i want to welcome you all to our presentation this evening under your child's heath university here at packard children's hospital. i'm nancy sanchez, from community relations, and we're very excited about this evening, this healthy pregnancy 101 class that's being presented to you. it's a great pleasure for me to introduce dr. natali aziz to you, she's a clinical assistant professor in obstetrics and gynecology and maternal fetal medicine at the stanford
school of medicine and lucile packard children's hospital. dr. aziz actually attended stanford school of medicine and she did her internship and residency at stanford, as well as a fellowship at ucsf. she's board certified in both ob-gyn and maternal fetal medicine. dr. aziz has published research on many pregnancy related topics, and has developed the curriculum for this healthy
pregnancy 101 class, which you are about to enjoy. and i will want to mention to you that, because we're videotaping, and we will have this posted on, on the web, we will not be recording your questions, we'd like to save your questions for the end. if you would, there are little cards if you want to jot down things to remember to ask dr. aziz so that we don't catch you or your questions for privacy reasons in, during the, during the lecture.
so it's my great pleasure, as i mentioned, to introduce tonight dr. natali aziz. thanks for coming and sharing with us. >> thank you so much for that kind introduction. and thank you. thank you so much for coming, and good evening. it is an absolute joy and pleasure to be here today to discuss with you what a patient along with her physician can do and steps that she
can take to help ensure a very optimal prenatal care both prior to and during her pregnancy. and this is a philosophy that's deeply embedded in our lucile packard children's hospital philosophy and mission and as we strive every single day to provide the best obstetric and pediatric care for our patients. so with that being said, thank you and we'll get started. and as a reminder, i will be happy to stay and answer any and
all questions you have at the end of the program, so thanks. so today we'll be discussing a wide variety of topics pertaining to pregnancy. we're going to first start off with preconception issues and then move forward to discussing what to expect at your first prenatal visit, followed by what to expect during the first, second, and third trimesters, and then specifically address counseling issues pertaining to nutrition and weight gain, work, exercise, travel, and some other issues associated
with pregnancy. so, preconception is a very important time. and preparing for pregnancy has many things to consider. to start off with, optimizing one's pre-existing medical conditions is extremely important. so that means things such as medical complications like diabetes, high blood pressure, hypertension, seizure disorder. all of those are very much aimed at helping to optimize them
prior to initiation of your pregnancy. next, we hope to aim for an ideal bodyweight, or close to it, with a normal body mass index. and then, finally, promoting a really healthy lifestyle, not only with diet, but also avoiding substances such as tobacco, drugs, and alcohol, is always helpful, especially in the organogenesis or organ development period during
pregnancy. and finally, consulting with your physician is very important regarding a variety of issues including medication safety. so there are many medications that we try to avoid in pregnancy including things like accutane, ace inhibitors which are used to treat high blood pressure, lithium which may be used to treat seizure disorders for example. you also want to avoid multi-vitamins with a high dosage of,
vitamin a, especially over 10,000 international units per day in that these levels have been associated with birth defects in particular neural tube defects or spina bifida for example. next, choosing a prenatal vitamin obviously is very important for many couples. in all reality many prenatal vitamins are wonderfully sufficient. things to keep in mind would be folic acid.
generally we need about 400 to 800 micrograms of folic acid daily. and you generally want to initiate that a month prior to your conception attempts. and certainly, to continue during this, two to three months into the pregnancy, and after conception. thereafter, about 600 micrograms daily is needed. and many of that, or much of that can be attained through nutrition.
but supplementing it will always ensure that you have the sufficient amount. next, you know, dha has played a big role lately in the news. and patients seem to ask, you know, why is it so important? so, dha is one of the omega 3 long chain fatty acids. and there has been some studies that show that there's some modest benefit to the promotion of visual as well as cognitive development in the fetus.
so generally a recommendation of about two to three hundred milligrams daily is made. now you can obtain that through consumption of fish that is low in mercury and we will discuss that a little bit later or supplement it through your prenatal vitamins as well. so generally you want about two to three hundred milligrams now next would be to track your menstrual period and to arrange your preconception appointment with your provider and that may be anyone such as a primary
care physician, ob-gyn, nurse practitioner, or a certified nurse midwife. and in that appointment you can certainly talk about not only your pre-existing medical conditions, preparing yourself for pregnancy, but also things such as updating your immunizations which is very important during the pregnancy period as well. things like your measles, mumps, and rubella vaccine and
your varicella vaccine are important to obtain prior to your prenatal care in case you are not immune and that generally if you are going to be vaccinated you want to avoid pregnancy for about a month thereafter. other things that you want to update your immunizations on would be the influenza, the tdap, or the tetanus, diphtheria, and acellular pertussis which is pretty big right now in, given the pertussis outbreaks in california that occurred about a year to two years ago,
and hepatitis b as needed. now these vaccines are safe in pregnancy, but during a preconception period if you want to start the series it's always beneficial to begin and become immunized prior to conceiving. and so finally you know why is it so important to keep track of that last menstrual period? well that's one of the first ways we actually date and give you a due date for your pregnancy, so a lot of people, you
know, it doesn't, it's not very intuitive. however the first day of your last menstrual period is the day that your cycle begins basically. and generally so we use that as the first day of your cycle and two weeks thereafter most women who have 28 day cycles will then ovulate and that'll be the time of conception. and thereafter we use those dates to give you an estimated due date.
