You and your pregnancy

If you are going to have a baby, you will likely have questions about changes you are going through. You may wonder what labor and delivery will be like. This booklet will help answer your questions. It can serve as a guide to help you have a happy, healthy pregnancy and birth. You could be pregnant even if you have been using birth control. You should have a test as soon as you can to show whether you are pregnant. Early Signs of Pregnancy If you have one or more of these signs, you may be pregnant:

Missed period
Light period or spotting
Tender breasts
Being tired
Upset stomach
Feeling bloated
Needing to urinate often

Prenatal Care Early and regular prenatal care (a program of care for a pregnant woman before the birth of her baby) can increase your chances of having a healthy baby. Prenatal care is more than just health care, though. It includes childbirth education and counseling, too. You may be cared for by an obstetrician-gynecologist while you are pregnant. Often, you will receive care from a whole health care team that may include doctors, nurses, nurse-midwives, and childbirth educators. Feel free to ask any of them questions you may have. Together you can work toward having a healthy baby. Tell your doctor about any changes you have noticed since your last visit. If you have problems between visits, call your doctor. If you have concerns about how to pay for care or how to get to an office or clinic, help is often available. Talk with your doctor, nurse, or local social service group. Your First Prenatal Visit Your first prenatal visit will be longer and more involved than other visits. It will include:

History
Physical exam
Estimation of due date
Tests
A plan for the next visits and tests

History. One of the things you will be asked about is your history. This includes your health and life style, the health of your family and the father's family, and your past pregnancies. This information can help your doctor to find problems that might come up. Your answers should be honest, complete, and accurate. Some questions you may be asked are:

Do you take any medicines?
Do you have any allergies or health problems?
Have you been exposed to any infections?
What are your periods like?
When was your last menstrual period?
What type of birth control have you used?
Do you use alcohol, tobacco, or other drugs?
Have you been pregnant before?
Have you ever had a miscarriage?
Have you ever had an induced abortion?
If you have had a baby before:
— What did the baby weigh at birth?
— How long did labor last?
— What type of delivery was it (vaginal or cesarean?)
— Were there any problems?
Is there a history of birth defects in your family?
— Have you had a previous child with a birth defect?
— What is your ethnic background? What is the ethnic background of the father?

Physical Exam. During the physical exam, your height, weight, and blood pressure will be measured. Other parts of your body will be checked. Your pelvic organs--cervix, vagina, ovaries, fallopian tubes, and uterus—are checked during a pelvic exam. Your doctor will also check for changes in your cervix and the size of the uterus. The Due Date. The due date is called the estimated date of delivery, or EDD. (The estimated date of confinement, or EDC, is a term that is also sometimes used.) An average pregnancy is 280 days, or 40 weeks, from the first day of the last menstrual period. However, a normal pregnancy can last between 37-42 weeks. Only about 5 of 100 babies are born on their due date. Most women give birth within 2 weeks of this date. The due date helps your doctor measure the growth of the fetus and the progress of your pregnancy. It also helps set the timing for some tests that are most accurate when they are done at certain times in pregnancy. Tests. Several lab tests may be done early in your care:

Blood tests to check for:
— Blood type (A, B, AB, or O)
— Rh factor (positive or negative)
— Anemia
— Past German measles (rubella)
— Hepatitis B virus
Urine tests to give information about levels of sugar and protein and to find some infections
A Pap test to check for changes of the cervix that could lead to cancer

Some of these will be done more than once. Your doctor also may suggest other tests based on your history, family background, and race. Some women may be tested for diabetes. Your doctor may ask you if you wish to be tested for sexually transmitted diseases (STDs) including HIV (human immunodeficiency virus), the virus that causes AIDS (acquired immunodeficiency syndrome). Other tests to find birth defects may be offered. Future Visits After your first prenatal visit, the other visits are usually shorter. They are to find out how you are doing and how the fetus is growing. Table 1 shows the changes you can expect. Miscarriage Miscarriage is the loss of a pregnancy, most often early on. About 15% of women who know they are pregnant will have a miscarriage. Common signs of miscarriage are vaginal bleeding and cramps. Pain often comes and goes. It may begin in the small of the back and may be felt as cramps low in the abdomen. Sometimes tissue passes through the vagina. If you bleed in early pregnancy, your doctor may perform a pelvic exam and may order testing. Most miscarriages cannot be prevented. It is the body's way of dealing with a pregnancy that was not normal. It doesn't mean that a woman cannot become pregnant again. Nor does it mean that anything is wrong with her health. There is no proof that stress or physical or sexual activity causes miscarriage.

The timing of your visits depends on your needs. You may follow a schedule like this:

To 28 weeks: monthly
28-36 weeks: every 2 weeks
36 weeks to delivery (at about 40 weeks): weekly

Women with health or pregnancy problems may need more visits. Your doctor will watch for signs of problems throughout your pregnancy. At each visit, your doctor will check:

Your weight
Your blood pressure
The growth and position of the fetus
The fetal heartbeat
Urine for protein and sugar

Some tests may be done. Lab tests and pelvic exams may not be done each time, though. Each visit will be noted on your medical record. The results of the first history, physical exam, and tests will be written there, too. Your doctor will discuss them with you. He or she will also give you advice on a healthy life style. Classes You and your partner can attend classes to prepare for having a baby. Prenatal care and exercise classes can help you learn good habits. Childbirth preparation classes will help you prepare for labor and delivery. Parenting classes can teach you basic skills in caring for a baby's needs. Some hospitals have breast-feeding classes after delivery. Some classes are free. Others have set or flexible fees. Check with:

Your doctor
Hospitals or clinics
Childbirth groups
Community groups
Health departments

