Congratulations! Pregnancy is a time of many emotions. You can be excited at the thought of a new baby, be anxious about the pregnancy, thrilled at the thought of motherhood, and be depressed about being so far away from your family, all at the same time. You may also be concerned about being in Bolivia during your pregnancy. These concerns are healthy if they make you take special care of yourself and your baby. They are not healthy if they keep you from being excited about your pregnancy.

This booklet is designed to answer some of your questions about pregnancy, outline the routine of prenatal care in Bolivia, and tell you about the State Department's policies for obstetrical medevacs. If you have any further questions, please feel free to contact the Health Unit.

Generally, a missed period is the first sign of possible conception. Other early signs include breast fullness or tenderness, skin changes, nausea, vomiting, fatigue, and the need to urinate more frequently. Since other conditions may also cause these symptoms, they are not diagnostic.

The Health Unit uses a urine pregnancy test to diagnose pregnancy. This test is very sensitive and may be positive within a week of the missed period. This test measures the amount of human chorionic gonadotropin (HCG) in the urine. HCG is a hormone secreted by a young placenta (the spongy structure, usually located in the uterus, which delivers nourishment to the fetus). The first urine of the morning contains the highest concentration of HCG and is, therefore, the best sample for the pregnancy test.

Since the average duration of a pregnancy from the last menstrual period is 280 days or 40 weeks, we can estimate the date of your delivery based on your last period.

If your pregnancy test is positive, we will schedule your first prenatal examination with an Obstetrician here. Although we can provide some of your prenatal care at the Health Unit, it is wise to be followed by a physician who is a specialist in that area in case there are any complications. There are English-speaking Obstetricians in Bolivia who trained in the U.S. and Germany. Because medical facilities are not as well-equipped to deal with delivery and newborn complications here as they are in the U.S., we do NOT recommend that you deliver here. We strongly urge you to travel to the U.S. for the final 6 weeks of pregnancy and for the delivery.

During your initial visit, the obstetrician will ask you about your health history, and do a physical exam, which will probably include a pelvic/PAP smear. Routine laboratory tests will be ordered. Some tests can be sent to a lab in the U.S., but others will need to be done at a local laboratory.

After the initial visit, you will be scheduled for monthly visits until your 28th week. During these visits the doctor will check your weight, blood pressure, uterine size, and listen for your baby's heart. (If the doctor has a doppler, he/she will be able to hear your baby's heart as early as 10-12 weeks. If not, your doctor will not be able to hear it until 18-22 weeks.) The doctor will also be checking your urine at each visit for the presence of protein and glucose.

After 32 weeks of gestation, your appointments will be increased to every two weeks. We expect that you will leave for the U.S. by your 34th week. (Please see the information on Obstetrical Medevac.)

Special tests may be ordered during your pregnancy:

Initial Visit: Hematocrit, hemoglobin, white blood cell count, blood group type, Rh factor, antibodies to blood group antigens, VDRL, rubella anti-Body titer, hepatitis B, toxoplasmosis, urine culture, and HIV.

16-18th week: Maternal serum alpha fetoprotein. This is a screen for certain birth defects.

28th week: Glucose tolerance test or fasting blood sugar to check for gestational diabetes. Hematocrit and antibody screens may be repeated.

36^th week: Vaginal culture for Group B streptococcus

Ultrasounds may be done frequently during your pregnancy to accurately measure your baby's growth. Research has not found any evidence that ultrasound scans harm the baby in any way.

Amniocentesis is the testing of the amniotic fluid surrounding the baby to test for birth defects. It is usually performed between 12 - 18 weeks after the last menstrual period for those who are thought to be at risk. The procedure is recommended for parents who have previously delivered a baby with chromosomal abnormalities or a neural tube defect (e.g., spina bifida), who are known to be carriers of chromosomal abnormalities, as follow-up on an abnormal alpha fetoprotein, and for mothers 35 years old or older. The procedure is not without risks. Maternal complications, rarely serious, include vaginal spotting and amniotic fluid leakage. For the baby, the risk of miscarriage is thought to be around 0.5%.

Chorionic Villus Sampling (CVS) is another method of testing for abnormalities in the fetus. With this test, a small amount of tissue is taken from the chorion (a membrane that will later become the placenta). Because the chorion is growing so rapidly, testing can be done at 9 to 11 weeks, earlier than amniocentesis. The benefit of this test is that it would allow for pregnancy termination (abortion) early in the pregnancy if a severe abnormality was found. There is, however, a slightly higher incidence of miscarriage with CVS, around 0.8%.

The medevac point from Bolivia for these procedures is Miami, with cost construct to points beyond. We can supply you with more information on these tests as well as names of various places where they can be done. The results are now usually available after two weeks. You are, however, only allowed three days per diem plus travel time. The State Department does NOT pay per diem through the waiting period for the test results, although some women opt to wait for the results and bear the additional costs. If, once back at post you are informed of a problem revealed by the test, you will be authorized to return for further counseling. Travel and half per diem may be authorized for children who can not be cared for adequately at post. This is an individual post decision and is not the decision of the Health Unit, but of post administration.

