my OB & ME: a guide

Table Of Contents

INTRODUCTION 10 THE MEDICAL STUFF – PREFACE (from Shieva the “my OB”) 12 HOW TO USE “MY OB & ME” - THE KIT 15 RANDOM PREGNANCY THINGS THAT CAUSE CONFUSION 18 The Term “High Risk Pregnancy” 18 A Note about Insurance Companies 19 How to Find a Doctor? 21 Types of Hospitals & Points about Your Doctor’s Practice 22 GENERAL OVERVIEW OF PREGNANCY 24 The Basic Timeline 24 How Many Weeks Is Each Trimester? 26 Months -vs- Weeks 26 OVULATION AND FOLIC ACID 28 WHAT TO EXPECT FROM THE SECOND YOUR “PEE HITS THE STICK” 30 YOUR G’S and P’S 33 34 & CHEMICAL 36 The Rates and Mindset 36 The Terms 38 The Causes 40 Options If It Happens 42 BLEEDING IN FIRST TRIMESTER 44

TRIBE CALLED V Page 1 my OB & ME: a pregnancy guide

RH AND BLOOD TYPE 46 TESTS IN THE FIRST TRIMESTER 48 The “Standard” List 49 The “POSSIBLE” List 50 GBS (Group B Strep) 53 GENETICS AND TESTS 56 The Parent’s Genetics aka the Carrier Screening 57 The Baby’s Genetics 61 Congenital -vs- Genetic 66 Anatomy 67 COMMON BIRTH DEFECTS 70 Club Foot 70 Cleft Lip/Palate 71 Congenital Heart Anomalies 72 ON GUILT 73 I’M NOT SURE I WANT TO KNOW THE GENDER? 75 TWINS 77 PREECLAMPSIA/HYPERTENSION 81 MELLITUS (GDM) 86 WHAT ARE SOME TYPICAL ACHES & PAINS? 90 SKIN ISSUES 92 Intrahepatic Cholestasis (ICP) 92 Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) 93 Other Skin Changes (Spots, Pigmentation, Skin Tags) 93

TRIBE CALLED V Page 2 my OB & ME: a pregnancy guide

Varicose Veins, Vulvar Varicosities, Hemorrhoids 94 FETAL MOVEMENT 98 The Basics 98 What Is Fetal Monitoring/Testing and Will I Need It? 100 A Note about “Changing the Due Date” 104 PLACENTAL ISSUES 105 Sub-Chorionic Hematoma (SCH) 107 Previa 107 Placenta Accreta 109 Marginal Cord Insertion (MCI) 110 Velamentous Cord Insertion 111 Vasa Previa 112 112 BLOOD ISSUES 114 Gestational Thrombocytopenia (GT) 114 Anemia 116 (AF) and AMNIOTIC FLUID INDEX (AFI) 118 THE CERVIX – WHAT YOU NEED TO KNOW 121 PRETERM CONTRACTIONS/LABOR (PTL) 123 WHAT HAPPENS IF MY BABY IS BREECH 128 BEFORE YOUR INDUCTION OR C-SECTION 133 WHEN IT COMES TO LABOR…. 134 The Basics 134 How to Stimulate Labor? 136

TRIBE CALLED V Page 3 my OB & ME: a pregnancy guide

Your Numbers during Labor 138 The Stages of Labor 139 Spontaneous Labor –vs- Induction 139 The Five P’s that Affect Labor 140 Pelvic Shape & Sunny Side Up 141 The Sure Signs That the Show is “Going on the Road” 144 It’s Official, You’re In Labor – What Happens Next? 145 Pain Medication & Fetal Heart Rate Monitoring 146 Unplanned C-Section –vs- Emergency C-Section 149 Birth Plan & Mindset 151 (aka Cord around the Neck) 154 155 Pooping While You Are In Labor (sh!t happens, like every day!) 159 Post-Partum Hemorrhage (PPH) 160 WHAT’S GONNA HAPPEN TO MY VAJAYJAY?? 164 Tears and Episiotomies 164 The Vagina & Vulva after Birthing a Human 169 Pelvic Floor Physical Therapy 172 Queef (Yes, I Said It) 173 MEDICAL SECTION CONCLUSION 175 LIFESTYLE SECTION - PREFACE 175 LIFESTYLE SECTION - INTRODUCTION 176 REAL FOOD –VS- PROCESSED FOOD 177 BASIC MEAL BREAKDOWN 179

