MOTHERHOOD A Guide from Pregnancy to Childbirth - THE MIRACLE OF - Cherokee Women's Health Specialists
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CHEROKEE WOMEN’S HEALTH SPECIALISTS
THE MIRACLE OF
MOTHERHOOD
A Guide from
Pregnancy to
Childbirth
BY
Peahen Hasmukh Gandhi, MD, FACOG, FPMRS
Michael Litrel, MD, FACOG, FPMRS ICHAEL LITREL, MD, FACOG, FPMRS
1
The Miracle of Motherhood
A Guide from
Pregnancy to Childbirth
By
Peahen Hasmukh Gandhi, MD, FACOG, FPMRS
Michael Litrel, MD, FACOG, FPMRS
Copyright © 2021 by Peahen Hasmukh Gandhi, MD, FACOG, FPMRS and Michael Litrel, MD, FACOG, FPMRS
All rights reserved. This book or any portion thereof may not be reproduced or used in any manner what-
soever without the express written permission of the publisher except for the use of brief quotations in a
book review.
2
Table of Contents
Dear Mothers-to-Be��������������������������������������������������������������������������������������������������������� 4
History of Cherokee Women’s Health Specialists, PC�������������������������������������������������� 6
The Pregnancy Timeline��������������������������������������������������������������������������������������������������8
Meet Your Clinical Team Partners�������������������������������������������������������������������������������� 12
The Pregnant Body Transformation���������������������������������������������������������������������������� 21
The First Trimester��������������������������������������������������������������������������������������������������������30
The Second Trimester���������������������������������������������������������������������������������������������������� 35
The Third Trimester ������������������������������������������������������������������������������������������������������42
Labor and Delivery ��������������������������������������������������������������������������������������������������������48
The Postpartum Stage���������������������������������������������������������������������������������������������������� 57
Body Image���������������������������������������������������������������������������������������������������������������������� 61
Fatherhood and How to Get Him Involved ���������������������������������������������������������������� 65
Final Thoughts����������������������������������������������������������������������������������������������������������������70
Glossary ���������������������������������������������������������������������������������������������������������������������������71
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Dear Mothers-to-Be,
Congratulations on your pregnancy! It is our honor and privilege to take care of you. We know you
want your baby to be perfect. Our job is to help you be as perfect as you can be! Our mission is
to be your ultimate team of obstetrical experts. We want to help you so you and your baby will be
wonderfully healthy.
Your pregnancy journey will be unique and exciting. There will be confusing times ahead too. But
the path of pregnancy has been traveled before, so there will be no shortage of advice. Friends,
family, and folks at the grocery store may share their opinions when they see your “bump.” We
created this guide with you in mind. We studied medicine and cared for thousands of pregnant
women over the decades. This guidebook is for you to gain knowledge as you learn more about
your pregnant body and your journey to motherhood.
We guide our care for you and your unborn baby based upon our understanding of biology. But in
our hearts, we know your pregnancy is a miracle. After all, a single cell — smaller than a grain of
sand — turns into a newborn baby inside your body. But miracles are not always easy. Becoming a
mother will present some physical and emotional challenges. But you are strong and your body is
designed for pregnancy and childbirth. And before you know it, you will be holding your baby in
your arms. Helping you realize your dream of motherhood is what makes us passionate about our
profession. Let’s start the journey together…
4
At Cherokee Women’s Health Specialists:
We Understand Science.
We Practice Medicine and,
We Witness Miracles every day.
But miracles and faith aside, pregnancy is not always easy. If you think about the biology for a mo-
ment, it’s simple to understand why. Pregnancy boils down to one brand new human being grow-
ing inside the body of another.
Sure, there are challenges such as nausea, difficulty breathing, pelvic pressure, and leg swelling, to
name a few. But women are strong both physically and emotionally, and women’s bodies were de-
signed for childbirth. And when it’s time to deliver you will be rewarded with your precious bundle
of joy.
5
History of Cherokee Women’s Health Specialists, PC
Our Founder, Dr. James Cross
In 1993, Cherokee County had one of the highest perinatal mortality rates in Georgia.
Dr. James Cross, a highly reputed Clinical Professor at Georgia Baptist/Atlanta Medical Center
and Atlanta based OB/GYN founded Cherokee Women’s Health Specialists, PC, to provide care to
the under-served women and families suffering this health crisis in Cherokee County.
Shortly after his arrival to Cherokee County, Dr. Cross was diagnosed with cancer. Rather than
close Cherokee Women’s Health Specialists, PC and return to Atlanta to address his own health
crisis, Dr. Cross remained the sole obstetrician in Cherokee County, overnighting in the hospital to
deliver babies while he, himself, received chemotherapy.
“These women and their babies need me. They
will get the care they deserve.”
- James Cross, MD, FACOG
Today, Cherokee County has one of the lowest perinatal
mortality rates in Georgia. Cherokee Women’s Health
Specialists is committed to providing dedicated prenatal
care services with our expert obstetric clinical team of
physicians and midwives. We deliver the highest quali-
ty of compassionate care for both our low and high-risk
obstetric patients. We aim to uphold Dr Cross’s priority
to the care of expectant mothers.
We remain forever committed to Dr. Cross’s vision for
Cherokee County and we continue our service working
with the Cherokee County Health Department and in-
digent women’s health care services providing co-care obstetrical services, colposcopy, IUD inser-
tion, staff training and direct patient care.
We are also leaders in gynecologic surgical technology, providing minimally invasive options for
our patients to help them recover quickly and experience less pain postoperatively. For over 25
years, Cherokee Women’s Health Specialists has utilized advanced laparoscopy application in
endometriosis treatment, single-incision laparoscopy, total laparoscopic hysterectomy and robotic
surgery. A number of procedures are performed in the office including endometrial ablation and
hysteroscopy in a safe, pain-free setting utilizing ambulatory anesthesia.
6
As founder of the Vaginal Health Center, Dr, Michael Litrel has pioneered surgical techniques in
urogynecology and cosmetic gynecology, as double-board certified in Obstetrics and Gynecology
and Female Pelvic Medicine and Reconstructive Surgery. We also offer non-invasive treatments
for urinary incontinence, non-hormonal laser treatment for vaginal atrophy and the O-shot for
libido enhancement.
