Patient Info


At Arizona Maternity & Women’s Clinic, our goal is to provide you with advanced and comprehensive care throughout your pregnancy.


At Arizona Maternity & Women’s Clinic, we believe in providing comprehensive care in all aspects of gynecology.


At Arizona Maternity & Women’s Clinic, we believe in providing comprehensive care in all aspects of midwifery.

Patient Info

What is incontinence?

Urinary incontinence is defined as the involuntary loss of urine. It can be stress, urge or mixed incontinence. When any part of the urinary system malfunctions, incontinence can result.

Who is affected by incontinence?

Urinary incontinence is reported to affect 13-25 million people in the United States. Many patients do not seek treatment due to embarrassment, or a misperception that nothing can be done about it. Many women believe that incontinence is a normal part of the aging process. It is important to know urinary incontinence can usually be successfully treated.

What causes incontinence?

Urinary incontinence can be caused by many factors. A few of the most common causes are:

  • Pregnancy and childbirth
  • Diabetes
  • Bladder or kidney infection
  • Menopausal drying/thinning of the urethra
  • Interstitial cystitis
  • Excess alcohol consumption
  • Excess caffeine consumption
  • Excess fluid consumption
  • Certain medications
  • Nervous system disorders that may effect the lower urinary tract
  • Spinal cord lesions
  • Multiple sclerosis
  • Parkinson’s
  • Stroke

What is a cystometrogram?

A cystometrogram or CMG is a test used to evaluate your bladder’s ability to store and release urine.

How to prepare?

  • Please arrive for your procedure on time.
  • Do not empty your bladder for 1 hour prior to your appointment time.
  • You may eat and drink as usual and remain active right up until the time of your cystometrogram.

What to expect when you arrive

  • You will be asked to empty your bladder into a special commode. This commode can record the rate at which you empty your bladder, as well as the amount of urine you emptied at that particular time.
  • A catheter (a thin, long, flexible tube) is then inserted into the bladder and any urine remaining in the bladder is drained and measured (post-void residual). Then, a second catheter is placed into the rectum.
  • The catheter will be used to fill your bladder with a sterile saline solution. Meanwhile, you will be asked several questions about the sensations you are experiencing. Then you will be asked to perform certain activities, such as coughing, or pushing, while your bladder is being filled.
  • Once you feel that your bladder is filled to capacity, you will be asked to empty it with the catheters in place. The computerized instrument will record the pressures generated by your bladder. The catheters will be removed after the computerized instrument collects sufficient pressure readings.
  • The test takes approximately 30 minutes to complete. You may resume your normal activities immediately.

How are the results interpreted?

  • NormalThe amount of urine left in the bladder after urinating, when the urge to urinate is felt, and when urine can no longer be held back are within normal ranges.
  • AbnormalOne or more of the following may be found:
  • More than a normal amount of fluid remains in the bladder after urinating. A large volume of urine remaining in the bladder suggests the flow of urine out of the bladder is partially blocked or the bladder muscle is not contracting properly to force all the urine out (overflow incontinence).
  • The bladder contains less fluid, or more fluid than is considered normal when the first urge to urinate is felt.
  • The person is unable to retain urine when the bladder contains less than the normal amount of fluid for most people.

Lifestyle Changes

  • Quit Smoking – Smoking can lead to:
  • Chronic Cough
  • Damage to Bladder
  • Damage to Urethra
  • Lose weight – Excess weight puts extra pressure on the pelvic floor muscles.
  • Avoid caffeine and alcohol as this may make you urinate more.

Timed Voiding

Your physician may instruct you to urinate every 2-4 hours, while awake. The goal of this therapy is simply to keep the patient dry. This will help to empty the bladder and avoid accidents.

Bladder Re-training

This involves timed voiding, but the length of time between the bathroom trips is gradually increased. This therapy trains the bladder to delay voiding for larger time intervals.

Kegel exercises are easy to learn and simple to do. If you do them right, no one can tell your doing them, so they can be done anywhere.

Isolating The Pelvic Floor Muscles

  • While urinating, try to stop the flow of urine. Start and stop as often as you can.
  • Tighten your muscles as if you were stopping your stream of urine, but do it when you are not urinating.
  • Tighten your rectum as if trying to not pass gas. Contract your anus, but don’t move your buttocks.
    If you have isolated the right muscles, your leg, buttock or stomach muscles should not move.

How long should I hold them?

Try holding each contraction for 5 seconds. This will be difficult at first but it will get easier as the pelvic floor gets stronger.

How often should I do them?

Thus Exercise can be done several times a day. The more you do, the stronger the muscles become. However, just like any exercise, the muscles can become fatigued if overworked.

When and Where can I do my Kegels?

Kegels can be done anywhere and anytime.

Below are some types of medications that may help treat incontinence.

  • Antispasmodics: These medications may increase the amount of urine the bladder can hold. They also help the bladder muscle work more efficiently. Examples of this type of medication are Detrol, Enablex, Sanctura, Vesicare, Ditropan, etc…
    Side effects of these medications include dry mouth, constipation, and blurred vision. Sucking on sugar free hard candy is recommended to help with dry mouth.
  • Mild Antidepressants
  • Estrogen: Hormone therapy may help to improve muscle tone in the bladder and urethra.
  • Antibiotics: This type of medication will be prescribed if infection is present.

Tips for Taking Incontinence Medication

  • Take your medication as prescribed by your doctor
  • Call your doctor if you have problems taking your medication or are experiencing side effects
  • Do not stop taking your medication until after you have been instructed to do so by your physician.
  • Be patient. Many of these medications take a few weeks to work. Some adjustments may be needed to find the right medication and dosage for you.

There are many types of different surgical procedures that may be used to treat incontinence. The type of surgery recommended will depend on the type and cause of your incontinence.

Slings: Urethral slings are used to treat stress incontinence (SI). SI is usually caused by sagging of the urethra and/or bladder neck, or by problems with the sphincter (muscular outlet of the bladder). This involves placing a “sling” around the urethra to lift it into place and to exert pressure on the urethra to aid in holding the urine.

The advantages of sling surgery are:

  • Usually done in an outpatient setting (go home the same day)
  • Quick recovery time
  • Very little to no pain
  • Extremely effective in eliminating incontinence

What are the risks and possible complications?