Milestones by weeks since the last menstrual period:

One of the most important things that you can do for your baby is to eat sensibly. During pregnancy, your body requires larger amounts of vitamins and minerals than usual. This is especially true at high altitudes. Extra protein (about 80grams a day), the building block of the body tissues, is needed so your baby can grow. Extra calcium (1.5 grams a day) is needed to build your baby. s bones and teeth. An adequate iron intake (30-60 mg a day) is needed for your baby to build its own blood supply. Folic acid (4mg a day) has been shown to effectively reduce the risk of neural tube defects (spinal cord) in high-risk patients. Vitamin B12 supplements are recommended for vegetarian pregnant women. Vitamins are essential for everyone. s metabolism, and doubly so for your rapidly growing baby. Although an undernourished mother may produce a healthy child, studies have shown a definite relationship between the diet of the mother and the condition of the baby at birth. In fact, researchers have found that some of the complications of pregnancy, such as anemia, toxemia, and premature delivery, may result from an inadequate diet. Recent research has shown that taking Vitamin supplements during pregnancy reduces a woman's risk of pre-eclampsia (a potentially fatal condition). The Health Unit will supply you with prenatal vitamins. These vitamins do not contain protein and other essential vitamins and minerals. You must also eat well.

You can expect to gain 22-27 pounds during this pregnancy. Most of this weight is from the baby, the placenta, amniotic fluid, and increased blood volume. Since the baby gains the most weight in the last 13 weeks of pregnancy, so you will probably gain the most weight during that time. You may be tempted to go on a weight-loss diet. Don. t! A diet will deprive your body of necessary vitamins and minerals. If you are gaining too much weight, cut down on unnecessary calories by reducing empty sugars, sodas, candy, and other "junk food".

A good diet during pregnancy includes the following each day:

At sea level, the fetus lives at oxygen tensions far below what an adult can tolerate. However, the amount of oxygen the baby receives is clearly enough for normal development. At high altitude, the fetus lives at even lower oxygen tensions. Unfortunately, this lower oxygen tension can slow the baby's growth (intrauterine growth retardation) and increase the mother's risk of pregnancy complications. Fortunately, most of the intrauterine growth retardation has been found to occur after the 32^nd week of pregnancy. Since we recommend that women return to the U.S. by their 34^th week, the risk of a small birth weight baby should be minimal. (The Health Unit is currently participating in a study to try to determine the risks of living at altitude until the 34^th week to the baby and mother. If you have not been asked to participate in the study and are interested in helping, please call us.)

Smoking and strenuous exercise may further decrease the oxygen available to your baby at altitude. Smoking decreases the amount of oxygen that your blood can carry to your baby. When you smoke, your red blood cells prefer to transport the carbon monoxide you are inhaling. This leaves fewer red blood cells available to transport the needed oxygen. When you exercise strenuously, your body needs and uses more oxygen so there's less oxygen left over for your baby. Especially at altitude, don't smoke while you are pregnant and avoid exercising too vigorously.

Dehydration in pregnant women has been linked to uterine contractions (possibly leading to premature labor). Pregnant women can dehydrate quickly if they are vomiting frequently and/or develop diarrhea. Also, pregnant women breathe more often than non-pregnant women. Just breathing rapidly in the dry environment of high altitude can lead to dehydration. Drink more fluids than you did before you became pregnant. Call the Health Unit or your Obstetrician if you cannot keep fluids down because of vomiting or you have diarrhea. Call right away if your mouth feels dry, you're feeling lightheaded, and you are urinating less than usual; you may already be dehydrated.

Pregnant mothers who live at altitude have a three- or fourfold increase in their risk of preeclampsia (a condition involving high blood pressure and protein in the urine, which can lead to severe seizures) and abruptio placenta (the placenta is released from the wall of uterus prematurely). Prenatal vitamins are thought to decrease the risk of preeclampsia. Take your prenatal vitamins as directed. Since the first signs of preeclampsia are elevated blood pressure and protein in the urine, you should have your blood pressure monitored and a urinalysis done at least monthly during your pregnancy.

Alcohol intake during pregnancy can lead to malformations of the baby, second trimester abortions, and fetal distress during delivery. Moderate to heavy alcohol consumption during pregnancy can cause fetal alcohol syndrome (FAS). A baby with FAS has growth retardation before and/or after birth, facial malformations, a small head, and mental retardation. The level of alcohol consumption which is "safe" for the baby is unknown. It appears that levels of less than one to two drinks/day are not associated with FAS, but, for safety, women should avoid drinking any alcohol during pregnancy. If alcohol use occurs, it should be limited to less than two drinks/day on an irregular basis. Binge drinking, which has been shown to increase the risk for FAS, should be avoided.

