Obstetrics

If you elect for obstetric care to be provided by WCA, you will be an obstetric patient of all three physicians: Drs Anderson, Halbach, and McPherson. You will not be assigned a single primary obstetrician. During the course of a routine pregnancy you will have 14-15 appointments at WCA and see each obstetrician 4-5 times. Hopefully, by the time of your due date, you will be most comfortable with all three physicians.

Each of our physicians considers obstetrics a most rewarding profession and feels it is an honor to provide maternity care. However, obstetrics often demands extremely long hours of work during both day and night. In order for us to provide you with an obstetrician who is well rested, alert, and attentive to your care, we must rotate on-call services and can not guarantee that any one physician will deliver your baby.

If you are going to be delivered by scheduled cesarean section or induction of labor, we will make every effort to accommodate by providing the physician of your choice. All other after hours obstetric care will be provided by one of the three on-call obstetricians.

At approximately 18-20 weeks gestation, you will be scheduled to see Dr. Richard Rosemond, a perinatalogist, (700 Sunset Drive, Ste 301, Athens GA 706-549-0087) for a complete anatomical ultrasound of your baby. This ultrasound is done with the most state of the art ultrasound equipment and is successful in detecting potential physical birth defects. It can also determine the gender of your baby if you desire this information.

Dr. Rosemond is a Board Certified Perinatalogist and therefore his area of expertise is in obstetric ultrasound and high risk obstetrics. Although your pregnancy man not be considered a high risk pregnancy, this 18-20 week ultrasound will provide you with the most expert and professional assessment of your baby that is available.

 -SONOGRAMS-

Ultrasound studies or sonograms will be performed at specific times in the course of your pregnancy:
1. Initial OB visit- The study is done to verify pregnancy, determine the gestational age, obtain fetal heart tones, and search the adnexal region for pelvic masses.
2. 9-12 weeks: At this stage in your pregnancy a study is done to determine the fetal heart rate, the dating parameter, and fetal activity (movement of limbs).
3. 18-20 weeks: At this time a study is done to scan the fetal organs and dating parameters for growth and weight, and determine the general well being of the fetus. During this scan the gender of the baby can be identified. Please note, if the mother wants to know the sex of the baby this is the only time the information can be given.

Sonograms generally take about 30 minutes and no preparation is needed prior to the study.

It may be necessary to do additional studies under the following conditions:
1. Elevated Quad Screen
2. Increased or decreased in fundal height
3. Fetal heart tones not detected with doppler
4. Determine position of fetus
5. Determine the amniotic fluid
6. Problems with pain or bleeding

-ADVISORY ON FISH/SHELLFISH CONSUMPTION-

The Food and Drug Administration (FDA) and the Environmental Protection Agency (EPA) have issued a joint statement concerning mercury in fish and shellfish. Research indicates that high levels of mercury in the bloodstream of unborn babies and young children may harm the developing nervous system. The key parts of the advisory are:

Fish and shellfish are an important part of a healthy diet. Fish and shellfish contain high quality protein and other essential nutrients, are low in saturated fat, and contain omega-3 fatty acids. A well balanced diet that includes a variety of fish and shellfish can contribute to everyone’s heart health and children’s proper growth development. Thus, women and young children in particular should include fish in their diets due to the many nutritional benefits.

By following these three recommendations for selecting and eating fish or shellfish, women and young children will receive the benefits of eating fish and shellfish and be confident that they have reduced their exposure to the harmful side effects of mercury:

1. Do not eat shark, swordfish, King Mackerel, or tilefish because they contain high levels of mercury.
2. Eat up to 12 ounces (two average meals) a week of a variety of fish and shellfish that are lower in mercury. Five of the most commonly eaten fish or shellfish that are low in mercury are shrimp, canned light tuna, salmon, Pollock, and catfish. Another commonly eaten fish, albacore (“white”) tuna, has more mercury than canned light tuna. So when choosing two meals of fish and shellfish, you may eat up to six ounces (one average meal) of albacore per week.
3. Check local advisories about the safety of fish caught by family and friends in local lakes, rivers, and coastal areas. If no advisory is available, eat up to six ounces (one average meat) per week of fish caught from local waters, but don’t consume any other fish that week.

Follow these same recommendations when feeding fish and shellfish to young children, but serve smaller portions.

If you would like a brochure, one can be obtained by calling the EPA at 1-800-490-9198, publication number EPA-823-F-04-009 (English) or EPA-823-F-04-010 (Spanish).

