1. Practice Setup.
The OB/GYN Department is set up as a collaborative practice which means you can see whichever provider you choose. The nurse-midwives who specialize in counseling, education, and support work closely with the obstetricians who specialize in complications of pregnancy. We also work closely with social workers, dieticians, and internal medicine physicians who focus on pregnancy medical problems. You may be asked to see the physician twice during your pregnancy if you have chosen the midwives so that they can be familiar with your pregnancy. Typical times for these physician visits would be 20 weeks and 32 weeks.

2. Content/Timing of Prenatal Visits.
Prenatal visits are generally done once per month until the seventh month or 28 weeks. After that, generally visits are every two weeks until 36 weeks; then weekly until due date. If the pregnancy goes post dates, visits may be scheduled more than once per week. It is possible, if your pregnancy is low risk (no issues or complications), that the time between visits might be greater than four weeks. This will be explained to you if you are eligible for longer intervals.

The content of prenatal visits is a combination of required elements and optional elements. The required elements include weight, BP, urinalysis, various laboratory tests at specified visits, and teaching elements. The flexible pieces are up to the patient and her family and might include such things as concerns about the mother's or baby's well-being; for example, less fetal movement. Other topics raised by mothers and families include everything from general health concerns, sexual concerns, personal needs such as education, housing, heat, transportation, and enough food. Later in the pregnancy, the pregnant woman is encouraged to write a birth plan to help the birth attendants understand how she wants her birth to go and what birth options are important to her. At many times during the pregnancy, various types of tests may be used to evaluate aspects of the mother's or baby's well-being. These tests are explained in detail including the risks and benefits of each.

3. Risk Assessment.
After reviewing the mother's history forms, performing a physical examination, and reviewing lab results, a risk of low, moderate, or high is assigned. This risk score reflects the level of concern all the factors above bring to bear on the outcome of the pregnancy. Once risk factors have been identified, a personal plan of care for each factor is made. Many risk factors can be handled by the nurse midwives working closely with the mother and her family. Other risk factors need input from specialists, including obstetricians who specialize in complications of pregnancy or other physicians who specialize in internal medicine or surgery, depending on the risk factor. Some risk factors and the complications they bring to pregnancy, such as maternal age, can be evaluated completely by testing. Once the results are known, the risk may be completely removed. Other risks remain through the pregnancy and may improve or get worse, but require constant work to manage for the best possible pregnancy outcome, such as diabetes or high blood pressure. Most risk factors can be controlled with treatments so that mother and baby can remain healthy.

4. Nutritional Assessment.
Based on the answers given to the questions about food intake and diet habits, an assessment will be made about whether a mother's diet contains adequate amounts of essential nutrients and calories for the best growth of the baby. Weight before pregnancy and height will be used to determine the optimal range of weight for the mother to gain through the pregnancy. Frequently, the mother is asked to remember everything she ate in the previous 24 hours or possibly record everything she eats for 3 to 7 days. This is called a food diary or diet recall. This helps the nurse-midwife or dietician make a closer analysis of the quality of the mother's diet. Suggestions can be made if too much food, too little food, or poor quality food choices are being made by the mother. Common food groups that are eaten in smaller than adequate amounts are the fruit and vegetable groups. Some mothers need to increase sources of calcium for development of strong, healthy teeth and bones in the baby. In our fast American lifestyle, many mothers are eating too much fat or empty calories. Once the area that needs adjustment is known, alternative food choices that the mother likes can be discussed.

Each visit the mother's weight will be measured and graphed for comparison to the ideal weight gain for that mother in her specific week of pregnancy. Repeat diet recalls will be done as needed for under or over weight gain.

Prenatal vitamins containing 1 mg of folic acid will be prescribed for mothers with private insurance. Mothers covered by Medicaid or PCAP will receive 3 bottles of prenatal vitamins throughout the pregnancy. These vitamins do not replace a balanced diet, they only supplement a healthy, balanced diet. An iron supplement will be prescribed or given out if the mother's blood iron, called her "hematocrit," is low enough to be considered anemic. These mothers will also be taught food sources of iron easy to add to the daily diet. More information of basic nutrition and a healthy diet for pregnancy can be in the nutrition section of your binder.

5. HIV Testing During Pregnancy.
The New York State Department of Health strongly recommends that every mother-to-be be tested for HIV during the early part of her pregnancy. The reasons for this are related to finding all mothers who are HIV positive (most of these women do not have any idea that they are infected) so that medications can be given to reduce the possibility of infection of the baby during the pregnancy. It is impossible to prevent infection of babies unless care providers can identify all the pregnant women who need medication for treatment. You will be asked a serious of questions to identify any risks for exposure to HIV infection. This information will be used to help reduce any behaviors that give you those risks. The NYS Department of Health now requires each pregnant woman to be tested during her early pregnancy or have a less accurate mandatory test during labor or a less accurate mandatory test on the infant. The test requires the woman's written permission and test results, by law, must be given face-to-face, in person, usually at the next visit. If a woman refuses to be tested, her decision will be written in her prenatal chart. The New York State Department of Health is currently changing the regulations regarding HIV testing. If a woman refuses testing during her pregnancy, she will be required to be tested during labor with a rapid test. This rapid test is less accurate than the test which takes 10-14 days that is done during prenatal care. Based on this less accurate test, antiviral drugs will be required during labor. If a mother refuses to be tested during labor, her newborn will be tested with the same rapid test (less accurate) and treated with antiviral drugs. This test on the newborn cannot be refused by the mother. We are encouraging all mothers to be tested with the most accurate test during early pregnancy. This will avoid all need for the less accurate test on mothers in labor or tests on newborns; with the possible need to give antiviral drugs after a possible false positive test. For additional information regarding HIV's effects and treatments during pregnancy, see pages 52-56 in the next section of your binder.

