Welcome Packet

Updated 9.21 2017

Northwest Hospital Midwives Clinic 10330 Meridian Ave N., Suite 190 Seattle, WA 98133

PHONE: (206) 668-6670 (use option 8 to talk to clinic staff during clinic hours ) FAX: (206) 668-6171 Website: www.nwmidwivesclinic.com

Office hours: Monday through Friday, 8:30 a.m.- 4:30 p.m.

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Northwest Hospital Midwives Clinic

TABLE of Contents

Introduction to our Practice

Welcome & Overview ...... 6 How To Reach the Midwives ...... 8 What to Expect at Your Appointments...... 9 Billing & Fees ...... 12

Early Pregnancy

Pregnancy Nausea ………………………………...... 16 Weight Gain During Pregnancy ………...………….... 18 Nutrition During Pregnancy …………...………….... 19 Exercising During Pregnancy ……………………...... 21 Prenatal Yoga ………………………………………. 23 Misc. Pregnancy Information ………………………... 25 Over The Counter Medications For Pregnancy ……….. 26 Influenza …………………………………………... 27 Genetic Testing: Screening and Diagnostic Tests …...... 28

Later Pregnancy & Birth Preparation

Labor: Contacting the Midwife & Warning Signs ……… 37 Fetal Movement ……………………………………. 38 Pertussis and Tdap ………………………………….. 39 Childbirth Classes ………………………………….. 40 Our Labor and Birth Practices ………………………. 41 Your Birth Plan …………………………………….. 43 Birth Doulas ………………………………………. 44 Vitamin K ………………………………………….. 45 Cord Blood Options ……………………………….. 46 GBS (Group Beta Strep) testing……………………... 47 Perineal Massage……………………………………. 48

After your baby’s birth

Postpartum Care at Home ...... 52 Postpartum Visits & Warning Signs ...... 53 Breastfeeding ...... 54 Postpartum Breast Care ...... 58 Postpartum Mood Problems ...... 59 Pelvic Floor Exercises ...... 62 Abdominal muscles/Diastasis Recti………………….. 63

Introduction to our Midwifery Practice

Welcome to the midwives clinic at Northwest Hospital Thank you for choosing us to care for you and your baby. We look forward to getting to know you and your family during the next several months. We understand how very special and precious your baby is, and we will strive to make your pregnancy, labor, birth, and postpartum experience as healthy and satisfying as possible. This booklet, our website resource list, the UWBaby mobile app, and our recommended book (Pregnancy, Childbirth, and the Newborn: The Complete Guide, by Penny Simkin, Janet Whalley, Ann Keppler) should give you the information you need to navigate this journey with us.

A few notes about our practice: Group Practice Model We are a group practice of five midwives. This means that, with few exceptions, we share our patients. This model allows us to have one of the midwives “on call” at all times, to be available for women in labor and any other urgent patient needs. We are all experienced midwives with a similar philosophy of pregnancy and birth as normal, natural processes. We also have good communication systems in place so that any one of us can easily pick up your story where one of the other midwives left it off. At the same time, the five of us are unique individuals and we each contribute to the practice in special ways. We recommend that you see the same midwife for your first few visits while we are getting to know one another, and then start meeting the others. A typical pregnancy will have 12 to 16 visits, so you should be able to meet all five midwives during your prenatal care. We want you to know the midwife who will be there with you when you go into labor and have your baby. Students We enjoy helping to educate midwifery graduate students from the University of Washington and Seat- tle University. You may have a chance to work with a student midwife during your clinic visits or at your birth. We also occasionally have a UW medical student with us in the clinic. You will always a choice as to whether to have a student participating in your care. Per diem midwives We currently have three wonderful per diem midwives who fill in for us on sick days or vacations. You can see photos and profiles of all the midwives on our website.

Physician Consultation

Midwives are expert in normal pregnancy, labor, birth, and newborns. We practice within the scope of practice determined by our education and experience, as well as hospital, state, and federal regulations. Most of our clients never need to meet an obstetrician, but we have a system in place to obtain medical

consultation and support whenever your condition might require them. An obstetrician from North- west Hospital is available to us at all times for consultation, co-management, or referral. We can also consult as needed with a variety of medical specialists throughout Northwest Hospital and UW Medi- cine, in order to provide you with the best possible care. If you have questions at any time, please do not

hesitate to ask us. We look forward to working with you!

Your midwives,

aditi Grandy Deborah Blue Mary Bolles Holder Mary Lou Kopas

Cindy Rogers

HOW TO reach the MIDWIVES

Our office number is 206-668-6670. Please listen to all the options listed. During office hours, if you do not hear what you need or need to reach someone right away, please push “8”. Your message will be sent to the clinic nurse and she will call you back to discuss your concerns and determine if the midwife needs to be called or if you need to be seen.

There is always a midwife on call available to patients 24/7. After hours, when the clinic is closed, you still call the same number 206-668-6670 and listen to the message. PRESS 1 to reach the midwife on call after hours. The answering service will take your message and call the on-call midwife. Your call should be returned within 15-20 minutes after you call the answering service. Please at- tempt to stay off your phone while waiting for a return call. If you have not heard from a midwife within 20 minutes, please call back and tell them this is your second time calling. It is possible that the on-call midwife may be in a delivery or in surgery and cannot return your call immediately. If your second call is not returned, call the Northwest Hospital Childbirth Center at 206-668-1882.

If you are calling about a medical emergency, call 911

E-care We encourage you to sign up for e-care to communicate about test results or NON-URGENT questions. If you need a same-day response, please call.

Warning signs Please call us for any of the following or any urgent problems or concerns:  contractions that occur 6 or more times in an hour  Vaginal bleeding or other fluids leaking from your vagina  if you fall or are in a motor vehicle accident  Any symptoms of an infection or fever  headache that does not get better with Tylenol, rest, and drinking water  vision changes such as seeing spots or floaters  decreased fetal movement after fetal movement has become regularly noticeable  abdominal pain, nausea, or loss of appetite  feeling sick or unwell

WHAT TO EXPECT DURING YOUR PRENATAL CARE

Schedule of visits After your initial prenatal visit, your appointments usually last about 20 minutes. The nurse or medical assistant will check your weight and blood pressure at each visit. (Some women would prefer not see their weight or have it discussed, so let us know if that is the case for you.) Starting at around 10 weeks, the midwives will listen to your baby’s heartbeat with a small ultrasound instrument called a Doppler. The midwife will also measure the size of your uterus and talk to you about any concerns or questions you might have. A full physical exam is usually only needed at your first visit and at your 6 week postpartum visit. We typically like to see you every 4 weeks up until 28 weeks, then every 2 weeks from 28 to 36 weeks, then weekly until the birth.

Ultrasounds Early Dating Ultrasound (6-10 weeks): You may or may not need an early ultrasound to check via- bility and dating. If you want an early ultrasound to confirm viable pregnancy and dating, we can offer this in the clinic. We will discuss dating and early ultrasound at your first visit. Nuchal Translucency (11-14 weeks): If you choose to do genetic testing, a special ultrasound called nuchal translucency will be ordered and performed at Radiology Department at the hospital. This is a measurement of the thickness at the back of the baby’s neck, which if enlarged, can be associated with some anomalies. Anatomy Scan (19-21 weeks): We order the standard anatomy scan ultrasound for everyone. This is done to look at all parts of the baby to assess for any abnormalities. The ultrasound technician will also look at your kidneys as well as the placenta, cord, amniotic fluid, and measure growth/size of the baby. If you want to know the sex of your baby, they will tell you. If you want to keep it a surprise, they will not tell you. If you prefer to have no ultrasounds, you should discuss this with the midwife. Additional ultrasounds are performed only if/when medically necessary. Ultrasounds are usually done at the Radiology Department on the main campus of Northwest Hospital, but the midwives can do certain types of ultrasound exams in the clinic.

WHAT TO EXPECT DURING YOUR PRENATAL CARE

Lab tests There are several blood tests performed during your pregnancy. Early in the pregnancy, we will check your blood type. We also check for anemia, hepatitis, syphilis, HIV, herpes, and immunity to German measles (Rubella). We also do standard screenings for chlamydia and gonorrhea and a urine test for bladder infection. There are additional testing options available if you want to check your risk for having a baby with Down’s syndrome, or other types of trisomy, or neural tube defects. These will be explained by your midwife, but are usually done between 10 and 18 weeks if you decide to have them. At 26-28 weeks, you will be asked to drink a sweet “glucola” drink and we will check for gestational diabetes and anemia. If you are Rh negative, you will also be retested at this time for antibodies and given an injection of Rhogam. If you develop any complications or other issues during pregnancy, additional blood work may be needed. At about 35-37 weeks your midwife will do a swab of your vagina and rectum to check for the presence of Group Beta Strep (GBS). Please refer to the page on GBS for further information. E-Care and Test results We encourage you to sign up for e-care so that you can review results and send or receive messages to us electronically. However, if you have an urgent concern or question that needs to be addressed the same day, please call and speak to someone here in the clinic. Do not use E-care for urgent problems. We will call you to go over your ultrasound report, usually within 24 hours. For lab results, we usually call to go over genetic screening results or anything that requires some immediate follow up ac- tion. All other test results will be reviewed via e-care or at your next visit. Going past Your due date Labor normally starts within 2 weeks (before or after) your due date. The majority of babies come within one week of their due date (from one week before to one week after the due date). If your are still awaiting labor at one week past your due date (41 weeks), we will do a non-stress test (NST) and Amniotic Fluid Index (AFI) ultrasound to check baby’s well -being. This involves an ultrasound exam and a 20-40 minutes tracing of your baby’s heartbeat. If these tests are reassuring, we can keep waiting for labor, but will want to schedule you for an induction (using medicine in the hospital to bring on labor) no later than two weeks past your due date (42 weeks).

WHAT TO expect at your visits

We may discuss a variety of topics and make different specific plans depending on your unique history and particular needs, but below is are some typical things that we do and discuss at various points in your pregnancy. Of course, we can see you anytime between regularly planned visits if problems arise.

