Doc, Make Vaginal Discharge Clear: When is it normal?

Vaginal discharge. Even though the words illicit a little laugh, an embarrassed look away, and even cause the listener to squirm, it is an ever present issue and normal physiologic thing women deal with. Often I hear women say “I just couldn’t tell if this was normal so I figured I’d take the time off work, and pay the co-pay and get naked in the exam room to hear you tell me it was normal….” As our loyal blog followers know, Dr Every Woman aka Dr McDonald and I are passionate about vaginal health and hygiene. I’ve included some of our past blogs in case you want to revisit and freshen up (lol. pun intended!!) on them. ( The Truth: Vaginal Health and Hygiene Myths Revealed). Dispelling the myths (thanks Goop (insert side eye here)….Vaginal Steaming: Yay or Nay? It may be okay…), reviewing the dos and donts, and overall just knowing the general anatomy and health of your lady bits (Lady Bits Exposed: Why Knowing Your Anatomy Matters) are great reads before visiting your gynecologist.

Let’s start with normal and less concerning discharge. Hormones cause changes in the pH of the vagina, and also cause changes in the discharge. It can become a bit stickier, thicker, thinner etc, based on the timing of your cycle. A great way to know if your

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Photo by Giagkos papadopoulos on Unsplash

vaginal discharge is related to your cycle is to keep a symptom diary of when you actually have the discharge in relationship to your menses. Most commonly, changes are seen about 2 weeks before your cycle during ovulation. Often it’s an odorless, colorless discharge that lasts 3-5 days. The big key is it resolves on its own. No medications, no changes in practice and all of a sudden you realize it is gone. Pregnancy is another big hormonal shifter that causes changes in discharge as well.

Now, let’s discuss some things that are maybe not so normal (That Itch You Just Cannot Scratch: Vaginal Itching (Vaginitis). As you can probably deduce, anything that does NOT go away on its own after a week or so should probably be looked at. If there are other symptoms associated with the discharge, for instance swelling of the vaginal or vulvar canal (Lady Bits Exposed: Why Knowing Your Anatomy Matters), itching, burning with urination, blood in the discharge, odor that is different

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Photo by YIFEI CHEN on Unsplash

from normal or a discharge that looks abnormal from your own normal are all reasons to get an exam and be checked out. Sometimes even changes in the season can irritate the vagina and necessitate some medication to “reset” the system. As I mentioned before, pregnancy can cause normal changes in the pH, but it can also make things more sensitive to abnormal shifts in bacteria.

Often times when women have a noticeable change in their vaginal discharge, it is worth it to examine any changes that have occurred in your other daily life. A new medication, diet, underwear, sexual partner, even birth control can affect the pH and subsequently the discharge. If you have changed something, try removing it for a week or so and see if that improves things.

In general, it is important to remember everyone has their own normal. Any time you are worried or feel there has been a change it is always best to get an exam before things get unbearable. Probiotics, drinking water and staying away from home remedies are a good way to avoid exacerbating the problem. And remember. Happy Vagina.  Happy Life.

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The Best Birth Plan: Doctor approved with the safety of Mom and Baby in mind

Birth plans are IN. Every app, every mommy website, every natural birth instructional anything contains mention of and often a template for a birth plan. In this post I will answer the following questions:

  1. What is a birth plan?
  2. What are some common misconceptions between doctor and patient?
  3. What are things that you, the mother, can do to increase chances for a vaginal delivery?
  4. What factors are unpredictable, so that you won’t be shocked if you encounter them?
  5. What items SHOULD be on EVERY PARENT’S birth plan?

Wait, you’ve haven’t heard of a birth plan? jonas-kakaroto-458503-unsplash

Well, a birth plan is essentially a written guide crafted by the mother that lists her requests for her labor management and delivery. Sometimes it contains lists of medications that are requested and ones to avoid. Sometimes it contains requests for who will participate in the labor and delivery- Attending physician versus midwife versus resident versus medical student etc. Sometimes it contains statements like this:

I do not want a C-section.

Why do people create birth plans?

The answer is simply two words: Vaginal Delivery. A birth plan is like a recipe for the best Thanksgiving dinner delivery. Most people want their baby to come out of their vagina as healthy as possible. At the end of the day, they want an uneventful vaginal delivery. If you get the ingredients just right, that baked macaroni and cheese delivery will be amazing. Right?

