Chapter Two - The Second Trimester

(14 to 28 Weeks)

When you reach 16 weeks, your baby weighs about 6 ounces and is 6 to 8 inches long. All major organs, such as the heart and lungs, are formed, but they are not mature. If you could see inside the uterus, you could easily tell the baby’s gender (a boy or a girl).

By 20 weeks, your baby weighs close to one pound and is 8 to 12 inches long. His/her body is covered with very fine hair called lanugo. Around 20 weeks, you will start to feel your baby move, which is initially a "fluttering" feeling in your lower belly. Be sure to note the day you first notice this. If this is your second or third baby, you might notice those little flutters a few weeks sooner because it is a lot easier to recognize movement when you’ve felt it before.

By 28 weeks, your baby is about 15 inches long and weighs 1 1/2 to 2 pounds. She/he is fully formed but not ready to come out. His/her skin is wrinkled and covered with vernix, a white sticky covering that protects the baby’s skin while in utero.

Most mothers feel well during the second trimester of pregnancy. Nausea is usually gone and appetite and energy return. If you are planning any trips during your pregnancy, this is a good time to travel.

Your metabolism is speeding up to take care of you and your baby, and you may notice your heart beating faster or that you sweat a lot. If you exercise, try to keep your heart rate at 150 beats or less. Since your heart is beating faster, it won’t take you as long to get your heart rate up, so be sure and check it during exercise.

Pregnancy hormones cause an increase in vaginal discharge. This is normal, but if you notice itching or a watery or greenish discharge, be sure to tell your provider. This could mean you have an infection or that you have ruptured your membranes (broke your bag of water).

By 20 weeks, your uterus will be at the level of your umbilicus (belly button). You might notice occasional tightening or contraction of your uterus, known as Braxton Hicks contractions. This is normal, but if the contractions start coming every 5 to 10 minutes for more than an hour or two, you need to notify your provider who will assess you regarding premature labor.

By this point in pregnancy, most women have gained about ten pounds.

Sex starts a pregnancy but pregnancy does not mean the end of sex! Intercourse can be enjoyed throughout the pregnancy, unless you develop a medical condition that precludes it. Making love during pregnancy is a special experience and includes ways to share pleasure and feel close with or without intercourse. Expectant couples often have questions about sex. Talking with each other is the key to a good sexual relationship, and it is important to share your feelings. Here are answers to some common questions:

No. While inside you, the baby is protected by a membrane (bag of water) and fluid as well as by the abdominal wall and the bony pelvis. Sex during pregnancy is safe unless your provider has advised against it due to a pregnancy complication.

Your desire for sex may increase or decrease during pregnancy. It is normal for feelings to vary a great deal due to hormonal and body changes in pregnancy. Physical changes include more blood flowing to the pelvis, which can intensify sexual feelings. The growing belly may get in the way and partners may need to try different positions.

Both partners need to adjust to these changes. While a woman can feel changes going on inside and outside, a partner can often only guess at how she feels. Many pregnant women feel the need for more affection and need to know they still look nice and are loved. Talk about your feelings with your partner. Sharing your feelings and concerns will help you meet each other’s needs.

No, it is not harmful to experience orgasm during pregnancy. If sexual activity and orgasm increase pelvic tension or even cause contractions to occur, the body will relax after an hour or so.

• Protect your baby and yourself from AIDS. Always have safe sex!
• Some sexually transmitted disease (STD’s) can be passed to your baby. If you think you have a STD, call your provider to be seen and evaluated.
• Taking drugs or alcohol to increase sexual feelings can cause serious damage to the unborn baby.
• Take care that bacteria from the rectum do not enter the vagina. This can cause infection. Bacteria from the rectum can pass to the vagina by anal intercourse.

One way to know that your baby is healthy is by his/her kicking or moving on a regular basis. You probably first felt your baby move between the 17th and 20th weeks of your pregnancy. By now, you should be aware of your baby’s kick pattern. Some babies move more in the morning or evening, while others kick throughout the day. This kicking movement should continue until your baby is born. In general, babies should move at least ten times a day.

If you feel your baby is moving less than usual, one way to reassure yourself that everything is o.k. is to do a fetal kick count. Lie down on your left side, have something sweet to drink, then count your baby’s movements.

If your baby does not move five times in an hour, he/she may be sleeping so try again in one to two hours. If the baby is still not moving five times in an hour, call the Family Medicine Center at 966-0212 and speak to a HealthLink nurse.

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Premature labor (also called preterm labor) is labor that starts before 37 weeks of pregnancy or more than three weeks before your due date. Premature labor can often be stopped if it is caught early.

• Uterine Contractions If you feel your uterus tightening or the baby "balling up" four times or more in an hour, you might be in labor.
• Menstrual-like Cramps These feel like you’re having your period. They may come and go or remain constant.
• Abdominal Cramps These are stomach cramps with or without diarrhea.
• Low Backache Back pain can be a warning sign of premature labor.
• Pelvic Pressure This feels like the baby is pushing down in your vagina.
• Change in Vaginal Discharge You may notice an increase in your discharge, or that it becomes more mucousy, watery, or slightly bloody.

1) Lie down on your left side

2) Drink two to three glasses of water or juice

If these symptoms are not gone in one hour, call the clinic right away for further instructions.

Dizziness Pregnant women often notice dizziness or lightheadedness when they get up quickly, change positions, skip meals, or stay in the heat too long. To avoid this, change your position slowly, eat regular meals, and avoid prolonged exposure to the sun. If you stand or sit all day at work, try to change positions every hour, even if it is only for five minutes. Wear low-heeled, comfortable shoes since pregnancy can also affect your balance.

Skin Changes You may develop acne because your body’s sweat glands are stimulated by the pregnancy hormones. You may also notice changes in the coloring and pigmentation of your skin. Be careful in the sun, because your skin may be more sensitive. Let your provider know if any moles change.

Heartburn If you have heartburn, try eating four to five small meals a day and drinking fluids between meals. Antacids like Maalox, Mylanta, Tums, etc. can be helpful.