6-10 weeks: Your first prenatal visit! This is where we start to get to know you. Please expect to be here about an hour and a half. We will review your complete health history including medications, supplements, surgeries, allergies, and any past or current medical conditions and health habits. You will complete some paperwork, much of which can be downloaded ahead of time from our website. The midwife will do a full physical exam and likely order some blood tests. She will also discuss genetic testing options, warning signs, and things you can do to have the healthiest possible pregnancy. A dating ultrasound may or may not be indicated in early pregnancy. We may or may not be able to hear the fetal heartbeat with our hand-held Doppler ultrasound before 12 weeks.

12 weeks: At this and all future visits, we listen to baby’s heartbeat and measure how your uterus is growing. You may have a nuchal translucency ultrasound at about this time. We will have you give a “clean catch” urine sample to screen for infections.

16 weeks: Order anatomy scan ultrasound to take place at around 20 weeks. 2nd blood draw of integrated screen or AFP screening blood test. Be sure you have mailed in your hospital registration form.

20 weeks: Anatomy scan ultrasound occurs about this time

24 weeks: We recommend you start to think about child birth education options.

28 weeks: You will have a Glucola test to screen for gestational diabetes. This test takes an hour and is usually done in the lab after your midwife visit. We also do a blood cell count (called a CBC). You will also have a Rhogam and antibody screen if blood type is Rh negative. At this visit we will also review and have you sign consent forms for your hospital stay

30 weeks: Review your 28 week labs results. Note visits are every 2 weeks now! You should be noting baby movement every day. We will also discuss plans for prenatal classes.

32 weeks: We recommend you get a Tdap vaccine to protect you and baby from Pertussis or Whooping Cough. Your immediate family members should also consider a Tdap vaccine.

34 weeks: Questions we may ask: Have you decided on baby’s pediatric care provider? Have you lined up extra help for your first days and weeks at home with a new baby? Are you working on your birth plan? Considering donating cord blood?

36 weeks: You will have an ultrasound in the clinic to determine whether the baby is head-down (i.e., not in “breech” position)

37 weeks: A GBS (Group Beta Streptococcus) screening test will be done

38 weeks: Review GBS result. We do not typically offer vaginal exams until the due date or later.

39 weeks: Discuss plans for labor and birth, being ready for labor, comfort measures for early labor at home.

40 weeks: We will review plan for 41 week visit IF you get that far. We might also discuss things to at home to encourage labor onset

41 weeks: Fetal well-being testing: non-stress test (NST) and in-clinic ultrasound including measure of amniotic fluid (AFI). Recom- mend a vaginal exam to check your cervix, offer to sweep membranes. Schedule and review plan for induction of labor, recommended no later than 42 weeks

41-1/2 weeks: Repeat NST, vag exam, possibly membrane sweeping.

Postpartum visits: At 2 and 6 weeks after baby’s birth (although most experienced moms can skip the 2 week visit) The 6 week postpartum visit involves a physical exam and possibly lab testing.

Billing Policy

Insurance In today's challenging and somewhat frustrating insurance environment, understanding your insurance coverage is key to avoiding unwanted medical bills. Becoming familiar with the requirements of your particular policy is vital.

We bill all routine obstetrical fees to your insurance company at the time of your delivery. This charge is referred to as “Global Billing” and includes your routine prenatal visits, the midwives’ time during labor and delivery, and your postpartum check up. If your baby ends up being delivered by on obstetrician (such as by a C-section), or if you transfer care during pregnancy, then the pregnancy episode is no longer a global billing, but instead charged out separately for prenatal visits, delivery, and postpartum visits. The fee for your obstetric care may be higher if your pregnancy or delivery is complicated or high risk. Examples include: preterm labor, hypertension, or cesarean section. If you should need additional monitoring during any part of your pregnancy (such as a non-stress tests or amniotic fluid assessment), these charges will be billed once the service is completed.

After your initial OB visit, our staff will contact your insurance carrier for a benefit determination and will provide you with an estimate of your out of pocket costs. Your estimate portion of the balance will be calculated and split into monthly pre-payments to be paid before your delivery. If an overpayment should occur, it will be immediately refunded to you after delivery. Any balance owed resulting from additional charges will be billed after delivery. If you are unable to make payments or need finical assistance please let our team know and we will contact you with our finical team to make alternative arguments.

Lab and Ultrasound Fees Your ultrasounds will take place at one of the Northwest Hospital radiology at main hospital, or at Via Radiology. Labs are sent to Northwest Hospital Clinical Laboratory, which is part of UW lab. These charges will be billed after the service has been completed. If you have questions regarding your lab or ultrasound bill, please contact Northwest Hospital Patient Financial Services directly at (206) 668- 6440.

Medical Records Fees The Midwives Clinic provides copies of patient's records upon written request. As a courtesy to our patients and other physicians, the Midwives Clinic provides copies of records to another physician or midwives’ office free of charge. If the patient should request a copy of their records there is a nominal copying fee.

Other Fees The estimate you will receive from us is for the Midwives Clinic professional fees ONLY. You will also be charged a facility fee for your hospital stay. For an estimate of hospital charges please contact Northwest Hospital & Medical Center estimated charge line at (206) 668-1719.

For non-baby-related office visits, such as birth control counseling and women’s health check ups, you may owe a co-pay due at the time of your visit. Please check with your insurance company for details.

Circumcision Fees Insurance plans vary in regards to covering the cost for circumcision. If you are considering a circumcision for your baby, please contact your insurance carrier before your birth. Check to see if they cover circumcision in the hospital or in an office setting. The coverage may be different depending on the location. With this information, we can guide you to the best provider. The out of pocket cost is typically between $250-400 and is due at the time of service.

Questions/Concerns If you have any questions or concerns about the fees that occur at our office, please contact clinic and ask for the office supervisor.

Early pregnancy Weeks 4-27 Gestation

Pregnancy NAUSEA 1. Nausea in pregnancy, with or without vomiting, is known as morning sickness but frequently occurs at other times of the day or evening. Since it is more apt to occur when the stomach is empty, nausea is usually worse in the morning. The cause of nausea in pregnancy is not known, although the rapidly rising hormone levels in early pregnancy are believed to be a factor. Fortunately, it usually only occurs during the first three months of pregnancy. There are numerous techniques to reduce nausea. Not all of them work for all women. Try any one, or all, or any combination, until you find what works best for you. 2. REMEMBER: If you go 24 hours without retaining any food or liquid, you should contact your midwife immediately. If nausea, with or without vomiting, is interfering with your daily life, and the measures outlined below are not helping, please call 206-668-6670. 3. Don’t let your stomach get completely empty. This is a vicious cycle: you are not hungry because you are nauseated, but if you go too long without eating, the nausea can get worse. Small meals are toler- ated better than large ones. Plan out what you need to eat for the day to meet your minimum nutri- tional requirements, then eat a few bites every hour or two, spacing the total amount of food out over the day. If you get up at night to go to the bathroom, eat a little. 4. Keep some crackers, dry toast, popcorn, or other dry carbohydrate food at your bedside and eat a little of it before you get out of bed in the morning. 5. Eat or drink a small amount of something sweet (like fruit or fruit juice) before getting up in the morning. 6. Avoid spicy foods and food with strong or offensive odors. 7. Avoid fats in your diet. These can be especially nauseating 8. Some women discover a certain food that just doesn’t agree with them during pregnancy. If you get extremely nauseated after eating a particular food, two or three times in a row, you may have to give it up for the duration of your pregnancy. 9. Suck on lemon drops, mint candy, or lifesavers throughout the day. 10. Peppermint tea settles the stomach and can relieve nausea. 11. Don’t drink liquids while eating solid foods. Space out small meals so that you wait 30-60 minutes after a solid meal before drinking anything. This prevents the stomach from getting too full.

12. Carbonated drinks, such as 7-up, ginger ale, ginger beer, seltzer water, club soda, or mineral water, may help settle the stomach when sipped between meals. 13. The stomach secretes less acid during pregnancy. Sometimes drinking half a glass of grapefruit juice with a meal will increase the acid and allow you to digest the food more easily. 14. Vitamin B6 (pyridoxine) can help relieve nausea if taken in large doses. Most prenatal vitamins contain only about 5mg. You can take Vitamin B-6 in 25mgtablets three times a day 15. Unisom (doxylamine), an over the counter sleeping pill, is often effective in decreasing symptoms of morning sickness when taken along with Vitamin B-6. One Unisom tablet with 25 mg Vitamin B-6 once in the morning and again at bedtime is the usual dosage, but since sleepiness is a side effect of Unisom, you may want to try half a tablet in the morning. 16. There is also a prescription medication that combines Vitamin B-6 with doxylamine in a time-released formula that make you less drowsy than the over-the-counter dose. It often costs much more than the over-the-counter preparations. Call the clinic if you would like to explore this option. 17. Ginger root (Zingiber officinale) was found to prevent motion sickness in a recent study and may help to relieve nausea. Gelatin capsules containing the powdered root can be purchased in health food stores. You can take 250mg four times a day. 18. Papaya enzymes can also bring some relief. They can be found in most health food stores. Take them according to the package directions. 19. Acupressure points: Studies have shown improvement in nausea when pressure is applied to the fore- arm three fingerbreadths above the wrist (same side as the palm). Sea-Bands are a simple device that can apply constant pressure on this point. They are available at the drugstore and are also used for seasickness.

It can be difficult to live with nausea, day-in and day-out, for three or more months. The unpleasantness is more tolerable if the people you live with try to be especially considerate, understanding, and loving. Ask them to pay special attention to little things that are important to you. And remember to return the kindness. Women often become introspective during pregnancy and need to make an effort to extend themselves to loves ones.

