The Second Trimester (13-28 Weeks)

You will begin to feel more like yourself now. The morning sickness should have passed and you will begin to feel good.

Your prenatal blood work will be drawn around the 16th week. Please ask a nurse when you will be 16 weeks, if you do not know. These laboratory tests must be performed at this time. A Trisomy profile will be included in this laboratory work and will identify if you are at increased risk for certain conditions. This is only a screening test and is not diagnostic if it comes back abnormal additional tests will be ordered.

All patients will be asked to have a Level 2 Ultrasound with our referring physicians. This is a more sophisticated Ultrasound, which shows more details of the baby. Your bladder should be comfortably full for the Ultrasound. If you bring a VCR tape you may be able to have the procedure taped for you. If you will be 33 years old or older at your expected time of delivery we can make a referral for an amniocentesis.

This is the time to choose your baby’s pediatrician. If you already have a family doctor or pediatrician that you wish to use then let us know this physician’s name so he or she can be notified when your baby is born. If you wish us to recommend a doctor, we will be glad to do so. If you have never met this doctor, you and the baby’s father may wish to make an appointment to meet the physician. You can then ask any questions about that doctor’s management of breast feeding, bottle feeding, well child care, insurance, office hours, etc. This will give you a chance to see if you feel comfortable with the medical management that this doctor offers.

Fetal Kick Counts

At 28 weeks, you likely have become accustomed to your baby movements. But be aware of fetal movement throughout the day. Sick babies do not move. Count and keep track of your baby’s movements. You will begin to see a pattern.

You will need to count the baby’s movement on the daily basis after 28 weeks. If the baby does not kick 10 times before noon please call the office immediately. A full day should never go by without feeling the baby move!

General Health Care

If I have a job, when should I stop working?
Generally, you can work right up until the end of your pregnancy if you feel up to it. The only types of jobs that might be a problem are those where you work around certain chemicals or x-rays or perhaps physically strenuous jobs. If you have any questions, ask us.

What about exercise?
Avoid sports where you might get hit in the belly. Otherwise, you can continue the same activities as before pregnancy. Try not to push yourself to the point of becoming overtired. You may find that you have less strength and energy than before you became pregnant, but exercise is still good for you.

What about high altitude stays above 8-9,000 ft?
In non-high-risk pregnancies, short stays (several days) at high altitude are generally not felt to be a significant problem.

In high-risk pregnancies, high altitude exposes the mother and developing fetus to less oxygen and creates physical stress so it should be avoided whenever possible.

Your physician will be happy to discuss your high risk pregnancy problems with you.

Can I continue regular sexual relations?
Yes, as long as it is not causing you to have pain or bleeding. For certain pregnancy problems, you may be told to avoid sex. Some women find that sex is more comfortable during pregnancy if they are on top or lying on their side. Feel free to ask us any questions about sexual relations during any of your prenatal visits.

Can I travel during pregnancy?
Yes. There are generally no problems with riding in a plane or taking auto trips. In case you will be away for more than a week or way from home near your due date, it is a good idea to get the name of a doctor or hospital in the area where you will be visiting.

What about dental care?
Keep getting your regular dental check ups. Take good care of your teeth. Let your dentist know that you are pregnant before any x-rays are taken or any medicines are given to you.

How should I take care of colds or small aches and pains?
You can take acetaminophen (Tylenol or Daatril) for mild aches and pains. This is safer than aspirin. Don’t take any other medicines without checking with us first. Please take your temperature and notify our office of any fever 104 degrees or greater.

What about clothing?
Wear comfortable clothes that are not tight on your belly. Flat heeled or broad heeled shoes are recommended. Use a bra that gives good support to your breasts.

How Far Along is my Baby?

Your baby, by the 4th month, weighs about four ounces and is close to seven inches long. The head is the longest part of the body which now has completely formed eyes, ears, nose, and mouth.

