* Avoid eating large meals 3 hours before going to bed.

* Get some mild exercise like walking.

* Avoid long naps during the day.

Weight Gain The amount of weight you need to gain during pregnancy depends upon how much you weighed before you became pregnant. According to the American College of Obstetricians and Gynecologists (ACOG) women who have a normal weight before getting pregnant should gain 25 to 35 pounds. Women who are underweight before pregnancy should gain 28 to 40 pounds. And women who are overweight should gain 15 to 25 pounds.

Research shows that women who gain more than the recommended amount during pregnancy have a higher chance of being obese 10 years later. Ask your doctor how much weight gain during pregnancy is healthy for you.

Is It Safe to Have s.e.x?

Unless your doctor tells you otherwise, s.e.xual intercourse is safe throughout your pregnancy. For many women, pregnancy increases their s.e.x drive. For others, it has the opposite effect. And almost all women need to try different positions when they start to get large bellies.

If you have problems during your pregnancy or have had miscarriages in the past your doctor may suggest you avoid s.e.xual intercourse. Call your doctor if you have any of the following problems during or after s.e.xual intercourse: * pain in the v.a.g.i.n.a or abdomen; * bleeding from the v.a.g.i.n.a; or * leaking of fluid from the v.a.g.i.n.a.

When to Call the Doctor When you are pregnant you should not hesitate to call your doctor or midwife if something is bothering or worrying you. Sometimes physical changes can be signs of a problem.

88.Physical Changes during Pregnancy Call your doctor or midwife immediately if you: * are bleeding or leaking fluid from the v.a.g.i.n.a; * have sudden or severe swelling in the face, hands, or fingers; * get severe or long-lasting headaches; * have discomfort, pain, or cramping in the abdomen; * have a fever or chills; * are vomiting or have persistent nausea; * feel discomfort, pain, or burning with urination; * have problems seeing or blurred vision; * feel dizzy; * sense a change in your baby's movement; and * suspect your baby is moving less than normally after 28 weeks of pregnancy (if you count less than 10 movements in 2 hours or less).

Section 9.2 Back Pain during Pregnancy "Back Pain During Pregnancy," Journal of Midwifery and Women's Journal of Midwifery and Women's Health, Health, September/October 2005. 2005 American College of Nurse-Midwives (www.midwife.org). Reprinted with permission. September/October 2005. 2005 American College of Nurse-Midwives (www.midwife.org). Reprinted with permission.

Most women have back pain at some point during pregnancy. The pain can be mild or severe, but it can usually be treated. In some cases, it can be prevented.

Why do pregnant women have back pain?

Pregnancy hormones loosen all of your joints. Your growing abdomen changes your posture. These changes can increase the normal curves that are in your back which can cause back pain. Later in pregnancy the looser joints in the pelvis move more from the growing 89 Pregnancy and Birth Sourcebook, Third Edition weight of your baby and this can cause general pain in your lower back and sometimes shooting pain in your b.u.t.tock or upper legs.

What makes the pain worse?

Lying on your back, sitting upright in a chair, rolling over at night, or getting out of bed or out of a chair can cause back pain to be worse.

How can I avoid and reduce back pain?

* Avoid sitting for long periods of time. Change positions and move frequently.

* Avoid bending, arching, and twisting motions; you will feel less discomfort.

* When lifting heavy things, keep your back straight and use your leg muscles instead of your back when picking things up.

* Whenever you are sitting, put your feet up on a stool or box so your hips tilt forward and the curve in your lower back flattens out.

* Many women get pain relief from using moist heat or cold packs, getting a ma.s.sage, or sitting in a warm bath.

* Some women find wearing supportive, low-heeled shoes or an abdominal support binder can also help.

* Gentle exercise, along with walking 20 minutes most days, can relieve or lessen back pain. Exercise helps strengthen the back muscles, decrease muscle tightness and spasm, and keep the joints in good position.

* Sleeping on your side with a body pillow in your arms and between your knees may help as well.

What strengthening exercises are helpful?

The following text has exercises that will strengthen the back muscles. The exercises can be held for 35 seconds and repeated 10 30 times. Be sure not to hold your breath when you are doing them.

What stretches are recommended?

Stretching the back and hamstring muscles after a warm shower or short walk can help reduce back pain. Hold each stretch for 20 seconds, and repeat 23 times. See the following text for directions.