Weight Gain During Pregnancy

Most women gain between 25-35 pounds during their pregnancy. We may recommend you to gain more or less than average, depending on your starting weight and your body’s unique pattern of weight gain during pregnancy. A well balanced diet and regular exercise are important factors in ensuring a healthy weight gain during pregnancy. Many pregnant women find the weight gain and body changes during pregnancy difficult to adjust to, especially since our society pushes the message that gaining weight is a bad thing. Weight gain during pregnancy is healthy, normal, and essential for your baby’s health and development. It is often helpful to see how the weight is distributed and puts your weight gain into perspective. The diagram below shows the components of an average woman’s weight gain by the end of her pregnancy:

Source: http://www.babyyourbaby.org/pregnancy/during-pregnancy/weight-gain.php

NUTRITION during PREGNANCY

For most pregnant women, the right amount of daily calories is:

 1,800 calories per day in the 1st trimester

 2,200 calories per day in the 2nd trimester  2,400 calories per day in the 3rd trimester

Most women need to increase their food intake by about 300 calories a day in the 1st and 2nd trimesters,

rd and 300-500 calories a day in the 3 trimester. Healthy options include ½ a turkey sandwich, yogurt and fruit, or a glass of milk and some fig cookies.

During the first trimester, it can be difficult to eat a balanced diet. We encourage you to listen to your body and eat what does not make you nauseated. For most women this is carbohydrate based foods (crackers, bread, popcorn). Try to choose foods in this category that are whole grain. To ensure you are getting enough protein, choose foods that provide high protein in the smallest amount of food. Examples are eggs, cottage cheese, cheddar or parmesan cheese, lentils, power bars, oatmeal, tofu, nuts, Greek style yogurt. As you start feeling better, try to increase your intake of protein, fruits, vegetables, and dairy. Try to reduce the amount of carbohydrate you eat and try to choose whole grain options. Good protein sources include meat, fish, poultry, eggs, soybean products, beans, lentils, nuts, and seeds. Fats are an important nutrient, but most of your oils and fats should come from plant sources. Limit solid fats from animal sources. Avoid eating raw meat or fish. If you enjoy sushi, feel free to eat options that include cooked fish or seafood. Deli meats should be cooked to steaming before eating. This is more of a concern for meat from the deli counter. Avoid unpasteurized dairy products. This included Brie, Feta, and Blue Cheese unless they have been made with pasteurized milk. If you drink caffeine (coffee, tea, soda), we advise you to limit your intake to one cup/can a day.

NUTRITION and supplements

FISH & SEAFOOD: Fish and seafood are important sources of nutrients, including important essential fatty acids. But, it is important to minimize your exposure to the heavy metal mercury.

 Good to eat 2-3 times a week: Anchovies, coastal Alaska Salmon (fresh or canned), Flounder, Sole, Cod, Catfish, Trout, Pollock, Herring, Crayfish, Canned Light Tuna, Sardines, Tilapia, Clams, Shrimp, Scallops, Crab, Squid

 Limit to 1 serving per week: Chinook Salmon from Puget Sound, Halibut, Mahi-mahi, Monk- fish, Red Snapper, Lobster, Croaker, Rockfish, Sablefish/Black Cod, Tuna, Albacore (fresh or canned white)

 Avoid/Do not eat: Swordfish, Shark, Tilefish, King Mackerel, Marlin, Tuna Steak (Bluefin, big eye)

 For further information and a more detailed list, visit www.doh.wa.gov/fish

Supplements in pregnancy and breastfeeding: A prenatal multivitamin can help ensure that you get enough of the various vitamins and minerals you need to help grow a healthy baby and placenta. Here are a few particularly important micronutrients to think about:

 Folic acid (folate): 400 mcg per day

 Iron: 27 mg per day. Food sources include lean red meats, dried beans and lentils, dark leafy greens, and dried fruits. Cooking in a cast iron pan also adds iron to your food. Iron is usually absorbed better when taken with vitamin C

 Calcium: 1,000 mg per day (1,300 mg for pregnant women<19 years old). Good food sources include milk and milk products, dark leafy greens, broccoli, and bone-in sardines,

 Vitamin D: the exact amount you should be getting is somewhat controversial, but we recommend 2,000 units (IUs) daily for most women

 Omega-3 fatty acids: important for brain development. Recommend at least 2-3 servings of fish or shellfish weekly, but see the safe fish guidelines below. Flaxseed (or flaxseed oil), can- ola oil, walnuts, sunflower seeds and soybeans (such as edamame) are also good sources of omega-3 fatty acids.

exercising During Pregnancy

What are the benefits of regular exercise during pregnancy?  Reduces back pain  Eases constipation  May decrease your risk of gestational diabetes, preeclampsia, and need for 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? It is recommended that pregnant women get at least 150 minutes of moderate-intensity aerobic activity every week, which is about 20 minutes per day, or 30-minutes 5 days per 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 may be breathing more deeply. But you should still be able to talk normally. 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 unless we tell you otherwise. If you have preterm labor or high blood pressure, for example, we may recommend that you lessen your activity.

What changes occur in the body during pregnancy that can affect my exercise routine?  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 are some safe exercises I can do during pregnancy?  Walking—Brisk walking gives a total body workout and is easy on the joints and muscles.  Swimming and water workouts—Water workouts use many of the body’s muscles. The water supports your weight so you avoid injury and muscle strain. If you find brisk walking difficult because of low back pain, water exercise is a good way to stay active.  Stationary bicycling—Because your growing belly can affect your balance and make you more prone to falls, riding a standard bicycle during pregnancy can be risky. Cycling on a stationary bike is a better choice.  Modified yoga and modified Pilates—Yoga reduces stress, improves flexibility, and encourages stretching and focused breathing. There are even prenatal yoga and Pilates classes designed for pregnant women. These classes often teach modified poses that accommodate a pregnant woman’s shifting balance. You also should avoid poses that require you to be still or lie on your back for long periods. If you are an experienced runner, jogger, or racquet-sports player, you may be able to keep doing these activities during pregnancy, but please discuss with one of the midwives. exercises to 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 hock- ey, boxing, soccer, and basketball  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 elevation

What are warning signs that I should stop exercising? Stop exercising and call the midwife or 911 if you have any of these signs/symptoms:  Bleeding or other fluid leaking 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

Prenatal yoga Yoga is a wonderful practice for helping you stay fit, relaxed, and healthy throughout your pregnancy. Postpartum yoga classes are also available. Even if you've never tried yoga before, when you're pregnant it's a good time to start. The benefits of prenatal yoga include: Increased flexibility and coping with discomforts Pregnancy releases hormones (like relaxin) that increase the movement in your ligaments and joints. This increased movement, especially when combined with the added weight of pregnancy, can cause discomfort. Prenatal yoga classes are designed to help with these discomforts. Yoga can increase flexibility while also increasing strength in your body. Some women say, "I can't do yoga. I'm not flexible enough." Yoga is about YOU. You start with where YOU are. and increase your own flexibility at your own rate. It doesn't matter what anyone else does on their yoga mat. Practicing mindfulness and relaxation: In yoga, with each pose and movement, there is opportunity to practice what is often called mindfulness: becoming present in the moment and using your breath to bring your mind to a calm state. This practice can enhance your ability to cope in labor. Prenatal yoga is a wonderful complimentary practice to those learned in childbirth classes. Being a Part of a Community of Women A prenatal yoga class often starts with each woman having the opportunity to share what's happening for her. It's a chance to meet women who will be having babies around the same time as you. Many women find it helpful to meet others who share their same concerns. You may even find that you develop friendships that continue after baby comes. Practicing Exercise That is Gentle and Safe for pregnancy Prenatal yoga is gentle and safe. We recommend to attend a prenatal yoga class instead of attending a regular yoga class. There are several yoga poses and practices that should be avoided during pregnancy, such as inversions, back bends, twisting, and abdominal/core postures, and some yoga teachers are not aware of poses to be avoided in pregnancy. Hot yoga and Bikrum yoga are not recommended.

Prenatal yoga

Some women say, "Prenatal yoga is too slow. I am used to feeling more challenged in my yoga practice." Pregnancy is a transformational time, a time for softening and opening into the new role of mothering. Prenatal yoga offers practices that help strengthen the body but also to relax and open, as these are the keys to labor, birth, and parenting. We cannot power our way into motherhood but need to find the space to allow and become.

Some potential additional benefits of prenatal yoga  Improved sleep  Reduced stress  Increased strength, flexibility and endurance  Decreased lower back pain  Decreased nausea  Decreased carpal tunnel syndrome  Decreased headaches  Reduced risk of preterm labor Studies have also found that prenatal yoga can reduce hypertension-related complications and improve the likelihood of a healthy baby.

You can find a list of area yoga studios on the Health Resources page of our website: www.nwhospital.org/locations/midwives-clinic/

Miscellaneous Pregnancy Information Dental Work It is safe to have dental work (treatment of cavities and root canals) and routine cleanings during pregnancy. Please inform your dental staff that you are pregnant so they can make the appropriate accommoda- tions for you. Dental x-rays are safe to have as long as the abdomen is shielded. Seat Belts Not only is it the law to wear your seatbelt at all time, it is also safer for you and your baby. The lap belt should be worn low on the hips. As your belly grows, make sure the lab belt is under your belly, not across or on top. Ensuring it is snug on your hips will distribute the force of impact to your hip/pelvic bones, instead of your abdomen. Hot Tubs/Saunas These are not considered safe to use during pregnancy as they dramatically raise the body’s temperature and keep it elevated. This can cause the temperature in the uterus to rise and creates a less than ideal environment for the developing baby. Warm/hot baths, however, are considered safe at any point during pregnancy. The water temperature begins to drop as soon you get in the bathtub and continues to drop. This may cause a slight increase in body temperature, but it does not keep the temperature elevated as a hot tub or sauna would. toxoplasmosis If you are newly infected with Toxoplasma while you are pregnant, or just before pregnancy, you could pass the infection on to your baby. You may not have any symptoms from the infection. Most infected infants do not have symptoms at birth but can develop serious symptoms later in life, such as blindness or mental disability. Generally if you have been infected with Toxoplasma before becoming pregnant your unborn child is protected by your immunity. However, to be safe, it is recommended that pregnant women:  Avoid changing cat litter if possible. If no one else can perform the task, wear disposable gloves and wash your hands with soap and warm water afterwards.  Ensure that the cat litter box is changed daily. The Toxoplasma parasite does not become infec- tious until 1 to 5 days after it is shed in a cat's feces.  Wear gloves when gardening and during contact with soil or sand because it might be contami- nated with cat feces that contain Toxoplasma.  Wash hands with soap and warm water after gardening or contact with soil or sand.

