* Repeat 10 to 15 times, three times a day.

* Start Kegel exercises lying down. This is the easiest position.

When your muscles get stronger, you can do Kegel exercises sitting or standing as you like.

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Chapter 23.

Weight Gain during Pregnancy Chapter Contents.Section 23.1-How Much Weight Should You Gain? ............... 202 Section 23.2-Gestational Weight Gain Warnings ................... 205 201.

Pregnancy and Birth Sourcebook, Third Edition Section 23.1 How Much Weight Should You Gain?

Excerpted from "Managing Gestational Diabetes: A Patient's Guide to a Healthy Pregnancy," by the National Inst.i.tute of Child Health and Human Development (NICHD, www.nichd.nih.gov), part of the National Inst.i.tutes of Health, September 2006.

Healthy weight gain can mean either your overall weight gain, or your weekly rate of weight gain. Some health care providers focus only on overall gain or only on weekly gain, but some keep track of both types of weight gain. First, let's look at overall weight gain.

The amount of weight gain that is healthy for you depends on how much you weighed before you were pregnant. Find your prepregnancy weight and height in Table 23.1. Then look at the bottom row of the table to find your overall healthy weight gain goal.

If you are expecting twins, an overall weight gain of 35 to 45 pounds is considered healthy.

Remember that these goals are only a general range for overall weight gain. Your health care provider will let you know if you're gaining too much or too little weight for a healthy pregnancy. Weight loss can be dangerous during any part of your pregnancy. Report any weight loss to your health care provider right away.

How do I do it?

To maintain a healthy weight gain, eat a healthy diet as outlined by your health care provider, and get regular, moderate physical activity.

If you think your weight gain is out-of-control, but you are following a recommended diet and physical activity program, tell your health care provider. He or she will adjust your treatment plan to get your weight gain back into healthy range.

When do I do it?

It's a good idea to keep track of how much weight you gain from the time you learn you are pregnant to the time you have the baby.

202.

Weight Gain during Pregnancy Knowing your weight status can help your health care provider detect possible problems before they become dangerous.

It's also a good idea to weigh yourself on the same day of the week and at the same time of day. Your health care provider can make a schedule for you so you know how often to weigh yourself and at what time of day. You will also be weighed at your prenatal appointments.

How do I know that I'm doing it right?

One way to determine if your overall weight gain is within the healthy range is to follow your weekly rate of weight gain. The information below gives some general guidelines for weekly rate of weight gain.

Table 23.1. Overall Weight Gain Goals by Prepregnancy Height and Weight Overall Weight Gain Goals by Prepregnancy Height and Weight Height Weight Status Category (Without Shoes) (Weight in pounds, in light, indoor clothing) ft.

in.

A*

B.

C.

D.

4.9.92 or less 93-113.

114134 135 or more 4.10.94 or less 95-117.

118138 139 or more 4.11.97 or less 98-120.

121142 143 or more 5.0.

100 or less 101123 124146 147 or more 5.1.103 or less 104127 128150 151 or more 5.2.106 or less 107131 132155 156 or more 5.3.109 or less 110134 135159 160 or more 5.4.113 or less 114140 141165 166 or more 5.5.117 or less 118144 145170 171 or more 5.6.121 or less 122149 150176 177 or more 5.7.124 or less 125153 154181 182 or more 5.8.128 or less 129157 158186 187 or more 5.9.131 or less 132162 163191 192 or more 5.10.135 or less 136166 167196 197 or more 5.11.139 or less 140171 172202 203 or more 6.0.

142 or less 143175 176207 208 or more Your overall weight gain goal is: 3540*

3035 2227 1520 *The weight gain goal for women in this category may range from 40 to 45 pounds.

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Pregnancy and Birth Sourcebook, Third Edition If your weekly rate of gain is low, you might need to adjust your diet to get more calories. If your weekly rate of gain is high, you may be developing a condition called preeclampsia, which can be dangerous.

What is a good weekly rate of weight gain?

Aim to keep your weekly rate of weight gain within these healthy ranges: * In the first trimester of pregnancy (the first 3 months): 3 to 6 pounds for the entire 3 months.

* During the second and third trimesters (the last 6 months): between 1/2 and 1 pound each week.

* If you gained too much weight early in the pregnancy: limit weight gain to 3/4 of a pound each week (3 pounds each month).

A weight gain of 2 pounds or more each week is considered high.

Keep in mind that your weekly rate of weight gain may go up and down throughout the course of your pregnancy. Some weeks you may gain weight, other weeks you won't; as a result, your weekly rate of gain may not match your overall weight gain goal exactly. Your health care provider will let you know if you're gaining too much or too little weight for a healthy pregnancy. Weight loss can be dangerous during any part of your pregnancy. Report any weight loss to your health care provider right away.

You may also notice that your weight gain slows down or stops for a time. It should start going up again after 1 to 2 weeks. If not, tell your health care provider immediately. He or she may need to adjust your treatment plan.

Are there any other ways I can maintain a healthy weight gain?

Some general guidelines that might help you reach your target weekly rate of gain include: * Try to get more light or moderate physical activity, if your health care provider says it's safe.

