Obstetrics

The first sign of labor is uterine contractions. Often described as tightening of the uterus, these contractions should be of significant strength to cause you to stop a conversation and take several deep breaths. When contractions are 5 minutes apart – from the beginning of one contraction to the beginning of the next contraction – contact your physician.

The second sign of labor is your water breaking. Some women notice a large gush of fluid, and some women notice a constant leaking of small amounts of fluid. In either case, you should go to the hospital right away.

The third sign is vaginal bleeding. If at any point you have bright red bleeding similar in volume to a period, go to the hospital. This is a medical emergency and may be a sign that your placenta is separating from your uterus. If you have a small amount of bleeding mixed with mucus, this is probably your mucus plug. You can lose the mucus plug at many points during pregnancy, but this is not necessarily a signal of impending labor.

Finally, if your baby is not moving normally, contact your physician. You should notice at least 10 movements per day.

It is recommended that a pregnant woman should gain about 25 to 35 pounds during pregnancy. If you were underweight prior to your pregnancy, your average weight gain should be 30 to 40 pounds. If overweight, it should be 20 to 30 pounds.

Most women gain approximately 5 to 6 pounds during the first trimester (three months) of their pregnancy. After the first trimester (at approximately 13 weeks), weight gain becomes more rapid, to approximately 1 pound per week.

During pregnancy it is important to maintain good nutrition and adequate caloric intake. The average calorie consumption for a pregnant woman should be approximately 300 calories more per day than usual. If you don't gain an adequate amount of weight during your pregnancy, you run the risk of a low-birth-weight infant, which can make the child weaker.

It is important not to diet during your pregnancy. On the same note, excess weight gain can lead to large babies and traumatic deliveries. Be sure to monitor your weight during pregnancy to ensure proper nutrition for both you and your child.

During the delivery of your baby, many of your vaginal tissues are stretched and often torn. Your cervix dilates and undergoes a certain amount of trauma.

It takes approximately 6 weeks for your uterus, cervix, and vaginal tissues to heal and return to their normal state. Because of this, you’ll likely be asked by your doctor to wait 6 weeks after delivery before having intercourse again.

Many women are concerned about experiencing pain the first time they have intercourse after having a baby. However, as long as it has been at least 6 weeks since delivery, most women don’t experience very much discomfort or pain. If you had an episiotomy, the stitches will have already dissolved if it has been 6 weeks, so that should not cause discomfort.

There are several schools of thought on whether it is appropriate for a woman to choose to induce labor. In medical terms, this is known as elective induction of labor.

Many factors come into play when physicians decide to induce labor.

First, 37 weeks is considered the minimum ideal term for a pregnancy without complications. However, it is preferred to reach at least 39 weeks for an elective induction. Recent data suggests that elective inductions at 39 weeks may decrease the likelihood of a C-section for patients in their first pregnancy.

Second, the accuracy of your due date will be under consideration if plans are made to induce labor. If you had an ultrasound in the first trimester that verified the due date (calculated by your last menstrual period), then your due date should be accurate, plus or minus one week. If you had a second-trimester ultrasound that was consistent with the first, your due date should be accurate, plus or minus two weeks. Therefore, delivery at 39 weeks, even if off by 2 weeks, should still result in the delivery of a full-term infant (greater than 37 weeks).

Finally, the dilation and effacement of your cervix prior to the induction of labor will be an issue. If your cervix has started to dilate and has started to efface, your physician may feel that an induction of labor is reasonable. If your cervix has not dilated or effaced, your doctor may consider waiting longer for an induction, performing a slow two-day induction, or even performing a C-section rather than inducing labor.

Many physicians feel that electively inducing labor is not appropriate until the pregnancy reaches 41 to 42 weeks, when there may be a decreased functioning of the placenta. However, many physicians – including the American College of Obstetricians and Gynecologists – feel it is reasonable to induce labor at 39 weeks if the mother has had prior rapid labor or has a long distance to travel to the hospital.

After 35 years of experience in the field, we strongly believe that 40 weeks should be the maximum term for any pregnancy.

The most common cause of cramping during pregnancy is the stretching of the round ligaments that hold the uterus in place.

Many women have cramping during early pregnancy. However, if you have persistent cramping – especially if the cramps are accompanied by bleeding or spotting – it is important that you see your physician immediately.

Although mild cramping is relatively normal, if associated with bleeding it may indicate a risk of a miscarriage or an ectopic pregnancy. An ectopic pregnancy is life-threatening and must be followed very closely. Be certain to contact your physician if your symptoms persist or if you have any associated bleeding.

Many women have concerns about the safety of air travel while pregnant. Flying in airplanes is safe during pregnancy, and there is no indication that it causes complications. The change in barometric pressure during a flight has no serious effect on pregnancy.

The biggest issue of flying relates to the timing of your travel and whether there have been any prior complications with the pregnancy. Although it is safe to travel at any point during your pregnancy, many airlines have restrictions on air flight beyond 36 weeks. You may need permission from your physician to fly at 37 weeks or later. (Airlines prefer not to run the risk of a woman suddenly giving birth on a flight.)

