“Prenatal Care Part One: An Overview of Prenatal Care” – with Dr. Sara Kostant

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, Dr. Sara Kostant, welcome back to the podcast. How are you doing?

Dr. Kostant: Not bad. It’s been a while.

Dr. Fox: Yeah, it’s been a while. So, you know, you are a fan favorite, so I’m glad we can get you back in the studio here, our makeshift studio to record. And we’re discussing a really…It’s interesting because we’ve been doing this podcast for, you know, three-plus years and we haven’t had a podcast on prenatal care as, like, a concept, like a global concept. We’ve done early pregnancy, we’ve done end-of-pregnancy, we’ve done pre-pregnancy, we’ve done postpartum, but not full prenatal care. So, this is great. I’m happy we’re doing this.

Dr. Kostant: Yeah. And I’ve done a lot of those other podcasts, so I feel this is appropriate. We’ll finally cover the middle.

Dr. Fox: Yeah. Right. This is like, you know, the best part of the sandwich, as they say. So, obviously, people who are pregnant or have been pregnant get what happens in prenatal care. People who aren’t pregnant or not yet pregnant or whatever it is, maybe don’t really. But, you know, I guess they have some sense of what’s going on. But I think it’d be a good idea for us to go very high level, sort of, like, what are the goals of prenatal care? Sort of how is it done? And then maybe get into the specifics of what’s gonna happen and why we do it, you know, sort of work our way down the pyramid, so to speak. So, ultimately, someone’s pregnant and they’re gonna deliver, right, so, you know, 38 weeks from now. What is the goal of prenatal care from the point they get pregnant until they deliver? Why do they come? What are we doing?

Dr. Kostant: So, I think the goal is pretty much to catch anything abnormal that might come out of this, otherwise, like, normal physiologic process. Prenatal care is interesting because, in theory, you could have someone become pregnant, go through their pregnancy, and deliver, and have never seen a provider and everything should be fine. Like, the pregnancy unfolded normally, and the mother is healthy and the baby is healthy and doesn’t have any issues, and things go well, you wouldn’t necessarily need anyone to check in on anything. But that’s pretty much to me, like, what I see prenatal care as being, as checking in and just making sure things are proceeding normally and being able to catch anything if it deviates from the normal path.

Dr. Fox: Right. Yeah. I mean, people who, you know, get pregnant on a desert island, most of the time, it’s gonna work out. They’re gonna be okay, baby is gonna be okay with, like you said, the pregnancy and the birth. In the same way I sort of think of it as, number one, we’re just trying to ensure as best as possible that the mother gets through the pregnancy healthy. Again, that’s sort of an expectation nowadays, but it wasn’t always that way, right? There are situations where pregnancy can be very dangerous to someone or they have complications very dangerous to them. And so that’s sort of our top goal, though, fortunately, it usually happens. And then our second goal is for the baby, that the baby gets through the pregnancy and the delivery okay, again, prenatal care, specifically the pregnancy.

And I think the third, which ends up being a lot of this, is the experience that sort of the pregnancy, to try to make it somewhat pleasant, you know, or somewhat happy, or to have a sense of what’s gonna be and be excited about it because it could be, obviously, a scary time, it could be a physically uncomfortable time, very difficult time. And so that’s sort of, like, a third goal, obviously, health of the mother, number one, health of the baby, two. But then a lot of what we’re doing is just trying to, even if they’re both healthy, to get them through their pregnancy in a way that’s as either pleasant or less unpleasant as possible, I would say.

Dr. Kostant: Even if we’re not finding any issue as a woman’s pregnancy progresses, we can still also just provide guidance to help with the common, you know, discomforts of pregnancy. Nausea, obviously, is a big issue and sometimes it can be quite severe. So, you know, in the first trimester, especially if it’s someone’s, you know, first pregnancy or even if it’s not, every pregnancy can be different. Some people have patients who it’s their third pregnancy and they’re sometimes having nausea for the first time, just using that as an example. So, part of it is even if there’s no major, you know, emergency happening or things are actually progressing well, there’s still a lot of questions that a mother will have about just general nutrition or vitamins or supplements or exposures. And we can provide guidance for that and just help with any…you talked about just making it a good experience. I think there’s a lot of emotional, you know, psychological changes that can happen.