* Use the Nutrition Facts labels on food packages to make lower-calorie food choices that fit into your meal plan.

204.

Weight Gain during Pregnancy * Eat fewer fried foods and fast foods.

* Eat healthy foods that fit into your meal plan, such as salads with low-fat dressings and broiled or grilled chicken.

* Use less b.u.t.ter and margarine on food, or don't use them at all.

* Use spices and herbs (such as curry, garlic, and parsley) and low-fat or lower calorie sauces to flavor rice and pasta.

* Eat smaller meals and have low-calorie snacks more often, to ensure that your body has a constant glucose supply, and to prevent yourself from getting very hungry.

* Avoid skipping meals or cutting back too much on breakfast or lunch. Eating less food or skipping meals could make you overly hungry at the next meal, causing you to overeat.

Section 23.2 Gestational Weight Gain Warnings "Researcher Warns about Gestational Weight Gain," by Eddy Ball, in Environmental Facto Environmental Facto r, by the National Inst.i.tute of Environmental Health Sciences (NIEHS, www.niehs.nih.gov), part of the National Inst.i.tutes of Health, March 2008. r, by the National Inst.i.tute of Environmental Health Sciences (NIEHS, www.niehs.nih.gov), part of the National Inst.i.tutes of Health, March 2008.

Nutritional epidemiologist Anna Maria Siega-Riz, Ph.D., had good reason to sound alarmed when she talked about pregnancy and weight gain in February 2008.

According to the University of North Carolina at Chapel Hill professor, overweight and obese women, as well as women who gain too much weight during their pregnancies, may be endangering their own health and the health of their children.

In her talk, "Maternal Obesity: The Number One Problem Facing Prenatal Care Providers in the New Millennium," Siega-Riz presented a preponderance of evidence that these women have a significantly greater risk of suffering from metabolic syndrome-related diseases, of bearing children with birth defects, such as spina bifida, and of giving birth to babies who will experience problems with their own health.

205.

Pregnancy and Birth Sourcebook, Third Edition More women are overweight and obese worldwide, and more of them are gaining excessive weight during pregnancy. Compounding the problem, Siega-Riz added, is the complacency of many pregnant women and, even more disturbing, their health care providers.

"Maternal obesity is not unique to the United States," Siega-Riz said as she began her lecture. "It is occurring globally." Many developing countries are facing the same problems as the United States, with obesity rates between 20 and 30 percent. Not only are rates increasing, Siega-Riz noted, but obesity is also emerging as a health disparity issue due to its greater prevalence among minority women.

According to Siega-Riz, in the United States about a third of women are overweight and 10 to 15 percent are obese. The majority of pregnant women are gaining 21 to 40 pounds during pregnancy, and since the 1990s, there has been a 30 percent increase in the number of women who gain 40 or more pounds. "Only about a third of women are gaining weight within the targeted weight-gain recommendations," she said. In addition to the significant health problems that obesity contributes to on its own, such as diabetes and cardiovascular disease, Siega-Riz pointed to studies suggesting that about 25 percent of problems with fecundity and fertility are due to obesity.

Maternal overweight and obesity have been a.s.sociated with a dramatic increase in risk for gestational diabetes, gestational hypertension, preeclampsia, cesarean delivery, fetal death, and birth defects.

The effects of overweight and obesity persist beyond childbirth and include postpartum weight retention, postpartum anemia related to the higher rate of cesarean sections, shorter duration of breastfeeding, and persistent glucose intolerance. Moreover, with excessive weight gain, a woman is also more likely to find herself in a higher weight cla.s.sification at 12 months postpartum than she was at conception, putting her at even greater risk for complications in a subsequent pregnancy.

Because of these trends, physicians are seeing a growing number of pregnant women weighing as much as 300 pounds. "Quite frankly, they don't know how to manage them," Siega-Riz observed. One study found that 33 percent of subjects reported receiving no advice on gestational weight gain from their providers. The few intervention studies thus far have failed to show promising results and have found poor rates of compliance with interventions on the part of physicians and pregnant women.

As she and her colleagues strive to close the gaps in research on gestational weight gain, Siega-Riz continues to push for translation 206 Weight Gain during Pregnancy of this research through education and policy change. She currently serves a member of the Inst.i.tute of Medicine's (IOM) Committee to Reexamine IOM Pregnancy Weight Guidelines. In 2004, she served on the IOM's Committee to Review the WIC [Women, Infants, and Children] Food Packages. As result of the recommendations from this committee, the United States Department of Agriculture made the first major changes to the food packages since WIC's inception 30 years ago.

207.

Chapter 24.

Sleep during Pregnancy Women from adolescence to postmenopause are underrepresented in studies of sleep and its disorders. Although sleep complaints are twice as prevalent in women, 75% of sleep research has been conducted in men. More sleep studies in the past five years have included women, but small sample sizes prohibit meaningful s.e.x comparisons. Thus, s.e.x differences in sleep and sleep disorder characteristics, in responses to sleep deprivation, and in sleep-related physiology remain unappreci-ated. Furthermore, findings from studies based primarily in men are often considered to be representative of 'normal' even when it is recognized that there are important sleep-related physiological differences in women, including timing of nocturnal growth hormone secretion and differential time course of delta activity across the night.

