Archive for the ‘40 Weeks of Your Pregnancy’ Category

The end of pregnancy

When will I start my antenatal classes and what types are there?
Antenatal, or parent education, classes start around 32 weeks and, if you are attending classes run by your local NHS trust, are free. The classes may run for 4-6 weeks, or some trusts have a monthly afternoon session. Some hospitals provide women-only classes evening or weekend classes and yoga and pilates classes (see p 60). There are also private or independent, midwives in most areas who may offer antenatal classes on a one-to-one or small group basis.
Antenatal classes are also available from the National Childbirth Trust (NCT), run by trained NCT teachers Classes are usually held in the evenings, making them more accessible to partners and friends, and they often provide ongoing postnatal support for up to six months after the birth. There is a fee, although in some cases a reduced fee or assisted places may be offered
Aquanatal classes are also popular These are gentle exercises in the swimming pool along with other pregnant women and often the teacher is a midwife who also provides antenatal information. Also many obstetric physiotherapists run relaxation and breathing technique sessions; your hospital antenatal clinic may have information on these.
What will I learn in my hospital antenatal classes?
Antenatal classes usually cover a different topic each week, including the physical changes that occur in pregnancy, the three stages of labour; hospital, home, and water births; pain relief, which should include breathing and relaxation techniques; breastfeeding; postnatal care of the baby; and changes in your relationships The most popular topics tend to be the stages of labour and pain relief, along with a tour of the maternity unit
Is it useful to learn and practise breathing and relaxation exercises before the birth?
Preparation before labour and delivery is
for most women and their partners, and breathing relaxation techniques in particular help you to focus on your breathing. which in turn can help you to fee- less tense and increase your confidence for dealing with the contractions Antenatal classes teach you
specific techniques and antenatal yoga (see p 60) also helps you to gain control through breathing
Should I practise positions for labour and birth beforehand?
Practising for labour is a good idea as you may find some positions suit you and others don’t (see below). This information can be documented in a birth plan (see p.149) so that it is available for your midwife to discuss with you. It’s also good for your partner to know your preferred positions during labour
Do you have any suggestions for labour positions?
Some popular positions for labour area
* Leaning on a work surface or the back of
a chair. Putting your arms round your partner’s neck or waist to lean against.
•    Leaning on to the bed in the delivery room
•    Kneeling on a large cushion or pillow on the floor and leaning forwards on to the seat of a chair * Sitting astride a chair and resting on a pillow placed across the top
* Sitting on the toilet; leaning forwards, or sitting astride. leaning on to the cistern.
•    Kneeling on all fours.
•    Kneeling on one leg with the other bent
•    Rocking your hips backwards and forwards or in a circled this can also be done using a birthing ball Ally of these positions can make your contractions Breech presentation
Breech position is when your baby is bottom first instead of head first. Breech babies lie in one of three positions: a flexed, or ”complete’ , breech, when the hips are bent, the thighs against the chest, and the knees bent with the calves against the back of the thighs and feet above the bottom; an extended. or
‘frank”, breech when the hips are flexed or bent the thighs against the chest, and the feet by the ears; and a ”footling” breech, like a flexed breech, but the hips aren’t so bent and the feet are below the bottom If your baby is breech at term, your doctor may recommend delivery by Caesarean section
more efficient and help you feel in control When you are in strong labour, you may find that you don’t want to move around much and will find a position that suits you If possible, keep rocking, leaning forwards during contractions, and straightening up in between. If you get tired, lie down on your left-hand side, rather than propped up on your back, which stops the pelvis being able to open effectively. Lying on your left side is much better for your baby than lying on your back because he receives more oxygen, and the contractions are still effective in this position. If you feel rested after a while, push yourself up with your hands into a sitting position and get up again
I’m 36 weeks and my baby is breech. Is this a concern?
Breech position is when your baby is bottom first instead of head first (see above) Quite a lot of
babies sit in the breech position in pregnancy and there is still a chance your baby will turn. It’s not until about 37 weeks that your midwife or doctor will focus on your baby’s position.
Is there anything I can do to help my baby turn?
If your baby is breech towards the end of pregnancy there are some exercises you can try in an attempt to turn your baby A ‘knee-chest” position can help To do this, kneel on your bed with your bottom in the air and your hios bent at just over 90 degrees Try to keep your head, shoulders and upper chest flat on the mattress Adopt this position for 15 minutes every two waking hours for five days If you feel nauseous or light-headed, do not continue. Positions in which the buttocks are elevated can also help, and sleeping with a pillow under your buttocks or kneeling on all fours so the weight of your pregnancy is unsupported may help You can combine ”all fours’ positions with household chores, such as cleaning the floor. If these are not successful, there are other ways to try to turn your baby (see below).
I’ve heard about doctors “turning” breech babies. How does this work?
Some obstetricians may try to turn a breech baby in late pregnancy, known as external cephalic version (ECV), which has a success rate of around 50 per cent. During an ECV, an obstetrician gently moves your baby by pressing his hands on your abdomen, using an ultrasound as a guide You may be given a drug to relax the uterine muscles You will be scanned first and if the baby is in an awkward position the procedure may not continue. Also, if your baby is large this can affect the procedure, as can the amount of fluid around the baby, as a low amount of fluid offers less protection to the baby, If you are Rhesus negative, you will have an injection of anti-D after the ECV (see p.79) because of a small risk of a bleed around the placenta An ECV is not recommended if you have a multiple pregnancy, have had bleeding in pregnancy, your placenta is low-lying, your membranes have ruptured, or there is a known problem with the baby
The procedure is not without risk and some think it only works with babies who would have turned anyway. If your baby remains breech, a Caesarean may be advised, although some obstetricians are willing to try a vaginal delivery You are not obliged to have an ECV and should discuss your options.
Finally, a form of acupuncture called
I f moxibustion”is sometimes used, whereby a fragrant herb is held over an acupuncture point, the aim being to relax the uterine muscles to help the baby turn Talk to your doctor or midwife before trying this and seek advice from a qualified acupuncturist.
What triggers labour?
While there are many theories, no one really knows what triggers labour One is that the mother’s pituitary gland secretes oxytocin, the hormone that
stimulates contractions, when the baby is ready to be born Others now believe that the baby starts labour by sending a signal to the mother’s body One theory is that a baby’s lungs secrete an enzyme when they are developed that causes a substance called prostaglandin, which triggers contractions, to be released into the mother’s body. Another theory is that, when the baby is ready to be born, its adrenal glands produce hormones; these cause hormonal changes in the mother that start labour
I don’t want to go overdue. How can I help labour to start?
Various methods have been tried, although none is proven. Popular methods include having sex, as the prostaglandins in semen are similar to the ones used to induce labour; stimulating your breasts to trigger the release of the hormone oxytocin, which stimulates the uterus; eating spicy food to bring on a loose bowel movement, thought to stimulate labour (see p 48) ; and taking long walks to help the baby move down in the pelvis and put pressure on the cervix Homeopathic remedies are also available; consult a registered practitioner for advice.
I’ve heard that raspberry leaf tea can start labour. Is this true?
Unfortunately this is a misconception as raspberry leaf tea doesn’t actually help to bring on labour, but it may help to reduce the length of labour In a study m Sydney, 192 first-time mums were given either a 1.2g raspberry leaf tablet or a placebo twice a day from 32 weeks. The tablet had no harmful effects. and the women who had taken the supplement had a shorter second stage of labour and a lower rate of assisted delivery (19.3 per cent to 30.4 per cent).
Raspberry leaf tea contains an alkaloid, ”fragine”, said to strengthen and tone uterine muscles, helping them to contract more efficiently. You should start taking raspberry leaf tea during the last eight weeks of pregnancy At 32 weeks, you could have one cup of raspberry leaf tea a day, gradually increasing to four cups or tablets a day (depending on the strength of the blend). The tea can be sipped in labour, too.

Fetal positions
Your baby in the uterus
Your baby can lie within your uterus in many different positions. Your midwife or doctor will palpate your abdomen (gently feel your tummy) to identify which way your baby is lying. There are two main positions in which your baby will lie: with his head downwards (cephalic presentation) or with his buttocks downwards (breech presentation). Occasionally your baby will lie across your uterus in a transverse position or even diagonally across you in an oblique position, particularly if there is too much fluid around the baby or you have had several babies previously. In about 17 per cent of cases, the midwives and doctors do not identify a breech presentation until the labour itself
What is LOA and ROA? Once your midwife has identified how your baby is lying, she will also try to determine whether the baby is lying on your right or left side The midwife will track where
Your baby’s position
your baby’s back is, and you will generally feel kicks on the opposite side. The midwife will describe your baby as being LOA or ROA, which stands for left or right occipital anterior -the occiput being the back of your baby’s head facing forwards, so your baby is actually facing backwards These are the best positions for your baby to lie in for labour.
What if the baby isn’t anterior? Sometimes babies lie in a posterior position, which means that their back is lying against your back and they are looking upwards This position may prolong your labour, which can be tiring If this is the case, you can try the same exercises for turning a breech baby (see p.143) to encourage your baby to turn to be in an anterior position towards the end of pregnancy Sometimes your baby will only turn with the help of strong, effective contractions when you are in fully established labour.

What is the “nesting instinct” and is this just a myth?
The nesting instinct is a well-documented natural phenomenon In the final weeks of pregnancy, many women have an uncontrollable urge to clean their house and to prepare and make the ”nest’ safe for the new arrival This is a primal instinct and females of the animal kingdom are all equipped with this need. Just as birds make their nests preparing for their young, mothers-to-be do exactly the same.
The act of nesting puts you in control and gives
•    sense of accomplishment You may also become
•    homebody and want to retreat into the comfort of your home and familiar people The nesting urge can be an indicator that labour is not too far away If you have the energy, take advantage and get on with tasks that you won’t have time for after the birth
Is it true that first babies are often late?
Birth normally occurs at a gestational age of 37 to 42 weeks and, while it certainly isn’t the case that all first babies are late, many do arrive after the predicted
due date. From the point of view of waiting if you approach the end of your pregnancy expecting your baby to be a couple of weeks late, then you may avoid feelings of frustration. It is worth considering that your body has never done this before and that your “due date” is an estimate, the majority of babies do not arrive on this date
I’m 39 weeks and my baby’s head isn’t engaged. Should I be worried?
Not all babies engage into the pelvis before
the beginning of labour It is likely, from about 36 weeks onwards of -your pregnancy, that you may experience your baby moving lower down in your abdomen, causing your baby’s head to enter the pelvis. This process is known as ”engagement’I and simply means that the leading part of the baby has ”engaged” the pelvic brim (see p.148) This is normal and helps to position your baby in preparation for the birth later on.
Engagement often happens earlier with first
babies because the uterine muscles have not been
Your hospital bag
Although hospital visits tend to be short, with many women staying around 24 hours or less after a normal delivery you will need a few essential items. Many mums have a bag for themselves and one for the baby, while others organize a labour bag and postnatal bag for mum and baby. It’s up to you. Basic requirements include:
•    Clothing for labour (including socks and/or footwear).
•    Nightwear.
Toiletries
A towel, sanitary pads disposable pants and a bra.
iIc Music, books, and magazines, as well as money, telephones, phone numbers, and cameras.
* A food bag with nutritious snacks to keep you going
For your baby you will need:
* Clothing, cleaning materials, and some clothes for returning home * Nappies (check with your midwife if the hospital provides these or whether you need to supply your own).

