose consciousness. These medications often are used during early labor to allow you to rest.

Systemic analgesics usually are given as a shot. Depending on the type of medication, the shot is given into either a muscle or a vein. In patient-controlled analgesia, you can control the amount of medication you receive through an intravenous (IV) line. This is a small tube that is placed into a vein through which medications or fluids are given.

What are the risks of systemic analgesia?

Systemic pain medicine can have side effects, such as nausea, feeling drowsy, or having trouble concentrating. Sometimes another drug is given along with a systemic analgesic to relieve nausea. Systemic analgesics can affect the baby’s heart rate temporarily. It can be more difficult to detect fetal heart rate problems when these drugs are used. High doses of these drugs can cause you to have breathing problems and also can slow down the baby’s respiratory system, especially right after delivery.

What is local anesthesia?

Local anesthesia is the use of drugs that affect only a small area of the body. Local anesthetics provide relief from pain in that area. Local anesthetics are injected into the area around the nerves that carry feeling to the vagina, vulva, and perineum. The drugs are given just before delivery. They also are used when an episiotomy needs to be done or when any vaginal tears that happened during birth are repaired.

What are regional analgesia and regional anesthesia?

Regional analgesia and regional anesthesia act on a specific region of the body. Depending on the types of drugs that are used, they can lessen or block pain below the waist. They include the epidural block, spinal block, and combined spinal–epidural (CSE) block.

What is an epidural block?

An epidural block (sometimes referred to as “an epidural”) is the most common type of pain relief used during labor and delivery in the United States. In an epidural block, medication is given through a tube placed into the lower back.

An epidural block can be used during labor and for a vaginal delivery or cesarean delivery. For labor and vaginal delivery, a combination of analgesics and anesthetics may be used. This combination of drugs causes some loss of feeling in the lower areas of your body, but you remain awake and alert. You should be able to bear down and push your baby through the birth canal. For a cesarean delivery, the dose of anesthetic may be increased. This causes loss of sensation in the lower half of your body. An epidural also can be used for postpartum sterilization.

How long does an epidural take to work?

Because the medication needs to be absorbed into several nerves, it may take a short time for it to take effect. Pain relief should begin within 10–20 minutes after the medication has been injected.

Will I be able to move or feel anything after receiving an epidural?

You can move with an epidural, but you may not be able to walk around. Although an epidural block will make you more comfortable, you still may be aware of your contractions. You also may feel your health care provider’s exams as labor progresses.

What are the risks of an epidural?

Although it is rare, an epidural block can cause the following side effects:

Decrease in blood pressure—An epidural can cause your blood pressure to decrease. This, in turn, may slow the baby’s heartbeat.
Fever—Some women develop a low-grade fever as a normal reaction to an epidural.
Headache—If the covering of the spinal cord is pierced while the tube is being placed and spinal fluid leaks out, you can get a bad headache. This happens rarely.
Soreness—After delivery, your back may be sore for a few days.

Serious complications with epidurals are very rare:

There is a small risk that the anesthetic medication could be injected into one of the veins in the epidural space. This can cause dizziness, rapid heartbeat, a funny taste, or numbness around the mouth when the epidural is placed.
If anesthetic enters your spinal fluid, it can affect your breathing muscles and make it hard to breathe.

What is a spinal block?

A spinal block—like an epidural block—is a form of regional pain relief. A small amount of medication is injected into the spinal fluid. Depending on the drugs used, it can be used for regional analgesia or anesthesia. It starts to relieve pain quickly, but it lasts for only an hour or two.

Will I be able to move or feel anything after receiving a spinal block?

You may be numb after receiving a spinal block and will need assistance moving.

What are the risks of a spinal block?

A spinal block can cause the same side effects as an epidural block.

What is a combined spinal–epidural (CSE) block?

A CSE block is another form of regional pain relief. It has the benefits of both a spinal block and an epidural block. The spinal part acts quickly to relieve pain. The epidural part provides continuous pain relief. Lower doses of medication can be used with a CSE block than with an epidural block for the same level of pain relief.

Will I be able to move after receiving a CSE block?

The CSE block sometimes is called a “walking epidural.” Depending on your hospital’s policy, you may be able to walk for a short distance after the block is in place. For example, you may be able to walk a few feet to the bathroom with assistance. However, some hospitals and birthing centers require women who receive any type of pain relief to remain in bed.

