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Questions Our Patients Frequently Ask

To learn more and read headlines about Obstetrics and Gynecology topics, please visit the American College of Obstetrics and Gynecology website at http://www.acog.org. Clicking on this link will take you out of Partners Obstetrics & Gynecology, P.A.’s web site. We do not endorse or control information contained on any linked sites.

Please click on the links below to read about these topics.

Obstetric FAQ
GYN FAQ
Medications During Pregnancy

1.  What over-the-counter (non-prescription) medications can I take during pregnancy?

OTC Medications thought to be safe in pregnancy

3rd Trimester FAQ

1. Do I really have to sign up for pre-natal class at the hospital? They cost money.

We especially encourage 1st time moms and dads to take prenatal class through HealthEast. They help prepare you for labor and your delivery. They also give you a tour of the hospital so you know where to park, where to go upon arrival and help eliminate some of the fears of the unknown. There is also a refresher course, and an online class.

2. How do I know if my water broke?

You may have a gush of fluids, or it might be a slow steady leak. Either way, if you change your underpants and they are wet right away again, you have probably ruptured your membranes. It does not have the ammonia smell of urine. Call the clinic during office hours or Labor and delivery weekend and evenings if you are unsure.

3. It feels like I’m contracting a lot. When should I be concerned?

If you are not yet 37 weeks and are having frequent contractions (greater than 5 or more per hour) we will want to try to stop your contractions, or at least slow them down. Call to come in to be evaluated, either at the clinic or at the hospital. The medication to be given if needed is only available at the hospital.

4. I can’t get my rings off or see my ankles. Does that mean I’m in trouble?

We do need to evaluate your swelling and find out if you have any other symptoms of Pregnancy induced Hypertension.

5. I have a severe headache and nothing is helping, should I come in?

If you’ve tried Tylenol every 4 hours and rested with a cold wet cloth to your forehead, we need to check your blood pressure either in the clinic or hospital.

6. I was just there for my pelvic exam and now I’m having some bleeding and I’m scared.

With your weekly pelvic exam during your final weeks of pregnancy many women have some bleeding or bloody discharge for approximately 24 hours after being examined. This is not placental blood but due to your own increased vascularity. Call if you see flowing red blood.

7. What does it mean that I have a positive Group B Strep culture result?

We let you know if you are GBS positive so you are aware that you will need to be given an IV antibiotic during labor. Many women carry GBS in their vaginal canal but their own immune system keeps them from being sick from it. However, babies can get quite sick if they contract it during a vaginal birth.

8. I’m having some shortness of breath and can’t sleep very well. What can I do?

Some women feel heart palpitations or shortness of breath due to their increased blood vascularity. Lying on your back your uterus presses on the greater blood vessels leading back to your brain, heart, and lungs that actually aren’t getting as much oxygenated blood flowing back. Also the increased size of your baby pushes on your diaphragm, making it harder to breathe. Try sleeping in a recliner if you have one, or lie on your left side for best results.

9. My baby’s movements have slowed way down should I be worried?

Try doing “fetal kick counts” to see if you get 10 movements within 2 hours. Be sure to eat and take in some fluids first. If the baby does not move after this call the office or labor and delivery

10. How do I know when I’m in real labor?

Early contractions tend to be irregular; they will become much more regular and stronger. We will send you to the hospital when they are every 5 minutes for about an hour. Be sure to call Labor & Delivery before you head in to the hospital.

2nd Trimester FAQ

1. I didn’t go to class and am now wondering if I should have any other available testing?

Since you are already in your 2nd trimester it is too late to do the 1st trimester Nuchal Translucency test. A quad screen test can be performed between 16-18 weeks to screen for Downs Syndrome. Amniocentesis is the only diagnostic test and is done between 15-18 weeks.

2. Yesterday my baby was moving quite a bit, but today it isn’t. Should I be worried?

Less than 28 weeks your baby is still small enough that if it gets into a new position you probably won’t feel it as much as you did the day before. It also can depend on the location of the placenta. Usually drinking some fluids or eating can help you feel your baby’s movement again.

3. I’m having some cramping, should I be worried?

Uterine cramping can be due to the baby growing and the round ligaments stretching. It can also be due to dehydration or doing too much. Decrease your activity level, rest, Tylenol, tub soaks, and avoiding heavy lifting can help. If uterine cramps are accompanied with spotting or bleeding, call the clinic

4. What can I do for headaches; Tylenol is not taking them away?

2nd Trimester hormonal headaches are very hard to deal with. If Tylenol isn’t helping, you may need to lie down in a dark quiet room with a cold wet cloth on your forehead. There should be no stimuli (no telephone or TV). Avoid straining your eyes. Call if you are seeing spots, blurred vision, and dizziness or vomiting with headache.

5. My ankles are getting swollen should I be concerned?

Edema or swelling can be due to the increased blood volume you have while pregnant or from prolong standing or sitting. It can also worsen in hot, humid weather or high salt intake. Try elevating your legs as much as possible, wearing support hose and drinking 8-10 glasses of fluids per day. Avoid salty foods and eat foods such as watermelon, asparagus, strawberries, and green tea. Call if you have a sudden increase in swelling, visual changes, nausea or vomiting.

6. How do I know what a contraction feels like?

Your uterus is a muscle, and just like your muscles in your arms that you don’t feel until you flex, you don’t notice your uterus until it has tightening all over. You may feel the tightness when you get out of a chair or climb some stairs, which is normal. The muscle has contracted but doesn’t necessarily hurt or cause pain.

7. I fainted yesterday at work and now I feel light-headed again. What should I do?

Your body needs time to adjust to your new increased blood volume, avoid sudden changes in position. Get up slowly, as your blood pressure can drop quickly and you’ll faint. Keep adequate fluid intake and don’t skip meals. Avoid stuffy rooms and overly long showers.

8. I didn’t pass my glucose test, what does that mean?

If you didn’t pass the One hour test you will need to schedule a three hour glucose tolerance test. This test is currently offered at St. Johns. The laboratory staff will give you an instruction sheet and fax your orders if you need to have this testing. In regards to the 3 hour test, you can fail 1 result and still pass, but if you fail 2 you will be called and told that we will be setting you up for the “Diabetes in Pregnancy Program” through Health East.

9. My tummy keeps feeling tight all over, how do I know if that’s a contraction?

If your entire uterus gets tight, that indeed is a contraction. If it’s only hard in one area, it could be the baby’s head, back or buttocks.