6. Smoking.
Many questions about present and past smoking are asked in the history questionnaire. If a woman has been unable to quit smoking by her first prenatal visit, her current level of smoking and her desire to quit or reduce will be evaluated. Separate educational materials are available for women who want to quit and those who do not want to quit. A review of the effects of smoking on the unborn baby will be discussed. At each visit, the current amount of smoking, a new goal to smoke less or quit will be chosen by the woman and written in her chart. If any type of support is needed to achieve the new lower smoking goal or quit altogether, it will be arranged. More written information on the effects of smoking is on pages 48-51 in the next section of your binder.

7. Alcohol.
Similar questions about alcohol use are asked on the history questionnaire. Drinking of alcoholic beverages during pregnancy can cause fetal alcohol syndrome, a life-long set of deformities and disabilities. Any woman using alcohol during pregnancy can be assisted to quit with help from the LEAF Council on Alcoholism. More written information on drinking during pregnancy can be found on page 48 in the next section of your binder.

8. Drugs.
Both legal and illegal drugs can have harmful effects on your unborn baby. Do not use any drug, even over-the-counter medications, during pregnancy without first discussing the effects and other possible options with your midwife or physician. Counseling and assistance to avoid the use of harmful drugs is available to expectant mothers. Arrangements for such assistance can be made at any prenatal visit or by calling 1-607-547-3535, the Birthing Center, or calling 1-800-BASSETT and asking the operator to page the midwife or physician on call.

9. Exercise and Rest.
Most expectant mothers experience a great amount of fatigue early in pregnancy. This normally lessens or disappears around 14-16 weeks, if the woman has taken all opportunities to nap and go to bed earlier than usual. If extra rest is not part of the woman's lifestyle early on, she may feel overtired for her entire pregnancy. Some women are able to continue with the same exercise routine they practiced before they got pregnant and they find they actually feel better if they get some scheduled exercise every day; others find they have to reduce, modify, or stop exercising for a short time before they feel enough energy to resume their usual exercise patterns. There is a very extensive and detailed section on safely exercising during pregnancy in the exercise section of the binder (see tab). The essential factor is to listen to your body. If any exercise seems to be too stressful, too much, or uncomfortable, you need to seek advice on how to modify it. Listening to your body also applies to getting enough rest. Your body will slowly stop feeling so tired when you are getting the right combination of sleep, naps, exercise, and daily tasks.

10. Hygiene.
There are many challenges faced by the pregnant woman, some of which are in the area of hygiene. The hormones of pregnancy may cause an increase in perspiration which can cause changes in body odor. The use of an antibacterial soap for bathing, such as Dial, and an underarm deodorant/antiperspirant combination product can help prevent embarrassment. Many women find they need an extra bath or shower during the day. Skin and hair can be more oily than prior to pregnancy. Shampoos and skin cleansers specifically formulated for oily skin or scalp may help control this change. Most women also experience an increase in vaginal discharge due also to the increase in the hormones estrogen and progesterone. If your discharge itches or burns, it may be a vaginal infection, but an increase in the amount of discharge alone is normal. The options for dealing with this change include panty liners, frequent panty changes, or mini peri-baths with a "peri-bottle" at each use of the toilet. Each method has advantages and disadvantages. Panty liners have compressed paper treated with chemicals backed by a plastic layer. The chemicals can cause a localized skin irritation from frequent contact and the plastic layer can trap so much heat and body moisture that it increased chances of yeast infections or allergic reactions. Infrequent use will probably be tolerated by most women. Frequent panty changes obviously creates extra laundry. Peri-care requires a "peri-bottle" which you may have if you have had a baby before. If not, they can be purchased at any drugstore for $1-2. This bottle is filled with comfortably warm water prior to using the toilet. A brief warm water bath is sprayed over the vaginal area after toileting and patted dry with a towel. This is very refreshing and creates a clean feeling of comfort.

11. Exposure to Workplace Toxins.
Every pregnant woman needs to carefully examine her workplace for chemicals that may be harmful to the unborn baby. Exposure to radiation or x-rays is also extremely dangerous. If you are concerned about any possible exposure, please obtain the complete name of the product in question. The New York State Department of Health will supply your midwife or physician with a fact sheet on any known chemical. Once the potential harm is evaluated, a plan for avoidance or change of work habits can be arranged. Other hazards at work may not be so obvious. Excessive hours during pregnancy are more than 8 work hours daily and more than 40 work hours per week. Your midwife or physician will be happy to write a note stating these limitations. Also of concern are job requirements for lifting greater than 20 pounds or lengthy periods of standing. Please discuss your work conditions with your care provider if you have concerns. Most pregnant women need to use the bathroom frequently and any job which limits access to bathroom breaks can discourage a woman from drinking adequate amounts of water on a daily basis. Please discuss any restrictions on the use of bathroom or taking breaks when you feel you need them.