What are the risks of a CSE block?

A CSE has the same risks as an epidural block.

What is general anesthesia?

General anesthesia causes you to lose consciousness so that you do not feel pain. It usually is used only for emergency situations during childbirth.

How is general anesthesia given?

It is given through an IV line or through a mask. After you are asleep, your anesthesiologist will place a breathing tube into your mouth and windpipe.

What are the risks of general anesthesia?

A rare but major risk is aspiration of food or liquids from a woman’s stomach into the lungs. Labor usually causes undigested food to stay in the stomach longer than usual. While you are unconscious, the contents of your stomach can come back into the mouth and go into the lungs. This can cause a lung infection (pneumonia) that can be serious. General anesthesia usually requires the placement of a breathing tube into the lungs to help you breathe while you are unconscious. Difficulty placing this tube is another risk. General anesthesia can cause the newborn baby’s breathing rate to decrease. It also can make the baby less alert. In rare cases, the baby may need help breathing after birth.

PRETERM (PREMATURE) LABOR AND BIRTH

What is preterm labor?

Preterm labor is defined as regular contractions of the uterus resulting in changes in the cervix that start before 37 weeks of pregnancy. Changes in the cervix include effacement (the cervix thins out) and dilation (the cervix opens so that the fetus can enter the birth canal).

What is preterm birth?

When birth occurs between 20 weeks of pregnancy and 37 weeks of pregnancy, it is called preterm birth.

Why is preterm birth a concern?

Preterm birth is a concern because babies who are born too early may not be fully developed. They may be born with serious health problems. Some health problems, like cerebral palsy, can last a lifetime. Other problems, such as learning disabilities, may appear later in childhood or even in adulthood.

Which preterm babies are at greatest risk of health problems?

The risk of health problems is greatest for babies born before 34 weeks of pregnancy. But babies born between 34 weeks of pregnancy and 37 weeks of pregnancy also are at risk.

What are risk factors for preterm birth?

Factors that increase the risk of preterm birth include the following:

Having a previous preterm birth
Having a short cervix
Short interval between pregnancies
History of certain types of surgery on the uterus or cervix
Certain pregnancy complications, such as multiple pregnancy and vaginal bleeding
Lifestyle factors such as low prepregnancy weight, smoking during pregnancy, and substance abuse during pregnancy

Can anything be done to prevent preterm birth if I am at high risk?

If you have had a prior preterm birth and you are planning another pregnancy, a preconception care checkup can help you get in the best possible health before you become pregnant. When you become pregnant, be sure to start prenatal care early. You may be referred to a health care professional who has expertise in managing high-risk pregnancies. In addition, you may be given certain medications or other treatment to help prevent preterm birth if you have risk factors. Treatment is given based on your individual situation and your risk factors for preterm birth.

What are the signs and symptoms of preterm labor and what should I do if I have any of them?

Call your obstetrician or other health care professional right away if you notice any of these signs or symptoms:

Change in type of vaginal discharge (watery, mucus, or bloody)
Increase in amount of discharge
Pelvic or lower abdominal pressure
Constant low, dull backache
Mild abdominal cramps, with or without diarrhea
Regular or frequent contractions or uterine tightening, often painless
Ruptured membranes (your water breaks with a gush or a trickle of fluid)

How is preterm labor diagnosed?

Preterm labor can be diagnosed only when changes in the cervix are found. Your obstetrician or other health care professional may perform a pelvic exam to see if your cervix has started to change. You may need to be examined several times over a period of a few hours. Your contractions also may be monitored.

Your obstetrician or other health care professional may do certain tests to determine whether you need to be hospitalized or if you need immediate specialized care. A transvaginal ultrasound exam may be done to measure the length of your cervix. The level of a protein called fetal fibronectin in the vaginal discharge may be measured. The presence of this protein is linked to preterm birth.

If I have preterm labor, will I have a preterm birth?

It is difficult for health care professionals to predict which women with preterm labor will go on to have preterm birth. Only about 10% of women with preterm labor will give birth within the next 7 days. For about 30% of women, preterm labor stops on its own.

What happens if my preterm labor continues?

If your preterm labor continues, how it is managed is based on what is thought to be best for your health and your baby’s health. When there is a chance that the baby would benefit from a delay in delivery, certain medications may be given. These medications include corticosteroids, magnesium sulfate, and tocolytics.