Back Pain, both upper and lower, is a common complaint in pregnancy. Maintaining good posture is important. Exercises can help relieve the discomfort as well. The "angry cat" position (get on all fours and rock you pelvis, described on page 7) can provide some relief.

Swelling in the hand and wrist area can cause pressure on the nerves, known as carpal tunnel syndrome. It may be worse in the morning. Hold your hands above your head and move your wrists around. Be sure to maintain good posture through the shoulders, too.

The round ligaments that support the uterus start to stretch significantly in the second trimester, often causing pain on either side of the pelvis. Try not to stand too long and try to stretch this area.

Stretch your calves by standing with your toes on a step and dropping your heels downward until you feel your calves stretch. Warm soaks can help, too.

Chapter Three - The Third Trimester

(28-40 weeks)

It is now time to start getting ready for the baby. If you haven’t registered for childbirth classes, do it now! All parents benefit from classes, whether they are choosing "natural" childbirth or not. There is a listing of local childbirth classes in the back of this workbook. If you have any questions about classes, please talk with your health care provider. You should also start think about decisions you’ll make after the baby arrives. You need, for example, to think about birth control. If you are planning to have your "tubes tied" after delivery and you have Medicaid/Baby Love, you need to sign a surgery consent form by 34 weeks. If you’re going back to work, now is also a good time to think about who will take care of your baby.

Did you know your baby can now suck its thumb? By the end of your 36th week, your baby will weigh about 5 1/2 pounds and be 18 inches long. Your partner and friends can try to hear the baby’s heartbeat by putting their ear on your abdomen.

During these last weeks, the fetal organs continue to mature to prepare your baby for life outside the uterus. The fetus also adds fat and gains weight. At birth, the average baby weighs seven and a half pounds and is 20 inches in length. Your baby’s skin is less wrinkled, the fine hair (lanugo) is mostly gone, and the vernix is thick. By 37 weeks, the fetus may move down into the pelvis, called "dropping."

As your body adjusts to the growing baby, you will probably start to notice a little more tugging and pulling. If this is your second or third baby, you may feel these discomforts sooner. Most mothers, especially in the summer, will notice swelling in their feet. Be sure to drink lots of water, cut down on salt (not just salty foods like chips but canned and frozen foods) and put your feet up. Pre-eclampsia is a condition that can develop in the third trimester. Symptoms include severe swelling of the hands and face, high blood pressure, and protein in the urine. Be sure to let your health care provider know if you develop significant swelling, a headache that is unrelieved with Tylenol, spots in front of your eyes, or pain in your upper belly.

By 36 weeks, the uterus is just below the breastbone and ribs. Amniotic fluid volume is decreasing. About 3 weeks before the birth, your profile may change, as the fetus descends into the pelvic cavity (this is called engagement, dropping or lightening). You may feel less pressure on your diaphragm and find it easier to breathe and eat. After the baby drops, you may feel an increased need to urinate. Your cervix begins to thin out (efface) and open (dilate) during the last weeks of pregnancy. Toward the end of your pregnancy, the uterine contractions become more obvious and more frequent.

If you have chosen to breastfeed, the first step is to become familiar with your breasts. Look at yourself in the mirror, keeping in mind that while the size and shape of breasts and nipples vary from woman to woman, these factors have virtually no effect on your ability to produce enough milk for your baby. You may notice that your breasts are larger now and possibly more tender than they were before pregnancy. Colostrum, which begins to collect in your breast during the middle of pregnancy, may leak from your breasts or appear as a dried crust on your nipples. The Montgomery glands (the small bumps on your areolae (the dark area around the nipple)) are also larger. Notice the shape and size of your nipples. Do they point out or in? If they are flat or inverted (dimpled), there may be some things you can do to help. Talk to your provider or our prenatal nurse if you have concerns.

Conditioning or toughening your nipples to prevent soreness has not been shown to be effective, but learning about breastfeeding before your baby is born is helpful.

You may be interested in taking a breastfeeding class or reading a book on breastfeeding, particularly if no one among your family and friends has successfully breastfed. UNC Hospitals offers a breastfeeding class (call 966-7890 for more information). Consider bringing your partner or other support people with you to the class so they can learn how to support and help you.

The first few weeks after birth require time to rest and feed your baby as you and your baby learn how to breastfeed. Try to identify friends or family who can help with cooking and caring for other children. Try to think of someone who breastfed their baby who you can call if you have questions.

Even though the birth of a baby is wonderful, it also is demanding and exhausting, and many new mothers feel overwhelmed. Additionally, your hormones are changing. This causes most new mothers to have feelings of unexpected sadness, often accompanied by crying. This is often called the "baby blues."

Think about who will be there to support you during this time. You will need help! Allow friends and family to cook, clean, run errands, and anything else you need so that you can rest and focus on the baby.

The "baby blues" are usually a temporary state, lasting less than a week. If the sad feelings persist longer, please call us.

Group B streptococci (GBS) are bacteria that can cause illness in pregnant women and their newborn babies. During pregnancy, GBS can cause urinary tract infections, infections of the uterus (womb), and stillbirth. In newborns, GBS is the most common cause of sepsis (blood infection) and meningitis (infection of the fluid and lining surrounding the brain), both of which can lead to death. Approximately l out of 3 women are GBS carriers, which means they carry GBS in their vaginal/anal area. Most of these women have no idea they are carriers because GBS usually causes no problems for the woman. However, for every 200 mothers who are GBS carriers, one will have a baby who does develop signs and symptoms of GBS infection. The babies most likely to contract GBS infection from their mothers include:

w premature babies (babies born at less than 37 weeks of pregnancy)

w babies born to mothers whose membranes have been ruptured for a prolonged time

period before delivery

w babies born to mothers who develop a fever while in labor

Women who are GBS carriers but do not have one of these three risk factors are at low risk for delivering an infant with GBS infection. However, the Centers for Disease Control and Prevention (CDC) recommends that all pregnant women be screened for GBS carrier status in late pregnancy. If a mother is identified as a carrier, treatment with IV antibiotics in labor is recommended as this significantly reduces the chance of transmitting the GBS bacteria to the baby.