so your first prenatal visit can be actually conducted with a variety of healthcare providers. you know, you can start off with a general ob-gyn or if your family practice physician conducts obstetric care, you can also continue with your family care provider. other people who may provide ob care include certified nurse midwives, as well as nurse practitioners. and we do have certain providers and a variety of providers in this area meeting all of these requirements.
of course a perinatologist or maternal fetal medicine physician is also a person who is a specialist for complicated pregnancies. and at our center we have an mfm service that not only serves as a consultant, but also as your primary care obstetrician. so if you do have any high risk complications you can either be referred for a one time consult and thereafter the doctor
will help care for your pregnancy along with your general ob-gyn, or people may choose to be transferred completely to our care. and so that's an option as well here. other things to think about are the type of practice. so we have private practice, which generally is a multi- person group as well as university service or hmo. and in terms of the university service, the thing to keep in mind is that it is a teaching institution so there are
groups of people that will help provide care for you. i think they're all wonderful including the attendings, fellows, residents, but additionally there's also the medical student component too that's involved, and all through excellent supervision. so you get to be a part of a multidisciplinary team. and generally what we aim for is to help establish your care with your ob clinic by about eight to ten weeks. so that means you call, you set up
your appointment. generally you go in and have your laboratory values drawn and meet with the nurse for your first time visit. and then by ten to twelve weeks you want to have your first visit with your doctor or your clinician. so as this little guy will show you here, who doesn't look too excited, the first prenatal visit can take a little bit of time. it is an extensive period where you get to find out about
your prenatal care and your physician gets to find out about your healthcare history. so although it is long, it is certainly worth it as it establishes the course for your medical care thereafter. so things that we review during this first visit include your medical history, you know again, diabetes, hypertension or high blood pressure, anemia, history of seizure disorder, your surgical history, which may actually pertain to your care
during your delivery if a c-section is needed, for example, your family medical history. and particularly your obstetric and gynecological history. we really want to know about past pregnancies, you know stillbirths, miscarriages, deliveries, or terminations, your last menstrual period, the duration of your cycles for example, and other details pertaining to your gynecological history as well such as abnormal pap smears, or history of sexually transmitted infections.
medications are always so important, and we like to review them in great detail. so prescription, but also over the counter including vitamins and supplements. allergies to both drugs or other substances. and then, it's a nice period of time during that prenatal visit to review some basic educational aspects of prenatal care, including your nutrition, exercise, substances to
avoid and, as well as kind of bring up the issue of domestic violence. now sometimes people are alarmed when we ask about domestic violence at the first visit. this should not be a stigma; it is something that we ask every woman, every woman who is pregnant. it is a very important time in prenatal care to establish that rapport and to question patients about any situations that may be harmful to them whether it's at home
or in other environments. so the prenatal exam in the first visit is also very exciting, not only because of the physical exam but also because you, generally have a first time ultrasound performed, where we actually look at the embryo, and we determine if the confirmation of the pregnancy as well as the dating of the pregnancy, so that's where it's important that we keep track of your last menstrual period and determine if our ultrasound measurement, actually
correlates. now this, embryo here is about seven weeks along and about perhaps almost the finger breadth of my index finger here. so very small, and we are able to demonstrate heartbeat at this point, which is very exciting, and a great time. so, you know, if partners want to come in for that first prenatal visit it's always very rewarding.
