When You’re Expecting

North Shore Associates

In Gynecology and Obstetrics, S.C.

Debi Lesnick CNM

Gaye Koconis CNM

Carrie Hanson CNM

Barbara Minnich CNM

Kendria Oliver-Hudson CNM

2500 Ridge #301	2550 Compass Road Unit J

Evanston, IL 60201	Glenview, IL

847-475-1224	847-998-9600

Debi Lesnick CNM ** Gaye Koconis CNM ** Carrie Hanson CNM

** Barbara Minnich CNM ** Kendria Oliver-Hudson

Certified Nurse Midwives

In association with Board Certified Obstetrician-Gynecologists:

H. Jacob Saleh, M.D. Pamela Goodwin, M.D. Gail Goldberg, MD

Kim Johnson, MD Abbe Kordik, MD

2500 Ridge Ave Suite 301, Evanston, IL 60201	847-475-1224

2550 Compass Road, Unit J Glenview, IL 60025	847-998-9600

We are glad you are considering or have chosen a nurse-midwife for your care. Soon we may know a lot about you; let us tell you a little about ourselves.

Debi: During my junior year at Barnard College in 1969 my husband and I went to live and study in Florence, Italy. I was pregnant and asked a woman whose children we were tutoring to recommend a doctor. Her reply baffled me. She insisted I go see her midwife! Before making this appointment we went to tour the maternity unit at the University Hospital. I was horrified by what I saw. There was a huge ward with women alone and frightened and screaming…so off to the midwife I went. I found the attention, warmth, and knowledge that I was hoping to find in a health care provider. I had a wonderful pregnancy and birth experience (I ended up being my own midwife since my labor went so quickly, but that’s a different story). I later found out that the reason I had to see a midwife was that it was required by law that a midwife signs all birth certificates!

In any event, I began to think about becoming a midwife during that year in Italy. Upon our return to the U.S. in 1970, I compared obstetrical notes with friends who had their babies here, and found that I had far and away a happier time having my baby with a midwife than most of them experienced in the traditional hospital setting with a mostly absent physician. My friends seemed uninformed and without choices concerning what was going on during their births. I also learned that there were a few midwifery programs in this country.

Continuing to follow my husband on his academic circuit, I studied at Oberlin, and finished my degree in Anthropology at the University of Rochester. Subsequently I also studied physics at Brown University, as well as Dante in the medieval Italian, and chemistry at Hiram College. We moved often, including back to Italy for a few extended periods. My second child was also born in Florence. By the time we were settled at the University of Alabama, my children were in school and I began a nursing program with the long range plan of attending midwifery school. During this time my third child was born. I worked as a labor and delivery nurse and childbirth educator (and always aspiring midwife) for ten years. Finally, a midwifery program opened at the University of Alabama in Birmingham where we were living and I graduated in the first class of 1993.

Since 1993 (more then twenty years after deciding that my calling was to be “with women”) I have been working as a certified nurse-midwife, happily catching babies at Northshore University Health System and Rush North Shore Medical Center, first with Humana Health Plans and later with Women’s Medical Group, and since 1999 at Northshore University Health System and St. Francis Hospital in association with Dr. Saleh and his colleagues. I have been on the University of Illinois adjunct faculty since the mid-nineties, and also provide care for patients and teach Northwestern medical students and residents in the obstetric clinic at Northshore University Health System.

My two “Italian” children are grown. My son Tommaso is married and has a Master of Fine Arts in printmaking and lithography. He works as a graphic designer. My daughter Jane is still working on her PhD at Johns Hopkins University studying the Humanities: French, English and Art. It seems that they both were influenced by their early years in the birthplace of the Renaissance. My youngest daughter Claire has recently graduated from Oberlin College with a Philosophy degree. We share our home with three cats.

Gaye: When I was newly pregnant with my first daughter, Jordan, I found myself locked out of my apartment. While I sat in the hallway waiting for someone to bring me a key, my neighbor and I talked about pregnancy, and she told me about the Bradley method of childbirth, a philosophy she had used during her labor. Later, after I was back in my apartment, she brought me the Bradley book, and I began reading it.

Strongly influenced by Bradley, I chose to approach my pregnancy and birth more naturally, and sought out midwife care. After an uneventful, normal pregnancy, my daughter Jordan, 10 days beyond her due date, began slowing down her movement. An ultrasound indicated she had a decreased level of amniotic fluid and my midwife recommended induction. I found myself with many interventions I had wanted to avoid, like continuous monitoring, IV’s, and Pitocin, but I still strongly believed my body was able to naturally birth a baby. Aside from the pitocin, I was able to have a non-medicated birth. While not exactly as I had planned, it was a very empowering experience.

At the time of Jordan’s birth, I was a high school English teacher. My original life plan was to teach for a few years and go to law school. I began to question that path after Jordan’s birth, but I had no medical background and changing to such a different path seemed impossible.

My second child, Conor, was born in 1993. Conor was two weeks late, but I was able to avoid pitocin and its associated interventions, for a “natural induction”, and he was born without continuous monitoring, IV’s or medications. It was a great way to have a baby! When Conor was born, I was no longer teaching, but working as a paralegal for an attorney. Soon after he was born I asked myself “if something catastrophic happened in the world, would we need another lawyer or a midwife?”. I decided to become a midwife.

After completing my BSN at Loyola in 1996, I worked as a labor and delivery nurse for 6 years until I completed my MS at UIC and become a Certified Nurse Midwife in 2002. I had two other children while in graduate school – Mikayla (only 8 days late and spontaneous labor!) in 1999; and Aidan (another “natural induction” at 42 weeks) in 2001.

Since 2001, I’ve worked as a midwife with the primarily Hispanic women of Pilsen at Alivio Medical Center, and with a private practice in Hinsdale. I have been with Northshore Obstetrics and Gynecology since 2005, very much enjoying my work with women who know about and choose midwifery care, in a neighborhood I am familiar with and live in. My goal as a nurse midwife is to always remember how special birth is, to treat each woman and her family with the individuality they deserve, and to respect each birth as the unique experience it is.

Carrie: I first learned about midwives while in the Peace Corps in Ecuador. A friend had decided to have a baby while in Ecuador and decided to deliver with an Australian midwife. My friend described the midwifery philosophy of birth and the support of women in labor. I decided to look into midwifery and when I returned to the States, I read everything I could about it. It complemented my desire to work in a medically-oriented profession; my dedication to women and their empowerment; and my confidence in natural healing. I received my undergraduate degree in nursing from the University of Wisconsin-Madison and I graduated from the University of Pennsylvania in 1994 in midwifery.

The first baby I ever caught was a beautiful baby girl born in a birth center in Pennsylvania. The mother was a 40 year old university professor who was so strong, so confident and so positive that she never let me, as a new provider, ever doubt that things would go well. I was so lucky to be with her for my first experience and I will always be thankful to her. After the baby was born, I remember driving home at the crack of dawn thinking, “wow a baby was born! Doesn’t anyone else realize what just happened? A BABY WAS JUST BORN!!!”

It has been 18 years since that time and in those years, I have delivered babies in their homes, in small hospitals, in big hospitals, in bath tubs and on the floor. I have cared for women from many different backgrounds and participated in many different labors. I am continually amazed and impressed by the birth process and the strength women have to birth their babies.

I am married to Sam and I have 2 sons, Nicholas and Alexander. They are an experienced midwife-family and are quite familiar with what my life passion and work entails. They are supportive and fascinated by what I do.