Dr. Fox: Sure.

Dr. Kostant: And life also goes on during a pregnancy and there’s outside stresses that go on. And there’s a lot of value even to providing just a listening ear and support, you know, even if you’re not medically doing anything. And also sometimes we actually do have to provide more referrals for, you know, extra mental health support. So, kind of, you know, catching that is something that we do as well. And having a set frequency of visits can help with that.

Dr. Fox: Yeah. I think people are surprised to learn how much of prenatal care is conversation. I actually had a student with me last week and the week before, and she’s not even in medical school. She’s a pre-medical student and she was with me for basically four days in the office, one of which I was in ultrasound, so doing a lot of ultrasound stuff, but the other three I was seeing prenatal patients, so new patients, follow-up patients. And basically, someone said to her, like, “How is it? What’s it like running around with him?” And she goes, “There’s a lot of talking.” She’s like, “They’re just sitting and talking. Every person, you know, of a 15-minute visit, 13 of which we’re speaking back and forth. I’m listening, I’m talking. They’re listening, they’re talking.”

Dr. Kostant: Sometimes even more than…

Dr. Fox: Yeah.

Dr. Kostant: Sometimes even a 15-minute, there’s 20 minutes of talking.

Dr. Fox: Yeah. And there’s very little of, like, stuff that has to be done. And I think that was surprising to her. And I think that a lot of people don’t recognize that, that it’s really…like you said, some of it is because we have questions we have to ask in order to ascertain, are things going okay? And a lot of it is people who are pregnant have a lot of questions they have and back and forth and whether that’s actually leading to healthier mother, healthier baby, or just leading to a better experience through this process. It’s really a lot of conversation. And that’s part of the reason when people talk about what should be the optimal frequency of visits, or when should you start? How often should they be? How long should they last? How do you determine that? Right? You can say, well, whether someone has 3 visits, 6 visits, or 12 visits, the mother is healthy and the baby is healthy either way. Maybe they find that, maybe they don’t. But the experience might be very different. And so different people need different things potentially. And so it’s hard to have an ideal, which is why there isn’t really an ideal for these things. It’s very person-dependent.

Dr. Kostant: Yeah. In our office, we follow a schedule of visits that’s very similar to the schedule of visits that in my residency we followed. But obviously, it has to be tailored to each person. And the visits start out less frequent in the beginning, although sometimes a little more frequent, then they space apart. And then as we get into more like the third trimester and then the last few weeks of the pregnancy, they get more frequent until the last few weeks they’re usually weekly. But that’s a template, again, that even we followed in residency and is very common in the U.S. But whether you actually need that number of visits, you know, whether that correlates with better outcomes is not necessarily clear because, I mean, there are gonna be people that are gonna need, obviously, many more visits than that. And then there probably are some patients that could have a few visits the whole pregnancy and would be totally fine, like, just at some key points in the pregnancy. And probably across the world, it does vary. And you can have patients come in for fewer visits than we have and still have a great pregnancy and feel good and do well and they’d be happy with that.

Dr. Fox: Right. Yeah. It’s sort of what their expectation is also. If everyone they know had a prenatal visit every month, they would think it’s normal, and if everyone they knew had a prenatal visit every week and they’re doing it every month, they’ll be like, “Why is it happening?” I mean, it sort of works out that the frequency of visits, again, as sort of, like, the backbone template, it tends to mirror the likelihood of something happening and the amount of questions people have. So, in the very beginning of pregnancy, a lot of stuff happens, right? A lot of symptoms, potentially bleeding. Is it singleton? Is it twins? Is it viable? All these things, you know, genetic testing, that all happens early. And people have a ton of questions because it’s a new pregnancy, and so visits are a little more frequent very beginning.

And then at the end of pregnancy, the same things happen because preparing for labor, they may have contractions, all these things, more symptoms, preeclampsia, swelling, blood pressure. And they have a lot of questions about the upcoming birth. So, you tend to have a lot of visits early and late. And in the middle, it’s about every month because usually it’s not that different month to month. And then, as I said, that’s, like, the backbone, but, obviously, we tailor it. Someone who has a more complicated pregnancy or more issues going on or they just have more questions and more anxiety, they usually have more visits. And some people are like, “Dude, I’m fine. It’s my third baby. I know what’s happening. Can we make this as infrequent as possible?” And then we’ll just make it as bare bones as possible. So, there should be some leeway in both directions for visits, in my opinion. And that’s how we do it typically. We have some people coming twice a week and other people who are trying to never come.

