Feeling beautiful and desirable is something every woman strives for, and it should be just as important to stay sexy during pregnancy as any other time.James W Brann, MD
Your Pregnancy MD
Pregnancy Week Thirty Two
At 32 weeks pregnant if you are carrying one baby your uterus should measure roughly five inches above your navel. You may find that your baby is placing more pressure on your abdomen now, which can contribute to heartburn and indigestion throughout your pregnancy.
You should be drinking plenty of water and consuming foods with plenty of fiber. This will help ward of constipation and the associated side effects (like hemorrhoids). Your body is also preparing for labor and delivery, as your hips expand and your ligaments continue to stretch in the upcoming weeks.
Some women start to experience shooting pain in their lower back or buttocks around now. This can happen as your center of gravity continues to shift, so be sure you take care to avoid unwanted slips or falls.
Every woman wants the best for herself and her baby during labor and delivery. You should prepare yourself for any situation however during birth. While most deliveries go as planned, sometimes the unexpected does occur. If you go into delivery well informed however and educated regarding your choices, you’ll find the birthing process less fearful and anxiety ridden.
Don’t be surprised if you start to feel very fatigued. All that extra weight that you are carrying around takes its toll on your body. Your exhaustion may also be related to the dramatic increase of the hormone progesterone.
Heartburn during Pregnancy
Is Heartburn Normal in Pregnancy
Many women complain of heartburn during pregnancy. Heartburn
during pregnancy is in fact one of the most common side effects of pregnancy.
If you’re one of the lucky few who has never experienced heartburn or
indigestion, you are in for an unpleasant surprise during pregnancy.
Heartburn, indigestion, and other gastrointestinal discomforts are common in the second and third trimesters. Even if you’ve never experienced these symptoms before, they may plague you from this point onward.
What is Heartburn?
Heartburn is the burning feeling that you get in your chest, right behind the breastbone. The burning sensation comes from your stomach and it rises up toward your neck. Heartburn can be accompanied by a sour taste in your mouth, or the sensation that vomit is coming up your throat.
During pregnancy, indigestion can occur with heartburn. You have indigestion if your stomach is upset, or if you’re feeling bloated, gassy, or very full.
Causes of Heartburn and Indigestion in Pregnancy
Heartburn and indigestion can be uncomfortable and even painful,
but they are both normal pregnancy symptoms. They are caused by the physical
changes in your body, accompanied by elevated pregnancy hormones.
Normally, food travels down your esophagus into your stomach. A circular valve near the bottom of the esophagus separates the two. When you swallow down food or take a sip of water, the valve relaxes so that the food can travel to your stomach.
When you’re not eating, the valve closes shut so that stomach acid can’t rise back up. However, if the valve happens to relax and you aren’t eating or drinking, stomach acid can flow back up the esophagus, causing a burning sensation. This is heartburn.
When you’re pregnant, your hormones (especially progesterone) relax all the muscles in your body, including this valve in your esophagus. As a result, heartburn becomes a very common occurrence during pregnancy.
In addition, the elevated levels of pregnancy hormones can also slow down your digestion, making it more likely for you to feel bloated, gassy, and full.
Another reason that indigestion and heartburn are so common in the second trimester has to do with your growing baby and expanding uterus. As you pack on the pounds, your uterus pushes upward, pushing against your abdominal cavity and abdominal organs. This can push food and stomach acid back up into your esophagus.
What remedies are there to treat heartburn?
Throughout pregnancy, you’ll learn that certain things can
contribute to heartburn and indigestion. For example, greasy or fattening foods
can make you feel gassy and uncomfortable. Say goodbye to Mexican food –
onions, garlic, and other spicy foods can be heartburn triggers.
You may not be able to completely eliminate heartburn or indigestion during pregnancy, but you can take steps to prevent it. Consider the following tips:
• Avoid eating large meals.
Eating smaller meals throughout the day and chewing your food thoroughly can make it easier for your digestive system to break everything down.
• You should avoid any foods that trigger heartburn.
Food triggers include spicy, greasy, and fatty foods. You may want to avoid chocolate and caffeine-laced foods. They can trigger heartburn and indigestion during pregnancy.
• Don’t drink when you’re eating.
Try to drink water and other fluids after your meal. When you drink, you should sip from the cup or glass. Stay away from straws during pregnancy – straws can make you gassy.
