Before You Become Pregnant

If you plan for your pregnancy, you can make choices that are good for your baby. Also, if you are prepared, it will help your body handle the stress of pregnancy, labor, and delivery.

Many women don't know they are pregnant until several weeks after they have conceived. These early weeks are key for the baby growing inside you. It's during this time, for instance, that the brain and other organs start to form. Poor health, smoking, drinking alcohol, and using certain drugs can harm normal growth. A healthy body and lifestyle will help promote it. That's why getting proper health care before you even begin trying to get pregnant is so important. It will decrease the chance that either you or your baby will be exposed to harmful things. It also will provide a chance to lower any risks and find and treat any medical problems that you may have.

The Pre-Pregnancy Checkup

If you're planning to become pregnant and have already planned a pre-pregnancy checkup, good for you—it's a smart move. If not, do so right away. As a part of this visit, your doctor will ask about your medical and family history, medications you take, any past pregnancies you've had, and your diet and lifestyle. Be open and honest when you respond to these questions. Your answers will help your doctor decide whether you need special care during pregnancy.

This is also a time for you to ask questions. You can seek advice or discuss concerns you might have. There's no such thing as a stupid question, and your health care team is there to inform and guide you.

Your Medical History

Some women have medical conditions—such as diabetes, high blood pressure, and seizure disorders—that can cause problems during pregnancy. If you have such a condition, the treatment may vary around the time of pregnancy. Ask your doctor what changes, if any, need to be made to bring your condition under control before you try to get pregnant.

Even if a health problem is well managed, the demands of pregnancy can cause it to worsen. To keep such conditions in check, you may need to make lifestyle changes, see your doctor more often, or get other special care during pregnancy.

When Should I Stop Birth Control? Depending on what you use, you may need to switch to another form of birth control a few months before trying to get pregnant. This is because some methods can affect your fertility even after you are no longer using them. When you stop taking oral contraceptives ("the Pill"), for instance, it may be a few months before ovulation resumes and your menstrual periods become regular. That makes it harder for you to know when you're fertile, so it may take longer to conceive. Periods that aren't regular also make it harder to pinpoint your due date once you become pregnant. If you do conceive while or shortly after using birth control pills, do not worry. It does not cause birth defects as once believed. There may be a delay in getting pregnant after stopping other forms of hormonal birth control, such as implants and injections. If you're using either method and want to become pregnant, have your doctor remove the implants or stop the injections a few months before you try to conceive. Use a backup method, such as condoms and spermicide, in the meantime. If you have an intrauterine device (IUD), be sure to have it removed before trying to get pregnant. If you become pregnant with an IUD in place, your doctor will need to remove the device right away so that its presence doesn't lead to infections or pregnancy loss.

Medications, Herbal
Remedies, and Supplements

Many women use medications, remedies, and nutritional supplements to promote their health. Sometimes drugs, herbs, and even vitamins can have the opposite effect during pregnancy. Some medications—including those bought over the counter—can be harmful to your baby and shouldn't be taken while you are pregnant. For instance, isotretinoin, a drug used to treat acne, can cause miscarriage or birth defects. Certain medications used to treat high blood pressure can cause kidney problems in the fetus. Herbal remedies (blue cohosh, for instance) may be harmful, too. Just because something is natural doesn't mean it's safe.

Even common nutritional supplements could be harmful. For instance, some multivitamins contain high levels of vitamin A, which has been shown to cause severe birth defects if taken in large doses during pregnancy.

If you take any medications, herbs, or supplements, let your doctor know. Better yet, take the bottles along with you to your pre-pregnancy checkup. You may need to stop using them or switch to others before you try to get pregnant.

Keeping a Menstrual Calendar When you are thinking of becoming pregnant, you'll want to keep track of your menstrual cycle. By charting your menstrual periods on a calendar for a few months, you'll be able to spot patterns in your cycle (how many days your periods last, for instance, and whether your cycle is typically 25 or 30 days long). You'll also be able to pinpoint the days that you are most fertile—it is most often halfway between the start of one period and the start of the next. To use the calendar, simply circle the days that you menstruate each month. If you can, chart your cycle for a few months and bring the calendar along with you to your checkup.
Jan.	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Feb.	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
March	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
April	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
May	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
June	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
July	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Aug.	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Sept.	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Oct.	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Nov.	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Dec.	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Your Family History

Some health conditions occur more often in certain families or ethnic groups. If a close relative has a certain condition, you or your baby could be at greater risk of having it. Your doctor will ask if any family member has diabetes, high blood pressure, seizure disorders, or mental retardation, for instance. Your doctor also will ask if any relatives have a history of twin pregnancies. Ask your closest relatives about their health history before your visit. This way, you'll have the information your doctor needs to detect any risk factors.

Based on your family history or ethnic background, you may be at risk for having a baby with a genetic disorder—a condition that's passed from parent to child. In that case, it's wise to seek genetic counseling before trying to become pregnant. Genetic counselors have been specially trained to assess the risk of inherited disorders. They can help couples understand their chances of having a baby with such a condition. Genetic counseling involves taking a detailed family history and sometimes doing a physical exam and lab tests to pinpoint the risk of inherited disorders. (Even if you show no signs of having a certain disorder yourself, it's possible to be a "carrier" and pass it along to your baby.)