we also perform the pelvic exam and breast exam in addition to the traditional, you know, lung, heart, abdominal exam. and then studies that we do at that time include a pap smear, studies for infections, as well as urine analysis and culture. and some additional prenatal labs if they haven't been done already, you know, with your nurse visit, include a complete blood count, again check for the level of
hematocrit and hemoglobin, and assess if someone has anemia, your blood type, the rh status. we have a panel of infections that we check for including hiv, syphilis, rubella, hepatitis b, as well as varicella, or the causative organism for chicken pox. things also, which we bring up, are genetic disorders, including cystic fibrosis, and others, as they apply to specific ethnic backgrounds. so the prenatal visit is also a wonderful time for you to
become more informed about your care. and a time for you to learn about the type of practice that your physician has for you. so it's important to review the scope of care. you know you can ask how many partners does that physician have, who covers when they are gone on vacation for example, what kind of call schedule they have perhaps. additionally, you know, you can discuss what tests will be done not only at this visit but future visits to come, your expected course of
pregnancy and of course it's always important to always ask what should i be concerned about, what things should i report to you. you know, signs and symptoms to report to your provider. and those include vaginal bleeding, leakage of amniotic fluid from the vagina or abnormal vaginal discharge, uterine contractions, pelvic pain. and once you feel the baby moving, fetal movement as well, which generally happens after the middle of the pregnancy,
after twenty weeks in general. and any unexpected fevers, for example. it's also important to discuss the type of scheduled visits you'll be having and we'll go over exactly how that is distributed. and then again physician coverage on labor and delivery because who you may see in the clinic, you know, may not be on call in the evening that you come in, in labor, so it's also nice to be aware of the partners that are available and
hopefully will be providing care for you in some capacity. and finally, just to summarize things, you know it's also a good time at that point to explore the, you know, cost of prenatal care if you want. if you're interested in your insurance coverage or your copays, that's a good time at the first visit to review that with the front desk staff. as well as, practices that promote safe health for pregnancy but also just throughout, including use of seatbelts and in
particular dental care for pregnant woman is very important in that poor dentition has been associated with preterm birth so it's also important to become aware of that component of preventive health that can be employed during and then what type of educational programs are available and additional services. for example, do you have a nutritionist or a dietician? is there an exercise program? are there available studies that you know patients may
participate in if they're interested? for exercise, for example or for different variety of things. so a typical pregnancy is generally 280 days or 40 weeks and just to be aware that, that does count from the first day of your last menstrual period. so that goes all of the way back there, again another reason why the lmp is important to track. and it's divided into three trimesters and the first
trimester is about from zero to thirteen weeks, second trimester from fourteen to 27 weeks and third trimester from 28 to term. so, the frequency of prenatal visits, obviously is dependent upon the trimester that you are in. so, generally, in the first trimester, until the twenty- eighth week, we see usually patients every four weeks, so unless there's a complication that needs more detailed or additional attention.
and then from 28weeks to 36 weeks, we generally see patients every two weeks and then weekly after 36 to 37 weeks. so, i'd love to go over some of the things that are routinely experienced in the first trimester. although these are mentioned here, we still want you to report them to your physician but this is a bit of a reassurance to let you know that these things are common. so if you are experiencing them it is not atypical. so in the first trimester generally there is nausea and
vomiting. fatigue may be experienced, definitely breast tenderness or constipation and as the second trimester comes along there's possibly skin changes, hyper-pigmentation or darkening of certain moles or other skin areas especially in the face or a vertical line down the abdomen, in the mid-line, which is called a linea nigra. stretch marks obviously increase, sense of shortness of breath due to the physiologic changes that are going on with
the gravity uterus increasing. there's also that, infamous broad ligament pain where women will have a stretching sensation on the lateral aspecst of their abdomen or uterus. and it really is the suspensory ligaments that are holding up the uterus, that are starting to stretch as the uterus is becoming larger. and of course, and unfortunately, varicose veins also may be more prominent during this time, as progesterone does
relax muscles, and therefore, varicosities may be more prominent. in the third trimester, you may start to feel contractions and, you know up to three or four per hour are actually within normal physiologic range, so that's something to be reassured about. obviously, we want you to report your contractions to your physician.
but, again it's nice to know that a few is, is appropriate. back pain can definitely be problematic during this time, as the weight gain of the pregnancy and the uterus can place strain on the back, for example. lower extremity pain and swelling is certainly very common as well. breast discharge may be common as lactation is starting to progress, increased vaginal discharge and gastric reflux. and gastric reflux seems to be a very, very common and very
common symptom during pregnancy. so if, if you do have that please let your doctor know. there are many things that we can do to help treat whether it's from lifestyle modification of the way that you sleep, or smaller meals, less spicy meals to additionally where we can actually treat you with medications. so, fetal development is this amazing [laugh] period where from about twelve weeks, the fetus actually goes from a, about a two inch
fetus basically, and to about twenty weeks where the length is about 6.5 inches and the weight is about half a pound or so. and then finally, this development goes on to 40 weeks to where the infant is at approximately 7.5 pounds and twenty inches when he or she is born. so there's a dramatic evolution of fetal development during that short 40 weeks of gestation.
and just to show you what your uterus looks like at twelve weeks, it's about the size of a grapefruit. so at twelve weeks, this is the size of your uterus, and this is the adorable size and look of your baby. so as you can see, at about twelve weeks or so, it ranges anywhere between six to seven centimeters. and it's amazing with newer advances in ultrasound technology, we are able to capture some really beautiful images of the fetus, even
at this very early stage. and it's always a lovely event to share with our families and parents and to again when undergoing your first trimester ultrasound nuchal-translucency, it's always nice if you do want to have a partner come in to share this lovely picture with them. so first trimester also is an important time to review the genetic counseling considerations for specific families.
