Basic Guidelines to Pregnancy

Congratulations on your pregnancy! This is a very exciting time in your life. In the coming months your body will go through many physical and emotional changes as the life inside you grows and develops. This brochure is designed to answer some of the first questions you may have about your pre-natal care.

The Office Routine

A team of physicians, midlevel providers (nurse practitioner, physician assistant, or midwife) and sonographers will provide your health care. The physicians will attend your labor and delivery and any hospital care necessary. You are welcome to select one physician as your primary provider, but may wish to visit with a number of the doctors over the course of your prenatal care so that you are more likely to be familiar with the doctor who will ultimately care for you during labor.

Appointments
•Average number of appointments is 13 total.
•Schedule your first appointment at 6–10 weeks from the start of your last period.
•Visit every 4 weeks until 28 weeks.
•Visit every 2 weeks from 28-36 weeks.
•Visit every week after 36 weeks until delivery.
•The visit between 24 and 28 weeks includes a screen for diabetes.

Postpartum visits are scheduled with the physician who performed the delivery at 6 weeks for vaginal births and at 2 and 6 weeks for Cesarean births.

All deliveries are at Sibley Memorial Hospital.

Very high-risk pregnancies will be managed by, or in concert with, a Maternal Fetal Medicine specialist. Premature (less than 32 weeks) deliveries will be managed by Maternal Fetal Medicine at Georgetown.
Weight Gain
You can anticipate an average of 25 – 35 pounds if you have a normal, healthy body weight at the beginning of the pregnancy. During the first trimester, weight gain varies considerably. The main goal in not to lose weight especially more than 5 pounds. Then expect about 4 pounds per month from 12 – 36 weeks. At 36 – 40 weeks, monitor for rapid or excessive weight gain and/or fluid retention with excessive swelling.

Diet

Work toward just a 300 cal/day increase over your baseline. This is all that is required to gain a healthy 25 – 35 pounds. In addition, include the following supplements:

•Folic acid, at least 0.4 mg/day (contained in all prenatal & multi vitamins) in the first two months to decrease the risk for neural tube
•Calcium 1200 – 1500 mg per day. This requires four or more servings of dairy products (low fat or skim) a day. Most women do not consume this much and will need to supplement. Prenatal vitamins do not contain enough to meet the daily requirement. Calcium carbonate –Tums, Oscal, Rolaids, Viactive, Caltrate – are good sources as well as calcium fortified orange juices
•Iron supplements are available in prenatal vitamins. Many women will need to add additional iron at about 20 weeks.
•Iron and calcium taken alone together will bind with each other and not be absorbed. Take with meals or separately.

Foods to Avoid

•Under or uncooked meat, fish, or poultry. No sushi.
•No swordfish, shark, mackerel, or tilefish – these fish may contain excessive amounts of mercury.
•Soft cheeses such as brie, feta, Camembert, or Roquefort made from unpasturized milk.
•Unpasturized milk or juices or products made from these items.
•If consumed, deli meats and hot dogs should be reheated before eating.

    Foods to Include

•The EPA recommends a maximum of 12 ounces (precooked) a week of fish other than the above that is purchased from a store or restaurant and 6 ounces (precooked) a week of fish caught in local waters.
•Aim for 8 ounces of protein per day (this can include the protein in dairy products).
•6+ glasses of liquids per day.
•Increase fruits and vegetables as well as bran to combat constipation.
List of calcium sources

10 Things to Avoid

•Smoking, including second hand smoke
•Alcohol, to avoid the risk of fetal alcohol syndrome
•Recreational drugs
•Limit caffeine to 0 – 1 serving per day
•Limit intake of artificial sweeteners
•Over the counter herbs and medicinals. We know little to nothing about the effects of these products on babies.
•Excessive heat: saunas, hot tubs, over exercising, temperature 100.4 or higher (treat with Tylenol)
•Changing kitty litter or exposure to cat feces, i.e. gardening without gloves, or playing in sandboxes
•Lying flat on your back for extended periods of time. This decreases the return of blood to the heart and can cause a drop in blood pressure and flow to the uterus.
•Consider avoiding hair dyes, perms, or relaxers at least in the first trimester.

Exercise

Unless otherwise instructed, plan to exercise 20 – 30 minutes 3 – 5 times a week. Walking, jogging, swimming, low impact aerobics, treadmill, and Stairmaster are generally well tolerated. Avoid potentially harmful sports (e.g. horseback riding, downhill skiing, and anything that requires you to use or wear protective equipment). Weights are ok, but decrease the amount of weight and increase the repetitions to maintain tone. Hydrate thoroughly before, during (if possible) and after exercise. Stop if you experience contractions, bleeding, excessive fatigue, or shortness of breath.