What are corticosteroids?

Corticosteroids are drugs that cross the placenta and help speed up development of the baby’s lungs, brain, and digestive organs. Corticosteroids are most likely to help your baby when they are given between 24 weeks of pregnancy and 34 weeks of pregnancy, but consideration can also be given to providing corticosteroids between 23 and 24 weeks of pregnancy.

What is magnesium sulfate?

Magnesium sulfate is a medication that may be given if you are less than 32 weeks pregnant, are in preterm labor, and are at risk of delivery within the next 24 hours. This medication may help reduce the risk of cerebral palsy that is associated with early preterm birth.

What are tocolytics?

Tocolytics are drugs used to delay delivery for a short time (up to 48 hours). They may allow time for corticosteroids or magnesium sulfate to be given or for you to be transferred to a hospital that offers specialized care for preterm infants. In addition to its role in protecting against cerebral palsy, magnesium sulfate also can be used as a tocolytic drug.

What happens if my labor does not stop?

If your labor does not stop and it looks like you will give birth to your baby early, you and the baby usually will be cared for by a team of health care professionals. The team may include a neonatologist, a doctor who specializes in treating problems in newborns. The care your baby needs depends on how early he or she is born. High-level neonatal intensive care units provide this specialized care for preterm infants.

EXERCISE AFTER PREGNANCY

What are some of the benefits of exercise for postpartum women?

Exercise has the following benefits for postpartum women: It helps strengthen and tone abdominal muscles.
It boosts energy.
It may be useful in preventing postpartum depression.
It promotes better sleep.
It relieves stress.

How much should I exercise after I have a baby?

After having a baby, it is recommended that you get at least 150 minutes of moderate-intensity aerobic activity every week.

What is aerobic activity?

An aerobic activity is one in which you move large muscles of the body (like those in the legs and arms) in a rhythmic way.

What is moderate-intensity activity?

Moderate intensity means you are moving enough to raise your heart rate and start sweating. You can still talk normally, but you cannot sing. Examples of moderate-intensity aerobic activities include brisk walking and riding a bike on a level surface. You can choose to divide the 150 minutes into 30-minute workouts on 5 days of the week or into smaller 10-minute sessions throughout each day. For example, you could go for three 10-minute walks each day.

What is vigorous-intensity activity?

A vigorous-intensity activity is one in which it is hard to talk without pausing for breath. If you followed a vigorous-intensity exercise program before pregnancy, it may be possible to return to your regular workouts soon after the baby is born. Be sure to get your health care provider’s approval. Examples include running, jumping rope, and swimming laps.

What are muscle-strengthening workouts and how often should I do them?

This type of exercise works the body’s major muscle groups, such as the legs, arms, and hips. Examples include yoga, Pilates, lifting weights, sit-ups, and push-ups. There also are special Kegel exercises that help tone the muscles of the pelvic floor. Muscle-strengthening activities should be done in addition to your aerobic activity on at least 2 days a week.

When can I start exercising after pregnancy?

If you had a healthy pregnancy and a normal vaginal delivery, you should be able to start exercising again soon after the baby is born. Usually, it is safe to begin exercising a few days after giving birth—or as soon as you feel ready. If you had a cesarean delivery or other complications, ask your health care provider when it is safe to begin exercising again.

What are some guidelines I can follow when I begin exercising after pregnancy?

Aim to stay active for 20–30 minutes a day. When you first start exercising after childbirth, try simple postpartum exercises that help strengthen major muscle groups, including abdominal and back muscles. Gradually add moderate-intensity exercise. Remember, even 10 minutes of exercise benefits your body. If you exercised vigorously before pregnancy or you are a competitive athlete, you can work up to vigorous-intensity activity. Stop exercising if you feel pain.

What are some ways to start exercising?

When you are ready to start exercising, walking is a great way to get back in shape. Walking outside has an added bonus because you can push your baby in a stroller. There are special strollers made for this kind of activity, but using a regular stroller is fine. Another good way to get daily exercise is by joining an exercise class. Working out with a group and socializing with group members can help keep you motivated.

Where can I find out about exercise classes?

Check with your local fitness clubs or community centers for classes that interest you, such as yoga, Pilates, spinning, and dance. Some gyms even offer special postpartum exercise classes and classes you can take with your baby. You also might consider working out with a personal trainer for the first few weeks.

