The certified nurse-midwife. If you're looking for a practitioner whose emphasis is on you the person rather than you the patient, who will take extra time to talk to you not only about your physical condition but also your emotional well-being, who will be more likely to offer you nutritional advice and breastfeeding support, and who will be oriented toward the "natural" in childbirth, then a certified nurse-midwife (CNM) may be right for you (though, of course, many physicians fit that profile, too). A CNM is a medical professional, a registered nurse who has completed graduate-level programs in midwifery and is certified by the American College of Nurse-Midwives. A CNM is thoroughly trained to care for women with low-risk pregnancies and to deliver uncomplicated births. In some cases, a CNM may provide continuing routine gynecological care and, sometimes, newborn care. Most midwives work in hospital settings, others deliver at birthing centers and/or do home births. Though CNMs have the right in most states to offer epidurals and other forms of pain relief, as well as to prescribe labor-inducing medications, a birth attended by a CNM is less likely to include such interventions. On average, midwives have much lower cesarean delivery rates than physicians, as well as higher rates of VBAC (vaginal birth after cesarean) success-but that may be due in part to the fact that they only care for women with low-risk pregnancies, which are less likely to take a turn for the complicated or result in surgical births. Studies show that for low-risk pregnancies, deliveries by CNMs are as safe as those by physicians. Something else to keep in mind: The cost of prenatal care with a CNM is usually less than that of an ob-gyn. If you're looking for a practitioner whose emphasis is on you the person rather than you the patient, who will take extra time to talk to you not only about your physical condition but also your emotional well-being, who will be more likely to offer you nutritional advice and breastfeeding support, and who will be oriented toward the "natural" in childbirth, then a certified nurse-midwife (CNM) may be right for you (though, of course, many physicians fit that profile, too). A CNM is a medical professional, a registered nurse who has completed graduate-level programs in midwifery and is certified by the American College of Nurse-Midwives. A CNM is thoroughly trained to care for women with low-risk pregnancies and to deliver uncomplicated births. In some cases, a CNM may provide continuing routine gynecological care and, sometimes, newborn care. Most midwives work in hospital settings, others deliver at birthing centers and/or do home births. Though CNMs have the right in most states to offer epidurals and other forms of pain relief, as well as to prescribe labor-inducing medications, a birth attended by a CNM is less likely to include such interventions. On average, midwives have much lower cesarean delivery rates than physicians, as well as higher rates of VBAC (vaginal birth after cesarean) success-but that may be due in part to the fact that they only care for women with low-risk pregnancies, which are less likely to take a turn for the complicated or result in surgical births. Studies show that for low-risk pregnancies, deliveries by CNMs are as safe as those by physicians. Something else to keep in mind: The cost of prenatal care with a CNM is usually less than that of an ob-gyn.

If you choose a certified nurse-midwife (about 8 percent of expectant mothers do), be sure to select one who is both certified and licensed (all 50 states license nurse-midwives). Most CNMs use a physician as a backup in case of complications; many practice with one or with a group that includes several. For more information about CNMs, look online at midwife.org.

Direct-entry midwives. These midwives are trained without first becoming nurses, though they may hold degrees in other health care areas. Direct-entry midwives are more likely than CNMs to do home births, though some also deliver babies in birthing centers. Those who are evaluated and certified through the North American Registry of Midwives (NARM) are called certified professional midwives (CPMs); other direct-entry midwives are not certified. Licensing for direct-entry midwives is also currently offered in certain states. in some of those states, the services of a CPM are reimbursable through Medicaid and private health plans. In other states, direct-entry midwives cannot practice legally. For more information, call the Midwives Alliance of North America at (888) 923-6262 or check their website at mana.org. These midwives are trained without first becoming nurses, though they may hold degrees in other health care areas. Direct-entry midwives are more likely than CNMs to do home births, though some also deliver babies in birthing centers. Those who are evaluated and certified through the North American Registry of Midwives (NARM) are called certified professional midwives (CPMs); other direct-entry midwives are not certified. Licensing for direct-entry midwives is also currently offered in certain states. in some of those states, the services of a CPM are reimbursable through Medicaid and private health plans. In other states, direct-entry midwives cannot practice legally. For more information, call the Midwives Alliance of North America at (888) 923-6262 or check their website at mana.org.

Types of Practice.

You've settled on an obstetrician, a family practitioner, or a nurse-midwife. Next you've got to decide which kind of medical practice you would be most comfortable with. Here are the most common kinds of practices and their possible advantages and disadvantages: Solo medical practice. In such a practice, a doctor works alone, using another doctor to cover when he or she is away or otherwise unavailable. An obstetrician or a family practitioner might be in solo practice; a nurse-midwife, in almost all states, must work in a collaborative practice with a physician. The major advantage of a solo practice is that you see the same practitioner at each visit. This way, you get to know and, ideally, feel more comfortable with this person before delivery. The major disadvantage is that if your practitioner is not available, a backup you don't know may deliver your baby (although arranging to meet the covering physician or midwife in advance helps remedy this potential drawback). A solo practice may also be a problem if, midway in the pregnancy, you find you're not really crazy about the practitioner. If that happens and you decide to switch practitioners, you'll have to start from scratch again searching for one who suits your needs. In such a practice, a doctor works alone, using another doctor to cover when he or she is away or otherwise unavailable. An obstetrician or a family practitioner might be in solo practice; a nurse-midwife, in almost all states, must work in a collaborative practice with a physician. The major advantage of a solo practice is that you see the same practitioner at each visit. This way, you get to know and, ideally, feel more comfortable with this person before delivery. The major disadvantage is that if your practitioner is not available, a backup you don't know may deliver your baby (although arranging to meet the covering physician or midwife in advance helps remedy this potential drawback). A solo practice may also be a problem if, midway in the pregnancy, you find you're not really crazy about the practitioner. If that happens and you decide to switch practitioners, you'll have to start from scratch again searching for one who suits your needs.

