The Last Month of Pregnancy
The last month of pregnancy is from 35-36 weeks to delivery. Full term is anywhere from 37 weeks and 42 weeks.
You will be seen every week from 36 weeks until delivery. Beginning at 36 weeks, we will check your cervix for signs of impending labor. At 36 weeks we will obtain a vaginal culture for Group B streptococcus screening.
By now, the baby should be head down or in the "vertex" presentation. If your baby is not head down we will discuss your options with you. These options include external cephalic version. External cephalic version is a procedure which we perform in the hospital to rotate the fetus from breech presentation to a vertex presentation. This is done by manipulation through the maternal abdomen. We will go through this procedure in detail if you are a candidate for this procedure. If you opt against external cephalic version you will need to schedule a cesarean section.
It is possible that the cervix starts to thin out or efface prior to dilation and this is not uncommon with the first baby. With the second (or later) baby, the head may or may not engage before labor. The cervix usually begins to dilate, then efface, and then the head descends.
Not infrequently, your cervix may dilate to 3 or even 4 centimeters before labor begins.
If you go beyond your due date, we use the term "Post-Dates." At your due date, we perform a biophysical profile (ultrasound to look at the placenta, fetal tone, movement, and amniotic fluid volume as well as fetal monitor strip). We typically induce labor at 41 weeks unless there is an indication for an earlier induction. Reasons for earlier induction would include diabetes, hypertension or other complication of pregnancy or pre-existing disease. We will evaluate the readiness of the cervix for labor with your cervical examination to determine your Bishop score. This will indicate to us the likelihood of a successful induction.
When to call: (Unless we instruct you otherwise)
1. Call when you are having strong contractions every 5 minutes for at least one hour. The contractions may at first feel like back pains, menstrual cramps or gas pains, and then get stronger. You may have slight bleeding ("bloody show") or a heavy mucous discharge. You do not need to call us when you pass your mucous plug. Passage of the mucous plug means your cervix is getting ready for labor, but your labor may not start immediately.
2. Call when your water breaks, even if you are not having any contractions. If your membranes are ruptured, but you are in labor, we may instruct you to stay at home for up to six hours to wait for labor only if all of the following are true:
- Your pregnancy has been normal
- Your group beta strep is negative
- The amniotic fluid is clear (not green or brown)
- The baby's head was down against the cervix at your last appointment
- You are feeling the baby kick after the membranes ruptured
- You do not have a history of rapid labor
Depending on your own individual characteristics and circumstances, if you are not in labor on your own after your water breaks, we may recommend Pitocin induction of labor after your water has broken. Our goal is to deliver your baby within 24 hours of when your membranes rupture.
3. Call when you have any bleeding like a period or more. If you have spotting on the toilet tissue, or blood-streaked mucous discharge, this is normal, and you shouldn't worry. But if you have bleeding that actually wets a pad, you need to call us.
Who to call:
During office hours, we can be reached by dialing our office number at 410-997-8444. When the office is closed call 410-368-8877. If you get no answer, you can call Labor and Delivery at 410-368-2610. If you call us during office hours, we may ask you to come in to the office for a labor check. If the office is closed, your call will be forwarded to the answering service at Saint Agnes Hospital, who will take your name and number. Please ensure to provide the operator with a number that you can be reached at. Whichever doctor is on call will answer you call as quickly as possible. If you have not heard from anyone in twenty minutes, call again. On nights and weekends, we will send you to the hospital for a labor check. You will need to go to the front entrance of the hospital and then proceed to the Admissions desk. They will direct you to Labor & Delivery.
On Labor and Delivery the nurse will have you change clothes and provide a urine specimen. The nurse will also check your blood pressure, place you on the fetal monitor and check your cervix. Your nurse will then call us and inform us of your condition. The hospital doctor may also be asked to evaluate you if we feel this is necessary.
With the first baby, labor is usually between 12 and 24 hours. It takes a variable amount of time to progress from 0 to 5 centimeters. After that, your cervix will usually dilate one centimeter per hour. When you get to 10 cm, you begin the second stage, or "pushing." This stage may take from one to three hours. You can expect us to be there by the time you are 5 cm, or earlier if you desire an epidural or have any problems.
With the second baby, labor is usually quicker.
If you are not planning to "go natural" and you need something for pain in early labor, we would administer narcotics through an I.V. Later in labor, we cannot give narcotics because there would not be enough time for the baby to clear the drugs from its circulation before birth. Later in labor, if you need medication for pain we would recommend an epidural. You will meet with the anesthesia team at the hospital upon your admission to discuss your pain management options, if you so desire. Typically, we try to avoid giving an epidural until labor is well established so we like to wait until you have a strong contraction pattern.
Labor and Delivery Expectations
We prefer our patients have an IV in place for any emergency situation that may develop. The IV is indicated for any abnormal fetal heart pattern, maternal dehydration, trial of labor after cesarean sections, epidural and IV pain management.
2. Fetal monitoring:
We prefer continuous electronic fetal monitoring during the active phase of labor. Prior to this point, fetal monitoring for at least twenty minutes every two hours is routine. If all is going well, and you wish to walk around the rest of the time, the on call provider will discuss whether you may remain of the monitor during this time. If you need Pitocin or you have meconium stained amniotic fluid, you must be monitored continuously.
3. Group beta streptococcus (GBS):
Approximately 10-30% of women are colonized with GBS bacteria in the vagina or rectum. It does not usually cause any problems to the woman. However, it may be a cause of urinary tract infection or cause of vaginitis. If a newborn comes in contact with the GBS bacteria, the baby may develop a severe infection. We screen all our OB patients between 35-37 weeks for presence of this bacteria. If it is present, we treat with antibiotics in labor to avoid transmission of the bacteria to the baby during delivery.
4. Episiotomy: This is not routine. If indicated your provider will discuss this with you.
5. Enemas are not used
6. Common Indications for Cesarean section:
- Fetal distress or intolerance to labor
- Cephalopelvic disproportion, baby is too big for your pelvis
- Breech presentation
- Placenta previa
Circumcisions are typically done the day after delivery. Circumcisions are not considered medically necessary and as such are considered an elective cosmetic procedure. The risks of the procedure include but are not limited to infection, excessive bleeding, scarring, penile injury, unhappiness with cosmetic result and need for surgical revision. The possibility of requiring a future procedure to take off more foreskin or correct scarring exist. If you do not choose to have this done there is less than a 10% chance it will ever need to be done for medical reasons. It is possible that the procedure may not be able to be performed if your pediatrician does not clear the baby for this procedure or we determine that your child is not a candidate for the circumcision.
Some insurance companies do not pay for circumcision so you should check with your insurance provider.
8. Hospital stay:
1-2 nights for a vaginal delivery; 3-4 nights for a cesarean section. Your insurance company will have rules about your length of stay. Unless there is a medical reason, such as heavy bleeding or fever, we cannot extend your stay in the hospital without risking a big bill for you.
After you have the baby, you will be given a postpartum instruction sheet in the hospital.
9. Follow up:
You will need to schedule a six week postpartum follow up visit. If you have had a cesarean section we typically have you follow up 2 weeks post your cesarean section. If you developed high blood pressure during your hospitalization or pregnancy you may be asked to return to the office within one week of discharge. Please refer to your specific postpartum instructions. If you are unclear of when you should follow up please call the office.