Approved Medications

Following is a list of approved medications during pregnancy. If possible, it is best to avoid any nonessential medication in the first trimester.

Approved Medications during Pregnancy

Travel

In general, travel during pregnancy is safe. You may wish to consider limiting out of town travel before 12 weeks or until a heartbeat is heard or seen as this is the most likely time for miscarriage, and medical attention will be required. Travel plans in the second and third trimesters should take into account current and past obstetrical and medical histories, destination, length of time away from home, and medical facilities available during travel. Wear seat belts at all times. The belt should rest between your breasts and underneath your stomach. On long trips, walk around every couple of hours to decrease the risk of blood clot formation.
**See Zika Warning Section**

Morning Sickness Suggestions

(To avoid dehydration and/or weight loss):

•Small frequent meals
•Avoid spicy and greasy foods and strong odors
•Wet/dry regimen – alternate solids and fluid intake
•Emetrol – follow label directions
•Vitamin B6 25 mg twice a day
•Ginger tea
•Lemon drops
•Sea bands – acupressure wrist bands
•Acupuncture
•Call if you are unable to hold down liquids, are dizzy, notice a decrease in urine output, or weight loss greater than 3 – 5 pounds.

Laboratory tests

1st visit

•Complete Blood Count (anemia screen)
•Blood Type and Antibody Screen
•Rubella – German Measles – Titer
•Varicella – Chicken Pox – Titer
•Urinalysis
•Urine Culture (Asymptomatic urinary tract infections are common in pregnancy and have been associated with pre-term labor and/or the development of pyelonephritis or kidney infection)
•Pap smear
•Sexually Transmitted Diseases
oSyphilis (RPR) – Required by law
oGonorrhea – Required by law
oChlamydia – Required by law
oHepatitis B – Recommended by the American Academy of Pediatricians
oHIV (AIDS) – Recommended by the American College of Obstetricians and Gynecologists
and the CDC

24–28 weeks

•One hour Glucola to screen for diabetes
•Complete Blood Count
•Antibody Screen and Rhogam (if Rh negative)
•Syphilis (RPR)

36 weeks

•Beta Strep vaginal and rectal culture (Approximately 10 – 30% of the population are carriers of this bacteria which has been associated with serious infections in the newborn. Mothers who test positive at any time will be treated in labor with intravenous antibiotics
•Gonorrhea culture
•Chlamydia culture
•Syphilis (RPR)
•Complete Blood Count

Ultrasounds

•First trimester to confirm dates
•18 – 20 weeks for anatomy screen

Optional Labs and Tests (recommended only if you fit the appropriate high-risk profile, please discuss with your health care provider)

•Parvovirus – Fifth Disease – screen: High-risk individuals include daycare providers, nursery and elementary school teachers and volunteers, and those who work or volunteer at children’s hospitals.
•Toxoplasmosis screen for cat owners
•Cystic Fibrosis screen
•Tay Sachs, Canavan’s, and Familial Dysautonomia screen
•Sickle Trait screen
•Thalessemia screen
•AFP or Quadruple (Tetra) Screen at 16 weeks to screen for neural tube defects, Down’s Syndrome, and Trisomy 18.
•Ultrascreen First Trimester Prenatal Screening (Nuchal Translucency) at 11 and 1 to 13 and 6 weeks for Down’s Syndrome and Trisomy 18.
•Amniocentesis at 16 weeks (This is an invasive procedure with approximately 0.3% miscarriage rate.)
•Chorionic Villus Sampling (CVS) at 10 – 12 weeks (This is an invasive procedure with approximately 1% miscarriage rate.)

Suggested Reading

What to Expect When You’re Expecting by Heidi Murkoff
Girlfriend’s Guide to Pregnancy by Vicki Iovine
Postpartum Survival Guide by Ann Dunnewold
The Complete Book of Pregnancy and Childbirth by Sheila Kitzinger
Today’s Mothers-to-Be
Relieving Pelvic Pain During and After Pregnancy: How Women Can Heal Chronic Pelvic Instability by Cecile Röst
Twin Set: Moms of Multiples Share Survive and Thrive Secret by Christina Boyle

Birthing Plan

BIRTHING PLAN

The providers at Reiter, Hill, Johnson, and Nevin congratulate you on your new pregnancy and welcome you to the practice.

During your pregnancy, we will strive to provide you with the most current and compassionate care. Our ultimate goal in the hospital is the delivery of a healthy baby to a healthy mother. The following information is an attempt to address the most frequently encountered questions, requests, and concerns raised by our laboring patients.

