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Mental Health Treatment Options

One in five adults in the United States will experience a mental health disorder in a given year. While 20% is a significant portion of the population, many people are still unaware of the variety of treatment methods that are now available for mental health conditions.

Dr. Irakli Mania, Psychiatrist and Medical Director of Keystone Behavioral Health, shares some treatment methods which many people are unaware of in today’s article.

Psychiatric Developments

Psychiatric treatment has come a long way in the past 100 years. In the early twentieth century, scientists were trying to figure out which regions of the brain were responsible for psychiatric problems. In the 1950s, antidepressants and antipsychotic drugs were accidentally discovered, allowing for treatment of what is called “chemical imbalances” in the brain. This discovery has been a very important breakthrough in the field of psychiatry allowing treatment and better quality of life for many people. However, the availability of these medications has steered the field away from the physical problems that could trigger psychiatric disorders.

In recent years there has been more interest in looking at physical abnormalities leading to different symptoms and disorders. The brain is an “electro-chemical” organ and its function can be influenced not only chemically but also with brain stimulation methods. We are able to map out circuits in the brain that are involved in various disorders and we can affect that particular circuit with brain stimulation methods.

We have now entered era of interventional psychiatry. Interventional psychiatry uses brain stimulation techniques or rapid-acting medications to treat symptoms that are not responding well to standard treatments with medication and/or therapy. There are many treatment methods that are being used by clinicians, but the ones I will discuss have been approved the U.S. Food and Drug Administration (FDA), meaning they have been approved as safe and effective.

Transcranial Magnetic Stimulation

Transcranial Magnetic Stimulation (TMS) is a non-invasive treatment for Major Depressive Disorder, Obsessive Compulsive Disorder (OCD), and migraines when medications have not been working well or are causing side effects. TMS involves placing a magnetic coil on a patient’s head while they remain awake and alert. The treatment is not painful and patients are able to resume their daily activities immediately after. There are very few side effects from TMS compared to antidepressants, and those who do experience side effects usually describe them as mild and short-term. TMS is available in Franklin County for people with Major Depressive Disorder, and we plan to soon have this treatment available in the area for those with OCD. The use of TMS has been increasing and it’s likely that it will soon be approved to treat Post-Traumatic Stress Disorder, Tobacco Use Disorder, Alcohol Use Disorder and Opioid Use Disorder. These disorders have a significant impact on our society and I believe that TMS can make a big difference.

Electroconvulsive Therapy

Electroconvulsive Therapy (ECT) has received a lot of bad attention through the media and some movies and is often referred to as “shock therapy.” Much of the stigma attached to ECT is based on early treatments in which high doses of electricity were given without anesthesia, leading to memory loss, fractured bones and other serious side effects. ECT is much safer today and it is one of the most effective treatment methods we have for severe depression including for those who have suicidal thoughts and psychosis. It is done under general anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental health conditions. ECT may still cause some side effects.

Vagus Nerve Stimulation

Vagus Nerve Stimulation (VNS) involves the use of a device to stimulate the vagus nerve (one of the nerves that connect the brain to the body) with electrical impulses. An implantable vagus nerve stimulator is currently FDA-approved to treat epilepsy and depression. In conventional VNS, a device is surgically implanted under the skin in the chest, and a wire connects the device to the left vagus nerve. When activated, the device sends electrical signals along the nerve to the brainstem, which then sends signals to certain areas in the brain involved in depression. Dosage of stimulation can be adjusted depending on a patient’s need. New, noninvasive vagus nerve stimulation devices, which don’t require surgical implantation, have been approved in Europe to treat epilepsy, depression and pain. A noninvasive device that stimulates the vagus nerve was recently approved by the FDA for the treatment of cluster headaches in the United States.

Neurosurgical Interventions

Surgical procedures have been done over the years in severe and debilitating cases. Today, a new era of neurosurgical intervention for psychiatric illness is emerging. These procedures are much more focused and much less invasive and destructive. Deep brain stimulation is an established and FDA-approved treatment for people with movement disorders such as refractory epilepsy, essential tremor, Parkinson’s disease, and dystonia, and also for psychiatric conditions such as Obsessive Compulsive Disorder. Although deep brain stimulation is minimally invasive and considered safe, any type of surgery has the risk of complications. Also, the brain stimulation itself can cause side effects. Deep brain stimulation involves creating small holes in the skull to implant the electrodes, and surgery to implant the device that contains the batteries under the skin in the chest.