12. Common Discomforts.
Most of the common discomforts felt by pregnant women are related to the softening of all joints and ligaments that hold the bones together. This is caused by progesterone, one of the major pregnancy hormones.

Because of this softening, it is very easy to overdo during pregnancy. For example, if you go bowling and have not done it for awhile, you may ache all over the next day. The same may happen after a long shopping day at the mall if you have not walked that much recently.

The two most common complaints in pregnancy are a pulling sensation low on one or both sides of the abdomen, called round ligament pain, and low backache. Both of these discomforts can be lessened by regular back exercises pictured on pages in the exercise section; particularly, the pelvic tilt exercise done in the hands and knees.

Other common discomforts include disturbance of intestinal tract functioning all the way from nausea, vomiting, heartburn, excessive gas to diarrhea or constipation. There are some comfort measures for each of these body changes in the "While Waiting" book in section 2, pages 21-37. If these measures do not achieve relief, please ask your midwife or physician.

13. Emotional Changes/Support.
Most women find pregnancy to be a very emotional time in their lives. Almost as many different types of emotions can be experienced by expectant women as other types of body changes. Some women feel happy, contented, and totally at peace when pregnant. Other women feel, at least some times, unpleasant emotions all the way to feeling in turmoil.

The wide variety of body changes make many women feel "out of touch" with their bodies. This feeling of being at odds with your changing body can be very distressing to some women. Most women have to make some type of mental/emotional adjustment which involves a mixture of both happy and sad feelings when they first become pregnant, even if they were trying to get pregnant. This mixture of positive and negative feelings is often a surprise. Some women even feel guilty because they do not feel happy all the time and seem to expect that they should feel happy all the time. Mixed emotions are very normal.

If you experience a difficult time with nausea or vomiting, your emotional bond with the newly developing pregnancy may be delayed until you are feeling physically improved.

Extreme swings of mood are also very common. It is not unusual for laughter to turn into tears in a matter of minutes. Partners and other family members may think that this rapid change of moods is strange unless they realize it is in response to rising hormones and is very normal. Extra attention to be helpful, affectionate, and supportive is the best advice for partners and family members.

Please be open about how you are feeling with your midwife or physician. If emotional adjustment is extremely difficult for either the woman, her partner, or other family members, counseling may be helpful.

14. Danger Signs.
In early pregnancy, danger signs include bleeding and cramping or vomiting greater than 24 hours. Bleeding and cramping is a threatened miscarriage. Report these symptoms to the midwife or physician on call. Evaluation will include monitoring of symptoms, a speculum examination, possibly blood work, and an ultrasound. The outcome of the pregnancy cannot always be determined quickly, it may take days or weeks before it is possible to tell whether the pregnancy will continue and progress normally. This is a very difficult situation emotionally. Please share your feelings with your partner and family if you can. Your midwife or physician can give you supportive information also.

15. Financial Need.
If you have no health insurance, you may be able to qualify for the PCAP or Prenatal Care Assistance Program. The income guidelines were included in your original packet of pregnancy materials, and other copies are available at all the clinics that give pregnancy care. You will also find a list of the papers you will have to bring for copying in part of the enrollment process.

Once you have been given preliminary approval, you will have Medicaid coverage for all your visits, lab tests, and you will receive bottles (3) of prenatal vitamins and iron if necessary. You are also eligible for any referral to specialists considered necessary during your pregnancy and for 6 weeks after you deliver.

16. VBAC.
This is a term that stands for Vaginal Birth After Cesarean. It is explained on pages 121-122 in your "While Waiting Book." Any questions you may have about VBAC can be answered by your midwife or physician.

17. Fetal Growth and Development.
The growth and development of your baby is pictured on pages 8-17 in "While Waiting" and on pages 57-65 in the next section of your binder. Color pictures of fetal development are available to look at in most health centers. If you have questions, please discuss them with your midwife or physician.

18. Genetic Screening.
There are some tests that can screen the unborn child for genetic problems including a blood test called Alpha Feto Protein or AFP. We now do a more accurate test called a Triple Test or Pyramid Test. They are explained on pages 81 and 109 in "While Waiting" and pages 27 and 28 in the next section of your binder. It is important to remember that both of these tests are only screening tests. This means they do not give the final answer if a possible problem is detected and further testing will be recommended to you. If the test is normal or negative, is it very reliable.

Amniocentesis is done if there is a family history of chromosome problems, the mother's age is 35 years or older, and as a follow-up for low value AFPs or Triple Tests. Amniocentesis is explained on pages 82-83 in "While Waiting" and on pages 29-31 in the next section of your binder. Any other questions can be answered by the midwife or physician.

