Obstetrics/Prenatal Patients
• About our practice
• Prenatal Care
• Advice and FAQs
• Warning signs
• Your questions
• Birthing Classes and Hospital Tours
• Labor
• Contacting Us
• Breastfeeding
• Post Partum
• Over–The– Counter Medications
Congratulations on your pregnancy, and welcome to our obstetrics practice! We would like to give you some basic information about ourselves and let you know some of the more important general guidelines for a healthy pregnancy. We will also try to answer some of the more common questions that we are asked. Since every patient is different, and every pregnancy is unique, this general information may not be enough for you, or entirely applicable to your specific situation. We suggest seeking further information in any of the readings or web sites included in this packet.
Please feel free to write down anything you’d like to discuss further, or any other questions you may have, and bring them with you to your appointment to discuss. Our nurse and clinicians will usually have an answer or some reading material for you, or we can direct you to an appropriate source. Being informed and involved in your care will make for a healthier pregnancy. Please keep this handout in a convenient place--you may need it later!
About Our Practice
There are six physicians and three nurse-midwives in our group who provide care and support throughout your pregnancy. The physicians are Board Certified in Obstetrics and Gynecology by the American Board of OB/GYN and the nurse-midwives are certified by the American College of Nurse-Midwives Credentialing Council. Please see our bios, available in the Yale Health provider booklet. Our physicians and nurse-midwives are specialists in managing both normal and high-risk pregnancies. Our nurse-coordinators are available daily for phone advice and to assist you with any concerns. Each of us is dedicated to making your pregnancy and delivery as enjoyable and as safe as possible. Our obstetricians are Doctors David Fox, Joann Knudson, Cynthia Negron, Ann Ross, David Roth, and Linda Starace. Our nurse-midwives are Betsy Cole, Rochelle Kanell, and Deborah Meredith. Of these nine clinicians, five physicians attend deliveries at Yale New Haven Hospital. Dr. Steven Fleischman, a partner in another community practice, covers some nights and weekends. They share call days equally, delivering whichever patients of our group are in labor that day, evening, or night.
We admit our patients to Yale-New Haven Hospital. The quality of nursing care in the Labor and Birth unit, as well as the nursery and neonatal unit, is excellent. We are fortunate to have a close professional relationship with the Department of Maternal-Fetal Medicine/High Risk OB, and from time to time we may ask physicians from that group to assist us in our practice.
While this is a group practice, we do offer individualized care. Some of you may prefer to select one clinician to see for prenatal visits, while others may prefer to rotate to all clinicians. Please communicate this at the start of your care, so that we can assist you. While we will make every effort to accommodate your requests, clinicians’ schedules and emergencies may require some flexibility in scheduling appointments. Many patients take the opportunity to meet each delivering clinician at a prenatal visit, usually in the last trimester, or when their clinician is not available. We work as a team, and we all have a similar approach to managing pregnancy, labor and delivery, which we have developed over the years. While we have not found this to be an issue for our patients, please discuss with us any concerns you may have over differences in style or information you have been given. Our group meets regularly to share information and updates about our patients.
Prenatal Care
Schedule of visits: The average length of a pregnancy is 40 weeks from the beginning of the last menstrual period (that is how we arrive at your due date). The first trimester lasts until 13 weeks, the second trimester until 26 weeks (viability starts at 24 weeks), and the third lasts until delivery.
We suggest that you make your first appointment at approximately 7-9 weeks from your last period. We will take a detailed history and provide you with general information about pregnancy. You will also see a clinician for a comprehensive physical exam. After your initial OB visit, the schedule of revisits (which usually last twenty minutes) will depend on how far along you are, and the particulars of your pregnancy. In general, visits are every 4-6 weeks for the first two trimesters, then more frequently after 28 weeks, until the last month, when weekly visits begin. With surveillance, and barring any warning signs, we usually wait up to 2 weeks after the due date before recommending delivery.
Testing: Following is an outline of the basic tests we recommend. Further tests may be necessary for specific indications.
