Pregnancy Information Packet Generations Healthcare for Women
www.generationsobgyntucson.com Pregnancy Information Packet Generations Healthcare for Women Northwest: 2171 W. Orange Grove Road Phone: 520.877.3800 Oro Valley: 1521 E. Tangerine Rd, Suite 361 Phone: 520.545.0573 Sahuarita/Green Valley: 1295 W. Duval Mine Road Phone: 520.877.3800 Lazos de Familia, 344 W. Ajo Way, Tucson Phone: 520.877.3800 www.generationsobgyntucson.com Pregnancy Information Packet Contents Enclosed you will find information on the practice and on common prenatal testing as well as answers to other frequently asked questions. The left pocket contains initial forms. Please complete and bring all forms to your first prenatal appointment. We welcome your questions. We believe the more you learn about what is happening during your pregnancy, the more fun you will have and the healthier you will be. Page 1: Page 2: Page 3: Table of Contents Welcome Office Visits Childbirth Education Program Telephone Availability Billing Information Disability and Pregnancy Patient Rights and Responsibilities Laboratory Testing During Pregnancy Sonograms Page 4: Page 5: Page 6: Page 7: APPENDIX Page 9: Page 10: Page 11: Page 12: Page 13: Page 14: Page 15: Page 16: A. Maternal Serum Screening for Birth Defects B. Group B Streptococcus and Pregnancy C. HIV and Pregnancy D. Advanced Maternal Age- Pregnancy After 35 E. Cystic Fibrosis Carrier Screening F. Rh Factor in Pregnancy G. Trisomy 21 (Down Syndrome) and Trisomy 18 Screening Tdap Patient Information Sheet RESOURCES: Page 18: Useful Web Links Page 19: Nutrition During Pregnancy Page 21: Heartburn Page 22: Common Foods: Select the Lower Risk Options Page 23: Over-the-Counter Medications Page 24: ACOG: Recommendations for Exercise During Pregnancy Page 25: Helpful Hints for Relieving Morning Sickness Page 26: How to tell you may be in labor Page 27: Location, contact information and maps Page 1 www.generationsobgyntucson.com Dear Patient: 2171 W. Orange Grove Road Tucson, Arizona 85741 Phone: (520) 877-3800 Fax: (520) 877-3801 1521 E. Tangerine Rd, Ste. 361 Oro Valley, Arizona 85755 Phone: (520) 545-0573 Fax: (520) 297-5597 1295 W. Duval Mine Rd Green Valley, AZ 85614 Ph. 520-877-3800 Lazos de Familia Health Center 344 W. Ajo Way Tucson, AZ 85713 Ph: 520-877-3800 www.generationsobgyntucson.com Victor Chen, M.D., FACOG Mary Kay Durfee, M.D., FACOG Howard Eisenberg, M.D., FACOG Katie Gillaspy, M.D. Robert J. Kahler, M.D., FACOG Janet Warner, M.D., FACOG Carol Bronte, ANP, CNM Valerie Crawford, FNP Congratulations on your pregnancy, and thank you for choosing Generations! During this anticipation-filled time of your life, you may experience many uncertainties or new sensations. Our goal is to be right there along with you, providing you with the best quality of medical care and service throughout your entire pregnancy and delivery. Generations has five obstetricians. You have chosen or been assigned to one doctor who will follow you through your pregnancy course, to answer your questions, examine you, and order tests. You can take comfort that your doctor will come to know you very well, because he or she will be seeing you for all of your visits. When you go into labor, the doctor who is “on-call” will care for you. It is possible that you may make specific arrangements with your obstetrician when your delivery is planned (i.e.: scheduled c-section or induction). The doctor who delivers your baby may or may not be the one who followed you through your pregnancy care, but rest assured, you will be in good hands. A brief introduction of our physicians: Dr. Victor Chen is a 1991 graduate of the University of Arizona College of Medicine. He completed his residency in 1995 at Texas Tech Health Sciences Center in Odessa, Texas. Dr. Chen is board certified by the American Board of Obstetrics and Gynecology. Dr. Mary Kay Durfee graduated as a member of the medical honor society Alpha Omega Alpha from the University of Minnesota School of Medicine in 1997. She completed her residency training at the University of Utah in 2001. Dr. Durfee is board certified by the American Board of Obstetrics and Gynecology. Dr. Howard “Howie” Eisenberg completed his medical degree at Mt. Sinai School of Medicine in 1987. His residency training was completed at Kaiser Permanente in California in 1991. Dr. Eisenberg is board certified by the American Board of Obstetrics and Gynecology. Dr. Katie Gillaspy graduated summa cum laude from the University of Arizona and then completed medical school at Ohio State University School of Medicine, Columbus, Ohio. She fulfilled her residency in OB/GYN at the University of Texas Medical Branch, Galveston, Texas. Dr. Janet Warner is a 1998 graduate of the University of Wisconsin Madison College of Medicine. She completed her residency training at the University of Arizona. Dr. Warner is board certified by the American Board of Obstetrics and Gynecology. We encourage you to ask questions, share your concerns (and your joys), and take comfort in knowing that you will receive compassionate high-quality pregnancy care from our doctors and staff. If you have routine questions, please call us during business hours and a medical assistant will be happy to assist you. Our regular office hours are Monday through Friday, 8:30 am to 4:30 pm. After hours, if you have an urgent matter that cannot wait, please call us and our answering service will page the on-call doctor. Welcome to Generations Healthcare for Women. - The Physicians and Staff Page 2 www.generationsobgyntucson.com Office Visits Each of our obstetricians works as a team with a nurse practitioner. Your obstetrician will follow your care throughout your pregnancy, to answer your questions, examine you, and order tests. You can take comfort that your doctor will come to know you very well, because he or she will be seeing you for all of your visits. When you go into labor, the doctor who is “on-call” will care for you. It is possible that you may make specific arrangements with your obstetrician when your delivery is planned (i.e.: scheduled csection or induction). The doctor who delivers your baby may or may not be the one who followed you through your pregnancy care, but rest assured, you will be in good hands. Appointments are made during business hours. Our regular office hours are Monday through Friday, 8:30 am to 4:30 pm. We suggest you make your appointments at least a month in advance. Your family members are welcome to come with you to your visits, however no more than two visitors can be accommodated in the exam room. We ask that if you are unable to keep an appointment to please call to cancel/reschedule. Someone else will be able to use the time we had reserved for you. If we need to reschedule your appointment due to an unexpected medical emergency, you will be contacted as soon as possible. Childbirth Education Program We believe that the more you learn about what is happening during pregnancy, birth and the months after delivery, the more fun you will have and the healthier you will be. Northwest Medical Center offers a variety of classes. We urge you to call 877-4156 or visit the Community Education page on the Northwest Medical