Normal pregnancy is not an illness and needs no treatment other than standard prenatal care. After the initial visit, during the first six months of pregnancy, the individual should see a doctor about once per month. Visits should be scheduled every two weeks during the seventh and eight month and weekly during the ninth month. If a woman's pregnancy is difficult or complicated, her treatment can vary from simple bed rest to diagnostic testing such as an amniocentesis. An ultrasound physical assessment or a stay in the hospital for testing or medication may also be part of the treatment.
Flu shots: Flu shots are recommended for women who are pregnant. A doctor can determine which shot is best for the mother.
Electronic fetal monitoring: Sometimes late in pregnancy, a woman who is pregnant may be placed on a fetal monitor to verify the health of the fetus or to see if the woman is in early labor.
Ultrasound biophysical profile test:
This is a noninvasive test that can assess whether or not the baby is obtaining an adequate supply of oxygen. It is typically performed in high risk pregnancies or if a woman has gone past her due date.
Medications: Because so many medicines are not safe to take during pregnancy, it is extremely important that a woman take only those that have been approved by her doctor. The U.S. Food and Drug Administration (FDA) lists five categories of labeling for drug use in pregnancy. A doctor or pharmacist can provide advice on the safety level (indicated by category) of medications before a woman who is pregnant takes anything. Expert recommend that expectant mothers follow the doctor's advice when taking prescription and non-prescription medications.
Strong scientific evidence
Folic acid: Folic acid and folate are forms of a water-soluble B vitamin. Folate occurs naturally in food and folic acid is the synthetic form of this vitamin. Folic acid is well-tolerated in amounts found in fortified foods and supplements. Sources include cereals, baked goods, leafy vegetables (spinach, broccoli, lettuce), okra, asparagus, fruits (bananas, melons, lemons), legumes, yeast, mushrooms, organ meat (beef liver, kidney), orange juice, and tomato juice. Folic acid is frequently used in combination with other B vitamins in vitamin B complex formulations. Studies have found that folate consumption during pregnancy prevents deficiency and anemia in pregnant women. Low folate levels during pregnancy may contribute to birth defects and pregnancy loss. Consuming a high dietary intake of folate and taking folic acid supplements orally during pregnancy may reduce the risk of neural tube birth defects in the infant.
Good scientific evidence
Acupuncture: The practice of acupuncture originated in China 5,000 years ago. Today it is widely used throughout the world and is one of the main pillars of Chinese medicine. Early evidence suggests that acupuncture may substantially reduce low back pain in pregnancy. More studies are needed to confirm these results.
Unclear or conflicting scientific evidence
Acupressure, Shiatsu: The practice of applying finger pressure to specific acupoints throughout the body has been used in China since 2000 BC, prior to the use of acupuncture. Shiatsu technique involves finger pressure at acupoints and along body meridians. It can incorporate palm pressure, stretching, massaging, and other manual techniques. Shiatsu practitioners commonly treat musculoskeletal and psychological conditions, including neck/shoulder and lower back problems, arthritis, depression, and anxiety. One study reports that LI4 and BL67 acupressure may reduce labor pain specifically during the first stage of labor. Further study is needed.
Acupuncture: Acupuncture has been reported to encourage uterine contractions during labor and to reduce the pain of labor. However, results of formal studies are mixed, and the research designs have been weak. More studies are needed to clarify the potential of acupuncture in labor.
Moxibustion, practiced along with acupuncture in some individuals, has been used historically in acupuncture to correct cephalic version (breech presentation) by turning the baby's head in utero. Further studies are needed to determine its role in the correction of breech presentation.
Aromatherapy: Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. Preliminary evidence on use of lavender oil in bath water suggests no benefit for post-partum perineal discomfort. More studies are needed before conclusions can be reached about this application of essential oils.
Beta-carotene: Beta-carotene is a member of the carotenoids, which are highly pigmented (red, orange, yellow), fat-soluble compounds naturally present in many fruits, grains, oils, and vegetables (green plants, carrots, sweet potatoes, squash, spinach, apricots, and green peppers). All-trans beta-carotene (synthetic beta-carotene) taken weekly before, during, and after pregnancy may reduce pregnancy-related mortality, night blindness, post partum diarrhea, and fever. A regular intake of a micronutrient supplement at a nutritional dose may be sufficient to improve micronutrient status of apparently healthy pregnant women and could prevent low birth weight in newborns. However, further research is necessary to consolidate the evidence in this area.