19. Lab Tests.
In addition to the genetic counseling tests discussed above, a panel of blood tests will be drawn at your first visit. A clean catch urinalysis and culture/sensitivity test will be also sent at your first visit. The purpose of the tests are to document your blood type, iron level, and immunity to several diseases as well as to screen for other diseases that can cause problems for your developing baby. A Pap smear and cultures from your cervix are taken for gonorrhea and chlamydia. Other tests may be added based on your individual history and needs.

All pregnant women are asked a series of questions to screen for risk for HIV exposure. The answers to these questions will help your midwife or physician counsel you for the best chance to avoid exposure to HIV. The NYS Health Department recommends that all pregnant women be tested for HIV so that they know their current status and take needed medications to reduce chances of the baby becoming infected.

All lab test results will be reviewed with you, if normal, at your next regular visit. You will be called for any abnormal lab results with a plan for how to manage the situation.

20. Options.
Many women have very mixed feelings when first learning that they are pregnant. Sometimes they are very frightening. Please try to discuss your feelings with your midwife or physician. If you need to discuss what options are available if you do not feel capable of continuing your pregnancy or caring for a new baby, please let your midwife or physician discuss this with you. There are many choices you can make to decide what is best for both of you. Planning and coordination is required for certain choices so if you have mixed feelings and want to explore any options, please discuss your concerns with your midwife or physician.

21. Sonograms.
Sonograms or ultrasound exams can make many different diagnoses in pregnancy. The scientific literature and insurance companies do not support doing a routine ultrasound, that is, without a specific problem or reason. Common reasons for ultrasounds include: check to see if fetus is alive, certifying unsure dates, diagnosing twins if uterus is too large, diagnosing restricted fetal growth if uterus is too small, determining the location of the placenta or afterbirth, evaluating fetal well-being in complicated or post-date pregnancies, following twins to see if they are growing equally. See a discussion of this issue on page 35 in the next section of your binder.

22. Emergency Numbers.
Most prenatal clinics close weekdays at 5:00 p.m. Some clinics hold evening hours such as Oneonta on Monday and Thursday evenings until 8:00 p.m. and Bassett on Tuesday and Thursday evenings until 8:00 p.m. Anytime after the clinic is closed and for all emergencies, please call the Birthing Center at 607-547-3536.

1. Review Labs.
All laboratory test results will be reviewed and explained. If any test results require retesting later in pregnancy or any other actions, plans for the appropriate actions will be made and explained.

2. Review Diet History.
Your weight gain since the first visit will be plotted on the graph and shown to you. If the weight gain is too great or too small, strategies to correct weight gain into the correct area of the graph will be discussed. Very often, you will be asked to recall everything you ate in the previous 24-hour period as a brief history of your dietary intake. This recall will be compared to the required number of servings from each of the four food groups. Feedback will be given on improvements or changes which will increase the nutrition in your diet. The baby's only source of nutrition is the food you eat every day. Part of this discussion will focus on food sources of iron because your body absorbs iron much more easily from foods than from what is in the prenatal vitamins or iron tablets, which mostly goes down the toilet. The other topic which will be discussed with you in detail is your need for fluids, specifically water, during pregnancy. The general recommended amount is 10 8-ounce glasses, but you may need more if you live or work in a warm temperature or if your job causes a lot of perspiration. The basic way to check whether you are drinking enough is to look at your urine in the toilet each time you go. If you are drinking enough, your urine should be as pale as lemonade or hardly color the water at all. If you have specific dietary needs or that work being done with your midwife or physician is not getting the needed results, you may be scheduled with a dietician for more specific information and dietary guidance.

3. AFP or Triple Screen.
These tests have been discussed in the first educational section under "genetic screening." The ideal time for this test is 16-18 weeks although there are values known for 14-22 weeks of pregnancy. At the visit you have which is closest to 16 weeks, you will be asked your permission to do this test unless you refuse. For more information, look on pages 81 and 109 in the "While Waiting" book, and pages 27-28 in the next section of your binder.

4. Common Discomforts.
Nausea and vomiting have usually subsided by the third or fourth month of pregnancy, and fatigue is lessened also. Many of the softening ligament type discomforts begin now for many women. Please refer to the "common discomfort" discussion in the first education section, page 5.

5. Sexual Concerns.
Concerns about sexual activity during pregnancy vary widely. Some women and men fear harming the baby which is actually very well protected. The only time you would need to refrain from penetrating or orgasmic sexual activity is if you are threatening to miscarry, premature labor or if you have a placenta previa (placenta covering the cervix).

Some women lose their sex drive mostly due to nausea, vomiting, fatigue, and sore breasts. As these common side effects of pregnancy subside, most women resume their normal desire for sex. For some women, pregnancy increases their sexual desire, sometimes very dramatically. The key to all changes relating to sexual function is open and honest communication with your partner about your changing needs. Sexual activity is also discussed in "While Waiting" on page 102 and in your binder on page 45 of the next section.

6. Rest and Activity/Work Patterns.
Fatigue is a very common complaint in early and late pregnancy. It is often difficult in our hurry-up lifestyle to justify taking naps or going to bed early. But it is essential to get as much extra sleep as possible in order to not feel fatigue throughout the entire pregnancy. Making extra rest or sleep a priority in your life requires explaining the reason to your partner and family so that they can assist you with household chores or shopping trips.