Barbara: When I went to nursing school, I had every intention of becoming an ER nurse. My first job as an RN had me working the Med/Surg floor to obtain a year’s worth of experience before transferring to the ER. It didn’t take long before I knew that Med/Surg was not for me. A few months in, a chance encounter in the elevator with the Director of Nursing opened my eyes to the area of Obstetrics. They had an opening, and she asked if I would be interested. Because I would have done anything to escape Med/Surg, I said yes. I knew right away that this was the place for me. Becoming an ER nurse was but a memory.

One evening, our charge nurse gave us all a copy of Ina May Gaskin’s Spiritual Midwifery. The seed was planted. It took almost 14 years, but the time was finally right to go back to school.

In my 16+ years of working as a Certified Nurse-Midwife, I have worked in a variety of settings, with women from every walk of life. One constant remained- every birth has been a unique and exciting experience, something which I will never tire being a part of.

Long ago, I committed myself to providing safe, individualized women’s health care; first as a Registered Nurse and now as a Certified Nurse-Midwife. My philosophy is simple- partner with each woman to assist/support her in achieving her health care goals- whether they be a supported, family centered birth, or a smooth transition through menopause.

In my spare time, I enjoy running, reading, baking, and spending time with my family.

Kendria: From childhood I’ve been intrigued with women’s health concerns and childbearing. I was always questioning my mother about the female body and reproductive process. While my siblings were playing, I was reading biology books, women’s health pamphlets, and watching the “Miracle of Life” on the Discovery Channel.

During my junior year of high school, I had an opportunity to shadow labor and delivery nurses. It wasn’t just an observation experience. They put me to work! I supported the patient during epidural placement, held a leg while she pushed, then assisted with cleaning and examining the newborn. I was amazed at the mother’s strength, the wonders of her body, how the nurse knew what to do for this mother and baby. It was an honor to participate in the exclusive birth event. I really enjoyed providing support and encouragement to that mother. I knew that this was where I belonged. Immediately, I began to research a path into maternity nursing. During research, I came across the concept of midwives. What could be better than supporting a woman through the entire journey of pregnancy to delivery!

I attended Loyola University Chicago’s nursing program. My last rotation was at Evanston Hospital Labor & Delivery. It was there that I met Trish Woollcott and Debi Lesnick. I chose to follow their patients every opportunity I had. The midwives had knowledge of what a woman’s body could do and how to assist her through the delivery process. Every experience reaffirmed my desire to become a midwife. In 2002 I completed Loyola’s BSN program and began working as an L&D nurse at Evanston Hospital.

After three years of L&D experience, I decided to pursuit my midwifery dream. I entered UICs Mater’s of Nursing program for Midwifery and Women’s Health Nurse Practitioner. During my last semester of the program, I delivered my first daughter with Debi. Giving birth was an empowering experience. It was proof that my body is strong and efficient. I also felt that I could now better empathize and educate my patients. I was able to complete my coursework (with baby in tow) the summer of 2008. Being a new mother, I took time to enjoy my baby before starting work as a midwife. In 2010 my second daughter was born (delivered by Debi).

In recent years, I have been practicing as an office nurse, Women’s Health Nurse Practitioner, and Clinical Nursing Instructor. I have missed midwifery and am eager to have the privilege assist you through your pregnancy and birth experience.

Mara Evans left in February, 2014 to move to Texas.

Alyson Lippman left February 2014 to have her 3rd child.

Jenny Carney left us in May, 2006 to start law school in Michigan.

Trish Woollcott retired to the woods of Michigan with her husband in 2004.

Nurse Midwives

Certified nurse-midwives care for women as young teenagers or as wise as grandparents, and provide a wide range of gynecological services ranging from routine exams and PAP smears (we can provide most forms of birth control or hormone replacement therapy) to diagnosing and treating menstrual irregularities, vaginitis, sexually transmitted diseases, pelvic, urinary or breast infections, etc. Any problems that are beyond our expertise, like large ovarian masses, abnormal PAPs, hemorrhages, persistent infertility, etc. are referred to the physicians we work with. Nurse-midwives are committed to teaching women to care for themselves well, and consider health care a partnership as well as a service.

In addition to our gynecological practice, we have a large obstetrical history. We remain fascinated by the miracle and unfolding of pregnancy and birth, and try to find ways to combine the best of the high-tech approaches to birthing with some of the wonderful traditions of midwifery. We are committed to helping couples discover the style and balance that fits them best. There are many “right ways” to give birth, and we believe our role is to work with couples to facilitate healthy and loving pregnancies and births, being watchful for the medical and obstetrical problems that can unexpectedly occur at any time, and providing for excellent medical backup of it should be needed.

Pregnancy, birth, and parenthood are an incredible journey, full of surprises and unexpected challenges and joys. It is not easy. It is not predictable. The path is often filled with difficult choices. And it is one of the most wonderful things we will ever do.

We feel it is an honor to be trusted to be a part of this process, and are delighted to be able to work as part of your obstetrical team which include Dr. Saleh, Dr. Goodwin, Dr. Goldberg, and Dr. Johnson, who will help care for you if your medical needs exceed our expertise as nurse-midwives. Our practice is a collaborative one, with patients moving freely between midwifery and physician care, depending on their needs and preferences. The styles may differ, but midwives and physicians all share the same commitment to high quality care, and to helping you make the right choices for you and your children.

Schedule of Prenatal Visits and Common Testing

Routine prenatal appointments are every month until your 7th month, then every two weeks until your last month, then every week until you have your baby.

weeks pregnant (wks)

(from LMP)

6-10 wks	First Trimester: Includes medical and family history, risk screening, initial prenatal teaching, physical exam with PAP, and cultures, blood work (hemoglobin to check iron levels, syphilis test, rubella (German measles) immunity, Hepatitis B screening, bloodtype and Rh factor, antibody screen, HIV screen and urine analysis.

10-14 wks	Chorionic Villi Sampling if desired to determine fetal chromosomes if mom is over 35 years of age or couples who have an increases risk of genetic diseases.

First Trimester Down Syndrome Screening (BUN) if desired to screen for Down Syndrome or trisomy 21 and trisomy 18

10-20 wks	Free Fetal DNA (also called Harmony, Maternity 21, Sequonom, or Non-invasive Prenatal Testing (NIPT)). This test is a blood draw that analyzes fetal DNA fragments to determine the risk for three chromosomal abnormalities and to determine sex chromosome abnormalities: Down syndrome, Trisomy 18 and Trisomy 13. This test has so far only been validated in “high risk” women (i.e. 35 years or older, previously affected pregnancy, or abnormal BUN or abnormal ultrasound.) This test has a 99% detection rate for Down syndrome, 97-99% detection rate for Trisomy 18, and 60-92% detection rate for Trisomy 13.

11-14 wks	First Trimester Down Syndrome Screening (BUN Test) if desired, includes a blood test and an ultrasound to screen for Trisomy 21 (Down Syndrome), Trisomy 13 and Trisomy 18.

15-20 wks	Alpha Fetal Protein (AFP) if desired, which is a blood test to screen for neural tube defects.

15-18 wks	Amniocentesis if desired to determine fetal chromosomes or genetic screening, by women over 35 years old, or couples with an increases risk for neural tube defects or genetic diseases.