• Resist the temptation to lie down.
Wait an hour or two after eating before you lie down. Why not do light house work, or a walk around the neighborhood? You want to give your body time to digest your food. Lying down immediately after eating may trigger heartburn.
• Chew a piece of gum after you eat your meal.
Your saliva is a base, and it can actually neutralize your stomach acid.
• Gain the recommended pregnancy weight for your body size.
Extra pounds places increased pressure on your belly, which will cause you to feel even more abdominal discomfort. (The recommended weight gain for the average sized woman is 25 to 35 pounds.)
Treatments to Reduce the Symptoms of Heartburn
The three main medicines to reduce heartburn symptoms are:
• Calcium carbonate (sample brand name: Tums®)
• Aluminum hydroxide, magnesium hydroxide, and simethicone (sample brand name: Maalox®).
• Ranitidine (brand name: Zantac®)
• Famotidine (brand name: Pepcid®)
• Cimetidine (brand name: Tagamet®)
Proton pump inhibitors
• Omeprazole (brand name: Prilosec®)
• Esomeprazole (brand name: Nexium®)
• Pantoprazole (brand name: Protonix®)
• Lansoprazole (brand name: Prevacid®)
• Dexlansoprazole (brand name: Dexilant®)
• Rabeprazole (brand name: AcipHex®)
All three of these medicines reduce or block the production of
stomach acid. Doctors usually recommend that pregnant women first try antacids
to see if this helps reduce the burning sensation and discomfort. You can buy
antacids without a prescription and they are considered relatively safe to use
When antacids don’t help your doctor will have you try a histamine blocker or proton pump inhibitor. These medicines work better than antacids and most can be bought without a prescription.
Before you use any over-the-counter medicines for acid re-flux, check in with your healthcare provider first. Most of the medicines are considered relatively safe to use during pregnancy, but you should always check the label and ask your healthcare provider if you have any questions.
Is Constipation in Pregnancy Normal?
More than half of all pregnant women will experience some degree
of constipation. You may feel the discomfort early in the first trimester, but
it’s typically more of a problem in the second trimester.
You’re considered constipated if you have fewer than three bowel movements a week; if you have difficulty or pain when you pass a hardened stool. Constipation can also be accompanied by bloating, abdominal pain and discomfort.
If you feel like you need to move your bowels even after you’ve finished, this may be another sign of constipation. Sometimes, excessive diarrhea can be a sign that you’re constipated. If a small amount of hard stool is blocking your intestines, your body may compensate by eliminate the waste via diarrhea.
Causes of Constipation during Pregnancy
Some pregnant women are more prone to constipation due to poor
fluid and fiber intake in their diet. If you don’t drink enough water and eat
enough fiber-containing foods during pregnancy, constipation may be a chronic
problem for the entire 40 weeks of your pregnancy.
Even if you’ve always been regular, you may still experience this symptom of pregnancy due to hormonal changes in your body. The elevated levels of progesterone relax all the “smooth” muscles in your body. As a result, this hormone decreases the strength of your bowel contractions, which slows down the motility of the bowel and increases the absorption of fluids and foods in your body. This change makes it more likely that your stool is more compact and hard, which makes it more uncomfortable to pass. It’s not uncommon for pregnant women to go five or more days without a bowel movement. Iron and calcium supplements, not enough fluids or fiber in your diet, and lack of exercise during pregnancy can all contribute to constipation.
In addition, the physical changes that occur in your expanding body can also play a role in causing you to be more constipation. As your uterus gets larger and your baby’s head is in your pelvis, the pelvic floor will relax, which causes your lower intestine and rectum to become compressed, making it harder for stool to easily pass through.
How to Prevent Constipation in Pregnancy
Because constipation is uncomfortable, the best thing you can do is to try to prevent this symptom before it occurs. To prevent constipation, consider the following tips:
• Eat high-fiber foods – Fiber will help form softer stools. You can find fiber in many unprocessed grains, vegetables and fruits. High-fiber fruits include apples, pears, prunes, raspberries, tangerines, and oranges. You can find in vegetables, such as broccoli, acorn squash, cabbage, carrots, cauliflower, zucchini, and Brussels sprouts. Fiber can also be found in kidney beans, lima beans, black-eyed peas, and whole-grain cereal.