In addition, we have contributed as top Principal Investigators at the national level for many clini-
cal studies in Gynecology and Urogynecology.
Together, our staff, administrators and physicians, as members of our Cherokee Women’s family,
are humbled by and honored to carry forward Dr. Cross’s vision of ‘Physician-Led Medicine’ in
Cherokee County and beyond.
7
1
CHAPTER ONE
The Pregnancy Timeline
The best time for your first pregnancy visit is actually before you get pregnant. This is called
pre-conceptual counseling. During this visit, we can identify health issues before you get pregnant.
However, it’s not a big deal if you skip your pre-pregnancy appointment because generally, any
woman healthy enough to conceive is healthy enough to have a baby.
Pregnancy can be a confusing time. There is a lot going on and you will have many questions. A
“normal,” full-term pregnancy is 40 weeks and can range from 37 to 42 weeks. It’s divided into
three trimesters. Each trimester lasts about 3 months. During the typical pregnancy, there are
about 14 doctor appointments. However, this will vary depending upon your schedule and preg-
nancy. How far along you are (gestational age) always determines what we do during our evalu-
ation. The first visit is usually the longest. You should allow 45 minutes. The remaining visits are
usually 10 to 15 minutes.
It is helpful to review your pregnancy as it progresses, so you stay oriented as to
what is truly going on when you come to your appointments.
Following is a brief overview of a typical pregnancy appointment schedule:
8 weeks: An ultrasound is done to make sure we know how far along you are. We compare the
ultrasound to your last menstrual period. We take a careful medical history. We also do basic lab
work and a physical examination, including a Pap smear. We want to see the fetal heartbeat and
make sure there are no other medical issues we need to address.
8
12 weeks: A screening ultrasound, called a Nuchal translucency scan, is performed to evaluate for
certain fetal problems. Genetic testing is done to make certain of normal chromosomes and even
gender identification. We can hear the heartbeat.
16 weeks: We offer other screening tests to identify problems with the fetal spine or brain de-
velopment. At each visit, you will have your blood pressure and weight checked, and your baby’s
heartbeat will be measured by Doppler.
20 weeks: This is a fun appointment! An ultrasound is done to evaluate your baby’s anatomy,
and you will get photos. We can also tell you if you are having a boy or a girl, if you want to know.
24 weeks: We listen to your baby’s heartbeat. This gestational age is a key milestone because it
marks the point when your baby is viable outside your body. (Even though we want your baby to
stay inside for another four months!).
28 weeks: We check for gestational diabetes and give Rhogam for those whose blood type is RH
negative. We educate you about preterm labor and fetal kick counts. With each week and month
that passes, your baby’s ability to be healthy — if born early — increases. However, we do not want
you to deliver before 37 weeks.
32 weeks: We evaluate to determine the health of you and your baby. We make sure there is no
preterm labor, elevated blood pressure or other issues that can cause problems. Sometimes we do
an ultrasound to measure your baby’s growth.
9
34 weeks: Same as above. We also educate you about the importance of kick counts, so you can
pay attention to your baby’s movement. Sometimes your baby is sleeping, sometimes your baby is
awake. We want to make certain your baby does not become ill inside your body. If this happens
your baby will slow down or stop moving. We need to get your baby delivered.
36 weeks: This is a milestone appointment. Your baby is just about full term. We check you for
Group B Strep infection with a vaginal culture. We do basic blood work to evaluate you for anemia
and infection.
Weekly Visits Three Weeks Before Due Date - Once you are three weeks before your due
date, we see you weekly. During each visit, we evaluate you for labor and for problems requiring
delivery.
Note: If your pregnancy is deemed high-risk then you will also be followed by a
perinatal specialist.
10Frequency of Appointments After Delivery
2-3 Weeks After Baby is Born
If you had a cesarean section we like to check the incision for proper healing.
6 Weeks After Baby is Born
If you delivered vaginally, we want to see you when your baby is about 6 weeks old. We also talk to
you about contraception. We recommend you do not get pregnant again for at least a year to give
your body time to fully recover. Feel free to bring your baby with you during these appointments
as we love seeing what you and God have done!
3-4 Months After Baby is Born
When your baby is about 3-4 months old, we give you a complete physical examination. From that
point on we would like to see you once a year for your routine annual GYN appointments.
If you have any issues, we are always here for you
and are happy to see you any time!
112
CHAPTER TWO
Meet Your Clinical Team Partners
Your team of experts are well-trained in the field of obstetrics. The care of a pregnant woman is a
collaboration of doctors, midwives, physician assistants, nurse practitioners, and certified ultraso-
nographers. Lactation specialists also help guide you through the postnatal breastfeeding challeng-
es. The philosophy of collaborative care is simple: individualized patient care via a team approach
resulting in maximizing best outcomes. You will be seeing a number of health care specialists
during your pregnancy, not just your “OB”. Each member of the team is working in concert to help
you achieve your optimal health.
The Obstetrician: Your “Baby Doctor”
This is the leader of the clinical team. He or she is specially trained through a residency program
after completing medical school in the field of obstetrics and gynecology. The physician, whether
and M.D. or D.O. is your source for the most up-to-date information regarding the health of your
baby. He or she is supervising your pregnancy along with the supportive team members. It is im-
portant in a group of OB doctors, you meet everyone.
As emergencies can arise and obstetrics is an unpredictable field, having a familiar face is com-
forting and reassuring. Your “OB” sometimes will need to refer you to a Perinatologist or high-risk
specialist. The perinatologist may perform specialized ultrasounds and help your OB doctor man-
age complications during pregnancy. However, the perinatologist does not deliver your baby.
12The Doctors
Michael Litrel, MD, Peahen Gandhi, MD,
FACOG, FPMRS FACOG, FPMRS
“To witness the miracle of life, it is truly a gift. “A good doctor should be listening a lot to
The process of life is biological, and that is get the whole story and not just one sim-
what science is for. The source of life is spir- ple complaint. I like the quote by Shakti
itual, and that is what faith is for. I am hon- Gawain, ‘Our bodies communicate to us
ored to witness God’s miracles every day.” clearly and specifically if we are willing to
listen to them’. I like to think that I genu-
Dr. Michael Litrel is dedicated to helping inely care and listen to my patients’ needs,
women achieve optimal health and is grate- and that helps guide my recommenda-
ful for each patient, treating each one as he tions.”
would treat his loved ones. He believes all
women are unique and special, creators of Dr. Gandhi loves her patients with a com-
life, strong, and courageous. passionate heart and is known for treating
each woman as a close friend.