OVER-THE-COUNTER remedies THAT ARE Relatively SAFE TO USE IN PREGNANCY

ALLERGIES: Fluticasone nasal spray, Loratidine (Claratin)10 mg daily CONSTIPATION: Best to increase water, fiber intake and do more walking. (If necessary, it’s ok to take a stool softener such as Docusate Sodium, a fiber supplement such as Metamucil, or a laxative on occasion such as Senna). COUGH: Cough drops, Robitussin DM DIARRHEA: Call us if diarrhea persists for more than 24-48 hours DIFFICULTY SLEEPING: Doxylamine 25 mg (Unisom), Diphenhydramine (Benadryl) 25-50 mg at bedtime: Do not use more than 3 times a week and do not use while breastfeeding FEVER/CHILLS/pain

 Acetaminophen: As needed, as infrequently as you can. Do not exceed dosage on the label.  Avoid Aspirin and Ibuprofen  Call if temperature is 101°F or higher HEAD CONGESTION: Steam, vaporizer, Neti Pot, saline drops HEARTBURN: Maalox, Mylanta, Tums, Ranitidine HEMORRHOIDS: Warm soaks (Sitz baths), topical Witch Hazel (Tucks pads) or hemorrhoid cream INDIGESTION/GAS: Mylicon, Maalox Plus, Mylanta II SORE THROAT: Cough drops, hot drinks VAGINAL YEAST INFECTION: Clotrimazole 1%: 1 applicator full in vagina nightly for 5-7 nights (3 days may not be enough in pregnancy) Call if symptoms persists despite use of the creams. If symptoms are unlike previous yeast infections, please call before using these creams

Influenza and the Flu shot

Influenza (the flu) is more than a bad cold. It usually comes on suddenly. Signs and symptoms may include fever, headache, fatigue, muscle aches, coughing, and sore throat. It can lead to complications, such as pneumonia. Some complications can be life-threatening. Normal changes in the immune system that occur during pregnancy may increase your risk of flu complications. You also have a higher risk of pregnancy complications, such as preterm labor and preterm birth, if you get the flu. You are more likely to be hospitalized if you get the flu while you are pregnant than when you are not pregnant.

What should I do if I get the flu while I am pregnant? If you think you have the flu and you are pregnant (or you have had a baby within the past 2 weeks), contact your midwives away because we might recommend starting an antiviral medication as soon as possible. Flu symptoms may include the following:  Fever or feeling feverish  Chills  Body aches  Headache  Fatigue  Cough or sore throat  Runny or stuffy nose

Antiviral medication is available by prescription. It is most effective when taken within 48 hours of the onset of flu symptoms, but there still is some benefit to taking it up to 4–5 days after symptoms start. An antiviral drug does not cure the flu, but it can shorten how long it lasts and how severe it is

The annual Flu Shot is recommended for all pregnant women and is safe to get at any point in your pregnancy. The flu shot can protect you from getting the flu, a potentially very serious illness in pregnancy. The flu vaccine also protects your baby. When you get a flu shot during pregnancy, the protective antibodies made in your body are transferred to your baby via the placenta. These antibodies will protect your baby against the flu until they can get the vaccine at 6 months of age. Since the types of viruses that cause the flu can change every year, the flu vaccine is updated each year. To be fully protected, you need to get the flu vaccine each year. We have flu shots available in our clinic and will offer one to you during flu season.

Prenatal Genetic testing

There is a lot you can do during pregnancy to help yourself have a healthy baby. Taking prenatal vitamins, eating healthy foods, and getting some exercise and enough sleep can help you have a healthy pregnancy. The human body is complicated. Even if you do everything “right” during your pregnancy, things don’t always develop normally. Between 3-5% of babies have some type of health problem when they are born. You can be tested during your pregnancy to learn more about your baby’s health before it is born. It is your choice as to whether to be tested. There are two basic types of tests:  Screening tests predict the chance, or odds, that your baby has a certain birth defect  Diagnostic tests tell you whether or not your baby has a certain birth defect

Screening Tests

Nuchal Translucency or NT Ultrasound This screening test is done between 11-14 weeks of pregnancy. Using ultrasound, your baby’s length is measured to confirm your due date. Ultrasound is also used to measure the small space under the skin behind your baby’s neck. This space is called the nuchal translucency (NT). The larger this space of fluid is, the greater the chance your baby has a chromosome problem. An NT ultrasound can be done only by specially trained staff.

Integrated Screen This screening test combines the results of the NT ultrasound with two blood samples. The first blood draw is done between 11-14 weeks, usually the same day as the NT ultrasound The second blood draw is done between 15-22 weeks. The blood tests look for patterns of proteins and hormones that are associated with certain birth defects. An integrated screen tells you the chances that your baby has Down Syndrome, Trisomy 18, or Spina Bifi- da. It does not diagnose these conditions. Most women who get an abnormal integrated screen result will have a healthy baby. The integrated screen can detect 9 out of 10 cases (90%) of Down syndrome and Trisomy 18, and 8 out of 10 cases (80%) of Spina Bifida. It will not detect all cases of these birth defects, and it does not test for any other health problems.

Quad Screen This screening test involves one blood sample, drawn between 15-22 weeks. It is like the integrated screen, because it looks for patterns of proteins and hormones that are associated with certain birth defects. A quad screen tells you the chances that your baby has Down Syndrome, Trisomy 18, or Spina Bifi- da. It does not diagnose these conditions. Most women who get an abnormal integrated screen result will have a healthy baby. The quad screen can detect 8.5 out of 10 cases (85%) of Down syndrome, 7.5 out of 10 cases (75%) of Trisomy 18, and 8 out of 10 cases (80%) of Spina Bifida. It will not detect all cases of these birth defects, and it does not test for any other health problems.

A quad screen may be a good option if you don’t start prenatal care until your fourth month or if the NT ultrasound is not available.

Aneuploidy Screening with Cell-free DNA You may have heard in the news or seen articles on the Internet about a new blood test that can screen for Down syndrome. This test is called advanced aneuploidy screening with cell-free DNA. It uses a blood sample from the mother, and it is done starting at 10 weeks of pregnancy. It screens for specific chromosome disorders in the baby. Everyone has some “free” DNA (DNA not contained within a cell) in their blood. When you are pregnant, most of that free DNA is from you, but some is from your pregnancy. In this test, the total amount of free DNA from chromosomes 21, 18, and 13 is measured in your blood. Like the other screening tests, this test does not tell you if the baby has, or does not have, a chromosome problem. But, if there is an increased amount of DNA from one of these chromosomes in your blood, there is a high probability that the baby has trisomy for that chromosome. Currently, this test is given only to women who have a high risk of having a baby with Down syndrome, trisomy 18 or trisomy 13. If you have already had a child with one of these trisomies, or if you have another type of screen and the results are abnormal, you may be offered advanced aneuploidy screening with cell-free DNA.

Prenatal Genetic testing

Screening Tests Name of Test When Description What It Tells You Nuchal translucency 11-14 Abdominal ultrasound to Chances your baby has (NT) ultrasound weeks measure small space behind a chromosome problem baby’s neck Integrated Screen 11-14 NT ultrasound plus 2 separate Chances your baby has weeks blood samples Down Syndrome, Trisomy and 15-22 18, or Spina Bifida weeks Quad Screen 15-22 1 blood sample Chances your baby has weeks Down Syndrome, Trisomy 18, or Spina Bifida Advanced Aneu- After 10 1 blood sample Chances your baby has ploidy Screening with weeks for Down Syndrome, Trisomy Cell-Free DNA high risk 18, or Spina Bifida women Diagnostic Tests Name of Test When Description What It Tells You Chorionic villus sam- 11-14 Sample of placenta taken via Whether or not your ba- pling (CVS) weeks vagina or abdomen by has chromosome problems and sometimes other inherited diseases Amniocentesis (with 16-22 Sample of fluid from around Whether or not your ba- ultrasound) weeks your baby by has chromosome problems, spina bifida, and sometimes other inherited diseases Other Tests Name of Test When Description What It Tells You Anatomy ultrasound 18-22 Abdominal ultrasound to Whether or not abnor- weeks check baby’s growth and de- malities are suspected velopment and if further testing is needed

Diagnostic Tests

Anatomy scan Ultrasound This test is done between 18-22 weeks. An ultrasound is used to look at your baby, the amount of fluid surrounding the baby, your placenta, and your uterus. It checks to see that the baby is growing and that all major organs are formed. Your baby is developed enough at this age that an ultrasound may find problems such as a severe heart defect, spina bifida, a missing kidney, and severe cleft lip. Although this test won’t diagnose chromosome problems, it may show signs of these or other conditions.

Chorionic Villus Sampling This diagnostic test is done between 10-13 weeks. The doctor used either a thin, flexible needle or a thin plastic tube to remove a small sample of the placenta. An ultrasound is done at the same time, so your baby can be seen during the procedure. The placenta sample is used to diagnose chromosome problems. If an inherited condition such as a muscular dystrophy or hemophilia runs in your family, the sample can be used to test your baby for that condition. There is a slight risk of miscarriage from this procedure. The chance of miscarriage after CVS is 1 in 100 (1%) to 1 in 50 (2%). Amniocentesis This diagnostic test is done between 15-22 weeks. The doctor uses a thin, flexible needle to take 2 tablespoons of fluid from around your baby. An ultrasound is done at the same time, so your baby can be seen during the procedure The fluid sample is used to diagnose chromosome problems and spina bifida. If an inherited condition such as a muscular dystrophy or hemophilia runs in your family, the fluid can be used to test your baby for that condition. There is a slight risk of miscarriage from this procedure. The chance that doing an amniocentesis will cause a miscarriage is 1 in 400 (0.25%)

Ancestry-Based Carrier Screening Your ancestry, or ethnicity, is one clue to help discover if your baby could have a rare genetic disease. Each ancestral group has inherited conditions that are more common in that group compared to other ethnic groups. The conditions associated with ancestral group are listed in the table below.