Engagement
Engagement is when your baby’s head starts to move down into the pelvic brim in preparation for birth, and this can occur any time from around 36 weeks until the start of labour In the last weeks of pregnancy, your midwife will palpate your abdomen to see if the head has started to engage. The degree to which a baby’s head is engaged is measured in fifths. If three- or four fifths of the head can be felt above the pubic bone, then
the baby is not engaged If only two-
fifths of the head can be felt, then the baby is said to be fully engaged, and if just one-fifth is felt, the baby is recorded as being deeply engaged.
previously stretched and so they tend to exert more pressure on the baby, moving it down into the pelvis earlier: whereas a second or third baby may not become engaged until your labour actually starts. When your baby’s head engages can also depend on other factors, such as the position in which your baby is lying within the womb (see p.145) and the shape of your pelvis
Am I likely to feel any different once my baby’s head has engaged?
Many women report feeling more physically at ease following the engagement of their baby’s head as there is a release of pressure within the abdomen As a result, you may find that it feels easier to breathe, sleep, and walk around
On the other hand, sometimes when the baby’s head engages this can increase the pressure on your bladder and you may experience a sensation of fullness and pressure between your legs. Many women also report shooting vaginal pains. Engagement is also likely to affect bowel sensations.
My midwife mentioned checking the position of the placenta. Is this normal?
This is not routine, but if your 20-week scan indicated that the placenta was low-lying, known as placenta praevia (see p.92), your midwife would suggest a further scan at 34 weeks to see if the placenta had moved up and away from the cervix.
My baby isn’t moving so much now - should I be worried?
There is some natural reduction in the range of your baby’s movements towards the end of pregnancy as he has less room to stretch his limbs However, you should still be familiar with your baby’s pattern of movement in later pregnancy as this is a good indicator of your baby’s health and is just as important as the number of movements a day (see p.103) You may find at this stage that your baby is developing a pattern for waking and sleeping, often different to yours, so your baby may be awake when you go to bed and may start kicking Or your baby may get the hiccups and you will feel the jerk of each hiccup, a sign that your baby is preparing for life after delivery. If your baby’s movements have reduced or stopped, contact your maternity unit. You could also try things like having a cold or hot drink, having a bath or shower or massaging your tummy. A formal assessment may be recommended and if there are concerns, you will be asked to make a conscious effort to increase your awareness of when your baby moves. There should never be fewer than 10 individual groups of movements a day between 9am. and 9pm. Some areas have walk-in antenatal day units (ANDLJ) where you can have a cardiotograph (see p.192) to record your baby’s movements.
I’m practically incontinent. Is there anything I can do to stop this?
During pregnancy, many women find that they leak urine slightly when they cough, laugh, exercise, bend over, or lift something. This is known as stress incontinence. The pelvic floor muscles are under strain during pregnancy as they have to support the weight of your growing uterus and cope with the changes caused by pregnancy hormones. As a consequence, a sharp increase in abdominal pressure when you cough and so on may be too much for the muscles to hold back the flow of urine. Stress incontinence may happen at any time in pregnancy, but is more common towards the end.
The best treatment for incontinence is regular pelvic floor exercises to keep the muscles toned (see p.57). Taking some gentle exercise each day can also help and, although you may not make a full recovery during pregnancy, regular exercise now will minimize the problem and help you towards a full recovery after your baby is born. Stress incontinence is often worse for a few days following the birth, when the muscles of the pelvic floor and other structures are recovering If it does not get better after this time, talk to your health visitor or doctor as you should not have to suffer long term without help.
Ask your midwife to refer you to your obstetric physiotherapist, who can review the problem and offer you advice and monitoring.
Birth plan
Stating your preferences for labour and birth
The purpose of a birth plan is to communicate your wishes for labour and birth.
Your plan can be as detailed or as brief as you like Do bear in mind that circumstances may dictate that not all of your preferences are met Discuss this plan with your midwife before the birth. Here are some suggestions of what to include:
* You may want to state who your birth partner will be, whether you want more than one birth partner, and if you want them present throughout. * You could include your preferences for managing labour pain Do you want to labour naturally (maybe using a birthing pool), or do you have a preferred type of medical pain relief? *You can state which positions would you like to use in the different stages of labour? Do you want to be active in the first stage, and in which position would you prefer to deliver your baby?
* Do you have concerns about being strapped to a fetal monitor? If so, do you want to request that this be done intermittently only?
* State your preferences for after the birth. Do you want your baby delivered on to your tummy, and how soon do you want to breastfeed?

Do babies need all this stuff?
shopping for your baby
What will I need for my baby after the birth?
For hospital births, it is recommended that you pack a labour and birth bag for yourself and a bag for the newborn baby You will need some clothes for your baby: vests and all-in-one stretchsuits, or babygrows, are easiest, especially when learning how to dress
and undress your baby. If you are in hospital for several days, you will need at least three stretchsuits and vests A baby blanket and/or a shawl can be useful and, depending on the temperature in the ward, your baby may need a hat, but be careful that she does not get too hot. Your baby needs an outdoor jumpsuit, or jacket and socks and soft booties, for when you leave hospital Any footwear should be loose so that it does not restrict your baby’s movements or circulation.
Most maternity units expect you to provide your own nappies, and one packet is usually enough. You may also need some cotton wool to clean your baby, If you choose not to breastfeed, many units provide formula milk, but this varies across units, so check what facilities are available before the birth.
You will need to have ready a baby car seat, as most hospitals won’t release you without one and the law requires that your baby travels in a car seat.
When is the best time to buy the essentials? I’m nervous about getting anything too early.
Many parents feel superstitious about buying baby items too early, especially if it is their first baby or they have had a previous difficult experience. However, some planning is needed as you may find that by the end of your pregnancy you are too tired to shop. You should also leave enough time in case you need to exchange items Try to buy items gradually. First, buy items that you will need for the
baby after the birth; these should be ready by the 37th week of pregnancy, although many parents have these by about 34 weeks. Other essential items, such as buggies, should be in the home before the birth (see right). Once you have bought the essentials, you can purchase any additions when it suits you, which may depend on how mobile you are after the birth and your access to shops. Many parents shop online as shopping with a baby can be difficult
I don’t have a lot of money - do I need to buy everything new?
Having a baby does bring financial pressures and so it is sensible to acquire second-hand items, whether handed down from friends and relatives or bought. Clothes in particular are worth acquiring secondhand as babies grow out of them long before they have made full use of them and most mothers admit to buying more clothes than necessary, so quite often you can receive second-hand unused items.
One of the main items parents worry about getting second-hand is the cot mattress. Some experts believe that you should buy a new mattress with each baby to reduce the risk of cot death (see p 276), while others believe that if the mattress is clean and dry this is not necessary, so this is a matter of preference.
What do I need to consider when choosing my baby’s mattress?
It is important for your baby’s wellbeing that you
buy a mattress that is the correct fit for your sleeping equipment So, for example, if you are using a cot, the mattress should fit the cot properly with no gaps between the mattress and the cot sides that a baby could get stuck in. As it is also important that the mattress is clean, dry. well aired, and firm, it may be preferable to buy a new rather than second-hand mattress (see p 136)
My mum wants to buy us something. What can I suggest?
The gift will depend on what you need, your mother’s budget, and what she would like to spend it on. You could plan a day shopping together and decide on the day, or you could browse a baby catalogue together for ideas. It also depends on whether the gift is for you and your partner, or for the baby Good gifts for mums include underwear, nightwear, a photo frame or album, or a baby album or naming book If your mother wishes to purchase something for the baby, this could include clothes, a baby bath, a sterilizing kit and bottles, a cot, a car seat, or a pram/buggy system.
Do I need a pram/travel system/buggy? Help!
Most parents are unsure about what type of transportation they will need for their baby and, as there are a number of options and types available, this can make choosing the right item difficult. You will certainly need to have some type of travel equipment for your baby and what you choose will vary depending on your circumstances. If you are mainly a car driver, you may want to consider a car seat that attaches to a pram, or a car seat and travel cot If you intend to walk a lot, you may find a lightweight pushchair or buggy more suitable What you choose should be practical, and within your budget, so it’s worth having a look around in shops and online to compare different models.
Is it OK to get a second-hand car seat?
Generally it is thought best not to use a second-hand car seat as you cannot be certain of its history and it may have been in an accident or damaged Car safety experts suggest that if you must use a secondhand seat, only accept one from a family member or friend, and then only if you are absolutely certain that you know its history that it comes with the original instructions, and it is not too old. They strongly discourage purchasing a car seat through a secondhand shop or classified advertisements.
Do I need to buy a cot yet, or can I start with a Moses basket?
It may help to think about the amount of space you have and where you want your baby to sleep. A Moses basket has the advantage of being small so your baby will feel snug and may settle sooner than in a cot, and it also means that your baby can sleep beside your bed. Some models come with a rocking motion so you can rock your baby to sleep while you are in bed A disadvantage is that your baby will grow out of the Moses basket after a few months. Once your baby starts to sit up, there is a danger of falling out of the Moses basket as the sides are low
At some stage you will need a cot Although at first your baby will look small in the cot and may feel less secure, there is plenty of growing room and your baby can stay in the cot for at least a couple of years (some cots convert into beds and last even longer) Some cots are available with adjustable bases, making it easier for you to put your baby into and lift her out of the cot. You will need a bigger space for the cot, which ideally will be in the baby’s bedroom.
What bedding do I need?
Most parents choose sheets and blankets. Cotton sheets can be used in layers along with a blanket, so that you can add or remove layers to keep your baby at the right temperature If your baby sleeps in a Moses basket or carry cot, you should buy sheets designed specifically for these It is important to get the right fit so that your baby is not too exposed or too covered up. Nowadays, many parents opt for baby sleeping bags (see
below). If you use a sleeping bag, you will still need a few bottom sheets for the cot.
What are the pros and cons of baby sleeping bags?
Baby sleeping bags, also known as grow bags, baby sacks, or sleep sacks, have been around for 25 years but recently have become more widely used (see
p 280). They can be used without other bedding with the baby in a vest and sleepsuit. Many parents prefer these as they keep the baby covered, regardless of how active they are during sleep, which in turn helps the baby feel secure However. the Foundation for the Study of Infant Deaths warns that you should avoid oversized bags as a baby could slide down inside, and although they can be used for newborns, some manufacturers recommend waiting a few weeks or months before using one to avoid this risk
Which baby monitor should I choose?
Baby monitors first appeared in the UK in the early 1980s and today there are over 400,000 on the
market, so choosing one can be daunting Although monitors vary they have the same basic component -a minimum of two units one to transmit your baby’s sounds and one that stays with you so that you can monitor your baby. Additional features include dual channels, a moving lights-sound display a sensor pad, low power and an out-of-range warning, the option to use mains or batteries, a talk-back function, and a temperature sensor. If they all have these features, it is down to personal choice and cost.
Should I buy disposable nappies?
Although many parents opt for disposable nappies as they find them more convenient, particularly when out and about, nowadays many people look for a more eco-friendly alternative, as disposable nappies, dumped in landfill sites may take hundreds of years to decompose Also, it is estimated that it costs parents about E2000 to use disposable nappies for each child You may want to investigate the different options (see p. 140).
What baby changing items do I need apart from nappies?
You need a waterproof changing mat that wipes clean. Some parents use warm water and cotton wool to ciean their baby’s genital area and bottom, or you can use baby wipes. You may also want to use a cream to prevent nappy rash. As well as the essentials, you could buy some oils (see p.219) and use changing time to massage your baby’s skin.
Should we put a dimmer switch in the nursery?
The benefit of a dimmer switch is that you can control the lighting, so that your baby’s eyes can adjust slowly However, a dimmer switch is not essential, as long as you have access to a soft light, such as a lamp or mobile that can project light
Should we buy a baby bath or can she use our big bath?
A baby bath is useful as you can use it in any room. Most parents area bit apprehensive when they first bathe their baby, and even experienced parents say that it can be tricky to hold a wriggling baby safely while trying to wash them, so using a smaller baby bath helps you to develop confidence For newborns, a washing-up bowl can also suffice. However, a baby outgrows a baby bath by around six months and the bath can take up a lot of storage space. Once your baby can sit up, at around four to six months, you could use a bath seat in your main bath, or enjoy a bath together as long as you keep the water tepid
I want to breastfeed, but should I buy some bottles just in case?
The problem with having bottles to hand is that it may weaken your resolve to breastfeed, and evidence shows that women are more likely to continue breastfeeding if they do not have an alternative readily available Having said that, if you wish to give your baby some water, or to start expressing once you are breastfeeding confidently, then you will need some bottles
I plan to bottlefeed. What do I need to get in advance?
You will need plastic bottles (teats are included), a sterilizing unit or kit, which often has everything you need. and your preferred formula. Each comes in a range of options, so you need to decide what works best for you As you get to know your baby, you may have to change the type of teat and/or formula, so it is not advisable to buy too many before the birth There is a range of sterilizers available (see p 239).