Partnership or group medical practice. In this type of practice, two or more doctors in the same specialty care jointly for patients, often seeing them on a rotating basis (though you usually get to stick with your favorite through most of your pregnancy and only start rotating toward the end of your pregnancy, when you're going to the office weekly). Again, you can find both obstetricians and family doctors in this type of practice. The advantage of a group practice is that by seeing a different doctor each time, you'll get to know them all-which means that when those labor pains are coming strong and fast, there's sure to be a familiar face in the room with you. The disadvantage is that you may not like all of the doctors in the practice equally, and you usually won't be able to choose the one who attends your child's birth. Also, hearing different points of view from the various partners may be an advantage or a disadvantage, depending on whether you find it reassuring or unsettling.

Combination practice. A group practice that includes one or more obstetricians and one or more nurse-midwives is considered a combination practice. The advantages and disadvantages are similar to those of any group practice. There is the added advantage of having at some of your visits the extra time and attention a midwife may offer and at others the extra medical know-how of a physician's extensive training and expertise. You may have the option of a midwife-coached delivery, plus assurance that if a problem develops, a physician you know is in the wings.

Maternity centeror birthing centerbased practice. In these practices, certified nurse-midwives provide the bulk of the care, and physicians are on call as needed. Some maternity centers are based in hospitals with special birthing rooms, and others are separate facilities. All maternity centers provide care for low-risk patients only.

The advantage of this type of practice is obviously great for those women who prefer certified midwives as their primary practitioners. A potential disadvantage is that if a complication arises during pregnancy, you may have to switch to a physician and start developing a relationship all over again. Or, if a complication arises during labor or delivery, you may need to be delivered by the doctor on call, who may be a complete stranger. And finally, if you are delivering at a freestanding maternity center and complications arise, you may have to be transported to the nearest hospital for emergency care. A big advantage is likely to be the bottom line: CNMs and birthing centers usually charge less than physicians and hospitals.

Independent certified nurse-midwife practice. In the states in which they are permitted to practice independently, CNMs offer women with low-risk pregnancies the advantage of personalized pregnancy care and a low-tech natural delivery (sometimes at home, but more often in birthing centers or hospitals). An independent CNM should have a physician available for consultation as needed and on call in case of emergency-during pregnancy, childbirth, and postpartum. Care by an independent CNM is covered by most health plans, though only some insurers cover midwife-attended home births or births in a facility other than a hospital. In the states in which they are permitted to practice independently, CNMs offer women with low-risk pregnancies the advantage of personalized pregnancy care and a low-tech natural delivery (sometimes at home, but more often in birthing centers or hospitals). An independent CNM should have a physician available for consultation as needed and on call in case of emergency-during pregnancy, childbirth, and postpartum. Care by an independent CNM is covered by most health plans, though only some insurers cover midwife-attended home births or births in a facility other than a hospital.

Finding a Candidate.

When you have a good idea of the kind of practitioner you want and the type of practice you prefer, where can you find some likely candidates? The following are all good sources:

Division of Labor.

Though not yet common practice nationwide, there's a trend that might be coming to a hospital (and an ob practice) near you. Some obstetricians, tired of running from long office hours to long overnights in the hospital delivering babies-and concerned that fatigue can affect the quality of care they provide-are looking for a better way. Enter the ob hospitalists, also known as laborists-obs who work exclusively in the hospital, only attending labors and delivering babies. These laborists don't have an office and don't follow patients through pregnancy.

If your practitioner tells you there's going to be a laborist at your birth, don't worry. But do take some steps to make sure you're comfortable with the arrangement. First, ask your practitioner if he or she and the hospital laborists have worked closely together in the past (and make sure their philosophies and protocols are similar). You might also want to call the hospital to ask if you can meet the staff docs before labor, so that you're not being attended by a complete stranger during childbirth. Make sure, too, that you arrive at the hospital with extra copies of your birth plan (if you have one) to hand out, so whoever is attending you is familiar with your wishes even if he or she isn't familiar with you.

If you're uncomfortable with the whole arrangement, think about switching practices sooner rather than later. Remember, though, that if you're with a multiple-doc practice already, there's a good chance your "regular" ob won't be on call the day you go into labor anyway. Keep in mind, too, that because hospitalists focus solely on deliveries, they're extra-prepared to give the best possible care during labor. And extra-rested, also, because they work on shifts instead of around the clock.