Penicillin is the recommended antibiotic for this type of prophylactic treatment in labor. Alternative antibiotics are used in women who are allergic to penicillin.

Your provider will do a GBS culture of your vaginal and anal area at 34-36 weeks of pregnancy, or sooner if you have signs of a vaginal infection, premature labor, or premature rupture of membranes.

• Try to walk straight and check your posture
• Wear good, supportive shoes with low heels
• Change you position once an hour
• If you sit all day, place a small stool under your desk to rest your feet on
• Try doing the pelvic rock exercise
• Consider using a pregnancy support belt for back support
• Do not lift anything heavy and squat instead of bending over to pick things up

• Change your position frequently and get up slowly
• Drink lots of fluids, especially if you are outside on a hot day

• Avoid constipation by eating lots of fruit, fiber, and vegetables
• Exercise regularly and drink plenty of fluid

• Put your legs up as much as you can during the day
• Point your toes towards your nose or stand on a step with your heels hanging over the edge to stretch your calves
• Use a heating pad, hot water bottle, or warm soaks in the tub

• Bathe your outer vagina often
• Use soap without perfume
• Wear cotton panties and avoid pantyhose and tight pants
• Tell your provider if your discharge won’t go away or if you have itching or burning

• Put your feet up as often as you can during the day

• Use lots of pillow for comfort and support
• Try drinking warm milk or chamomile tea before bed

We believe that labor progresses easier when one labors in the comfort

and privacy of one’s home. We encourage you to remain at home as long

as you are comfortable, keeping in touch with your provider for updates, reassurance, and support. We have written the following guidelines, but remember that labor has many different patterns. Call if you have any questions or are unsure about what to do.

As your due date approaches, learn to recognize if you are experiencing labor.

contractions

• Contractions that begin in the front and do not move around to the back
• Contractions may not get longer, stronger, or closer together
• Contractions stop if you stop your activity, or they increase with activity
• Drinking water may stop contractions

If your membranes rupture ("breaking the bag of water"), take note of the time and the color of the fluid. Please call and let us know if this happens. Amniotic fluid will often contain small flakes or some blood. You should report fluid that looks green or appears bloody. It is not always easy to tell if your membranes have ruptured so we may need to see you to determine this.

If This Is Your First Baby …. Call when you have 60-second contractions, five minutes apart for one hour. We may not ask you to come to the hospital right away, but your practitioner will give you further instructions after talking with you.

If This Isn’t Your First Baby …Call when your contractions are five to seven minutes apart and last about a minute, or when you notice a significant change in your labor.

The following is a stage-by-stage guide of what to expect, what to do, and how your coach can help.

Labor is exactly what it sounds like -- hard work. In fact, giving birth may well be the hardest work you will ever do in your life. But under the right conditions, it can also be your most exciting and satisfying experience. The work of labor is concentrated in the uterus. The job of the uterus is to protect and nourish the unborn baby during pregnancy, and then, when the time is right, to push it out into the world.

The pregnant uterus is the largest muscle in the body. When the uterus contracts, it compresses and squeezes and then relaxes. Each time the uterus contracts, the squeezing action pulls up and out on its lower portion, the long, narrow "neck" called the cervix. The contraction, combined with the pressure of the baby’s head, causes the cervix to open (dilate) and shorten (efface). This gives the baby a shorter, wider passage to travel through during birth.

Stage I The cervix must dilate to a diameter of 10 centimeters (about four and a half inches) and efface (thin out) from 0 to 100 percent in order for a full-term baby to pass through it. This shape-changing process is called Stage I, and it is the longest stage of labor. If this is your first baby, Stage I can last anywhere from eight to 24 hours. If you’ve given birth before, it will probably be a good deal shorter. Stage I usually begins slowly and hesitantly with short contractions that are mild and far apart. As Stage I progresses, the contractions will get longer, stronger, and closer together. You may spend much of early labor at home.

Stage II When Stage I is complete, and the cervix is fully dilated and effaced, and Stage II begins. During Stage II, baby is pushed out of the uterus, down the birth canal, and into the world. Stage II takes a lot of hard, physical work from the mother. It lasts an average of 2 hours for first time mothers and about 1 hour or less for mothers who have given birth before.

Stages III Stage III lasts from the birth of the baby until the placenta delivers and can take from 10 to 45 minutes. The uterus will contract to deliver the placenta and then will continue to contract to get the bleeding to stop.

Many women ask questions about what they can do in labor to help cope with the pain of contractions. There is no question that labor hurts, but what other painful experience ends with a new baby! Your attitude has a lot to do with how your labor progresses and what choices you make. Your providers are not against using drugs in labor, but we often find that other ways to reduce pain work as well or even better. What is most important is that you know the advantages and disadvantages of your options for pain relief in labor.

Studies have shown that women who have support in labor have shorter labors. If you have your partner, your mother, or a friend with your during labor, you are likely to feel safe and supported. You might want to ask your mother or grandmother about their birth experience. Chances are they didn't have someone with them and it was scary to be left alone. Think about your preferences during labor and let your support person(s) know. We believe that providing support and encouragement is an important part of our role as well.

YES! One of the most helpful things you can do for yourself and your baby is to attend a childbirth class so you will know what to expect in labor. You will learn how to tell if you are in labor, when to call, relaxation methods and breathing techniques. There are lots of choices YOU can make if you are prepared. After you go to classes, talk with your doctor or nurse midwife about your birth plan (see birth plan in the appendix).

Some women hire a professional DOULA. This is someone who stays with women in labor. She does not provide medical care, but comforts and supports you and your partner during labor. It is your decision as to whether you would like to hire a doula. Check the list of resources for doulas who work in this area in the back of this workbook.