90.Physical Changes during Pregnancy Figure 9.2. Pelvic tilt start position: Note arch in lower back. Kneel on your hands and knees; you'll notice an arch in your lower back. Tilt your pelvis backwards, so you flatten your back, keeping your b.u.t.tocks relaxed. Pelvic tilt start position: Note arch in lower back. Kneel on your hands and knees; you'll notice an arch in your lower back. Tilt your pelvis backwards, so you flatten your back, keeping your b.u.t.tocks relaxed.

Figure 9.3. Pelvic tilt end position: Note absence of arch in lower back. Pelvic tilt end position: Note absence of arch in lower back.

Figure 9.4. Back stretch: Kneel on your hands and knees, with your legs spread apart, and a small pillow under your belly. Sit back and reach your arms forward to feel a stretch along your spine. Back stretch: Kneel on your hands and knees, with your legs spread apart, and a small pillow under your belly. Sit back and reach your arms forward to feel a stretch along your spine.

91.Pregnancy and Birth Sourcebook, Third Edition Figure 9.5. Hamstring stretch: Face a chair and place one foot on it. Keep your back straight as you gently lean forward to stretch the back of the thigh. Hamstring stretch: Face a chair and place one foot on it. Keep your back straight as you gently lean forward to stretch the back of the thigh.

What is sciatica?

The sciatic nerve is a large nerve that runs down the back across the b.u.t.tocks and down the back of your legs. Sciatica is pain in the sciatic nerve which is caused by pressure on the nerve. The symptoms of sciatica that are different from normal back pain in pregnancy are: pain down the b.u.t.tock and back of your leg past your knee, tingling, numbness, or if you have trouble moving your leg. The treatment for sciatica is the same as the treatment for back pain but your health care provider may also suggest bedrest and physical therapy. Sciatic pain usually goes away in 1 to 2 weeks.

92.

Chapter 10.

Pregnancy, Pelvic Floor Disorders, and Bladder Control Chapter Contents.Section 10.1-Pregnancy Increases Risk of Pelvic Floor Problems ................................................................. 94 Section 10.2-Pregnancy and Bladder Control ........................... 96 93.Pregnancy and Birth Sourcebook, Third Edition Section 10.1 Pregnancy Increases Risk of Pelvic Floor Problems From "Pelvic Floor Disorders," 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, January 10, 2007.

What are pelvic floor disorders?

The term "pelvic floor" refers to the group of muscles that form a sling or hammock across the opening of a woman's pelvis. These muscles, together with their surrounding tissues, keep all of the pelvic organs in place so that the organs can function correctly.

A pelvic floor disorder occurs when the pelvic muscles and connective tissue in the pelvis weaken or are injured.

An estimated one-third of all U.S. women are affected by one type of pelvic floor disorder in her lifetime. Disorders may result from pelvic surgery, radiation treatments, and, in some cases, pregnancy or v.a.g.i.n.al delivery of a child.

What are the most common pelvic floor disorders?

There are a variety of problems related to the pelvic floor. The most common include the following: * Pelvic organ prolapse: Pelvic organ prolapse: A "prolapse" occurs when the pelvic muscles and tissue become weak and can no longer hold the organs in place correctly. In uterine prolapse, the uterus can press down on the v.a.g.i.n.a, causing it to invert, or even to come out through the v.a.g.i.n.al opening. In v.a.g.i.n.al prolapse, the top of the v.a.g.i.n.a loses support and can drop through the v.a.g.i.n.al opening. A "prolapse" occurs when the pelvic muscles and tissue become weak and can no longer hold the organs in place correctly. In uterine prolapse, the uterus can press down on the v.a.g.i.n.a, causing it to invert, or even to come out through the v.a.g.i.n.al opening. In v.a.g.i.n.al prolapse, the top of the v.a.g.i.n.a loses support and can drop through the v.a.g.i.n.al opening.

Some symptoms of pelvic organ prolapse may include: * a feeling of heaviness or fullness or as if something falling out of the v.a.g.i.n.a; * some women also feel a pulling or aching or a "bulge" in the lower abdomen or pelvis; and 94.Pregnancy, Pelvic Floor Disorders, and Bladder Control * prolapse may also cause a kinking in the urethra, making it harder for a woman to empty her bladder completely, or causing frequent urinary tract infections.

* Urinary incontinence: Urinary incontinence: This can occur when the bladder drops down into the v.a.g.i.n.a. Because the bladder is not in its proper place, a key symptom of urinary incontinence is urine leaking without a woman's control. Other symptoms might include urgency to urinate, frequent urination, and painful urination. This can occur when the bladder drops down into the v.a.g.i.n.a. Because the bladder is not in its proper place, a key symptom of urinary incontinence is urine leaking without a woman's control. Other symptoms might include urgency to urinate, frequent urination, and painful urination.