• Drink plenty of water and fluids – Dehydration can cause constipation, so you will want to get plenty of water and other fluids in your diet. To ward off constipation, consider drinking at least six to eight glasses of water a day.
• Exercise regularly – Unless your doctor was warned you against it, exercise is perfectly safe and healthy during pregnancy. Regular exercise can help your digestive system stay active and healthy.
• Go when you have the urge – Don’t ignore the urge to go to the bathroom. Holding it in can lead to constipation.
It’s very important that you don’t use too much force to push your bowel movements along. You may pop blood vessels and cause hemorrhoids (which are very common in pregnancy). Constipation is hard enough to deal with without those difficulties added to the mix.
Treatment for Pregnancy-Related Constipation
If you’re experiencing severe constipation, call your doctor. Your doctor may be able to recommend stool softeners, which moisten your stool and make it easier to pass. Stool softeners are usually safe during pregnancy because the active ingredients aren’t absorbed, so it’s unlikely to harm your developing baby.
Bulk forming laxatives — Bulk forming laxatives include psyllium seed (eg, Metamucil), methylcellulose (eg, Citrucel), calcium polycarbophil (eg, FiberCon), and wheat dextran (eg, Benefiber). They are natural or synthetic polysaccharides or cellulose derivatives that primarily exert their laxative effect by absorbing water and increasing fecal mass. These laxatives are effective in increasing the frequency and softening the consistency of stool with a minimum of adverse effects. They may be used alone or in combination with an increase in dietary fiber.
Saline laxatives, such as Milk of Magnesia, can also help treat constipation. Be careful not to use any irritant laxatives, mineral oils, or edemas – all of these can cause your uterus can contract prematurely.
Always talk to your doctor before taking any over-the-counter medications or laxatives. You want to be safe rather than sorry.
If you experience pain or itching in or around the rectum and bleeding, you may be surprised to find a swollen or inflamed mass of tissue that looks something like a giant skin tag. This is usually a sign of hemorrhoids. Hemorrhoids during pregnancy are common and result from blood vessels in the rectal area or vagina that become overly swollen. They may be small in size or quite large, itchy or for some even painful. Some women experience rectal bleeding along with hemorrhoid pain.
importantly you should focus on eating a high fiber diet complemented by plenty of fluids. This
will help keep you more regular and reduce the amount of constipation you
experience during pregnancy. More often than not hemorrhoids result from
constipation. Your best chance for preventing them is to stay as regular as possible
during pregnancy. You might even consider drinking a cup of prune juice daily
to help promote regular bowel movements.
If you develop hemorrhoids try a sitz bath. Most drugstores sell the supplies you need for a sitz bath. Basically this is just a mini bath that allows you to soak your rectum in warm water. This can help relieve the pain and irritation associated with hemorrhoids.
Try using an ice pack or other cold compress on the affected area. This can help reduce swelling and help minimize the pain associated with hemorrhoids.
Try using hemorrhoid pads. These contain witch hazel, and are generally safe to use during pregnancy. While there are other hemorrhoid related products on the market, you should check in with your doctor before using them during pregnancy. Some may result in more irritation than when you started. Remember that skin is overly sensitive when pregnant, hence it is best to err on the side of caution.
Wipe gently when pregnant. This will help reduce irritation and help prevent bleeding from hemorrhoids. You may find pre-moistened feminine cleansers or wipes more useful than toilet paper when dealing with hemorrhoids.
Some medications are available over the counter without a prescription. They come in the form of either creams or ointments that you rub on your hemorrhoid to relieve the pain, itching, and swelling. Other hemorrhoid treatments come in a suppository form that you place inside your rectum. It is OK to try the various hemorrhoid medicines, but do not use medicines that have hydrocortisone (a steroid medicine) for more than a week, unless your doctor gives the OK.
If you still are having problems after trying these medications, you may need your doctor to destroy or remove the hemorrhoids.
A popular treatment to remove your hemorrhoids is called “rubber band ligation.” For this treatment, the doctor will place a tiny rubber band around the hemorrhoids. In a few days the hemorrhoid will shrink and fall off.
Hip Pain during Pregnancy
pain is a normal pregnancy symptom that usually plagues women in the third
trimester. You may have experienced hip discomfort in the second trimester, but
it’s usually more of a problem in the final weeks of pregnancy.