There are lots of comfort techniques that you will learn about in childbirth classes. Your nurse and your provider will also know techniques that may help you in labor. Here are a few basic things you and your partner can do during labor:

1) Change positions frequently. Position changes are important to help the baby move down the birth canal. If your baby is doing well in labor, you will be free to move around as you like. Positions include standing, sitting in a rocking chair or on the toilet, squatting, using the birth ball, walking, or taking a shower or bath. Practice your breathing exercises in different positions. Practice squatting ahead of time in order to strengthen those muscles. If you have a lot of back pain in labor, try getting in a hands and knees position.

2) Hands-on techniques. There are lots of things your partner can do to help you in labor. Here are a few ideas:

• Hot compresses (you can fill a sock with uncooked rice and put it in the microwave in the hospital, or bring a hot water bottle)
• Cold compresses
• Massage
• Effleurage (light, tickling massage to the abdomen)
• Water (cool washclothes, warm soaks in the tub or shower)

To relieve back pain during labor, you may want to try the following;

• back rub with hands or objects
• counterpressure (constant steady pressure to the middle of the lower back with a fist or object (like a tennis ball)
• Hot towels on your back (you can also bring a tupperware rolling pin and fill it with hot water).
• Inward pressure on the highest part of the hip bones from both sides at once.

3) Visualization /Relaxation techniques. Staying relaxed is important in labor. If you have a technique that you are familiar with, it may work well for you in labor. You can also try visualizing a comforting place that you have been. Try to bring back the memories of tastes, smells, and sounds that went with it. Breathing slowly and deeply concentrating carefully on each breath can also help. You can also bring a favorite object or picture with you to focus on during the contractions.

4) Eating and drinking in labor. Labor is hard work and you need to keep your energy level up. Ask your partner to remind you to drink something every 15 minutes. You can try fruit juice (orange may have too much acid, but grape juice has lots of sugar for quick energy), popsicles, or hot tea with honey. Because you are drinking, remember to empty your bladder regularly as well, which will also help your baby have more room in the birth canal.

There are two choices for drugs in labor -

1) Narcotics (as a shot or in your IV)

2) Epidural.

A narcotic can be given in your veins (through an IV) or as a shot in your hip. Some narcotics last longer than others, so your provider will select one that is best for you based on where you are in labor. For example, if this is your third baby and the labor is likely to progress quickly, it is safer to give you a short-acting narcotic (it won't last too long) so that it wears off by the time the baby is born (so the baby isn’t sleepy).

An epidural is a needle placed in between the spines in your back. A small catheter is fed through the needle into the epidural space, the needle is removed and the catheter stays in your back so medicine can be given through it. It is very effective in providing pain relief, even allowing a woman to sleep. However, like all choices there are risks/side effects to be aware of:

• Epidurals dilate (open up) your blood vessels and sometimes your blood pressure drops. Whenever an epidural is placed, mothers must have an IV and must have continuous electronic fetal monitoring to make sure the blood pressure stays adequate so that fetal circulation is not compromised.
• Epidurals make your legs numb so mothers can no longer walk around or use sitting positions. They often cannot feel their bladder and a urinary catheter may be necessary to keep the bladder empty.
• If an epidural is given too early, it may slow down labor, which can require the use of pitocin, a drug to stimulate more contractions.
• Some women do not have a strong urge to push with epidurals and may require the use of a vacuum or forceps to help the baby out.
• If you want an epidural, the anesthesiologist will come to your room and talk with you about how the procedure is done and what the risks are. If you are thinking about having an epidural, talk to your doctor or midwife before labor so you can ask questions. Labor is not the time to learn about your options; you'll be too busy!

Massaging the perineum (the skin/tissue between your vagina and rectum) daily for the last few weeks of pregnancy may help you to avoid the need for an episiotomy and/or prevent tearing by stretching the perineal tissue. It will also acquaint you with the sensations you may feel as your baby's head emerges (crowns), so that you can better prepare for the birth. The massage should be done each day for five to 10 minutes beginning at 36 weeks (four weeks before your due date). You may do the massage yourself, but many women have found it easier and more helpful for their partner to do it.

1. Begin by emptying your bladder and positioning yourself comfortably. When starting the massage, you might find that a warm bath softens your perineal tissues. Use a mirror the first few times so you become familiar with the area you are massaging.

2. Use a natural oil, such as wheat germ, olive oil, or plain salad oil, to massage the tissues of the perineum just outside the vagina. Pay special attention to any scar tissue from past episiotomies or tears.

3. Insert one or two fingers about one inch into the vagina. Press downward towards the rectum. While maintaining a steady pressure, move the finger(s) upward along the sides of the vagina with a rhythmic "U" or "sling" type of movement from four o'clock to eight o'clock. Avoid rubbing the urinary opening, which is at the top, in order to prevent urinary tract (bladder) infections.

4. As you massage, your tissues should relax and stretch. Gently stretch the vaginal opening as wide as possible each time you do the massage until you feel a tingling or burning sensation. This helps you to recognize the feelings that you will experience when your baby's head begins to crown. Hold this stretch, without hurting, for 45-60 seconds, then release. Massage with more oil, stretch again to the maximum, hold, then release and rest. When you first begin the massage, your perineum may feel tight, but with time and practice, the tissues will stretch and relax.

It may also help to practice Kegel exercises. Do a Kegel exercise and feel how strong the muscle is getting. Feel how difficult the stretching is when you are tensing the muscles of the pelvic floor. Now, consciously release the muscles as you do the massage. Remember to do Kegel exercises before and after the baby is born to improve muscle tone and strength.

In order to decrease the likelihood of perineal tearing, it is also helpful to consider what position you will deliver in. Positions such as kneeling or side-lying tend to reduce the tension on the perineum.

This massage should not be painful. If you have any problems or concerns about the massage, talk with your physician or nurse-midwife.

DO NOT DO PERINEAL MASSAGE IF YOU HAVE ACTIVE HERPES LESIONS.

Many women find it helpful to put their thoughts about their birth experience in writing and share them with us before labor. This is called a "birth plan." It is not necessary to describe every possible situation and how you would like it managed, we want to know what you need that is special to you, your partner, or your baby. We believe that labor and birth is a normal process and unless complications require it, we like to use as little intervention as possible. Therefore, we do not routinely use continuous electronic fetal monitoring (either internal or external), episiotomies, IV’s, or enemas. We will encourage you to move around during labor and change positions as much as you like, including in the tub or shower if your room has one. We also try to share with you any concerns we have about your labor progress and to include you in any decisions, unless there is a true emergency (which is rare). We hope that you have developed enough trust in your physician or nurse-midwife so that there can be open communication during your labor.