18-22 wks	Ultrasound to confirm dates, check fetus for obvious abnormalities, check placental location. Ultrasounds can be done in our office and/or at Fetal Diagnostic Centers at Evanston, Glenbrook, Highland Park, or Skokie. If baby cooperates you may find out his/her gender, if you want.

24+ weeks	Childbirth education classes. Classes usually start in the 6th or	7th month. See list of teachers and classes.

26—28 wks	Blood work to check hemoglobin (iron levels) again, and to screen for gestational diabetes. You will drink a cola drink containing 50 grams of sugar (or eat 26 jelly beans) wait one hour, and then have your blood drawn to check sugar levels. We also check your urine for infection one more time.

28 wks	Rhogam injection after negative antibody screen if you are Rh negative and the father of the baby is Rh positive.

35-37 wks	Group Beta Strep (GBS) vaginal/rectal culture. While GBS is a normal present in the vagina and bowel of about 10-30% of women, we now know it can be dangerous for newborns. Accordingly, we check all women for GBS in the last month of pregnancy. If you are found to be a GBS carrier, we recommend treating you with antibiotics while you are in labor, in order to decrease the amount of bacteria the baby might be exposed to during delivery. Since Penicillin is our preferred antibiotic for GBS, please be sure to remind us if you are allergic to penicillin when we collect the culture.

Second and third trimester: If this is the first time you plan to breastfeed, please attend breastfeeding classes. For first time parents, consider attending classes on parenting, newborn baby care etc. See list of classes available at Northshore University Health System, sometimes with prenatal classses, and possibly through La Leche League.

Plan a tour of the hospital. If you have other children over the age of three, Evanston occasionally has a sibling tour available that most kids really enjoy. Schedule these well in advance since they are very popular.

If you are considering having your other children attend this birth, they will need to attend special “Sibling Birth Class” given by the labor and delivery nurses, and each child will need an adult attendant at the time of the birth.

Around the 7th month we start seeing you every two weeks, and this is a good time to make sure you have had appointments with all the midwives. If you are interested, you are also welcome to make an appointment with one of our collaborating physicians, Dr. Jacob Saleh, Dr. Pam Goodwin, Dr. Kim Johnson, Dr. Goldberg and/or Dr. Kordik, so that if you have a problem towards the end of the pregnancy that requires their expertise-such as a breech baby, preeclampsia, or preterm labor- you will have met one of them already. One of the physicians is always available if needed when you are in labor and delivering with your midwife.

37-42 wks	Your baby can come any time!!! If you have not delivered by 40 wks, plan an ultrasound to check amniotic fluid levels and a non-stress test (NST) to be sure your baby is healthy. We repeat this testing twice during your final week 41-42 weeks.

If you are sure of your due date, we usually consider inducing labor if you go more than two weeks past that date. Most studies show increased risks to the baby with an “old” placenta, with increased chances of the more mature baby having passed meconium (bowel movement) into the bag of waters (which can be dangerous if it gets into the baby’s lungs), and with the increased possibility that there is not enough fluid in the bag of waters to dilute meconium as well as to protect the umbilical cord.

As always, decisions about induction or waiting for labor to start spontaneously are made jointly, after discussions of risks versus benefits. Every situation is different. Remember, there are usually several “right ways” to do things, and we will do our best to help you discover what seems right for you and your baby.

Pregnancy Warning Signs

Please call or page us at any time if you have any of these signs during your pregnancy. Most pregnancies develop normally, and the range of normal is very wide, but we prefer to err on the side of caution. So do not hesitate to call even if “you are not sure” if you have a problem or not.

Constant Vomiting: This is not the same as morning sickness, when you might throw up once or twice a day but are able to keep some meals and fluids down in spite of feeling miserable. Severe vomiting can occur at any time in the pregnancy and usually accompanied by weight loss.

Vaginal Bleeding: First trimester up to 14 weeks: Painless light spotting-pink, red, or brown-is quite common in the first trimester when the placenta is growing very rapidly. It is also common after a PAP test, cervical cultures, sex or vaginal exam, because of the increased circulation to the cervix. However, if you have cramping and have bleeding that resembles the start of a menstrual period, please call. Often the pregnancy is still fine, but there is an increased risk of a miscarriage or ectopic (tubal) pregnancy. If we have heard the baby’s heart tones in the office already, the chance of miscarriage is much less, 2-4%.

14 weeks to 36 weeks: You should call at once if you have any bleeding at all. It may be due to a harmless infection or cervical polyp, but it may be a sign of preterm labor or placental abnormality.

After 36 weeks: Spotting is again common, especially after a vaginal exam or sex, and sometimes means that labor will be starting soon. If the bleeding is like a menstrual period, or is accompanied by abdominal pain, call at once.

Abdominal Pain: Any sharp or continuous abdominal pain that is not relieved by rest or position changes should be reported at once. Unfortunately pregnant women frequently have sharp pains under their ribs from stomach acid (heartburn) or sharp gas pains in their intestines. Very often (and more often with each pregnancy), women have “round ligament pains” on either side, or most commonly, low in their groin. These pains can be quite sharp, but are usually brief and are associated with changing positions or walking. The good news is that they are harmless; the bad news is that there is not much that you can do to avoid them. Sometimes a pregnancy support band (Renee Belt) or girdle helps, or resting on your side with a pillow between your legs, or a warm bath.

Painful Urination: Call if you have burning with urination, or urgency with increased frequency and small amounts of urine. In the first trimester, urinary frequency with no other symptoms is common but should resolve when the uterus moves up out of the pelvis. In the last few weeks of pregnancy frequent urination with small amounts may happen again as the baby’s head moves down into the pelvis.

Chills and Fever: Call if your fever goes over 101 degrees. Tylenol (Acetominephen) is safe to take at any time in pregnancy. Ibuprofen (Motrin) and aspirin are safe to take up to seven months of pregnancy.

Severe Headache: Call if you have a severe headache unrelieved by Tylenol and rest. Headaches are common in the first trimester and usually can be slept off. Sometimes headaches in the second trimester are related to excessive salt intake, so watch your diet! Severe headaches in the third trimester can be a sign of preeclampsia, or toxemia, especially if accompanied by swelling in your face, excessive weight gain, and spots or flashes of light before your eyes. Call at once!

Women with a history of migraines may suffer more or less migraines in pregnancy. DO NOT take migraine medication without checking with us first!

Excessive Swelling or Edema: Pregnant women usually have some swelling, and this is actually a healthy response to good nutrition and an increase in blood volume. In hot weather, swelling in the hands and feet is quite normal, but annoying. Exercise, support hose, and especially swimming are helpful to minimize the discomfort of normal pregnancy edema. Too much swelling (especially around the face and eyes), along with excess “water weight” and a rise in blood pressure, can be a danger sign of preeclampsia and should be reported at once.

Depression: Pregnancy is not always the romantic lovely time we would like it to be. If you feel you are slipping into a depression or find that your anxiety levels are increasing enough to interfere with your normal activities, please schedule an appointment with us to discuss this as soon as possible.

Gush of clear, greenish, or bloody fluid from the vagina: Call immediately!

Leaking of fluid from the vagina at any time: Sometimes it is hard to distinguish between urine, sweat, or increased vaginal discharge. Empty your bladder, put on a pad, and see what happens in the next hour or two and call.