Ancestral Disease Chance of Being a Carrier** Group African-American Beta Thalassemia 10% (10 out of 100)

Sickle Cell Disease 11% (11 out of 100) Eastern European Canavan Disease 2.5% (2 to 3 out of 100) (Ashkenazi) Jewish Cystic Fibrosis 3-4% (3 to 4 out of 100) Familial Dysautonomia 3% (3 out of 100) Tay-Sachs Disease 3% (3 out of 100) European Cystic Fibrosis 3% (3 out of 100) Caucasian Mediterranean Beta Thalassemia 3-5% (3 to 5 out of 100)

Sickle Cell Disease 2-30% (2 to 30 out of 100) East and Southeast Alpha Thalassemia 5% (5 out of 100) Asian* Beta Thalassemia 2-4% (2 to 4 out of 100) Hispanic* Beta Thalassemia 0.25-8% (fewer than 1 to 8 out of 100) Sickle Cell Disease 0.6-14% (fewer than 1 to 14 out of 100) Middle Eastern and Beta Thalassemia 0.5-5.5% (fewer than 1 to 6 out of 100) South Central Asian* Sickle Cell Disease 5-25% (5 to 15 out of 100)

*Frequencies are approximate and may vary within an ancestral group depending on exact ethnicity.

In most cases, a couple can only have a child with one these disorders when both parents are “carriers” for the same disorder. Carriers usually have no symptoms of the disease. Also, most carriers have no family history of the disease. If someone in your family has one of these conditions, tell your health care provider. If you and your partner are both carriers for the same genetic condition, then you baby might have inherited that disease. If you want to know for sure before birth, an amniocentesis or a CVS can be done. The integrated screen, quad screen, and ultrasound will NOT diagnose these disorders.

What is Down syndrome? Down syndrome, also known as Trisomy 21, is caused when a person has an extra copy of chromosome number 21. Down syndrome affects people in different ways. People with Down syndrome always look different from other members of their family. They always have some developmental delay, but the level of delay differs from person to person. Adults with Down syndrome may be able to play sports, hold a basic job, and enjoy friends. However, they usually can’t live on their own without supervision. Many babies with Down syndrome have a heart defect, which can sometimes be fixed with surgery. Other health problems and birth defects sometimes occur with Down syndrome, but they are rare. What is Trisomy 18? Trisomy 18, also known as Edwards syndrome, is caused when a person has an extra copy of chromosome number 18. Most babies with trisomy 18 do not survive the pregnancy. Children with trisomy 18 have severe brain damage and usually other problems such as heart defects and clubfoot. What is Spina Bifida? Spina bifida is a condition in which part of the baby’s spine does not form normally, and the nerves in the spine are damaged. This happens within the first few weeks of pregnancy. Spina bifida affects people in different ways. Some people have trouble walking and may need to use braces or a wheelchair. Some have trouble controlling their bladder or bowel. At times, spina bifida can cause brain damage and developmental delay. Deciding Whether to Do genetic Tests Choosing whether to have any of these tests, or deciding which ones are best for you, can be difficult. There is no “right” choice. Some women choose only an anatomy ultrasound and no other tests. Others may choose an integrated screen and anatomy ultrasound. And, if one of these tests is abnormal, they may have amniocentesis. And some women prefer a CVS or amniocentesis without any of the screening tests. Making an Informed Decision Our philosophy at Northwest Hospital is to partner with patients and families in making decisions about their care. We encourage you to ask questions to help you to make these decisions. some questions you may want to consider about genetic testing:

 Do I want any of this information?  How would learning about these birth defects before my baby is born help me and my provider prepare and plan?  How would this information help me to make choices about my pregnancy if a birth defect is found?  Will taking these tests help me to feel more reassured?  Will my insurance cover the test? If not, can I afford the cost?

Later pregnancy & Preparation for birth Weeks 28-42 Gestation

HOW TO CALL the Midwife when labor starts

If your second call is not returned, call the Northwest Hospital Childbirth Center at 206-668-1882.

Late pregnancy Warning SIGNS

AND onset OF LABOR Labor normally begins between 38 and 42 weeks of pregnancy, but it may occur earlier. You should call the midwives if you experience any of the following:  Contractions lasting 45-60 seconds, occurring every 3-5 minutes for an hour or more  Leaking fluid from the vagina (possible rupture of membranes)  Vaginal bleeding (similar to that which occurs during your period)  Severe abdominal pain (the most severe in your life, lasting more than a minute)  Any symptoms of labor, such as regular or painful contractions before 37 weeks gestation You do not need to call if you lose your mucous plug or are experiencing bloody show. After a vaginal exam it is common to see a small amount of blood-tinged discharge.

Fetal Movement

Most mothers become aware of fetal movement at around 18-21 weeks of pregnancy, and even at this early stage the number of movements a normal, healthy baby makes varies widely. Some babies move less than others. Some mothers may feel more movements than other mothers. As your baby gets older and bigger, and his/her home inside gets smaller, the types of movements you feel usually change. Babies also normally have “nap” periods and these grow longer as you get closer to your due date.

how can you know when to be concerned that your baby is not moving enough? We recommend that you pay attention to fetal movements at least once a day after 28 weeks (6-7) months. It is not necessary to count every hour and you can count at any time of day. However, choose a time of day when the baby tends to be more active (evening for some people). You should feel four or more movements in one hour. These can be rolls, kicks, jabs, wiggles, or any movement from your baby. If you do not feel four fetal movements in one hour, we recommend that you encourage the baby to be more active. You can do this by doing the following:

 Drink a large glass of water or juice (if you are not diabetic)  Eat a snack  Lie down on your side Count the movements again for one hour. If you still don’t feel four fetal movements in one hour, please call our office at 206-668-6670. Research has shown that babies whose mothers have chronic health problems, like a heart condition, high blood pressure, or insulin-dependent diabetes, have more problems during their pregnancies. In these cases, it has been shown that the counting of fetal movements is an excellent early warning system to detect babies in trouble. We feel that using this same measure of four fetal movements in one hour is adequate for the clients in our clinic since most are normal and healthy and their pregnancies are progressing without problems. Do not feel silly reporting decreased fetal movement. All of us would prefer to be reassured that your baby is just fine, just as you would. If you have questions about fetal movements and counting them, please ask the nurse or midwife.

Pertussis (Whooping cough) & T-dap vaccine

Pertussis, also known as whooping cough, is a highly contagious respiratory disease. It is caused by the bacterium Bordetella pertussis. It is spread from person to person, usually by coughing or sneezing while in close contact with others. Pertussis can cause uncontrollable, violent coughing which often makes it hard to breathe. After fits of many coughs, someone with pertussis often needs to take deep breaths which result in a "whooping" sound. Pertussis can affect people of all ages, but can be very serious, even deadly, for babies less than a year old. The best way to protect against pertussis is by getting vaccinated.

The Centers for Disease Control and Prevention (CDC) recommends that pregnant women receive the whooping cough vaccine called “Tdap vaccine” during the third trimester of each pregnancy. After receiving the whooping cough vaccine, your body will create protective antibodies (proteins produced by the body to fight off diseases) and pass some of them to your baby before birth through the placenta. These antibodies provide your baby some short-term protection against whooping cough in early life. These antibodies can also protect your baby from some of the more serious complications that come along with whooping cough.

Your protective antibodies are at their highest about 2 weeks after getting the vaccine, but it takes time to pass them to your baby. So the preferred time to get the whooping cough vaccine is early in your third trimester.

The concentration of whooping cough antibodies in your body decreases over time. When you get the vaccine during one pregnancy, your antibody levels will not stay high enough to provide adequate protection for future pregnancies. It thus is important for you to get a whooping cough vaccination during each pregnancy so that each of your babies gets the best protection possible against this disease.

We recommend that your partner and other close family members be vaccinated as well. If they have already had a Tdap vaccine, they will not need a booster. However, pregnant women should get a booster in each pregnancy, even if they have had the shot before.

The recommended time to get the shot is sometime during your 27th through 36th week of pregnancy. We have the Tdap vaccine available in clinic and typically offer it at your 30 or 32 week visit.

Childbirth preparation classes

There are many different ways to approach childbirth. We strongly encourage all our first-time parents to take a childbirth preparation class. This is a great way to meet other parents and spend some time learning about and preparing for labor and birth as well as breastfeeding and baby care.

Many of our moms are interested in experiencing natural childbirth, but no matter how you plan to approach labor pain, childbirth education classes can be helpful. Many of our families are learning Hyp- nobirthing, or Birthing From Within. Others take yoga-based, Lamaze, or Bradley classes. There are many schools of thought, but most of them will teach you some useful relaxation and breathing techniques that will help you to cope and allow your body do its work in labor, whether or not you end up using pain medications. Most women find natural childbirth very challenging, but also deeply satisfying. Staying relaxed, calm, and open to whatever is unfolding will allow your body to do what it needs to do. We recommend that you look at the different class offerings and decide which program feels right for you.

You can find a list of area Childbirth Preparation Classes on the Health Resources page of our website: www.nwhospital.org/locations/midwives-clinic/

Labor and Birth care at the hospital

The midwives support physiologic birth by allowing labor to start and progress on its own. We avoid inducing labor before 41 weeks of gestation unless there is a legitimate medical indication. If the fetal status is reassuring, we will allow up to two weeks past the due date (42 weeks) to wait for the onset of spontaneous labor. Some higher risk conditions may require labor to be induced earlier.

At the time you are admitted in labor, we will monitor your baby's heart rate for at least 20 minutes to ensure your baby is doing well. Thereafter, we tend to monitor baby's heart rate intermittently. There are situations where moms need continuous fetal monitoring in labor, such as if the baby’s heart rate is not reassuring, or if mother is having epidural for pain relief or needs Pitocin (synthetic oxytocin) during labor.

We usually need to do a cervical exam at the time of admission and at certain points throughout the labor. We tend to minimize exams and only recommend them when needed. You can request a cervical check if you want to know how far along you are.

You will have a blood draw when you are admitted in labor and we would like you to have an IV saline lock for access in case you need IV fluids or medication later on. If your labor is low risk and you do not want an IV "just in case," that is your choice, but know that it may delay our ability to intervene in an unanticipated emergency such as heavy bleeding (hemorrhage) immediately after baby is born.