  1. Infection
  2. Bleeding
  3. Injury to surrounding area
  4. Mesh erosion or rejection of the sling material (the sling material may wear away the tissue of the urethra or vagina)
  5. A small percentage of patients will have trouble urinating immediately following the procedure and may need a catheter until normal bladder emptying is established. This catheter is usually removed 3-7 days post-op.

What can I expect during recovery?

Most women return home within 24 hours of the procedure. You will be sent home once you are feeling well and are able to urinate. If you need pain relief, mild analgesics are usually enough. It is important to rest after the operation and allow yourself to heal.

General recommendations are:

  • Restrict activity for first 2 weeks following procedure
  • Weeks 2-6, light activity only
  • Avoid heavy lifting for 6 weeks. This includes shopping bags, laundry baskets, and children.
  • No sexual activity for 6 weeks
  • No sports or strenuous exercise for 6 weeks

Urethral slings are used to treat stress incontinence (SI). SI is usually caused by sagging of the urethra and/or bladder neck, or by problems with the sphincter (muscular outlet of the bladder). This involves placing a “sling” around the urethra to lift it into place and to exert pressure on the urethra to aid in holding the urine.

The advantages of sling surgery are:

  • Usually done in an outpatient setting (go home the same day)
  • Quick recovery time
  • Very little to no pain
  • Extremely effective in eliminating incontinence

What are the risks and possible complications?

  1. Infection
  2. Bleeding
  3. Injury to surrounding area
  4. Mesh erosion or rejection of the sling material (the sling material may wear away the tissue of the urethra or vagina)
  5. A small percentage of patients will have trouble urinating immediately following the procedure and may need a catheter until normal bladder emptying is established. This catheter is usually removed 3-7 days post-op.

What can I expect during recovery?

Most women return home within 24 hours of the procedure. You will be sent home once you are feeling well and are able to urinate. If you need pain relief, mild analgesics are usually enough. It is important to rest after the operation and allow yourself to heal.

General recommendations are:

  • Restrict activity for first 2 weeks following procedure
  • Weeks 2-6, light activity only
  • Avoid heavy lifting for 6 weeks. This includes shopping bags, laundry baskets, and children.
  • No sexual activity for 6 weeks
  • No sports or strenuous exercise for 6 weeks

Myomectomy is the surgical removal of uterine fibroids without removing the uterus.

What are Uterine Fibroids?

Fibroids are common solid pelvic tumors. They arise from the muscle tissue of the uterus; they may be single or multiple. About 25% of all women over the age of 35 have fibroids; among African-American women fibroids are even more common.

What Symptoms Do Fibroids Cause?

Submucousal fibroids (grow into the uterine cavity) may cause heavy bleeding, anemia, pain, infertility, or miscarriage. Mural fibroids (located in the uterine wall) and sub-serous fibroids (protrude outside the uterine wall) may reach a large size before causing symptoms. These symptoms may include pressure on the bladder with difficulty voiding or urinary frequency and urgency, pressure on the rectum with constipation, lower back and abdominal pain, as well as heavy bleeding.

What is the Conventional Treatment for fibroids?

Hysterectomy remains the most common surgical treatment for fibroids because it is the only definitive treatment. When fibroids are small and causing no symptoms, no treatment is required. In the presence of symptomatic or large fibroids, a woman who wishes to preserve her fertility may be offered a myomectomy, an operation that removes the fibroids while sparing the uterus. However, the conventional treatment for women 40 years of age and older is hysterectomy. Even women younger than 40 who have completed childbearing are usually offered hysterectomy.

A Physician’s Response:

My conviction as a physician is to respect the personal viewpoints of every patient. If an informed patient wishes to preserve her uterus in the presence of a benign condition and if her medical problem can be safely resolved without hysterectomy, the physician should comply with the patient’s desire, even if this involves referring her to another specialist.

Effective Treatment for Uterine Fibroids:

Myomectomy, when performed by an expert, is a safe and effective alternative to hysterectomy. The gynecologic surgeon who has extensive experience with myomectomy is able to remove fibroids. The successful myomectomy should result in resolution of symptoms related to fibroids.

Myomectomy: The Operation

Depending upon the location of the fibroid(s), myomectomy can be accomplished by either an abdominal or vaginal approach. When the fibroid causing symptoms is bulging into the uterine cavity (sub-mucous), it is usually possible to remove it by using a hysteroscopic technique. This technique involves using an operating “telescope”: which is inserted into the uterus through the vagina. Hysteroscopic myomectomy is performed on an outpatient basis; the short recovery period at home is 2-3 days before resumption of full activity. In the presence of large fibroids in the uterine wall (mural) or bulging out of the uterus (sub-serosal), abdominal myomectomy through an abdominal incision is usually required. In most cases this can be accomplished through a low horizontal incision along the bikini line. Following an uncomplicated abdominal myomectomy, discharge from the hospital is usually possible within 2-3 days. There is a variable recovery period at home of 2-6 weeks.

A critical part of successful myomectomy is optimal reconstruction of the uterus. A reconstructed uterus may rupture during a subsequent pregnancy or delivery. In this regard, removing large fibroids through the laparoscope (telescope inserted through the navel) is not advisable in most cases because optimal reconstruction of the uterus is not accomplished in this manner.

What If Cancer is found?

About 1 in 200 women with fibroids is found at surgery to have a malignant tumor of the uterus (sarcoma). Therefore, the preoperative discussion between the woman and her surgeon should include consideration of this unlikely circumstance. The patient should be counseled regarding the importance of hysterectomy and removal of both ovaries as a life-saving procedure if cancer is found during the operation.

What is the Role of Hormone Treatment?

Some physicians advocate hormone treatment with GnRH agonists, such as Lupron, in preparation for myomectomy. This treatment postpones the operation for 2-4 months. During this time the fibroids decrease in size and the bleeding is markedly reduced. Although some surgeons feel that this makes the operation easier and diminishes blood loss, many other experienced surgeons find this very expensive treatment unnecessary with few exceptions. However, it is generally agreed that if a woman is very anemic, hormone treatment along with iron supplements promotes recovery from the anemia prior to surgery. Concern has been raised that GnRH treatment may shrink small fibroids, which could, therefore, be missed at surgery only to enlarge again and cause problems later.

As women become increasingly aware of the important issues related to fibroids and hysterectomy, there is growing interest in alternative treatments. Many of these issues are controversial among both professionals and laypersons. The ethical physician should inform the patient of the issues and options and, above all, respect her convictions and her right to make the ultimate decisions regarding her body.