10. I got exposed to Fifth Disease (or Chicken Pox) at work. Now What?

If you are concerned that you have been exposed to Fifth Disease, there is an antibody test that gives us two results. The results will show if you already have immunity or if you have had a recent exposure. If the results show a recent exposure, we can re-test in two to three weeks to see if your test rises, this would show an active case.

1st Trimester FAQ

1. I am nauseated all the time, what will help me the most?

Try leaving some crackers at your bedside.

Make yourself a baggie filled with dry sugared cereal to eat as a snack between meals.

Drink fluids between meals and take Vitamin B6 three times a day with meals.

Small frequent meals can help.

Try a Unisom tablet with a vitamin B6 tablet at bedtime.

Some people need medication and the provider makes that decision

2. I throw up every time I try to eat or drink something and I’m losing weight. What should I do?

Call to schedule an appointment with your provider to be evaluated. The Physician may want you to be set up with Home Care for IV fluids and IV meds, or she may send you to the hospital for some IV fluids if she feels they are necessary.

3. Why do I have to attend a class if I’ve had a baby before?

Our Early OB Class is your initial visit to the clinic with this pregnancy. You will get your prenatal lab work drawn. You will also be able to get many questions answered without having to wait until you see your Provider at the 10-12 week visit. Two videos are shown regarding common discomforts during your pregnancy, nutritional dos and don’ts, and also information regarding exercise. Safe medications will be discussed. Chromosomal screening availabilities/options are discussed as well as what appointments you will need to make and when.

4. I don’t know how far along I am. Do I need an ultrasound or how do I know when to come in?

If you have been having regular 28 day menstrual cycles, you probably conceived on day 14 of your cycle. At your 1st OB visit, your Provider will determine if your uterus measures what it should at that time. If you have no idea when your last menstrual period was or have irregular cycles, call to speak with one of our nurses, she can get you set up for an early ob ultrasound at 7-8 weeks to help determine a due date.

5. I have some brownish discharge. Do I need to be concerned?

Brownish discharge usually means it is older blood, not current bleeding. It can happen if you’ve had a recent spike in activity levels, including sports events, stair climbing, and vacuuming, or recent intercourse within the past 5 days. You don’t need to be concerned unless it becomes bright red or fresh flowing blood.

6. Is it too soon to be having some cramping?

From the beginning of pregnancy, some women experience cramping. Ligaments holding your uterus in place can be getting stretched. Dehydration can also be a cause, or from “over doing it”. Avoid heavy lifting.

7. I have a history of miscarrying. Do I need to be seen sooner?

If you have a history of several miscarriages, your doctor has probably told you to call as soon as you get a positive pregnancy test. She may want some lab work drawn or an early ultrasound around week 7-8.

8. When does my risk of miscarrying decrease?

Up to 12 weeks gestation, the risk for miscarrying is greater. Up to 25% of all pregnancies end in miscarriage, the majority during the first trimester.

9. Can I continue the same exercise regimen?

If you were exercising prior to your pregnancy, you should be able to continue. This is not the time to join a high impact aerobics class. Walking and swimming are great during pregnancy. Keep your heart rate less than 140, stop exercising if you feel pain.

10. Why don’t I see my doctor till I’m 10-12 weeks?

10-12 weeks is the earliest providers can hear a baby’s heartbeat at your clinic appointment. If you are having any complications prior to that, they will certainly see you regarding the problems.

Postpartum Excercise

Postpartum Exercise:

Pregnancy greatly affects the abdominal and pelvic floor muscles. After birth the abdominal muscles need to be firmed and the pelvic floor muscles need to be toned to provide support for the pelvic organs in order to control urination and promote sexual pleasure. The lower back muscles may need to be stretched after going through labor and birth. It is okay to stretch right away after delivery if you had a vaginal birth without complications. Exercise in the postpartum period is beneficial for both your physical and mental health. By about six weeks postpartum most women feel ready to resume their normal exercise routines. If you ever have any concerns or questions about exercise, don’t hesitate to call us at Partners.

Tips for Success:

-Do fewer repetitions if you need to.

-Don’t exercise to the point of pain.

-Stop and rest if you feel dizzy.

-Split exercises into groups and do them throughout the day rather than doing them all at once.

-Watch your breathing; don’t hold your breath.

-Walking is an excellent way to start exercising again after having your baby, starting small with just a couple blocks and work your way up to greater distances.

-Postnatal yoga is another great way to start exercising postpartum.

Other Stretching/Exercise Options:

-General stretching: Lie on your back with a pillow under your hips with your arms above your head, feel the stretch from your head to your toes and make yourself as long as possible. Squeeze your buttocks together and tighten your abdomen for more toning. Relax and repeat. Lie on your stomach for about 10 minutes.

-Pelvic tilt/rock:  To strengthen abdominal muscles and release back ache; while lying on your back with bent knees, breathe in slowly. Tighten your abdominal and buttocks and tilt or rock your pelvis so you feel the small of your back flatten again the floor or bed. Don’t push with your feet. Hold for five seconds, and then relax. Do five repetitions three times per day.

-Abdominal tightening and breathing: To enhance abdominal muscle tone, while lying on your back with bent knees, breathe in slowly. Inhale deeply through your nose allowing the abdomen to rise up and keep the ribs as still as possible. Exhale slowly through pursed lips while tightening your abdominals. Imagine that you are touching your abdominals to your spine. Hold for five seconds and relax. Do five repetitions three times a day.

-Heel slides: To increase strength and circulation following a cesarean birth, lie on your back with your legs straight. Slide heels alternatively toward and away from you buttocks. Start doing three to five repetitions four or more times per day.

-Partial sit-ups or curls: To strengthen abdominal muscles and improve back posture, lie on your back with your knees bent and feet flat on the floor. Breathe in, tilt your pelvis and keep your lower back presses against the floor. While breathing out, raise your head and shoulders from the floor, reaching your outstretched arms toward your knees. Keep your waist on the floor. When shoulders are raised about eight inches, hold this lift for about five seconds. Relax and gently lie back. Repeat about five times per day.

-Knee to chest: To relieve back ache, lie on your back with your knees bent, feet flat, and pelvis tilted. Breathe out as your bring one bent knee toward your chest. Hold the position for three second and feel the stretch in your lower back. Repeat with other knee. Do five repetitions.