Past Pregnancies

Your doctor will review your obstetric history. He or she will ask about any previous pregnancies and any problems you may have had during them.

If you had a problem in a past pregnancy, that doesn't mean it will happen again or that you shouldn't try to get pregnant. Some problems do recur in later pregnancies, but most do not—especially if you receive proper care before and during your pregnancy.

Women who have lost a pregnancy often fear that it will happen again. It's true that 1 in 5 known pregnancies ends in miscarriage and many more occur before a woman even knows she is pregnant. However, most women who miscarry once go on to have normal pregnancies and healthy babies the next time around.

If you have chosen to end a prior pregnancy, you may worry that you'll have trouble getting pregnant again. You may fear you will not be able to carry a baby to term. Most doctors agree that having a single abortion has no effect on future pregnancies. It is possible, though, that having more than one abortion might increase the risk for a low-birth-weight or preterm baby. Even in that case, the chance of having a healthy baby is good.

Be sure to let your doctor know if a past pregnancy was complicated by diabetes, high blood pressure, premature labor, preterm birth, or birth defects. If you and your doctor keep a close eye on your health and take steps to reduce your risk, the odds are that problems such as these won't happen again.

Your Lifestyle

Diet

You and your baby will start out with a good supply of the nutrients you both need if you eat right before you become pregnant. A balanced diet is important at all times in your life, but it's vital during pregnancy. The food you eat is the main source of nutrients and energy for your baby. As the baby grows and places new demands on your body, you'll need more calories and nutrients. If you eat a healthy diet before you are pregnant, it's much easier to make minor changes to your diet while you are pregnant.

The nutritional needs of the fetus are small at first, but there's one nutrient that's vital for normal development from the start: folic acid. This B vitamin helps prevent neural tube defects (abnormalities of the brain, spine, or their coverings). It's also believed that folic acid helps prevent cleft lip, congenital heart disease, and other birth defects. See the box to find out more about this important vitamin.

Your doctor will want to know about your diet, so think about these questions before your checkup:

• Are you a vegetarian? If so, do you eat dairy products?
• Do you have any food allergies?
• Do you have trouble digesting milk and other dairy products?
• Do you ever fast?
• Are you trying to lose weight?
• Do you have an eating disorder (anorexia nervosa or bulimia)?

Weight

Keeping your weight in a normal range before and during pregnancy is good for your health and your baby's. Excess weight can cause high blood pressure or diabetes. It also puts a strain on the heart. This strain becomes even greater during pregnancy, when your heart works harder to supply blood to you and your baby.

Folic Acid: The Vital Vitamin Folic acid, taken before pregnancy and for the first 3 months of pregnancy, can reduce the risk of neural tube defects. The U.S. Public Health Service suggests that all women (even if they are not trying to get pregnant) consume 0.4 mg of folic acid a day. Although folic acid is found in foods such as leafy dark-green vegetables, citrus fruits, and beans, it's hard to eat enough of them to meet the requirement. Breads and cereals are supplemented with folic acid, but they also do not contain enough of the vitamin to meet the requirement. For this reason, doctors advise women to take a daily vitamin with the nutrient. Women who have had a previous pregnancy that involved a neural tube defect have a higher than average risk of the problem recurring. Such women should take 4 mg daily—10 times the amount normally recommended—for 1 month before conception and during the first 3 months of pregnancy. These women should take folic acid alone rather than as part of a multivitamin. That way, they don't risk overdosing on the other vitamins contained in multivitamin formulas.

Being too thin, though, can lead to trouble getting pregnant. Being underweight may raise the odds of delivering a low-birth-weight baby. These babies are not easier to deliver and are at risk for problems during labor and after birth.

A woman who's slightly underweight most often can make up the difference by gaining a few extra pounds during pregnancy. But a woman who is overweight should never try to lose weight while she's pregnant. A low-calorie diet could deprive her baby of nutrients needed to grow and develop. In either case, the safest bet is to reach a healthy weight well before you get pregnant. Your doctor can give you advice on the best ways to do that or refer you to a nutritional specialist if needed.

Fitness Level

Good health at any time in your life involves getting plenty of exercise. The type and amount you can do safely during pregnancy depends on your health and how active you are before you are pregnant.

It is best to exercise regularly before getting pregnant. If you are just starting out, decide on your goals—do you want to improve your heart and lung function, strengthen your muscles, or both? Then choose the exercises that will help you meet your goals. It's best to start with walking, swimming, or bicycling. If you are not used to a lot of exercise, discuss safety guidelines with your doctor ahead of time and take it slow at first. Your target heart rate is a good guide to tell how hard you are working.

Fit or Fat? Fat is the form in which energy is stored. If you consume too many calories, your body stores the excess as fat. To lose 1 pound, you must use up 3,500 of these stored calories. Body weight alone isn't a good measure of fat. Exercise burns fat and builds muscle—and muscle is heavier than fat. So a fit woman can have an above-normal body weight, but a below-normal amount of fat. A woman who is not very active, by contrast, may weigh just as much as a fit woman but have more fat and less muscle. A method for evaluating your weight is "body mass index" (BMI), which compares height to weight. To find out your BMI, find your height on the left-hand column of the chart below. Next, read across the column until you find the weight that's closest to yours. Then look at the bold-faced number at the top of the column. That number is your BMI. Having a BMI above 25 means that you need to shed some pounds. Any amount above 29 is thought to be obese.