The recommendations for work hours are as follows: Do not exceed 8 hours/day or 40 hours/week. Lifting is not to exceed 20 pounds and should be done with proper body mechanics shown on pages 46-47 in the next section of your binder. It is very easy to strain or tear ligaments if lifting is done by bending over at the middle. If you need a note stating these work limitations, please ask your midwife or physician. Most employers are willing to make necessary adjustments in hours or shifts and work requirements. As pregnancy progresses, please bring any concerns you have regarding work to your prenatal visits for discussion.

7. Maternal Seat Belt Use.
Pregnant women must use their seat belts whenever they are in a car to prevent as much harm as possible to themselves and their baby in an accident. The lap belt should be worn low beneath the pregnant belly.

1. Listening to Fetal Heart With Stethoscope.
Your baby's heartbeat will be listened to with an old-fashioned stethoscope. Most babies can be heard at 20 weeks by this method. It helps to be sure about the dating and due date of the pregnancy.

2. Quickening.
You will be asked to make a note of the date that you consistently feel the baby's movements, also called quickening. This usually occurs around 18-21 weeks for most women expecting their first baby. You may feel this much earlier if you have been pregnant before.

3. Support.
Your sources of support during the pregnancy will be discussed at this visit. You will be asked to begin thinking about who you plan to have with you during labor and birth.

4. Dietary Follow Up.
A. Addressing Problems: Inappropriate Weight Gain

• If weight gain is below or above the target range, explore possible reasons.

• Suggest strategies to adjust food intake, if appropriate.

B. What to Look for If Weight Gain is Very Rapid and/or Excessive

• Is there a measurement of recording error?

• Is there evidence of edema?

• Are twins or triplets a possibility?

• Are there signs of gestational diabetes?

• Have you greatly increased your food intake?:

• If serious overeating is occurring, explore why:

C. Tips for Behavior Modification to Help Promote a Lower Rate of Weight Gain

• If you gained weight too fast because of overeating:

1. Prepared Childbirth Classes.
Registration forms for Prepared Childbirth Classes should be completed and brought or mailed to your clinic by your 24-week visit. This allows adequate planning to avoid overly large classes. All pregnant women and their main support person should take these classes during their first pregnancy to learn what to expect and methods to deal with labor pain.

2. Common Discomforts.
In addition to the discomforts listed in the initial educational topics section, page 5-6, other discomforts begin to be annoying as you enter the seventh month of pregnancy. You may again experience fatigue and need to take naps and go to bed earlier. Some modification of decreased work hours may need to be made soon.

Bladder pressure and the need for frequent emptying begins again similar to what you may have felt in the early months of pregnancy. Even though frequent trips to the bathroom may seem to be a nuisance, large fluid intakes are still critical to healthy bladder function and prevention of uterine irritability (contractions).

Other discomforts include rib pain from stretching as the abdomen expands upward and softening of the rib attachments to the sternum or breast bone. Another discomfort at this point can be the appearance of hemorrhoids.

Low backache and round ligament pain, discussed in the education section 1 on pages 5-6, can increase or appear for the first time now for some pregnant women. Please reread the advice in section 1 and look at pages 5-8 of the exercise in the binder for back strengthening exercises and body mechanics to prevent these two problems.

3. Warning Signs of Preterm Labor.
Labor that starts before the end of the 36th week is considered preterm or premature labor. It may be possible to stop the process with medications if you arrive early in the process at the Birthing Center. The warning signs are listed and pictured on page 1 of the labor section in your binder. This page should be taken out of your binder and taped to your refrigerator door so it is in front of you and your family. The signs of preterm labor can be very easy to miss, so we want you to call us for any signs, even if you are not sure or if the signs seem vague. There is also a page in the "While Waiting" book for preterm labor, on page 132. Remember - if you are not sure, please call the Birthing Center at 607-547-3535 or 3536.

4. Tubal Discussion.
The seventh month of pregnancy is a good time to consider what birth control you want to use after you deliver. There is no pressure on your decision making during pregnancy. You can talk, read, and carefully consider what is best for you and your situation.

If you are thinking of permanent birth control, the choices are a vasectomy for the male or tubal ligation for you. When you compare these two, the male choice, vasectomy, has less risk because the operation does not enter the abdominal cavity or belly. Handouts discussing vasectomy are available in all prenatal clinics.

If you decide that tubal ligation is best for you, it requires some planning. A discussion of the risks, benefits, failure rate, and complications, will be held with both partners at a prenatal visit. Certain types of insurance require completion of specific extra paperwork.

5. Birth Certificate Workbook.
At the visit that your 1-hour glucola (or sugar test) is done, you will be asked to fill out the Birth Certificate Workbook. This will help us file your child's birth certificate which is done electronically. In your first packet of papers from Bassett, you received a page telling you what documents you would need to begin the birth certificate process, or you may pick up another copy at any prenatal clinic. The Birth Certificate Workbook should be completed and left at your prenatal clinic where it will be filed with your chart and sent to the Birthing Center. This is located on page viii in the Introduction Section of your Binder

6. 24-28 Week Lab Tests.
The 1-hour glucola (sugar test) and a second hematocrit (iron level) will be drawn somewhere between 24 and 28 weeks (see page 34 in the next section of your binder). If you have Rh-negative blood, you may also need to receive a shot, called Rhogam, at this visit. The subject of Rh-negative mothers is discussed in "While Waiting" on pages 109-110 and pages 38 and 39 in the next section of your binder.