Special Tests Depending on your history and the results of your routine tests, your doctor may recommend that you have more tests. Special tests, procedures, and counseling can help your doctor find some problems before the baby is born. Some of these tests look for birth defects. Others check to see if the fetus is under stress. Table 2 explains several tests and why they may be offered to you.
No test is perfect. Your fetus may have a birth defect even if the test does not show it. It may not have that defect even if the test does show it. Or, your fetus may have a problem that the test was not meant to find. If your doctor offers you a test for birth defects, it is your choice whether to have it. Some people choose not to test for birth defects. If you do have a test, make sure you know what the results mean. If tests show your fetus may have a major birth defect, you are faced with a hard decision. You may choose to have the baby. If so, you may need to deliver your baby at a special hospital. You and the baby may also need extra help after delivery. You may choose to have an abortion. If so, you should make this decision as soon as possible. The earlier an abortion is done, the safer it is for you. When making your decision, get as much information about the defect as you can. Talk with doctors, counselors, or parents with a child with the same type of defect. Ask friends or family for advice and support to help you with either decision. Knowing as much as you can will help you to make the best choice.

Common Changes As your fetus grows, it is normal for you to have some discomforts. Some of these may occur only in the early weeks of pregnancy. Others may occur only at the end. Still others may appear early, then go away, only to return. Backache Backaches are common. They are usually caused by the strain put on your back by your growing uterus and by changes in your posture. Try doing some of these things to help your back feel more comfortable:

Change position.
Wear low-heeled shoes.
Avoid lifting heavy things or children.
Do not bend over at the waist to pick things up. Squat down, bend your knees, and keep your back straight.
Place one foot on a stool or box when you have to stand for a long time.
Sleep on your side with one knee bent. Support your upper leg on a pillow.
Apply heat, cold, or pressure to your back.
Ask your doctor or nurse for special exercises you can do.

Breast Changes Early in pregnancy, your breasts begin to grow and change to prepare for breast-feeding your baby. They will feel firm and tender. As your breasts grow, wear a bra that fits well and provides support. Your nipples may stick out more and get darker. This will help your baby to breast-feed. Some women's nipples do not stick out but sink inward (retracted nipple). If you have retracted nipples and you plan to breast-feed, your doctor may suggest that you try massaging the nipples so they stick out. Breathing Problems As the fetus grows, the uterus takes up more room. Your lungs do not have as much room to expand, so you may be short of breath. A few weeks before you give birth, the fetus's head will move down in the uterus, or "drop," and press against the cervix. This usually happens between 36-38 weeks of pregnancy in women who have not had a baby before, but may happen later. In women who have already had a baby, it may not happen until the start of labor. When the fetus drops, it will be easier to breathe. If you are short of breath, here are some things to try:

Sit up straight.
Sleep propped up.
Ask your doctor or childbirth educator about breathing exercises.

Constipation At least half of all women are constipated at some point during pregnancy. Changes in hormones slow food's passage through your body. During the last part of pregnancy, your uterus may press on your rectum. This may add to the problem. Some things may help:

Drink lots of liquids. Include fruit juices, such as prune juice.
Eat foods high in fiber, such as raw fruits and vegetables and bran cereals.
Exercise each day—just walking is fine.

Cramps In the last part of pregnancy, you may have leg cramps. Stretching your legs before going to bed can help ease cramps. Avoid pointing your toes when stretching or exercising. Frequent Urination You will need to urinate often during the first 12-14 weeks of pregnancy. This feeling may go away in the middle of pregnancy. In the last few weeks, you may need to urinate more often again. If you also have pain, fever, or a change in the odor or color of your urine, you may have an infection. Contact your doctor right away. Hemorrhoids Very often, pregnant women who are constipated also have hemorrhoids. Hemorrhoids are varicose (or swollen) veins in the rectum. They are often painful. Straining during bowel movements and having very hard stools may make hemorrhoids worse. Some products for treating pain from hemorrhoids and the tips about constipation should help. Inability to Sleep After the first few months, you may find it hard to sleep. This often happens in the last weeks of pregnancy. Your abdomen is large, and it is hard to get comfortable. To get the rest you need:

Take a warm bath at bedtime.
Try the tips to relax that you learned in childbirth classes.
Lie on your side with a pillow under your abdomen and another between your legs.
Rest for short breaks during the day.

Indigestion Indigestion is also called "heartburn," but it does not mean that anything is wrong with your heart. It is a burning feeling in the stomach that seems to rise up into the throat. Changes that take place in your body during pregnancy may make indigestion worse. Changes in your hormone levels slow digestion and relax the muscle that keeps the digested food and acids in your stomach. Also, your growing uterus presses up on your stomach. For relief:

Eat five or six small meals a day instead of three large ones.
Avoid foods that you know cause gas.
Sit up while eating.
Wait an hour after eating before lying down. Do not eat before going to bed.
Wait 2 hours after eating before exercising.
Do not take any medicines, including antacids and baking soda, unless you first check with your doctor.

Lower Abdominal Pain As the uterus grows, the muscles that support it are pulled and stretched. You may feel this as sharp pains or a dull ache in your abdomen. Resting and changing your position seem to help the most. The pains are most often felt between 18-24 weeks. Nausea and Vomiting Nausea and vomiting are common during the first 12-14 weeks of pregnancy, but sometimes happen throughout pregnancy. This is called "morning sickness," but it can occur any time during the day. It is common when the stomach is empty. Here are some tips to make you feel more comfortable:

Eat dry toast or crackers before getting out of bed in the morning.
Get up slowly and sit on the side of the bed for a few minutes.
Eat five or six small meals each day. Try not to let your stomach get completely empty.
Avoid unpleasant smells.
Contact your doctor if nausea or vomiting is severe.
Always check with your doctor before taking any medicines.