Plank position: This position is great for building back up abdominal muscles and strengthening the core. It sculpts your abs and waistline and helps improve posture. Lie on the floor on your stomach and when ready push yourself up on your elbows and toes while tightening your abdominal muscles. Try to keep your back flat and hold for as long as is comfortable. Rest and repeat for three to five reps.

-Kegels: To strengthen and tone pelvic floor muscles and increase circulation, squeeze the muscles that you use to stop the flow of urine. Hold for about 5-10 seconds, then release. May repeat up to five times.

 

Postpartum Discharge Instructions

1. Activity: Keep stairs to a minimum and no heavy lifting. If you have a toddler, encourage him or her to climb up on you lap rather than lift.

2. After pains: After delivery, uterus is hard, round, felt at naval, and weighs 2 ½ pounds; 6 weeks later is weighs only 2 ounces. The uterus contracts as it returns to normal size. Contractions are generally mild with first baby and stronger with subsequent babies, and with nursing. They last only a few days. For discomfort, try change of position, lie on abdomen, keep bladder empty, and take Tylenol or Advil.

3. Bathing: Tub baths or showers-use plain water-no bubble baths or oils or you may run the risk of infection.

4. Breasts: Wear a good supportive bra 24 hours a day for 1-2 weeks if not nursing, and continuously if nursing. If you notice a tender, redden, or warm area on one breast, this may be an early sign of infection. Call the office, hot pack the tender area, and continue to breastfeed.

5. Constipation: Reduced movement through intestines and relaxed abdominal muscles may contribute to post delivery constipation. Fear of pain from having a bowel movement may contribute. Eat a high fiber diet and drink a lot of fluids. You can use Colace or an over the counter stool softener if needed.

6. Episiotomy: Continue tub baths once or twice a day to promote healing and for comfort. It is important to keep the area clean; cleanse with tap water as instructed in the hospital. Occasionally stitches may separate at the skin level. This is not uncommon and will heal by itself. Call the office if you notice any drainage, increased tenderness, or inflammation of the stitches. It takes about 1-3 weeks to heal and may be tender.

7. Exercise: Exercise will help restore muscle strength and return your body to its pre-pregnant state. Start when you feel up to it. Start slowly and gradually increase the intensity.

8. Hemorrhoids: These are very common after pregnancy and delivery and will gradually decrease in size and may even disappear. For comfort we recommend (1) cold compresses, (2) warm tub baths, (3) over the counter ointment or suppositories such as Preparation H or Anusol HC, (4) Tylenol or Advil.

9. Vaginal Discharge/Lochia: For the first few days after delivery the discharge is bright red, perhaps with a few clots. The flow becomes darker and decreases, although the bright red flow may resume on occasion. It will gradually change to a straw-colored discharge. Expect this to last from 4-6 weeks. Activity may affect the amount of flow. If you have a dramatic increase in bleeding, rest more. Call the office if you are saturating more than 1 pad per hour. Do not use tampons. 10. Lovemaking: Intercourse may be resumed when lochia stops, or approximately 4 weeks postpartum. You may experience some discomfort at first especially if you have had an episiotomy. For vaginal dryness you can use KY-Jelly or Gyne-Moistrin. This tenderness is temporary and should improve with time.

11. Nutrition: Eat the same well balanced diet as instructed during pregnancy. Do not diet without consulting you doctor. Include plenty of fluids to prevent constipation. Continue you prenatal vitamins unless otherwise instructed.

12. Postpartum Blues: You may be surprised at how fragile, alone, and overwhelmed you feel. About 70% of women have baby blues after childbirth. Feelings of moodiness, sadness, weepiness, anxiety, and anger usually begin about 3 days after birth. These bewildering and sometimes frightening feelings usually last from a few hours to a week or so and go away without treatment. Call if your feelings are severe, last longer than 2 weeks, or disrupt your ability to function.

13. Pattern of Menstrual Period: Your period will return about 4-9 weeks after delivery if you are not breastfeeding. If you are nursing, your periods may not return for several months, or possibly not for 6-12 weeks after weaning. The first few periods may be heavier, but will gradually return to what is normal for you. You may ovulate and could become pregnant before your first period so use reliable contraception if you don’t want to become pregnant.

14. Rest: You may be surprised at how tired you become after minor activity. Plan to rest when the baby sleeps. Limit visitors the first week or so.

15. Weight Loss: You may lose up to 20 pounds within 10 days after delivery. It is best to lose about ½ pound per week, after that be patient. A well-balanced diet coupled with exercise will help you return to you pre-pregnant weight.

Warning Signs

Call immediately if you have any of the following symptoms:

  • Fever over 100 degrees
  • Nausea and vomiting
  • Frequent and painful urination
  • Bleeding heavier than 1 pad per hour
  • Red, tender, painful area on the breast
  • Persistent perineal pain with increasing intensity
  • Pain, swelling, and tenderness in leg
  • Chest pain and cough
Circumcision

We know you have been overwhelmed with information at this time in your pregnancy. However, in the event you have a baby boy, we would like you to take an additional few minutes to review the information below about infant circumcision. Infant circumcision is an optional procedure.

This information might prompt questions that can be answered by your physician at one of your prenatal visits. Read it carefully and ask about anything you do not understand.

Circumcision is an irreversible, elective operation that is controversial.

Although generally safe, the possibilities of complications that may occur with this procedure are:

A. Bleeding – Less than 1% (if there is a history of easy bleeding in the family, please alert the staff).

B. Infection – Less than 1%.

C. Meatitis – Inflammation of the tip of the penis from friction on the diaper that can in some cases lead to narrowing of the opening (meatal stenosis) that could require future surgery to correct.

D. Removal of too much or too little foreskin. In some cases, the circumcision may need to be revised.

E. Adhesions (fibrous band from the head of the penis to the shaft).

Any medical procedure has the possibility of unforeseen complications occurring.

Most physicians performing the procedure inject local anesthesia to decrease pain. There are rare, significant complications with anesthesia, and bruising of the skin at the injection site may be very common.

You should contact your baby’s doctor prior to your due date to find out how and when he/she will do your son’s circumcision if you decide to have it done.

Pediatricians

BE CHOOSY

Selecting a pediatrician or a family practice physician is a big step. Where do you begin to look? What should you expect in a baby doctor? Consider these guidelines to help you choose Doctor Right:

Pediatricians are graduates of a 4-year medical school with 3 additional years of residency training solely on pediatrics. The initials FAAP after a pediatrician’s name mean the doctor is a Fellow of the American Academy of Pediatrics and certified by the American Board of Pediatrics. To earn the FAAP designation, pediatricians must pass a qualifying exam in advanced principles and practices of pediatric care for newborn infants, babies, toddlers, children and adolescents.