Sometime over the next month you should begin to feel the baby moving. At first this may feel like a faint, gentle fluttering in your belly. This movement is called “quickening”. By the fifth month of pregnancy your baby is 12 inches long and weighs about one pound. Hair may be starting to grow on the head. Even though many important inside parts of the baby such as the heart and kidneys are well developed, the baby cannot survive outside the mother at this time.

Trisomy and Alpha-Fetaprotein Test (AFP)

Why should I consider having this test done? This test is used to identify babies with a spine defect. Spine defects occur when the baby is growing inside the womb and doesn’t form a complete covering around the major parts of the nervous system (Brain and Spinal Cord). The defect is usually called spina bifida. It may lead to various physical problems ranging from needing braces to walk to severe handicaps including the inability to walk, as well as mental problems and even death. The AFP test is used to screen for this.

AFP testing is routinely offered to all women who are pregnant. The decision to have the test done is the patients. In this country, the overall chance of having a child born with this defect is about one in one thousand (1:1000). However, if you, the baby’s father, or any relatives have had a child with spina bifida, the chance goes up to 10 to 20 out of 1000 babies. If you or the baby’s father actually have spina bifida, then the chances go up to 50 out of 1000. You should notify your physician if anyone in your family, including yourself, the baby’s father, or other children have had spine defects. Remember, if you have had a child with anencephaly (where the brain and scalp do not develop normally), this is considered a type of spinal defect and should be reported to your physician. Even though there is an increased risk of having a child with a spine defect because of a family history, most of the children with spine defects are born to couples without a family history of this.

How is the AFP test done? The AFP test involves a simple blood test, with blood taken from an arm vein at 16-18 weeks of pregnancy. If there is a history (either in the family, a previous pregnancy, or the parents) of a spine defect, genetic amniocentesis is a more appropriate test than the blood test. More testing is needed when high levels of AFP are found in the blood or amniotic fluid. Low levels of AFP can also be a sign that the baby has a problem and should be tested further.

Why is the test done so early in pregnancy? The test is most accurate early in pregnancy. Early testing also lets us give you counseling about the choices open to you if a problem is found. These may include planning which hospital and medical staff will be needed for the pregnancy and delivery, or giving you appropriate counseling and offering termination (an abortion) of the pregnancy, but it cannot predict if your child will have a spine defect once you are past 22 weeks. This is why the test is not done after 22 weeks.

Does an abnormal test always mean that the baby has a spine defect? No, there are other conditions that can cause an abnormal test. There are some normal conditions which cause an abnormal test including twins, not being as far pregnant as you thought you were, or nothing actually wrong with the baby. There are other things which can cause an abnormal test (high or low). These include some birth defects that have a high value, of Down syndrome (which was called a Mongoloid child in the past) which can have a low value. In any case, an abnormal test will require further testing to see if your baby has a spine defect or any of these problems. If you need to have these extra tests done, you will have a lot of worry and extra expense. This is the main reason why the decision to have this test done is left up to the patient instead of just doing it on everyone. After you have read this material, you should discuss any questions with your doctor or medical staff.

What will be done if the test is abnormal? Your doctor will explain the possible meanings of the abnormal test and order some further tests which may include a repeat AFP, ultrasonography and/or an amniocentesis to help discover the cause of the abnormal alpha-fetoprotein test. The decision of having these other tests done will be left up to you. Your physician will do the further testing or refer you to a specialist.

Does the test always detect babies with these abnormalities? No test is absolutely foolproof. Rarely, this test can be normal even though you may be carrying a baby with a spine defect. Fortunately, this test is very good. Just by itself, it will detect 80% of all spine defects. With the test and a complete ultrasound, it can detect 90-95% of all spine defects. But remember, a normal result on this test does not guarantee a normal baby or a baby free of this or other birth defects.

When will the results of the test be ready? Usually the results of the test are back by 1 week.

Breast or Bottle Feeding

Even though your delivery is months away, this is a good time to think about how you’re going to feed your baby during the early months. Will you use breast milk or formula?

