Pregnancy After 35

Having a baby when you're over 35 can mean more health concerns and extra tests, but it shouldn't be cause for alarm or distress. In fact, nearly 1 in 10 babies are born to women over 35, and the majority are delivered without complications. "Women over 35 are at higher risk for developing high blood pressure and gestational diabetes, but with good prenatal care, they should be off to a healthy start," says Lynn Simpson, M.D., an ob/gyn at Columbia Presbyterian Medical Center in New York City. Here, a look at what older pregnant women should consider:

General health Women this age need to eat properly, exercise, and attend all prenatal appointments. "Since older women tend to be a bit heavier, they should follow a well-balanced diet throughout pregnancy," says Dr. Simpson. Most women need to add about 300 calories to their daily diet.

Testing It's standard for women over 35 to be offered genetic testing, as the risk of chromosomal abnormalities increases at this age. You can usually choose between a chorionic villus sampling (CVS) at 9 to 11 weeks or an amniocentesis at 15 to 16 weeks. (Miscarriage risks are a bit higher with the CVS test.) If the results are positive, further tests or counseling can be arranged, says Maria Hayes, M.D., a reproductive endocrinologist at Oakwood Hospital in Dearborn, Michigan.

Complications Pregnancy in women over 35 can trigger high blood pressure and diabetes, and the risk of preeclampsia (pregnancy-induced hypertension) may also increase. The risk of miscarriage and stillbirth goes up with age as well, possibly due to chromosomal abnormalities or uterine fibroids (benign tumors found in nearly one-quarter of women over 35), which may interfere with fetal development. The incidence of twin births also increases and can cause preterm labor, which occurs in almost half of all multiple pregnancies. Older women have a higher rate of cesarean sections as well, which involve a longer recovery.

Emotions Moms-to-be over 35 are usually ready for the life change that comes with the birth of a baby. Managing the emotions and added strain that may accompany pregnancy, however, is important as high stress levels have been linked to an increased risk of complications. In addition to eating well and exercising, making time to relax should be a priority. Yoga, massage, and leaning on a support network of friends and family will help expectant mothers wind down during this emotionally charged time. 

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Pregnancy at 20, 30, 40

Most experts would say there's no one right time to start a family. But there are both advantages and disadvantages to giving birth at different ages: In your 20s, for instance, you'll have more energy to run after and care for your child but fewer financial resources and less personal life experience on which to draw; in your late 30s and 40s you may be more established financially but have a tougher time getting and staying pregnant and, afterward, keeping up with an active baby and toddler.

What follows is a look at the pros and cons of pregnancy at different ages.

Ages 20 to 24

YOUR BODY

These are your most fertile years. Your periods are probably regular, and most, if not all, of them are ovulatory. Even now, however, you may not conceive exactly when you want to. The average woman between 20 and 24 years old has about a 20 percent chance each month of getting pregnant when she has unprotected intercourse.

Once you do conceive, your blood pressure will probably be checked at each prenatal appointment, even though most women in their 20s have only a small risk of hypertension during pregnancy. New research shows that you have about half the risk of gestational diabetes that women in their 40s do, which is why recent guidelines from the American Diabetes Association suggest eliminating the once routine test for gestational diabetes in women age 25 or under.

YOUR EMOTIONAL SELF

How you feel about your pregnancy may depend, in great part, on other things in your life. Some women who postpone job advancement to have a baby feel ambivalent or resentful at first, says Diane Ross Glazer, Ph.D., a psychotherapist in Woodland Hills, CA. "Another concern is body image, which is a bigger issue for most women in their 20s than for those who are older. Also, a woman at this age is likely to be focused more on her marriage than on other parts of her life, such as her job, and adding a third person into the mix may be difficult," says Glazer.

RISKS TO YOUR BABY

The miscarriage rate during these years is about 9.5 percent, the lowest it will ever be. Because your eggs are still relatively young, your baby is much less likely to be born with a birth defect such as Down syndrome (1 in 1,667 births among women age 20) or other chromosomal abnormalities (1 in 526 among women age 20). Yet more infants with these disorders are born to women in their 20s because those in this age group have more babies and women past 35 are more likely to be offered screening tests and may elect to terminate a pregnancy in which the fetus has a birth defect.

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The Real Poop on Labor

The two most common questions women have about labor are, when will it start? and, how much will it hurt?

 The answer to both: Who knows? Fortunately, there are plenty of answers to other questions we all have but are afraid to ask because they seem silly, scary, or downright gross. "There's an awful lot about childbirth that is, shall we say, visually unfriendly," says Margaret Buxton, M.S.N, C.N.M., a certified nurse-midwife with the Vanderbilt University School of Nursing in Nashville, Tennessee, and a mother of two little girls. From placentas to mucous plugs to bodily fluids galore, here's what you always wanted to know about childbirth but were too mortified to mention.

What if my water breaks in public?

First off, only about one in four women experience their water breaking prior to the onset of labor, notes Buxton. And if you suspect that you're in labor, you probably won't be heading out to get your hair cut or browse for antiques.

Even if your water does break unexpectedly, your amniotic fluid is more likely to leak out slowly than to gush down your legs like a raging river. (Often, the baby's head will act as a "cork.") Meanwhile, it's not like people are going to think you peed in your pants. What's actually happening will be obvious to even casual observers, and they'll probably fall over themselves trying to help. Take all the sympathy you can get, because in a few short hours your baby will begin to show you no mercy, and that won't abate for the next 18 years, if ever. You can also greatly ease your anxiety by keeping a change of clothes in the trunk of your car or in your office. One caveat: If your water does break in public, call your health care provider. Since the risk of infection increases once the protective amniotic sac is broken, your provider will want to discuss when you should be admitted to the hospital or birth center.

I keep hearing about this mucous-plug thing and it sounds totally gross. When exactly is it likely to fall out, and will it clog up my toilet or what?

 

We cannot tell a lie: The mucous plug isn't pretty. It's basically a gelatinous glob that seals off the opening of your uterus (think of a cork in a wine bottle). You can lose the plug -- a thick vaginal discharge of mucus, sometimes tinged with blood -- all at once or in pieces. If you do lose your plug all at once, it's not going to be any worse than a menstrual clot, says Kate Abello, M.D., an obstetrician-gynecologist in private practice in Baltimore, Maryland. Wear a pad or panty liner and be alert for other signs of labor, which may begin soon after or still be weeks away. Note that the mucous plug is different from "bloody show" -- a vaginal discharge of stringy mucus streaked with blood that precedes labor by a day or two.

Women in my family tend to have fast labors. I'm terrified mine will begin at work and I'll have to deliver in front of my coworkers and male boss.

 

The short answer to this worry is to take an earlier maternity leave; if you're not in the office, it can't happen. You sure as heck aren't going to feel like being there the last week or two and will probably have lost so many brain cells you won't be that useful anyway. Seriously, though, discuss your family history with your health care provider. "Fast labors can indeed be a hereditary thing, and your doctor will want to be more vigilant about checking your cervix for dilation," notes Dr. Abello. "Then we can make sure you're in a safe place for delivery if we see signs of quick progress."

If you would like to work up until your due date, pay superclose attention to subtle signs of labor (backache and cramping are not just backache and cramping at this point!), and make a quick exit on days you just "don't feel right." You can also ask your boss if it would be possible for you to work from home during your final stretch. Worst case scenario, if you do go into labor at work, insist that your colleagues clear out an office and call 911, so some cute firefighter or paramedic who you never have to see again can do the honors.

Someone told me the placenta looks like a big kidney. Is this true? Because if so, I'm telling my doctor to keep it to himself.

 

Well, the placenta can look that way, and frankly, you'll be lucky if yours does. "A big, red, beefy placenta that looks a lot like organ meat is exactly what we hope for," Buxton says. "A tiny, shriveled placenta may mean you didn't take care of yourself or that your baby may not have gotten the nutrients and oxygen she needed." Of course, once your baby is born you will be so ecstatic and involved with her that you will barely be aware of the staff going about their business, known as the third stage of labor (the easy part, to you).