What is a colposcopy?

A large microscope called a colposcope to look at the vagina and cervix and possibly take a sample of tissue.

When is it used?

This test may be done after you have had an abnormal Pap smear. Colposcopy is a test used for diagnosing precancerous or cancerous changes in the cervix or vaginal cells. The results of this test will help your physician to make a plan for adequate treatment.

How do I prepare for a colposcopy?

No particular preparation is necessary.

What happens during the procedure?

You will be positioned on the examining table just as for a regular pelvic exam. The physician will use a colposcope at the vaginal opening to look inside the vagina or look at the cervix.

If your doctor sees any abnormalities, he or she may take a small tissue sample. You may feel a pinch or slight cramp. The tissue will be sent to the lab for testing.

What happens after the procedure?

You could have some mild cramping and or bleeding or dark discharge for up to two weeks after the procedure. The test results should be ready in a about two weeks.
Ask your doctor what recommendations they have and when you should come back for a checkup.

What are the benefits of this procedure?

To make a plan for future treatment.

What are the risks associated with this procedure?

Minor bleeding. Other risks include:

  • Heavy bleeding (more than one pad per hour or more bleeding than your menstrual flow)
  • Infection

You should ask your physician how these risks apply to you.

When should I call my doctor?

Call the doctor immediately if you have these problems after the procedure:

  • Heavy bleeding
  • Fever greater than 100.4 degrees
  • Pelvic pain

What is tubal ligation?

Tubal Ligation is a form of birth control in which a woman’s fallopian tubes are surgically closed. Normally, the fallopian tubes carry the eggs to the uterus. Closing the tubes with surgery prevents pregnancy.
It is important to realize that sterilization is usually permanent and can not be reversed. However, if the fallopian tubes are clamped or tied, a woman may possibly become fertile again through the use of microsurgery.
A woman also becomes sterile if her uterus is removed (a hysterectomy). A woman cannot become fertile again after a hysterectomy.

When is it used?

Doctors generally recommend sterilization in the following situations:
A couple has had as many children as they want.
Your life may be endangered by pregnancy.
There is a high risk of passing on a serious hereditary disease.
In the U.S. nearly one in every four married women between the age of 15 and 44 chooses sterilization as a means of birth control.

What happens during the procedure?

Laparoscopy is the most common procedures used to seal the tubes. Surgery is done under a general anesthetic.
A hysterectomy is an operation to remove all or part of the uterus. Sometimes the ovaries and fallopian tubes are also removed; this is called an oophorectomy. Doctors do not recommend a hysterectomy unless there are reasons other than sterilization for having it.

What happens after the surgical closing of the tubes?

You may feel some pain or discomfort for 24 to 48 hours after a laparoscopy.
The doctor will want to see you again to be sure that you are healing properly, usually around 2 weeks after your surgery.
If you were using birth control pills before the sterilization, you may notice menstrual changes after the procedure. These menstrual changes are not caused by the surgery. They occur because you are no longer taking the birth control pills.

What are the benefits of this procedure?

Sealing of the fallopian tubes almost always results in permanent sterilization and is a very reliable form of birth control.

What are the risks associated with this procedure?

Complications after sterilization are rare. In some cases, an ectopic pregnancy (pregnancy outside the uterus) may occur, particularly if the fallopian tubes were burned. Other risks include infection, possible bleeding, and scar tissue formation (adhesions).

When should I call the doctor?

Call the doctor immediately if:
You develop a fever
You have bleeding or discharge from the vagina.
You are bleeding around the surgical site.
You notice a green or yellow discharge from the surgical site.
You develop redness or tenderness around the surgical site.

Call the doctor during office hours if:
You have questions about the procedure or its result.
You want to make another appointment.

Congratulations on the birth of your new baby. Many women focus on the pregnancy and forget to ask about what will happen following delivery. Recovery from vaginal and cesarean birth takes about six weeks, sometimes it can take longer. During this time, your body will gradually be returning to normal. When you leave the hospital, expect to be wearing maternity clothes (you will still look about 6 months pregnant). Below are a few things to expect when you return home with your newborn.


Your post partum visit is very important and should be scheduled as soon as possible (preferably before you leave the hospital). Please try to make your appointment with the same doctor that delivered your baby. If you had a c-section, see your provider or doctor 1-2 weeks following your surgery and again at 6 weeks postpartum.


You may notice cramping or “afterbirth pains”. This is the uterus contracting to return to its pre-pregnancy size. These pains are usually worse with each pregnancy. They also get stronger while breastfeeding. Therefore, you may want to take a mild pain reliever before each nursing session.


You will have vaginal bleeding for up to 6 weeks following delivery (even after cesarean sections). Flow will gradually decrease in amount and darken in color. Do not be alarmed if bright red bleeding reappears from time to time throughout the first 6 weeks. Increased activity can increase flow and change the color from brown to red. If your bleeding increases to more than a heavy menstrual flow, get off your feet and rest for a few hours. If it continues to be heavy after resting, please call your provider.

To prevent infection and promote healing:
Use pads instead of tampons
Do not insert anything into the vagina
No douching
No sexual intercourse for 6 weeks after delivery

It is not unusual for your first period to be heavier or different. You may notice an increased menstrual flow with clotting. Your period may also last longer than normal. If you are saturating a new sanitary pad every hour – get off your feet until the bleeding slows. If it continues, please call your provider.


Don’t be surprised if you are not feeling great on your first day home. You will notice a gradual increase in your stamina over time. It is important to rest when the baby rests, and sleep when the baby sleeps. If family and friends offer to help out, take them up on it. If no one offers, ask. Your energy should be directed toward taking care of yourself and your new baby.

Do not lift anything over 10 lbs (gallon of milk)
No heavy exercising
Light walking is okay
Do not drive while you are on prescription pain medication

Perineal Care/Stitches

It is very common to feel bruised and sore in the vaginal, perineal, and rectal areas after delivery. If you have stitches, these will dissolve gradually over the next six weeks. Keep the area as clean as possible. Pour water over the entire area, and then pat dry (front to back). Change your sanitary pad frequently. You may use a sitz bath for relief from discomfort (sit in a bath with 6-8 inches of warm water for 15-20 minutes, this can be done 3-4 times/day). You may use a topical anesthetic spray such as Dermoplast for additional relief.