Unless otherwise expressed or medically contraindicated, our assumption is that the preferred mode of delivery is an unassisted vaginal delivery. Should an operative vaginal or cesarean delivery be considered, a thorough discussion of the indications risks and benefits will be held with you and your partner.

EARLY FIRST STAGE OF LABOR
Many women like to ambulate in the early stage of labor. Such ambulation in your room or on the unit is permitted if your baby is doing well and you have no medical reason for continuous monitoring (such as a trial of labor after Cesarean section or pitocin induction/augmentation). Hospital policy does require intermittent fetal monitoring.

Since blood work is drawn on admission, and you will likely need an IV when in active labor, you will be encouraged to have a saline lock (IV site that is not attached) placed with the initial blood draw that can later be converted to an IV. This will permit ambulation unencumbered by an IV pole.

We typically allow you to have either ice chips with sips of water or clear liquids. Solids are not permitted because of the risk for aspiration should cesarean delivery ultimately be required.

You may shower as long as you are comfortable. There are no tubs or whirlpools at Sibley.

ACTIVE LABOR
IV hydration is recommended in active labor to maintain your considerable fluid needs and provide ready access should the need for medication and/or blood replacement arise.
When in active labor, women typically limit themselves to their bed, a rocking chair or a birthing ball. Monitors will be placed on the abdomen at this time but should not interfere with repositioning yourself as frequently as you wish.

You are welcome to bring your own music. Room lighting can be adjusted to your preferences.

You may bring your own clothing but most find hospital supplied apparel more practical because they allow easy access to blood pressure cuffs, IV’s, catheters, etc.

You will be asked your preferences for pain management upon admission to the unit but such preferences may change at any time. If you are considering an epidural, early IV hydration and blood work are encouraged because these are necessary before placement. If you wish natural childbirth, you will be supported and encouraged in that decision.

There are occasions when pitocin augmentation/induction is medically indicated. Appropriate discussion would then be held with you and your partner prior to starting the medication. Administration of pitocin requires continuous fetal monitoring.
Rupture of membranes may be recommended to enhance the labor process. Again, the appropriate discussion would occur prior to its performance.

SECOND STAGE/DELIVERY
A number of safe pushing approaches are available. We will attempt to identify what works best for you.

Delivery is generally accomplished in a semi-seated position in the birthing bed with legs in rests.

Hospital policy prohibits filming of the delivery or any medical procedures. Photographs are permitted once the appropriate hospital personnel have given their approval.

Although routine episiotomies are not performed, it is very likely that natural tearing will occur during the birth process.

In the absence of complications, your baby will be placed on your abdomen after delivery and your partner will be allowed to cut the cord.

On occasion deliveries may need to be expedited for maternal or fetal indications. Discussion will be held about the indications for vacuum or forceps assisted delivery before any procedure is performed.

Should cesarean delivery be required you will be taken to the operating room and prepped for surgery. Your partner may then join you just before the operation begins. Unless special care is required for your baby, he or she will remain in the operating room until you go back to your room. Should general anesthesia be required you partner will wait in the recovery room for you.

After delivery of the placenta, pitocin will be given through the IV to help the uterus contract and decrease bleeding.

In uncomplicated deliveries, your baby will remain with you in the LDR until you are transferred to the postpartum floor.

Breastfeeding is encouraged in the delivery room.

Labs CPT Codes NIPT Cost Estimator Genetic Testing Screening vs. Diagnostic Genetic Testing Options

Genetic Testing Letter to Patients

During your pregnancy, our office tries to offer the most up-to-date genetic testing options. Some of the laboratories that we contract for these tests may be considered out-of-network for your plan. We have agreements with these laboratories to provide you with discounted costs should your insurance not cover these tests. Please review the following information and provide your insurance company with the test CPT codes (refer to CPT table here) should you have further questions.

1. Ultrascreen (first trimester screen) – This is the first screening test for Trisomy 21, Trisomy 18, and Trisomy 13. This test is sent to NTD Laboratories, part of PerkinElmer Labs. If your insurance company denies the claim and your receive a bill, please contact the lab directly in order to process any appeals that are available. Once NTD receives a decision from the insurance company, you will be billed for any remaining cost. If this amount exceeds $75, contact NTD Laboratories directly. The maximum cost for this test is $75. NTD’s phone number is 888-683-5227.