Dr. Kostant: Yeah, exactly. It’s funny because I’ll sometimes tell patients, you know, “We’ll see you again in four weeks,” and they’ll look at me like, “I have to come back in four weeks? Can I come back in two months?” And then I’ll have some patients, I’ll say the same thing, and they’ll say, “Oh, well, that sounds like a long gap. Can I come back in two weeks?” And the answer to that is yes. We will never say to someone, “No, you have to come back in four weeks.” But that’s just how people can have just…Even if these are both people with fairly similar, let’s say, like, uncomplicated pregnancies where they don’t absolutely need to be seen in two weeks and they probably could come back in two months, like, you’ll have two very different views from the patient.

Dr. Fox: Yeah. And one of the interesting things, sort of an exercise that we had out of necessity was when COVID hit and especially in the first six months or whatever it is, and everyone’s basically locked up at home, what do you do about prenatal visits? Right? So, a lot of people sort of put off, let’s say, “elective” or “scheduled” medical things, whether it’s an annual visit or going to their dermatologist or getting this or getting that. And a lot of discussion, whether that was a good thing, whether it was a bad thing, we’re gonna leave that aside, but it happened. And so people said, “Well, what are you gonna do about prenatal care?” Right? We have all these people who are pregnant and they’re vulnerable medically because COVID is worse if you’re pregnant, so you don’t want them to get COVID, but on the other hand, they need prenatal visits where have to see them.

And so there was sort of everyone at the same time had to really actually think about the frequency of prenatal visits instead of just doing sort of what we always did and say, “All right. Who actually needs to show up and who doesn’t and when does that have to happen?” And people landed very differently on that. And some practices or some hospitals that had much lower-risk populations really basically kept them at home other than, you know, they figured out a way for them to do their blood pressure at home, they did telehealth visits so they could talk, and they only came in when they needed an ultrasound or something. Okay. And then you realize a lot of this can be done, you know, sort of virtually or from home. And some patients loved that, some patients hated it. Our practice, we couldn’t quite land on that because, again, just the nature of our population of patients is they’re high risk, they need more physical examination things or ultrasound. So, we couldn’t cut back that much in our own practice, for some people, yes. But it did cause us all to think about it again. And so I think that rebooted the discussion about how often do people really need to come in.

Dr. Kostant: And I think there’s a place even in non-COVID times, I think there can be a place for virtual visits, but I feel it should also be that the patient should be completely 100% enthusiastic about it. And even during COVID, we set up a schedule for patients that were lower risk, that for starting visits, visits that were more middle of the pregnancy where there was no blood work required, that they could do a virtual visit. And many patients were happy with that. But I think if a patient didn’t feel comfortable with that, we didn’t tell them, “No, you can’t come in.” Say, “Okay. You can come in for an in-person visit. We’re just offering, you know, for patients who wanna still shelter at home as much as possible.” I think that even in non-COVID times there are practices and there are also practices in areas that are, let’s say, more rural where it’s a big schlep to go to the doctor, that they will set up some visits as virtual visits and patients will check their blood pressure at home and, you know, report it. They’ll weigh themselves, report it to their provider, and have, you know, a conversation. And I think many people are really happy with that.

I think having a…I don’t know that I would wanna do…in my own, like, ideal practice. I think there is something about the face-to-face encounter, though, especially for patients that are more anxious or concerned. Even if they don’t have a particularly, like, high-risk pregnancy, I think they do better with being seen face-to-face. But there’s definitely a role for doing that for the visits where the patient overall is doing well, low risk, you know, again, doesn’t need anything special done in the office that day. And for those patients also, you know, we obviously can’t check the baby’s heartbeat by ultrasound or Doppler if they’re at home, but we would, you know, just ask them about fetal movement and they would report that. And obviously, if there was any concern that came out of the virtual visit, you know, we would have them come into the office.