- 1st Trimester: New OB blood panel (Maternal Blood type and Rh factor, Antibody screen, Blood count, Rubella status, Syphilis screen, HIV antibody, Hepatitis B surface antigen and baseline urine culture), Pap smear and chlamydia/gonorrhea testing referral for 1st trimester screen for genetic defects (trisomies), if desired
- 14-20 weeks: Serum screen for open neural tube defect (like spinal bifida)
- 15-16 weeks: Amniocentesis (offered if mother 35 or older, or abnormal serum screen or other increased risk for chromosome abnormality)
- 18-20 weeks: OB sonogram to check baby’s major anatomic structures
- 26-28 weeks: One-hour glucose challenge test (to screen for diabetes of pregnancy), blood count, syphilis screen, and antibody screen (and RhoGAM injection) if Rh negative mother
- 35-37 weeks: Vaginal/rectal culture for Group B Strep screening
- 41 weeks: NST (Fetal heart rate monitoring) and sonogram of fluid level
Advice and FAQs
Activity: We recommend maintaining your fitness level. Walking and swimming are good, safe activities. Due to changes in balance, please avoid the riskier sports, such as biking, rollerblading, etc after the 2nd trimester. You should avoid activities that get you so short of breath you can’t talk easily. Saunas and hot tubs may raise body temperature, and so should be avoided. Sex is safe, unless you have certain complications that we would warn you about, until the very end of pregnancy.
Diet: It is very important to stay well hydrated. In the early part of pregnancy, even if you do not feeling like eating much, it is very important to drink fluids. Keep a water bottle with you and sip frequently. Please try to eat a “healthy” diet, avoiding fats, oils, fried foods, etc. Please avoid raw/undercooked fish and meats, soft, runny cheeses and unpasteurized fruit juices and milk. Fiber-rich foods may help avoid the constipation and hemorrhoids common in pregnancy. While we recommend prenatal vitamins, they are not a necessity in healthy, well-nourished women. It is important, however, that pregnant women achieve a daily intake of 0.4mg (400mcg) of folic acid through the first trimester (to lower the risk of certain nervous system birth defects) as well as 30mg of elemental iron and 1200mg calcium (from low-fat dairy products or supplements like Tums) throughout the pregnancy.
Weight Gain: The average weight gain recommended is between 25-35 pounds. This may be more or less, depending on your baseline weight. Most of the weight gain occurs in the second half of pregnancy. Don’t be concerned if you have a small weight gain in the first few months (5-10 lbs.). We do not recommend dieting during pregnancy.
Exposures: Especially during the first trimester, when organs are forming, it is important to try to avoid exposure to toxins, medicines, drugs, infections, etc. Although there is approximately a 2-3% chance of a congenital anomaly (birth defect) happening just by chance in any pregnancy, it still pays to avoid risk where you can.
Medications: Please inform us of all medicines you take. If another doctor wants to prescribe a medication, you or she/he should clear it with us first, even over-the-counter medicines. Tylenol (acetaminophen) is considered safe to use during pregnancy. We advise avoiding aspirin, ibuprofen or naprosyn unless prescribed by an obstetrician.
- Illicit Drugs (cocaine, marijuana, etc.)—Obviously, these substances should not be used at all, and especially in pregnancy. However, we should be informed of any past or current drug use to help us assess and lower your risk. Counseling is available for anyone who needs assistance.
- Alcohol is known to cause abnormalities in the fetus. However, one or two glasses of alcohol before you realized you were pregnant are highly unlikely to cause a problem. We do recommend you do not use alcohol once you know you are pregnant.
- Cigarette smoking, including second hand smoke, decreases the oxygen supply to your baby. It is associated with poor outcomes (such as low birth weight, prematurity, learning disabilities), not to mention the risk to your health. Smoking cessation counseling is available through Yale Health, so please let us know if you are in need of assistance.
- Caffeine in small amounts has not been associated with pregnancy problems.
Infections: Resistance to infection is diminished in pregnancy. Certain infections can affect the baby, and some infections are harder to treat in pregnancy. Therefore, we recommend avoiding exposure to infections when possible. Common colds do not harm the fetus. Some infections to avoid are: rubella, toxoplasmosis (from undercooked beef and handling outdoor cats), Fifth disease, listeria (from soft and unpasteurized cheeses, tainted meats), TB, and, of course, STD’s like chlamydia, gonorrhea, syphilis, hepatitis, and HIV. Please inform us if you think you may have been exposed. Most people have had chicken pox, but if you don’t remember having had it, we can check your immunity. Flu vaccine is safe in pregnancy (we encourage our OB patients to be immunized), but you should not get a rubella or chicken pox (varicella) vaccine during your pregnancy.