2. Sequential (second trimester screen) – This is the second screening test for Trisomy 21 and Trisomy 18 and tests for open neural tube defects. This test is also sent to NTD Laboratories. If your insurance company denies the claim and you receive a bill, please contact the lab directly in order to process any appeals that are available. Once NTD receives a decision from the insurance company, you will be billed for any remaining cost. If this amount exceeds $90, contact NTD Laboratories directly. The maximum cost for this test is $90. NTD’s phone number is 888-683-5227.

3. AFP Only (second trimester screen) – This is a test done alone or with the Ultrascreen in the second trimester for open neural tube defects, such as spina bifida and anencephaly. This test is sent to Quest. The maximum cost for this test is $99. If your insurance denies the claim please contact the office for assistance. You can reach Quest at 844-750-4024.

4. AFP Tetra (second trimester screen) – This test is done in the second trimester alone or in combination with the Ultrascreen and NIPT. It evaluates your risk for Trisomy 21, Trisomy 18, and open neural tube defects. This test is sent to Quest. Your insurance will be billed $419. If your insurance denies the claim, please contact the office for assistance. You can reach Quest at 844-750-4024.

5. Cystic Fibrosis – This tests the genetic carrier status for Cystic Fibrosis (CF). We are currently using the laboratory test offered by NxGen Labs. The maximum cost to you will only be $20.00. If you ever receive a bill for more than this, please contact NxGen and they will amend the invoice to the reduced cost. NxGen’s number is 855-776-9436.

6. NIPT – This tests for Down Syndrome, Trisomy 18, Trisomy 13, and abnormalities associated with the sex chromosomes. We use the MaterniT21 Plus test offered through Sequenom Labs, a subset of LabCorp. Insurance companies generally cover this test if you are of advanced maternal age (35 years or older at delivery), if you have an abnormal finding on another test or ultrasound, if you have relevant family history, or if you have had a prior pregnancy with aneuploidy. If you do not qualify as above for testing, your insurance company may still provide coverage. The total cost of this test is $1100, and we recommend all patients use the online cost estimator for an out-of-pocket estimate tailored specifically to their pregnancy and insurance plan prior to having this test done. You can reach Labcorp at 800-845-6167.

7. NxGen– This is a genetic carrier screening test for genetically inherited disease, which can help determine your risk of having a child with a genetic disorder. This test will be billed to your insurance company as in-network genetic screening by NxGen Laboratories. Your individual insurance plan may or may not cover genetic screening. Please call NxGen if you receive a bill. If you have further questions, you may call our office. NxGen’s number is 855-776-9436.

Additional Resources

The American Congress of Obstetricians and Gynecologists (ACOG) is a wonderful resource for patients. The following links refer to the most commonly asked questions. Please visit their website for a full list of informative materials: http://www.acog.org/Patients

Prenatal Genetic Screening Tests
Prenatal Genetic Diagnostic Tests
Gestational Diabetes
Back Pain During Pregnancy
Group Beta Strep
The Rh factor
A Partner’s Guide to Pregnancy
Nutrition During Pregnancy
Zika Virus

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Nested Website Nested 4 x 6 Flyer

"Nested has been such a great value for my patients. The classes and information presented are up to date, concise and exactly what my patients are looking for. Nidhi and her team have years of experience and expertise and they share a passion for what they do. I am thrilled to have Nested on our team!"
-Dr. Peterson


"Nidhi is a highly valued health care provider at RHJN. Her passion for patient education prompted her to create and develop curriculum for "Nested" a program of education for our expecting parents. She is an entertaining and knowledgeable creator and speaker. She and her "nested" team are well prepared to provide excellent education and support to our expecting parents.Her energetic and caring personality is apparent when she sees her patients for consults and office visits."
-Mona Milberg

"I have been getting great feedback from our patients who have done a Nested class. They really felt the classes were well taught and informative. One patient said the class has helped to relieve some of her anxiety and fears about the labor process. Others have liked the charitable aspect to the program. Keep up the good work!"
-Dr. Nevin

Vaccinations

CDC Guidelines for Vaccinating Pregnant Women
Cord Blood Banking

What is cord blood?
Cord blood, or umbilical cord blood, is the blood remaining in your child’s umbilical cord following
birth. It is a rich, non-controversial source of stem cells that must be collected at the time of birth.

What are stem cells?
Stem cells are the building blocks of our blood and immune systems. They are found throughout the
bone marrow, cord blood and peripheral blood. They are particularly powerful because they have the ability to treat, repair and/or replace damaged cells in the body.