What can I do if I want to exercise but I don’t want to join a gym?

If you do not want to join a gym but want the benefits of having someone to exercise with, ask a friend to be your workout buddy. If you want to exercise on your own, check out fitness DVDs and online exercise programs. Many are designed for women who have just had a baby. Some even show you how to involve your baby in the exercise routines.

How can I stay motivated once I start exercising?

You may already have a great exercise tool in your pocket. Smart phone apps for exercise and fitness can help you stay motivated, keep track of your progress, and connect you with others with the same exercise goals. Many apps are free or cost very little.

How should I prepare for my workout?

As you get ready for your workout, follow these steps:

Wear loose-fitting clothing that will help keep you cool.
If you are breastfeeding, feed your baby or express your milk before your workout to avoid any discomfort that may come from engorged breasts.
Wear a bra that fits well and gives plenty of support to protect your breasts.
Have a bottle of water handy and take several sips during your workout.

How should I warm up before my workout?

Spend 10 minutes warming up to get your muscles ready for exercise. Try stretches for the lower back, pelvis, and thighs. Hold stretches for several seconds and return to the starting position. Walking in place also is a good way to warm up.
How should I cool down after my workout?

End your workout with a 5-minute cool-down period that brings your heart rate back to normal. Walk slowly in place and stretch again to help avoid soreness.

LABOR INDUCTION

What is labor induction?

Labor induction is the use of medications or other methods to bring on (induce) labor.

Why is labor induced?

Labor is induced to stimulate contractions of the uterus in an effort to have a vaginal birth. Labor induction may be recommended if the health of the mother or fetus is at risk. In special situations, labor is induced for nonmedical reasons, such as living far away from the hospital. This is called elective induction. Elective induction should not occur before 39 weeks of pregnancy.

What is the Bishop score?

To prepare for labor and delivery, the cervix begins to soften (ripen), thin out, and open. These changes usually start a few weeks before labor begins. Health care providers use the Bishop score to rate the readiness of the cervix for labor. With this scoring system, a number ranging from 0–13 is given to rate the condition of the cervix. A Bishop score of less than 6 means that your cervix may not be ready for labor.

What is “ripening the cervix”?

Ripening the cervix is a process that helps the cervix soften and thin out in preparation for labor. Medications or devices may be used to soften the cervix so it will stretch (dilate) for labor.

How is cervical ripening performed?

Ripening of the cervix can be done with prostaglandins or with special devices.

What are prostaglandins?

Prostaglandins are drugs that can be used to ripen the cervix. They are forms of chemicals produced naturally by the body. These drugs can be inserted into the vagina or taken by mouth. Some of these drugs are not used in women who have had a previous cesarean delivery or other uterine surgery to avoid increasing the possible risk of uterine rupture (tearing).

What devices are used to ripen and dilate the cervix?

Laminaria (a substance that absorbs water) can be inserted to expand the cervix. A catheter (small tube) with an inflatable balloon on the end also can be inserted to widen the cervix.

What is “stripping the membranes?”

Stripping the membranes is a way to induce labor. The health care provider sweeps a gloved finger over the thin membranes that connect the amniotic sac to the wall of your uterus. This action may cause your body to release prostaglandins, which soften the cervix and may cause contractions.

How can rupturing the amniotic sac bring on labor?

Rupturing the amniotic sac can start contractions. It also can make them stronger if they have already begun. The health care provider makes a small hole in the amniotic sac with a special tool. This procedure, called an amniotomy, may cause some discomfort.

When is amniotomy done?

Amniotomy is done to start labor when the cervix is dilated and thinned and the baby’s head has moved down into the pelvis. Most women go into labor within hours after the amniotic sac breaks (their “water breaks”).

What is oxytocin?

Oxytocin is a hormone that causes contractions of the uterus. It can be used to start labor or to speed up labor that began on its own. Contractions usually start in about 30 minutes after oxytocin is given.

What are the risks associated with labor induction?

With some methods, the uterus can be overstimulated, causing it to contract too frequently. Too many contractions may lead to changes in the fetal heart rate, umbilical cord problems, and other problems. Other risks of cervical ripening and labor induction include the following:

Infection in the mother or baby
Uterine rupture
Increased risk of cesarean birth
Fetal death

Medical problems that were present before pregnancy or occurred during pregnancy may contribute to these complications.