Center website for more information. We also strongly recommend taking a tour of Northwest Medical Center, giving you an opportunity to get comfortable with the Labor &Delivery area and the Mother/Baby Units. These tours are free. For information regarding the Northwest Medical Center Childbirth Education Classes and for information on tours please call (520)877-4156 or visit www.NorthwestMedicalCenter.com. Page 3 www.generationsobgyntucson.com Telephone Availability We are available to you at all times, but request that you call during business hours, unless it is an emergency. During business hours, the physicians or their medical assistants will return non-urgent calls in late morning or the end of the day. If you call after hours, you will be able to leave a message or be connected to the answering service in the case of an emergency. Please remove all blocks on incoming calls to your phone. The answering service will contact the physician on call, and your call will be returned. We are prompt about returning after hours calls. If you are not at a number where we can call you back, the answering service can keep you on hold and “patch” you through to the physician. If you haven’t heard from us in 15 minutes, please call back. If we arrange to meet you at the hospital, please allow at least 30 minutes for us to arrive. In the rare event of an answering service equipment failure, call Northwest Medical Center’s Labor and Delivery Unit (520) 877-4200. They will be able to reach us directly. In case of medical emergency, call 911 Generations Healthcare for Women Locations and Phone Numbers 2171 W. Orange Grove Road, Tucson, Arizona 85741 Phone: (520) 877-3800 Fax: (520) 877-3801 1521 E. Tangerine Road, Suite 361, Oro Valley, Arizona 85755 Phone: (520) 545-0573 Fax: (520) 297-5597 1295 W. Duval Mine Rd, Green Valley, AZ 85614 Phone. (520) 877-3800 Fax: (520) 877-3801 Lazos de Famillia Health Center, 344 W. Ajo Way, Tucson, AZ 85713 Phone: (520) 877-3800 Northwest Medical Center Labor and Delivery Unit 6200 N. La Cholla Blvd. Tucson, AZ 85741 Telephone :( 520) 877-4200 (map enclosed in this packet) Page 4 www.generationsobgyntucson.com Billing Information Business Office: (520) 352-1032 It is our intention to provide and fully explain all financial policies and arrangements. Generations Healthcare for Women accepts most insurance plans and will bill all insurance companies with whom we participate. If you have questions about your coverage, referrals, co-pays, etc., please contact the business office. If your insurance provider has a special form for deliveries, you will need to provide us with the completed form as soon as possible. Your insurance will be billed at the time of your delivery. If you do not have insurance, you may be eligible for Arizona’s program for maternity care, Baby Arizona. The Generations Healthcare for Women business office can assist you with processing the application. Generations Healthcare for Women will charge an “Obstetrical Package Fee”, which includes all office visits, and physician charges for delivery. These packages can be arranged for women who are self-pay or those with high deductible insurance plans. Charges may vary depending on the type of delivery you have. Payment arrangements can be made with the billing office. Payments are to be made monthly with total payment due one month before your due date. If you leave Generations Healthcare for Women care during your pregnancy, a bill will be generated for services provided rather than the package fee. Hospital care, anesthesia, ultrasounds, pediatric care and lab charges will be billed separately by those providers. To inquire about insurance coverage or cost for these services, contact Northwest Medical Center’s billing office at (520)469-8611. Cost will vary depending on the type of delivery you have. Disability and Pregnancy The majority of expectant mothers can continue to work until late in pregnancy without any complications. Sometimes, however, the physical changes that occur during pregnancy and/or the demands of a woman’s job can create difficulties. Please let us know if you have any concerns in this regard. We are usually able to suggest simple steps to deal with fatigue, “morning sickness”, or aches and pains that can be particularly challenging when at work. If you experience more serious symptoms, or concerns about potential workplace hazards to you or your baby, please inform us. We will evaluate the situation and respond accordingly. If your doctor determines you should be placed on disability or medical leave, you will need to obtain forms from your employer. There is a $25.00 fee for processing the disability forms. Please allow 7-10 business days for completion of these documents. Page 5 www.generationsobgyntucson.com Patient Rights and Responsibilities The patient has the right to a reasonable response to her requests and needs for treatment of service within the healthcare providers capacity, stated mission and applicable regulations. The patient has the right to considerate, compassionate, and respectful care that recognizes her personal values and belief systems. The patient has the right in collaboration with her healthcare provider to make decisions involving her healthcare, including the right to accept medical care, or to refuse treatment and to be informed of the medical consequences of such refusal. The patient has the right to information necessary to enable her to make treatment decisions that reflect her wishes and participate in the consideration of ethical decisions that arise in her care. The patient has the right to be informed of any human experimentation or other research/educational projects affecting her care or treatment. The patient has the right to personal privacy and confidentiality of information. The patient is entitled to have privacy during examination, to have visitors excused and to be informed why any observer is present, and to grant or refuse another person’s presence. The patient’s guardian, next of kin, or legally authorized responsible person has the right to exercise certain rights on the behalf of the patient. The patient has the right to expect explanation of any portion of the bill. Where appropriate the business office staff will assist the patient in making arrangements for payment of the bill through a payment schedule or assistance program. The patient has the responsibility to provide a complete and accurate medical history to the best of her knowledge. The patient has the responsibility to ask questions and seek clarification about her diagnosis and treatment and participate in decisions involving her care. The patient has the responsibility to make it known whether a proposed course of treatment is understood, and whether she is willing and able to comply. The patient has the responsibility to provide information about complications or symptoms. The patient has the responsibility to be considerate of the rights of other patients and clinical personnel, and to treat them with respect. Page 6 www.generationsobgyntucson.com Laboratory Testing During Pregnancy As part of good prenatal care, our staff recommends certain tests to detect infections and other