Family Practice Physicians are also graduates of a 4-year medical school and have completed 3 additional years of residency training. The training prepares these physicians to provide care for the majority of medical problems that children encounter. Since family physicians care for both children and adults, the entire family can see a single physician. To become certified by the American Board of Family Practice, family physicians must also pass a qualifying exam that includes the proper assessment and care of children.

Consider these additional tips when choosing your baby’s doctor:

  • Ask your obstetrician or friends who are parents – or call the referral service at the hospital nearest you.
  • Set up an interview with each doctor during the final months of your pregnancy. You and the dad-to-be should try to attend so you both fully understand the doctor’s policies and philosophy of care.

Here are some questions to ask during the interview:

  • How soon after birth will the doctor see the baby?
  • What are the office hours? Are they compatible with your schedule?
  • How often will the doctor see your baby for checkups and immunizations
  • How are routine telephone calls handled in the office?
  • Which hospitals is the doctor affiliated with?
  • How are emergency calls handled during and after office hours?
  • Who “covers” the practice when a doctor is unavailable? Other doctors within the practice or within the community?
  • Does the practice include services provided by a nurse practitioner or physician’s assistant? If so, what type of care/service will the practitioner provide? Will you likely receive visit (s) from a home health care nurse when you come home from the hospital?
  • How much does routine care cost? Does the charge for routine visits include the cost of immunizations? What methods of payment are accepted? Is payment expected on the day of the visit? Does the doctor bill the insurance company directly?
Breastfeeding

The benefits of breastfeeding have been well documented, but many mothers find it difficult to continue to nurse when they return to work.  Often times when women are discharged from the hospital to home, they are overwhelmed and need additional help outside of the hospital setting.  Many organizations offer support and information.  Some resources include:

La Leche League:  A support group that offers information about local groups and leaders.  They also published “The Womanly Art Breastfeeding”.  Call 1-877-452-5324 (877-4 LA LECHE) or www.llli.org

Kelly Mom:  Anything and everything about breastfeeding, backed up by studies.  www.kellymom.com

WIC:  Women’s, Infants and Children have local lactation counselors and consultants on staff to help with breastfeeding needs.  Call 651-201-4444.

TALPP/ILCA:  Websites to find local IBCLCs and CLCs. www.talpp.org & www.ilca.org

 

LACTATION CONSULTS

 

Polly Torkelson, CLC (In-house Certified Lactation Counselor)

651-747-3200

HealthEast Outpatient Lactation Clinic:

651-232-3147

Preventing Preterm Labor

Pre-term birth is the most important problem affecting newborns today. Normal labor begins after the 37th week of pregnancy. Babies born before this time may experience problems due to incomplete growth and development. Pre-term labor is labor that starts more than 21 days before the due date. Early identification of pre-term labor may help prevent early delivery.

Who is at Risk for Pre-term Birth?

The following conditions may be associated with increased likelihood of pre-term labor:
1. Previous pre-term labor or delivery
2. Abnormally shaped uterus, DES daughter, uterine surgery
3. Two or more 2nd trimester abortions or miscarriages
4. Incompetent cervix, cone biopsy, large fibroids
5. Multiple gestations; twins, triplets, etc.
6. Severe kidney or urinary tract infections
7. Cervical dilation or effacement before 36 weeks
8. Excessive uterine activity before 36 weeks
9. Bleeding, placenta previa, increased or decreased amniotic fluid
10. Age less than 18 or more than 35; unusual physical or mental stress

Warning Signs:

1. Change in Vaginal Discharge

  • Gush or continuous trickle of thin watery discharge
  • Normal to have increased discharge in pregnancy.
  • Itching or burning may be symptom of vaginal infection and should be checked.

2. Bleeding from Vagina

  • Small amount after cervical checks is normal
  • Any other bleeding should be reported

3. Uterine Contractions

  • May not be painful, may feel sensation of baby “balling up”
  • Not normal to have 5 or more contractions in one hour

4. Menstrual-like Cramps

  • Low in abdomen, may come and go or be constant

5. Low Dull Backache

  • Felt below waist
  • May come and go or be constant

6. Increased Pelvic Pressure

  • Heaviness in lower abdomen, pelvis, back, or thighs
  • Feeling baby is pushing down

7. Abdominal Pressure

  • Continuous, nagging pain (like gas, indigestion, or flu) with or without diarrhea

What to Do If You Have Warning Signs:

  • If you have bleeding or fluid leakage from the vagina, CALL IMMEDIATELY
  • For other symptoms:
  • Empty bladder
  • Drink 3-4 glasses of fluid
  • Lie down on your left side with your back supported
  • Feel for contractions for one hour
  • If, after one hour, your symptoms are gone, go on with whatever you were doing

If, after one hour, you are still having symptoms, call

Between 8:30 am and 4:30 pm, call the office. After hours or on the weekend, call Labor and Delivery at the hospital where you plan to deliver.
Office 651-770-3320
St. John’s 651-232-7550

How to Feel For Contractions:

With your fingertips, press down on the uterus. It is normally soft. If it feels tight and hard, then it is probably a contraction. To time the frequency of the contractions, count from beginning of one tightening through relaxation to start of next contraction.

Things You Can Do to Help Prevent Pre-term Labor

  • Drink 10-12 glasses of water every day
  • Prevent and treat constipation—call if you are having a problem
  • Empty your bladder frequently
  • Decrease stress in your life
  • Avoid strenuous activities if they produce contractions
  • Stop smoking
  • Do not prepare you nipples for breastfeeding until 37 weeks gestation
  • Report signs of a bladder infection
  • Check daily for contractions and warning signs
Preterm Labor

If you have experienced any of the signs of a preterm labor or if you are being followed for a possible preterm delivery, the following measures may be advised.

1. INCREASE YOUR REST PERIODS. These rest periods may vary from twice a day for 2 hours each to modified bed rest, which consists of complete rest with activity limited to going to the bathroom and sitting up for meals. Again, resting on your side is helpful to keep your uterus relaxed. Also, elevating your bed so that your hips are slightly higher than your head will help to keep the pressure of your baby’s head off your cervix.

2. DECREASE STRENUOUS ACTIVITY. No strenuous physical sports or activities are to be performed, including jogging, running, tennis, frequent trips up and down stairs.