Regular contractions, cramps, or backache before your 36th week: Braxton-Hicks contractions (‘practice contractions”) are common, especially if this is not your first pregnancy. But call if you have any contractions that are regularly 10 minutes apart or less for at least an hour. If you think you might behaving regular contractions, drink several large glasses of water or juice (dehydration can bring on Braxton Hicks contractions) and lie down to rest. If the contractions persist, call.

Decreased Fetal Movement: By the 30th week you should be aware of your baby’s movement at least every hour or so. Babies can have sleep cycles lasting up to 40 minutes, but when you are paying attentions you should feel your baby at least ten times in 6-8 hours. If you notice a sharp decrease in fetal movements, or no fetal movement in spite of eating and drinking to wake up the baby, and lying down on your side to pay close attention, call! Statistically, babies are most active in the evenings, and, alas, until around 2 in the morning!

What to do

Although AFP, Level II ultrasound, and amniocentesis can identify most fetuses with neural tube defects, they cannot predict how severely the baby will be affected. Some defects can be surgically corrected very successfully while a few defects result in a lifetime restricted to a wheelchair without bowel or bladder control.

Likewise, CVS, free fetal dna testing and amniocentesis can identify fetuses with Down Syndrome, but they cannot predict the baby’s potential, which varies widely.

Many couples are confused and conflicted about what they would do if faced with the terrible choice of whether or not to continue a pregnancy with a fetus diagnosed with serious problems. These are not abnormalities physicians can “fix” during the pregnancy, and the real purpose of these tests is to allow couples the choice of not continuing a pregnancy with a handicapped fetus.

Fortunately the vast majority of women will have normal babies whether or not they do testing, but we would like you to be a knowledgeable partner in the decisions about whether to test or not. There are a significant number of couples who would prefer no testing at all, primarily because they would not terminate a pregnancy for other than-or maybe even with-defects incompatible with life.

If you discover that you are one of the few women pregnant with an affected fetus, whether a neural tube defect or abnormal chromosomes, you will have extensive counseling concerning the condition, and you will have the option of terminating or continuing the pregnancy, in both cases with our full support.

There is a lot of current research concerning the identification of fetal abnormalities in utero, and new studies are published all the time. Please discuss any questions or concerns you have with us at any time concerning the appropriateness of such diagnostic testing.

Testing for Birth Defects and/or Chromosomal Abnormalities

Nobody likes to think about birth defects, especially when pregnant. But most of us worry about them. Fortunately birth defects are rare, approximately 2-3 in a hundred births. Ultrasound between 16-20 weeks is able to identify many major birth defects, but some fetal abnormalities will not be detected by either routine ultrasound or a Level II ultrasound (which is an ultrasound done by a physician with special training in high risk obstetrics).

Other tests include screening tests for chromosomal abnormalities like the BUN (or First Trimester Down’s Screening Test) and free fetal dna screening. Screening tests have no risk for the pregnancy.

REMEMBER THAT MOST OF THE BABIES IDENTIFIED BY SCREENING TESTS AS “AT RISK” ARE ENTIRELY NORMAL! If the screening test is normal that is very reassuring, but is not a promise of a healthy baby.

The only way to know for sure whether the baby’s chromosomes are normal is to do a CVS (inserting a catheter through the abdomen into the uterus or through the cervix to remove a tiny piece of the placenta) or an amniocentesis (inserting a needle through the abdomen and then through the uterus into the bag of waters around the baby so that a small amount of fluid can be withdrawn). Both CVS and amniocentesis involve some risk of causing a miscarriage.

Screening Tests

BUN (First Trimester Screen) and Non-Invasive Prenatal Testing (otherwise known as Maternity 21)

The BUN test is done both in our office and within the Northshore University Health System Network, and looks for Down Syndrome (Trisomy 21) and Trisomies 13 and 18 fetuses at 11-14 weeks of pregnancy. This method utilizes the fact that fetuses with chromosomal abnormalities often have neck edema (thickened nuchal fold) evident on the ultrasound at 11-14 weeks, and certain maternal blood tests (PAPP-A and human gonadotrophon) are elevated. By 18-22 weeks the ultrasound views of the neck are often normal, even on affected fetuses. If the computer generated “risk” is greater than the risk of a 35 year old woman, or greater than 1:270, the next step is to offer CVS at that time or amniocentesis at 15-16 weeks. The BUN tests do not evaluate the risk of neural tube defects, although some significant neural tube defects could be identified by ultrasound even at this early gestation. A normal BUN is certainly reassuring, and has no risk, but will miss a few babies who do have abnormal chromosomes.

Non-Invasive Prenatal Testing is a newer test, which is also a screening test for Trisomy 21 (Down Syndrome), and Trisomy 13 and 18. This testing can be done between 10-20 weeks, but it presently takes about 2-3 weeks to get the results. It has only been studied in high risk women (women over 34, women who have had affected babies, women with abnormal BUN or ultrasound results). In studies of high risk women it is able to pick up about 99% of babies with Down syndrome, but it is a little less accurate with Trisomy 13 and 18 (97-99% and 6-92% respectively). Some high risk women opt for this Non-Invasive Prenatal Testing instead of a BUN, so in this situation, we still do the ultrasound to measure nuchal translucency and assess for nasal bone.

AFP

This test is on the mother’s blood only, and is done between 15 and 20 weeks. AFP (or alpha-fetoprotein), can identify women at risk for having a fetus with abnormal development of the brain or spinal cord, the so-called neural tube defects, such as spina bifida. Approximately two to four women in a hundred will have an elevated AFP, indicating an increased risk for neural tube defects or other abnormalities. But since only one or two babies in a thousand actually have a neural tube defect, most of these “at risk” babies will be anatomically normal. If AFP is abnormal, the next step is an amniocentesis to see if the fluid around the baby also is elevated, and a careful Level II ultrasound looking for neural tube defects.

About 25 % of women with elevated AFP tests will have normal babies but have preterm labor, placental abnormalities, or an increased risk of severe preelampsia (toxemia), presumably because the elevated AFP reflects some underlying problem with the placenta. Unfortunately, we currently have no way to identify which women are at risk, and while 75% have entirely normal pregnancies, we generally watch all these pregnancies more carefully.

Level II Ultrasound

A Level II ultrasound can also be used to try to determine if the fetus really has a neural tube defect with about 99% accuracy. The abnormalities missed are usually rather small.

Using ultrasound to measure the thickness of the neck, the length of the leg bones, the position of the ears relative to the eyes, the size and position of the fingers, and by looking for certain cardiac or intestinal malformations, many Down Syndrome fetuses can be identified after 18-20 weeks. This method is between 50-80% accurate, depending on who is doing the ultrasound and the resolution of the machine used.

Therefore the Level II ultrasound, with no risk, can be suspicious or reassuring concerning Down Syndrome or Trisomy 18, but rarely diagnostic.

Diagnostic Testing for Chromosomal Abnormalities

CVS

Chorionic Villi Sampling (CVS) is the removal of a piece of placenta under ultrasound guidance from the wall of the uterus (through the abdomen like an amniocentesis or through the vagina and cervix) at 10-12 weeks for chromosomal or genetic analysis. This procedure is available for women who want to know for sure that their baby has normal chromosomes or does not carry certain genetic diseases. The test is done by the maternal-fetal specialists in the Northshore University Health System Network, and has a 0.5% to 3% complication rate. Occasionally the results are not clear (mosaic findings) and an amniocentesis is necessary to clarify the chromosomal analysis. Results are 99+% accurate and available within two weeks. Women for whom first trimester results are essential, or who may have unusually high risks for abnormalities, may choose to have CVS performed. CVS gives no information concerning the risks of neural tube defects, maternal AFP at 16 weeks and/or Level II ultrasound is recommended.