conditions in pregnancy. At your first OB visit the following tests will be ordered: CBC This test will check for anemia and other factors. Blood Type and RH A pregnant woman who is Rh negative may need to receive a blood product called anti-D Immune Globulin (RhoGAM). This prevents the breakdown of your baby’s red blood cells, a serious condition which causes hemolytic. Antibody Screen This test will check for red blood cell antibodies. Syphilis A sexually transmitted disease which can cause birth defects. Hepatitis B If the mother has this viral infection of the liver there is an increased chance that without treatment the baby will be infected. The baby can be treated at birth to prevent infection in most cases. Rubella (German measles) An infection can lead to severe birth defects. If a woman is not immune, a vaccine can be given to her after the baby is born. Pap Smear A screening test for cervical cancer. Chlamydia and/or Gonorrhea Screening cultures that can detect sexually transmitted diseases that can potentially be harmful to you and your baby if not treated. Urinalysis A screening test for urinary tract infection and culture. TSH A screening test for thyroid disease. Your 28-Week Visit: Glucose Screen To check for diabetes in pregnancy. Blood Count To recheck for anemia. Antibody Screen If you are RH negative, administration of RhoGAM Recommended Tests: HIV: A blood test screening for AIDS. You can have HIV for years and not have any symptoms. If you have HIV, even without symptoms, there is a 1 in 4 chance you could pass it to your baby. There is treatment available during pregnancy that can reduce the risk of transmission of HIV to the baby Page 7 www.generationsobgyntucson.com Optional Tests: AFP Quad: A blood test done between 15 to 18 weeks of pregnancy to detect increased risk of having a baby with certain birth defects, such as an open neural tube defect (spina bifida) or Down syndrome. CF: A screening test for Cystic Fibrosis. NT (First Trimester Screen): A blood test which shows if you are at increased risk of having a baby with Down Syndrome of Trisomy 18 (chromosomal disorders). It requires a sample of your blood and a special ultrasound measurement performed in the first trimester. Sonograms: Sonograms are done when medically indicated (to assist us in determining your due date, to check on the growth of the baby, to assess bleeding, to survey the baby and placenta, etc). We only order sonograms and ultrasounds for medical reasons. You will probably be referred by your physician to one of the following: Genesis OB/GYN Women’s Diagnostic Imaging Center 6060 N. Fountain Plaza Drive, Suite 200 Tucson, AZ 85704 Phone: (520) 545-0930 http://www.genesisobgyn.org/ultrasound.html Maternal-Fetal Medicine Associates of Arizona Christopher A. Sullivan, M.D., FACOG 6060 N. Fountain Plaza Drive, Suite 200 Tucson, AZ 85704 Phone: (520) 392-7500 http://www.mfm-az.com Page 8 www.generationsobgyntucson.com APPENDIX A MATERNAL SERUM SCREENING FOR BIRTH DEFECTS What is the AFP screening test? A screening test that can be done using a small sample of a pregnant woman’s blood to identify pregnant women who may be at increased risk for having a baby with certain birth defects, such as an open neural tube defect (spina bifida), Down syndrome, and Trisomy 18. How is the AFP screening test done? A small amount of blood is drawn from a vein in the pregnant woman’s arm. The test is done at 15 to 18 weeks of pregnancy in most cases as this produces the most accurate results. Four substances present in the blood sample will be measured. These substances are Alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), unconjugated estriol (uE3), and dimeric inhibin A (DIA.) The amount of each substance in the blood sample as well as number of weeks pregnant, height, weight, race, insulin dependent diabetes, single or twin pregnancy, maternal age and any significant family history are all taken into account to calculate the individual patient’s specific risk. Why is the AFP test called a screening test? A screening test can help predict the risk of a problem. It is not a diagnostic test and cannot give you a definite “yes” or “no” answer. What does an abnormal screening result mean? Some women having an AFP screening test will be identified as being in the high-risk group even though they are carrying a normal fetus. This screening result does not always mean there are problems in the baby. For example, the due date might have been estimated incorrectly, or twins might be present instead of just one baby. Women in the high-risk group are offered diagnostic tests, which can give a definitive answer. A sonogram or amniocentesis is examples of further testing, which might be offered if the screening results are abnormal. No test is perfect. Not every abnormal result of a screening test will mean that your baby has a birth defect. Sometimes there is no reason for an abnormal screening test. Not every normal result of a screening test will mean that your baby does not have a birth defect. It is up to you whether to be tested. Some women find having the screening test is reassuring, and other women would rather not have the information. The results of the tests can help some women make decisions about their options. Page 9 www.generationsobgyntucson.com APPENDIX B GROUP B STREPTOCOCCUS (GBS) AND PREGNANCY GBS is a type of bacteria that can be found in 10-30% of pregnant women. It usually does not cause serious illness. It may be found in the digestive, urinary, and reproductive tracts of men and women. In women, it is most often found in the vagina and rectum. GBS is not a sexually transmitted disease. A woman with GBS can pass it to her baby during delivery. Most babies who get GBS from their mothers do not have any problems. A few, however, will become sick. This can cause major health problems or even threaten their lives. If the bacteria are passed from a woman to her baby, the baby may develop GBS infection. This happens to only 1 or 2 of every 100 babies whose mothers have GBS. Babies who do become infected may have early or late infections. Both early and late GBS infections lead to death in about 5% of infected babies. A culture is the most accurate way to test for GBS. This is a simple painless procedure performed at 35 to 37 weeks. The swab is sensitive in only 97% of women. A swab is placed in the woman’s vagina and rectum to obtain a sample. If the test results are positive, showing that GBS is present, you will receive antibiotics during labor to help prevent GBS from being passed to your baby. Babies of women who are carriers of GBS and do not get treatment have more than 20 times the risk of getting infected than those who do receive treatment. The antibiotics work only if taken during labor. The bacteria grow so fast that if treatment is given earlier, the GBS may grow back before labor. If you had a previous baby with GBS infection or you had a urinary tract infection caused by GBS during pregnancy, you do not need to be tested. You will need to get antibiotics during labor. In women who have planned a cesarean birth, it is not necessary for them to be given antibiotics during delivery, whether or not they