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Letter to Our Patients

Dear Expectant Mother:

This prenatal packet contains specially selected information designed for you to read and refer to throughout your 40 weeks of pregnancy. The material is intended as a guideline to help you understand and enjoy your pregnancy. We hope that this will encourage you to ask questions. Please read all materials. The California Screening Program booklet printed by the State of California contains important information regarding the Full Integrated Screening. You will need to read this booklet in order for you to make an informed decision about genetic testing.

If you wish to contact us, we are available through our office telephone number (951) 677-4748. If we are not available at the office, the answering service will locate us to return your emergency calls. This telephone number is answered day or night, holidays and weekends. Should Dr. Elfelt, Dr. Yang, Dr. Lebo, or Dr. Hayton be unavailable as a result of illness, vacation, or attendance at a medical conference, another physician whom we personally selected will care for you.

During the first 30 weeks of your pregnancy, your prenatal appointments will be scheduled in four-week intervals. We will see you every two weeks during the period from 30 weeks to 36 weeks and then every week during the last 36 to 40-week period.

We urge you to keep appointments faithfully. If you are unable to keep an appointment, please contact our office at least 24 hours prior to your appointment time to reschedule a new appointment. It is an established fact that good prenatal care contributes to the optimum health of both mother and infant. Your appointments should be scheduled when baby-sitting arrangements can be made for your other children. This is in compliance with the Public Health Department ruling to protect all women of childbearing age against communicable diseases, including Rubella, which can cause serious birth defects. Please call the office prior to your appointment if you have flu-like symptoms or elevated temperature. We encourage fathers to attend appointments for prenatal visits and to feel free to discuss problems or ask questions.

For your information and reading pleasure, we recommend a book entitled, “What to Expect When You’re Expecting,” by Eisenberg, Murkoff and Hathaway. Information about childbirth preparation classes is available through Southwest Healthcare Systems (Rancho Springs and Inland Valley Hospitals). These classes offer early prenatal education. We recommend that you sign up for these classes as soon as possible.

Pre-certification

Dear OB Patient,

This will serve as our instrument to remind you that you must pre-certify with your health insurance plan 30 days before your delivery date.

The phone number of your health insurance plan is located on the back of your insurance card. Also, please be aware that some insurance companies will not pay claims unless you pre-certify.

We suggest that you place this notice on your refrigerator in hopes that it will remind you to call your insurance.

Thank you,
Temecula Valley OB/GYN

OB Schedule of Services

Services Include

  • Consultation including complete history and physical examination.
  • Normal prenatal office visits in our office. This does not include office visits due to injuries or illness not directly related to pregnancy.
  • Routine urinalysis testing for sugar and albumin at each prenatal visit.
  • Postpartum examinations at six weeks following a normal delivery, and one and six weeks following cesarean section.
  • Delivery of the infant.

Examples of Services Not Included:

  • Laboratory work including blood typing and Rh factor, complete blood count and urinalysis, serology repeat hemoglobins, Rh titer, rubella titer, AFP, Cystic Fibrosis Screening, cultures and pap smears. All lab work will be billed separately from the laboratory itself. In some cases, there may be a blood drawing fee or other charges billed by our office, such as:
  • X-ray and/or ultrasound examinations.
  • Non-stress tests, oxytocin challenge tests, amniocentesis, etc.
  • Emergency room calls or hospital visits.
  • Medications, injections, postpartum rubella immunizations, etc.
  • Surgical assistant if necessary. Surgical consultations if a second opinion is required.
  • Hospital admissions for problems and complications such as toxemia, intractable vomiting of pregnancy, threatened miscarriage, diabetes control, kidney infections, etc.
  • Elective or medically indicated induction of labor.
  • Appointments made specifically for cold and flu symptoms.
  • Care of infant in the hospital and circumcision of male infants.
  • Anesthesiologist, pathologist and other providers’ charges are billed outside of our office.
  • Charges incurred while in the hospital are also billed outside of our office

Obstetrical Cost and Health Insurance / Hospitalization

Southwest Healthcare System

We are affiliated with the Southwest Healthcare System (Inland Valley Medical Center and Rancho Springs Medical Center).

