Perinatal Care Toolkit

Transcripción

DRAFT
Perinatal Care
Toolkit
2013
Dear Doctor:
L.A. Care Health Plan (L.A. Care) is pleased to provide you with this copy of the Perinatal Care Quality
Improvement Toolkit. Establishing prenatal care early in pregnancy has been shown to improve the risk of
adverse pregnancy outcomes and the risk of birth defects, fetal loss, low birth weight, and preterm delivery for
mother and/or child. Similarly, postpartum visits are critical to women’s health to provide follow up on any
complications related to delivery, as well as to initiate family planning efforts, and screen for postpartum
depression. The American College of Obstetricians and Gynecologists (ACOG) recommend that all women
have a prenatal visit in the 1st trimester and postpartum visit approximately 4-6 weeks after delivery, in addition
to a visit within 7-14 days for a cesarean delivery.
The L.A. Care network currently performs at the 50th percentile for Prenatal Care and below the 25th
percentile for Postpartum Care visit rates nationally among Medicaid Managed Care Plans. (see Table
below). In measurement year 2012, 55% of L.A. Care members who delivered a child did NOT receive a
postpartum visit within the recommended timeframe. At L.A. Care we are committed to improving this
performance, and providing more timely care to our members. We urge you to partner with us and our members
to improve these rates of perinatal care. We have provided the enclosed toolkit in an effort to improve
timeliness to prenatal and postpartum care, and to optimize maternal and infant health.
HEDIS Rates
Thank you for joining us in this effort. Please contact Maria Casias, RN, MPH at (213) 694-1250 ext. 4312 or
[email protected]. If you have any questions or would like to provide any feedback.
You can access additional copies of the toolkit by downloading it from the L.A. Care website at
http://www.lacare.org/providers/resources/providertoolkits.
Sincerely,
Jennifer N. Sayles, MD, MPH
Medical Director
Quality Improvement &
Health Assessment
Perinatal Care Provider Toolkit
Contents
Material Sources
A. Provider Guidelines 1 Perinatal Care Guideline Quick Reference
2 Prenatal and Postpartum Care: HEDIS Codes
The American College of Obstetricians and Gynecologists L.A. Care Health Plan
B. Additional Resources 1 Prenatal Care Provider Policies and Procedures to Prevent Perinatal Centers for Disease Control Hepatitis B Virus Transmission 2 Group Prenatal Care and Perinatal Outcomes
3 Improving Perinatal Care: A Focus of Patient‐Centered Care and Institute for Healthcare Evidence‐Based Measures 4 Additional Materials available: L.A. Care Website @ L.A. Care Health Plan
http://www.lacare.org http://www.lacare.org/providers/resources/healtheducation/order‐
form National Institute of Health C. Member Health Education Resources
1 Pregnancy: Common Questions (English/Spanish)
L.A. Care Health Plan
2 What is Prenatal Care (English/Spanish)
3 Adapting to Pregnancy: First Trimester
(English/Spanish) L.A. Care Health Plan
4 L.A. Care Health Plan
6 Adapting to Pregnancy: Second Trimester
(English/Spanish) Adapting to Pregnancy: Third Trimester
(English/Spanish) Healthy Eating Habits During Pregnancy
7 Exercise During Pregnancy L.A. Care Health Plan
8 What is Gestational Diabetes L.A. Care Health Plan
9 Understanding Preterm Labor L.A. Care Health Plan
10 After Giving Birth: Changing Expectations for Parents
11 After Giving Birth: How to Feel Healthy
5 L.A. Care Health Plan
PREN
NATAL
ACOG
SCHEDU
ULE &
FREQUE
ENCY
HISTO
ORY
AND
D
PHYSIC
CAL
DIAGNO
OSTIC
LABS
COUNSE
ELING
AND PLAN
L
ANTEPARTUM
POSTPAR
RTUM
refer to page 3 for additional details
er, as soon as possiblle after a missed men
nses
1st trimeste
Demograph
hic and family/genetic
c information
Medical, me
enstrual, obstetrical history,
h
LMP, EDD
Psychosocial history – depressio
on, domestic violence
e, abuse
ons and infection/STD
D history
Immunizatio
Initial physical and obstetrical ex
xam
Fetal heart tones and position
Allergies
s
Medications
Pregnancy test if indicated
Pap test if indicated
Administrattion of immunizations & PPD (if indicated)
Urine culturre/screen
Obstetric pa
anel (Rh [D] and ABO blood
b
typing, RBC antibo
ody screen,
CBC with diff, pla
atelet count, HBsAg)
Rubella/AB
BO/Rh
TORCH antibody panel
hea
VDRL, HIV, Chlamydia, Gonorrh
Ultrasound
sting (if indicated: >35 as of EDD or genetic risk factors present)
Genetic tes
GDM risk assessment
a
Plan of prenatal, delivery and po
ostpartum care
nd exercise – Prenata
al vitamins/iron – weig
ght gain
Nutrition an
Tobacco/alcohol/drug use
C medications, vitamin
ns, herbal supplemen
nts
Use of OTC
Physical/se
exual activity
Sauna and hot tub exposure
d vomiting
Nausea and
Signs of lab
bor/danger signals
Toxoplasmosis precautions (cats
s/raw meat)
Travel/seatt belt use
Work/enviro
onmental hazards
Fetal move
ement
Re
ecommendation for un
ncomplicated pregnan
ncies:
0-2
28 weeks - every 4 we
eeks
29-36 weeks - every 2-3
3 weeks
ek until delivery
37 + weeks - every wee
We
eeks gestation
Fundal height
ment and presentation
n
Fetal hear t rate, movem
ood pressure
Blo
We
eight
Ed
dema
Ce
ervical exam
On
ngoing risk assessment/danger
sig
gnals/signs of prematu
ure labor
Ulttrasound when indicated
HC
CT/HGB/MCV
Dia
abetes screen
GT
TT if diabetes screen is abnormal
D (Rh)
(
Antibody screen
Group B Strep
DRL, Chlamydia, Gonorrhea tests when ind
dicated
VD
Uriine albumin/glucose
Oth
her tests when indica
ated
Pre
eparation for delivery
Sig
gns of labor
Labor and delivery proc
cess, anesthesia
Tubal sterilization
hildbirth classes
Ch
Bre
eastfeeding resources
s
Cirrcumcision
Ne
ewborn care – breast//bottle, car seat, pedia
atrician
Da
aily fetal movement as
ssessment
4-6 weekss after delivery
Interval history
wborn adaptation and
d
Evaluation of parent/family/new
bonding
exam: weight, blood pressure,
p
Physical e
breasts, a
abdomen, pelvic exam
m, uterine involution,
episiotom
my repair, etc.
Pap test , as indicated
Administrration of immunization
ns, as indicated. (Wom
men
who have n
not received Tdap should receive after delivery and
a
before hospital discharge if 2 years
s or have elapsed since
nt dose)
most recen
Hemoglob
bin/Hematocrit
econception counselin
ng regarding future
Begin pre
pregnanccies
Review/in
nitiation of contraceptiive methods
Breast fee
eding
Maternal//infant bonding, family
y support
Postpartu
um depression
Nutrition a
and exercise, Kegel exercises
e
Sexual acctivity
Domesticc violence/child abuse
e
Communiity resources, ie parenting groups
Specific ccounseling for those with
w an abnormal
pregnanccy outcome
REFERENCE
ES
1.
2.
NCQA HEDIS 2013 Volume 2: Technical
T
Specifications Access/Availability
A
of Carre measure: Prenatal and
d Postpartum Care.
Guidellines for Perinatal Care, 7th
7 Edition; American Aca
ademy of Pediatrics and The
T
American College of Obstetricians and Gynec
cologist, 2012
FREQUE
ENCY
OF VIS
SITS
6-12
W
Weeks
0-28 weeks: every 4 week
ks | 29-36 weeks: every 2-3 weeks
s | 37+ weeks: ev
very week until delivery
d
Standard screening at each visit: Vital signs, weight,
w
fetal assess
sment (heart sound
d, activity) from 10
1 th week, fundal he
eight, urine albumin & glucose
SC
CREENING
•
•
•
•
16-18
W
Weeks
•
•
•
•
•
Revie
ew H&P, Lab
Revie
ew GDM risk
Offerr screening for aneu
uploidy which will include
i
1st trimeste
er
seein
ng (nuchal translucency combined witth blood test)
Those
e with increased ris
sk should be offere
ed genetic counseliing
and option
o
of chorionic villus sampling or second trimester
amniiocentisis1
Fundal height
Urine
e albumin and gluco
ose, GDM Risk
Ultrasound
Offerr screening for aneu
uploidy with Quad Screen if not done
e in
1st triimester. This also incorportates
i
neura
al tube defect
scree
ening2
Amniiocentisis if desired
d1
20
•
•
24
•
28
•
•
•
GDM Screening (if not yet
y done. 24-28 we
eeks)
Repeat type and screen
n if Rh negative, H&
&H
Immu
unization:
o
Rhogam if Rh –
o
Influenza (optiional)
31
•
Repeat test for at risk for
f STD women including RPR, HIV,
gonorrhea, and Chlamy
ydia
3
32-34
•
Fetal position
36
•
•
GBS screening
Confiirm fetal position
37
•
Check cervix (if indicate
ed)
>41
•
Check cervix (if indicate
ed)
W
Weeks
NOTE
ES
1
Ultrasound (optional) gender prediction
Immu
unization: Tdap affter 20 weeks. Counsel patient that
those
e in close contact with
w
baby during firrst 12 months of liffe
should also receive Tdap
GDM Screening (glucose tolerance test)
COUNSELIN
NG
•
Discuss VBAC
V
if previous C-Section.
C
Lifestyle, sub
bstance abuse, nutrition, weight gain,, fetal growth, brea
astfeeding,
occupational hazards
•
Fetal mo
ovement, S/S prete
erm labor
Review resultts of 1st trimester screening
s
if done a
and offer genetic co
ounseling, if
indicated
•
•
Preterm S/S preterm laborr
Childbirtth classes
Baby’s medical
m
provider if available
a
Preterm S/S preterm labor
•
•
•
•
•
Discuss / provide info on co
ord blood banking
Confirm baby’s medical pro
ovider
Documenting kick counts
Preterm S/S preterm laborr
Birthing options, pre-registtration
•
•
•
Discuss Group
G
B Strep prottocol
Travel ac
ctivities
Considerration of pediatricia
an
Circumciision choice and schedule
Sign and
d symptoms preterm labor
•
Discuss risk and benefits of HSV prophylaxis in women with hx of genital herpes
Labor ed
ducation: S/S Labor, when to call MD,, labor phases, ana
algesics, c-sec,
etc.
Review labor education
Importan
nce of postpartum follow-up
Baseline non stress test (N
NST), contraction te
est (CST), ultrasonography (US),
biophysical profile (BPP) orr combination of te
ests
Discuss labor induction >41 weeks
•
•
Check for prop
per insurance coverag
ge
REFERENCE
ES
1.
2.
T
A
d Postpartum Care.
T
cologist, 2012
PR
RENATAL TI
IMELINE
POST
TPARTUM TI
IMELINE
In the FIIRST TRIMESTER OR
R WITHIN 42 DAYS
S OF ENROLLMENT, depending the date
of enro
ollment and any ga
aps in enrollment during the pregnanc
cy. When counting
prenatal visits,
v
include visits
s with PA, NP, midw
wives, RN, provided a co signature by
ya
physicia
an is present, if req
quired by state law
w.
BETWEEN
N 21-56 DAYS AFT
TER DELIVERY,
PRENA
ATAL ENCOU
UNTER CODES
POSTPART
TUM ENCOU
UNTER CODES
DESCRIP
PTION: CODES TO IDENTIFY
D
PRENATAL CARE AND VISITS
Any prenatal care visit to an
a OB practitioner,, a midwife or family practitioner or
other PC
CP with documentation of when prena
atal care was initiatted
CPT
59400*, 59425* 59426*, 59510*, 59610*, 59618*
DESCRIP
PTION: CODES TO IDENTIFY
D
PRENATAL CARE AND VISITS
Any prenatal care visit2 to an OB practitionerr, a midwife or fam
mily practitioner
with a pregnancy
p
related ICD-9-CM
I
diagnosis code.
Must me
eet criteria in [Partt A and (Part B or Part C)] or Part D.
•
Obstetric panel
•
Rubella antibody//titer with Rh incom
mpatibility
(ABO/Rh blood ty
yping)
•
Ultrasound of the
e pregnant uterus
•
TORCH antibody panel
Pregnancy-related
•
d diagnosis code
PART A: ANY CPT WITH ANY ICD-9-CM DIAGNOS
SIS CODE
CPT
99201- 99
9205, 99211- 9921
15, 99241-99245
640.x3, 641.x3, 642.x3, 643
3.x3, 644.x3,
645.x3, 646.x3, 647.x3, 648
ICD-9-C
CM
8.x3, 649.x3, 651.x3, 652.x3,
653.x3,
Diagnosis
654.x3, 655.x3, 656.x3, 657
7.x3, 658.x3, 659.x3, 678.x3,
679.x3, V22-V23,
V
V28
PART B: ANY ONE CODE
76801, 76
6805, 76811, 7681
13, 76815-76821,
CPT
76825-76
6828, 80055
ICD-9-C
CM
88.78
Procedure
even if seen
s
7-14 days follo
owing delivery
(for suture
s
removal, forr example)
DESCRIPTIO
ON: POSTPARTUM VISIT
I
A postpartu
um visit to an OB/G
GYN practitioner or midwife, family prractitioner or
other PCP fo
or a pelvic exam or postpartum care with
any of the following
f
codes
57170, 58300,, 59400*, 59410*, 59430, 59510*, 59515*,
5
59610*,
CPT
59614*, 59618
8*, 59622*, 88141
1-88143, 88147, 88148, 88150,
88152-88155, 88164-88167, 88174, 88175, 99501
1
CPT
0503F
Category
II
HCPCS
G0101, G0123
3, G0124, G0141, G
G0143-G0145, G01
147, G0148,
P3000, P3001,, Q0091
ICD-9-CM
Diagnosis
ICD-9-CM
Procedure
e
UB-92
Revenue
LOINC
V24.1, V24.2, V25.1, V72.3, V76
6.2
89.26, 91.46
0923
10524-7, 1850
00-9, 19762-4, 197
764-0, 19765-7, 19
9766-5, 19774-9,
33717-0, 4752
27-7, 47528-5
*Generally, these
e codes are used on the date of delivery, not on the date of the postpartu
um visit,
so this code may
y be used only if the claim
m form indicates when postpartum care was rend
dered
PART C: TORCH A CPT COD
DE FOR EACH OF THE FOUR
F
INFECTIONS
MUST BE PR
RESENT FOR THIS COM
MPONENT
Cytomegalovirus
Herpes sim
mplex

Rubella
Toxoplasm
ma
ABO, Rh
PART D:: ANY ONE CODE
CPT
99500
NOTE
ES
2
86644
86694, 86695, 86696
86762
86777
86900, 86901
When using ‘vis
sit’, it is necessary to
o determine prenatal care
c
was rendered an
nd member was not merely
m
diagnosed as pregnant
p
and referred
d to another practition
ner for prenatal care
REFERENCE
ES
1.
2.
T
A
d Postpartum Care.
T
cologist, 2012
PRENA
ATAL
Documentation in the medic
cal record must inc
clude:
• Proogress notes with basic
b
physical OB exam
e
that includes auscultation for fe
etal
he
eat tone or pelvic ex
xam with OB obserrvations or measurrement of fundic he
eight
• Lab report – OB paneel, TORCH antibodyy panel
• Echography of a preg
gnant uterus / pelv
vic ultrasound
• Doocumentation of LM
MP or EDD in conjuc
ction with either prrenatal risk assessm
ment
an
nd counseling/education or complete OB
O history
POSTPAR
RTUM
Documenta
ation in the medica
al record must inclu
ude a note indicatin
ng the date when a
postpartum
m visit occurred and
d one of the follow
wing.