[image]Your gynecologist or family practitioner (if he or she doesn't do deliveries) or your internist, assuming you're happy with his or her style of practice. (Doctors tend to recommend others with philosophies similar to their own.)[image] Friends or coworkers who have had babies recently and whose personalities and childbearing philosophies are similar to yours. Friends or coworkers who have had babies recently and whose personalities and childbearing philosophies are similar to yours.[image] An obstetrical nurse who practices locally. An obstetrical nurse who practices locally.[image] The local medical society, which can give you a list of names of physicians who deliver babies, along with information on their medical training, specialties, special interests, type of practice, and board certification. The local medical society, which can give you a list of names of physicians who deliver babies, along with information on their medical training, specialties, special interests, type of practice, and board certification.[image] The American Medical Association (ama-assn.org) can help you search for a doctor in your area. The American Medical Association (ama-assn.org) can help you search for a doctor in your area.[image] The American College of Obstetricians and Gynecologists Physician Directory has the names of obstetrician-gynecologists and maternal-fetal specialists. Go to acog.org, or call 202-638-5577. The American College of Obstetricians and Gynecologists Physician Directory has the names of obstetrician-gynecologists and maternal-fetal specialists. Go to acog.org, or call 202-638-5577.[image] The American College of Nurse-Midwives if you're looking for a CNM. Go to acnm.org or mybirthteam.com, or call 240-485-1800. The American College of Nurse-Midwives if you're looking for a CNM. Go to acnm.org or mybirthteam.com, or call 240-485-1800.[image] The local La Leche League, especially if you're strongly interested in breastfeeding. The local La Leche League, especially if you're strongly interested in breastfeeding.[image] A nearby hospital with facilities that are important to you-for example, birthing rooms with whirlpool tubs, rooming-in for both baby and dad, or a neonatal intensive care unit-or a local maternity or birthing center. Ask them for the names of attending physicians. A nearby hospital with facilities that are important to you-for example, birthing rooms with whirlpool tubs, rooming-in for both baby and dad, or a neonatal intensive care unit-or a local maternity or birthing center. Ask them for the names of attending physicians.[image] If all else fails, check Yellow Book online or the phone book, under "Physicians." Look for the headings "Obstetrics and Gynecology," "Maternal-Fetal Medicine," or "Family Practice." If all else fails, check Yellow Book online or the phone book, under "Physicians." Look for the headings "Obstetrics and Gynecology," "Maternal-Fetal Medicine," or "Family Practice."

If your health insurance company hands you a list of practitioners, try to check them out with friends, acquaintances, or another physician to find the one in the bunch that seems right for you. If that's not possible, visit and meet with several of the candidates personally. In most cases, you should be able to find someone who is compatible. If not, finances permitting, you may want to see if you can switch plans.

Making Your Selection.

Once you've secured a prospective practitioner's name, call to make an appointment for a consult. Go prepared with questions that will enable you to sense if your philosophies are in sync and if your personalities mesh comfortably. Don't expect that you'll agree on everything-that doesn't happen even in the most productive of partnerships. Be observant, too, and try to read between the lines at the interview (is the doctor or midwife a good listener? A patient explainer? Does he or she seem to take your emotional concerns as seriously as your physical ones?). Now's the time to find out this candidate's positions on issues that you feel strongly about: unmedicated childbirth versus pain relief as needed in childbirth, breastfeeding, induction of labor, use of fetal monitoring or routine IVs, cesarean deliveries, or anything else that's important to you. Knowledge is power-and knowing how your practitioner practices will help ensure there won't be unpleasant surprises later.

Almost as important as what the interview reveals about your potential practitioner is what you reveal about yourself. Speak up and let your true patient persona shine through. You'll be able to judge from the practitioner's response whether he or she will be comfortable with-and responsive to-you, the patient.

You will also want to know something about the hospital or birthing center the practitioner is affiliated with. Does it provide features that are important to you-for example, plenty of LDR or LDRP rooms, breastfeeding support, a tub to labor in, the latest fetal monitoring equipment, a neonatal intensive care unit? Is there flexibility about procedures that concern you (say, routine IVs)? Are siblings allowed in the birthing rooms? Is extended family allowed during a surgical delivery?

Before you make a final decision, think about whether your potential practitioner inspires trust. Pregnancy is one of the most important journeys you'll ever make; you'll want a copilot in whom you have complete faith.

Pregnant and Uncovered.

If you're expecting and uninsured, you're probably more concerned with figuring out how you're going to be able to afford prenatal care than you are with who's going to provide it. For tips that can help you get the care you and your baby need, see page 56 page 56.

Making the Most of the Patient-Practitioner Partnership.

