Congratulations!

Congratulations on your pregnancy. We look forward to serving you during your pregnancy and afterwards. We are here for you. Know that we pray for you and your family daily. Please ask questions and tell us how you are feeling from visit to visit. We encourage you to write down your questions and bring them to your next visit.

Due to the fact that each doctor cannot be on call seven days a week for 24 hours a day, it is the policy of this practice that all prenatal patients rotate appointments through the doctors. This is done for the welfare and protection of both the patient and the physician. By following this procedure, the patient is familiar with all our delivering doctors and that each doctor is are familiar with the patient.

Below you will find information on some common topics and general information regarding your pregnancy. This is general information and you should feel free to discuss any specific concerns at your next visit. If you have any immediate questions please contact the Tepeyac Family Center Office.

What is going on in my body?

• Timeline of Development
• What to Expect the Last Few Weeks of Pregnancy
• Miscarriages and terminal diagnoses

How can I care for my body and my baby?

General Information	Medical Topics
General Information	Considering Circumcision?
Office Visit Schedule	Cystic Fibrosis Carrier Testing
Reminders in Early Pregnancy	Kristen Anderson Perinatal Hospice Program
Fees and Charges	Morning Sickness
Medicines for Mommies	Nutrition for Gestational Diabetes
Your 24 Week OB Appointment	Preeclampsia & Eclampsia
Prenatal Care and Birth Plans	Prenatal Screening Options
Do I need a doula?	Rhogam
Nutrition for Mommies  [Under Construction]	Vaginal Birth After Cesarean Section (VBAC)

Frequently Asked Questions

Please email us or call the office if you have further questions or would like clarification. 

1. If I think I'm in labor, when should I call the doctor?

   • If you are having contractions every 5 minutes for an hour.
   • If you think your water might have broken—even just a little!
   • If you are bleeding heavily, like a period. (A small amount of bleeding is normal in the last few weeks. Passing some mucous or the mucous plug is also normal; we do not need to know this.)
   • If your baby is not moving. (Your baby may not be as active, but should still be moving throughout the day.)
   • At the time that you and your doctor decided upon together at your office appointment.  The patient should ALWAYS talk to the doctor on-call first before going to the hospital. (The doctors need to call in admission orders, etc. to labor and delivery. They actually get in trouble if a patient shows up unannounced.)

 

2. Can I go swimming while I'm pregnant?
   • Yes, up until your water breaks or you are asked to stop due to complications in your pregnancy.
     
3. What kind of exercise can I do while I'm pregnant?
   • Swimming, water aerobics and walking are all excellent forms of exercise.  You may not participate in contact sports or anything that could cause you to fall or fall off of something.  If you are already an exerciser, keep doing what you are doing! Pregnancy is a time of increased metabolism, so listen to your body.  The duration and intensity will need to be adjusted down.  Your target heart rate should be adjusted down 10 to 15 beats a minute.  You should be able to talk in complete sentences while exercising, if you are too out of breath to do so, then back off.  Remember that the blood flow is shifted from the uterus to your muscles so be careful.
     
4. What precautions should I take when I'm going to be traveling?
   • You always need to be seen prior to any travel greater than 2 hours away for clearance.  When traveling by car stop every 1½ to 2 hours and get out of the car and walk around for 10 to 15 minutes.  While sitting in the car, always be shifting in your seat and moving your legs, do not sit stationary for long periods of time.  Drink at least eight 8oz glasses of water while traveling.  If you are flying, get up and walk up the aisle to the bathroom periodically, and again shift in your seat and move your legs.  Our concern is the risk of blood clots in your legs and/or complications (preterm labor, water breaking & delivery) while you are out of town.
     
5. What is an episiostomy?
   • It is a small incision made to the perineum during childbirth to enlarge the vaginal opening for delivery.
     
6. Am I at risk for gestational diabetes?
   • You are at increased risk for gestational diabetes if you answer yes to two or more of the following questions. Have you had a previous pregnancy with gestational diabetes or a baby that weighed more than 9 pounds?  Does your father, mother, brother or sister have diabetes? Are you overweight or very overweight?  Are you a member of a high risk ethnic group (Hispanic, African American, Pacific Islander, Asian or Native American)?  Are you older than 25?  Have you ever had an abnormal glucose tolerance?  If you are at an increased risk of developing diabetes, the doctor may choose to initiate screening tests earlier in your pregnancy.
     
7. Can I drink alcohol while pregnant?  Caffeine?
   • We recommend that you abstain completely from alcohol during your pregnancy.  It is best to limit caffeine to one cup of coffee or tea per day (or equivalent amount). 
     
8. Is it okay to continue breastfeeding my older child while I am pregnant?
   • For the majority of women, the short answer is:  Yes! Breastfeeding provides infants and young toddlers with ideal nutritional and psychological support, and has innumerable documented benefits later in life.  Continuing to breastfeed throughout a pregnancy allows a toddler these wonderful benefits of mother’s milk, and no research has found that this poses any risk to the baby in the womb.  If a woman is facing complications in a pregnancy, however, she should consult her physician as to whether or not it is safe to continue breastfeeding -- for example, if she has a history of preterm labor or is experienceing extreme fatigue it is best to wean the baby.
     