TRIBE CALLED V Page 4 my OB & ME: a pregnancy guide

Fiber 181 Protein 182 Healthy Fats 185 Carbohydrates 187 FOOD ISSUES! 188 Nausea & 188 Hunger & Weight Gain 193 Emotional Eating 194 Food Safety, Aversions & Cravings 195 GUT HEALTH AND THE IMMUNE SYSTEM 198 Gut Health & Pregnancy 199 The Microbiome & Antibiotics 200 The Immune System 202 The Vaginal Microbiome 203 VITAMINS AND SUPPLEMENTS 205 COMMON ISSUES 207 Heartburn & Indigestion 207 Constipation 208 High Blood Sugar 211 High Blood Pressure and Lifestyle 212 EXERCISE & PELVIC STRENGTH 214 EVIRONMENTAL TOXINS 217 SLEEP 219 STRESS MANAGEMENT 222 CONCLUSION FROM JENNY & SHIEVA 225 From Shieva (the “my OB”) and Jenny (the “Me”)

TRIBE CALLED V Page 5 my OB & ME: a pregnancy guide

INTRODUCTION You know that feeling when you meet another person and feel like you have known them forever and never lack something to discuss? That was the feeling when we were rst introduced in 2019! While we could both write books on our individual crazy, complicated and interesting life stories, we will spare you all the details and give you the bullet points instead.

SHIEVA:

OB/GYN veteran since 1999 Mother of 3, miscarrier of 6 Ovarian Cancer Experiencer (she hates the word survivor) Weight Battler with Gastric Bypass Fear and Anxiety Reducer JENNY:

Holistic Health and Nutrition Coach Former Restauranteur Serial Entrepreneur Egg Freezing Fertility Explorer Pregnant for the rst time at age 45 (using her frozen eggs) Girl, do we have stories.

When we rst met and began sharing our life journeys, there was an immediate explosion of ideas like reworks. While we both have our “day jobs”, (and Shieva jokes her “day/night job”) we decided to form a company and partnership using our shared experiences as our guide.

First, we named our company Tribe Called V which, to put it simply, is the creation of a female focused “tribe”. Within it we offer myriad resources to support and educate women on ALL things related to their health – from obstetrics, to gynecology, to nutrition and overall general wellness, and perhaps most importantly a healthier mindset.

TRIBE CALLED V Page 6 my OB & ME: a pregnancy guide

In the near future we will be launching the Tribe Called V Membership which will include educational videos and classes, Facebook live events, coaching calls, and the creation of groups of like-minded women who may need the support of other women who are experiencing similar life events. Stay tuned for this exciting endeavor as it unfolds and follow on social media @tribecalledv.

When the COVID19 virus arose, another arm of our business was crystallized, called my OB & ME . In the midst of a global pandemic coupled with the rise in telehealth visits (patients were now “allowed” to have video discussion with their doctors)—we realized that obstetrics was a place where this new paradigm could be adopted!!

Throughout a pregnancy, you will typically see your doctor for 14-15 visits— many of which need to be “in person”. But depending on your risk factors (something you and your doctor should address), there can be anywhere from 2-6 visits that can be done “virtually” with the aid of a home blood pressure monitor, a fetal doppler and urine dipsticks.

What initially was incubated as a notion for keeping patients safely at home to avoid crowded ofces and thus viral exposure, morphed into a realization that this may actually serve a greater purpose. The busy mother of a toddler who cannot get a sitter or does not want to wake her little one; the working woman who cannot leave the ofce; the teacher who would need to take an entire personal day for one visit; the patient who will be working or travelling during part of her pregnancy. These are all examples of how a telehealth visit can improve everyone’s experience. Not to mention the value of not having to commute and then wait in the waiting room, only to discuss the same issues that could be discussed on a video call!