Additional information is available at:
1. 1-888-SAFEFOOD
2. www.cfsan.fda.gov/seafoodl.html
www.epa.gov/ost/fish

-PROTECT YOUR BABY FROM FOODBORNE ILLNESSES-

Pregnant women are at high risk for getting sick from Listeria, harmful bacteria found in many foods. Listeria can lead to disease called Listeriosis. Listeriosis can cause miscarriage, premature delivery, serious sickness, or death of a newborn baby. If you are pregnant, you need to know what foods are safe to eat.
What can I do to keep my food safe?
• Listeria can grow in the refrigerator. The refrigerator should be 40 F or lower and the freezer 0 F or lower. Use a refrigerator thermometer to check your refrigerator’s inside temperature.
• Clean up all spills in your refrigerator right way-especially juices from hot dog packages or raw meat or chicken/turkey.
• Clean the inside walls and shelves of your refrigerator with hot water and liquid soap then rinse.
• Use precooked or ready to eat food as soon as you can. Don’t store it in the refrigerator too long.
• Wash your hands after you touch hot dogs, raw meat, chicken, turkey, or seafood or their juices.

Fight Bacteria
1. CLEAN: Wash hands often with soap and warm water. Use clean dishes, spoons, knives and forks. Wash countertops with hot soapy water and clean up spills right away.
2. SEPARATE: Keep raw meat, fish, and poultry away from other food that will not be cooked.
3. COOK: Cook food to a safe internal temperature. Check with a food thermometer. Ground beef 160 F; Whole turkey 180 F; Pork 160 F.
4. CHILL: Refrigerate or freeze within 2 hours-refrigerate or freeze within 1 hour in hot weather (above 90 F). Don’t leave meat, fish, poultry, or cooked food sitting out.
What can I do to keep my baby and myself from listeriosis?
• Do not eat hot dogs, luncheon meats, bologna, or other deli meats unless they are reheated until steaming hot.
• Do not eat refrigerated pate, meat spread from a meat counter or smoked seafood found in the refrigerated section of the store. Foods that don’t need refrigeration, like canned tuna and calmed salmon, are okay to eat. Refrigerate after opening.
• Do not drink raw (unpasteurized) milk and do not eat foods that have unpasteurized milk in them.
• Do not eat salads made in the store such as ham salad, chicken salad, egg salad, tuna salad, or seafood salad.
• Do not eat soft cheese such as Feta, queso blanco, queso fresco, Brie, Camembert cheeses, blue-veined cheeses, and Panela unless it is labeled as made with pasteurized milk. Make sure the label says, “MADE WITH PASTEURIZED MILK”

For more information about food safety:
U.S. Department ofAgriculture Food Safety and Inspection Service
www.fsis.usda.gov/

USDA Meat and Poultry Hotline
1-888-MPHotline (toll-free nationwide) or 1-888-674-6854
TTY: 1-800-256-7072

 -WORK DURING PREGNANCY-

Now that you are pregnant you should inquire to your employer about company maternity leave benefits and policies. These policies may vary from employer to employer, but standard maternity leave ranges between 6 and 12 weeks. Some people choose to use some of their maternity leave prior to the estimated due date, such as starting leave two-three weeks prior to the due date. This leave time should be outlined by and through your employer.

Should you develop any medical complications during pregnancy (high blood pressure, diabetes, etc.) then your doctor may limit or halt your work activity prior to your estimated due date.

Most pregnant workers should be able to continue working until the onset of labor, according to the report on pregnancy to the American Medical Association from its Council on Scientific Affairs, Division of Scientific Activities.

In its report, the council recommended that the AMA continue to endorse the “Guidelines on Pregnancy and Work” from the American College of Obstetrics and Gynecology (ACOG) and National Institute for Occupational Safety and Health (NIOSH) for employees with normal pregnancies.

The guidelines include recommendations for maximum levels of work during a woman’s pregnancy:
• Secretarial and light clerical: May continue up to 40 weeks gestation;
• Professional and managerial: May continue up to 40 weeks gestation;
• Standing for prolonged periods of time (more than 4 hours per work day): May continue
up to 24 weeks of gestation;
• Stooping and bending below knee level-repetitive (more than 10 times per hour) may
continue up to 20 weeks gestation. Intermittent (less than 10 times per hour not more than 2) may continue up to 28 weeks of gestation. Infrequently (less than 2 times per hour) may continue up to 40 weeks gestation.
• Repetitive lifting, no greater than 25 lbs may continue up to 20 weeks gestation.
• Intermittent lifting, no greater than 25 lbs may continue up to 30 weeks gestation.
DISABILITY CERTIFICATION FOR OBSTETRICAL PATIENTS
Pregnancy is a completely normal and healthy state. It is not a sickness. Although patients may encounter occasional tiredness, nausea, vomiting, pelvic discomfort, back pain, or minor swelling of hands and feet during pregnancy, they should be able to carry on with normal activities that they were accustomed to performing before they became pregnant. Physicians cannot certify to employers or insurance companies that patients are disabled due to any of the above reasons.