Choosing the right practitioner is only the first step. The next step is nurturing a good working partnership. Here's how: [image] Tell the whole truth, and nothing but the truth. Give your practitioner an accurate and complete general, gynecological, and obstetrical medical history. Fess up about an eating disorder you've battled or eating habits that are otherwise unhealthy. Speak up about any drugs-prescription or over-the- counter (including herbal), legal or illegal, medicinal or recreational, including alcohol and tobacco-that you are currently taking or have taken recently, as well as about any past or present illnesses or surgeries. Remember, what you tell your doctor is confidential; no one else will know. Tell the whole truth, and nothing but the truth. Give your practitioner an accurate and complete general, gynecological, and obstetrical medical history. Fess up about an eating disorder you've battled or eating habits that are otherwise unhealthy. Speak up about any drugs-prescription or over-the- counter (including herbal), legal or illegal, medicinal or recreational, including alcohol and tobacco-that you are currently taking or have taken recently, as well as about any past or present illnesses or surgeries. Remember, what you tell your doctor is confidential; no one else will know.[image] When a question or concern that doesn't require an immediate call comes up between visits, write it down and take it to your next appointment. (It may help to keep your PDA handy or to keep pads in convenient places-the refrigerator door, your purse, your desk at work, your bedside table-so that you'll always be within jotting distance of one.) That way you can be sure that you won't forget to ask all your questions and report all your symptoms (you will if you don't write them down; as you'll soon discover, pregnant women are notoriously forgetful). Along with your list of questions, bring a pen and pad (or your PDA or the When a question or concern that doesn't require an immediate call comes up between visits, write it down and take it to your next appointment. (It may help to keep your PDA handy or to keep pads in convenient places-the refrigerator door, your purse, your desk at work, your bedside table-so that you'll always be within jotting distance of one.) That way you can be sure that you won't forget to ask all your questions and report all your symptoms (you will if you don't write them down; as you'll soon discover, pregnant women are notoriously forgetful). Along with your list of questions, bring a pen and pad (or your PDA or the What to Expect Pregnancy Journal and Organizer What to Expect Pregnancy Journal and Organizer) to each office visit so you can record your practitioner's recommendations. If your practitioner doesn't offer up all the information you'll need (side effects of treatments, when to stop taking a medication if one's prescribed, when to check back about a problem situation), ask for it before you leave so there's no confusion once you get home. If possible, quickly review your notes with the practitioner to be sure you've written down just what the doctor (or midwife) ordered.[image] When in doubt, call. A symptom has you freaked? A medication or treatment seems to have triggered an adverse reaction? Don't just sit there worrying. Pick up the phone and call your practitioner (or e-mail, if your practitioner prefers to answer nonemergency questions online). Though you won't want to call or e-mail at every pelvic twinge, never hesitate to check in about questions that can't be answered in a book such as this one, and that you feel can't wait until the next visit. Don't be afraid that your concerns will sound silly-if it has you worried, it's not silly. Besides, doctors and midwives expect expectant moms to ask lots of questions, especially if they're first timers. When you do pick up the phone or compose that e-mail, be prepared to be very specific about your symptoms. If you're experiencing pain, be precise about its location, duration, quality (is it sharp, dull, crampy?), and severity. If possible, explain what makes it worse or better-changing positions, for example. If you have a vaginal dis charge, describe its color (bright red, dark red, brownish, pinkish, yellowish), when it started, and how heavy it is. Also report accompanying symptoms, such as fever, nausea, vomiting, chills, or diarrhea. (See When to Call Your Practitioner, When in doubt, call. A symptom has you freaked? A medication or treatment seems to have triggered an adverse reaction? Don't just sit there worrying. Pick up the phone and call your practitioner (or e-mail, if your practitioner prefers to answer nonemergency questions online). Though you won't want to call or e-mail at every pelvic twinge, never hesitate to check in about questions that can't be answered in a book such as this one, and that you feel can't wait until the next visit. Don't be afraid that your concerns will sound silly-if it has you worried, it's not silly. Besides, doctors and midwives expect expectant moms to ask lots of questions, especially if they're first timers. When you do pick up the phone or compose that e-mail, be prepared to be very specific about your symptoms. If you're experiencing pain, be precise about its location, duration, quality (is it sharp, dull, crampy?), and severity. If possible, explain what makes it worse or better-changing positions, for example. If you have a vaginal dis charge, describe its color (bright red, dark red, brownish, pinkish, yellowish), when it started, and how heavy it is. Also report accompanying symptoms, such as fever, nausea, vomiting, chills, or diarrhea. (See When to Call Your Practitioner, page 138 page 138.)[image] Keep up to date. Read those parenting magazines and visit those pregnancy websites, by all means. But also realize that you can't believe everything you read, especially since the media often report medical advances before they are proven safe and effective through controlled studies-or report worrisome pregnancy warnings based on preliminary data that's yet to be backed up. When you read (or hear) about something new in obstetrics, ask your practitioner-usually your best information resource-for his or her take on it. Keep up to date. Read those parenting magazines and visit those pregnancy websites, by all means. But also realize that you can't believe everything you read, especially since the media often report medical advances before they are proven safe and effective through controlled studies-or report worrisome pregnancy warnings based on preliminary data that's yet to be backed up. When you read (or hear) about something new in obstetrics, ask your practitioner-usually your best information resource-for his or her take on it.[image] When you hear or read something that doesn't correspond to what your practitioner has told you, don't keep it to yourself. Ask for an opinion on what you've heard-not in a challenging way, just so you can get your facts straight. When you hear or read something that doesn't correspond to what your practitioner has told you, don't keep it to yourself. Ask for an opinion on what you've heard-not in a challenging way, just so you can get your facts straight.[image] If you suspect that your practitioner may be mistaken about something (for example, okaying intercourse when you have a history of incompetent cervix), speak up. You can't assume that he or she, even with your chart in hand, will always remember every aspect of your medical and personal history. As a partner in your own health care, and one who knows your body like the back of your hand (and then some), you share the responsibility of making sure mistakes aren't made. If you suspect that your practitioner may be mistaken about something (for example, okaying intercourse when you have a history of incompetent cervix), speak up. You can't assume that he or she, even with your chart in hand, will always remember every aspect of your medical and personal history. As a partner in your own health care, and one who knows your body like the back of your hand (and then some), you share the responsibility of making sure mistakes aren't made.[image] Ask for explanations. Find out what the potential side effects of a prescribed medication are, and whether there's a nondrug alternative. Be sure you know why a test is ordered, what it will involve, what its risks are, and how and when you'll learn the results. Ask for explanations. Find out what the potential side effects of a prescribed medication are, and whether there's a nondrug alternative. Be sure you know why a test is ordered, what it will involve, what its risks are, and how and when you'll learn the results.