In this new paradigm—the visit we envision can be more engaged when the other stressors like commuting, scheduling constraints and ofce frustrations are eliminated! You and your doctor can now fully focus on you and your growing human!

With Shieva’s medical knowledge and deep-seated desire to decrease women’s anxiety and Jenny’s aggressive capabilities at organization and business development, we created the my OB & ME Pregnancy Kit as a useful tool for both pregnant mamas and doctors alike!

TRIBE CALLED V Page 7 my OB & ME: a pregnancy guide

Your kit will include a blood pressure monitor, a fetal doppler to listen to the baby’s heart beat and urine dipsticks to measure protein and glucose levels. Additionally, you are receiving this e-book! A pregnancy guide as we like to call it! We are not re-inventing the wheel or trying to improve the pregnancy guides that already exist to inform you of the basics. Instead, we tackle the many events that MAY arise from beginning to end. We believe that if we can preemptively tell you what MAY happen, we can increase your knowledge (calmly) to decrease your anxiety! Knowledge, if delivered in a non-angst provoking way is power.

Remember—our goal should always be a healthy baby and healthy mama— we are not striving for a pregnancy journey of perfection. Just like unicorns, this perfect journey may only exist in our imagination and clinging to the notion of “mythicism” can be damaging. Reality is beautiful in its imperfection if you approach it appropriately.

Cheers (non-alcoholic of course!) to you and your growing babe!

love, shieva & jenny tribe called V

TRIBE CALLED V Page 8 my OB & ME: a pregnancy guide

THE MEDICAL STUFF – PREFACE (from Shieva the “my OB”) Pregnancy is a time marked by stark dichotomies of intense excitement mixed with underlying anxiety—mostly of the “unknown”. Through my years as an OB/GYN, I’ve found that the more information patients receive, the more potential to quell their angst OR fuel it. So, it has been one of my main pursuits to help describe, highlight and expose many of the common concerns of pregnancy so as to encourage women to understand the bottom line fact—that the vast majority of women will birth healthy children!! I’ve found that the tone with which “issues” are discussed can have a profound effect on the receiver’s anxiety.

Now, you may notice throughout this guide I am using words that are more GENERALLY optimistic, while acknowledging “the shite”—for it is my deep belief that when we all examine what we truly desire, it is not PERFECTION, but rather a generally healthy pregnancy and baby. The mature adult woman in us, when really engaged with this notion, understands, accepts and even expects that the road to “healthy mom and baby” may likely be bumpy.

For example, I often highlight that, “I cannot guarantee that you won’t have issues during your pregnancy; or that you will deliver vaginally; or that you will be able to easily breastfeed! You may in fact have miscarriages, or gestational diabetes, or preeclampsia, or a cesarean section, or need to solely formula feed.” But again, if we deeply believe that a general sense of health for moms and their offspring can take many different iterations, the pressure to do things in what society deems “the right way” can be debunked. And all women who birth can have a generally good experience if the nal result is healthy (despite all the bumps in the road!).

TRIBE CALLED V Page 9 my OB & ME: a pregnancy guide

Media and various organizations seem to imply to us that we can achieve “perfection”. This notion distances us from the truth and from what we actually believe and feel comfortable with. Which is the fact that “perfection” is a nebulous notion that cannot be achieved and its pursuit will, in fact, lead to INCREASED anxiety and fear! When the perception of perfection is dangled in front of us - then ANY other outcome lesser than this will inevitably leave us feeling disappointed. It is this very damaging ideology that I rail against.

This general notion has irked me from the beginning of my medical career. I have seen the damage it can do to even the strongest of souls. We are better than this ladies. We are intelligent and mature and hardy enough to acknowledge the truth. In fact we have each shown over and over that we can address personal adversities and still persist and thrive! Thus, we need to reject this notion that there is only one right way to reach our goal.

