Dr. Lee: We tell our patients to make an appointment with their OB. Often when people find out they’re pregnant, they’re often newly pregnant. We usually make the appointment for eight weeks after their last menstrual period. We encourage them to call if they have any other questions before then.
Dr. Lee: We see our patients at eight weeks. We get their medical history, their family history, genetic issues that run through the family, medications that they’re on, talk to them about their diet, exercise, travel history. We do an examination and we get them set up for the first round of lab work that we do.
We check their blood type. We make sure they’re not anemic. We make sure that they’re immune to certain viruses like rubella, which is German measles, and chicken pox. We do a check for sexually transmitted infections. We also make arrangements for them to do a first trimester California Prenatal Screening Program for Down syndrome and trisomy 18. Trisomy 18 is where instead of having two pairs of chromosome 18, the baby has three pairs, and it causes birth defects, developmental delays and can be fatal in the baby as well.
Dr. Lee: The second trimester, we see them for their second trimester screen. We do additional blood work and get a final calculation of Down syndrome, trisomy 18. We also check something called alpha-fetoprotein, which screens for certain birth defects of the brain and the spinal column.
Around 20 weeks, we do an anatomy ultrasound and that is looking at all parts of the baby. We look at the amniotic fluid, the placenta, the length of the cervix, the uterus and the ovaries.
Dr. Lee: Different things can happen during the last three months. Every visit, we’re checking their blood pressure to make sure they are not having blood pressure issues during pregnancy. We also check the size of the uterus to make sure the baby is growing appropriately, not too big, not too small.
Some of our patients have additional ultrasounds in the third trimester if they’re considered high risk or they have twins or certain medical problems where we would worry about the birth of the baby.
Toward the last few weeks of the pregnancy, we’re also checking their cervix to see if they are starting to dilate. We do a vaginal swab for something called Group B strep, which is not an infection in women. But it’s a bacteria that can cause an infection in the baby during labor.
We’re also checking the position of the baby to make sure they’re head down, that it is not a breech birth.
Dr. Lee: Preeclampsia is a condition where blood pressure rises. There can be protein in the urine. It can cause certain abnormalities in kidney function and liver function. A blood test called platelet count is done.
Preeclampsia is a condition that has a wide spectrum. It can be mild, moderate, severe. If it’s toward the end of the pregnancy, we recommend delivery because it can become more severe. If it’s something where the patient is not close to delivery time, then we put them in bed rest and follow them very closely for changes.
Dr. Lee: For prenatal care, we basically have our patients come in, depending on where they are in their pregnancies. It is usually about once a month. We check their blood pressure. We listen to the baby’s heartbeat. We check the size of the uterus. We ask them about symptoms they’re having, go over their lab work with them and tell them what to anticipate for the next few months.
We also encourage our patients to call at times other than during their prenatal visits because they will get all sorts of advice from everybody around them about their pregnancy. We’re open to phone calls. They also can email us as well. We encourage that communication.
Dr. Lee: We have a nice team of perinatologists who are maternal fetal medicine specialists. We work very closely with them. They see most of our patients for their first trimester Nuchal Translucency ultrasound, which is part of the California Prenatal Screening Program, as part of that calculation for Down syndrome and trisomy 18. But they also work with us for our patients who are considered high risk. High risk can be a variety of things, from age-related — if women are over the age of 35 — if they have underlying high blood pressure or high blood pressure in pregnancy, diabetes, or gestational diabetes, lupus and all sorts of different issues. Sometimes we have them help us with our twins as well.
Sometimes you don’t know you’re having a high risk pregnancy and you don’t know until you go to the office and we check your blood pressure and find that it’s elevated.
We know that it may be a high risk pregnancy. For instance, there may be an underlying medical condition, such as high blood pressure or diabetes. But sometimes you may have these problems and have a perfectly normal pregnancy.
Dr. Lee: It should be well-balanced with plenty of protein, variety of vegetables, fruits, dairy and grains. There are certain restrictions. We recommend not having raw meat or fish during pregnancy. This is to prevent certain foodborne illnesses. There’s also a disease called toxoplasmosis that you can get from eating raw beef.