Incision Care for Cesarean Section

Your staples may be removed before you leave the hospital or at your 1 week follow-up visit in the office. After the staples are removed, you may have clear plastic strips called steri-strips covering parts of your incision. If these strips have not fallen off on their own in a week, you may remove them. The easiest time to remove the tape is after a shower while the strips are damp. Be sure to keep the incision clean and dry. Leave the incision open to the air to facilitate healing. Call the office it you notice any increased redness, increased pain, pus-like drainage or odor from the incision site.

Breast Care While Bottle Feeding

Wear a well fitting, sturdy bra day and night for the first few weeks following delivery. Keep all stimulation away from your breasts – stand with your back to the water in the shower. Even though you are not breast feeding, your body will begin to make milk. Your breasts may get engorged (hard, lumpy, tender, hot) as the milk is produced and not released. Expressing milk for relief may lead to more milk production. You may apply ice packs or cabbage leaves to your breasts 3 or 4 times/day for up to 20 minutes at a time. You may bind your breasts with an ace bandage for added support. Call the office if you have tenderness, redness, fever of a particular area of the areal.

Breast Care While Breastfeeding

Wear a good supportive bra. When showering, do not use soap on the breasts. Call your lactation consultant if you develop dry, cracked nipples. Lanolin cream may be applied to the nipple area. If you notice a warm, red, tender, lump or induration on the breast, have a fever and flu-like symptoms, please call your provider.

Breastfeeding and Diet

Now that you are no longer pregnant, you can be more liberal with your dietary choices. Continue with a balanced diet. You will need an additional 500 calories per day for breast milk production. Try not to skip meals. Take your prenatal vitamin as long as you continue to breastfeed. You should try to drink at least 8-10 glasses of water/day. It is helpful to have a glass of milk, water, or fruit juice available to drink every time you nurse.


The first bowel movement is usually within 2-3 days. To help alleviate or prevent constipation, you should consume 8-10 glasses of water a day. Eat high fiber foods, such as fresh fruits and vegetables, whole grain bread and crackers, high fiber cereals, raisins, and prunes. If you need a medication for constipation, you may try over the counter fiber supplements, such as Fibercon, Metamucil, or Citrucel, a stool softener such as Colace, or a mild laxative such as Milk of Magnesia. For gas, you may take Gas-X (simethicone 40-80mg) three to four times a day.


Hemorrhoids are varicose veins in the rectum. Pregnancy can cause hemorrhoids to develop when the growing uterus interferes with the blood flow in the region of the rectum. When you are constipated or strain with a bowel movement, these veins become enlarged and painful. You may notice some itching and slight bleeding. They are generally most uncomfortable in the first week following delivery. The hemorrhoids will begin to shrink and many go away. For comfort, you may use a sitz bath 3-4 times a day. You may also apply Tucks pads (witch hazel) to the area as needed. Drink plenty of fluids and eat a diet high in fiber. You may take a stool softener (Colace) as needed. Anusol and Preparation H may be purchased over the counter and used according to directions on the package.

Postpartum Depression and “Baby Blues”

Emotional lability, anxiety, irritability, sadness, anger, and fatigue are common after delivery. The postpartum period may be a time of anxiety and uncertainty for new parents, and when combined with hormonal changes and lack of sleep, a transient depression known as “baby blues”, is not unusual. While 70-80% of all women experience “baby blues”, only about 10% will have postpartum depression. With postpartum depression, the feelings of sadness, anxiety, or despair are more severe and interfere with the ability to function. Postpartum depression can develop many days later. If you feel you may be suffering from postpartum depression, if you are unable to care for yourself or your child, or if you feel you may harm yourself or your child, please call your provider.

ConditionApprovedDO NOT USE
AllergiesClaritin, Benadryl, Chlortrimeton 
Artificial Sweeteners (limit quantity)Nutrasweet, SplendaSweet & Low, Saccharine
ConstipationColace, FiberCon, Metamucil, Citrucel, Milk of Magnesia 
Cough/ColdsTylenol SinusNyquil/Dayquil
Heartburn/IndigestionMylanta, TUMS, Pepcid, Maalox, GavisconPepto-Bismol
HemorrhoidsPreparation H, Anusol HC 
Nasal CongestionSaline Nasal Spray (Ocean Mist), Claritin, Robitussin 
Pain/Fever/HeadacheTylenol (regular & extra strength)Aspirin, Advil, Ibuprofen, Motrin, Advil, Aleve
Rash/ItchingBenadryl, Benadryl Lotion, Hydrocortisone cream 1% 
Sleep AidBenadryl, Tylenol PM 
Sore ThroatCepacol, Chloraseptic Spray 
Yeast InfectionMonistat 7, Lotrisone-7 

*In general, try to avoid taking any medication in the first 12 weeks of pregnancy. However, if you do need to take something, the medications listed above are considered safe in pregnancy. If your symptoms persist after treatment, please call our office.

During pregnancy, certain lab tests are routinely performed on all women. They are done at specific times during the pregnancy to help your doctor identify possible problems with your pregnancy. They will also give clues to how your baby is doing. Other tests that may be done will depend on your medical history, age, family background, ethnic background, or exam results.

Initial Lab Tests – New OB Visit

Pap Smear: Check cervical cells that could lead to cancer.
Cultures: To check for STD’s (sexually transmitted disease) such as Gonorrhea and Chlamydia.
Ultrasound: Used to determine the date of delivery
Blood Work: You will be given an order to go to the lab to have the following blood tests drawn:

  • CBC (complete blood count): This is used to detect anemia as well as any possible infection or clotting problems.
  • Blood Type and Antibody Screen: To check blood type. It can be Rh positive or Rh negative. Problems can arise when the mother’s Rh factor is negative and the baby’s is positive. To prevent these problems, the Rh negative mother will be given a Rhogam injection at 28 weeks.
  • Syphilis: Syphilis is an STD which can be treated. If you have syphilis and are not treated, you can pass it to your baby.
  • Rubella: Your blood will be checked for antibodies against German measles (either from past infection or prior vaccination).
  • Hepatitis B: Hepatitis B is a virus that infects the liver.
  • HIV: HIV is the virus that causes AIDS. Pregnant women are tested even if they don’t have special risk factors. Your doctor will tell you that you are being tested for HIV. If you have HIV, there is a chance that you can pass it to your baby. You can be given medication during pregnancy to reduce this risk.
  • Urinalysis: A urine sample will be collected to test for a urinary tract infection. You will be treated with antibiotics if you have been diagnosed with a urinary tract infection.