Your hip pain or hip discomfort may be mild or excruciating. Some women find that their hip pain is so uncomfortable that it keeps them awake at night; others have a hard time walking in the morning due to their pain.
What causes hip pain in pregnancy?
pregnancy, your body releases an important hormone (called relaxin), which
relaxes and softens all your joints and muscles.
Relaxin is released in high amounts to prepare your body for labor. This hormone is responsible for softening the joints in your pelvis, so that it’s easier for your baby’s body to move through the birth canal when it’s time for delivery.
Unfortunately, relaxin also increases your susceptibility to injury, and it results in hip pain for some women.
Physical changes in your body also contribute to the development of hip pain in pregnancy. The softening and shifting of your pelvic bones, paired with the pressure of carrying around a huge uterus, can lead to hip pain and discomfort in the third trimester.
How to get relief from pregnancy hip pain
Because hip pain is caused by the normal physical and hormonal changes of pregnancy, you cannot prevent this uncomfortable sensation. Not to worry – there are a number of things you can do to try to minimize your hip pain and discomfort.
- Use a full body pregnancy pillow when you sleep. Most pregnant women experience hip pain when they’re trying to sleep. This is typically due to poor posture or lack of good support in the joints in your pelvic area during sleep.
- Don’t cross your legs when you sleep. Some pregnant women notice that their hip pain is worse in the morning, especially if they have slept with their ankles crossed. This position may increase pressure to your hips.
- Rest when you can. Standing on your feet all day can really aggravate pregnancy-related hip pain. Make sure that you sit down or rest as much as you can during the day.
- Take a swim. When you’re in the water, you are weightless and this can take the pressure off your joints. Swimming is actually one of the best exercises for pregnant women.
- Schedule a prenatal massage. A prenatal massage is targeted to easing the aches and pains of pregnant women. Not only do prenatal massages relax all your muscles and de-stress you, but they make you feel better and offer relief from hip pain. A trained prenatal massage therapist knows exactly where an expectant mother’s sore spots are, and they will adjust their techniques based on how far along you are.
- Try out Yoga or Pilates.
Many pregnant women find that yoga and Pilates helps relieve their back and hip pain in pregnancy. You can probably find a prenatal yoga or Pilate’s class in your local area. The instructors who teach these pregnancy exercise classes know exactly what positions may stretch and align your hips and pelvis to give you some relief.
During pregnancy, you might also benefit from going to see a chiropractor. Make sure that you find a chiropractor that is specially trained to treat expectant mothers. Getting regular adjustments may help you feel better, since an experienced professional will know exactly how to relieve your aches and pains.
If you decide to seek the assistance of a chiropractor, ask your doctor or healthcare provider for a referral.
Symptoms of Sciatica Nerve Pain
There are many interesting side effects of pregnancy, one of which is sciatica during pregnancy. While not solely a pregnancy related condition, sciatica does affect many women during pregnancy.
sciatic nerve is a long nerve that runs from the lower back down the outside of
the thigh and down to the top of the foot. Typically this nerve allows feeling
in the muscles of the legs and feet. There are times however when the sciatic
nerve can become inflamed, whether from pressure in the back or injury. When
this happens people experience sciatic pain.
Sometimes persistent or chronic pressure to the sciatic nerve can result in weakness in the leg or surrounding areas, numbness or even tingling. Some women describe the sensation as similar to the feeling of pins and needles you get when your leg falls asleep.
Typically the symptoms of sciatica in pregnancy include the following:
- Pins and needles in the lower back or leg, possibly the affected foot.
- Shooting or burning in the leg, buttock or lower back.
- Pain in the lower back or back of the pelvis that may extend into the foot.
- Numbness in the leg (mostly the outer thigh) or top of the foot.
Pelvic Girdle Pain
In many cases, you may think you are suffering from sciatica, but the pain is actually pelvic girdle pain, which is more common in pregnancy. Pelvic girdle pain causes discomfort and pain similar to sciatica pain. Sometimes, the pain is concentrated in your buttocks and radiates down one leg. This is why pelvic girdle pain is often confused with sciatica.
General Hip Pain
Some women are fortunate enough to have never experienced sciatica or pelvic girdle pain. Instead, they experience general hip pain and discomfort. Your generalized hip pain is probably caused by the pressure of the pregnant uterus, combined with the hormone relaxin causing the bones in your pelvis to soften and shift.