13James Haley, MD, FACOG, FPMRS Britton Crigler, MD, FACOG
“As an OB/GYN of nearly 30 years, and a “I am overwhelmed at the absolute joy
father, I am still in awe of God’s gift of life. of childbirth as both an OB/GYN and a
From the time we hear the heartbeat, to the father. The raw emotion is humbling. It’s
time I’m honored to hand over the baby to the truly an honor to share this miraculous
mother, I am privileged to see the miracle of moment with my patients. Every. Single.
God’s hand throughout.” Time.”
Dr. James Haley loves a challenge, which is Dr. Britton Crigler is a firm believer in
why he’s so passionate about helping women treating each patient like he would treat
solve their female health problems. his own wife and loved ones, with the ut-
most compassion, care, and kindness.
14Leah Goodson-Gerami, Mariya Zhukova, MD
DO, FACOOG (Dr. G.G.) (Dr. Z)
On her philosophy of patient care, Dr. G.G. Dr. Z is passionate about delivering ba-
likes to tell her patients, ‘Don’t be shy, there’s bies. “As a mother myself, I can relate to
nothing you can say that I haven’t heard!’ She how special childbirth is to a woman. I
loves getting to know her patients and espe- especially love the joy of birth, when I am
cially loves being a part of their experience able to share that intimate time with the
and journey into motherhood. family bringing a new life into the world.
What an honor!”
Dr. Goodson-Gerami listens to her patients,
is always honest, and appreciates her role in Dr. Z. is grateful she became an OB/GYN
helping women stay in optimal health. and enjoys the privilege of taking care of
other women.
15Lisa McLeod, DO, FACOOG
Dr. McLeod is passionate about communi-
ty outreach and is passionate about patient
education. She is committed to empowering
women to understanding the physiologic
changes that occur and decided to specialize
in obstetrics, where she knew she found her
purpose.
Dr. McLeod has done multiple speaking
engagements and has participated in clinical
and public health activities in Haiti, Ecuador,
Ghana and Cuba.
16The Midwife: Your Ultimate “Labor Coach”
Meeting the needs of varied patient preferences requires exposure to alternative clinical philos-
ophies. Certified nurse midwives receive advanced training and work alongside obstetricians to
provide holistic maternity care. The tenet of care involves therapeutic use of human presence and
skillful communication. The main goal is to help you realize your own strength by empowering you
to listen to your body and engaging it during labor with as little intervention as necessary.
The Midwives
Susan Griggs, APRN, CNM Robin Hurley, APRN, CNM
Susan states the term midwife means “with Robin values sharing information with her
woman” and is committed to providing patients, especially teens and young moms.
compassionate support throughout a wom- “They are the ones who need education and
an’s pregnancy and even beyond. listening right now.”
“I always think of every birth as if this is She is focused on making women feel like
the only birth this woman will ever expe- they can change their health for the better, by
rience. My goal is to educate patients and making good decisions. Robin has provided
help them understand what’s happening to comprehensive women’s health care for thou-
their bodies.” sands of patients, with a range of experience
in obstetric care, as well as family planning
and gynecologic well exam visits, including
menopause.
17Rachelle Denney, APRN, CNM, LCCE Susan Fischels, CNM
Rachelle has a true love for obstetrics and As a seasoned midwife, Susan has practiced
even a family tie. “I love babies and my as a midwife since 1998. She became inter-
great grandmother was a midwife. I always ested in midwifery after working alongside
knew I wanted to be a midwife from the midwives as a labor and delivery nurse.
age of 12.”
“I loved how the midwives interacted with
During high school, she became a certified their patients and I knew I would enjoy
doula and volunteered her time for at-risk taking care of women, not only at the time of
teens. Having been practicing as a certified delivery, but also providing care as a lacta-
midwife since 2015, Rachelle finds deliver- tion consultant.”
ing babies a rewarding honor.
18The Physician Assistant
A Physician Assistant (PA) is a Master’s prepared individual that works interdependently with
physicians who are licensed in their specialty. These medical professionals work with your OB doc-
tor to care for you during your pregnancy and postpartum time period. They have been trained in
the field of women’s healthcare and can be a tremendous source of education and guidance.
Courtnay Staab, PA-C
On her philosophy of care, Courtnay states
“I believe in the importance of patient
education and really enjoy communicating
with women about their health care op-
tions.”
Courtnay is an Atlanta native who did her
undergraduate studies at Georgia Institute
of Technology before receiving her Master
of Medical Science in PA Studies at Mercer
University. She has a special interest in
women’s reproductive health.
19The Ultrasonographer
Your certified obstetric ultrasonographer utilizes specialized equipment using sound waves to
produce pictures of a baby (embryo or fetus). It does not use ionizing radiation, has no known
harmful effects, and is the preferred method for monitoring pregnant women and their unborn
babies. A Doppler ultrasound study – a technique that evaluates blood flow in the umbilical cord,
fetus or placenta – may be part of this exam. The sonographer is a key member of the team as they
will be providing the images used to confirm the well-being of your baby. These images are inter-
preted by your doctor and then relayed to you at your visit.
The Lactation Specialist: Your Breastfeeding Mentor
Your lactation consultant has met specific training requirements to get credentialed by the Inter-
national Board-Certified Lactation Consultant (IBCLC) or Certified Lactation Consultant (CLC).
They will help mentor you via prenatal breastfeeding courses and also after delivery to optimize
your nursing goals.
203
CHAPTER THREE
The Pregnant Body Transformation
The pregnant body is the ultimate proof that the human body’s ability to adapt is miraculous.
From changes in over six different organ systems to a complete renovation of the pelvic anatomy,
the body prepares itself for labor and birth meticulously. For example, the uterus grows from the
size of an orange to that of a watermelon! Your baby is truly witnessing his or her mother’s unself-
ish physical and physiologic generosity. Most of the changes reverse after birth. However, the bond
with your baby created by undergoing these changes, is everlasting.