Substance Use

Target Heart Rate for Nonpregnant Women To check your heart rate, locate the pulse on the inside of your wrist. Count your pulse for the first 10 seconds after you stop exercising. Multiply this number by 6 to calculate how many times a minute your heart is beating. To find your target heart rate as well as the heart rate it may be unsafe to exceed, find the age category closest to yours on the table below and read across.
Age (years)	Target heart rate (beats per minute)
20	100–150
25	98–146
30	95–142
35	93–138
40	90–135
45	88–131
50	85–127
55	83–123
60	80–120
65	78–116
70	75–113
National Heart, Lung, and Blood Institute, American Heart Association. Exercise and Your Heart. NIH Publication No. 93-1677. Washington, DC: U.S. Government Printing Office, 1993

Most women know that heavy smoking, drinking, and drug use during pregnancy can have a harmful effect on their baby's health. But what many don't know is that even using these substances only once in a while, or in small doses, still can do harm. This is also true of medications that are not used as prescribed.

Women who smoke or drink alcohol may have a harder time getting pregnant. Also, there's growing evidence that if your partner smokes, drinks, or uses drugs, it can lower his fertility, damage his sperm, and have a harmful effect on the fetus. At the very least, living with someone who smokes means that you are likely to breathe in harmful amounts of secondhand smoke. In turn, your developing baby is exposed. This is also a risk for the baby after he or she is born.

If you smoke tobacco, drink alcohol, or take drugs, now is the time to quit. Even if you can't quit, cutting back helps. It takes patience and plenty of support to end a habit—especially if it's long-standing. Don't be afraid or ashamed to ask for help. Your doctor can suggest ways to get through the early stages as well as refer you to support groups. Giving up something that you rely on to relax or to deal with stress may be one of the hardest things you'll ever do, but it also will be one of the most worthwhile.

Your Environment

Some substances found in the home or the workplace may make it harder for a woman to conceive or could harm her fetus. If you are planning to get pregnant, look closely at what's around you. Think about the chemicals you use in your home or garden. Some hobbies, such as stained glass and darkroom work, might expose you to harmful substances. Find out from your employer whether you might be exposed at work to toxic substances such as lead or mercury, chemicals such as pesticides or solvents, or radiation. Then discuss your level of exposure with your doctor as well as your employee health division, personnel office, or union representative. If you do come into regular contact with a substance that may be harmful, take steps to avoid it.

Radiation, a form of energy sent out in invisible waves, is used in certain medical and industrial jobs. It's also used to take X-rays to diagnose disease. Women who are planning a pregnancy and who come into contact with radiation at work should ask for monthly exposure readings. The amount of radiation used to take a chest X-ray or single dental film won't affect fertility or harm a fetus. It's wise, though, to avoid being exposed as much as you can and to wear abdominal shields if you have an X-ray done. However, the level of radiation used to treat diseases such as cancer is much higher and can be harmful during pregnancy.

Infections

Certain infections during pregnancy can cause severe birth defects or illness in a fetus. These infections may be prevented with proper vaccination. Before you start trying to get pregnant, ask your doctor if you need to be immunized against measles, mumps, tetanus, polio, hepatitis, chickenpox (varicella), or rubella (German measles). Try to get your childhood vaccination record before your pre-pregnancy checkup. Even if you were vaccinated as a child, though, your immunity to certain diseases may have worn off.

Some vaccines cannot safely be given during pregnancy. If you need vaccines, get them at least 3 months before trying to conceive. During this time, keep using birth control. If you are planning a trip to a country where you might come into contact with diseases that aren't common in the United States, you may need other vaccines.

Other infections that can be harmful during pregnancy are those passed on by sexual contact—sexually transmitted diseases (STDs). These diseases can affect your ability to conceive and can infect and harm your baby. The most common STDs are:

• Chlamydia
• Gonorrhea
• Genital herpes
• Genital warts
• Trichomoniasis
• Hepatitis B virus
• Syphilis
• Human immunodeficiency virus (HIV)

Are Your Immunizations Up-to-Date? Although some vaccines are safe to receive during pregnancy, it's best to have all needed immunizations before you become pregnant. Women should have the following immunizations: 3 months before pregnancy Measles–mumps–rubella vaccine (once if not immune) 1 month before pregnancy Varicella vaccine* Safe during pregnancy Tetanus–diphtheria booster (every 10 years) Hepatitis A vaccine* Hepatitis B vaccine* Influenza vaccine (if you will be in the second or third trimester of pregnancy during flu season) Pneumococcal vaccine* *These immunizations are given as needed based on risk factors. If you don't know whether you need one, check with your health care provider.

Using condoms and spermicide regularly will lower your risk of getting an STD. A woman who isn't using these forms of birth control (for instance, if she's trying to conceive) is at a higher risk of getting an STD if she has sex with more than one partner or if her partner has sex with someone else.