At Every Visit

Blood Pressure
Urine Dip: checks for protein and glucose
Fetal Heart Rate
Estimate fetal growth by checking the size of the uterus

At 15-20 Weeks:

Quad Screen. This is a blood test and does not pose a risk to the mother or the fetus. Positive results may indicate the baby may have:
Neural tube defects: problems with the brain or spine such as spina bifida or anencephaly.
Abdominal wall defects: problems with the body of the fetus.
Ultrasound: Used to screen for malformations and appropriate fetal growth.
Genetic defects: physical or mental defects such as Down’s Syndrome.

Please remember that this is a screening test and is not used to diagnose these conditions. If your test is positive, additional testing will be ordered to diagnose any abnormalities. These include ultrasound and amniocentesis.

At 24-28 Weeks:

Glucola or 1 hour glucose tollerance test (GTT): This is a blood test to screen you for gestational diabetes. If this test is positive, you will need the more comprehensive 3 hour glucose tolerance test.

Preparing for the 1 hour glucola:
On the day of your test, do not drink or eat anything for 2 hours before the test.
Plan to be at the lab for at least an hour.
The lab tech will give you a sweet drink called glucola. Exactly one hour after you finish the drink, your blood will be drawn. Do not eat, drink, or chew gum during this hour.
Bring a light snack to eat after the test. This helps to relieve nausea and shakiness that some people feel during the test.

At 28 Weeks (if Rh negative):

Antibody screen and Rhogam injection.

At 35 Weeks:

Group B Strep Culture: A swab is taken from the vagina and rectum to determine if the mother is a carrier of the bacteria. This is a type of bacteria that is normally found in the vagina and/or rectum of some women, and causes no symptoms or problems in adults. However, sometimes it can cause a serious infection in the newborn as he/she passes through the birth canal.

If your test is positive, IV antibiotics will be given to you while in labor to prevent this infection in the newborn. If any problems or complications arise in your pregnancy, additional testing may be ordered, such as:
Ultrasound and/or Biophysical Profile
Non-Stress Test
Blood tests

Nausea & Vomiting

This usually occurs during the first 13 weeks of pregnancy and is often referred to as “morning sickness”. However, these symptoms can occur at any time of the day or night. For some women, these symptoms continue throughout the entire pregnancy. This is caused by the reaction of the stomach and intestines to the increase in hormones related with the pregnancy.

Prevention & Treatment:
Eat small frequent meals
A light snack which may include carbohydrates (crackers, bread, etc…) before getting out of bed in the morning. For more information see information on Morning Sickness


This is usually described as a burning sensation, first in the stomach and then rising into the throat.

Prevention & Treatment:
Eat small frequent meals
Sit upright for 30-60 minutes after eating
Prop your head and shoulders up on a pillow while sleeping
See approved medication list


This is caused by a slowing of the intestinal activity and pressure of the growing uterus. There are several factors that contribute to this problem during pregnancy, such as iron supplements, insufficient fluid intake, lack of exercise, and lack of sufficient fiber in the diet.

Prevention & Treatment:
Keep feet elevated.
Lie on your left side to improve circulation
Reduce intake of foods high in salt. Do not use table salt.
Increase water intake

Varicose Veins

This is due to the interference of blood flow by the expanding uterus.

Prevention & Treatment:
Keep feet elevated.
When you have to be on your feet, move around to encourage better circulation
Support hose may be used to help relieve discomfort.


These are varicose veins of the rectum. They are extremely common during pregnancy and in the period after delivery. Usually they shrink or resolve within a few weeks following delivery.

Prevention & Treatment:
Use the steps described above to relieve constipation since straining with bowel movements can make hemorrhoids more uncomfortable.
Witch hazel compresses.
Sitz baths.

Shortness of Breath

This is caused by a crowding of the diaphragm by the uterus.

Prevention & Treatment:
Some relief may be given by extending arms above head.
Sleep with head elevated on pillows.
If not better by above means call your doctor or providor immidiately.


This is due to several body changes in pregnancy: muscle fatigue, change in the center of gravity and pressure from the growing uterus.

Prevention & Treatment:
To avoid undue strain to the back, bend from the knees if possible.
When standing for long periods, try to keep one foot on a stool or book.
Alternate elevated foot as needed.
When you have to sit for long periods, try to get up and walk around every so often.
Heating pad or hot compress (low to medium heat) applied to the area, 20 min. on, 20 min. off.

Leg Cramps

This may be caused by several factors: stretching of muscles, circulatory impairment, or by a mineral imbalance.

Prevention & Treatment:
Change possition, stand or walk.
Apply counter pressure at the bottom of the foot
Speak with your provider about additional supplementation

Urinary Frequency

This is caused by pressure on the bladder by the enlarging uterus.

Prevention & Treatment:
Drink plenty of fluids.
Keep bladder empty.


There are many possible causes, including shortness of breath, general discomfort, or anxieties about the pregnancy and baby.

Prevention & Treatment:
Use relaxation techniques and slow down breathing to help induce sleep.
Discuss any concerns with your provider

Vaginal Discharge

Discharge is normally increased during pregnancy.

Prevention & Treatment:
There is no specific treatment for normal pregnancy discharge, but if the discharge has an unpleasant odor or is accompanied by itching or burning, please call your provider.
Do not douche
Wear cotton underwear

Itching and Stretching of Skin

This usually occurs on the abdomen in mid to late pregnancy.

Prevention & Treatment:
Use a non-irritating, unscented soap and rinse well
Creams and lotions may reduce itching but will not prevent stretch marks.

These are some simple remedies for the most common discomforts. However, if problems persist or if the discomfort is extreme, please contact your provider.

In the early months of pregnancy, you may experience some nausea and vomiting, which can occur any time during the day or night. This is believed to be caused by hormonal changes that slow the digestive system. This can be a serious medical problem if not controlled as it can leat to dehydration. Not everyone will be able to tolerate the same foods, so let your body dictate what you eat.

To Prevent morning sickness, try these suggestions:

Have a “pre-breakfast” snack. Keep bread or crackers at your bedside and eat some before getting up.
Get out of bed slowly, sudden movements may increase nausea.
Eat multiple times per day as hunger can worsen nausia and vommiting.
Drink plenty of fluids and star hydrated.
Eat high protein foods such as eggs, cheese, nuts, lean meats, etc to help prevent drops in your blood sugar.
Avoid caffeine in coffee, tea, colas, and chocolate
Avoid greasy, fried, highly seasoned foods and foods topped with butter, margarine, sour cream, or gravy.