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It is a delicate line to walk as a physician.

BIRTH PLAN FOR MY PERFECT DELIVERY

No induction.

No pain medication.

No IV fluids.

No Pitocin.

No breaking the bag of water.

No C-section. No C-section. No C-section.

GLOWING VAGINAL DELIVERY

These are common components of birth plans, large and small. It is technology’s fault that vaginal deliveries don’t always happen. It is because we doctors want to rush ladies through the labor process and have a baby before our own dinner time. If we doctors would let labor happen on its own, with minimal intervention, there would be less C-sections. Right? Wrong. I have no incentive to rush your labor. I am not motivated during your labor by any other goal than to get you and baby through labor and delivery unscathed.

I want to tackle a few facts.

  • 99% of OB/GYNs want you to have a vaginal delivery as much as you do.
  • There are things you can do to increase your chances for having a vaginal delivery, and I will share those.
  • There are factors that are out of both the doctor’s and patients control that can lead to a c-section, birth plan or no birth plan. I will give some examples.

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Picture this: You need to get from one end of the country to the other. You have never traveled outside in the elements before. You can’t drive and the only map you have is one drawn by a friend or acquaintance who once traveled a long distance on foot in the past. The only difference is that they started from a different place and had a different destination than you. Some had luggage, some didn’t. Some exercised, some didn’t. Some traveled in the summer. Some traveled in the winter. Some traveled over mountains. Some over flat land. Some traveled 2 miles, and some traveled 20 miles.

Oh and one friend had a brand new prosthetic leg when she made the trek.

In my analogy, the distance represents the labor course. I’ve cared for women who were in labor for 5 hours and women who were in labor for 5 days. The luggage represents not only the woman’s weight, which can matter in labor, but also the size and shape of her pelvis. How easy or hard is it for this baby to make it through the pelvis? The season and weather can represent the baby’s well being, which is very unpredictable, variable and can change in an instant without warning. The prosthetic leg represents the different circumstances that make us each unique. Maybe this woman has fibroids. Another woman has had surgery on her cervix. Another has severe back pain resulting from a slipped disc. They are all different, and because of this, the labor course is unlikely to be the same.

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Where do I, the OB/GYN, fit into the mix of this analogy? Well, rather than being guided by a person or people who have traveled a hand full of times over limited terrain and have drawn you a picture, consider me an in-person hiking guide who has made thousands of trips over variable terrain in every season in every storm. Who do you want as your guide?

Technology is not the enemy.

In places and countries where interventions are not available, there may be less C-sections, but there are more complications. In the United States, one of the biggest risks for a woman in labor is hemorrhage or excessive blood loss. A working IV is essential to be able to give fluids during labor for baby’s safety, but also to slow the effects and allow intervention during hemorrhage. While a person is bleeding excessively, this is the WORST time to try to start an IV (the veins practically disappear) or to find out that an IV that does not have fluid flowing through it is not working or had clotted shut. In my hospital, you can still walk and be mobile with an IV. It is like a labor seatbelt.

Likewise, monitoring the baby’s heart beat ensures that you and baby are getting through labor safely. Some desire to not have their babies monitored because they don’t want interventions as a result of monitoring. Keep in mind, if the baby looks healthy and safe, interventions aren’t necessary. If the baby looks like they aren’t getting enough oxygen based on the heart rate, this may lead to intervention, but you would want that intervention. In that moment, the safety of you and baby is more important than the route you take on you cross-country trek.

If you are in a car accident, that is not the time to put on the seat belt. It is the time to use it. Allow the IV.

Pregnant trimester

Some things that a woman can do to increase her chance of having a vaginal delivery are to exercise before and during the pregnancy, to try to be at a healthy, non-obese body weight at the beginning of the pregnancy, to keep diabetes and high blood pressure under good control if present, and to deliver before 2 weeks past the due date. These are just a few examples.

Some factors that are relatively out of the mother and doctor’s control are the baby’s ability to tolerate labor, the size and shape of a woman’s pelvis, the size of the baby (sometimes it is just genetic) and the baby’s position. I am actually writing a post about some factors that may increase breech or head up positioning at term (the due date) and some ways to encourage normal positioning. Stay tuned for that.