Your physician may not want you to travel far distances by airplane after approximately 34 to 35 weeks, especially since access to medical care is limited or nonexistent during a plane flight. It may be best for you to stay closer to home late in your pregnancy to ensure that you receive proper medical attention if you go into labor.

If you do choose to travel, it is a good idea to have copies of your medical records with you in case of an emergency.

Health care officials have issued an advisory on the potential dangers of eating fish. The advisory is in regards to the consumption of fish by expectant mothers, nursing mothers, and women who are seeking to get pregnant. It is believed that the level of mercury in fish may pose risks to a developing fetus, because the metal is absorbed quickly and is not excreted efficiently.

If exposed to mercury while in the womb, babies may be born with symptoms that resemble cerebral palsy, or have other movement-type abnormalities. They are also more susceptible to convulsions, visual problems, and abnormal reflexes. In children who have died as a result of mercury poisoning, autopsy results show loss of neurons in the cerebellum and throughout the cerebral cortex in the brain.

The developing system of a baby and a young child is more sensitive to the effects of mercury than is the system of an adult or older child.

Contamination from mercury in freshwater fish can occur naturally through environmental factors or by contamination from industrial wastes. Larger fish (such as sharks, swordfish, king mackerel, and tilefish) that prey on smaller fish accumulate the highest levels of mercury – and therefore pose the greatest risk.

A person’s mercury levels can be measured in blood, urine, and hair samples.

It is recommended that pregnant women and young children limit their consumption of freshwater fish to one meal per week, or the equivalent of 8 ounces of fish (as measured before cooking) for adults or 3 ounces for young children.

We do not recommend consumption of raw fish such as sushi or ceviche during pregnancy.

The Apgar score measures a newborn baby’s health in regards to:

• Heartbeat
• Breathing
• Skin tone
• Muscle tone
• Response to stimuli

This scoring system was first developed by anesthesiologist Virginia Apgar in 1952 at NewYork-Presbyterian Hospital, and it continues to be used to evaluate the health of newborns.

Apgar scores are divided into the five categories listed above, with a value of 0 to 2 points for each category – and therefore a maximum “perfect” score of 10. Apgar scores are determined within the first 5 minutes after delivery. If the 5-minute Apgar score is 6 or less, the infant will receive a 10-minute Apgar score evaluation to determine whether the child is already improving or not.

Apgar scores are poor indicators of neonatal outcome, but they do help determine the effectiveness of resuscitative efforts. Specifically, Apgar scores at 1 minute are only a gauge to determine whether immediate support is needed. Low scores (0 to 3) at these intervals have correlated with a slightly increased risk of cerebral palsy.

Apgar scores are also poor indicators of long-term outcomes for an infant who experiences hypoxia (lack of oxygen) at birth. Multiple factors must be considered to make these assessments.

This is a very common question, and an important one for all women to understand.

Any bleeding during pregnancy is considered abnormal – although it is not unusual to have some spotting early in a pregnancy. You may also have some bleeding as a result of a break in one of the superficial blood vessels on the cervix. However, this should be rather minimal and should last only a short time. If you are pregnant, you should not be having any regular bleeding; if you do, see your doctor as soon as possible for an evaluation.

It is not possible to continue having your period while you are pregnant.

Also called a tubal pregnancy, an ectopic pregnancy develops outside of the uterus. It usually occurs in the fallopian tube, but it can occur anywhere in the immediate area. A fetus cannot survive outside of the uterus.

Due to the restricted area in the fallopian tube, fetal growth cannot occur normally. As a result, the fetus may burst through the fallopian tube and cause internal bleeding. This is a medical emergency. If not treated promptly, ectopic pregnancy can result in the death of the mother.

Once diagnosed, there are treatment options for an ectopic pregnancy. Regardless of what type of treatment you and your physician choose, some form of treatment must be undertaken promptly.

If your ectopic pregnancy meets certain criteria, your physician may recommend treatment with methotrexate. This medicine is frequently used to treat cancer and arthritis, because it stops cells from dividing. When treating an Ectopic pregnancy, methotrexate is given in doses much lower than those used to treat cancer, and therefore has few side effects.

The physician will give you an injection of methotrexate, then follow your hormone levels closely to be certain that the pregnancy resolves. If the levels do not decrease appropriately, you may need a second injection or surgery.

If you do not meet the criteria for use of methotrexate, your physician may recommend surgery.

Two surgical approaches can be used, depending on the seriousness of the situation. The first option is known as Laparoscopy With laparoscopy, a small incision is made in or around your navel (belly button), and a small light is inserted into your abdomen. The fallopian tube can then be examined.

If necessary, your physician will make a few small incisions lower on your abdomen through which he or she can insert instruments and either remove the ectopic pregnancy or remove the entire fallopian tube. (You have two fallopian tubes, so one would remain.)