Physical Changes
Breast Changes - Since breasts are designed to feed your baby, it should come as no surprise
that your breasts will change during pregnancy. Your breasts will likely become larger, firmer, and
more tender. You may notice veins under the skin as the blood flow increases to your breasts in
preparation for breastfeeding. Your areola, which surrounds your nipples, may darken and be-
come larger, too. In your second or third trimester, clear fluid called colostrum may be secreted
from your nipples. There are special pads you can purchase to protect your bra, or you can use
small feminine pads.
Gastrointestinal Changes
Nausea - The surprising thing about “morning sickness” is that is does not just occur in the morn-
ings. The good thing about morning sickness though, is that it means your pregnancy is healthy.
By the time you get to about 15 weeks or four months, the nausea gets a lot better.
To reduce morning sickness, try these remedies:
• Eat small meals of simple foods, avoiding spicy and highly acidic foods
• Lie down immediately after eating for just a few minutes
• Eat bread or crackers before you get out of bed each morning
21• Get out of bed slowly, do not jump up
• Try yogurt, milk, or juice just before bedtime
• Avoid greasy, fried foods, or spicy, heavily seasoned foods
• Eat several small meals during the day rather than a few large meals
• When nauseous, get fresh air, take deep breaths, and sip water
• Take prenatal vitamins or iron during the day when nausea is not a problem
• Over-the-counter medications to try: Emerol, Seabands, Dramamine, and Bonine.
If you still don’t feel well, come see us. There are some medications that may help you that are safe
during pregnancy. If you are suffering significant vomiting and cannot hold anything down, you
may need intravenous fluids. A liter or two of intravenous fluids can make all the difference in how
you feel.
Excessive Salivation - Some women generate
more saliva during pregnancy. This is called ptyal-
ism. For some reason, the salivary glands become
overly enthusiastic. There is not much we can do
about it, but it doesn’t cause problems with the
pregnancy. Sometimes gum or ice can be helpful.
Heartburn - Heartburn is another common
complaint of pregnant women. It is not your heart
that is burning, it is your stomach. This is common
indigestion, but it can still feel terrible. Acidic fluid
from your stomach backs up into your esophagus
because your pregnancy is pushing your organs up
under your rib cage. A simple way to handle this is
to elevate the head of your bed. You may need to
sleep in a recliner, so the contents of your stomach
stay where they belong.
Prescription medication is usually not needed
but, of course, is available should your symptoms
warrant them. But first try over-the-counter med-
ication. Maalox, Mylanta, Tums, Simethicone, or
Pepcid AC are a few over-the-counter medicines
you can try.
22Constipation - Constipation for a woman suffering from indigestion or morning sickness is
adding insult to injury. But sadly, this is not uncommon. As the uterus enlarges it presses against
the colon and rectum acting as a literal physical barrier preventing stool from exiting your body.
Drinking lots of water is the first step to helping with this. You need to drink a lot of fluids during
pregnancy anyway – you are growing another person inside your body! Exercising every day helps
with constipation as well. Just walking around helps stool move down the colon simply because of
the force of gravity. Eat plenty of fruits and vegetables.
Try all the natural remedies first, including the addition of bran products to your diet. Insoluble
fiber bulks up stool, which can help. Over-the-counter medications for constipation are generally
safe if your suffering is not alleviated. Metamucil, Colace, Citrucil, Milk of Magnesia, Fiberall, and
Senokat/Surfak are a few over- the-counter medications.
Hemorrhoids – Women pregnant with their first child may be surprised to get hemorrhoids.
There is nothing enjoyable about the experience. Maybe this will not happen to you but don’t be
surprised if it does. It can occur earlier in pregnancy, simply from constipation. Straining to have
a bowel movement may result in the dilation of rectal veins. Later in pregnancy, the baby’s head
can block the circulation of these veins. And unfortunately, pushing during delivery can make this
worse.
Try to prevent constipation by following our recommendations under the section on constipation.
If you do suffer with hemorrhoids, try lying on your side or elevating your hips on a pillow. Soak-
ing in a warm tub can help as well. Over-the-counter ointments and remedies are generally safe.
Ask us to be certain. Some prescription medication is available as well. Sometimes surgical remov-
al is necessary but that would be done after your baby is born. Fortunately, surgery is usually not
necessary.
Pica - Pica is the medical term for unusual cravings for strange foods during pregnancy. We do
not know why this happens, but we would like to hear about your experiences.
There are three reasons why sharing the details matter:
• Sometimes a desire to eat starch, clay or dirt indicates a nutritional deficiency that requires
evaluation.
• We want to make certain that despite your cravings you are eating a balanced diet.
• Sometimes the stories you share are so entertaining it puts us in a good mood! Job satis-
faction is liking what you do, and our patients become our friends. From life-long vegans
switching over to rare steak sandwiches to fathers being sent out emergently in the middle
of the night for a pint of Ben and Jerry’s Chunky Monkey and a fresh spinach salad. We
have heard many stories and want to hear yours!
23Abdomen Changes
The pregnant uterus enters into the abdominal cavity by the fifth month, when you can feel the top
of your uterus at the umbilicus. At this point you may notice that the abdomen may ache on one
side or the other, as the abdominal wall and the ligaments that support the uterus are stretched.
Round Ligament Pain- This pain feels like a sharp, sud-
den pain on one or both sides of the lower belly, hips or groin
area. Round ligament pain can also make your lower belly feel
achy after you’ve done more physical activity than usual. This
type of pain is not harmful, but a reminder of how hard your
body is working to grow your baby. You can relieve this pain
by taking it easy, soaking in a warm bath, wearing a pregnan-
cy support belt or just moving about at a slower pace.
Contraction Pain - The uterus or womb is a muscle in
which the baby grows. The uterus contracts just like all mus-
cles in the body. Contractions normally occur from time to
time as early as the first trimester of pregnancy, well before
the onset of real labor. These contractions are usually irregu-
lar and painless and are called Braxton Hicks contractions. Sometimes these early contractions are
painful. Many pregnant women become alarmed by the discomforts of pregnancy. Indeed, painful
contractions that are intense and regular enough to dilate your cervix (the opening of your womb
at the top of the vagina) is labor.