• Pelvvic exam, or
• Evaaluation of weight, BP, breasts and abbdomen, or
• Nottation of postpartum
m care, including, but not limited to:
– Notation
N
of “postpa
artum care,” “PP ca
are,” “PP check,” “6
6-week check”
– A preprinted “Postppartum Care” form in which informatioon was documenteed
d
during
the visit.
REFERENCE
ES
1.
2.
T
A
d Postpartum Care.
T
cologist, 2012
Prenatal Care Provider Policies and Procedures
to Prevent Perinatal Hepatitis B Virus Transmission
Prenatal care providers should test every woman for hepatitis B surface antigen (HBsAg)
during an early prenatal visit (e.g., in the first trimester), even if a woman has been
previously vaccinated or tested.
In addition, prenatal care settings should incorporate each of the following actions into
their policies and protocols:
For a pregnant woman with a positive HBsAg test result
• Report the positive test result to the health department.
• Provide a copy of the original laboratory report indicating the pregnant woman’s
HBsAg status to the hospital where the delivery is planned and to the health-care
provider who will care for the newborn.
• Attach an alert notice or sticker to the woman's medical record to remind the
delivery hospital/nursery that the infant will need hepatitis B vaccine and HBIG at
birth.
• Educate the mother about the need for immunoprophylaxis of her infant at birth,
and obtain consent for immunoprophylaxis before delivery. Consider printing
additional reminder notices for mothers about the importance of
immunoprophylaxis for infants and attaching the notices to the inside front or
back cover of the medical record.
• Advise the mother that all household, sexual, and needle-sharing contacts should
be tested for HBV infection and vaccinated if susceptible.
• Provide information to the mother about hepatitis B, including modes of
transmission, prenatal concerns (e.g., infants born to HBsAg-positive mothers
may be breastfed), medical evaluation and possible treatment of chronic hepatitis
B, and substance abuse treatment (if appropriate).
• Refer the mother to a medical specialist for evaluation of chronic hepatitis B.
For a pregnant woman with a negative HBsAg test result
• Provide a copy of the original laboratory report indicating the pregnant woman’s
HBsAg status to the hospital where the delivery is planned and to the health-care
provider who will care for the newborn.
• Include information in prenatal care education about the rationale for and
importance of newborn hepatitis B vaccination for all infants.
• Administer the hepatitis B vaccine series if the patient has a risk factor for HBV
infection during pregnancy (e.g., injection-drug use, more than one sex partner in
the previous 6 months or an HBsAg-positive sex partner, evaluation or treatment
for a sexually-transmitted disease [STD]).
• Repeat HBsAg testing upon admission to labor and delivery for HBsAg-negative
women who are at risk for HBV infection during pregnancy or who have had
clinical hepatitis since previous testing.
NIH Public Access
Author Manuscript
Obstet Gynecol. Author manuscript; available in PMC 2008 March 31.
NIH-PA Author Manuscript
Published in final edited form as:
Obstet Gynecol. 2007 August ; 110(2 Pt 1): 330–339.
Group Prenatal Care and Perinatal Outcomes:
A Randomized Controlled Trial
Jeannette R. Ickovics, PhD, Trace S. Kershaw, PhD, Claire Westdahl, CNM, MPH, Urania
Magriples, MD, Zohar Massey, Heather Reynolds, CNM, MSN, and Sharon Schindler Rising,
CNM, MSN
From Yale School of Public Health, New Haven, Connecticut; Department of Gynecology and Obstetrics,
Emory University, Atlanta, Georgia; Department of Obstetrics and Gynecology, Yale University, New Haven,
Connecticut; Yale School of Nursing, New Haven, Connecticut; and Centering Pregnancy and Parenting
Association, Cheshire, Connecticut.
Abstract
OBJECTIVE—To determine whether group prenatal care improves pregnancy outcomes,
psychosocial function, and patient satisfaction and to examine potential cost differences.
METHODS—A multisite randomized controlled trial was conducted at two university-affiliated
hospital prenatal clinics. Pregnant women aged 14−25 years (n=1,047) were randomly assigned to
either standard or group care. Women with medical conditions requiring individualized care were
excluded from randomization. Group participants received care in a group setting with women having
the same expected delivery month. Timing and content of visits followed obstetric guidelines from
week 18 through delivery. Each 2-hour prenatal care session included physical assessment, education
and skills building, and support through facilitated group discussion. Structured interviews were
conducted at study entry, during the third trimester, and postpartum.
RESULTS—Mean age of participants was 20.4 years; 80% were African American. Using intentto-treat analyses, women assigned to group care were significantly less likely to have preterm births
compared with those in standard care: 9.8% compared with 13.8%, with no differences in age, parity,
education, or income between study conditions. This is equivalent to a risk reduction of 33% (odds
ratio 0.67, 95% confidence interval 0.44−0.99, P=.045), or 40 per 1,000 births. Effects were
strengthened for African-American women: 10.0% compared with 15.8% (odds ratio 0.59, 95%
confidence interval 0.38−0.92, P=.02). Women in group sessions were less likely to have suboptimal
prenatal care (P<.01), had significantly better prenatal knowledge (P<.001), felt more ready for labor
and delivery (P<.001), and had greater satisfaction with care (P<.001). Breastfeeding initiation was
higher in group care: 66.5% compared with 54.6%, P<.001. There were no differences in birth weight
nor in costs associated with prenatal care or delivery.
CONCLUSION—Group prenatal care resulted in equal or improved perinatal outcomes at no added
cost.
CLINICAL TRIAL REGISTRATION—ClinicalTrials.gov, www.clinicaltrials.gov,
NCT00271960
LEVEL OF EVIDENCE—I
Corresponding author: Jeannette R. Ickovics, PhD, Yale University, School of Public Health, 60 College Street, Room 432, New Haven,
CT 06520−8034; e-mail: [email protected]..
Financial Disclosure Dr. Westdahl receives approximately $3,000 per year from the Centering Pregnancy and Parenting Association
Inc (Cheshire, CT) for training facilitation. Ms. Rising is the executive director of the nonprofit entity, the Centering Pregnancy and
Parenting Association Inc, which promotes the Centering Pregnancy model of care nationally and internationally. The other authors have
no potential conflicts to disclose.
Ickovics et al.
Page 2
Preterm birth rates have increased globally over the past quarter century. Although assisted
reproductive technology and the increase in multifetal gestations account for some of the
increase, the etiology for most preterm delivery remains elusive. To date, pharmacological,
clinical, and psychosocial interventions have had limited success in preventing preterm birth.
1 Racial disparities persist, with a twofold higher rate of preterm birth and low birth weight
among African-American women. Preterm birth has numerous adverse consequences,
including neonatal and infant deaths, childhood neurologic disability, prolonged
hospitalization, increased cost, and potential lifelong adverse developmental and medical
consequences.1–3
There have been prior randomized controlled trials on augmented prenatal care to reduce
preterm birth.4–10 Hobel et al4 reported a 19% reduction in preterm birth among high-risk
patients in county clinics randomized to an enhanced program that included education and
increased visits. Klerman et al5 reported significantly increased patient satisfaction and
knowledge. Although rates of preterm delivery, cesarean delivery, and length of stay in the
neonatal intensive care unit decreased, there was no statistically significant difference. Results
of other randomized controlled trials of augmented care are equivocal,6–10 except among
certain subgroups: primiparous mothers7 and high-risk African-American women.8,10 Lu et
al11 suggest that preterm birth prevention will require a reconceptualization of prenatal care
as part of a broader strategic approach.
Group prenatal care (CenteringPregnancy, Cheshire, CT) has been implemented in over 100
clinical practices in the United States and abroad since 1995.12–13 It provides an integrated
approach to prenatal care in a group setting, incorporating family members, peer support, and
education (Table 1). In prior studies of group prenatal care among minority teens14 and women,
13 investigators documented lower rates of preterm birth and low birth weight. However, these
studies were limited by lack of randomization and potential self-selection bias.
The primary objective of this study was to conduct a multisite randomized controlled trial to
evaluate whether group prenatal care would result in decreases in human immunodeficiency
virus (HIV) risk behavior and sexually transmitted diseases. This is a secondary analysis to
determine whether group prenatal care leads to better reproductive health outcomes, such as
reductions in the numbers of preterm births and low birth weight infants, as well as improved
psychosocial outcomes and patient satisfaction, and also to examine potential differences in
health care costs.
MATERIALS AND METHODS
Young women (aged 14−25 years, n=1,047) entering prenatal care at two publicly funded
clinics were randomly assigned to standard individual care or group care (Fig. 1). The
differences in the quantity and quality of prenatal care are substantial between individual care
and group care as described in Table 1. Individual prenatal care across the pregnancy occurs
over the course of approximately 2 hours. Group prenatal care across the pregnancy occurs
over the course of approximately 20 hours.
Participants were randomly assigned by using a blocked randomized controlled design,
stratified based on site and expected month of delivery. Allocation was concealed from
participant and research staff until eligibility screening was completed and study condition was
assigned. These tasks were completed by trained research team members who were
independent of prenatal care. A computer-generated randomization sequence, password
protected to recruitment staff and participants, was used to assign participants. Although it was
not possible to have treatment blinded (common practice in clinical interventions), all
Ickovics et al.
Page 3
measurement and data collection were conducted in blinded fashion independently of the care
setting. Moreover, medical record abstracters were independent of clinical care.
Participants were recruited from large obstetrics clinics in two university-affiliated hospitals.
Procedures were approved by Human Investigation Committees at both sites (No. 11972, Yale
University, New Haven, CT, and No. 197−2001, Emory University, Atlanta, GA). AfricanAmerican women with limited financial resources are overrepresented, reflecting clinic use
patterns. There were no deviations from the study procedures as originally planned, with the
exception of expanded access by age at study entry from 14−19 years to 14−25 years; this
expanded access was implemented before randomization.
Between September 2001 and December 2004, women attending their first or second prenatal
care visit were referred by a provider or approached directly by research staff. Inclusion criteria
were as follows: less than 24 weeks of gestation, age 25 years or less, no medical problems
requiring individualized care as “high-risk pregnancy” (eg, diabetes, HIV), English or Spanish
language, and willingness to be randomized. Potential participants were screened; if eligible,
research staff explained the study in detail and obtained informed consent. Baseline interviews
occurred at an average gestational age of 18 weeks (standard deviation [SD] 3.3). Each patient
underwent second-trimester ultrasonography for confirmation of dating and anatomy.
Estimated date of confinement was established by an attending obstetrician who was
independent of the study, and this was confirmed by ultrasonography. Participants were
followed prospectively through 1 year postpartum. All participants were paid $20 for each
interview.
Of the 1,538 eligible women, 1,047 (68%) enrolled. Compared with those who declined
enrollment, participants were more likely to be African American, older, and at a later
gestational age at initial screening (all P<.01). Recruitment was nearly equivalent between the
two study sites: Atlanta (n=546, 52%) and New Haven (n=503, 48%). Intervention effects were
not statistically different on primary outcomes by study site; therefore, analyses were combined
across sites.
Even with randomization, baseline differences can emerge by chance. To evaluate this, we
conducted χ2 and t tests comparing the study conditions on demographic, medical history, and
major study variables assessed at the baseline interview (Table 2). Despite randomization, three
differences by study condition were documented. By chance, individuals assigned to group
prenatal care were more likely to be African American, less likely to have a history of preterm
birth, and more likely to have high levels of prenatal distress. Therefore, all subsequent analyses
controlled for these variables.
Groups of eight women (on average) are formed based on estimated delivery month and led
by a trained practitioner (eg, midwife, obstetrician). The model provides integrative prenatal
care by combining three primary components: assessment, education and skills building, and
support. All prenatal care occurs within the group setting, except for the initial assessment at
entry to care, health concerns involving need for privacy, and cervical assessments late in
pregnancy. After the first visit, participants in the study were randomly assigned to continue
care individually or in the group setting. When group participants arrive, they engage in selfcare activities of weight and blood pressure assessment and update their medical records.
Individual prenatal assessments (eg, fundal height, fetal heart rate) are completed by the
practitioner during the first 25−30 minutes within the group space. The majority of time is
spent with women and clinicians engaging in discussion, education, and skills building to
address explicit learning objectives in prenatal care, child birth preparation, and postpartum
and parenting roles. Handouts and self-assessment sheets facilitate group discussions and
stimulate self-care and evaluation. The full curriculum consists of 10 structured sessions (120
Ickovics et al.
Page 4
minutes each) conducted from 16 through 40 weeks of gestation. Table 1 provides a
comparative assessment of traditional care and group care.
Structured interviews by audio computer-assisted self-interviewing (audio-CASI) were
conducted upon study entry: before session 1 among group participants, and before 24 weeks
of gestation in individual care. Audio-CASI allows respondents to simultaneously listen with
headphones and see questions on a computer laptop, facilitating completion for participants
with lower reading skills. Audio-CASI has been previously validated among pregnant women.
15 Trained study staff was present to facilitate the self-interview process by answering any
questions and assisting with any technical issues. Medical records were reviewed for 993
participants (95%) by trained medical abstractors who were independent of care and blinded
to study assignment.
All encounters to one of the facilities (Yale New Haven Hospital) are recorded electronically
in a computerized database used for billing purposes, which identifies sites of care, inpatient
compared with outpatient status, International Classification of Diseases, 9th Revision (ICD-9)
codes, and cost of care. Therefore, cost data were available at this site (n=503). Cost data
included charges, revenue, and actual costs, but only actual costs were used because they are
not dependent on reimbursement rates.
Primary outcomes included gestational age at delivery, dichotomized as term or preterm (less
than 37 weeks), and infant birth weight, dichotomized as normal or low birth weight (less than
2,500 g).16 All patients underwent second-trimester ultrasound examination for confirmation
of dating and anatomy. Estimated date of confinement was established by a consulting
obstetrician who was independent of the study, and the date was confirmed by ultrasonography.
Decisions on inpatient management and delivery were made by attending physicians and
midwives, who were independent of the site of outpatient care, on a pre-established rotating
call schedule.
Adequacy of prenatal care was measured by using standard scoring on the Kotelchuck Index.
17 Apgar scores at 5 minutes were taken from hospital labor logs. Breastfeeding initiation was
based on participant self-report at the first postpartum interview.
All psychosocial outcomes were measured during the third trimester of pregnancy (average
gestational age 35 weeks, SD 3.1). Psychosocial outcomes included five domains. Pregnancy
knowledge was measured by using a tool developed by the research team to assess prenatal
and infant care knowledge; this was not validated. Prenatal distress was measured with the
established Pregnancy Distress Questionnaire.18 Readiness for labor and delivery and
readiness for infant care scales queried preparedness for delivery and infant care. Satisfaction
with prenatal care was measured by using an adaptation of the Patient Participation and
Satisfaction Questionnaire.19
Initial analyses were based on intention-to-treat models, with randomized study condition as
the primary independent variable: individual compared with group prenatal care. General linear
model and logistic regression analyses for basic group differences on birth outcomes,
psychosocial factors, and patient satisfaction were conducted. Given differences despite
randomization, race, preterm distress, and history of preterm birth were statistically controlled.
Additionally, analyses controlled for relevant clinical risks for adverse perinatal outcomes (ie,
smoking, history of preterm birth, history of miscarriage or stillborn birth).
Beyond the primary intention-to-treat analyses, several additional analytic approaches were
used. Cox proportional hazards analysis was conducted to provide more detailed assessment
of time to preterm delivery. Post hoc analysis was conducted to determine if group care had
differential outcome for African Americans, who represented 80% of participants. Finally, we
Ickovics et al.
Page 5
evaluated whether there was a potential “dose-response” intervention effect for the primary
outcome variables of gestational age and birth weight.