NO SUSTAINED HEAVY LIFTING is permitted, including small children, grocery bags, and laundry.

NO HEAVY CLEANING should be done, including scrubbing and vacuuming floors, changing curtains, and moving furniture.

NO LONG TRIPS are permitted, including driving or being driven for more than 1 hour.

3. EMPLOYMENT MAY BE CHANGED. Outside work may have to be decreased, stopped, or modified depending on the type of job you have and your chances of experiencing a preterm birth.

4. SEXUAL ACTIVITY. Sexual activity may be limited or stopped depending on your medical condition and your chances to experience a preterm birth. Some women may be advised to stop sexual activity if they experience any of the signs of preterm labor and to report these signs if they persist for more than 1 hour. Other women may be advised to stop sexual activity completely. If you are advised to stop sexual activity completely, it is important for both you and your mate to talk about your feelings and to express your concerns to each other.

5. BREAST PREPARATION. Preparation should be avoided until 3 weeks prior to your delivery date. Breast preparation (breast massage or nipple rolling) may cause uterine contractions.

6. CHILDBIRTH CLASSES. These classes should be attended, but you may be advised to avoid all the physical exercises except for the breathing activities. Prenatal classes presented in your home are available if you are unable to attend at the hospital.

Fetal Movement

Fetal activity is one of the most reliable and inexpensive ways to monitor fetal well-being. The fetus goes through periods of wakefulness and periods of sleep. Some fetuses are more active than others and more active at certain times than others.

Decreased fetal activity or cessation of fetal activity may be associated with fetal distress and should be investigated.

Fetal Movement Guidelines:

1. Once you begin to feel fetal movement, you should feel some movement every day.

2. The type of movement that you feel will change as the baby grows and changes positions.

3. Your baby should remain active until delivery. It is not true that the baby gets less active as delivery approaches.

4. Beginning at 28 weeks gestation you can monitor your baby’s well-being by doing Fetal Kick Counts:

  • Begin a habit of counting your baby’s movements EACH morning.
  • You should feel at least 10 movements (kicks, rolls, flutters, hiccups) in two hours.
  • Babies may be more active after you eat and drink (especially something sweet like orange juice), so do not skip breakfast.
  • If you have not felt 10 movements in two hours, lie down on your left side (this gives the baby the most oxygen) and drink some juice or have a snack.
  • Count movements in this position for one hour. If you do not feel at least 5 movements, call your doctors office.
  • You may be instructed to come into the office or labor rooms for a “non stress test.” You will be placed on the fetal monitor to observe fetal heart beats and activity. This test is a good screening tool to assess fetal well-being.
Non Prescription Medication

Nonprescription Medications Thought to be Safe in Pregnancy

(take medication according to package directions)

Nausea and Motion Sickness

  • Vitamin C 500 mg, once a day with food
  • Vitamin B6 50 mg, one three times a day
  • Unisom tablets(not gel tabs) ½ to 1 tab at bedtime; may also take ½ tab in the morning and mid-afternoon
  • Dramamine
  • Sea Bands
  • Ginger tablets

Congestion and Colds

  • Robitussin and Robitussin DM
  • Chlortrimton
  • Benadryl
  • Vicks Vapor Rub
  • Cough Drops
  • Mucinex
  • Sudafed (ok after 16 weeks)

Allergies

  • Alavert
  • Claritin
  • Tavist
  • Benadryl
  • Zyrtec

Headaches

  • Tylenol 325 mg 2-3 four times a day
  • Tylenol 500 mg 1-2 four times a day
  • DO NOT EXCEED 4,000 MG A DAY
  • DO NOT TAKE IBUPROFEN, MOTRIN, ADVIL, ASPIRIN, OR ALEVE UNLESS ADVISED BY A PROVIDER

Vaginal Yeast Infection

  • Monistat 3 or 7
  • Gyne-Lotrimin

Hemorrhoids

  • Preparation-H
  • Anuson
  • Anusol HC

Heartburn

  • Tums
  • Zantac
  • Maalox (tablets or liquid)
  • Rolaids
  • Mylanta
  • Gaviscon
  • Pepcid AC
  • NO PEPTOBISMOL (contains aspirin)
  • NO ALKASELTZER (contains aspirin)

Diarrhea (do not treat for the first 24-48 hrs)

  • Kaopectate
  • Imodium AD
  • Constipation
  • Colace (Docusate Sodium) -stool softener
  • Peri-Colace (Colace + mild stimulant)
  • Any fiber supplement (Metamucil, Fibercon, etc.)

Gas

  • Gas-X
  • Mylanta II with Simethicone
  • Mylicon

Insect Bites

  • Lotions: Calamine, Caladryl, Benedryl
  • Oral: Benedryl tabs 25-50 mg (every 6-8 hrs)
Cold & Flu

A cold is an acute inflammation of the upper respiratory tract involving the nose and throat. Symptoms usually come on suddenly. The throat is frequently irritated ~ the nose runs, there is some sneezing, and a feeling of discomfort. There may be headache, loss of smell or taste, vague aches, and occasionally a cough occurs. Later the nose becomes obstructed, necessitating constant blowing. The void may become either weak or husky.

Influenza is a viral respiratory infection that usually occurs in the winter months. Symptoms appear suddenly and include chills, fever, headache, and aches in the back, muscles, and joints. Weakness, excessive fatigue, and sweating are common. There may be mild cold symptoms such as runny nose, sneezing, sore throat, and dry or hacking cough. The acute phase of the illness runs 4-5 days, but fatigue can persist for weeks.

Since we have no medications to destroy a virus, treatment involves controlling the symptoms and keeping yourself comfortable during illness.

Because many medications pass through the placenta during pregnancy, we generally suggest you avoid using any drugs. However, during illness it may be necessary to use some medications to control fever and other symptoms. Those mentioned below are used frequently during pregnancy and believed to be safe for you and your baby if used in moderation and for short periods of time. Never take more medicine than is directed on the package. Antibiotics are not usually helpful because cold and flu are viral. They are prescribed only if a secondary bacterial infection occurs. If antibiotics are needed, we will prescribe one that is safe for use during pregnancy.