Is labor induction always effective?

Sometimes labor induction does not work. A failed attempt at induction may mean that you will need to try another induction or have a cesarean delivery. The chance of having a cesarean delivery is greatly increased for first-time mothers who have labor induction, especially if the cervix is not ready for labor.

ELECTIVE DELIVERY BEFORE 39 WEEKS

What is a “medically indicated” delivery?

A medically indicated delivery is done for a medical reason. These reasons may be the woman’s medical condition or a problem with the baby. Labor may be induced (started with the use of certain drugs or other means) or a cesarean delivery may be performed (in which the baby is born through incisions made in the abdomen and uterus).

What is an “elective” delivery?

An elective delivery is performed for a nonmedical reason. Some nonmedical reasons include wanting to schedule the birth of the baby on a specific date or living far away from the hospital. Some women request delivery because they are uncomfortable in the last weeks of pregnancy. Some women request a cesarean delivery because they fear vaginal birth.

How long does a normal pregnancy last?

A normal pregnancy lasts about 40 weeks. It was once thought that babies born a few weeks early—between 37 weeks and 39 weeks—were just as healthy as babies born after 39 weeks. Experts now know that babies grow throughout the entire 40 weeks of pregnancy.

How does the baby grow and develop during the last weeks of pregnancy?

The lungs, brain, and liver are among the last organs to fully develop during pregnancy. The brain develops at its fastest rate at the end of pregnancy—it grows by one third just between week 35 and week 39. Also during these last weeks, layers of fat are added underneath the baby’s skin. This fat helps keep the baby warm after birth.

What are the risks for babies born before 39 weeks?

Babies who are born before 39 weeks may not be as developed as those who are born after 39 weeks. Because they may be less developed, they may have an increased risk of short-term and long-term health problems. Some of these problems can have lasting effects.

What health problems are possible for babies born too early?

The following health problems are possible in babies who are born too early:

Breathing problems, including respiratory distress syndrome
Temperature problems—Babies born early may not be able to stay warm.
Feeding difficulties
High levels of bilirubin—Too much bilirubin can cause jaundice. In severe cases, brain damage can result if this condition is not treated.
Hearing and vision problems
Learning and behavior problems

Why is it not a good idea to have an elective labor induction or cesarean delivery before 39 weeks?

Health care professionals recommend that unless there is a valid health reason or labor starts on its own, delivery should not occur before at least 39 weeks. If you have a cesarean delivery or labor induction for a medical reason, it means that the benefits of having the baby early outweigh the potential risks. But when they are done for a nonmedical reason, the risks—both to you and to the baby—may outweigh the benefits. When your pregnancy is normal and healthy, it should continue for at least 39 weeks, and it is preferable for labor to start on its own.

What are the risks associated with induced labor?

When labor is induced, there is an increased chance of infection, uterine rupture, and hemorrhage (life-threatening bleeding) compared to when labor starts on its own. Labor induction also may increase the likelihood of having a cesarean delivery, especially if you are giving birth for the first time and if your cervix is not ready for labor.

What are the risks associated with cesarean delivery?

A cesarean delivery is major surgery. Like all surgical procedures, it has risks, including infection, hemorrhage, and problems related to the anesthesia used. An elective cesarean delivery may pose additional risks if you plan to have more children. With each cesarean delivery, the chance that you will have a serious complication—including uterine rupture and needing a hysterectomy at the time of delivery—increases.

What are my alternatives to having an elective delivery before 39 weeks?

If you are considering an elective delivery before 39 weeks, it is important to discuss the potential risks and benefits with your health care provider as well as your reasons for requesting this type of delivery. If discomfort is a reason, it may help to know that it is normal to feel uncomfortable at the end of pregnancy. Your health care provider may be able to suggest ways to help you feel better. If you live far away from the hospital, you might want to stay with someone who lives closer.

You also may be able to set out for the hospital when you are in early labor. Talk to your health care provider to get other suggestions and advice.

ASSISTED VAGINAL DELIVERY

What is assisted vaginal delivery?

Assisted vaginal delivery is vaginal delivery of a baby performed with the help of forceps or a vacuum device. It sometimes is called operative vaginal delivery.

How common is assisted vaginal delivery?

Today, assisted vaginal delivery is done in about 3% of vaginal deliveries in the United States.

What are the types of assisted vaginal delivery?