are GBS carriers. However, these women should still be tested for GBS because preterm labor may occur before the planned cesarean birth and your baby’s pediatrician will want to know the results. GBS is fairly common in pregnant women. Yet, very few babies actually become sick from GBS infection. Treatment during labor and delivery may help prevent infection in your baby. If you would like additional information about GBS, please ask for a brochure, and/or talk with your doctor or nurse practitioner. Page 10 www.generationsobgyntucson.com APPENDIX C INFORMATION ON HIV AND PREGNANCY The human immunodeficiency virus (HIV) causes AIDS, a disease that is increasing among women of childbearing age. A person who is infected with HIV does not get sick right away. The virus lives in the body of an infected person for the rest of her life, and breaks down the immune system over time. It may take many years after being infected to develop symptoms of AIDS. AIDS is a very serious disease causing much suffering and many deaths throughout the world. There is no current cure for AIDS. HIV is spread by contact with the body fluids of an infected person (blood, semen, vaginal secretions and breast milk). Contact with these fluids can occur during sex, breastfeeding, sharing needles, blood transfusions and pregnancy. HIV affects 2 out of every 1,000 pregnant women. A woman can pass the infection to her baby as early as the 8th week of pregnancy. About half of the children infected with HIV get it from their mother during labor and birth. Breastfeeding is another way a mother can pass the virus to her baby. Pregnant women infected with HIV need to have their health watched more closely, with careful monitoring of blood levels and symptoms of infection. A woman can decrease the chance of her baby getting infected by taking medication during her pregnancy. Without treatment, about 25% of babies born to women with HIV will get the virus. With treatment, that number drops to about 8%. To lower the risk, infected women must take the anti-viral medications throughout her pregnancy and during labor. Babies are given the medications for the first 6 weeks after they are born. Some women who are HIV positive choose to terminate their pregnancies. Generations Healthcare for Women and the American College of Obstetricians and Gynecologists (ACOG) recommend that all women be tested for HIV early in pregnancy. It is important for your health, the health of your baby and the health of your sexual partner. Before we order the test, we will talk to you about the testing procedure and reporting of the results. We recognize that it is your choice whether or not to be tested. The HIV test is a blood test, and determines if you are carrying the virus by looking for antibodies to HIV. Antibodies usually appear within 3 months of getting the infection, but it may take up to 6 months, so we recommend a second test if there is a chance of recent infection. Results of testing are confidential. They will be a part of your medical record, and will be released only with your permission. Our medical office and hospital staff will have access to your records may also see the results. “Anonymous” testing, where your name is not recorded, is available through the Southern Arizona AIDS Foundation (520)628-7223 and the Pima County Health Department (520)791-7676. If your test is positive, you will need special health care and counseling. We will assist you in obtaining the support, information and care that you need. The CDC National Aids Hotline is 1-800-232-4636.We can add this test to your first prenatal blood tests. Tell the person drawing your blood or sending you to the lab that you want the test (you will need to sign a consent form); or wait and talk with you provider if you want more information before you decide whether to be tested. Page 11 www.generationsobgyntucson.com APPENDIX D ADVANCED MATERNAL AGE-PREGNANCY AFTER 35 Advanced maternal age is defined as an expectant mother who will be 35 at the time of delivery. If you’re over 35 and pregnant, you’re not alone. Many women well into their 30s and beyond are delivering healthy babies. There’s nothing special about age 35. However, it is the age at which certain issues are recognized in pregnancy. UNDERSTAND THE RISKS Some of the risks associated with a pregnancy after 35 include a multiple pregnancy, a higher risk of pregnancy loss and a higher risk of delivering a baby with chromosomal abnormalities. Women that fit into the advanced maternal age category are also more likely to develop gestational diabetes and high blood pressure. Some of these risks may make it necessary for you to deliver your baby by cesarean section. MAKE HEALTHY CHOICES Seeking regular prenatal care during your pregnancy will help your provider monitor your health and your baby’s health. Eating a healthy diet is extremely important to your baby’s growth and development. We encourage women to take a prenatal vitamin with folic acid daily and to eat lots of protein and other essential nutrients. Staying active can help to improve your overall health and prepare your body for labor and childbirth. LEARN ABOUT PRENATAL TESTING AVAILABLE There are several screening and diagnostic test available to you during pregnancy. Diagnostic tests, such as chorionic villus sampling, genetic amniocentesis and the first trimester screen, are tests that can provide definite results regarding the health of the baby. These tests are accurate and performed at different stages in the pregnancy. Screening tests, such as the maternal serum screening and ultrasounds, are tests that can provide information about whether you are at increased risk for certain conditions during the pregnancy. If you are interested in more information regarding screening or diagnostic testing during your pregnancy, please ask your Healthcare provider at your next visit. Page 12 www.generationsobgyntucson.com APPENDIX E CYSTIC FIBROSIS CARRIER SCREENING Cystic Fibrosis (CF) is a life-threatening condition affecting the ability to secrete mucus fluids normally. Individuals with CF commonly have problems with the lungs, digestive system and reproductive system. They often suffer from pulmonary infections and organ damage due to difficulty in clearing secretions. The severity of CF varies from person to person. CF does not affect intelligence, appearance or development. There is no cure for CF currently. The average life expectancy of a person with CF is 30 years, but children born with CF today may live longer as treatments improve. WHAT IS A CF CARRIER? People who receive one normal cystic fibrosis gene and one abnormal cystic fibrosis gene are called CF carriers. They do not have the disease but have a 50% chance of passing the abnormal gene on to their child. In order for the child to be born with cystic fibrosis, he or she would need to inherit an abnormal gene from both parents. WHAT IS CF CARRIER SCREENING? Cystic fibrosis (CF) carrier screening is a genetic test that lets you know what your risk is for carrying an abnormal gene, as well as what your chances are of having a child with CF. HOW IS CF CARRIER SCREENING DONE? Your blood will be drawn and sent to the laboratory