Respiratory Changes
Shortness of Breath - Shortness of breath is a common problem during pregnancy. If you be-
come short of breath by walking up a flight of stairs, a common cause could be anemia. You may
need to take additional iron supplements. Make sure you discuss these symptoms with us at your
appointment or call our phone nurse. Sometimes shortness of breath is related to the pregnancy
itself and there is nothing we can do, other than eventually help you when it is time to deliver your
baby. There are two reasons for this: In the second trimester, the hormones of pregnancy may
result in changes to the tissue of your lungs which result in the symptoms of this sensation. This is
not well understood but we see it a lot. In the third trimester, your enlarging uterus pushes against
your breathing muscles, physically interfering with your ability to take a deep breath. Remember,
we said that pregnancy can be both a wonderful time and a challenging time. The symptoms of
shortness of breath fall into the latter category. If you have trouble sleeping due to shortness of
breath, prop yourself up with pillows at night.
24Cardiovascular Changes
During pregnancy the pressure of the expanding uterus on the large veins causes blood return to
slow on its way back to the heart. The blood volume increases and there is an elevation in the rest-
ing heart rate. These changes help to increase cardiac output to support your growing baby and
maintain good flow to the placenta.
Dizzy Spells - Dizziness or even fainting may occur during pregnancy. Common reasons include
lowering of your blood pressure or lowering of your blood sugar. You need to listen to your body as
pregnancy progresses. Make sure you stay well hydrated by drinking water throughout pregnancy.
Many women need frequent, healthy snacks throughout pregnancy to help with both dizziness and
nausea. Make sure you are taking your vitamins and iron to build your blood. Your body is doing
all the work for your baby. Take care of yourself first and your baby will be healthier.
Later in pregnancy, dizziness can occur simply by lying on your back. This is because your en-
larging uterus may compress the large vein on your spine called your inferior vena cava, slowing
blood flow to your heart. Lying on your side is recommended to relieve pressure of the womb on
this large blood vessel. Do not change positions suddenly. When you are lying down, ease yourself
up to standing position in stages. Do not move too quickly as your womb enlarges. Listen to your
body.
Skin Changes
Hyperpigmentation - Darkening of the umbilicus, nipples, abdominal midline (linea nigra),
and face (cholasmsa) are common due to the hormonal changes of pregnancy
Spider Veins- Increased circulation and high levels of estrogen during pregnancy may cause spi-
der veins also called spider naevi.
Palmer erythema - You may also notice that your palms have increased redness and warmth
and this is also due to the changes in the peripheral vascular system and hormone levels.
Stretch Marks - Stretch marks develop during most pregnancies. The skin has layers. The skin
you see is called the epidermis. The layer under this is called the dermis. This is the thick part of
the skin you can feel if you pinch the skin on your hand. Collagen and elastin proteins allow your
skin to stretch and return to normal. But if your skin stretches too much, it can tear slightly. When
you rapidly gain weight during pregnancy, the underlayer or dermis of your skin can be injured.
The hormones of pregnancy such as cortisol and estrogen decrease the fibroblasts’ ability and ef-
fectiveness to protect the skin. As the dermis heals, a scar is formed. You see this scar as cracks on
your epidermis or outer layer. These are called stretch marks, or striae gravidarum.
25You may see stretch marks start to develop before five months, but it is more common to notice
them by month seven (30 weeks). Stretch marks start out as pinkish streaks and are commonly
seen around your abdomen, hips, side, thighs, and breasts.
You have the best chance of reducing the appearance of stretch marks when they are new and
pink. Treatment is much more difficult once the scars fade to white. Medical science does not yet
offer scientific proof of how to prevent stretch marks, but there is anecdotal advice that makes
sense. The ancient Greeks and Romans used olive oil. Maybe this worked, no one knows. We be-
lieve skin lotions and good hydration will help your skin stretch and heal more effectively. You can
start moisturizing your skin as soon as you find out you are pregnant. Focus on those areas where
stretch marks are more likely to develop. We also recommend drinking plenty of water.
There are many skin lotions advertised for the preven-
tion of stretch marks. Remember, none have been
scientifically demonstrated to be effective so there is
not one that is necessarily better than the other.
A simple, natural skin lotion without too many fra-
grances is what we recommend. You do not have to get
too fancy or spend too much money but there are com-
panies such as Mustela or Mederma who offer a wide
range of products. We recommend you moisturize your skin in the morning and evening. You can
even take a warm bath (not hot) with a skin emollient like Bio Oil in the tub.
But the most important advice for preventing or diminishing stretch marks is to not gain excessive
weight. 25-30 pounds is a typical recommended weight gain for pregnancy. But if you are over-
weight, you should not gain as much because stretch marks tend to form over fatty deposits and
the skin is already stretched on an overweight person, meaning obese patients are more suscep-
tible to significant stretch mark damage. Good nutrition is also key so eat well during pregnancy.
Your body is going under so many changes and your baby even more so.
2627
Endocrine Changes
The endocrine system is the organ system of the body which regulates our hormones. There are
amazing changes that occur through increases in the hormones of pregnancy. The placenta, itself,
acts as a temporary endocrine organ as it produces large amounts of estrogen and progesterone
by the twelfth week of pregnancy. It serves to maintain the growth of the uterus, helps to control
uterine activity and is responsible for the physical changes of the pregnant body.
Different endocrine organs in your body go through changes. For example, you parathyroid gland
increases in size to meet the increased requirements for calcium during pregnancy. Later in preg-
nancy, your pituitary gland secretes oxytocin to help initiate labor. During breastfeeding, you also
secrete prolactin to stimulate the production of breast milk.
Urogenital System Changes
Urination - Pregnant women discover they need to use the bathroom more. This happens be-
cause you have more blood flow in your body as pregnancy progresses. This means more blood will
flow to your kidneys and more urine is made. Also, as your baby gets bigger there is more pressure
on your bladder, making your bladder effectively smaller. The bottom line is that you will need to
empty your bladder more often. This is normal and healthy. Drink plenty of water and stay hy-
drated. It’s also a good idea to urinate just before you go to bed at night. Also, make sure you have
a night light on and there are no objects on the floor or in your way that could cause you to trip
should you need to wake up to use the restroom.