To Remedy morning sickness, try these suggestions:

Sip soda water (carbonated water) or ginger ale when you begin to feel nauseated.
Get fresh air; take a walk, sleep with an open window… use an exhaust fan if you have to cook.
Take your prenatal vitamin in the evening after dinner or at bedtime.
Drink mint tea

If your nausea and vomiting is severe or prolonged, or you think you are becoming dehydrated, contact your healthcare provider. If you are unable to keep down any food or drink for more than 24 hours, call the office. Do not take any medication unless prescribed by your healthcare provider.

Suggested foods to try:


  1. Saltines
  2. Graham crackers
  3. Animal cracker
  4. Plain toast
  5. Hot or cold cereal
  6. Bananas
  7. Applesauce
  8. Oatmeal


  1. Apple, Grape, Cranberry juice
  2. Kool-Aid
  3. Soup broth
  4. Gatorade
  5. Popsicles
  6. Sherbet
  7. Clear soft drinks
Once you can tolerate the above foods for at least 24 hours, try adding these foods one at a time.


  1. Low-fat cheese
  2. Sandwiches
  3. Cheese & crackers
  4. Yogurt
  5. Vanilla wafers
  6. Baked or mashed potatoes
  7. Bagels/English muffins
  8. Plain noodles
  9. Rice


  1. Milkshakes
  2. Lemonade
  3. Milk/Chocolate Milk

What is Preeclampsia?

Preeclampsia is a condition that develops after the 20th week of pregnancy. There is high blood pressure and protein in the urine. Preeclampsia is also called toxemia or pregnancy induced hypertension. If preeclampsia is not identified and managed appropriately, it can have serious consequences for both the mother and the baby.

How does it occur?

The cause of preeclampsia is unknown. It affects about 5-8% of all pregnancies. Preeclampsia is more likely to occur in:

  • A first pregnancy
  • A woman less than 25 yrs old
  • A woman greater than 35 yrs old
  • An overweight woman
  • A woman pregnant with twins, triplets or more
  • A woman with preexisting conditions, such as Chronic hypertension, Diabetes or Kidney disease

What are the symptoms?

The following are the most common symptoms of preeclampsia. However, many women report no symptoms. This is why it is so important to attend all your prenatal appointments.

  • Hypertension
  • Water retention or swelling (most noticeable in the ankles, feet, hands, and face)
  • Protein in your urine
  • Headaches
  • Changes in vision
  • Lethargy
  • Nausea and vomiting
  • Pain in the upper right abdomen
  • Shortness of breath

How is it diagnosed?

Your healthcare provider will measure your blood pressure and test your urine at each prenatal visit. If preeclampsia is suspected, blood tests will be ordered to confirm the diagnosis.

How does preeclampsia affect the mother and the fetus?

Preeclampsia causes a constriction of blood vessels. It is currently the leading cause of preterm birth and maternal and neonatal death. In the mother, preeclampsia results in decreased blood flow to the liver, kidneys, and brain. This causes the organs to fail. It can also cause seizures (eclampsia) and more life-threatening disorders.

In the fetus, preeclampsia leads to decreased blood flow to the placenta (the organ that carries nutrients and oxygen to the baby). This can result in a low birth weight baby or in severe cases stillbirth. Rarely, it may cause placental abruption (the placenta separates from the uterus). This leads to severe bleeding in the mother and may result in maternal and neonatal death. Many of the effects of this condition in the newborn are related to prematurity.

What is Gestational Diabetes?

This is a type of diabetes that happens only during pregnancy. This occurs when your body is unable to make and use all of the insulin it needs for pregnancy.

Am I At Risk for Developing Gestational Diabetes?

According to the American Diabetes Association, you are considered at high risk for this condition if:

  • You’re obese (BMI > 30)
  • You have had gestational diabetes in a previous pregnancy
  • You have a family history of diabetes
  • You have previously given birth to a large baby (>9 lbs)
  • You have had an unexplained stillbirth

How Does Gestational Diabetes Affect My Baby?

Gestational diabetes occurs in pregnancy when the baby is busy growing. Because of this, gestational diabetes does not cause the kinds of birth defects seen in women with preexisting diabetes. However, if this condition goes untreated or is poorly controlled, it can have serious consequences.

The extra glucose in your blood goes through the placenta to the baby, giving the baby high glucose levels. Since the baby is getting more energy than it needs, it is stored as fat. This can lead to large babies. A macrosomic baby has a larger than normal head and/or shoulders, which can make it difficult for the baby’s head to enter the birth canal. Sometimes the shoulders get stuck. This is called shoulder dystocia. Shoulder dystocia can result in fractured bones and/or damaged nerves in the baby. Because of these risks, if your doctor suspects your baby may be overly large, he/she may recommend delivery by cesarean section.

Newborns may have very low blood glucose levels at birth and are also at higher risk for breathing problems. These babies are also at greater risk of becoming obese and developing type 2 diabetes later in life.

How is Gestational Diabetes Treated?

Treatment for gestational diabetes aims to keep blood glucose levels equal to those of pregnant women who don’t have gestational diabetes. Listed below are some of the most common ways to control your blood sugar:

  • Eat Right: You will be sent to a nutrition counselor, who will determine a target caloric intake. You will need to avoid foods that are high in sugar and/or fat. Never skip meals.
  • Exercise: Your body uses more glucose when you exercise. Many women benefit from 30 minutes of walking or swimming, each day.
  • Check Your Blood Sugar: You will be taught how to check your blood sugar.
  • Take Your Medication: If you are not able to control your blood sugar well enough through diet and exercise alone, your doctor will prescribe medication or insulin shots.


Will I Have Additional Testing During My Pregnancy?

If you have gestational diabetes, you will most likely have to start testing at 32 weeks which includes testing the baby by us. This includes non-stress tests, biophysical profiles, and additional ultrasound exams to monitor growth and determine the size of your baby. You may have to monitor fetal movements.

Will I Have Diabetes After My Baby is Born?

Once you’ve had gestational diabetes, your chances are 2 in 3 that it will return in future pregnancies. You are also at higher risk of becoming diabetic later in life.

To help prevent this:

  1. Lose Weight.
  2. Make Healthy Food Choices.
  3. Exercise.

Performing a non-stress test is a simple, painless, and non-invasive way to assess the well being of your baby.