there are many families such as african american or mediterranean that may need counseling in sickle cell anemia or thalassemias, for example, tay-sachs disease, cystic fibrosis, canavans, and familial disautonomia is again... are considerations of genetic disorders for specific ethnic backgrounds. of course inheritable diseases are also important to
consider. so if your prior child for example, had a heart defect for example, we'd definitely want to know with subsequent pregnancies for further evaluation. and then finally, for screening and testing of chromosomal abnormalities, there are a variety of screens, diagnostic procedures that you can be offered. so to start off with the screening includes a nuchal-translucency, which is generally performed between about eleven to fourteen
weeks and that is combined with the first and second trimester blood screens and it's a very, high sensitivity, mode of screening patients for chromosomal abnormalities of the fetus. and then finally for diagnostic evaluation, which includes testing that is invasive though either a chorionic villus sampling, which is actually sampling of the placental tissue in the first trimester or an amniocentesis can be performed in the second
trimester where we actually sample the amniotic fluid. so nuchal-translucency and the analyte or hormonal screening is done between about ten to thirteen weeks for the blood work and the nuchal-translucency is about eleven to fourteen weeks. chorionic villus sampling is performed about ten to thirteen weeks, so very early on you will be offered the option of deciding whether you want screening or diagnostic testing. and this is a picture of what our nuchal-translucencies look
like for babies that are very well behaved. if you've ever gone to an ultrasound, sometimes the fetuses won't exactly, you know, have that perfect mid, mid-line profile, and we have to, you know, be very patient with them, but ultimately, they usually come around. so, the nuchal-translucency is this area here of fluid that we measure behind the baby's back of the neck, and this has actually been associated with chromosomal abnormalities when it's beyond a certain point and we combine that with the
maternal hormones to actually give patients a screening number. so, common things that may occur in the first trimester. this is, again, something that you should always report to your physician. but i just want to bring about how common it is, so that when, if it does happen, that we can hopefully continue to keep you reassured.
but vaginal spotting is extremely common and can occur in up to twenty to 25% of early pregnancies. and not all of those pregnancies end in miscarriages. for example, most of those pregnancies will actually continue to be a viable pregnancy which is the reassuring aspect of this. additionally, nausea and vomiting is very common in pregnancy, particularly in the first trimester. it can affect as many as, you know, at various degrees up to
70% of pregnant women. generally we recommend lifestyle and diet changes. again, potentially eating smaller meals, avoiding spicy foods. things that you can use include ginger, vitamin b-6, unisom which is a sleeping agent and has actually been used to treat nausea and vomiting associated with pregnancy as well. we can also provide prescription medications that have really been very safe for use in pregnancy and unfortunately
in about two percent of pregnancies this will be hyperemesis, meaning severe nausea and vomiting and some of those patients may actually require hospitalization and iv fluids or other type of medications and iv nutrition, but that is a rarity. so, in the second trimester fetal development occurs where all the major organs and systems have actually formed. and then thereafter they just develop and grow further. the remainder of the time after the second trimester is
really devoted to increase in weight. and the fetus will actually increase its weight by seven times over the next few months. so there's a dramatic period of growth in the fetus in the third trimester. fetal movement generally is felt at about twenty weeks for first time pregnant women. and as early as eighteen weeks or so for recurrent pregnancies as moms get to know a little bit more about how
a fetal movement may be and are able to recognize it a little bit earlier. so no matter how many ultrasounds i've done in my life you know every one of these is a very special moment as, as we perform the anatomy ultrasound at about twenty weeks or so. this is the time where we get to introduce you to your baby and all of his or her parts. and that's when we do a very detailed survey of the fetal anatomy where we look at the head, the heart, the
gastrointestinal tract. we look at the genitourinary areas. we look at the limbs and assess also the pelvic organs including the uterus and the cervix, which is the lower portion of the uterus in the ovaries. so this is always a very exciting time. and with the advent of, and use of 3-d imaging as well it's amazing what pictures you can capture during these ultrasound assessments.
in the second trimester we also do the quad marker. which assesses for the some common genetic abnormalities, including trisomy 21 and eighteen. and for neural tube defects such as spina bifida or abdominal wall defects. we also perform amniocentesis if desired. and, again this is an invasive testing where we actually sample the amniotic fluid. and this occurs anywhere between fifteen to twenty weeks.
