Call the Doctor, STAT! Eclamptic Seizure

We have been looking at various reasons your Labor Room nurse would be shouting, "Call the Doctor, STAT!" All of the others have been things which would occur prior to the birth of the baby. An Eclamptic seizure, however, could occur before delivery, after delivery and even up to two weeks postpartum. To fully understand an Eclamptic seizure, we must first discuss what used to be called Pre-eclampsia, now referred to as Pregnancy-Induced-Hypertension, or PIH.


PREGNANCY INDUCED HYPERTENSION


Pregnancy-Induced-Hypertension, or PIH, is a form of high blood pressure particular to pregnancy which occurs after twenty weeks of gestation and occurs in 5-8 percent of pregnancies. Years ago this was known as toxemia, then it was called Pre-eclampsia. While no one knows for sure what causes PIH, there are some factors which can increase the likelihood of PIH occuring:

• A mother younger than 20
• A mother older than 40
• A mother with chronic hypertension
• Multiple gestation (twins or triplets)
• Kidney disease
• Diabetes
• PIH with previous pregnancies
• Subsequent pregnancy with a new partner

SIGNS AND SYMPTOMS

There are three primary signs of PIH. These are:

• Protein in the urine
• Edema (swelling)
• High blood pressure (this would be compared to your blood pressure taken at your first visit with your health care provider.)

Other symptoms which could be associated with PIH are:

• Sudden weight gain - which can be a sign of retained fluid
• Visual changes such as blurred or double vision - can be related to swelling in the brain
• Nausea and vomiting - can be related to liver involvement
• Right-sided upper abdominal pain or pain around the stomach -- related to liver involvement
• Urinating small amounts or darker colored urine
• Headaches

When a pregnant woman develops PIH, the resistance in the blood vessels increases causing hinderance against the blood flow to organ systems, including the liver, kidneys, brain, uterus and placenta. This is why the signs and symptoms include so many different types of symptoms.

PIH can also contribute to Placenta Abruption and intrauterine growth restriction (poor fetal growth)

Perhaps the most frightening of the complications of PIH is the possibility of Eclamptic seizures. Eclampsia (the term for PIH once a woman has had a seizure related to PIH), is a severe form of PIH which occurs less than once in every 100 women with PIH.

Eclamptic seizures can occur in the woman with PIH prior to delivery or within the first 24 hours after delivery. More rarely, they can occur up to a week after delivery. These seizures are almost always treated with an infusion of Magnesium Sulfate which helps to block the neuromuscular transmission of seizure activity.

Your health care providers will also want to limit your central nervous system stimulation during your treatment by keeping your room darker and quiet. They may want to limit visitors to help accomplish this. Blood levels of Magnesium may be tested at regular levels to make sure the levels are therapeutic, but also not too high. Since Magnesium also causes extreme muscle weakness, you may be confined to bed during treatment. Monitoring your fluid levels will be extremely important and you will most likely have an indwelling (foley) catheter inserted while the Magnesium is being infused.

Eclampsia is a serious complication of pregnancy and your health care provider will be monitoring your condition very carefully. While you may find that many of the things you expected from your birth experience may be different from what you imagined, it is important to remember that your health, and the health of your baby is the first and primary goal throughout labor and delivery.

Most women and babies have good outcomes in spite of complications of PIH or eclampsia.

Call the Doctor, STAT! Non-reassurring Fetal Heart Tones

We've been looking at emergency situations during labor which prompt the nurse to "Call the Doctor, STAT!" Perhaps the most confusing of these is the situation of Non-reassuring fetal heart tones, formerly known as "fetal distress".

Unlike Placenta Previa, or Placental Abruption, this condition can't be confirmed with an ultrasound or lab test. The diagnosis is totally in the eyes of the health care provider interpreting the fetal monitor tracing. Before we can discuss exactly what is involved in "non-reassuring fetal heart tones", we have to discuss the basics of fetal monitoring.

FETAL MONITORING

The electronic fetal monitor continuously records the fetal heart rate. It shows a cumulative pattern of increases and decreases in the fetal heart rate over time and in response to uterine contractions. There are several components of the fetal heart rate tracing which the health care provider will examine when trying to predict the status of the baby:

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• Baseline rate -- the normal term fetus will have a heart rate between 110 and 160 beats per minute, exclusive of when the baby's heart rate is accelerating or decelerating. This means that if the heart rate is going up or going down, that isn't the baseline unless it has been that way for ten minutes. There are things that can cause the baby's heart rate to be less than 110 beats and still be normal. Certain positions of the fetal head can cause the baby's heart rate to run a little lower, for example. There are also things which can cause the baby's heart rate to run a little faster, such as maternal infection or fever.