for testing. Additional information regarding family history, your race and ethnicity and your personal history will be provided to the lab. This additional information is essential to aid in the interpretation of the blood results. WHAT DOES A NEGATIVE SCREEN MEAN? A negative screen does not guarantee that you are not a carrier. This test detects only the most common changes in the CF gene. WHAT DOES A POSITIVE TEST MEAN? A positive screen means that the laboratory found a change in one of your two CF genes and that you are a carrier. There is a 50% chance that you will pass this gene to your child. With a positive finding, we recommend that your partner be screened for CF carrier status. Additional testing will be recommended as needed based on the results. DOES MY INSURANCE PAY FOR THE TEST? All insurance plans are different. If you aren’t sure your insurance plan covers the test speak with the customer service department at your insurance company or your provider. Page 13 www.generationsobgyntucson.com APPENDIX F Rh FACTOR IN PREGNANCY During pregnancy it is necessary to do a blood draw to find out your blood type. There are two components to this testing, a major blood group (A, B, AB, and O) and an Rh factor (positive or negative). WHAT IS Rh FACTOR? Rh factor is a protein that is found on your red blood cells. Most of the population has the Rh factor present on their red blood cells. These groups of people are considered to be Rh positive. The rest of the population does not have the Rh factor present on their cells, these people are Rh negative. WHAT ARE THE HEALTH ISSUES FOR Rh NEGATIVE PREGNANT WOMEN? During pregnancy you do not share blood systems with your baby. However, your baby’s blood can cross the placenta into your blood. The Rh factor becomes a problem when an Rh negative person’s blood comes into contact with an Rh positive person’s blood. If this contact occurs, the person with Rh negative blood develops antibodies to fight the Rh factor. In this instance the antibodies see the Rh factor as a harmful substance, or a foreign substance that does not belong in the blood. This is called Rh sensitization. When sensitization occurs these antibodies can go and attack the baby’s blood. This can cause a serious health condition in the baby called hemolytic disease. Rh sensitization can also affect future pregnancies. An Rh negative woman’s blood can become sensitized if she is pregnant with an Rh positive fetus. Other ways an Rh negative woman’s blood can become sensitized are with a miscarriage, an induced abortion, an ectopic pregnancy, or a blood transfusion. HOW CAN YOU BE SCREENED FOR Rh SENSITIZATION? A simple blood test, a red blood cell antibody screen, can be drawn and sent to the laboratory to check for antibodies against the Rh factor. HOW CAN Rh SENSITIZATION BE PREVENTED? If your body has not made antibodies against the Rh factor, hemolytic disease can be prevented. Rh immunoglobulin (RhIg), or RhoGAM, is a human blood product (made from human blood plasma) that can prevent sensitization of an Rh negative woman. In a normal pregnancy, when the woman is Rh negative, the RhoGAM is given by intramuscular injection at 28 weeks gestation and again after you deliver your baby. RhoGAM is safe for use in pregnancy and has been used since the late 1960’s. WHAT DO I DO IF I’M Rh SENSITIZED? Every situation is unique and requires individualized treatment. Your health care provider will work closely with you throughout the pregnancy to plan the safest course of treatment for your baby. Page 14 www.generationsobgyntucson.com APPENDIX G First Trimester Screening for Trisomy 21 (Down Syndrome) and Trisomy 18 -Frequently Asked Questions – Courtesy Duke University Health System What is first trimester screening? First trimester screening is the combination of a maternal blood test and an ultrasound measurement to screen for chromosomal defects associated with significant mental disability, Down syndrome, Trisomy 13, and Trisomy 18. Down syndrome, Trisomy 13, and Trisomy 18 are chromosome problems that happen randomly at the time of conception. These conditions are relatively uncommon, but the risk increases with a woman’s age. The blood screen measures two pregnancy proteins in the mother’s blood, free beta-HCG and PAPPA. The ultrasound measures the nuchal translucency, an area behind the baby’s neck that contains fluid. First trimester screening is performed between 11 weeks and 14 weeks gestation and is safe for the mother and baby. How accurate is this screening? First trimester screening can identify 80 to 90 percent of pregnancies with Down syndrome and up to 97 percent of pregnancies with Trisomy 18. The results are expressed in a ratio, such as “the risk of Down syndrome is 1 in 200.” This means that of 200 women with those same results, only one would have an affected pregnancy. It is important to realize that first trimester screening cannot diagnose or rule out any specific condition. What does an abnormal result mean? An abnormal screen means that the estimated chance of having a baby with Down syndrome or Trisomy 18 is higher than expected. Only a small number of women with an abnormal screen result will have an affected pregnancy. If the screen does identify an increased chance, genetic counseling and further testing will be offered. Tests that diagnose chromosome problems in pregnancy include chorionic villi sampling (CVS) and amniocentesis. Each has a small risk of complications that can lead to miscarriage. Can this screen identify other problems? Although first trimester screening is specific to Down syndrome, Trisomy 13, and Trisomy 18, other birth defects such as heart defects can be associated with an increased nuchal translucency. Page 15 www.generationsobgyntucson.com For those who have an abnormal ultrasound measurement and otherwise normal test results, targeted ultrasound in the second trimester will be recommended. How does this screen compare with screening in the second trimester? Maternal blood screening in the second trimester, offered between 15 and 21 weeks gestation, measures multiple pregnancy proteins to estimate the risk of Down syndrome, Trisomy 18, and open neural tube defects (ONTDs). ONTDs are openings along the fetal spine (open spina bifida) and skull (anencephaly). About one to two babies per thousand are affected with an ONTD. Second trimester maternal blood screening can identify 60 to 80 percent of pregnancies with Down syndrome or Trisomy 18 and 80 percent of pregnancies with ONTDs. First trimester screening cannot identify a risk of an ONTD. If you elect first trimester screening, maternal serum AFP or targeted ultrasound in the second trimester are recommended. Who should consider first trimester screening? First trimester screening is available to anyone who desires early pregnancy screening for Down syndrome, Trisomy 13, and Trisomy 18. Or, a couple with an increased chance of these chromosome problems (due to maternal age or family history) might find it helpful to have more specific information about the pregnancy before making decisions about diagnostic testing. If you have decided to have amniocentesis or CVS, then this test is not necessary. Review