To certify either partial or complete disability, physicians must find a definite medical indication that either a patient’s health of her baby’s health would be endangered by continuing normal activities. Such indications may include: hypertension, excessive edema, severe anemia, kidney or heart disease, severe diabetes, or a previous history of complications during pregnancy such as premature rupture of membranes or premature onset of labor. If these or other signs are not clearly indicated, the physicians cannot state that a patient is disabled.

The American College of Obstetricians and Gynecologists have recommended that disability for pregnancy be certified two weeks before term in uncomplicated cases, but that patients who prefer to work until labor begins should be allowed to do so. Patients should not return to work until six weeks after delivery.

Contemporarv OB-GYN Vol 16, Sept, 1980

-EXERCISE DURING PREGNANCY-

Regular exercise sessions are recommended for all healthy, pregnant women because of exercise’s favorable cardiovascular, metabolic, and biomechanical effects.

Exercise should be done three or more times per week at a comfortable intensity that does not result in fatigue. In women who have exercised regularly prior to pregnancy, the overall exercise load may be higher than that recommended for women who are beginning to exercise regular.

For safety’s sake, the continuous portion of each session should be limited in intensity and duration while paying specific attention to environmental conditions and adequate fluid and caloric intake. This avoids undue physiologic stress. For the same reason, each session should begin with a warm up period and end with a cool down period.

The type of exercise should also minimize the risk of fetal and maternal trauma. Stationary cycling and swimming are two recommended forms of exercise because the risk of physical injury is minimal.

Most, if not all, complications of pregnancy, as well as any chronic maternal disease, are either relative or complete contraindications to exercise during pregnancy.

Weight bearing exercise, at the levels recommended by ACOG, are safe for sedentary women who wish to begin a regular exercise regimen as early as the 8th week. Women who exercise regularly prior to pregnancy can safely maintain a weight bearing exercise regimen up to a level of 60 minutes of moderate intensity exercise 5 days a week throughout pregnancy.

Moderate exercise in early pregnancy stimulates placental growth.

The amount of exercise in late pregnancy has significant effect on the infant size at birth.

The type of carbohydrate in a mother’s diet has a significant affect on both maternal weight gain and infant size at birth. (Unprocessed sources of carbohydrates are best: nonroot vegetables, nuts, fruits, and whole grain bread. As opposed to “bad” carbohydrates: root vegetables, packaged cereals, breads, snack foods, beverages, and dessert foods.).

-BREASTFEEDING-

Most physicians believe that breast feeding is far better than bottle feeding for a baby’s health, and that it enhances the quality of mother child bonding. Each mother’s breast milk is genetically unique, and is therefore tailored to meet her infant’s specific nutritional needs. Besides being more easily digestible than formula, a mother’s milk contains a number of immune boosting elements that can prevent certain childhood diseases. There is no current hard evidence that infants who are formula fed are developmentally at risk, however. The decision on which method to use is a personal one
and ideally should be made by both expectant parents.

Nursing babies are known to have fewer gastrointestinal infections, ear infections, allergic disorders, and respiratory illnesses than those who are formula feed. Recent evidence also suggests that infants who are breast fed have a lower incidence of Sudden Infant Death Syndrome (SrDS) and juvenile diabetes. There even exists some evidence that breast fed infants have higher levels of intelligence and are less apt to develop learning disorders than those who are bottle fed.

On another tangent, breast feeding enables a woman to establish a psychological “bond” with her child that occurs naturally during the intimacy of the feeding. It is also more convenient than bottle feeding and is less expensive than the cost of bottles and store bought formulas.

Perhaps the only disadvantage to nursing is that the father is unable to directly partake in the process. He can, however, become part of the bonding process in the first few weeks by carrying the infant to the mother for the feeding or by changing the baby’s diapers. After the third week, the mother may also hand express or pump her milk into a bottle so that the father can feed the child.

Underscoring the medical community’s support of breasting feeding, one of the surgeon general’s goals for the year 2000 was for 75% of all mothers to nurse their infants upon discharge from the hospital. As of 1988, when that goal was established, the figure stood at 54%.

The American Academy of Pediatrics recommends that all infants be breast fed during the first year of life. However, breast feeding even a shorter period of time can benefit infants for up to a year after nursing has stopped.

Successful breast feeding is a process that must be learned by a mother and child, and it therefore requires practice and patience. Understanding the way in which lactation, or milk secretion, occurs will help you carry out the process. The first step in successful suckling is the ability of the mother to eject her milk, a process known as “let down”. Because the hormone to eject milk originates in the brain, sometimes stress, anxiety, or other stimuli in the environment can interfere with her ability to carry out the process. The length of time between putting the baby to the breast and letting down, therefore, is highly variable. Let down may be accompanied by a tingling sensation or a sharp pain; however, in the beginning, there usually is no sensation at all. Typically, an infant will suckle 90% of the milk in one breast 10 minutes after let down.