So You Won't Forget.

Because there'll be times when you'll want to do a little writing with your reading, jot down a symptom so you can share it with your doctor, make a note of this week's weight so you can compare it to next week's, record what needs recording so you'll remember what needs remembering-you'll find plenty of space in the The What to Expect Pregnancy Journal and Organizer The What to Expect Pregnancy Journal and Organizer for all your note taking. for all your note taking.

[image]Put it in writing. If you find your practitioner doesn't seem to have time to respond to all your questions or concerns, try providing a written list. If it isn't possible for you to get a complete response at the visit, ask if you can get the answers you need through a follow-up phone call or e-mail or a longer visit next time.[image] Follow your practitioner's recommendations on appointment schedules, weight gain, bed rest, exercise, medication, vitamins, and so on, unless you have a good reason why you feel you shouldn't or can't (in which case, talk it over with your practitioner before you follow your instincts instead). Follow your practitioner's recommendations on appointment schedules, weight gain, bed rest, exercise, medication, vitamins, and so on, unless you have a good reason why you feel you shouldn't or can't (in which case, talk it over with your practitioner before you follow your instincts instead).[image] Remember that good self-care is a vital component in good prenatal care. So take the best care of yourself that you can, getting enough rest and exercise, eating well, and steering clear of alcohol, tobacco, and other nonprescribed drugs and medications once you find out you're pregnant, or better still, once you start trying to conceive. Remember that good self-care is a vital component in good prenatal care. So take the best care of yourself that you can, getting enough rest and exercise, eating well, and steering clear of alcohol, tobacco, and other nonprescribed drugs and medications once you find out you're pregnant, or better still, once you start trying to conceive.[image] If you have a gripe about anything-from regularly being kept waiting too long to not getting answers to your questions-speak up, in as nice a way as possible. Letting a problem fester can get in the way of a productive practitioner-patient relationship. If you have a gripe about anything-from regularly being kept waiting too long to not getting answers to your questions-speak up, in as nice a way as possible. Letting a problem fester can get in the way of a productive practitioner-patient relationship.[image] Insurance companies often serve as mediators between patient and practitioner when there is a conflict or complaint. If you have a problem with your practitioner that good communication isn't solving, contact your health organization for help. Insurance companies often serve as mediators between patient and practitioner when there is a conflict or complaint. If you have a problem with your practitioner that good communication isn't solving, contact your health organization for help.

If you feel you can't follow your practitioner's instructions or go along with a recommended course of treatment, it might be because you're just not on board with the person you've chosen to care for you and your baby during your pregnancy, labor, and delivery. In such a case-or if, for some other reason, your relationship with your practitioner just isn't working-consider looking for a replacement (assuming that's financially feasible and your medical plan permits it).

CHAPTER 3.

Your Pregnancy Profile.

THE TEST RESULTS ARE BACK; the news has (sort of) sunk in: You're having a baby! Excitement is growing (along with that uterus of yours), and so is your list of questions. Many, no doubt, have to do with those wild and crazy symptoms you might already be experiencing (more on those later). But many others may have to do with your personal pregnancy profile. What's a pregnancy profile? It's a compilation of your gynecological, general medical, and obstetrical (if you're not a first timer) histories-in other words, your pregnancy backstory. You'll be discussing this backstory (which can actually have a lot of impact on the pregnancy story that's about to unfold) with your practitioner at your first prenatal visit. In the meantime, this chapter can help you take stock of your pregnancy profile and figure out how it may affect-or may not affect-your nine months of baby making.

This Book's for You.

As you read What to Expect When You're Expecting, What to Expect When You're Expecting, you'll notice many references to traditional family relationships-to "wives," "husbands," "spouses." These references are not meant to exclude expectant mothers (and their families) who may be somewhat "untraditional"-for example, those who are single, who have same-sex partners, or who have chosen not to marry their live-in partners. Rather, these terms are a way of avoiding phrases (for instance, "your husband or significant other") that are more inclusive but also a mouthful to read. Please mentally edit out any phrase that doesn't fit and replace it with one that's right for you and your situation. you'll notice many references to traditional family relationships-to "wives," "husbands," "spouses." These references are not meant to exclude expectant mothers (and their families) who may be somewhat "untraditional"-for example, those who are single, who have same-sex partners, or who have chosen not to marry their live-in partners. Rather, these terms are a way of avoiding phrases (for instance, "your husband or significant other") that are more inclusive but also a mouthful to read. Please mentally edit out any phrase that doesn't fit and replace it with one that's right for you and your situation.

Keep in mind that much of this chapter may not apply to you-that's because your pregnancy profile (like the baby you're expecting. is unique. Read what fits your profile and skip what doesn't.

Your Gynecological History.

Birth Control During Pregnancy.

"I got pregnant while using birth control pills. I kept taking them for over a month because I had no idea I was pregnant. Will this affect my baby?"