Baby clothing
When buying clothes for your newborn, bear in mind that babies grow very quickly, so buy just a few items in smaller sizes Choose easy-to-clean, machine-washable natural fabrics and avoid fussy styles with ribbons or tricky openings, opting instead for easyto-use poppers Essential clothing items for your newborn include,
3 or 4 vests.
4 or 5 all-in-one sleepsuits, or babygrows, with front-opening poppers
* A snowsuit or jacket for outdoors, or a cardigan for warmer months.
* A woolly hat in the winter months and a light hat for your baby in the summer.
Loose-fitting bootees or cotton socks.
A blanket or shawl for outdoors.

Essential items

As well as clothes and nappies for your newborn, there are several other items that you will ideally have ready before the birth.
* A cot or Moses basket for your baby to sleep in and a clean, dry mattress. * Suitable bedding for your newborn! either lightweight blankets and sheets or newborn baby sleeping bags.
* A pushchair or buggy to transport your baby You may also want a sling to carry your baby around.
* A baby car seat if you are travelling with your baby in a car.

Twins and multiple births

We are expecting twins following IVF treatment. How will we cope?
Although finding out that you will be the parent of two babies rather than one can be a shock, the initial surprise will settle and you will soon start to get used to the idea There are many associations that offer information and support to parents of twins, as well as companies that make products for parents of two or more children (see p.310) Your midwife and obstetrician will offer information and support and may put you in touch with local multiple birth support groups You will also be invited for more regular antenatal appointments and scans than if you were having just one baby to keep an eye on the growth of your babies.
As with all multiple births, there are no additional financial benefits if you are having twins, although you may receive more of certain benefits that are dependent on income (see below).
We’re having triplets. Help! My wife is over the moon, but I feel numb. Where can we get advice?
As having triplets is relatively rare - only 149 sets
of triplets were born in the UK in 2006 - the majority of information and support for couples does relate to having twins. However, more and more research is being carried out into how to help and support parents having more than two children
Your midwife and obstetrician will be great sources of information and will be able to put -you in touch with other parents of multiple-birth children. There are also several organizations that offer support and information for parents having a multiple birth (see p.310). As you and your wife learn more about having triplets, your anxiety will hopefully start to ease
Will we receive any additional financial or practical support
as we’re having more than one baby?
Unfortunately, there are no financial benefits available to all parents having twins or multiple births. However, there are some benefits that are dependent on your income, some of which you may be able to claim per baby One of these is the Child Tax Credit, made up of three elements: a family element: an amount payable per child dependent on your joint income; and a baby element of £545 if you have cne or more children under a year old This credit is the focus of the Twins and Multiple Birth Association’s current campaign, as they feel strongly that the baby element should be paid per baby, so that a family with newborn triplets would be entitled to £1635. The Sure Start Maternity Grant, a payment of £500, is payable per baby so if you are entitled you would be able to claim £ 1500 for triplets. This must be claimed within three months of the birth so it is important to apply as soon as possible For practical support, it is worth finding out about Home Start schemes in your area. Home Start is a charity that provides trained volunteers to lend support at home. Each scheme is locally based, managed, and run by individual communities, supporting families in that community.
IDENTICAL TWINS: NON-IDENTICAL TWINS:
Does taking folic acid increase the incidence of twins?
There has been some debate and conflicting studies about whether taking folic acid pre-conceptually could increase the chance of having twins. A study in Sweden in the 1990s found a higher incidence of multiple births among women taking folic acid. However, this could be attributed to other factors, such as a greater number of women undergoing fertility treatment, which carries an increased probability of twins. Also, subsequent studies have refuted these findings; in 2003, the medical journal The Lancet reported on a large-scale study in China that found there was no significant difference in the number of women who had taken folic acid carrying twins.
Are all same-sex twins identical?
No. Whether or not twins are identical depends on how they were conceived, not on what sex they are (see above). While identical twins are obviously the same sex, non-identical same-sex twins are as similar or different as any other non-twin siblings.
How likely is it that our twins will be identical?
One in 80 pregnant women carries twins and one-third of twins are identical Although there are factors that make you more likely to have non-identical twins, such as a family history of twins or being over 35, having identical twins is not an inherited trait and there are no other factors that make this more likely.
Will I know before the birth if they are identical?
The term “zygosity determination” means finding out whether twins, triplets, or more are identical (monozygotic) or non-identical (dizygotic or fraternal). It is natural for parents to want to learn all about their babies, and with twins this includes their zygosity As well as for reasons of natural curiosity, knowing whether twins are identical can help parents to determine the chance of having a multiple pregnancy again, and also has implications on care during pregnancy, as identical twins, especially if they share a placenta, are higher risk, and so the pregnancy may be more closely monitored.
In two-thirds of cases, the placenta provides the answer as to whether twins are identical. If the babies have a single amniotic sac surrounded by one outer protective membrane, known as the chorion, they are monozygotic However, one-third of identical twins whose egg split early, before the placenta started to form, have two chorions with either a fused placenta, where two placentas grow together, or two separate placentas. These placentas are hard to distinguish from those of dizygotic twins
We don’t know if our twins are identical. Will it be obvious after the birth?
In a third of cases, twins are different sexes and therefore obviously non-identical In same-sex twins by the time the children are around two
years old their’ zygosity” is usually quite clear from their physical features Before this, there are many indications as to whether twins are identical such as the colour of their hair and eyes, the shape of their ears, the eruption and formation of teeth, the shape of the hands and feet, and the pattern of growth
If there is doubt as to whether twins are identical, the most accurate way to determine zygosity is by the DNA probe method when tiny amounts of DNA are collected with a swab from inside each twin’s mouth. A laboratory examines specific markers present in the DNA and 12 diagnostic targets are compared. Although non-identical twins may share five marker patterns by chance, monozygotic or identical, twins will have the same pattern for all 12 markers
Will I love one twin more than the other?
Although this can be a concern, it is more likely to be the case that rather than favour one child over the other, a parent gives more love and attention to the baby who needs it most at that particular time
It is also possible that the strain of having two new babies in the house may increase the likelihood of delayed bonding, although this can also happen_ the birth has been traumatic if the mother or indeed the father is exhausted: or if one baby has taken time to establish feeding, or is more fractious than the other This does not mean that bonding will not take
Am I likely to have a normal birth?
Although many women having twins have normal deliveries, the rate of Caesareans is increased with twin births With one baby the Caesarean rate is around 25 per cent in the UK; with twins, the rate is closer to 50-60 per cent which also means that 40-50 per cent of twins are delivered vaginally. Triplets and above are generally delivered by Caesarean in the UK and Europe Whether or riot twins are born vaginally depends on their position in the womb ~ whether one or both twins is head down (see p 133).
There may be an indication as to the type of birth in pregnancy as women with twins are usually scanned to check the position of the babies near to term, at around 27-34 weeks.
place over time, but if this is worrying you, you should mention it to your midwife or health visitor, as they may well be able to offer some helpful advice
In every family, there are bound to be ebbs and flows of love between parents and children, which is normal and not a cause for concern When a parent has two children born at different times, that parent may love one child differently to the other, but this does not mean that the love a parent has for one child is to the detriment of the other.
Will the side effects of pregnancy be much worse with a multiple pregnancy?
Although in some cases the side effects of pregnancy may be the same when you are expecting two or more babies, the likelihood is that many pregnancy symptoms will be exaggerated Symptoms such as morning sickness, fatigue or exhaustion, disturbed sleep and swollen hands and feet are often worse with a multiple pregnancy Unfortunately, women with multiple pregnancies also tend to suffer more from varicose veins (see p.86) In addition to these increased side effects, weight gain is greater and more rapid for mothers carrying more than one baby and the uterus measurement is often increased for the gestational age This extra weight and size caused by carrying two or more babies may also cause more constipation haemorrhoids (piles), urinary tract infections, and vaginal thrush infections.
Although there may be more exaggerated symptoms with a multiple pregnancy the majority of these problems can be monitored by your midwife or doctor, and they may be able to offer advice and treatment to ease these symptoms.
Will my weight gain be much greater than for someone who is having just one baby?
Mothers of twins or triplet pregnancies are likely to gain more weight than women having one baby. Indeed, in the first trimester, rapid weight gain may be an indicator of a multiple pregnancy The increased blood volume and size of the uterus, as
well as each baby’s weight, possibly two placentas, and the amniotic fluid for each baby, will continue this pattern of greater weight gain during pregnancy
Although on average a woman having a multiple pregnancy is likely to put on around I Okg (221b) or more than a woman having one baby, this is not double the weight gain If you are having twins, you should raise your calorie intake by only 500 calories per day in the last trimester, compared to 200 calories more for a single pregnancy
I’m only 24 weeks, expecting twins, and already I’ve got high blood pressure. What can I do?
Unfortunately high blood pressure is more likely to start, or worsen if you already have the condition, in a twin pregnancy as the rates of pregnancy-induced hypertension (PIH) and pre-eclampsia (see p 89) are increased in multiple pregnancies
There is little that can be done to prevent PIH General lifestyle changes, such as reducing your salt intake, avoiding alcohol and tobacco, taking gentle, regular exercise, and getting enough rest, are thought to help. You should also ensure that you attend all your antenatal appointments and contact your midwife or doctor if you experience headaches or visual disturbances such as flashing lights or there is reduced movement from your baby
What can go wrong if I have a vaginal delivery?
If both twins are head down, a vaginal birth is usually possible. Sometimes, the first twin may be head down and born vaginally, but the second twin may be breech Sometimes, the second twin will turn and be head down after the birth of the first twin, and you are then more likely to deliver both twins vaginally Studies suggest that there has been a significant increase in combined vaginal-Caesarean births of twins and a decrease in vaginal only births, which may be due to the fact that there is a greater willingness nowadays to allow women carrying twins to try for a vaginal delivery, which also increases the likelihood of this scenario. If you have a vaginal delivery, there is a greater chance of one or both twins having an assisted delivery by vacuum extraction or forceps (see p.202), either because one or both twins is positioned in a tricky -way, for example facing the mother’s back, or because the labour may be longer and weaker because of the amount of work involved in pushing two babies out, which means that the mother is therefore likely to be more tired and needing help at the end of labour.
Why might the doctors decide to deliver my twins by Caesarean section?
An elective Caesarean (see p.206) might be recommended for a twin delivery for several reasons, but ultimately it is your decision The optimum time for delivering any baby is at term (37-40 weeks’ gestation) and this remains the case for delivering twins as they may well be smaller than a singleton baby, having had to share your supply of nutrients However, if one or both of the babies are compromised, possibly due to twin-totwin transfusion syndrome (see p 134) or raised
blood pressure in pregnancy there may be a need to deliver the babies preterm.
Many units recommend a Caesarean for a breech baby where the baby is bottom down inside the womb, because there are more risks associated with a breech vaginal delivery In a twin pregnancy if the first baby is breech, this puts the second twin at risk too Also. if the first twin is breech and the second is head first (cephalic), a Caesarean is recommended due to the rare complication of ”locked” twins, when the babies’ chins get locked together
If both babies are head down and appear to be thriving, many maternity units will encourage a normal delivery Your doctor and midwife will discuss this with you nearer the delivery time.
Will my triplets need to be delivered before 40 weeks?
Yes, it is very likely that your triplets will be delivered before 40 weeks. Although most twins are born at around 37 weeks, which is considered to be a term pregnancy it is rare for triplets to reach term, and most are delivered at around 32-36 weeks’ gestation
As a woman’s body is designed to carry one infant at a time, carrying more than one increases the risks for both mother and babies, and the decision to deliver your triplets will be taken when one or more of the babies is not coping well. To improve the chances of a good outcome, get plenty of rest and eat a healthy diet (see p.50) Although premature deliveries do carry a risk to the infant, if the baby’s wellbeing is compromised an early delivery is necessary. If you go into premature labour, you may be given medication (see p.162) to try to stop labour for long enough to administer steroids, which will help to mature the babies’ lungs before delivery -as long as this does not put the babies at risk
How likely is it that my twins will have a lower than average birth weight?
Over 40 per cent of twins are born with a lower than average birth weight, which is mainly due to the fact that they are born earlier than singleton babies.
Do twins run out of room to turn in the womb?
It does tend to be the case that, in the third trimester, twins find a position and settle there at an earlier stage of pregnancy than if there was just one baby. Generally, with twin pregnancies there seems to be a lot less movement in presentation from about 32-34 weeks. However, how your twins are likely to be delivered depends largely on the direction that the twin who is lowest in the pelvis is facing. If this twin is head down, then a vaginal delivery should be possible and the second twin may be able to be gently coaxed into a favourable position, or may need to have an assisted delivery (see p 202)
I’ve been told that one baby isn’t developing as well as the other.What will the doctors do?
Although it is common for twins to grow at a different rate in the womb, if there is a significant difference in size, it may be that one baby is getting a greater proportion of the nutrients than the other. It is important to check that your babies are developing in line with their gestational age. It is not unusual for some babies to grow slowly and then accelerate later on, which is not a concern if it’s within the accepted range of growth for their gestational age. However, if your midwife or doctor is concerned about the development of one baby, they will probably refer you to a fetal medicine specialist: an obstetrician with additional training in caring for the unborn baby He or she may do blood tests and perform an ultrasound to assess the growth of each baby and investigate why there is a difference.
You may continue to have additional scans, known as growth scans, which will help the doctor to assess if one baby is small or growing slowly These usually start around 26-28 weeks and continue every 2-4
weeks until your babies are due to be delivered They look at a number of areas including the head, abdomen, and thigh bone measurements; the amount of amniotic fluid around the babies; the babies’ levels of activity; the blood flow in the umbilical cord; and the position of the placentas. Your doctor should
explain the findings of the scans and if there is a concern you will be closely monitored.
What is twin-to-twin transfusion syndrome?
This is a rare but serious condition that occurs only in identical twins who share a placenta. It is caused when there is an abnormal blood supply and a blood vessel directly connects the twins. One twin pumps blood around his own body and that of his twin and, as a result, he does not grow properly An early delivery is usually needed to save the smaller twin.
Am I likely to lose one or more of my babies?
There are increased risks for both mother and babies associated with multiple pregnancies and sadly there are occasions when one or more of the babies dies in the womb This occurs in around 2 5-5 per cent of twin pregnancies. In some circumstances, for example if there is a fetal abnormality in one twin such as a heart defect, the doctor may suggest that one or more of the babies is terminated in the very early weeks to allow the normal healthy development of the other baby or babies. However, many doctors believe that this is unnecessary as the procedure itself carries the risk of losing all the babies.
Although incredibly hard, this is ultimately your decision so you should spend time discussing the options with your doctor.
Unfortunately the death of a baby in a twin pregnancy can sometimes cause problems for the surviving twin, although the degree and type of problem depends on whether the twins were identical or non-identical. If the twins were identical, the doctors will want to assess whether it was a monochorionic pregnancy (in which the twins share the same placenta) or a dichorionic pregnancy (in which they have a different placenta). This is because, when the placenta is shared, there is a 30 per cent risk of death or a neurological problem to the surviving twin if the other dies, whereas if there are two placentas, there is a lower risk of 5-10 per cent, of death or disability occurring in the surviving twin.