     Physically, some women may be unable to continue nursing during their next pregnancy because of breast tenderness or inadequate milk production.    For some children, the changes in taste and content of the mother’s milk -- especially in the second and third trimester of pregnancy – may induce the toddler to wean naturally.  These instances aside, if mother and child are willing and able to continue nursing, it is fine to do so.  During this period, it is especially recommended that the mother pay close attention to eating well in order to nourish both children and to maintain her own energy.
     
9. Is it okay to have sexual relations during pregnancy?
   • Yes!  It's perfectly fine to have sexual relations during pregnancy unless the doctor has told you to be on pelvic rest or bed rest.
     

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General Information

Every routine OB visit we will check weight, blood pressure, urine dip, fetal heart tones, and fundal height (the size of the uterus).

There may be extra visits for special problems (high risk conditions like diabetes). Care for problems such as yeast infections, urinary tract infections, and upper respiratory infections can be provided, but must be billed separate from the OB care.

Fathers and children are encouraged to accompany mom for the visits, but please make arrangements for children at appointments where you need an exam or culture done. A female doctor cannot be guaranteed at every visit or for deliveries.

Hospital:

Labor and delivery is arranged at Fair Oaks Hospital (about 10 minutes from the office). Pre-admission registration forms are available at our office.

Office Procedures:

Blood tests can be done in our office or at a lab convenient to you, according to your insurance company. Initial tests include: CBC, blood group and Rh types, antibody screen, rubella titer, syphilis screen, hepatitis screen, and an optional HIV test. A sickle cell test is needed for all women of African heritage, unless the result is known.

Gonorrhea and Chlamydia cultures may be done at the office as needed.

Sonograms (Ultrasound) are not covered routinely in pregnancy by all insurances. They are always covered for medical problems. Most sonograms past 12 weeks are not done in our office. Parents are responsible for the cost of uncovered and unnecessary sonograms.

For abnormal lab and ultrasound results you will receive a call. Normal results will be discussed at the next prenatal visit.

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Office Visit Schedule

• 8 weeks: Initial history, Pelvic exam only
• 12 weeks: Full history, Full exam with pap test, Labs referral given
• 16 weeks: Alpha-Fetoprotein Test discussed, 20 wk Level 2 sonogram referral given
• 20 weeks: Review sonogram, Discuss birthing classes
• 24 weeks: Instructions for glucola test, to be done at 28 wk visit
• 28 weeks: Lab done or referral given for glucola test, CBC, antibody screen if needed. Rhogam shot arranged for RH-negative moms, birth Plan Guide handed out
• 32 weeks: Discuss labs, Pre term labor info, Discuss birth plan (does not need to be written)
• 34 weeks: Group B Strep culture (GBS), Preadmission for hospital
• 36 weeks: Review GBS result
• 37 weeks: Discuss NFP
• 38 weeks: Cervical check if needed or desired
• 39 weeks: Cervical check if needed or desired
• 40 weeks: Cervical check if needed or desired
• 41 weeks: Non-Stress Test, Check of amniotic fluid amount, discuss scheduling induction
• 42 weeks: Non-Stress Test, Check of amniotic fluid amount, Induction by end of 42 weeks

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Reminders in Early Pregnancy

• Eating- multiple small meals (5-7+), with a good balance of carbohydrates and protein (at least 70 grams of protein/day) usually keeps energy level and blood sugar in a better range.
• Morning Sickness – Vitamin B6 (100 mg/ day), ginger (ale, tea, snaps), peppermint. 2/1 ratio of carbohydrates to protein, (e.g. sandwich) is recommended.
• Vitamins – over the counter "Prenatal vitamins" or prescription prenatals are fine.
• Fluids – plenty of fluids, at least 8 8-ounce glasses daily, including 4+ glasses of water is recommended.
• Bowel Movements – colace (stool softener), senekot (bulk fiber) and warm prune juice are recommended for constipation.
• Exercise – if you already exercise, continue doing what you're doing. As you feel tired or sore, cut back moderately (e.g. low impact aerobics). If you need to start exercising, walking 30-45 minutes, 3-5 times a week would be great. Keeping your heart rate to less than 150 bpm for up to 20 minutes is recommended.
• Reading – There are many popular books on pregnancy in bookstores and libraries. A couple of suggestions are: The Glory to be Revealed in You, A Spiritual Companion to Pregnancy, by Kristen West McGuire, Alba House, 1995; What to expect (From God) When you are expecting, by Cathy Hickling, Creation House, 1995; and Prayer in Pregnancy by Janet Alampi, St. Paul Books and Media, 1995.
• Writing – Journaling, keeping a diary of your thoughts and feelings, mom and dad writing letters to the baby at different times during the pregnancy may be very helpful.
• Childbirth Classes – Marsha Jacobeen, R. N. and mother of 6, offers a nine week Bradley Method Childbirth Class. Her phone number is (703) 378-2660. At times she also offers a one evening Early Pregnancy Class. We strongly recommend all new moms to attend the one night session and all patients for her childbirth classes.
• Pediatrics – We are able to refer to pediatricians in the area. Tepeyac Family Center may soon have pediatric services available here in house. As you get closer to delivery please check with us.
• Talking/Praying – Mom and dad spending time talking and praying with your baby every day is encouraged. In your own words, beginning to greet and talk to your little one is a great habit to start early in pregnancy. Asking God to daily bless your baby (and mom, dad, sibling, etc.) is often comforting and fun.