Why do families choose to collect and store their baby’s cord blood?
Today, cord blood stem cells have been used successfully in the treatment of over 70 diseases. For most families, banking their baby’s cord blood offers peace of mind that their family’s stem cells are readily available should they need them. Others save cord blood because of its emerging use in treating Type I Diabetes and Cerebral Palsy, which requires a child’s own cord blood. Stem cells from a related source are the preferred option for all treatment, and transplants using cord blood from a family member are twice as successful as transplants using cord blood from a non-relative (i.e.
public source).

How is cord blood collected?
The collection process is safe, easy and painless for both mother and baby and does not interfere with the delivery. After the baby is born, but before the placenta is delivered, a medical professional will clean a 4 to 8 inch area of the umbilical cord with antiseptic solution and insert a needle connected to a blood bag into the umbilical vein. The blood flows into the bag by gravity until the umbilical vein is emptied. The blood bag is clamped, sealed, labeled and shipped by courier to a processing lab. The collection itself typically takes about 2 to 4 minutes.

Who can use my newborn’s cord blood stem cells?
Your newborn’s cord blood stem cells have the potential to be used by the child, and, if there’s an adequate match, by siblings and sometimes parents. An adequate match using related cord blood is defined as a 3 of 6 HLA match. When two people share the same HLAs, they are said to be a “match,” which means their tissues are immunologically compatible. With your newborn’s cord blood there is a 100% probability of an adequate match for the child and a 75% probability for siblings.

How long do cord blood stem cells last?
It is well-established that stem cells are still viable after 25 years of storage. Although there’s no definitive data on how long cord blood stem cells last, the New York State Health Department Guidelines for cord blood banking state “there is no evidence at present that cells stored at -196°C in an undisturbed manner lose either in-vitro determined viability or biologicactivity.”

What are the odds of having a stem cell transplant?
The latest statistics suggest there is a 1 in 217 chance for any given individual to undergo a stem cell transplant by age 70.

How much does it cost to preserve cord blood with a Family Bank?
Generally, the cost for cord blood stem cell preservation has a one time charge of about $1375 for cord blood and $1020 for cord tissue and an annual storage fee of about $150. Many companies offer extended payment plans as low as $44 a month. Also, there are promotions available with the providers. There will be a collection fee of $200 billed to your insurance by your physician’s office. It will be the patient’s responsibility if insurance doesn’t cover the fee.

What is the difference between cord blood stem cells and umbilical cord tissue?
The umbilical cord tissue has an additional and abundant source of mesenchymal stem cells.
Mesenchymal stem cells are expected to play a role in treatment of disease and are being studied for their regenerative properties in cartilage, muscle and nerve cells.

Private banking:This allows families to save their child’s cord blood and cord tissue exclusively for their family’s use. This type of banking will charge a fee to collect, process, freeze and store your child’s stem cell-rich umbilical cord blood for your family’s future medical use.

The following links are for private banking:
Viacord
Cordblood
N I H
ACOG
Cryo-Cell

Donation: Cord blood donation is a way for you to preserve the potentially life-saving stem cells found in the blood of your child’s umbilical cord and placenta in a donation facility for the public good. Once you donate the cord blood to a public facility, your family does not retain ownership of the cord blood. The paperwork for cord blood donation should be completed prior to 34 weeks. Our practice will waive the $200 collection fee.
The following is a link for public cord donation: www.cordforlife.com

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Signs and Symptoms of Labor

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Disability Forms

DISABILITY FORMS

All disability forms are done on a first come, first serve basis; therefore, processing time may vary. There is an additional charge if a patient needs their forms expedited. Payment is expected prior to releasing forms back to the patient.

PROCESSING TIME AND COST

Average Processing Time:5-7 days
Cost:$45.00 (one time fee per pregnancy)
Expedited Charge:$15.00

If you have any special instructions regarding the forms, please indicate this on a separate sheet of paper. Include any callback numbers, fax numbers, etc.

When the processor has completed the forms, you will be contacted by phone. If contact is not made, then a voicemail message will be left. The forms will be enclosed in an envelope and placed at the front desk for pickup at your next office visit.

RECOVERY TIME FOR OBSTETRICAL PATIENTS

Vaginal Delivery: 6 weeks
Cesarean Delivery: 8 weeks

Patients may have other indications that will extend their recovery time. This is to be discussed and authorized by their provider.

EXTENDED LEAVE
Many obstetrical patients choose to extend their leave beyond what is required for recovery. For any additional leave that a patient wishes to take, they will need to contact their HR Department. According to the Family and Medical Leave Act (FMLA) of 1990, every obstetrical patient is entitled to 16 weeks of leave.

Sibley Pre-Registration Information

Sibley Memorial Website

Zika Virus

ACOG Zika Information CDC Response to Zika