The position of twins
Twins can lie in a variety of positions in the uterus and these positions can determine how your baby will be born One baby will always be lower than the other one, and this baby will be known as the first baby - it is closer to the birth canal and will
generally be born first.
What are the possible positions? Babies can be in the head down position (cephalic) or buttocks or feet first (breech). Occasionally a baby may be lying across you diagonally or horizontally (transverse) Twins can lie in any combination including: cephalic-cephalic, cephalic-breech, breech-breech, breech-cephalic These positions can change throughout the pregnancy, As with a singleton pregnancy (one baby), once the presenting baby nearer to the cervix goes down into the pelvis, it will stay in that position ready for birth.
Can I have a vaginal birth? When both babies are in a cephalic position you may be offered the chance to try for a normal labour and vaginal birth Sometimes, the first baby is cephalic and the second twin is in a breech position. If this is the case, your obstetrician may suggest that you have a Caesarean from the outset, or may suggest that you have a vaginal birth with the doctor assisting the birth of the second twin with forceps or ventouse (see p 202) if necessary You can certainly be party to these discussions and it’s important to share your feelings about the birth and birth choices. If the first baby is breech and the second baby is cephalic, then it is highly likely that your doctor will recommend that you have a Caesarean delivery. If both your babies are in the breech position you will almost certainly need a Caesarean, as is the case if both babies are lying across you in the transverse position

How are twins conceived?
Identical ”monozygotic” twins are produced when a single egg is fertilized by a single sperm, and the egg then splits into two. The babies may share the membranous, or amniotic, sac that surrounds them in the uterus Depending on when the egg splits, they may also share a placenta. Identical twins, therefore, are the same sex and look almost completely alike as they share the same genetic makeup. Non-identical, or ”dizygotic”, twins result when two eggs are fertilized by separate sperm at the same time and each therefore has its own individual genetic makeup Each fetus also has its own amniotic sac and placenta.