Meanwhile, your health care provider will quietly inspect the placenta to make sure it's normal and healthy and intact, but by then you'll be tallying up your little one's Apgar score and cooing about her already obvious brilliance.

I was hoping to invite some family members to be with me at the birth, but now I'm getting worried I'll lose control and start screaming at everyone.

It's the stuff of many a movie or TV show: Mom on the delivery table cursing out her husband for getting her into this mess. If you've ever been in a hospital maternity unit, you certainly may have heard a few screams. Still, you're not likely to morph into a totally different personality, says Trish Booth, a former childbirth educator and doula in Manlius, New York, and the author of Pregnancy Q&A: Authoritative and Reassuring Answers to the Questions on Your Mind. "You do not become someone else in labor -- it's an intensification of who you already are," she explains. "If you turn inward and get quiet under stress, that's what you'll do in labor. If you yell and scream normally, then you may during childbirth too."

Is it true -- do women really end up pooping when they push the baby out?

There's a very good reason they tell you pushing the baby out feels like a bowel movement -- you're probably having one of those too. "The vagina and rectum are parallel, so when the baby's head begins to crown, anything in the rectum gets expelled as well," explains Buxton. "It's just physics. Women get upset because it's a private thing, but like vomiting, it's no surprise to anyone who works in a labor room. We just discreetly clean it up and move on." And rest assured that no one is going to allow your baby to land in poop -- this event happens in the early stages of pushing, not when the baby comes out.

My husband fainted at my last birth -- he said all the blood was too scary looking. I'm not squeamish, however, and would like to try to watch the birth in the hospital mirror this time around. Do I dare -- and what do I do about him?

We love dads -- we wouldn't be procreating without them, after all -- but not all men are created equal when it comes to delivery-room support. Research shows that men fear losing their partner more than anything else about childbirth, explains Booth. Labor can be frightening for them to watch, and when it comes to medical decisions, "many dads will defer to anyone in scrubs," she says. Chances are your partner will hold up better the second time around -- just like you, he has some idea of what to expect -- but don't force a 360-degree view on him if he seems wary of the idea.

The beauty of the delivery-room mirror is that it is easily adjustable. Your health care provider can angle it so that you can see what's going on while Dad averts his eyes. And if you change your mind, it can be quickly rotated so you don't have to watch either. Actually, the reverse often happens: "Watching your own progress can be a good motivational tool," says Buxton. "Moms get inspired to push harder when they see the head coming. And dads who come into the delivery room insisting they don't want to see any blood may totally change their tune and become fascinated if the caregivers explain what's happening. The next thing you know, Dad's putting on gloves and catching the baby."

A few of my friends got a full-monty wax job before they delivered. I can't imagine that, even if I weren't pregnant. Is it really necessary?

 There is a trend toward vaginal shaving and waxing among women, especially younger ones, in our society in general, but it's hardly something you need to do if you're not inclined, assures Buxton. In the more primitive days of childbirth (like only a few decades ago), women were routinely shaved and given an enema when they were admitted to the hospital. The logic: It provided a more hygienic environment for delivery. Fortunately, that attitude went the way of leaving dads out in the waiting room. Waxing isn't necessary and certainly doesn't matter to your doctor.

I've heard the pain relievers can make you nauseous. What if I start to throw up on top of everything else coming out of my body?

Some pain relievers can, and likely will, make you nauseous, most notably the analgesic family, also known as narcotics, which includes Demerol, Nubain, and Stadol. These medications don't remove your pain, but "dull" it instead. If you're prone to queasiness, you may want to pass on them altogether, or ask for an antinausea medication to be given with them. An epidural can sometimes cause your blood pressure to drop, which can leave you feeling a bit light-headed and therefore queasy.

But bear in mind that not having any type of anesthesia doesn't guarantee that you won't vomit. You know how they say contractions come in waves? Normal, active labor alone is enough to make some women spill their guts. That's one of the reasons why women are advised not to eat much after labor begins. But here's an unexpected plus: The same reflex that causes you to vomit helps push the baby out. "I've had moms-to-be who were only four or five centimeters dilated; then they vomit and suddenly hit ten centimeters," notes Buxton.

Will I still be the same "down there" when this is all over? Even if I have an episiotomy?

Trust us: You're probably not going to be too worried about this right after having the baby. Sex will not be nearly as enticing as sleep, and when you begin to feel amorous again, all will be healed and you will have had time to perform a gazillion Kegels to regain your muscle tone, if you're that motivated. As for the tightness factor, if your episiotomy or tears are repaired well and you exercise to get your muscle tone back, especially between pregnancies, your pelvic floor should return to normal, insists Dr. Abello.

Sex can feel different at first because scar tissue may need some stretching, but take it slowly and gently and the pleasure will return. Buxton recommends doing Kegels while nursing your baby -- not only to regain muscle tone, but because they promote blood flow, which will help your perineum heal. And remember: There are other ways to be intimate when you're not in the mood for sex.

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10 Ways to Boost Your Fertility

It's an aspect of our health that most of us take for granted: Have sex, get pregnant, right? In reality, even minor stressors can throw your body out of whack. If you're trying to conceive, these simple health moves can help protect your fertility.

Watch Your Weight

 

Aside from the other risks it poses to your health, excess body fat can lead to an overproduction of certain hormones that disrupt ovulation. Your cycles may be less regular, you may ovulate less often, and you lower your chances of getting pregnant. On the flip side, too little body fat means your body may not produce enough hormones to ovulate each month or to sustain a pregnancy if you do conceive. Exercise can help you maintain a healthy weight. Just don't overdo it, says Christopher Williams, MD, a reproductive endocrinologist at the University of Virginia, in Charlottesville, and author of The Fastest Way to Get Pregnant Naturally (Hyperion). Women who exercise intensely (like long-distance runners or competitive athletes) may stop ovulating or ovulate less frequently. Overexercising also raises miscarriage risk. Talk to your doctor or midwife about your workout routine before trying to get pregnant.

Eat Well

 

Staying well nourished boosts your odds of conceiving. Make sure to include enough protein, iron, zinc, and vitamin C, because deficiencies in these nutrients have been linked to lengthened menstrual cycles (and therefore less frequent ovulation) and a higher risk of early miscarriage. Women athletes are prone to being deficient in zinc, Dr. Williams says. "Oysters are a rich source, but it's probably easier for most women to get zinc -- plus all other essential vitamins and minerals -- from a daily multivitamin supplement." Also include protein-rich foods in your diet, such as meat, fish, low-fat dairy products, eggs, and beans. Vegetarians can get their complete amino acids by including flavorful combinations of protein-containing foods, such as rice and beans or stir-fry with tofu.

Kick Butt (Cigarettes, That Is)

 

As if you needed another reason to quit smoking: Cigarette toxins not only damage a woman's eggs, interfering with the fertilization and implantation process, but also cause the ovaries to age. That means that the ovaries of a 35-year-old smoker function as if they belong to a 42-year-old and are therefore less fertile, says Robert Barbieri, MD, head of obstetrics and gynecology at Brigham and Women's Hospital, in Boston, and coauthor of 6 Steps to Increased Fertility (Simon & Schuster). "Smoking does permanent damage to your fertility, but when you cut out cigarettes, you get some ovarian function back."

Know Your Cycle

A normal menstrual cycle lasts about 25 to 35 days (start counting on the first day of your period). If your cycle is noticeably longer -- say, 42 days -- you can assume you're ovulating less often and may want to see your ob-gyn or midwife, says Michael Soules, MD, past president of the American Society for Reproductive Medicine and managing partner of Seattle Reproductive Medicine, a fertility clinic in Seattle, Washington. When you're ready to conceive, find your "fertile window," during which you should have intercourse regularly. A woman's fertile days are usually the day of ovulation and the four of five days before, not after. But don't assume that you automatically ovulate on day 14 of your cycle: A study from the National Institute of Environmental Health Sciences found that ovulation varies dramatically from woman to woman, occurring as early as day 6 and as late as day 21 of a cycle. How can you determine when you're ovulating? You can try an ovulation test kit, which checks for certain hormones in your urine, or note daily changes in your basal body temperature and cervical mucus.