and then in the late second trimester which is up to 28 weeks or so we do our gestational diabetes screen and then check the blood count again because there's a component of physiologic anemia or lower blood count that is very common in pregnancy due to hemo dilution and we just want to assess and make sure
that we have a, a good account and marker of the current blood count status. so third trimester, you know we'll see you more frequently. after 28 weeks we generally see you every two weeks and then in the last four weeks or so, we see you weekly. those times again, we are measuring your weight, measuring your blood pressure, measuring the uterus to check for proper growth of the fetus. we perform physical exams if there is any discomfort, again
if people are having discomfort with their hands or swelling. something that commonly occurs in pregnancy is carpal tunnel syndrome, where the median nerve is actually compressed due to the swelling that occurs in pregnancy. many moms will have potential symptoms of that, that we assess. and then obviously swelling of the feet and lower extremities as well. we assess the urine to make sure that we check for sugar and
protein levels as those are markers for diabetes and preeclampsia respectively, and obviously every time you come in we will check the baby's heart rate and make sure that it's in an appropriate range. and then at 35 to 37 weeks we also perform a group b streptococcal culture. this is a transient organism that generally lives in our gastrointestinal tract, and sometimes it colonizes the vagina or bladder, and at 35 to 37 weeks we'll check with a
rectal vaginal swab, and if mom has colonization, then we will administer antibiotics during labor to help prevent baby from acquiring the infection at the time of birth. so, it's amazing. i don't know how nature did this, but it did. after twenty weeks, fundal height mysteriously correlates to the gestational age which is very interesting. so at twenty weeks, fundal height is about at the umbilicus or so
or belly button. and then thereafter, it actually progresses to increase along with your gestational age. so, at 24 weeks of gestational age, typically from the pubic symphysis to the tip of the fundus of the uterus is about 24 centimeters plus or minus a few centimeters. so, that's a way of us assessing if the fundal height is appropriate or if it's too large which could be an indication that the baby's growing very largely or has
extra fluid. or if it's too small which would be an indication that perhaps growth isn't appropriately progressing or that there may be low fluid. now, most of the times, though, reassuringly when we do have ultrasounds to assess for size greater than dates or size less than dates on a fundal height, most of the times it is reassuring and there's appropriate growth. it's just that not every body is going to adhere to this
tight rule but it's always nice to have as a way of a screening. so, in your subsequent prenatal visits, very importantly, it's a great idea to discuss with your physician the options for labor. and you know, some families have preferences and it's nice to let your physician know what your preferences may be, for example. and it can be as small as i want my partner or my
partner wants to cut the cord for example. but those are all nice things to discuss and to review and how feasible they may be at the time of labor. pain control in labor is very important, to assess if there' s an obstetrician at all times, on labor and delivery for or if they have to be called in. at our institution we actually have a 24 hour obstetric, obstetric anesthesiology service, which we're very, very
fortunate. we have one of the leading programs in the nation and so we have our doctors there readily available to provide pain control for moms who may be interested in that. again, planning for delivery, postpartum child care, asking about, you know hospital tours, car seat fittings, for example are important things and usually your office will have that information. breastfeeding benefits are always great to discuss with
your provider as well and choosing a child's physician. and we may not know exactly who to send you to but i think it's nice to discuss it with your obstetrician and they can guide you for specific referrals. so some of the things also in the subsequent visits or to begin with to discuss with your doc are your nutritional counseling. so what is healthy and perhaps what do we need to avoid during pregnancy? so one of the things that's important is generally to limit
your caffeine intake to less than 200 milligrams per day. now that being said it sounds like it's quite restraining, it's actually not. you know roasted ground drip has about a 100 milligrams per cup, tea about 30 to 35. a starbucks coffee though has just about that limit, about 250 and then a coke or pepsi is about 50 or so. so as you can see you don't have to cut out caffeine completely but drinking in moderation is an appropriate
consideration. as we reviewed before, limiting your vitamin a intake is always very important to consider. and for those who have an exclusively vegetarian diet, it's really important to make sure that you take in the appropriate amino acids, iron, minerals, vitamin b12, vitamin d, and calcium and complex lipids. these minerals and vitamins are all really essential for normal embryonic development, and so
it's important to incorporate them in your diet. and i think consultation with a registered dietitian or a nutritionist is very helpful to help you prepare and to continue to provide appropriate nutrition during your so another nutritional counseling matter that comes up is fish and how much can i eat and what form can i eat. so this is a very excellent topic to discuss with your methyl mercury exposure definitely is something that causes severe central nervous damage and it can on a milder level
cause intellectual motor or psychosocial impairment. so it's very important to be aware of the levels of mercury in the fish that you may be eating and to gauge your consumption accordingly. things that you want to avoid, fish specific types are shark, swordfish, king mackerel, tilefish, because they have really high levels of mercury. otherwise, eating about up to twelve ounces. so, on average, one to two average meals of either shrimp,
canned light tuna, salmon, pollock, or catfish, are actually appropriate, and very reasonable. and, one of the things to keep in mind, also, is the albacore white tuna actually has more mercury than the canned light tuna. so avoiding the albacore might be a good idea or limiting its consumption to only about half, or six ounces.
and it's very helpful, the fda has a website where you can actually click on and look at the fish mercury levels so that if you particularly have a craving for some type of fish you can have you can actually see mercury levels that are noted by the fda. and obviously always checking local advisories is a good idea. for example our west coast specifics may be a little bit different than east coast. additionally for nutritional counseling a very important
thing to remember is to avoid undercooked or raw foods. you know there is a risk of food poisoning, whether it's bacteria or parasites. and food poisoning not only causes dehydration of the mother and deprives the fetus of nutrition, but it can also cause, you know significant and severe maternal disease. and in the fetus there's a variety of possible adverse risks, including congenital disease, which may be associated with toxoplasmosis that can be associated with eating raw foods,
for example, raw meats or undercooked meats. premature labor, if there is significant infection, miscarriage, meningitis, which is inflammation and infection of the lining of the brain and spinal cord, pneumonia, and even death for fetuses. so it's important to avoid these, especially bacterial and parasitic food-bourne illnesses. you know, things to do. really thoroughly cook your food, from animal sources,
including beef, pork, poultry, and fish. so, no sushi. [laugh]. wash your raw vegetables thoroughly as well. and keep your uncooked meat separate from your vegetables, and from cooked foods, and ready to eat food, so that they don't cross contaminate. obviously, avoiding unpasteurized milk, cheese, and foods made from raw milk is very important.