The second surgical option, although very uncommon in our practice, is known as a laparotomy. This involves making a large incision lower on the abdomen and removing the ectopic pregnancy or the fallopian tube. If the ectopic pregnancy has already ruptured (burst through the fallopian tube), this will be the quickest way to remove the fallopian tube and stop the bleeding.

If you suspect an ectopic pregnancy, it is important that you contact your doctor immediately.

Every pregnant woman is faced with the decision of whether she will use a form of pain relief during labor and delivery. Some women are very certain that they will want pain relief, while others are unsure.

There are also those women who prefer to give birth without any form of pain relief. For women who do not desire any form of analgesia during labor, it is important that they understand their options. During an emergency delivery, some form of analgesia or anesthesia may be necessary.

Under ideal circumstances, an anesthetic agent would allow you to deliver your baby with minimal pain and minimal risk, and it would allow you to push when it is time to do so. The ideal anesthetic would also not stop your contractions or make you or your baby sleepy.

There are many types of anesthesia that can be used during labor and delivery, including the following:

• Local Anesthesia: Local anesthesia requires a series of injections in the vaginal outlet. It is generally used for women who need an episiotomy or who require the placement of sutures after delivery.
• Intravenous Sedation: Sedatives are administered as an injection or intravenously. This can help reduce the pain of labor, but it will not eliminate the pain entirely.
• Pudendal Block: The pudendal nerve is one of the primary nerves that provide sensation to the vaginal outlet. Pudendal block is administered using an injection of local anesthesia through the vagina and into the pudendal nerve. It is given just prior to delivery and may be supplemented with local anesthesia.
• Epidural: An epidural is an anesthetic delivered through a tiny catheter placed in the lower part of the back in the epidural space. A woman will continue to feel touch and pressure, but the pains of labor are significantly reduced.
• Spinal Block: The spinal block is similar to the epidural, but the anesthetic is actually placed within the spinal fluid. Spinal anesthetics are sometimes used at the time of delivery (saddle block) or at the time of cesarean section. Like an epidural, a spinal block cannot be used if you are using blood thinners, have an infection in the back or the blood, or have an unusual spinal abnormality.
• General Anesthesia: General anesthesia is administered by giving an anesthetic intravenously and through breathing an anesthetic gas. A general anesthesia may be needed for an emergency, or if a cesarean section is required and the patient cannot have an epidural or a spinal block. Because it carries additional risks, it is not the first choice of pain relief during labor and delivery.

If your prenatal care has been started in a different city, the following are the studies that we request you bring with you.

Initial Studies

• Gonorrhea and chlamydia vaginal cultures
• Hepatitis A IgG antibody titer
• Hepatitis B surface antigen
• Hepatits C IgG antibody titer
• Blood type and RH
• RPR or VDRL (syphilis test)
• Rubella IgG antibody (immunity)
• Complete blood count (CBC)
• Urine analysis and culture
• HIV titer
• Early ultrasound (7 to 10 weeks of pregnancy)
• Varicella titer
• cell free DNA testing for genetic abnormalities (Natera) 
• vitamin d levels

Studies 12 to 18 weeks

• Nuchal translucency ultrasound (11.1 to 13.6 weeks)
• Genetic chromosomal screening (11.1 to 13.6 weeks)
• Maternal alphafetoprotein (15 to 18 weeks) if natera done

Studies 20 to 28 weeks

• Anatomic ultrasound (20 to 22 weeks)
• Glucose tolerance test (1 hour) (24 to 28 weeks)
• Repeat CBC (with glucose test)

Studies 28 to 36 weeks

• Studies 28 to 36 weeks
• HIV titer (repeat)
• RPR or VDRL (repeat)
• repeat Hepatitis B surface antigen
• Group B strep vaginal culture
• Final ultrasound (36 weeks) for lie or weight
• repeat vitamin d levels

I encourage vaginal deliveries as long as there are no contraindications. Sometimes it becomes necessary for the safety of the baby and/mother to have a cesarean birth.  However, I believe that all women if safe to do so, should have a vaginal birth.  My cesarean section rate averages 9-12% (well below the national average of 33% and below the recommend threshold of 25%). Indications for cesarean sections will be discussed during your prenatal visits.  I also provide mother friendly/family centered cesarean section deliveries  This is not offered much anywhere but offers a woman that has a cesarean section to have a memorable, safe delivery and feel apart of the birth and not have "procedure" done.  Most women are extremely grateful to have been offered the birth experience not normally felt during a cesarean section.  If you require a cesarean section, ask Dr. Quezada about this option.  It's really cool!!!!!! 

No, if you prefer a scheduled cesarean section we will happily do that as long as you have a normal pregnancy and are at least 39 weeks of gestation.  This is called a maternal choice driven cesarean and will need extensive counseling on the risks of using this approach, the fears you may have with a vaginal birth and what the short and long term implications of this decision mean.  I still respect a woman's decision on how to approach HER pregnancy and delivery as long as she is well educated about the prospects.    This topic needs to be discussed during your prenatal visits.