Ideally, once you stop using oral contraceptives, you'd have at least one normally occurring menstrual cycle before you tried to become pregnant. But conception doesn't always wait for ideal conditions, and occasionally a woman becomes pregnant while taking the Pill. In spite of warnings you've probably read on the package insert, there's no reason for concern. There's just no good evidence of an increased risk to a baby when mom has conceived while on oral contraceptives. Need more reassurance. Talk the situation over with your practitioner-you're sure to find it.

"I conceived while using a condom with spermicides and kept using spermicides before I knew I was pregnant. Should I be worried about birth defects?"

No need to worry if you got pregnant while using a condom or diaphragm with spermicides, a spermicide- coated condom, or just plain spermicides. The reassuring news is that no known link exists between spermicides and birth defects. In fact, the most recent and most convincing studies have found no increase in the incidence of problems even with the repeated use of spermicides in early pregnancy. So relax and enjoy your pregnancy, even if it did come a little unexpectedly.

"I've been using an IUD as birth control and just discovered that I'm pregnant. Will I be able to have a healthy pregnancy?"

Getting pregnant while using birth control is always a little unsettling (wasn't that why you were using birth control in the first place?), but it definitely happens. The odds of its happening with an IUD are pretty low-about 1 in 1,000, depending on the type of device used, how long it's been in place, and whether or not it has been properly inserted.

Having beaten the odds and managed conception with an IUD in place leaves you with two options, which you should talk over with your practitioner as soon as possible: leaving the IUD in place or having it taken out. Which of these options is best in your situation will depend on whether or not your practitioner can-on examination-see the removal cord protruding from your cervix. If the cord isn't visible, the pregnancy has a very good chance of proceeding uneventfully with the IUD in place. It will simply be pushed up against the wall of the uterus by the expanding amniotic sac surrounding the baby and, during childbirth, it will usually deliver with the placenta. If, however, the IUD string is visible early in pregnancy, the risk of infection developing is increased. In that case, chances of a safe and successful pregnancy are greater if the IUD is removed as soon as feasible, once conception is confirmed. If it isn't removed, there is a significant chance that the fetus will spontaneously miscarry; the risk drops to only 20 percent when it is removed. If that doesn't sound reassuring, keep in mind that the rate of miscarriage in all known pregnancies is estimated to be about 15 to 20 percent.

If the IUD is left in during the first trimester, be especially alert for bleeding, cramping, or fever because having an IUD in place puts you at higher risk for early pregnancy complications. Notify your practitioner of such symptoms right away.

Fibroids.

"I've had fibroids for several years, and they've never caused me any problems. Will they, now that I'm pregnant?"

Chances are your fibroids won't stand between you and an uncomplicated pregnancy. In fact, most often these small nonmalignant growths on the inner walls of the uterus don't affect a pregnancy at all.

Sometimes, a woman with fibroids notices abdominal pressure or pain. If you do, report it to your practitioner, though it usually isn't anything to worry about. Bed rest for four or five days along with the use of safe pain relievers (ask your practitioner to recommend one) usually brings relief.

Very occasionally, fibroids can slightly increase the risk of such complications as abruption (separation) of the placenta, preterm birth, and breech birth, but these minimal risks can be reduced even further with the right precautions. Discuss the fibroids with your physician so you can find out more about the condition in general and the risks, if any, in your particular case. If your practitioner suspects that the fibroids could interfere with a safe vaginal delivery, he or she may opt to deliver by C-section. In most cases, however, even a large fibroid will move out of the baby's way as the uterus expands during pregnancy.

"I had a couple of fibroids removed a few years ago. Will that affect my pregnancy?"

In most cases, surgery for the removal of small uterine fibroid tumors (particularly if the surgery was performed laparoscopically. doesn't affect a subsequent pregnancy. Extensive surgery for large fibroids could, however, weaken the uterus enough so that it wouldn't be able to handle labor. If, after reviewing your surgical records, your practitioner decides this might be true of your uterus, a C-section will be planned. Become familiar with the signs of early labor in case contractions begin before the planned surgery (see page 358 page 358), and have a plan in place for getting to the hospital quickly if you do go into labor.

Endometriosis.

"After years of suffering with endometriosis, I'm finally pregnant. Will I have problems with my pregnancy?"

Endometriosis is typically associated with two challenges: difficulty in conceiving and pain. Becoming pregnant means that you've overcome the first of those challenges (congratulations!). And the good news gets even better. Being pregnant may actually help with the second challenge.

The symptoms of endometriosis, including pain, do improve during pregnancy. This seems to be due to hormonal changes. When ovulation takes a hiatus, the endometrial implants generally become smaller and less tender. Improvement is greater in some women than in others. Many women are symptom free during the entire pregnancy; others may feel increasing discomfort as the fetus grows and begins packing a stronger punch, particularly if those punches and kicks reach tender areas. Fortunately, however, having endometriosis doesn't seem to raise any risks during pregnancy or childbirth (though if you've had uterine surgery, your practitioner will probably opt to deliver via C-section).

The less happy news is that pregnancy only provides a respite from the symptoms of endometriosis, not a cure. After pregnancy and nursing (and sometimes earlier), the symptoms usually return.

Colposcopy.

"A year before I got pregnant, I had a colposcopy and cervical biopsy performed. Is my pregnancy at risk?"