Because the study was originally powered statistically to detect differences in incident sexually
transmitted infection, secondary power analyses were conducted for the purposes of these
analyses, based on preterm birth as the outcome. With a targeted sample size of 1,040 (n=416
in control and n=624 in the intervention group), we calculated 80% power to detect a 33%
reduction in preterm birth (P<.05). This calculation was based on national U.S. base rates for
preterm birth, weighted by racial and ethnic distribution in this sample, equivalent to a weighted
preterm birth rate of 16.4% (U.S. National Center for Health Statistics, 2006).
RESULTS
The average age was 20.4 years (SD 2.6), with 49% aged 14−19 years. Eighty percent were
African American. Thirty-eight percent had completed high school (or graduate equivalency
degree), 36% were still in high school, and 26% had dropped out. Only 31% were currently
employed; the remainder received economic support from a partner or family member (47%)
or from public assistance (22%). There were no significant differences in age, parity, education,
or median income between study conditions (Table 2). There were no systematic differences
between those who were retained and those who were lost to medical record review nor any
differential loss to follow-up between those randomly assigned to group care and those assigned
to individual care. In addition, among those who were lost to follow-up, there were no
differences between group and nongroup participants on demographic and main study
variables.
To examine birth outcomes, only singleton infants were evaluated. Excluded from analyses
were eight sets of twins and three infants not viable using clinical standards, ie, gestational age
20 weeks or less or birth weight 350 g or less. Women assigned to group care were significantly
less likely to have preterm births than those in individual care: 9.8% compared with 13.8% (61
of 623 compared with 51 of 370, respectively; Table 3 and Fig. 2). This is equivalent to a risk
reduction of 33% (odds ratio [OR] 0.67, 95% confidence interval [CI] 0.44−0.99, P=.045), or
40 per 1,000 births. Excluding those with prior pre-term birth (n=48), results remain
significantly different favoring group care (P=.05).
To explore the nature of the difference on pre-term birth, Cox proportional hazards was
conducted to model weeks of gestational age until preterm birth (censored outcome). Results
indicate that group prenatal care significantly influenced the preterm hazard function after
adjustment for race, age, prenatal distress, history of preterm birth, smoking, and prior
miscarriage or stillbirth (χ2=3.79, P=.048). By 26 weeks of gestation, women in individual
care were more likely to deliver preterm, continuing until maximum differentiation between
individual and group care at 35−37 weeks of gestation (Fig. 3).
Post hoc analysis was conducted to determine if group care had differential outcome for African
Americans, who represented 80% of participants. When African Americans were examined
alone, the impact of group care on reduced risk for preterm birth was strengthened: 10.0%
compared with 15.8% (χ2=5.22, P=.02; OR 0.59, 95% CI 0.38−0.92) (Fig. 2).
Using intention-to-treat analyses, we found no significant differences in gestational age
(measured in weeks), birth weight, percentage of low birth weight infants, or percentage of
small for gestational age infants (less than 10th percentile by gestational age) (Table 2).
Therefore, we evaluated whether there was a potential “dose-response” intervention effect.
The number of visits was significantly associated with both gestational age (r=0.31, P<.001)
and birth weight (r=0.28, P<.001). This effect remained significant, although attenuated, when
attendance was adjusted to include eligible visits (ie, date of health care entry to birth or demise,
Ickovics et al.
Page 6
even if preterm) (r=0.14, P=.003 for gestational age; r=0.13, P=.003 for birth weight). To
illustrate, we trichotomized the number of eligible visits attended (less than 33%, 33−66%, 67
−100%). Mean gestational age and birth weight for each category increased sequentially from
37.9 to 39.0 to 39.2 weeks and from 2,874.3 to 3,103.2 to 3,181.6 g, respectively.
Using intent-to-treat analyses, adequacy of prenatal care indicates that group patients were
significantly less likely to have inadequate care: 26.6% compared with 33% (P = .01). There
was no difference in Apgar score at 5 minutes nor in the percentage of infants admitted to the
neonatal intensive care unit. Rates of breastfeeding initiation were significantly improved for
women in group care compared with those in individual care: 66.5% compared with 54.6%
(P<.001). There were no adverse effects.
Women in group care had significantly better psychosocial outcomes compared with those in
individual care. They had more prenatal care knowledge and felt more prepared for labor and
delivery (both P<.001). They also had significantly higher satisfaction with prenatal care (P<.
001) (Table 3).
Basic billing data from hospital records was available at one site only (Yale-New Haven
Hospital, n=503). Results indicated no significant difference in raw costs (in U.S. dollars) of
prenatal care (M=$4,149 compared with $4,091, P=.69) or delivery care costs (M=$3,433
compared with $3,417, P=.94). These analyses controlled for variables as in all other prior
analyses (race, prenatal distress, history of preterm birth, smoking, history of miscarriage or
stillborn birth).
DISCUSSION
Investigators and clinicians have called for changes in the health care delivery system to address
intransigent problems like preterm birth.11,20 Based on the results of this randomized
controlled trial, it appears that group prenatal care may be one potential approach toward
meeting this aim. Davidoff et al21 specifically identify a need for further investigation of
optimal obstetric and neonatal management for late preterm infants. These late preterm births
account for three fourths of all preterm births in the United States and Europe and, therefore,
are important from a public health perspective of cumulative adverse consequences and costs.
We documented a 33% reduction in the odds of preterm birth, with time to preterm birth delayed
for those randomized to group prenatal care. This delay began at 26 weeks of gestation, and
the largest differences were documented in the late preterm period. In the United States, these
late pre-term births (34−36 6/7 weeks) represent the fastest-growing segment and the largest
proportion (74%) of singleton preterm births.21 Despite their relatively large size and apparent
functional maturity, compared with term infants, late preterm infants are at increased risk for
neonatal morbidity (eg, respiratory distress, jaundice) and mortality, along with consequent
excess hospital costs.22–24 In a study quantifying the costs of prematurity by gestational age,
Gilbert et al24 document that the total costs for each gestational age group from 25 to 36 weeks
were roughly the same, concluding that opportunities to prevent pre-term delivery and decrease
costs are potentially available at all preterm gestational ages.
Young women assigned to group prenatal care had other clinical and psychosocial advantages
compared with those receiving individual care. Birth weight was not significantly different
using intent-to-treat analyses, although a dose-response effect was observed: the greater the
exposure to the intervention (ie, more group visits), the longer the gestation and higher the
birth weight, even after adjusting for important clinical factors and preterm birth. This reflects
our current clinical understanding of only partial concordance between gestational age and
birth weight overall, with only two thirds of low birth weight babies also being premature.1
Being born too early and being born too small have distinct multifactorial causes and risk
Ickovics et al.
Page 7
factors.20 Unfortunately, risk factor screening has no demonstrated effect on reducing adverse
perinatal outcomes, and few interventions have successfully reduced preterm birth or low birth
weight.25,26 Group prenatal care is more multifaceted than many other clinical and
psychosocial interventions that seek to augment care with more visits or more information
using didactic approaches, which may be one reason for these relatively favorable outcomes.
This study is limited in several ways. First, favorable results of the intervention were not
uniform. The intervention resulted in some documented benefits as well as some nonsignificant
differences with intent-to-treat analyses. Nonetheless, there were no apparent adverse effects,
and costs were neutral. Given rising rates of preterm birth with few effective interventions
documented, group prenatal care may provide an alternative model of prenatal care. Second,
the sample represents a relatively restricted group of young, ethnic minority women of low
socioeconomic status who attend urban hospital clinics for prenatal care. This is a group at
high risk of adverse perinatal outcomes and, therefore, may be most in need of substantive
clinical interventions to reduce risk. Replication with diverse patient populations and within
diverse clinical settings is essential to ensure reliability, generalizability, and clinical
effectiveness. Rigorous clinical assessment through larger multicenter trials is warranted.
Future research will evaluate the biologic, behavioral, and social mechanisms by which group
care may have its effects. For example, one potential biologic mechanism for our salutary effect
on preterm delivery is stress reduction, altering the maternal and fetal hypothalamic pituitary
axes, which can precipitate preterm delivery by way of endocrine changes.27 A clinical and
social benefit is that group prenatal care provides substantially more contact with providers;
medical and ancillary support services are integrated to respond to the complex needs of
pregnant women.28 Mechanisms should be identified by which groups may facilitate
development of community norms to enhance healthy behaviors in general and to reduce
perinatal risk specifically. Finally, future research on group prenatal care will include a full
cost-effectiveness analysis and evaluation of service use for mother and baby from pregnancy
through first year of life.
In the United States alone, which ranks at the bottom among developed nations for infant
mortality, preterm birth accounts for 35% of all U.S. health care spending for infants, with
direct charges of $15.5 billion in 2002.20 Even modest risk reduction may have beneficial
effects on lifetime costs and risks if changes occur when the likelihood of adverse outcomes
is high.29 Any intervention that shows promise to reduce preterm birth warrants further clinical
and empirical attention.
Acknowledgements
Funded by National Institute of Mental Health grant R01 MH/HD61175 to Jeannette R. Ickovics, PhD.
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Fig. 1.
CONSORT study description. All outcomes were measured using medical records or at the
trimester 3 interview, with the exception of breastfeeding initiation, which was measured at
the interview conducted 6 months postpartum (n=783). There was no differential dropout
between group and individual care (P=.95).
Ickovics et al.
Page 11
Fig. 2.
Preterm delivery for total sample and African Americans only. All analyses were controlled
for factors that were different by study condition (P<.10), despite randomization (race, age,
prenatal distress, history of preterm birth) and clinical risk factors strongly associated with
birth outcomes (smoking, prior miscarriage or stillbirth). Total sample: odds ratio (OR) 0.67,
95% confidence interval (CI) 0.44−0.99, P=.045; African American only: OR 0.59, 95% CI
0.38−0.92, P=.02.
Ickovics et al.
Page 12
Fig. 3.
Hazard function for preterm birth. χ2=3.79, P=.048.
Ickovics et al.
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Table 1
Traditional Prenatal Care Compared With Group Prenatal Care
Delivery of care
Content of care
Traditional
Group Care
1. Accepted model of prenatal care using
one-to-one examination room visits.
2. Care is provided by a credentialed
prenatal provider.
3. Variable continuity of provider
throughout pregnancy.
4. Physical assessment completed inside an
examination room by a provider.
1. Prenatal care provided within the group space
(community or conference room).
2. Care is provided through a partnership of a credentialed
provider and pregnant woman.
3. Continuity of care from a single provider.
5. Education is provider-dependent and may
be random based on time available for
education and/or response to patientinitiated queries.
6. Few opportunities for women to interact
socially with other pregnant women.
7. Care is focused on medical outcomes and
recommended testing.
Patient access to or involvement in
care
Time spent by providers and
patients
Administration and scheduling
Provider, resident, student
education
8. Prenatal care records are maintained by
the provider and not shared with the patient
unless requested.
9. Provider schedule determines patient
appointment dates and times.
10. Patient services are often fragmented
(eg, smoking cessation and nutrition
counseling, WIC, labor preparation).
11. Limited opportunity for women to have
contact with other women after delivery.
12. Variable waiting time.
13. May be difficult to adapt care to
accommodate cultural issues.
14. Providers may find the provision of
prenatal care to be repetitive and often lack
sufficient time to go into more detail
regarding specific patient questions or
concerns.
15. Average visit time is limited by provider
schedule.
16. Efficiency marked by scheduling of
patients at 10- to 15-minute intervals.
17. Student education is limited by
examination room space and time
constraints.
4. Patient participation in physical assessment (eg, blood
pressure, weight) and documentation. Fundal height and
heart rate monitoring occur in group space. If required,
health concerns that require private consultation and
cervical examinations are conducted in ancillary visits in a
private examination room.
5. Education runs throughout the 10 sessions with trained
providers and structured materials. Self-assessment sheets
at sessions provide continuous feedback.
6. Opportunities for community building are present
throughout prenatal and postpartum period.
7. Care is focused on health outcomes and personal
empowerment. Testing, such as blood draw, can be done in
group setting.
8. Women contribute data to their own record by
performing their weight and blood pressure as well as
documentation. They are encouraged to keep copies of their
progress for their personal records. Transparency of the
medical chart should contribute to increased safety.
9. Schedule of group visits is available at first session,
which occurs at approximately 16 weeks.
10. Group provides “one-stop shopping” with all services
available within the group, providing services more
efficiently.
11. Community building throughout pregnancy often leads
to ongoing support postpartum
12. All care, education, and support take place within the
2-hour time period. No waiting room.
13. Group can provide a setting that is supportive of cultural
and language differences.
14. Groups minimize repetition and permit sufficient time
for more in-depth discussion.
15. Total provider/patient time throughout pregnancy is
approximately 20 hours.
16. Within a 2-hour period, 8−10 women can receive total
care in a conference or community room. This allows
examination rooms to be used for other purposes.
17. Students and preceptors work together within the group,
incorporating student education and direct supervision.
WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.
The quality and context of prenatal services differs between the United States and other developed and developing nations. The description of prenatal
care in this table reflects typical traditional individual care in a public health care setting and may not be inclusive of the quality of services in other
settings. However, it is noteworthy that nearly all prenatal care is provided in this group space with the same health care provider. Moreover, there is
substantially more time shared between patient and provider (20 hours across the pregnancy in the group setting), and there is typically no need for separate
visits for labor preparation or laboratory testing. More information is available at www.centeringpregnancy.com.
Ickovics et al.
Page 14
Table 2
Baseline Differences by Study Condition
Group Prenatal Care
(n=623)
Individual Prenatal
Care (n=370)
81.3
11.1
7.5
20.3±2.6
11.4±1.5
34,415±15,291
73.8
17.2
9.0
20.6±2.7
11.3±1.6
33,198±13,774
.014
61.8
4.0
18.7
27.0±7.1
18.0±3.4
52.5
35.8
20.9
39.7
8.8
17.8±6.9
15.2±7.1
61.4
7.1
17.9
26.7±7.4
18.4±3.3
50.0
33.8
20.0
38.9
7.9
17.7±6.9
13.7±7.3
.30
.04
.75
.54
.11
.43
.55
.74
.80
.62
.70
<.001
Demographic characteristics
Race
African American
Latina
White or other
Age (y, mean±SD)
Last year of education (mean±SD)
Median household income from census (US $, mean±SD)
Clinical characteristics
Nulliparous
History of preterm birth
Prior miscarriage or stillbirth
Prepregnancy BMI (kg/m2, mean±SD)
Gestational age at study entry (wk, mean±SD)
History of sexually transmitted infection
Smoking prior to pregnancy
Smoking since pregnancy
Drinking prior to pregnancy
Drinking during pregnancy
General life stress (mean±SD)
Prenatal distress (mean±SD)
SD, standard deviation; BMI, body mass index.
Data are expressed as percentages except where otherwise indicated.
P
.07
.51
.22
38.5±6.8
12.93±7.1
68.6±33.2
86.9±26.0
108.4±14.4
41.1±7.3
12.43±7.0
76.2±30.6
90.0±21.9
113.3±13.3
F=27.08
F=1.96
F=12.77
F=3.68
F=27.16
F=0.60
χ2=0.07
χ2=12.5
χ2=4.01
F=0.70
χ2=0.03
F=1.40
χ2=0.67
χ2=1.34
χ2=6.49
Statistic
<.001
.16
<.001
.056
<.001
.44
.80
.001
.045
.40
.90
.24
.42
.25
.01
P
1.06 (0.66−1.72)
1.73 (1.28−2.35)
0.86 (0.59−1.24)
0.55 (0.20−1.50)
0.68 (0.50−0.91)
0.98 (0.64−1.50)
0.67 (0.44−0.98)
OR (95% CI)
All analyses controlled for factors that were different by study condition (P<.10) despite randomization (race, age, prenatal distress, history of preterm birth) and clinical risk factors strongly associated
with birth outcomes (smoking, prior miscarriage, or stillbirth). Analyses for continuous variables were conducted with analysis of covariance, and analyses for dichotomous variables were conducted
with logistic regression with covariates.