Amniocentesis

The fetal cells found floating in the amniotic fluid can be studied to see if the baby has normal chromosomes or carries certain genetic diseases, and the fluid can be checked for abnormally high AFP. By inserting a needle into the abdomen and uterus under ultrasound guidance, a small amount of fluid can be withdrawn for study. Amniocentesis has a small but real risk of disrupting the pregnancy (about 1:200 to 1:400), usually by causing the fluid to leak out or by infection. The results are available in about 10-14 days, and essentially 99+% accurate. A faster screening test on the amniotic fetal cells for the most common chromosomal abnormalities, a FISH analysis, can be available in a few days.

Other Available Genetic Testing Options

Cystic Fibrosis Carrier Screening

Ashkenazi Jewish Panel (which includes Cystic Fibrosis Carrier Screening)

Spinal Muscular Atrophy

Additional information is available regarding these tests, which are typically first performed on mom’s blood sample to determine if she is a carrier. Please check with your insurance company to determine coverage.

Medications in Pregnancy

Please be sure that you are taking a vitamin with iron which has 400-1000 micrograms (equal 0.4 milligrams to 1 milligram) of folic acid.

If you are on a thyroid replacement medication, (such as Synthroid), continue taking your usual pills. We will check your thyroid levels several times during your pregnancy to see if you need to adjust the dosage. Actually, postpartum is the most common time that thyroid levels change.

Minimize all other medications in the first trimester on general principles. Most medications are probably safe, but our long term data on such things is poor, and it is better to err on the side of caution. Be aware of fumes, chemical, and heavy metals that you might be exposed to at work as well.

Tylenol in moderation seems to be safe in all trimesters.

If you have a cold you may certainly use saline spray, a netti cup with salt water or Tylenol. Throat lozenges are fine, although avoid ones with excessive zinc, since we have no data on safe levels. After the first trimester, Sudafed, Tylenol Cold (which has Sudafed in it) etc. seem to be fine, as are limited use of the medicated nasal sprays such as Neosynephrine or Afrin. Unfortunately, there is almost no data on the safety of herbal preparations in pregnancy. Homeopathic remedies are probably fine since the active ingredients are at such a minuscule level. Vitamin C up to 2 grams per day (2000 mg) is safe. Of course, lots of fluids, humidifiers, long hot showers, teapots boiling in the kitchen, as well as rest and relaxation are probably most helpful.

If you think you have a vaginal yeast infection let us know so we can check under the microscope to verify it, but the over the counter anti-yeast preparations are safe in pregnancy.

Many antibiotics have been shown to be safe in pregnancy, especially the penicillin’s, erythromycins (including Azithromycin, or Zithromax), metronidazole (Flagyl), Keflex and other cephalosporins. Tetracyclins and some of the newer antibiotics are not a good idea. None the less, check with us first before taking antibiotics.

For nausea and vomiting, be sure to eat frequent meals, whatever appeals to you. Don’t drink much with your meals; separate eating and drinking times. Avoid strong odors or highly spiced foods. Try wearing the “sea bands” that provide pressure on your wrists at the acupressure site for nausea; these can be bought at most drug stores. Ginger is often helpful, try it as a hot tea or make ice tea to sip, or ginger tea ice cubes, or get some Sushi style. Fresh powdered ginger on your food may help, or mixed with cinnamon on toast, etc. Mint may also give you some relief. Vitamin B6, 10-50 mg. every 4-6 hours may help. If you tend to throw up brushing your teeth, AVOID toothpaste with fluoride in it.

If nothing else works, try combining Vitamin B6 25 mg. with over the counter UNISOM.

Unisom is a sleep and antinausea antihistamine that was used extensively in the past combined with B6 for pregnancy nausea (“Bendictin”); it was taken off the market because pregnancy related law suits, none of which were won (the extensive data clearly is very reassuring), but all of which were very expensive. For this reason, the packaging for Unisom will include a warning not to take in pregnancy. For many women it can be very helpful when all else fails.

Diclegis is a newer preparation of Vitamin B6 and the active ingredient of Unisom, which has very good safety data, and has been used for many years in Canada. It is available by prescription, so please talk to us if you feel you need additional help in controlling your nausea.

Nutrition – What not to Eat

During pregnancy, you can eat the same things that you normally eat when you were not pregnant. But especially in the first few months of your pregnancy, your baby can be hurt by poisons (toxins) or germs (bacteria). For this reason, you need to be aware of these food dangers and learn how to choose and prepare your food safely.

What Foods Might Be Harmful to My Baby During Pregnancy?

The foods of most concern are fish, meat, milk, and cheese. Because these are important parts of most diets, you will want to learn to choose the right fish, meat, milk, or cheese.

What’s the Problem With Fish?

Many fish, especially fish that are large, eat other fish, and live a long time, have mercury in them. Mercury can cause problems with the development of your baby’s brain and nerves. Fish may also have dioxins and polychlorinated biphenyls (PCBs). These toxins may cause problems with the development of your baby’s brain and may cause cancer.

So Should I Just Stop Eating Fish?

No. Fish is a wonderful food. It has lots of good protein and other nutrients. You can continue to eat fish, but you may wish to cut down on the amount of fish you eat and change the kind of fish you eat. Information about which fish are good to eat during pregnancy is listed further down.

What Meat Is Dangerous?

In the United States most of our meat is safe to eat. However, meat that has not been kept cold or that has not been prepared properly may have germs or parasites that could harm you or your baby. Raw meat may contain toxoplasmosis. Toxoplasmosis is a germ that can damage your growing baby’s eyes, brain, and hearing.

What Do I Need to Know About Milk and Cheese?

Some cheese may contain germs (bacteria) called listeria. These germs can cause a disease called listeriosis, which may cause miscarriage, stillbirth, or serious health problems for your baby. To avoid listeriosis, be sure to eat only pasteurized cheese.

How Do I Prepare Food Safely?

. Wash your hands and cooking surfaces often.

. Keep raw meat away from raw fruit and vegetables and cooked meat.

. Cook your food until it is steaming hot. Keep uneaten food cold or frozen.

Eating Safely During Pregnancy: Fish, Meat, Milk, and Cheese

Food Recommendations

Fresh Fish

Do not eat - Shark, swordfish, king mackerel, tile fish

Eat no more than 1 meal a month - Farmed salmon

Eat no more than 1 meal a week - Albacore tuna ("white" tuna)

Eat no more than 2 meals a week - Shrimp, canned light tuna, canned or wild salmon, pollock, and catfish

Deli Meats and Smoked Fish

Do not eat - Deli meat spread

Do not eat unless you reheat to steaming hot - Hot dogs, lunch meat, deli meat, deli smoked fish

Eat no more than 2 meals a week - Canned smoked fish or meat spread

Meat, Beef, Chicken, Pork

Do not eat - Any meat that is rotten or raw

Milk and Cheese

Do not eat or drink - Unpasteurized milk, feta cheese, brie cheese, camembert cheese, blue veined cheeses, Mexican-style queso blanco fresco. Pasteurized soft cheese is ok.