Here are some questions, which may help you work on your birth plan:

l. The word "labor" makes me think about:

2. I worry the most about:

3. What I want my doctor or nurse-midwife and the nurses at the hospital to know most about me is:

4. What are things that you would like to happen during your labor and birth?

Please write your birth plan with a positive focus. It makes the project fun and is more helpful to your doctor or midwife and to the labor nurse. We encourage you to write down what you do want instead of what you don't want. Our experience has shown that couples who approach labor with an open mind ultimately have the most positive experience.

Please share your birth plan with your provider during your last few weeks of pregnancy.

There are many things you can do to help your children prepare for a new addition. Many children are jealous when the crib goes up, especially if it is their crib! Here are a few suggestions:

• Tell your child what s/he was like when s/he was a baby. Go through the baby album.
• Make a family baby book. Collect pictures of family members and talk about how everyone may look alike, and how he or she looks different.
• Let you child/children help pick the baby’s name.
• Bring your child with you to a prenatal visit so they can hear the baby’s heart beat and ask questions.
• Get a baby doll for him/her to "take care of."
• Have your child draw a picture of what s/he thinks the baby will look like.
• Try going through a rehearsal of what happens when you go to the hospital. Consider taking your child on a hospital tour so s/he knows exactly where you’ll be.
• Make a special bag/box of goodies for your child to play with when you are at the hospital.
• If appropriate, explain to your child that you will be breastfeeding the new baby.

• Have the children give each other a gift.
• Create homemade birth announcements drawn by your child.
• Spend some time with your older child to show him/her the new baby’s characteristics.
• When you are feeding your baby, read to your child or have special toys for the child to play with.
• Talk to your older child about when s/he breastfed
• Sometimes older children will remember breastfeeding and want to try again, but they usually will not reinitiate breastfeeding once they have weaned.
• Your older child can breastfeed a doll while you breastfeed your new baby.

Be sure your child wants to be there. Most children will tell you if they are interested or not. Sometimes parents want their children to be there so much, they forget that the child may not want to be there. UNC Hospitals supports your decision of having your child present for birth; however there are some requirements which must be met:

You need to bring a support person for your child. This person must be there for your child and not have a strong need to see the birth. Share materials about birth with your child and consider bringing him/her to several prenatal visits. There are children’s books about childbirth such as Mom and Dad and I are Having A Baby as well as videos to rent or buy. Talk about what will happen during labor and the birth, what your child might see, and how you might act.

A birth certificate is an important legal document that will be needed many times during your child’s life. The hospital is required to prepare and file this record, and you will be asked to provide the information listed below.

In the hospital, you will be given the completed birth certificate to review and sign. Make sure all information is correct, especially the name because after the certificate is filed, the name cannot be changed except by court order.

PROPOSED NAME(S): Boy________________________________________________________________________

Girl________________________________________________________________________

MOTHER________________________________________________________________________

First Middle Last Maiden

RACE_____________________________HISPANIC ORIGIN______________________

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17+

Is this address inside the city limits? yes no

Specify White, Black, American Indian, etc. Hispanic Origin yes/ no Specify

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17+

How many other children are still living?__________How many pregnancies not result in live birth?_________

How many were born alive, but are not dead?_______Date last live birth_______Date last stillbirth________

All 50 states require that children, including newborns, ride in car seats. You will need a car seat to bring your baby home from the hospital. The safest way for your new baby to ride is in the car’s back seat with the car seat and infant facing backwards.

Important: Don’t ever strap your child into your safety belt with you. Don’t use an infant carrier as a car seat.

• Small babies can get caught or hurt themselves if the crib isn’t safe.
• The space between the crib bars should be no wider than 2 1/16 inches.
• Make sure the bars are not loose or missing.
• There should not be any posts sticking up or any cutout areas on the crib’s headboard or footboard.
• The mattress should fit snugly into the crib frame. If you can put two fingers between the mattress and the side of the crib, you need a bigger mattress.

New cribs will probably be safe for your baby. If you use an old crib, check it carefully for safety. If the crib was made before 1978, it may be painted with lead paint and should not be used.

Keep the crib away from windows so your baby won’t fall out. Keep the crib away from the cords for window shades or curtains because your baby could become strangled on them.

Monitors let you listen to your baby when you are in another room. You plug in one part of the monitor in the nursery, and you take the other part of the monitor with you wherever you go. You can hear if your baby wakes up, coughs, or starts to cry. You can buy a monitor at a baby store or in the baby section of a department store.

Important: Even if you use a monitor, you should still check on your sleeping baby from time to time.

If you have a son, one of the first decisions you will make is whether or not to have him circumcised. The United States is one of the few countries where this is performed. In some cultures, circumcision is done for religious reasons. In most of the world, it is not done at all. The United States is the only country where so many boys are circumcised for nonreligious reasons. We would like to answer some of the most common questions parents ask about circumcision. Please discuss this with your provider before your baby is born.

1. What is circumcision? Circumcision is a surgical procedure where the foreskin is removed from the glans (the head of the penis).

2) What is the purpose of the foreskin? The foreskin protects the glans, produces schmegma (a lubricant that assists in smooth retraction of the foreskin), and may play a role in increasing sexual sensitivity.

3) How is circumcision done? The procedure is performed with the baby boy restrained at both the arms and legs. An anesthetic shot is given at the base of the penis, the foreskin is cut and peeled back from the glans, clamped at the base, and cut away. A metal bell-shaped device covers the glans so the penis itself is not cut, just the skin. The procedure usually takes about 15 minutes.

4) What does a circumcised penis look like? Right after the procedure, the glans looks red where the protective skin has been removed. The cut skin will circle the penis at the base of the glans. It can swell a little for the first few days.