Seek Serenity

Stress and depression may hamper your fertility. A Danish study, which followed 393 couples who were trying to get pregnant, found that women were less likely to conceive during months when they reported psychological distress. Experts suspect that stress, like heavy exercise, may throw off your body's hormone production, making your menstrual cycle less reliable. But learning to manage stress through relaxation techniques (such as mindfulness meditation or yoga) or support from a counselor or a group, can get your hormones back on track, Dr. Barbieri says.

Think Before Drinking

 

A growing body of research has linked alcohol consumption with a decreased ability to get pregnant (not to mention the harm it can cause to a developing fetus). Alcohol alters estrogen levels, which may interfere with egg implantation, although pouring an occasional glass of Pinot with your dinner is unlikely to harm fertility. You should also consider cutting back on caffeine while you try to conceive and during your pregnancy. A recent study published in the American Journal of Obstetrics and Gynecology found that women who drank the equivalent found in two cups of coffee were twice as likely to miscarry as those who didn't consume any. The bottom line: If you're thinking about getting pregnant, be a teetotaler and limit your daily java fix.

Get Busy in the Bedroom

 

If the demands of your hectic life have dampened your sex drive, it's a good idea to start having sex more often. Some research suggests that women who engage in regular (at least weekly) intercourse are more likely to have predictable menstrual cycles and normal ovulation than women who have sporadic sex. One theory: Your husband emits sex hormones that influence your reproductive system. Weekly sex may also make you produce more estrogen. And there's no question that frequent sex helps when you're actually trying to conceive. Having sex every 36 to 48 hours in the few days before ovulation will make the most of your fertile window, Dr. Williams says. But because mandatory sex on certain days can become a chore, you might also try making love every few days all month long.

Don't Douche

 

This can wipe out normal, protective bacteria in the vagina, shifting the balance and putting you at risk for bacterial vaginosis, a common but often overlooked vaginal infection. A fishy odor and grayish discharge are often the only signs. Untreated BV has been linked to preterm labor and may be associated with higher risk of miscarriage and infertility. See your healthcare provider if you notice any new vaginal symptoms (itchiness, burning, unusual discharge, or sores). A reproductive-tract infection is unlikely, but it's best to be safe when your fertility is at stake.

Protect It with the Pill

  Yes, the birth-control pill may actually enhance your fertility. "I suspect that oral contraceptives, which halt ovulation, quiet down your reproductive system, protecting your ovaries from aging," Dr. Barbieri says. For some women, the pill can be critical in preserving fertility because it keeps two common conditions, endometriosis and uterine fibroids, under control by slowing uterine-tissue growth. (With endometriosis, uterine tissue grows outside the uterus, causing painful cramps and often harming the fallopian tubes or other organs. Uterine fibroids are benign growth that can make pregnancy difficult or impossible.) Once you go off birth-control pills, your cycle will return to its pre-pill pattern in about a month.

Don't Overlook His Health The same things that harm your fertility can do a number on your husband's reproductive health too. Cigarettes, alcohol, a poor diet -- any of these can contribute to lower sperm production or motility (ability to swim). Studies have also traced chromosomal damage in sperm to cigarette smoke and heavy alcohol intake. Getting enough nutrients every day -- particularly vitamins E and C and the mineral selenium -- will help him produce healthy sperm. Taking a daily multivitamin is a good step, Dr. Williams says. "It takes almost three months for a man to make new sperm, so he needs to think ahead too."

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Get Pregnant Faster: Your 7-Step Plan

Go Off Your Birth Control -- Ahead of Time

Have you been popping those little white pills since high school? Take a pass on your prescription a few months before you plan to start trying, says Christopher Williams, MD, a reproductive endocrinologist in private practice in Charlottesville, Virginia, and author of The Fastest Way to Get Pregnant Naturally. That goes for other forms of hormonal birth control too, including the patch, the ring, Mirena IUC, and Implanon. (You should stop getting Depo-Provera, injectable shots of progesterone about nine months before you want to try getting pregnant.)

"After you've been using birth control for awhile, it may take your body a few cycles to start ovulating regularly and be primed for pregnancy," he says. Plus, this gives you time to track your cycle to figure out exactly when you ovulate (step #2), which is key for timing your babymaking.

FYI: Once you stop using birth control, you can get pregnant at any time. So if you're not quite ready to see that pink line on the stick, make sure to use a barrier method like a condom or diaphragm in the interim.

 

Figure Out Your Fertile Days No matter how often you and your partner get horizontal, if you skip the key days out of the month when your egg is raring to go, you won't get pregnant. "The biggest mistake my patients make is not knowing exactly when they ovulate," says Dr. Williams.

Until recently, many women did this by tracking their temperature first thing in the morning, called basal body temperature (BBT). Since your temperature spikes slightly -- about .5 degrees -- around ovulation, this gives you basic info on your cycle. But the problem with this low-tech method is that by the time you notice the change in temperature, you've likely already ovulated -- and missed out on the best time to have babymaking sex.

Now, most doctors recommend using ovulation predictor kits (OPKs) for a more accurate measure of ovulation. Though you can still use BBT charting to help you get in the ballpark, ovulation predictor kits give you advance warning that your egg is about to be released, so you can plan accordingly. OPKs work by detecting a surge in luteinizing hormone (LH) in your urine, which occurs about 36 to 48 hours before you ovulate.

There are two basic types of OPKs available: Those you use only around the week before you ovulate (these are better for women with very regular cycles, since you need a rough idea of when you ovulate to know when to start using the kit) and those you use every day of the month (a better choice for women with less regular cycles; they're also a bit pricier).

FYI: For the most approximate way to determine when you ovulate, subtract 14 from the length of your cycle. For example:

* If you have a 28-day cycle, you ovulate around day 14.
* If you have a 25-day cycle, you ovulate around day 11.
* If you have a 35-day cycle, you ovulate around day 21.

 

 

Have Sex Before You Ovulate Those hardy sperm can stick around in your uterus and fallopian tubes for two to three days, but your egg only lasts for 12 to 24 hours after it's released. So having sex before you ovulate boosts the chances that there'll be sperm around to greet your egg as soon as it debuts.

For a typical 28-day cycle (where you ovulate on day 14), here's what you'll do:

* Start having sex a few times a week as soon as your period ends. Getting busy that often ensures you won't miss your most fertile time, especially if your cycle length varies from month to month.

* Make a point to have sex every other day starting around day 10.

* When you have a positive result on your OPK (around day 12), have sex that day and the next two days -- these are your primo days out of the month to conceive.

Sex Session Dos

What really works and what's purely the stuff of old wives' tales is somewhat debatable. Dr. Williams helps us separate myth from fact

Do:

* Lie on your back after sex. "Because the vagina naturally slopes downward, resting on your back after sex allows sperm to pool there, which gives them an edge in swimming toward your egg," says Dr. Williams. Should you keep your legs elevated, too? It can't hurt, he says, but it probably doesn't help any more than lying down does.
* Have sex before bed. Though some sources report that sperm count is highest in the morning, the truth is that there's no optimal time of day to have sex. However, doing so before you hit the hay is an easy way to ensure you stay on your back afterward.
* Keep it vanilla(ish). While there's no single sex position that's best for babymaking (or for choosing your baby's sex), stick to one where you'll be on your back when it's over.