Eat all you want - Hard cheeses, semi-soft cheeses like mozzarella, processed cheese slices, cream cheese, cottage cheese, yogurt made with pasteurized milk

Drink all you want - Skim or 1% pasteurized milk

Note: Check local advisories about the safety of fish caught by family and friends in your local waters. If you can’t get advice on this, eat no more than 1 meal a week from fish caught in local waters and don’t eat any other fish that week.

Cook fish by broiling, baking, steaming, or grilling. Remove skin and fat before cooking. Do not eat the fat that drains from the fish while cooking.

Cook all meats all the way through. When you eat meat, you should not see any pink inside the flesh. After cutting up raw meat, clean the cutting surface with bleach, soap, and hot water before cutting any raw fruit or vegetables.

For More Information

Tracking your diet: http://www.cdc.gov/foodsafety

Nutrition and Safety information: http://www.marchofdimes.com/pregnancy/eating-and-nutrition.aspx

Weight gain in pregnancy: http://win.niddk.nih.gov/publications/two.htm

What you need to know about Nutrition and Weight Gain

Generally, during pregnancy you should eat an additional 300 calories a day (beginning the second trimester), and if you plan to breastfeed, you should plan on an additional 500 calories a day, for a total of 1900-2500 calories/day.

Examples of 300 calorie snacks:

1 cup of fat-free fruit yogurt and a medium apple

1 piece of whole-wheat toast spread with 2 tablespoons of peanut butter

1 cup of beef and bean chili sprinkled with 1/2 ounce of cheddar cheese (You can also substitute various vegetables for the beef.)

1 cup of raisin bran cereal with 1/2 cup of fat-free milk and a small banana

3 ounces of roasted lean ham or chicken breast and 1/2 cup of sweet potatoes

1 flour tortilla (7-inch), 1/2 cup of refried beans, 1/2 cup of cooked broccoli, and 1/2 cup of cooked red pepper

The recommendations for pregnancy weight gain are as follows:

If you are normal weight before pregnancy:
Gain 25 to 35 pounds during pregnancy.

If you are overweight before pregnancy:
Gain 15 to 25 pounds during pregnancy.

If you are underweight before pregnancy:
Gain 28 to 40 pounds during pregnancy (depending on your pre-pregnancy weight).

If you have a multiple pregnancy (twins, triplets or more): See your health care provider. You will need to gain more weight during pregnancy depending on the number of babies you are carrying.

Gaining the right amount of weight will make it easier to shed pounds after delivery and will prepare your body for breastfeeding. It also helps protect the health of your baby.

It is okay to maintain a vegetarian diet in pregnancy, but important to be conscious of including enough protein, iron, vitamin B12 and vitamin D.

What is All This Weight For?
Baby	7.5-8.5 lbs
Fat and protein store	7.5 lbs
Blood	4 lbs
Tissue Fluids	2.7 lbs
Uterus	2 lbs
Amniotic Fluid	1.8 lbs
Placenta & umbilical cord	1.5 lbs
Breasts	1 lbs
Total:	28-29 lbs

What you Should be Eating

Group	Serving Size	Servings/day
Breads, cereal, rice, and pasta group	1 slice bread 1/2 cup of cooked cereal, rice, or pasta 1 cup ready-to-eat cereal	9
Vegetable group	1 cup raw leafy vegetables 1/2 cup of other vegetables, raw or cooked; 3/4 cup vegetable juice	4
Fruit group	1 medium apple, banana 1/2 cup chopped fruit 3/4 cup of fruit juice	3
Milk, yogurt, and cheese group	1 cup of milk or yogurt 1 1/2 oz. natural cheese 2 oz. processed cheese	2-3*
Meat, poultry, fish, dry beans, eggs, and nuts group	2-3 oz. of cooked lean meat, poultry, or fish 1 oz. meat = 1/2 cup cooked dried beans, 1 egg, 1/2 cup tofu, 1/3 cup nuts, 2 T.	2 (6 oz.) Peanut Butter

Exercise in Pregnancy

Fitness for Two

For many women, exercise is an important part of their lives, and they want to continue their exercise programs during pregnancy. In most cases, they can. Numerous studies have demonstrated that, in low-risk pregnancies, moderate or even vigorous exercise is safe for the baby. The American College of Obstetricians and Gynecologists (ACOG) now recommends that most pregnant women participate in 30 minutes or more of moderate exercise on most, if not all, days of the week.

Advantages to exercising regularly in pregnancy include improved fitness, relieving many of the common discomforts of pregnancy such as constipation, backache, fatigue and varicose veins. Regular exercise may also help prevent pregnancy-related forms of diabetes and high blood pressure. Fit women may be able to cope better with labor and have a faster recovery after delivery.

Pregnant women who have not exercised regularly should consider gradually increasing their activities or starting a mild exercise program to reap some of these health benefits. Women who were already regularly exercising prior to pregnancy will likely be able to continue their exercise program throughout pregnancy, with minimal modification.

Is exercise safe for all pregnant women? No. Women who should not exercise while pregnant include those who have heart disease that compromises blood flow or who have restrictive lung disease; those with obstetrical complications including preterm labor in the current pregnancy, an incompetent cervix, multiple gestation (twins, triplets or more) at risk of preterm labor, persistent vaginal bleeding in the second or third trimester or ruptured membranes (bag of waters); and those with preeclampsia (a pregnancy-related form of high blood pressure). Women with a history of medical problems, such as severe anemia or poorly controlled high blood pressure, diabetes, thyroid disease or seizure disorder should exercise only with the approval of their health care provider.

Can exercise harm the baby? There is no evidence that exercise has any harmful effects on the unborn baby, or that it increases the risk of miscarriage or birth defects in a normal pregnancy. In the past, there were few good studies on the effects of exercise on the baby. Doctors had theoretical concerns that it could trigger premature labor because exercise increases the levels of hormones that may stimulate uterine contractions. Recent studies have provided reassurance that exercise does not increase the risk of premature labor in low-risk pregnancies. In fact, exercise may actually decrease the risk.

Doctors also were concerned that regular exercise could slow fetal growth because during exercise, blood tends to be diverted to the exercising muscles and, possibly, away from the uterus. Most studies have found that exercise has no effect on birthweight, and a few studies suggest that moderate exercise may actually increase birthweight. Recent studies have found that moderate exercise in early pregnancy improves growth of the placenta. The placenta supplies the baby with oxygen and nutrients, possibly contributing to an increase in birthweight. Even though strenuous exercise may slightly reduce birthweight, it does not appear to increase a woman’s risk of having a low-birthweight baby. A 1996 study found that women who exercised strenuously throughout pregnancy had babies who were, on average, about 8 ounces lighter than the babies of a group of fit women who stopped exercising during pregnancy. However, the weight difference was mainly in body fat, and the babies remained in the normal range for weight. The researchers followed this group of babies and found that at age 5, the children of exercisers continued to be somewhat leaner than the children of nonexercisers, although their growth was in the normal range. And, for reasons that are not clear, the children of the exercisers scored significantly higher than the other children in tests of intelligence and language skills.