5) What are the risks? There are risks such as taking away too much skin or bleeding.

6) Does it hurt? Yes. Your son will also experience discomfort with urination and from rubbing the incision site and the newly exposed glans against the diaper, though this can be minimized with a vaseline dressing.

• Circumcision is still very common in this country, so you may want your son to look like other boys. Many boys are circumcised because their father is circumcised.
• There is evidence that circumcised boys have a lower risk of urinary tract infections (but these infections are uncommon in boys anyway).
• Circumcised men may be less likely to carry and transmit sexually transmitted infections to their adult sexual partners.
• It reduces the risk of cancer of the penis (but if uncircumcised men clean themselves regularly, it is unlikely they’ll get this uncommon disease).

What are some reasons not to have my son circumcised?

• Many people say the uncircumcised penis is difficult to keep clean, but this is not true. The uncircumcised boy (when he gets older) simply has to learn how to retract his foreskin and clean the tip of the penis regularly.

• It is an elective surgical procedure done primarily for cosmetic or cultural reasons rather than medical reasons.

The foreskin of newborn boys requires little attention. You should not pull the foreskin back, but gently wast the outside of the penis as you would with a circumcised boy. Little boys have erections, thus causing the foreskin to eventually retract naturally, usually sometime after age 5.

There is really no clear medical reason to circumcise your son, so this decision is usually based on your assessment of your son’s social needs. We understand that this can be a difficult decision, particularly since circumcision rates reached their peak in men who are now having children themselves.

Please discuss this issue with your provider. We are happy to answer questions and will respect whatever decision you make.

The Center for Disease Control of the US Public Health Service recommends that all newborns receive a hepatitis B vaccination before being discharged from the hospital. You will be asked to sign a consent form before any shot is given to your child. North Carolina law stipulates that any child born after January 1, 1994, must receive the Hepatitis B series before enrolling in kindergarten.

The hepatitis B virus is passed by sexual contact or by exchange of infected blood (drug abusers sharing needles or accidental needlesticks in health care workers). Mothers can also give their babies hepatitis B during pregnancy. It infects the liver where it can cause acute illness that may persist as a chronic infection that can lead to cirrhosis or liver cancer. Some infected individuals have milder disease but become chronically infected and can spread the disease to others. In the US, there are 200,000 - 300,000 new infections annually and the reported incidence of acute hepatitis B increased by 37% from 1979 to 1989. Each year 4,000-5,000 persons die from chronic liver disease due to hepatitis B. There are no drugs that can cure this viral infection, but there is an effective vaccine available. The vaccine has been widely used in high-risk populations including infants of mothers who are infected with hepatitis B and health care workers. The goal is to eventually immunize the entire population so that the spread of the virus can be stopped and eventually eliminated from this country.

The vaccine is produced from common baker’s yeast which has been changed to produce the hepatitis B antigen (an antigen is a substance that will cause your body to produce antibodies, or substances that resist the infection). The vaccine used in the US is over 90% effective in preventing hepatitis B infection. Protection persists for at least 9 years after completion of a 3 shot series.

Some parents choose not to have the vaccine for their newborn because the disease is primarily spread by adult behaviors.

• Pain where the shot is given is the most common side effect
• Temperature

The Pill This method works by stopping your body from making an egg. Less than one woman out of 100 will get pregnant if a pill is taken every day. The hormones in birth control pills are low dose and, because of this, the pill’s side effects are much less now than in the past. Breastfeeding mothers can take these low dose pills. If you choose this method, your health care provider will discuss when you should start to take them. Many women will have irregular bleeding (spotting) for the first few months and may feel nauseated. You should not use the pill if you are over 35 and smoke.

Norplant Norplant consists of six tiny capsules that contain the hormone progesterone. These capsules are placed under the skin in your arm, a procedure takes about 15 minutes. Once in place, Norplant works immediately and continues to work for five years, though it can be removed anytime you wish. Side effects include weight gain, hair loss, and irregular periods. For those who use Norplant, less than one woman in 100 will get pregnant the first year of use. If not breastfeeding, you can receive a Norplant implant soon after delivery. If you are breastfeeding, it is usually placed about six weeks after delivery.

Depo-Provera Depo-Provera, an injection that contains progesterone, will prevent pregnancy for three months. Progesterone is the same hormone that is contained in Norplant. If you are interested in using Depo-Provera for long-term birth control, you will need to receive an injection every three months. Some women have spotting, weight gain, or headaches while receiving Depo-Provera. There is some evidence to suggest that Depo- provera may interfere with a new mom’s milk coming in. You need to consider how important it is to have a shot right after you deliver vs. 2 weeks or even 6 weeks postpartum.

An IUD is a small device shaped like a "T" that is inserted into the uterus through the cervix (mouth of the womb). The Progestasert IUD is good for one year, while the Paragard IUD is good for 10 years. An IUD should only be used by women who have only one sexual partner, with that partner having no other partners as well. This is because it can be dangerous to acquire a sexually transmitted disease with an IUD in place. Less than one woman out of 100 who use an IUD will get pregnant during the first year of use. Side effects include cramping, backaches, and an increased amount of bleeding during periods. If you choose this method, it is usually put in no sooner than six weeks postpartum.

Diaphragm The diaphragm is a rubber cup that is filled with contraceptive (birth control) jelly and put into the vagina by the woman or her partner before making love. It prevents the man’s sperm from reaching the woman’s egg. For a diaphragm to work, you must use it every time you have intercourse and leave it in your vagina for six to eight hours after making love. If used correctly every time you have intercourse, about 2 to 10 out of 100 women will get pregnant in one year of use. This method does not work, however, if you leave the diaphragm in the dresser drawer! A few women report more bladder (urine) infections while using the diaphragm. If you choose this method, you will be fitted for one at your check up six to eight weeks after delivery.