Numbness and Tingling As the uterus grows, it rests on some of your nerves. Some nerves may also get pressed if you are swollen from retaining water. This may cause numbness or tingling in the legs, toes, and sometimes the arms. It is usually not serious. It will go away after the baby is born. Skin Changes The hormones in your body often cause some normal changes on your skin. Some women have brownish, uneven marks around their eyes and over the nose and cheeks. This is called chloasma. These marks usually disappear or fade after delivery, when hormone levels go back to normal. Being in the sun tends to make the marks darker. In many women, a line running from the top to the bottom of the abdomen becomes dark. This is called thelinea nigra. In others, streaks or stretch marks may appear on the abdomen and breasts as they grow. This is caused by the skin tissue stretching to support the growing fetus. There is no way to prevent stretch marks. They may slowly fade after pregnancy. Swelling Some swelling (called edema) is normal in pregnancy. It happens most often in the legs and usually in the last few months. It may happen more often in the summer. Swollen hands and face may mean there is a problem. Let your doctor know if they swell. You can help reduce the swelling in your legs if you:

Put your legs up when you can.
Rest in bed on your side. Your left side is best.
Limit salty foods.
Wear support pantyhose or stockings.

Never take medicines (fluid pills) for the swelling unless your doctor has prescribed them. Tiredness You may often feel tired during pregnancy—especially in the beginning and at the end. If you get enough exercise and rest (including naps) and eat a healthy diet, you are likely to feel better. Varicose Veins Varicose veins are swollen veins. They appear most often in the legs but can appear near the vulva and vagina. They are caused by pressure from your uterus on your veins. They often occur if you must stand or sit for a long time. They are usually not serious. They can be uncomfortable, though. You may have aching, sore legs. For some relief:

Put your legs up when you can.
Lie down with your legs raised.
Try not to stand for a long time.
Do not wear anything that binds your legs, such as tight bands around stockings or socks.
Try wearing support stockings, or your doctor can recommend special stockings.
If you must sit a lot on the job, stand up and move around from time to time.

Special Care Pregnancies Most pregnant women have normal pregnancies. Sometimes, though, a problem may come up that needs special care. If you start prenatal care early and visit your doctor regularly, many of these problems can be prevented or easily treated. Always be sure to tell your doctor about any changes that you have questions about. Anemia When you are anemic (have a low blood count), you often feel very tired. The most common cause of anemia is not getting enough iron in your diet. Women who are anemic in pregnancy are less able to cope with bleeding, infections, and other problems that may occur at the time of birth. The fetus may suffer because less oxygen is passed to the placenta. A change in diet or taking iron pills may be needed. Red meat, dried beans and peas, enriched cereals, and prune juice are some foods rich in iron. Gestational Diabetes Diabetes occurs when there is a problem with the way the body makes or uses insulin. Insulin is a hormone that helps the body use sugar, the body's main source of fuel. Women with diabetes have too much sugar in their blood. Some women first have diabetes while they are pregnant. This is called gestational diabetes. It can occur without symptoms. Usually, it goes away after delivery. Women who have gestational diabetes have a higher risk of having diabetes again later in life. Your doctor may test you for diabetes during pregnancy. Some women with gestational diabetes have to take insulin. Others are able to control it with a special diet. If you are overweight, weight loss toward your ideal body weight after pregnancy may decrease your chance of having diabetes later in life. High Blood Pressure High blood pressure can occur for the first time during pregnancy. The cause is unknown. If it is not treated, it can be very serious. Many women do not have symptoms. Others, though, may have some or all of these signs:

Headaches
Swelling, especially of the hands and face
Dizziness
Blurred vision or spots in front of the eyes
Sudden or uneven weight gain
Stomach pain
Protein in the urine

Treatment may range from bed rest at home to special care in the hospital. Sometimes the baby will need to be delivered early.
Infections While you are pregnant, you can still get illnesses such as colds, upset stomach, flu, bladder infections, and sexually transmitted diseases (STDs). Do not try to treat yourself or take over-the-counter medicines without discussing your symptoms with a doctor or nurse. Most common viral infections, such as those that cause colds, have no effect on the fetus. Others can cause serious problems if you first get them during pregnancy. Rubella (German measles) can cause birth defects. Hepatitis can cause miscarriage, stillbirth, and preterm labor.
Problems With the Placenta Heavy vaginal bleeding in late pregnancy usually means a problem with the placenta. Bleeding can occur when the placenta begins to pull away early from the wall of the uterus. This condition is called placental abruption. If this happens, you may feel constant, severe abdominal pain. The fetus may get less oxygen, which could be dangerous. You increase your risk of abruption if you use crack or cocaine or smoke. Placenta previa occurs when the placenta partly or completely covers the cervix. This blocks the baby's exit from the uterus. Bleeding can occur when the cervix starts to open. Both of these conditions require medical care.
Multiple Pregnancy When there is more than one fetus in the uterus, this is a multiple pregnancy. Most women who have multiple pregnancy have twins. Twins occur naturally about once in every 90 births. In multiple pregnancy, the normal discomforts of pregnancy are worse because the uterus is much larger. High blood pressure and anemia are more likely. Preterm labor is the greatest risk. If twins share the same placenta, there is slightly greater risk of problems.
Preterm Labor Labor that starts before 37 weeks of pregnancy is preterm. It is not known why some women go into labor early. If the fetus is not fully grown, its best chance for doing well is inside the woman's uterus. In this case, every effort will be made to stop labor. Your doctor may try a number of treatments—bed rest, intravenous (given by vein) fluids, or special medications that help to relax the uterine muscle. However, treatment does not always work. It is more successful if it is started early in labor (see box).
Signs of Preterm Labor Sometimes the signs that preterm labor might be starting are fairly easy to see. Other times, the signs are mild and harder to find. Call your doctor right away if you have any of these signs:

Vaginal discharge
— Change in type (watery, mucous, or bloody)
— Increase in amount
Pelvic or lower abdominal pressure
Low, dull backache
Abdominal cramps, with or without diarrhea
Regular contractions or uterine tightening

Taking Care of Your Health It is very important to take good care of both your physical and mental health now. Everything a woman comes in contact with can affect the baby. What she does in her daily life can affect the baby, too. Nutrition and Weight Gain Nutrients are passed from woman to fetus through the placenta. The fetus gets all its food from the woman. Without a good diet, the growth of the fetus could be harmed. There are government programs that can help if money for healthy food is a problem. An average woman requires about 2,200 calories a day. When you are pregnant, you need about 300 calories more each day to stay healthy and help the fetus grow. Choose a diet that gives you needed calories and nutrients. The Food Guide Pyramid was developed by the U.S. Department of Agriculture to help men and women choose foods that will give them the nutrients they need. The following count as 1 serving in the pyramid:

Bread, cereal, rice, and pasta group: 1 slice of bread; 1 ounce of cereal; ½ cup of cooked cereal, rice, or pasta
Vegetable group: 1 cup of raw, leafy vegetables; ½ cup of other cooked or raw vegetables; ¾ cup of vegetable juice
Fruit group: 1 medium apple, banana, or orange; ½ cup of cooked or canned fruit; ¾ cup fruit juice
Milk, yogurt, and cheese group: 1 cup of milk or yogurt, 1½ ounces of natural cheese, 2 ounces of processed cheese
Meat, poultry, fish, dry beans, eggs, and nuts group: 2-3 ounces of cooked lean meat, poultry, or fish; ½ cup of cooked dry beans; 1 egg; 2 tablespoons of peanut butter

Healthy snacks are a good way to get the nutrition and extra calories you need. Pick snacks that are not high in sugar or fat. Fruit, cereal, and low-fat yogurt are good choices. Avoid candy, soda, and chips. You may feel better if you eat small meals six times a day, especially toward the end of pregnancy. To make these mini-meals, divide the number of servings of the basic foods needed each day into smaller portions. Milk and a sandwich made with meat, chicken, fish, peanut butter, or cheese with lettuce and tomato makes an excellent mini-meal. Other ideas are milk and fresh fruits, fruit juices, cheese and crackers, raw vegetables, and soup.
Where Does the Weight Go? In pregnancy, your body must store nutrients and increase the amount of blood and other fluids it produces. Here is where the weight will go:
7 pounds Maternal stores (fat, protein, and other nutrients)
4 pounds Increased fluid
4 pounds Increased blood
2 pounds Breast growth
2 pounds Uterus
7½ pounds Baby
2 pounds Amniotic fluid 1½ pounds Placenta

A woman of normal weight before pregnancy should gain 25-35 pounds. Women who are underweight should gain about 28-40 pounds. Women carrying twins should gain as much as 45 pounds. Women who are very overweight should gain about 15 pounds. Women who do not gain enough weight in pregnancy are more likely to have small babies. Babies who have a low weight at birth (less than 5Æ pounds) find it harder to live outside of the uterus. Labor is not easier if your baby is small or weighs too little. You should not try to gain less weight so you can have a smaller baby. Women who weigh too much can have problems, too. Still, do not try to lose weight now. You may keep your fetus from getting needed nutrients. It is best to try to lose weight before you are pregnant and then again after birth. Alcohol, Tobacco, and Other Drugs When a pregnant woman drinks alcohol, it soon reaches the fetus through the placenta. Alcohol can harm the fetus. How much alcohol it takes to harm the fetus is not known. Therefore, the safest plan is not to drink at all in pregnancy. Women who smoke tend to have babies who do not weigh enough, preterm births, miscarriage, and other problems more often than women who do not smoke. Less oxygen and nutrients may reach the fetus. Babies born to women who smoke have a higher risk of upper respiratory infections, colds, and ear infections. They also have a higher risk for sudden infant death syndrome (SIDS). If you smoke, now is a good time to quit. It is a good time for the family to quit, too. Secondhand smoke is also bad for the baby. Other drugs—such as crack or cocaine, heroin, PCP, and tranquilizers—can also harm the fetus. Use of these drugs can cause problems with the placenta, preterm birth, and birth defects. The baby can have learning problems and be addicted to drugs. Do not use any drug unless your doctor says it's okay.
Work Most of the time, a healthy woman with a pregnancy without problems can keep working if her job poses no more risk than daily life. Discuss with your doctor the type of work you do both at your workplace and at home. There could be hazards in your workplace:

Do you work around chemicals, gas, dust, fumes, or radiation?
Do you have to lift heavy loads, work at heights, or use high-speed machines?
Do you stand for most of your day?

Give your doctor a complete picture of your work and life style. Most women are able to work into their last weeks of pregnancy. Some may need to make some changes. Your family should be able to help you at home.
Home Life Taking care of the home and family still must be done. More work may need to be shared with your partner or others. Be sure you get enough rest. You should limit lifting or moving heavy things and try to stay away from cleaning products, fumes, or paints. Careful planning is very important to avoid too much stress and strain.
Exercise Exercise can help strengthen muscles used in labor and delivery and lessen some of the discomforts of pregnancy. It may give you more energy and make you feel better. Your balance changes while you are pregnant. You tire more easily. It takes longer to recover, too. Caution should be the rule:

Avoid getting overheated.
Limit outdoor exercise in hot weather.
Avoid exercise that make you very tired.
Drink lots of water.
Wear good support shoes and bra.