 

 

Sex Session Don'ts

Don't:

* Use lube to give sperm a leg up. Some people may think that a lubricant may help sperm move more quickly, but the truth is that this can actually hinder your pregnancy efforts. Many formulas may alter the pH balance in the vagina and decrease sperm mobility.
* Worry if you don't have an orgasm. A great perk of satisfying sex, sure, but don't count on your postcoital bliss to help you get pregnant more quickly. Though some speculate that orgasms boost conception by drawing more sperm into the vagina and uterus, this theory lacks scientific proof.
* Worry about boxers vs. briefs. Because some fertility problems in men stem from a condition where the temperature in the testicles is excessively warm, which affects sperm production, it's natural to believe that favoring briefs over boxers could hinder conception. However, there's no good evidence this is true, says Dr. Williams. There's certainly no downside to his sticking with boxers, but it's unlikely to significantly speed up your pregnancy timeline.

Get Ready to Test

The earlier you know you're pregnant, the sooner you can see your doctor to start prenatal care and make sure your eating, drinking, and other habits are as healthy as possible. Though some of today's home pregnancy tests allow you to start testing super-early (as soon as 10 days after you ovulate), you'll get the most accurate results if you wait until the day you expect to get your period.

Home pregnancy tests work by detecting levels of human chorionic gonadotropin (hCG) in your urine. Levels of this hormone, produced by the placenta, continue to rise in early pregnancy. Tests marketed as "early results" or "early response" may be more sensitive at detecting lower levels of hCG earlier.

Testing too early is likely to yield what experts call a "false negative" result -- where the test says you're not pregnant, but you really are. What's happening is that your body isn't producing enough hCG yet to be detected by the test. Waiting and testing again a few days after your missed period is likely to turn up the plus sign you're looking for.

If the Test Is Negative...

Didn't get pregnant this month? Don't panic. Most couples don't succeed the first time out of the gate (more than half get pregnant by 6 months, about 85 percent by one year). Most likely, you miscalculated your most fertile days, so your partner's sperm never had the chance to fertilize your egg. Consider switching to a daily OPK if you haven't already tried it, and get psyched to try again next month.

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Stillbirths tied to Secondhand Smoke

Pregnant women who live or work with smokers may be at slightly higher risk of having a stillborn baby, giving birth to a slightly smaller baby or having a baby with a smaller head, according to a Canadian study.

Secondhand smoke is thought to expose people to about one per cent of the smoke that active smokers inhale, and the study adds to evidence that even passive smoking can harm unborn babies.

“This information is important for women, their families and healthcare providers,” wrote Joan Crane, of Eastern Health in St. John’s, Canada, in the BJOB: An International Journal of Obstetrics and Gynaecology.

“Undiluted sidestream smoke contains many harmful chemicals and in greater concentration than cigarette smoke inhaled through a filter.”

Crane and colleagues noted that those chemicals may harm the fetus in a variety of ways — for instance, by restricting blood flow and possibly damaging the placenta.

Using a database of pregnant women from the Canadian provinces of Newfoundland and Labrador, they looked at the rate of stillbirths as well as other birth outcomes, such as head circumference, which has been linked to the later intellectual development of children.

Of nearly 12,000 women in the database, 11 per cent said they had been exposed to secondhand smoke.

The rate of stillbirth, in which the baby dies during the third trimester of pregnancy, was 0.83 per cent in passive smokers and 0.37 per cent in women who didn’t breathe tobacco fumes.

This doesn’t prove that smoke itself was the culprit, yet when researchers accounted for other risk factors — including age and the women’s drinking and drug habits — passive smokers still had three times the odds of stillbirths.

In other words, if smoke is indeed to blame, one extra baby would die in the womb for every 117 women exposed.

“This is huge,” said Hamisu Salihu, an expert on stillbirth at the University of South Florida in Tampa.

“We can now inform patients to secondhand smoke means they can lose their baby.”

That link had not been firmly established until now, Salihu, who was not involved in the study, told Reuters Health.

The Canadian researchers also found that babies born to passive smokers weighed 54 grams, or nearly 2 ounces, less than babies whose mothers lived and worked in smoke-free places.

And their heads were slightly smaller too, measuring 0.24 centimeters (about 0.1 inch) less on average.

Salihu said head circumference has been associated with IQ, although the link is indirect.

“Policy makers should really take this matter seriously. We need to enact laws to protect these babies,” Salihu added.

On a global scale, the most common causes of stillbirth are complications during childbirth, infections during pregnancy such as syphilis, health problems such as high blood pressure or diabetes, fetal growth restriction — in which babies fail to grow at the proper rate — and birth defects.

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Pregnancy Weight Gain

About Pregnancy Weight Gain


Talking to your doctor about your weight gain is important. Try not to worry if you're slightly above or below these weights. Working with your doctor on food intake will get you on track.

Facts About Weight Gain


The American College of Obstetricians and Gynecologists recommends a weight gain of 25 to 35 pounds during pregnancy, for women who are at normal weight when pregnancy occurs.

Women who are underweight should gain 28 to 40 pounds, unless your doctor says differently.
Women who are overweight should gain 15 to 25 pounds, unless your doctor says differently.
Women who are obese should gain 11 to 20 pounds, unless your doctor says differently.

Eating low fat meals will allow you to gain weight correctly for your pregnancy. Putting on weight that is unnecessary is easy to do when eating junk food and foods that are higher in fat.
Eating a well-rounded diet is important. According to the American College of Obstetricians and 
Gynecologists, pregnant women should have 4 servings of milk, 3 to 4 servings of protein (2 to 3 from animal and 1 to 2 from legumes/nuts), 5 servings of fruits and vegetables (2 of Vitamin C, 2 of Vitamin A, and 1 of another), 4 servings of whole grain products, and 2 servings of other.


Weight Distribution


7 ½ pounds is about how much the baby will weigh by the end of pregnancy
1 ½ pounds is how much the placenta weighs
4 pounds is attributed to increased fluid volume
2 pounds is the weight of the uterus
2 pounds is the weight of breast tissue
4 pounds is because of increased blood volume
7 pounds is attributed to maternal stores of nutrients and muscle development
2 pounds for the amniotic fluid

Total: 30 pounds

On a Trimester Basis


First trimester: 1 pound per month
Second trimester: 1/2 a pound per week
Third trimester: 1 pound per week

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Umbilical cord abnormalities

The umbilical cord is a narrow tube-like structure that connects the developing baby to the placenta. The cord is sometimes called the baby's “supply line” because it carries the baby's blood back and forth, between the baby and the placenta. It delivers nutrients and oxygen to the baby and removes the baby's waste products.

The umbilical cord begins to form at 5weeks after conception. It becomes progressively longer until 28 weeks of pregnancy, reaching an average length of 22 to 24 inches (1). As the cord gets longer, it generally coils around itself. The cord contains three blood vessels: two arteries and one vein.

• The vein carries oxygen and nutrients from the placenta (which connects to the mother's blood supply) to the baby.
• The two arteries transport waste from the baby to the placenta (where waste is transferred to the mother's blood and disposed of by her kidneys).

A gelatin-like tissue called Wharton's jelly cushions and protects these blood vessels.

A number of abnormalities can affect the umbilical cord. The cord may be too long or too short. It may connect improperly to the placenta or become knotted or compressed. Cord abnormalities can lead to problems during pregnancy or during labor and delivery.

In some cases, cord abnormalities are discovered before delivery during an ultrasound. However, they usually are not discovered until after delivery when the cord is examined directly. The following are the most frequent cord abnormalities and their possible effects on mother and baby.

What is single umbilical artery?
About 1 percent of singleton and about 5 percent of multiple pregnancies (twins, triplets or more) have an umbilical cord that contains only two blood vessels, instead of the normal three. In these cases, one artery is missing (2). The cause of this abnormality, called single umbilical artery, is unknown.