Data are expressed as percentages except where otherwise indicated.
At 6-month postpartum interview (n=783).
*
8.8±1.0 (9)
7.8
54.6
13.8
38.9±2.5
10.7
3,111.8±636.8
15.1
2.2
33.0
8.8±1.1 (9)
8.5
66.5
9.8
39.1±2.8
11.3
3,160.6±626.3
14.3
1.3
26.6
Individual Prenatal
Care (n=370)
OR, odds ratio; CI, confidence interval; SD, standard deviation; PNC, prenatal care; NICU, neonatal intensive care unit.
Birth outcomes and prenatal care
Preterm birth
Gestational age (wk, mean±SD)
Low birth weight (less than 2,500 g)
Birth weight (g, mean±SD)
Small for gestational age
Fetal demise
Less than adequate PNC (based on Kotelchuck Index)
Neonatal outcomes
Apgar, 5 minutes [mean±SD (median)]
Admitted to NICU
Breastfeeding initiation*
Psychosocial outcomes (mean±SD)
Prenatal knowledge
Prenatal distress
Readiness for labor and delivery
Readiness for infant care
Satisfaction with prenatal care
Group Prenatal Care
(n=623)
Table 3
Pregnancy and Psychosocial Outcomes, by Study Condition
Ickovics et al.
Page 15
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Last Modified: 02/28/2012
Middlesex Hospital
Middletown, Connecticut, USA
Team
The team at Middlesex Hospital is a participant in IHI’s Collaborative on Improving
Perinatal Care.
Arthur McDowell, MD, Vice President Clinical Affairs, Team Sponsor
Kenneth Eckhart, MD, Pregnancy and Birth Center Department Chair
Terisa Brainard, RN, Nurse Manager
Mary Lynne Riley, MA, CHCQM, Quality Improvement (QI) Coordinator
Anne Bingham, MD
Beverly Byrd, MD
Julie Flagg, MD
Aysegul Ozbek, MD
Karren Collins, RN
Sue Beebe, RN
Jamie Hull, RN
Katherine Focacci, RN
Sharon Finn, MSN, Director Quality Improvement
Using Care Bundles to
Improve Health Care
Quality
Perinatal Ticket to
Discharge
View All
Featured Content
Elective Induction and
Augmentation Bundles
IHI Perinatal Trigger Tool
Aim
The Middlesex Pregnancy and Birth Center is a level two Labor, Delivery, Recovery, and
Postpartum (LDRP) facility with approximately 1,100 births per year. Middlesex is
committed to ongoing improvement of the quality and safety of perinatal and post partum
care. We will demonstrate this by implementing interventions for patient-centered care,
and through evidence-based measures designed to reduce variation in care, reduce harm,
and improve team communication and staff satisfaction. While our hospital strives to
improve several aspects of perinatal care, this report focuses specifically on four areas of
improvement.
Perinatal Bundles (Elective Induction and Augmentation Bundles)
By February 2007, improve patient safety and reduce the incidence of birth trauma by
implementing the IHI Perinatal Bundles (Elective Induction and Augmentation)
Achieve 95 percent compliance rate by June 2008
Beginning January 2009, maintain 98 percent compliance rates
Instrumented Delivery Bundle (Vacuum and Forceps Deliveries)
By June 2008, begin processes required to implement the Instrumented Delivery
Bundle, including a policy and procedure, documentation checklist, and audit tool
Implement the Instrumented Delivery Bundle by May 2009
Achieve a 95 percent compliance rate by June 2009
Perinatal Harm: Trigger Tool Audits
Implement Trigger Tool audits starting November 2006
Achieve a goal of 5 percent or less of adverse events per 100 live births
Patient Centeredness
Include patient centeredness as part of the post partum priority group that oversees
patient satisfaction by including two to four patients in the group by September 2008
Design and implement a post partum support group (“Parents and Babies Connect”) by
July 2009
Trial hourly rounds for four “Ps” (potty, position, pain, oral nutrition) by February
2009
Trial “Ticket to Discharge” by November 2008
Continue breast feeding support group, ongoing approximately 10 years
Measures
http://www.ihi.org/knowledge/Pages/ImprovementStories/ImprovingPerinatalCareAFocus... 4/19/2013
Compliance rate for Elective Induction Bundle
Compliance rate for Augmentation Bundle
Compliance rate for Instrumented Delivery Bundle
Perinatal Harm: Trigger Tool Audits
Percentage of harm per 100 live births using a sample of 20 records per month
Press Ganey satisfaction scores
Changes
Utilized situational DVDs through IHI: Conducted movie nights for staff and physicians
and individuals could watch on their own; staff and physicians needed to sign off that
they watched the videos. The Advanced Fetal Monitoring and Assessment program
developed by Advanced Practice Strategies was utilized to test competencies of staff
and physicians to ensure improved communication related to electronic fetal
monitoring (EFM) and accurate reporting of Situation, Background, Assessment, and
Recommendations (SBAR) communication technique.
Utilized IHI Perinatal Bundle criteria in our order sets initially on paper, then in the
computerized physician order entry (CPOE) system. Implemented initially with two
obstetrics (OB) groups prior to spreading to all groups.
Established nurses as gatekeepers for enforcing compliance with 39 weeks for elective
inductions.
Utilized audit tool to conduct weekly audits to initially complete five per week and then
all inductions (since we have a low rate of inductions) for composite and compliance
rates.
Developed hyperstimulation (tachysystole) algorithm to ensure common language.
Standardized no scheduled Cesarean section prior to 39 weeks (twins 38 weeks).
Deep dive: Using IHI criteria and one month of data for patients who had pitocin, we
conducted chart audits twice yearly. Instrumented deliveries and post partum
hemorrhage were noted in the deep dive and subsequently, policies and procedures
were implemented for these (instrumented delivery policy and procedure, code red and
hemorrhage kit with all appropriate supplies).
Utilized IHI’s recommended criteria for Vacuum Bundle.
Utilized other teams’ policies and procedures as a guide, manufacturer’s guidelines,
and American College of Obstetrics and Gynecology (ACOG) guidelines to develop a
policy for instrumented deliveries (both vacuum and forceps).
Developed a checklist that is included as part of the chart to ensure all appropriate
criteria are documented.
Developed an audit tool and conduct monthly audits of all instrumented deliveries.
Perinatal Harm: Trigger Tool
Utilized IHI recommended criteria and Trigger Tool and made modifications to the tool
that were appropriate for our organization.
Conducted audits on 20 random charts per month. Nurse Manager, QI Coordinator,
Department Chair, and staff nurse conduct the audits. This may vary depending on
availability of staff. Due to staffing changes and constraints, we were several months
behind in conducting audits; as a result we have reconvened the audits starting April
2009 and are now tracking adverse events and specific triggers to determine if further
inquiry into process improvements are needed.
Standardized our epidural drip order sets to bupivicaine or robivicaine with or without
Fentanyl.
Standardized ephedrine administration in our epidural order sets — premixed syringes
in five milliliters.
Added patients to our post partum priority task force to review Press Ganey and
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) results
and provide feedback for improvement. Presented this idea to the task force, task force
formulated specific criteria and interview questions for the potential members. We
contacted physician groups to obtain names of possible candidates for objective views
by patients who had a good or bad experience. We then interviewed individuals via
telephone. We chose two patients initially and when they were unable to attend due to
scheduling conflicts, they were replaced and we continue to replace patients as
needed.
Received a letter from a patient who had benefited from attending our breast feeding
support group requesting a post partum support group for patients not breastfeeding.
We subsequently developed a post partum support group with post partum depression
as the central topic and also include journaling, infant massage, infant growth and
development, and dance. We continue to refine and add other topics based on patient
feedback.
Huddles: To promote team communication we conduct a brief overview of patients and
unit status, including census done at the beginning of every shift and ad hoc as needed
due to patient status or census changes.
Hourly Rounds: Rounds are conducted hourly from 7 AM to 10 PM; must be seen
between 10 and 2, 4 and 7. Includes the four “Ps” (potty, position, pain, oral
nutrition). Can be seen by nurse, secretary, or patient care technician. We have
noticed an increase in patient satisfaction with pain control per Press Ganey results.
Ticket to Discharge: Developed to assist with patient partnering in the discharge
process. Green ticket attached to the baby’s crib includes all processes needed to
discharge mom and baby from the hospital.
Whiteboards in all patient rooms with patient name, medications and administration
times, and plan of care.
Pain management posters with alternate pain management techniques placed in all
patient bathrooms; patients have since requested sitz bath and abdominal binders.
Breastfeeding Group: Continues to be extremely popular and is run by our lactation
consultant.
Results
Summary of Results / Lessons Learned / Next Steps
Summary of Results
From January 2007 to October 2009 we increased our augmentation composite rate from
72 percent to 97 percent. This is attributed in large part to physician awareness of the
importance of assessing estimated fetal weight and documentation prior to the start of
Oxytocin. We had recent changes in CPOE that affected documentation of the Bishop score,
which contributed to our one month dip in results. With virtually consistent results at 95
percent or above, we have started to track compliance rates. For elective inductions, we
improved from 89 percent to 98 percent for the same time period and currently have no
elective inductions prior to 39 weeks. We have significantly reduced bottlenecking due to
the decrease in overall elective inductions that lasted two to three days.
We have seen a decrease in infants (37 to 39 weeks) transitioning in our special care
nursery. We implemented the Instrumented Delivery Bundle in March 2009 following
extensive work to develop a policy and procedure for both forceps and vacuum deliveries.
We also developed an audit tool and a checklist; our team determined that the checklist
should be part of the record and helps to assist with our documentation efforts. This has
proven to be very beneficial and we continue to educate physicians on the importance of
utilizing the sheet to ensure appropriate documentation.
From March 2009 to October 2009 we increased our compliance with the Instrumented
Delivery Bundle from 64 percent to 100 percent, with variation occurring month to month.
Consistent utilization of the check list will stabilize our results. We have noticed reduced
variation in the usage of the vacuum related to pulls and pop-offs. In our patientcenteredness efforts we now think of our patients and community members as active team
members to reduce harm and improve patient care and satisfaction. Each member of our
team and the Pregnancy and Birth Center staff have commented that participation in the
IHI initiatives has measurably improved collaboration and teamwork between all levels of
staff.
Next Steps
As we continue our improvement journey we are interested in management of second
stage labor to decrease primary C-sections. We are developing checklists and/or algorithms
for management of specific conditions and emergent situations, and plan to develop
protocols to address the safety aspects for managing obese patients. We currently have an
evaluation form for our post partum support group and are making changes to the program
based on this valuable feedback. We have faced challenges with staffing constraints to
consistently complete audits for defensibility (i.e., can be explained by complete
documentation of patient records); however, we have revised the IHI defensibility tool to
meet our needs and plan to move forward with this initiative by having nurses complete
the audits in addition to physicians completing some of their own record audits, with the
goal of improving our medical record documentation. We continue our training programs
for ongoing staff education and will be administering a new culture of safety survey by year
end, when we look forward to making further strides in our goals toward improving
perinatal care.
Contact Information
Terisa Brainard, Manager, Pregnancy and Birth Center
[email protected]
Mary Lynne Riley, Quality Improvement Coordinator
[email protected]
© 2013 Institute for Healthcare Improvement. All rights reserved.
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84209
Pregnancy: Common Questions
There are plenty of myths and “old wives’ tales” surrounding pregnancy. You may need help separating
fact from fiction. On this sheet, you’ll find answers to a few common questions. If you have other
questions, talk with your health care provider.
Will Working Harm My Baby?
In most cases, working throughout your pregnancy is not harmful at all. There may be concerns if the
job involves dangerous machinery or chemicals, lifting, or standing for very long periods of time. Talk
to your health care provider and employer about your particular job and pregnancy.
Why Can’t I Change the Cat Litter Box?
Cats carry a disease called toxoplasmosis. In adult humans, it shows up as a mild
infection of the blood and organs. If you are infected during pregnancy, the
baby’s brain and eyes could be damaged. To be safe, have someone else change
the litter. If you must handle it, wear a paper mask over your nose and mouth.
Also, wear gloves and wash your hands afterward.
Which Medications Are Safe?
No prescription or over-the-counter drug is safe for everyone all of the time. But sometimes medications
are needed. Be sure your health care provider knows you are pregnant. Then use only the medications
are needed. Be sure your health care provider knows you are pregnant. Then use only the medications he
or she advises you to take.
Is It True That I Can Overheat My Baby?
Yes. To avoid making your baby too warm:
z
z
Don’t sit in a jacuzzi. A long, warm bath is fine, but not in water over 100°F.
Exercise less intensely if you feel fatigued. Base your workout on how you feel, not your heart rate.
Heart rates aren’t a good way to measure effort during pregnancy.
Can I Lift and Carry Safely?
Yes, if your health care provider doesn’t tell you otherwise. Learn to lift and carry safely to avoid injury
and reduce back pain during pregnancy. To protect your back:
z
z
z
z
Bend at the knees to bring the load nearer.
Get a good grip. Test the weight of the load.
Tighten your abdomen. Exhale as you lift.
Lift with your legs, not with your back.
z
z
Carry the load close to your body.
Hold the load so you can see where you are going.
What If I Get Sick?
Most women get sick at least once during pregnancy. Talk with your health care provider if you do.
Most likely it will not affect your pregnancy. Get plenty of rest and fluids, and eat what you can. Talk to
your health care provider before taking any medications.
© 2000-2011 Krames StayWell, 780 Township Line Road, Yardley, PA 19067. All rights reserved. This information is
not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.
84210
Pregnancy: Common Questions
Embarazo: Preguntas frecuentes
El embarazo está rodeado de innumerables mitos o “cuentos de viejas”; tal vez necesite ayuda para
distinguir la realidad de la ficción. En esta hoja encontrará respuestas a varias preguntas comunes; si
tiene otras dudas, diríjase a su proveedor de atención médica.
¿Dañará a mi bebé el que yo trabaje?
En la mayoría de los casos, seguir trabajando durante todo el embarazo no causa ningún daño. Pero tal
vez constituya un problema si su empleo requiere que usted maneje maquinarias o sustancias químicas
peligrosas, levantar objetos pesados o pasar mucho tiempo de pie. Hable con su proveedor de atención
médica y su jefe sobre su trabajo durante el embarazo.
¿Por qué no puedo cambiar la arena de mi gato?
Los gatos son portadores de la toxoplasmosis, una infección leve que aparece en
la sangre y los órganos de los adultos. Si usted la contrae durante el embarazo,
podrían dañarse el cerebro y los ojos del bebé. Por si acaso, encargue a alguien
que cambie la arena. Si se ve obligada a hacerlo usted, cúbrase la nariz y la boca
con una máscara de papel y póngase guantes; lávese las manos al terminar.
¿Qué medicamentos son seguros?
Ningún medicamento, sea con o sin receta, es seguro para todas las mujeres en todo momento; sin
embargo, a veces hace falta tomarlos. Asegúrese de que su proveedor de atención médica sepa que usted
está embarazada, y use sólo los medicamentos que le recomiende.
¿Es cierto que puedo sobrecalentar a mi bebé?
Sí. Para evitar que el bebé se caliente demasiado:
z
z
No se bañe en tinas Jacuzzi. Puede tomar baños prolongados en agua tibia, a temperaturas por
debajo de 100°F.
Si está cansada, disminuya la intensidad de sus ejercicios. Básese en cómo se siente en lugar de
fijarse en su pulso cardíaco; durante el embarazo, el pulso cardíaco no es una buena medida del
esfuerzo.
¿Puedo alzar y cargar cosas sin peligro?
Sí, a menos que su proveedor de atención médica le indique lo contrario. Aprenda a levantar y cargar
con seguridad para no lesionarse y disminuir los dolores de espalda durante el embarazo. Para
protegerse la espalda:
z
z
z
Doble las rodillas para acercar la carga a su cuerpo.
Agarre bien la carga y sopésela antes de levantarla.