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Fees and Charges

We at the Tepeyac Family Center are committed to you and your unborn child. The following is an outline of the fees and maternity services provided by the Tepeyac Family Center. Please note that some of these sevices listed may not apply to you, and are provided according to medical necessity.

Fee Descriptions

This applies to patients that, from the start of their pregnancy, are insured by the same insurance company that they are insured by when they deliver. The services that are not included in the Global Fee are as follows:

Policies and Procedures for Antepartum Care

All illness oriented visits (i.e. UTI, Bronchitis, pharyngitis) and hospitalizations due to complications are outside the global and are billed separately and patient may be required to pay co-pay at time of visit.

Resources: CPT 2005, CPT Assistant Aug 02:1, Decision Health Audio Conference 9/20/05

*Itemized Services:

This applies to the following patients: For those that are uninsured at the start of the pregnancy and later become insured; or who are insured by one insurance carrier at the start of the pregnancy, and then deliver while insured by a different insurance company than they originally started with; or who miscarry or transfer to another facility for the duration of care. The birth will be billed as a delivery only charge, in addition to any other hospital services that are provided. It is important that the patient notify us immediately once they become effective with a new insurance carrier. Prior-Authorization must be obtained before you are admitted to the hospital for the birth of your child.

Self-Pay Patients:

Patients who have no insurance coverage, we expect that you will pay in monthly increments so that when you deliver the charges will be paid in full. We are happy to set up a payment plan that suits both yours and our needs. If you need to set up a payment plan with Fair Oaks Hospital, please call #(703) 645-2864 once you start to go into labor.

Please note that this is a separate charge from the delivery and is charged under you infants name, with exception to a few insurance companies. For this reason, we will need you to supply us with the child's full name and insurance information. Please let us know if the child is insured through the father under a separate policy from the mother

Finally, we want to encourage you to familiarize yourself with your insurance benefits so that there are no surprises when you receive a billing statement. Please note, most hospital admissions require prior-authorization. Because this is ultimately your responsibility, we ask that you please contact you insurance prior to your delivery to inform them of the future admission. For your convenience, we accept both Visa and MasterCard, as well as offer payment plans. If you have any questions about your benefits, please call us at (703) 273-9440, extension 109. For billing inquiries, please call Capture Billing and Consulting at 703-327-1800. Thank you!

Should you have any questions, please feel free to ask us at any time.

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Medicines for Mommies

This guide will help answer some questions about using medicines during pregnancy. Please feel free to ask us any questions left unanswered.

Prenatal Vitamins: Every pregnant woman should be taking vitamins. Non-prescription prenatal vitamins are fine. If you are having trouble taking a prenatal vitamin because of nausea, constipation, or some other reason, please discuss it with us. We can find solutions for most problems. Taking the vitamin with your largest meal or before bedtime usually decreases problems.

Calcium: Most prenatal vitamins have very little calcium in them, usually 200mg. (Natafort has no calcium.) You need 1200 mg of Calcium every day to build your babies’ bones. You can get your calcium from your diet or a supplement. To get all the calcium from your diet you would have to eat and drink 4 portions (300mg) a day: an 8oz glass of milk, a cup of yogurt, a large portion of cheese, or a bowl of ice cream. If you don't like milk, that is not a problem. Don't drink a lot of chocolate milk just to get calcium. 8oz Tropicana Pure Premium calcium fortified orange juice has 350mg of calcium. The Viactive chocolate chews have 500mg of calcium in each square. At the end of the day, while brushing your teeth, count up how much calcium you got. Take the calcium that is missing as a calcium tablet or Tums. There is a 600mg extra strength Tums, and a 400mg regular strength Tums.

Allergies: Many women can stay on their allergy medicine during pregnancy. It you just need and antihistamine occasionally, Benadryl (Diphenhydramine) or Chlortimaton are fine. Remember that many decongestants, like Afrin (Oxymetazoline HCL), can cause dependence or rebound congestion.

Backache: is common in pregnancy. Hot water bottles are great for carrying around the house. Heating pads and hot baths help, too…so do massages from a loving family member or friend. Back support belts can be bought at some maternity stores. See Pain Relief.

Colds: Colds are usually caused by viruses, so an antibiotic will not help in most cases. All you can do is treat each symptom.

Constipation is easy to prevent. Ask for a prenatal vitamin with a stool softener in it. Drink lots of fluids. Buy a stool softener called Docusate Sodium (Colace). It is a red gel capsule. Take 2 at night with half glass of water if you did not have a soft, painless bowel movement that day. This will prevent constipation the following day. If you need the stool softener every night that is all right. It will not harm the baby. It will not cause you to be dependent on it like a laxative can. If you are still having hard stools using docusate sodium at night, start drinking a teaspoon full of Metamucil (powdered fiber) every morning in a glass of water. Cereals with good fiber are "All Bran with Extra Fiber", "Raisin Bran" and "Fiber One." If you already have bad constipation use Milk of Magnesia or a Fleet enema or both. Rectal Glycerin suppositories are safe. See Hemorrhoids for more information.

Diarrhea: You can use Kaopectate or Imodium (Loperamide HCL) over the counter. If this does not work, ask us for a prescription medicine. Remember to drink lots of fluids, especially sports drinks.

Fever: Call the office if you have a fever above 100.4 degrees Fahrenheit. For lower fever, use Tylenol. See Pain Relief for doses. Remember to drink a lot of fluids and rest.