This is where the damage occurs. Not in the lack of reaching said goal; but in setting an unrealistic unicorn goal in the rst place. It serves no purpose but to devolve the general psyche of women—women who actually have shown and continue to show themselves to be lionesses on every level.

This pregnancy guide is meant to help you achieve one thing—a generally happy/healthy pregnancy DESPITE the unexpected twists and turns along the way. I cannot and will not ever promise a woman that she will have an easy pregnancy. I’m frequently heard saying things like “nerves are normal and in fact WARANTED because pregnancy is an unpredictable and nerve racking state!” But I am emphatic in stressing that if you and your doctor work together—then the end result will be great, and therefore there is never a need to be “scared”.

A few extra but important comments to note: I will be using “doctor” throughout this guide but we are fully aware and fully supportive of the fact that some patients are being seen exclusively by (or in addition to) a mid- wife. We will continue to say “doctor” merely for simplicity. Similarly, I will often refer to your doctor as “she” but I am also fully aware and supportive of the fact that some patients are seen by a male doctor. In fact in my practice, at the time of this writing, I have three male partners and two female nurse !

TRIBE CALLED V Page 10 my OB & ME: a pregnancy guide

Also, it is my desire with this book to HELP you as the patient and we as the docs to better UNDERSTAND each other’s perspective and while that is a tall order it means addressing some onerous, boring and frankly ANNOYING topics like the logistics behind lab tests and insurance payments—the reason I include these is that I SEE and HEAR how often they are a source of frustration and discontent and even create a rift in the doctor/patient relationship on occasion. SO you’ll bear with me ;)

And just a note about me; as I often quip, I am not only the “hair club president, I am also a member” (if you don’t get this reference ask your mother!). The point I’m trying to make is that I’ve gone through a lot and been on the patient side of the equation more times than I’d like to recall. I have had my fair share of “OB/GYN issues” and therefore have a unique perspective of both doctor and patient.

My list includes (but isn’t limited to): HPV, abnormal pap smears, 6 miscarriages (some with D &C’s), abnormal tests indicating risk of downs syndrome, a challenging vaginal delivery, 2 cesarean sections, surprise pregnancy at 40, a child with an intrauterine stroke, a child with a clubfoot, difculty nursing, ovarian cancer, complications from surgery and chemotherapy (to name a few). I say these not to garner pity but merely as examples of experiences that have helped shape me and my ability to communicate with my patients. There is only so much that can be taught in medical school, so I nd my personal medical experiences to be invaluable in how I practice medicine.

Through both the doctor/patient lens, I have compiled this guide—much of which is very straight forward and basic but some of which is based on my own personal experience. As with anything you read, please remember to ask your doctor how she feels about any of the concepts we cover. Your personal doctor should always be your main guide throughout the pregnancy process—though I am happy to be whispering in your ear along the way!

TRIBE CALLED V Page 11 my OB & ME: a pregnancy guide

HOW TO USE “MY OB & ME” - THE KIT While the typical pregnancy schedule is to see the doctor every 4 weeks from 8-28 weeks, then every 2 weeks from 28-36 weeks, then every week thereafter —one thing we have always known is that some patients need or want to come more frequently. Conversely, some patients want to and can come less frequently. In fact our main scholarly journal “The Green Journal” had a great article called “Right Sizing pre-natal care”.

It has been been brought up within ACOG (American College of Obstetrics and Gynecologists) that we should really tailor this schedule to the patient’s physical and emotional needs as opposed to a “one size ts all” approach. With that line of reasoning, this kit was developed.

In the wake of the Covid19 pandemic, we realized that many patients could not get to their doctor for all their visits either because they couldn’t accept the risk or because their doctor’s ofce had temporarily closed or had modied their schedule. During this time many doctors substituted some visits with telehealth; but without the standard tools we use for OB appointments, the visits seemed less impactful.

For example blood pressure monitoring is a very simple and medically important part of every visit. We realized that not only in times of crisis, but more so during times of routine and calm, this kit can help both you and your doctor. You may already know that some visits require in-person evaluations like a sonogram or a physical exam, while many only involve a urine dip, blood pressure check, weight, fetal heart check and a discussion.