• Variability -- this is a jagged or uneven aspect to the baseline, the fact that the line is not straight or flat. This is actually the most important indicator that the baby is doing well, receiving sufficient oxygen and responding well to any stress it might be experiencing. Even in the presence of drops in the baby's heart beat, this is a reassuring feature.

• Accelerations -- episodes of increases in the baby's heart rate that increase for at least fifteen beats above the baseline for at least fifteen seconds are very reassuring and indicate the baby is receiving sufficient oxygen and responding well to any stress it might be experiencing.

• Decelerations -- most babies will have some type of drops, or decelerations, of the fetal heart rate in labor. The most important thing is not how low the heart rate drops, but the pattern of the deceleration, especially in relation to the contraction, and the physiology of deceleration. In other words, why did the deceleration occur?
  • Some may occur simply due to pressure on the baby's head as the baby comes down the birth canal.
    
  • Some may occur as a result of compression of the umbilical cord. These types are actually the most common of all the fetal heart rate decelerations.
    
  • Some may occur as a result of diminished placental/uterine functioning. This could happen because of something as simple as the mother positioned directly on her back, compressing the large blood vessels, or because of severe emergency situations we have already discussed such as prolapsed cord, abruption or placenta previa.

NON-REASSURING FETAL HEART TONES

Your health care provider will examine the fetal heart rate tracing carefully, especially looking for reassuring features such as a normal baseline rate, normal variability and accelerations. Absence of one or more of these reassuring features will be noted by your health care provider. If decelerations are present, the pattern and depth will be viewed in light of the reassuring features and also the stage of labor. The plan of care would be different for a woman who is minutes away from labor than for a woman who is only dilated one centimeter.

Sometimes the baby's heart rate will go down precipitously. The nurse will often turn the mother from side to side (in an attempt to alleviate any pressure on the umbilical cord and to maximize uterine/placental blood flow). Oxygen may be administered to the mother to increase the amount that can be transported to the baby. IV fluids will be started or increased. A vaginal exam may be performed to ascertain the status of labor and to rule out prolapsed cord. If the fetal heart rate has a positive response to these actions, your health care provider may decide to continue to watch your baby carefully as your labor continues. If the fetal heart rate does not respond, your health care provider will most likely decide immediate intervention is warranted.

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It is not uncommon to have a baby that shows concerning signs on the fetal monitor, who at delivery is vigorous, crying and has perfect Apgar scores. This is because the electronic fetal monitor is meant to be a positive predictive device -- it is meant to predict that a baby is doing well, not to predict which baby is doing poorly. Also, even though a baby may show signs of stress, babies often have more reserve and resilience than we suspect. There is no way to know before the baby is born, which one will and which one won't have that extra reserve. The goal is to have a healthy baby and a healthy mother.

Call the Doctor, STAT! Placenta Previa

We have been looking at reasons why your nurse may suddenly cry out, "Call the Doctor, STAT!" while you are in labor. We have previously looked at Prolapsed Cord and Placental Abruption. Today we will look at another potential hemorrhagic emergency, placenta previa.


PLACENTA PREVIA

First of all, placenta previa is uncommon. It occurs in about 1 out of every 200 or so pregnancies. It can cause excessive bleeding in pregnancy because it is a condition in which the placenta attaches low in the uterus, and either partially or completely covers the cervix. When the cervix begins to efface (thin out) and dilate (open up) in preparation for labor --or in response to preterm contractions -- the placenta becomes detached, triggering bleeding and sometimes hemorrhaging.

Unlike placenta abruption, which we discussed last time, placenta previa is most often found before a serious threat to mother or baby occurs, or during a routine ultrasound.

SIGNS AND SYMPTOMS

The most common sign of placenta previa is painless, bright red bleeding. If you read our discussion on placental abruption, you may remember bleeding with abruption was associated with abdominal pain, often severe. Placenta previa however, is painless. The bleeding with placenta previa will usually occur during the end of the second or beginning of the third trimester. There may also be contractions with the bleeding. If the contractions were significant to cause cervical effacement or dilation, that could have precipitated the bleeding episode. If not, the bleeding itself could have irritated the uterine muscle enough to begin contractions.