The type of exercise you can do now depends on your health and on how active you were before you became pregnant. This is not a good time to take up a new, hard sport. If you were active before, though, you can continue to be, within reason. If, for example, you played tennis, you can likely still play unless you have special problems or feel very tired. The following activities, in moderation, are especially good during pregnancy:

Swimming
Brisk walking
Prenatal exercise classes

Travel Most women can travel safely until close to their due date. For most women, the most comfortable time to travel is in the middle of pregnancy. You probably have more energy. Morning sickness is usually no longer a problem. Problems are least likely to happen during this time. Here are some hints that apply no matter what type of travel you choose:

Use safety and lap belts.
Walk around every hour and a half or so.
Wear comfortable shoes and clothing that doesn't bind.
Take some crackers, juice, or other light snacks with you to help prevent nausea.
Drink plenty of fluids.
Do not take motion-sickness pills and laxatives unless you check with your doctor.
Take a copy of your medical record with you if you will be far from home.
You may want to have a prenatal visit before you leave.
If you plan to travel very late in pregnancy, check with your doctor. Going into labor away from home can cause problems you may not be prepared for. (For example, your insurance may not cover a delivery in another city.)

Sexually Transmitted Diseases (STDs) If you have more than one sexual partner—or if your partner has more than one—you greatly increase your chances of getting an STD. Examples include HIV (the virus that causes AIDS), gonorrhea and chlamydia, syphilis, and the herpes virus. These diseases pose a risk for the woman and the fetus, so condoms should be used. If you think you might have an infection or other disease, tell your doctor. Emotional Changes Pregnancy is a time of emotional changes. Especially early on, the hormones in your body may cause mood swings. Being very tired in early and late pregnancy may also make you feel irritable or depressed. Regular rest, relaxation, and exercise will help your mental as well as physical well-being.
Abuse Abuse of women by their male partners is one of America's most common problems. This may be physical, sexual, or emotional abuse. Men who abuse their partners often abuse their children, too. Abuse often begins or increases during pregnancy, putting both the woman and the fetus at risk. During pregnancy, the abuser is more likely to aim his blows at the woman's breasts and abdomen. Dangers to the fetus include miscarriage, low birth weight, and direct injury from the blows. Sometimes, though, abuse decreases during pregnancy. If you are being abused, tell your doctor. He or she can help you get in touch with support services, such as crisis hot lines, domestic violence programs, legal aid services, or counseling. Shelters exist for abused women and children. A close friend, counselor, or clergy member may also be able to help.

Relationships Many women have mixed feelings over pregnancy and parenthood. You may be afraid and unsure about pregnancy, birth, and your body and self-image. You may worry about being a parent. Sharing plans, attending birth classes, and naming the baby can strengthen caring and sharing with your partner. Single mothers need special support during pregnancy. The father of the baby, a close relative, or another person you choose can share in the duties and the joys of this time. Your partner may wish to be there when you are in labor to share the birth. If your partner cannot be there, most hospitals will allow you to have a close relative or friend there.
Sex Some people worry about having sex during pregnancy. They may be afraid it will cause a miscarriage. For a healthy woman with a normal pregnancy, sex is safe into the last weeks of pregnancy. The fetus is well cushioned by amniotic fluid. For your comfort, you and your partner may want to try different positions. Your doctor may advise you to limit or avoid sex if there are signs of problems in your pregnancy. Both you and your partner may find your sex drives change now. Some women find they have a lower sex drive, some greater. Some see no change at all. Your partner's feelings change, too. Share your feelings with each other.
Family Pregnancy is often a time of planning and excitement. Children become aware of the changes around them. Include them in plans for the new baby. Books with pictures for all age levels can help them understand pregnancy and birth. A child needs to know not only the duties of being a sister or brother but also the joys. Children also need to be prepared for their mother's absence. Sometimes extended family members can help. They can care for older children when you need rest or when you go to the hospital.

Labor You cannot predict when labor will start. Still, there are some things you can do ahead of time to be ready. For instance:

Pack your suitcase for the hospital.
—Small suitcase with a few personal items
—Larger suitcase to be brought later
Leave jewelry and other valuables at home.
Plan your hospital route. Know how long it will take to get there. Consider distance, means of transportation, time of year, time of day, who will take you, and if you need a babysitter.
Ask whether to call your doctor first or go to hospital first when you go into labor.
Get a car safety seat to bring your baby home.

Usually, you do not need to go to the hospital as soon as your contractions begin. While you wait at home, rest if you can. Labor is work, and you will need your energy later. Some women, however, may find it more comfortable to walk around. Discuss eating during labor with your doctor. You may be told not to eat or drink anything once labor has begun.
True Labor versus False Labor In the last weeks of pregnancy, your uterus might start to cramp. These cramps may become uncomfortable or even painful as you get closer to your due date. These irregular cramps are called Braxton-Hicks contractions, or false labor. They are normal. Many women have them. One good way to tell true labor from false labor is to time the contractions. Time how long each lasts and how long it is from the start of one to the start of the next. It is hard to time labor pains if they are weak. Keep a record for an hour. Call your doctor if:

The contractions last at least 30-70 seconds.
They occur regularly.
They don't go away when you move around.

It is time to go to the hospital if:

Your amniotic sac ruptures (your "water breaks"), even if you are not having any contractions. Write down the time it happens.
You are bleeding from the vagina, more than spotting.
The contractions come 5 minutes apart or closer.
You have constant, severe pain. Call your doctor right away. Don't wait for a whole hour to pass before you call.