Vaginal discharge - You will have increased vaginal discharge during pregnancy. There is both
increased blood supply in your vagina and cervix and increased mucus production. This is to
protect your pregnancy. If there is an odor or symptoms of itching or discomfort or discharge with
a yellow color, we will want to do a physical exam. Sometimes infections can occur and should be
treated. If you notice a gush of fluid or bleeding, that is something else entirely. Always be evaluat-
ed for these issues immediately.
Know that we care for you and your unborn baby with all our hearts and feel blessed to participate
in the miracle of your pregnancy. Sometimes we can’t do much for normal symptoms of pregnancy
other than lend a sympathetic ear. You are doing God’s work!
Musculoskeletal changes
There is realignment of the spinal curvature and a shift in posture with an exaggerated lumbar
lordosis or “the protruding belly and buttocks.” Increased ligament laxity caused by the release of
relaxin can cause pubic symphysis pain or even contribute to the back pain many women suffer
from in pregnancy.
28These changes are occurring to prepare you for labor and birth, but can be uncomfortable to say
the least. Seeking the care of a chiropractor is safe during pregnancy, unless otherwise specified
by your provider.
Emotional Changes
Pregnancy is a wonderful time, but it is natural to experience changes in your feelings and mood.
The unexpected yet normal physical discomforts, as well as the changes in your physical appear-
ance, along with the increased stresses can cause you to feel more tired, irritable, or worried.
While mood changes during pregnancy are common, symptoms can sometimes become severe
enough to require evaluation by a healthcare provider. Depression and anxiety during pregnancy
can worsen and continue into the postpartum period and beyond. The symptoms of depression are
common for many pregnant women to experience from time to time.
294
CHAPTER FOUR
The First Trimester
The first trimester begins on the first day of your last period and lasts until the first three months.
The first trimester is crucial to the normal development of the fetus. You may not be showing
much on the outside, but inside your body all the major body organs and systems of the fetus are
forming during that first ten weeks called the organogenesis time period. It is during this first
trimester that the fetus is most susceptible to damage from substances, like alcohol, drugs, certain
medicines, and illnesses, like rubella (German measles). During the first trimester, both your body
and the fetus is changing rapidly.
Track your own progress below, visit by visit. This will help you be engaged in the important
changes your body and the developing baby inside you are going through.
30The First Prenatal Visit
The first prenatal visit is the most thorough. A complete medical history is taken, a physical exam
is done, and certain tests and procedures are performed to assess the initial health of the mother
and her unborn baby.
Testing Done During This Visit
Personal medical history - Previous and current medical conditions, like diabetes, high blood
pressure (hypertension), anemia, and/or allergies
Current medicines - Prescription and over-the-counter
Previous surgeries
Maternal and paternal family medical history - Including illnesses, such as diabetes or in-
tellectual or developmental disabilities, and genetic disorders, like sickle cell disease or Tay-Sachs
disease
Personal gynecological and obstetrical history - including past pregnancies—stillbirths,
miscarriage, deliveries, terminations—and menstrual history (length and duration of menstrual
periods)
Education - including a discussion regarding the importance of proper nutrition, regular exer-
cise, the avoidance of alcohol, drugs, and tobacco during pregnancy, and a discussion of any con-
cerns about domestic violence
Pelvic exam - This exam may be done for 1 or all of the following reasons:
• To note the size and position of the uterus
• To determine the age of the fetus
• To check the pelvic bone size and structure
• To perform a Pap test (also called Pap smear) to find the presence of abnormal cells
Lab tests - including the following:
• Urine tests - These are done to screen for bacteria, sugar, and protein.
• Blood tests - These are done to determine blood type.
31All pregnant women are tested for the Rh factor during the early weeks of pregnancy. A mother
and fetus may have incompatible blood types. The most common is Rh incompatibility. Rh incom-
patibility happens when the mother’s blood is Rh-negative and the father’s blood is Rh-positive
and the fetus’ blood is Rh-positive. The mother may make antibodies against the Rh-positive fetus,
which may lead to anemia in the fetus. Incompatibility problems are watched and appropriate
medical treatment is available to prevent the formation of Rh antibodies during pregnancy.
• Blood screening tests. These are done to find diseases, like rubella, an infectious disease
that is also called German measles.
• Genetic tests. These are done to find inherited diseases, like sickle-cell anemia, Tay-Sachs
disease.
• Screening tests. These are done to find infectious diseases, like sexually transmitted dis-
eases.
Keys to success:
• Hydrate, hydrate, hydrate! Take your prenatal vitamin, DHA and Vitamin D
• Eat small meals of simple foods, avoiding spicy and highly acidic foods
• Exercise! It is important for mood and weight management.
The 12 Week Visit
At this point, you are nearly at the end of your first trimester. The baby has been undergoing a lot
of exciting changes! Your baby is about three inches long and weighs nearly an ounce. The head
is much larger than the body and the brain and spinal cord are developing rapidly. Sex organs are
forming, and while it is early to see the gender on the ultrasound, a genetic test can be ordered
during this time, which can include the sex chromosomes. Your baby is now able to open and close
his or her mouth and even make a fist. The baby is moving freely in the amniotic sac but you can-
not feel the kicks just yet.
Testing Done During This Visit
Nuchal Translucency ultrasound - This is a routine test offered to all pregnant women and
is an ultrasound performed to measure clear space at the back of a growing baby’s neck called the
nuchal fold. Research reveals that increased fluid in the back of the baby’s neck can be associated
with a statistically increased risk of certain chromosomal abnormalities such as Down’s syndrome
and other disorders of an extra copy of chromosomes.
32Blood tests - Genetic screening tests will be offered to every pregnant woman. These tests are not
invasive and involve collecting a blood sample from your arm to screen for chromosome abnor-
malities such as Down’s syndrome. A newer test called a cell-free DNA test is also available to all
pregnant women. This is also a screening test, but more accurate. The technology utilizes methods
to analyze the small amount of DNA that spills into your bloodstream from the developing baby
and placenta. Results typically take one week to obtain.
First Trimester Concerns
Early Pregnancy Bleeding
If you bleed during early pregnancy, there are two things we worry about:
• Miscarriage - more common
• Ectopic pregnancy - can be life threatening.