You may pre-register online at either Inland Valley Medical Center or Rancho Springs Medical Center.

You must complete REGIE at least 72 hours, or three full business days, before your scheduled check-in date. You may also call Southwest Healthcare System Rancho Springs Campus Pre-Registration Department at 951-696-6106 to pre-register over the phone

Classes and Tours

Maternity Tours, Childbirth Preparation Classes & Breastfeeding Support Groups are available through the hospital. Please contact the hospital at 1-800-879-1020. The 2011 Maternity Education Calendar is also available online.

Loma Linda Medical Center – Murrieta

We are also associated with the new Loma Linda University Medical Center – Murrieta. We support the above facilities and encourage you to visit the hospitals. Please let us know when you have decided where you are going to deliver.

You are responsible to know if your insurance company makes that determination

For your convenience, you should make admission arrangements with your hospital by your 36th week of pregnancy

Birth Options

“Birth Options” is designed for those expectant parents who would like to record their preferences about various aspects of their maternity care. It also serves to assist us in understanding and clarifying your desires. Please check off those options you consider desirable and worthy of further discussion. Feel free to add any items you feel are important.

Please understand no labor is entirely predictable so that, although this will be included as part of your prenatal record, circumstances may change, requiring flexibility in options. Every effort will be made to comply with your wishes, and when this is not advisable or possible, we will explain the reasons to you. Secondly, please trust that our foremost desire is for the optimal medical outcome for both mother and baby.

Breast Feeding... The Good Beginning

Techniques That Work

Breast-feed your baby as soon as possible after birth.

Let your nurse know that you intend to breast-feed

Ask your nurse for help with the first few feedings. The nurses will help you get the baby positioned and latched-on properly to prevent sore nipples. They have been trained to help you.

Use the 3 steps of latch-on:

Positioning: Have baby rolled toward you with the head in the crook of your arm. The face, abdomen and knees should all be towards you. Hold your breast with all your fingers under and your thumb on top. The entire hand should be behind the areola (dark portion of breast).

Stimulate rooting reflex: Move your breast to tickle baby’s lips with your nipple until the mouth opens wide (the big Ah…). Latch-on: Center the nipple in baby’s mouth and pull baby in close (Do this very quickly in motion).

Breast-feeding is a learned skill for both you and your baby. The first few feedings may seem a little awkward. Check with the hospital for available breast-feeding courses.

It is best for baby to room-in with you. If baby is in the nursery, request rooming-in as soon as you are able.

To establish your milk supply during the first week, nurse your baby frequently, every 2-3 hours, day and night. Baby should have 8-12 feedings in a 24 hour period. Baby will gradually go longer between feedings. It is recommended that baby not sleep more than one 6 hour stretch in a 24 hour period until after 6 weeks. (Many do not sleep 6 hours at a time until after 12 weeks)

Since colostrum, your first milk, is thick (concentrated), feeding may take 20-60 minutes. Switch breasts approximately every 10 minutes. In a few days the mature milk will come in and is thinner so feedings will not take as long. At birth, an infant’s stomach is the size of a marble so it may need more frequent feedings. By day 3 the stomach is about the size of a golf ball and by day 5, the size of an egg.

Newborns may be very sleepy and difficult to arouse for feedings. It is important that you do not let your baby sleep through a feeding. If you can’t keep baby awake long enough for a feeding, wait 20-30 minutes and try again. Also, try to latch baby on to the breast as soon as baby begins to stir in the crib. Take advantage of baby’s sleep-awake cycles.

It is recommended that artificial nipples be avoided in the newborn period (first 3 weeks). A bottle should be introduced between 3-7 weeks if it will be needed later on (such as returning to work). Someone other than mother should give the first bottle.

General Information

Wash your hands, not your breasts, before nursing your baby.

Wear a good fitting, supportive nursing bra as much as possible. Avoid tight fitting bras that can lead to plugged ducts.

We recommend using breast milk on sore, cracked or bleeding nipples. Once the milk is dry, you can then use a thin layer of lanolin on the nipples.