External Trigeminal Nerve Stimulation

The most recent FDA approval has been External Trigeminal Nerve Stimulation (eTNS) for children ages 7-12 who have Attention Deficit/Hyperactivity Disorder (ADHD). This is the first non-drug treatment option for ADHD. This treatment is intended to be used in the home under the supervision of a caregiver. The cell-phone sized device generates a low-level electrical pulse and connects via a wire to a small patch that adheres to a patient’s forehead, just above the eyebrows, and should feel like a tingling sensation on the skin. The system delivers low-level electrical stimulation to the branches of the trigeminal nerve, which sends signals to the parts of the brain thought to be involved in ADHD. While the exact mechanism of eTNS is not yet known, neuroimaging studies have shown that eTNS increases activity in the brain regions that are known to be important in regulating attention, emotion and behavior. One should consult with a behavioral health provider in order for this to be recommended.

New Medications

Another area of development is new medications. This is important because Treatment Resistant Depression is common and available medications, in addition to being ineffective at times, may take a long time to work or find the correct dosage. One medication which has been given fast-track FDA approval is Esketamine (Spravato). This is used as a nasal spray and can be effective within hours of administration. Unfortunately, it still has significant side effects and administration can only happen in a licensed facility under observation.

With all the above developments we have to increase awareness of these treatment methods in our society. I see the need for a center for interventional psychiatry across the country including in our community. For more information about any of the treatments mentioned above, consult a behavioral health specialist.

This article contains general information only and should not be used as a substitute for professional diagnosis, treatment or care by a qualified health care provider.

For more information about Keystone Health’s TMS Program, click here.

Chambers Hill Construction Progress

You may have noticed ongoing construction over the past year for Keystone Health’s newest facility. Construction will be completed this summer, and we expect to occupy the building in early fall.

The 68,000 square foot building will be located at Chambers Hill, on the corner of Norland and Fifth avenues in Chambersburg. Several of our current practices will relocate to the new site to allow for expansion so we can better serve the community.

The sites planned for relocation are:

  • Keystone Urgent Care
  • Keystone Pediatric Dentistry
  • Pediatric Therapies including Audiology and Speech
  • Keystone Infectious Diseases and HIV/STD Services
  • Keystone Community Outreach
  • Keystone Administration and Billing

Keep an eye out in the coming months to see the completed project, and for information about a community open house!

Keystone Health’s newest facility, a 68,000 square foot building, expected to be completed in September.

Better Speech & Hearing for Kids

Communication is much more than only spoken words and sentences. From early infancy, parents and caregivers can begin to encourage and promote their child’s overall communication and speech-language skills.

Laurie Kaufman, Speech Language Pathologist at Keystone Audiology and Speech, gives some important tips that all parents and caregivers should know about making sure children are on track with proper communication development.

When do speech and language skills start developing?

Beginning at birth, infants communicate with their cries, smiles, laughter, facial expressions and body language. Before children begin to use words, one-on-one interactions with the important people in their lives significantly influence their language learning. They imitate the speech models provided by their caregivers including gestures (waving, giving kisses), sounds (mama, moo) that evolve into words, and strings of words that evolve into meaningful language. Children who are provided with strong language stimulation develop strong communication and language skills. Research has shown that during the first years of life, children who are talked to, read to and played with have better language skills than their under-stimulated peers. Children with strong language skills are also more likely to enter school ready to learn, are less likely to have difficulties learning to read and are more likely to have academic success.

How can I help my child develop these skills?

From birth, parents and caregivers can encourage the development of a child’s communication and language skills. Caregivers can begin by simply responding to babies’ vocalizations – their cries, coos and babbling. Gaining a baby’s attention by responding to them with eye contact, facial expressions, sound play and commenting encourages turn-taking and promotes positive communication interactions. Even when children are too young to respond with words, it is important for caregivers to provide language stimulation by talking to and engaging their child in “conversation.” Parents and caregivers should consider themselves to be the “narrators” of their child’s life, providing ongoing models of spoken language through labeling, commenting on and describing objects, daily routines and play-based interactions. Children are more likely to imitate first sounds and words when they are used repeatedly within routine activities and play. During play routines, caregivers can pair actions with sounds or words which promotes imitation of both the action and the spoken sound or word, such as saying “Pop” as you pop bubbles or saying “Beep beep” as two toy cars collide. Additionally, singing favorite songs, repeating nursery rhymes and performing finger plays also encourage imitation and language development. Reading books with repetitive text patterns or reading the same books over and over also encourages imitation. Additionally, limiting screen time in favor of personal interactions and play-based opportunities greatly enhances a child’s chances for social and language development.