What are the advantages of breast feeding? Breast feeding or nursing is unquestionably an excellent way to feed your baby. It can give you much pleasure to have your child in close contact with you during feedings, and of course, this contact gives much pleasure to your little one.

Breast milk is the most easily digestible food that a baby can consume. In other words, it is very agreeable and is unlikely to cause spitting-up or any stomach problems.

No special preparation is needed such as measuring and sterilizing and it’s definitely cheaper than formulas. If asthma or allergies run in the family, it seems that breast feeding can cut down the chances of these happening in the baby.

Breast milk contains antibodies that protect young babies against infections. They are made in your body and passed to your child in the breast milk.

Breast feeding helps your body get back to it’s normal size and shape. The baby’s sucking stimulates the muscles of your uterus (which got stretched out during pregnancy) to return to normal.

Breast feeding can help prevent overfeeding. Breast fed infants usually get just what they need during each feeding. There is sometimes a problem of bottle fed babies getting too many calories and gaining too much weight. Overweight babies often grow up to have weight problems.

What are the problems with breast feeding? Almost any mother can breast feed her baby. Women with certain diseases or those taking certain medicines, may be told that they should not nurse. Your doctor will discuss this with you.

One of the greatest problems of breast feeding is a mother’s fear that she can’t do it. This is common, but with a little help and instruction these fears can be removed. If you think you want to breast feed, someone at the office here will help you and give you information on how to prepare for it and how to handle problems that can come up during nursing.

Some mothers think their breast size is too small. The part of the breast that makes milk has little to do with the breast size. Women with any size breasts or nipples should be able to nurse their children.

Some mothers fear that breast feeding limits their freedom. Many women have gone back to full time jobs after having a baby and continued to nurse when at home. There are ways to save breast milk so it can be put into a bottle for use when the mother is not home.

What about bottle feeding? Some women may choose not to nurse their baby and, instead, desire to give them formula. Formula is safe and healthy. It is easy to buy. Most supermarkets and drugstores sell it.

Formulas are easy to prepare. In fact some are already premixed so no preparation is needed. If you choose to bottle feed, it is important to remember a few things:

1. Keep bottles and nipples clean so germs don’t get into the baby’s milk.
2. Try to hold the baby close to you while giving the formula. This can help you and the baby build a closer relationship. Propping a bottle on a blanket, so the baby lies alone and drinks, is not a good habit and can be dangerous. Babies need and like close contact.
3. Always use formula for the entire first year of your baby’s life. Using regular or low fat homogenized milk before your baby is a year old is not recommended and can lead to anemia or a low blood count in the baby.
4. Later during your pregnancy, more information will be given to you regarding the feeding of your baby.

Involving your Family in the Pregnancy

How might the baby’s father be affected by my being pregnant? Often when a woman becomes pregnant, she begins experiencing different moods and concentrates on these feelings and on how her body is changing. These changes can make the father feel neglected. He most likely wants to be an important part of your life. He is probably having many concerns about the new baby. All these things can put some strain on your relationship. It is often helpful to talk about the feelings both of you are having about the new baby. Several other helpful things you can do are :

Bring him with you for some of your prenatal visits. Let him feel the baby as it kicks and moves. Have him take childbirth classes with you.

If you have more questions, ask one of the staff here.

Sometimes the father does not seem interested in the upcoming baby or even worse, may seem angry. If this is a problem for you, please let us know so we can help you better deal with it.

How might my other children react to my pregnancy? Children, except for very young infants, usually notice that their mom and dad are going through something new. It is important to tell them that a new baby will be coming and explain how they can help take care of the new child. Let little ones practice diaper changing on a doll and let the older ones know how they’ll be able to help take care of their new brother or sister. Let them feel the baby moving and kicking. Hospitals offer classes and tours of the nursery for siblings. They may get jealous because they think your new baby will be more important than they are. It doesn’t hurt to remind them how much you love them and that they are just as important as the new baby.

Preparing for the Hospital

If you have not yet discussed at which hospital you will deliver your baby, you should do this today. The phone numbers are located in the front of this book.

