The Third Trimester (28 Weeks to Delivery)

During this time of your pregnancy, your baby will be gaining weight very fast.

Car Seats: Hospitals will require you to take your baby home in a car seat. If you do not have one, you may rent one from the hospital.

How to know when you are in labor:

1. If you bleed more than a teaspoon of blood.
2. When your contractions are five minutes apart for at least one hour.
3. If you feel a gush of fluid. It means your membranes ruptured which is normal when you are ready to deliver.

The vast majority of pregnancies are uncomplicated and end with the birth of a normal, healthy baby. Even when complications do occur, early diagnosis and treatment will often prevent serious problems.

It is important that you notify us immediately of these early warning signs:

• Bleeding from the vagina, rectum, nipple, or from coughing
• Swelling or puffiness of the face or hands
• A sudden large weight gain
• Persistent severe swelling of the legs
• Severe or repeated headaches
• Dimness, blurred vision, flashes of light, or spots before you eyes
• Sharp or prolonged pain in your abdomen
• Severe or continued vomiting
• Chills and/or fever
• Sudden escape of fluid from the vagina
• A significant decrease in fetal movement

How far along is my baby? By the eighth month your baby probably weighs between two to four pounds and is somewhere between 15 to 17 inches long. Most important, is that your baby is now able to survive outside of you, if you were to deliver. He or she would be very premature but could be helped to develop normally.

Fetal development at term: At the end of nine months (or at term) the average sized baby weighs about seven or seven and a half pounds. Your baby’s length is approximately 20 inches. The skin is coated with a creamy coating and hair and fingernails are developed. By this time your baby should do well living outside the uterus, whenever that specific day comes.

Patient instructions for induction of labor: If Dr. Rosenfeld has scheduled an induction of labor for you. The following is a list of directions that you should follow. As always any questions may be addressed to the Nursing Staff here in Dr. Rosenfeld’s office.

1. Nothing to eat or drink after midnight the night before your induction day. You may brush your teeth in the morning, but do not swallow any water.
2. Call your hospital’s Labor and Delivery Unit by 6:00 a.m. to see if you can come on in.
3. An induction of labor, unless an emergency is an elective procedure. This means that if the hospital can work you in they will. If for some reason all of the labor rooms are full they will cancel you and place you on the next available day. In most instances inductions are not done on the weekends. Sometimes the babies don’t come on the first day of induction.
4. Sometimes the staff nurses in Labor and Delivery will ask that you wait a few hours and they will call you in when a room becomes available. If this should happen continue fasting and wait for their call. The hospital will notify Dr. Rosenfeld if they are unable to call you in.
5. As always, be watchful for fetal movement, bleeding, leaking of fluid, signs of labor, and if something “doesn’t feel right”. If these should occur while waiting, or at any other time, please call the office at 713-790-0099.

What are the problems for which I should call the doctor right away?

• Any bleeding from the vagina
• Chills and fever
• Sudden gush of water from the vagina or slow leak or fluid that is not urine
• Any unusual pains in the head, chest, belly, or in any part of your body
• The baby is moving less
• A lot of swelling or puffiness in your legs, hands or face that doesn’t go away after lying down.

Episiotomy

What is an episiotomy? An episiotomy is a surgical cut, which is made just before the baby is born, to make the vaginal opening larger.

Why is an episiotomy done? As the baby is being born, the tissue and muscles in and near the mother’s birth canal are often stretched, bruised, and torn. These tears may extend many different ways at once and even go down into the rectum. Tears usually have ragged edges which are very difficult to sew back together. An episiotomy is a straight cut and is easily sewn back together. Having an episiotomy is thought not only to prevent ragged-edged tears, but also is thought to prevent problems in later life.

Is an episiotomy always done? The decision, as to whether or not an episiotomy is necessary, is made by your doctor at the time of delivery. Episiotomies are nearly always done on mothers delivering for the first or second time as the tissue tends to be rather tight. Your doctor’s decision is also based on the size of your baby, it’s position, and how your labor is moving along.