Treatment of Cold and Flu

1. Increase rest

•Bed rest makes sense if the cold or flu is severe

•Fatigue always worsens disease

2. Increase fluid intake

•Greater than 2 quarts per day

3. Fever

•Try to keep your temperature below 100.4°

•Light, loose clothing allows heat to escape from your body

•Wrapping up in a blanket or sweater retains your body heat

•A lukewarm bath may help lower your body temperature

•Use of Tylenol or other acetaminophen can be used according to the package directions

4. Congestion

•Extra humidity can relieve nasal stuffiness

•Decongestants may help dry up nasal secretions and relieve pressure in the ears

•Sudafed, Actifed, or Tylenol Sinus are fine to use

5. Cough

•Prudent use of Robitussin DM cough medicines is recommended as needed.

Nausea and Vomiting in Pregnancy

Nausea and vomiting in pregnancy is a real physical problem. In most cases it is not “just in your head”. Women experience this problem in varying degrees. The same woman may also have different experiences in succeeding pregnancies. Some experience “morning sickness”, but it is not uncommon to experience nausea only in the evening or all day long.

What causes morning sickness? At this time, we are still not sure. Nausea seems to follow the rise and fall of a hormone called HCG, which is the hormone tested for in pregnancy tests. It helps to maintain the early pregnancy. As it decreases at the end of the first trimester, nausea usually improves.

What can be done to relieve nausea and prevent vomiting? We have compiled a list of suggestions we have found helpful. Remember, each woman is an individual and what works for one may not be the answer for another. Listen to your body and eat the kinds of foods that make you feel best.

Suggestions for diet:

1. The most important rule is to eat small amounts often – even if you are not hungry. Try not to go more than three hours without eating during the day or 10 hours at night. An empty stomach triggers nausea.

2. Eat slowly and avoid foods that are spicy or high in fat. These are difficult to digest. Do not overfill your stomach.

3. Drink fruit juices, water, and milk between meals.

4. Eat a few crackers, dry toast, or vanilla wafers before rising in the morning. Stay in bed 15-20 minutes after eating and then get up slowly. Give yourself extra time in the morning.

5. Do not brush your teeth until you have been up for a while.

6. Do not skip breakfast.

7. Have a snack at bedtime that includes both carbohydrates and protein, i.e., peanut butter toast.

8. A specific food or drink may trigger nausea in one woman and alleviate it in another. Milk is a good example of this. Find out what works best for you and eliminate those foods that cause nausea.

9. Most women tolerate ice cold drinks and foods best. Sherbet and fruit juices are good examples.

10. Avoid coffee and products containing caffeine, it increases stomach acid.

11. Avoid smoking, it also increases stomach acid.

REST

Your body requires more sleep in early pregnancy. Try to get plenty of sleep at night and a short nap during the day. Being tired often triggers nausea. If you find nausea is worse in the evening, try taking a nap before dinner.

EXERCISE

Energy levels are normally low in early pregnancy and exercise may be the last thing you’d think of to relieve nausea, but getting out and walking briskly for 30 minutes each day will increase metabolism, relieve stress and psychologically improve your outlook.

VITAMINS

Vitamins B6 and vitamin C may improve nausea. There have been no definite studies to prove this effective, but some women do note improvement.

*To prevent nausea take 50 mg vitamin B6/day.

*If experiencing nausea, take 50 mg vitamin B6/meal. (Not to take more than 3 a day or take 25 mg (or ½ tablet) every 3 hours).

*Take 500 mg vitamin C daily.

*Yogurt is a good source of the B vitamin.

*If taking your prenatal vitamin increases or causes nausea, stop for 7-10 days then try again.

MEDICATION

Unisom taken as directed. It may be used with vitamin B6.

Do not take any other medication without consulting your doctor.

INFORM YOUR DOCTOR IF:

1. You cannot keep any solid food down for 24 hours.

2. You cannot keep liquids down.

3. You are losing weight.

4. You are running a temperature greater than 100°.

Remember, nausea will improve as the pregnancy progresses. By 12-14 weeks, you will begin noticing more good days than bad. Generally, in the middle months the majority of women report more energy and no nausea.

Diarhea and Vomiting

Diarrhea and/or vomiting may be caused by such things as food allergies, food poisoning, certain medications and some diseases and infections. Intestinal flu is probably the most common cause of vomiting and diarrhea. Other flu symptoms include chills, fever, backache and weakness. We generally do not recommend medications to stop vomiting or diarrhea, as most intestinal flu is self-limiting and lasts only 24 hours. Treatment involves resting the GI tract for a short period of time. You may rest assured that both you and your baby will do fine with limited food and fluid intake for one day.

Diet Instructions for Treatment of Vomiting

1. You should have nothing by mouth for 3-4 hours after the last episode of vomiting.

2. During the following 2 hours take 1 tablespoon of ice chips or water every 15 minutes if desired.

3. If this is retained, try small amounts (1 oz) of clear liquids for 2 hours. Allowable fluids are water, 7-Up, ginger ale, weak tea, bouillon, popsicles, Jell-o, apple juice, and Gatorade. No milk or dairy products. If tolerated, gradually increase the amount of liquids until your thirst is satisfied.

4. After 12-24 hours you may progress to a soft, bland diet. This is sometimes called a “white diet” and includes such foods as boiled white rice, white bread or toast, saltine crackers, boiled or mashed potatoes, baked or broiled chicken or turkey without skin, and pasta without sauce.

Dietary Instructions for Treatment of Diarrhea

1. Go on a BRAT diet for 24-48 hours.

a. This consists of bananas, rice (white), applesauce, toast (dry white).

2. Lots of clear liquids – as listed under vomiting.

3. No milk or dairy products for 72 hours.

Diabetes in Pregnancy

Diabetes is a condition that affects blood glucose levels. It can be present prior to pregnancy or may be diagnosed during pregnancy. Diabetes during pregnancy is called gestational diabetes. Either way, it required special attention and testing.

All patients (except women who already have diabetes prior to pregnancy) get tested for diabetes around the 26th week or pregnancy. This is called glucose challenge test or GCT. You are given a drink with high doses of sugar and then one hour later your blood glucose level is tested. You do not need to be fasting for this test; however, you cannot eat or drink during the one-hour waiting period. The results will be immediately available after the glucose level is checked. If it is normal, then no further testing is needed.

If the GCT is abnormal, then you need to be scheduled for a glucose tolerance test (GTT). Whereas the GCT is only a screening test, the GTT is a diagnostic test and is much more sensitive. For this test, you need to be fasting overnight. This test is performed at the hospital. You will be given a sugar drink once again and then your blood glucose levels will be tested every hour for three hours. The results will be sent to our clinic. If you do not hear from us within a week, please call the Triage nurse to discuss the results. If the GTT is normal, then no further testing is needed.