* a.n.a.l incontinence: a.n.a.l incontinence: This can occur when the r.e.c.t.u.m bulges into or out of the v.a.g.i.n.a, making it difficult to control the bowels. It can also occur when there is damage to the a.n.a.l sphincter, the ring of muscles that keep the a.n.u.s closed. This can occur when the r.e.c.t.u.m bulges into or out of the v.a.g.i.n.a, making it difficult to control the bowels. It can also occur when there is damage to the a.n.a.l sphincter, the ring of muscles that keep the a.n.u.s closed.

What are the treatments for pelvic floor disorders?

Many women don't need treatment for their pelvic floor disorder.

In other cases, treatment for symptoms includes changes in diet, weight control, and other lifestyle changes. Treatment may also include surgery, medication, and use of a device placed in the v.a.g.i.n.a called a pessary that helps support the pelvic organs.

Exercises for the pelvic floor muscles (known as Kegel exercises) can often help strengthen the muscles around the openings of the urethra, v.a.g.i.n.a, and r.e.c.t.u.m. Treatments for incontinence can also include medication and bladder or bowel control training.

95.Pregnancy and Birth Sourcebook, Third Edition Section 10.2 Pregnancy and Bladder Control From "Pregnancy, Childbirth, and Bladder Control," by the National Inst.i.tute of Diabetes and Digestive and Kidney Diseases (NIDDK, www.niddk.nih.gov), part of the National Inst.i.tutes of Health, May 2002.

Reviewed by David A. Cooke, MD, FACP, March 31, 2009.

Do pregnancy and childbirth affect bladder control?

Yes. But don't panic. If you lose bladder control after childbirth, the problem often goes away by itself. Your muscles may just need time to recover.

When do you need medical help?

If you still have a problem after six weeks, talk to your doctor. Without treatment, lost bladder control can become a long-term problem.

Accidental leaking can also signal that something else is wrong in your body.

Bladder control problems do not always show up right after childbirth. Some women do not begin to have problems until later, often in their 40s.

You and your health care team must first find out why you have lost bladder control. Then you can discuss treatment.

After treatment, most women regain or improve their bladder control. Regaining control helps you enjoy a healthier and happier life.

Can you prevent bladder problems?

Yes. Women who exercise certain pelvic muscles have fewer bladder problems later on. These muscles are called pelvic floor muscles.

If you plan to have a baby, talk to your doctor. Ask if you should do pelvic floor exercises. Exercises after childbirth also help prevent bladder problems in middle age.

Ask your health care team how to do pelvic exercises.

96.Pregnancy, Pelvic Floor Disorders, and Bladder Control How does bladder control work?

Your bladder is a muscle shaped like a balloon. While the bladder stores urine, the bladder muscle relaxes. When you go to the bathroom, the bladder muscle tightens to squeeze urine out of the bladder.

More muscles help with bladder control. Two sphincter muscles surround the tube that carries urine from your bladder down to an opening in front of the v.a.g.i.n.a. The tube is called the urethra. Urine leaves your body through this tube. The sphincters keep the urethra closed by squeezing like rubber bands.

Pelvic floor muscles under the bladder also help keep the urethra closed.

When the bladder is full, nerves in your bladder signal the brain.

That's when you get the urge to go to the bathroom. Once you reach the toilet, your brain sends a message down to the sphincter and pelvic floor muscles. The brain tells them to relax. The brain signal also tells the bladder muscles to tighten up. That squeezes urine out of the bladder.

Strong sphincter (bladder control) muscles prevent urine leakage in pregnancy and after childbirth. You can exercise these muscles to make them strong. Talk to your doctor about learning how to do pelvic floor exercises.

What do pregnancy and childbirth have to do with blad- der control?

The added weight and pressure of pregnancy can weaken pelvic floor muscles. Other aspects of pregnancy and childbirth can also cause problems, such as: * changed position of bladder and urethra; * v.a.g.i.n.al delivery; * episiotomy (the cut in the muscle that makes it easier for the baby to come out); and * damage to bladder control nerves.

Which professionals can help you with bladder control?

Professionals who can help you with bladder control include: * your primary care doctor; 97.Pregnancy and Birth Sourcebook, Third Edition * a gynecologist: a women's doctor; * a urogynecologist: an expert in women's bladder problems; * a urologist: an expert in bladder problems; * a specialist in female urology; * a nurse or nurse pract.i.tioner; and * a physical therapist.

