Welcome Packet & Guide

Congratulations on your pregnancy!

You’re pregnant – congratulations from our Gynics Associates OB/Gyn physicians and staff. This is an exciting time in your life and we are pleased to share this experience with you.

Our goal is to provide the highest quality of health care available to each and every woman in any stage of the life cycle in a respectful, caring and positive manner, within a welcoming and professional environment. We believe that in order to provide this quality care, we must work together as a team. No single person can provide this care alone; therefore each and every person is a highly valued member of the Gynics Associates team. Patients cared for in such an environment can be assured that they are cared for by a team with one common goal – an enjoyable obstetrical experience and the delivery of a healthy, happy baby!

Gynics Associates has four qualified and experienced OB/Gyn physicians: Robert Crumb, Cynthia Coyne, Delia DeLeon, Allison Urrutia, and Courtney Wiener. Our physicians are specialists in routine and high risk obstetric care. Each Gynics Associates physician is Board Certified/Eligible by the American Board of and Gynecology. Our practice also includes an Advanced Nurse Practitioner, Natalie Baldwin who enhances our ability to deliver individualized and personal care to all of our patients.

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Our Physicians

Dr. Robert Crumb

Having grown up with a father in the petroleum industry Dr. Crumb graduated from Jakarta International School in Indonesia. He then attended Texas A&M University graduating with a degree in Biochemistry. After transferring from the University of South Alabama College of Medicine in Mobile, Alabama Dr. Crumb graduated from the University of Chicago, Pritzker School of Medicine. He then completed his residency training in Obstetrics & Gynecology at the University of Chicago Hospitals. Dr. Crumb completed a Master of Public Health degree by distance education from the University of London School of Hygiene and Tropical Medicine. Dr. Crumb is Board Certified, and a Fellow in the American College of Obstetricians​ and Gynecologists. His practice includes Obstetrics including High Risk Populations, Pediatric and Adolescent Gynecology, Menopausal Medicine, Advanced Minimally Invasive Surgery, Complicated Open and Pelvic Gynecological Surgery, and Ultrasound. His practice philosophy is to provide Personalized, Expert, and Compassionate Care. While not working, Dr. Crumb enjoys spending time with his wife and college aged children.

Dr. Delia DeLeon

Dr. Delia Gonzalez DeLeon completed her undergraduate degree at North Carolina State University where she double majored in Biological Engineering and Biomedical Engineering, summa cum laude. Dr. DeLeon then returned to Texas to pursue her medical degree at the University of Texas Southwestern Medical Center in Dallas. She was fortunate to complete her Obstetrics and Gynecology residency here in Austin where her family resides. Her passion for women’s health is realized in the sincere and caring relationship she builds with every patient. She believes creating a trusting and comfortable environment is of the utmost importance. She is committed to learning and utilizing ​ the newest and most advanced technologies to better serve her patients. She is particularly interested in minimally invasive procedures, including the DaVinci Robot and Single Incision Laparoscopy (SILS). She enjoys listening to live music around town, watching movies, and spending time on Lady Bird Lake with family.

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Dr. Allison Urrutia

As the eighth of twelve children, Dr. Allison Urrutia’s interest in obstetrics began at an early age. She was born in Ohio and relocated to Austin upon completion of medical school at Northeastern Ohio Medical University. She completed her training in Obstetrics and Gynecology at the University of Texas Southwestern in Austin in 2011. While in training, she began her family with the birth of her two children, Emma and Oliver. Dr. Urrutia is committed to building a trusting relationship through each office visit. By creating a warm and inviting atmosphere, her patients feel at home. Dr. Urrutia’s obstetric practice includes expertise in both routine and high risk pregnancy care. Her gynecologic expertise includes preconceptual counseling, contraceptive management, infertility evaluation and treatment, treatment of abnormal pap smears, menstrual problems, menopause and hormone replacement therapy, pelvic organ prolapse and urinary incontinence. Dr. Urrutia is board certified and a Fellow of American Congress of Obstetrics and Gynecology. Her practice interests include minimally invasive surgery. She is certified in DaVinci Robotic surgery and SILS (Single Incision Laparoscopic Surgery). Dr. Urrutia is fluent in English and in Spanish.

Dr. Cynthia Coyne

As a Miami native with a Hispanic background, Dr. Cynthia Coyne is familiar with cultural diversity. She moved to Texas for her OB/Gyn training at the University of Texas Health Science Center at Houston where she graduated in June 2017. After four years in Houston, and meeting her husband - an ER physician, she sought to stay in Texas. She is honored to be a part of Gynics Associates in Austin, the city where her husband attended undergraduate school. Her main focus in OB/Gyn is to provide an environment where women can be open about their private concerns. Her interests include , contraception, cervical dysplasia, health care maintenance, abnormal uterine bleeding, minimally invasive surgery, urinary incontinence and menopause. She is excited to be a part of the hill country, enjoying yoga, swimming and salsa dancing. Dr. Coyne is fluent in English and in Spanish.

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Dr. Courtney Wiener

Dr. Courtney Wiener was born and raised in Austin, Texas. She received her undergraduate degree in Neuroscience and Behavioral Biology at Emory University and then went on to earn her medical degree from the University of Texas San Antonio as a member of Alpha Omega Alpha and Gold Humanism Society. She completed her residency training in Obstetrics and Gynecology at Baylor College of Medicine in Houston. Dr. Wiener is thrilled to be home practicing with a group dedicated to providing compassionate, patient focused care with the highest level of medical scholarship. She is privileged to provide obstetric and gynecologic care through all stages of life and become partners in her patient's health. Her clinical interests include adolescent health, family planning and contraception, dermatologic disorders of the vulva, and minimally invasive gynecologic surgery. Dr. Wiener loves exploring new restaurants around Austin, spending time with her two brothers, running at Town Lake, and listening to live music.

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Contact Information

Gynics Associates Main phone number: 512-451-3131 Our website: www.gynics.com ​

Office hours: Monday through Friday, 8:00am to 5:00pm

Dr. Robert S. Crumb Jamee, MA Extension 3

Dr. Delia G. DeLeon Maria, MA Extension 2

Dr. Allison A. Urrutia Gloria, MA Extension 1

Dr. Cynthia D. Coyne Mary, MA Extension 4

Dr. Courtney Wiener Extension 5 Khat, MA

Please note, prescription refills and appointment changes will be handled during office hours only. ​

Julie Roth, OB financials Direct Line 512-350-2582

For Medical Emergencies Only: After hours and on weekends, call the Medical Exchange 512-483-9022