Labor, unlike many other aspects of life, is very difficult to control.

Most people can walk a short distance. A few blocks or even a mile or two on foot on a mild spring day could literally be a walk in the park. But what if your destination is a little farther. What if you unexpectedly have two suitcases, you are wearing high heels, and your grandma who gets short of breath when she walks is with you? In a blizzard? How are you going to get to your destination in one piece with all of your stuff and your grandma? That’s what your guide is for.

So what SHOULD you put on your birth plan? At my hospital most of these items are automatic, but just in case, here are some suggestions for a term (not premature) pregnancy:

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  1. What kind of pain management am I interested in, if any.
  2. I would like any labor interventions discussed with me for understanding and clarity.
  3. I would like skin-to-skin with myself and baby if the baby is breathing well. Dry the baby first to maintain body temperature but then chest-to-chest contact with mom is important.
  4. I would like delayed cord clamping for at least 30 seconds if there is no meconium and baby is breathing well.
  5. I would like BLANK PERSON to cut the cord.
  6. I would like to breastfeed if possible. It is the healthiest thing for baby if I am able. I understand that occasionally supplementation is necessary depending on the amount of baby’s weight loss and/or blood sugar measurements.
  7. Do I want music playing? Who is bringing the play list.

While these are not the only items that can go on a birth plan, notice that these few suggestions do not include labor management. You have to trust that your doctor is making appropriate decisions with and for you and your baby’s safety. If you aren’t clear about the reasons things are happening during the management of your labor, ask for explanations from the nurse and/or doctor.

Informed consent and shared decision making…

… means that we – the doctor and the patient – discuss the management, including, risks, benefits and alternatives of the various options and together come to a mutually agreed upon decision. This will continue to foster trust and allow the labor process to take place with low risk for complications and with clear expectations.

My birth plan as your doctor: To get you and baby through your delivery as safely as possible, with as little intervention as is necessary, but as SAFELY AS POSSIBLE. Try this:

The OB/GYN Serenity Prayer

In pregnancy, grant me the SERENITY to accept the things I cannot change,

The KNOWLEDGE and MOTIVATION to change the things that can increase my chances for having my dream delivery,

The PEACE and UNDERSTANDING that my healthcare providers have the best interests of myself and my baby at heart,

And the WISDOM to know the DIFFERENCE between what can be changed and what cannot while understanding all associated risks, benefits and alternatives.

What do you think?

I made this little video one day in my car…

Visit and subscribe to my YouTube channel for more!

unsplash-logoAlex Hockett
unsplash-logoJonas Kakaroto
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unsplash-logoAndre Adjahoe

Bringing Your Teen To The Gynecologist: When to do it and what to expect

One question I often am asked is “Doc, when should I start bringing in my teenaged daughter?” The mother continues,

She is fifteen. I’m SURE that she isn’t sexually active but she can be quite a pill during her period.

My answer: Yes. Bring her in. There is no age cut off for most gynecologists (the youngest patient I have seen was 10), and the visit covers a myriad of topics (sexually active or not) and questions.

A big benefit to bringing girls in early is they have a trusted resource besides Google and their friends.

Let’s review what to expect during a gyn visit for a teenager.

  • First she will get triaged by the nurses, this includes a blood pressure and weight check, and a general review of any medical concerns or issues she may have.
  • Although every doctor is a little different, the guidelines do NOT recommend a pelvic exam unless the patient wants an STD test, has pelvic pain/ discharge, or has another complaint that requires an exam.
  • Most of the visit is a counseling visit when they come to see me. We discuss any concerns they may have, questions about myths they have heard online or from friends.
  • We review the recommendations for vaccines (Gardasil, meningitis, flu when applicable).
  • Sometimes during our chat, it becomes clear there may be a menstrual issue that we can address to help improve quality of life.

emmanuel-bior-563567-unsplashSpeaking of menstrual issues, did you know girls are still missing school because of bad periods??? In some households, pads/ tampons become too costly. It pains me when I hear what some of these girls suffer through. Parents, an easy way for you to gauge if your daughter’s cycle is too heavy is if she is bleeding through her clothes and sheets at night. That means her flow is TOO heavy.

What can we do about it?