It is a good idea to make a practice trip to the hospital at some time before actually going into labor. This way you can make sure you know the correct roads and how long the drive takes. Many hospitals will give you a tour of their labor and delivery area and tell you where in the hospital you should go, when you arrive for your child’s birth. Even if they don’t give a tour, check with them about all their general policies for labor, delivery, and postpartum care.

If you have other children, you might want to make arrangements ahead of time for someone to watch them when you go to the hospital for the delivery.

What will I need to bring with me to the hospital? Sometime during the month before your due date you might want to pack a suitcase of things, to take with you to the hospital.

Some of the things you might want to bring are:

• bathrobe, slippers
• cosmetics
• 2 or 3 nightgowns
• nursing bras (if you plan to breast feed or otherwise just 2 good support bras)
• toothbrush, toothpaste
• hairbrush
• loose fitting outfit to wear home

About all you’ll need for the baby is a baby blanket, a sleeper or nightshirt and two diapers. If you are expecting cold weather, then make sure these items are heavy enough to keep the baby warm on the way home.

Preparing for Child Birth

What is prepared childbirth? A satisfying childbirth experience requires a lot of work from both your mind and your body. The best way to make each birth experience the best possible is to be prepared. You can become prepared by learning what to expect during labor and delivery, including the medications and anesthesia used. Also, it is important to know about caring for the new baby. By knowing what to expect and how to respond, the prepared woman can overcome fear and frustration. The woman and her partner, usually the baby’s father, can then take an active part in the birth process. Fear is thought to be a factor in causing significant pain during childbirth. Reducing fear makes labor and delivery easier and the whole experience more enjoyable.

Are there special classes? We feel the best way to prepare for childbirth is to take a series of classes. Unfortunately, there are many classes with different names that make for some confusion. Besides the term “prepared childbirth” you may come across the terms “natural childbirth”, “childbirth without fear”, “childbirth without pain”, “conditioning for childbirth”, “the Lamaze method”, “childbirth and family life”, and many more. All of these classes are directed toward education about and overcoming fear of childbirth.

Almost always, hospitals that permit the father or “coaches” in the delivery room, require that the couple attend that hospital’s parent classes. These may be given along with other prepared childbirth classes such as “Lamaze”, or you may have to find classes through another organization. The phone numbers for these classes are located in the front of this book.

Fetal Monitoring

What is fetal monitoring? This is a technique used to watch the pattern of your uterine contractions and the pattern of the baby’s heartbeat. It is usually done during labor. Fetal monitoring allows us to detect certain problems. If such problems develop, the baby can usually be delivered by Cesarean Section to prevent birth complications.

Will I be monitored? This depends on whether or not you have certain problems during your pregnancy (such as high blood pressure) or other problems during labor. Your doctor will decide if it is needed. If you have an epidural your blood pressure will be monitored regularly until delivery of the baby.

If you are monitored, don’t get scared. It doesn’t mean anything is going wrong. It’s usually just a precaution to make sure you have a healthy baby.

What is a nonstress test and an oxytocin challenge test? Sometime before you go into labor, you may be asked to have fetal monitoring done just to see if the baby is doing well. This special monitoring, called a nonstress test, is done while you are resting. An oxytocin challenge test is done with the administration of a medication called oxytocin which is given to you through an IV needle into a blood vessel in your arm. This medicine causes your uterus to contract. If these tests are normal, it usually means your unborn baby will do well for at least a week. Once you have a test done, it is usually repeated weekly until the baby is born.

What if the monitoring is not normal? Your doctor will probably want to get your baby delivered quickly. This may sometimes mean having a cesarean section.

How is the monitoring done? It is done in the hospital. It can be done with external or internal monitors. The external ones are on two belts fastened around your waist. The internal monitors are the ones placed gently into the vagina and into the uterus next to the baby and onto the skin of the baby’s scalp. Generally, monitoring is very safe.