Safety: You are now responsible for another life, so please be safe. Seat belts are safe in pregnancy. Make sure to wear the lap belt low, over your hip bones, not your belly. Shoulder belts add to safety. Keep your seat as far back as you can from the steering wheel and still have proper control of your car. Helmets are a necessity for activities such as biking and rollerblading (if you must) early in pregnancy. We also provide assistance and referral in cases of domestic violence.
Travel: Please inform your clinician of your travel plans and we can give you any specific advice. Travel is not restricted during an uncomplicated pregnancy prior to 36 weeks. After 36 weeks we advise you not to travel more than an hour or so away from New Haven—you should be able to reach Yale New Haven Hospital easily should labor occur. Please contact Member Services (432-0246) for any questions regarding Yale Health insurance coverage while traveling out of the area.
Warning Signs
First Trimester: An occasional cramp or spotting may occur in any pregnancy. However, 20% of pregnancies do miscarry in this trimester. So please call if you are having severe pain or cramps, fainting, or prolonged spotting or bleeding like a period or heavier. Pain with urination, severe back pain, or fever of 101°F or higher should also be reported.
Second Trimester: Pelvic pressure, persistent cramps or contractions, unusual vaginal discharge, or water from the vagina should be brought to our attention, in addition to the symptoms listed above.
Third Trimester: Any of the above, plus a noticeable, sustained decrease in the amount of fetal movements, should be reported. If you are more than a month from your due date, you should call if you are having painful contractions that occur more than 6 per hour and last for more than an hour despite hydrating, emptying your bladder and resting. Severe swelling (more than the usual lower leg swelling), severe headache, visual disturbances, significant abdominal pain, and diminished urine may also be danger signs.
Your Questions
Please write down any questions, especially if you are unable to find appropriate answers in your reading material or if anything you read raises a concern. We are happy to answer these routine questions at your prenatal visits. Certainly, if you have any doubt that symptoms you are experiencing might be of a serious nature, you should call any time. During our office hours, our nurse-coordinators or one of the clinicians should be able to answer your concerns. After hours, if you feel that the question is urgent and can’t wait, you can speak with the on-call doctor (see below, “Contacting Us”).
One important philosophy of our group is that you have the right to understand why we may be recommending certain tests, treatments or procedures during your pregnancy or in labor. We strive to keep you informed of all decisions. If you do not understand why we are making a certain recommendation, by all means ask.
Birthing Classes and Hospital Tours
Yale-New Haven Hospital offers a variety of programs, such as dancing through pregnancy, childbirth preparation classes, breastfeeding classes, parenting classes, sibling tours, and labor and delivery tours. If you are interested, please call 203-688-WELL or email W.E.L.L.@YNHH.org. You can also visit www.ynhh.org/maternity to review class offerings and other information.
Labor
You should call us if you break your water (either a gush or trickling), if you have heavy bleeding, or when you’ve been having painful, regular contractions. You do not need to call just for a show (discharge of mucus, small amount of blood) or loss of your mucus plug. If this is your first baby, generally you should try to wait until contractions are very painful, coming every 3-4 minutes regularly for an hour, (timed from beginning to beginning of each contraction) and lasting 40-60 seconds.
Although you might be having pains before this, it is usually too early for admission to the hospital or for pain medication. We encourage you to go through the early part of labor walking around at home and feel it is best not to admit our labor patients (if all is well) until active labor (about 3-4 cm dilation).
If you have had previous births, depending on your history and your cervical exam, we usually recommend calling a little sooner, such as when contracting regularly every 4-6 minutes.
Pain medication, if relaxation/Lamaze methods are not adequate, is an option that you may request in labor. We may also suggest it in certain circumstances, but the decision is yours. We usually try to wait until you are in active labor, and may recommend intravenous medication, epidural or spinal anesthesia, depending on a number of factors. Please understand, though, that while the timing and choice of pain relief is a clinical decision we make in consultation with our patient, it sometimes is not possible to give pain medication if there is any question it will jeopardize the safety of the mother or her baby.
We encourage you to let us know about your preferences for your labor and birth. We always make an effort to accommodate these, as long as they do not compromise the health and safety of mother and baby. If we feel that it is inadvisable to accommodate one of your requests, we will be happy to explain.