Drink at least 8 glasses of fluids per day. Drink to thirst.

Eat well. Good nutrition means adequate quality and quantity of calories. You will need an average of 2200-2500 calories per day. Don’t diet! Breast-feeding will help you lose weight.

Rest and sleep are important to your general well-being. Nap when baby does, try not to overdo it.

After the first 5 days, baby should have at least 6 wet diapers in 24 hours and at least 1 stool. Baby may have stool after every feeding. Loose stools, resembling egg yolks, are normal. If you have questions regarding your infant’s feedings or bowel movements, please contact your pediatrician.

If, for any reason, you need to temporarily discontinue breastfeeding, you must pump your breasts at regular intervals (every 2-3 hours) to maintain milk supply

Other Breast Feeding Resources

The Loving Support Organization’s breast feeding clinic is free to all Riverside County residents. Please visit their website for more information.

Labor Precautions

If You Are Less Than 36 Weeks, go to the hospital if you have

Contractions – You have more than 6 contractions in an hour, even after you have rested and drank at least 16 ounces of water.

Vaginal Bleeding – You have bleeding requiring a pad.

Leaking Fluid – You have fluid leaking from your vagina, enough to soak a pad when you are walking around.

Decreased Fetal Movement – If you are not feeling your baby move, eat a snack and rest on your left side in a quiet room for one hour. If you still have not felt the baby move more than 6 times in that hour go to the hospital.

If You Are Over 36 Weeks, go to the hospital if you have

Contractions– You have strong and uncomfortable contractions you are unable to talk through (every 5 minutes for an hour if it is your first baby, or contractions every 7 minutes for an hour if you have had a baby before).

Vaginal Bleeding– You have heavy bleeding, similar to a heavy period, not just spotting.

Leaking Fluid– You have fluid leaking from your vagina, enough to soak a pad when walking around.

Decreased Fetal Movement– If you are not feeling your baby move, eat a snack and rest on your left side in a quiet room for one hour. If you still have not felt the baby move more than 6 times in that hour go to the hospital.

DO NOT CALL THE OFFICE OR THE HOSPITAL. GO DIRECTLY TO THE HOSPITAL – The hospital will contact us after you have been evaluated. IF YOU ARE STILL UNSURE OF WHAT TO DO AFTER READING THIS, PLEASE CALL (951) 677-4748

Post Partum: When to Call the Office

If You Are Within Normal Limits

  • Bleeding: discharge made up of blood-mucous-tissue and occasionally blood clots, moderate in amount. May last approximately 3 to 6 weeks.
  • Fatigue.
  • Temperature under 100 degrees after 24 hours of delivery.
  • Some pain, discomfort or numbness in vaginal area after vaginal deliver.
  • Diminishing incisional pain, numbness or discomfort at c-section site.
  • Breast soreness – engorgement.
  • General achiness.
  • Hair loss.
  • Feeling overwhelmed.
  • Post-partum blues: mood swings resolving within 2-3 days.

When to Call Our Office

  • Heavy vaginal bleeding – soaking more than one pad per hour and/or “lemon sized” blood clots Discharge with foul odor.
  • Temperature over 100 degrees 24 hours after delivery
  • Significant or worsening pain/discomfort in abdomen past the first few days after delivery.
  • Lump in a breast with any redness, tenderness, heat, hardness or fever.
  • Chest pain, calf or thigh pain, and/or headache.
  • Swelling, redness, heat or discharge from c-section incision.
  • Difficulty urinating – pain or burning
  • Depression – hopelessness, helplessness, aggressive feelings.

Solutions for Common Problems

Sore Nipples

  • Long, frequent feedings prevent engorgement, which can lead to sore nipples.
  • Repositioning the baby at the breast until the latch is not painful.
  • Nurse on the least sore side first.
  • Expose nipples to air. Keep bra flaps down.
  • Use breast milk on your nipples after feedings.
  • DO NOT USE NIPPLE SHIELD unless assessed by a lactation consultant.
  • Avoid breast pads with plastic barriers.
  • Improper latch-on leads to sore, cracked nipples.
  • Get help if the problem persists, or if your nipples become cracked, or bleed.