We do think fish is very healthy in pregnancy, but try to avoid fish that’s high in mercury, including tilefish, and swordfish. Some of the fishes that just hang around in the ocean a long time have a lot of mercury. Experts recommend no more than eight to 12 ounces of fish a week.
Obviously, avoid caffeine, smoking and drugs — unless they’re drugs that your doctor has prescribed or that they recommend you continue in your pregnancy. Some caffeine is fine in pregnancy. Doctors recommend no more than 200 milligrams of caffeine daily as long as it does not make your pressure higher.
We recommend avoiding alcohol during pregnancy. Alcohol use can cause something called fetal alcohol syndrome. We don’t know a low limit of alcohol that’s safe, so we recommend just avoiding it completely.
Dr. Lee: For most women, exercise is great during pregnancy. Many women can continue what they had been doing prior to getting pregnant. We discuss it at the first prenatal visit. Sometimes, our patients come in before they get pregnant, and we talk about that as well.
Certain things that we recommend against are contact sports where something could hit your abdomen. We want to avoid that. We recommend against doing things, such as skiing, snowboarding, scuba diving and horseback riding, where there is a risk that you could fall.
If you’re a runner, we don’t recommend running an hour. Usually 30 to 45 minutes for most women is going to be adequate. The Centers for Disease Control and Prevention recommends 150 minutes of aerobic exercise a week and that can be broken up into 30-minute increments, five days a week.
Sometimes, we recommend against exercise during pregnancy. If a woman is in pre-term labor or having vaginal bleeding, if her bag of water has broken prematurely, we would recommend no exercise at that time.
Montiel: A midwife is a health care professional who is trained to work with women during the course of their pregnancy, their labor and post delivery.
At Scripps hospitals,we have a team of eight or nine midwives. We function as hospitalists. We come into the hospital for shift work. We care for all the patients that come through the doors on our particular shift, as long as it’s within our scope of practice.
The hospitalist nurse midwives deliver an average of 100 babies a month.
Dr. Lee: We have a wonderful relationship with Rady Children’s Hospital. We work very closely with the neonatologists, the nurse practitioners, the ALS (advanced life support) nurses and the respiratory therapists. They come to a lot of our births.
There’s usually an ALS nurse and respiratory therapist at many of the births as a precaution. Most of the time, there’s not an issue, which we’re very grateful for. But we are really happy that they’re in the hospital because they can help us with babies that may need extra attention. If there’s an infection and they need antibiotics, if they’re born pre-term and they need extra support, we have the level III NICU that’s right there.
Montiel: Most of the time, if the physician is on and it’s their patient, they will care for their patient. Otherwise, we take care of everyone that comes through the hospital that is low risk or within our scope of practice. That can vary slightly depending on the case and the person.
We always offer, or explain to the patients who we are and what we do. The beauty of the way that our program works is that we have two physicians who are in house every 24 hours. If we run into a pickle, or if we have something that we’re not happy with what’s going on with the baby or the mom, we collaborate quite closely with our physicians. They’re in the room within 30 seconds.
Our patients do have the option — which we offer every time that we meet them — whether or not they’re comfortable with midwifery care. If they’re not comfortable with midwifery care, we pass them on to the physician.
Montiel: A lactation consultant is usually a registered nurse who has done special training in helping women with breastfeeding.
We have lactation consultants who are always in the hospital helping our patients with their breastfeeding. Our postpartum nurses are amazing with that as well. There’s a lot of support because it definitely is an art to be learned.
The nice thing is that once the patients are home, they have access to lactation support groups and lactation consultants. There are consultants who come to the home and help. We feel grateful for that support.
Dr. Lee: It depends. Breastfeeding is great, but sometimes it doesn't work. When it does work, it’s really healthy. I think most pediatricians recommend exclusive breastfeeding through the first six months, and then start introducing different foods. If a mom can breastfeed the first year of life, that’s great. Some women choose to do it longer. So it’s really an individual thing.