What Should I Expect?

  • This test is usually done in the doctors office.
  • You will need to be reclining or lying down for the test.
  • You will have 2 belts strapped around your abdomen, one to measure the baby’s heartbeat and one
  • to monitor for contractions. These will be attached to a fetal monitor.
  • The test usually takes 20-30 minutes, but can take longer depending on the activity of the baby or if you are carrying multiples.

What is the Doctor Looking for?

The fetal heartbeat should be within the normal baseline range of 120-160. The baby’s heartbeat should accelerate in response to movement (these accelerations need to meet a certain requirement to be considered reactive). There should be no dangerous signs, such as a deceleration in the heart rate. If you are less than 36 weeks, there should be no contractions. If your NST is not reactive, don’t panic. Usually, there is nothing wrong with the baby. Additional testing, such as ultrasound, or prolonged monitoring, will be ordered to be sure your baby is doing okay.

Why Am I Having an NST?

Non-stress tests are frequently done in high risk pregnancies to determine if the fetus is well enough for the pregnancy to continue or if delivery should be considered, but they are also done in routine pregnancies. Some of the most common reasons for an NST are:

  • Decreased or no fetal movement
  • Diabetes (gestational or pre-exisiting)
  • Multiples (twins, triplets)
  • High blood pressure
  • Preeclampsia
  • Preterm labor or history of preterm delivery
  • Post dates (> 40 weeks)
  • Recurrent pregnancy loss
  • Advanced maternal age
  • Abnormalities in laboratory tests (such as an abnormal triple screen)
  • Thyroid dysfunction

With a breech presentation, your baby is in a buttocks or feet first presentation. A breech presentation can make it hard for the baby’s head to fit through the birth canal during a vaginal delivery. This can cause a lack of oxygen or nerve damage in your baby.

How will I know if my baby is breech?

Your doctor can tell the presentation of the baby by pressing on your belly or during a vaginal exam. If you are more than 35 weeks and your healthcare provider is unsure of the position of your baby, you may have an ultrasound to determine the baby’s position before delivery.

What can I expect during delivery?

Although some breech babies are born vaginally, it can result in complications. For this reason, you will usually be scheduled for a cesarean delivery.

What happens after I deliver?

Just because your baby is in a breech position, it doesn’t mean that he or she will have health problems. Most likely, you and your baby will be fine.

Most expectant mothers will feel their baby move by the 20th week of pregnancy. Fetal movement is an indicator of fetal well being. One way for you to know if your baby is doing well is to record your baby’s movements. This is called a fetal kick count. Kick counts work best after the 27th week of pregnancy.

How do I do a fetal kick count?

  • Sit comfortably and lie on your left side
  • The first time your baby moves, write down the time
  • Count each movement the baby makes until the baby has moved 10 times (This can be less than 5 minutes or up to 2 hours)
  • If you have felt less than 4 movements in 1 hour, get up, walk around, change position, have some juice or a snack, and try again.

When should I call the doctor?

  • If you feel less than 10 movements in 3 hours
  • If your baby moves significantly less often than it has been
  • If you have not felt your baby move all day
The goal of most of the other measures is to help you relax, as this is the most important thing you can do to be more comfortable.
  • Birthing muscles relax.
  • Raises pain threshold.
  • Conserves energy, reducing exhaustion.
  • Passive relaxation can be done by yourself.
  • Touch relaxation has been shown to make a laboring woman less anxious and better able to cope with contractions.
BreathingHelps you relax.Slow deep breathing and vocalization usually works best.
FocusingKeeps your mind focused so you have decreased ability to recognize pain signals.You can focus inwardly or outwardly.
Position Changes
  • Helps relieve nerve & joint irritation.
  • Upright positions use gravity to speed labor.
The more positions you try, the more comfortable you will be and easier your labor will progress.
SupportLabor can be very tiring, support people can give you a boost.Helps the most when there is help give more than one support person.
MeditationClears your mind of disturbing thoughts and fills it with pleasant & calming thoughts.Scripture can be wonderful to meditate on during labor.
  • Visualizing normal progress helps insure it.
  • You may also visualize yourself in a different place to help you relax more.
Rehearsing beforehand will make it more effective during labor.
Whatever music is soothing to you, but consider your birthing team also.
  • Helps your body to “go with the flow”.
  • Fills mind with pleasant sensations rather than painful ones.
  • Mellows whole environment and birthing team.
Studies show that moms usingmusic during labor need less pain medication.


  • As deep as possible.
  • Start whenever you feel discomfort.
  • Especially useful for back labor.
  • DO NOT submerge yourself in water after your bag of waters break, use shower only from that point on.
  • Supports muscles and bones, leaving more energy for the uterus.
  • Causes relation of thigh, back, abdominal, and birthing passage muscles.
  • Allows for surrender of body & mind that is not possible outside of water.
  • Bombards the nervous system with pleasant sensations, grid-locking the pathway for pain sensations to travel.
  • Research shows that laboring in water is safe.
  • Shorter, easier labors.
  • C-Section rate 1/3 less than women with the same risk factors.
  • Moms with high blood pressure showed a dramatic reduction in BP within minutes of immersing in the water.
  • Cervical dilation was twice as fast for those in water.
  • Decent of babies was twice as fast for those in water.
  • Mothers reported feeling less pain – more gain for less pain.
IV Pain Medication and EpiduralsProvides immediate pain relief and relaxation so you can rest.
  • Because it may slow or stop labor progression, it is not recommended for use in early labor.

Cesarean birth or c-section is the birth of a baby through surgical incisions made in the abdomen and uterus. There are many reasons why a c-section may be used to deliver your baby. A cesarean delivery may be planned in advance when certain conditions are known. In most cases, if problems arise, the decision is made during labor.

What are some of the reasons for a cesarean delivery?