Studies suggest that babies with single umbilical artery have an increased risk for birth defects, including heart, central nervous system and urinary-tract defects and chromosomal abnormalities (2, 3). A woman whose baby is diagnosed with single umbilical artery during a routine ultrasound may be offered certain prenatal tests to diagnose or rule out birth defects. These tests may include a detailed ultrasound, amniocentesis (to check for chromosomal abnormalities) and in some cases, echocardiography (a special type of ultrasound to evaluate the fetal heart). The provider also may recommend that the baby have an ultrasound after birth.

What is umbilical cord prolapse?
Umbilical cord prolapse occurs when the cord slips into the vagina after the membranes (bag of waters) have ruptured, before the baby descends into the birth canal. This complication affects about 1 in 300 births (1). The baby can put pressure on the cord as he passes through the cervix and vagina during labor and delivery. Pressure on the cord reduces or cuts off blood flow from the placenta to the baby, decreasing the baby's oxygen supply. Umbilical cord prolapse can result in stillbirth unless the baby is delivered promptly, usually by cesarean section.

If the woman's membranes rupture and she feels something in her vagina, she should go to the hospital immediately or, in the United States, call 911. A health care provider may suspect umbilical cord prolapse if the bay develops heart rate abnormalities after the membranes have ruptured. The provider can confirm a cord prolapse by doing a pelvic examination. Cord prolapse is an emergency. Pressure on the cord must be relieved immediately by lifting the presenting fetal part away from the cord while preparing the woman for prompt cesarean delivery.

The risk of umbilical cord prolapse increases if:

• The baby is in a breech (foot-first) position.
• The woman is in preterm labor.
• The umbilical cord is too long.
• There is too much amniotic fluid.
• The provider ruptures the membranes to start or speed up labor.
• The woman is delivering twins vaginally. The second twin is more commonly affected.

What is vasa previa?
Vasa previa occurs when one or more blood vessels from the umbilical cord or placenta cross the cervix underneath the baby. The blood vessels, unprotected by the Wharton's jelly in the umbilical cord or the tissue in the placenta, sometimes tear when the cervix dilates or the membranes rupture. This can result in life-threatening bleeding in the baby. Even if the blood vessels do not tear, the baby may suffer from lack of oxygen due to pressure on the blood vessels. Vasa previa occurs in 1 in 2,500 births (4).

When vasa previa is diagnosed unexpectedly at delivery, more than half of affected babies are stillborn (4). However, when vasa previa is diagnosed by ultrasound earlier in pregnancy, fetal deaths generally can be prevented by delivering the baby by cesarean section at about 35 weeks of gestation (4).

Pregnant women with vasa previa sometimes have painless vaginal bleeding in the second or third trimester. A pregnant woman who experiences vaginal bleeding should always report it to her health care provider so that the cause can be determined and any necessary steps taken to protect the baby.

A pregnant woman may be at increased risk for vasa previa if she:

• Has a velamentous insertion of the cord (the umbilical cord inserts abnormally into the fetal membranes, instead of the center of the placenta)
• Has placenta previa (a low-lying placenta that covers part or all of the cervix) or certain other placental abnormalities
• Is expecting more than one baby

What is a nuchal cord?
About 25 percent of babies are born with a nuchal cord (the umbilical cord wrapped around the baby's neck) (1). A nuchal cord, also called nuchal loops, rarely causes any problems. Babies with a nuchal cord are generally healthy.

Sometimes fetal monitoring shows heart rate abnormalities during labor and delivery in babies with a nuchal cord. This may reflect pressure on the cord. However, the pressure is rarely serious enough to cause death or any lasting problems, although occasionally a cesarean delivery may be needed.

Less frequently, the umbilical cord becomes wrapped around other parts of the baby's body, such as a foot or hand. Generally, this doesn't harm the baby.

What are umbilical cord knots?
About 1 percent of babies are born with one or more knots in the umbilical cord (1). Some knots form during delivery when a baby with a nuchal cord is pulled through the loop. Others form during pregnancy when the baby moves around. Knots occur most often when the umbilical cord is too long and in identical-twin pregnancies. Identical twins share a single amniotic sac, and the babies' cords can become entangled.

As long as the knot remains loose, it generally does not harm the baby. However, sometimes the knot or knots can be pulled tight, cutting off the baby's oxygen supply. Cord knots result in miscarriage or stillbirth in 5 percent of cases (1). During labor and delivery, a tightening knot can cause the baby to have heart rate abnormalities that are detected by fetal monitoring. In some cases, a cesarean delivery may be necessary.

What is an umbilical cord cyst?
Umbilical cord cysts are outpockets in the cord. They are found in about 3 percent of pregnancies (2).

There are true and false cysts:

• True cysts are lined with cells and generally contain remnants of early embryonic structures.
• False cysts are fluid-filled sacs that can be related to a swelling of the Wharton's jelly.

Studies suggest that both types of cysts are sometimes associated with birth defects, including chromosomal abnormalities and kidney and abdominal defects (2). When a cord cyst is found during an ultrasound, the provider may recommend additional tests, such as amniocentesis and a detailed ultrasound, to diagnose or rule out birth defects.

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Gestational diabetes

Pregnancy is a time of promise and expectation, but it can also raise the possibility for some women that they will develop gestational diabetes mellitus (GDM).

Finding out you have GDM can be very frightening. Not only do you have to deal with all the emotions (the ups and the downs) and the questions that come with being pregnant, but also the uncertainty of this new-found condition. Fortunately, as with all types of diabetes, there are many well-informed health professionals to help answer your questions and to guide you through this very important time in your life. The more you know, the easier it is to accept and make the necessary changes for a successful and happy pregnancy.

GDM is defined as high blood sugar (hyperglycemia) with onset or first recognition during pregnancy. In Canada, GDM is higher than previously thought, varying from 3.7% in non-Aboriginal women to 8–18% in Aboriginal women.

Risk factors for developing GDM:

• a previous diagnosis of GDM or delivery of a macrosomic (excessive birth weight) infant
• being a member of a high-risk population, including women of Aboriginal, Hispanic, South Asian, Asian and African descent
• being 35 years of age or older
• being obese (BMI of 30 kg/m2 or higher)
• a history of polycystic ovary syndrome (PCOS)
• acanthosis nigricans (a skin disorder characterized by the appearance of darkened patches of skin)
• use of corticosteroids

Although some women are at greater risk than others, the Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada recommend that all women be screened for GDM between 24 and 28 weeks' gestation using a gestational diabetes screening test†. For women with multiple risk factors, this screening test should be done during the first trimester, then again during the second and third trimesters, even if the first test is negative.

Prompt diagnosis of GDM is important, as it carries several risks to both mother and infant. For example, children born to mothers with GDM may be “macrosomic”, a medical term meaning “excessive birth weight”, associated with higher rates of cesarian deliveries. This poses a risk of trauma to both mother and baby during the delivery. These babies also have a higher risk of dangerously low blood sugar levels after birth (hypoglycemia) and excess levels of insulin in the blood (hyperinsulinemia). They are also at higher risk for potential long-term obesity and glucose intolerance.

Although the diagnosis should be taken seriously, GDM can be managed by some of the same measures with which type 2 diabetes is managed.

Lifestyle

During pregnancy, women with GDM should be evaluated and followed by a registered dietitian to ensure that nutrition therapy promotes normal levels of blood glucose, appropriate weight gain and adequate nutritional intake. Physical activity is encouraged with the frequency and intensity of activity decided with your doctor based on your pregnancy and risk factors.

If women with GDM do not reach the recommended blood glucose target levels within two weeks of nutrition therapy alone, insulin therapy may be initiated. Certain types of insulin can be safely used during pregnancy.

Recommended blood glucose targets during pregnancy*

	A1C**	Fasting blood glucose / blood glucose before meals (mmol/L)	Blood glucose one hour after eating (mmol/L)	Blood glucose two hours after eating (mmol/L)
Target for most pregnant women	≤6.0% (normal)	3.8 to 5.2	5.5 to 7.7	5.0 to 6.6

* This information is based on the Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada and is a guide only. In some women, particularly those with type 1 diabetes, higher targets may be necessary to avoid excessive low blood sugar (hypoglycemia). Talk to your doctor about YOUR blood glucose target ranges.