There are two types of assisted vaginal delivery: 1) forceps-assisted delivery and 2) vacuum-assisted delivery. The type of delivery that is done depends on many factors, including your obstetrician’s experience and your individual situation.

How is forceps-assisted delivery performed?

Forceps look like two large spoons. They are inserted into the vagina and placed around the baby’s head. The forceps are used to apply gentle traction to help guide the baby’s head out of the birth canal while you keep pushing.

How is vacuum-assisted delivery performed?

A vacuum device is a suction cup with a handle attached. The suction cup is placed in the vagina and applied to the top of the baby’s head. Gentle, well-controlled traction is used to help guide the baby out of the birth canal while you keep pushing.

Why might assisted vaginal delivery be done?

Some of the reasons why an assisted vaginal delivery may be done include the following:

There are concerns about the baby’s heart rate pattern during labor.
You have pushed for a long time, but the baby’s head has stopped moving down the birth canal.
You are very tired from a long labor.
A medical condition (such as heart disease) limits your ability to push safely and effectively.

What factors will be considered before choosing assisted vaginal delivery?

Before choosing this option, your obstetrician assesses a number of factors to ensure that the highest levels of safety are met. These factors include your baby’s estimated weight, where your baby is in the birth canal, and whether the size of your pelvis appears adequate for a vaginal delivery. Your cervix should be fully dilated, and the baby’s head should be engaged (this means that the baby’s head has dropped down into your pelvis).

What are the benefits of assisted vaginal delivery?

One of the main advantages of assisted vaginal delivery is that it avoids a cesarean delivery. Cesarean delivery is major surgery and has risks, such as heavy bleeding and infection. If you are planning to have more children, avoiding a cesarean delivery may help prevent some of the possible future complications of multiple cesarean deliveries. Recovery from a vaginal delivery generally is shorter than recovery from a cesarean delivery. Often, assisted vaginal delivery can be done more quickly than a cesarean delivery.

What are the risks for me if I have assisted vaginal delivery?

Both forceps-assisted delivery and vacuum-assisted delivery are associated with a small increased risk of injury to the tissues of the vagina, perineum, and anus. A very small number of women may have urinary or fecal incontinence as a result of these injuries. Incontinence may go away on its own, or treatment may be needed.

What are the risks for my baby if I have assisted vaginal delivery?

Although the overall rate of injury to the baby as a result of assisted vaginal delivery is low, there still is a risk of certain complications for the baby. These include injuries to the baby’s scalp, head, and eyes; bleeding inside the skull; and problems with the nerves located in the arm and face. There is no evidence that assisted vaginal delivery has any effect on a child’s development.

What are the chances of having a repeat assisted vaginal delivery in a future pregnancy?

If you have had one assisted vaginal delivery, you have an increased risk of having one in a subsequent pregnancy. However, chances are good that you will have a spontaneous vaginal delivery. Some of the factors that increase the risk of another assisted delivery include a long (more than 3 years) interval between pregnancies or a fetus that is estimated to be larger than average.

What can I expect after having an assisted vaginal delivery?

After an assisted vaginal delivery, you may have perineal pain and bruising. It may be hard to walk or sit for a time. If you have had a perineal tear, it may require repair with stitches. Minor tears may heal on their own without stitches. You likely will have a few weeks of swelling and pain as the perineum heals.

What can I do to help relieve pain and swelling after an assisted vaginal delivery?

To help ease pain and swelling after delivery, try the following tips:

Take an over-the-counter pain reliever. Ibuprofen is preferred if you are breastfeeding. Acetaminophen also is a good choice.
Apply an ice pack, cold pack, or cold gel pads to the area.
Sit in cool water that is just deep enough to cover your buttocks and hips (called a sitz bath).
Try putting a witch hazel pad on a sanitary napkin. Witch hazel, which has a cooling effect, is a liquid made from certain plants that are distilled in water. It is available over the counter.
Use a “peri-bottle” while using the bathroom and afterward. This is a squeeze bottle that sends a spray of warm water over your perineum. It can help you urinate with less pain and is a great alternative to using toilet paper for clean-up.
Ask your obstetrician or other member of your health care team about using a numbing spray or cream to ease pain. Some of these sprays are available over the counter without a prescription.
If sitting is uncomfortable, sit on a pillow. There also are special cushions that may be helpful.