Assuming you and your doctor agree (i.e. depending on your level of risk, your doctor’s comfort with remote/telehealth and which visits lend themselves to this type of assessment) these types of telehealth visits may not only be “as good as” an in-ofce visit , but may occasionally satisfy both you and your doctor even MORE!

TRIBE CALLED V Page 12 my OB & ME: a pregnancy guide

From the patient point of view, if you are a rst-time mom, it may be a challenge to leave your job, travel to the doctor’s ofce, wait in the waiting room and then wait in the exam room, only to have your appointment last a mere 15 minutes. Or if you are a stay at home mom, you may need to work around nap time, hire a sitter just for your visits, or drag a tired or sick toddler to the doctor’s ofce. Should a snow day occur or other natural disaster, the ability to have this type of visit can be very helpful. Additionally as a veteran mom, you may feel more comfortable stretching out the interval with which you need a face-to-face visit with your doctor.

From your doctor’s point of view, reducing the number of face-to-face visits can ease the strain of multiple patients in the waiting room (sometimes with children, spouses, etc.), scheduling issues, dissatisfaction with wait times, need for more staff to check vitals and room the patients, and wear and tear on the staff and space. As well, your doctor may be able to cluster her telehealth visits so that she can also work remotely if need be. Here is an example of a pre-natal visit schedule incorporating both in person and telehealth visits.

So, from both the patient and doctor perspectives (coupled with decreased transportation effect on the environment), using a kit like this in conjunction with a telehealth visit, is clearly benecial to the whole system when used appropriately.

TRIBE CALLED V Page 13 my OB & ME: a pregnancy guide

It is our theory that there are two main things that a pregnant woman needs and wants: 1.) To be taken care of clinically to ensure a safe healthy pregnancy and 2.) To feel engaged in her pregnancy process with less frustration of long wait times and super short doctor visits. We believe this kit can help achieve both of these needs.

However, in using this kit there are three very important factors to consider:

1. We envision this kit to be used with your doctor’s approval, NOT IN LIEU OF ALL DOCTOR’S VISITS! 2. This kit is for patients who are not considered to be “at risk” for pregnancy complications (ask your doctor) 3. This kit is to be used only during certain visits, not every day and not if you don’t feel the baby move. Please call your doctor if that happens. For example, weeks 16, 24, 30, 32, 34 represent visits where there is typically no major testing done outside of weight, blood pressure, documentation of fetal heart rate and a urine dip for protein and sugar. Any or all of these represent possible visits that can be collaboratively performed via video or phone call with your doctor. You can check your weight, blood pressure, fetal heart rate and urine either synchronously on the call with your doctor, or beforehand and report the results to her.

Precedent already exists in the medical eld for self-monitoring of blood pressure and heart rate, for patients with hypertension or heart arrhythmias, in concert with their cardiologists for example. All of these efforts increase the patient’s ability to understand the process and ease the tension from multiple ofce visits.

Please note that the purpose of this kit is not to discourage patients from seeking medical attention during their pregnancy—it is meant to add to and enhance the patient/doctor relationship. As a doctor, who has also been a patient, I love processes that can help both sides!

Note of caution: if you ever think you are not feeling appropriate fetal movement (dened by the movements you have felt before) then this kit is NOT TO BE USED instead of a visit or call to your doctor.

TRIBE CALLED V Page 14 my OB & ME: a pregnancy guide

LIFESTYLE SECTION - PREFACE (from Jenny the “ME”) It’s weird being pregnant at 45. For the better part of the last 20 years, I’ve observed and listened to most of the young women in my life go through many pregnancies. You hear about all the classic symptoms, the nausea, the cravings, the aversions and the one thing that is clear is that every woman has a different experience and yet there are commonalties that bind us. I always wondered what I’d be like as a pregnant person. Would I be moody, would I get super nauseated, would I actually want to eat goldsh, pickles and ice cream?