Biotin: Biotin, or vitamin H, is an essential water-soluble B vitamin. Marginal biotin deficiency has been found to commonly occur during pregnancy. Biotin supplementation during pregnancy in not currently standard practice, and prenatal vitamins generally do not contain biotin. However, individual patients may be considered for biotin supplementation by healthcare practitioners on a case-by-case basis. Additional study is needed in this area.
Borage seed oil: Borage (Borago officinalis) is an herb native to Syria that has spread throughout the Middle East and Mediterranean. Borage flowers and leaves may be eaten and borage seeds are often pressed to produce oil very high in gamma-linolenic acid (GLA). Preterm infants may need essential fatty acid supplementation. Gamma linolenic acid supplementation may increase cognitive development, weight gain, and length gain, particularly in boys. Other studies are needed to confirm these results.
Folic acid: Based on preliminary data, applying folic acid topically may improve gingivitis in pregnant women. Well-designed clinical trials are needed to confirm these results.
Ginseng: One small study found that ginseng (Panax ginseng) saponins might be useful in treating intrauterine growth retardation. However, the sample size was small and no blinding was used, so results cannot be considered reproducible.
Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. There is preliminary research of the effects of giving birth in water on labor pain, duration of labor, perineal damage to the mother, and birth complications. Further studies of effectiveness and safety are necessary before a conclusion can be drawn.
Hypnosis: Several studies report the effects of pre-natal hypnotherapy on duration of labor and pain medication use. Additional evidence is necessary before a clear conclusion can be drawn.
L-carnitine: L-carnitine, also known as acetyl-L-carnitine or carnitine, has been used in limited studies for miscarriage prevention. Currently, there is insufficient evidence to support the use of carnitine for miscarriage.
Massage: Various forms of therapeutic superficial tissue manipulation have been practiced for thousands of years across cultures. Different massage approaches have been used during pregnancy and labor, and are more commonly used in Europe than in the United States. Reduction of pain or anxiety is a common goal. It is not clear how birth outcomes are affected, or if this is a safe intervention. Women who are pregnant should consult with their obstetrician before beginning massage therapy.
Moxibustion: Moxibustion is a traditional Chinese medicine technique that involves the burning of mugwort, a small, spongy herb, to facilitate healing. Moxibustion is a long-used traditional remedy in China for cephalic version (a way to try to turn a baby from breech position to head-down position while it's still in the mother's uterus), including as a self-administered technique at home by mothers. The available evidence confirming its efficacy, while showing some promise, is mixed. More studies are needed to verify whether there are predictable benefits in moxibustion for cephalic version.
Physical therapy: Physical therapy with a focus on specific stabilizing exercises may be more effective than a regimen without specific stabilizing exercises in the treatment of pelvic girdle pain, functional status, and quality of life. Physical therapy may help with an individual's comfort level during pregnancy.
Prayer: Prayer can be defined as a "reverent petition," the act of asking for something while aiming to connect with God or another object of worship. Prayer on behalf of the ill or dying has played a prominent role throughout history and across cultures. Initial studies report fewer birth complications in people who are religious or pray, although due to methodological problems these results cannot be considered conclusive.
Probiotics: Probiotics are beneficial bacteria (sometimes referred to as "friendly germs") that help to maintain the health of the intestinal tract and aid in digestion. They also help keep potentially harmful organisms in the gut (harmful bacteria and yeasts) under control. Most probiotics come from food sources, especially cultured milk products. Probiotics can be consumed as capsules, tablets, beverages, powders, yogurts and other foods.
Probiotic supplementation may foster better growth and higher counts of healthful bacteria in the gut of preterm infants. Saccharomyces boulardii when added to formula for preterm infants may bring their stool flora closer to that of breastfed babies, and E. coli Nissle 1917 may stimulate immune responses. Lactobacillus GG, however, is considered a relatively poor colonizer in infants, especially those with low birth weight. Furthermore, Lactobacillus GG may not be effective in reducing the incidence of urinary tract infections, NEC, and sepsis in preterm infants. More studies are needed to clarify specific guidelines for probiotics in preterm infant care.