Condoms Also known as safes or rubbers, condoms look like long balloons. Like the diaphragm, the condom prevents the man’s sperm from reaching the woman’s egg. Your partner or you must unroll the condom onto the erect penis before the penis touches the vagina. You must leave one-half inch of room at the tip to collect the man’s sperm and hold on to the condom when taking the penis out of the vagina after ejaculation to prevent it from slipping off and spilling the sperm. When used correctly every time intercourse takes place, about two out of 100 women will become pregnant in a year, though in reality about 12 out of 100 women become pregnant in one year because they are often not used correctly. There are not any serious side effects. One good side effect is that condoms can protect against sexually transmitted diseases (STDs), including AIDS.

Vaginal spermicides are usually found as foam but can also be a cream, jelly, or suppository and can be purchased without a prescription in any drugstore. Spermicides work by killing the man’s sperm so it never reaches the woman’s egg. When used correctly, but without a condom, about four out of 100 women will get pregnant in a year. If you use a spermicide with a condom, pregnancy rates are similar to "the pill" - about 99% will not get pregnant in a year. Spermicides helps protect against sexually transmitted diseases, though not as well as a condom. Occasionally a woman will have an allergic reaction to the chemicals in a spermicide.

The most popular method of Natural Family Planning (NFP) uses cervical mucus charting. Vaginal discharge that is clear, thick, slippery and stretchy enables a woman to become pregnant. NFP teaches a woman how to recognize this mucus as a sign of her fertility. Intercourse is then avoided while the woman is fertile. You must be very committed and well informed regarding this method for it to work. Women with regular, predictable menstrual cycles are more likely to be successful in preventing pregnancy with this method. When using the mucus method of NFP for birth control, estimates vary from one out of 100 women becoming pregnant in one year to 25 out of 100. There are no side effects to this method and it is acceptable to most religions.

Breastfeeding is also considered a natural method of birth control. Mothers who breastfeed their babies every three hours or so are unlikely to get pregnant, although the reliability of this method falls off as the months go on and soon becomes unreliable.

You should only choose permanent sterilization if you are absolutely sure that you do not want to have more babies. You can choose tubal ligation for the woman or vasectomy for the man. Both methods are very effective, with only about one in 500 couples getting pregnant after such a procedure.

Tubal Ligation Tubal ligation, often called "getting your tubes tied," is a simple surgery in which your tubes are PERMANENTLY cut, preventing the sperm from reaching the egg. It is a very effective method of birth control, however, if you do get pregnant, you are more likely to have a pregnancy in your tubes, which can be very serious. If you choose this method, you can have it done within a few hours after delivery while you are in the hospital anyway, or it can be done after you are six weeks postpartum. It requires local anesthesia with sedation, an epidural, or general anesthesia. If you are interested in this method and you have Medicaid, you need to sign a consent form at least 30 days before you deliver.

Vasectomy This is done by PERMANENTLY cutting the tubes that carry the sperm from the es to the penis. It should have no effect on sexual desire or performance. This procedure can be done in the office under local anesthesia.

A non-stress is a way of seeing if your baby is doing well. You may have a non-stress if you have medical problems (like high blood pressure or diabetes) or if you are over-due or think the baby is moving less.

A nurse will place the fetal monitor belts around your belly. One monitor will tell us what your baby’s heart rate is while another monitor will pick up any contractions you might have. What we are looking for is for your baby’s heartbeat to go faster when he or she moves (you do the same thing when someone touches you or you’re moving quickly). If the is reactive (the baby’s heart rate went up), that reassures us that things are going well. If the is non-reactive, it does NOT mean your baby is in trouble, it just means we need to check on your baby in other ways. Sometimes the is non-reactive when you haven’t eaten or when the baby is asleep (babies sleep up to one hour at a time).

Pre-eclampsia is a high blood pressure problem that some pregnant women develop in their last trimester. It is a problem related to how your kidneys and blood vessels work. First time mothers or mothers with a new father in this pregnancy are more likely to develop pre-eclampsia than others. Women with a history of high blood pressure, kidney disease, poor nutrition, twins, or who are younger than 18 or older than 35 are at increased risk for this illness.

The signs and symptoms of pre-eclampsia are:

• Elevated blood pressure
• Swelling
• Protein in your urine
• Headache
• Spots in front of your eyes
• Abdominal pain

If a woman develops signs of pre-eclampsia, she is at risk for becoming quite sick, jeopardizing her and her baby’s health. If you develop signs of pre-eclampsia, your provider may ask you to do these things:

• Rest in bed on your left side (to increase the blood flow to your uterus)
• Bring in a 24-hour urine specimen collection for s
• Order blood s
• Do kick counts to ensure that your baby is moving every day.
• Complete a non-stress using fetal monitor.
• Have an ultrasound.

Many women are frustrated when they have not had their baby by their due date. Remember that a due date is an average; it is common for women to deliver up to two weeks before, or two weeks after their due date. If you go two weeks past your due date, we will talk with you about a plan to induce your labor.

If your cervix is not "ripe," then we will consider other ways to get it ready. A special gel or tablet called "prostaglandin" may be placed in your cervix. Labor induction with Pitocin is more effective is your cervix is "ripe".

There are other ways to stimulate labor when you are overdue. These include having sex, nipple stimulation, enemas, or ingestion of castor oil. There are some herbs that may also open your cervix or stimulate labor. Evening primrose oil is a popular natural method of cervical ripening. We will discuss these with you IF they are appropriate for you to use.

A cesarean section is delivery of the baby through an incision in the abdomen and the uterus (womb). Sometimes it is the only way to get the baby out safely and it is not a sign of failure. About 15% of our family practice patients end up with a cesarean section.

Common reasons for a cesarean section are:

• The mother previously had a cesarean section and either she or her provider choose to repeat this method
• The baby is too big to pass through the mother’s pelvis.
• The baby’s heartbeat indicates it is experiencing signs of distress.
• The baby is not in a head down position (is breech or transverse).
• Labor is not progressing in spite of efforts to try and help it along

• A nurse will shave the area above your pubic hair and clean your abdomen
• A catheter will be inserted into your bladder
• An IV needle will be inserted into your arm.
• You will be given an antacid to drink to neutralize acids in your stomach
• Most mothers have an epidural for anesthesia unless it is an emergency requiring immediate general anesthesia (put to sleep).