the American College of Obstetricians and Gynecologists position statement. Duke Health.org, Duke University Health System. Published: Mar. 21, 2007 Updated: Mar. 21, 2007 www.dukehealth.org/healthLibrary/CareGuides/Perinatal/treatment_instructions What is the chance that my baby will have an open neural tube defect? The chance of having a baby with an open neural tube defect does not depend on the age of the mother. The chance is approximately 1 in 1,000 for all ages. © 2009 BC Prenatal Genetic Screening Program. Page 16 www.generationsobgyntucson.com Tdap Patient Information Sheet from the CDC http://www.cdc.gov/vaccines/vpd-vac/pertussis/tdap-pregnancy Centers for Disease Control and Prevention CDC 24/7: Saving Lives. Protecting People™ February 2013 October 2012 The CDC’s Advisory Committee on Immunization Practices (ACIP) voted to recommend that health care personnel should administer a dose of Tdap during each pregnancy irrespective of the patient’s prior history of receiving Tdap. To maximize the maternal antibody response and passive antibody transfer to the infant, optimal timing for Tdap administration is between 27 and 36 weeks gestation. For women not previously vaccinated with Tdap and if Tdap is not administered during pregnancy, Tdap should be administered immediately postpartum. Pertussis can cause serious and sometimes life-threatening complications in infants, especially within the first 6 months of life. In infants younger than 1 year of age who get pertussis, more than half must be hospitalized. The younger the infant, the more likely treatment in the hospital will be needed. Of those infants who are hospitalized with pertussis about 1 in 5 will get pneumonia and 1 in 100 will die. Tdap Vaccine Safety for Mother and Infant In addition to the mother being vaccinated with Tdap, she should encourage others – including dads, grandparents and other caregivers – to get vaccinated with Tdap at least two weeks before coming into contact with their infants. ACIP concluded that there is no elevated frequency or an unusual occurrence of adverse events among pregnant women who have received Tdap vaccine, or in their newborns. Tdap vaccine is recommended after 20 weeks gestation because that optimizes antibody transfer and protection at birth. The immune response to the vaccine peaks two weeks after administration. Both tetanus and diphtheria toxoids (Td) and tetanus toxoid (TT) vaccines have been used extensively in pregnant women worldwide since the 1960s to prevent neonatal tetanus. Td and TT vaccines administered during pregnancy have not been shown to harm either the mother or baby/fetus. Breastfeeding Safety after Tdap Vaccination Breastfeeding is not a contraindication for receiving Tdap vaccine. Tdap vaccine can and should be given to women who plan to breastfeed. Breastfeeding is fully compatible with Tdap vaccination, and preventing pertussis in mothers can reduce the chance that the infant will get pertussis. Also, by breastfeeding, mothers can pass antibodies they’ve made in response to the Tdap shot onto their infants, which may reduce an infant’s chances of getting sick with pertussis. This is especially important for infants younger than 6 months of age, who have no other way of receiving enough pertussis antibodies, since they are not fully protected until their third dose of DTaP vaccine at 6 months of age. Genesis Tdap Information Sheet 2.2013 Page 17 www.generationsobgyntucson.com Useful Web Links Please visit the Pregnancy Services page of our website at www.genesisobgyn.org for a complete listing of helpful links and information on the web. Useful Links: American Academy of Pediatrics http://www.aap.org/topics.html American College of Obstetrics and Gynecology (ACOG) patient information http://www.acog.org/publications/patient_education ACOG Exercise During Pregnancy http://www.acog.org/publications/patient_education/bp119.cfm Babycenter.com – products and services for expectant and new mothers http://www.babycenter.com/ Babynamer. Com – will help you find the perfect name http://babynamer.com/ Breastfeeding – La Leche League Tucson home page http://www.lllusa.org/web/TucsonAZ.html Breastfeeding.com – Information and support http://www.breastfeeding.com/ Centers for Disease Control and Prevention – Pregnancy Information http://www.cdc.gov/ncbddd/pregnancy_gateway/ Child Safety Seats – National Highway Transportation Safety Administration http://www.nhtsa.gov/portal/site/nhtsa/ H1N1 Flu (Swine Flu): Resources for Pregnant Women http://www.cdc.gov/h1n1flu/pregnancy/ Diapers.com – free shipping and coupons on baby items www.diapers.com Mayo clinic.com Pregnancy Week by Week http://www.mayoclinic.com/health/pregnancy-weekby-week/MY00331 Morning Sickness http://www.femalepatient.com/pdf/pat_0309.pdf Pregnancy information library http://www.femalepatient.com Womenshealth.gov The federal government source for Women’s Health Information (Spanish) http://www.womenshealth.gov/pregnancy/ http://www.womenshealth.gov/espanol/elembarazo/ HOSPITALS Maternity Services at Northwest Medical Center Childbirth Education Classes http://www.northwestmedicalcenter.com/prenatal.html The Women’s Center http://www.northwestmedicalcenter.com/womens_ctr.html TMC Maternity Car Seat Loaner Program https://www.tmcaz.com/TucsonMedicalCenter/Maternity/Car_Seat_Program If you need help obtaining healthy food and health care for you and your child contact: State Children's Health Insurance Program 877-KIDS-NOW (877-543-7669) www.insurekidsnow.gov U.S. Department of Agriculture Food Stamps Program www.fns.usda.gov/fsp/ Women, Infants, and Children Program (WIC) www.fns.usda.gov/wic/ Page 18 www.generationsobgyntucson.com Nutrition During Pregnancy Your diet must provide both you and your developing baby with the protein, carbohydrates, fats, vitamins, and minerals you both need. A balanced diet includes eating from each of the food groups every day. In addition, the March of Dimes suggests that pregnant women should eat the recommended number of portions in each food group. Daily Requirements: 6 servings of bread and other whole grains 3-5 servings of vegetables 2-4 servings of fruits 4-6 servings of milk and milk products (low fat or non-fat) 3-4 servings of meat and protein foods (lean meats, NO fried) 6-8 glasses of water It is important that pregnant women not overdo their intake of fats, oils and sweets. Expectant moms often hear they are “eating for two,” however they actually only need to increase their calorie intake by 300 calories per day. One place where dad can take a role in a healthy pregnancy is by helping mom to get the vitamins and minerals she and the developing baby need. Some women have trouble getting enough of certain foods. For example, lactose intolerant women may be unable to have milk products. A prenatal vitamin and mineral supplement should be taken once a day to help fill the gap. One vitamin, called folic acid, deserves special mention. Getting at least 0.4 mg of folic acid every day in the months preceding pregnancy and the first 6 weeks of pregnancy has been shown to decrease the incidence of spina bifida, a common birth defect. Many women take prenatal vitamins or multivitamins