Gas Pain: Use products with Simethicone or Mylicon like Mylanta Gas or Maalox Anti-Gas or a generic brand. Drops, tablets and gel tabs are all fine.

Heartburn or Indigestion: is common all through pregnancy. Tums often helps – see Calcium. You can also use Maalox or Mylanta. Do not use Pepto-Bismol or other products containing Bismuth. Avoid Alka-Seltzer (contains Aspirin).

Headaches: can be frequent in early pregnancy. See Pain Relief. There are prescription pain medications for migraines.

Hemorrhoids: The best way to prevent Hemorrhoids is to prevent Constipation – read this. If you already have hemorrhoids they may not go away during pregnancy, but you can prevent them from getting worse by preventing constipation.

If your hemorrhoids are painful or bleeding you need to treat them. Buy an over the counter hemorrhoid medicine. Ointment is a better water repellant than cream. Make sure it has 1% Cortisone in it for healing. Buy the least expensive brand. Usually Preparation H is the most expensive. Witch Hazel Pads (Tucks medicated pads) help too. For severe pain there are prescription medicines.

Ligament Pain: is the most common from 15 – 20 weeks for pregnancy. The ligaments that hold the uterus in place begin stretching. The pains are usually sudden and sharp in the lower pelvic area. They do not last a long time. These pains are harmless. Contact us for any sharp pains that last for a long time, or if there is also a fever.

Nausea and Vomiting: This usually gets better after the first trimester, unless it is caused by illness. If none of your tricks are working, ask us about a prescription.

Pain Relief: Tylenol is the only over the counter that you can use. NSAIDS like Ibuprofen (Motrin, Advil) are not safe in late pregnancy. We do use them in certain situations, but please only take them when we advise it. Avoid Aspirin also. Tylenol (Acetaminophen) is safe for the baby, if taken correctly. Regular strength is 325mg. Two every 4 hours is the correct dose. Only take 3 for a very strong pain. Extra strength is 500mg. Two every 6 hours is the correct dose for very strong pain. Try to take just 1 and ˝ tablets or 2 regular strength tabs. Never take 3 extra strength. If this does not help enough, ask us. There are prescription pain relievers we can give you.

Sciatic Pain: The sciatic nerve is the biggest nerve in the body. It runs from the buttocks down the back of the legs. It gets irritated easily in pregnancy and produces sharp pains. These pains are harmless, but they can make movement difficult. Pain relievers may help some. A few women will need to get physical therapy, which can help a lot. Some women will need to limit activity.

Sleeping Problems: Women complain the most about trouble sleeping at the end of pregnancy. One or two Benadryl 25mg 1 hour before bed is not harmful to the baby and may help you sleep. If you need more help, ask us.

Yeast: In pregnancy the body is much sweeter. Yeast loves this. You can help prevent yeast by avoiding a very sugary diet (including drinks and starches). Taking acidophilus (a healthy milk bacteria) wards off yeast. It is found as a tablet or in certain milk and yogurt, if the label says so. Avoid yogurt with sugar in it. Take it twice a day, if you have yeast or are on an antibiotic. Otherwise once a day is enough. All over the counter yeast medications are o.k. all through pregnancy. The yeast pill (Diflucan) can not be used in pregnancy.

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Vaginal Birth After Cesarean Section (VBAC)

If you are considering attempting a Vaginal Birth After Cesarean Section, also known as a VBAC, we at the Tepeyac Family Center want to assist you in any way we can to make the best decision for both you and your baby. We are very supportive of VBAC because it can be quite a rewarding birth experience. If you are successful at having a vaginal delivery, you will probably recover faster, lose less blood, and avoid the risks of major surgery. However, we want to be aware of both the pros and cons of the VBAC procedure, and of a recent study that is less supportive of VBAC than the previous literature has been.

Recently, the New England Journal of Medicine published an article, which analyzed over 20,000 patients who delivered a child vaginally after having had one previous cesarean. The results were rather astounding, and as a result, this may change the way both you and we approach labor after having undergone a cesarean.

1.9 patients per 1000 who did not labor at all experienced uterine rupture. Spontaneous labor was associated with a tripling of the risk when compared to women who underwent a scheduled repeat cesarean. Induction of labor with pitocin was associated with 5 times the risk, and if prostaglandin's were used, the risk skyrocketed to over 15 times that of someone who did not labor.

We realize that if a woman has already successfully undergone a VBAC, the likelihood of her success is higher than if she has not yet delivered vaginally. However, uterine rupture is still more likely than if she had not undergone a cesarean.

Previous studies have shown there to be a further increase if the woman has had more than one cesarean. If the incision on the uterus runs vertically, known as a "classical" incision, the risk of rupture is increased so much that these women are not even candidates for VBAC.

The obvious question then becomes "What is the significance of uterine rupture?" That is a very good question because the range of effects to the mother and child vary from a mild separation which is totally a symptomatic and simply noted at cesarean, to hemorrhage requiring hysterectomy and / or blood transfusion, to a catastrophe in which the mother, the child, or both, die. Granted, these disastrous outcomes are rare, but they do happen. The biggest difficulty is that they are not always predictable.

So what does this mean to you? We will continue to offer VBAC to our patients, but we will be more selective in our choice of candidates. Each case will be considered individually. As always, we want you to have the very best birth experience which is safe for you and your particular circumstances. We encourage you to take an active role in this very important decision. We also realize it is the mother who ultimately decides what risks she is willing to undertake for herself and her child. We ask you to pray that God enlighten your mind and give you the graces necessary for you to experience the birth He wants for you.