What are the milestones for speech development?

If you are concerned about your child’s speech, language or hearing, it’s important to know what is considered developmentally appropriate. Every child develops skills at his or her own pace; however, most children acquire certain communication skills within an expected age range. A child who has not yet demonstrated an expected communication milestone, within the expected age range, may have a problem. It is important for caregivers to be aware of communication milestones in order to recognize signs of a delay or disorder, and consult the child’s healthcare provider with any concerns. Below is a list of basic communication milestones within the expected age ranges.

From birth to 3 months, infants should smile, coo and show interest in others. From 4-7 months, babies should babble and engage in sound play. Babies 7-12 months should make a variety of sounds and sound combinations, including early words (mama, dada, etc.), use gestures like waving or pointing, and follow routine commands.

From 12-18 months, they should use 5-10 words, combine words and gestures, imitate the speech of others, point to objects/people in pictures, consistently follow simple directions, and understand and respond to yes/no questions. Toddlers from 1 ½ – 2 years should use approximately 50 words and combine them into two-word phrases, follow two-step directions (pick up your cup and bring it to me), and enjoy listening to stories.

By three years old, children should be able to consistently use three or four word phrases with longer sentences noted, use early grammatical markers such as plurals and present progressives (dogs, walking) and have most of their speech understood by a caregiver. They should enjoy playing and talking with other children, ask and answer questions, follow two-step unrelated directions (give me the ball and go get your coat), and have emerging understanding of concepts including color, space and time.

Can having chronic ear infections impact my child’s speech?

Yes. During ear infections, children can have mild or even moderate hearing loss which makes hearing speech difficult. Speech will sound muffled or indistinct. As your child learns new words he or she may not know how they are actually pronounced. With continued ear infections, your child may not hear all the words in a sentence or not hear the ends of words and therefore not use those sounds or words.

What can I do to protect my child’s hearing?

There are several ways that you can protect your child’s hearing. The most obvious is to use hearing protection when exposed to excessive noise at sporting events, concerts, races and around power tools or mowers. Children that use earphones or headphones should use volume limiting versions until they are able to learn to moderate the volume to safe levels. In addition, maintaining overall ear health can prevent hearing loss. Some tips are: consult a physician if ear infections are suspected, eat a healthy diet that includes lots of vegetables and fruits but limits empty calories, avoid second hand smoke and get exercise to build a strong circulatory system.


This article contains general information only and should not be used as a substitute for professional diagnosis, treatment or care by a qualified health care provider.


Employee Spotlight – Geetha Potineni

The Keystone Health Employee Spotlight for May shines on Geetha Potineni, Network Security Administrator in our Information Systems Department!

Geetha started working at Keystone in January 2016 after completing her master’s degree in Computer Science.

“I was in search of a job in the area when an opportunity became available at Keystone,” she said. “My husband was already working for Keystone and I had heard many great things about the organization, so I was naturally excited to become a part of it.”

Geetha’s daily job responsibilities include checking on the servers and making sure they are backed up, monitoring computer systems and servers for potential threats and preventing them from happening, responding to threats when they do happen as part of the IT team, and maintaining logs for compliance. She can also be found helping staff through the Keydesk when they encounter issues with their computers, logins, websites, emails, pagers, etc. and also provides IT security awareness training to new employees and providers.

“I enjoy every aspect of my job,” Geetha said. “As a Network Security Administrator, I am responsible for continuous monitoring of some of the IT systems and servers and it gives me a sense of pride when I find something critical early and can address it in time so patient care is not interrupted.”

She’s also glad to take part in Keystone’s overall goal.

“I’m proud to be part of Keystone Health, which is driven by the mission of providing access to healthcare for everyone, irrespective of one’s ability to pay for the services.”

In her free time, Geetha keeps busy with her family life.

“I live in Greencastle with my husband, Venkat, who is a Pediatrician at Keystone, and our two daughters, Sindhu and Shriya. My daughters keep me busy, but I love to cook and travel, and I run whenever feasible.”