98.

Chapter 11.

Pregnancy and Bone Health Both pregnancy and breastfeeding cause changes and place extra demands on a woman's body. Some of these may have an effect on her bones. The good news is that most women do not experience bone problems during pregnancy and breastfeeding. And if their bones are affected during these times, the problem is often easily corrected.

Nevertheless, taking care of one's bone health is especially important during pregnancy and when breastfeeding-for the good health of both the mother and her baby.

Pregnancy and Bone Health During pregnancy, the baby growing in its mother's womb needs plenty of calcium to develop its skeleton. This need is especially great during the last three months of the pregnancy. If the mother does not get enough calcium, her baby will draw what it needs from its mother's bones. So, it is disconcerting to realize that most women of child-bearing years are not in the habit of getting enough calcium.

Fortunately (unless a mother is still a teenager), pregnancy appears to help protect a woman's calcium reserves in several ways: * Pregnant women absorb calcium better from food and supplements than women who are not pregnant. This is especially true From "Pregnancy, Breastfeeding, and Bone Health," by the National Inst.i.tute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS, www.niams .nih.gov), part of the National Inst.i.tutes of Health, June 2005.

99.Pregnancy and Birth Sourcebook, Third Edition during the last half of pregnancy, when the baby is growing quickly and has the greatest need for calcium.

* During pregnancy, women produce more estrogen, a hormone that protects bones.

* Any bone ma.s.s lost during pregnancy is typically restored within several months after the baby's delivery (or several months after breastfeeding is stopped).

Some studies suggest that pregnancy may be good for bone health overall. There is some evidence that the more times a woman has been pregnant (for at least 28 weeks), the greater her bone density and the lower her risk of fracture.

In some cases, women develop osteoporosis during pregnancy and/ or breastfeeding, although this is rare. Osteoporosis is bone loss that is serious enough to result in fragile bones and increased risk of fracture.

In many cases, women who develop osteoporosis during pregnancy and breastfeeding will recover lost bone after their pregnancy ends or they stop breastfeeding. It is less clear whether teenage mothers recover lost bone and are able to go on to optimize their bone ma.s.s.

Teenage mothers may be at especially high risk for bone loss during pregnancy and for osteoporosis later in life. Unlike older women, these mothers are still building much of their total bone ma.s.s during their teenage years. The unborn baby's need to develop its skeleton may compete with the teenage mother's need for calcium to build her own bones, compromising her ability to achieve optimal bone ma.s.s that will help protect her from osteoporosis later in life. Pregnant teens should be especially careful to get enough calcium during and after their babies are born to minimize any bone loss.

Breastfeeding and Bone Health Breastfeeding also has an effect on a mother's bones. Studies have shown that women often lose three to five percent of their bone ma.s.s during breastfeeding, although it is rapidly recovered after weaning.

This bone loss may be caused by the growing baby's increased need for calcium, which is drawn from the mother's bones. The amount of calcium the mother needs depends on the amount of breast milk produced and how long breastfeeding continues. Bone loss may also occur during breastfeeding because the mother produces less estrogen-the hormone that protects bones. The good news is that like the bone lost 100 Pregnancy and Bone Health during pregnancy, bone lost during breastfeeding is usually recovered within six months after breastfeeding ends.

Tips to Keep Bones Healthy during Pregnancy, Breastfeeding, and Beyond Taking care of your bones is important throughout life, including before, during, and after pregnancy and breastfeeding. A balanced diet with adequate calcium, regular exercise, and a healthy lifestyle are good for mothers and their babies.

Calcium: Although this important mineral is important throughout your lifetime, your body's demand for it is greater during pregnancy and breastfeeding, because both you and your baby need it. The National Academy of Sciences recommends that women who are pregnant or breastfeeding consume 1,000 mg (milligrams) of calcium each day. For pregnant teens, the recommended intake is even higher: 1,300 mg a day. Although this important mineral is important throughout your lifetime, your body's demand for it is greater during pregnancy and breastfeeding, because both you and your baby need it. The National Academy of Sciences recommends that women who are pregnant or breastfeeding consume 1,000 mg (milligrams) of calcium each day. For pregnant teens, the recommended intake is even higher: 1,300 mg a day.

Good sources of calcium include: * low-fat dairy products, such as milk, yogurt, cheese, and ice cream; * dark green, leafy vegetables, such as broccoli, collard greens, and bok choy; * canned sardines and salmon with bones; * tofu, almonds, corn tortillas; and * foods fortified with calcium, such as orange juice, cereals, and breads.