If you are more than 6 weeks from your due date, but have more than five contractions in an hour, you may be in preterm labor. Call your doctor. Table 3. True Versus False Labor Type of Change True Labor False Labor (Braxton-Hicks contractions) Timing of contractions Are regular and, as time goes on, get closer together Often are irregular and do not consistently get closer together Change with movement Contractions continue, despite movement Contractions may stop when you walk or rest, or may even stop with a change of position Location of contractions Usually felt in the back and move around to the front, but may be felt in the front first Often felt in the abdomen Strength of contractions Increase in strength steadily Usually weak and do not get much stronger False labor often happens just at the time you expect to go into labor. This makes it hard to tell it from true labor. Sometimes only a pelvic exam can show if true labor has begun. The doctor will look for changes in your cervix that show the start of labor. Each woman is different, though. Don't wait too long to call your doctor if you think you are going into labor. Table 3 gives you some of the ways true labor and false labor differ.
What Happens During Labor Knowing what happens in labor makes it easier for you to relax and do your part. On average, labor lasts about 12-14 hours for a first birth. In later births, labor may be shorter. Labor is divided into three stages. During each stage, certain changes take place in your body.

First Stage This stage is usually the longest. It begins when the cervix starts to open and ends when it is completely open (fully dilated). Blood-tinged mucus is passed from the vagina ("show"). Near the end of this stage, contractions become longer and stronger.

Second Stage Once your cervix is fully dilated, the baby needs help to move down the vagina. You will be asked to push the baby out by bearing down during each contraction, until the baby is born. This is a lot of work. The second stage may last up to 2 hours or longer, especially during a first birth. It ends with the birth of the baby.

Third Stage After the baby is born, the uterus will continue to contract and the placenta will be delivered. These contractions are closer together than the contractions that push out the baby. They usually cause less pain. This last stage may last from just a few minutes to 15-20 minutes.

Labor begins when the uterus contracts and the cervix starts to open. The uterus tightens and relaxes at regular intervals, causing the abdomen to feel hard, then soft. These are contractions. They make the cervix thin out (efface) and open as wide as it can (dilate). Early labor is often felt as a low backache that moves around to the front. As labor continues, the contractions come closer together, last longer, and are usually felt in the lower abdomen. Contractions help the baby come through the vagina. Throughout labor, the baby moves deeper into the pelvis and farther down in the vagina. The baby's head and body move and turn for the easiest fit through your pelvis.
Monitoring During Labor The heart rate of the fetus is monitored during labor. Fetal monitoring cannot prevent a problem. It can help your doctor be alert to warning signs. Fetal monitoring can be done either by listening with a stethoscope or electronic fetal monitoring:

The doctor and nurse can listen to the fetal heartbeat at certain intervals. The heartbeat can be heard with a type of stethoscope or an ultrasound device. The heart rate of the fetus is usually checked and recorded after a contraction.
Electronic fetal monitoring uses electronic equipment to measure the fetus's heart rate and uterine contractions. This equipment provides a constant record of information that can be read by the doctor or nurse. This monitoring can be done with instruments attached to the woman's abdomen (external). It can also be done by having a small device attached to the scalp of the fetus (internal). Sometimes both internal and external devices are used.

Pain Relief For most women, having a baby involves some pain. There are several ways to help you deal with the pain. Relaxation techniques give some women very good control of the discomfort of labor. These techniques include breathing in certain patterns and imagining you are elsewhere. They are often taught in prenatal classes. Your labor nurse may be able to teach you, too. Drugs can also ease pain. Analgesics are drugs that ease pain. They can be injected into the muscle or vein. These may make you more comfortable and allow you to rest between contractions. Anesthetics are drugs that remove pain. Local anesthesia numbs a small area. Regional anesthesia (spinal or epidural) takes away painful feeling in the uterus and pelvic area. It allows you to be awake and take part in the birth of your baby without feeling pain.

Delivery The hospital is the safest place to deliver your baby. Ask to tour the hospital in advance so that you know what to expect. Once you are in labor and arrive at the hospital, you will know where to go.
Vaginal Delivery Most women deliver their babies through the vagina. Sometimes, other procedures are needed to help deliver the baby. When your baby's head appears at the opening of the vagina, the tissue of the vagina becomes very thin and tightly stretched. Sometimes it is hard for the baby's head to fit through without tearing the woman's skin and muscles. To prevent these tears and to ease some of the pressure on your baby's head, your doctor may make a small cut in the area while it is numbed with an anesthetic. This is called an episiotomy. It is one of the most common operations in the United States. Sometimes the doctor needs to help delivery along. In these cases, forceps or vacuum cups can be used. A forceps looks like two large spoons. The doctor puts the forceps into the vagina, places it around the baby's head, and gently delivers the baby. Vacuum cups can be used instead of forceps. In this method, a plastic cup is attached to the baby's head by using a vacuum pump. The baby is gently pulled from the vagina. Cesarean Delivery In some cases, a cesarean birth may be needed. Cesarean birth is delivery of the baby through a cut made in the abdomen and uterus. Sometimes the decision to have a cesarean birth can be made before labor begins for several reasons:

The position of the fetus in the uterus makes it difficult to come through the vagina.
A woman may have a medical condition that would make it harmful for her to go through labor.
A certain type of cut was used to deliver the baby in a past cesarean birth.

Sometimes a cesarean birth may be needed if labor is not going well. The baby may be too large for vaginal delivery. Sometimes, opening of the cervix may be slow or incomplete. Some babies have a problem coping with the stress of labor. The fetus's heart rate may drop or slow for a long time. Cesarean birth may also be needed because of a problem for the woman, such as heavy bleeding. At one time, it was thought that once a woman had a cesarean birth, she would have to give birth the same way in any later pregnancies. Today, though, most wo-men who have had cesarean births are being urged to try to give birth through the vagina. Most of these women have vaginal births with no problem.