Apriete los músculos del abdomen y espire mientras levanta la carga.
z
z
z
Levante con las piernas y no con la espalda.
Transporte la carga cerca del cuerpo.
Sostenga la carga de modo que no interfiera con su visibilidad.
¿Qué pasará si me enfermo?
La mayoría de las mujeres se enferman al menos una vez durante el embarazo. Si usted se enferma,
llame a su proveedor de atención médica; lo más probable es que su embarazo no se vea afectado.
Descanse mucho, beba abundante líquido y coma lo que pueda. Antes de tomar cualquier medicamento,
consulte con su proveedor de atención médica.
© 2000-2011 Krames StayWell, 780 Township Line Road, Yardley, PA 19067. Todos los derechos reservados. Esta
información no pretende sustituir la atención médica profesional. Sólo su médico puede diagnosticar y tratar un
problema de salud.
82288
What Is Prenatal Care?
Before becoming pregnant, you may have adopted good health habits to prepare for your baby. But if
you didn’t, start today. One of the first steps is learning how to take care of yourself. See your healthcare
provider as soon as you think you may be pregnant. Then, continue prenatal care throughout your
pregnancy.
Prenatal Care Helps You Have a Healthy Baby
During prenatal care:
z
z
z
Your healthcare provider assesses the health of your pregnancy. A
“due date” is determined. This is when your doctor predicts you will
deliver your baby.
The progress of your pregnancy is checked. This includes your baby’s
growth, changes in your weight, and your overall health and comfort.
Your healthcare provider may find new concerns and manage existing Your healthcare provider
ones before problems occur.
will guide you and your
You Are Part of a Team
partner through
pregnancy.
When you’re pregnant, you’re part of a team that includes you, your baby, and your healthcare provider.
Your team also may include a partner or a main support person. He or she could be a loved one, such as
a spouse, a family member, or a friend. As you work toward giving your baby a healthy start, rely on
your team members for support.
It’s Not Too Late to Start Good Habits
What matters most is protecting your baby from this moment on. If you
smoke, drink alcohol, or use drugs, now is the time to stop. If you need
help, talk with your healthcare provider.
z
z
z
z
Smoking increases the risk of losing your baby or having a low-birthweight baby. If you smoke, quit now.
Alcohol and drugs have been linked with miscarriage, birth defects,
mental retardation, and low birth weight. Avoid alcohol and drugs.
Developing a healthy
Eat a healthy diet. This helps keep you and your baby strong and
lifestyle is one of the first
healthy. Follow your healthcare provider's instructions for nutrition. things you can do for your
Also stay within the guidelines you are given for healthy weight gain.
child.
Regular exercise will help you stay fit and feel good during
pregnancy. It can also help prevent or minimize back pain. Be sure to talk with your healthcare
provider about how to exercise safely during pregnancy.
82838
What Is Prenatal Care?
¿Qué es la atención prenatal?
Antes de quedar embarazada, es posible que haya adoptado costumbres saludables a fin de prepararse
para la llegada del bebé. Pero si no fue así, comience hoy mismo. Una de las primeras medidas que debe
tomar es aprender a cuidarse a sí misma. Visite a su proveedor de atención médica tan pronto como crea
que está embarazada, y luego, continúe con la atención prenatal a lo largo de todo su embarazo.
La atención prenatal le ayudará a tener un bebé sano
Durante la atención prenatal:
z
z
z
Su proveedor de atención médica evalúa el estado de su embarazo y
determina la fecha oficial en que se espera el parto, es decir, predice
cuándo es probable que nazca su bebé.
Se evalúa el progreso del embarazo, lo cual incluye el crecimiento del
bebé, los cambios de peso que usted experimenta y su nivel general
de salud y bienestar.
Su proveedor de atención
Su proveedor de atención médica podrá detectar nuevos problemas y médica la guiará a usted y
controlar los ya existentes antes de que den lugar a complicaciones.
a su pareja durante el
embarazo.
Usted es parte de un equipo
Cuando usted está embarazada, es parte de un equipo formado por usted, su bebé y su proveedor de
atención médica. Su equipo también puede incluir a su pareja o a una persona encargada de darle apoyo.
Esta persona podría ser alguien cercano, como su cónyuge, un miembro de su familia o un amigo(a).
Cuente con la ayuda de los miembros de su equipo para tratar de dar a su bebé un comienzo sano en la
vida.
No es demasiado tarde para iniciar costumbres saludables
Lo que más importa es que sepa cómo proteger a su bebé a partir de este
momento. Si usted fuma, bebe alcohol o toma drogas, éste es el momento
de dejarlo. Si necesita ayuda, hable con su proveedor de atención médica.
z
z
z
z
Fumar aumenta el riesgo de que pierda al bebé o de que éste nazca
con poco peso. Si fuma, deje de hacerlo hoy mismo.
El alcohol y las drogas están relacionadas con los abortos
espontáneos (pérdida del bebé), los defectos de nacimiento, el retraso
Desarrollar un estilo de
mental y el bajo peso al nacer. Evite el alcohol y las drogas.
vida saludable es una de
Coma una dieta saludable. Esto la mantendrá a usted y a su bebé
las primeras cosas que
fuertes y sanos. Siga las instrucciones sobre nutrición que le dé su
usted puede hacer por su
proveedor de atención médica. También manténgase dentro de las
bebé.
pautas que le dieron para subir sanamente de peso.
El ejercicio regular le ayudará a estar en forma y sentirse bien durante el embarazo. También puede
ayudar a prevenir o minimizar el dolor de espalda. Asegúrese de consultar a su proveedor de
atención médica sobre cómo hacer ejercicio de manera segura durante el embarazo.
problema de salud.
84207
Adapting to Pregnancy: First Trimester
As your body adjusts, you may have to change or limit your daily activities. You’ll need more rest. You
may also need to use the energy you have more wisely.
Your Changing Body
Almost every part of your body is affected as you adapt to pregnancy. The uterus and cervix will begin
to soften right away. You may not look very pregnant during the first three months. But you are likely to
have some common signs of early pregnancy:
Bloating of the abdomen
z
z
z Missed or light periods
z Nipple or breast tenderness, breast swelling
It’s Not Too Late to Start Good Habits
z
Nausea
Fatigue
z
Frequent urination
Mood swings
z
What matters most is protecting your baby from this moment on. If you smoke, drink alcohol, or use
drugs, now is the time to stop. If you need help, talk with your healthcare provider.
z
z
Smoking increases the risk of losing your baby or having a low-birth-weight baby. If you smoke,
quit now.
Alcohol and drugs have been linked with miscarriage, birth defects, mental retardation, and low
birth weight. Avoid alcohol and drugs.
Tips to Relieve Nausea
Although nausea can occur at any time of the day, it may be worse in the
morning. To help prevent nausea:
z
z
z
z
z
z
Eat small, light meals at frequent intervals.
Get up slowly. Eat a few unsalted crackers before you get out of bed.
Drink water with lemon slices.
Eat a Popsicle in your favorite flavor.
Drink flat sodas.
Talk with your healthcare provider if you take vitamins that upset
your stomach.
Eat stomach-friendly
foods like cottage cheese,
crackers, or bread
throughout the day.
Work Concerns
The end of the first trimester is a good time to discuss working during
pregnancy with your employer. Follow your healthcare provider’s advice
if your job requires you to stand for a long time, work with hazardous
tools, or even sit at a desk all day. Your workspace, workload, or
scheduled hours may need to be adjusted. Perhaps you can change body
postures more often or take an extra break.
Take a break and put your
Advice for Travel
feet up.
Talk to your healthcare provider first, but the second trimester may be the best time for any travel. You
may be advised to avoid certain trips while you’re pregnant. Food and water can be concerns in
developing countries. Travel by car is a good choice, as you can stop, get out, and stretch. Bring snacks
and water along. Fasten the lap belt below your belly, low over your hips. Also be sure to wear the
shoulder harness.
Intimacy
Unless your healthcare provider tells you to, there is no reason to stop having
sex while you’re pregnant. You or your partner may notice changes in desire.
Desire may be less in the first trimester, due to nausea and fatigue. In the
second trimester, sex may be very enjoyable. The third trimester can be a
challenge comfort-wise. Try different positions and see what’s best for you
both.
Talk about your
feelings with your
partner.
84208
Adapting to Pregnancy: First Trimester
Adaptación al embarazo: El primer trimestre
A medida que su cuerpo se adapta al embarazo, tal vez usted tenga que cambiar o limitar sus actividades
cotidianas. Necesitará descansar más, y podría beneficiarse usando su energía con más prudencia.
Los cambios en su cuerpo
Casi todas las partes de su cuerpo se ven afectadas mientras éste se adapta al embarazo. El útero y el
cuello uterino comienzan a ablandarse inmediatamente. Durante los primeros meses, es probable que no
tenga aspecto de estar embarazada, pero probablemente tendrá algunos síntomas comunes en el
principio del embarazo, como por ejemplo:
z
z
z
z
z
z
z
Falta de menstruación o menstruación muy ligera
Náuseas
Sensibilidad en los pezones o en los senos; hinchazón de los senos
Sensación de llenura o hinchazón en el abdomen
Fatiga
Orinar con frecuencia
Cambios de estado de ánimo
No es demasiado tarde para iniciar costumbres saludables
Lo que más importa es que sepa cómo proteger a su bebé a partir de este momento. Si usted fuma, bebe
alcohol o toma drogas, éste es el momento de dejarlo. Si necesita ayuda, hable con su proveedor de
atención médica.
z
z
Fumar aumenta el riesgo de que pierda al bebé o de que éste nazca con poco peso. Si fuma, deje de
hacerlo hoy mismo.
El alcohol y las drogas están relacionadas con los abortos espontáneos (pérdida del bebé) los
defectos de nacimiento, el retraso mental y el bajo peso al nacer. Evite el alcohol y las drogas.
Consejos para aliviar las náuseas
Aunque las náuseas puede ocurrir en cualquier momento del día, suelen
ser más intensas en la mañana. Para ayudar a prevenir las náuseas:
z
z
z
z
z
z
Ingiera cantidades de comida pequeñas y ligeras a intervalos
frecuentes.
Levántese lentamente. Coma algunas galletas saladas antes de
levantarse de la cama.
Beba agua con rodajas de limón.
Coma un helado de jugo en su sabor favorito.
Beba refrescos sin colorante.
Hable con su proveedor de atención médica si toma vitaminas que le
provocan problemas de estómago.
Coma alimentos suaves
para el estómago, como
requesón, galletas
saladas o pan.
Asuntos de trabajo
El final del primer trimestre es un buen momento para que usted hable con
su jefe sobre su trabajo durante el embarazo. Si su empleo exige que usted
esté mucho tiempo de pie, maneje herramientas peligrosas o pase el día
entero sentada en un escritorio, siga los consejos de su proveedor de
atención médica; tal vez tenga que cambiar su área de trabajo, sus
responsabilidades o su horario. Quizás le convenga cambiar de postura
más a menudo, o tomarse un receso adicional.
Tómese un receso y eleve
los pies.
Consejos para viajar
Hable primero con su proveedor de atención médica, pero el segundo trimestre suele ser el mejor
momento para viajar. Tal vez le aconsejen que se abstenga de hacer ciertos viajes mientras está
embarazada. La comida y el agua pueden constituir un problema en países subdesarrollados. Los viajes
en automóvil son una buena elección, porque le permiten hacer paradas, salir y estirar las piernas. Lleve
consigo bocadillos y agua potable. Abróchese la parte horizontal del cinturón por debajo del vientre, lo
más abajo posible en las caderas, y no olvide ponerse la parte diagonal sobre el torso.
La intimidad
A menos que su proveedor de atención médica le indique lo contrario, no hay
ningún motivo que le impida tener relaciones sexuales durante el embarazo.
Tal vez cambie su deseo sexual o el de su pareja; por ejemplo, sus deseos
podrían disminuir durante el primer trimestre, por las náuseas y el cansancio.
El sexo podría resultarle muy agradable durante el segundo trimestre, aunque
tal vez tenga problemas de incomodidad el tercer trimestre. Pruebe con varias
posiciones para encontrar la que mejor les funciona a usted y su pareja.
Cuéntele cómo se
siente a su pareja.
problema de salud.
84215
Adapting to Pregnancy: Second Trimester
Keep up the healthy habits you started in your first trimester. You might
be a little more tired than normal. So plan your day wisely. Look at the
tips below and choose the ones that suit your lifestyle.
If you have any questions,
check with your health care
provider.
If You Work
If you can, adjust your work with your employer to fit your needs. Try these tips:
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If you stand for long periods, find ways to do some tasks while sitting. Also, try to stand with one
foot resting on a low stool or ledge. Shift your weight from foot to foot often. Wear low-heeled
shoes.
If you sit, keep your knees level with your hips. Rest your feet on a firm surface. Sit tall with
support for your low back.
If you work long hours, ask about adjusting your schedule. Try taking shorter breaks more often.
When You Travel
The second trimester may be the best time for any travel. Talk to your health care provider about any
special plans you may need to make. Always:
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Wear a seat belt. Fasten the lap part under your belly. Wear the shoulder part also.
Take frequent breaks during long trips by car or plane. Move around to stretch your legs.
Drink plenty of fluids on flights. The air in plane cabins is very dry.
Avoid hot climates or high altitudes if you are not used to them.
Avoid places where the food and water might make you sick.
Taking Time to Relax
Find time to rest and relax at work or at home:
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Take short time-outs daily. Do relaxation exercises.
Breathe deeply during stressful times.
Try not to take on too much. Plan tasks for times when you have the most energy.
Take naps when you can. Or just sit and relax.
After week 16, avoid lying on your back for more than a few minutes. Instead, lie on your side.
Switch sides often.
Continuing as Lovers
Unless your health care provider tells you otherwise, there is no reason to stop having sex now. Blood
supply increases to the pelvic area in the second trimester. Because of this, sex might be more enjoyable.
Try different positions and see what’s best. Also, talk to your partner about any changes in desire.
Keeping Your Environment Safe
You can still clean house and use scented products. Just take some simple precautions:
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Wear gloves when using cleaning fluids.
Open windows to let in fresh air. Use a fan if you paint.
Avoid secondhand smoke.
Don’t breathe fumes from nail polish, hair spray, cleansers, or other chemicals.
84216
Adapting to Pregnancy: Second Trimester
Adaptación al embarazo: El segundo trimestre
Siga practicando los hábitos saludables que había adoptado durante su
primer trimestre. Ya que podría sentirse un poco más cansada de lo
normal, planifique su día con prudencia. Tenga en cuenta estos consejos:
Si tiene dudas, consulte a
su proveedor de atención
médica.
Si usted trabaja
Si puede, hable con su jefe para adaptar su trabajo a sus necesidades. He aquí algunos consejos:
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Si pasa mucho tiempo de pie, encuentre maneras para hacer algunas tareas sentada. Cuando esté
parada, trate de apoyar un pie en un banquito y desplace a menudo su peso de una pierna a la otra.
Use zapatos de tacón bajo.
Si trabaja sentada, mantenga las rodillas a la altura de las caderas. Apoye los pies en una superficie
firme y siéntese derecha, soportando la zona lumbar de la espalda.
Si trabaja por muchas horas, investigue la posibilidad de cambiar su horario; pruebe a tomar recesos
más cortos con más frecuencia.
Cuando viaje
El segundo trimestre puede ser el mejor momento para hacer cualquier tipo de viajes. Hable con su
proveedor de atención médica sobre algún plan especial que usted podría necesitar. En todo momento:
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Use un cinturón de seguridad. Abróchese la parte horizontal debajo del vientre, y póngase también
la parte diagonal del cinturón.
Durante los viajes largos en automóvil o avión, tome recesos frecuentes y pasee de un lado a otro
para estirarse las piernas.
Beba mucho líquido durante los vuelos en avión; el aire de las cabinas es muy seco.
Evite los climas cálidos o las grandes altitudes si no está acostumbrada a estas condiciones.