TYPES OF PLACENTA PREVIA

There are three different types of placenta previa:

• Total previa -- the placenta totally covers the cervix
• Partial previa -- the placenta partially covers the cervix
• Marginal previa -- the placenta extends to the edge of the cervix

RISK FACTORS

While it is not possible to determine precisely who will and who won't develop placenta previa, it is more common in women with one or more of the following:

• Having had more than one child
• Having had a previous Cesarean delivery or uterine surgery
• A large placenta (as with multiple pregnancies)
• An unusually shaped uterus
• Asian women
• Smokers
• Women 35 or older

If you have been diagnosed with a placenta which is NOT placenta previa, you do not have to worry, your placenta will not move down to the cervix. If you have been diagnosed with placenta previa early in your pregnancy, as your pregnancy continues and the uterus grows and expands, the placenta usually moves upward and away from the cervix. Depending upon the type of previa initially, you may have little to be concerned about by the time labor rolls around. However, the earlier the diagnosis and the more of the placenta covering the cervix at the time of diagnosis, the more likely you are to have the condition for the entire pregnancy.

DIAGNOSIS

Diagnosis of placenta previa is done by ultrasound. Many cases of placenta previa are detected during routine ultrasounds.


TREATMENT

If you have been diagnosed as having placenta previa, there is one sentence you should practice over and over: "I have placenta previa!" If you go to the hospital for any reason, or you see a health care provider other than the one you normally see, these should be the first words out of your mouth. Once you have been diagnosed with placenta previa, examining the cervix can lead to heavy bleeding, even hemorrhaging. Health care providers need to know about your previa as soon as they see you.

By the same token, anything else that can put pressure against the cervix and placenta can also cause bleeding. So intercourse will be off-limits for the rest of the pregnancy as well.

Your physician will also ask you not to travel once a diagnosis of placenta previa has been made. Some health care providers ask that you no longer exercise when you have placenta previa. Some even put you on bedrest for the remainder of the pregnancy.

Treatment for placenta previa will depend upon the extent of your bleeding and the status of your baby. If the bleeding is severe enough to cause hemorrhage and it cannot be controlled, an emergency cesarean delivery will usually be done regardless of the gestational age of your baby. This is because this type of bleeding can lead to maternal shock or even death.

If you have bleeding episodes that are not threatening to you or the baby, you may remain on bedrest and have frequent hospital visits.


If you have none or minimal bleeding, you may be allowed to continue your routine -- with a few modifications-- and with frequent visits to your health care provider. Depending upon the gestational age of your baby, your health care provider may desire to give you steroids to help mature the baby's lungs in case the baby has to be delivered prior to term.

DEALING WITH BEDREST AND PREVIA

If you are placed on bedrest for the remainder of your pregnancy, the thought may be heavenly -- for the first day. But it won't take long to seem like a prison. Try to take advantage of the time. Remember the goal is to have a healthy mother and baby, which is well worth the price! Here are some suggestions for your time in bed:

• Write a daily letter to the baby
• Read about newborn care each day
• Organize your photo albums
• Catch up on thank-you notes
• Shop for the holidays online
• Read about C-Section and prepare for that possibility
• Make a list of questions to ask your health care provider at your next visit
• Balance your checkbook (maybe you should do this one before you do the shopping)
• Call relatives you haven't talked to in ages but have been meaning to call
• Write a journal for the baby about yourself: your childhood, growing up, how you met the baby's father, where you live, how you prepared for the baby, etc.

TAKE HELP THAT IS OFFERED

Most people mean it when they say "Call me if you need anything." They just don't know what you need, or what you want them to do. Find specific, concrete things for them to do. Does your best friend make killer lasagna? Tell her what night you want her to bring it! Does your mom make great shopping runs? Make a list and ask her to pick up what you need from the store.

When you ask you family and friends to help you in times of need, they feel as if you trust them. They feel more of a part of what you are experiencing and that they have lightened your load in some way. Let them help, it helps you and it helps them, too.

Call the Doctor, STAT! Abruption

We are continuing our discussion of emergency situations in Labor & Delivery. We all would prefer that our labor experience go as smoothly as possible, with as few interventions as possible, but sometimes things happen that necessitate the nurse crying out, "Call the Doctor, STAT!"