Smoking tobacco is associated with decreased birth weight and increased risk of miscarriages, placental problems, and sudden infant death syndrome (SIDS). The risk of miscarriage, for example, is up to twice as high in smokers as in nonsmokers. A direct relationship has been found between the number of cigarettes smoked and the severity of the effects. The level of smoking at which no effects are found, however, is currently unknown. Pregnant women should not smoke. If unable to stop smoking, reducing to as few cigarettes a day as possible is beneficial.

Illegal drugs can also cause problems in pregnancy. Marijuana, cocaine, amphetamines, and opiates cause growth retardation. Cocaine can also increase the risk for miscarriage, fetal death, premature birth, and fetal distress. Babies exposed to cocaine, amphetamines, and opiates go through withdrawal after delivery. Pregnant women should not take recreational drugs.

For dental procedures, local anesthetics, used in appropriate amounts, are acceptable during pregnancy. Nitrous oxide is also okay, but is less desirable than a local anesthetic because it can cross the placenta to the baby. However, it has not been shown to cause birth defects. Normal dental cleanings and fillings are not containdicated at any time during pregnancy. In fact, evidence suggests that the bacterial overgrowth from cavities could increase the risk of transmission of infection to the newborn. Any x-rays that are necessary can be done with a lead apron shield.

Some over-the-counter medications are not recommended during pregnancy. Aspirin, ibuprofen (Motrin, Advil), and naproxen (Naprosyn) should not be used during pregnancy, except in special cases, because of their association with fetal kidney malformation and malfunction. Aspirin has also been found to increase the mother. s blood loss during delivery. (Some doctors, however, are now prescribing low-dose aspirin therapy to prevent preeclampsia and low birth weight.) Acetaminophen (Tylenol) is the pain/fever medication that poses the least risk to the mother and baby.

Cough and cold medications are among the drugs most commonly used during pregnancy. Antihistamines such as chlorpheniramine (Chlor-Trimeton) and triprolidine have been used for many years and have not been found to pose any risk during pregnancy. A small increase in birth defects (none serious) has been noted in the infants of women who used decongestants during pregnancy. If a decongestant is needed, pseudoephedrine (Sudafed) has the best safety record during pregnancy. Preparations containing guaifenesin and/or dextromethorphan (Robitussin, Robitussin DM) are recommended for the treatment of cough. Iodine cough medications should be avoided because of the potential for newborn thyroid toxicity.

Although caffeine doesn. t seem to cause birth defects, some studies have suggested that caffeine may cause low birth weight or premature birth. Heavy caffeine intake during pregnancy can cause caffeine withdrawal in newborns. Infants with caffeine withdrawal have feeding difficulties, vomiting, excessive crying, irritability and poor sleep patterns. Symptoms can last for days to weeks. Pregnant women should moderate their caffeine consumption. Caffeine can be found in coffee, tea, colas, chocolate, and some over-the-counter medications.

Aspartame (NutraSweet) has not been found to cause fetal or maternal problems, either in laboratory animals or humans. It is virtually impossible for a woman to ingest enough aspartame to raise the quantity in her blood high enough that it reaches the fetus in significant amounts.

Hair care products, such as dyes, straighteners, and permanents have not been shown to cause any problems for the fetus. There also is no evidence that cosmetics and other personal care products affect pregnancy.

Many pregnant women are employed in positions that require the use of video display terminals. Early reports suggested that VDT. s may cause an increase risk of birth defects and miscarriages. Larger studies have failed to demonstrate any association.

Because oil-based paints and paint thinners contain a number of aromatic solvents, exposure to these products should be limited or avoided, particularly during the first trimester. Brief exposure to water-based paints in a well-ventilated area should not pose a significant risk.

Despite the quantity of pesticides used by homeowners, surprisingly little information is available about the effects of exposure during pregnancy. Many pesticides are known to cause cancer, but whether they cause birth defects is less than clear. In general, pregnant women should not apply pesticides in the home or the yard. In particular, they should avoid the use of fumigants. Pesticides should be applied by someone else, and only local application of a liquid, spray or dust should be done. Contact with products such as insecticide strips and flea collars should also be avoided, since these products may pose some increased risk during pregnancy.

Nausea and vomiting are common complaints during early pregnancy. Typically, the symptoms begin early during pregnancy and continue until the fourth month. Sometimes, the symptoms may continue throughout the entire pregnancy. The cause of nausea is unknown. Eating small frequent meals usually decreases the nausea but rarely eliminates it. Getting out of bed slowly after eating a few crackers and avoiding spicy or greasy foods have also been beneficial. You can also try eating ginger (soda, tea or ginger snaps), sucking on hard candy, eating salty/tart foods combined (e.g., potato chips with lemonade), taking a vitamin B6 supplement (25mg three times a day), and wearing Sea-Band (an elastic band worn on wrists to counter nausea caused by sea-sickness. Anti-nausea medications may be required. Promethazine (Phenergan), diphenhydramine (Benadryl), and Doxylamine (Unisom) are anti-nausea medications that have not been shown to cause birth defects. If vomiting is severe and persistent, intravenous fluids may be needed.