Scotch broom: Scotch broom (Cytisus scoparius), also referred to as broom, is a perennial woody plant native to Europe. Scotch broom herb has been used historically to stimulate uterine contractions at birth, and to reduce post-partum hemorrhage (bleeding after birth). There is a scientific basis of this use, due to the presence in scotch broom of small amounts of the alkaloid sparteine, which was studied and used through the 1970s as an oxytocic drug (to induce labor). This use was discontinued due to serious toxicities associated with sparteine. Currently, other drugs such as oxytocin (Pitosin) are used for this purpose. The safety and efficacy of scotch broom preparations in labor are not well studied or established. Women who may require labor induction should be evaluated and supervised by a physician.
Selenium: Selenium is a trace mineral found in soil, water, and some foods. It is an essential element in several metabolic pathways. Selenium supplementation has been studied in low birth weight infants. Additional evidence is warranted in this area before a clear conclusion can be drawn.
TENS: Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Electrodes are temporarily attached with paste in various patterns, depending on the specific condition and treatment goals. TENS is often used to treat pain, as an alternative or addition to pain medications. TENS is normally used in conjunction with acupuncture. Therapy sessions may last from minutes to hours.
Vitamin A: Vitamin A is a fat-soluble vitamin, which is derived from two sources: preformed retinoids and provitamin carotenoids. Retinoids such as retinal and retinoic acid are found in animal sources like liver, kidney, eggs, and dairy produce. Carotenoids like beta-carotene (which has the highest vitamin A activity) are found in plants such as dark or yellow vegetables and carrots. Maternal vitamin A deficiency is common in developing countries. Beta-carotene may reduce pregnancy-related complications and mortality in such individuals. However, excess intake of vitamin A has been reported to increase the risks of some birth defects. Vitamin A supplementation above the RDA is therefore not recommended by healthcare professionals for use in pregnancy.
Vitamin B6: Vitamin B6 (pyridoxine) is required for the synthesis of the neurotransmitters serotonin and norepinephrine and for myelin formation. Studies of the use of pyridoxine alone or in combination with other antinausea treatments in pregnant women yield conflicting results.
Studies of birth outcomes with vitamin B6 supplementation during pregnancy yield mixed results. Further well-designed clinical trials might be helpful in this area.
Vitamin C: Vitamin C (ascorbic acid) is a water-soluble vitamin, which is necessary in the body to form collagen in bones, cartilage, muscle, and blood vessels, and aids in the absorption of iron. Dietary sources of vitamin C include fruits and vegetables, particularly citrus fruits such as oranges. The data are too few to say if vitamin C supplementation alone or combined with other supplements is beneficial during pregnancy. Preterm birth may increase with vitamin C supplementation. However, some study results show that daily supplementation can effectively lessen the incidence of premature rupture of chorioamniotic membranes (PROM). A gynecologist and pharmacist should be consulted before taking any herbs or supplements.
Vitamin E: Vitamin E is a fat-soluble vitamin with antioxidant properties. Premature infants are at risk of vitamin E deficiency, particularly when they are born with very low birth weight. There are numerous studies of vitamin E given to premature infants to try to prevent potentially serious complications such as intraventricular hemorrhage (bleeding into the brain), retinopathy (eye damage), or death. The quality of published research is variable, and is not clearly conclusive. Premature infants should be under strict medical supervision, and decisions regarding vitamin supplementation should be made with the infant's physician.
Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Yoga has been described as "the union of mind, body, and spirit," which addresses physical, mental, intellectual, emotional, and spiritual dimensions towards an overall harmonious state of being. Early research suggests yoga during pregnancy is safe and may improve outcomes. Additional research is needed before a clear recommendation can be made. Pregnant women who wish to practice yoga should discuss this with their obstetrician or nurse-midwife.
Zinc: Zinc is necessary for the functioning of over 300 different enzymes and plays a vital role in an enormous number of biological processes. According to one review, there is no evidence to suggest that zinc supplementation offers benefits during pregnancy, although there is a possible reduction in labor complications and pre-term deliveries. However, results from individual studies suggest a possible benefit of zinc supplementation on blood pressure during pregnancy. Further research is needed before a conclusion can be drawn.