Signs of Labor

When should I expect to go to labor? Labor normally starts when your baby is full grown or as we call it “term”. This can be as early as two weeks before your due date to as late as two weeks after your due date. If labor begins before the two weeks ahead of your due date, your baby can be born too early or premature. If it doesn’t happen until after the two weeks following your due date, your baby can be born overdue or post maturely.

How will I know that I am in labor? Labor occurs when your uterus begins to tighten over and over again in an effort to push the baby out. This tightness or contractions are felt from the back which spread over the whole belly area. They last from about 45 to 60 seconds and occur about every 10 to 20 minutes. After an hour or two, these contractions usually become stronger and closer together.

Sometimes a small amount of thick blood streaked mucous may come from the cervix, through the vagina during labor. This mucous plug is normal. Some women experience a sudden gush or slow leaking of clear fluid (amniotic fluid) from their vagina. This is the liquid that has surrounded and cushioned the baby so far. Usually this fluid is forced out toward the end of labor, but sometimes it occurs earlier. You should call your doctor if this happens to you.

What is false labor? These are pains, that are often felt in the low belly which don’t follow a regular time pattern. They usually go away in a few hours.

What should I do if I’m really in labor? First, use a clock to check how far apart the contractions are and how long they last. When they are strong and occurring about 10 minutes apart, call us and we will tell you the best time to go to the hospital.

If you think you are in labor, don’t eat or drink anything since it is possible that you may get sick to your stomach during labor.

What if I’m supposed to have a cesarean section? Let us know as soon as your labor begins, since you will need to get to the hospital very soon and we will want to be ready for surgery when you arrive.

What are the warning signs in labor that tell me I need to call the doctor or go to the hospital as soon as possible?

• Decreased fetal movement
• Vaginal bleeding
• Rupture of membranes (bag of water)
• Pain is not associated with uterine contractions

Labor and Delivery

What happens when I get to the hospital? If you have visited and toured the hospital already, you will know where to go and you may have already pre-registered. If you do not already know the hospital’s procedures, go directly to the labor and delivery section of the hospital.

You will be admitted to the hospital and then taken to the room where you will spend the rest of your labor. This room may be a labor room or a birthing room. If it is a labor room, you will be moved to a delivery room shortly before the baby is born. If it is a birthing room, you will stay in this room when you deliver the baby.

After you get to your room you will be asked to put on a hospital gown. Your temperature and blood pressure will probably be taken and the nurse will listen to your baby’s heartbeat. An internal exam may be done at this time to check the progress of your labor. This will be done several times while you are in labor. If needed, an IV may be started in order to give you fluids and medicine through a needle in the veins in your arm. If your doctor has requested that your labor be monitored electronically, a monitoring device will be set up that checks the baby’s heartbeat and your contractions.

You can then rest while your contractions get stronger and your cervix begins to open up, or dilate. If the bag of water that surrounds the baby has not broken and the fluid has not leaked out, your doctor may painlessly break the bag and allow the fluid to leak out so your labor can move faster.

When your cervix has dilated all the way and the baby’s head is beginning to push at the vaginal opening, you will be taken to the delivery room if you are not in a birthing room. You may be placed on a special table or bed almost like the one used for a pelvic exam at our office. Prior to the delivery the nurse will usually prepare you for delivery by washing your pubic area. If an episiotomy is needed (a surgical cut to make the vaginal opening larger), it will be done at this time. Now you will help push the baby out. When the baby is out, the cord is cut and the baby is wiped off and wrapped in a blanket. The baby may then be placed on your belly, placed next to you, or may be put into a warmer.

Finally the placenta comes out. Often a little pushing by you will help get it out. If an episiotomy was made, it will be sewn at this time.

If your baby is delivered in a delivery room, you will be taken to a recovery room to rest and be watched for several hours. If your baby is delivered in a birthing room, you will remain in that room and be closely watched. At the same time, your baby will be taken to the nursery for observation.

How long should labor last? It can take as long as a total of 20 hours. Most of the time is spent waiting for the gradual opening and enlargement of the cervix. Your first baby usually takes the longest, and the total time often gets shorter with each later pregnancy.le