Testings During Pregnancy. FAQ

Testing, testing
investigations in pregnancy
What is the difference between diagnostic and screening tests?
Screening tests identify your baby’s ”risk factor” for a particular condition, but do not confirm that your baby definitely has a condition. For example, a screening test for Down’s syndrome may give your baby a risk factor of 1:200 This means that your baby has a 1 in 200 chance of being affected by Down’s syndrome. Another way to view this result could be that the baby is most likely to be healthy. If your baby has a high risk factor, you may then decide to have a diagnostic test, such as amniocentesis or chorionic villus sampling (see pp 122-123), which gives a definite yes or no as to whether or not a condition is present. These tests are more invasive, as they require a sample of amniotic fluid or blood from the fetus or placenta, and they carry a slight risk of miscarriage.
Certain screening tests, such as first- or second-trimester screening for Down’s syndrome, are offered routinely to all women regardless of any factor other than they are pregnant. These tests, in the form of scans or blood tests, identify who would benefit from further diagnostic tests. This avoids subjecting all pregnant women to diagnostic tests, which carry some risks (see p. 125). Any benefit from a test should outweigh the potential risk.
What do these tests look for?
Screening and diagnostic tests aim to identify abnormalities in the unborn baby, which may be congenital, genetic, or chromosomal. Congenital abnormalities are often detected in the 18-22 week scan (see p.121) and these include conditions such as heart abnormalities or extra digits These abnormalities can sometimes be treated after, or sometimes even before, the birth and are not inherited. Some conditions, such as spina bifida, are thought to be due to a combination of genetic and
environmental factors; a dietary deficiency of folic acid may also contribute to this condition. Other congenital abnormalities may be caused by infections caught in pregnancy.
Diagnostic tests are usually carried out to identify genetic or chromosomal abnormalities, such as Down’s syndrome, cystic fibrosis, sickle-cell anaemia, and muscular dystrophy. (Cystic fibrosis and muscular dystrophy are screened for if there is a family history) These conditions occur either because there is a problem with the inherited genetic material, for example a gene has mutated, or because there is a chromosomal problem, for example there may be an incorrect number of chromosomes, as in Down’s.
Down’s syndrome, or ”trisomy 21”, is a chromosomal abnormality in which there is an extra copy of the chromosome 21. It is the most common ”trisomy” disorder. Babies born with this condition have physical anomalies, such as slanting eyes and
a protruding tongue, and there is a high incidence of heart, intestinal, hearing, and sight problems. Down’s is the biggest single cause of learning difficulties. The majority of Down’s syndrome conceptions are lost through spontaneous miscarriage early on in pregnancy, although over 600 babies are born with Down’s syndrome in the UK each year.
I’m 38 - will I have more tests because I’m older?
Although the risk of Down’s syndrome increases as you get older (see p 118) currently many women regardless of age are offered one of two types of screening test for Down’s. This is either a first trimester screening that involves a blood test and a scan to measure nuchal translucency (see p.118), or second trimester screening which is a blood test only, called the triple, or Bart’s. test (see below) Both tests give the result as a risk or a percentage risk. If the test indicates there is a high risk of Down’s, then all women are offered a diagnostic test such as amniocentesis (see p.123). However, if you are over 35. amniocentesis is offered routinely in the UK.
Your midwife should discuss with you in detail all the tests that are available and give you written information about them. Ideally, you should have this information several weeks before you are asked to decide if you wish to go ahead with any screening or diagnostic tests so that you have plenty of time to consider the possible outcomes and whether these tests are something -you wish to undergo
Depending on your past medical history and other factors, such as your blood pressure during your pregnancy or problems you had in previous pregnancies, you may be offered additional scans to check your baby’s growth after 26-28 weeks.
We don’t want invasive tests as we will love the baby whatever. Can we refuse diagnostic tests?
Whether or not you have a diagnostic test is your choice and you can refuse at any time to have any test offered As well as the question of whether you are prepared to have a Down’s baby, there is also the risk of miscarriage to consider (see p.125) On the other hand, you might decide you want a definite diagnosis to be able to prepare for your child.
What blood tests will I be having, and when?
There are various blood tests offered during pregnancy As well as routine blood tests taken during antenatal checks to assess your health, there are also blood tests to screen for problems with the baby. Within the first 12 weeks you will be given a routine blood test to check your levels of haemoglobin, the oxygen-carrying part of blood. Although these fall slightly in pregnancy as the blood becomes more diluted, a significantly low haemoglobin level indicates iron-deficiency anaemia (see p 8 1). You will also have tests to identify your blood group, Rhesus factor, and rubella immunity (see p 15). and to screen for infectious diseases including syphilis, HIV, and hepatitis B. You may also be tested for sickle cell and thalassaemia, inherited blood conditions more commonly found in people of African, Caribbean, Indian, or southern Mediterranean origin.
Other blood tests may be offered to screen for congenital abnormalities in the baby Between 10 and 14 weeks, a blood test that measures the levels of the substance known as pregnancy associated plasma protein (PAPP-A) may be offered that is combined with the nuchal translucency scan (see opposite) to calculate a risk of Down’s syndrome.
If first trimester Down’s syndrome screening isn’t available, then second trimester blood screening tests are offered, which also include screening for neural tube defects, such as spina bifida These tests, carried out between 16 and 18 weeks, include the triple, or Bart’s, test, which measures the levels of the hormones AFR hCG, and oestriol; and the quadruple test, which, in addition to the other three hormones, measures inhibin A and PAPP-A.
Will I have a test for HIV?
Ali screening and diagnostic tests recommended in pregnancy are optional, so it is up to you and your partner to decide whether to have them. One of these is a blood test to check if you have the human immuno-deficiency virus, or HIV, and, indeed, some women only find out about their HIV status in pregnancy It is worthwhile to test for HIV in pregnancy as, if the result is positive, anti-retroviral medication, careful monitoring of maternal blood levels, and careful, safe delivery of the baby can reduce the chance of transferring the infection to the baby from 40 per cent to 2 per cent.
For pregnant women with HrV, a blood test is taken around the time of delivery to measure the levels of the virus. Depending on the results of the blood test, the obstetrician will either recommend a planned Caesarean section or decide that the levels are low enough to have a normal delivery.
After the delivery, HIV-positive mothers are advised to bottlefeed, again to reduce the risk of transferring the virus to the baby
How do ultrasound scans work?
Ultrasound scans use high-frequency sound waves — so high we can’t hear them — that bounce off solid objects and create a picture, visible on a
computer screen, of your baby, the placenta, and your organs in the surrounding area.
How many scans will I have and when?
All women should routinely be offered two scans, a dating scan between 10 and 14 weeks and an anomaly scan between 18 and 22 weeks. Some units routinely offer a screening scan for Down’s syndrome between 11 and 14 weeks, known as the nuchal scan (see opposite), although this isn’t available nationwide. You can also arrange to have private scans that may be 3D/4D (see p, 124) and which you have to pay for
I’m quite scared about my first scan. What happens during the scan and what does it feel like?
Although not painful, early scans can cause discomfort as you need a full bladder (see p, 124). Ultrasound scans can be carried out by a doctor,
a midwife, or a sonographer. You will lie on a couch and need to wear something that makes it easy to expose your tummy. The person doing the scan puts cold gel on the lower part of your tummy, which improves contact with the skin, making it easier to view the baby. You will feel a little pressure as a transducer is pressed against your skin and moved around to look at the baby from different angles and to take measurements The image produced by the scan is viewed on a screen similar to a computer monitor. The person carrying out the scan may spend some time first studying the image and taking measurements before talking to you about what they can see Although this can be unnerving, it does not mean that anything is wrong
Some units offer a transvaginal scan in early pregnancy, which can give an improved image at this stage. This internal scan is done using a probe that is covered by a condom and gently inserted into your vagina. The image is viewed on the screen in the same way as an abdominal scan. This may be offered before 10 weeks if there is bleeding or pain.
Many units offer to print an image from the scan for you to take home Although ultrasound scans
Should I have a scan? is ultrasound safe ill pregnancy’?
Ultrasound scans in pregnancy, first introduced 40 years ago, have become a routine part of antenatal care.
* Most research indicates that they are a safe way to view the baby even when extra scans are needed for medical reasons * Suggested links between additional scans and growth problems and dyslexia are tentative as babies scanned more often are more likely to have problems linked to other factors.
* Recommendations are that scans are carried out only for clinical reasons and the number done is kept to a minimum.
How long do scans last?
The length of time an ultrasound scan takes varies depending on the reason for the scan and the experience of the ultrasonographer.
During the dating scan, performed at around 10-14 weeks, the sonographer takes some basic measurements. This includes the measurement from the top of the head to the end of the bottom, known as the ”crown-rump” measurement, used to calculate how many weeks old your baby is and
therefore your due date. This scan can take around 20-30 minutes. The nuchal fold scan (see p 118), during which the sonographer measures the fluid at the back of the baby’s neck, takes around 20 minutes. Anomaly scans, performed between 18 and 22 weeks, are detailed scans that take approximately 40 minutes (see opposite) At this scan, the sonographer measures the baby and looks at physical and structural development. The size and position of the placenta are examined and the amniotic fluid around the baby is measured
If, during your pregnancy, your midwife has any concerns about your baby’s growth or wellbeing, she may refer you to an obstetrician who may recommend another scan. As this will be to identify a specific problem, such as whether there is a concern about your baby’s growth, it may take a bit longer. This may be in the form of a Doppler scan, which measures the blood flow in the uterus, placenta, and umbilical cord and can help to identify growth problems in the baby This procedure usually takes around 30 minutes.
Do I have to have scans in pregnancy?
Official guidelines are that all women should be offered two routine scans during their pregnancy, but the choice to have one is yours. As scans are screening tests to look for anything out of the ordinary some women choose not to have any as they prefer not to know about any problems until the baby is born, or are confident that they will continue with the pregnancy regardless. You need to decide whether you fall into this category
Can my partner come along for the scans?
There is no reason why your partner should be excluded from attending these appointments if you want him to be there and, indeed, it’s very common for partners to attend ultrasound scans For many couples, the scan is a special moment as it’s the first time they get to see their baby and begin to think of themselves as parents.
primarily area clinical screening tool to determine if your baby is growing and developing as expected, they are also an opportunity to see your baby for the first time and often see your baby moving even before you feel the first flutters inside your uterus.
So scans become part of the developing relationship between you and your partner and the baby. In recognition of this, most units offer the facility of providing photos of the scan for a small charge to cover printing costs. Ask your community midwife whether the maternity unit where you are having your scan has this facility.
Do you have to drink pints of water before a scan? I’m scared I’ll have an accident.
For the 10-14 week dating scan it’s important to have a full bladder to make it possible to view the baby. This is because until 12 weeks the uterus stays in the pelvis and the bowel obscures the view. a full bladder raises the uterus and pushes the bowel out of the way. You may need a full bladder for a nuchal scan, between 11 and 14 weeks, depending on when it is done. Some units do transvaginal. scans (a small ultrasound probe placed inside your vagina) before 10 weeks if the image from an abdominal scan is poor In this case, you won’t need a full bladder and research indicates that transvaginal scans are more comfortable in early pregnancy compared to abdominal scans. You don’t need a full bladder for the 18-20-week scan, as the position of the uterus has changed
I’m pregnant through IVE Will I have more scans than normal?
It’s usual to have one extra scan in an IVF pregnancy usually carried out by the centre where you had the
3D and 4D ultrasounds
Many companies now offer special scans that reveal your baby in three dimensions or moving on film or video. These 26-32 week scans can be quite expensive and are carried out for curiosity value and not for medical reasons The quality of the pictures is usually amazing and parents are sometimes able to spot genetic similarities between themselves and
procedure This scan is usually done around two weeks after the embryo has been transferred to confirm the pregnancy and make sure that the pregnancy is within the uterus rather than in a Fallopian tube (see ectopic pregnancy, p.25) Although the main purpose is to reassure you that all is well, the centre also has to inform the Human Fertilisation and Embryology Authority (HYEA) of the outcome of the IVF treatment. Once your pregnancy is confirmed, you will continue with routine antenatal care like any other pregnancy
Can they really tell the sex
of the baby early on? I’m 18
weeks and not sure if I want to know.
It is possible to identify the sex of a baby on routine ultrasound scans from around 20 weeks, but this is dependent on a number of factors, including the expertise of the person performing the ultrasound, the quality of the equipment being used, the position the baby is lying in, and the position of his or her legs. Even if all of these factors are favourable and the genitalia can be seen, there is an error factor, so
their baby However, the scan is often lengthy which means the baby is exposed to ultrasound for longer than is normal Also, if the baby is in the wrong position, it may be difficult to get a clear picture The position of the placenta, the amount of amniotic fluid, and the size of the mother can also affect the quality of the pictures obtained  the information given about gender from a scan is never seen as 100 per cent accurate Some research has been carried out to try and determine gender at an earlier stage, but this was even less accurate. Sometimes when you are watching the scan you may be able to see the genitalia yourself and may decide you know the sex of your baby without being told. But remember you may be wrong. If you have an amniocentesis the sex of the baby can be definitely identified during the procedure.
Most units have a written policy only to reveal the baby’s sex if this information is requested Some units have a policy of not telling anyone the sex of the baby from scans alone, partly because they cannot be 100 per cent accurate and also because, in a small number of cases, the information about gender may lead to a request for termination. If you want to know the policy in your area, ask your community midwife.
I’ve seen lots of companies advertising scans and videos of scans - are these safe?
Many companies offer 3D scans (still pictures) and 4D scans (moving pictures copied onto video or DVD) (see opposite), and the detail in these can be very good. If you have a private scan, you should check the expertise of the person carrying out the scan, and check if the company has a referral policy to an appropriate consultant obstetrician if anything untoward is discovered, as not all companies employ the services of obstetricians or midwives.
There are twins in our family. When will they be able to check whether I’m having twins?
Most women find out that they are having twins
at their ultrasound dating scan between 10 and 14 weeks Very occasionally, one twin is hidden on the first scan and is seen at the second ultrasound scan, but nowadays this is less likely due to advances in scanning Family history also gives a clue to the possibility of twins, but only if they are fraternal, or non-identical (see p.129).
Is everyone offered amniocentesis?
Amniocentesis is a diagnostic test (see p 123) that is routinely offered if you are over 35 and so have a higher risk of having a baby with Down’s syndrome Alternatively, you may be offered the test if your family history suggests there may be a risk of your baby having muscular dystrophy, haemophilia, cystic fibrosis, or another genetic disorder. Also, if you have had a screening test that suggests your baby has a high risk for a congenital condition, you will be offered a diagnostic test to confirm or rule it out For example, if the nuchal scan (see p.118) showed a high risk of Down’s, amniocentesis may be offered.
I’ve heard that amniocentesis carries a risk. Is this true?
Amniocentesis does carry a small risk of miscarriage. It is thought that the risk of miscarriage is increased above the normal risk by 1 per cent immediately following an amniocentesis, but after two days the risk returns to normal. You need to balance the risk against the value of the test to you and also be aware that a normal test result is not a guarantee that there will not be any other problems, but is nonetheless reassuring
Can chorionic villus sampling cause miscarriage?
Chorionic villus sampling (CVS) is another diagnostic test used to establish whether a baby has Down’s syndrome (see p.122). Unfortunately, as with other invasive tests, this carries a risk of miscarriage, of around 1.5-2 per cent, with the risk reducing each day, Larger hospitals carrying out more than 100 CVS tests a year may have lower miscarriage rates due to the opportunity for the doctors to fine tune their ability to carry out the procedure.
When is cordocentesis used?
Cordocentesis is a diagnostic test used to diagnose Down’s syndrome and other problems
in a baby It can also detect infection from diseases such as toxoplasmosis (see p.45). Additionally,
cordocentesis is used to detect rubella infection (see p.15), as well as to perform a blood count on a baby that is suspected of having anaemia From 18 weeks, the baby’s blood is examined using a sample of
blood carefully extracted from the umbilical cord The test is carried out in a similar way to that of amniocentesis, though results are available within 72 hours. The risk of miscarriage is 1-2 per cent.
Will I get weighed at my antenatal appointments?
In 1941, routine weighing of all pregnant women at each antenatal appointment began Although it was thought that there was a connection between a mother’s weight gain and a baby’s birth weight,
it was decided more recently that this is not a good indicator of when a baby is not growing, and so over the last 10 years routine weighing at each appointment has been abandoned. Furthermore, weight gain can vary from woman to woman in normal healthy pregnancies as widely as 3-18 kg (7-401b).
Nowadays, all women are weighed once at the beginning of pregnancy and then, together with a height measurement, their BMI (body mass index) is calculated (see p.18), which helps to predict certain risk factors, for example in women who have a very high or very low BMI The only time that you might be weighed on successive visits is if there is a medical reason to do so, for example if you had significant weight gain in a short space of time that could indicate excessive fluid retention (oedema), a sign of pre-eclampsia (see p 89).
My friend is 27 and has had a Down’s baby - is that unusual?
Although the risk or chance of having a baby with Down’s syndrome increases with age, particularly over 35, the majority of Down’s babies are born to younger mothers. This is probably due to the fact that more women have their babies younger, and also because women over 35 are likely to have more tests The risk of having a baby with Down’s at the age of 20 years is 1 in 1,700. This risk increases to 1 in 1,400 by the age of 25 and by the time the mother reaches 35, the risk has increased to about 1 in 400
My partner wants to hire a Doppler so we can listen to the baby’s heartbeat. Is this a good idea?
During pregnancy your midwife listens to the baby , s heartbeat with an instrument called a Doppler sonicaid or pinard (ear trumpet). Most midwives use a sonicaid so the parents can hear the heartbeat too This passes sound waves through the abdomen. which pick up movement and bounce it back to the machine, where it is converted into sound.
Being able to hear your baby’s heartbeat during pregnancy is reassuring, especially when the earlier symptoms wear off but the baby’s movements have yet to be felt. However, your baby’s heart beats at a rate approximately double the rate of your heart. If the closest moving thing to the ”beam” is your blood pulsating through your aorta, the sonicaid will pick this up, and if you pick up your heart rate, this might cause you anxiety Also, depending on your gestation and the position of your baby the heartbeat will be found in different areas on the abdomen. If you can’t pick up a heartbeat, you may be unduly worried.
Midwives undergo specialist training to find the heartbeat and many won’t try to find the heartbeat until the baby is around 16 weeks, and even then may have difficulty Occasionally, due to the baby’s position, they may need to call another midwife or doctor to help them locate the heartbeat
It is up to you and your partner if you decide to hire a sonicaid, but it would be wise to be aware of the anxieties that may accompany this decision.