Fair negative scientific evidence
Copper: Copper is a mineral that occurs naturally in many foods, including vegetables, legumes, nuts, grains, and fruits, as well as shellfish, avocado, and beef (organs such as liver). Because copper is found in the earth's crust, most of the world's surface water and ground water used for drinking purposes contains small amounts of copper. The risk of neural-tube defects is decreased in women who take folic acid and multivitamins during the periconception period. Supplementation with trace-elements alone (such as copper) does not appear to prevent these defects.
Physical therapy: Physical therapy does not appear to help motor performance in infants born very preterm with very low birth weight. Besides the lack of benefit, available studies show a risk of causing fractures in preterm infants.
Traditional or theoretical uses lacking sufficient evidence
Integrative therapies used in pregnancy and related conditions that have historical or theoretical uses but lack sufficient clinical evidence include: homeopathic aconite (Aconitum napellus), adrenal extract, Alexander technique, algin, anise (Pimpinella anisum), arginine, arnica (Arnica montana), aromatherapy, art therapy, astragalus (Astragalus membranaceus), bay leaf (Laurus nobilis), bee pollen, beta-carotene, bitter melon (Momordica charantia), black cohosh (Actaea racemosa), blue cohosh (Caulophyllum thalictroides), bromelain, chasteberry (Vitex agnus-castus), choline, chondroitin sulfate, dandelion (Taraxacum officinale), dong quai (Angelica sinensis), fennel (Foeniculum vulgare), goldenseal (Hydrastis canadensis), jequirity (Abrus precatorius), liver extract, meditation, niacin (vitamin B3), organic foods, reiki, riboflavin (vitamin B2), stinging nettle (Urtica dioica), tansy (Tanacetum vulgare), and white willow bark (Salix alba).
prevention and self‑management
Many health problems that occur during pregnancy can be managed at home using methods recommended by healthcare professionals.
Constipation and hemorrhoids: One of the reasons for constipation may be changes produced in the digestive tract due to hormones slowing down the movement of food. Additionally, during the last trimester of pregnancy there is more pressure on the rectum from the uterus. To avoid these problems, healthcare professionals recommend drinking plenty of water and eating fruit and vegetables with a high fiber content, such as green, leafy vegetables. Some pregnant women experience relief drinking a glass of room temperature water before breakfast. Over-the-counter (OTC) stool softeners may be used, such as docusate sodium (Colace®). It is recommended to tell the doctor of any OCT medication or dietary supplement taken during pregnancy.
Nausea: Nausea occurs due to metabolic changes. In the morning before getting up, eating crackers and standing up very slowly is recommended to decrease feelings of nausea. It is best to try to eat in small quantities every three hours (fractionated diet). During pregnancy, it is good to eat proteins (meat, eggs, beans) before going to bed at night.
Heartburn: Heartburn can occur when stomach acid from digesting food is pushed into the esophagus. During pregnancy, all digestive processes are slowed down and the engrossed uterus presses up on the stomach. To avoid heartburn, eat in small quantities, several times a day. Avoiding spicy and greasy foods and not eating at least one hour before going bed is important. Some pregnant women experience relief resting at night by elevating their heads with two or three pillows.
Fatigue: Pregnancy may stress a woman's body. It is important to try to sleep eight hours daily and if possible, take a nap during the day. Avoiding hard work and eating a balanced diet throughout pregnancy is recommended by healthcare professionals.
Headaches: Headaches may develop during pregnancy. This may be in part due to stress or in some cases it is cased by the higher level of blood in the body during pregnancy. Relaxing in a dark room may help decrease the pain and length of a headache. It is recommended by healthcare professionals to not take medications for headaches while pregnant unless directed by a doctor.
Frequent urination: During pregnancy, the uterus is pressing down on the bladder. Even if the bladder is almost empty, this pressure produces the same sensation as if it were full. Do not avoid the urge to urinate.
Cramps: Cramps are due to circulatory problems associated with the weight gain as the individual progresses in pregnancy. Exercises can be recommended by a healthcare professional to alleviate these discomforts.