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TABLE OF CONTENTS

Welcome .. 1 ………………………………………………………………………… Our Physicians 2 …………………………………………………………………… Contact Information .. 5 …………………………………………………………… Estimate of Benefits .. 7 …………………………………………………………… Medicaid .. 9 ………………………………………………………………………… FMLA and Short Term Disability . 10 ……………………………………………… Prenatal Appointment Schedule . 11 ……………………………………………… How Your Baby Grows .. 12 ………………………………………………………… Getting Prepared .... 15 ……………………………………………………………… Common Problems 17 ……………………………………………………………… Medications 20 ……………………………………………………………………… Travel .. 21 …………………………………………………………………………… Nutrition . 23 ……………………………………………………………………… … Exercise .. 26 ………………………………………………………………………… Work 28 ……………………………………………………………………………… Sex 29 ………………………………………………………………………………… Smoking, Alcohol & Street Drugs ... 29 ………………………………………… … How To Tell When Labor Begins 32 ……………………………………………… Postpartum Depression 34 ………………………………………………………… Hospital Regisstration .. 37 ………………………………………………………… Check List ... .. 38 …………………………………………… ………………………… Notes ... .. 39 ……………………………………………………………… ……………

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OB Estimate of Benefits

The following information should provide answers to some of the most frequently asked questions regarding the cost of and delivery. Julie, our OB financial counselor, will meet with you to go over your individual estimate at your second or third OB visit or sooner if requested.

1. What should I expect for costs with my prenatal care and delivery? Gynics Associates charges each pregnant patient an OB Global Fee, which ​ ​ includes routine/non-complicated prenatal visits, delivery and one postpartum visit:

*Vaginal Delivery $3,342.00 *Vaginal Delivery after a cesarean section (VBAC) $3,520.00 *Cesarean section delivery $3,784.00

2. What is NOT included in the OB Global Fee but may be covered by my insurance? These services are billed separately from the Global Fee. Initial OB office visit charge Ultrasounds, Fetal Non-Stress Tests and Biophysical Profiles Newborn circumcision Laboratory testing, genetic testing Medications Shots/injections ER visits Hospital fees: St. David’s Medical Center 919 E. 32nd St. Austin 78705 Austin Anesthesiology Group fees

3. What should I expect my “out of pocket” portion to be? Depending on your individual insurance policy coverage, an OB payment plan may be required for the Global Fee. If your policy has a deductible, it must be met before your insurance will make payments. Services that are not included in the Global Fee will be billed separately and balances due when applicable. It is your responsibility to make timely payments and pay statements when due. If your insurance changes in the middle of your pregnancy, the charges are split between the two insurance carriers which means it is no longer a Global Fee. In that case, you may incur copay charges for each visit which is determined by your insurance carrier.

4. What if I do not have insurance and will have to be SELF PAY?

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You will need to meet with Julie at your first or second OB appointment to discuss payment and payment plan options. All OB fees will be due 6 weeks prior to your estimated due date.

5. What will happen if I move or transfer care to another Obstetrician during my pregnancy? You will only be charged for the individual office visits and co-pays for each visit that you have had up until your date of transfer plus you will be responsible for any statement that you receive for care that falls outside the Global Fee.

6. I have Medicaid insurance coverage. Do you accept it and if yes, what managed Medicaid plans are you in-network with? We accept Medicaid for only. We are contracted with Superior and BCBS Star only. We are out-of-network with all CHIP plans and the Healthy Texas Women Program. It is important to keep in close contact with your caseworker. If they cannot reach you, you may be reassigned to another out-of-network Medicaid plan or you could possibly lose your benefits entirely.

Our billing office will contact your insurance company as a courtesy and obtain an estimate of your maternity coverage. This is not a guarantee of benefits and YOU are ultimately responsible to know your OB benefits and insurance requirements.

**Be sure to let us know if you change your insurance coverage at any point in your pregnancy!

Failure to disclose your most current and accurate insurance information at the time of service may lead to a loss of payment to your doctor, which in turn shifts the cost to you. Furthermore, willful misrepresentation of your insurance carrier(s) could not only result in loss of payment, but in some circumstances is considered fraud. In these cases, it is possible the patient-doctor relationship will be terminated.

If you have any questions or concerns, please see Julie in our business office at your next OB visit or you can call her directly at 512-350-2582, 8am - 4pm Monday through Friday.

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OB Patients With Medicaid

We accept Medicaid for pregnancies only.

We are contracted with Superior and BCBS Star plans only. We are out-of-network with all CHIP plans and the Healthy Texas Women Program.

It is important to keep in close contact with your caseworker. If they cannot reach you, you may be reassigned to another out-of-network Medicaid plan or you could possibly lose your benefits entirely.

If you have private commercial insurance through your employer or through a parent, you may still be eligible for Medicaid as a secondary insurance.

You MUST notify us of ALL insurances you have. Federal law requires us to file with ALL insurances you have. You cannot pick and choose which insurances to use.

If you add an insurance or term an insurance, whether commercial or Medicaid, you must notify us immediately. You are also responsible for notifying Medicaid when you term a commercial insurance. We cannot do this for you. Failure to notify us of any change to your insurance is considered fraud.

If you have any questions or concerns, please see Julie in our business office at your next OB visit or you can call her directly at 512-350-2582, 8am - 4pm Monday through Friday.

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FMLA and Short-Term Disability Paperwork

If you will need FMLA or Short-Term Disability paperwork to be filled out by our office, please keep the following in mind:

● The standard time off is 6 weeks for both vaginal deliveries and ​ caesarean sections, so discuss with your physician if additional time off ​ is/will be needed.

● Once you have talked with your physician, we will need your paperwork as soon as possible in order to give us ample time to complete and return your paperwork to you. If your doctor has ​ approved more than the standard six weeks recovery time, please let us know when you give us your form(s)!

● Make sure your forms include your name and date of birth. Provide a contact number you can be reached at once your forms have been completed. If forms are to be faxed in, include that number as well.

● Allow at least 2 weeks for your paperwork to be completed. ​ ​

● Be proactive in finding out the requirements from your employer regarding your request for time off. Don’t just wait for your ​ employer/HR Department to supply you with the necessary forms. Your employer may have a deadline for submitting forms. In some cases, FMLA and Short Term Disability requests are denied if not ​ submitted in a timely manner. It is your responsibility to get us your ​ forms well in advance of the deadline.

If you have any questions, please contact our business office at 512-451-3131.

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Prenatal Appointment Schedule

8 weeks Physical exam, confirmation ultrasound, Pap smear, blood work drawn, counseling 12 weeks Routine obstetrical visit, First Screen for Trisomy 13, 18 and21 risk if desired 16 weeks Routine obstetrical visit, Quad Test for Trisomy 13. 18, and 21 risk if desired 20 weeks Routine obstetrical visit, ultrasound for fetal anatomy 24 weeks Routine obstetrical visit 28 weeks Routine obstetrical visit, screening for gestational diabetes and anemia Rhogam injection if Rh negative 31 weeks Routine obstetrical visit 34 weeks Routine obstetrical visit 36 weeks Routine obstetrical visit, Group B strep screening, HIV screening Weekly thereafter: Routine obstetrical visit with cervical examinations beginning 36 - 40 weeks Postpartum visit: 2 weeks if delivery was c/section, second postpartum visit at 6 weeks 4-6 weeks if delivery was vaginal

It is good to remember that problems or high risk factors may warrant additional visits. Your physician will discuss this with you if need be.