ABRUPTION

Placental abruption is the separation of the placenta from the inner wall of the uterus before

Image by {tribal} photography via Flickr

delivery. This is a serious, but uncommon, complication of pregnancy, occurring in only about 1% of all pregnant women. It usually occurs in the third trimester of pregnancy, but can occur as early as the 20th week of pregnancy. Most cases of abruption can be successfully treated, depending upon the amount of and type of separation that occurs, but abruption always requires immediate medical attention. Because placental separation can deprive the baby of oxygen and can cause heavy bleeding in the mother, untreated placental abruption puts both the mother and the baby in danger.


SIGNS AND SYMPTOMS

So how do you know if you might be expericing a placental abruption? The signs and symptoms would include one or more of the following:

• Vaginal bleeding (although in some cases, there is no bleeding)
• Abdominal pain
• Uterine tenderness
• Rapid uterine contractions, often with only a few seconds rest in between
• Back pain (may be felt in place of or with, abdominal pain)
• If being monitored in the hospital, changes in the fetal heart rate may be noticed

The amount of bleeding with placenta abruption can vary greatly, from none at all (in 20% of cases) to hemorrhaging. The amount of bleeding isn't necessarily proportionate to how much the placenta has separated from the uterus. For this reason any vaginal bleeding in the third trimest should be reported to your health care provider.

The pain associated with placental abruption can be just as varying as the bleeding. Some women can come in with incredible pain, some with a continual nagging backache and some with no pain at all. The abdominal and back pain often can begin suddenly.

FACTORS AND CAUSES

While no one can accurately predict when and to whom an abruption will occur, there are some factors which can increase the risk of placental abruption, including:

• Previous pregnancies -- the more times you have been pregnant, the more risk you have for placental abruption
• Multiple pregnancy --Being pregnant with twins, triplets or other multiples
  
• Previous placenta abruption --having had an abruption before may increase your risk by as much as 15 percent or more
• High blood pressure -- Both chronic hypertension and pregnancy-induced hypertension increase the risk of placental abruption
• Tobacco usage
  
• Cocaine and/or Methamphetamine use during pregnancy -- both of these substances can contribute to placental abruption
• Age -- Women of advanced maternal age --older than 35 -- have higher risk for an abruption
• Abdominal trauma -- such as a motor vehicle accident, a fall on the abdomen or a direct blow to the abdomen

DIAGNOSIS AND TREATMENT

Diagnosis of placental abruption will depend upon the severity of the symptoms. If there is hemorrhaging present or fetal heart rate changes inconsistent with expected fetal oxygenation, your health care provider will not spend much time on diagnostics. The primary focus will be a healthy baby and a healthy mother. If the extent of abruption is such that it jeopardizes your health or the baby's health, emergency delivery will be in order. The placenta can actually completely detach, causing severe changes in the fetal heart rate and hemorrhaging in the mother. In severe cases of abruption, fetal death is possible.

There is no way to stop the placenta from detaching once it has begun and no way to reattach it once it has begun to separate.

If the baby's fetal heart rate is stable and the bleeding is minimal, or stable, then there is probably time for more diagnostic testing. These tests may include an ultrasound, blood tests and continued fetal monitoring.

If it is determined that the abruption is minimal and the fetal heart pattern is normal, you may remain in the hospital for close monitoring. If your bleeding stops, and the baby's condition is stable, you may be allowed to go home with frequent follow-up visits at your health care provider.

CONCLUSION

The final diagnosis of placental abruption can only be made after delivery, when the placenta is examined. Don't hesitate to call your health care provider for any episode of third trimester bleeding, or for abdominal or back pain that is unlike the normal back discomfort you have been experiencing toward the end of labor.

Call the Doctor, STAT! Prolapsed Cord

Whenever we are in labor, the last thing we want to hear is our nurse call for our health care provider emergently. We want everything to go smoothly, calmly and as gently as possible.

There are times in Labor & Delivery, however, when things just don't go the way we would like --from either the patient's viewpoint or the nurses'. Working in a busy obstetric unit is a series of moments of tedium punctuated by moments of sheer excitement and awe. Sometimes that excitement is good, sometimes not.

We will begin today looking at some of the many causes of that excitement in Labor & Delivery, some of those reasons to "Call the Doctor, STAT!"

PROLAPSED CORD

The first emergency situation we will discuss is that of a prolapsed cord. This is a true obstetrical emergency and when it occurs, things will be happening very fast. The word prolapse literally means, to fall out of place. This is exactly what occurs with a prolapsed cord.