No matter if you’re suffering from sciatica, pelvic girdle pain, or general hip pain, you can get relief from your symptoms with the following techniques:
- Consider heat therapy. You may want to use a heating pad and place it to the affected painful muscles. If you don’t have a heating pad, sit in a warm bath.
- • Avoid lifting or pushing anything that’s heavy. Even pushing a grocery cart can cause you to feel pain. Go shopping with your partner or significant other and have him push the cart around.
- Don’t make any sudden movements. Take everything slow. Move slower than before.
- Switch out your soft mattress for a firm one. If this isn’t an option, buy a firm mattress topper, or ask your partner to place a board between the box spring and mattress.
- A therapist can also provide you with a list of beneficial exercises to not only improve your comfort but also strengthen the pelvic floor muscles, abdominal muscles and back muscles. These will prove beneficial for labor and delivery, and the time after.
- Still others find chiropractic care helpful for relieving sciatica pain. If you do choose to see a chiropractor or other manual therapist, be certain they have experience working with prenatal patients.
- Some women find massage therapy helpful for relieving inflammation and symptoms associated with sciatica. A massage can certainly help reduce muscle tension. Some theories suggest that gluteus or psoas muscles that are too tight can help contribute to sciatic pain. Massage therapy may help relieve some of this tightness and reduce the symptoms associated with sciatica.
- When your pain is unbearable, consider taking acetaminophen (Tylenol), which is considered safe during pregnancy. If this does not help you can ask your physician for something stronger.
I’m Pregnant and have Extreme Fatigue, What Can I Do?
Many women report fatigue
in pregnancy as one of their most trying symptoms. After
all, it is hard to get up and go when all you really feel like doing is
Fatigue during pregnancy is common for many reasons. Remember your body is working twenty four hours a day seven days a week creating a new life inside. That’s enough work to make anyone tired and cranky!
During pregnancy many women also have more difficulty sleeping at night, and this can contribute to pregnancy fatigue. Hormone changes including rising levels of progesterone can contribute to feelings of fatigue in pregnancy as well.
Most women experience more fatigue during the first trimester,
when their body is just becoming used to the idea of being pregnant.
Many women experience a pick me up during the second trimester, but notice that their energy level once again drops during the third trimester, as your body slowly prepares for labor and delivery.
By the third trimester your body is also carrying around more weight. This can contribute to your discomfort and result in more insomnia and cramping, making it difficult to rest easy.
Coping With Fatigue in Pregnancy
There are several steps you can take to help deal with fatigue in pregnancy. Here are some of the more effective strategies for overcoming fatigue in pregnancy.
- Go to bed early. There is no reason to stay up until 11 because that is what you normally do. During pregnancy your body needs as much sleep as possible, so there is nothing wrong with turning in early. Pat yourself on the back for taking care of yourself and your baby.
- Take a nap. You should try to take a catnap each day if possible during your pregnancy, particularly during the last trimester. You don’t have to rest long, but even 15 minutes of downtime can improve your spirits and provide you the pick me up you need to get through the day.
- Eat several mini meals per day. This will help keep your energy reserves up and prevent you from feeling sluggish due to inadequate nutrition.
- Exercise every day. This may seem extremely hard when you are tired. No matter how tired you are however, you should try at the very least to go for a walk and get some fresh air every day. Exercise boosts the body’s production of endorphins and can help get blood circulating throughout the body. This will help charge you up and allow you to feel more energetic during the day. You might also consider a short yoga video first thing in the morning, which may serve as a pick me up in place of your cup of java.
- Invest in a body pillow. This will help alleviate some of the backache and leg cramps you experience during the evening and may help you sleep better despite your growing belly.
- Get some help around the house. Ask others to pitch in and consider ordering out on occasion. The less work you have to do the more rested you will feel. There’s nothing wrong with taking a break every now and again. Your baby will appreciate a rested mommy more than a clean house after all.
- Eat healthy. The more junk food you eat the more likely you are to feel zapped and tired during the day. Try to eat plenty of lean proteins during the day and be sure you drink plenty of water. This will help maintain a steady stream of energy to your body and provide you with the vitamins and minerals you need to take on the day.
While you won’t be able to fend off fatigue completely, by following these few easy steps you should find you have a bit more energy to get through the day.