Your nurse will contact you with any laboratory results that are abnormal and need attention. Normal results will be discussed at your next OB visit. If you have questions or concerns at times other than your routine visits, please give us a call to speak with your nurse or the on-call nurse if needed.

As much as possible, we will try to have your OB visits scheduled with your physician or with Natalie our nurse practitioner. However, due to deliveries, emergencies, surgeries or vacations, you may need to see one of the other physicians in our practice.

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Prenatal Development: How Your Baby Grows During Pregnancy

How does pregnancy begin? Fertilization, the union of an egg and a sperm into a single cell, is the first step in a complex series of events that leads to pregnancy. Fertilization takes place in the fallopian tube. Over the next few days, the single cell divides into multiple cells. At the same time, the small cluster of dividing cells moves through the fallopian tube to the lining of the uterus. There it implants and starts to grow. From implantation until the end of the eighth week of pregnancy, the baby is called an embryo. From the ninth week of pregnancy until birth, it is called a fetus.

What is the ? The placenta is formed from some of these rapidly dividing cells. The placenta functions as a life-support system during pregnancy. Oxygen, nutrients, and hormones from the mother are transferred across the placenta to reach the baby, and waste products from the baby are transferred to the mother for removal.

How will my uterus change during pregnancy? During pregnancy, the lining of your uterus thickens and its blood vessels enlarge to provide nourishment to the fetus. As pregnancy progresses, your uterus expands to make room for the growing baby. By the time your baby is born, your uterus will have expanded to many times its normal size.

How long does pregnancy last? A normal pregnancy lasts about 40 weeks from the first day of your last menstrual period (LMP). Pregnancy is assumed to start 2 weeks after the first day of the LMP. Therefore, an extra 2 weeks is counted at the beginning of your pregnancy when you are not actually pregnant. Pregnancy “officially” lasts 10 months (40 weeks)—not 9 months—because of these extra weeks.

How is the length of my pregnancy measured? Pregnancy can be divided into weeks and sometimes days. A pregnancy that is “36 and 3/7 weeks” means “36 weeks and 3 days of pregnancy.” The 40 weeks of pregnancy often are grouped into three trimesters. Each trimester lasts about 12–13 weeks (or about 3 months):

● First trimester: 0 weeks–13 and 6/7 weeks (Months 1–3) ● Second trimester: 14 and 0/7 weeks–27 and 6/7 weeks (Months 4 –7) ● Third trimester: 28 and 0/7 weeks– 40 and 6/7 weeks (Months 7–9) What is the estimated due date (EDD)? The day your baby is due is called the estimated due date (EDD). Only about 1 in 20 women give birth on their exact due dates. Still, the EDD is useful for a number of reasons. It determines your baby’s throughout pregnancy so that the baby’s growth can be tracked. It also provides a timeline for certain tests that you will have throughout your pregnancy.

How is my EDD calculated? Your EDD is calculated from the first day of your LMP. But when the date of the LMP is uncertain, an ultrasound exam may be done during the first trimester to estimate the due

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date. If you have had in vitro fertilization, the EDD is set by the age of the embryo and the date that the embryo is transferred to the uterus.

What happens during weeks 1–4 of pregnancy? ● The dividing fertilized egg moves down the fallopian tube toward the uterus. ● At about 5 days after fertilization, the cluster of dividing cells enters the uterus. ● At about 8–9 days after fertilization, the cluster of cells (now called a blastocyst) attaches to the lining of the uterus. What happens during weeks 5–8 of pregnancy? ● The placenta begins to form. ● The brain and spinal cord begin to form. ● The tissues that will form the heart begin to beat. The heartbeat can be detected during an ultrasound exam at about 6 weeks of pregnancy. ● Buds for limbs appear with paddle-like hands and feet. ● The eyes, ears, and nose begin to develop. Eyelids form, but remain closed. ● The genitals begin to develop. ● By the end of the eighth week, all major organs and body systems have begun to develop. What happens during weeks 9–12 of pregnancy? ● Buds for future teeth appear. ● Fingers and toes start to form. Soft nails begin to form. ● Bones and muscles begin to grow. ● The intestines begin to form. ● The backbone is soft and can flex. ● The skin is thin and transparent. ● The hands are more developed than the feet. ● The arms are longer than the legs. What happens during weeks 13–16 of pregnancy? ● Eyebrows, eyelashes, and fingernails form. ● Arms and legs can flex. ● External sex organs are formed. ● The placenta is fully formed. ● The outer ear begins to develop. ● The fetus can swallow and hear. ● The neck is formed. ● Kidneys are functioning and begin to produce urine. ● In male fetuses, the testicles begin to descend from the abdomen. ● Genitals become either male or female at week 14. What happens during weeks 17–20 of pregnancy? ● The sucking reflex develops. If the hand floats to the mouth, the fetus may suck his or her thumb. ● The skin is wrinkled, and the body is covered with a waxy coating (vernix) and fine hair (lanugo). ● The fetus is more active. You may be able to feel him or her move. ● The fetus sleeps and wakes regularly. ● Nails grow to the tips of the fingers. ● The gallbladder begins producing bile, which is needed to digest nutrients. ● In female fetuses, the eggs have formed in the ovaries. ● It may be possible to tell the sex of the baby on an ultrasound exam. What happens during weeks 21–24 of pregnancy?

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● Real hair begins to grow. ● The brain is rapidly developing. ● The eyes begin to open. ● Finger and toe prints can be seen. ● The lungs are fully formed but not yet functioning. What happens during weeks 25–28 of pregnancy? ● The eyes can open and close and sense changes in light. ● Lanugo begins to disappear. ● The fetus kicks and stretches. ● The fetus can make grasping motions and responds to sound. ● Lung cells begin to make surfactant. What happens during weeks 29–32 of pregnancy? ● With its major development finished, the fetus gains weight very quickly. ● Bones harden, but the skull remains soft and flexible for delivery. ● The different regions of the brain are forming. ● Taste buds develop, and the fetus can taste sweet and sour. ● The fetus may now hiccup. What happens during weeks 33–36 of pregnancy? ● The fetus usually stays in a head-down in preparation for birth. ● The brain continues to develop. ● The skin is less wrinkled. ● The lungs are maturing and getting ready to function outside the uterus. ● Sleeping patterns develop. What happens during weeks 37–40 of pregnancy? ● The fetus drops lower into the pelvis. ● More fat accumulates, especially around the elbows, knees, and shoulders. ● The fetus gains about 1/2 pound per week during this last month of pregnancy.