Does it hurt? An episiotomy is usually done under some type of anesthesia. With some anesthesias the woman may still feel pressure from the baby. But she usually does not feel pain when the episiotomy cut is made. Several stitches, that do not need to be removed, are used to repair the cut. This incision may be tender and uncomfortable for the first few days after delivery, but it usually heals quickly and without any problems.

What can be done to lessen the discomfort from the episiotomy? To decrease the discomfort, placing ice packs to the painful area of sitting in a tub of warm water several times a day may be helpful. Sprays that numb the skin are available. Bowel movements may be painful due to the incision. It is helpful to keep the bowel movements soft. This can be done by drinking lots of fluids, eating bulky foods such as raw fruits, raw vegetables, and bran cereal.

Are there any risks? Occasionally an episiotomy may become infected, and antibiotics, pain medication, and sometimes removal of some of the stitches may be necessary. However, episiotomy infections are unusual

For what reason should I call my doctor? Be sure and call him if you are experiencing fever, having extreme pain, or notice foul smelling yellowish-white drainage from the area around the stitches. Be sure and call his office if there is anything else about which you are concerned.

Complications of Labor and Delivery

What are some of the problems that can happen during labor and delivery? Most pregnancies will go well without any problems. However, it is good to be aware of some of the common problems that do occur.

One thing that sometimes happens, is that the labor does not move along at a steady pace. It may even just stop. To help your contractions, your doctor may give you a medicine called oxytocin. Oxytocin is the same chemical that your own body makes to cause labor. This medicine is adjusted to strengthen your contractions so your labor will move along.

Another problem is that the baby’s head may stop from moving out, before it reaches the opening of the vagina. Often, the baby can be helped out with forceps. These are metal instruments that carefully fit over the baby’s head.

The easiest way for babies to come out is head first. Sometimes the baby may be turned around with the rump (breech), legs, or arms coming first. Your doctor will carefully decide in these situations whether to perform a cesarean section or try to deliver the baby through the vagina. Your safety and the baby’s safety will be the most important factors in making such a decision.

Cesarean Section

What is a Cesarean Section?
This is an operation where the baby is delivered through an opening made in the lower belly area.

Why is it done?
Many of these operations are done because the woman has had a previous cesarean section. If you had one done for your last pregnancy, most doctors prefer to have all your other babies delivered by cesarean section. This is especially true if the first section was done because the baby couldn’t fit through your pelvic area.

Other cesarean sections are done when you and your baby may be in some danger. The cesarean section allows the baby to be delivered in minutes to prevent damage to you or the baby.

How is it done? You usually will have an IV started to allow fluids and medicines to be given to you through a needle in your arm. Anesthesia will be used to prevent pain. You may be put to sleep (general anesthesia) or you may get medicine in the lower part of your spine (spinal or epidural anesthesia) which numbs your body from slightly above the waist and downward. The doctor will discuss these options with you.

Your belly will be cleaned off and then a cut is made in the lower part of your belly and then through your uterus. The baby and placenta are removed. The cuts are sewn.

When the baby is out, the cord is cut and the baby is cleaned up. The baby will be placed next to you for you to see and hold or may be put into a warmer.

You will then be taken to a recovery room to rest and be watched for several hours. At the same time the baby will be taken to the nursery to be watched.

What is general anesthesia?
Many women do not want to be awake or know what is going on. General anesthesia consists of gases which are inhaled and circulated throughout the mother’s body which make her go to sleep. She, then, wakes up when everything is all over.

This type of anesthesia takes a short time to administer and has almost immediate effects. It may also be used if there is an emergency and not a moment to waste.

What is epidural anesthesia?
The anesthetic provides numbing of the body from the waist to the toes, while the mother remains awake. This is the type most frequently given for cesarean sections. A numbing medication, something similar to novacaine, is injected into the lower portion of the back which gradually causes the mother’s lower part of her body to feel tingly, heavy, and eventually without any feeling or ability to move her legs. She feels no pain during delivery, but the feeling gradually returns in an hour or so.