Does pregnancy change how a woman’s body responds to physical activity? During pregnancy, a woman’s body changes in a number of ways that alter her response to exercise. For example, a pregnant woman’s tolerance for strenuous exercise decreases as pregnancy progresses. Pregnant women require more oxygen than non-pregnant women, even at rest. As pregnancy progresses, women have to work harder to breathe because the enlarging uterus crowds the diaphragm (the large muscle separating the chest and abdomen). These changes mean that there is less oxygen available for use during exercise, making it easier to become out of breath. The cardiovascular system also changes during pregnancy. It responds differently to certain body positions. If a woman in her second or third trimester exercises while lying flat on her back, her expanding uterus may compress the major vein (vena cava) that carries blood back to the heart from the legs. This causes her heart to beat more slowly. A slow heartbeat can cause dizziness and interfere with normal blood flow to the uterus. Similarly, motionless standing also causes the heart to beat more slowly. Therefore, pregnant women should avoid these positions.

Some studies suggest that a pregnant woman’s body dissipates heat more efficiently. This adaptation may help protect the baby. The body temperature of non-pregnant women rises about 1.5 degrees F after exercising strenuously for about 20 minutes; that of fit pregnant women decreases slightly after exercise. Pregnant women should still take steps to avoid overheating, especially during the first trimester, because during this time a sustained body temperature of 102.5 degrees F or higher may increase the risk of certain birth defects of the brain and spine. However, studies have not shown any increase in these or other birth defects among babies of women who exercise vigorously during pregnancy.

Pregnancy alters a woman’s sense of balance. The enlarging uterus and breasts shift her center of gravity. High hormone levels make her connective tissues more lax and her joints may be more susceptible to injury. All of these changes determine the types of exercises that are safest for pregnant women.

What are some guidelines for exercising safely during pregnancy? These precautions can help assure that an exercise program is safe for mother and baby:

· Avoid contact sports and any activities that can cause even mild trauma to the abdomen, such as ice hockey, kickboxing, soccer and basketball.

· Avoid activities with a high risk of falling, such as gymnastics, horseback riding, downhill skiing and vigorous racquet sports.

· Avoid scuba diving throughout pregnancy. This activity puts the baby at increased risk of decompression sickness and may contribute to miscarriage, birth defects, poor fetal growth and preterm labor.

· Avoid exercising on your back after the first trimester. Also avoid prolonged periods of motionless standing. Both can reduce blood flow to the uterus.

· Avoid jerky, bouncing or high-impact movements that may strain joints and cause injuries.

· Avoid exercising at high altitudes (more than 6,000 feet) because it can lead to reduced amounts of oxygen reaching the baby.

· Eat an adequate diet to gain 25 to 35 pounds (or the amount of weight recommended by her health care provider) over the nine months. Most pregnant women require approximately 300 additional calories a day. Those who exercise regularly may require more. Diets should include plenty of carbohydrates, as pregnant women who exercise use this fuel source more quickly during exercise than non-pregnant women.

· Avoid overheating, especially in the first trimester. Drink plenty of fluids before, during and after exercise. Wear layers of "breathable" clothing and do not exercise on hot, humid days. Avoid hot tubs, saunas and Jacuzzis.

What types of exercise are best during pregnancy? Most pregnant women can continue their pre-pregnancy exercise programs, though they may need to modify some activities or decrease the intensity of workouts as pregnancy progresses. For example, a jogger who quickly becomes fatigued or breathless may switch to brisk walking.

A pregnant woman should stop exercising immediately if she experiences symptoms such as vaginal bleeding, dizziness, shortness of breath, headache, chest pain, muscle weakness, calf pain or swelling, uterine contractions or amniotic fluid leakage. Women who perform nonweight-bearing activities, such as cycling or swimming, are more likely to be able to continue exercising at high intensity through the third trimester than women who perform weight-bearing exercises, such as jogging or aerobic dancing. Nonweight-bearing activities appear to decrease the risk of injury, though bicycle riders may want to switch to a stationary bicycle, because it may be more difficult to maintain balance as pregnancy proceeds. Women who lift weights can safely continue to train with light weights (about 5 to 10 pounds) but should probably avoid lifting heavier weights or lifting weights while lying flat on their backs. If a pregnant woman is just starting an exercise program (with her health care provider’s OK), walking, swimming and cycling on a stationary bicycle are activities that are usually safe.

When can postpartum exercises begin? Once the baby arrives, a woman generally is eager to regain her pre-pregnancy figure. If she has exercised regularly during pregnancy, she is that much closer to her goal: the stamina and muscle tone she acquires will allow her to build up to her previous level of exercise more quickly than mothers who do not exercise regularly. New mothers who resume exercise (and moms who breastfeed) lose more weight than those who do not exercise, and most exercising mothers are back to their pre-pregnancy weight by their baby’s first birthday. A 1999 study showed that exercise has psychological payoffs for new mothers. Women who resumed their exercise program within six weeks of delivery felt better about themselves and adjusted more quickly to being a mom than women who did not exercise. While exercise benefits body and mind, women need to remember that pregnancy-related changes in bodily systems (such as the cardiovascular system) persist for about four to six weeks after giving birth. Therefore, a woman should start slowly. If she feels pain or has other unusual symptoms during a specific exercise, she should temporarily avoid that exercise (or do fewer repetitions or a shorter routine). A woman who has had a cesarean delivery should not exercise strenuously until her health care provider gives her the go-ahead.

http://win.niddk.nih.gov/publications/two.htm#physicalactive

http://www.marchofdimes.com/professionals/14332_1150.asp

Traveling in Pregnancy

Factors Affecting the Decision to Travel

In general, there is nothing inherently unsafe in traveling while pregnancy. Women may be most comfortable traveling during their second trimester (18-24 weeks) since their risk of spontaneous miscarriage or premature labor are quite low.

Preparation for Travel

Some considerations while traveling:

Ensure health insurance is valid while traveling abroad

Check for available medical facilities at destination site in case of emergency

Consider taking a copy of your prenatal record with you if you are traveling in your 2nd or 3rd trimester of pregnancy

Remember, pregnant women are more likely to experience blood clots simply due to the hormonal changes of pregnancy, and sitting for prolonged periods of time increases that risk. Increasing water intake, ambulating often and flexing the calf muscle while sitting are ways to help avoid blood clots.

Signs and symptoms that indicate the need for immediate medical attention are bleeding, passing tissue or clots, abdominal pain or cramps, contractions, ruptured membranes, excessive leg swelling or pain, headaches, or visual problems.

Air Travel during Pregnancy

Commercial air travel poses no special risks to a healthy pregnant woman or her fetus. The American College of Obstetricians and Gynecologists (ACOG) states that women can fly safely up to 36 weeks gestation. The lowered cabin pressures (kept at the equivalent of 1,524–2,438 meters [5,000–8,000 feet]) affect fetal oxygenation minimally because of the favorable fetal hemoglobin-oxygen dynamics.

Severe anemia, sickle-cell disease or trait, or history of thrombophlebitis are relative contraindications to flying. Pregnant women with placental abnormalities or risks for premature labor should avoid air travel. Each airline has policies regarding pregnancy and flying; it is always safest to check with the airline when booking reservations because some will require medical forms to be completed. Domestic travel is usually permitted until the pregnant traveler is in her 36th week of gestation, and international travel may be permitted until weeks 32–35, depending on the airline. A pregnant woman should be advised always to carry documentation stating her expected date of delivery.