The feeling of fatigue is common in the first trimester of pregnancy. Pregnant women should get adequate rest (1-2 hours a day) and avoid becoming over-tired.

Constipation in pregnancy is probably caused by a hormonal suppression of bowel activity and the compression of the intestines by the enlarging uterus. Constipation aggravates hemorrhoids, which are another common complaint during pregnancy. Women who had normal bowel habits before pregnancy can usually maintain reasonably normal bowel function during pregnancy by drinking water liberally, exercising, and having generous amounts of fruits, vegetables, and salads in the diet. Stool softeners such as Colace or Metamucil may help. Mild laxatives such as milk of magnesia should be used sparingly and only if the other measures have failed.

Heartburn is a common complaint toward the last part of pregnancy. It is caused by the movement of food and gastric acid into the esophagus from a crowded and displaced stomach. Women who suffer with heartburn should eat five small meals instead of three larger ones, avoid greasy or spicy foods, and avoid eating before going to bed. If symptoms continue, a liquid antacid may help. Elevating the head of the bed on two-inch blocks may help if symptoms occur at night.

Backache is also common in the third trimester. The growing size of the uterus and the resulting change in posture strain the back muscles and a relaxation of the pelvic joints may cause some pelvis instability. A maternity girdle that supports the hips and growing abdomen may relieve the pain. Since high-heeled shoes will accentuate these postural changes, pregnant women should wear low-heeled (2" heel) shoes. The pelvic rock is an exercise that may help. To do the pelvic rock, lie on your back with knees bent, head on small pillow. Breathe in and tuck buttocks in, flattening your back against the floor. Relax and exhale. Repeat twelve times, at least. This exercise can also be done on your hands and knees (better in the third trimester). Arch your back up and release, bringing spine straight and head up. Tylenol, taken every four hours as needed, can also be helpful.

Varicose veins are caused by the pressure of the uterus on the leg veins. Treatment involves rest, elevation of the feet and the use of elastic support stockings.

Leg cramps in pregnancy may be caused by calcium deficiency or too much phosphorus. Decrease your intake of phosphate (also present in milk) and increase your intake of calcium in the form of calcium carbonate or calcium lactate supplements. If leg cramps occur, leg massage, gentle flexing of the feet, and local heat may be helpful. Avoid pointing your toes when you stretch your legs and practice "leading with the heel" when you walk.

Breast engorgement may cause some discomfort, especially during early and late pregnancy. A well-fitting brassiere worn 24 hours a day offers some relief. Application of ice packs may be helpful temporarily.

WORK: Most pregnant women can safely work until term without complications, but they may have less tolerance to heat humidity, prolonged standing, and heavy lifting. Recommendations regarding work, therefore are individualized. Pregnant women who should probably not work include those with a history of two premature deliveries, incompetent cervix, uterine abnormalities, heart disease, and third trimester bleeding.

EXERCISE: Women who have enjoyed good physical health before pregnancy can continue their exercise routines. Women who are carrying more than one baby, have high blood pressure, or had a previous premature delivery should limit their exercise, however. Swimming is an excellent non-weight bearing exercise that can be continued throughout pregnancy. Walking also provides a safe exercise. Exercise should be varied during the third trimester to avoid too much stress on knee and ankle joints.

SEXUAL ACTIVITY: There is no strong evidence that sexual intercourse is harmful during pregnancy. Whatever is comfortable and pleasurable may be continued unless a pregnancy complication occurs (e.g., undiagnosed bleeding, rupture of the membranes, or premature labor). If a complication occurs, intercourse should be avoided.

TRAVEL: Prolonged periods of sitting should be avoided during pregnancy. Long trips should be broken up with frequent stops (about every two hours) to allow for periods of walking. Seat belts should be worn with the lap belt low and snugly across the hip bones. Pregnant women should also avoid prolonged sitting in aircraft by occasionally walking in the aisle.

HYGIENE: Douching is rarely recommended during pregnancy. If it is necessary, use a douche bag only and never a bulb syringe. Do not place the douche bag higher than two feet above the level of the hips and do not insert the nozzle to more than three inches through the vulva. Tub baths can be taken throughout pregnancy because water does not usually enter the vagina.

Danger signs that should be reported to your Obstetrician and to the Health Unit include:

• Vaginal bleeding
• Persistent vomiting
• Chills or fever
• Painful urination
• Abdominal cramping
• Swelling of the face or fingers
• Dizziness, mental confusion, or spots before the eyes
• A severe reduction in the amount of urine
• A severe headache that doesn. t respond to Tylenol
• Leakage of fluid from the vagina
• A marked decrease in fetal movements

EMPLOYEE LEAVE

For the period of time before and after childbirth or for any other reason, a pregnant employee may use the following leave categories: sick leave; donated leave under the voluntary leave transfer program; annual leave; leave without pay (LWOP); home leave (provided that eligibility for home leave coincides with the mother's period of incapacitation); or any combination thereof. Advance sick and annual leave may be requested. Accrued compensatory time off may also be used. For further information or clarification regarding leave issues, contact HR/ER/EP at (202) 261-8171 or Fax (202) 261-8182 or e-mail Anita A. Brown.

