PPrreeggnnaannccyy aanndd CChhiillddbbiirrtthh This edition of “Pregnancy and Childbirth” is based on the VA/DoD Management of Pregnancy Clinical Practice Guideline, revised in 2009. Compared to the previous Guideline, the scope of this version of the Guideline has expanded to include evidence based research recommendations for prenatal care for all pregnant women receiving care in the DoD and VA healthcare systems. The Guideline also addresses several minor or common complications of pregnancy. The full text of this Guideline can be found at https://www.qmo.amedd.army.mil or http://www.healthquality.va.gov. This book has become known as “The Purple Book” for an obvious reason. It is designed primarily as a resource for pregnant women but is also a useful tool for obstetric care providers. It provides quality information that can serve as a reference, guide, journal, and springboard for further discussion and education. It can be used in either one-on-one traditional or group based prenatal care. The Pregnancy Guideline itself and the recommendations and information contained in this book serve as a basis for world-class prenatal care. However, the very best recommendations can quickly become outdated as new information becomes available. As individual circumstances are unique, the Guideline and this book are no substitute for the personal care and recommendations given by a qualified obstetric provider. Indeed, the very best prenatal care A Goal Oriented Guide mandates occasional, well-reasoned deviation from these recommendations. to Prenatal Care As a final word, we wish to thank the many individuals who have voluntarily given thousands of hours developing the Guideline and this edition of the “Purple Book”. This work represents the efforts of individuals from the Air Force, Army, Version 3.1 Navy, and VA communities. Obstetric and non-obstetric personnel from various healthcare professions contributed. Talented pregnant volunteers read the February 2012 drafts and provided fantastic editorial support. We all hope this book will be of great use to our Nation’s Heroes and their families as they welcome an infant. The Editors VA/DoD Management of Pregnancy Clinical Practice Guideline – 2009 Congratulations on Your Pregnancy The Department of Defense and the Department of Veterans Affairs are proud to welcome you to our Obstetrical Services. We will do everything possible to help you receive the best prenatal care for you and your baby. That’s why we have implemented Goal-Oriented Prenatal Care. If you have any complications in your pregnancy, you may need additional visits and testing. Visits and testing outlined here form the basis of care for all pregnant women. With goal-oriented care, we design each visit to cover precise goals that are most appropriate to that specific time in your pregnancy. So no matter where you are located you will receive all critical aspects of prenatal care at the appropriate time. We have eliminated practices that do not have sound scientific backing (such as taking urine at each visit and early pregnancy cervical checks) and have added practices that have been shown to help promote a healthy pregnancy. With this approach, you will know what to expect and when to expect it. When possible, we encourage you to involve your baby’s father or support person in your care. This book will guide you each step of the way through your pregnancy. Please bring it to every visit. We have divided the contents by visits with additional material in the Resource Section. Each visit section will include what to expect at your visit, signs to report, patient education, and a space to record related information. We encourage you to read each visit section carefully prior to each appointment. Please ask your healthcare provider if you have any questions or concerns. In this way, you will be well prepared for each step in this very special journey! Thank you for allowing us to take this journey with you! Important Information Hospital Name Healthcare Provider Important Telephone Numbers OB Clinic Labor & Delivery (L&D) Labor & Delivery Triage Line Emergency Department My Childcare Provider Appointment List DATE TIME PROVIDER LOCATION ii Prenatal Information Sheet: Introduction Table of Contents The Birth of a Mother ..................................................................................v Visit Summary Pages ................................................................................vii This section provides a quick overview of goals and expectations for each visit. Keeping You and Your Baby Safe ............................................................x Visit Information This section provides detailed information for each visit. Each visit section includes what to expect in your pregnancy, what to expect at your visit, and general pregnancy education. We suggest you be cautious about information and advice you may receive from family members, friends, the Internet or other outside sources. While most of these sources are well-meaning and may provide important support, bad advice and inaccurate information are common. Please make sure to discuss your specific concerns with your provider. Week 6 - 8 . . . . . 1 Week 24 . . . . . .33 Week 36 . . . . . .63 Week 10 - 12 . . 13 Week 28 . . . . . .43 Week 38 - 41 . . 73 Week 16 - 20 . . 23 Week 32 . . . . . .53 After Delivery . . 87 R esource Section: • Pregnancy Information - Active Duty Information ......................................................................95 - Veteran’s Information ........................................................................101 - Father’s Information .........................................................................103 - Anatomy (front & side views) ...........................................................105 - Common Discomforts and Annoyances of Pregnancy .........................107 - Exercise ..........................................................................................115 - Travel During Pregnancy ..................................................................116 - Having Twins, Triplets or More .........................................................117 - Fetal Movement Count Charts ..........................................................118 - Immunizations ................................................................................123 - Nutrition in Pregnancy .....................................................................125 - Weight Gain Chart .........................................................................135 - Dental Care ....................................................................................136 - Tobacco, Alcohol, and Drug Use in Pregnancy ..................................137 - Sexually Transmitted and Other Infections in Pregnancy .....................139 - Genetic Screening ...........................................................................142 - Specific Genetic Testing ...................................................................149 - EPDS - 28 Week .............................................................................151 - Testing and Monitoring During Pregnancy .........................................153 - True versus False Labor ....................................................................155 - Preterm Labor .................................................................................156 - Labor and Delivery Procedures .........................................................157 - Labor and Delivery Basics ................................................................159 - Cesarean Delivery ...........................................................................176 - Birth Plan ........................................................................................181 - Baby Supplies .................................................................................183 - Family Planning ..............................................................................185 - Breastfeeding ..................................................................................195 - Bottle Feeding .................................................................................205 - Safety Tips for Baby ........................................................................207 • Common Terms .........................................................................................209 • Types of Providers .....................................................................................216 • EPDS - Postpartum ....................................................................................219 Prenatal Information Sheet: Introduction iii Suggested Additional Reading (available in your clinic): - Prenatal Fitness and Exercise WEB SITE INFORMATION: Links to non-federal organizations in this book are provided solely as a service to our users and are not an all inclusive list of non- federal organizations. Links do not constitute an endorsement of any organization by the Department of Defense or the Department of Veterans Affairs and none should be inferred. The Department of Defense and the Department of Veterans Affairs are not responsible for the content of the individual organizations web pages found via these links. General Pregnancy and Childbirth http://www.nlm.nih.gov/medlineplus http://www.healthfinder.gov http://familydoctor.org http://marchofdimes.com http://www.childbirth.org http://www.text4baby.org (text messages about baby) http://www.midwife.org/consumer_information http://www.plannedparenthood.org http://www.mypyramid.gov/mypyramidmoms http://www.dodparenting.org (Parent Review) Baby/Child Care http://www.aap.org http://www.dodparenting.org (Parent Review) Breastfeeding http://www.lalecheleague.org http://www.ilea.org http://www.4women.gov http://www.womanshealth.gov/breastfeeding/learning General http://www.militaryonesource.com iv Prenatal Information Sheet: Introduction The Birth of a Mother In this book, you are asked questions focused on how you feel about your pregnancy and your relationship with your mother and the father of your baby. There is space provided to record your thoughts. As you go through your pregnancy and adapt to being the mother of a new baby, it is important that you realize you are being “born” or reborn into your role as a mother to this baby. Even if this is not your first baby, the transition to being a mother is a process that involves feelings, behaviors, attitudes, and character developed from life experiences and expectations. While responses to being a mother may come from life experiences, maternal attitudes and behaviors change in relation to the age, condition, and situation of one’s child. Each mother-child relationship, each pregnancy, each delivery, and each childbirth experience are different for each woman. This is true even if you already have children. Each pregnancy, labor, and delivery is unique. Supportive sharing from significant persons, especially your family, balances the process of becoming a mother. The support you receive from your mother and the father of your baby assists you in the changes you go through to become a mother. If your mother and/or the father of the baby are not involved, other supportive relationships have to fill this gap. For you and the father of the baby, mutual sharing provides the best foundation for adapting to your roles as mother and father. The ability to see yourself as a mother and expand on the idea that the new child will impact your dreams and fantasies is a building process that occurs throughout pregnancy. It happens best with the support and help of your partner. Some of the questions raised in this book are to help include the father in this important process. The ability to imagine and think about being a mother depends on your life experiences. Good “mothering” role models, whether your own mother or another woman you respect, will help you be confident and identify with being a mother. Many women feel a tremendous sense of relief in having a female friend or mentor with whom they can share feelings about their pregnancies. Regardless of the relationship you have with the father of your baby, you may feel unable to express certain feelings or fears with him. This is normal. Women often say that they recognize their husband or partner “kind of understands”, but worry about discussing their fears, thoughts, hopes and dreams with him. It is important to try to talk about some of these things with him but very important to identify a woman who can help you as well. Keep in mind that it is natural to have doubts and conflicts about this immense role change. This usually happens every time you have a baby. Becoming a mother affects your sense of self. If you are expecting your first child, you are truly between roles. Often there is fear of the impact the baby will have on marriage, family, and career. Generally, a vision of your image as a mother becomes clearer as pregnancy continues. The questions throughout this book are to help you define your idea of motherhood. Being able to picture or express your idea of motherhood takes