Well, one option to decrease the amount of blood loss is to start birth control. No, birth control does NOT increase sexual activity. Nor does it give a girl the green light to have sex. There is virtually no correlation between using birth control and sexual activity. A young girl’s quality of life can dramatically improve because of either the pill, or the depo provera shot or really any form of birth control. It does NOT affect future fertility either. Check out my previous article about this very subject for more information.

sharon-mccutcheon-580064-unsplashAny teenage girl that seems to be struggling with her menstrual cycles should definitely come in to be seen.

All teenagers should see their gynecologist at least once a year if they are sexually active, and every 12-18 months if not.

It can help tremendously to diminish the nerves and anxiety surrounding the gynecologist. It also helps foster a trusting relationship between the teen and he doctor so if she needs something and is too embarrassed to ask her parents, she has someone to turn to. We want your these young women to be as safe and healthy as they can be, just like you.

When in doubt, bring them in!

 

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Too cool for school. Wait, stay in school, lol

 

Photo by Daniel Apodaca on Unsplash
Photo by Emmanuel Bior on Unsplash
Photo by Sharon McCutcheon on Unsplash
Photo by Thabang Mokoena on Unsplash
Photo by Trust “Tru” Katsande on Unsplash

Deodorant: To stink or not to stink. Five things you should know about deodorant as a woman.

Deodorant is a regular use item, or at least it should be (in my opinion.)

If you are natural, that’s great, but natural smell is often synonymous with straight up funk! So we learn as we approach puberty, or maybe even before, that every shower should be accompanied by a deodorant or antiperspirant of some sort. If not, you can pretty much count on sitting alone in the lunch room after PE.

In recent years there has been a concern with the use of aluminum containing antiperspirants when it comes to breast cancer risk. In fact, as I type in aluminum deodorant in my search engine, one of the first thinks that comes up is “aluminum deodorant risk.”

Dr. Google Strikes Again

But, the question has value and the results are interesting. The first thing I want share is that there is a difference between deodorant and antiperspirant. Sidebar: I am actually going to include five points in this post, unlike the vague five of my last post. It was still a great post though…

  1. Antiperspirants contain ingredients like aluminum salts that block the sweat ducts and prevent perspiration. Deodorants absorb wetness and neutralize odors. If you choose a deodorant over an antiperspirant, you should be prepared to “pit out” in stressful situations because you WILL sweat.

If you prefer an antiperspirant I would like to share some concerns about aluminum antiperspirant use that have been challenged.

What concerns have been disproven:

2. Aluminum does not cause breast cancer. The initial concerns were not founded or replicated in research on the subject.

3. Aluminum does not cause Alzheimer’s disease. The research in that space was also not reproduced in enough data to demonstrate a correlation between aluminum and Alzheimer’s.

4. Aluminum salts in antiperspirants are not absorbed into the skin or blood stream to any significant degree. These salts form a chemical reaction with water in the duct and block the actual sweat duct where applied. For those who think that we humans should sweat, feel free to sweat in other areas of your body. Under the arms where odor is likely to form? I’ll pass.

But there are concerns with any commercial skin care product that you should look out for.

Parabens have some estrogenic qualities, though not conclusively linked to breast cancer. I try to avoid skin products containing parabens for myself and especially for my children. Few antiperspirants contain parabens but it is worth checking the label, especially in adolescents.

5. Natural deodorants exist as well. The Environmental Working Group is an organization that has closely scrutinized thousands of products and rated them based on ingredients and manufacturing practices. They have a whole section on deodorants here. 

Since becoming a mother of three, I find that what I put on my skin and under my arm pits gets a higher level of scrutiny. There is nothing like motherhood to level up a baseline level of paranoia. (No shade to the ladies without kids. You have the right to be just as paranoid as I am.) I appreciate the results of this investigation giving me license to be de-funkdafied (#dabrat) in peace. I don’t want to put my kids or my co-workers at risk of a nasal offense if I don’t have to.

My sons still have aluminum and paraben free deodorant. Somethings may never change.

Diastasis Recti: 5 Things You Should Know So It Doesn’t Happen to You

Yep, that’s me and my three kids.

Two on the outside and one still in my uterus. And no, I don’t have Diastasis recti anymore. I just have a small umbilical hernia that made my “inny” turn to an “outy” for about nine and a half months. No band-aid in the world was going to hold that back. I had Diastasis during my pregnancy, but I don’t have it now, 2 years later.