If you suspect that you may have been exposed to an STD, see your doctor right away to be tested and treated. Your partner also should be treated. Neither of you should have sex until treatment is finished. STDs such as herpes, HIV, and hepatitis B have no known cures. If your doctor knows that you have one of these conditions, though, he or she can take steps during your pregnancy and delivery to lower the risk of your baby being harmed by the disease or catching it from you.

Keep in mind, too, that many STDs have no symptoms in the early stages. The earlier an STD is found and treated, the lower the long-term risk.

Later Childbearing

These days, women are becoming mothers later in life than in prior generations. This may be because more women are working and living longer and healthier lives. Women also can use new techniques to promote their fertility. Older moms often worry that their age will affect their fertility and the health of their babies. There's no set age that is unsafe for women to become pregnant. For women older than age 35, the chances of having a normal pregnancy and healthy baby are great—especially if they get good pre-pregnancy and prenatal care. Even so, more mature mothers often have concerns about pregnancy that don't apply to younger mothers. Among them:

• Infertility. A woman's fertility slowly declines starting in her early 30s. After that time, it may take longer to get pregnant.
• Medical and obstetric problems. As women get older, conditions such as high blood pressure and diabetes tend to occur more often. Because pregnancy puts new demands on a woman's body, the risk of complications may be higher for expectant mothers with these problems. They are more likely to need to visit the doctor more often, need special tests, stay in the hospital before the baby's birth, and require special care during labor and delivery.
• Birth defects. The risk of some birth defects increases with age, but it remains low well into a woman's 30s. In most cases, women age 35 and older are offered testing for genetic disorders and other medical problems before and during pregnancy. If there's a problem, it often can be spotted early enough to allow time to decide whether to become pregnant or continue a pregnancy.
• Breast cancer. Because of changes that occur in women's breasts during pregnancy and after the baby is born, breast cancer screening through self-exams or breast exams by the doctor are less able to detect breast cancer. Thus, if you are planning a pregnancy and are age 40 or older, you may wish to have a mammogram (an X-ray of the breasts) before getting pregnant.

Planning Your Pregnancy Care

Aside from you and your partner, the person who will care for you during pregnancy is one of the most important players in your pregnancy. Choosing a caregiver isn't a choice to make lightly.

What's the best way to go about finding the right person? Some women are happy to stick with the health care provider they have been seeing for routine gynecologic care. Other women ask friends or relatives who have become mothers not too long ago. Still others choose the hospital or birthing center where they'd like to deliver their baby and ask the staff there to refer them to someone. (Keep in mind that your health insurance policy may restrict your choices.)

Three types of providers offer medical care for pregnancy and birth: obstetrician–gynecologists (ob-gyns), family practitioners, and certified nurse–midwives (CNMs).

• Obstetrician–gynecologists. Ob-gyns are doctors who specialize in the reproductive care of women. After graduating from medical school, ob-gyns complete a 4-year course of specialized training in obstetrics and gynecology. To be certified, a physician must pass written and oral tests to show that he or she has obtained the knowledge and skills required for the medical and surgical care of women. A certified ob-gyn can become a Fellow of the American College of Obstetricians and Gynecologists. This group offers continuing educational programs to help physicians stay up-to-date with the latest medical advances.
• Family practitioners. Doctors in family practice provide general care for most conditions, including pregnancy. After completing medical school, family practitioners receive further training in family practice (including obstetrics) and become certified by passing an exam. They are able to care for normal pregnancies and deliveries.
• Certified nurse–midwives. CNMs are registered nurses who have been specially trained to care for women and their babies from early pregnancy through labor, delivery, and the weeks after birth. They have completed an accredited nursing program and have a graduate degree in midwifery. To be certified, they must pass a national exam and maintain an active nursing license. They also must have an arrangement with a qualified doctor to provide backup support. They are trained to care for healthy women with normal pregnancies and consult with or refer patients to a doctor if medical problems arise.

Other specialists are part of a team of health professionals that provides care based on an expectant mother's special needs. Some may be employed by the doctor's practice or the teaching hospital where the doctor works. Others are consulted as needed. Their qualifications differ, but each one has an important role in making sure your pregnancy and birth go well. Here's a brief look at who may be members of this team.

Physicians

• Residents are physicians who have graduated from medical school but are still in training at a teaching hospital.
• Pediatricians are doctors with specialized training in the medical care of infants and children.
• Neonatologists are pediatricians with special training in the medical care of newborns.
• Anesthesiologists are doctors who provide pain relief during labor and delivery. This also can be done by a nurse anesthetist.
• Maternal–fetal medicine specialists are ob-gyns with extra training in handling pregnancies complicated by medical or obstetric problems. Women most often are referred to them by their regular doctor.

Nurses

• Nurse practitioners perform duties such as taking medical histories, doing physical exams, and diagnosing and treating common illnesses. They are registered nurses who have completed further training and, in some cases, passed a certification exam.
• Registered nurses assist obstetricians in providing care, education, and medical counseling to women. They have graduated from nursing school and passed a number of exams.
• Labor and delivery nurses help care for women and their babies during labor, delivery, and right after birth.
• Neonatal nurses help care for newborns before they are discharged from the hospital.
• Postpartum nurses help care for the mother after birth.