An abnormal GTT result means that you have diabetes of pregnancy. For this condition, we refer our patients to a diabetes specialist who monitors sugar levels and decides whether medications are needed (i.e. insulin).
Women who have diabetes, whether prior to pregnancy or gestational, should be aware that the following problems may arise:

  • Large Babies – Large amounts of glucose transfer through the placenta to the baby. this makes the infants larger than non-diabetic infants. This increases the risk of cesarean delivery and sometimes difficulty delivering the infant’s shoulders, called shoulder dystocia. Neither of these is predictable, but we know that it occurs more often in diabetic patients. Higher birthweight also increases the risk for diabetes in the child.
  • Preeclampsia – Diabetes can increase the risk of blood pressure problems during pregnancy.
  • Stillbirth – Fetal death has been seen in women whose sugars are not well controlled in insulin dependent diabetes.

Because of these issues, blood sugars are tightly controlled by the diabetes specialist. A balanced diet, exercise and medications work together to manage blood sugar levels. Because of the diabetes, we monitor patients very closely. Depending on sugar levels, we may get an ultrasound for growth or monitor the infant more closely. These tests do not apply to everyone with diabetes. Your doctor will determine whether these are needed based on your sugar levels, weight gain, abdominal size and medication requirements.

After delivery, the effects of the gestational diabetes go away and most women have normal sugars immediately after delivery. Nonetheless, these women have a 50% chance of getting diabetes in their lifetime. We recommend another GTT test in the postpartum period, sometime after six weeks. For this, a fasting blood sugar will be drawn and after drinking a sugar solution, a two-hour sugar level will be check in the office. If these tests are normal, then we recommend a yearly fasting blood sugar test. If this is every abnormal, you will be referred to a diabetes specialist.

Tetanus, Diphteria, and Pertussis (TDAP)

The Physicians at Partners Obstetrics & Gynecology, PA have decided to offer the Tdap immunization during mid class appointments. The Tdap vaccination can protect you against Tetanus, Diphtheria, and Pertussis (Whooping Cough). Until recently, the recommendation for adults was to be immunized with a Td booster every ten years. There has been a rise in cases of Pertussis (Whooping Cough) recently so it is recommended that the booster include Pertussis.

Partners Obstetrics & Gynecology would like to provide new moms and infants immunity to Pertussis. Newborn infants do not receive their first vaccination against Pertussis until two months of age, so if women are immunized during pregnancy, it will therefore extend immunity to the baby. Your baby will receive this immunization along with their other vaccinations at their pediatrician’s office.

It is important to remember that this vaccination is not harmful during pregnancy to the patient or the fetus. Of course, as with any vaccination, if there has been any previous allergic reaction to this or any similar vaccination, you should not receive the vaccine.

Screening for Birth Defects

First Trimester Screening

First trimester screening combines the results of an ultrasound and blood tests, which are done between 11-13 weeks of pregnancy. This screening detects signs of Down syndrome, Trisomy-18 and possible heart defects.

The ultrasound test is called nuchal translucency screening. This test measures the thickness at the back of the neck of the fetus. An increase in this measurement may be a sign of Down syndrome, Trisomy-18 or heart defects.

Two blood tests are performed, pregnancy associated plasma protein – A (PAPP-A) and free beta human chorionic gonadotropin (hCG).

The combined results of the nuchal translucency screening and the blood tests show if the fetus might have Down syndrome, Trisomy-18 or a heart defect. If a nuchal translucency is increased but the combined screening does not show an increased risk of Down syndrome or Trisomy-18, a detailed examination of the fetal heart is done later in pregnancy at 20 weeks.

Second Trimester Screening

In the second trimester, maternal blood testing is used for screening for Down syndrome, neural tube defects, Trisomy-18 and abdominal wall defects. These blood tests include alpha-fetoprotein (AFP), Estriol, Human chorionic gonadotropin (hCG) and Inhibin-A. The test is called a quad screen. This screening test is performed between 15-20 weeks of pregnancy.

Because first trimester screening is done too early to check for neural tube defects, maternal blood is drawn for AFP between 15-20 weeks to be tested for this problem.

If first trimester screening has been done, only AFP and not a full quad screen will be checked in the second trimester.

A detailed ultrasound examination of the baby between 19-22 weeks evaluates the baby’s anatomy. While ultrasound is an excellent and safe noninvasive screening tool, it will only pick up 50% of defects, leaving 50% undetected that will only be found at birth.

If a screening test result shows an increased risk for having a baby with a certain defect, further tests can help diagnose the problem. In most cases, the baby is healthy even if there is an abnormal screening test result, false/positive. A specialized ultrasound or amniocentesis may be discussed in the case of an abnormal screening test result.

Chorionic Villus Sampling and Amniocentesis

Chrorinic Villus Sampling (CVS)

This procedure involves taking a sample of placental cells to test for genetic abnormalities. This sampling of cells is done either through the cervix or through the abdomen at 10-12 weeks. A perinatology specialist performs this test. An ultrasound is required prior to seeing the perinatologist for this appointment.

CVS cannot detect neural tube defects, i.e. anencephaly or spinabifida, and an alpha-fetoprotein test done at 16-18 weeks is recommended for neural tube defect screening. Results of the CVS are generally known in 7-10 days. The risks of CVS include miscarriages (approximately 1%), infection, possible limb defects, mouth and jaw defects, bleeding or cramping.

Amniocentesis:

Amniocentesis is performed between 15-20 weeks of pregnancy. A needle is placed through the abdomen and into the uterus to remove a small amount of amniotic fluid under ultrasound guidance. This amniotic fluid is sent to the lab and cells are grown on a special culture. The cells are then evaluated for chromosomal abnormalities such as Down syndrome or Trisomy-18. The alpha-fetoprotein level in the amniotic fluid can also be tested to determine if the fetus has a neural tube defect.

 

Quad Screen

A screening test has been developed to help identify pregnant women who are at increased risk for having a baby with Down syndrome (trisomy 21), spinabifida (open neural tube defects), and Edwards syndrome (trisomy 18). The QUAD screen is a blood test that measures the pregnant woman’s level of four proteins: HCG (human chorionic gonadotropin), AFP (alpha-fetoprotein), estriol (a form of estrogen), and DIA (dimeric inhibin A). The determination of these levels combined with clinical information about the pregnant woman such as her weight, race, and whether she takes insulin can help identify a woman who has a higher risk of having a baby with spinabifida or these two chromosomal abnormalities (trisomy 21, trisomy 18).