 
The 18-22 week anomaly scan
Your baby’s physical examination
Also known as the fetal anomaly or anatomy scan, this detailed scan is offered to all women between the 18th and 22nd week of pregnancy. At this stage of gestation, your baby has well-developed limbs and facial features and all its major organs and
body systems are in place and can be checked.
How is it done? The scan involves transmitting high-frequency sound waves through the uterus that bounce off the baby and the returning sounds are converted into an image (see p.119), The biggest echoes are from hard tissues, such as bones, which appear white in the image on the screen, while soft tissues are grey-flecked. Fluid-filled spaces, such as the stomach, bladder, blood vessels, and amniotic fluid surrounding the baby, do not return sound waves so appear black. It is
the difference between echoes and colours that enables the ultrasonographer to interpret images
What will be checked? The ultrasonographer starts by checking the fetal heartbeat and then counts the babies - rarely, twins are not revealed until 20 weeks! She will measure the head circumference and diameter (biparietal diameter), and the abdominal circumference and the femur (thigh bone) to date the pregnancy and ensure your baby is growing well She will check for abnormalities in the brain, face and lips, spine, abdomen, heart, stomach, kidneys, bladder, and hands and feet. Lastly, the placenta, umbilical cord, and amniotic fluid are examined You may be able to find out the sex of your baby, although you can ask not to be given this information (see p.124).

Diagnostic tests
Identifying fetal abnormalities
Diagnostic tests give a definitive answer as to whether or not your baby has an abnormality such as Down’s syndrome These tests are not carried out routinely and you will be offered one only if a screening test indicated that your baby had a higher risk for Down’s syndrome, if you are over 35, or you have a family history that puts you at a higher risk of having a baby with an abnormality, All diagnostic tests also carry a small risk of miscarriage and you will need to weigh up the pros and cons before deciding to go ahead with one
Chorionic villus sampling (CVS) This is a
diagnostic test that involves taking a tissue sample from the placenta to identify for certain whether your baby has Down’s syndrome or a genetic
Chorionic villus sampling
needle and
syringe  ultrasound transducer
abnormality This can be done as the placenta contains the same genetic information as the baby The test is carried out between 11 and 13 weeks, The advantage of this test is that it can be performed earlier in pregnancy than amniocentesis, so if an abnormality is found and you decide to terminate, it is early enough to have a suction termination.
How is it done? There are two procedures for CVS: one method extracts a sample of the placenta via the abdomen, and the other method carries out the procedure vaginally With the abdominal method, a fine needle is inserted through your abdomen and, using an ultrasound scan for guidance, the doctor removes a very small sample of tissue from the placenta You have to wait about
ultrasound transducer
catheter 10 days for the results, which means that if your baby has an abnormality and you want to terminate your pregnancy, you can do so well before you start to feel your baby kicking.
To carry out CVS vaginally the doctor inserts a small tube through your vagina and the cervix, which then passes through the uterine wall. As with the abdominal method, the doctor then takes a small sample of tissue from the placenta, using ultrasound for guidance. The sample is sent to a laboratory where it is grown in a culture for around seven days. The sample is then studied under a microscope to check for chromosomal abnormalities or other defects.
Amniocentesis Amniocentesis is a diagnostic test used mainly to identify a chromosomal abnormality and it is the most commonly used test for identifying Down’s syndrome. During the test, a sample of amniotic fluid containing cells from the baby’s system is taken from the uterus. It is a relatively quick and painless
Amniocentesis test
ultrasound — needle and
transducer syringe
placenta uterus — amniotic  
fluid
cervix
procedure and may be offered at around 16-19 weeks of pregnancy It is offered later than CVS because there may be insufficient fetal cells in the amniotic fluid before this stage of pregnancy The results from this procedure are usually very accurate and, although there is a slight risk of miscarriage, this is lower than the risk of miscarriage with CVS, especially in units where a large number of the tests are carried out and the doctors are particularly practised at conducting the test Apart from the slight risk of miscarriage, the main disadvantage of amniocentesis is that it has to be carried out later in pregnancy, so if the result comes back as positive, then you will be half way or even further into your pregnancy should you decide to terminate and would need to be induced to undergo a vaginal delivery
How is it done? Using an ultrasound scan to guide the procedure, a long, thin needle is inserted through the mother’s abdomen into the amniotic sac and a small sample of amniotic fluid is extracted. This contains fetal cells, which are then grown in a culture in a laboratory to be analysed. As there is a small risk of miscarriage, you may be advised to rest for a day or two afterwards to minimize this risk. Depending on the maternity unit and the laboratories used, there may be a chance that the result could be back before the end of one week, but the majority of units still have to wait two or even three weeks. It usually takes 2-3 weeks for the fetal cells to grow, Very occasionally this does not happen and you may need to have another amniocentesis test
Cordocentesis This diagnostic test is also known as ”fetal blood sampling” or “umbilical vein sampling”. In this test, blood is taken from the baby’s umbilical cord to diagnose Down’s syndrome when earlier screening tests have shown a possible problem. Since this is an extremely specialized procedure, it can only be carried out at a regional specialist fetal medicine centre in certain parts of the country.

 
Nuchal fold and dating scans
Ultrasound examinations
A dating scan at 10-14 weeks measures fetal growth so that a gestational age can be given The nuchal fold scan, or nuchal translucency scan, is offered between weeks 11 and 14 and assesses the risk of Down’s syndrome. Only some hospitals offer this scan at the moment The risk of Down’s syndrome rises with age. At 20 the risk is 1:1527; at 25 it is 1:1352; at 30 it is 1:1895; at 35 it is 1: 356; and at 40 it is 1,97,
What does the dating scan look for? The distance is measured from the top of the baby’s head to its bottom (crown-rump measurement), and the diameter of the head is recorded, known as the biparietal diameter - the distance between the parietal bones either side of the head
How is the nuchal fold scan done? The sonographer will measure the width of the fold of
skin behind your baby’s neck to see if any excess fluid has collected there This measurement is calculated into a risk ratio based on your age The ratio is considered high if it is above 1:300. You will be given the results of the scan immediately If your baby has a high risk, you will be offered further tests and, depending on the results and after counselling, the choice of continuing your pregnancy with support or having a termination.
Is it reliable? The nuchal fold scan is considered to be 80 per cent accurate, which means there is a 20 per cent (1:5) chance of it being inaccurate If your hospital offers you a blood test (PAPP-A, see p.119) with the scan, it becomes 85 to 90 per cent accurate. When the nasal bone is also measured, the accuracy rises to 95 per cent. Your local maternity unit should be able to provide you with information as to how accurate their scans are.

Sex in pregnancy

Can having sex in pregnancy harm the baby in any way?
Unless you have been told by your midwife or doctor to avoid intercourse because of specific problems, such as a history of miscarriage or unexplained bleeding, then sex is perfectly safe as your baby is cushioned in fluid in the amniotic sac inside your womb and protected by a cervical plug, and even deep penetration isn’t harmful. Enjoying intimacy with your partner will also be beneficial for your relationship.
I’m either uncomfortable when we make love or not in the mood. Should I fake it?
Levels of sexual desire in pregnancy vary greatly, with some women finding their sex drive is heightened, while others feel too ill, anxious, hormonal, or just too uncomfortable to attempt sex at all. If you really don’t want sex, be as honest and open as you can about your lack of sex drive. Don’t be pressurized into doing something you really don’t want to do, as this could complicate your relationship. Communication is very important at this time, so talk to your partner about how you are feeling — you may find that he is completely unaware of your feelings, anxieties, and worries.
You could use the presence of your ”bump” as an ideal excuse to experiment with different positions, as most couples find the missionary position very uncomfortable in late pregnancy Some couples prefer it if the woman is on top as this allows her more control over the amount of penetration and there is less weight on her bump. A ‘’spooning” position, with your partner behind you, also allows for shallower penetration and removes pressure on your bump totally Having a baby is all about adapting to new experiences, and most couples find they need to adapt their sex life too
Since we hit the second trimester I’ve wanted sex more than ever - why is this?
Often, in the second trimester, women find that once early pregnancy symptoms wear off they feel far more energetic and sexier than ever! However, this may not be the case for everyone as each woman is affected differently by the physical and psychological changes that occur in pregnancy, and women have different views about their changing bodies, which can affect their libido.
From a physiological point of view, an increased blood flow to the pelvic area combined with an increased lubrication of the vagina means that, in theory, having sex can be better than ever So if you and your partner are quite happy with your increased sex drive, this is not a problem.
My placenta is low and I’ve been told to avoid sex. Why is this? I’m only 30 weeks’ pregnant.
As the baby develops and grows so does the womb, with the result that the placenta is carried upwards away from the opening of the womb. However, in
10 per cent of women, the placenta remains low-lying during late pregnancy and then poses a risk because of potential bleeding (see p 92). A low-lying placenta is often first detected at an early scan and, if this is the case, it is usual for a repeat scan to be carried out at around 34 weeks of pregnancy to determine if the placenta is still low and exactly where it is situated in respect of the opening of the cervix (neck of the womb).
The biggest risk from a low-lying placenta is bleeding and if you have already experienced any bleeding, it is usual to recommend that you avoid sexual intercourse, as agitation of the cervix, which happens during sex, can encourage more bleeding If in doubt, it’s probably best to discuss your particular circumstances with your midwife or consultant obstetrician
My partner hasn’t wanted sex at all since I’ve become pregnant. Will he ever fancy me again?
It isn’t uncommon for either partner to experience a reduced sexual desire in pregnancy for a variety of reasons. It is important that you talk to your partner and ask about his feelings while also explaining your own thoughts and feelings.
Some partners find pregnancy a little scary, and some of these fears centre around sex and concerns about harming the baby or you. Sometimes, these worries may be based on real concerns, for example if there have been any problems in early pregnancy such as threatened miscarriage, bleeding, pain, or excessive morning sickness. Equally they can be based on misunderstanding, and this is where discussion between the two of you will help.
Although you may feel more attractive and sexy, perhaps your partner is feeling clumsy and
Talking to each other
Maintaining a healthy relationship
It is essential that you and your partner keep the lines of communication open during this time of change and some uncertainties.
* If you have gone off sex completely, reassure your partner that this is a
temporary situation and explain how the pregnancy is making you feel mentally and physically.
* Likewise, if your partner seems reluctant to initiate lovemaking, don’t take it
personally. Try to find out how he is feeling. * Don’t allow a quieter sex life to stop you being affectionate at other times.
uncomfortable. Each couple is different and you will need to talk to each other to find your way through this. You may also feel that you want to talk to someone who isn’t so closely involved, such as your midwife, doctor, a trusted friend, or a relative
Is it best to stick to oral sex during pregnancy?
Research on the benefits and risks associated with oral sex in pregnancy is limited and the findings are very often contradictory There is nothing that indicates that oral sex is recommended in place of penetrative vaginal sex unless you have been advised to avoid sexual intercourse because of the risk of bleeding, threatened miscarriage, or premature labour, when avoiding orgasm is also advisable and so complete abstinence is the better option for a while. Apart from this, it is important to remember that some infections can still be passed on easily by oral sex.
Will having an orgasm cause me to go into labour?
In a pregnancy without problems, an orgasm alone will not cause premature labour, and at full term orgasm will only cause the onset of labour if your body is ready for labour anyway. If you have had any signs of premature labour, or if you have had premature rupture of your membranes (see p.167) you will be advised to avoid sexual intercourse. This is because the hormone oxytocin increases during sexual arousal and the effect from the oxytocin is to cause the muscles of the uterus to contract.
During pregnancy the muscles of the uterus experience practice contractions, known as Braxton Hicks (see p 168), which are not harmful, and orgasm may increase these practice contractions
If you have gone past your due date and are at a point when your body is ready to go into labour, then sexual intercourse may help things to start for two reasons the prostaglandins in semen will help the cervix to soften at this stage of pregnancy, and the contractions stimulated by orgasm have more chance of developing into early labour contractions.
I’ve got problems with my pelvis - is there a comfortable way for us to have sex?
Problems with the pelvis, particularly symphysis pubis dysfunction or SPD (see p.82), tend to be made worse by moving your legs too far apart, so it is a matter of finding a position that you feel comfortable in that doesn’t involve too much stress on the pubic area. Many women find the “missionary position” the most difficult as it involves significant parting of the legs, plus there is the weight of a partner to consider Some, although not all, women find an all-fours position for intercourse more comfortable, both for sexual intercourse and for giving birth. If intercourse is really proving difficult, then it could be that while you are experiencing significant problems you will need to find alternative ways for you and your partner to be intimate that don’t involve penetrative sex.
Many women find that pelvic discomfort improves significantly once they have had the baby. A very useful organization that has a lot
of information and advice on pelvic pain during
pregnancy is the Pelvic Partnership (see p 310). You can also talk to your midwife or doctor for a referral to a physiotherapist, which may be beneficial and help you to achieve a greater degree of comfort during pregnancy
I’m 36 weeks. My boyfriend insists on regular sex and has been a bit abusive. Is this normal?
It is not normal for someone to be abusive to another person or to force them to have sexual intercourse when they don’t want to You should never be forced to do something that is against your will. In almost 30 per cent of all domestic abuse cases, the first incidence occurs in pregnancy. It is very important that you talk to someone about how your boyfriend is treating you, perhaps to a close friend or relative There are also organizations that offer confidential advice and help you if you really feel there is no one you can talk to or trust (see p.3 10). You could also try talking to your midwife, who will treat everything you say in the strictest confidence and will have details of local organizations that can help and advise you.