** A1C is a blood test that indicates an average of your overall blood glucose levels over the past 120 days.

After the baby is delivered

Women who have had GDM are at increased risk of developing subsequent type 2 diabetes later in life. A blood glucose test should be performed between six weeks and six months after the baby is born.

To reduce the risk of developing type 2 diabetes in the future, women with previous GDM should:

• Be encouraged to breastfeed
• Follow a healthy lifestyle
• Be screened regularly for the development of type 2 diabetes or impaired glucose tolerance
• Consult their physician and be screened for type 2 diabetes when planning another pregnancy

With prompt diagnosis and good management, women with GDM can expect to have a healthy pregnancy and a happy, healthy baby.

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The suggested test for GDM is the Gestational Diabetes Screen (GDS). This test usually takes place in a medical diagnostic laboratory. An initial sample of blood is drawn (to be used as a baseline blood glucose reference level). The person then drinks a liquid that contains 50 grams of glucose (sugar). After one hour, a second blood sample is drawn. The purpose of this test is to see how well the body deals with the glucose in the blood over time. In a person without diabetes, glucose levels rise and then fall quickly. In someone with GDM or diabetes, glucose levels rise higher than normal and fail to come back down as quickly. The 2008 Canadian Diabetes Association Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada recommend diagnosing GDM if glucose levels 1 hour after the GDS is 10.3 mmol/L or greater.

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Antidepressants and Pregnancy

Depression is a common affliction among women in general, and pregnant women are no exception. According to the Women's Mental Health Program at Loyola University Health System, between 12 to 20 percent of pregnant women suffer from depression, and many cases may go undiagnosed.

Many women are concerned about taking antidepressants while pregnant, for fear of harming their unborn child. Studies show, however, that there is no evidence that antidepressants cause any serious problems, and suggest that leaving depression or anxiety untreated during pregnancy may actually have negative effects.

Many studies in the last few years have shown no increase in the incidence of birth defects, behavioral problems, learning disabilities, mental retardation, pre-term labor, or low birth weight with women who take selective serotonin reuptake inhibitors (SSRIs) such as Prozac, Paxil, and Zoloft during their pregnancy.

However, if depression or anxiety is left untreated during pregnancy, there is an increased likelihood of preterm labor, premature delivery, low-birth weight, and small head circumference. Untreated depression can also inhibit a woman's ability to care for herself; impair her nutrition; lead to an increase in her use of tobacco, alcohol, and drugs; and interfere with her ability to bond with the child.

Depression during pregnancy is also a strong risk factor for postpartum depression. Women in the United States have a higher incidence of postpartum depression than any other country in the world. This is believed to be caused by shorter maternity leave in this country, women feeling pressured to return to work quickly to help with the family income, fragile support systems, and parents and other family members living far away. Other risk factors for postpartum depression include being a single mother, an unwanted pregnancy, a history of depression and anxiety, and having a child with special needs.

Depression is a serious condition that affects many women. If you are suffering from depression, talk to your doctor about getting treatment. Group therapy and one-on-one counseling with a psychotherapist are also great medication-free ways to deal with depression. Getting proper treatment is important for your health, and the health of your baby.

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Caffeine

Many women are told by their doctors or midwives to limit their caffeine consumption while they are pregnant. Giving up that morning cup (or cups) of coffee may be a struggle for some pregnant women, and many question if it is really necessary to give up caffeine completely while they are pregnant.

The topic is a controversial one and the answer is still under debate. Some studies have shown a slightly higher risk of miscarriage with women who consume more than 300 mg of caffeine a day. Others have shown that babies born to women who consumed more than 500 mg of caffeine a day while pregnant had faster heart and breathing rates, and spent more time awake in the first few days after birth. However, the research is inconclusive and the amounts of caffeine generally used in the studies were vastly greater than what a normal person would consume on a daily basis. The most consistent finding with studies performed on caffeine consumption during pregnancy was a possible association with low birth weights. According to the March of Dimes, high caffeine consumption may slightly increase the risk of preterm labor or low birth weight; and in a fetus who is already experiencing difficulties, this slight increase could make all the difference.

Most experts agree that moderate caffeine consumption is probably safe for a healthy woman experiencing a normal pregnancy. However, decreasing or cutting out caffeine altogether will probably make you feel better because caffeine can cause or exacerbate many common pregnancy-related complaints. Since caffeine is a stimulant, it can cause insomnia, nervousness, and headaches. It can contribute to heartburn because it stimulates the secretion of stomach acid, and it's a diuretic so it will enhance dehydration. It also causes your bones to lose calcium; and contains phenols which impede your body's ability to absorb iron, a nutrient many pregnant women are already lacking.

Coffee and tea are the most obvious culprits for caffeine, but it's also found in chocolate, some soft drinks (including several orange sodas and root beers), energy drinks, and some over-the-counter medications.

Here is a list of common caffeinated foods and beverages and their caffeine content:

Food or Beverage	Quantity	Caffeine Content
Brewed coffee	8 ounces	100-300 mg
Espresso	2 ounces	40-70 mg
Decaffeinated coffee	8 ounces	1-8 mg
Brewed tea	8 ounces	35-175 mg
Green tea	8 ounces	8-30 mg
Instant tea	8 ounces	40-80 mg
Iced tea	12 ounces	65-75 mg
Soft drinks	12-ounce can	30-60 mg
Hot cocoa	8 ounces	3-30 mg
Milk chocolate	1 ounce	1-15 mg
Dark or semisweet chocolate	1 ounce	5-35 mg

If you are a regular coffee, tea or cola drinker and want to kick the habit completely while you are pregnant, ease off gradually. Going cold turkey may cause headaches, fatigue, and lethargy.

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Choosing an OB or Midwife

Expectant couples have several options when it comes to quality obstetrical care. Think about which options in pregnancy and childbirth are important to you so that you can find a healthcare provider who shares your birth philosophy. Here is a good list of the types of caregivers available.

Obstetrician (OB/GYN): An obstetrician is a physician who specializes in pregnancy and childbirth. OBs usually deliver in hospitals or birthing centers. If they have a FACOG credential, it means that they are a Fellow of the American College of Obstetrics and Gynecology.

Family Physician: A family practitioner is trained in all aspects of family care including obstetrics, pediatrics, gynecology and internal medicine.

Nurse-Midwife: A certified nurse-midwife has a degree in nursing with specialty training in obstetrics. They can provide complete care for normal healthy pregnancies and must be associated with a backup OB in the event of complications. They can deliver in hospitals, birthing centers and homes. Midwives are an appealing option for expectant parents who want a more individual, less routine approach for the birth of their baby. This isn't to say midwives are better or more qualified than doctors. They're different professionals with different philosophies.

Traditional or Lay Midwife: This type of midwife has training in midwifery only and works with low risk pregnancies. You need to check with your state to see what types of licensing/certification is required. They usually attend home births or births at birthing centers.

Maternal-Fetal Medicine Specialist (Perinatologist): This type of physician is an obstetrician with special training in the care of high risk pregnancies. Usually, a perinatologist will see patients referred by an obstetrician or family practitioner and will work with them in managing high risk care.

Once you decide what type of caregiver you want, make a list of potential providers. After you've narrowed down the list, call to schedule interviews. Be sure to tell the receptionist that this is an interview only and ask if there will be a fee. Before you go to the interviews, make a list of questions and TAKE THE LIST WITH YOU.

If possible, both expectant parents should attend the interviews. Use the questions below as a guide you during your interviews. Although the doctor or nurse-midwife may answer all the questions effectively, trust your instincts if the relationship doesn't feel like a good fit, and ask yourself why. Most doctors only have about 10-15 minutes to spare for your interview. Midwives may be able to give you a little more time. If the interview takes longer (up to 30 minutes) you may be charged a consultation fee. Remember, when you choose a doctor or nurse-midwife, you're also choosing the institution where you'll deliver, which will have its own protocols and procedures. Make sure and check with support staff in the front office about where the doctor or nurse-midwife has hospital privileges.