Designed as an aid to patients, this document sets forth current information and opinions related to women’s health. The information does not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other acceptable methods of practice. Variations, taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice, may be appropriate. ACOG, 2015

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Getting Prepared - Talking with your Doctor

Nine months may seem like a long time, but there are a lot of things to do to prepare for the big day and for life with your new little one. Use this time to talk with your doctor, plan for , spruce up your nursery and plan for life with your baby. As your pregnancy progresses, new questions may arise. Before each prenatal check-up, make a list of questions and concerns you want to discuss with your doctor or nurse practitioner. Some things to consider:

Take a Childbirth Preparation Class - Birth classes teach you about pregnancy and help lower your anxiety about labor and delivery. A variety of topics are offered, from your baby’s development to prenatal yoga. Relaxation techniques for labor and delivery are popular topics. The two most common techniques in the United States are the Lamaze technique and the Bradley method.

Visit the Pediatrician and our hospital, St. David’s Medical Center - Many pediatricians and our hospital offer open houses for you to meet the staff and tour the facilities. Take advantage of these services. Ask your friends and your doctor for a referral to a pediatrician. Visit the open house for new patients since this is a good way to get to know and to choose one. This pediatrician will see your baby soon after discharge. Take a tour of the maternity ward at St. David’s. Ask about the rooms and whether a family member can stay over. Ask about policies, such as who can be present for the birth, visiting hours and bringing in outside food and flowers. Most important - do a dry run. See how long it will take to drive from home to the hospital. Determine the best route if there might be traffic or other delays.

Call the St. David’s HealthCare Help Center to register for classes and events. Their number: 1-888-868-2104 or you can register online.

St. David’s Hospital Registration Go to www.gynics.com, click on FORMS on the top menu. Scroll to St. David’s ​ ​ picture and click. OR

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https://stdavids.com/patients-visitors/patient-services/hospital-pre-registra tion.dot

Prepare your home - When you come home with your new baby, it’s helpful to have things set up. Think ahead to what you’ll need for yourself, the baby and the rest of the family. When friends and family offer to help, take them up on it! When you’re only getting a few hours of sleep at a time, you’ll really appreciate a home-cooked meal or someone else to walk the dog. Here are some ideas to start preparing your home:

❖ If necessary, arrange for someone to help you the first couple of weeks at home. ❖ Shop and prepare food for you for the first weeks back home. Collect take-out menus. ❖ Prepare a nursery for your baby. Suggestions of things you might need: ➢ A crib or bassinet ➢ A table or other sanitary place to change diapers ➢ Diaper bag packed with diapers, receiving blankets, change of clothes, plastic bag for soiled diapers and baby wipes. ➢ Diaper pail or garbage can ➢ Storage area for baby clothes and diapers ➢ If using cloth diapers, set up delivery; you’ll need 90 diapers for the first week. ➢ If using disposable diapers, stock up; you’ll need 350 for the first month. ❖ Stock up on clothes and accessories for the baby ➢ T-shirts or onesies ➢ Booties or socks ➢ Hat ➢ Sleepers ➢ Receiving blankets ➢ Fitted crib sheets ➢ Burp cloths ➢ Baby scissors or nail clippers ➢ Baby thermometer ➢ Mild soap, baby lotion, baby wipes ❖ Be sure to wash all clothing, bedding, towels and washcloths before using them with your baby.

Be ready for the big moment - Once your contractions become regular, you should be ready to jump in the car and get to the hospital. Pack your bags and

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keep them by the door or in the car so you’re ready at a moment’s notice. Here are some things to think about: ❖ Always keep your gas tank full. ❖ Bring an infant car seat; you may not need to take this with you initially but you will need it to bring the baby home. ❖ Bring your insurance card, birth plan and any other useful health information. ❖ Leave jewelry, cash and other valuables at home. ❖ Pack these things for yourself: Warm socks, hand lotion and lip balm, lollipops or hard candy,

toiletries such as toothbrush/toothpaste, contact lenses/glasses, deodorant, shampoo, comb or brush and elastics for long hair, several pairs of underwear, socks and bras, pajamas with button front if you plan to breastfeed, bathrobe and slippers, loose fitting outfit and shoes ​ to wear home, paper and pencil to write down questions, camera. ❖ Pack these things for your baby: Name and contact information for your baby’s pediatrician, outfit for baby’s photo and an outfit to wear home, mittens to cover baby’s nails, one receiving blanket, one outer blanket, one hat and pair of booties/socks, if the weather is cold bring a heavy blanket, sweater and hat ❖ Your partner should pack a bag as well: Underwear and a change of comfortable clothes, pajamas if staying overnight, toiletries, books or magazines.

Try to relax - When you are well prepared, you can go into the delivery room feeling confident. Keep in mind though, that this is a natural process with natural ups and downs. Use your relaxation techniques and focus on the miracle of birth to help get you through the difficult parts.

Common Problems During Pregnancy & Solutions

Along with pregnancy and your changing body, it is likely you will experience a variety of discomforts. Additionally, you will be limited in the types of medications that are safe to take for common illnesses and ailments, such as allergy and gastrointestinal disturbances. Below, you will find a list of common problems and ways to alleviate them, along with a list of medications that can be used during pregnancy.

NAUSEA OR “MORNING SICKNESS”: Can occur at any time during pregnancy and ​ ​ is the most common complaint, especially during the first twelve weeks. Often

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this nausea is referred to as “morning sickness” but it can occur at any time of day. The cause of this nausea is a hormone called HCG which is released by the placenta. The HCG level is at its highest during the first twelve weeks of pregnancy and then begins to drop and level off for the rest of pregnancy. Prevention & Treatment: ❖ Take small bites and eat slowly ❖ Eat frequent, light meals throughout the day ❖ Avoid fried, greasy and highly seasoned foods as well as sweets and caffeine. ❖ Increase your intake of foods high in Vitamin C, such as fresh fruits, vegetables and juices. ❖ Increase your intake of Vitamin B, which is in foods with brewer’s yeast, whole grains, dairy products and organ meats. ❖ Have unsalted unbuttered toast and crackers in the morning. ❖ Engage in some light exercise, such as walking, after eating to help digestion. ❖ If vomiting occurs, drink plenty of clear liquids such as Gatorade, ginger ale, Sprite, broth or Jello. If you are unable to tolerate clear liquids for 12-24 hours, notify our office. ❖ Sip on room temperature or warm liquids, such as broth, tea or chicken noodle soup. Try Jello, toast, popsicles, bananas, rice, applesauce or plain baked potatoes when you’re feeling better.