Are there any complications to a cesarean section?
Since there is a cut made into the abdomen there is a chance that a bleeding problem may occur or an infection could develop. There are also certain problems that may occur because of the anesthesia used. Anesthesia will be discussed with you in greater detail later. However, should a problem develop, prompt treatment usually corrects the difficulty. Complications following cesarean sections are not common.

Circumcision

What is circumcision?
Circumcision is a minor surgical procedure in which the foreskin is removed from the top of the penis. It is usually performed in the first few days of life by Special Pediatric Surgeons.

This procedure has been performed for various reasons for quite some time. If you have a boy child, you will be asked before you deliver to make a decision on whether you want him circumcised. In order to make a decision, you may want to consider reasons for and against circumcision.

What are the reasons for doing a circumcision?
You should know that there is no absolute medical reason for removing the foreskin on a newborn baby.

Males are born with a normally tight foreskin which cannot be pulled back. However, if the foreskin opening is too small to allow urine to flow easily, your sugeon may feel it necessary to have the foreskin removed.

There are several other reasons for which circumcision is thought to be necessary. These include:

1. It is thought that it is easier to clean the penis when the foreskin is removed. With better hygiene, fewer infections occur.
2. Cancer of the penis may be less likely to develop in adults who are circumcised.
3. If the baby’s brothers or father have been circumcised, you may want your new son to look the same as they do.

What are some of the reasons for remaining uncircumcised?
Many experts feel that good cleaning beneath the foreskin is very possible without circumcision. In that case, proper hygiene would prevent build up of secretions from which infections, ulcers, and ultimately cancer could occur. Since cancer of the penis is so rare, many physicians feel it is not worthwhile to do a circumcision for this reason alone.

Are there any risk to the operation?
There are some rare complications with circumcisions. These include bleeding, infection, and very rarely a deformity. Your doctor will answer any questions you may have.

When is circumcision performed?
Most often it is performed in the first few days after birth, if the baby is healthy.

Will the baby feel pain?
Usually no anesthesia or painkiller is given for this short operation. The baby generally will become quite irritable and cry, but is quickly comforted afterwards, being held and offered something to drink.

After the operation, for what reasons should I notify my doctor?
Some swelling is natural; as long as your baby continues to wet diapers there is no reason for alarm over this. Should there be any abnormal bleeding, signs of infection, or if there is anything about which you are concerned, do not hesitate to call your baby’s doctor.

Preparing to Breastfeed

How can I prepare my breasts for nursing?
Keep the skin around your nipples healthy. Avoid excess rubbing or stimulation since this might damage the skin. Your body will prepare your breasts for breast-feeding. Rubbing or stimulating your nipple can cause your uterus to contract, leading to a possibility of preterm labor if you are early in your pregnancy, or undue stress on the baby if you are near delivering. It’s best to avoid using lotions or alcohol on your breasts. You can do normal cleaning of the breasts when bathing or showering. If you have inverted nipples (nipples that are turned inward) ask about what you may need to do when breast-feeding. Ask your doctor or nurse for more information.

Should my diet be any different?
You will need to take in about 500 extra calories each day to help you produce good breast milk. Otherwise your diet should be like the diet recommended during pregnancy. To be sure you are not getting too many calories, watch your weight. You should not gain weight at this time.

What about medicines, drugs, and alcohol?
These can get into your breast milk. Don’t use anything, even nonprescription medicine from the drug store unless you first check with your doctor. It’s best to avoid alcohol and smoking while you are pregnant and even later, when breast-feeding.

How do I nurse the baby?
The first time to breast feed should be as soon as possible after the delivery since the baby is more awake and willing to nurse at this time. Nursing about every one and a half to three hours helps bring in milk, gives the baby fluid that it needs, and helps the baby’s digestive system start cleaning itself out.