During a prolapsed cord, the baby's umbilical cord prolapses -- or falls out of place -- most often after the membranes have ruptured, through the cervix into the vagina ahead of the baby. The pressure from the presenting part of the baby compresses the umbilical cord, resulting in a lack of blood flow to the baby. If rapid interventions are not implemented, the baby can suffer from a lack of oxygen. Because of this risk of decreased oxygenation to the baby, cord prolapse must be dealt with immediately.

Cord prolapse occurs roughly in about 0.6% of births. Conditions in which the presenting part of the baby does not apply well against the cervix can lead tocord prolapse. These might include breech presentations (where the baby is coming buttocks or feet first), premature infants, (whose smaller heads do not apply as well again the cervix) and women who have had several babies before (whose babies do not tend to descend until the later phases of labor). Increased amniotic fluid, a longer umbilical cord and a presenting part which is not engaged in the pelvis (has not reached the level of the ischial spines in the pelvis, or 0 station) when the membranes rupture, can also be contributing factors.

SIGNS OF PROLAPSED CORD

Often the first sign that a prolapsed cord has occurred is a severe and persistent drop in the fetal heart rate. A vaginal exam will confirm the presence of a loop of cord in the vagina. The cord does not have to be visualized to know it is there, the pulsating of the fetal heart rate through the cord is unmistakable during a vaginal exam to the trained examiner. Treating the problem begins immediately.

TREATMENT

The examiner will gently lift the presenting part off the cord with the two fingers used during the vaginal examination. The examiner will continue to relieve the pressure off the cord, thereby keeping compression of the cord from occurring and restoring fetal blood flow, while preparations for an emergency Cesarean Section are being completed. Don't be shocked when the examiner has to climb into the bed to fit through the doorway -- removing their hand won't be an option until your baby is safe.

Sometimes the mother is placed in a knee-chest position in an attempt to allow gravity to relieve the pressure off the cord. If she has had an epidural already, this may not be an option.

The mother may also be given a medication called Terbutaline, or Brethine, to stop or slow down any contractions she is having. Some of these medications can make your heart race, or make you feel somewhat anxious. These are normal side effects.

On a rare occasion, a prolapsed cord can present as an occult prolapse. This can occur even if the mother's membranes are not ruptured. The cord is compressed by the baby's head or

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shoulder, resulting in a fetal heart rate pattern that becomes suggestive of potential hypoxemia (low oxygen). Attempts to resuscitate the baby in utero would be made first by changing the mother's position -- this can often change the position of the cord; giving the mother oxygen, increasing intranvenous fluids to the mother (to increase her blood volume and the amount of oxygen she can transport to the baby). If these measures are ineffective, a Cesearean delivery would be necessary. Often when performing a Cesarean Section for deliveries such as this, immediately prior to delivering the baby, the loop of cord can be seen at the baby's head.

Fortunately, if quick interventions are implemented, most babies have adequate reserve to withstand this stressful situation.

MY FIRST

Of all the times I have been involved in a prolapsed cord, and been the one to be lifting up the presenting part until the baby was delivered, none has been quite as memorable to me as the first.

She was pregnant with her first baby which was in a breech position and when her water broke, the umbilical cord washed out with the amniotic fluid. There we were, she and I in her bed together. My hand was in her vagina, my two fingers holding the baby off the umbilical cord, our faces only a couple of feet apart. I spoke quietly to her, to calm her fears as I explained to her everything the other nurses were doing to her to prepare her for surgery. She kept her eyes riveted on mine as if eye contact with me was the only thing that kept her from sheer panic.

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Occurring back in the days before routine ultrasounds, she didn't know the sex of her baby. I told her on the way to the operating room that she was having a boy since I could easily feel the little boy parts with my fingers.

After this little boy was born and she had awakened from the groggy haze common after general anesthesia, I went to see her in the Recovery. We chatted for a few minutes about the baby and the general rush of the delivery.

Then she smiled at me and said, "I have only been intimate like that with one other person." She paused and asked, "Will you marry me?"

I Should Have Known Better

Dedicated to my grandson who is even more precious now that he was then. Here is the story of his birth-day:

After more than thirty years of helping babies come into the world, I had participated in many roles. I had been the nurse, the scrub nurse, a surgical first assistant and yes, I had delivered more than my share of babies myself. I had been the mother and I had filled the role of coach for missing or inadequate fathers over the years. But there was one role I had not yet had; I had never been the grandmother.