• Childbirth educators teach parents-to-be about pregnancy, childbirth, and parenting.
• Dietitians give advice on nutrition during pregnancy and breastfeeding.
• Genetic counselors evaluate a baby's risk of having birth defects and provide counseling to expectant parents.
• Social workers can provide counseling and information about community services for families.
• Lactation specialists are breastfeeding experts who can tell you more about such things as methods of breastfeeding and pumping your breast milk.
• Physician assistants work under the guidance of doctors and perform a variety of medical duties.

Your Baby's Birthplace

Interviewing the Provider Before you decide who will care for you during your pregnancy, visit different providers until you find one that you like and trust. Call the practice ahead of time to get basic questions about location, hours, and insurance out of the way before you meet with the doctor. During the interview, feel free to discuss anything that is of concern to you or your partner. Some questions to think about: How close is the practice to your home or work? ________ Does the practice accept your insurance plan?__________ What are the provider's fees and how is payment handled? _________________________________ Where does the doctor have hospital privileges? _________ How are urgent questions or emergency care handled? ___ _________________________________________________ What's the provider's belief about pain relief during labor, fetal monitoring, episiotomy, cesarean birth, breastfeeding, and other issues that interest you? _______ _________________________________________________ _________________________________________________ Is it likely that your doctor will deliver the baby? _________ What is the doctor's cesarean birth rate and how does it compare with the hospital's rate of cesarean births? ______ _________________________________________________ _________________________________________________

The day your baby enters the world may seem like it's ages away. But the setting for your newborn's delivery can have a big impact on your pregnancy care and your birth experience. Thus, it's wise to weigh your options before you are pregnant.

Your choices will depend on what your area offers, where your caregiver handles deliveries, and what your health insurance provider will cover. The areas for labor and delivery vary from one hospital to another. You will be given information about the choices available. You can tour the hospitals in your community to see which types of settings appeal to you.

Many hospitals offer birthing rooms where the family can stay with you and provide support. Birthing rooms share the staff and services of a more traditional labor and delivery suite, which may be needed if a problem occurs. They provide a comfortable setting for labor, delivery, and, in most cases, postpartum recovery. Some allow the entire birth process, including the postpartum stay, to happen in one room. These rooms are called LDRs (labor/delivery/recovery) or LDRPs (labor/delivery/recovery/postpartum).

There are also freestanding birthing centers that are not in a hospital. These centers may not offer all the services you may need if an emergency arises. Because of this, the safest places to give birth are thought to be a hospital or birthing center within the hospital complex.

Evaluating Birth Sites When you tour a facility, be sure to come with a list of questions about certain policies. For instance: Who's allowed to be present at the birth? ___________ Are there a limited number of birthing rooms (meaning you may be booked into a traditional delivery room if they are full)? __________________________________ Does the hospital have set rules about the use of medical procedures such as fetal monitoring and intravenous (IV) lines during labor, or does it leave such decisions up to individual caregivers? ______________ _____________________________________________ Are women in labor allowed to move about freely or are they required to stay in bed? _____________________ What special care (such as a Neonatal Intensive Care Unit) can the hospital provide if your baby is born with a medical problem? ______________________________ Will your baby be allowed to room with you after birth, or will he or she need to stay in the newborn nursery? _____________________________________________ Does the hospital or birthing center employ a lactation consultant or provide other services to help new mothers breastfeed? ____________________________ Does the hospital have an anesthesiologist on site full time? ________________________________________

When selecting your care, you may wish to ask about policies regarding fathers or others in the delivery room. Most hospitals permit support people in both labor and delivery rooms. It is wise to know the hospital's policy in advance so you can plan.

If you have health problems during your pregnancy or complications are likely during birth, you may have to deliver at a specific hospital. It is possible that the hospital, which must be equipped to handle complex procedures, may not be near where you live.

Money Matters

The cost of having a baby is high. You should consider in advance how you will pay for it. If you have insurance, it's vital to make sure that you are covered for all that you think you are. Some health plans, for instance, don't include pregnancy care or will pay for only the most routine medical tests and procedures. That could become an issue if you develop problems during pregnancy or birth or have a baby with health problems. Read your policy to make sure you are covered. Also check to see how much of the cost of infertility treatments (if needed), obstetric care, prenatal tests, hospital charges, well-baby care, and postpartum birth control your insurer will cover.

If your coverage doesn't start until a certain date, you may want to think about delaying your pregnancy until then. Also make sure that the provider you'd like to see is part of the plan, as is the hospital where you want to deliver. In many cases, seeing a provider or going to a facility that's out of an insurance company's "network" means that you'll be out, too—that is, out-of-pocket for some or all expenses.

How Much Do Babies Cost? To get a better idea of the impact a baby can have on your pocketbook, think about these questions: Will you need to move to a bigger house or apartment to make room for the baby? How much more money will you need to pay for it? ___________________________________ How long will you take off work? Are you planning to leave your job? How much income will you lose? ______________ __________________________________________________ Do you have a partner who earns enough to cover costs during your time at home? ____________________________ If not, do you have money in savings you could use? How much? ____________________________________________ Will you need to pay for childcare? What can you afford? __________________________________________________ Can you get baby clothes and supplies from friends or relatives, or will you need to purchase these items? _______ __________________________________________________ Does your state or county have programs that can help you? (You may qualify for help even if you are working. Federal assistance programs also are available.) ________________ __________________________________________________

The Health Insurance Portability and Accountability Act, passed in 1996, protects most women who switch health plans during pregnancy or enroll in a plan after they become pregnant. This means that if you change jobs and insurance plans during your pregnancy, you cannot be denied insurance coverage for care related to your pregnancy. It does not matter how long you were with your insurance plan before you switched. Also, your newborn cannot be denied coverage as long as you sign him or her up for health insurance within 30 days of birth.