While she and her husband are not Franklin County natives, they are glad they chose this area to raise their family.

“Franklin County is really beautiful, especially during spring,” she said. “Also, neither I nor my husband likes a long commute to work, so we both enjoy shorter commutes and the area’s relatively slow-paced lifestyle. Its proximity to Washington D.C is also another thing that we love.”

Thank you, Geetha, for all that you do for Keystone and our patients!


Free Mental Wellness Event

We hope you will join us on May 28 for an informative discussion on mental wellness and self-care by Dr. Jagdeep Kaur! Light refreshments will also be provided. Don’t forget to RSVP as space is limited.


Caring For Your Child’s Teeth

While most parents are diligent about taking their children to the doctor for routine medical visits, many people don’t treat their children’s teeth with the same importance. Developing a proper oral hygiene routine, including regular visits to the dentist, is one of the most important habits parents can pass on to their children to help them have healthy teeth for life.

Dr. John Palm of Keystone Dental Care shares some information about how to properly care for babies’ and children’s teeth and how to prepare for their first dental office visit.

How and when should parents begin caring for their baby’s teeth?

Begin cleaning your baby’s mouth during the first few days after birth by wiping the gums with a clean, moist gauze pad, teeth wipes or washcloth. Gently wipe his or her gums after each feeding.

For children younger than 3 years, start brushing their teeth as soon as they begin to come into the mouth by using fluoride toothpaste in an amount no more than the size of a grain of rice. Brush teeth thoroughly twice per day with a small, soft-bristled toothbrush or finger brush. Supervise children’s brushing to ensure that they use the appropriate amount of toothpaste and remind them not to swallow the toothpaste. When your child has two adjacent teeth that touch side-by-side, you should begin cleaning between his or her teeth daily with flossers.

Introduce a pea-sized amount of fluoridated toothpaste for children 3 to 6 years of age. Do not do this until the child is old enough to spit out the toothpaste after brushing. Use only the recommended amount of toothpaste and tell your child to spit out—not swallow—the toothpaste.

Until you’re comfortable that your child can brush on his or her own, continue to brush your child’s teeth twice a day with a child-size toothbrush and a pea-sized amount of fluoride toothpaste. Allow the child to watch you brush, and follow the same brushing pattern to minimize missed spots. Typically around age 8, most children are able to brush on their own with minimal supervision.

Prevent baby bottle tooth decay: Don’t give children a bottle of milk, juice or sweetened liquid at bedtime or naptime. Don’t allow children to walk around with a sippy cup filled with sugary beverages all day long. Encourage water between meals, and limit milk and other drinks that may contain sugar to mealtime.

Avoid foods and treats that increase tooth decay: hard or sticky candies, gummy fruit snacks, multi-vitamins that are high in sugar and sweetened drinks and juice. Offer fruit rather than juice; the fiber in fruit tends to scrape the teeth clean, whereas juice just exposes the teeth to sugar.

When should the first dental appointment be scheduled?

The American Dental Association, American Academy of Pediatric Dentistry, and American Academy of Pediatrics all recommend that the first dental visit should occur within six months after the baby’s first tooth appears, but no later than the child’s first birthday. Baby teeth are vulnerable to tooth decay from their very first appearance, on average between six months and one year of age. Being proactive about your child’s dental health today can help keep his or her smile healthy for life. It is important to have his or her teeth screened by a dental professional at medical well-child visits. This service is offered at both Keystone Dental and Keystone Pediatrics Chambersburg.

What will be done at the first dental appointment?

Most initial office visits are to help acquaint the child with the dental professional. The first visit usually lasts 30-45 minutes. During the visit, you will be seated in the dental chair with your child on your lap if your child isn’t able to — or doesn’t want to — sit in the chair alone. The dentist will check the teeth, jaws, bite, gums and oral tissues to monitor growth and development. Once the exam is over, the dental professional will gently clean the teeth, which includes polishing teeth and removing any plaque, tartar and stains. The dentist will give you tips for good oral hygiene practices for your child’s teeth and gums. At this time, the dentist can provide or recommend information on baby bottle tooth decay, infant feeding practices, teething, pacifier habits, and finger-sucking habits.