How did I get rid of Diastasis Recti? Let’s get right into it.justyn-warner-532058 small

First, if you don’t know me by now, I love to run the numbers. If you could hear how many of my patients are asking about Diastasis lately, you would think that it affects 100% of pregnant women. It doesn’t, at least not longterm. And while we are on the subject, let’s practice saying it so that you can ask about it with confidence.

DIE-UH-STAY-SIS. You got it. (You know how I feel about the pronunciation of medical terms.)

Diastasis recti (the full name is actually Diastasis recti abdominis or DRA) is around a 2-centimeter separation of the rectus abdominis muscles. The rectus muscles are the “abs”. Pictured below, they are the ones that give you the “pack” that you have, or in my case, want.

Rectus_abdominis mod

As the uterus grows in pregnancy, those muscles can separate. At 35-weeks pregnant, the prevalence of this degree of muscle separation is 100%. By the 6-month post-delivery mark, only about 39% or women have it. That number isn’t small, but it isn’t the majority.

So what do the 39% do to get their abs back? Well first, what is the problem with Diastasis? Some may get uncomfortable hernias that result from this separation. Some are even born with it and need surgical correction to keep the abdominal contents contained. The problem is often cosmetic though. 18424159_10209329163812249_2213968896285513287_n

Some may experience core weakness after childbirth and if not corrected, can find themselves having difficulty lifting objects and having back pain. In that case, the problem isn’t necessarily the Diastasis. The core weakness is the problem. It is VERY NECESSARY to do proper exercises to not worsen the separation, but still strengthen the abs.

If you suspect that you have persistent Diastasis after about the 8-week mark after having your baby, first do this: Lie flat on your back and do a half crunch. If you can fit 2 fingerbreadths between your abs, you may have it. The actual process for diagnosis is more technical than that, but this works for at-home use. Those most likely to be affected are women who carried twins or other multiples, women who have larger babies, women who are over 35 years old,

Here are my 5 Must-Knows.

  1. Pregnancy does not irreparably damage your abs. Even women who have c-sections can come back to flat mid-section. We do not cut the ab muscles during c-sections either. That is a common misconception. Your glory days can come again.

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    There is no treatment during pregnancy. Wait until at least 6 weeks postpartum to try any of these exercises.
  2. Don’t do crunches. They can worsen the separation. Do these exercises if you think you have Diastasis recti:
    1. Core contraction – In a seated position, place both hands on abdominal muscles. Take small controlled breaths. Slowly contract the abdominal muscles, pulling them straight back towards the spine. Hold the contraction for 30 seconds, while maintaining the controlled breathing. Complete 10 repetitions.[9]
    2. Seated squeeze – Again in a seated position, place one hand above the belly button, and the other below the belly button. With controlled breaths, with a mid-way starting point, pull the abdominals back toward the spine, hold for 2 seconds and return to the mid-way point. Complete 100 repetitions.[9]
    3. Head lift – In a lying down position, knees bent at 90° angle, feet flat, slowly lift the head, chin toward your chest, (concentrate on isolation of the abdominals to prevent hip-flexors from being engaged),[6] slowly contract abdominals toward floor, hold for two seconds, lower head to starting position for 2 seconds. Complete 10 repetitions.[9]
    4. Upright push-up – A stand-up push-up against the wall, with feet together arms-length away from wall, place hands flat against the wall, contract abdominal muscles toward spine, lean body towards wall, with elbows bent downward close to body, pull abdominal muscles in further, with controlled breathing. Release muscles as you push back to starting position. Complete 20 repetitions.[9]
    5. Squat against the wall – Also known as a seated squat, stand with back against the wall, feet out in front of body, slowly lower body to a seated position so knees are bent at a 90° angle, contracting abs toward spine as you raise body back to standing position. Optionally, this exercise can also be done using an exercise ball placed against the wall and the lower back. Complete 20 repetitions.[9]
    6. Squat with squeeze – A variation to the “squat against the wall” is to place a small resistance ball between the knees, and squeeze the ball while lowering the body to the seated position. Complete 20 repetitions.[9]
  3. Don’t make the mistake of making the call too soon. If you don’t have pain and you are still trying to lose the baby bump, give it time. Your mid-section took 9 months to get to that size. The 6-week snapback is not a realistic expectation for many, no matter what Instagram and Pinterest say. lol

    Planks
    Planks are good, and we do Sculpsure in my office- laser fat removal. loopobgyn.com
  4. Keep your bowels moving well. Constipation may not worsen Diastasis, but it won’t make it better either. Excessive regular bearing down for bowel movements has other health implications that are worth avoiding. (Check out my post about that too.)
  5. If you are worried that it isn’t improving, ask your doctor about it. Physical therapy may be an option, and in extreme circumstances, surgery. Don’t be afraid to ask.