Travel to High Altitudes during Pregnancy

All pregnant women traveling to high altitude should avoid altitudes > 4,000 meters (13,123 feet). In addition, altitudes >2,500 meters (8,200 feet) should be avoided in late or high-risk pregnancy. All pregnant women who have recently traveled to a higher altitude should postpone exercise until acclimatized.

http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-8/traveling-while-pregnant.aspx

Resources

Childbirth Education:

Birthways	Ohana

3717 North Ravenswood Ave #140	2956 Central Street

Chicago, IL 60613	Evanston, IL 60201

888-506-0607	872-222-9234

www.birthwaysinc.com	ohanaparents.com

Mother Me Inc.	Birthing from Within

Rita DiRito-Surgal	birthingfromwithin.com

www.mothermeinc.com

Yoga and Prenatal Classes	Bradley Instructors

Grateful Yoga	(www.bradley.com)

Lela Beem

Evanston, IL	Barb Lindgren

847-644-3623	Mundelein, IL

http://www.gratefulyoga.com	847-566-6511

b.lindgren@sbcglobal.net

Sweet Pea’s Studio	www.birthbabynaturally.com

3717 North Ravenswood #213-214

Chicago, IL	Denyse Ffrench

http://sweetpeasstudio.com/	Classes at Swedish Covenant & Sweet Pea

773-248-YOGA	773-318-2096

www.denyseffrench.com (also teaches private classes)

Bloom Yoga

4663 North Rockwell	Juli Billings Walter

Chicago, IL	Classes at Swedish Covenant Hospital

773-463-YOGA	Chicago, IL

bloomyogastudio.com	773-725-8891 www.juliwalter.com

Ananda Within Yoga	Karalyn Voelkner

Private, group, prenatal and postnatal yoga	Western Suburbs

www.anandafromwithin.com	630-788-7389

1841 Waukegan Rd

Glenview, IL 847-769-9410

Doula Support: Please ask for a list of resources

Chiropractic Care:

Lapp Chiropractic	Thomas Bayne

400 Lake Cook Road # 100A	535 Lake Cook Rd # 404

Deerfield, IL 60015	Northbrook, IL

847-714-1531

Well Adjusted Mother & Child	Robert Richart

Sean Manning	Certified Chiropractic

708-257-5107	908 Waukegan Road

715 Lake Street #273	Glenview, IL 60025

Oak Park, IL 60301	847-657-8686

Lactation Support:

Evanston Northwestern Lactation Support	Faith Fairclough, RN BSN IBCLC

847-570-2000	847-867-3218

(main number)	lakeshorelactation@gmail.com

(Faith has support group in our Glenview

Office on Tuesdays 10-11am for $10.00)

Lactation Associates, Inc.	Nancy Holdsworth

Jane O’Connor	Family Nurse Practitioner

847-509-8302	909 Davis

Evanston, IL 60201

847-866-3700

Accupuncture:

Julie Segall	The Nest

666 Dundee Road Suite 604	4650 North Rockwell Avenue

Northbrook, IL	Chicago, IL 60625

224-406-8800	773-267-0248

healinggroundtcm.com	thenestchicago.com

Mail Order Breastfeeding Supplies,

Support Stockings:

Perinatal Home Medical Supply, Inc.

808-404-7467

http://www.perinatalhomemed.com/default.aspx

Depression/Mental Health Referrals:

Northshore University Health System

888-ENH-MOMS

Susan Feingold	Libby Rosencrans	Brooke Laufer

Highland Park and Skokie	Evanston, IL	826 South Madison Street

847-831-7731	847-997-5664	Evanston, IL 847-440-7361

Cord Blood Resources:

Cord Blood Donation

ITxM Clinical Services

1-877-GIV-CORD

Cord Blood Banking

Cord Blood Registry	ViaCord

www.cordblood.com	www.viacord.com

1-800-CORD BLOOD	1-888-862-2652

Websites:

www.childbirthconnection.org

www.spinningbabies.com

ourmomentoftruth.midwife.org

www.cdc.gov

www.modimes.org

www.birthlink.com

www.breastfeedingonline.com

Books:

Pregnancy

Kitzinger, Sheila. The Complete Book of Pregnancy and Childbirth

Natural Childbirth the Bradley Way

Nilseen, Lennard A Child is Born

Noble, Elizabeth. Having Twins-A Parents Guide to Pregnancy, Birth and Early Parenting

Bing, Elizabeth and Colman, Libby. Making Love During Pregnancy

Balaskas, Janet. New Natural Pregnancy

Verny, Thomas and Pamela Weintraub. Nurturing the Unborn Child

Thomas Verny and John Kelly. Secret Life of the Unborn Child

Albi, Johnson, Catlin, Overloo and Greatwood. Mothering Twins (Advice and support from five moms who’ve been there and lived to tell the tale)

Shelly Lavigne and Penny Carter. Boy or Girl? 50 Fun Ways to Find Out

Exercise and nutrition

Elizabeth Noble Essential Exercises for the Childbearing Year

Rose Elliott Vegetarian Mother Baby Book

Holly Roberts Your Vegetarian Pregnancy: A Month-by-Month Guide to Health and Nutrition

Mariam Erick No More Morning Sickness: A Survival Guide for Pregnant Women

Sylvia Olkin Positive Pregnancy Fitness: A Guide to a More Comfortable Pregnancy and Easier Birth

Elizabeth Somer Nutrition for a Healthy Pregnancy, Revised Edition: The Complete Guide to Eating Before, During, and After Your Pregnancy

Birth

Penny Armstrong and Sheryl Feldman A Wise Birth (out of print but worth it)

Penny Armstrong A Midwife’s Story

Cassidy, Tina. Birth

Ina May Gaskin. Ina May’s Guide to Childbirth

Ina May Gaskin. Spiritual Midwifery

Shiela Kitzenger. Your Baby, Your Way: Making Pregnancy Decisions and Birth Plans

Pam England, Rob Horowitz. Birthing from Within: An Extra-Ordinary Guide to Childbirth Preparation

Ricky Lake’s movie: The Business of Being Born

Peggy Vincent. Baby Catcher: Chronicles of a Modern Midwife

Barbara Harper, Suzanne Arms. Gentle Birth Choices: A Guide to Making Informed Decisions about Birthing Centers, Birth Attendants, Water Birth, Home Birth, Hospital Birth

Henci Goer, Rhonda Wheeler. The Thinking Woman's Guide to a Better Birth

Diana Korte, Roberta Scaer

A Good Birth, A Safe Birth : Choosing and Having the Childbirth Experience You Want, Third Revised

Edition

Husband-Coached Childbirth (Fifth Edition): The Bradley Method of Natural Childbirth by Robert A Bradley, Marjie Hathaway, Jay Hathaway, James Hathaway

Cesarean Birth

Carl Jones Expectant Parent's Guide to Preventing a Cesarean Section

Lynn Baptisti Richards The Vaginal Birth After Cesarean Experience: Birth Stories

Maternity Center Association. What Every Pregnant Woman Needs to Know about Cesarean Section. Available: http://www.maternitywise.org/pdfs/cesareanbooklet.pdf

Richard Hausknecht, Joan Rattner Heilman Having a Cesarean Baby

http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000000667/Should%20I%20Have%20a%20Cesarean%20Section.pdf

http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000002465/Preventing%20Cesarean%20Birth.pdf

Breastfeeding

Sheila Kitzenger. Breastfeeding Your Baby: Revised Edition

La Leche League International. Womanly Art of Breastfeeding

Jan Riordan Practical Guide to Breastfeeding

We have additional information specific to most of these resources, including some books we are willing to loan out. Please ask!

Debi, Gaye, Carrie, Barb and Kendria

(revised 1/2/15)