Chloasma: Chloasmas are obscure marks in the skin caused by the hormones secreted during pregnancy. They tend to disappear after delivery. Common areas of chloasmas include the forehead, temples, cheeks, or upper lip. Avoiding sunlight on sensitive areas can help prevent chloasma.
Stretch marks: Skin tissue that has to support extra weight causes these marks. They appear on the abdomen and breasts and in most cases slowly disappear after delivery. Creams that contain cocoa butter may be useful in preventing stretch marks.
Varicose veins: Varicose veins are produced by the pressure of the uterus on the lower part of the abdomen that causes difficulty in circulation during the nine months of pregnancy. Varicose veins usually appear in the legs especially if the mother must stand or sit for long periods of time. Moving frequently helps improve circulation. Elevate the legs when possible or lie in bed with a pillow under the feet. While sitting, try to keep the feet up. Do not wear tight clothing. A doctor may recommend support stockings.
Breathing difficulties: Breathing difficulties may happen during the third trimester of pregnancy because the fetus is occupying more space in the abdomen; breathe deeply several times a day but avoid hyperventilation. Sleep propped up and avoid crowded places and smoggy environments.
Backaches: Backaches are a consequence of the growing of the abdomen and weight increase associated with pregnancy. If an individual is suffering from backaches, healthcare professionals recommend: to avoid wearing high-heeled shoes; try to keep the back straight; and avoid lifting heavy weights. It is good to practice some relaxation exercises that will help to lower the tension in the muscles.
Swelling: Swelling can occur due to the retention of water in the tissues. Swelling has a high occurrence in the feet. Try to elevate the legs whenever possible and avoid tight clothes that bind the legs. It is important to notify a doctor if swelling is taking place in uncommon areas, such as the face, or if weight increases suddenly.
Abstinence: Abstinence is a lack of sexual relations. There are many ways to prevent pregnancy, but only abstinence is 100% effective.
Natural family planning (NFP): Researchers have found that a method of natural family planning that uses two indicators to identify the fertile phase in a woman's menstrual cycle is as effective as the contraceptive pill for avoiding unplanned pregnancies if used correctly. The study specifically investigated the efficacy and the acceptability of the symptothermal method (STM), a FAB method that uses two indicators of fertility, temperature and cervical secretions observation. In the largest study of STM, the researchers found that if the couples either abstained from sex = during the fertile period, the rate of unplanned pregnancies per year was 0.4%. The study authors suggested that the effectiveness of STM is comparable to the effectiveness of modern contraceptive methods such as oral contraceptives, and is an effective and acceptable method of family planning.
A number of fertility awareness based methods of family planning have been advocated over the years, but comparisons between different methods and studies of their effectiveness have been limited and hampered by problems such as differences in cultural backgrounds, different ways to measure the effectiveness of a FAB method, different ways of classifying unintended pregnancies and other study design problems. Researchers recommend that women or couples who want to learn the method should buy a book, attend an NFP course, or get some teaching by a qualified NFP teacher.
Early studies have also suggested that couples who practice NFP: have a dramatically low (0.2%) divorce rate; experience happier marriages; are happier and more satisfied in their everyday lives; have considerably more marital relations; share a deeper intimacy with their spouse; and realize a deeper level of communication with their spouse. Further, more well-designed studies are needed.
Sterilization: Sterilization in the male is termed vasectomy and in the female tubal ligation, tubal implant, or essure sterilization.
Tubal sterilization, or tubal ligation, is surgery to block a woman's fallopian tubes. Tubal sterilization is a permanent form of birth control. After this procedure, eggs cannot move from the ovary through the tubes (a woman has two fallopian tubes), and eventually to the uterus. Also, sperm cannot reach the egg in the fallopian tube after it is released by the ovary. Thus, pregnancy is prevented.
Vasectomy is a procedure in which the two tubes that carry sperm from the testicles to the urinary tract are surgically altered so sperm cannot pass through and be released to fertilize a woman's egg during sexual intercourse. For couples who have made the decision not to have any further children, vasectomy is the safest and easiest form of surgical sterilization. While reversible in many cases, vasectomy should be considered a permanent form of birth control.
Hormonal contraception: Hormonal contraception to prevent pregnancy includes birth control pills, birth control patches, and birth control vaginal rings.