Nursing can usually begin when the baby is first brought to you. The baby’s body should be turned toward you with the baby’s tummy turned to your tummy and the baby’s knee against your stomach. This position prevents the baby’s mouth from slipping and helps keep your nipples from getting sore. Touching the baby’s lower lip will usually make it’s mouth open wide, then bring the baby to your breast. As much as possible of the areola (the dark circle around your nipple) should be in the baby’s mouth. After about ten to fifteen minutes, gently put your little finger in the corner of the baby’s mouth and push the mouth open. This breaks the suction and lets you easily remove the nipple. Switch to the other breast and let the baby nurse for another ten to fifteen minutes. By the time you get home, the feeding time should approach about ten minutes on each breast. Babies don’t follow set schedules and may not nurse the same amount of time at each feeding. Most babies need and want about 10-12 feedings every 24 hours. It is okay to nurse about every one and a half hours. The feedings don’t have to be timed exactly.

The first few feedings are usually a “get acquainted time. Your baby may not be very hungry at first, and your milk will not yet have started flowing fully. Try to nurse anyway, but don’t get discouraged if the baby does not seem to get much. The baby will be getting colostrum (the very early milk that the breast makes) which is very healthy.

How can I tell if baby is getting enough milk?

1. Watch that the baby is swallowing while nursing.
2. The baby should be content for one or more hours after feeding.
3. The baby has 6-8 wet cloth diapers a day, or 5-6 wet disposable diapers a day (the baby may have less the first few days after birth).
4. The baby is having stools (bowel movements) at least every day or two.

What can I do if I have problems nursing?
If you have any problems at all, don’t get discouraged and think it would be easier to switch to a bottle. First, talk to your doctor or the nursing staff and let them help you. You can also call the hospital nursery (anytime day and night). There are support groups and breast-feeding centers in many states. Ask the doctor, the hospital nursery or check your phone book. One suggestion would be to call the La Leche League (281-480-2555).

What if I have to stop nursing for some reason?
If breast-feeding is delayed after birth, stopped for a while, or if you and baby are separated, you will want to use a breast pump or hand expression to keep up your milk supply and empty your breasts. Ideally, if the baby is not nursing 6 hours after birth, you should begin to stimulate your milk supply by stimulating your breasts. Ask the hospital personnel for assistance with this.

To use a breast pump, follow these steps:
There are many types of breast pumps you can buy. Your hospital can recommend a breast pump to use (some may even sell or rent them). Whichever type you choose, always:

1. Read the instructions carefully.
2. Wash your hands and cleanse your breast with clean water and dry.
3. Get comfortable and relax. Think about the baby.
4. Massage your breast from the chest wall to the nipple with the flat of the hand. Use your fingertips to massage in circles from the full area toward the nipple.
5. Begin pumping (it should NOT hurt).
6. Alternate breasts as the flow decreases, or every 5-10 minutes if pumping to stimulate supply.
7. Save the milk in a sterilized baby bottle or throw away bottle liner. Cover it and place it in the refrigerator. It can stay for a few days and given to your baby through a bottle. It can also be frozen for longer periods.

To hand express, follow these steps:

1. Wash your hands and cleanse your breasts with clean water and dry.
2. Get comfortable and relax. Think about the baby.
3. Massage your breast from the chest wall to the nipple with the flat of the hand. Use fingertips to massage in circles from the full area toward the nipple.
4. Place thumb and fingers one and a half inches from the nipple.
5. Push back towards the chest wall.
6. Roll your fingers around the breast to empty all ducts.
7. Work your fingers around the breast to empty all ducts.
8. Switch from the right to the left breast to increase the amount expressed.
9. Save the milk in a sterilized baby bottle to throw away bottle liner. Cover it and place it in the refrigerator. It can stay for a few days and be given to your baby through a bottle. It can also be frozen for longer periods

Avoid sliding your fingers over skin or pulling on the nipple itself. Fingers should remain away from nipple so milk doesn’t run over the fingers. milk that runs over your fingers might get germs in it and should be thrown away.

Whatever method you choose, pump or hand, it will take time and practice to master this. Consider your first few attempts as practice and don’t expect any milk on your first few tries. If you do get milk the first few times, consider it a bonus.