From our perspective, we are looking for VBAC candidates who have an excellent chance of succeeding with a minimum of intervention. This means, for example, that we prefer you to be delivered by your due date; go into labor on your own (no pitocin inductions, although augmentation may by considered); have a reasonable estimated fetal weight; and continue to make good progress once in labor. If any of these conditions is not met, then the rupture rate may represent too high of a risk for you to undertake.

We understand this may be a difficult decision for you. Please feel free to ask any further questions you have in order to make an informed choice about trying a VBAC or scheduling a repeat cesarean.

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Rhogam

How to go about getting your Rhogam shot.

You've been told you need Rhogam. What does this mean? Rhogam is a shot that mothers need due to an RH incompatibility between mother and father of an unborn baby (Example: Mother is A-; Father is A+). Due to insurance purposes, we no longer do these in the office.

You need to go to the Diagnostic Center at Fair Oaks Hospital, which is located in the building next door to the hospital on the fourth floor. Their address is 3700 Joseph Siewick Drive. Before going please check with your insurance to make sure Rhogam is covered. The number to the Diagnostic Center is (703) 391-4155. You need to bring with you the order that was given to you by the doctor and your insurance card. You do not need to make an appointment for this, but you need to make sure you go early in the day. They will draw your blood first and ask you to come back in approximately two hours to get your shot.

If you have any problem or questions feel free to give the office a call.

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What to Expect the Last Few Weeks of Pregnancy

You may have noticed that it has been quite a while since you have seen your toes. Yes, those sleepless nights, frequent potty stops and "I just can't find a comfortable position" complaints are normal. To help make your last weeks as pleasant as possible, here are a few suggestions:

• Realize and admit your limits. If you are tired, lay down. Listen to your body, it offers good advice.
• Drink plenty of water. Avoid too much caffeinated or diet sodas, processed foods, pizza, Chinese food, etc. They contain salt, which may result in water retention and swelling.
• Wear comfortable clothes. Flat shoes will lessen the strain on your lower back. Many women find support garments helpful also. Pillows, pillows, and more pillows!

After 36 week of pregnancy we do not try to stop a woman from having her baby early. That means that you only need to call us when you are ready to go to the hospital, because:

• You are having contractions every 5 minutes for an hour.
• You think your water might have broken.
• You are bleeding heavily, like a period.
  A small amount of bleeding is normal in the last few weeks. Passing some mucous or the mucous plug is also normal. We do not need to know this.
• The baby is not moving. The baby may not be as active, but he or she should move throughout the day.

Call the doctor immediately if you experience any of the signs for pre-eclampsia

1. A strong headache that won't go away, especially if you see "spots in front of your eyes".
2. Vomiting, upper abdominal pain, flu-like symptoms without a fever.
3. Swelling of the face. Swelling ankles is usually harmless. Please call us if the swelling extends up the leg.

If something unusual is happening, please do not hesitate to call us.

If you have a history of rapid labors, talk to us in the office about when to call.

The Pediatrician: If you do not have one yet, it is time to choose one. We have a list at the front desk. If you do not have one by the time the baby is born, then the Fair Oaks Hospital pediatrician will examine your baby. Your baby will be discharged to go home either by the hospital pediatrician or your own.

Having a baby is a sacred time. If you are a member of a faith, you may want to ask your Priest, Minister, Rabbi, Mullah, etc., to visit you in the hospital. Nobody will come automatically. Fair Oaks Hospital is in St. Veronica’s parish. If you would like Father Pollard to bring you the Sacraments, please call him at: office: (703) 689-4409.

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Nutritional Guidelines for Women With Gestational Diabetes

Eat 3 meals and 3 snacks daily.

• Space snacks so that there is no more than 3 hours without eating.

Omit foods high in sugar and concentrated sweets.

• Avoid adding sugar (white sugar, brown sugar, or honey) to foods. Avoid soda pop, lemonade, and sweetened yogurt.

Omit juices, but instead use whole pieces of fruit (apples instead of applesauce).

Spread carbohydrates out throughout the day.

• If after breakfast glucose levels are outside the target range, you may be asked to shift some carbohydrates (starch and fruit) to other snacks or meals.

Choose foods high in fiber: whole grains, whole fruits and vegetables, beans and legumes, oats.

Choose high quality but smaller portions of meat selections, such as lean cuts of beef, pork and lamb. Emphasize more fish. Choose:

• Baked, broiled, or roasted instead of fried chicken or fish
• Yogurt instead of butter and sour cream on a potato
• Herbs to season vegetables instead of cream or butter sauces
• Pretzels, unbuttered popcorn, or bread sticks instead of foods fried in oil, such as doughnuts, chips and French fries

Limit foods from fast food restaurants. Ask for nutritional information on menu selections, and choose foods that are low in fat. For many women, a burger and fries or more than 2 pieces of pizza will cause high blood glucose levels.

Be careful to gain at least ˝ lb a week. Cutting back too much on calories and weight gain can increase your risk of a low birth weight infant.

Adapted from Understanding Gestational Diabetes: A Practical Guide to a Healthy Pregnancy. Bethesda, MD National Institutes of Health, National Institutes of Child Health and Human Development. (NIH Publication no. 93-2788), 1993.

Permission is granted to reproduce this material for nonprofit educational purposes. Written permission is required for all other purposes.