while they are trying to get pregnant. Foods rich in folic acid include green leafy vegetables and whole grains. (Fish oil capsules or a DHA supplement is also advised) Various foods should be eaten in moderation or may not be suitable for a pregnant woman’s diet due to possible health implications. Acid indigestion, most commonly known as heartburn, can cause discomfort and is characterized by a sharp, burning sensation just below the ribs. The pain usually comes after meals and is often triggered by oils, chocolate, vinegar, tomato-based or citrus products, carbonated beverages, caffeinated beverages, and foods high in fat. If you experience heartburn during your pregnancy, you may find relief by avoiding these foods or consuming them in moderation, not eating within 2-3 hours of sleeping, or by taking an antacid recommended by your physician. The Food and Drug Administration (FDA) advises pregnant women, women of childbearing age who may become pregnant, nursing mothers, and young children not to eat shark, swordfish, king mackerel and tile fish. These fish may contain high levels of a form of mercury, called methyl mercury that may harm an unborn baby’s developing nervous system. Because seafood is beneficial in meeting dietary requirements for pregnant women, the FDA advises these women to select a variety of other kinds of fish; including shellfish, canned fish, smaller ocean fish or farm raised fish. In addition, 12 ounces per week of cooked fish can safely be eaten with a typical serving size range from 3 to 6 ounces. Page 19 www.generationsobgyntucson.com Expectant mothers also need to be aware of harmful bacteria during their pregnancy. Listeria monocyotogenes is bacterium that can cause a serious infection in humans called listeriosis. Food borne illness caused by this bacterium in pregnant women can result in severe health implications for the mother, the unborn fetus, and the nursing baby. The FDA is providing the following advice to pregnant women and other at risk consumers about foods that have a greater likelihood of containing listeria monocyotogenes. DO NOT EAT Do not eat hot dogs and luncheon meat unless they are reheated until steaming hot Do not eat soft cheese such as Feta, Brie, and Camembert cheeses, blue-veined cheeses (NO Mexican white cheeses) Do not eat refrigerated pates or meat spreads Do not eat refrigerated smoked seafood, such as salmon, trout, whitefish, cod, tuna or mackerel. These types of smoked seafood are most often labeled as “nova-style”, “Los”, “kippered”, “smoked”, or “jerky”. Do not drink raw (unpasteurized) milk or eat foods that contain unpasteurized milk (NO raw sushi or rare meats) Finally, keep in mind that more is not always better. Some vitamins, such as vitamin A, are harmful in high dosages. If you are taking any vitamin or herbal supplement, be sure to talk to your health care provider about it; avoid any that are not labeled for use during pregnancy. If you are pregnant, may become pregnant or are a nursing mother, it is important to be aware of the food and nutrients you put into your body. Remember, maintaining a healthy lifestyle before, during and after pregnancy benefits both mother and child. Editorial provided by George Macones, M.D., Director of Maternal Fetal Medicine at University of Pennsylvania Medical Center (Also: General Pregnancy Precautions: Minimize or eliminate caffeine Eliminate all Alcohol Stop Smoking or exposure to secondhand smoke Avoid heavy lifting, greater than 30 pounds DO NOT handle cat litter Wear gloves when gardening Avoid HOT water; ex: hot tubs or spas. WARM baths are fine! Minimize fast food/junk food Stop soda use Remember, you are building your baby from the healthy food and water you eat and drink.) Have a safe and healthy pregnancy! * Notes in bold and parentheses were added by Grace Maternity and Women’s Health Page 20 www.generationsobgyntucson.com Heartburn Pregnant women may get heartburn because the stomach muscles relax and food tends to back up. Sometimes the stomach makes more acid during pregnancy. The growing womb, pressing against the stomach, can force acid upwards causing heartburn. Prevention Greasy, fried or highly seasoned foods may produce heartburn. Try to figure out what foods give you heartburn and don’t eat them. Coffee and cigarettes can make heartburn worse because they irritate the stomach. Avoid both. Eat several small meals a day, instead of 3 larger meals. Drink plenty of liquids (six 8-ounce glasses daily). Wear clothing that is loose around the waist Sleep and rest with your head slightly elevated. Useful Remedies When you have heartburn, sip water, milk or carbonated water or have a tablespoon of yogurt, heavy cream or half and half. Try the flying exercise to reduce heartburn. Sit cross-legged, and raise and lower your arms quickly, bringing the backs of your hands together over your head. Repeat several times. Sit up. Lying down can make heartburn worse. If heartburn is worse at night, try sleeping with the head of the bed elevated or use two or three pillows instead of one. A leisurely walk reduces heartburn for some women. For others, sitting quietly and breathing deeply is helpful. Antacids may bring relief from heartburn by reducing stomach acid (for example: Maalox, Mylanta, Riopan, Gelusil). Ask your healthcare provider for antacids that are low in salt. Use these antacids only occasionally since they contain minerals which may be harmful in large amounts. Medicines to Avoid Some widely available heartburn medicines contain aspirin which should not be taken during pregnancy (for example: Alka Seltzer, Fizrin) Do not take heartburn medicines that contain large amounts of salt (for example: baking soda, soda mint). If the suggestions offered above do not work for you, talk to your healthcare provider. Page 21 www.generationsobgyntucson.com COMMON FOODS: SELECT THE LOWER RISK OPTIONS Type of Food Higher Risk Lower Risk Meat and Poultry Raw or undercooked meat/poultry Meat/poultry cooked to a safe minimum internal temperature Seafood Any raw or undercooked fish, shellfish, or food containing undercooked seafood, e.g., sushi or ceviche Partially cooked seafood, e.g. shrimp or crab. Previously cooked seafood heated to 165°F. Canned fish or seafood Seafood cooked to 145°F Milk Unpasteurized (raw) milk Pasteurized milk Egg* Foods that contain raw/undercooked eggs, such as homemade Caesar salad dressings, homemade raw cookie dough or homemade eggnog. Use pasteurized eggs/ egg products when preparing recipes that call for raw/undercooked eggs. When eating out ask if pasteurized eggs are used. (*Most pre-made foods from grocery stores, such as Caesar dressing, pre-made cookie dough, or packaged eggnog are made with pasteurized eggs.) Sprouts Raw sprouts (alfalfa, bean or any other sprout) Cooked sprouts Vegetables Unwashed fresh vegetables, including lettuce/salads Washed fresh vegetables, including salads Cheese Soft cheeses made from unpasteurized (raw) milk Feta Brie Camembert Blue-veined Queso fresco Hard cheeses Processed cheeses Cream cheeses Mozzarella Soft cheeses labeled “made from pasteurized milk” Hot Dogs and Deli Meat Hot dogs, deli meats and lunch meats that have not been