1. Late Pregnancy Complications.
The complications that can occur in the last part of pregnancy include bleeding, inadequate fetal growth, and preeclampsia or toxemia. Your midwife or physician will explain if you have any of these complications, what needs to be done, and when it is best for you to give birth.

If bleeding is caused by a condition called placenta previa, or low-lying placenta, it may not be possible to give birth vaginally. If a cesarean section is necessary for the safe birth of your baby, your provider will discuss the plans with you. Sometimes this condition is diagnosed earlier in your pregnancy and a later sonogram or ultrasound may show that the placenta no longer blocks your cervix. In cases where no blockage remains at 34 weeks, vaginal birth may be the best choice.

A true obstetrical emergency exists when bleeding is caused by a separation of the placenta from its attachment to the uterus, called an abruption. This sudden onset of bleeding, often heavier than a period, can occur with or without pain. The pain is constant, when it occurs, and happens because the blood is trapped behind the placenta. If the blood is coming out the vagina, there is usually no constant pain. This condition may require birth by cesarean section if the bleeding is severe enough to cause the baby to be in distress or oxygen compromised. This condition can threaten the safety of both mother and baby and should be evaluated immediately.

Other problems can cause the baby to be unable to tolerate labor. Depending on where this happens in the labor process, different types of delivery may be recommended by your midwife or physician. Before the cervix is completely dilated, cesarean is the only birth option for rapid birth. If the cervix is fully dilated, other birth options may be possible including vacuum-assisted birth or forceps delivery.

Despite all of the screening that occurs during pregnancy, it is possible, although unlikely, that the baby may have some undetected condition. Any needs that become apparent for the baby after birth will be arranged by the pediatric staff. Consultations with specialists in medicine or surgery are available as well as transfer to the neonatal pediatric specialists at Albany Medical Center.

2. Work Plans/Employment.
Most women are experiencing some difficulties tolerating a full-time work schedule by 36 weeks of pregnancy. Although there are no hard and fast rules about leaving work on disability, most women need 1-3 weeks before their due dates to increase rest periods and prepare last minute arrangements for birth and the first few weeks at home with a new baby. Some jobs which require lifting or very strenuous actions may need to have an earlier stop time or some change in work duties or hours; this is to prevent over-exertion by the mother. Some thoughts should be given to plans for return to work after the post-partum period. Some women do not plan to return to work and they resign late in pregnancy. Many women feel they have no other choice financially than to return to work. Some women, especially teachers, are able to take 6 months or more without losing their jobs. If you know that you must return to work, this is a good time to begin to plan daycare for your child and explore whether you could find a private place to pump breast milk if that is your wish. Electric breast pumps with tandem tubing make pumping a 15-minute task. Storage and proper refrigeration are the other pieces that require planning.

3. Feeding Method.
The choice to breast or bottle-feed is a very personal one. There is factual material you should read in your binder before you make your choice; see the Breastfeeding section and pages 6-11 of the After Delivery section. After you know the facts, you need to choose the method that you feel comfortable with because you need to feel relaxed with your baby. A class on breast-feeding is taught by a lactation consultant once per month. If you are planning to breast-feed, this class will prepare you for a good start. If you are undecided about a feeding method, you should definitely attend this class and bring someone close with you. When two people listen to the same material, more is remembered and they can talk about the information with each other. One of the topics of discussion will be how to prepare your breasts for feeding with the least amount of discomfort. There is a whole section of your binder which discusses breast-feeding,and a section in "While Waiting," on pages 158.

4. Perineal Massage.
There is an exercise called perineal massage which helps prepare your tissue around your vagina to stretch during the birth of your baby. It is described on page 17 in the Labor section in your binder. The purpose of this exercise is to desensitize you from the natural tendency to "tighten up" when something is uncomfortable and teach you to develop a relaxation response instead.

5. Tour of the Birthing Center.
If you are planning to take childbirth classes, your class will include a tour of the Birthing Center. Tours can also be arranged before or after any clinic visit or any other time you are in Cooperstown. Please call the Birthing Center to make sure that there is an empty room to show you and adequate staff to take you on your tour. A tour of the Birthing Center has also been recorded on videotape and may be borrowed at any clinic where prenatal care is given. It helps to be familiar with the place you will be during labor; it eliminates one more thing that is unfamiliar and adds to feeling uneasy, which decreases your ability to relax.