Dr. Fox: Yeah. What about group prenatal care versus one-to-one? So, most people are used to individualized one-to-one and that means, basically, you come in, you see the doctor, the midwife, and you’re the only two people in the room. You may have someone with you, your partner or a friend, a family member, whatever it is, and they may have a nurse or a student or whatever. But basically, the primary interaction is one patient, one pregnant person, one provider, whereas in a group model, there are some visits or some portion of the visits where it’s like, you know, you got 2, 4, 6, 8, 10 people in the room and one provider and it’s sort of, like, you know, either a sort of teaching in a classroom type of setting or a group discussion around nausea and vomiting or whatever it might be. What are your thoughts on that?

Dr. Kostant: I think it could be great. We don’t do that in our practice, but I have a family member who that was part of her prenatal care. And I think it was a very positive experience because also then you get familiar with another group of women who are due around the same time as you, and it gives you a chance to hear other people’s questions that other people in your group may ask things that you didn’t think of, but then later are saying, “Yeah. I’m glad someone asked that.” So, yeah. I think that’s a great model. I know in hospitals that have it, because I think it’s usually a health system or a hospital that tends to run it, It still, I think, tends to be…and again, lower risk is very subjective, but overall it kind of tends to be a lower-risk group. And, obviously, pregnant patients participating, you know, want that. They want to be in a situation where they can do these group visits. So, I think it could actually be great.

Dr. Fox: Yeah. I mean, I think there’s some advantages in terms of, let’s say, efficiency, meaning if I’m talking about genetic screening, let’s say, my preamble is basically the same, right? And so from an efficiency standpoint, it makes sense for me to say it once and 10 people to listen. And when people have questions, frequently, they have the same questions, and so 1 person could ask and 10 people can hear the answer. So, that’s one advantage. A second advantage is, like you said, being in a group setting, there may be questions that someone else has, like, “Oh, I didn’t think of that question, but that’s a really good question. I wanna know that.” So, maybe things will come up in the conversation that they wouldn’t have heard otherwise.

And also there’s that just sort of, maybe there’s a question that’s asked, they don’t wanna ask because maybe it’s very sensitive or maybe that there’s sort of, like you said, this camaraderie aspect to it, that you meet people who are in similar circumstance, you get that group sense, you know, you can make social relationships or whatever, but, obviously, that there’s…It’s hard to replace prenatal care with that because there’s, obviously, conversations that people wanna have privately. And also, sometimes people need more directed counseling to their specific circumstances that would not be productive in a group setting. And so I assume that all the places that do this, it’s a hybrid model.

Dr. Kostant: It is.

Dr. Fox: Yeah. That, you know, you have your visits and then on top of that, you know, you may have a group setting visit. But I think it’s great. And I think some of that gets replaced with things like podcasts, for example, because you can hear it, or in terms of, like, the social aspect, a lot of people join, like, Facebook groups or some sort of online social group for people who are due at the same time or have similar questions. So, I think there’s a lot of that maybe going on in the background anyways without it being formal, but it’s a very interesting model. Again, it’s hard to set up logistically and we don’t have a lot of people clamoring for it. And again, our population tends to have more issues going on that it wouldn’t be as relevant. But I do think it’s a really cool thing and they’re definitely doing it.

I think one of the other parts of prenatal care that you touched on before is there are ancillary, I would say, it’s a strange word, services that people frequently need during their pregnancy. And sometimes they’re woven into prenatal care, whether that’s mental health, whether that’s nutrition, genetic counseling, social work, again, based on exactly what you’re doing. And sometimes prenatal visits have that part of it. Like for example, we always do depression screening during pregnancy, after pregnancy. And so that’s part of prenatal care, but it’s somewhat different in a certain sense. It’s critical part of prenatal care or we have a nutritionist in our office. So, it is part of prenatal care, but it’s a different discipline, I would say. And so that’s another thing that gets woven in in different ways based on, sort of, where you’re going and whether they have it in-house or they refer to somebody or they do it themselves. Again, and that’s gonna differ from place to place.