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Prenatal Care and Birth Plans

All of us at Tepeyac Family Center want to support your pregnancy and birth in any way we can. We are happy to have the opportunity to be partners in your health care. We greatly appreciate couples taking the time to educate themselves about their pregnancy through books, classes, etc. Once a week a childbirth educator, Marsha Jacobeen, teaches and excellent childbirth class.

We want you to feel secure that we will honor your birth plan to the best of our ability, as long as we are given the chance to review it before the birth. We would like to feel confident that you will work with us in respecting some of the limits we feel necessary.

Birth Plans: Our practice does not require that you make a written birth plan, but it is an excellent communication tool. www.babycenter.com has a birth plan you click. It is a great thing a couple can do together and it helps you to think about what is on your "wish list".

Cesareans: We would like to reassure you that we have no desire to do even one unnecessary c-section. Every one of us can remember a delivery where we had almost given up hope of a vaginal delivery. Unless it is a medical emergency, there usually is plenty of time to discuss the necessity of a c-section with the parents.

Cutting the Cord: We deliver babies that are born vaginally and are doing well onto mom’s tummy. Babies who have medical difficulties, such as meconium in the amniotic fluid, are handed immediately to the neonatologist or newborn nurse. If your baby does not need immediate care, the cord is usually cut shortly afterwards. It is not difficult to let it pulse for 5 minutes, but if we wait until it completely quits pulsing, this can take 20 minutes or longer. Waiting more than 5 minutes to cut the cord delays the routine procedures the nurses expect to do. They want to weigh, measure and dress the baby, so that they can move on to another job. They do this at the warmer in the room and do not keep the baby long if she is well. While the baby is being attended to the mother can deliver the placenta and get any stitches she may need. After that she can sit up and hold her baby for breast feeding.

Circumcision: This optional surgical procedure is performed by the doctors on the 1st or 2nd day after the birth, not on the day of delivery.

Doulas: A doula accompanies a woman or couple to their birth as a trained support person. They bring lots of knowledge, tools, and skills with them. They provide physical and emotional support to help you fulfill your childbirth goals. Having a doula at your birth can be amazingly beneficial. If you are considering hiring a doula, you can look on the doula bulletin board in the waiting room.

Electronic Fetal Monitoring: This is done externally, on the abdomen in most cases. Internal monitoring is used only if medically indicated. Monitoring the baby’s heartbeat with a stethoscope or hand held doppler is not sufficient, because this does not produce any permanent record. A woman does not have to be in the bed for external monitoring. Sitting in a rocking chair next to the bed, or standing is also fine, as long as the heartbeat is being picked up. Internal monitoring of the contractions is only used in special occasions.

Episiotomies: We are not eager to cut an episiotomy. We make one either because the baby’s heart rate is worrying us, baby’s head is starting to bruise, or we suspect that the mother will have a large tear. If you do not want an episiotomy, even to prevent a large tear, please talk to us and add this to the birth plan.

Eye Ointment: Virginia state law requires hospital personnel to administer an antibiotic ointment (erythromycin) to the newborns’ eyes within one hour of birth. The nurses are willing to wait until the baby has been breast fed and can put the ointment in the eyes while the baby is in a parent’s arms. Parents who refuse the ointment for their baby must put this in writing. Please add this to your birth plan.

Food and Drink: The hospital anesthesiologists are uncomfortable with women eating solid foods in labor. They do accept clear liquids, which includes any drinks that are see through without pulp, Jell-O, popsicles, hard candy, and gum. The hospital provides apple juice, cranberry juice, and grape juice. They have cherry, orange and grape popsicles, and cherry and orange Jell-O. any similar item can be brought to the delivery. Women planning a vaginal birth after cesarean (VBAC) may be restricted to ice chips and gum.

Induction of Labor: Your due date is the start of the 40th week of pregnancy. A baby is "on time" if she comes between 37-42 weeks. We will not try and stop a woman’s labor if she is 36 weeks. We may suggest an induction before 42 weeks, but each couple can choose to wait until the baby would be truly late, >42 weeks. In this case a monitor strip of the baby’s heart beat and any contractions (called and NST) would be done in the office at 41 weeks. Of course there are individual medical conditions that alter our advice.

IV’s: IV’s are required only if a woman chooses an epidural, is on pitocin, or had some other medical reason for one. The hep lock is the name of the IV access that is capped off, without fluid running. This is a good solution for a woman who tested positive for the group B Strep bacteria (GBS). She will need antibiotics every 4 hours during labor to protect the baby. A heplock also makes walking in labor easier. If a woman is GBS negative and does not want even a heplock, this should be discussed with one of us ahead of time during a prenatal visit.

Laboring at Home: We are not currently able to offer home births. If you plan to work through a lot of the labor at home, please discuss this plan with us ahead of time. If you are in early labor and still comfortable you do not have to go to the hospital immediately. Until 9 p.m., call the office number (703) 273-9440, to give us a heads-up that labor has started. The answering service will page the person on call. After 9 p.m., just call when you are ready to go to the hospital or have a question you need answered.

Lotion: Remember to bring lotion or massage oil. Most moms appreciate massage during some part of their labor.

Music: It is fine to bring a CD or tape player with you. It is a simple way to create an atmosphere that you feel "at home" in.