The substance emitted from the woman’s breast during the first few days following birth is not actually milk. Rather it is a substance called colostrums, which is a thick, yellow fluid rich in protein and other substances that help to fight infection. Several days after delivery, the body will begin to produce milk and the production of colostrums will subside. The fat content of the milk will increase during the suckling session, often starting out thin and watery and becoming increasingly fatty as the feeding goes on. Given this fact, it is crucial that infants not only be fed when they want to be (usually ranging between 1 ½ – 4 hours), but that they also be allowed to nurse until they are satisfied, rather for an arbitrary period of time.

The baby should suckle on as much of the areola (dark circumference around the nipple) as possible in order to receive enough milk. Also if the infant is being held in a cradle position, he or she should be turned so that the tummy is against the mother’s. During each feeding, the baby should be allowed to feed on both breast, and the mother should alternate which breast she begins with each time. This may reduce some of the pain and soreness that many women often experience as they begin nursing. The infant should be burped once or twice with each feeding.

COMMON QUESTIONS ABOUT DONATING UMBILICAL CORD BLOOD

What are umbilical cord blood cells?
Umbilical cord blood contains a special type of cells, called stem cells. Stem cells live a long time and can develop into many different types of blood cells. Stem cells are found in many parts of the body. The
stem cells that are leftover in a baby’s umbilical cord and placenta are typically thrown away after a baby is born.

What are stem cells used for?
Stem cells can be used to make new blood cells. Often they are used for treating some medical problems including leukemia (a type of blood cell cancer), some types of anemia, and several other medical conditions. These cells are not used for cloning.

How are they collected?
Until recently, the extra blood in the placenta and umbilical cord was routinely thrown away after a delivery. Now, stem cells from leftover blood in a baby’s umbilical cord and placenta can be collected after a baby is born and before the placenta is thrown away. There is no pain or risk for the mother or the baby since cells are collected after the umbilical cord has been cut and the baby has been delivered.

How is cord blood stored?
After cord blood is collected it can be frozen for future use. There are two options for storing these frozen cells; (1) a private cord blood bank, or (2) a public cord blood bank.

How does a public cord blood bank work?
• After delivery, a specially trained person collects blood from the placenta and umbilical cord. In some situations, a specially trained obstetrical provider may collect the cells at the time of delivery.
• Once blood is collected, the amount of cells in the blood are tested to be sure that the unit is usable, in addition, other tests for various infections are performed.
• Since each person has a unique HLA blood type, cord blood cells need to be tested to see what “type” they are. This information is put into a secure computer database.
• Cells are frozen and saved in a central storage facility where they are available to any patient that needs them for treatment It is important to remember that if you use a public bank. Your baby’s cord blood cells are not saved for your baby or your family. They can be used by anyone who needs them.
• Public cord blood banks are free.
• Public banks typically collect from only a few designated hospitals in their area.

How does a private cord blood bank work?
• When cells are collected for a private cord blood bank, the provider who delivers your baby collects them using a kit that the private bank has sent to you before the birth.
• These cells are sent to a private bank where they are frozen and stored.
• These cells are then reserved for your baby or your family.
• Private cord blood banks charge a fee for storing these cells, The cost depends upon the specific bank used; however, there is usually an initial fee for freezing the cells and then an additional yearly fee to keep the cells stored.

As a parent, how can I possibly figure out if it’s worth paying the fees to have umbilical cord blood stored in a private cord blood bank?
Keep these things in mind in making your decision:
• The slim overall chance of a child using its own cord blood for transplant has been estimated to be about one case in 2,700.
• Many private banks do not have a program in place to check the quality of the cells. Even when specially trained people collect cord blood, almost 1 in 3 units are deemed unusable and discarded by public cord banks.
• Many doctors who treat children with leukemia or other medical problems do not think that these children should receive their own stem cells for two reasons: (1) A child’s own stem cells may already have a genetic change that caused their disease. (2) In children with leukemia, these cells may not fight off the child’s leukemia cells as well as the stem cells from another person (this is called graft-vs.-leukemic effect).
• Directed donation of cord blood (either through private banking or through special arrangements with a public bank) should be considered when there is a specific diagnosis of a disease within a family known to be treatable with stem cell transplantation.
• Although stem cells from umbilical cord blood could be used for adult relatives, very few of these attempts have been successful to date. A major problem is that there are not enough stem cells in one baby’s umbilical cord blood to be sufficient for an adult transplant

Source: Adapted with permission from M.K. Moos. Chair, North Carolina Women’s Hospital Patient Education Steering Committee, Chapel Hill. N.C.
Updates available at:
http://www.mombaby.org/index.php?c=1&s=25; Donation of Umbilical Cord Blood Cells.