We prefer that your write some sort of Birth Plan or Birth Preferences so that we know what your thoughts and plans are for comfort measures in labor and preferences at the birth. Of course, we cannot predict how each individual labor and birth journey will unfold, so please try to keep an open mind and know that your midwives will not recommend interventions unless we believe they are necessary to keep you and baby safe.

We usually try to keep the birthing environment quiet, calm, and dimly lit. We can help you to have natural, un-medicated labor and will usually offer comfort measures such as position and activity changes, tub immersion, and massage, as needed.

If you want or need pain medication in labor, there are a few options, including a short-acting IV nar- cotic, nitrous oxide gas by mask, and a regional anesthetic block, or epidural. The midwives can order any of these options. An anesthesia doctor would place and monitor an epidural. We usually support your spontaneous urge to push and will give you instructions and directions on how to push only when necessary. You may push in a variety of positions, including sitting lying down, squatting, hands and knees, etc. We two different types of birth stools available. After birth, the baby typically goes directly into your arms unless he or she needs help with breathing or has other complications. We support skin-to-skin bonding time and on-demand breastfeeding. The baby will usually get weighed and thoroughly examined at around two hours old. Your nurse will also give baby a Vitamin K injection in the leg and antibiotic ointment in their eyes. There are some routine procedures and screening tests done for babies before they go home. These include:  Hepatitis B vaccine  Congenital cardiac defect screening (uses a non-invasive red light probe to measure oxygen saturation on baby’s wrist and foot) is done at 24 hours old.  Screening for congenital metabolic disorders (we poke baby’s heel to collect a small amount of blood to test for PKU and other metabolic disorders—more information is available at www.doh.wa.gov/YouandYourFamily/InfantsandChildren/NewbornScreening)  Hearing screen to identify babies born with little or no hearing  Jaundice screening (blood draw for bilirubin level) is done at 24 hours old. Some amount of jaundice may be normal, but some babies could get dangerously high bilirubin levels and we can prevent harm by doing this screening test. We recommend you let baby spend lots of time skin-to-skin in the first days and let them breastfeed on demand as often as they want for as long as they want. Do not give them any pacifiers, bottles, or formula unless there are medical complications that prevent baby from breastfeeding exclusively. The nurses, lactation specialists, and midwives will help you if you have difficulties latching baby or discomfort or pain with breastfeeding. If for any reason you are unable, or prefer not, to breastfeed, we have infant formula available and can help you with learning to bottle feed your baby. You and your baby will likely go home around 24-36 hours after a vaginal birth, or about 48 hours or so after a C-section, unless there are complications in your recovery. If baby has an increased risk for infection, due to prolonged rupture of membranes or untreated GBS, for example, you may need to stay 48 hours.

Your Birth plan

In order for you to have a safe and fulfilling birth experience, we would like to know your preferences and to discuss with you any concerns, hospital policies, or anything else that may affect your labor and birth. Since birth cannot be totally controlled or predicted, part of our role is to support you and help you think of alternatives if things don't go as planned. This is a guide for some important things to discuss with us.

 Who will be your main support?

 Who is invited to be present in the room for the birth?

 Who would you like to cut the cord?

 Is it important to you to delay cord clamping/cutting?

 Are you planning cord blood banking or donation?

 Do you want to take your placenta home?

 Do you want the baby placed immediately on your abdomen/chest?

 Who will be your baby’s pediatric provider after you leave the hospital?

There are many ways to cope with labor. Please share with us what you are currently planning to use:

 Relaxation, breathing, positions, movement, or other low-tech comfort measures

 Do you plan to try the tub?

 Hypnobirthing or other specific labor preparation program

 Medications/anesthesia only at your request? Or offer it as soon as possible?

 How committed are you to avoiding an epidural? What else is it important that we know about you and your birth?

Birth doulas

Questions to ask when interviewing a prospective doula:

 What training have you had?

 Do you have one or more backup doulas for times when you are not available? If so, ss it possible to meet with them?

 What is your fee? What does it include and what are your refund policies?

 Tell me about your experience as a birth doula. What is your philosophy about birth and supporting people through labor? Is it possible to meet to discuss my birth plan and the role you will play in supporting me through birth? May I call you with questions or concerns before or after the birth?

 When do you join me in labor? Do you come to my home or meet me at the birth location? How often and when do we meet after the birth to review the labor and answer questions? Once you have talked to a few doulas on the phone, it is a good idea to meet at least two of them for an in-person interview. This is an opportunity for you to see how you feel in the doula’s presence and to ask more questions. Since doulas support both the pregnant person and her partner (if applicable), it is strongly recommended that both of you attend the interviews. When you meet with a doula at an interview, pay attention to how well they listen, how well they communicate, their comfort with you and your birth choices, and their level of knowledge and experience. Note that the doula with whom you feel most comfortable may be able to offer you more support than the doula with the most experience.

This website can help you find a doula for your birth: www.palsdoulas.org We have a list and cards for some of our favorite doulas at the patient resource table in our clinic.

Vitamin K and the newborn

Vitamin K is a vital nutrient that our body needs for blood to clot (which helps us to stop bleeding). We get vitamin K from the food we eat. Some vitamin K is also made by the good bacteria that live in our intestines. Babies have very little vitamin K in their bodies at birth because:

 Vitamin K from the mom is not easily shared with the developing baby during the pregnancy

 The intestine of the newborn baby typically does not have enough bacteria to make the smount of vitamin K the baby will need. Without enough vitamin K, blood may not clot well. As a result, bleeding can occur anywhere in the body. This means not only that bleeding from a cut or bruise may continue for a long time, but that un- controlled bleeding into the brain and other organs may occur. Vitamin K deficiency bleeding (VKDB) is a condition that occurs when a baby does not have enough Vitamin K. Without enough vitamin K, your baby has a chance of bleeding into his or her intestines and/or brain, which can lead to brain damage and even death. VKDB is a rare complication, occurring in 2.5-17 cases per 1,000 newborns, but it is very serious and can even be fatal. Infants who do not receive the vitamin K shot at birth can develop VKDB in the first days or weeks or up to 6 months of age. Infants who have classic VKDB are often ill, have delayed feeding, or both. Bleeding commonly occurs in the umbilicus, GI tract (ie, melena), skin, nose, surgical sites (ie, circumcision), and, uncom- monly, in the brain. Some parents decline the vitamin K shot and you are within your rights to do so, but you need to know that the single of vitamin K shot at birth can prevent this potentially dangerous bleeding.

CORD BLOOD options What is cord blood? Cord blood is the blood remaining in the cord and placenta after your baby is born. This blood is often discarded with the placenta, but cord blood is special in that it contains a substantial number of pluripo- tent stem cells (cells that can develop into any type of mature human cell). Stem cells can be used to treat a variety of illnesses. How is cord blood collected? While waiting for the placenta to be delivered, the midwife cleans off the cord, then collects the blood from the umbilical cord into a special collection bag. The collection process is painless, risk-free, and will not interfere with immediate mother-baby bonding. If you wish, you can still take your placenta home. Why donate cord blood? Your baby’s donated cord blood could save a life! Cord blood is rich in stem cells that generate all of the blood cells and immune system cells needed in a human body. Cord blood stem cells can be used to treat cancers such as leukemia and blood disorders such as sickle cell anemia. Patients are less likely to reject stem cells from cord blood than stem cells from donated adult bone marrow. cord blood options? At Northwest Hospital, there are three options for your umbilical cord blood:  Donate to a cord blood bank for public use. The donated blood would not be guaranteed to be available for your family. There is no cost. We collect donations through BloodWorks Northwest. You can print their online donation form and bring it to the hospital with you.  Discard the cord blood along with the placenta  Bank the cord blood through a private service for the exclusive use of your family. This would involve a setup fee and annual maintenance fee, which can be quite expensive. If you plan to do private cord blood banking, we will do our best to collect the blood at the birth for you. What about delayed cord clamping? There are known benefits to delaying the clamping and cutting of the umbilical cord, particularly for preterm babies. For this reason, and to support physiologic birth, the Northwest Hospital Midwives typically delay clamping and cutting the cord. In certain unusual situations, such as if baby is in need of immediate resuscitation, we will cut the cord quickly. When clamping is delayed, the cord keeps pulsing with the baby’s heartbeat as baby transitions to breathing. During the first minute or so, an average of 100 ml of net blood flow will move from the placenta to the baby. As far as we know, most of the benefit occurs in the first minute. The longer we wait to collect cord blood, the less likely we are to get an adequate sample because the blood starts to clot. Therefore, if donating is important to you, we recommend clamping the cord at about 1 minute after birth. Many families request the cord not be clamped until it stops pulsing, which may take 5-10 minutes or more. Please know that in such cases we are unlikely to get an adequate sample for donation or banking.

GROUP BETA STREP (GBS) TESTING

GBS is a bacteria commonly found in the digestive system and the vagina. In healthy adults, GBS is not harmful and does not cause problems. But pregnant women and newborn infants who become infected with GBS can experience serious illness. Approximately 30% of pregnant women in the U.S. carry GBS in their gastrointestinal system and/or in their vagina. Carrying GBS is not the same as being infected with GBS. Carriers are not sick and do not need treatment during pregnancy. There is no treatment that can stop you from carrying GBS. Pregnant women who are carriers of GBS infrequently become infected with GBS. GBS can cause urinary tract infections, infection of the amniotic fluid (bag of water), and infection of the uterus after delivery. GBS infections during pregnancy may lead to preterm labor. Pregnant women who carry GBS can pass on the bacteria to their newborns, and some of those babies become infected with GBS. Newborns who are infected with GBS can develop pneumonia (lung infection), septicemia (blood infection), or meningitis (infection of the lining of the brain and spinal cord). These complications can be prevented by giving intravenous antibiotics during labor to any woman who is at risk of GBS infection. You are at risk of GBS infection if:

 You have a urine culture during your current pregnancy showing presence of GBS

 You have a vaginal and rectal culture during your current pregnancy showing GBS

 You had previous baby who was infected with GBS We will do a vaginal/rectal swab to culture for GBS at 36-37 weeks of pregnancy. If your GBS test is positive, you will be given an intravenous antibiotic during labor (usually penicillin). Being treated with an antibiotic during labor greatly reduces the chance that you or your newborn will get sick with early onset GBS infection. It is important to note that young infants up to three months old can also develop septicemia, meningitis, and other serious infections from GBS. Being treated with an antibiotic during labor does not reduce the chance that your baby will develop this later type of infection. There is currently no known way of preventing this later-onset GBS disease.