An employee/mother or employee/father is entitled to use any of the following leave programs for any maternity reason. There need not be a complication or emergency.

An employee may be granted sick leave if she cannot perform her duties because of pregnancy or childbirth. Sick leave regulations also provide that full-time employees may use up to 12 weeks of accrued sick leave for family-care purposes. A total of 480 hours of sick leave may be used by a full-time employee to care for a family member with a serious health condition, including a period of incapacity due to pregnancy and childbirth or for prenatal care. Up to 104 hours of sick leave may be used by a full-time employee to provide care for a family member receiving medical exams or treatment related to pregnancy. Part-time employees receive this benefit on a pro-rated basis. Whether using sick leave to care for a family member with a serious health condition or to attend to a family member receiving medical treatment, the total amount of sick leave granted may not exceed 12 weeks.

The Family and Medical Leave Act (FMLA) is an entitlement separate from the entitlement under sick leave regulations. Employees qualify for an unpaid or paid absence under FMLA if they have been employed at least 12 months (not necessarily consecutive). Covered employees are entitled to take up to 12 administrative workweeks of leave without pay in one 12-month period for childbirth and to care for a newborn child. In the case of a tandem couple, both mother and father are entitled to the full 12-week period. Employees applying for all or part of the 12-week absence should complete form DS-1923, application for family medical leave, at least 30 days in advance of the absence whenever practical, or as soon as possible. An absence under FMLA may begin prior to the birth and must be concluded within 12 months after the date of birth. The FMLA provides that the employee may chose to substitute applicable paid leave for leave without pay. Questions on the FMLA can be directed to HR/ER/EP, Terry Poyner (202) 261-8178, fax (202) 261-8182, e-mail Teresa A. Poyner.

With the Voluntary Leave Transfer Program (VLTP), the employee/mother may apply for donated leave for her period of incapacitation which may include time before and after childbirth, with proper medical documentation. Any accrued annual and sick leave and compensatory time off must be exhausted before she may draw from VLTP. To apply for VLTP to care for an ill mother or child, the requesting employee must exhaust his/her entitlement to sick leave and all other types of leave and compensatory time off. A full-time employee can apply for BLTP when it is apparent that he/she will face at least 24 hours of Leave Without Pay (LWOP). A part-time employee must face LWOP in an amount that is at least 30% of the average number of hours in the employee's biweekly scheduled tour of duty. Donated leave may be used to liquidate advance sick leave.

For State employees, an approving official at post may approve Leave Without Pay (LWOP) of 80 hours or less. Requests for LWOP for more than 80 hours but not exceeding 90 calendar days may be approved by the approving official at post or the executive director or administrative office of the employing bureau. The employee must submit requests for LWOP of more than 90 calendar days to his/her assigned career development officer in HR/CDA for approval. For all requests for LWOP in excess of 80 hours, an SF-50, notice of personnel action, must be issued. Allowances may be affected for an employee who has been in LWOP status for more than 14 days.

OBSTETRICAL TRAVEL

The Department of State Office of Medical Services (MED) recommends that a pregnant employee or covered family member be medevaced to the United States to have her baby, so long as it is medically appropriate for her to travel. Recent changes to MED's policy permit the expectant mother to travel to anywhere in the U.S., rather than to the first point of entry in the U.S., so that she has help and support before, during, and after childbirth.

The Health Unit should alert the Office of Medical Services-Foreign Programs (tel. 202-663-1662, fax 202-663-1661) early in your pregnancy by sending a telegram to Foreign Programs requesting a medevac. In order to send the telegram, the Health Unit must have the following information: name and address of your attending physician (if known); name and address of the hospital where you will deliver; contact name, address, and phone number where you can be reached in the U.S. If you will be staying at a hotel or apartment or don't know where you will be staying, tell us the name of a family member with whom you will be in close contact. MED will respond with 1) a MED CHANNEL telegram authorizing the medevac and 2) an open channel telegram giving a fund cite for medical travel if you are a State employee or a covered family member (other agency employees must request fiscal data from their parent agency). These telegrams contain important instructions on medical issues, such as letter of authorization for hospitalization (form FS569) issued by MED, medical insurance, processing and reimbursement of medical claims, and medical clearances for the mother and newborn. Please review these cables carefully and ask for prompt clarification of any questions you may have.

We will start the process of getting your travel orders prepared, sending the cable to M/MED with the above information and seeing that your GTR is prepared for your ticket. When your travel order is prepared, you may wish to contact B&F or your administrative officer for a travel advance. You can make your airline reservations before your GTR is ready and it is best to do this early. You will be given a letter stating your due date and certifying that you are cleared to travel. This is required by the airline and they do NOT want you to fly after your seventh month, so DO NOT plan to fly after 34 weeks!