HEARTBURN OR INDIGESTION: A very common complaint of pregnant women. ​ During pregnancy, your body and the placenta secrete progesterone. This hormone relaxes the esophageal sphincter, allowing the stomach contents to reflux up the esophagus, creating heartburn. Prevention & Treatment: ❖ Take small bites, eat slowly and chew food completely ❖ Avoid greasy and highly seasoned food ❖ Increase your Vitamin B intake ❖ Do not mix fats and sweets in the same meal ❖ Antacids - see list under Medications

CONSTIPATION: Also caused by elevated progesterone levels, which causes ​ relaxation of the intestines and slows digestion. Prevention & Treatment: ❖ Drink an 8 ounce glass of water at least 6 - 8 times each day ❖ Maintain a high fiber diet ❖ Exercise daily ❖ Do not use artificial laxatives as they inhibit the absorption of nutrients from the intestines. ❖ Stool softener - see list of Medications

HEADACHES: Can be caused by the hormonal changes in pregnancy, most ​ commonly during the first eighteen weeks of pregnancy. Stress and tension can also cause headaches. Prevention & Treatment: ❖ Eat regularly ❖ Get plenty of rest ❖ Avoid crowded and noisy places ❖ Avoid poorly ventilated or smoke filled rooms

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❖ Acetaminophen can be taken for headaches according to the package directions. If this, along with rest, does not help your headache, notify our office.

DIARRHEA: ​ ❖ Avoid dairy, caffeine, raw fruits and vegetables ❖ Drink clear liquids such as Sprite, Ginger Ale, Apple Juice, water, broth

FATIGUE OR INSOMNIA: ​ ❖ Increase calcium and Vitamin B intake ❖ Exercise ❖ Take relaxation breaks ❖ Take warm tub baths ❖ Massage LEG AND JOINT PAIN: ​ ❖ Rest ❖ Increase Magnesium and Vitamin B intake ❖ Exercise ❖ Maintain a good posture ❖ Use a heating pad on a low to moderate setting

BURNING, ITCHING, VAGINAL DISCHARGE: ​ ❖ Eat yogurt and buttermilk to keep bacterial balance in the vagina and body ❖ Wear white, all cotton undergarments ❖ Do no douche as this will only worsen the symptoms ❖ Notify our office and speak with your nurse. They will guide you about treatments/medications that can be used. You may be instructed to make an appointment to see your OB doctor or our nurse practitioner. ❖ Notify our office if symptoms persist

SWELLING IN YOUR ANKLES, FEET AND HANDS: is common during pregnancy ​ and is caused, in part, by the increased blood volume caused by pregnancy. Swelling is also caused by the body’s inability to transport the extra volume without displacing extra fluid in dependent areas of the body, such as feet and ankles. Prevention and Treatment: ❖ Elevate your feet and lie on your left side as much as possible. Lying on your left side allows for unrestricted return of blood from the limbs to the heart through the vena cava, a major vein on the right side of your body. ❖ Avoid adding salt to your diet. Be aware of foods high in sodium and avoid them. Instead of using salt, try onion, lemon, garlic or pepper to season food. Hide your salt shaker!

ANEMIA, LOW RED BLOOD CELL COUNT: can occur during pregnancy. The ​ developing baby often takes from the mother’s iron stores and if they are not replaced by adequate iron intake, anemia will occur. Prevention and Treatment: ❖ Increase dietary iron intake by increasing consumption of foods such as red and organ meats (three times per week), dark green leafy vegetables such as greens and spinach (at least once or twice a day), raisins, prunes, and

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sunflower seeds. Other good iron sources are peaches, grapes, dried apricots, egg yolks and peanut butter. ❖ Take your prenatal vitamins ❖ Your physician will add an iron supplement if indicated

DEPRESSION occasionally can result from hormonal changes during and after ​ pregnancy. Prevention and Treatment: ❖ Don’t be afraid to voice your concerns and to talk things out. ❖ Do things that you enjoy. Get out of the house. Take care of yourself. ❖ If you have severe symptoms and are unable to sleep, eat or participate in daily activities, please notify our office.

VARICOSE VEINS ❖ Increase intake of Vitamins E and C ❖ Elevate your feet ❖ Do not cross your legs at the knee ❖ Do not wear tight clothing or garters around your legs ❖ Do wear support hose ❖ Walk daily ❖ If you note severe pain or redness, notify our office

Medications

Every medication carries with it risks and benefits. It is important to discuss with your doctor all prescription and non-prescription medications you are or may consider taking. This includes vitamin supplements, herbal and so call “natural” supplements. We would prefer that you do not take any medications during your pregnancy, however we do realize that this is not possible for many patients. Do not discontinue any medications prescribed for significant medical problems unless you have first talked with the physician who prescribed the medication and with your obstetrician. If you are prescribed a medication during pregnancy, please take the entire course of the prescription. Listed below are common conditions and medications that are thought to be safe to use on an occasional basis for these conditions. If you find that you need one of these medications frequently, please discuss this with your doctor or nurse. Generic forms are acceptable.

Allergies: Benadryl, Claritin, Zyrtec Cough/cold: Robitussin (plain), Tylenol, Mucinex, Actifed, Drixoral, Delsym. NO decongestants of any type. Increase fluid intake, use a vaporizer at night if congested. Constipation: Citrucel, FiberCon, Konsyl, Metamucil, Colace Increase your water intake to 6-8 glasses per day.

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Increase dietary fiber including bran cereals, fruits, raw vegetables. Diarrhea: Imodium, Kaopectate Fever: Acetaminophen (Tylenol) only. Call our office if your temperature is higher than 100.4 degrees. Gas : Mylanta, Gas-X, Mylicon Headache/Fever: Acetaminophen (Tylenol) only. Do not use Ibuprofen products such as Advil, Aleve, Nuprin or Aspirin. Heartburn: Maalox, Milk of Magnesia, Mylanta, Rolaids or Tums. Pepcid, Zantac and Prilosec are also allowed. Hemorrhoids: Anusol cream, Tucks, Preparation H. Warm baths may help Insomnia: Getting some exercise during the day might make you sleepier at night. Try a warm shower or bath and a glass of milk and a good book might help. Avoid electronic devices. Sleeping pills are not allowed. Nausea: Antacids, Altoid mints, ginger tea, lemon drops may help. Eat 6-8 small meals per day. Keep saltine crackers at your bedside at night, eat them before getting out of bed in the morning. A small snack before bedtime also may help. Sore throat: Cepacol lozenges, warm salt water gargles Skin irritation: Calamine, Caladryl, Corticaine, Neosporin Vomiting: Try nausea remedies listed above but if excessive, call our office and talk with your nurse.

Travel During Pregnancy

Your physician should examine you prior to any travel in the third trimester. If your pregnancy is considered high risk or if you have had any complications, consult your physician prior to any travel during the course of your pregnancy, regardless of trimester.