Dr. Kostant: Yeah. And part of what we do, I think, more in the first trimester, but even throughout the pregnancy is figuring out if anyone needs any of those resources. There are gonna be some patients that really don’t need a nutrition consult throughout the pregnancy. They’re overall in good health, have a balanced diet, you know, feel good throughout the pregnancy, baby’s growing well, you know, they don’t have any significant issues with nausea really past the first trimester. But we do have patients that do need it. And so that’s an example of if someone wasn’t getting prenatal care or wasn’t getting prenatal care in a place that could provide that, they might have a more difficult pregnancy. And meeting with a nutritionist could potentially improve their outcome.

Dr. Fox: Yeah. We’ve been talking about sort of the different models and how it’s done. And again, it’s gonna vary greatly from place to place, country to country, whatever it might be. I think in the U.S. there’s a lot of similarities, a lot of people do it the same way in terms of frequency and whatnot, but definitely, still there’s gonna be variation. But I think that sort of the principles, how we…We spoke about the goals about, you know, healthy mom, healthy baby, a good experience. I think the principles of what happens in prenatal care, and this is really what dictates what kind of tests are done and how often and this, we’re essentially doing four things, at least the way I thought about it broken down.

The first thing we’re doing is we’re checking the general health of the mother, right? So, part of our assessment, and a lot of it is on the front end, but then throughout pregnancy, general things like, you know, does she have any medical conditions? Does she have any risk factors for issues? Does she have mental health concerns? I mean, just how is she as just a person? Whether she’s pregnant or not pregnant, what is her health like? And so we focus on that. That’s one aspect of it. The second thing is, using that, we’re assessing her risk of things in pregnancy. Like you said, we’re trying to see if someone’s sort of, like, deviating from that sort of everything’s going fine path, and we’re trying to assess it at the time and to predict it, like, things that we do to predict that might happen or to assess that’s happening at the time. And the third thing we’re doing is potentially intervening, right, to maybe either treat that or prevent it or avert it, whatever it might be. And the last thing we’re doing is just education, to talk about, you know, what things should be, what are warning signs, to know what to expect, you know, all these things.

And so each of the visits is gonna focus maybe a little bit more on one versus the other. So, like, you know, the early part of pregnancy we’re focusing a lot more on the health of the mother and risk assessment. And there’s a component of education and sort of late in pregnancy, there’s a tremendous amount of education because we’re talking about labor, but those are sort of the four things. Again, the health of the mother, assessing risk for things, interventions that we may do to prevent some of those things or treat them, and then education. And again, which one of those we’re gonna focus on the most depends on where you are in pregnancy and what’s going on, but it’s some component of those four, I would say.

Dr. Kostant: Yeah. I think the first trimester is more to lay the groundwork for the rest of the pregnancy in a patient who doesn’t necessarily have any specific significant past obstetric history or health issues. Now, once we’ve sorted that out, it’ll mean talking about if or if not, does the patient want any type of genetic testing, which is done earlier in the pregnancy, providing the education about nutrition, vitamins, exposures, things to avoid because we don’t necessarily re-go over that again and again at each and every visit. We’ve set that. That’s a lot of the discussion in the first trimester. And so we ended up seeing patients in the first trimester, sometimes about every couple of weeks, because some of our patients will initially come in at 6 to 8 weeks and then around 10 weeks. At 10 weeks, that’s when we will discuss genetic testing further and do any genetic blood work that a patient is interested in doing. And then, again, at 12 weeks, this is a whole other discussion on genetic testing, but usually, there’s an ultrasound and nuchal translucency ultrasound that we’ll do in patients who wanna have, you know, genetic screening.

So, that’s pretty much every two weeks. And it just works out that, especially for patients that are doing genetic testing, we just have to have them come back at a certain timeframe to get the blood work done that they want to do. But also it does provide just more opportunities to answer a lot of questions that come up. And again, you know, we answer questions at every single visit in the pregnancy, but there are just a lot more of them, I feel, in the first 12 or 13 weeks. Also, usually when patients are not feeling…it’s not the part of the pregnancy that patients recall they felt their best. And I think it’s reassuring to patients to come in every couple of weeks and just, you know, even to just talk about how they’re feeling.