If you have dental anxieties, be careful not to relate those fears or dislikes to the child. If your child cries a little or wiggles during the exam, don’t worry. It’s normal, and your dental team understands this is a new experience for your child.

How can parents prepare their child for their first dental visit?

Start early! To get your child ready for the visit, talk to him or her about what’s going to happen and be positive. Have your child practice opening his or her mouth to get them ready for when the dentist counts and checks their teeth. Reading books or watching videos about first dental visits may help your child be less fearful and more confident. Explain why it is important to go to the dentist. Build excitement and understanding.

Moms and dads can prepare, too. When making the appointment, it can’t hurt to ask for any necessary patient forms ahead of time. It may be quicker and easier for you to fill them out at home instead of at the office on the day of your visit.

Make a list of questions as well. If your child is teething, sucking his or her thumb or using a pacifier too much, your dentist can offer some advice.

Tips for a great visit

Be sure to schedule all dentist appointments for times when your child will be comfortable and in a good mood. Don’t schedule an appointment during naptime. Instead, pick a time your child is usually well-rested and cooperative. Make sure your child has had a light meal and brushes their teeth before their appointment so they won’t be hungry during their visit.

Think of the appointment as a happy and fun experience. If your child becomes upset during the visit, work with your dentist to calm your child. You’re on the same team!


This article contains general information only and should not be used as a substitute for professional diagnosis, treatment or care by a qualified health care provider.

Employee Spotlight – Monica Heinbaugh

Monica with her sons Jaxson and Abel.

The Keystone Health Employee Spotlight for April shines on Monica Heinbaugh, Lead Licensed Practical Nurse at Keystone Pediatrics Chambersburg!

Monica began working at Keystone in 2001. She had previously worked as a night-shift nurse for a year and was looking for a change that would allow her to have daytime hours without working weekends and holidays.

Almost 18 years later, Monica still enjoys her role at Keystone. She works in dual positions – part-time as Dr. Michael Colli’s nurse, and part-time fulfilling administrative duties.

“I get to work with the best family I could ask for,” she said. “And I love watching the families we see grow up. I have met some life-changing people here and I am so grateful!”

Monica’s job involves a variety of duties each day. When she’s not with Dr. Colli taking care of patients, she keeps busy with other responsibilities, including giving vaccines, doing the nursing schedule, doing vaccine inventory and management, charting, and attending meetings.

When asked about what makes her proud to work at Keystone, helping patients is at the top of Monica’s list.

“Seeing some patients who I remember as babies now graduating and becoming adults, and some becoming parents themselves makes me proud,” she said. “I like being able to help patients, especially kids who can’t help themselves and offering services, medical care, and education to those in need and knowing they are leaving with more than they came with.”

Monica was born and raised in Chambersburg and is now raising a family of her own here. She has two boys with her husband Brad – Jaxson, 7, and Abel, 2. Outside of work she keeps busy with trying new DIY projects, enjoys spending time with friends and family, and with her sons.

“These boys keep me on my toes,” she said. “We have soccer and baseball and love being outside!”

Thank you, Monica, for all that you do for Keystone and our patients!

What You Need To Know About Colorectal Cancer

March is Colorectal Cancer Awareness Month. Also known as colon cancer, this disease is one of the most commonly diagnosed cancers and is the second leading cause of cancer-related deaths in Pennsylvania and the United States.

The good news is, many of these deaths can be prevented by being proactive. Gregory Gibson, Certified Registered Nurse Practitioner at Keystone Internal Medicine, shares information about the disease, including what signs to look for and what testing options are available, in today’s Take Care article.

What is colorectal cancer?

Colorectal cancer (CRC) is a common and potentially fatal disease. Cancers are cells that overgrow and begin to invade other parts of the body, and this is a cancer that affects the lower part of the digestive tract. There are nearly 150,000 new cases reported each year with approximately 51,000 deaths yearly from this disease. This cancer can affect both sexes but it does affect men more than women. Environmental and hereditary factors are both contributors to a person’s risk for colorectal cancer.

What are some warning signs and symptoms?

Signs of colon cancer include changes in bowel habits such as diarrhea or constipation or other changes that last for more than a month. Bleeding from your rectum or blood in your stool is another possible sign of CRC. Other symptoms can include persistent abdominal pain or a feeling that you cannot completely empty your bowels when you go. Weakness, fatigue, unexplained anemia and unexplained weight loss may also occur but are less specific signs.