Taking these steps before you even start trying to get pregnant may seem like a lot of work. Making plans ahead of time is well worth the time and effort, though. Starting your pregnancy with a healthy body will give your baby the best start in life. Knowing the issues involved in becoming a parent will make them seem more fun and less scary. You and your partner will be well prepared to deal with all that's in store during the thrilling months ahead.

Each month during ovulation an egg is released (1) and moves into one of the fallopian tubes (2). If a woman has sex around this time, an egg may meet a sperm in the fallopian tube and the two will join (3). This is called fertilization. The fertilized egg then moves through the fallopian tube into the uterus and becomes attached there to grow during pregnancy (4).

How Reproduction Occurs

Now that you have taken care of your pre-pregnancy checkup and made some healthy lifestyle changes, you can start trying to make a baby. A finely tuned series of events must take place for conception to occur and for the cells to start growing into a tiny human being.

Knowing how reproduction works will help you figure out when you are most fertile—in other words, when you're most likely to get pregnant. It also will help you understand the rapid changes that take place in your body during early pregnancy.

The Menstrual Cycle

A woman's fertility depends on her menstrual cycle. Changes that occur during each cycle are caused by hormones—substances made by your body to control certain functions. Each month, hormones direct your uterus to build up a lining of blood-rich tissue (endometrium). These hormones also send a signal for an egg to ripen in a follicle—tiny, fluid-filled clusters of cells in your ovaries. When the egg is ripe, it's released from the ovary and moves into a fallopian tube, one of a pair of ducts that connects the ovaries to the uterus. This process is called ovulation. Signs that you may be ovulating include a twinge or cramp—called mittelschmerz, for "middle pain"—in your lower abdomen or back. You also may notice some breast tenderness, an increase in cervical mucus (vaginal discharge), or an increase in sexual desire around the time an egg is released.

The average menstrual cycle lasts about 28 days, counting from the first day of one period (day 1) to the first day of the next. Cycles ranging from as few as 23 days to as many as 35 days are normal. Your own cycle may vary somewhat from month to month. By keeping a menstrual calendar (see "Before You Become Pregnant") for a few months, you can get an idea of what's normal for you. When you become pregnant, the calendar will make it easier to figure out your baby's due date.

Ovulation most often occurs halfway through your cycle—on day 14 of 28, for instance. After you have ovulated, the egg moves through one of the fallopian tubes toward your uterus. If it isn't fertilized (joined by a sperm) in the fallopian tube, your body absorbs it. Then, the levels of hormones decrease. This signals the lining of the uterus to shed. This shedding is your monthly period.

If the egg is fertilized, it becomes attached to the lining of the uterus. The fertilized egg then starts to grow in the lush uterine lining that will become its home for the next 40 weeks. You may not know it for weeks, but you're pregnant!

Fertilization

Fertilization is the fusion of an egg and a sperm in the fallopian tube. If all goes according to plan during the days and weeks that follow this union, pregnancy results. Each sperm and egg contains half of a fetus's genetic makeup.

Hormones: Key Players in Menstruation and Pregnancy Each step in the creation of new life—from menstruation to ovulation to implantation—is led by these hormones: Estrogen and progesterone. Produced by the ovaries, these hormones trigger the lining of the uterus to thicken during each menstrual cycle and to be shed if pregnancy doesn't occur. After an egg is fertilized, a sharp increase in estrogen and progesterone levels prevents further ovulation. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH). These hormones are made by the pituitary gland, a small organ at the base of the brain. FSH causes eggs to ripen in the ovaries. LH triggers their release. Gonadotropin-releasing hormone (GnRH). This hormone, also made in the brain, tells the pituitary gland when to produce FSH and LH. Human chorionic gonadotropin (hCG). Made by certain cells from the fertilized and quickly dividing egg, hCG spurs increased estrogen and progesterone production during pregnancy. It's the telltale hormone that pregnancy tests are designed to detect.

Sperm are tiny cells made by a man's testes in the sac (scrotum) below his penis. When sperm cells mature, they leave the testes through small tubes called the vas deferens. The vas deferens transport the sperm to the seminal vesicles and the prostate gland, small organs located near the bladder. There, the sperm mix with seminal fluid to create semen.

When a man climaxes during sex, this semen spurts (ejaculates) from his penis through a tube called the urethra. This deposits millions of sperm in a woman's vagina. A man's orgasm, therefore, is vital to conception. A woman, however, doesn't have to climax to get pregnant.

After ejaculation, the sperm "swim" up through the cervix, into the uterus, and out into the fallopian tubes. Sperm can live inside a woman's body for 3 days or more. An egg's life span, though, is short—12–24 hours. If an egg is waiting in a fallopian tube when a man ejaculates, or if one is released during the next few days and fuses with a sperm, fertilization occurs.