Sometimes, it’s going to be painful. Because honestly, for most women, that’s not what their breasts have been used to before. To help prevent pain we have nipple shields that actually can help protect the skin of the nipple. When engorgement happens, we teach them different things. There are breastfeeding support groups and classes throughout San Diego County.
A lot of our patients get breast pumps during the pregnancy. It’s covered by insurance now, which is great. They can get the prescription from us in the office and get the breast pump and have that at home before they deliver. In the hospital, there are pumps in every room. That’s something that the postpartum nurses or lactation specialists will consult with them on. If they want to rent a hospital grade breast pump, that’s available as well. It’s a little bit stronger than the one they would have at home.
Montiel: We have amazing childbirth educators and classes. We work really closely with them. The classes are just basic childbirth preparations that go through what to expect in labor, how to deal with the pain of labor, what epidurals are and what cesarean sections look like. They go through all of the birth process. We also have lactation and breastfeeding classes. Husbands are welcome to that too. There is a grandparents class. There is a siblings class. There is a dog and baby class. We love our dogs. We want them to be ready for their world changing when the baby comes home.
Montiel: Our goal really is to provide an environment where our patients feel safe. They feel heard. They feel like they’re in control.
We’re there to provide what we think our best recommendation would be with the information that’s given, and really try and keep them safe and their baby safe. But we’re notorious for being watchful waiters, meaning that we really believe in the normal process of labor. But we understand the value of technology and intervention, and we utilize it when it’s necessary.
What I tell my patients all the time is that they really have the best of both worlds. They really have every opportunity to create their experience the way that they envision it. But when or if anything goes a little bit off track, we’re there to help them through it.
Dr. Lee: Postpartum depression, unfortunately, is very real. What I tell my patients is that 85 percent of all women will have postpartum blues, which is different than postpartum depression. It’s very common. Women will feel overwhelmed. They’ll cry at the drop of a hat. Sometimes, they’ll feel a little bit sad. That’s all very normal. That’s part of being a new mom. Usually, I tell my patients to be prepared for that and be forgiving to yourself and to your body. It’s just done an amazing feat for you. Be good to it.
What I do warn them about though is that if it persists past a couple of weeks, or if it’s really exaggerated for your character, it can become a problem. For example, if they’re crying all the time, or they don’t want to leave the house, don’t want to hold the baby, touch the baby, feed the baby. It’s very common to wake up in the middle of the night and make sure your baby is breathing. That’s very normal, but when it’s exaggerated for your personality, it then becomes a problem. About one in eight women are affected with postpartum depression.
Patients absolutely need to be educated. When you’re exhausted, you may not be assessing yourself as well as you could. So, education is huge. We talk about it prenatally and at the hospital. Every time a patient comes in postpartum, they fill out a postpartum assessment form, and it’s actually a test. We use that form to refer people to the Postpartum Health Alliance, which is an amazing group of therapists that specialize in postpartum depression, anxiety, any mood disorders associated with having a new baby. There is a very fine line between being exhausted and overwhelmed, which is a normal reaction, to having postpartum depression. We definitely encourage people to call us with that. Therapy is really important as is getting plenty of sleep. There are anti-depressants that are safe with breastfeeding.
Montiel: Women need to know that they have no reason to feel ashamed if they’re feeling really badly after they just had their baby. I think that’s the biggest factor preventing health care professionals from helping women. They don’t want to admit that they’re feeling crummy because they feel terrible after the just got this beautiful gift.
I want women to know that they have a very safe place to call. We’re not going to pass judgment. We’re just going to make sure that we help them the best way that we can.
Dr. Lee: Thankfully, the babies don’t come home walking. Pediatricians are great at guiding parents along the way. We recommend that babies sleep on their back. They will recommend some stomach time. But sleeping on their backs helps decrease the risk of SIDS. SIDS is Sudden Infant Death Syndrome.
Getting animals ready is important so that the cat is not trying to sleep with the baby.
Montiel: Sometimes, we will save blankets that were used with the baby, and send them home prior to the baby going home so that their animal can get familiar with their smell.