My son and his wife were scheduled to deliver their first child, my first grandchild on Tuesday, August 1^st, in the Labor & Delivery unit where I was Assistant Nurse Manager. I felt a great deal of pressure that their day should be as perfect as I could make it. I had asked one of our charge nurses, and a good friend of mine to sit with them. Sheila had a sweet, steady personality and I trusted her ability and skill impeccably. She also had a nurse with her on orientation. Ashley was not a new nurse; she came to us from the Cardiac department, but she was new to obstetrics. Being close to Noah and Aimee’s age, I felt they would relate to her very easily and her experience with adult emergencies gave me an even greater layer of comfort. I looked forward to visiting with them throughout labor. I should have known better, as babies have a way of changing plans, and Jackson was no different.

Monday, July 31^st started off as a very busy day. We had a unit full of patients from the very beginning. Just as we would think we would be clearing off our board a little, the phone would ring with another patient on the way. One of those calls really got my attention. Aimee was coming in today! Her water was broken and she was on her way to the hospital. We readjusted the patient assignments and prepared room eight for this most special – to me – of patients.

A few minutes later the Emergency Room called with a familiar phone call. They had an “OB” downstairs. I was quick to volunteer to go and pick up this patient! Downstairs, I found Aimee in the wheelchair, but was surprised to see my son already there, as well. As Sheila and Ashley began the admission process, I checked on my patient – it was busy enough that day I had an observation patient that ironically worked with Aimee's father. My plan was to give report to another nurse when our census dropped down, so that I could take the role of "Mom" and enjoy the day. I should have known better. We only got busier.

As one patient delivered, another patient came in to take her place. I would check on my patient, help a nurse admit another patient, check on my patient, help a nurse in a delivery, check on my patient, pop my head in Aimee's room, check on my patient. I don’t think I spent ten whole minutes visiting with Aimee and Noah during her labor! Finally, about 5:30pm, I was able to relinquish the role of nurse and manager and simply be Mom.

It looked like we had a few hours left to go in Aimee's labor, so Noah, his sisters and I went to the cafeteria grab a bite to eat. As hungry as I was, I couldn’t eat more than soup. I felt nervous about what was happening upstairs and I thought Noah was experiencing the same thing.

Then the phone rang. Aimee was an anterior lip! This meant that her cervix had dilated to 9+ centimeters. It’s called an anterior lip because the cervix is felt only over the top (or anterior) portion and this soft, crescent portion of cervix feels much like a lip. She would be ready to push in just a few minutes. As we headed back upstairs, I told them that since this was her first baby she might have and hour or two to push, it may still be awhile before we would see a baby. I should have known better!

Aimee and Noah began the pushing process to Sheila and Ashley’s coaching. To maintain their privacy, the door was closed. Noah’s sisters, Aimee’s mother and sister and I waited in the labor room next door.

It felt odd, after decades of being such an integral part of so many deliveries to be on the outside of this very important one, but it also felt perfect. This was their moment. I had seen enough pushy grandmothers over years who mistakenly thought the delivery of their grandchild was all about them to know I didn’t have to be there at all. So I sat on a chair outside the door, listening. For anyone else, this might have been a futile experience. The door was thick and it was difficult to hear, but after attending literally thousands of deliveries, I knew exactly what I was listening for.

I could hear, muffled through the door, the sounds of Noah coaching Aimee. The tenderness of his encouraging words touched my heart. Then heard what I was really listening for…that small, sweet baby cry. Our baby was here -- it makes me cry again just writing about it -- Jackson was here. I didn’t have to be in there. I knew what was happening and I knew it was more special for them because they shared it together alone. I trusted Sheila enough to know she could handle any emergency and the fact that the door stayed closed was a very reassuring sign – no additional help was needed. Noah and Aimee would share their son with us when they were ready.

What a wonderful experience it was to be introduced to this new life with our family and the people I with whom I work so closely. What a beautiful mother! What a proud father! And what a beautiful baby! We passed Jackson around and took pictures and enjoyed the moment and then went home with the expectation to spend the next day doing much the same. I should have known better.