Just because you have bleeding early in pregnancy does not mean that you have one of these con-
ditions. But we will need to see you – typically several times – to make the correct diagnosis and to
make certain you receive the care you need. Often, bleeding during early pregnancy is just a scary
situation and your pregnancy turns out fine. However, sadly, this is not always the case.
Miscarriage
A miscarriage is when a woman loses an early pregnancy. This occurs in 20 percent or more of
pregnancies. Sometimes a woman does not even know she was pregnant; her menses might be a
few days late and then she has a heavy flow. She thinks her period was just late. Other times she
had a positive pregnancy test.
The reason most women miscarry is because the pregnancy simply did not develop correctly. Com-
monly, there are too few or too many chromosomes. This is fundamental damage to your fetus and
not compatible for a healthy life. A miscarriage can have a profound emotional impact, not only on
the woman herself, but also on her partner, friends, and family. We are sad to give the diagnosis of
miscarriage and grieve right along with you and your loved ones.
Getting support from loved ones or professional counseling is often necessary in helping with the
healing process. There are also many support groups online or at your local hospital.
Following are resources you may find helpful for your recovery process:
• H.E.A.R.T. Strings Support Group – Hope, Empathy, Alliance, Resources and Teamwork
• Perinatal Bereavement of Palliative Care. Email them at northsidepnl@gmail.com or call
them at 770.224.1817.
33Ectopic Pregnancy
When a pregnancy has not developed inside the uterus or womb but instead is located outside, it is
called an ectopic pregnancy. Ectopic pregnancy occurs in less than one percent of all pregnancies.
It is a serious diagnosis, and it can be life threatening. The most common location for an ectopic
pregnancy to implant is inside the fallopian tube. The uterus or womb is the only place a pregnan-
cy can grow into a healthy baby. If the pregnancy implants anywhere other than your uterus, you
will likely experience pain and internal bleeding. Internal bleeding is why an ectopic pregnancy is
so dangerous.
Treatments for miscarriage and ectopic pregnancy include medication, surgery, or simply close
observation. Our recommendation will depend upon your clinical presentation and medical histo-
ry. We know this is a frightening and painful time. We will always treat you liked a loved one — be-
cause you are.
Keys to success:
• Keep a list of medications that are safe during pregnancy handy (refer to index)
• Begin to learn about your clinical team and schedule appointments with as many team
members as possible going forward
• Discuss your pregnancy with your family and friends if that feels right to you and surround
yourself with a positive, supportive team.
Care Plan: The next visit will be at 16 weeks and I will officially be in my second trimester! I will
hear the baby’s heart beat and also have blood testing for neural tube defects such as spina bifida.
If I have vaginal bleeding or significant pelvic pain I will call my provider.
345
CHAPTER FIVE
The Second Trimester
The second trimester marks the beginning of your baby’s journey to using those organs that
formed in the first trimester. The brain develops quickly and begins to take over functions such
as fetal movements, breathing, suckling and sensory sensations such as sound, taste and smell by
the end of the second trimester. You start to get stronger as well. Your appetite improves and you
begin to regain some energy. The breast tenderness and morning sickness wane. The uterus grows
at a rapid pace, as does the placenta to keep up with your growing baby’s needs.
Your visits will continue every four weeks and emphasis will be placed on tracking fetal growth,
screening for complications such as gestational diabetes and monitoring the fetal heart rate using
a Doppler instrument.
35The 16 Week Visit
This is an exciting visit as you will hear your baby’s heart beat with the Doppler instrument. Your
baby is now approximately five inches long and weighs four ounces. Small, fine hair called lanugo
will grow on the baby’s head. Fingers and toes are now apparent. Your body goes through chang-
es too! The uterus is now midway between your pubic bone and your navel. You may notice an
improvement in your mood as first trimester fatigue eases up. Your friends and family will start
noticing other physical changes, such as the pregnancy “glow.”
Testing Done During This Visit
Blood tests:
Screening for neural tube defects will also be offered during this time. It is a blood test done be-
tween 16-20 weeks. The neural tube develops into the fetal brain and spinal cord. Detecting risks
of these abnormalities, such as spina bifida can be done with this simple blood test, along with an
ultrasound that will be done at 20 weeks. Folic acid is an important nutrient in the prenatal vita-
min that helps to prevent neural tube defects.
Second Trimester Concerns
Sex During Pregnancy
A woman’s sex drive may rise or fall during pregnancy. But at some point, most pregnant wom-
en will lose interest in sex. As the baby grows and the normal discomforts of pregnancy increase,
sexual activity can become increasingly uncomfortable. Ask your doctor or midwife if you have
specific questions.
Work Life
Most women can work throughout their entire pregnancies unless issues arise. There are some
obvious precautions you must take. Work that exposes you to chemicals or radiation is not ide-
al. Work that puts you at risk for falling is not good either. Some women have work that requires
strenuous physical effort, such as working in a post office, waiting tables, or certain daily chores at
home. In these cases, you may need to curtail your activities.
Please discuss with your provider what is going on in your life
so we can make recommendations.
36No matter what kind of work you do there will come a time when you will need to build in some
time to rest and put your feet up. On the other hand, if your work is sedentary or includes a lot of
sitting, build in some time for walks to help circulation.
If you have complications with your pregnancy, we may advise you to take a few days off or even
take early maternity leave.
Exercise Recommendations
Certain types of exercise are safer during pregnancy than others. Walking and swimming are ex-
amples. Both are easy on the joints and help build endurance and muscular strength, and you are
less likely to fall.
Cycling is okay early in pregnancy, but not later
due to the risk of falling. Stationary or recum-
bent biking is more acceptable. Aerobic classes
such as water and low impact aerobics and those
especially designed for pregnancy are perfect.
Other exercises such as running, racquet sports,
and weightlifting are more appropriate for preg-
nant women who did them prior to pregnancy.
These exercises should be done in moderation. If
weightlifting, make certain you do high repetition
rather than heavy weights and use proper technique. A personal trainer can be helpful.
Certain physical activities should be avoided during pregnancy. These activities can increase the
risk of injury to you and your baby. Examples include contact sports such as soccer and ice hockey.
Downhill snow skiing poses a risk of falls and injuries as well as altitude sickness, making it harder
to breathe and limiting the supply of oxygen to your baby. Scuba diving should be avoided during
pregnancy. Other activities such as horseback riding, and water skiing increase the risk of falling
and injury.