Sleepy Baby

  • You MUST wake the baby for feedings during the first week. He/She may not wake when hungry.
  • Wake the baby by taking off the blankets, undressing, talking, patting.
  • Stimulate by bathing, skin to skin contact, cool washcloth to face.
  • Avoid overheating your home (over 80) as this can cause baby to be more sleepy.
  • Use pain medication only if needed.
  • Seek assistance if the baby seems too sleepy, doesn’t want to nurse as often as expected, or constantly falls asleep at the breast before at least 10 minutes of active nursing.


Getting Discouraged

  • Seek assistance from supportive family members.
  • Get plenty of rest. Nap when the baby does.
  • Avoid being a “super mom”.
  • The first 2 weeks are the most difficult, regardless of feeding method.
  • Remember that you can do it if you persist.
  • Get help.
  • Could it be the blues? (Postpartum depression).
  • Call the Lactation Clinic when you need assistance.


Engorgement

  • Feed frequently (every 2-3 hours).
  • Apply warm, moist packs to breast before feeding.
  • Use gentle fingertip massage over breasts.
  • Take very warm showers.ext.
  • Manually express milk to soften areola prior to putting baby to your breast.
  • Avoid using breast pumps to “get rid of the milk”.
  • Use pump gently, only if the milk is flowing.
  • Use cold compress (only AFTER feeding).


Artificial Nipple Preference

  • Avoid using artificial nipples until baby is at least 3 weeks old.
  • Try football hold to assist with latch-on.
  • Express milk on the nipple prior to latch-on, or use an eyedropper to drip milk down the breast.
  • BE PATIENT – Don’t force baby
  • If you are unable to correct after 1 or 2 feedings, call the Lactation Clinic for assistance.


Fussy Baby

  • Don’t confuse fussiness with colic, CRYING IS NORMAL!
  • Feed as often as demanded, about every 2-3 hours from start of feed to start of feed is normal.
  • Feeding helps to soothe baby.
  • Burp frequently during feedings and following crying. Breastfed babies may not always burp. That is okay.
  • Baby will be more fussy during evening hours.
  • Call the Lactation Clinic if the problem continues.


Plugged Duts / Mastitis

  • Increase your bed rest (bed rest for 24 hours if you develop mastitis).
  • Do not skip nursing – increase frequency.
  • Begin feedings on the affected side.
  • Apply warm, moist packs to affected area prior to feedings (cold compress may be applied after feeding)
  • Gently massage lump during feeding


BE ALERT FOR SIGNS OF MASTITIS

  • Breast lumps, hard, reddened or painful areas.
  • Flu-like aches and pains, shaking chills.
  • Watch your temperature, report any fever.
  • Over 101º F to your physician.
  • Contact the lactation clinic or our office if you think you have mastitis.

Adequate Milk Supply

  • Eat what you like, but don’t overdo on any one type of food or drink.
  • Drink fluids to have pale urine.
  • Eat 3 meals and 2 small snacks per day.
  • Eat 2200-2500 calories per day of well-balanced foods.
  • Use both breasts at each feeding.
  • Nurse more frequently. Lengthen feedings.
  • Avoid supplemental bottle of water, formula or juice. Avoid using a pacifier.
  • Remember, baby shouldn’t get cereal until 4-6 months of age. Cereal WILL NOT make the baby sleep through the night.
  • Call the Lactation Clinic if you suspect a low milk supply.

Top 10 Pregnancy Questions

Most patients will wait up to four weeks before they ask their doctor questions regarding their pregnancy. Worse than waiting, they could get unreliable information from their friends, neighbors or the internet. Here are the top ten most frequently asked pregnancy questions with advice from the physicians of Temecula Valley OB/GYN.

1) How much weight gain is normal during pregnancy? A healthy weight gain during pregnancy is 25 to 35 pounds. Add five pounds if you are underweight and subtract ten pounds if you are overweight. Twin pregnancies can gain 10 pounds more. More weight gain is expected (3-4 lbs/month) after the first 12 weeks.