PERINEAL MASSAGE IN PREGNANCY What Is My “Perineum”? Your perineum is the area between your vaginal opening and your rectum. This area stretches a lot during childbirth, and sometimes it tears and needs to be stitched. Episiotomy is when a cut is made to the perineum during delivery. We hardly ever do this procedure because it is only necessary in rare circumstances. How often do tears (aka lacerations) occur? On average about 65% women who give birth vagi- nally with us have some type of tear and most of these need stitches. The stiches dissolve on their own without needing to be removed. Some factors that increase your risk of tearing are if you push a very long time and your tissue is very swollen OR if your baby comes out super-fast or is particularly large. First time moms are also a little more likely to tear. How can I Avoid a Tear? Good nutrition and exercise, including Kegels, help your tissue be as healthy as possible so that it can stretch the way it is designed to do. Things that your midwives do to help avoid or minimize tearing include encouraging you deliver your baby’s head slowly during crowning (when the widest part of the head is coming out), by gently pushing or breathing the baby out. Birthing in a side- lying or hands-knees positions can also help. Several studies have found that perineal massage during the last weeks of pregnancy can reduce tearing at birth, particularly for women 30 years or older having their first baby. Can My Partner Help? Yes! Many women find that it is easier to have their partners do this massage, but it must be your choice. If you want your partner to do the massage, make sure it is a pleasant interac- tion and that the pregnant woman receiving the massage is always in control. Are There Any Risks to Perineal Massage During Pregnancy? Not that we know of. It is free. It doesn’t hurt. It is easy to do. And most women don’t mind doing it. However, if you believe your bag of waters is leaking, check with a midwife before putting anything in your vagina.

INSTRUCTIONS FOR PERINEAL MASSAGE DURING PREGNANCY If you wish to use perineal massage, begin 6 weeks before your due date and follow these suggestions: Wash your hands well, and keep your fingernails short. Relax in a private place with your knees bent. Some women like to lean on pillows for back support.

 Lubricate your thumbs and the perineal tissues. Use a lubricant such as vitamin E oil or almond oil, or any vegetable oil used for cooking—like olive oil. You may also try a water-soluble jelly, such as K-Y jelly, or your body’s natural vaginal lubricant. Do not use baby oil, mineral oil, or petroleum jelly.

 Place your thumbs about 1 to 1.5 inches inside your vagina (see figure). Press down (toward the anus) and to the sides until you feel a slight burning, stretching sensation. Hold that position for 1 or 2 minutes.

 With your thumbs, slowly massage the lower half of the vagina using a “U” shaped movement. Con- centrate on relaxing your muscles. This is a good time to practice slow, deep breathing techniques.

 Massage your perineal area slowly for 10 minutes each day. After 1 to 2 weeks, you should notice more stretchiness and less burning in your perineum.

 Partners: If your partner is doing the perineal massage, follow the same basic instructions, above. However, your partner should use his or her index fingers to do the massage (instead of thumbs). The same side-to-side, U-shaped, downward pressure method should be

 If you choose to have your partner do massage, you should both try to have fun with it and avoid painful or uncomfortable sensations. Also make sure that the pregnant woman is in control and can choose to stop the practice at any time.

After your baby’s birth Postpartum recovery and newborn care

Postpartum care at home

Rest and recovery In the first days at home, we recommend you spend most of your time lying around, resting, sleeping, and feeding your baby. Postpartum depression is unheard of in cultures where the birth mother lies in bed and is waited on for the first month. Postpartum depression is much less likely in women who sleep when their baby sleeps. Enlist family, friends, church members, etc. to help you out at home. You should not being doing any housework for the first two weeks. As you feel ready, you can slowly increase your activity, but listen to your body and do not go too fast. Most women are not fully recovered physically until six weeks postpartum.

Perineal care After your baby’s birth, you may need stitches in the skin near your vagina from a laceration (tearing). These stitches should dissolve within two weeks. Until then, here are some tips to ease any discomfort and aid healing.

Keep clean  You can reduce your risk of infection by keeping the area around the stitches clean. These hints can help:  Gently wipe from front to back after you urinate or have a bowel movement.  After wiping, spray warm water on the stitches. Pat dry. If you are too sore, just spray the area after urination and then pat dry without wiping.  Do not use soap or any solution except water unless instructed by your healthcare provider.  Change sanitary pads at least every 2 to 4 hours.

Eat to stay regular  Having bowel movements is easier if you’re not constipated. Follow these tips:  Eat fresh fruit and vegetables, whole grains, and bran cereals.  Drink plenty of water.  Don’t strain to have a bowel movement. Use a stool softener if needed, but healthy diet and water intake are the best ways to keep stools soft.

Reduce your discomfort  Sit in a warm bath (sitz bath) 1-3 times a day  Place cold or heat packs on your stitches. Keep a thin towel between the pack and your skin.  Sit on a firm seat so the stitches pull less.  Use topical cream if prescribed, as needed  You can also try applying medical grade wound honey

Postpartum visits & warning signs

We usually want see our new moms in clinic at two weeks postpartum for a check in to see how things are going, and then at six weeks postpartum for a full exam and to plan for contraception, if needed. Experienced mothers without any high-risk conditions can skip the two-week visit and just be seen at six weeks. If you have high blood pressure or other concerns, we might need to see you at one week or sooner. The midwife who discharges you from the hospital will make a specific plan for you. Call the Midwives Clinic (206) 668-6670 right away if you have any of the following:  A fever of 100.4°F (38.0°C) or higher  Bleeding that requires a new sanitary pad after an hour, or large blood clots  Pain in your vagina that gets worse and isn't relieved with medicine  Swelling, discharge, or increased pain from vaginal tear or episiotomy  Burning, pain, red streaks, or lumpy areas in your breasts that may be accompanied by flu-like symptoms  Cracks, blisters, or blood on your nipples  Burning or pain when you urinate  Nausea or vomiting  Dizziness or fainting  Feelings of extreme sadness or anxiety, or a feeling that you don’t want to be with your baby  Any pain that isn’t relieved with medicine  Vaginal discharge that has a bad odor  No bowel movement for 5 days  Painful urination  Redness, warmth, or pain in the lower leg  Chest pain  Feeling sick or unwell or that something may be wrong

Benefits of Breastfeeding

Breastfeeding offers an unmatched beginning for children. Providing infants with human milk gives them the most complete nutrition possible. Human milk provides the optimal mix of nutrients and antibodies necessary for each baby to thrive. Scientific studies have shown us that breastfed children have far fewer and less serious illnesses than those who never receive breast milk, including a reduced risk of SIDS, childhood cancers, and diabetes (as child or adult). Research also shows that breastfed babies have higher IQ scores, as well as better brain and nervous system development.

Mothers who breastfeed are healthier Recent studies show that women who breastfeed enjoy decreased risks of breast and ovarian cancer, anemia, and osteoporosis. They are empowered by their ability to provide complete nourishment for their babies. Both mother and baby enjoy the emotional benefits of the very special and close relationship formed through breastfeeding.

Families who breastfeed save money In addition to the fact that breast milk is free, breastfeeding provides savings on health care costs and related time lost to care for sick children. Because breastfeeding saves money, the family feel less financial pressure and take pride in knowing they are able to give their babies the very best.

Communities reap the benefits of breastfeeding Research shows that there is less absenteeism from work among breastfeeding families. Resources used to feed those in need can be stretched further when mothers choose to give their babies the gift of their own milk rather than a costly artificial substitute. Less tax money is required to provide assistance to properly feed children. Families who breastfeed have more money available to purchase goods and services, thereby benefiting the local economy. When babies are breastfed, both mother and baby are healthier throughout their lives.

The environment benefits when babies are breastfed Scientists agree that breast milk is still the very best way to nourish babies, and may even protect babies from some of the effects of pollution. Breastfeeding uses none of the tin, paper, plastic, or energy necessary for preparing, packaging, and transporting artificial baby milks. Since there is no waste in breastfeeding, each breastfed baby cuts down on pollution and garbage disposal problems. (adapted from Baby Friendly USA website)

The best start to Breastfeeding for you & baby

Importance of skin to skin for first hour Mother-baby kin to skin contact immediately after birth, which lasts for at least an hour (and should continue for as many hours as possible throughout the day and night for the first number of weeks) has the following positive effects. The baby:  Is more likely to latch on well for breastfeeding  Maintains his or her body temperature better  Maintains his or her heart rate, respiratory rate, and blood pressure better  Has higher blood sugar  Is less likely to cry  Is more likely to breastfeed exclusively and breastfeed longer  Will indicate to his mother when he or she is ready to feed There is no reason that the vast majority of babies cannot be skin to skin with the mother immediately after birth for at least an hour. Hospital routines, such as weighing the baby, can be safely delayed for one to two hours. Importance of family-centered care At Northwest Hospital, we provide family-centered care. Your baby will stay with you throughout your time in the hospital. This allows you to be close with your baby, learn to care for your baby and read his/ her cues. We have a nursery available if your baby has any medical issues, but otherwise all the care for your baby will occur in your room. Feeding baby on demand: signs of being ready to eat Your baby will give you cues about when he/she is ready to eat. Offer the breast when baby starts root- ing, sticking out his or her tongue, opening his or her mouth, sucking on the hand---even if baby still ap- pear sleepy. Feed your baby as often as he/she wants for as long as he/she wants. Do not give your baby anything other than the breast (unless you have a specific provider-prescribed feeding plan). Your baby should be going to the breast AT LEAST every three hours. Newborns typically feed every one to three hours, or 8-12 times in 24 hours. Many babies will “cluster feed” almost continuously for a few hours and then sleep for 2-3 hours. The new mother needs to SLEEP WHEN THE BABY SLEEPS!