If the baby is doing well (cesarean babies sometimes need extra time and stimulation to begin breathing on their own), and you are awake, you should be able to hold your baby. If the father is in the delivery (operating) room, he should be allowed to hold and cuddle the baby, too. Once in the recovery room, you can begin to breastfeed the baby.

Although "once a cesarean section always a cesarean section" used to be the rule, it is now recognized that most women can deliver safely by vaginal delivery in a subsequent pregnancy. This is called a "trial of labor".

We will review the records of your previous cesarean birth to determine if it is safe for you to attempt a vaginal delivery. This is based on the type of uterine incision: low transverse (back & forth) versus a vertical (up & down). Vertical incisions are weaker and at greater risk of rupturing (opening) during labor. If you have had a vertical incision of the uterus, you will need to have another cesarean section. Most women have had a low transverse incision and are able to attempt a vaginal birth, with about 70-80% succeeding.

It is important that you understand the risks and benefits involved and discuss these with your provider. The benefits of a vaginal delivery include a shorter hospital stay, less anesthesia, no need for an operation, and better stimulation of the infant by the vaginal birth. The risks include the fact that 1% of women with a scar on their uterus from a previous cesarean section will rupture their uterus during labor. In about 25% of this small group of women, the baby or the mother will have a poor outcome, meaning that the baby could have problems after birth or the mother will need a hysterectomy (removal of the uterus).

If you have had a previous cesarean section, the options for delivery will be thoroughly discussed with you and your questions answered. You will be given a consent form to review and sign should you decide to proceed with a trial of labor.

We believe that all parents benefit from childbirth preparation, especially if this is their first baby. Classes are not just for women who want natural childbirth; they help to prepare you for all of your options in labor, including medications, labor and birth positions, etc. There are many classes available in the Triangle area. You need to consider the type of class, location, and cost. Many of the instructors will work with you if cost is a problem. Some of the classes are covered by MEDICAID or are at lower cost if you have MEDICAID. If this is not your first baby, you might consider refresher classes, not just to provide you with information, but more often to give you and your partner an opportunity to discuss your plans for this birth. In order to get the class of your choice, you need to sign up early! Start thinking about classes any time after your 20th week. It is best if you finish the classes two to four weeks before your due date.

THE FOLLOWING CLASSES ARE SPONSORED BY UNC HOSPITAL – For more information and a registration form, call UNC HealthLink at 966-7890.

The Prepared Childbirth series is a six-week course for expectant parents taught by experienced certified instructors. The sessions are held once a week for two hours and focus on understanding the normal birth process, with emphasis on how couples can work together to have a healthy, positive experience. Various medical and non-medical options are discussed and variations from normal birth are explored. Sessions focus on relaxation, massage, and positions to enhance labor. Birth videos are shown. The cost of the course is $75 ($70 if you are a member of "Our First" Maternity Club). Participants who qualify for Medicaid may be eligible for a reduced fee for this class. Your maternity care provider can give you more information. Weekend sessions available.

The Refresher Childbirth Class is an individualized 2 1/2 hour class for expectant couples who have previously attended childbirth classes. Content is determined by the needs of the class. Meetings are scheduled at a time and location convenient for everyone taking the class. Cost is $50.

This class is designed to acquaint mothers with the basics of breastfeeding, including the advantages of breastfeeding, getting started, correct positioning, establishing a good milk supply, how to tell if the baby is getting enough milk, the father’s role, preventing problems, and community resources for breastfeeding moms. Cost is $20.

Infant/Child CPR and Home Safety is a two-part class designed to teach new and expectant parents emergency techniques for infants and children. The class also provides information on how provide a safe home environment for children. This class is also ideal for individuals who work with infants and children on a regular basis. Participants will learn techniques taught by the American Heart Association and the National Safety Council and will receive a one-year pediatric CPR certificate upon successful completion of this six-hour course. Classes are held in two parts beginning on Monday, from 6:30-9:30 p.m. and concluding on Saturday from 9:00 a.m. to 12:00 p.m. Both classes are held at the UNC Hospitals Administrative Office Building. Cost is $25 per participant.

Class offerings include childbirth preparation classes, a comprehensive series of classes for first-time parents, refresher classes geared to the needs of experienced parents, and sibling preparation classes. Class content includes normal labor and delivery, variations and complication, medical interventions including cesarean birth, late pregnancy, birth planning and informed consumerism, newborn care, breastfeeding, positioning, massage, affirmation, visualization, and others. The approach is eclectic and focuses on developing a confident and informed attitude towards pregnancy, birth and parenting. Cost is $120.

Four-week childbirth preparation classes based on Lamaze methods. Classes are held in the instructor’s home. Participants are taught techniques for breathing, relaxation, and concentration to enhance the birth experience. The laboring individual and her partner’s self-confidence improves for coping with labor and delivery. Information is included on negotiating an individualized birth experience. In addition, emphasis is placed on how to breastfeed and how to handle the early weeks of parenting. Cost is $60 per series. Refresher class available.

Wanda is a childbirth educator certified through the International Childbirth Educators Association. She is also a Nationally Certified Massage Therapist specializing in pregnancy and postpartum massage, and a professional doula (childbirth support person). She teaches a six week consumer-based series which includes prepared childbirth information and child development, as well as a wealth of hands-on techniques for labor support. The cost of the class is $100. Classes are held on Tuesday evenings 7:30 to 10:00 pm. Please call for class schedule and more information. Refresher courses available.

Call Alamance Hospital Office of Education at 538-7550.

Classes are available at the Chatham Health Department. Your maternity care coordinator can give you more information.

A comprehensive six-week series that helps parents know what to expect during the last months of pregnancy, understand the birth process, learn the tools that work best for each individual, and develop a birth plan. Derived from several methods, content is presented with emphasis on personal exploration and support of the uniqueness of each woman’s needs. Other topics include practical tips for the labor partner, variations from normal, medical and nonmedical options, normal newborn appearance and procedures, postpartum, and Cesarean birth. An Infant Care class