Is travel safe during pregnancy? For most women, traveling during pregnancy is safe. As long as you and your fetus are healthy, you can travel safely until you are 36 weeks pregnant. When is the best time to travel during pregnancy? The best time to travel is the middle of your pregnancy—between week 14 and week 28. Most common pregnancy problems happen in the first and third trimesters. During mid-pregnancy, your energy has returned, morning sickness usually is gone, and it is still easy to get around. Paying attention to the way you feel is the best guide for your activities. When is travel not recommended during pregnancy?

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Travel is not recommended if you have certain pregnancy complications, including preeclampsia, premature , and preterm labor. Travel also may not be a ​ ​ ​ ​ ​ good idea if you are pregnant with more than one fetus. Are there areas that I should avoid traveling to while I am pregnant? Travel is not recommended for pregnant women in areas where Zika outbreaks are ongoing. Zika is an illness spread by mosquitoes that can cause serious birth defects. Travel also is not recommended to areas with malaria, another mosquito-carried illness that is dangerous for pregnant women. What should I do before going on a trip? There are a few things you can do to make sure your trip is safe and comfortable:

● Schedule a checkup with your obstetrician–gynecologist (ob-gyn) before you leave. ​ ​ ● Know your estimated due date. If you have a problem while you are traveling, your caregivers will need to know how far along you are in your pregnancy. ● Plan to bring any over-the-counter medications that you may need, such as pain relievers, hemorrhoid ointment, a first aid kit, and prenatal vitamins. Also bring any prescribed medications. ● Check that you are up to date with your vaccines. ● Think about how long it will take to get to your final destination. The fastest way often is the best. ● Make your travel plans easy to change. Consider buying travel insurance to cover tickets and deposits that cannot be refunded. What is deep vein thrombosis and why is it a concern for pregnant travelers? Deep vein thrombosis (DVT) is a condition in which a blood clot forms in the veins in the legs or other areas of the body. DVT can lead to a dangerous condition in which the clot travels to the lungs. Sitting or not moving for long periods of time, such as during long-distance travel, can increase the risk of DVT. Pregnancy further increases the risk of DVT. If you are planning a long trip, take the following steps to reduce your risk of DVT:

● Drink lots of fluids. ● Wear loose-fitting clothing. ● Walk and stretch at regular intervals. For example, when traveling by car, make frequent stops to get out and stretch your legs. What are some tips for traveling by car? During a car trip, make each day’s drive as short as possible. Wear your seat belt every time you ride in a car. Buckle the belt low on your hip bones, below your belly. Place the shoulder belt off to the side of your belly and across the center of your chest (between your breasts). Plan to make frequent stops so that you can move around and stretch your legs.

What are some tips for traveling by plane? Keep your due date in mind when booking your flight. Complete your flight before you reach 36 weeks of pregnancy. Some domestic airlines restrict travel completely or require a medical certificate during the last month of pregnancy. For international flights, the cutoff point often is earlier, sometimes as early as 28 weeks. Check your airline’s policies when planning your trip.

Book an aisle seat so that you can get up and stretch your legs. Plan to do this every 2 hours or so. Avoid gas-producing foods and carbonated drinks before your flight. Gas expands in the low air pressure in airplane cabins and can cause discomfort. Wear your seatbelt at all times. What are some tips for traveling by ship?

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Make sure a doctor or nurse is on board the ship. Also make sure that your scheduled stops are places with modern medical facilities. Before you leave, ask your ob-gyn which medications are safe for you to take if you get seasickness.

A concern for cruise ship passengers is norovirus infection. Noroviruses are a group of viruses that can cause severe nausea and vomiting for 1–2 days. People easily can become infected by eating food, drinking liquids, or touching surfaces that are contaminated with the virus. Wash your hands frequently while on board the ship. If you have diarrhea and vomiting at the same time, seek medical care.

The Centers for Disease Control and Prevention (CDC) performs periodic inspections of cruise ships to prevent widespread virus outbreaks. You can check whether your ship has passed this health and safety inspection at www.cdc.gov/nceh/vsp/. ​ ​

What are some tips for traveling outside the United States? Check your health insurance policy to see if you are covered internationally. If not, you may be able to buy special health care insurance for international travelers.

Travel to developing countries comes with the risk of consuming contaminated food and water. Travelers can become sick if they eat raw or undercooked food or drink local water. This short-term illness, called “traveler’s diarrhea,” may be a minor problem for someone who is not pregnant, but it is a greater concern for pregnant women. Serious illnesses, such as hepatitis A and listeriosis, also can be spread by contaminated food and water. These diseases ​ ​ can cause severe complications for a pregnant woman and her fetus.

If you get diarrhea, drink plenty of fluids to combat dehydration. Before taking a diarrhea treatment, check with your ob-gyn or other health care professional to make sure it is safe. The best way to prevent illness is to avoid unsafe food and water. When should I seek emergency medical care when traveling? Go to a hospital or call emergency medical services right away if you have any of the following:

● Vaginal bleeding ● Pelvic or abdominal pain or contractions ● Rupture of the membranes (your “water breaks”) ● Signs and symptoms of preeclampsia (headache that will not go away, seeing spots or other changes in eyesight, swelling of the face or hands) ● Severe vomiting or diarrhea ● Signs of DVT

Nutrition During Pregnancy

What are the five food groups? 1. Grains—Bread, pasta, oatmeal, cereal, and tortillas are all grains. 2. Fruits—Fruits can be fresh, canned, frozen, or dried. Juice that is 100% fruit juice also counts. 3. Vegetables—Vegetables can be raw or cooked, frozen, canned, dried, or 100% vegetable juice.

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4. Protein foods—Protein foods include meat, poultry, seafood, beans and peas, eggs, processed soy products, nuts, and seeds. 5. 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 fetal 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 fetus. 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 fetus'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 fetus’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.

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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. Limiting your weight gain during pregnancy will allow a return to a normal healthy weight after pregnancy. Consult with your doctor on ways to meet your target weight gain. 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 women 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 fetus’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 before getting pregnant, while pregnant, and while 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, marin, orange roughy, 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 fetus. 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

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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 fetus. 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

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 , 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. The best rule to follow regardless of what exercise you choose to do is “Listen to your body”. If it’s uncomfortable, then “back off”...do not try to push through the discomfort. In addition, it is very important to stay well hydrated and avoid overheating, especially in our hot Central Texas weather. What are the benefits of exercise during pregnancy? Regular exercise during pregnancy benefits you and your fetus 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.

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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.

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● 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.

Work during Pregnancy If you work, you might be wondering if you can continue working throughout your pregnancy. Many women do so without any problems. Pregnancy causes many changes in your body and your ability to continue working depends on our overall health, the health of the fetus and what sort of work you do. Many jobs are safe to continue through pregnancy; other jobs may be okay at the beginning of pregnancy but later on, some duties may need to be changed or stopped. Sometimes your schedule or hours may need to be changed. Remember, if you continue working, the goal is to stay safe and comfortable.