I’m still surprised how many patients will admit, “Yeah, I’m nauseous, but, no, I don’t need any medication.” And I’ll kind of press them and say, “Well, you know, like, how bad is your nausea?” And usually they’re there with their partner, the partner is like, “She throws up three times a week and she’s always, you know, talking about how nauseous, you know, she is.” And I’ll say, “Okay. Well, let’s address that.” So, I think there is some benefit then really to coming in just because there’s so many people just don’t feel well and we can actually…But people, I think, try to sometimes tough it up a little bit and I wanna kind of say, “No, it’s okay to, you know, admit you’re not feeling well. And let’s talk about it and kind of get you through this trimester, you know, not feeling so awful.”

Dr. Fox: Yeah. It’s interesting that when you mentioned, I was thinking, because we didn’t touch on this before, for prenatal care, the difference between seeing the same person for every visit, the same provider versus a group of providers. And again, those are different models as well. Even in a group that, let’s say, has multiple providers delivering, right? So, you know, you could see someone, I’m seeing one person all pregnancy, and he or she’s gonna deliver me. But even if you’re in a group where, let’s say, there’s four, five, six, seven people who rotate, who’s covering the labor floor, there’s different models where you either see the same person for every prenatal visit or you rotate. And some people think, “Well, it’s because it’s always better to see the same person, but since there’s different people delivering me, I wanna meet them.”

And that’s one aspect of it. But I think that there’s pros and cons just from a prenatal visit standpoint of talking to the same person every time versus a different person. Now, on the one hand of the same person, maybe there’s less, like, introductory stuff that has to happen because they know you, they know what happened, they know your last conversation. So, again, it may be a little bit more efficient. But there’s a lot of value, I think, to getting different people’s opinions and different eyeballs looking at you and you being able to ask the same question to two different people, sometimes you’ll get a different take on it. And I’m not advocating the one’s better versus the other. I think they both have, sort of, merits, but it is an interesting difference between that.

I think if you are having multiple people providing prenatal care, it’s imperative that they are on the same page, that they’re not telling you things that are opposite from one another because that’s not healthy, and that they can see what happened last time, you know, that they have good notetaking and they write legibly or it’s electronic. That needs to be done on sort of the backend. But assuming that’s the case, I think it’s interesting, which is better. I don’t know if you found that people prefer to see you every visit or they prefer to move around from person to person because we have a group practice, so we have patients who do both.

Dr. Kostant: Yeah. I’ve had patients do both. I’ve sometimes had patients who I saw for the first visit, see me again for the second visit just to kind of tie up some loose ends, and then maybe for the third visit of their prenatal care will start seeing some of the other doctors in the group. I’ve definitely had patients that if they know I’m gonna end up delivering them, like, let’s say they have a scheduled delivery where I’m for sure gonna be there, some of them will just try to see me because they know I’m gonna be there. And that’s true with any of the doctors in the practice. Yeah, I think that…I even had one patient who saw me for most of the visits and she understood that I might not be there for the delivery, but her attitude was, “I just wanna see the same person. And I’m okay with someone else. I trust all the doctors in your group. I’m sure they’ll take good care of me, but just when I come in for the visits, it’s nice to see the same person.” And I ended up not delivering her, but she had a great delivery and great experience. So, I saw her for most of her visits.

And I really think many people are fine seeing different people. I think for some people it can be a little overwhelming and, you know, they may stick to two or three people. But I think it’s important if you’re in a practice where you’re not 100% sure who’s gonna be doing the delivery…And I’ll tell patients that. I’ll say, “You can focus on seeing, let’s say, two or three people if it makes you more comfortable, but as long as you are okay with the fact that it’s not a guarantee one of them will be there for your delivery, and if it would make you feel better, maybe you should just meet everyone.” And most people then will say, “Okay. I’ll see Dr. Kostant next time.”

Dr. Fox: Yeah. Excellent. I think what we’re gonna do is I think this is a pretty good…I think we’re gonna wrap up this podcast here in terms of, I would call it an overview of prenatal care. And I think that what we’ll do is we’re gonna have you come back and we’re gonna talk about more of the specifics, like what do we do in each part of pregnancy so people have an expectation of what’s gonna happen then? So, thank you for part one.

Dr. Kostant: You’re welcome.

Dr. Fox: And we’re gonna bring you back for part two.

Dr. Kostant: Can’t wait.

Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.

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