If you are not sure of names of your doctor or hospital, you may phone M/MED at (202) 663-1662 with the information when you have it. It is a good idea to call them at that number when you are settled to let them know you have arrived. They are always available to you by phone for questions or to help solve any problems you may encounter.

If you elect to travel to an overseas location for delivery, travel will be cost constructive, based on travel to the nearest adequate medical facility. In the case of Bolivia, the nearest adequate medical site is Miami.

You can travel once medevac and fund cite telegrams have arrived. Your ticket must be issued with an open return. American carriers generally refuse to transport any pregnant woman during the last six weeks of pregnancy. You must plan on traveling before the 34^th week of pregnancy. You may, however need to depart even earlier from post if you develop problems with the pregnancy.

The Department's Office of Medical Services authorizes up to 90 days of per diem for periods before and after delivery, usually six weeks each, to a pregnant employee or covered family member medevaced to the U.S. or elsewhere. Periods of hospitalization are not covered by per diem. Generally, per diem is not extended beyond six weeks after delivery. Per Diem in excess of 90 days, but not to exceed 180 days, may be authorized by the medical director or designee or the Foreign Service medical provider when there is a clear medical complication necessitating early departure from post or delayed return to post. Per Diem for newborns is authorized at 1/2 the applicable local rate, excluding periods of hospitalization.

If you are eligible for home leave or transfer orders, you must use those orders rather than medevac orders. No per diem may be granted while on home leave. Minimum home leave when transferring to another overseas assignment is 20 workdays and maximum is 45 workdays. When transferring to a domestic assignment, the maximum number of home leave days authorized has recently been increased from 15 to 25.

After your travel orders have been issued, you may request a travel advance of 80% of the first 30 days per diem. The advance may be deposited directly into any U.S. bank account, but allow TWO WEEKS for this to take place.

M/MED will issue a paper called an FS 569. It is sent directly to the hospital. This paper contains the fiscal data against which your claims are paid by M/MED. When you see your doctor and check into the hospital, it is wise to have your insurance forms and information with you. Some insurance companies require a 60-90 day pre-registration for obstetrical care. Clarify this with your insurance company early in your pregnancy. It is a good idea to write both your physician and hospital a letter explaining that your insurance company is to be billed first and any balance that remains will be paid by the Medical Claims Department. This is what the FS 569 guarantees, but most health care facilities (except those in the Washington, D.C. area) are not familiar with the routine. To save yourself dunning letters, it is best to make sure the billing offices know the procedure for reimbursement. There are doctors and hospitals that will make you pay the difference between what your insurance covers and the actual bill. In that case, you may submit expenses incurred to M/MED Claims yourself. All medical expenses related to your pregnancy will be paid. It is, however sometimes a lengthy process.

Your medical clearance is automatically lifted any time you are medevac'd to the U.S. To have your clearance reinstated before returning to post, have your doctor call M/MED Foreign Programs (202) 663-1662 to say that he/she has cleared you to return to post. This is usually done at about 6 weeks after delivery. The doctor may then send a written report to M/MED for inclusion in your records. Reinstatement of medical clearance is mandatory; if you fail to obtain it, you may lose your coverage. Once you have your medical clearance, you should be prepared to return to post within a reasonable time or your per diem will cease.

The Health Unit will give you a physical examination form for the baby. Have this filled out by the examining Pediatrician as soon as possible after birth. Make several copies of this form and send the original to M/MED. Lab tests are not required for newborns. Bring a copy of the form to post for inclusion in the baby's record. Your baby's Pediatrician should also phone Foreign Programs.

A layette shipment is a separate airfreight allowance not to exceed 250 pounds gross weight (including packing materials) for a newborn child who is a covered family member. Once post has certified that suitable layettes are not available locally, post must submit a cable to your personnel technician requesting that the employee's original travel (TM-4) orders be amended to authorize a layette shipment. This telegram must include post certification of unavailability. After the orders are amended, you must contact the Office of Transportation and Travel Management in the Department to make arrangements for onward shipment (tel. 202-647-4140 or 800-424-2947, fax 202-647-5396). Your shipment may be sent up to 120 days before the expected birth, which means you can do your shopping upon arrival in the U.S. and have it arrive at post before your return. If not done before returning to post, you should arrange for a family member, a friend, or a store to obtain a layette and coordinate with Transportation for the shipment. Air shipment of the layette must occur no later than 60 days after the birth of the child.

Be careful not to exceed the weight limit as the cost is very high and your shipment will not be sent until you pay the excess. You can ask the shipper to pick up any bulky items directly from the store where they were purchased and bring them to your residence to be packed with the rest of the layette. As with any air shipment where weight is critical, try to eliminate any unnecessary weight consumed by packing materials. For example, use diapers to pad more fragile items or to fill up a partially empty carton, otherwise the shipper will use newsprint or other heavy materials. Ask the shipper to bring scales with them. Before you leave post, make a list of items needed. Ask other mothers for suggestions.