Prenatal Care: We provide you with a yellow handout that explains the timing of prenatal visit and what tests are usually ordered during pregnancy. If you wish to come less frequently or to decline one of the tests, please make sure that we have discussed it. Many women prefer special combinations of vitamins in pregnancy. If this is the case, please discuss it with us.

Vacuum vs. Forceps: Many couples include in a birth plan that they prefer a vacuum extraction over forceps. A vacuum is seen as gentler, but it can only be used to pull with. It is not appropriate for adjusting the position of the baby’s head. Your doctor would always explain why she feels one of these assistive devices is needed, if time allows.

Vitamin K Shot: A small vitamin K injection is routinely given to the baby in the thigh muscle shortly after birth. This protects the baby from bleeding due to insufficient blood clotting. If you plan to refuse this injection for your baby, please discuss this with the baby’s future pediatrician before the 35th week of pregnancy. Please note this in the birth plan.

Walking in Labor: Fair Oaks hospital policy requires electronic fetal monitoring once and hour. It usually takes 20 minutes to determine that the baby’s heart rate pattern is good, unless the baby is taking a nap. After monitoring, a woman can move around the room freely, or walk around the halls. They prefer patients not to leave the floor without notifying the nurse.

Water Breaking: If your water breaks, we would like you to call and tell us. The only exception is if it is in the middle of the night, you are Group B Strep negative, you are not having contraction, and want to stay home a while longer. Your water must be clear, not GREEN. By 6:30 a.m., at the latest, we want to know that your water has broken. We will not break your water during labor without discussing it with you first.

Whirlpool: Fair Oaks Hospital has 3 rooms with whirlpools: 17, 18 and 25. They leave these rooms open for couples, who want to try natural childbirth. When you call us to tell us you are in labor, please tell us if you want one of these rooms, if available. The whirlpool can not be used after the membranes have been ruptured. All of the rooms have showers and the same type of adjustable birthing bed.

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Your 24 Week OB Appointment

Congratulations! Welcome to your 24 week OB appointment. While there are no blood tests today, there will be at the 28 week visit. If you like, you may have those blood tests done at your appointment. We suggest a morning appointment if you choose to do that. If it is more convenient, we can give you a lab order to have them done at a laboratory close to you that your insurance accepts. These tests include:

• Complete Blood Count, or CBC (everyone): Tests for anemia and your need for iron.
• 1 Hour Glucola (everyone): Tests for gestational diabetes. Although this is not a fasting test, we find it is wise not to eat sugary foods beforehand (i.e. fruit juice, soda, candy, breakfast cereals, doughnuts, syrup or jelly, etc.). Then when you arrive here you will be given a sugar drink. However, eating something - particularly a protein-rich food such as eggs, cheese, or meat - before or after the test may help prevent some lightheadedness or "wooziness" that can occur after drinking the Glucola.  Your blood will be drawn one hour later. Bring something to read. 
• If you are Rh-negative: you will be given special instructions and an order sheet to have the appropriate blood test and receive the Rhogam injection at Fair Oaks Diagnostic Center next to the hospital, or another hospital closer to your home.

We at the Tepeyac Family Center hope this helps to make your life a little easier during these busy days before your baby arrives. As always, we will keep you, our patients, in our prayers.

Preeclampsia & Eclampsia

Pregnancy-Induced Hypertension [PIH]; Toxemia of Pregnancy

Basic Information

DESCRIPTION
A serious disturbance in blood pressure, kidney function and the central nervous system that may occur from the 20th week of pregnancy until seven days after delivery. Eclampsia is an extension of the preeclampsia process.

FREQUENT SIGNS AND SYMPTOMS
Mild Preeclampsia (mild PIH):

Severe Preeclampsia (sever PIH):

Eclampsia:

CAUSES
Unknown. Believed to be caused by a substance or toxin produced by the placenta.

RISK INCREASES WITH

PREVENTIVE MEASURES

EXPECTED OUTCOME
If diagnosed and treated throughout the pregnancy, the problem usually disappears without complications within 7 days after delivery. Severe PIH and hypertensive disease continues to be a significant contributor to maternal mortality. If premature labor occurs, the newborn’s survival chances depend on its maturity. Fetal death is common.

POSSIBLE COMPLICATIONS

TREATMENT

GENERAL MEASURES

MEDICATION

ACTIVITY
Rest often; this is important in controlling preeclampsia. Rest on your left side to help circulation.

DIET
Your doctor will advise you if a special diet is necessary.

NOTIFY OUR OFFICE IF

• You or a family member has symptoms of preeclampsia at any stage of pregnancy.
• The following occur during treatment:
  
  Severe headache or vision disturbance.
  Weight gain of 3 or more pounds in 24 hours.
  Nausea, vomiting and diarrhea.
  Cramping abdominal pains.
  Excessive irritability.

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Considering Circumcision?

Sometime during the course of your pregnancy, the question of circumcision will surface and invade the pleasantries of "being with child". "I want to do what to my son?" Why? When? Where? What for? Seeking answers to these conundrums will be a memorable part of your becoming two in one flesh with your spouse as you prepare for the birth of your child. It will be these very questions that this brief summary will address.

Historically, the first representation of circumcision was found in an Egyptian hieroglyphic from 2400 BC. However the initial and central reason for circumcision is found in the 17th chapter of Genesis where God uses the removal of the male foreskin as a sign of the covenant between Him and His chosen people. This is the basis for the use of circumcision by Muslims and Jews alike. Christians, who are spiritual Semites, have through the centuries, followed or departed from this prescription via their individual cultural backgrounds since circumcision was no longer necessary for salvation.