Who should be tested, and what testing methods are available?

The United States Preventive Services Task Force recommends that everybody over the age of 50 should be tested for colorectal cancer, and screening should continue until at least age 75. The US Cancer Society has suggested that screening should begin at age 45. People with a family history of colorectal cancer, inflammatory bowel disease (ulcerative colitis or Crohn’s disease), history of radiation treatments to the abdomen or pelvis, Lynch syndrome or familial adenomatous polyposis should consult with their primary care provider to see if screening should begin sooner.

There are several different options for screening of colorectal cancer. There are multiple stool-based tests that may be performed in the privacy of your own home such as FIT, FIT-DNA, and gFOBT. These tests need to be performed every year except for the FIT-DNA which may be performed every one to three years. These methods offer the advantage of not having to have any anesthesia and not requiring bowel preparation before being performed. Patients may also have a sigmoidoscopy performed every five years or colonoscopy performed every 10 years. Advantages of these tests are that they have to be performed less often, and during the screening some issues can be addressed without additional procedures. The disadvantages of these tests are that they require anesthesia and bowel prep before the procedure.

Why is it important to not put off screening?

The reason to not put off screening is because colorectal cancer does not always have signs and symptoms in the earlier stages or when it is just a precancerous polyp. Screening tests allow providers to find these abnormalities earlier and treat them before they have a chance to spread to other parts of the body. It is a missed opportunity to not screen for this cancer because we cannot screen like this for every disease. Screening has proven to be very effective over the past few decades at decreasing mortality rates from colorectal cancer.

Even if the screening may seem unpleasant to you, I assure you it is a much better alternative of finding you have colorectal cancer because you have not had any screening. Some of my own family and friends are still here with us today because of early detection. This allowed them to begin treatment early and they have overcome this diagnosis. They are still with us 20 years later.

What are the benefits of early detection?

If colorectal cancer is detected before it spreads to other parts of the body, the survival rate over a 5-year period is 90%. The mortality rate of this disease has decreased steadily since the 1980s partly because of the early detection of cancer through screening. Colonoscopies in particular are very useful. Not only do they detect colorectal cancer but they can see and remove growths, and biopsy them before they cause problems. The mortality rate for colorectal cancer is much lower when detected early.

We do preventative maintenance and screening on our cars, so why would we not do it for ourselves? Prevention is always preferable treatment. People need to play an active role in their healthcare. Your provider can make suggestions but unless you are an active participant in your healthcare and participate in screenings, disease can only be reacted to instead of prevented.


This article contains general information only and should not be used as a substitute for professional diagnosis, treatment or care by a qualified health care provider.

Free Produce at Keystone Health

Join us on Thursday, March 28, to get some FREE fruits and veggies!

Third Trimester FAQs

For pregnant women, by the time the third trimester arrives many changes have already taken place. As the body grows and prepares to give birth, more changes are on the way – both physically and mentally.

Dr. Radha Rani Padhy of Keystone Women’s Care shares information about what women can expect during the last trimester of pregnancy, and when they should seek medical advice.

What kind of physical changes start to happen during this trimester?

During this trimester, the uterus gradually expands from the pelvis up to the rib cage. This can cause tremendous physical pressure and discomfort. In addition to lower back pain, there may be pressure on the sciatic nerves causing pain, tingling or numbness down the legs. Finding a comfortable position to sleep may become challenging. The best position is lying on the side, preferably the left side to allow for maximum blood flow. Body pillows may be helpful in maximizing comfort.

Hemorrhoids may develop, which are varicose veins in your rectum, and swelling of the fingers, face and ankles may become more evident. The skin across the abdomen may become dry and itchy from the stretching. Pink, reddish or purplish indented streaks may become visible reflecting stretch marks.

False contractions, known as Braxton Hicks contractions, may become more frequent. These are irregular and sporadic contractions. As unpleasant as the physical symptoms become, the highlight will be consistent movement of the baby. Get to know your baby’s patterns of movements, including the frequency and intensity. There may be a slight decrease in activity in the last few days before birth as the baby descends further down in the pelvis in preparation for delivery.

What kind of emotional changes may be taking place?

By this point, the fatigue of pregnancy may be overwhelming, leading to growing eagerness towards the estimated due date. Many women also experience feelings of apprehension about the birthing process. A good way of overcoming this is to talk with others who have had positive birth experiences. If you’re frightened and anxious during labor, your birthing experience may be more difficult. Educating yourself and asking questions about the process can greatly ease your qualms.