A colposcopy is usually performed only after a routine Pap smear shows some irregular cervical cells. The simple procedure involves the use of a special microscope to better visualize the vagina and cervix. If abnormal cells are noticed on a Pap smear, as they probably were in your case, your physician performs a cervical, or cone, biopsy (in which tissue samples are taken from the suspicious area of the cervix and sent to the lab for further evaluation), cryosurgery (during which the abnormal cells are frozen), or a loop electrocautery excision procedure (LEEP, during which the affected cervical tissue is cut away using a painless electrical current). The good news is that the vast majority of women who have had such procedures are able to go on to have normal pregnancies. Some women, however, depending on how much tissue was removed during the procedure, may be at increased risk for some pregnancy complications, such as incompetent cervix and preterm delivery. Be sure your prenatal practitioner is aware of your cervical history so that your pregnancy can be more closely monitored.

If abnormal cells are noted during your first prenatal visit, your practitioner may opt to perform a colposcopy, but biopsies or further procedures are usually delayed until after the baby is born.

HPV (Human Papillomavirus).

"Can having genital HPV affect my pregnancy?"

Genital HPV is the most common sexually transmitted virus in the United States, affecting more than 75 percent of sexually active people, yet most of those who become infected with it never know. That's because most of the time, HPV causes no obvious symptoms and usually resolves on its own within six to ten months.

There are some times, however, when HPV does cause symptoms. Some strains cause cervical cell irregularities (detected on a Pap smear); other strains can cause genital warts (in appearance they can vary from a barely visible lesion to a soft, velvety "flat" bump or a cauliflower-like growth; colors range from pale to dark pink) that will show up in and on the vagina, vulva, and rectum. Though usually painless, genital warts may occasionally burn, itch, or even bleed. In most cases, the warts clear on their own within a couple of months.

Other STDs and Pregnancy.

Not surprisingly, most STDs can affect pregnancy. Fortunately, most are easily diagnosed and treated safely, even during pregnancy. But because women are often unaware of being infected, the Centers for Disease Control and Prevention (CDC) recommends that all pregnant women be tested early in pregnancy for at least the following STDs: chlamydia, gonorrhea, trichomoniasis, hepatitis B, HIV, and syphilis.

Keep in mind that STDs don't happen just to one group of people or only at a certain economic level. They can occur in women (and men) in every age group, of every race and ethnic background, at every income level, and among those living in small towns as well as in big cities. The major STDs include: Gonorrhea. Gonorrhea has long been known to cause conjunctivitis, blindness, and serious generalized infection in a fetus delivered through an infected birth canal. For this reason, pregnant women are routinely tested for the disease, usually at their first prenatal visit. Sometimes, particularly in women at high risk for STDs, the test is repeated late in pregnancy. If infection with gonorrhea is found, it is treated immediately with antibiotics. Treatment is followed by another culture, to be sure the woman is infection free. As an added precaution, an antibiotic ointment is squeezed into the eyes of every newborn at birth. (This treatment can be delayed for as long as an hour-but no longer-if you want to have some unblurry eye-to-eye contact with your baby first.) Gonorrhea has long been known to cause conjunctivitis, blindness, and serious generalized infection in a fetus delivered through an infected birth canal. For this reason, pregnant women are routinely tested for the disease, usually at their first prenatal visit. Sometimes, particularly in women at high risk for STDs, the test is repeated late in pregnancy. If infection with gonorrhea is found, it is treated immediately with antibiotics. Treatment is followed by another culture, to be sure the woman is infection free. As an added precaution, an antibiotic ointment is squeezed into the eyes of every newborn at birth. (This treatment can be delayed for as long as an hour-but no longer-if you want to have some unblurry eye-to-eye contact with your baby first.) Syphilis. Because this disease can cause a variety of birth defects as well as stillbirth, testing is also routine at the first prenatal visit. Antibiotic treatment of infected pregnant women before the fourth month, when the infection usually begins to cross the placental barrier, almost always prevents harm to the fetus. The very good news is that mother-to-baby transmission of syphilis is down in recent years. Because this disease can cause a variety of birth defects as well as stillbirth, testing is also routine at the first prenatal visit. Antibiotic treatment of infected pregnant women before the fourth month, when the infection usually begins to cross the placental barrier, almost always prevents harm to the fetus. The very good news is that mother-to-baby transmission of syphilis is down in recent years.

Chlamydia. There are more cases of chlamydia in this country than gonorrhea or syphilis, with the disease affecting sexually active women under 26 years old most often. Chlamydia is the most common infection passed from mother to fetus, and it is considered a potential risk to the fetus and a possible risk to mothers. Which is why chlamydia screening in pregnancy is a good idea, particularly if you have had multiple sexual partners in the past, increasing your chance of infection. Because about half the women with chlamydial infection experience no symptoms, it often goes undiagnosed if it's not tested for.

Prompt treatment of chlamydia prior to or during pregnancy can prevent chlamydial infections (pneumonia, which fortunately is most often mild, and eye infection, which is occasionally severe) from being transmitted by the mother to the baby during delivery. Though the best time for treatment is prior to conception, administering antibiotics (usually azithromycin) to the pregnant infected mother can also be effective in preventing infant infection. The antibiotic ointment routinely used at birth protects the newborn from chlamydial, as well as gonorrheal, eye infection.