2) How much exercise can I do during pregnancy? A minimum of 30 minutes of aerobic activity, 3 times per week, is advised during pregnancy. There is no limit on the amount of exercise but there are some guidelines.

  • Stay hydrated.
  • Avoid lying on your back after the first 12 weeks.
  • Avoid contact sports such as football or soccer.
  • Scuba diving should be avoided
  • If you have any questions about a particular activity, please ask your doctor.
  • IF YOU HAVE HAD ANY COMPLICATIONS DURING YOUR PREGNANCY, SUCH AS PRETERM LABOR OR BLEEDING, CHECK WITH YOUR DOCTOR FIRST.

3) Can I dye my hair during pregnancy?Hair dyes are most likely safe after the first trimester of your pregnancy because very little gets absorbed through the skin.

4) Can I drink caffeinated beverages like coffee or soda? Multiple studies have shown there is no increased risk of miscarriage or growth restriction during pregnancy when less than 300mg (15 ounces of coffee) is consumed daily. It is generally considered safe to consume less than 1-2 cups of a caffeinated beverage per day.

5) Can I fly in an airplane? Up until 36 weeks, you may fly in a commercial airplane for any length of time. It is important to get up and walk around if possible during the flight to avoid blood clots in the legs. IF YOU HAVE HAD ANY COMPLICATIONS DURING YOUR PREGNANCY, CHECK WITH YOUR DOCTOR BEFORE LEAVING THE AREA.

6) Can I eat fish? Avoid eating long-lived, large fishes such as shark, swordfish, tilefish and mackerel. Albacore tuna should be limited to six ounces per week. (There are high levels of mercury found in some fish which can cause neurological impairment in the fetus).

Please see FDA article, “What You Need to Know About Mercury in Fish and Shellfish” for additional recommendations regarding consumption of fish and shellfish during your pregnancy. Additional information is also available under “Environmental Influences” in your handbook.

7) Can I take care of my cat? If you have a strictly indoor cat, it is safe to change the litter box, otherwise have someone else do it. (Toxoplasmosis can be acquired by coming in contact with cat feces infected with the parasite Toxoplasma gondii. Strictly indoor cats are unlikely to be infected).

8) What can I take if I have a cold? For congestion, try saline nasal spray (Ocean, Sea Mist) according to the package instructions. For cough, try Robitussin DM. If you have allergies, Benadryl (25mg every 6 hours), Zyrtec, Zyritex and Claritin may help. These remedies have been generally accepted as safe during pregnancy. IF YOU HAVE A HIGH FEVER, SHORTNESS OF BREATH OR OTHER SIGNS OF SEVERE INFECTION, CONTACT YOUR DOCTOR.

9) What can I take for a headache? Headaches are common during the first half of pregnancy. First try regular strength acetaminophen (Tylenol) according to packaging. If not relieved, try a caffeinated beverage (coffee or cola). These remedies have been generally accepted as safe during pregnancy. IF STILL NOT RELIEVED WITHIN ONE HOUR, CONTACT YOUR DOCTOR.

DO NOT TAKE NSAIDS (IBUPROFEN, MOTRIN®, ADVIL®, ALEVE OR ASPIRIN).

10) What do I do if I am nauseated? First try some dietary changes. Eat six small meals a day instead of three large ones. Eat crackers, cereals or other dry foods, especially before you get out of bed in the morning. Drink small, frequent amounts of liquids (room-temperature sodas work well). If not relieved, over-the-counter vitamin B6 (25 mg three times per day) and Unisom (12.5 mg at bedtime) are considered safe. IF CONTINUED VOMITING, HIGH FEVER OR SEVERE ABDOMINAL PAIN OCCURS, CONTACT YOUR DOCTOR.

Environmental Influences

We feel that it is important to note in this letter, the importance of good health habits during pregnancy. The health habits of a pregnant woman affect the growth and development of the unborn child.

Nutrition

A healthy diet includes well-balanced meals with emphasis on the four basic food groups. Protein intake is essential in pregnancy to the neurological development of the growing fetus. Supplementary prenatal vitamin/mineral tablets have been prescribed for you to ensure optimum daily intake of the elements which are necessary for proper cardiac development, skeletal growth and fetal development. Additional iron tablets may also be prescribed if your laboratory results show anemia.