When I came around the corner in L&D the next morning I could tell by the general state of the unit that it had been a wild night and one glance at the board told me it would likely be a wild day as well. We had a board full of patients, again, and not a board full of nurses. It appeared I would be spending my day, not out in Aimee’s room visiting and spoiling my grandson as I had planned, but taking patients and running this crazy board. I made assignments as fast as possible and ran over to the nursery to get my hands on my grandson while I could. Sitting in the quiet of the nursery, the sweetness of that fragrant bundle nestled in my arms, I felt whisked away to some sweet, lovely planet. I could have sat there all day – or until Jackson needed to nurse—but as it was, I only had ten minutes at the very most. But I relished those ten minutes and then reluctantly put him back in his bassinet and headed back to work. I remember thinking how that would be a great way to start every workday! I thought I would have more time throughout the day to see Noah and Aimee and hold Jackson than I ended up having, --yes, I should have known better --but the patients and babies just kept coming. In the end, we had about thirteen patients through the unit that day, a busy day for us. I was exhausted, physically and emotionally. By seven pm (four hours after my shift was supposed to end) I had not eaten all day or seen my grandson. My family had popped in to see me on the way to see Jackson, which only accentuated the fact that I had not seen Jackson since early in the morning.

Finally, I was able to make my way to Aimee’s room and to do what I had been longing to do all day long. I took my grandson in my arms, and had a visit with my son and daughter-in-law, my husband and daughters and enjoyed the quiet pleasure of being a grandmother instead of a nurse.

It had been an incredibly busy day which had begun with me rocking this baby in a rocker in the nursery and it had ended twelve hours later with me rocking this baby in a rocker in his mother’s room.

As I looked into his face I didn’t want to take my eyes away, partly because I found him to be so handsome, but also because I saw in that face the face of history. I saw my husband, my son; I saw my own father; I saw my daughter-in-law and her father. As I looked at this face that already I loved so much, I couldn’t help but remember the words from a Dan Fogelberg song:

“And the sons become the fathers,

and the daughters will be wives,

The torch is passed from hand to hand

in the struggle through our lives.

As the generations wander,

the lineage survives.

And all of us from dust to dust,

we all become forefathers by and by.”

As I sat and rocked my first grandchild…my grandson… I realized that in becoming a grandmother, I had actually become…a forefather.

“Children's children are the crown of old men;

and the glory of children are their fathers.”

Proverbs 17:6

Eating For Two

That’s a phrase we often hear to describe the dietary habits of the pregnant woman, and sometimes it really feels like you are eating for two. The fact is, you only need 300 more calories everyday when you are pregnant.

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Watch your portion size, it's easy to eat more than you think you are eating. Also, watch out for empty calories, like sugar and fat, that are high in calories, but offer little in the way of nutrients. This is one way, even before you hold your baby for the first time, you can begin to take special care of your baby, and take care of yourself, too.


The foods you eat during pregnancy are important, because those foods contain the nutrients your baby is using to grow and develop. You will need to make good choices for both of you, eating a variety of different foods that will provide the necessary vitamins and minerals you both need.


Start Before the Beginning

The best time to eat right for your baby is even before you become pregnant. If you are planning on becoming pregnant, visit your health care provider. You can discuss how to make healthy food choices before and during your pregnancy and which nutrients are especially important.


Once You Are Pregnant

Early in pregnancy, you may find that morning sickness can affect how you feel about eating. The smell of certain foods may take away your appetite, or you may even find yourself craving certain foods. It is important to continue to eat a variety of foods each day to ensure you are getting the right amount of nutrients.


Less, More often. Instead of eating three large meals during the day, think of eating several smaller meals, or "grazing" throughout the day. Often, these smaller meals are easier to tolerate, especially if morning sickness or heartburn become problems.


Begin each day with breakfast. If you have trouble with morning sickness, try to eat a few bites of crackers - the whole grain variety offers more nutrients and may settle your stomach better. Try keeping some by your bedside so you can eat them even before you get out of bed. Then eat the rest of your breakfast as usual.


Eat high fiber foods each day. Fresh fruits and vegetables, whole grain pastas, beans, whole grain breads and brown rice help to counteract or prevent the constipation that can occur during pregnancy. Drink plenty of water -- enough to keep your urine a pale yellow -- and get some form of daily activity, even a short walk.

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Keep it close. Make healthy choices easy by keeping healthy foods on hand. A bowl of fresh fruit makes it easy to grab a healthy snack when you are hungry. (Remember, fatty foods, sweets and junk food don't supply your baby with the necessary nutrients to grow and develop and give you added weight to be removed after the baby is born.) Plan ahead for those moments of hunger and you won't be so tempted to make poor choices.


Guidelines for Pregnancy

You should eat at least the minimum number of servings from each group and then add additional servings to meet your caloric needs. Remember, a serving and a "helping" are not always the same thing. For example, a serving of Grain is 1/2 cup of cooked pasta, but often the helping size we are given is much more.