What are common tests that will be run during this time?

Prenatal visits become more frequent during this trimester. After 28 weeks of pregnancy, visits occur every two weeks and visits will be scheduled weekly after 36 weeks. These appointments are important as they include checking the position of the baby to see whether the head or the buttocks is facing the down towards the mother’s pelvis.

A group B strep test is performed, which is a swab of the vagina and rectum. Group B strep is a bacteria that is normally found in the vagina or rectum, but it can cause a serious infection for the baby if there is exposure during birth. If you test positive for group B strep, you will require antibiotics during labor.

If you pass your due date, the baby’s heartbeat may be monitored with an electronic fetal monitor. An ultrasound may also be performed to assess the baby’s breathing, movement, muscle tone and the amount of amniotic fluid. You may also be offered an induction of labor, which involves the stimulation of uterine contractions before labor begins in order to achieve a vaginal birth. Your provider will explain in detail all the modalities of induction available and individualize a plan appropriate for you.

What do healthcare providers generally recommend when it comes to over the counter medications and physical activity during this trimester?

As stressed throughout your pregnancy, always ask your provider before starting any medications. This includes prescription and over-the-counter medications. Daily exercise is still recommended (30 minutes at moderate intensity) if there are no medical or obstetric complications. However, avoid lifting heavy weights (greater than 20 pounds) and any exercises that involve lying on your back.

What warning signs should the expectant mother be concerned about? When should she call her doctor or midwife?

Babies establish movement and sleep patterns as the pregnancy progresses. It is important to be aware of and account for these movements. If you perceive decreased fetal movement, sit down in a quiet place and count your baby’s kicks. You should count at least 10 movements within two hours. If there are less than 10 kicks or you don’t feel any movement at all, call your provider immediately.

Toward the end of the trimester, it may be difficult to tell the difference between false contractions and true contractions. False contractions usually are irregular, don’t get consistently closer together, vary in length and intensity and dissipate with walking, changing positions or resting. They are mainly centered in the lower abdomen and pelvis. True contractions have a regular pattern that grow closer together, last at least 30 seconds, become longer and stronger and strengthen despite walking, changing positions or resting. They most often radiate throughout the abdomen and lower back. If you start experiencing contractions every two to three minutes lasting for one or more hours, or painful contractions with heavy vaginal discharge, call your provider immediately.

Other reasons to call your provider immediately during any trimester include: heavy bleeding or bleeding that lasts longer than a day, severe abdominal or pelvic pain (especially if accompanied by a fever or bleeding), a fever greater than 102 degrees Fahrenheit, a severe and persistent headache (especially with dizziness, faintness or visual disturbances), severe shortness of breath or chest pain, inability to urinate or painful urination, leg pain with redness or swelling, worsening swelling of the hands or feet, heavy or foul-smelling vaginal discharge and a low mood, loss of pleasure and thoughts of harming yourself or others.

What are common concerns that expectant parents have during this time?

Concerns about breastfeeding, scheduling difficulties with maternity and/or paternity leave and anxiety over becoming parents are common worries. The best way to overcome this anxiety is to be organized before the baby is born. Find a pediatrician or provider with whom you are confident and stock up on baby supplies that you will need immediately once you arrive home with your baby for the first time.

Buy a car seat as it is one of the most important pieces of equipment in the care of your baby, starting with the first ride home from the hospital. Car seats are required by law in every state. Correct and consistent use of them is one of the best ways to protect your child. You should also buy a crib as the newborn baby will spend more than half their time sleeping. When purchasing or borrowing a crib, make sure that it meets specific safety guidelines.

Fears about the birthing process are also normal. As you anticipate the day of your baby’s arrival, it becomes exciting but can also be very stressful. Knowing what to expect can help you have the most positive birth experience. Acknowledge that childbirth can be painful, so inquire about all the pain management options that are available. Address all your fears with your provider and ask as many questions as you need to be prepared. Remember that you are not alone. Childbirth can be a scary experience, but we are here to guide you through it every step of the way. As your provider, we take the utmost pride and pleasure in having a healthy mom and healthy baby.


This article contains general information only and should not be used as a substitute for professional diagnosis, treatment or care by a qualified health care provider.