The fused egg and sperm then move through the fallopian tube to the lining of the uterus. There it implants and starts to grow. This fertilized egg is called an embryo for the first 8 weeks. Then it is called a fetus.

Some couples worry that having sex every day will reduce the number of sperm from a man's body and make it harder for him to get his partner pregnant. There's no need for concern—healthy testes produce new sperm all the time, so daily sex shouldn't be a problem as long as a man's sperm count is normal. The sperm count is the number of active sperm in one milliliter (less than a half teaspoon) of semen. A normal sperm count—one of the first things doctors check if a couple is having trouble conceiving—is between 20 million and 250 million per milliliter.

Detecting Ovulation

To raise the odds of getting pregnant, sex has to happen during a small window of time near ovulation. How do you know when you are ovulating? There's no foolproof method to make sure that an ovary has released an egg, but there are a number of methods that are useful. One method is to note changes in your body. Look out for telltale signs of ovulation: cramps, tender breasts, cervical mucus, or an increased desire to have sex. Other methods—especially when they are used in combination—can give you a pretty good idea:

• Chart your cycle. The simplest way to spot your fertile days is to check the menstrual calendar you have been keeping. First, figure out how long your cycles tend to last and pinpoint the day your next period is due to start. If your periods are regular, count back 14 days. If they are not regular, count back to the first day of your last period and divide the total. Chances are, the result will be the day you will ovulate.
• Know when you are most fertile. You also can detect ovulation by watching for changes in your cervical mucus. A few days after your period ends, rising estrogen levels trigger the production of cervical mucus. As your body prepares to release an egg, this mucus increases in volume and becomes thicker. (To get a good look at your cervical mucus, gently wipe your vaginal opening with a clean finger or a piece of toilet tissue before you urinate.) Just before ovulation, you produce more cervical mucus. It becomes clear, slippery, and stretchy—it looks and feels like a raw egg white. This kind of mucus smoothes the way for sperm to enter the uterus and swim up the fallopian tubes. Your fertile period begins with the first signs of slippery mucus and continues through the day you ovulate. After ovulation, an increase in progesterone makes cervical mucus sparse and dense. This makes it harder for sperm to swim through the cervix.
• Track your temperature. Most women's basal body temperature increases slightly—about half a degree—after they ovulate. To use this method, take your temperature at the same time every morning, before you get out of bed. Chart the temperature on a graph that also shows the days you menstruate. After you have done this for a few months, you'll begin to spot a pattern that will help you predict when you will ovulate. Your temperature will go up 24–48 hours after you ovulate.
• Use ovulation-predictor kits. Ovulation-predictor kits are home tests that you can buy without a prescription. They measure the level of luteinizing hormone (LH) in your urine. When LH levels increase, it means that one of your ovaries is about to release an egg.

This chart may help you predict the days you will be ovulating. You produce more cervical mucus just before ovulation—about halfway through your menstrual cycle.

How long will it take before you become pregnant? That depends on a number of factors—your age, your health, and how often you have sex, for instance. Most couples are able to conceive within 6 months of having regular sex without birth control. Almost all (85 out of 100) are pregnant within a year. The remaining 15% face fertility problems—they have tried to get pregnant but cannot.

Couples who have not been able to conceive after 12 months of having regular sex should discuss it with their doctor. Many of these couples will be able to have children without medical help—it's just a matter of time. Women older than age 35, whose natural fertility has begun to decline and whose reproductive time is more limited, may want to consult a doctor after 6 months of trying.

A fertility evaluation begins with a medical history and general physical checkup for the woman and the man. The medical history includes questions about past pelvic surgery or illness such as appendicitis or sexually transmitted diseases (STDs), which can harm the reproductive organs. The doctor also asks about the couple's sexual habits to find out if infertility may be tied to the timing or frequency of sex. In that case, they may simply need advice on their sexual practices. Also, possible physical causes of infertility, such as diabetes or being over- or underweight, are ruled out.

If the medical histories and physical exams don't turn up any clues, more in-depth testing will be needed to find the cause of the problem and to find out whether it can be treated. An infertility workup often includes:

• Semen analysis. A sample of a man's semen is examined under a microscope. This is done to count sperm and to see whether they are formed correctly and move the way they should.
• Hormone screening. The levels of the hormones that allow ovulation and implantation to take place are measured in a woman's blood and urine.
• Evaluation of reproductive organs. A doctor examines the uterus, fallopian tubes, or ovaries using an X-ray, ultrasound (a device that uses sound waves to examine the fetus), or a laparoscope (a tiny device like a telescope that is inserted into the body to view the pelvic organs or perform surgery). The purpose is to see whether these organs are normal.

In some cases, these tests find nothing and the reason for a couple's infertility remains unknown. If doctors can find the cause of the problem, though, they often can correct it. Treatment options include:

• Medications to induce ovulation
• Artificial insemination with sperm from the partner or a donor
• Assisted reproduction techniques (such as in vitro fertilization)
• Surgery to open blocked fallopian tubes

The Months Ahead

Once conception has taken place, a new life begins to grow inside a woman's body. Whether your pregnancy is a long-wished-for goal or a pleasant surprise, the coming months will bring with them drama and suspense, questions and knowledge, and tears and joy.

Glossary

Anorexia Nervosa: An eating disorder in which distorted body image leads a person to diet excessively.