Comfortable lovemaking
You and your partner may need to experiment more during pregnancy to find lovemaking positions that are comfortable for you and your rapidly growing bump As pregnancy progresses, most women find that lying on their back in the missionary position becomes increasingly uncomfortable as your partner presses on your bump. You may find being on top an enjoyable position, which allows you to control penetration and does not put pressure on your tummy. Lying in the spoons position, with your partner behind you, can be pleasurable and puts no pressure on your abdomen. Other positions that don’t restrict your pleasure and are comfortable include sitting together, kneeling while your partner enters from behind, and lying side by side with your legs bent over your partner’s legs.

What’s happening to my body?
how your body changes
I’m feeling like a beached whale and I’m only 16 weeks, what can I do?
Weight gain during pregnancy is not only due
to the baby, placenta, and amniotic fluid, but to a number of factors. Changes in your metabolism, the development of certain organs such as the uterus and breasts, and an increase in your blood supply causing more fluid retention and swelling,
all contribute to your weight. In addition, extra stores of fat are laid down as pregnancy requires more energy for the work involved in developing the fetus and coping with the demands of labour. Although most of this fat is stored in the first 30 weeks, weight gain is usually slower at the beginning of pregnancy and suddenly increases in the second half.
The average weight gain is 12 5kg (271b), 4.5kg (101b) of which is gained in the first 20 weeks, and the remainder thereafter. If you feel you have put on more than this, my advice is to eat healthy, smaller, more regular meals and take some gentle exercise.
People keep telling me I’m too small, but the midwife says everything is fine. Can you explain?
Tell them to mind their own business! If your midwife says she is not worried, then I would feel reassured -some women just hide a pregnancy very well! Your midwife starts to measure your tummy at around 26-28 weeks, as by then the major organs are more or less developed and your baby is concerned with growing and laying down fat supplies. Most units use personalized growth charts that are designed to take into account your individual traits such as your race and height, which influence how big your baby is likely to be By taking these factors into account, your midwife can predict more accurately the expected weight and measurements of your baby.
I’m 17 weeks and my breasts have changed - they’re painful and look different. Is that normal?
It’s perfectly normal and very common to
experience breast changes in pregnancy. These are caused by both an increased blood supply and a rise in pregnancy hormones, particularly in the
first 12 weeks. Before your pregnancy was confirmed you may have felt tingling sensations (especially in the nipple area) as the blood supply increased. As early as 6-8 weeks, breasts can get larger and more tender and may begin to look different on the surface, with threadlike veins starting to appear. At around 8-12 weeks, the nipples darken and can become more erect, and as early as 16 weeks, colostrum, the first milk, may be expressed.
Why am I getting more vaginal discharge since becoming pregnant?
In pregnancy, the layer of muscle in the vagina thickens and this, combined with an increase in the pregnancy hormone oestrogen, causes the cells in the vagina to multiply in preparation for childbirth. As a side effect, the extra cells mean that there is an increase in vaginal discharge, known as leucorrhoea.
If you feel sore or itchy and the discharge is anything other than cream or white, or smells, see your midwife or doctor so that a swab can be taken to rule out infection Some infections: such as thrush, cause an abnormal discharge They are common in pregnancy and are easily treated.
Dark patches have appeared on my face. What could they be?
The dark patches on your face are called “chloasma’ or `pregnancy mask” and these patches affect around half of pregnant women. Nearly all pregnant women notice some changes in skin colouring, with skin usually darkening from 12 weeks. This is due to an increase in the hormones that stimulate skin pigmentation, with darker-skinned women affected more. This darkening may be more apparent on certain areas, such as the nipples, perineum (skin between the vagina and anus), and naval, or areas that experience ”friction rubbing”, such as the inner thighs and armpits. You can reduce or prevent dark patches on your face by minimizing your exposure to the sun and using high-factor sun creams.
I’m a model and I’m worried I’ll get stretch marks. Is there anything I can do to avoid them?
I appreciate your concern, especially as looking good affects your work. Stretch marks, also called striae gravidarum, are thought to be connected to the collagen and elastin content of your skin rather than to how much your stomach expands They occur as the collagen layer of the skin stretches over areas of fat deposits on the breasts, abdomen, and thighs. Unfortunately, there are no pills, creams, or magic lotions that can influence whether or not you will get stretch marks or, if you do, how badly you will get them, although taking regular exercise can help you to maintain an ideal weight during pregnancy and so minimize your chances of developing stretch marks.
Take comfort from the fact that although the marks may be red and livid in pregnancy, in the months following the delivery they lose their colour, usually becoming silvery-white and less obvious.
My tummy is really itchy. Is it safe to use moisturizers on my skin in pregnancy?
As your abdomen grows it can become itchy as the skin stretches You can use moisturizers on your body in pregnancy, and these may relieve the discomfort. Choose non-perfumed lotions oils, or creams to avoid further irritation Rubbing almond oil, vitamin E, or wheatgerm oil over the abdomen may also help.
Eating a healthy diet with fruit and vegetables and drinking plenty of clear fluids to keep you well hydrated will also help the condition of your skin.
I can’t look in the mirror as I’m feeling so depressed about my size. Will things get better?
You are not alone in battling with your self-image in pregnancy For many women, their changing body shape can create very negative feelings Eating a healthy diet and taking some exercise helps to keep weight gain to a minimum, and exercise will help to lift your spirits and improve your sense of wellbeing. There is no set emotional response to pregnancy, but as well as coming to terms with a momentous life and body change, you are also under the influence of fluctuating hormones, all of which affect your moods and add to feelings of negativity.
Mild depression in pregnancy is often helped by reassurance and support from your partner, family, or friends. Talking over your fears and concerns with your partner, or with other pregnant women at antenatal classes, may help to relieve your anxieties -you will probably find that other pregnant women are experiencing the same feelings.
If your depression is very severe and you
feel desperate, consult your midwife or doctor as antenatal depression is now recognized as having an effect on pregnancy and birth outcomes, with studies showing a possible link between medication given to treat depression in pregnancy and a lower birth weight and increased risk of premature birth. Your doctor or midwife may refer you for counselling, and some areas hold group classes for pregnant women suffering from antenatal depression.
Why do people talk about the second trimester as the time when pregnant women “bloom”?
For many women, the second trimester is the most enjoyable part of pregnancy. As women find themselves released from the draining symptoms of early pregnancy, this can lead to an upsurge of energy and many find it easier to eat, sleep, and work. Many women also notice that their skin is glowing and their hair is glossier than usual. It is also around this time when you first feel your baby move and, as your baby grows, you start to notice a definite bump and begin to look pregnant - changes that can help you feel more positive and excited
However, not all women feel this way A sizeable minority of women don’t feel any better as the second trimester progresses, with nausea, tiredness, and other symptoms continuing unabated Some may find it hard to come to terms with physical changes such as weight gain, or skin and hair changes. If this is the case, it’s important to remind yourself that almost all of pregnancy’s downsides clear up as soon as the baby is born. If you’re feeling particularly down or low on energy it may be a sign of other problems, such as anaemia (see p 81) Speak to your midwife or doctor for further advice.
I’m worried that my husband doesn’t find me attractive any more. Am I being paranoid?
Self-image can be a big problem with pregnant women and many worry that they are unattractive to their partners in the latter stages of pregnancy This worry is usually unfounded and more to do with their own feelings about their increased size. Keeping anxieties bottled up can make them seem bigger than they actually are, so talk to your husband about your worries and explain how you are feeling. He may be completely unaware of what you are thinking
As your husband isn’t carrying the baby he cannot truly understand the physical demands of pregnancy. Informing him about the changes your body is going through can help him to understand the process of pregnancy and be better equipped to
provide support when you need it most Some men actually find their partners more attractive during pregnancy but you won’t know this unless you talk to each other about your changing shape.
If you are worried about gaining too much weight in pregnancy, focus on eating a healthy, balanced diet (see p 50) and take some light, daily exercise. Even if this is only a short walk or swim, it will help to keep you toned and supple, which will help your confidence as well as prepare you for childbirth
Can I wear high heels?
Although lots of pregnant women continue to wear the same footwear during pregnancy, it is advisable to avoid heels and opt for a flatter shoe, particularly as your pregnancy progresses.
Later in pregnancy, your posture and centre of balance changes, as your increased weight is now mainly at the front of your body. In addition to this, increased levels of hormones secreted during
pregnancy, such as relaxin, make the joints and muscles of the body more lax So wearing high heels can increase the strain on the lower back and pelvic
Looking good
Making the most of the pregiiar..cy “bloom”
Whether you are ecstatic about your body shape, or feeling like a beached whale, spending time pampering yourself will help you enjoy the new you. *Your hair may feel thicker and glossier o:- become more unmanageable. TYeat yourself to a new haircut to make the most of your pregnancy hair.
* Book yourself in for a massage to relax and chill out. Find a masseur experienced in dealing with pregnant women.
* If you’re feeling low about your size, splash out on some new maternity clothes, nowadays available in fabulous styles.
joints, oints, giving rise to aches and pains in those areas However, it’s alright once in a while to wear high heels, for example at a party, but it might be wise to take flat shoes to change into for walking home.
What shall I do about my pierced belly button?
If you are pregnant and your navel is pierced, your midwife will probably recommend that you remove any metal jewellery from your navel for the duration of your pregnancy Some women are happy with this advice, but a lot of women do not want to risk letting their piercing heal up, and then having to have it re-pierced after their baby is born, so they try to wear jewellery in their navel through their pregnancy
You can use something called a”pregnancy retainer” Due to the popularity of body piercing, these have been manufactured to help pregnant women maintain their piercing as their body shape changes. They are made up of a soft, flexible substance called PTFE (polytetrafluoroethylene) in the shape of a ”banana” bar that has two acrylic screw-on end balls. There is a wide range of sizes and styles for women to choose from. As a general rule, you should choose a retainer that is at least 4mm longer than the size of the jewellery you are currently wearing, although, as you can imagine, every tummy is different and will obviously change in size as your pregnancy progresses The important factor is that your pregnancy retainer should not pinch into your skin at any time - if you feel your retainer is causing you discomfort, then buy a larger size.