The last part of that question is a particularly tricky one, because I’m also a health coach with a heavy focus on gut health and nutrition. A pregnant person who also has an enormous amount of food and nutrition knowledge presents a bit of a conundrum. What happens when you know what you should be putting in your body, but can’t do it because the mere sight of salmon makes you want to puke? Or what happens when all you want to eat is a sugar lled blueberry scone, but you know it will make your blood sugar go bananas? The struggle is real. I nally get it. So in the following pages I’ll tell you what I know and walk you through some of the decisions I made. Hopefully, it will help you make some good decisions and also assuage some of the guilt.

TRIBE CALLED V Page 15 my OB & ME: a pregnancy guide

LIFESTYLE SECTION - INTRODUCTION We all know we need to eat well during pregnancy. We all know that what we eat while pregnant directly impacts our growing baby. It’s a fairly simple concept right? And there are zillions of books and resources out there on the subject of nutrition for pregnancy. The problem is, there are so many resources, and so much information it can be incredibly overwhelming. Especially when much of this information is conicting. Eggs are good for you, eggs are bad for you, blah blah blah. Yes, I get it.

It’s hard to keep up with the ever changing landscape of health and wellness advice. But here is the one concept that is the most important to understand regardless of the latest nutrition headline: our bodies are designed to be healthy. They are incredible machines functioning at a level far above any computer on this planet. Every second of every day our bodies breathe, and pump blood and digest and detox, and ght viruses, and grow babies, all of which happens without us ever having to ask our body to do so. It just happens, all day every day. Unconsciously. The human body is quite literally a miracle and as I stated above, it’s designed to be healthy.

The problem is, we mess it up. We get in the way of the body’s natural ability to do everything really darn well. The body doesn’t just decide one day it no longer wants to digest food well. I have this image in my head of the intestines making an announcement over the PA system inside our body, letting the rest of the organs know that it’s done doing its job and is on sabbatical until further notice. No, this doesn’t happen.

Typically, things go wrong in the body after years and years of us doing something to mess up the beautiful symphony that is supposed to take place every day. Whether it be the air we breathe, or the food we ingest or the lifestyle we choose to live. We make choices every day and those choices either fuel disease or they heal disease. Some things we can’t control (the air we breathe) but other things are very much in our control, such as the food we ingest and the lifestyle we choose to live.

TRIBE CALLED V Page 16 my OB & ME: a pregnancy guide

Regardless of the choices we make, the body wants to procreate. And yes things can go wrong. But wouldn’t it be anxiety relieving to know in your heart, you are doing everything in your power to create the most optimal environment inside your body to create another human? And as I started this section, I know there is a LOT of information which can be overwhelming. However, my goal is to help you understand that it isn’t all that complicated.

Food is like computer code going into your body. If the right code goes in, the computer will run smoothly. If the wrong code goes in, the computer will freeze up and glitch out and drive you crazy. And sadly, the human body doesn’t have a reboot button that we can just push and everything resets. Wouldn’t that be awesome though? But sorry, it ain’t an option.

Instead we have to put the right code in. Food is medicine. Period. It’s as simple as that. As I said before, food either heals disease or it fuels disease. And by disease I am referring to ANY dis – ease in the body. People hear the word disease and they immediately jump to cancer. Nope, I’m referring to any sort of imbalance in the body. This concept is particularly important during pregnancy. We want to achieve balance, calm and ease so your body can focus on its number one job: growing that tiny human inside of you. So we need to stop getting in its way.

Before we dive into a few key lessons, I want to make sure you understand one simple concept. We all know that we can google anything and get ten different answers. We also know that there is a lot of information out there on the internet that can be anxiety provoking. So in an effort to solve these two issues we created this e-book to include the most important bullet points in a condensed form. In other words, we know we are simplifying very complicated subjects. We just want to make sure that if you do nothing else but read this e-book, the most important subjects are covered. We acknowledge that when we see ten different answers it means there is no ONE RIGHT ANSWER, merely different opinions. Our book is as “factual” as can be with hints of personal opinion.

TRIBE CALLED V Page 17