6. Family Roles/Adjustment.
Expecting your first child or adding another child to your family requires new roles for all family members and adjustment of household routines. The final section in your binder is about life with a new baby, the After Delivery section. Read this section and watch some of the videos that are available on parenting and family adjustment at the Birthing Center and all prenatal clinic sites. After reading and watching suggested material, a discussion of which tasks each partner or family likes or feels good at would be a place to start. If there are tasks that remain unchosen, sharing them equally would be a place to start. As the days and weeks after bringing the new baby home pass, adjusting partner's workload to reflect fatigue and capabilities can be done. Asking extended family and friends to assist is also an option chosen by many new parents. If either of you feel overwhelmed, look at which tasks can be put aside for completion at a later time. Taking on new responsibilities or beginning new projects is best delayed so that it does not occur in the first four to six weeks after the new baby comes home. For example, this is a very difficult time to move or change jobs. Limiting new, challenging tasks should be your goal during this time.

7. Birth Plan.
Writing a birth plan helps you let us know if there are particular needs or desires you have related to labor. There is an example of a birth plan in your binder on page 2 of the labor section. You may use this if it is helpful or you may just write down what is important to you or what you wish to avoid during labor. After your birth plan is written, bring it to a prenatal checkup to be reviewed by your midwife or physician.

8. Help at Home After Birth.
The first few weeks at home with your new baby should be planned with enough help so that you can eat meals prepared by someone else, sleep and feed your baby ONLY. This means arranging for adequate help from your partner, family, or friends. The reasons for this reduced activity are many. It is important to really get to know your baby's pattern of sleeping and eating without any pressures or other responsibilities. Sleeping or napping when your baby is asleep assures that you get the maximum amount of sleep possible. This helps prevent post-partum depression and helps your milk be fully developed. Household chores such as cooking, laundry, cleaning, and shopping should be delayed until the second or third week. Once you have tried one task, watch your bleeding. If it increases, you are not ready for chores yet and you need to slow down and ask others for extra help. See pages F29 in your binder on "Right From the Start."

9. Contraception PP.
The type of birth control you want to use after your delivery should be planned during your pregnancy when there is no pressure and you can carefully consider what you need. Sexual activity may be resumed when your bleeding stops and your perineum or bottom is healed; usually 3-4 weeks. Foam and condoms must be used each time you have intercourse before your 6-week examination. That is the time you can get your chosen method of birth control. If you have had unprotected intercourse you will have to wait for a pregnancy test to be done before you can begin another method. See birth control pamphlets available at your health center or the Birthing Center.

10. Infant Car Seat Use.
You must have an approved infant car seat to take your baby home from the hospital. If you do not have one at the time of the baby's discharge, you can rent one from the hospital. Additional information on approved car seats is available in clinic or from your childbirth educator.

11. Beta Strep Culture.
Between 35 and 37 weeks, you will have a culture taken from your vagina for group B strep, the same bacteria which causes step throat infections. Most women who culture positive have no symptoms and are surprised at the results. Since it is not possible to clear the vagina of this bacteria, antibiotics are given to you during labor to prevent or lessen the baby's chances of becoming ill. You will also be asked to stay in the hospital 48 hours. This is because the pediatricians need to observe your baby for at least 48 hours for signs of infection.

1. Labor and Delivery.
Concerns you have about your birth experience can be discussed anytime throughout your pregnancy, but if you have any remaining concerns, this is a good time to bring them up. If you took Prepared Childbirth Classes, you have had a lot of exposure to videos and discussions of the birth process, if not, you may borrow birth videos from your health center's lending library. Any issues that remain can and should be discussed with your midwife or physician. Unresolved issues only increase your anxiety level which is counter-productive in labor. Concerns of family members may also be addressed at this time.

2. Comfort Measures.
It is very challenging for most women, and difficult for some, to achieve comfortable sleep and activities of daily living in the last few weeks of pregnancy. The baby's head presses on your bladder and rectum so you must void frequently and may experience constipation. It is tempting to drink less in order to decrease trips to the bathroom, but you must resist this temptation. Your body and your baby still need 10 glasses of water, milk, or juice daily. This much fluid plus a high-fiber diet can help prevent constipation. Eating small, frequent meals can help minimize heartburn; also sleeping with the upper body elevated like in a lounge chair, and taking Tums, Maalox, Gelusil, or Mylanta. Avoid baking soda or other antacids with a sodium bicarbonate base.

Sleeping at night can be accomplished with attention to common problems. As mentioned above, avoid large meals in the evening, as there may be inadequate time to digest the food leading to waking up with heartburn. Laying on your left side for a few hours before trying to go to sleep begins the process of making more urine after getting off your feet, so you make less trips to the bathroom during the night. It may also help decrease any swelling you have in your lower legs. Many pillows, or at least one body pillow, help to support your joints which all have softened ligaments and begin aching after 1 or 2 hours of sleep if unsupported by pillows front and back. If you awaken during the night and cannot easily fall asleep again, it may be better to get up and read a book or do something else which makes you drowsy. Chamomile tea helps some people feel drowsy enough to go back to sleep. Most women are out of work by this time so if sleeping at night is interrupted, taking naps during the day can make up for lost sleep. If you have painful contractions that keep you awake, discuss this with your midwife or physician.

3. FMC (Kick Counts).
Counting fetal movements gives you a better idea how active your baby is during the last few weeks before birth. To do this, lie on your left side shortly after you have eaten or at times when the baby is usually active. Count how many minutes it takes to feel 10 fetal or baby movements. A recording sheet and directions are available at all OB clinics.