Importance of good positioning and latch To help baby to get the best latch on the breast, turn the baby tummy to tummy with you. This allows baby to face the breast easily. Wait for baby to open his/her mouth very wide. Bring baby to your breast. With a good latch, the mouth will be wide with lips curled open and most of the areola (dark part around the nipple) will be in baby’s mouth. A good latch will decrease the chance of sore nipples and help the baby get the most milk each feeding.

Risks of feeding baby anything besides breastmilk Breastfeeding is based on supply and demand. When the baby sucks, you will make milk. IF you feed the baby any other substance (formula, water, sugar water) it can lead to the baby not feeding on a normal pattern and your milk supply could decrease in amount. Breastmilk has the perfect nutrition for baby. Babies will grow while drinking formula but breast milk has the best nutrition. Water and sugar water do not have enough nutrition and are not needed. If your pediatric provider advises you to start using formula, please ask about the safe method for preparing formula and bottle feeding.

How long to breastfeed It is best if baby receives only breast milk until six months of age. Your baby's provider will advise you about starting solid foods after that time. In addition to the solid foods, the American Academy of Pediat- rics recommends that your baby breastfeed for a year. Breastfeeding beyond the first year continues to provide nutrition and benefits to baby. The World Health Organization recommends two years of breastfeeding.

BREASTFEEDING Resources You can find some great web resources about breastfeeding on the Health Resources portion of our webpage: www.nwhospital.org/locations/midwives-clinic/

Breastfeeding positions

tips for postpartum breast care

Coping with swelling Here are tips to cope with swelling:  Use cold compresses or an ice pack to help reduce the ache or pain.  Breastfeed often to keep milk from clogging your breast ducts.  If your nipples are flat from breast swelling, hand express some milk. Squeeze out a few drops of milk by massaging and compressing your breasts.

 If you have swelling with pain or fever, call your healthcare provider. Preventing sore nipples  Make sure baby latches on to your breast correctly. The baby’s mouth should be opened very wide and your entire areola should be in the baby's mouth.  You can let milk dry on your nipples. This dried milk can protect the skin on your nipple.  Do not use alcohol, soap, or scented cleansers on your breasts. These can cause the nipples to dry and crack.  Do not wear nursing pads that are lined with plastic. They hold in moisture and can cause chap- ping.  If you have cracked or bleeding or painful nipples, consult the midwives or a lactation consult- ant. He or she will make sure that your baby's latch is correct and may suggest topical treatment Choosing a good bra Wearing the right-sized bra is especially important now. If a bra is too tight, it may cause a duct in your breast to clog and become irritated. If possible, have a salesperson help fit you for a new bra. Look for one that’s 100% cotton and comfortable. Also, choose a bra with wide straps that won’t dig into your back and shoulders. If you’re breastfeeding, find a nursing bra that allows you to uncover one breast at a time. If you are not breastfeeding Here are tips to avoid discomfort:  Avoid stimulation of nipples  Wear a tight-fitting bra  Apply cold compresses or ice packs for discomfort

Postpartum mood problems

The first weeks of caring for a newborn baby are more than a full-time job. Although it is often a happy time, your feelings and moods may not be what you expected. Many women experience “baby blues.” Here are some tips to help you understand when feelings of sadness are normal, and when you should call your health care provider. What are the baby blues? As many as three of every four women will have short periods of mood swings, crying, or feeling cranky or restless during the first weeks after birth. These feelings can be worse when you are tired or anxious. Women who have the “baby blues” often say they feel like crying but don’t know why. Baby blues usually happen in the first or second week postpartum (after you give birth) and last less than a week. If you are not sleeping, becoming more upset, don’t feel like you can take care of your baby, or your sadness lasts two weeks or more, you should call and speak to a midwife. What is postpartum depression/postpartum mood disorder? About one in every five women will develop depression and/or anxiety during the first few months postpartum that may be mild, moderate, or severe. Women who have postpartum mood disorder may have some of these symptoms:

 Feeling guilty  Not being able to enjoy your baby and feeling like you are not bonding with your baby  Not being able to sleep, even when the baby is sleeping  Sleeping too much and feeling too tired to get out of bed  Feeling overwhelmed and not able to do what you need to during the day  Not being able to concentrate  Feeling anxious, agitated, or nervous a lot of the time  Not feeling like eating  Feeling like you are not normal or not yourself anymore  Not being able to make decisions  Feeling like a failure as a mother  Feeling lonely or all alone  Thinking your baby might be better off without you

If you have any of these symptoms, please call us: (206) 668-6670

Postpartum mood problems

Which symptoms of postpartum depression are dangerous? Sometimes a woman with postpartum depression will have thoughts of harming herself or her baby. If you find yourself thinking about hurting yourself or your baby, call us immediately.

What is postpartum psychosis? Postpartum psychosis is a rare severe form of mental illness that begins during the postpartum period. Women who have postpartum psychosis may hear or see things that are not really there, and they act strangely. This may only be noted by a family member. Women who have postpartum psychosis may think that the baby is being harmed even if the baby is not in danger. This is a true emergency as this woman may hurt herself or hurt her baby. If you have thoughts of wanting to hurt yourself or your baby, call 911 and have someone you trust stay with you until help arrives.

Who is likely to have postpartum depression? Postpartum depression can happen to any woman after giving birth. The exact cause is probably fa combination of factors, including hormone changes after birth that can affect how the brain works. Women with a personal history of anxiety or depression (even times of just feeling low) or stressful life events, or with a family history of depression are more likely to have postpartum depression. If you think that any of these risks apply to you, talk with a midwife before your labor and birth. Planning ahead can help prevent problems that occur during depression after birth. Sleep is extremely important for preventing postpartum mood problems. We recommend that you sleep whenever your baby sleeps, especially in the first several days home after the birth.

What will help me if I have postpartum depression? Eating well  Women who are depressed after birth often don’t feel like eating or making meals. The body needs good food to heal, so every effort should be made to eat well. Your family and friends can help you by providing fresh, healthy meals.  A multi vitamin and Omega-3 supplement will provide some of your basic needs for vitamins.  Fluids are important for your health and for breastfeeding. Drinking 8 to 10 glasses of water every day will help both you and your baby.  Don’t drink alcohol because it can make postpartum depression worse.

Postpartum mood problems

What will help me if I have postpartum depression? Understanding  Women who are depressed after having a baby feel like their world has come to an end and often feel very guilty and a shamed. If you have such feelings, this is not your fault.  It is important for your family and friends to understand that postpartum depression can happen to anyone.  Your midwife or other provider and a mental health therapist can help you cope with the depression and get better.  Support groups or group activities help some women. Other women who have had postpartum depression understand what you are going through. Our website’s Health Resources page lists some local postpartum support groups: www.nwhospital.org/locations/midwives-clinic/ Rest

 Sleep is very important for health and healing. Most women with postpartum depression have a hard time sleeping. We recommend that you plan to sleep whenever the baby sleeps, especially in the early days at home.  Try different things to help yourself sleep, such as a warm bath before bedtime, massage, relaxation techniques, or meditation.  Call for help if you go without sleep for more than two days.

 Try to think of things that made you happy in the past

 Try to do something that made you happy before you had postpartum depression, such as practicing your faith or religion, listening to music, going out with a friend, or exercising. Exercise

 Exercise helps your brain work and produces hormones that help you feel better.  Take small steps to increase your activity regularly. Family and friends can help with short walks or take care of your baby while you exercise.

For More Information about postpartum depression and some good resources, go to the website for Perinatal Support of Washington State: www.perinatalsupport.org

Pelvic floor exercises

Kegel exercises can help your pelvic floor muscle tone after pregnancy. Healthy pelvic floor muscle tone can help prevent (or treat) urinary incontinence and improves your sexual function. Kegel exercises can be done any time you are sitting or lying down. You can do them when you are eating, sitting at your desk, driving, and when you are resting or watching television.

How to Find the Right Muscles A Kegel exercise is like pretending you have to urinate and then holding it. You relax and tighten the muscles that control urine flow. It’s important to find the right muscles to tighten. Next time you have to urinate, start to go and then stop. Feel the muscles in your vagina, bladder, or anus get tight and move up. These are the pelvic floor muscles. If you feel them tighten, you’ve done the exercise right. Picture your pelvic floor slowly rising up into your pelvis, then slowly releasing down. If you still are not sure you are tightening the right muscles, insert a finger into your vagina. Tighten the muscles as if you are holding in your urine, then let go. You should feel the muscles tighten and move up and then down.

How to do Kegel Exercises Once you know what the movement feels like, do Kegel exercises three times a day:

 Make sure your bladder is empty, then sit or lie down.  Tighten the pelvic floor muscles. Hold tight and count to 6 to 8.  Relax the muscles and count to 10.  Repeat 10 times, three times a day (morning, afternoon, and night). Breathe deeply, and relax your body when you are doing these exercises. Make sure you are not tightening your stomach, thigh, buttock, or chest muscles. After four to six weeks, you should feel better and have fewer symptoms. Keep doing the exercises, but do not increase the number you do. Overdoing it can lead to straining when you urinate or move your bowels. Once you learn how to do them, do not practice Kegel exercises at the same time you are urinating more than twice a month. Doing the exercises while you are urinating can weaken your pelvic floor muscles over time.

Your Abdomen Postpartum: Diastasis Recti During pregnancy, your abdominal muscles (rectus abdominus, pictured here) stretch apart to accommodate your growing baby. After birth, the muscles don't always bounce back, leaving a gap called diastasis recti (sometimes referred to as the “mommy pooch”).

There's a simple way to see whether you have diastasis recti: 1. Lie flat on your back with your knees bent. 2. Put your fingers right above your belly button and press down gently. 3. Then lift up your head about an inch while keeping your shoulders on the ground. If you have diastasis recti, you will feel a gap between the muscles that is wider than an inch.

There are a few patented programs designed to help women bring the separation back together. Most recommend that you NOT do sit-ups or crunches until the muscles have come back together. Likewise AVOID exercises that twist your torso (no bicycle or crossover crunches). Instead, choose gentle core- strengthening exercises to train these muscles back together, closing the gap. With hands on your belly, slowly pull your abdomen in toward your spine as you slowly exhale, then hold it while you breath. You can also join a postpartum yoga or exercise class.

(206) 668-6670