Evite ir a lugares en que el agua o los alimentos podrían causarle una enfermedad.
Tome el tiempo para relajarse
Reserve tiempo para descansar y relajarse en el trabajo o la casa.
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Tome descansos breves todos los días; haga ejercicios de relajación.
En períodos de tensión, respire hondo.
Trate de no asumir demasiadas responsabilidades. Programe sus quehaceres para los momentos en
que tenga más energía.
Siempre que pueda, duerma siesta o siéntese y relájese.
Después de la semana 16, no se acueste de espalda por más de unos minutos; acuéstese de costado y
cambie de lado a menudo.
Las relaciones sexuales
A menos que su proveedor de atención médica le indique lo contrario, no hay ningún motivo que le
impida tener relaciones sexuales ahora. El suministro de sangre a la zona pélvica aumenta en el segundo
trimestre, por lo que el sexo podría resultarle más agradable. Pruebe con diferentes posiciones para ver
la que mejor le funciona. Además, hable con su pareja si nota algún cambio en su apetito sexual.
La seguridad de su ambiente
Podrá seguir limpiando su casa y usando productos perfumados; basta con que tome unas sencillas
precauciones:
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Use guantes con detergentes y desinfectantes líquidos.
Abra las ventanas para que entre aire fresco; si está pintando, use un ventilador.
Evite el humo de segunda mano.
No inhale los vapores del esmalte de uñas, las lacas para el pelo, los limpiadores u otras sustancias
químicas.
problema de salud.
87075
Adapting to Pregnancy: Third Trimester
Although common during pregnancy, some discomforts may seem worse in the final weeks. Simple
lifestyle changes can help. Take care of yourself. And ask your partner to help out with small tasks.
Limiting Leg Problems
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Wear support hose all day.
Avoid snug shoes and clothes that bind, such as tight pants and socks with elastic tops.
Sit with your feet and legs raised often.
Caring for Your Breasts
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Wash with plain water. Avoid using harsh soaps or rubbing alcohol. They may cause dryness.
Wear a nursing bra for extra support. It can also hide any leaks from your nipples.
Controlling Hemorrhoids
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Eat foods that are high in fiber. Also, exercise and drink enough fluids. This will reduce
constipation and hemorrhoids.
Sleep and nap on your side. This limits pressure on the veins of the rectum.
Try not to stand or sit for long periods.
Controlling Back Pain
As your body changes during pregnancy, your back must work in new ways. Back pain is due to many
causes. Physical changes in your body can strain your back and its supporting muscles. Also, hormones
(chemicals that carry messages throughout the body) increase during pregnancy. This can affect how the
muscles and joints work together. All of these changes can lead to pain. Pain may occur in the upper or
lower back. Pain is also common in the pelvis. Some pregnant women have sciatica, pain caused by
pressure on the sciatic nerve running down the back of the leg. Ask your healthcare provider for specific
tips and exercises to help control your back pain.
Tips to Help You Rest
Good rest and sleep will help you feel better. Here are some ideas:
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Ask your partner to massage your shoulders, neck, or back.
Limit the errands you do each day.
Lie down in the afternoon or after work for a few minutes.
Take a warm bath before you go to sleep.
Drink warm milk or teas without caffeine.
Avoid coffee, black tea, and cola.
Stopping Heartburn
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Avoid spicy or acidic foods.
Eat small amounts more often. Eat slowly.
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Wait 2 hours after eating before lying down.
Sleep with your upper body raised 6 inches.
Managing Mood Swings
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Know that mood changes are normal.
Exercise often, but get plenty of rest.
Address any concerns and limit stress. Talking to your partner, other women, or your healthcare
provider may help.
Dealing with Urinary Frequency
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Drink plenty of water all day. If you drink a lot in the evening, though, you may have to get up
more in the night.
Limit coffee, black tea, and cola.
87076
Adapting to Pregnancy: Third Trimester
Cómo adaptarse al embarazo: el tercer trimestre
Aunque las molestias son comunes a lo largo del embarazo, algunas de ellas podrían empeorar durante
las últimas semanas. Quizás le resulte útil hacer algunos cambios sencillos en su estilo de vida. Cuídese
a sí misma y pida a su pareja que la ayude con las pequeñas tareas.
Para limitar las molestias en las piernas
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Póngase medias de compresión todo el día.
Evite usar zapatos ajustados y ropa demasiado apretada, como pantalones ceñidos y medias con
elástico en su parte superior.
Siéntese a menudo con los pies y las piernas elevadas.
El cuidado de sus senos
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Lávese con agua corriente. Evite usar jabones fuertes o alcohol isopropílico, ya que estas sustancias
pueden resecar la piel.
Use un sostén de maternidad; no sólo le brinda un mayor soporte, sino también puede absorber la
leche que le gotee de los pezones.
El control de las hemorroides
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Para reducir el estreñimiento y las hemorroides, coma alimentos con mucha fibra, haga ejercicios y
beba suficiente líquido.
Duerma y tome siestas de lado, para limitar la presión en las venas del recto.
Procure no permanecer de pie o sentada por largos períodos.
Control del dolor de espalda
A medida que el cuerpo cambia durante el embarazo, la espalda debe adaptarse y funcionar de nuevas
maneras. El dolor de espalda se debe a muchas causas. Los cambios físicos del cuerpo pueden
sobrecargar la espalda y los músculos que la soportan. Asimismo, los niveles de ciertas hormonas
(sustancias químicas que transportan información por el organismo) aumentan durante el embarazo, lo
cual puede afectar la manera en que los músculos y las articulaciones funcionan unos con otros. Todos
estos cambios pueden provocar dolor. Puede haber dolor en la parte superior o inferior de la espalda.
También es frecuente que haya dolor en la pelvis. Algunas mujeres tienen ciática, un dolor causado por
el exceso de presión sobre el nervio ciático que se extiende a lo largo de la parte posterior de las piernas.
Pida a su proveedor de atención médica que le dé consejos y ejercicios específicos para ayudarle a
controlar el dolor de espalda.
Consejos para ayudarla a descansar
Se sentirá mejor si puede descansar y dormir bien. Aquí tiene algunas ideas:
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Pida a su pareja que le dé un masaje en los hombros, el cuello o la
espalda.
Limite las diligencias que hace todos los días.
Recuéstese unos minutos por las tardes o después del trabajo.
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Tome un baño tibio antes de acostarse a dormir.
Beba leche tibia o infusiones sin cafeína.
Evite tomar café, té negro y refrescos de cola.
Para poner fin al ardor de estómago
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Evite las comidas picantes o muy ácidas.
Coma más a menudo en porciones más pequeñas, masticando lentamente.
Después de terminar de comer, espere 2 horas antes de acostarse.
Duerma con el tronco y la cabeza elevados unas 6 pulgadas (15 cm).
El control de los cambios de estado de ánimo
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Sepa que es normal tener cambios del estado de ánimo.
Resuelva sus preocupaciones y controle su estrés. Quizás le sirva de ayuda hablar con su pareja,
otras mujeres o su proveedor de atención médica.
Haga ejercicios a menudo, pero descanse en abundancia.
El manejo de la frecuencia urinaria
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Beba abundante agua todo el día. Sin embargo, si bebe mucho líquido de noche, quizás tenga que
levantarse a menudo en el transcurso de la noche.
Limite su consumo de café, té negro y refrescos de cola.
84501
Healthy Eating Habits During Pregnancy
It’s important to develop healthy eating habits while you are pregnant, for you as well as for your
baby. Here are some ways to stay healthy.
Aim for a Healthy Weight
A slow, steady rate of weight gain is often best. After the first trimester, you may gain about a pound a
week. If you were overweight before pregnancy, you need to gain fewer pounds. Your doctor can give
you a healthy weight goal for your pregnancy.
Don’t Diet
Now is not the time to diet. You may not get enough of the nutrients you and your baby need. Instead,
learn how to be a healthy eater. Start by doing it for your baby. Soon, you may do it for yourself.
Vitamins and Supplements
Talk with your healthcare provider about taking these and other prenatal vitamins and supplements.
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Iron makes the extra blood you need now.
Calcium and vitamin D help build and keep strong bones.
Folic acid helps prevent certain birth defects.
Some vitamins may not be safe to take. Your healthcare provider will tell you which ones to avoid.
Fluids
Drink at least 8–10 cups of fluid daily. Your baby needs fluids. Fluids
also decrease constipation, flush out toxins and waste, limit swelling,
and help prevent bladder infections. Water is best. Other good choices
are:
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Water or seltzer water with a slice of lemon or lime (these can help
ease an upset stomach, too)
Clear soups that are low in salt
Low-fat or fat-free milk; soy or rice milk with calcium added
Fruit juices mixed with water
Popsicles or gelatin
Things to Avoid
Some things might harm your growing baby. Don’t eat or drink:
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Alcohol
Unpasteurized dairy foods and juices
Raw or undercooked meat, poultry, fish, or eggs
Fish that are high in mercury, such as shark, swordfish, king mackerel, tilefish, and albacore tuna
Things to Limit
Ask your healthcare provider whether it’s safe to eat or drink:
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Caffeine
Artificial sweeteners
Organ meats
Certain types of fish
Fish and shellfish that contain mercury in lower amounts, such as shrimp, canned light tuna, salmon,
pollock, and catfish
84232
Healthy Eating Habits During Pregnancy
Buenos hábitos alimenticios durante el embarazo
Ya que su salud puede afectar el desarrollo del bebé mientras usted está embarazada, es importante que
adopte buenos hábitos alimenticios. He aquí algunos consejos que la ayudarán a conservarse sana.
Propóngase tener un peso saludable
Generalmente, lo ideal es aumentar de peso a ritmo lento y constante. Después del primer trimestre,
puede ganar mas o menos 1 libra por semana. Si usted tenía sobrepeso antes del embarazo, necesitará
aumentar una menor cantidad de libras. Su médico puede indicarle cuál puede ser su meta para tener un
peso saludable durante su embarazo.
No se ponga a dieta
Éste no es el momento para ponerse a dieta, porque si lo hace se arriesga a no obtener las cantidades
suficientes de nutrientes que usted y su bebé necesitan. Más bien, aprenda a alimentarse bien. Empiece
haciéndolo por su bebé; pronto lo estará haciendo también en beneficio propio.
Vitaminas y suplementos
Consulte con su proveedor de atención médica antes de tomar estas y otras vitaminas y suplementos
prenatales.
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El hierro ayuda a elaborar la sangre adicional que usted necesita.
El calcio y la vitamina D ayuda a formar y mantener huesos fuertes.
El ácido fólico ayuda a prevenir ciertos defectos de nacimiento.
Algunas vitaminas podrían no ser seguras durante el embarazo. Su proveedor de atención médica le
dirá las que debe evitar.
Los líquidos
Tome al menos 8–10 tazas de líquido al día. Además de ser necesarios
para su bebé, los líquidos ofrecen otras ventajas: alivian el
estreñimiento, permiten expulsar las toxinas y los desechos del cuerpo,
limitan las infecciones y ayudan a prevenir las infecciones de la vejiga.
Lo ideal es que tome agua, pero otras buenas elecciones son:
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Agua o soda con una rodaja de lima o limón (estas bebidas sirven
también para asentarle el estómago)
Consomés con poca sal
Leche con poca grasa o descremada; leche de soya o de arroz, con
calcio añadido.
Jugos de fruta diluidos con agua
Paletas heladas o gelatina
Evite estas comidas
Algunos alimentos o bebidas pueden perjudicar al bebé en crecimiento. Evite comer o beber lo siguiente:
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Alcohol
Productos lácteos y jugos no pasteurizados
Carne, pollo, pescado o huevos crudos o poco cocidos
Pescados que tengan alto contenido de mercurio, tales como tiburón, pez espada, caballa gigante,
blanquillo (tilefish) y atún de albacora
Limite estas comidas
Pregúntele a su proveedor de atención médica si es seguro incluir estos alimentos en su dieta:
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Cafeína
Dulcificantes artificiales
Vísceras (hígado, riñones, etc.)
Pescados y mariscos que contengan mercurio en pocas cantidades, tales como langostinos, atún
enlatado, salmón, pollock y bagre
problema de salud.
82266
Exercise During Pregnancy
Regular exercise can help you adapt to the changes your body is going through during pregnancy.
Exercising may help you relax, and it gets you ready for labor and delivery. Talk to your healthcare
provider about the kinds of activities you can do. Then go ahead and enjoy them.
Get Started
Even if you didn’t exercise before pregnancy, it is not too late to start.
Choose an activity that you like and that fits your lifestyle. Begin
slowly and build up a little at a time. And be sure to check with your
doctor before starting any exercise program. The following tips may
help you get started:
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Choose a time and place to exercise each day.
Wear loose-fitting clothes and comfortable athletic shoes.
Stretch before and after you exercise. (Be sure to stretch slowly
and to hold stretches for 30 to 40 seconds.)
Be Active
Unless your doctor says otherwise, try to exercise for 30 minutes or
more most days of the week.
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Overall conditioning, such as swimming, bicycling, or walking, is especially beneficial.
Aerobics and exercises that increase your pulse rate help condition your body and strengthen your
heart. Ask about special prenatal aerobics classes.
Exercise Safely
These tips will help you have a safe, healthy workout:
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Stay cool. Stop exercising if you feel overheated.
Slow down if you’re out of breath. If you can’t talk while you’re exercising, your heart rate may be
too high.
Stay off your back. Lying on your back can decrease blood flow to your baby.
Drink water. Drink one cup of water before and after your workout, and two cups during.
Eat 300 extra calories a day. A light snack before and after you exercise will help keep your energy
up.
Avoid activities requiring balancing skills later in pregnancy.
Do Kegel Exercises
Kegel exercises strengthen the pelvic floor muscles used in childbirth. These muscles are the same ones
used to stop the flow of urine. Do Kegel exercises daily.
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Squeeze your pelvic floor muscles for at least 5 seconds.
Relax, then squeeze again.
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Work your way up to 50 or 100 Kegels a day.
You can do Kegel exercises anytime and anywhere.
Keep Walking
No matter what other exercise you do, try to walk whenever you can.
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If you’re working all day, take a lunchtime walk in the park with a friend.
When you shop, park away from the store entrance and walk the extra distance.
Take the stairs instead of the elevator.
When to Stop Exercising and Call Your Healthcare Provider
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Shortness of breath before starting exercise
Vaginal bleeding
Dizziness or feeling faint
Chest pain
Headache
Decreased fetal movement
Preterm contractions
Muscle weakness
Calf pain or swelling
Fluid leaking from the vagina
82267
Exercise During Pregnancy
El ejercicio durante el embarazo
El ejercicio regular puede ayudarle a adaptarse a los cambios que experimenta su cuerpo durante el
embarazo. También puede ayudarle a relajarse y a prepararse para el parto. Hable primero con su
proveedor de atención médica sobre las actividades que puede hacer. Luego empiece a disfrutarlas.
Empiece a moverse
Aunque no hiciera ejercicio antes del embarazo, no es demasiado tarde para empezar. Elija una actividad
que le guste y que se adapte a su estilo de vida. Empiece lentamente y vaya aumentando poco a poco la
intensidad. Además, asegúrese de consultar con su médico antes de iniciar un programa de ejercicios.
Los siguientes consejos pueden ayudarle a empezar:
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Elija una hora y un lugar para hacer sus ejercicios diariamente.
Use ropa holgada y zapatillas de deporte que le queden cómodas.
Haga estiramientos antes de iniciar su ejercicio. (Asegúrese de estirarse lentamente y sostenga los
estiramientos de 30 a 40 segundos.)
Manténgase activa
A no ser que su médico le diga lo contrario, trate de hacer ejercicio
durante 30 minutos o más la mayoría de los días de la semana.
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Un acondicionamiento físico general, como nadar, montar en
bicicleta o caminar, es muy beneficioso.
Los ejercicios aeróbicos y los que aceleran el ritmo cardíaco
ayudan a acondicionar su cuerpo y a fortalecer el corazón.