Breads, Cereals and Grains

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Pregnant women need 6 to 11 servings from this food group.

A serving from this group is one slice of bread, 1 cup of ready-to-eat cereal or 1/2 cup cooked rice, pasta or cereal.


Vegetables
You should eat 2 1/2 to 3 cups of vegetables each day.

Vegetables are a primary source of vitamins A and C along with minerals and fiber. Eating foods rich in Vitamin C will help your body absorb the iron in the foods you eat. The vegetables offering the best sources of nutrients you need when you are pregnant:


· Carrots

· Sweet potatoes

· Pumpkin

· Spinach

· Cooked greens (such as kale, collards, turnip greens, and beet greens)

· Winter squash

· Tomatoes and tomato sauces

Fruits

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You need 1 1/2 cups of fruit each day.

1/2 cup of fruit could be 16 grapes, or 1/2 cup of fruit juice, a half a small orange, apple or banana. When possible, the whole fresh fruit is preferred over fruit juice. The fruits offering the best sources of nutrients you need when you are pregnant:


· Cantaloupe

· Honeydew melon

· Mangoes

· Prunes or prune juice

· Bananas

· Apricots

· Oranges and orange juice

· Red or pink grapefruit

· Avocado


Milk, Yogurt and Cheese

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You will need 3 cups of dairy products each day.

These will provide calcium and protein. Calcium is essential in the formation of bones and teeth. 1 cup of milk is equal to 1 1/2 cups of natural cheese.


If you don't like milk, try adding milk to casseroles, meat loaf or soups in the form of non-fat dry or powdered milk. This will give you the needed calcium, but won't affect the taste of your recipe.


Try adding cheese to a salad, on top of soup, on vegetables or in a sandwich. Substitute plain yogurt for mayonnaise. Eat pudding for dessert, but limit your intake of pudding and ice cream. Even though they provide the necessary calcium, they are also high in sugar and fat.


NOTE: Soft cheeses such as feta, Brie, and goat cheese should be avoided.


Meat, Poultry, Fish, Dry Beans, Eggs and Nuts

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You need 5 1/2 to 6 1/2 ounces from this group daily.

The major nutrient of this group is protein, necessary for the growth of new cells. Recommended sources of protein include:


· Cooked dry beans and peas (such as pinto beans, soybeans, white beans, lentils, kidney beans, chickpeas)

· Nuts and seeds (such as sunflower seeds, almonds, hazelnuts, pine nuts, peanuts, and peanut butter)

· Lean beef, lamb, and pork

· Shrimp, clams, oysters, and crab

· Halibut, cod, rainbow trout, herring, sardines, rockfish, and yellowfin tuna


An ounce of this food group could be one egg, 1/2 cup of nuts or 1/4 cup of cooked dried beans.


Eat no more than 12 ounces of any fish per week (equal to four 3-ounce servings—each about the size of a deck of cards).


NOTE: Avoid shark, swordfish, king mackerel, or tilefish when you are pregnant or breastfeeding. They contain high levels of mercury. Ready-to-eat meats including lunch meats, hot dogs, and deli meats may contain bacteria called listeria that are harmful to unborn babies. Cooking lunch meats, hot dogs, and deli meats until steaming hot can kill the bacteria and make these meats safe to eat.


Raw fish such as sushi, sashimi, or ceviche and raw or undercooked meat and poultry should be avoided. These foods can contain harmful bacteria. Cook fish, meat, and poultry thoroughly before eating.



What Not To Eat


Just as there are foods to concentrate on eating during pregnancy, there are things to avoid as well. Certain foods may harm your baby if you ingest them while you are pregnant.


Alcohol. Instead of wine, beer, or a mixed drink, enjoy apple cider, tomato juice, sparkling water, or other nonalcoholic beverages.

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Large amounts of caffeine-containing beverages. If you are a heavy coffee, tea, or soda drinker, talk to your health care provider about whether you should limit your caffeine intake. Try a decaffeinated version of your favorite beverage.


Non-food. Some pregnant women may crave eating things that are not food, such as laundry starch or clay. Talk to your health care provider if you crave something that is not food as this can be a sign of a more serious problem.


Sometimes a common sense way to approach an item is to ask yourself, would I give this to a baby, a toddler or a child? If the answer is an obvious "NO!", then you can be pretty sure it isn't safe for your unborn baby, either.



Visit the US Government My Pyramid site for Pregnant and Breastfeeding Mothers.