The QUAD screen does not diagnose these conditions, it only identifies pregnancies in which they are more likely. The result is given as a risk ratio. If the pregnancy is at increased risk, further testing will be discussed. Amniocentesis is the only test that provides a definitive diagnosis of both chromosomal abnormalities and spinabifida, and ultrasound adds additional information about the baby’s anatomy and development.
A normal test result (low risk ratio) reduces the likelihood of a baby having an open neural tube defect, trisomy 18, or Down syndrome; however, it cannot completely rule out the possibility of these problems. About 80% of spinabifida, 75% of Down syndrome, and 60% of trisomy 18 pregnancies will be detected. There is also a false positive rate of about 10% (meaning the test result is abnormal but the pregnancy is not).
This test is offered to pregnant women of all ages. Those age 35 and older can proceed with invasive genetic testing (CVS and amniocentesis) directly for diagnosis or use the QUAD screen as a screening tool.
Please be aware that some insurance companies may not cover the additional expense of a QUAD screen. In that case, you will be responsible for the added expense. Our business office can give you additional information about the cost of this laboratory test if you wish.

Urinary Tract Infections
Ovarian Cancer in Midlife Women
Reducing Your Osteoporosis Risk
What you should know about Quitting Smoking
What you should know about Emergency Contraception
Omega-3 Fatty Acids for your Heart
Lab Work

Can I get labs drawn at your clinic if another doctor has ordered the lab work, and vice versa?

  • We may be able to perform lab work if we have a written order with a diagnosis from the ordering physician. However, sometimes we do not have the necessary equipment to do all the lab work. Please check with us first. Likewise, we may have you get the labs done elsewhere, but an order will be given to you, along with a diagnosis for the testing.

 

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Contraception

The following are contraceptive options we offer at our clinic:

  • Orals Contraceptive Pills (OCP)
  • NuvaRing
  • Intrauterine Device (IUD)
  • Mirena
  • Paragaurd
  • Implanon/Nexplanon
  • Depo Provera
  • Ortho Evra Patch
  • Diaphragm
  • Tubal Ligation

Essure (non-reversible)

Abnormal Pap Smears

My pap smear came back abnormal. Should I be worried?

The following are different levels of abnormal Pap smear results:

  • ASCUS is generally mild and accounts for 5% of pap smears;
  • LGSIL is when cellular features are mildly abnormal, enough to warrant further testing in the form of colposcopy. These changes rarely indicate cancer and may or may not require some form of treatment;
  • AGUS indicated changes in cells from inside the cervical opening. This could be from inflammations, menses, low-grade changes, or, in rare cases, cancer. Further evaluation is needed such as colposcopy, endometrial biopsy, and/or ultrasound, which will be determined by the physician.
Pap Smear Guidelines
  • First pap smear at 21 years of age
  • Repeat pap smears every 3 years age 21-30
  • Pap smears every 3 years between 30-65, or every 5 years if HPV test is negative.

These guideline are ONLY for people that have all normal pap smears, if there are abnormal pap smears patients fall into a higher risk category and pap smear follow up or further testing are dependant on the results. If a patient has been treated for a cervical abnormality of moderate dysplasia type or more severe, pap smear follow is yearly for 20 years.

Women who have had DES exposure in the uterus need more frequent pap smears as do women that have HIV or other issues with immunosuppression.
It should be noted however, that the recommendations for routine preventive health care visits have NOT changed and women should continue to have a regular checkups. In most cases this should be on a yearly basis.

Regular Check Ups

Do I have to be seen yearly if I’ve been told that I don’t need a pap smear every year?

  • Yes! While a woman’s risk of cervical cancer may decrease with age, her risk of breast, uterine, and ovarian cancer increases. Consequently, the physical exam should be done yearly.

When should I have my first pap smear?

  • Age 21+ :every 2 years if pap smear results are normal
  • Age 30+ :every 3 years if there are 3 previously normal pap smears and/or the HPV viral test is negative.
Birth Control Pills

I missed one or two of my birth control pills, what now?

  • If you only missed one pill, you need to make it up as soon as you remember it. If you’ve missed 2 you need to take 2 at a time for 2 days. Call the clinic if you’ve missed 3 or more.

I started taking birth control pills for the first time and I’m having a lot of spotting; what does this mean?

  • This could mean any of the following:
  • Your body is just getting used to the pills;
  • You are taking your pills irregularly, missing or skipping pills. Please remember to take your pills at the same time every day;
  • Or you could possibly have a sexually transmitted infection.

Make an office visit and this can be determined by your provider

Pelvic Pain

Pelvic pain may indicate a gynecologic, bowel, or bladder problem. An office visit is necessary to evaluate.

Vaginal Discharge

I have colored vaginal discharge with a foul odor; do I need to be seen?

  • Experiencing vaginal discharge may indicate a yeast infection, bacterial overgrowth, bacterial vaginosis, or an infection with a parasite called trichonosis. A test done in the office called Affirm with an examination can make the diagnosis.
Menopause

Do the providers prescribe bio-identical hormones?

  • Bio-identical hormones are hormones that are the same molecular composition of what our own body makes. For women that are appropriate candidates we do prescribe FDA approved manufactured products that are bio-identical.

I’m having a lot of hot flashes and night sweats. What should I do?

  • Hot flashes and night sweats can be caused for various reasons:
  • Hot flashes and/or night sweats that are associated with perimenopause or menopause are due to a drop or lack of estrogen in the body. The symptoms can vary in severity from being just a nuisance up to being debilitating. Treatment depends on the severity.
  • Nuisance hot flashes can be dealt with by dressing in cooler clothing, avoiding hot beverages, baths or showers, hot a spicy foods, caffeine, smoking and alcohol.
  • Alternative medicine treatments can include black cohosh and acupressure.
  • There are also hormonal and/or non-hormonal prescription medications that a woman may be a candidate to use.
  • You and your provider can discuss the options and decide what may be best for you.
The following are recommendations for normal screening mammograms

Age 40+ : Every 1-2 years
Age 50+ : Yearly
If you find a lump or anything abnormal you are advised to make an appointment with your doctor for a breast exam immediately.
A breast abnormality should be examined here with an office visit. This way a provider can then get a good history regarding abnormality. Further testing may or may not include a diagnostic mammogram.

Postpartum Excercise

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Pediatricians

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Cold and Flu

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Nausea and Vomiting

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