4. Peds (Where/Whom).
By the time you are planning to go home from the hospital, we need to know who you want as your baby's pediatrician. The baby's first follow-up appointment will be made before you leave the Birthing Center. Generally, babies who leave the hospital breast-feeding are seen in 1 week, and bottle-feeding seen in 2 weeks. Any issues or special concerns may require an earlier follow-up appointment than usual.

5. Circumcision.
Parents continue to struggle with the decision whether or not to circumcise a boy baby after birth. The decision can be based on personal preference, religious beliefs, or hygiene concerns. A video tape of a circumcision is available to borrow from the OB Clinic.

6. Danger Signs of Late Pregnancy.
Decreased or no fetal movement needs to be reported immediately to the Birthing Center. You may be asked to eat something and observe for movements of the baby. If you do not begin to feel normal movement, you will be asked to come into the Birthing Center for a non-stress test or monitoring of the baby's heartbeat.

Any bleeding that is heavier than a period needs to be reported to the Birthing Center for evaluation. If you know that you have any complications with your placenta or afterbirth, such as placenta previa, low-lying placenta, or placental separation (abruption), any amount of bleeding needs to be reported immediately to the Birthing Center.

Symptoms of toxemia or preeclampsia are signs of danger and they include: sudden or greatly increased swelling, visual disturbances or loss of vision, headache unrelieved by usual measures, and right upper abdominal pain that is steady or constant. All of these should be reported immediately to the Birthing Center.

1. Fetal Movement Counts (Kick Counts).
This method of counting the movements of your baby was discussed earlier on page 20 in the 37-40 week section. It is one of the main ways to tell if your baby is still getting the food and oxygen it needs through your afterbirth or placenta. If your baby's movements slow down or it takes longer than usual to feel 10 movements, you need to call your health center or the Birthing Center. If the baby's movements do not return to normal after eating a meal you will be asked to come in for fetal heart monitoring. This evaluates the baby's well-being.

2. Post-Date Testing.
The period between 40 weeks (your due date) and 42 weeks is called the post-dates period. Technically you are not overdue until you reach 42 weeks. However, during this time, it is very important to do your kick counts twice daily and call if it is slower than usual. Testing of fetal well-being will also be done with scheduled fetal monitor tests called Non-stress Tests and if you go past 41-1/2 weeks and ultrasound called a Biophysical Profile. The monitor test looks for accelerations (increases) in the fetal heart rate that last a certain length of time and go up to a certain level above the baby's baseline. If you wish to be shown what we are looking for, ask to look at the monitor strip after your tests. The ultrasound evaluates the baby on four criteria: body tone, breathing movements, baby movement, and amount of amniotic fluid. If the baby scores above a certain number combined with the results of the monitoring test, it means the baby is tolerating the uterus well. If the score is too low, it can mean decreasing or poor tolerance of being in the uterus. In other words, it may be time to induce your labor.

3. Labor Induction.
Once the decision has been made that your baby would be better off outside your uterus, the challenge is to get you into labor. There are several different substances or medications that can be used. Prostaglandin gel, made in the hospital pharmacy, and cervidil, a commercial time-release product, work essentially the same way. These two compounds work best to "ripen" the cervix. If your cervix is closed or barely opened and still thick or uneffaced, then we will probably start with one of these two products. The gel is inserted into your vagina during an examination and you must stay on your side on the fetal monitor for at least one hour after placement. At that point, if the baby's heart rate is normal, you will be allowed to be up and around until the next dose is due, four hours later. The cervidil is placed behind your cervix followed by a piece of gauze and the same one hour of monitoring at least before you can walk around. Cervidil stays in place for 12 hours unless your contractions get too close. It would be removed then or at the end of 12 hours.

Pitocin given through an IV may be necessary if the prostaglandin does not result in progressive labor. When pitocin is running, you must be on continuous fetal monitoring. This does not necessarily mean in bed, but you must stay within the length of the cord to the monitor. Pitocin is usually run for 8-10 hours, and if nothing results, it may be turned off to let you sleep. A second day of pitocin will occur the next day.

Occasionally, if efforts to get you into labor are not successful, but your baby tolerates all the contractions the medications cause, a decision to take a break for a day or two may be made. Sometimes going home for a day or two can give you the mental and physical break that you need to resume induction. Kick counts would be continued if a decision to take a break at home is made.

4. Birth Plan Review.
Your birth plan should be completed by this time and you should take it to your next prenatal visit for review with your midwife or physician. It works much better to talk about what situations might mean having to change something in your birth plan. For instance, many women want to avoid having an IV. It may be appropriate to have no IV based on your risk status in labor but if you cannot drink fluids and keep them down because you are nauseated or vomiting, an IV may become necessary to prevent dehydration. It is much easier to talk about these types of common labor symptoms that may require changing your birth plan before you are dealing with contractions every two to three minutes. It is very difficult to concentrate at that time. So talking about changes to your birth plan depending upon how your labor goes makes it easier to understand if your labor midwife or physician needs to recommend something you wanted to avoid.