re-heated Hot dogs, lunch meat, and deli meats reheated to steaming hot or 165°F (You need to reheat hot dogs, deli meats, and lunch meats before eating them because the bacteria Listeria monocytogenes grows at refrigerated temperatures (40°F or below). These bacteria may cause severe illness, hospitalization, or even death. Reheating these foods destroys these dangerous bacteria and makes these foods safe for you to eat.) Page 22 www.generationsobgyntucson.com Recommended Medication List for Pregnant/Lactating Patients Take as directed on label Call 877-3800 if you have any questions Cold Medications- Tylenol products (cold and flu or allergy), Robitussen (alcohol free), Theraflu Decongestants- Afrin or saline nasal spray, Sudafed, Tylenol sinus, Chlor-Trimeton, Dimetapp, Tavist-D Sore Throat- Chloraseptic, Cepacol, Sucrets, Halls Cough- Robitussen DM, Halls, Vicks Vapor Rub Allergy- Benadryl, Claritin, Zyrtec Nausea- Vitamin B6 (25mg twice a day) Diarrhea- Imodium AD Constipation- Metamucil, Colace, Senokot, Fibercon, Milk of Magnesia Heartburn- Tums, Rolaids, Mylanta, Zantac 75, Pepcid AC Pain- Acetaminophen (Tylenol) 650mg every 4-6 hours as needed; OR Acetaminophen (Tylenol extra strength) 1000mg every 6-8 hours as needed. Yeast Infection- Monistat (5, 7), Femstat 3, Mycelex 7, Gyne-Lotrimin 3 Hemorrhoids- Anusol HC, Preparation H, Hydrocortisone, Nupercaine, Tucks, Sitz bath Itching (due to minor skin irritations)- Benadryl cream/spray, Coladryl, Aveeno, Hydrocortisone Sore Muscles/Joints- Flexall, Icy Hot Sleep Aids- Tylenol PM, Benadryl, Unasom Eye Drops- Visine, Aqua site Sunburn- Soarcaine, Dermoplast, Hydrocortisone Athletes Foot- Lotrimin cream or powder, Tinactin, Micatin Dental Care- Local anesthesia, penicillin antibiotics, Tylenol with codeine for pain X-Rays- Notify the technician you are pregnant, A shield of the abdomen should be provided during the XRay. Page 23 www.generationsobgyntucson.com ACOG Guidelines: Recommendations for Exercise Benefits of Exercising Throughout Your Pregnancy Help relieve pregnancy related aches and pains Maintain or increase your level of fitness Boosts your mood and sense of an overall feeling of well-being Promotes muscle tone, strength, and endurance Gain less overall weight Helps you sleep better Easier for you to get back in shape after baby is born Recommendations for Exercise During pregnancy, women can continue their exercise program; just keep in mind to avoid any sport/exercise that could injure your abdomen. Pregnant women gain health benefits from mild-moderated exercise. Regular exercise (at least 3 times per week) is preferred, however even 30minutes a day is beneficial. Start with 5 minutes of exercise and work your way up to 30 minutes. Women should be aware to modify the intensity of their aerobic exercise. You should be able to talk without gasping for air during your routine. Stop exercising when you feel fatigued and DO NOT exercise to exhaustion. Women should avoid lying on your back without movement after the first trimester. This position can decrease cardiac output in pregnant women potentially decreasing blood flow to uterus. Contraindications to Exercising Pregnancy induced hypertension Preterm rupture of membranes Incompetent cervix/cerclage Persistent second or third trimester vaginal bleeding Intrauterine growth restriction Women with certain medical/obstetric conditions should be evaluated to determine if exercise regimen is appropriate. Page 24 www.generationsobgyntucson.com Helpful Hints for Reliving Morning Sickness Keep snacks by the bed- Try eating dry toast or crackers in the morning before you get out of bed to avoid moving around on an empty stomach. Drink Fluids- Your body needs more water in these early months so aim to drink fluids often during the day. Avoid smells that bother you- Foods or odors that may have never bothered you before may now trigger nausea. Do your best to stay away from them. Eat small and often- Make sure your stomach is never empty by eating five or six small meals each day. Try the “BRATT” diet (bananas, rice, applesauce, toast, and tea), which is low in fat and easy to digest. Try ginger- Ginger ale, tea, or candies made with real ginger can help settle your queasy stomach. Peppermint/Spearmint- Either smelling it in aromatherapy or tea can help curb nausea. Take a supplement- Vitamin B6 is known to help relieve nausea. (25mg twice a day). When to call the office- When nothing is working and you are unable to keep any fluids down. Call our office for other prescription options. Page 25 www.generationsobgyntucson.com Labor Instructions: How to tell you may be in labor How to tell you may be in labor: What to do: 1. You have regular contractions every 3 to 5 minutes, for at least 2 hours. The contractions don’t change no matter what you do, and may even get stronger when you walk (Do It!). Remember to time your contractions form the beginning of one to the beginning of the next one. 1. If the contractions hurt so much that they make you cry, then come in to Labor & Delivery. If the contractions are regular but not strong yet, then you may stay at home where you are more comfortable and continue with normal activities. 2. You may have “bloody show”: It may be pink, light red, or brown. It may be just a little when you wipe, or with a lot of mucus. 2. “Bloody show” is a normal sign of EARLY labor. It is not necessary to come to the hospital for bloody show. Heavy bleeding, like a period is NOT normal and you need to come right in. 3. Your “bag of water” may break. It could be a large gush of fluid or a CONSTANT leak, not just when you wipe. 3. Come to Labor & Delivery, even if contractions haven’t started yet. Notice the color of the fluid. Please call us RIGHT AWAY if: You have severe headache that doesn’t get better after Tylenol and resting quietly. Your baby is not moving as much as usual, and you have tried to feel baby while resting quietly and having a cold drink. Your baby is NOT due yet and you are having ANY signs of labor. You have been given special instructions by your nurse-midwife or doctor to call in certain circumstances. If you have a problem, question, or concern about your pregnancy which you believe needs immediate attention, please CALL US! We are happy to assist you. Northwest, Green Valley and Lazos offices: (520) 877-3800 Oro Valley office: (520) 545-0573 If your questions can wait, write them down for your next regular clinic visit. Remember: The final decision to come to the hospital is YOURS! Page 26 www.generationsobgyntucson.com Generations Healthcare for Women Locations and Phone Numbers In case of medical emergency, call 911 Northwest: 2171 W. Orange Grove Road Phone: 520.877.3800 Oro Valley: 1521 E. Tangerine Rd, Suite 361 Phone: 520.545.0573 Sahuarita/Green Valley: 1295 W. Duval Mine Road Phone: 520.877.3800 Lazos de Familia Health Center 344 W. Ajo Way, Tucson Phone: 520.877.3800 More Information at www.generationsobgyntucson.com Northwest Medical Center Labor and Delivery Unit 1900 W. Rudasill Road Tucson, AZ 85741 Telephone :( 520) 877-4200 (map enclosed in this packet) Page 27 www.generationsobgyntucson.com
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