and that, for prevention of listeria or listeriosis. and although, generally, it's in unpasteurized products, as you may all be aware, there was a recent outbreak in cantaloupes, for example. so, it can also be in fruits and vegetables, but usually, advisories are given for those types of situations and those are uncommon in, in, in the grand scheme of things. and finally washing hands, knives and cutting boards after
handling uncooked food is also sanitary. and not only for pregnancy but for all cooking practices. so you may ask what's an appropriate weight gain now that we've talked about all the foods that i can and cannot eat? well, our weight gain is generally based on our body mass index. and body mass index we calculate using your weight divided by two times the height, basically your height squared, i should
say. so for lower body mass indexes, there is more generous recommendation for weight gain anywhere between about 28 to 40 pounds. for normal bmi which on average is about eighteen to 25 or so general weight gain is about 25 to 35 pounds and for high bmi's, so between 25 to almost 30 is about fifteen to twenty and obviously the higher the bmi such as obese which is greater than 30 the lower the recommended weight gain.
an average weight gain per trimester, and this is just average because in all reality, it very, not many people may fit this standard. however, generally we quote about three to four pounds in the first trimester twelve to fourteen pounds in the second trimester, and about eight to, eight to ten pounds in the and in terms of all the weight, and what components make up this weight. well, at term, your baby is about, approximately seven and a
half pounds or so. your extra maternal energy sources, including fat, protein, and other nutrients make up another seven pounds that you have stored. fluid volume that also, we store, in third space, the lovely swelling that may come about, for example, is an additional four pounds, breast enlargement is two pounds. the uterus, itself, becomes very large and engorged with vessels.
and it, itself, weighs two pounds. amniotic fluid is another two pounds, and then the placenta is approximately one and a half pounds. and the thing to remember is that, generally, for pregnancy, an increase of about 300 calories per day is recommended for a goal of 2,500 for singleton pregnancies. now, this goal is a little bit higher for twin pregnancies, as moms need additional nutrients. so, additionally, the specialized counseling that we talk
about during pregnancy. if, vaccinations were perhaps not updated prior to reassuringly things like the flu vaccine, hepatitis b, hepatitis a, t-dap, pneumococcal and meningococcal vaccines can all be administered safely during your prenatal care. we try to avoid the measles, mumps, rubella and varicella vaccine in pregnancy. however, this is for theoretic concern so if one does inadvertently get the vaccine during pregnancy please
consult your physician, and hopefully they'll reassure you as to, that it's just a theoretical risk, and not significant severe outcomes have been demonstrated when people do get these vaccines inadvertently. additionally, whenever you go to a physician that may not be an ob-gyn, and that there's need for x-rays, please always consult your physician of your prenatal care. generally, dental and chest x-rays are permitted during other types of imaging, we consider, but only if they're
needed for significant maternal management issues. so it's always a good idea to talk about any x-rays with your ob-gyn before proceeding with them. additionally, i think pregnancy is a great time for specialized counseling for individuals that may need assistance in terms of tobacco, substance abuse, domestic violence or medication use whether it's prescription or over the counter. it's an amazing period of time when the inspiration and
motivation for healthy, wellbeing and prenatal care can really motivate individuals to lead healthier lifestyles. so i think it's a great time to modify one's lifestyles to benefit not only one's long term outcomes but also your prenatal care. so, in addition, pregnancy brings to the conversation of what to do during everyday activities. you know, this includes work, exercise, sex, sleep, travel,
air travel, car travel. so i'm going to just go over, very briefly, some considerations for each of these topics. so during pregnancy, many or most women will actually continue to work without complications. you know it really does depend on the type of work and your medical condition. but for most low-risk or uncomplicated pregnancies, a pregnant woman can continue until her third trimester, until
she's ready to take her time off basically. so physical job demands that though include prolonged standing or walking, heavy lifting, working at various shifts for example, or job stress, may affect pregnancy. and so if that's the case it, i really encourage you to discuss these things with your physician so that you can kind of modify your perhaps work environment to best benefit a optimized prenatal course.
things that you want to watch out for in the workplace include metals like mercury and lead, solvents in the house cleaning industry for example, cleaning agents and pesticides, exposure to pharmaceutical agents, in particular for example, those medical personnel that work with chemotherapy. it's very important to remember chemotherapy can be associated with miscarriage, low birth weight or malformations.
and so being aware of your environment is very important. infections are another, common work place adverse event that we deal with quite often. so whether you're a school teacher, or a nurse, or a physician, or just a plain mom who is at home with her two year old, there's things that can happen such as hepatitis or chicken pox, rubella, cmv, parvovirus or toxomoplasmosis other infections that may actually influence pregnancy and so those types of infections not only need to be reported to
your physician but it's good to kind of access your work environment to see what you may be exposed to and discuss that with your ob. and then finally physical agents like radiation and radioactive waste are definitely need to be avoided as they can actually lead to birth defects, miscarriage and development issues and extreme heat especially in the first trimester, has been associated with birth defects. so if you have a really high fever, especially in your first
trimester, or you just love the jacuzzi and sauna, those are things to actually discuss with your ob-gyn because you really want to avoid high heat environments. so the ama, or american medical association recommends these lovely things for pregnant women. and i really emplore you to bring them up at your workplace. you need to take a break every few hours. you need to take a longer meal break if possible, every four hours.