Basic Questions for Doctor Interviews:

• How long have you been in practice?
• How available will you be to answer my questions?
• Are you a solo or group practice?
• If solo, who covers for you when you're not available?
• If a group practice, how often will I see the other doctors or nurse-midwives?
• Prenatal Care: Do you perform VBACs (vaginal births after cesareans)?
• What tests do you routinely perform during pregnancy?
• Do you recommend any childbirth classes?
• If I become high risk, what changes might I expect in my prenatal care?

Labor and Delivery:

• Do you, or one of your partners, meet me at the hospital when I'm in labor?
• At what point in my labor do you come to the hospital?
• What procedures do you routinely perform at the hospital(i.e.enemas, IV's, continuous fetal monitoring, episiotomies, etc.)?
• What if I don't want one of these procedures?
• Will you help me develop a birth plan?

Basic Questions for Midwife Interviews:

• How long have you been in practice?
• How many babies do you deliver a month?
• Are you licensed by the state?
• How do I reach you in an emergency?
• Who covers for you if you're not available?
• Who is your back-up obstetrician?

• Are you solo or with a group practice?
• If solo, who covers for you?
• If with a group, how often will I see others in the practice?

Prenatal Care:

• What tests do you routinely perform during pregnancy?
• Can you give me some examples of when you might manage my care jointly with the back-up OB or transfer me to an OB full-time?
• If I had to have a cesarean, would you stay with me during the procedure?
• Do you recommend any childbirth classes?

Labor and Delivery:

• What do you suggest to help me manage pain during labor?
• What procedures do you routinely perform at the hospital or birth center (i.e. enemas, IVs, fetal monitoring, episiotomies, etc.)?
• What if I don't want one of these procedures?
• Will you help me develop a birth plan?

Questions to Ask Yourself after Interviewing a Doctor or Nurse-Midwife:

• Did you feel comfortable with the doctor or nurse-midwife?
• Is the office convenient?
• How long were you kept waiting?
• How helpful were the nurses and support staff?

After you've decided on the type of caregiver you prefer, you'll need to decide which kind of medical practice you'll be most comfortable with. The solo medical practice is one where the doctor works for himself or herself using another doctor to cover when your doctor is away or otherwise unavailable.

An OB or a family practitioner may be in a solo practice but in almost all states a nurse-midwife must work in a practice with a physician. A major advantage to a solo practice is that you see your doctor at every checkup and you have the opportunity to really get to know them and feel comfortable. A major disadvantage is that if your doctor isn't available at the time of delivery, your baby may possibly be delivered by a doctor that you've never had the chance to meet. Also, if you're seeing a doctor who's in a solo practice and you decide that things just aren't "clicking" with the doctor halfway through your pregnancy, you may be stuck unless you can afford to pick up the bill and move to a different doctor.

The partnership or group medical practice is made up of two or more doctors in the same specialty. They care for patients jointly and see patients on a rotating basis. With this arrangement, the advantage is that by seeing a different doctor each time, you will get to know them all, and when labor is coming hard and fast there will be a familiar face in the delivery room. The disadvantage is that you may not like all the partners and you won't have any control over who you will see at the delivery.

A combination practice is a group practice that includes one or more OBs and one or more nurse-midwives. The advantages and disadvantages are similar to those of a group practice. One advantage of having a nurse-midwife on staff is that they can usually spend extra time with you at your prenatal appointments.

A maternity or birth center- based practice is the type of practice where nurse-midwives provide the bulk of care to the patients and OBs are on call as needed. Birth centers provide care for low risk pregnancies only. This is favorable to women who choose midwives as their primary practictioners. The main disadvantage in this type of practice is that if a pregnancy becomes a high risk situation, you'll have to switch to a physician in a more traditional setting and start new with them.

Finding the perfect doctor or midwife can be quite a journey but once you have settled in with a caregiver and a practice that's on the same "pregnancy wavelength" as you, you'll be well on your way to delivery.

You can make the job of caring for you and your baby easier by being prepared for each visit by having a list of questions ready. Don't withhold information. It's crucial to tell your caregiver everything he or she needs to know.

Get the expectant father or partner involved; ideally the father or partner and caregiver should meet and be familiar with each other long before the first pang of labor hits. Finally, speak up and don't hesitate to tell your caregiver if you're dissatisfied and give him or her the opportunity to correct the problem.

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Eating for Two

The food cravings and aversions that sometimes accompany pregnancy aren't just motivated by hormonal fluctuations, they are due in part to your baby's nutritional demands and to physiological changes in your body that affect the absorption and metabolism of certain nutrients. These changes help insure normal fetal development and later, fulfill the demands of lactation.

During pregnancy, your natural levels of vitamin B12 and B6, electrolytes, proteins, glucose, and folate decrease; while lipids, triglycerides, and cholesterol increase. In Nutritional Impacts on Women, researchers Frank E. Hytten, M.D. and Angus Thomson wrote that changes in nutritional needs occur too early in a pregnancy to be exclusively a response to fetal needs, and instead appear to be caused by the woman's body adapting to the new pregnancy.

The food you eat, as well as nutrients that are stored in your bones and tissues and those that are synthesized in the placenta, supply your baby with all the nutrients he or she needs for growth and development. However, exactly how nutrients are exchanged between you and your baby is not well understood. In the past, pregnancy was believed to be a host-parasite relationship, with the fetus taking whatever nourishment it required from the mother. But recent research has shown that the fetus can be more severely affected by lack of nourishment than the mother. "Contrary to the idea of fetal parasitism, there seem to be feedback mechanisms operating in the mother that would reduce the maternal supply line to the fetus when nutrients are in short supply," states Pedro Rosso, M.D., of Columbia University's Institute of Human Nutrition.

The placenta acts as a doorway through which nutrients, hormones, and other substances are transferred from you to the fetus. According to Dr. Roslyn Alfin-Slater, Nutrition expert and author of "Human Nutrition, A Comprehensive Treatise," if the mother-to-be is poorly nourished, her placenta does not function well. In addition, her health may suffer and the baby may be born at a low birth weight and suffer growth abnormalities if deprived of essential vitamins and nutrients over a prolonged period of time.

The following are essential nutrients, vitamins, and minerals that are often affected by pregnancy. To ensure your health and that of your baby, eat a healthy, well-balanced diet and talk to your doctor about vitamin supplements. However, if you do take vitamin and mineral supplements during your pregnancy, be sure they are at RDA levels and avoid large doses of vitamins and minerals. For example, in animal studies, megadoses of vitamins A and D have resulted in fetal defects and the same is likely to be true in humans.

Iron

Iron is an essential component of proteins found in red blood cells that transport oxygen to tissues, and it is also essential for the regulation of cell growth and differentiation. Extra iron is needed during pregnancy because your blood volume increases 40 to 50 percent to support your growing fetus. A woman who is not pregnant absorbs about 10 percent of the iron contained in the food she eats; but a pregnant woman's body absorbs up to twice as much. The Recommended Daily Dietary Allowance (RDA) of iron for pregnant and lactating women is 27 mg a day. Good sources of iron include meat (especially liver and other organs), egg yolks, and legumes. However, the average American diet does not contain enough iron to meet these requirements, so many pregnant women are encouraged to take a daily iron supplement of 30 to 60 milligrams.

Inadequate iron levels can cause anemia, which decreases your ability to fight off infection and tolerate hemorrhaging during childbirth. It has also been suggested that pica, the craving for substances with little or no nutritional value (such as dirt, clay, starch, and ice), may be associated with iron deficiency. According to the National Research council, as many as 50 percent of the pregnant women attending southern health department clinics ate clay. Eating these substances may take the place of nutritionally valuable foods; and many pica substances, such as starch, are high in calories and may contribute to obesity. In addition, some pica substances (such as charcoal, air fresheners, and mothballs) contain toxic substances, which can interfere with the absorption of minerals. Although it is not known whether anemia is the cause or effect of pica, the craving abates when the anemia is corrected.