Consider carefully where you and your family will stay during your medevac period. Some women may opt to stay with their parents or other family members. The State Department does provide subsistence allowance at a daily rate for the first 30 days, half that for the next period of time, and half for accompanying children, including newborn. Some people have found it burdensome to be with family for such a long period and have rented furnished apartments or "suite hotels" which have kitchens, laundry facilities as well as hotel services. Full per diem is paid if you stay in a hotel or apartment. Certain suite hotels in the D.C. area will accept USG per diem rates. The allowable lodging expense is based on the single room rate for the lodging used. If double occupancy is used, it should be shown on the travel claim voucher. If the person sharing the room is a Government employee on official travel, his/her name and employing agency/office should be stated. One-half of the double occupancy charge will be allowed for each employee. If that person is not a Government employee, his/her identification is not required and the employee shall be allowed the single room rate.

• Carry the name and telephone number of the employee's personnel technician in HR/CDA/ASD (202-747-9765)
• A blank OF-126 (Foreign Service Residence and Dependency Report)
• A blank diplomatic or regular passport application.
• A blank DS-1622 (Medical History and Examination for Foreign Service) for children 11 years and under. This form can be obtained from the Health Unit.
• A letter of referral with medical reports in English.
• Insurance information for the attending doctor in the United States.

When you arrive in the U.S., call MED Foreign Programs (202-663-1662) to notify them of your arrival. MED will provide you with administrative assistance.

The Federal Employees Health Benefits Program requires that all hospitalizations must undergo pre-certification in the United States. Therefore, you or your doctor must call your insurance company prior to admission to the hospital to give birth (or within two working days in the event of an emergency hospitalization) to receive full insurance benefits. To ensure maximum insurance coverage, you should choose a preferred provider within the scope of your health insurance. MED pays the deductible and co-insurance for covered pregnancies when a letter of authorization (FS 569) is issued.

If you plan to go on Leave Without Pay (LWOP), you may make arrangements with your personnel section at post to repay your health insurance premiums when you return to duty. It is your responsibility to make sure that your baby is added to your health insurance policy. If both parents are U.S. Federal government employees who have self-only coverage, two SF-2809s must be completed to terminate one self-only plan and change the other to family coverage. Questions regarding this or other health insurance issues on the addition of a child should be faxed to HR/ER/WLP (202-261-8182) or e-mailed to Shelly V. Kornegay.

A pregnant employee who has her baby in the United States generally spends at least six weeks in the United States prior to the delivery of her baby and 4-8 weeks after delivery. If you, as a pregnant employee, are traveling to the Washington, D.C. area and want to work at the Department during this time, a short-term detail in your bureau or in another bureau may be possible through your employing bureau's executive director and personnel officer. If you work a short-term detail in the Department, you will be considered on work status without charge to leave and MED will continue to authorize per diem.

Getting the baby's passport and ticket is a little tricky. Tickets cannot be issued with travel orders. Travel orders cannot be issued without medical clearance from M/MED, and a medical clearance cannot be issued without a physical examination from a doctor. Simultaneously, a passport must be requested for the baby. This can all get a little frustrating, especially while you are trying to enjoy your new baby and recover. To help you, we recommend the following schedule:

Before birth

• Inform the hospital that you need to obtain a passport for the baby and will need the birth certificate as soon as possible after the delivery.

Shortly after birth

• Remind the hospital that you will need the birth certificate as soon as possible. The hospital should expedite the paperwork to the town clerk, city hall, or other appropriate government office to issue the birth certificate.

• The birth certificate is usually prepared approximately three days after birth. Obtain two certified copies

• Take the baby to a photographer for passport photos. Hospital crib shots are okay, but it usually takes a while to get them. The cost of the above is reimbursable on your travel voucher.

• If staying in Washington, D.C., once your personnel technician has forwarded a completed DS-1640 (request for passport services) to passport services, deliver the baby's passport photos, application and a certified copy of the birth certificate to the Passport Office. If outside the city, you have two options: obtain a regular passport at a regional passport office for a $45 passport fee plus a $35 expedite fee; or obtain a diplomatic passport through the Passport Office. For information regarding diplomatic passport issuance and visa requirements, please contact passport services at 202-955-0198 or e-mail them at diplomatictravel#state.gov prior to the baby's birth. Once the baby is born and has been added to your orders, your personnel technician can fax or mail you a completed form DS-1640 authorizing issuance of a no-fee diplomatic passport for the child. Present the DS-1640 form and a completed passport application including photos at either a regional passport office or an authorized U.S. post office. If the clerk is unfamiliar with the processing of diplomatic passports, explain that the Department is expecting the application. Provide the clerk with a stamped express mail envelope addressed to Passport Services, Special Issuance Agency, 1111 19^th St., N.W. Suite 350, Washington, D.c. 20036, Attn: Diplomatic Travel Branch.