Practically, circumcision is the removal of the male foreskin. we now can use an anesthetic cream, Emla, to numb the area prior to removal, and beta dine to clean the penis prior to the removal of the foreskin. The cream is placed by the nursing staff one to three hours prior to the circumcision. The most common instruments used are the Gomco, the Mogen and the Plastibell. The procedure is done in the nursery while you and the baby are still in the hospital. The child is gently secured on an operating surface as the procedure takes about ten minutes. Some of you may want to wait the eight days from birth like the Israelites to perform the circumcision, however, a pediatrician or rabbi can help you with those plans. Insurance coverage of the circumcision is a variable proposition, and we at the present time do not do this procedure at our Center.

Are there risks with the procedure? The most common issue with risk is taking too much, or too little foreskin off the penis. Approximately 1 in 100 have excessive bleeding from the dorsal vein to the penis that warrants intervention at the time of circumcision. Occasionally, a membrane is left over the head of the penis; this may or may not be handled by us at the time of the circumcision. Usually an urologist at a later date redoes the membrane removal. Now if you do not have the circumcision done at the time of birth, there is 8% chance of needing it done at a later date due to adhesions or infections developing.

Is it necessary? That is the questions we want to have answered with assurance. None of us want to hurt our children, especially our newborns if there is not a great reason for doing so. And yet extrapolating data from the general to the individual or in the reverse is fraught with statistical and personal pitfalls since babies, penises, situations, and physicians are all variable each time the procedure is done. What we in the scientific community can agree on are:

• There is a slightly increased risk with cervical cancer in women whose partners were not circumcised. But sexual behavior, i.e.. multiple partners, smoking and early age of sexual initiation, were far greater risks for cervical cancer.
• Epidemiologic evidence suggests that you have a 3.2 times greater risk of penile cancer if you are not circumcised. However, this cancer is so rare, (2.2 per 100,000) that we would have to perform 140 circumcisions per week for 25 years to prevent just one case.
• Circumcision is an independent variable to getting, or giving an STD, with no protective effect noted.
• In 1996, substantial evidence accumulated that circumcision provided protection against HIV infection, with uncircumcised men being between 1.5 and 9.6 times more likely to become infected with the virus than circumcised men.
• Twelve fold increase in urinary tract infections in uncircumcised boys.

The ambiguity in data caused the American Academy of Pediatrics in 1999 to issue their "Circumcision Policy Statement" which read: "Existing evidence demonstrates potential medical benefits of new born circumcision; however, these data are not sufficient to recommend routine neonatal circumcision."

We at the Tepeyac Family Center want you to make an informed decision about this most common of surgical procedures. We find the procedure awkward because our patients are usually adults, not babies fresh from their Mom's wombs. We perform the procedure daily at Fair Oaks Hospital. Fathers and Mothers are welcomed to be present if they so desire to lend "moral support". Circumcisions are done by our hospital doctor when they have some free time between surgeries in the operating room and deliveries on labor and delivery. We do not believe that it leaves psychological ore post traumatic issues with the child.

The decision to circumcise entirely yours. We want to strongly remind our families that they should pray for their children, especially their boys. We want these boys to grow in to men that honor and cherish the women in their lives, never using their penises to traumatize women while desensitizing themselves. Women are never to be seen as objects and obviously never treated as such.  Please talk to us at an appointment if you have any further questions. God Bless.

• American Academy of Pediatrics, Task Force on Circumcision
  "Circumcision Policy Statement,"
  Pediatrics 103 (1999), 686-93.
• Circumcision: A History of the World's Most Controversial Surgery,
  David Gollaher, Basic Books, New York, 2000

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Kristen Anderson Perinatal Hospice Program

For additional information, please read here.

What is the Kristen Anderson Perinatal Hospice Program (KAPHP)?

Named in loving memory of Kristen Anderson after her fatal auto accident in July of 2004, the KAPHP is a special program of the Tepeyac Family Center designed to provide medical, emotional, and spiritual comfort to pregnant women and their families after being told that the child that she is carrying could have a lethal anomaly.

Who is the KAPHP for?
The KAPHP is for any pregnant mom who is carrying a baby who has been diagnosed as having a lethal anomaly. Of course, her family is also welcomed to participate.

Why do we have it?
Carrying a child who has received an adverse diagnosis is a heavy cross to bear, but that child is still growing anticipating the day when he/she will be free of the warm tummy of Mom and out into the world. Just because there may be little hope for a "normal" life, the child is still a gift and needs the nourishment and encouragement throughout his/her life regardless of how long that life may be. As Mom and her family suffers through the anticipated future, the KAPHP offers prayerful hope that the life of the child living in her womb is not for naught, but has a purpose and value.

How does the KAPHP work?
Contact us as (703) 273-9440 or email at info@tepeyacfamilycenter.com. We will schedule a consultation, determine your needs and provide you with the resources that you need to provide a comforting home for your young child through the remainder of the pregnancy and then after the delivery. In cooperation with Capital Hospice, we provide a multidisciplinary approach to coordinate and communicate the needs of the family in the medical, spiritual, and emotional setting.

What is the alternative?
Some think that we can control death by terminating the pregnancy, the aborting of the life is an attempt to eliminate the suffering. We have found that the exact opposite to be true. The suffering remains.