At the end of the day, know that your abs will go through changes due to pregnancy.  Stay optimistic that you can be beach-ready again if you so desire.

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Don’t forget to subscribe to always know when we’re busting myths and dropping science at The Gyneco-(b)Logic.

Photo by Justyn Warner on Unsplash; Photo by Form on Unsplash

References: https://www.ncbi.nlm.nih.gov/pubmed/25282439 https://www.ncbi.nlm.nih.gov/pubmed/2968609

 

Early Pregnancy Test Is Positive: Do’s and Don’ts from the Doctors

It’s your first trimester. Let the takeover begin!

Dos and Don’ts in pregnancy

Practicing as an OB/Gyn I’ve come to realize almost everyone is afraid of pregnant women. Other medical specialties don’t want to take care of them, employers are afraid of imminent labor during working hours, husbands don’t want to upset them, generally a population surrounded by this shield of protection from the outside world. This has created a sense of mystery and confusion around the pregnant woman, and often they come in completely lost on what they can and cannot do. In general, I tell pregnant women to do whatever they want. There are a few things to avoid, and we will get into that here, but otherwise they should sleep when they can, eat what they crave, and avoid all housework (haha).

Fish/ seafood:

The big concern with fish and seafood is the level of mercury because it can lead to birth defects. Fish that are generally safer in pregnancy: shrimp, salmon, catfish, canned light tuna (***not albacore) and sardines. Fish that are NOT safe because of the levels of mercury are shark, swordfish, king mackerel or tilefish. Also, raw fish should be avoided because of risks of bacteria and food poisoning, so make sure the fish is cooked. I generally tell people to eat fish in moderation (ie limiting intake to 6 ounces a week)

FullSizeRender 18Caffeine:  

Ahhh coffee… How to survive without this wonderous nectar? So, good news is you do not have to out all caffeine. However it is important to limit it. One cup of caffeine (coffee, tea, soda, red bull (ok don’t drink red bull)) in safe.

Listeriosis:

This is a bacteria that usually causes a mild illness, but in pregnant women can make you very ill. Foods to avoid in this category are unpasteurized milk or cheese made from said milk (is feta, queso blanco, queso fresco, camembert, brie), deli meat (unless they are served steaming hot), pates or meat spreads and refrigerated smoked seafood. Remember, nothing raw or uncooked. Everything should be cooked before consuming in pregnancy!

Exercise:

Moderate exercise is not only safe in pregnancy, it is recommended. Whatever exercise you were doing before pregnancy should be modified and continued. Your heart rate should not exceed 120 bpm for greater than 20 mins in any period of cardiac exertion.

Saunas/ Hot tubs:

This is one of the few don’ts in pregnancy. Your body temperature gets too high when submerged in hot water and it is unsafe in pregnancy. Soaking your feet or legs is ok, but that’s it.

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Photo by Leio McLaren on Unsplash

Travel:

The big restrictions when it comes to travel is the time in which you choose to go. The last trimester (especially after 34 weeks) should be avoided because not only is it uncomfortable, but the risks of labor are of course, the greatest. Early in pregnancy travel is safe, as long as you get up and walk every 2-3 hours for 10/15 mins and drink plenty of fluids. One big thing to consider is that Zika is STILL a very real thing. Please please please do NOT travel to Zika infested areas if you are considering getting pregnant or are pregnant. The CDC is constantly updating their site with countries to avoid.

Cats:

You don’t have to avoid cuddling with your feline friends, but you should NOT change the litter box for the duration of pregnancy.

This is not an inclusive list, and as always all concerns should be discussed with your obstetrician as they know you and your medical history best. Happy pregnancy!

Don’t forget to subscribe and follow us on social media. We have a ton more posts related to pregnancy and non-pregnancy issues that you don’t want to miss.