drink plenty of fluids on the job if possible. and you want to vary your work positions you know, continuously, from sitting to standing to walking. and you really want to minimize heavy lifting and bending. i had a patient who you know, is an employee at costco, and had to go up on really high ladders. and that was just something that was not very safe for her during her pregnancy. so we modified her work activity, and that's something that
your ob-gyn will be happy to do, depending on the certain situation. so, people may also ask, are video display terminals dangerous for me and for my baby? actually, fortunately video display terminals do not emit x-rays, and so, and there has been no link to exposure of the electromagnetic field and the risk to pregnant women. so, fortunately, you don't have to worry about that.
now computers, just as in non-pregnant individuals, can be associated with neck, wrist, hand, shoulder, and back pain. and this may be exaggerated in pregnancy. so, prolonged sitting at a computer terminal may not be the best for these symptoms. so, if that happens, just bring it up with your physician, and i'm sure that they can work something out with your boss, basically, to help relieve some of those symptoms. and, just like in non-pregnant patients, you definitely want
to take frequent work breaks. you want to use detachable keyboards, and adjustable chairs, and use non-reflective glass on the screen to basically adjust the lighting and contrast. now, exercise in pregnancy. it's very important to stay healthy throughout your life, but additionally during your pregnancy course. so pregnancy and exercise is actually a wonderfully symbiotic relationship, and we've definitely determined that
exercise has many benefits during pregnancy. it can minimize the physical discomforts of pregnancy itself. it's beneficial for women with diabetes and can help keep both gestational diabetes and preconception or pre- gestational diabetes in better control. it actually has been proved to improve mood, energy, sleep patterns. it can increase your endurance and strength and muscle
tone and it can improve or help with the recovery after the birth of your baby as well. so if someone is healthy and has been exercising and physically fit before the pregnancy, they can safely continue to exercise throughout their pregnancy course. obviously, you want to let your physician know, throughout your pregnancy but generally continuation is very appropriate. however, women who have not had an exercise regimen prior to
pregnancy, we highly encourage you to really speak to your physician before starting one. it's very important to discuss this in consultation with your doctor so you can set up a reasonable regimen to begin you gradually. so your target heart rate in terms of how hard can i exercise. so we usually like to say keep it below about the one forties or so.
and really, this is a level where you can conduct a normal conversation with an individual. so if you're able to talk without taking deep breaths, and huffing and puffing, that's generally a very appropriate exercise level and correlates to less than one hundred and forty beats per minute. your goal is up to about thirty minutes per day and you know again for those individuals who have never started an exercise program, you want to start this gradually and
discuss it with your physician first. you want to drink plenty of fluids. you want to avoid extreme exhaustion, excessive heat, and lying flat on your back as well. and, of course, if any of the following things occur in your pregnancy, we do ask for potentially modifying your exercise regimen. so, whether it's preterm labor in the current or past pregnancies, if there's active vaginal bleeding or cervical
issues, if there's leakage of amniotic fluid, if you ever experience shortness of breath you should stop and discuss it with your physician and probably obtain some additional studies. dizziness or fainting is another period of time where exercise may not be safe. decrease fetal activity or other complications. if your heart rate is greater than the 140 and you're not able to exercise at a level where you can sustain it below
level, and then obviously certain health problems, such as high blood pressure for example, may not make you an ideal candidate for the exercise regimen that we discussed. however again, these things are all done in consultation with your physician and bringing these up to your physician is important. so exercises to avoid in a healthy individual. things that obviously could potentially be unsafe, if there was an accident, or a fall, so including horseback riding,
water skiing, scuba diving, contact sports, high altitude skiing. so virtually any exercise that can cause a serious fall. things to also consider for exercises that are not within this group. so exercising on your back for the first trimester may, after the first trimester, may actually reduce blood flow to your uterus so we generally say avoid exercise on the back in the second and third trimesters.
exercising in a vigorous, hot, humid environment or weather conditions is also not recommended in that you have less of an ability to have efficient exchange of heat at that time and so we don't want to dehydrate you or cause a hyperthermia situation. and then finally exercise, which consists of the valsalva maneuver, which is holding a breath during some type of exertion, can cause increased abdominal pressure so we recommend avoiding those types of valsalva maneuvers.
so although some people seem to water ski we do recommend that pregnant women do not. but it seems like it's very tempting right here is that it's so easy for so many people. so sex during pregnancy? that's a question that comes up often and it is a very appropriate question. in most cases sex during pregnancy is completely safe and, is appropriate.