Pregunte sobre clases de aeróbicos prenatales.
Haga ejercicio de manera segura
Estos consejos le ayudarán a hacer ejercicio de manera sana y segura:
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Manténgase fresca. Suspenda el ejercicio si se siente recalentada.
Disminuya el ritmo si se siente sin aire. Si no puede hablar mientras hace ejercicio, su ritmo
cardíaco puede estar muy alto.
Trate de no apoyarse en su espalda. Acostarse boca arriba puede disminuir el flujo de sangre a su
bebé.
Beba agua. Beba un vaso de agua antes y después de su sesión de ejercicios, y dos vasos durante la
misma.
Coma 300 calorías adicionales al día. Un refrigerio ligero antes y después de su ejercicio mantendrá
su nivel de energía.
Evite las actividades que requieran destrezas de equilbrio para una etapa más adelante del
embarazo.
Haga los ejercicios de Kegel
Este tipo de ejercicios fortalece los músculos de la pelvis que intervienen durante el parto. Estos
músculos son los mismos que se usan para detener el flujo de orina. Haga los ejercicios de Kegel todos
los días.
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Apriete los músculos de la pelvis durante por lo menos 5 segundos.
Afloje, luego vuelva a apretar.
Aumente hasta llegar a hacer de 50 a 100 ejercicios de Kegel por día.
Puede hacer los ejercicios de Kegel en cualquier momento y lugar.
Siga caminando
Sin importar qué ejercicio haga, trate de salir a caminar siempre que pueda.
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Si trabaja todo el día, salga a caminar al mediodía por un parque con una amiga.
Cuando salga de compras, estacione lejos de la entrada para caminar un poco más.
Suba por las escaleras en lugar de tomar el ascensor.
Cuándo dejar de hacer ejercicio y llamar al proveedor de atención médica
Llame de inmediato a su médico si tiene algo de lo siguiente:
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Falta de aire antes de iniciar un ejercicio
Sangrado vaginal
Mareos o siente que va a desmayarse
Dolor de pecho
Dolor de cabeza
Menos movimiento fetal
Contracciones antes de término
Debilidad muscular
Dolor o hinchazón en las pantorrillas
Escape de líquido de la vagina
problema de salud.
82285
What Is Gestational Diabetes?
Gestational diabetes is a special kind of diabetes that happens only during pregnancy. Normally, as food
is digested, it turns into sugar (glucose) that goes into your bloodstream. Your body makes a substance
called insulin that helps your cells use this blood sugar. Changes that occur in your body while you’re
pregnant cause your blood sugar to be too high. This can be risky for both you and your baby. You can
take steps to control your blood sugar and reduce these risks.
Managing Gestational Diabetes
Managing gestational diabetes means controlling your blood sugar
while you are pregnant. Your healthcare team will help you put
together a plan to do this. This plan will include:
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Eating Right. Eating the right foods is the main way to control
your blood sugar. You need to eat a variety of foods from each
of the food groups each day. To help you with the changes that
may be needed in your diet, you will likely work with a
registered dietitian (an expert on food and nutrition). The
dietitian can help you understand how specific foods affect your Eating the right foods will help
blood sugar. He or she can also teach you the skills you need to you keep your blood sugar at
safe levels for you and your
plan healthy, balanced meals.
baby.
Getting Exercise. Your body uses more blood sugar when you
exercise. Your healthcare team can decide on the best kind of exercise for you, and the best times
for you to exercise.
Checking Your Blood Sugar. You will most likely check your blood sugar at home 2 or more
times a day. Your healthcare team will teach you how to check. They will also discuss your blood
sugar goals with you. Your blood sugar may also be tested every week or so in the lab.
Risks to Your Baby
If you don’t control your blood sugar, your baby is more likely to have these problems:
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Your baby may grow too large. If your blood sugar stays too high, your baby may grow too large
(macrosomia) to come through your vagina without injuring the baby’s arms and shoulders.
Your baby’s organs may not be fully developed before birth. If your blood sugar stays too high,
your baby might grow so large that he or she has to be born early. Then the baby’s lungs may not
work well. This is called respiratory distress syndrome (RDS). Your baby’s liver also may not work
well. Then your baby may have yellowing of the skin and eyes (jaundice) after birth.
Your baby’s blood sugar may be low after birth. If your blood sugar is too high, your baby
makes extra insulin. The baby still makes extra insulin right after birth. Then he or she may have to
be treated for low blood sugar.
Your baby could be stillborn. This is very rare, but your baby could die before birth if your blood
sugar stays high for too long.
Risks to You
If you don’t control your blood sugar, you are more likely to have these problems:
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You may have high blood pressure. High blood sugar makes you more likely to have high blood
pressure during your pregnancy (preeclampsia). This is a danger to your health. And it could mean
your baby will have to be delivered early.
You may have more infections. High blood sugar makes you more likely to have bladder, kidney,
and vaginal infections.
You may be uncomfortable or short of breath. High blood sugar can cause too much fluid
around the baby (polyhydramnios). Your abdomen gets big and pushes on your lungs. You may
also go into labor early.
Your delivery may be harder, and recovery may take longer. If your blood sugar stays too high,
your baby may grow too large. A large baby might cause injury to you during birth. So the baby
may have to be delivered by cesarean section (C-section). This means making a cut (incision) in
your abdomen and uterus. Needing a C-section is one of the most common risks of gestational
diabetes.
Reduce Your Future Risk of Type 2 Diabetes
Women who have gestational diabetes are at higher risk for developing type 2 diabetes. To help reduce
your risk, lose weight if you’re overweight. Be as active as you can. Eat more fruits and vegetables and
fewer processed foods. And have your doctor screen you regularly for diabetes.
Who Gets Gestational Diabetes?
Gestational diabetes is more likely in women who:
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Are overweight.
Have a family history of diabetes.
Have had a baby who weighed more than 9 pounds at birth.
Have had a baby who died before birth.
Have had gestational diabetes in the past.
Are Latina, African American or Native American, South or East Asian, or Pacific Islander.
For More Information
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American Diabetes Association
800-342-2383
www.diabetes.org
American Dietetic Association
www.eatright.org
82286
What Is Gestational Diabetes?
¿Qué es la diabetes gestacional?
La diabetes gestacional es un tipo especial de diabetes que ocurre solamente durante el embarazo
(gestación). Normalmente, durante la digestión los alimentos se convierten en azúcar (glucosa) que
luego pasa a la circulación sanguínea. El cuerpo produce una sustancia denominada insulina que ayuda
a las células a usar el azúcar presente en la sangre. Los cambios que se producen en el cuerpo durante el
embarazo hacen que el nivel de azúcar en la sangre se eleve demasiado, lo que puede ser peligroso tanto
para la mamá como para su bebé. Es posible tomar medidas para controlarse el azúcar en la sangre y
disminuir estos riesgos.
El manejo de la diabetes gestacional
El manejo de la diabetes gestacional requiere que usted se controle el
azúcar en la sangre durante el embarazo. Su equipo de atención
médica le ayudará a elaborar un plan para lograrlo, que incluirá los
siguientes aspectos:
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Alimentarse bien. Comer los alimentos adecuados es la mejor
manera de controlar el azúcar en la sangre. Es importante que
coma todos los días una variedad de alimentos de los distintos
grupos. Para ayudarle a hacer los cambios que pudiera requerir
en su alimentación, es probable que consulte a un nutricionista Llevar una dieta adecuada la
ayudará a mantener unos
titulado (un experto en los alimentos y la nutrición). El
niveles de azúcar en la sangre
nutricionista puede ayudarle a entender cómo afectan los
alimentos específicos su nivel de azúcar en la sangre. Tambien que sean adecuados tanto para
usted como para su bebé.
puede enseñarle las técnicas necesarias para planificar comidas
saludables y balanceadas.
Hacer ejercicio. Cuando hace ejercicio, el cuerpo usa más azúcar de la sangre. Su proveedor de
atención médica le puede recomendar el mejor tipo de ejercicio para usted y el mejor momento para
hacerlo.
Medirse el nivel de azúcar en la sangre. Lo más probable es que usted se haga exámenes de
sangre en su casa 2 o más veces al día para medirse el nivel de azúcar. Su proveedor de atención
médica le enseñará a hacerse este examen y le explicará los valores en que debe mantener su azúcar
en la sangre. Además, es posible que le hagan exámenes de azúcar en la sangre en el laboratorio,
aproximadamente cada semana.
Riesgos para el bebé
Si usted no se controla el azúcar en la sangre, es más probable que su bebé tenga los problemas
siguientes:
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El bebé podría crecer demasiado. Si su nivel de azúcar en la sangre permanece demasiado
elevado, su bebé podría tener un tamaño demasiado grande (macrosomia) como para atravesar la
vagina sin lesionarse los brazos y los hombros.
Los órganos del bebé podrían no estar completamente desarrollados antes del nacimiento. Si
su nivel de azúcar en la sangre permanece demasiado elevado, el bebé podría aumentar de tamaño
al punto tal de tener que nacer prematuramente. Es posible que los pulmones de un bebé prematuro
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no funcionen bien y el niño nazca con síndrome de distrés respiratorio (SDR). También es posible
que al bebé no le funcione bien el hígado, en cuyo caso podría nacer con ictericia y tener la piel
amarilla.
Es posible que el nivel de azúcar en la sangre del bebé sea bajo después del nacimiento. Si
usted tiene un nivel de azúcar demasiado elevado, su bebé produce insulina adicional incluso
apenas después de nacer. En ese caso, podría ser necesario tratarlo por baja de azúcar.
El bebé podría nacer muerto. Esto es muy poco frecuente, pero su bebé podría morir antes del
parto si usted tiene el nivel de azúcar elevado por demasiado tiempo.
Riesgos para usted
Si usted no se controla el azúcar en la sangre, es más probable que experimente los problemas
siguientes:
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Quizás tenga la presión arterial alta (hipertensión). Tener un nivel elevado de azúcar en la
sangre aumenta la probabilidad de hipertensión durante el embarazo (preeclampsia). Esto es
peligroso para su salud y podría traer como consecuencia que su bebé nazca prematuramente.
Quizás contraiga más infecciones. Tener un alto nivel de azúcar en la sangre aumenta la
probabilidad de contraer infecciones de la vejiga, los riñones y la vagina.
Quizás sienta molestias o falta de aire. Tener un alto nivel de azúcar en la sangre puede provocar
la acumulación de líquido alrededor del bebé (polihidroamnios). El abdomen de la madre se
agranda y le presiona los pulmones. También puede adelantarse el trabajo de parto.
Tal vez tenga un parto más difícil y tarde más en recuperarse. Si su nivel de azúcar en la sangre
permanece demasiado elevado, es posible que su bebé crezca excesivamente. Ya que los bebés de
gran tamaño pueden lesionar a sus madres durante el parto, es posible que usted tenga que hacerse
una cesárea. Se trata de una operación en que se efectúa un corte (incisión) en el abdomen y el útero
de la madre. Necesitar una cesárea es uno de los riesgos más comunes de la diabetes del embarazo.
Reduzca su riesgo de tener diabetes tipo 2 en el futuro
Las mujeres que tienen diabetes durante el embarazo corren un riesgo más elevado de desarrollar
diabetes tipo 2. Para reducir su riesgo, adelgace si tiene sobrepeso, haga la mayor cantidad de actividad
física posible, coma más frutas y verduras y menos alimentos procesados, y pídale a su médico que le
haga pruebas de detección de diabetes regularmente.
¿A quién le da la diabetes gestacional?
La diabetes gestacional es más probable en las mujeres que:
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Tienen sobrepeso.
Tienen antecedentes familiares de diabetes.
Han tenido un bebé que pesó más de 9 libras al nacer.
Han tenido un bebé que murió antes del parto.
Han tenido diabetes gestacional en sus embarazos anteriores.
Son de raza hispana, negra, indígena americana, del sur o del este asiático o de las islas del Pacífico.
Para más información
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American Diabetes Association
800-342-2383
www.diabetes.org
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American Dietetic Association
www.eatright.org
problema de salud.
82243
Understanding Preterm Labor
Going into labor before your 37th week of pregnancy is called preterm labor. Preterm labor can cause
your baby to be born too soon. This can lead to a number of health problems that may affect your baby.
Before labor, the cervix is In preterm labor, the
cervix begins to efface
thick and closed.
(thin) and dilate (open).
Symptoms of Preterm Labor
If you believe you’re having preterm labor, get medical help right away. But contractions alone don’t
mean you’re in preterm labor. What matters more are changes in your cervix (the lower end of the
uterus). Symptoms of preterm labor include:
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Four or more contractions per hour
Strong contractions
Constant menstrual-like cramping
Low-back pain
Mucous or bloody vaginal discharge
Bleeding or spotting in the second or third trimester
Evaluating Preterm Labor
Your doctor will try to find out whether you’re in preterm labor or
whether you’re just having contractions. He or she may watch you for a
few hours. The following tests may be done:
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Pelvic exam to see if your cervix has effaced (thinned) and dilated
(opened)
Uterine activity monitoring to detect contractions
Fetal monitoring to check the health of your baby
Ultrasound to check your baby’s size and position
Amniocentesis to check how mature your baby’s lungs are
Caring for Yourself At Home
A pelvic exam can help
your doctor find out
whether your cervix has
thinned and opened.
If you have contractions preterm but your cervix is still thick and closed, your doctor may ask you to do
the following at home:
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Drink plenty of water.
Do fewer activities.
Rest in bed on your side.
Avoid intercourse and nipple stimulation.
When to Call Your Doctor
Call your doctor or other healthcare provider if you notice any of these:
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Four or more contractions per hour
Bag of water breaks
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Bleeding or spotting
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If You Need Hospital Care
Preterm labor often requires that you have hospital care and complete bed rest. You may have an IV
(intravenous) line to get fluids. And you may be given pills or an injection to help prevent contractions.
Finally, you may receive medication (corticosteroids) that helps your baby’s lungs mature more
quickly.
Are You At Risk?
Any pregnant woman can have preterm labor. It may start for no reason. But these risk factors can
increase your chances:
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Past preterm labor or past early birth
Smoking and drug or alcohol use during pregnancy
Multiple fetuses (twins or more)
Problems with the shape of the uterus
Bleeding during the pregnancy
The Dangers of Preterm Birth
A baby born too soon may have health problems. This is because the baby didn’t have enough time to
mature. The baby then is at risk of:
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Not breastfeeding well
Having immature lungs
Bleeding in the brain
Dying
Reaching Term
Your goal is to get as close to term as you can before giving birth. The closer you get to term, the higher
your chance of having a healthy baby. Work with your healthcare provider. Together, you can take steps
that may keep you from giving birth too early.
82244
Understanding Preterm Labor
El trabajo de parto prematuro
El trabajo de parto prematuro consiste en el desencadenamiento de los síntomas del parto (el “trabajo
de parto”) antes de la semana 37 de embarazo. El trabajo de parto prematuro puede resultar en un
nacimiento prematuro y en consecuencia provocar diversos problemas en la salud del bebé.
Antes del trabajo de
parto, el cuello uterino
está espeso y cerrado.
Durante el trabajo de
parto prematuro, el
cuello uterino comienza
a perder espesor y a
dilatarse (abrirse).