Fish

Seafood can be a great source of protein and iron, omega-3 fatty acids and other nutrients. However, some fish and shellfish contain high levels of mercury which may be harmful to your developing baby’s nervous system. The Food and Drug Administration (FDA) encourages you to avoid the following types of fish during your pregnancy: Swordfish, Shark, King mackerel, Tilefish

The FDA also indicates that you should be able to safely eat up to 12 ounces a week of the following: Shrimp, Canned light tuna (limit albacore and tuna steak to nor more than 6 ounces), Salmon, Pollock, Catfish and Cod Review additional resources regarding the nutrition and safety of consuming seafood during your pregnancy.

Water

Pregnant women need plenty of fluids including ten glasses of water daily to help hydration and prevent urinary problems.

Medications

Do not take ANY over-the-counter medicines without first advising our office. Do not take aspirin. Regular strength Tylenol may be taken instead of aspirin. Do not smoke during pregnancy. Pregnant women should avoid enclosed areas where others are smoking. Even secondary smoke has been shown to be harmful to you and the unborn child. Cocaine, crack, marijuana and alcohol intake may cause serious problems to the unborn child and may also cause complications following delivery. For the sake of your unborn child who is so dependent upon you, do not smoke, consume alcohol or experiment with drugs or hallucinogenic agents.

Our ultimate goal is to provide you with the best obstetrical care possible so that you and your bay may be as healthy as possible. We hope that the experience of this pregnancy and delivery will be a happy and enjoyable time, and that the addition of the new little baby to your family unit will be a blessing.

Cystic Firbosis Carrier Testing

What is Cystic Pibrosis?

Cystic fibrosis (CF) is an inherited disease that affects more than 25000 American children and young adults. Symptoms of CF vary but include lung congestion, pneumonia, diarrhea and poor growth. Most people with CF have severe medical problems and some die at a young age. Others have so few symptoms they are unaware they have CF. CF does not affect intelligence.

Although there is no cure for CF at this time, scientists are making progress in improving treatment and in searching for a cure. In the past, many people with CF died at a very young age. Today, many are living into their 20’s and 30’s.

Is there a chance my baby could have cystic fibrosis?

You can have a child with CF even if there is no history in your family (see chart below) Approximate risk that a couple with no family history of CF will have a child with CF

Ethnic Background Risk

  • Caucasian Couple: 1 in 3,000
  • Hispanic Couple: 1 in 8,000
  • African American Couple: 1 in 15,000
  • Asian American Couple: 1 in 32,000

CF testing can help determine if you are a carrier and at risk to have a child with CF.

  • If both parents are carriers, there is a 1 in 4 (25%) chance, with each pregnancy, that they will have a child with CF.
  • Carriers have one normal CF gene and one altered CF gen.e
  • People with CF have two altered CF genes.
  • Most people have two normal copies of the CF gene.

What CF testing is available?

Pregnant women need plenty of fluids including ten glasses of water daily to help hydration and prevent urinary problems.

Medications

There is a blood test that can be done to find out if you or your partner is a carrier. A National Institutes of Health (NIH) consensus statement developed by a panel of experts representing medical, legal, ethical and public perspectives recommends that CF carrier testing be offered to any couple planning a pregnancy and to any individual with a family history of CF. It is important to understand that CF carrier testing does not detect all CF carriers. If the test shows that you are both CF carriers, your unborn baby can be tested to find out if the baby has CF.

HOW MUCH DOES IT COST TO HAVE CYSTIC FIBROSIS CARRIER TESTING?

Cost and insurance coverage for CF carrier testing vary depending upon the laboratory used and your insurance policy. IT IS THE PATIENT’S RESPONSIBILITY TO VERIFY INSURANCE COVERAGE, IF ANY, FOR CYSTIC FIBROSIS (CF) CARRIER TESTING. I AM ALSO AWARE THAT I AM RESPONSIBLE FOR ALL COSTS ASSOCIATED WITH THIS TEST.