Contacting Us
Our office phone is 203-432-0222. There is a menu that will allow you to speak immediately with someone for an emergency or extremely urgent problem, to make an appointment, or to leave a voicemail message for your clinician for a non-urgent matter (such as questions, test results, etc.). If you need to get in touch with us, Monday through Friday during the hours of 8:30AM – 5:00PM please call our office number. For non-emergent calls, we will return your call as soon as possible. Please keep in mind that we are best able to respond to routine calls, including prescription refills and test results, during our regular office hours.
You may also visit www.yalehealthonline.yale.edu to register for our confidential email service. We do not correspond with our patients via “regular” email because confidentiality may be compromised.
In the case of labor or an emergency at night, during weekends, holidays, and after routine office hours, please call Acute Care at 203-432-0123. They will contact the on-call doctor who will return your call. Please stay by the phone and off the line. If we do not call back within 15 minutes, please call again. Rarely, the beep fails to go through, or the call doctor may be in a delivery or in surgery. If, instead of waiting for a call back, you feel this is a dire emergency that can’t wait, you should go directly to the hospital (call 911 if you feel it’s a life-threatening situation) and communicate this to Acute Care.
Breastfeeding
We encourage virtually all of our patients to breastfeed for as long as they can. There are many benefits for both baby and mother. The staff in the hospital is very helpful as new mothers are learning to nurse. Increasing your fluid and calcium intake is important. Since many medications may pass into mother’s milk, please check with us before taking a new medicine. The pain medications we give for postpartum are safe for lactation.
Yale Health Center Lactation Room
The Yale Health Center has a quiet space designated for mothers to breastfeed their babies or pump milk. The lactation room, located on the lower level of the building to the right of the elevators, is a safe, peaceful space with a rocking chair, footstool and refrigerator. It can accomodate one person and is available on a first come, first served basis.
Breastfeeding Resources
Yale Health offers a free Breastfeeding Class.
Your Guide to Breastfeeding (Chinese) (Spanish)
Yale Health also has three lactation counselors available for breastfeeding consultations. Women who want to speak to a lactation counselor can call:
Cris Donovan in Pediatrics, 203-432-0206
Susan Walkely in OB/GYN, 203-432-0222
Elisabeth Reilly in Care Coordination, 203-432-5266
Post Partum
Your stay in the hospital, after delivery will usually be 2 days following a vaginal delivery, and 3-4 days after a cesarean section. During this time, you will be kept comfortable as you rest, recover, and heal. Bringing home a new baby is a joyous occasion, a time to be cherished forever. There are many physical, emotional, hormonal, social, and family adjustments associated with this transition as well. Rest, quiet time with your immediate family and some help with the new responsibilities are very important, if possible. Fatigue, stress, and the “baby blues” are the opposite side of the excitement. In some instances women experience postpartum depression. If you are concerned about marked mood changes, difficulty in coping, or thoughts of harming yourself or your baby, please let us know immediately. We can refer you for help.
You will have bleeding, called lochia, which will taper off during the few weeks after delivery. You should call us for any severe pain, prolonged heavy bleeding with clots, fever over 101°F, or any problem with incisions or stitches, or signs of breast infection. We recommend nothing in the vagina until after your postpartum checkup (usually 6 weeks after delivery). Please call our office to schedule your postpartum visit. If possible, try to schedule it with your delivering clinician. During this visit we will discuss contraception options.
All our best wishes for a happy and healthy pregnancy!
Over-The- Counter Medications
Safe to use during Pregnancy
While in general we advise minimizing medication use during pregnancy, the medications listed below are safe to use if necessary.
Acne Topical benzoyl peroxide
Allergies Benadryl (diphenhydramine) 25 mg tablets or capsules, 1 or 2 up to every 4 hours as needed
Constipation Colace (docusate sodium) capsules, 1 capsule twice a day as needed
Milk of Magnesia (magnesium hydroxide)
Metamucil
Cough Robitussin cough syrup (dextromethorphan)
Congestion Sudafed
Headache Tylenol (acetaminophen) regular or extra strength
Nausea Mylanta
Tums
Vitamin B6, oral 50 mg twice a day
Vaginal Yeast Monistat, Gyne-Lotrimin, or any over the counter anti-fungal infection topical cream or suppository (NOT DIFLUCAN)
Hemorrhoids - Preparation H ointment, Anusol HC ointment, Balmex ointment
If you are prescribed any medication, be sure the prescribing clinician knows you are pregnant.