Your Baby at 32 Weeks Pregnant
Your Baby is Growing
By pregnancy week 32 your baby weighs in at roughly 3.75 pounds. Your baby is probably also roughly 16.7 inches long and may remain so for the next couple of weeks.
Your baby will continue to grow strong and hardy for delivery. Your baby will continue to put on weight and mature during the last weeks of pregnancy. By now your baby has smooth fingernails and toenails to decorate her hands and feet.
Your baby is starting to fatten up this week. Your baby is packing on fat and muscle underneath the skin, giving your baby a more rounded look. By the time that your baby is born, he or she will simply be the cutest, chubby baby that you ever did see!
baby may even be smiling. It is not uncommon for unborn babies to smile,
sticking out their tongues, and even make faces. Now that your baby’s face is
more mature and developed, it is much more rounded and cute.
The skin is less translucent and has also become pinker. It’s harder now to see the blood vessels underneath the skin. You can now see creases on the skin of your baby’s wrists and on the palms.
Childbirth Classes – Prenatal Classes
Types of Childbirth Classes
No matter if you want a natural or medicated labor, childbirth
preparation classes are a wonderful source of education, and they’re also great
places to make new friends.
If you’re anxious about the arrival of your baby, taking a childbirth class will help ease your mind as you prepare for labor and delivery. You will learn about breathing and relaxation techniques, pain relief options, medical interventions that may occur during delivery, and even basics on how to care for your newborn baby.
Although pregnant women often start taking these classes in
their sixth or seventh month of pregnancy, classes fill up fast, so it’s a
smart idea to research the right class for you in the second trimester.
Childbirth classes are available in many hospitals and community centers. If you’re interested in taking a class, talk to your healthcare provider about what he or she recommends. In the second trimester, you need to make a list of classes you’re interested in and when the registration deadlines are. Childbirth classes are usually not expensive, and the fees can often be waived for couples in financial need.
There are a variety of childbirth or prenatal classes that you can take. These include:
- General Childbirth – If you are just looking for an overview of what to expect during labor and delivery, consider taking a general childbirth class. These classes will give you basics on both vaginal births and cesarean delivery. If you take the general childbirth class at the hospital, you will probably get a hospital tour and you’ll learn about what will happen during your hospital stay. General childbirth classes also teach you breathing and calming techniques that will come in handy during labor and delivery.
- Lamaze Method – Lamaze is one of the most popular natural childbirth techniques in the United States. Developed by a French obstetrician in the 1950s, Lamaze will teach the pregnant woman and her birth coach (which can be her husband or partner, family member, or friend) about the various stages of labor and delivery. The expectant mother is taught how to decrease and manage pain through various techniques, including relaxation and breathing exercises, positioning, and deliberate focusing. While Lamaze promotes a natural childbirth experience, expectant mothers can use pain relief medication if that’s what they desire.
- Bradley Method – Similar to the Lamaze Method, the Bradley Method also teaches expectant couples to have a natural childbirth experience. The Bradley Method is stricter than Lamaze in that it discourages pain medication and medical intervention during childbirth. Classes are twelve weeks long, and they usually start three months before delivery. The curriculum stresses the importance of physical training (exercise) and diet and nutrition in pregnancy. Pregnant women are taught deep breathing, relaxation techniques, squatting and other birthing positions. The goal is a medication-free labor and delivery.
- Hypno-Birthing (Mongan Method) – HypnoBirthing is an up and coming natural childbirth technique. It involves women self-hypothesizing themselves during childbirth. Women are taught to use self-hypnosis, relaxation, and visualization to help them achieve a comfortable and calm birth.
- Breastfeeding/Lactation Classes – If you are planning to breastfeed your new baby, you should consider taking a breastfeeding class. These classes teach you about the benefits of breastfeeding your child, the anatomy of lactation, how to get started breastfeeding, proper latch on and positioning, how to tell when your baby has had enough to eat, and strategies for pumping and storing breast milk.
- Sibling Classes – For pregnant women with other children, sibling classes will help the big brother or sister prepare for the new arrival. Your older children will be shown what newborn babies look like; they’ll get to tour the maternity ward; and they will be taught about the changes a new baby brings to a family. Sibling classes are usually taught in a hospital setting, and they are intended to help your older child feel more comfortable in a hospital.