intercourse, however may be avoided in special circumstances. again those need to be discussed with your ob. so when there's vaginal bleeding. if there's any discomfort that is atypical for you, leakage of amniotic fluid or significantly different discharge and contractions. and in terms of sleep positions, most of you may be aware that we do recommend not lying flat on your back,
especially in late pregnancy, in that, this places, when you're flat on your back, it actually places pressure on the blood vessels that return blood back to your lower body from your heart, including your uterus. so it actually may prevent the appropriate and sufficient amount of blood getting back to your uterus, and to profusing the placenta, and reaching the fetus. so that's why we recommend you to sleep on your side.
sleeping on the stomach, again, also, is not recommended late in pregnancy as it applies pressure on the fetus that may be not completely safe for the fetal environment. and finally, on the side is the best sleeping position. usually we say left, but sometimes you just can't stay on the left and you do need to change your positions and that's completely appropriate. it does allow for maximum blood flow to the fetus. it
improves the kidney function of the mother. and it may actually reduce the swelling as it allows for better profusion and return of blood from the lower extremities to the heart. one of the things that is really challenging for pregnant women is to sleep on their sides, and so that's why we recommend placing a pillow between the knees. it actually really helps improve the side position and makes it more tolerable and many women find it much more
comfortable. so travel during pregnancy. fortunately, traveling during a pregnancy is actually, it is appropriate and maybe performed but always remember to consult your physician. you want to make sure that you've been recently seen by your ob-gyn before you take a big trip. you want to have a copy of your prenatal records. hopefully nothing adverse will occur, but if you needed to
go to a hospital, it's always very nice to have a clear record of your documented pregnancy course, when you are being evaluated by a physician that may not be familiar with your case. during long airplane or car rides, we definitely recommend you ambulating, if possible. you want to wear compression stockings, especially on long trips,
for example, airline trips or car trips. and travel, usually after 36 weeks thereafter, is not recommended. and that's either by car or plane, where you are going significant distances, is that, that's the time where most labor will occur, and we really want you to avoid having to present to an unfamiliar area and in labor, for example. and then always using a seatbelt either in a car or plane. and this little schematic here
demonstrates. so a seatbelt should be placed underneath the belly and not over or across the belly. so the green area here is the appropriate way or place of placement of the safety belt. and then finally just as a reminder you know, the most pivotal and important time for organogenesis and organ development of the fetus is in that first trimester, generally before you even find out that you're pregnant. so in that preconception period where you are thinking about
pregnancy it's very important to keep your medications in mind. the period of organogenesis is between four to eight weeks of gestation and this is the time when the fetus is most vulnerable to birth defects from prescription medications or nonprescription medications even, and so that's an important time to always keep that in the back in your mind as especially even before you are pregnant to think ahead and see
what types of medications would be safe if i were to become pregnant. that being said, it's very important also to balance mom's health and maternal wellbeing with pregnancy and prenatal wellbeing. so it's very important that we discuss the medications that are needed. we don't want to penalize or, you know make it a stigma for moms who do have to take medications. so there's usually a general safe medication alternative
that you can discuss with your physician and usually we can transition patients very safely. and then finally we, you know use the medication that's least likely to cause birth defects and least teratogenic, and fortunately most drug classes will have medications that do not cause birth defects that we can safely transition moms to. and finally just keeping the risks of alcohol and drugs, cigarettes, infectious diseases, medications, uncooked or
unpasteurized food and then medical conditions as well in mind, including diabetes, high blood pressure, sexually transmitted infections. and kind of wrap it all up and to think of these things as being potential situations or environments or substances to avoid during pregnancy is always a good, healthy rule. and finally when to call your doctor. we reviewed things, signs and symptoms to report to your physician but additionally, you know, any vaginal bleeding, pelvic cramps,
or pressure should be reported. fevers that are greater than approximately one hundred and one degrees should be reported. leg swelling, especially asymmetric leg swelling which pregnant women are more at risk for blood clots in their lower extremities. so we always, we never take this lightly. it's always a serious situation and we definitely want to evaluate you as soon as possible. severe headaches as well, pain or burning with which could
be the sign of a bladder or kidney infection. severe vomiting or inability to keep anything down because it can lead to dehydration for the mom and that's something that we definitely want to avoid and can treat with iv fluids. abnormal vaginal discharge or symptoms and especially of abdominal trauma. whether it's through a motor vehicle accident or fall we always want to know if they, if there has
been an abdominal trauma and then especially in the late second and third trimesters. we like to monitor the fetus so it's always better for you to call us as soon as possible. and finally, thank you. i want to thank everyone for your time and attention, especially in this late evening. and i want to thank mrs. sanchez and stonestrom for the office of community relations and
community programs for helping us establish this evening. and thanks for the opportunity to allow me to come in and, and talk about things that may, hopefully, be of value to you in your prenatal care and help lead to a very happy, healthy, and informed pregnancy. and on a personal note, i just want to thank you all for potentially choosing or considering lucile packard children's hospital as the medical facility to have your prenatal care.
we really believe and value the fact that pregnancy is not only one of the most important healthcare periods, but also, one of the most important personal life events for an individual and her family. and we're honored to be a part of that for you. and with that, i'll take any questions that you may have, and thanks for your attention.