Hormonal changes and physical discomfort are common during pregnancy and both can affect sleep. Although nearly all pregnant women will experience disturbed sleep by the third trimester, there have been only two longitudinal sleep studies of subjective and objective sleep measures during pregnancy. There have been no reports of intervention studies to improve sleep quality during pregnancy.

Some have a.s.sumed that disturbed sleep is a 'natural' consequence of pregnancy, labor, delivery, and postpartum that resolves over time Excerpted from "Sleep, s.e.x Differences, and Women's Health: National Sleep Disorders Research Plan," by the National Heart, Lung and Blood Inst.i.tute (NHLBI, www.nhlbi.nih.gov), part of the National Inst.i.tutes of Health, July 2003.

Revised by David A. Cooke, MD, FACP, April 29, 2009.

209.

Pregnancy and Birth Sourcebook, Third Edition since few women seek a.s.sistance to improve sleep. Research has not shown a relationship between sleep quality and quant.i.ty and any perinatal adverse outcome, length of labor, or type of delivery.

More studies are needed, however, to clarify the extent to which sleep-related problems during pregnancy may have adverse fetal, perinatal, or infant-related consequences.

Very little is known about the effects of late stage pregnancy sleep disturbances on labor and delivery, emotional distress, or postpartum depression. However, nighttime labor and a history of sleep disruption in late stage pregnancy are related to a higher incidence of postpartum blues. Certain sleep disorders such as restless legs syndrome (RLS), periodic limb movement disorder (PLMS), sleep-disordered breathing (SDB), or insomnia may emerge during pregnancy and the extent to which these disorders resolve or place women at higher risk for sleep disorders later in life is not clear. Pregnancy induces changes in the upper airway and in functional residual capacity that predispose women to snoring, SDB, and reduced oxygen stores.

Pregnant women who snore may be at risk for preeclampsia and/ or SDB. The number of pregnant women with SDB may be substantial, but the prevalence has not been defined in either uncomplicated or complicated pregnancy. Women with preeclampsia and excessive weight gain during pregnancy are at greater risk for the development of SDB and pregnancy-induced hypertension, which have been a.s.sociated with adverse perinatal outcomes, but few polysomnographic studies have been done in these women.

Sleep in Pregnancy and Postpartum * Longitudinal studies indicate that age combined with anemia is related to first trimester fatigue and that reduced sleep time is related to fatigue during the third trimester. Both reduced sleep time and anemia are related to fatigue postpartum. Significant changes in sleep are evident in the first trimester of pregnancy with increased total sleep time coupled with more awakenings, but postpartum sleep efficiency is lower than prepregnancy. Slow wave sleep percentage is reduced throughout pregnancy compared to prepregnancy and postpartum. REM sleep was reduced during pregnancy in one study, but was reduced in another longitudinal study, most notably during the third trimester.

* Restless legs syndrome (RLS) occurs in about 15%25% of pregnant women and becomes more common in later pregnancy. RLS is known to be a.s.sociated with iron deficiency in non-pregnant 210 Sleep during Pregnancy patients, and some data suggest this is true in pregnant women as well. There is also some evidence that RLS in pregnancy may be a.s.sociated with reduced levels of folate. It is unclear whether taking iron or folic acid supplements (both of which are usually recommended in pregnancy for other reasons) affects the risk of pregnancy-related RLS.

* Thirty percent of pregnant women begin snoring for the first time during the second trimester. However, there continues to be very limited information regarding whether pregnancy increases the risk for sleep apnea.

* Preeclamptic women show evidence of SDB a.s.sociated with increased blood pressure. Pregnant women who snore have a two-fold greater incidence of hypertension, preeclampsia, and fetal growth restriction compared to nonsnorers.

* Self-reported sleep quality derived from sleep diaries shows considerable sleep disturbances in the early postpartum period.

Sleep efficiency improves during the first year postpartum, but it is unclear whether sleep quant.i.ty and quality return to prepregnancy levels.

* There is a relationship between sleep and mood during pregnancy and through the first three to four months postpartum.

Increased disturbances in self-reported sleep and decreased reported total sleep time are a.s.sociated with depressed mood postpartum.

211.

Chapter 25.

s.e.x during Pregnancy If you're pregnant or even planning a pregnancy, you've probably found an abundance of information about s.e.x before pregnancy (that is, having s.e.x in order to conceive) and s.e.x after childbirth (general consensus: expect a less active s.e.x life when there's a newborn in the house).

But there's less talk about the topic of s.e.x during pregnancy, perhaps because of our culture's tendency to dissociate expectant mothers from s.e.xuality. Like many parents-to-be, you may have questions about the safety of s.e.x and what's normal for most couples.

Well, what's normal tends to vary widely, but you can count on the fact that there will be changes in your s.e.x life. Open communication will be the key to a satisfying and safe s.e.xual relationship during pregnancy.

Is It Safe to Have s.e.x during Pregnancy?