Preconception education: should be started when women are considering pregnancy. Physical and laboratory evaluations regarding family history, prior fetal anomalies, previous cesarean sections, contraception usage, exposure to infections, animal contacts (feline), medical conditions as anemia, systemic lupus, hypothyroidism, diabetes, hypertension, seizures, and other disorders.

First visit: History including medical, psychosocial, and genetic.

  • Physical exam: general blood pressure, height, weight, pelvic/cervical examination, breast examination, fundal height, fetal position, and heart rate.
  • Laboratory tests: hemoglobin or hematocrit, Rh factor and blood type, antibody screen, Pap smear, and diabetic screen.
  • Urine: dipstick, protein, sugar, culture.
  • Infections: Rubella, syphilis, gonococcal culture, hepatitis B, HIV (offered) and toxoplasmosis.
  • Illicit drug screen: (offered)
  • Genetic Screen: (offered)
  • 11-13 weeks: Nuchal translucency and PAPP-A.
  • 14-16 weeks: medical and psychosocial update, blood pressure, weight, fundal height, fetal position and heart rate, and Quad screen.
  • 20 weeks: Fetal anatomy scan.
  • 24-28 weeks: medical and psychosocial update, blood pressure, weight, fundal height, fetal position and heart rate, hemoglobin, antibody screen, and diabetic screen.
  • 32 weeks: medical and psychosocial update, blood pressure, weight, fundal height, fetal position and heart rate.
  • 36 weeks: medical and psychosocial update, blood pressure, weight, fundal height, fetal position and heart rate, hemoglobin, group B streptococcus.
  • 40 weeks: medical and psychosocial update, blood pressure, weight, fundal height, fetal position and heart rate, non-stress test.

 

Nutrition: The U.S. Department of Agriculture has published the new food guide pyramid. This consists of 6-11 servings per day of bread, cereal, rice, and pasta; 3-5 servings per day of vegetables; 2-3 servings per day of fruit; 2-3 servings per day of milk, yogurt, and cheese; 2-3 servings per day of meat, poultry, fish, beans, eggs, and nuts. Fats, nuts, oils, and sweets should be used sparingly. Pregnant women need three servings per day of daily products, a cup of milk or yogurt, 1.5 oz of natural cheese, or 2 oz of processed cheese.

Weight gain: Total weight gain recommended is 25-35 lbs for normal women. Underweight women may gain up to 40 lbs and overweight women should limit their weight gain to 15-25 lbs. 2-3 lbs occur from increased fluid volume, 3-4 lbs from increased blood volume, 1-2 lbs from breast enlargement, 2 lbs from enlargement of the uterus, 2 lbs from amniotic fluid, and at term the fetus weighs an average 6-8 lbs, and placenta 1-2 lbs. Usually, 3-6 lbs are gained in the first trimester and 0.5-1 lb per week in the last two trimesters.

Inadequate weight gain is associated with increased risk of low birth weight, thus nutritional status should be assessed. Excess weight gain, assessment for fluid retention should be performed. Dependent edema in the legs is normal as pregnancy advances because of the venous compression by the weight of the uterus. Elevation of the feet and bed rest on the left side will help correct this problem.

Rest: First trimester women feel more tired and should be advised to go to bed earlier. Fatigue often lessens in the second trimester, but in general, most women need additional rest during pregnancy.

Activity and employment: Most women may maintain their normal activity levels in pregnancy. Modification of pregnancy activity is seldom needed except for physical danger. Exercise should be encouraged and prenatal exercise classes should be taken. Women should be counseled to discontinue activity when they experience discomfort.

Travel: Women should be advice against prolonged sitting during a car or airplane because of risks of clot formation. Recommendation is a maximum of 6 hours per day driving, with stopping at least every 2 hours for 10 minutes to allow for walking. Support stockings are also recommended.

Sexual activity: No restriction need is generally placed on sexual intercourse. Women may experience changes in comfort and sexual desire. Increase uterine activity is experienced after intercourse, may be due to breast stimulation, female orgasm, or prostaglandin in male ejaculation. For women with risk of preterm labor or history of bleeding, sexual intercourse should be restricted.