Trichomoniasis. The symptoms of this parasite-caused STD (also referred to as trichomonas infection, or "trich") are a greenish, frothy vaginal discharge with an unpleasant fishy smell and, often, itching. About half of those affected have no symptoms at all. Though the disease does not usually cause serious illness or pregnancy problems (or affect a baby whose mom is infected), the symptoms can be irritating. Generally, women are treated during pregnancy only if they're having symptoms. The symptoms of this parasite-caused STD (also referred to as trichomonas infection, or "trich") are a greenish, frothy vaginal discharge with an unpleasant fishy smell and, often, itching. About half of those affected have no symptoms at all. Though the disease does not usually cause serious illness or pregnancy problems (or affect a baby whose mom is infected), the symptoms can be irritating. Generally, women are treated during pregnancy only if they're having symptoms.

HIV infection. It is becoming increasingly routine for pregnant women to be tested for HIV (human immunodeficiency virus), whether or not they have a prior history of high-risk behavior. Many states actually require doctors to offer HIV counseling and testing to pregnant women, and ACOG recommends that all pregnant women, regardless of risk, be tested. Infection in pregnancy by the HIV virus, which causes AIDS, is a threat not just to the expectant mother but to her baby as well. About 25 percent of babies born to untreated mothers will develop the infection (testing will confirm it in the first six months of life). Luckily, there is plenty of hope with the treatments that are now available. But before taking any action, anyone who tests HIV positive may want to consider a second test (tests are highly accurate but can sometimes be positive in someone who does not have the virus). If a second test is positive, then formal counseling about AIDS and the treatment options is absolutely imperative. Treating an HIV-positive mother with AZT (also known as zidovudine-ZDV-or Retrovir) or other antiretroviral drugs can dramatically reduce the risk of her passing the infection on to her child, apparently without any damaging side effects. Delivering by elective C-section (before contractions begin and before membranes rupture) can reduce the risk of transmission further. It is becoming increasingly routine for pregnant women to be tested for HIV (human immunodeficiency virus), whether or not they have a prior history of high-risk behavior. Many states actually require doctors to offer HIV counseling and testing to pregnant women, and ACOG recommends that all pregnant women, regardless of risk, be tested. Infection in pregnancy by the HIV virus, which causes AIDS, is a threat not just to the expectant mother but to her baby as well. About 25 percent of babies born to untreated mothers will develop the infection (testing will confirm it in the first six months of life). Luckily, there is plenty of hope with the treatments that are now available. But before taking any action, anyone who tests HIV positive may want to consider a second test (tests are highly accurate but can sometimes be positive in someone who does not have the virus). If a second test is positive, then formal counseling about AIDS and the treatment options is absolutely imperative. Treating an HIV-positive mother with AZT (also known as zidovudine-ZDV-or Retrovir) or other antiretroviral drugs can dramatically reduce the risk of her passing the infection on to her child, apparently without any damaging side effects. Delivering by elective C-section (before contractions begin and before membranes rupture) can reduce the risk of transmission further.

If you suspect that you may have been infected with any STD, check with your practitioner to see if you've been tested; if you haven't, ask to be. If a test turns out to be positive, be sure that you-and your partner, if necessary-are treated. Treatment will protect not only your health but that of your baby.

How does genital HPV affect a pregnancy? Luckily, it's unlikely to affect it at all. Some women, however, will find that pregnancy will affect their HPV, causing the warts to become more active. If that's the case with you, and if the warts don't seem to be clearing on their own, your practitioner may recommend treatment during pregnancy. The warts can be safely removed by freezing, electrical heat, or laser therapy, although in some cases, this treatment may be delayed until after delivery.

If you do have HPV, your practitioner will also want to check your cervix to make sure there are no cervical cell irregularities. If abnormalities are found, any necessary cervical biopsies to remove the abnormal cells will likely be postponed until after your baby is delivered.

Because HPV is highly contagious, practicing safe sex and sticking with one partner is the best way to prevent reoccurrence. Though there is a vaccine available now to prevent HPV in women under 26, it's not recommended for use during pregnancy. If you started the vaccine course (it's given in a three-dose series) and then became pregnant before completing the series, you'll need to hold off on the remaining doses until after your baby is born.

Herpes.

"I have genital herpes. Can my baby catch it from me?"

Having genital herpes during pregnancy is cause for caution but definitely not for alarm. In fact, the chances are excellent that your baby will arrive safe, sound, and completely unaffected by herpes, particularly if you and your practitioner take protective steps during pregnancy and delivery. Here's what you need to know.

First of all, infection in a newborn is quite rare. A baby has only a less than 1 percent chance of contracting the condition if the mother has a recurrent infection during pregnancy (that is, she's had herpes before). Second, though a primary infection (one that appears for the first time) early in pregnancy increases the risk of miscarriage and premature delivery, such infection is uncommon. Even for babies at greatest risk-those whose mothers have their first herpes outbreak as delivery nears (which in itself is rare because it's tested for routinely)-there is an up to 50 percent chance that they will escape infection. Finally, the disease, though still serious, seems to be somewhat milder in newborns these days than it was in the past.

So if you picked up your herpes infection before pregnancy, which is most likely, the risk to your baby is very low. And with good medical care it can be lowered still further.

To protect their babies, women who have a history of herpes and have recurrent herpes during pregnancy are usually given antiviral medications. Those who have active lesions at the onset of labor are usually delivered by cesarean. In the unlikely event a baby is infected, he or she will be treated with an antiviral drug.

After delivery, the right precautions can allow you to care for-and breastfeed-your baby without transmitting the virus, even during an active infection.