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Desk jobs: most desk and computer jobs are safe during pregnancy but ​ because of fluid buildup during pregnancy, some women develop carpal tunnel syndrome which can make keyboard work difficult. As your body and posture change, back, neck and shoulder strain may also become an issue if you sit all day. These tips may help:

❖ Take frequent breaks. Get up and walk around to improve blood flow and reduce swelling. ❖ Use a pillow or cushion for lower back support. ❖ Use correct hand and arm positions when using a computer. Use a wrist rest if you use a keyboard and mouse. ❖ Use a phone headset to relieve neck and shoulder strain. ❖ Don’t cross our legs and feet. Standing work: jobs that require standing for long periods can be hard on the ​ pregnant body, causing back and leg pain. This is especially true late in pregnancy. Standing for long periods can also reduce blood flow to the fetus and may slow baby’s growth. If you stand, try these tips:

❖ Prop one foot on a short stool or box to help relieve back pain. ❖ Ask if you can sit on a tall stool rather than stand. ❖ Take breaks often, sit down with your feet up if possible. ❖ Wear good, comfortable, well-fitting and low-heeled shoes. Heavy labor jobs: if you have a job that requires heavy lifting, pulling, pushing ​ or other physical labor, talk with your OB provider about whether it is safe to continue. Pregnancy symptoms, like dizziness and extreme tiredness can make some physical jobs dangerous. As your center of gravity changes, your sense of balance may suffer, making you more likely to fall.

Sex during Pregnancy In most cases, sex during pregnancy is safe. In fact, with your OB provider’s approval, sexual relations can continue until delivery. However, fluctuating hormone levels and certain pregnancy symptoms, like nausea and tiredness, can temporarily reduce a pregnant woman’s libido. By the third trimester, interest in sex often lags and finding a comfortable position may prove difficult.

Sexual intercourse may have to be avoided if the following symptoms happen:

❖ Heavy vaginal bleeding ❖ Pain during intercourse ❖ Leaking of ❖ Contractions after intercourse that do not resolve

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Check with your OB provider if you experience any of these symptoms.

Smoking, Alcohol and Street Drugs during Pregnancy

Why is smoking dangerous during pregnancy? When a woman smokes cigarettes during pregnancy, her fetus is exposed to many harmful ​ chemicals. Nicotine is only one of 4,000 toxic chemicals that can pass from a pregnant woman to her fetus. Nicotine causes blood vessels to narrow, so less oxygen and fewer nutrients reach ​ ​ the fetus. Nicotine also damages a fetus’s brain and lungs. This damage is permanent.

How can smoking during pregnancy put my fetus at risk? Several problems are more likely to occur during pregnancy when a woman smokes. These problems may include preterm birth, which is birth that occurs before 37 weeks of pregnancy. Babies that are born too early may not be fully developed. They may be smaller than babies born to nonsmokers, and they are more likely to have colic (with uncontrollable crying). These babies are at increased risk of sudden infant death syndrome (SIDS). They also are more ​ ​ likely to develop asthma and obesity in childhood. If you are smoking when you find out you are pregnant, you should stop. Why should I avoid secondhand smoke during pregnancy? Secondhand smoke—other people’s smoke that you inhale—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. These babies are more likely to have asthma attacks and ear infections. If you live or work around smokers, take steps to avoid secondhand smoke. Take this opportunity to encourage everyone in the family to quit smoking. Are e-cigarettes safe to use during pregnancy? Electronic cigarettes (known as “e-cigarettes”) are used by some people as a substitute for traditional cigarettes. E-cigarettes contain harmful nicotine, plus flavoring and a propellant that may not be safe for a fetus. E-cigarettes are not safe substitutes for cigarettes and should not be used during pregnancy. Why is drinking alcohol dangerous for my fetus? Alcohol can interfere with the normal growth of a fetus and cause birth defects. When a ​ ​ woman drinks during pregnancy, her fetus can develop physical, intellectual, behavioral, and learning disabilities that can last a lifetime. The most severe disorder is fetal alcohol syndrome ​ (FAS). FAS can cause growth problems, intellectual disability, behavioral problems, and ​ abnormal facial features. It is best not to drink at all while you are pregnant.

What is illegal drug use? Use of substances—including heroin, cocaine, methamphetamines, and prescription drugs(opioids) taken for a nonmedical reason—is a widespread problem in the United States.

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How can my drug use affect my fetus? Different drugs may affect the fetus in different ways. Using illegal drugs early in pregnancy can cause birth defects and miscarriage. During the later weeks of pregnancy, illegal drug use ​ ​ can interfere with the growth of the fetus and cause preterm birth and fetal death. How can my drug use affect my baby after he or she is born?

Babies born to women who used illegal drugs during pregnancy may need specialized care after birth. These babies have an increased risk of long-term medical and behavioral problems. I use medical marijuana. Can I keep using it during pregnancy? Some women use medical marijuana with a prescription ordered by a healthcare professional. The American College of Obstetricians and Gynecologists recommends that pregnant women and those planning to become pregnant stop using medical marijuana. You and your health care professional can discuss alternative treatments that will be safe for your fetus.

What are opioids? Opioids—also called narcotics—are a type of medication that relieves pain. Doctors may ​ prescribe opioids for people who have had surgery, dental work, or an injury. Prescribed opioids include oxycodone, hydromorphone, hydrocodone, and codeine. Can I take prescription opioids during pregnancy? If you are prescribed an opioid during pregnancy, you and your obstetrician or other health care professional should discuss the risks and benefits of this treatment. When taken under a doctor’s care, opioids are safe for both you and your fetus. It is important to take the medication only as prescribed. What is opioid addiction? Most people who use a prescription opioid have no trouble stopping their use, but some people develop an addiction. Those who become addicted may look for other ways to get the drug when their prescription runs out. They may go from doctor to doctor to have new prescriptions written for them. Some people use the illegal drug market to supply themselves with opioids. How can opioid addiction affect my fetus? Misusing opioids during pregnancy can increase the risk of serious complications, including placental abruption, fetal growth problems, preterm birth, and stillbirth. ​ Why should I seek treatment for opioid addiction? When you are pregnant and have an opioid addiction, you should not suddenly stop using the drug without medical supervision. Withdrawal, especially when done abruptly, often leads to relapse, which can be harmful for you and your fetus. Talk with you OB doctor about your options. What is the treatment for opioid addiction during pregnancy? The best treatment for opioid addiction during pregnancy is medication-assisted therapy (MAT). The medications that are given are long-acting opioids. This means that they stay active in the body for a long time. These opioids, called methadone and buprenorphine, reduce cravings but do not cause the pleasant feelings that other opioids cause. In addition to MAT, treatment involves drug counseling.

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How will treatment for opioid addiction affect my fetus? Treatment with either methadone or buprenorphine makes it more likely that the fetus will grow normally and not be born too early. Neither medicine has been found to cause birth defects. Some babies born to women taking opioids, including methadone or buprenorphin taken for treatment of addiction, can have temporary withdrawal symptoms. This is called neonatal abstinence syndrome (NAS).