Folic Acid

Pregnancy doubles a woman's need for folate (folic acid or folacin), yet folic acid absorption may be impaired by hormonal changes during pregnancy. Repeated studies have shown that women who consume 400 micrograms (0.4 milligrams) daily prior to conception and during early pregnancy reduce the risk that their baby will be born with a serious neural tube defect (a birth defect involving incomplete development of the brain and spinal cord) by up to 70 percent. Doctors and scientists still aren't completely sure why folic acid has such a profound effect on the prevention of neural tube defects, but they do know that it is crucial in the development of DNA, cell growth and development, as well as tissue formation.

You can get additional folate by eating more green leafy vegetables, certain fruits, and liver and other organ meats. Because folic acid is crucial to cell multiplication, the fetus's needs are met before those of the mother; therefore, pregnant women are at an increased risk of folate deficiency. Severe folate deficiency can result in a condition called megaloblastic anemia, in which the mother's heart, liver and spleen become enlarged and the life of the fetus may be threatened.

B-Vitamins

Pregnant women have an increased need for vitamins B6 and B12. B12 maintains healthy nerve cells and red blood cells, and is also essential for creating DNA, the genetic material in all cells. Vitamin B6 is essential for normal brain development and function, and aids in the formation of important brain chemicals called neurotransmitters. You can usually meet B6 requirements usually can be met by eating more whole grains, milk, egg yolks, and organ meats. Vitamin B12 is found in animal foods, including meat, eggs and milk products; vegetarians who eat no eggs or dairy products and vegans should ask their health-care professionals about B12 supplements.

Calcium

Calcium is crucial during pregnancy for synthesis of fetal bones and teeth. It is also necessary for proper blood clotting and regulation of blood pressure, heartbeat, water balance in cells, and muscle contractions. If your diet does not supply sufficient calcium, the fetus will draw from reserves in your bones, which can cause osteopenia (a similar, but milder condition than osteoporosis). Fortunately, increased estrogen production during pregnancy facilitates calcium absorption.

The U.S. RDA of calcium for adult women (pregnant or not) is 1000 mg. You can achieve this by consuming three or more servings of milk or other dairy products a day. For women who are lactose intolerant, there are a variety of low-lactose or lactose-free dairy products available, or your doctor may recommend a calcium supplement. However, you should not take calcium supplements such as bone meal and dolomite, which FDA surveys have shown may contain substantial amounts of lead. In addition, do not take a calcium supplement at the same time as your prenatal vitamin-mineral supplement because iron inhibits the absorption of calcium.

Calories and Weight Gain

In the past, pregnant women were told to limit their weight gain to about 15 pounds. Excessive weight gain was thought to be related to toxemia (also called preeclampsia or pregnancy induced hypertension), a condition of unknown origin that occurs after the 20th week of pregnancy and is characterized by high blood pressure, protein in the urine, and water retention.

Although sudden large weight gain, water retention and blood pressure elevation are still recognized danger signs of toxemia, most physicians agree that weight gain does not cause toxemia. In fact, the consequences of restricted weight gain and weight loss appear to be potentially more harmful than unrestricted weight gain, particularly to the fetus, even in women who were overweight before becoming pregnant.

If a woman's calorie intake is restricted during pregnancy, she may not get enough protein, vitamins, and minerals to adequately nourish the fetus. It can also result in a breakdown of the mother's fat stores, leading to the production of ketones in her blood and urine. Ketones are produced during times of starvation, and chronic production of ketones can result in mental retardation in the fetus.

For these reasons, the National Academy of Sciences recommends that pregnant women eat approximately 300 calories more per day than they did before becoming pregnant, and gain about 25 to 35 pounds over the entire nine months. The pattern of gain is considered more important than the actual number of pounds: weight gain should be at its lowest during the first trimester and steadily increase through the second and third. You should gain the most weight in your third trimester when the fetus is developing its protective fat stores. During pregnancy, your fat deposits increase by more than one third.

Experts estimate that if you gain 25 pounds during your pregnancy, it consists of the following:

• Baby: 8 pounds
• Placenta: 1 pound
• Amniotic fluid: 1.5 pounds
• Breasts: 3 pounds
• Uterus: 2.5 pounds
• Stored fat and protein, water retention, and blood volume: 8 pounds

Most women lose much of this extra weight during the birth process and in the first several weeks after birth, especially if they are breastfeeding, which burns an impressive amount of calories. Breastfeeding expends 600 to 800 calories each day. Your body needs the additional calories to synthesize lactose, protein and fat into milk and to ensure the milk is nutritious. Severely undernourished women produce less milk; however, obese women produce the same amount of milk as those of average weight. The amount of vitamins in breast milk, particularly water-soluble vitamins such as C and the B complex, is closely related to how much is consumed in the mother's diet. However, the concentrations of trace elements such as copper fluoride and fat-soluble vitamins seem to be less dependent on the fluctuations in maternal eating habits.

Protein

Protein is necessary to produce new blood cells and circulating proteins for your increased blood volume, and for the physical growth and cellular development of your baby. It is also needed to create the placenta, amniotic tissues, and maternal tissues. Pregnant women need approximately 60 grams of protein a day, or 10 grams more than non-pregnant women. This requirement can be met by eating two large eggs and 2 ounces of cheese, or a 4-ounce serving of meat. Protein is also used to produce breast milk and nourish the baby, so lactation will increase your daily requirements of protein by up to 20 grams (compared to non-lactating and non-pregnant women).

Sodium

Your sodium requirements increase during pregnancy; however, the sodium provided by the average diet is probably adequate for expectant mothers and consumption of additional salt is rarely warranted. Americans typically consume 4,000 to 8,000 mg of sodium each day, well above their daily needs of 2,400 mg. Excessive sodium intake does contribute to high blood pressure in some people, so women who have been advised to limit sodium before becoming pregnant should continue this practice until they discuss it with their doctors.

Sugar

Experts at the American Diabetes Association believe that hormones secreted during pregnancy may make it hard for your body to use insulin (a condition called insulin resistance), which allows more glucose to stay in your bloodstream. When glucose remains in the bloodstream instead of being converted to energy, it can lead to a condition called gestational diabetes which affects approximately 2 to 5 percent of pregnant women. Women with gestational diabetes should be closely monitored to make sure their blood sugar levels remain steady. If blood sugar rises too high, the increased sugar crossing the placenta can result in an abnormally large fetus, which can complicate labor and delivery and cause additional problems for the baby after birth.

Nausea

Nutrition and eating habits can even relieve some women's nausea during early pregnancy. To help alleviate morning sickness, try the following:

• Keep meals small, and avoid long periods without food.
• Drink fluids between, but not with, meals.
• Avoid foods that are greasy, fried or highly spiced.

Improvements in the ability to diagnose birth defects early in pregnancy have focused attention on ways to correct certain fetal defects by manipulating the mother's diet. For example, researchers are investigating the use of vitamin and mineral supplements to prevent neural tube defects. Other research is being conducted on the ways maternal nutrition can help fetuses with inherited birth defects, usually inborn errors of metabolism, in which certain nutrients are not processed normally.

Scientists are also analyzing the extent to which pregnancy affects a woman long-term. Jean Pennington, Ph.D. of the United States Department of Health and Human Services, says it is known that a woman who has a large number of children may have depleted calcium stores. Walter H. Glinsmann, M.D., Past Associate Director for Clinical Nutrition, FDA Center for Food Safety and Applied Nutrition, counsels that having babies should be considered a major life effort that begins long before conception, "Getting pregnant is like running a race. You have to get yourself in condition."

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