  • Fetal Distress: While being monitored, the baby may show signs of distress. There are many causes, some of which are not foreseeable or preventable
  • Cephalopelvic Disproportion (CPD): If the baby’s head is poorly positioned or too large, the baby is unable to fit into the birth canal.
  • Failure to Progress: The cervix does not dilate completely. Therefore, the baby is unable to descend into the birth canal.
  • Multiple Pregnancy: When there are two or more babies, the babies may be born too early or not in good positions in the uterus so a cesarean birth may be needed.
  • Breech or Transverse Lie: This refers to the position of the baby in the uterus. If the baby is breech, with feet or buttocks descending first, or the baby is lying sideways (transverse) a cesarean is needed.
  • Bleeding: A problem with the placenta may cause excessive bleeding. Placenta previa is a condition in which the placenta is below the baby and covers all or part of the cervix. This will block the baby’s exit from the uterus. Another problem is placental abruption. This is when the placenta separates from the uterus before the baby is born and cuts off the flow of oxygen to the baby.
  • Previous Cesarean Birth: Having had a cesarean birth before plays a part in whether you will need to have one again. A vaginal delivery after a previous c-section is not a good option for women when there is a significant risk of rupture of the uterus.
  • Maternal Health Problems: The mother may have an ongoing health problem that makes vaginal birth risky. Such health problems include diabetes, kidney disease, high blood pressure, and uterine fibroids (or previous surgery for fibroids).
  • A Baby with Special Needs: If the baby is significantly premature, has a known health problem or birth defect, labor or vaginal birth could be risky.
  • Herpes: If the mother has an active herpes outbreak, the infection can be passed during vaginal birth. If you have a history of herpes, please inform your provider so you can start suppressive therapy in your third trimester.

What will happen if I need a C-Section?

All cesarean births, scheduled or not, require certain steps. Below are some of the things you can expect to happen in preparation for your surgery.

  • You will be asked to sign a consent
  • Your abdomen may be shaved
  • Your abdomen will be washed with a disinfectant
  • An IV will be started (if not already in place) to supply medications and fluids
  • A foley catheter (small tube) will be placed in your bladder to drain urine
  • A fetal monitor will be used to check the baby’s heart rate
  • Anesthesia will be given so that you do not feel pain during surgery. You may be given general anesthesia, an epidural block, or a spinal block. If general anesthesia is used, you will not be awake during delivery. In most hospitals, your birth partner may be with you in the operating room for the birth. However, this may depend on the urgency of the surgery.

What happens during the surgery?

In a cesarean birth, incisions are made in both the skin and the uterus. The skin incision may be transverse (side to side) or vertical (up and down), just above the pubic hairline. The muscles in your abdomen are moved and, in most cases, do not need to be cut. Another incision will be made in the wall of the uterus. This incision will also be either transverse or vertical. Your skin and uterine incisions may differ.

Once the incisions are made, the doctor presses on the top of your abdomen. You may feel a lot of pressure or find it hard to breathe when this is happening. This helps guide the baby out of the uterus. In some cases, a vacuum-like device may be needed. After the baby is delivered, the cord will be clamped and cut, and the placenta will be removed. The uterus will be closed with stitches that dissolve in the body. Stitches or staples may be used to close your skin.

What can I expect during recovery?

A cesarean section is major abdominal surgery and recovery takes 6-8 weeks. During this time you should rest as much as possible and do little more than care for your self and your new baby. Please call the office before you leave the hospital to schedule your 1 week post-op appointment.

While you recover, you may have:

  • Cramping, especially during breastfeeding
  • Bleeding or discharge for up to six weeks
  • Bleeding with clots
  • Pain in your incision

Here are some hints to make your recovery a little easier:

  • You can usually clean the incision with a little soap and water and pat dry.
  • Do not cover your incision unless it is draining.
  • Watch your incision for signs of infection, such as increasing redness, pain, and drainage.
  • Hold a pillow against your incision when changing positions or when you laugh or cough.
  • Avoid heavy lifting— nothing heavier than your baby.
  • Wait six weeks prior to sexual intercourse or introducing any foreign body into the vagina.

Call your healthcare provider if you experience:

  • A fever greater than 100.4
  • Redness, pain, or discharge at the incision site that gets worse
  • Clots (larger than a quarter) passing from the vagina repeatedly
  • Vaginal bleeding that excessively saturates a new maxi pad every hour
  • Severe abdominal pain

Unfortunately, no one can tell you the exact time you will go into labor. However, there are a few things you may experience as labor approaches.


This is when the baby “drops” down into the birth canal. With a first pregnant mother, this can happen 2-3 weeks before labor begins. You may suddenly find it easier to breathe but now feel the need to urinate more frequently. If this is not your first baby, “lightening” usually occurs immediately before or even during labor.


This is more commonly referred to as “show”, or your mucous plug. During pregnancy, a thick mucus plug covers the cervix to serve as a barrier against infection. When the cervix begins to thin and open, this discharge is expelled through the vagina. It may come out in one piece or in small amounts. The mucus can be green (snot-like) or blood-tinged (bloody show). This “show” may occur a few days or even a few weeks before labor begins. Many women do not even notice losing their mucus plug.

Rupture of Membranes:

This is when the amniotic sac that surrounds the baby (“bag of waters”) breaks. This may happen a few hours before the onset of contractions, or at any time during labor. The fluid should be clear, but it may be green or blood tinged. If your “bag of waters” breaks, whether you are having contractions or not, you should go to the hospital.


Throughout the second half of your pregnancy, you may have noticed your abdomen getting hard, then soft again, or you may feel like the baby is “balling up”. These irregular contractions may increase in frequency and intensity as your due date approaches. They may become very uncomfortable or even painful. These irregular contractions “false labor pains” are called Braxton Hicks contractions.

Could this be false labor?

Sometimes it is difficult to tell the difference between false labor and true labor without having your cervix checked by a doctor or nurse. A good way for you to tell the difference is to time the contractions. To time a contraction, put your hand on your abdomen. When your uterus begins to feel hard (pain/discomfort starts), that is when the contraction begins. When the uterus softens (pain/discomfort ends), that is when the contraction ends. To time the frequency of your contractions, start from the beginning of the first contraction to the start of the next contraction. This is how far apart your contractions are. You should time the frequency and duration of your contractions for at least an hour.

During true labor:

  • Contractions usually last about 30-70 seconds.
  • The contractions occur at regular intervals, getting longer, stronger, and closer together.
  • The contractions do not go away if you change position
  • The contractions are felt in the lower abdomen or back and come around to the front

During false labor:

  • The contractions are irregular and do not usually get closer together
  • The contractions may stop when you change position or rest
  • The contractions are often felt only in the abdomen

Go to the hospital when:

  • Your water breaks, regardless of contractions
  • You are having vaginal bleeding
  • You have constant severe pain
  • If you are more than 36 weeks pregnant and your contractions are consistently 5-7 minutes apart, or if you are less than 36 weeks pregnant and having more than 6 contractions/hour

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