Stop any exercise immediately if you feel dizzy, faint, or short of breath. Rest and drink some flu-
ids. If you don’t feel better, be evaluated medically. Although it’s not common, any bleeding or flu-
id leakage from your vagina or significant abdominal pain or increase in pelvic pressure, requires
immediate evaluation by your doctor. Drink lots of water and wear good shoes and a supportive
bra when you are exercising. And do not go for personal physical fitness records during pregnancy!
37Weight Gain
Weight gain during pregnancy depends upon a few things, including genetics, body weight before
pregnancy, and your dietary habits. In general, a woman will gain between 25-40 pounds during
pregnancy. For first-time moms, the changes in your body are remarkable. The most important
thing is to eat healthy food.
Keys to success:
• Nutrition is key. Choose foods that are fresh — not packaged — and try to prepare foods at
home.
• Iron is essential as towards the end of your second trimester, many women get anemic. Get
a head start and choose foods rich in iron, like greens, beets, dried fruits, kidney beans, and
eggs to name a few.
• Stay active! Walking outside if weather permits is also great for stress relief.
Care Plan: The next visit will be at 20 weeks and I will have a very detailed ultrasound that will
examine all of the baby’s organ systems, including the genitals!
The 20 Week Visit
You are halfway there and bonding with your baby just reached a new level! Quickening is the
fluttering sensation or fetal kicks first felt at approximately 20 weeks. Your baby is about six inch-
es long and weighs nine to eleven ounces. The uterus is now at the navel and you may be noticing
drastic changes in your breasts. They increase in size and you may also begin to develop Montgom-
ery tubercles in the areola. These small, painless bumps have antiseptic and lubricating qualities,
and help support breastfeeding later on.
You may also begin to experience slight leakage of breast milk at this time. This milk is colostrum,
or the first form of breast milk. These early signs of your body preparing for delivery are encour-
aging and normal. This is also a great time to get your partner involved. Allowing your partner
to experience the sensations of fetal kicks and be present during the ultrasound, helps with their
bonding too.
Testing Done During This Visit
Anatomy ultrasound: This is a detailed ultrasound that generally takes 30-45 minutes and is
an important part of your prenatal care. All of the baby’s organ systems are examined for proper
growth, size and anatomic location.
38The placenta will also be closely examined for its position. The cervix and its length may also be
examined. Other pathology such as fibroids or ovarian cysts will be measured and addressed if
present. Please invite your partner also if possible! It is important to hydrate yourself well and
optimally have a snack or a meal prior to the exam.
Keys to success:
• This is a great time to learn and sign up for childbirth classes.
• Topics to concentrate on may be labor techniques, pain control during labor, breastfeeding,
baby safety and CPR, and big brother/big sister training.
Care Plan: The next visit will be at 24 weeks and I will be having a quick appointment to check
the baby’s heart beat with the Doppler and address any concerning pregnancy changes I may be
experiencing.
The 24 Week Visit
This gestational age is a key milestone, because it marks the point when your baby is viable outside
your body should you develop preterm labor. Talking about preterm labor symptoms and pre-
vention is key. You may be experiencing Braxton-Hicks contractions and differentiating from real
labor is important. Managing chronic medical problems is also crucial. At this stage your baby is
approximately 11 inches long and 1.5 pounds. Your baby’s sensitivity to hearing is increased. You
may notice the baby’s movements increase when you or your partner are playing music or talking
to him or her.
Now let’s talk about the placenta — “the organ of life”. You may be curious whether your baby
is getting all the nutrients it needs and also how well your baby is being protected from harmful
environmental substances. The placenta, which is connected to the umbilical cord, is helping to
exchange nutrients and oxygen to your baby. It also functions as an endocrine organ producing
hormones important in metabolism. Human placental lactogen and placental growth hormone to-
gether increases your insulin resistance, this leaves more circulating glucose to cross the placenta
for the baby.
However, it can also increase your risk for gestational diabetes if you consume too many simple
carbohydrates and do not get enough healthy fats and protein in your diet. The health of your pla-
centa can be affected by other factors also. High blood pressure, blood clotting disorders, maternal
age (for example, problems with the placenta are more common in women who are older than 40),
trauma to the abdomen, substance misuse, and a history of uterine surgery are all factors that can
affect placenta health.
39Testing Done During This Visit
Assessment of fundal height: Your provider may take a measuring take to determine the dis-
tance between your pubic bone and the top of the uterus. Most of the time this measurement will
coincide with your gestational age. However if consecutive measurements are not consistent then
another ultrasound to check for growth may be ordered.
Fetal heart rate: The fetal heart rate is considered normal when 110-160 bpm.
Pregnancy Concerns
Threatened preterm labor
As mentioned earlier, it is important to know the signs of preterm labor. Preterm labor pain may
come in the form of lower abdominal cramping or even low back pain. You may experience more
pelvic pressure. Other symptoms such as vaginal bleeding or leaking fluid are also concerning.
Sometimes you may feel a strong cramp that will release in a minute or so and come every 10 min-
utes or more frequently.
All of these symptoms are concerning and notifying your provider will help early detection and
intervention. At 24 weeks, your baby is able to survive with proper, timely intervention in a level 3
NICU. Northside Hospital-Cherokee has a level 3 NICU. The number one cause of preterm labor is
history of preterm labor. Thus if you have a history of preterm birth it is crucial to discuss this with
your provider at your first prenatal visit, as there are treatments as early as 16 weeks that can help
prevent another preterm birth.
Chronic medical problems
You may have a chronic medical problem that was present even before you found out you were
pregnant. These were most likely discussed at your first prenatal care visit. Some women have
history of high blood pressure, diabetes, thyroid conditions, and asthma to name a few. It is of the
utmost importance to have your medical condition under control and closely monitored.
Multiple gestation like twins
Finding out you have more than one baby growing can be exciting and frightening at the same
time. If you have been diagnosed with twins for example, you will have growth scans every 4 weeks
starting at this 24 week visit. Your nutrition, risks for preterm labor and fetal growth restriction
will all be points of discussion at each of your visits-but even more crucial nearing the mid-late
second trimester. Your need for increased frequency of visits will be determined by your care team.
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