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 Lightening. This is known as the “baby From a few baby has dropping.” The baby’s head has settled deep weeks to a few dropped lower into your pelvis. hours before labor begins

Increase in Show. A thick mucus plug has accumulated at Several days vaginal discharge the cervix during pregnancy. When the cervix before labor (clear, pink, or begins to dilate, the plug is pushed into the begins or at the slightly bloody) vagina. 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?

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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 Often are irregular and do not Come at regular intervals and, as contractions get closer together (called time goes on, get closer together. Braxton Hicks contractions) Each lasts about 30–70 seconds.

Change with Contractions may stop when Contractions continue, despite movement you walk or rest, or may even movement stop with a change of position

Strength of Usually weak and do not get Increase in strength steadily contractions much stronger (may be strong and then weak)

Pain of Usually felt only in the front Usually starts in the back and contractions 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: If you have further questions, contact your Gynics Associates obstetrician at 512-451-3131. For Medical Emergencies Only!

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After hours and on weekends, call the Medical Exchange 512-483-9022 Postpartum Depression

What are the postpartum blues? About 2–3 days after childbirth, some women begin to feel depressed, anxious, and upset. They may feel angry with the new baby, their partners, or their other children. They also may:

● cry for no clear reason ● have trouble sleeping, eating, and making choices ● question whether they can handle caring for a baby These feelings, often called the postpartum blues, may come and go in the first few days after ​ ​ childbirth. How long do the postpartum blues usually last? The postpartum blues usually get better within a few days or 1–2 weeks without any treatment. What is postpartum depression? Women with postpartum depression have intense feelings of sadness, anxiety, or despair that ​ ​ prevent them from being able to do their daily tasks. When does postpartum depression occur? Postpartum depression can occur up to 1 year after having a baby, but it most commonly starts about 1–3 weeks after childbirth. What causes postpartum depression? Postpartum depression probably is caused by a combination of factors. These factors include the following:

● Changes in hormone levels—Levels of estrogen and progesterone decrease sharply in ​ ​ ​ ​ ​ ​ the hours after childbirth. These changes may trigger depression in the same way that smaller changes in hormone levels trigger mood swings and tension before menstrual periods. ● History of depression—Women who have had depression at any time—before, during, or after pregnancy—or who currently are being treated for depression have an increased risk of developing postpartum depression. ● Emotional factors—Feelings of doubt about pregnancy are common. If the pregnancy is not planned or is not wanted, this can affect the way a woman feels about her pregnancy and her unborn baby. Even when a pregnancy is planned, it can take a long time to adjust to the idea of having a new baby. Parents of babies who are sick or who need to stay in the hospital may feel sad, angry, or guilty. These emotions can affect a woman’s self-esteem and how she deals with stress. ● Fatigue—Many women feel very tired after giving birth. It can take weeks for a woman to regain her normal strength and energy. For women who have had their babies by cesarean birth, it may take even longer. ​

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● Lifestyle factors—Lack of support from others and stressful life events, such as a recent death of a loved one, a family illness, or moving to a new city, can greatly increase the risk of postpartum depression.

If I think I have postpartum depression, when should I see my health care provider? If you think you may have postpartum depression, or if your partner or family members are concerned that you do, it is important to see your healthcare provider as soon as possible. Do not wait until your postpartum checkup. How is postpartum depression treated? Postpartum depression can be treated with medications called antidepressants. Talk therapy ​ ​ also is used to treat depression, often in combination with medications. What are antidepressants? Antidepressants are medications that work to balance the chemicals in the brain that control moods. There are many types of antidepressants. Drugs sometimes are combined when needed to get the best results. It may take 3–4 weeks of taking the medication before you start to feel better. Can antidepressants cause side effects? Antidepressants can cause side effects, but most are temporary and go away after a short time. If you have severe or unusual side effects that get in the way of your normal daily habits, notify your health care provider. You may need to try another type of antidepressant. If your depression worsens soon after starting medication or if you have thoughts of hurting yourself or others, contact your health care provider or emergency medical services right away. Can antidepressants be passed to my baby through my breast milk? If a woman takes antidepressants, they can be transferred to her baby during breastfeeding. The levels found in breast milk generally are very low. Breastfeeding has many benefits for both you and your baby. Deciding to take an antidepressant while breastfeeding involves weighing these benefits against the potential risks of your baby being exposed to the medication in your breast milk. It is best to discuss this decision with your healthcare provider. What happens in talk therapy? In talk therapy (also called psychotherapy), you and a mental health professional talk about your feelings and discuss how to manage them. Sometimes, therapy is needed for only a few weeks, but it may be needed for a few months or longer. What are the types of talk therapy? You may have one-on-one therapy with just you and the therapist or group therapy where you meet with a therapist and other people with problems similar to yours. Another option is family or couples therapy, in which you and your family members or your partner may work with a therapist. What can be done to help prevent postpartum depression in women with a history of depression? If you have a history of depression at any time in your life or if you are taking an antidepressant, tell your health care provider early in your prenatal care. Ideally, you should tell your health care provider before you become pregnant. Your health care provider may

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suggest that you begin treatment right after you give birth to prevent postpartum depression. If you were taking antidepressants before pregnancy, your health care provider can assess your situation and help you decide whether to continue taking medication during your pregnancy.

What support is available to help me cope with postpartum depression? Support groups can be found at local hospitals, family planning clinics, or community centers. The hospital where you gave birth or your health care provider may be able to assist you in finding a support group. Useful information about postpartum depression can be found on the following web sites:

National Women’s Health Information Center http://www.womenshealth.gov/mental-health/mental-health-conditions/postpartum-depres sion

Postpartum Support International www.postpartum.net

Medline Plus www.vsearch.nlm.nih.gov

Online PPD Support Group http://www.ppdsupportpage.com

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Hospital Registration

To register for prenatal classes, hospital tour and pre-registration for delivery, you can either: ● Log on to St. David’s Medical Center Pre-registration : https://prereg.app.medcity.net/ ● or https://stdavids.com/patients-visitors/patient-services/hospital-pre-registration.dot

or

● Log on to Gynics website Forms page: http:\\www.gynics.com/forms for ​ ​ direct link to St. David’s Medical Center

Check List

❏ Register for childbirth classes, baby care and sibling classes by 24 weeks

❏ Take a tour of the St. David’s Medical Center Labor & Delivery

❏ Decide about circumcision if you are having a boy

❏ Learn about options for pain management

❏ Turn in pre-registration form for the hospital by 34 weeks

❏ Choose a pediatrician by 36 weeks

❏ Choose a car seat

❏ Pack a bag for labor and delivery by 37 weeks

❏ Relax!

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NOTES

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October 2018

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