Birth control pills, also known as oral contraceptives, have been marketed in the United States since 1962. Over the past 40 years, the type of estrogen and progestin (hormones) used in the pills has changed and the amounts of those hormones has been lowered. Birth control pills today are designed to improve safety and reduce side effects. Lower doses of estrogen are associated with a decrease in side effects, such as weight gain, breast tenderness, and nausea.
Over 30 different combinations of birth control pills are available in the United States. Most of the combinations of these pills have 21 hormonally active pills followed by seven pills containing no hormones. A woman begins taking a pill on the first day of her period or the first Sunday after her period has begun.
If a dose of oral contraceptive is missed, the individual may not be protected from pregnancy. A backup method of birth control, such as condoms, may be used for seven days or until the end of the cycle. Every brand of oral contraceptives comes with specific directions to follow if one or more doses have been missed. It is recommended to call a doctor or pharmacist with questions regarding missed oral contraceptive dosages. It is recommended by healthcare professionals to continue to take the tablets as scheduled and use a backup method of birth control until the questions are answered. Advantages of using birth control pills include their use to treat irregular menstrual periods. Women can manipulate the cycle to avoid a period during certain events, such as vacations or weekends by extending the number of intake days of hormonally active pills or by skipping the non-active pill week. Birth control pills may help prevent certain conditions, such as benign breast disease, pelvic inflammatory disease (PID), and functional cysts. Functional cysts are reduced by the suppression of stimulation of the ovaries. Ectopic pregnancies are prevented by the cessation of ovulation. The relationship between birth control pills and certain types of cancer is still being studied.
Disadvantages of birth control pills include nausea, breast tenderness, breakthrough bleeding, no periods, headaches, depression, anxiety, and lower sexual desire. Birth control pills do not provide protection from sexually transmitted diseases (STDs). Taking the pills daily and consistently (same time every day) is important. If a woman stops taking birth control pills, she may need a few months to get her normal ovulatory cycle back. After six months, her healthcare provider may need to examine her.
Additional risks include blood clots (venous thrombosis). At particular risk are heavy smokers (especially those older than 35 years), women with high or abnormal blood lipids (cholesterol levels), and women with severe diabetes, high blood pressure, and obesity. The association of birth control pill use and breast cancer in women remains controversial.
The relationship between birth control pill use and cervical cancer is also quite controversial. Important risk factors include early sexual intercourse and exposure to the human papillomavirus (HPV). Women who use birth control pills should have a periodic Pap test.
Intra-uterine device (IUD): An intrauterine device (IUD) is a small T-shaped plastic device that is placed in the uterus to prevent pregnancy. A plastic string is attached to the end to ensure correct placement and for removal. IUDs are an easily reversible form of birth control, and they can be easily removed. However, an IUD should only be removed by a medical professional.
Birth control barriers: Birth control barriers such as diaphragms, cervical caps, and condoms may also be used.
Spermicides: Spermicides are chemical barriers to conception. They are a reversible method of birth control, meaning that when a woman stops using them, full fertility returns. Vaginal spermicides are available in forms such as foam, cream, jelly, film, suppository, or tablet. Spermicides are not as effective as many other forms of birth control when used alone. They are often used with barrier methods of birth control and are much more effective when used in this context.
Emergency contraception: Plan B is the only emergency contraceptive pill ("morning after pill" or "day after pill") being sold in the United States today, although women can also use many kinds of daily birth control pills to prevent pregnancy after sex.
Plan B contains the hormone progestin. Other options for emergency contraception include taking a different dose of daily birth control pills (most of which contain both progestin and estrogen, so they are called "combined" pills) or having a healthcare provider insert an IUD within five days after the birth control failed and having had sex without using contraception, or if the individual was forced to have sex. Preven®, the brand name of a combined emergency contraceptive pill that was approved for use in the United States, is no longer being sold here. Plan B is more effective and has fewer side effects than other emergency contraceptive pills.
Emergency contraceptive pills are available without prescription to women and men 18 and older in the United States, though women 17 and under will still need a prescription from a healthcare provider to buy them. In some states, women of all ages can get emergency contraceptive pills directly from a pharmacist, without having to see a doctor first.