Backache: Can be prevented to a large degree by avoiding excessive weight gain. Posture is important, wearing sensible shoes, and not high heels.

Nausea and vomiting: Very common and patients should avoid eating greasy or spicy foods. Frequent small feedings in order to keep some food in the stomach at all times is helpful. A protein snack is advised and patients are instructed to keep crackers at her bedside so that she can have before arising in the morning.

Heartburn: Occurs because of relaxation of esophageal sphincter. Over eating contributes to this problem. Women should be advised not to eat before lying down.

Hemorrhoids: Varicose veins of the rectum. Avoid straining and prolonged sitting, for they will often regress after delivery.

Constipation: Physiologic during pregnancy and dietary modification with increased bulk, such as fresh fruit and vegetables and plenty of water can help the problem.

 

Lactation & Post Partum

Human Milk’s Nutritional Benefits

Human milk, the best food for babies, contains the right amount of nutrients in the right proportions for the growing baby.

 

Breastfeeding and the Immune System

Human milk is the baby’s first immunization. It provides antibodies which protect the baby from many common respiratory and intestinal diseases, and also contain living immune cells.

 

Breastfeeding in Special Circumstances

Breastfeeding has other special benefits for premature infants. Premature breast milk contains different amounts of some nutrients than term breast milk, more suited to the needs of premature babies. Necrotizing Enterocolitis, a serious bowel inflammation, is very rare for breastfeed infants. And of course they get the same immune protection, which may be even more critical for the premature, and has been shown to reduce the risk in these babies.

 

Physical Health Benefits for Mothers

Immediately after birth, a repeated burst of oxytocin is released in response to the baby’s sucking cause contraction of the uterus. This protects mothers from postpartum hemorrhage (bottle-feeding mothers get oxytocin intravenously immediately after birth, but for the next 24-48 hours during which risk of hemorrhage is highest, they’re on their own). Continues exclusive nursing (i.e., breastfeeding without added bottles of formula or solids) tends to delay the return of ovulation and menstruation. In fact, the lactational amenorrhea method (LAM) is a well-studied method of child spacing which is 99% effective in preventing pregnancy in the first six months as long as exclusive nursing is practiced. For mothers who don’t practice exclusive breastfeeding, there is still some relative protection; and most contraceptives including barrier methods, IUD’s and even progesterone-only hormonal contraceptives such as the “mini-pill” or injectable “depo” progesterone, are all compatible with breastfeeding. So there’s no need to stop breastfeeding in order to use effective birth control.

 

Postpartum Blues, Depression, & Psychosis

“Maternity blues” or “baby blues”

This condition rises after 40% to 85% of deliveries, practitioners and patients often view it as a “normal” phenomenon. Nonetheless, patients and their families are distressed by the patients’ depressed mood, irritability, anxiety, confusion, crying spells, mood lability, and disturbances in sleep and appetite. These symptoms peak between postpartum days 3 and 5, and typically resolve spontaneously within 24 to 72 hours. The primary treatment is supportive care and reassurance about the transient nature of the condition.

 

Postpartum depression

is increasingly recognized as a unique and serious complication of childbirth. Its insidious onset and chronic course complicates 10% to 15% of all deliveries. The majority of patients suffer from this illness more than 6 months and, if untreated, 25% of patients are still depressed a year later. More than 60% of patients have an onset of symptoms within the first 6 weeks postpartum.

Puerperal psychosis

is a comparatively rare disease. It complicates only 0.1% to 0.2% of deliveries. Symptoms generally present within the first 4 weeks postpartum, when the risk of hospitalization is 22 times greater, but can manifest up to 90 days after delivery. A second, smaller, peak in incidence is evident at 18 to 24 months. Patients suffering from puerperal psychosis are severely impaired, suffering from hallucinations and delusions that frequently focus on the infant dying of being divine. These hallucinations often command the patients to hurt themselves or others, playing these mothers at the highest risk for committing infanticide and/or suicide.