• To obtain travel orders, send a copy of the birth certificate and a completed, signed OF-126 (FS Residence and Dependency Report) to your personnel technician. The technician will amend the orders to include the newborn and forward a copy to the Travel Management Center in Main State.

• MED will provide clearances after the mother's Obstetrician and the baby's Pediatrician call in their clearances to Foreign Programs (202-663-1662). Generally, MED will not clear the newborn until at least four weeks of age. Ask the baby's doctor to complete Form DS-1622 ("Medical History and Examination For the Foreign Service for Children 11 Years and Under") within 90 days of the birth and send it to MED/Clearances to enroll a new dependent baby in the Department of State Medical Program.

• Make travel reservations for the baby. Call the Travel Management Center (800-424-2947) at Main State for reservations. Make sure you request a crib. Remember that travel to post may take place only after medical clearances have been given and after the HR/CDA personnel technician has provided the Travel Management Center with a copy of the amended travel orders. Depending on the circumstances, the travel center may either mail you the baby's ticket or provide a prepaid ticket at the airport on the day of travel.

• Make arrangements for the shipment of your layette (6 FAM 126.8). Call Traffic Manager for name of shipper and instructions at (202) 647-8282. A layette should weigh no more than 250 pounds, including boxing and packing. Many people prefer to pack and ship their own.

• Travel light, but remember to pack a change of clothing for you and the baby. Weight allowance (accompanied baggage) for the baby and mother is 44 pounds each or 2 pieces per traveler. It may be easier to carry the baby in a Snugli, or front-pack.

• Check with the steward(ess) before takeoff to make sure a crib is on board. Make sure you get a boarding pass and assigned seat for a full-fare infant. Check to make sure the seats are together and there is a place for a crib hookup.

• The Comptroller General of the United States has held that employees and their dependents who receive medical care at Government expense and who are covered by private medical insurance policies shall claim and transfer to the Government such benefits as may be payable under these policies. In keeping with this ruling, the Department requests that you file a claim with your insurance carrier for the benefits due you under your medical insurance policy. When you receive the insurance carrier's check, please endorse it to the order of the Treasurer of the United States and forward it to the B&F office for credit to the appropriation from which your medical expenses were paid.

• You are responsible for keeping track of travel voucher expenses. Vouchers must be completed by State employees and submitted within seven workdays once travel has been completed. Post is expected to report to MED within ten days of receiving the voucher the amount of transportation, per diem, taxi, and miscellaneous expenses claimed on the voucher.

OBSTETRICAL MEDEVAC CHECKLIST

_____ Copy of medical records.

_____ Copy of cables relating to medevac.

_____ Private health insurance information with name of insurance company, group ID number and policy number.

_____ Travel orders.

_____ Passport with valid reentry visa, and your international (yellow) immunization card.

_____ Airline tickets with open return, if needed.

_____ Travellers' checks, credit cards, and cash. You may wish to contact B&F for a travel advance of 80% of the first 30 days per diem.

_____ A blank international (yellow) immunization record for your newborn.

_____ A "Medical History and Examination For the Foreign Service For Children 11 Years and Under" form (Form DS-1622).

_____ A letter from the Health Unit, to give to the airline, stating your due date and certifying that you are cleared to travel.

_____ Have your personnel officer file form OF-126 to amend the employee's TMFour. The baby returns to post on the amended TMFour orders. The amended TMFour should also include authorization for the layette shipment.

_____ Obtain the paperwork for a passport for the baby.

_____ Notify the Health Unit with the following information: name and address of attending physician; name and address of hospital where you will deliver; contact name, address, and phone number where you can be reached in the U.S.

_____ Call Foreign Programs (202) 663-1662 to check in. Do this soon after arrival.

_____ Call Transportation office (202) 647-8282 regarding layette shipment specifics.

_____ Send a copy of the birth certificate and a completed, signed OF-126 (FS

Residence and Dependency Report) to your personnel technician. Request

travel orders.

_____ Ask your Obstetrician and the baby's Pediatrician to contact Foreign Programs

(202-663-1662) to re-instate your clearance and to clear your newborn. Ask the

Pediatrician to complete the DS-1622 (Clearance exam form) within 90 days of

your baby's birth and mail it to Medical Clearances.

_____ Obtain your newborn's passport and visa. Call passport services at 202-955-0198 for assistance. To obtain a passport you will need an original (or certified copy) of the birth certificate completed by the state of birth, passport photos, and a completed application form. You may also need a photocopy of the employee's diplomatic passport.

_____ Call the Travel Management Center (800-424-2947) to make travel reservations for the baby.

_____ Finalize arrangements for the shipment of your layette.

_____ Submit travel voucher to B&F with required itemized bills within 5 working days of completion of travel.

_____ Check with your personnel officer to see if there is anything else that needs to be done.