place by rehearsing or imagining yourself in the role of a mother. It is normal to dream of yourself as a mother. Prenatal Information Sheet: Introduction v This process helps you identify the characteristics of a good mother. The ongoing process of the “birth of a mother” requires you to accept the loss of a former part of yourself. It is important to recognize your new role, with all its responsibilities, has many rewards. In other words, any losses you might have are balanced by rewards you will receive. Preparing for any role change requires a desire to learn. During the process of becoming a mother, you will seek out information or models of your new role. Vari- ous confidants, whether your mother, a close friend, or the father of the baby can all help provide information and act as role models. Watching other mothers with their children and attending birthing and prenatal classes are sources of informa- tion to help you through this process. At many military installations, the DoD provides assistance through the New Parent Support Program. This program employs nurses, social workers and other individuals who can provide you access to many education programs. They can provide you written or video educational information and sometimes they can even come to your home to help you adapt to your role of becoming a new mother. For women veterans receiving services through the Department of Veterans Affairs, each facility has a Women Veterans Program Manager who can assist you with finding the resources you need during your pregnancy and after delivery. This book will provide you with a lot of valuable information and should help answer many of your questions but it is no substitute for a wise and supportive mentor. Some places have support groups for women whose spouses are deployed. Other places have groups where experienced women volunteer to provide guidance to new mothers. We encourage you to take advantage of these kinds of opportunities. We wish you the very best in your own birth as a mother! vi Prenatal Information Sheet: Introduction Visit Summary Information Goal-oriented visits: 6–8 Week Visit Goal: Exchange information and identify existing risk factors that may impact your pregnancy To Do: 1. Read the visit information and any additional related topics prior to your visit. Write down any questions you may have. 2. Ask your family about any medical problems that exist in your family members such as diabetes, cancer, hypertension, and genetic problems. 3. Fill out questionnaire, if provided prior to your appointment, in preparation for this visit. 4. Suggested reading in Resource Section: Common Discomforts and Annoyances of Pregnancy, Travel and Pregnancy, Tobacco, Alcohol and Drug Use in Pregnancy, Specific Genetic Testing, Nutrition, Dental Care, and Genetic Screening. Think about whether you wish to have blood tests to screen for birth defects. 10–12 Week Visit Goal: Determine current health status and work toward a healthy pregnancy To Do: 1. Read the visit information and any additional related topics prior to your visit. Write down any questions you may have. 2. Wear clothing easy to change out of for physical exam. 3. Suggested reading in Resource Section: Common Discomforts and Annoyances of Pregnancy, Genetic Screening, Breastfeeding, Exercise, Immunizations, and Sexually Transmitted and Other Infections. 4. Review Prenatal Fitness and Exercise brochure. Prenatal Information Sheet: Introduction vii 16–20 Week Visit Goal: Work toward a comfortable and safe pregnancy To Do: 1. Read the visit information and any additional related topics prior to your visit. Write down any questions you may have. 2. After visit, schedule your appointment for an ultrasound if not already scheduled. 3. Suggested reading in Resource Section: Breastfeeding and Testing and Monitoring during Pregnancy. 24-Week Visit Goal: Prevent preterm labor for a safe and healthy baby To Do: 1. Read the visit information and any additional related information prior to your visit. Write down any questions or concerns you may have. 2. Suggested reading in Resource Section: Preterm Labor and Fetal Movement Counting Chart. Check out available prenatal classes at your hospital. 28-Week Visit Goal: Monitor your baby and your progress and learn to count fetal movements To Do: 1. Read the visit information and any additional related topics prior to your visit. Write down any questions or concerns you may have. 2. Follow instructions given to you for your one hour glucola test. 3. Suggested reading in Resource Section: Fetal Movement Count Chart, Testing and Monitoring during Pregnancy, and True versus False Labor. 32-Week Visit Goal: Prepare for your baby’s arrival To Do: 1. Read the visit information and any additional related topics prior to your visit. Write down any questions or concerns you may have. 2. Fill out Fetal Movement Chart and bring with you to visit. 3. Suggested reading in Resource Section: Labor and Delivery Basics, Labor and Delivery Procedures, Family Planning, Birth Planning, Breastfeeding, and Bottle Feeding. viii Prenatal Information Sheet: Introduction 36-Week Visit Goal: Begin preparations for your hospital experience To Do: 1. Read the visit information and any additional related topics prior to your visit. Write down any questions or concerns you may have. 2. Fill out Fetal Movement Chart and bring with you to visit. 3. Suggested reading in Resource Section: Labor and Delivery Basics, Labor and Delivery Procedures, Birth Plan, Promoting Safety in Childbirth, Baby Supplies for First Week, and Safety Tips for Babies. 38–41 Week Visit Goal: Preparing for birth and baby’s arrival at home To Do: 1. Read the visit information and any additional related topics prior to your visit. Write down any questions or concerns you may have. 2. Fill out Fetal Movement Chart and bring with you to visit. 3. Suggested reading in Resource Section: Labor and Delivery Basics, Labor and Delivery Procedures, Birth Plan, Promoting Safety in Childbirth, Baby Supplies for First Week, Safety Tips for Babies, Breastfeeding, and Bottle Feeding. Post Delivery Visit 6-8 Weeks after Delivery: Determine health status and promote adjustment to being a mother To Do: 1. Read the visit information and any additional related topics prior to your visit. Write down any questions or concerns you may have. 2. Think about family planning needs if that has not already been decided. 3. Call the clinic to confirm whether or not you may bring baby with you for this appointment. Prenatal Information Sheet: Introduction ix