Basal Body Temperature: Body temperature when taken at its lowest point (in most cases, before getting of bed in the morning) used to predict ovulation.

Bulimia: An eating disorder in which a person binges on food and then forces vomiting or uses laxatives.

Cervix: The lower, narrow end of the uterus, which protrudes into the vagina.

Cesarean Birth: Delivery of a baby through an incision made in the mother's abdomen and uterus.

Chlamydia: A sexually transmitted disease that can cause pelvic inflammatory disease, infertility, and problems during pregnancy.

Cleft Lip: A congenital defect in which a gap or space occurs in the lip.

Conceive: To become pregnant.

Congenital Heart Disease: A condition that occurs when a baby is born with a heart defect.

Diabetes: A condition in which the levels of sugar in the blood are too high.

Embryo: The developing fertilized egg of early pregnancy.

Endometrium: The lining of the uterus.

Episiotomy: An incision made into the perineum (the region between the vagina and the anus) to widen the vaginal opening for delivery.

Estrogen: A female hormone produced in the ovaries that stimulates the growth of the lining of the uterus.

Fetal Monitoring: A procedure in which instruments are used to record the heartbeat of the fetus and contractions of the mother's uterus during labor.

Fetus: A baby growing in the woman's uterus.

Follicle: The saclike structure that forms inside an ovary when an egg is produced.

Follicle-Stimulating Hormone (FSH): A hormone produced by the pituitary gland that helps an egg to mature and be released.

Genital Herpes: A sexually transmitted disease caused by a virus that produces painful, highly infectious sores on or around the sex organs.

Genital Warts: A sexually transmitted disease that is linked to cervical changes and cervical cancer.

Gonadotropin-Releasing Hormone (GnRH): A hormone that tells the pituitary gland when to produce follicle-stimulating hormone and luteinizing hormone.

Gonorrhea: A sexually transmitted disease that may lead to pelvic inflammatory disease, infertility, and arthritis.

Hepatitis B Virus (HBV): A virus that attacks and damages the liver, causing inflammation, cirrhosis, and chronic hepatitis that can lead to cancer.

Human Chorionic Gonadotropin (hCG): A hormone produced during pregnancy; its detection is the basis for most pregnancy tests.

Human Immunodeficiency Virus (HIV): A virus that attacks certain cells in the body's immune system and causes acquired immunodeficiency syndrome (AIDS).

In Vitro Fertilization: A procedure in which an egg is removed from a woman's ovary, fertilized in a dish in a laboratory with the man's sperm, and then reintroduced into the woman's uterus to achieve a pregnancy.

Intrauterine Device (IUD): A small device that is inserted and left inside the uterus to prevent pregnancy.

Lactation: Production of breast milk.

Luteinizing Hormone (LH): A hormone produced by the pituitary glands that helps an egg to mature and be released.

Mammogram: An X-ray of the breast, used to detect breast cancer.

Menstruation: The discharge of blood and tissue from the uterus that occurs when an egg is not fertilized.

Miscarriage: The spontaneous loss of a pregnancy before the fetus can survive outside the uterus.

Neural Tube Defect (NTD): A fetal birth defect that results from improper development of the brain, spinal cord, or their coverings.

Oral Contraceptives: Birth control pills containing hormones that prevent ovulation and thus pregnancy.

Ovaries: Two glands, located on either side of the uterus, that contain the eggs released at ovulation and that produce hormones.

Ovulation: The release of an egg from one of the ovaries.

Pituitary Gland: A gland located near the brain that controls growth and other changes in the body.

Prenatal Care: A program of care for a pregnant woman before the birth of her baby.

Preterm: Born before 37 weeks of pregnancy.

Progesterone: A female hormone that is produced in the ovaries and matures the lining of the uterus. When its level decreases, menstruation occurs.

Sexually Transmitted Disease (STD): A disease that is spread by sexual contact, including chlamydial infection, gonorrhea, genital warts, herpes, syphilis, and infection with human immunodeficiency virus (HIV, the cause of acquired immunodeficiency syndrome [AIDS]).

Syphilis: A sexually transmitted disease that is caused by an organism called Treponema pallidum; it may cause major health problems or death in its later stages.

Trichomoniasis: A type of vaginal infection caused by a one-celled organism that is usually transmitted through sex.

Ultrasound: A test in which sound waves are used to examine internal structures. During pregnancy, it can be used to examine the fetus.

Urethra: A short, narrow tube that sends urine from the bladder out of the body.

Uterus: A muscular organ located in the female pelvis that contains and nourishes the developing fetus during pregnancy.

Vaccination: To inoculate with a virus to produce immunity.

Vagina: A passageway surrounded by muscles leading from the uterus to the outside of the body, also known as the birth canal.

Reprinted from Planning Your Pregnancy and Birth, Third Edition
Copyright © 2000
The American College of Obstetricians and Gynecologists
409 12th Street, SW, Washington, DC 20024-2188

Designed as an aid to patients, Planning Your Pregnancy sets forth current information and opinions on subjects related to women's health and reproduction. The information does not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other medical opinions or acceptable methods of practice. Variations taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice may be appropriate.

To order additional copies, call 800-762-2264, ext 109, or order online at sales.acog.com.

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