Síntomas del trabajo de parto prematuro
Si cree que está teniendo síntomas de trabajo de parto prematuro, obtenga ayuda médica
inmediatamente. Recuerde que las contracciones por sí solas no significan necesariamente que esté
teniendo un trabajo de parto prematuro. Lo más significativo son los cambios en el cuello uterino (el
extremo inferior del útero). Entre los síntomas del trabajo de parto prematuro se encuentran los
siguientes:
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Cuatro o más contracciones por hora
Contracciones fuertes
Cólicos constantes del mismo tipo que los cólicos menstruales
Dolor en la parte inferior de la espalda
Secreción vaginal sanguinolenta o con mucosidad
Sangrado o manchas en el segundo o tercer trimestre de embarazo
Evaluación de los síntomas de parto prematuro
Su médico tratará de determinar si está teniendo realmente un trabajo de
parto prematuro o si se trata simplemente de contracciones. Es posible que
el médico la mantenga en observación durante algunas horas y que le
hagan las siguientes pruebas:
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Examen pélvico para determinar si el cuello uterino ha perdido
espesor o se ha dilatado (abierto)
Observación de la actividad uterina para detectar si hay
Un examen pélvico ayuda
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al médico a determinar si
contracciones
el cuello uterino ha
Observación del feto para comprobar la salud del bebé
perdido espesor y se ha
Ultrasonido para determinar el tamaño y la posición del bebé
abierto.
Amniocentesis para determinar el grado de madurez de los pulmones
del bebé
Cómo cuidar de sí misma en su casa
Si tiene contracciones prematuras pero el cuello uterino todavía está espeso y cerrado, es posible que el
médico le pida que haga lo siguiente en su casa:
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Beber abundante agua.
Reducir su nivel de actividad.
Descansar en la cama, sobre el costado.
Evitar el acto sexual y la estimulación de los pezones.
Cuándo debe llamar al médico
Llame al médico o a otro proveedor de atención médica si nota alguno de estos síntomas:
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Cuatro o más contracciones por hora
Rompimiento de fuente
Sangrado o manchas de sangre en la ropa interior
Si necesita atención en el hospital
El trabajo de parto prematuro suele requerir atención en el hospital y reposo total en la cama. Es posible
que le pongan una sonda intravenosa para administrarle líquidos y tal vez le den pastillas o una
inyección para ayudarle a prevenir las contracciones. Por último, es posible que reciba medicamentos
(corticoides) para favorecer un desarrollo más rápido de los pulmones del bebé.
¿Corre usted el riesgo de trabajo de parto prematuro?
El trabajo de parto prematuro puede afectar a cualquier mujer y puede comenzar sin ningún motivo
aparente, pero los siguientes factores de riesgo aumentan las probabilidades de que se produzca:
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Tiene antecedentes de trabajo de parto prematuro o nacimientos prematuros
Ha fumado o tomado drogas o alcohol durante el embarazo
Está embarazada con más de un bebé
Problemas con la forma del útero
Sangrado durante el embarazo
Los peligros del nacimiento prematuro
Un bebé que nace demasiado pronto puede tener problemas de salud debido a que no ha tenido tiempo
suficiente para madurar. En ese caso, el bebé corre los siguientes riesgos:
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No amamantarse bien
Pulmones inmaduros
Hemorragias cerebrales
Muerte
Llegar al término
Su objetivo es llegar lo más cerca posible del término antes de dar a luz a fin de aumentar las
probabilidades de tener un bebé sano. Trabaje en colaboración con su proveedor de atención médica.
Juntos, podrán tomar las medidas necesarias para evitar el nacimiento prematuro del bebé.
problema de salud.
88718
After Giving Birth: Changing Expectations for Parents
Congratulations on your new baby! Diapers won’t be the only thing you’ll change in the months ahead.
Your sense of yourself and how you relate to your partner will also be different. If you have other
children, expect some emotional swings, as you and all of the other members of your family try out your
new roles.
Not Always Rosy
Most new mothers experience some form of the baby blues. These mood
swings are caused by hormonal shifts in your body. Stress due to the recent
changes in your life and lack of sleep also have an effect. The baby blues
may last a few days or even weeks. You may feel a sense of loss,
frustration, or anger. Or you may be sad that having a baby isn’t what you’d
imagined. Sometimes a birth triggers childhood memories or reminds you
about the death of a loved one.
Balancing the Blues
Recognize your need to talk, to feel protected, to have private time. Allow yourself to cry, to sit, to
think. Ask for help when you need it, and accept help when it’s offered. Knowing your needs is not a
weakness. Share your thoughts with your partner. Or pick up the phone and call a friend, your mother, a
sister, or an aunt. Rest, eat right, and get some light exercise. The mind feels best when the body feels
good.
Shaping Your Family
Over the next year, your household will go through many changes. If this is your first child, you and
your partner will have to adjust to the idea of being a family. If you have older children, help them
adjust to the new baby. Sharing chores, time, and attention is something you’ll all need to work on. If
you’re a single mother, you may find that your baby has a “family” of friends as well as relations.
Share Activities
As a newborn, your baby has many needs. These must be blended into the family’s style. Take the baby
on outings, so he or she is part of the family from the beginning. Involve everyone in activities you all
can enjoy doing together.
As Parents and Lovers
The demands on your relationship have just increased. So do your best to
strengthen your partnership ties. Set aside time to talk every day. Put away
the dinner dishes together or take a break before bedtime. Also, try to spend
time alone. It will help you remember why you’re together. Return to sex
when it feels right and it’s okay with your doctor. But don’t think of
breastfeeding as a form of birth control. Instead, talk with your healthcare
provider about birth control methods that might be right for this time in
your life.
When to Call the Doctor
Call your doctor or healthcare provider if you have any of the following concerns:
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You don’t want to be with the baby.
You have no interest in eating or are not able to sleep.
Your symptoms are not getting better, and you’re getting more upset.
You think you may harm yourself or the baby.
The Depression After Delivery hotline (800-944-4773) may also be helpful.
88719
After Giving Birth: Changing Expectations for Parents
Después de dar a luz: expectativas cambiantes para los padres
¡Felicitaciones por su nuevo bebé! Los pañales no serán la única cosa que deberá cambiar en los meses
venideros. La imagen que tiene de sí misma y su relación con su pareja también cambiarán. Si tiene
otros hijos, es normal que haya ciertos altibajos emotivos a medida que usted y los demás miembros de
su familia se acostumbran a sus nuevos papeles.
No siempre de color de rosa
La mayoría de las madres experimentan algún tipo de depresión
postparto. Estos cambios de humor se deben a los cambios hormonales en
su cuerpo, al estrés causado por los recientes cambios en su vida y a la falta
de sueño. La depresión postparto puede durar algunos días o incluso
semanas. Tal vez tenga una sensación de pérdida, frustración o enojo, o es
posible que se sienta triste de que el nacimiento de un bebé no resulta ser lo
que había imaginado. En algunas ocasiones, un nacimiento puede
desencadenar ciertos recuerdos o traer a la memoria la muerte de un ser
querido.
Cómo controlar la depresión
Reconozca su necesidad de hablar, sentirse protegida y disponer de tiempo a solas. Dése a sí misma la
oportunidad de llorar, estar tranquila y reflexionar. Pida ayuda cuando la necesite, y acéptela cuando se
la ofrezcan. Conocer sus propias necesidades no es una debilidad. Comparta sus pensamientos con su
pareja, o bien llame por teléfono a una amiga, a su madre, a su hermana o a una tía. Descanse,
aliméntese bien y haga ejercicio suave. La mente se siente mejor cuando el cuerpo también se siente
bien.
Comparta actividades
Como recién nacido, su bebé tiene muchas necesidades que deben combinarse con el estilo de vida de la
familia. Lleven al bebé con ustedes cuando salgan de casa para que forme parte de la familia desde el
principio. Implique a todos en actividades de las que puedan disfrutar todos juntos.
Como padres y amantes
Las presiones sobre su relación acaban de aumentar, por lo que es importante que traten de fortalecerla.
Reserven tiempo todos los días para conversar. Recojan juntos los platos de la cena o tómense un
descanso antes de irse a la cama. Traten de pasar tiempo en compañía uno del otro. Esto les ayudará a
recordar por qué están juntos. Reanuden las relaciones sexuales cuando crean que ha llegado el
momento adecuado, si el médico les ha dicho que pueden hacerlo. Pero no piense en el amamantamiento
como un método anticonceptivo. Hable con su proveedor de atención médica acerca de los métodos
anticonceptivos que podrían ser adecuados para usted en esta época de su vida.
Adaptación familiar
Durante el próximo año, su hogar atravesará muchos cambios. Si este es su primer hijo, usted y su pareja
deberán adaptarse a la idea de que ahora son una familia. Si tiene otros niños, ayúdeles a adaptarse al
nuevo bebé. Compartir los trabajos, el tiempo y la atención son cosas en las que deberán ponerse de
acuerdo. Si usted es una madre sin pareja, tal vez descubra que su bebé tiene una “familia” de amigos y
parientes.
Llame a su médico o a su proveedor de atención médica si tiene cualquiera de estos problemas:
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No quiere estar con el bebé.
No tiene apetito o no es capaz de dormir.
Sus síntomas no mejoran y cada vez está más preocupada.
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Cree que podría llegar a hacerse daño a sí misma o al bebé.
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La línea telefónica gratuita para la depresión postparto (800-944-4773) también puede resultarle útil.
88720
After Giving Birth: How to Feel Healthy
Helping yourself feel fit is one of the best things you can do for your baby. A little exercise will tone
your muscles. You’ll feel stronger and more energized. You’ll also feel more awake and aware. Don’t
worry about your weight right now. Your goal is to feel healthy. Part of feeling good is dressing for
comfort. If you dress “smart,” you can be a busy new mom and still look great.
Continue Kegel Exercises
You probably were told to do Kegel exercises during pregnancy. These exercises strengthen the muscles
that are strained by carrying and delivering the baby. You can return to your Kegels as soon as you feel
ready. Why not start today? Squeeze your pelvic floor muscles (the ones that control your urine stream)
for at least 5 seconds. Relax, then squeeze again. Work your way up to 50 or 100 Kegels a day.
Exercise Often
Exercise helps you get in shape. It also strengthens your muscles, so you are better fit for lifting the
baby. As an added benefit, exercise gives you a sense that you’re doing something good for yourself.
Take your baby for a short walk, or spend 10 minutes stretching. If you were active during pregnancy,
you can probably begin light exercise as soon as you feel ready. But be sure to check with your doctor
before you begin.
Stay Off the Scale
For the first month, think about regaining energy, not about losing weight. Losing weight too soon can
make you feel more tired. Instead, focus on caring for your baby and eating balanced meals. You may
lose some weight without even trying, especially if you’re breastfeeding. Once your energy level’s back
to normal, you can begin to lose weight. A gradual weight loss of 4 or 5 pounds a month is safest.
Pelvic Tilt
Lie on your back, with your knees bent and your feet flat on the floor.
Now tighten the muscles in your abdomen and buttocks. As you
inhale, press down until your low back flattens against the floor. Hold
for a moment, then relax. Repeat 5 times twice a day.
Abdominal Curl
Lie on your back with your knees bent and feet flat on the floor. Cross
your arms over your chest. Exhale and tighten the muscles in your
abdomen. Gently raise your shoulders off the floor. Hold for 5 counts.
Slowly lower your shoulders. Relax, then repeat 3 to 5 times twice a
day.
Dress Smart
You’ll want to be comfortable during the first days after delivery. Wear a robe, pajamas, or sweats—
whatever feels best. Soon you may want to look more like your prepregnant self. Do your hair and wear
makeup, if you normally do. A loose-fitting dress may feel good. But do yourself a favor: Don’t reach
for your jeans. It’s likely to be a month or more before you can wear them. If leaking breasts are a
problem, put pads inside your bra and dress in layers. If you’re breastfeeding, shirts that open in front or
pullover tops are good choices. A scarf or shawl can be used as a drape if you breastfeed when others
are present.
When to Call the Doctor
Remember to schedule your postpartum visit. If you delivered by cesarean, be seen within 2 weeks. For
vaginal delivery, be seen 4–6 weeks after the birth. Also, call your doctor or healthcare provider if you have
bleeding that turns bright red or gets heavier.
88721
After Giving Birth: How to Feel Healthy
Después de dar a luz: cómo sentirse saludable
Tratar de mantenerse en forma es una de las mejores cosas que usted puede hacer por su bebé. Un poco
de ejercicio le tonificará los músculos. Se sentirá más fuerte, tendrá más energía y también se sentirá
más despierta y alerta. No se preocupe por su peso de este momento. Su objetivo es sentirse en forma.
Parte de este objetivo implica vestirse de forma confortable. Si se viste con buen gusto, podrá seguir
siendo una mamá atareada y aún así tener un aspecto elegante.
Continúe haciendo los ejercicios de Kegel
Probablemente le hayan dicho que haga ejercicios de Kegel durante el embarazo. Estos ejercicios
fortalecen los músculos que deben hacer mayor esfuerzo durante el embarazo y el parto. Podrá reanudar
sus ejercicios de Kegel tan pronto como se sienta capaz. ¿Por qué no empezar hoy mismo? Contraiga los
músculos del suelo pélvico (los que controlan el flujo de orina) durante al menos 5 segundos. Relájese y
luego contraiga de nuevo los músculos. Aumente gradualmente hasta 50 o 100 ejercicios de Kegel al
día.
Haga ejercicio a menudo
El ejercicio le ayudará a mantenerse en forma y a fortalecer los músculos a fin de que esté mejor
preparada para alzar al bebé. Como beneficio adicional, el ejercicio le da la sensación de que está
haciendo algo saludable. Salga a dar un paseo con el bebé o haga ejercicios de estiramiento durante 10
minutos. Si se mantuvo activa durante el embarazo, probablemente podrá comenzar a hacer ejercicio
ligero tan pronto como se sienta capaz. Pero asegúrese de consultar con su médico antes de empezar.
Manténgase alejada de la balanza
Durante el primer mes, piense en cómo recobrar la energía, no cómo perder peso. Perder peso
demasiado pronto puede hacerle sentirse más cansada. Concéntrese en cuidar a su bebé y comer de
forma bien equilibrada. Es probable que pierda peso sin siquiera intentarlo, especialmente si está
amamantando. Una vez que su nivel de energía regrese a la normalidad, podrá comenzar a perder peso.
Una pérdida de peso gradual de 4 o 5 libras al mes es el método más seguro.
Inclinación pélvica
Acuéstese boca arriba con las rodillas flexionadas y las plantas de los
pies apoyadas en el piso. Contraiga los músculos del abdomen y de las
nalgas. A medida que inhala, haga presión hacia abajo hasta que la
parte inferior de su espalda se ponga plana contra el suelo. Mantenga
esta posición unos instantes, luego relájese. Repita hasta 5 inclinaciones, dos veces al día.
Flexión abdominal
Acuéstese boca arriba con las rodillas flexionadas y las plantas de los
pies apoyadas en el piso. Cruce los brazos sobre el pecho. Expulse el
aire y contraiga los músculos del abdomen. Eleve ligeramente los
hombros del suelo. Sostenga esta posición mientras cuenta hasta 5 y
luego baje los hombros lentamente. Relájese y repita el ejercicio 3 a 5 veces cada día.
Vístase de forma adecuada
Es aconsejable que se vista confortablemente durante los primeros días después del parto. Póngase una
bata, piyama o sudadera; lo que le resulte más cómodo. Al poco tiempo es probable que quiera
comenzar a tener el aspecto que tenía antes del embarazo. Hágase un peinado y póngase maquillaje si
esto es algo que hace normalmente. Un vestido holgado probablemente le resultará cómodo. Pero hágase
un favor a sí misma: no intente ponerse pantalones vaqueros (jeans todavía. Probablemente pasará más
de un mes antes de que pueda usarlos. Si tiene pérdidas de leche, póngase discos protectores absorbentes
en el interior del sostén y vístase usando varias capas de ropa. Si está amamantando, es aconsejable que
use blusas fáciles de abrir o suéteres. Puede usar un chal o mantón para cubrirse si está amamantando en
presencia de otras personas.
Recuerde programar una visita postparto. Si ha tenido el parto mediante cesárea, vaya al médico en un plazo
de 2 semanas. Si ha tenido un parto vaginal, programe una visita con el médico 4–6 semanas después del
parto. Asimismo, llame al médico o a su proveedor de atención médica si tiene un sangrado que se vuelve de
un color rojo intenso o se hace más abundante.

Perinatal Care Toolkit

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