Postpartum Right After Delivery After delivery you will be watched closely to be sure that there are no problems. Your temperature, pulse, breathing, and blood pressure will be checked often. During this time, you can begin getting to know your new baby. Unless you or your baby are having medical problems, you will be able to hold the baby. If you had planned to breast-feed, you may be able to start now. It is good for you and your partner to look at, hold, and talk to your baby just after birth.
Hospital Stay Most women spend about 1-2 days in the hospital after a vaginal birth. If you had a cesarean birth, or if problems occur, you will likely stay longer. Hospitals vary greatly on visitor rules. Some allow only the baby's father and grandparents to visit. Many also will allow brothers and sisters to see the new baby. Others may let anyone visit. You may choose not to have visitors for a while. This gives you more time to rest and to learn about your baby. Help may be available to teach you some of the beginning skills of being a parent. You may learn about feeding, bathing, and changing the baby. This can help you to feel more comfortable in the way you handle your newborn. Before you go home, your baby may begin to get vaccines. They protect against diseases like rubella and hepatitis. Be sure you know what shots your baby should receive, and when.
Car Safety Seats Plan to bring your baby home from the hospital in a special safety seat. Child safety seats and belts decrease the chances of an injury in a car accident by over 80%. Because of this, these seats are required by law. Check with your doctor, hospital, car dealer, baby stores, or local consumer safety group about buying or renting one before you go into the hospital. Be sure the seat is approved for use by newborns.
Breast-Feeding Breast-feeding is the best way to feed newborns. It protects them, too. Mother's milk helps the baby resist disease and allergies. Breast-feeding is also more convenient and cheaper than bottle-feeding. It can form a bond between mother and baby. Don't be upset if nursing is not easy right away. Both you and the baby need to get comfortable. If the baby calms down after nursing, makes urine, and is growing, he or she is getting enough milk. Some women supplement breast-feeding with bottle-feeding. Once breast-feeding is established (a few weeks after birth), you can keep producing breast milk by breast-feeding the baby at least twice a day. If you are breast-feeding, you will have special nutrition and calorie needs. Now is not the time to try to lose weight. You need food for your own body plus extra food to produce milk for your baby. This means you need about 500 more calories a day than before pregnancy. This is about 200 more calories than you needed during pregnancy. It is easy to add the extra food you need if you are already eating a healthy diet. Calcium is very important for nursing mothers. It is found in milk used as a drink or in cooking. Yogurt, cheese, cottage cheese, and ice milk are other good sources. If you do not like milk products or if they make you sick, your doctor can suggest other sources of calcium. Tobacco, alcohol, and other drugs can hurt the baby if you breast-feed. If you smoke, drink alcohol, or take drugs, be sure to discuss this with your doctor. Do not smoke around the baby. Breast-feeding may not be for all women. Many factors are involved in each woman's decision: life style, desire, attitude, time, and support. Even breast-feeding only for a few weeks has health benefits for the baby. Discomforts During your first days after birth, you may feel uncomfortable at times. These discomforts are common and often don't last long.
Afterbirth Pains. The uterus contracts and relaxes as it begins to return to normal. This can cause afterbirth pains. These pains may be increased by breast-feeding. The contractions usually are mild with first babies. They are stronger with the next babies. They last only a few days. To feel more comfortable:

Change your position.
Lie with a pillow under your abdomen.
Empty your bladder often.
Take medication if prescribed by your doctor.

Breast Swelling. Your breasts may be full and hurt a bit about 2-4 days after delivery. Wearing a well-fitting support bra will help. If you are not breast-feeding, ice packs may also be used. Some doctors may give medication that keeps milk from being produced. Do not stimulate or pump your breasts. This will only make the problem worse. The discomfort will go away in about 3 days.
Constipation. Constipation may still be a problem after you give birth. An episiotomy or hemorrhoids may make a bowel movement painful. A diet high in fiber and plenty of water, milk, and juices—such as prune juice—can help.
Episiotomy. Use of cold packs right after delivery can help ease discomfort. Later, heat can also make you more comfortable and help you heal. Either a heat lamp or warm sitz baths (sitting for a short time in warm water) can help. You will be taught how to clean this area very carefully to help prevent infection.
Hemorrhoids. Hemorrhoids can stick out or swell and hurt during pregnancy, labor, and delivery. Sprays, creams, and dry or wet heat (as for the episiotomy) provide some relief. Witch hazel compresses are also very soothing. The hemorrhoids will gradually shrink and may possibly disappear.
Physical Changes While you were pregnant, changes in your body and the growth of the fetus took place over 40 weeks. Now that your baby has been born, your body goes back to its usual state much more quickly. Many changes begin right after delivery. Following are some of the changes that may be happening to you.
Abdomen. After delivery, your cervix is still open and stretched. In just 1 week, the size of its opening will be about the size of a dime. Your uterus is still hard and round. It can be felt around your navel and weighs about 2½ pounds. In 6 weeks, it will weigh only 2 ounces. It will no longer be felt by pressing on your abdomen. But, it will take some time for the stretched abdomen muscles to become tight again. Doing simple exercises will help. You may tend to get a backache until the abdominal muscles tighten up and once again help your back muscles to keep an erect posture.
Hair Loss. A few weeks after delivery, you may find that you are losing large amounts of hair. This is not unusual. Your hair will soon return to its normal growth cycle.
Lochia. After delivery, you will have a vaginal discharge. This is called lochia. It is made mostly of blood and what is left of the uterine lining that was needed during the pregnancy. For the first few days, the discharge is bright red. After 2 or 3 days, it becomes pinker and decreases in amount. In about 10 days or so, the discharge changes to a white or yellow color. It gradually decreases until the flow has stopped. (Some women, however, may have a brief period of increased bleeding 7-10 days after delivery.) The length of time the discharge lasts is different for each woman. Do not use tampons while the flow is heavy. Menstrual Periods. Your menstrual periods will usually return 7-9 weeks after delivery. They may be shorter or longer than before. Gradually, they will return to what is normal for you. If you are breast-feeding, your periods may not return for several months, maybe not until you stop breast-feeding. Your ovaries may begin to function soon after delivery, though. You can become pregnant even if you do not have a period, so you should use some form of birth control.
Warning Signs Watch for any odd changes in your health. Call your doctor if you notice any of the following:

Fever over 100.4°F (38°C)
Nausea and vomiting
Painful urination, burning, and urgency (sudden, strong need to urinate)
Bleeding heavier than your normal period
Pain, swelling, and tenderness in the legs
Chest pain and cough
Hot, tender breast
Pain between the vagina and rectum that gets worse with time

Emotional Changes After the first week or so, you may begin to notice mood changes. Changes in hormones, being tired, and feeling overwhelmed with all the new responsibilities can make you feel depressed. This is called postpartum or baby blues. These are normal feelings that will go away in a few weeks. Some women, though, develop a more serious condition called postpartum depression. If the blues last longer than 2 weeks or if they seem serious, you should discuss them with your doctor and take steps right away to get the support and help you need.
Sex and Birth Control You can usually have sex again when everything, including your episiotomy, is healed and you feel comfortable. This usually takes about 3-4 weeks. You may need to use some type of lubrication, especially if you are breast-feeding. You can get pregnant even if you are breast-feeding or your periods have not yet started. This means that you need to choose some form of birth control before you have sex for the first time. Discuss birth control options with your partner and doctor. Choose a method that meets your needs:

Birth control pills
Contraceptive implants
Contraceptive injections
Intrauterine device (IUD)
Barrier methods
— Diaphragm
— Cervical cap
— Condom
— Female condom
— Vaginal sponge
— Spermicidal cream, jelly, foam
Periodic abstinence (also called natural family planning)
Sterilization
—Male (vasectomy)
—Female (tubal ligation)

Keeping Healthy Getting enough rest is one of the most important things to do—and often the hardest. Try to nap when the baby does, even if it means not doing something else. You may need help around the house so that you do not become too tired. Ask your partner, a friend, or a relative to take over some chores, such as laundry, dishes, or meals, until you are back on your feet. You may weigh a few more pounds than you did before pregnancy. Good eating habits and exercise will help you regain your shape and lose weight gradually. Cut calories from junk foods, not from basic nutrients. Drink plenty of fluids. If you are breast-feeding, you need even more calories than when you were pregnant. Do not try to lose weight until you stop breast-feeding. Exercise can help you get your muscles get back in shape. Easy exercises can be done as soon as 24 hours after delivery. Harder exercises are started later. If you had a cesarean birth, talk to your doctor or nurse before you start to exercise. As always, exercise must be started slowly and increased gradually. Your doctor may suggest some exercises or you may learn some in a childbirth class.

Finally... You can improve your chances of having a healthy baby by leading a healthy life style during pregnancy and getting proper prenatal care. Learn as much as you can before the birth of your baby. Know your own body and what to expect during pregnancy, labor, and delivery.

Glossary
Amniotic Sac: Fluid-filled sac in the woman's uterus in which the fetus develops.
Areola: The darker skin around the nipple.
Birth Control (Contraception): Method to prevent pregnancy.
Cervix: The lower, narrow end of the uterus.
Chloasma: The darkening of areas of skin on the face during pregnancy.
Down Syndrome: A genetic disorder caused by the presence of an extra chromosome and characterized by mental retardation, abnormal features of the face, and medical problems such as heart defects.
Episiotomy: A surgical incision made into the perineum (the region between the vagina and the anus) to widen the vaginal opening for delivery.
Fallopian Tubes: Tubes through which an egg travels from the ovary to the uterus.
Fetus: A baby growing in the woman's uterus.
Hormones: Substances produced by the body to control the functions of various organs. Induced Abortion: The planned termination of a pregnancy before the fetus can survive outside the uterus.
Miscarriage: The spontaneous loss of a pregnancy before the fetus can survive outside the uterus.
Neural Tube Defect (NTD): A fetal birth defect that results from improper development of the brain, spinal cord, or their coverings.
Nutrients: Nourishing substances supplied through food, such as vitamins and minerals. Obstetrician-Gynecologist: A physician with special skills, training, and education in women's health. The initials FACOG mean that he or she is a Fellow of the American College of Obstetricians and Gynecologists.
Ovaries: Two glands, located on either side of the uterus, that contain the eggs released at ovulation and produce hormones.
Placenta: Tissue that connects woman and fetus and provides nourishment to and takes away waste from the fetus.
Uterus: A muscular organ that is located in the female abdomen and contains and nourishes the developing embryo and fetus during pregnancy.
Vagina: A passageway surrounded by muscles leading from the uterus to the outside of the body.
This Patient Education Pamphlet was developed under the direction of the Committee on Patient Education of the American College of Obstetricians and Gynecologists. Designed as an aid to patients, it sets forth current information and opinions on subjects related to women's health. The information in this pamphlet does not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other acceptable methods of practice. Variations taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice may be appropriate. Photographs © 1998 EyeWire, Inc.
Copyright © January 1999 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. ISSN 1074-8601
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