I don’t have much to spend on maternity clothes, any ideas?
Lots of women are faced with this predicament when they become pregnant, but you don’t need to spend a lot of money Most women’s clothes shops now stock selections of maternity wear at very reasonable prices. Invest in a couple of pairs of trousers or skirts that you will be able to adapt as your pregnancy progresses and then mix and match colours and styles with a few tops. The tops don’t have to be maternity wear - you could just buy ones a couple of sizes up from your normal size.
You could look in charity shops too, or loan maternity clothes from friends and family, as women wear maternity clothing for such a short period that it is often in good condition. Ebay is a good place to pick up a bargain, and local NCT (National Childbirth Trust) sales have plenty of items in excellent condition. Lastly, don’t forget your partner’s tops and jeans, which may be the perfect fit!
I’m 20 weeks’ pregnant and have noticed that I get short of breath very easily. Is this normal?
When you’re pregnant, your lungs have to work much harder to meet your body’s increased oxygen needs. To help you take in more air, your ribs flare out and your lung capacity increases dramatically This can make you feel breathless, particularly from mid-pregnancy onwards. In the last three months, most women find they get breathless even during mild exertion, which happens as the expanding uterus pushes up against the lungs. However, being breathless can also be a sign of anaemia, which may need to be treated (see below). Your breathing may start to get easier when your baby engages - moves down into your pelvis ready to be born.
My midwife has told me I’m anaemic. Can I improve my iron levels through my diet?
All pregnant women should be offered screening for anaemia, which is done early in pregnancy (at the first appointment), and again at 28 weeks. Generally,an iron-rich diet is advised in pregnancy and this
is enough to prevent or improve anaemia. Eat plenty of lean red meat, beans, dried fruits, dark green vegetables, fortified cereals, and bread Try including a vitamin C-enriched food or drink in your diet, as vitamin C helps the body to absorb iron more efficiently. Vegetarians need to eat plenty of eggs, pulses, beans and nuts to boost iron supplies. Iron tablets may be recommended depending on how low your iron levels have become.
I have developed a dark vertical line down the middle of my tummy. What is this?
A brown line down the centre of your stomach is known as the linea nigra This occurs due to changes in skin pigmentation, which are extremely common in pregnancy, affecting 90 per cent of all women in some way or another, and is often more noticeable if you are darker sl6nned. As well as the line on your tummy, you may also notice a darkening of the skin around your nipples and a darkening of freckles, moles, or birthmarks. A few women may also experience brown patches on their face called chloasma or ”pregnancy mask” (see p.105), These changes are caused by the extra amounts of the hormone oestrogen in pregnancy, which affects the melanin-producing cells of the skin - the cells that produce the pigment that darkens the skin. These colour changes are normal and will usually fade once the baby is born
I’m 32 weeks and my pelvis
is really aching now - what are the reasons for this?
Mild pelvic discomfort is a common symptom in pregnancy as your ligaments loosen due to the increased levels of the hormones relaxin and progesterone in pregnancy These changes in your pelvis prepare your body for the birth. This feeling is quite normal and happens to most pregnant women. If your pelvis continues to give you discomfort, you can try to adapt your day-to-day living to relieve the symptoms Keep your legs together and swing them
round when getting in and out of a car or bed. Think about your activities for the day and plan your movements ahead so as not to exacerbate any discomfort you have Avoid wearing high-heeled shoes and take a rest whenever the discomfort becomes more noticeable
If your pelvis is more than just uncomfortable, seek medical advice More extreme discomfort that causes chronic pain is a sign that there’s a dysfunction in the pelvic area, which may require treatment and support as pregnancy progresses The most common form of pelvic dysfunction is symphysis pubis dysfunction (SPD), which is caused by the pubic joint not working as it should (see p.82)
I’ve never looked better -why is that?
Hormone levels in early pregnancy can make for a miserable time for many women as they battle against morning sickness, tiredness, and sore breasts. However, at around 12-16 weeks, when pregnancy hormones begin to settle and these symptoms start to subside, many women feel that their skin and hair are in great condition and their energy levels are at a high. This is sometimes called ”blooming” (see p 108) and you may be lucky and find that this continues throughout your pregnancy.
If you are feeling particularly well, you may feel tempted to do too much, but you should exercise some caution as there will still be times when your body needs additional rest and you need to store up energy in preparation for labour and birth.
GETTING COMFORTABLE:
I’m 36 weeks and have noticed that I’m more comfortable and breathing more easily. Why is this?
It sounds like your baby has moved down into the pelvis. The baby’s head is ”engaged” when the widest part of the head has passed down into the pelvis. This means that when the midwife feels your abdomen, less than half of the head can be felt abdominally. Engagement is normally recorded in your antenatal notes in fifths, ranging from 1/5 to 5/5, so if the midwife has written ” 1/5 palpable” your baby’s head is deeply engaged in the pelvis, as this means that 4/5 of your baby is down within the pelvis The timing and significance of engagement depends on several factors. Women expecting their first baby tend to have firmer abdominal muscles, which gently ease the baby down into the pelvis during the last four weeks of pregnancy. This appears to be what your baby has done, and that is why you suddenly feel you can breathe a little easier as your lungs and rib cage are not so squashed A second or third baby may not become engaged until labour starts, as the abdominal muscles tend to be more lax.
What is perineal massage?
Perineal massage is the practice of massaging the perineum, the stretch of skin between the vagina and anus, to make it more flexible in preparation for childbirth. The intention is to prevent tearing of the perineum during birth, and the need for an episiotomy or an assisted (forceps or vacuum extraction) delivery, as the skin in this area may become more stretchy as a result of massage. Clinical trials indicate that perineal and vaginal massage can reduce the seriousness of tears and so some consider it beneficial.
Use a lubricant such as KY jelly cocoa butter, olive oil vitamin E oil, or pure vegetable oil on your thumbs and massage around the perineum Place your thumbs about 3-4cm (1-1%zin) inside your vagina and press downwards and to the sides at the same time. Gently and firmly keep stretching until you feel a slight burning, tingling, or stinging sensation. With your thumbs, hold the pressure steady for about two minutes, or until the area becomes a little numb and you don’t feel the tingling as much. As you keep pressing with your thumbs,slowly and gently massage back and forth over the lower half of your vagina, avoiding the urinary opening, and along your perineum, working the lubricant into the tissues for three to four minutes. This helps stretch the skin in much the same way that the baby’s head will stretch it during birth. Do this massage once or twice a day, starting around the 34th week of pregnancy. After about a week, you should notice an increase in flexibility
I’m 35 weeks and feeling as tired as I did in the first trimester. Is that normal?
Tiredness can cause real problems for women in the first and last trimesters and is often worse for women who are overweight or who have a multiple pregnancy In the early stages, you may feel tired
and lethargic due to hormonal changes, while later in pregnancy tiredness is caused by the extra demands on your body Rest is the best cure, though this may be difficult if you’re working or looking after children.
Boost your energy levels with regular, balanced meals. Late pregnancy is also the time to get your
partner, family, and friends to help out with things like shopping. chores around the house, and cooking
Severe tiredness in the last trimester may indicate that your iron levels are low, so it may be worth getting your iron levels checked
I’ve gone from an A cup to a size D - my husband hopes this will last forever, but it won’t will it?
Many women notice an increase in the size of their breasts in the second trimester and some maintain a bigger size after the birth, especially if they breastfeed. This is due to the effects of oestrogen, which causes fat to be deposited in the breasts. As your breasts enlarge, the veins become noticeable under the skin, the nipples and area around the nipples (areolae) become darker and larger, and bumps may appear on the areolae. Some women get stretch marks on their breasts, but these fade in time After the birth, your breasts may get even bigger when the milk comes in! They do reduce in size once you finish breastfeeding, although the majority of women report a permanent increase of some degree.

Maternity bras
Breast changes are one of the first signs of pregnancy, as from around 3-4 weeks’ gestation there is an increased blood flow, which increases tenderness. Some women notice a change in breast size early in pregnancy. while others may not notice any change until they breastfeed Nevertheless, it’s a good idea to get advice from a shop that stocks maternity bras with staff trained to measure and advise on what size you need. If your current bra fits well, wait until later in pregnancy to get measured when changes in cup size are more likely In the early days of feeding, you may experience some engorgement of your breasts, but don’t panic and send your partner out for a bigger size as this settles in a few days.

 
Weight gain in pregnancy
Monitoring your weight
The recommended weight gain in pregnancy depends on your pre-pregnancy weight. If your BMI was less than 19.8 you should aim for a gain of between 12.5-18kg (28-401b): between 19.8 and 26 you should aim for 11 5-16kg (25-351b); above 26 you should aim for 7-1 lkg (15-251b).
What if I gain too much or too little? There is a link between not putting on enough weight in pregnancy and low birth weight babies. If you gain too much weight, you are more likely to suffer from pre-eclampsia, high blood pressure, diabetes, backache, varicose veins, tiredness, shortness of breath, and to have a large baby
How do I maintain a healthy weight?
Take moderate exercise, eat healthily (see p.50), and follow a weight-reducing diet only under supervision. You need only 200-300 calories more per day so ”eating for two” is not a healthy option.

What’s happening to my baby?
fetal development
Is it true that much of the really important brain development happens in the first trimester?
Your baby’s brain starts to develop soon after conception when brain cells begin to form at the tip of the embryo After about three weeks, a structure called the ”neural tube” begins to change in order to form the spinal cord, and the brain and brain cells (neurons) start to develop and send messages to each other In the early weeks, brain cells multiply at a rate of about 250,000 per minute.
After about 20 weeks of pregnancy, the rate at which brain cells multiply begins to slow down and the brain starts to organize itself into over 40 systems to direct vision, language, movement, hearing, and other functions By the time you are half way through your pregnancy, almost all the brain cells your baby needs for life are present
During the third trimester, the connections between the brain cells start to mature and the baby’s nervous system becomes more developed. Brain development is not totally complete by the time the baby is born and many important brain connections that help your baby develop skills and personality are made after the birth.
So, although fetal brain development occurs throughout pregnancy, and after, crucial foundations are certainly laid during the first three months
Is there anything I can do to help the development of my baby’s brain?
You can ensure that your diet includes good sources of omega-3 fatty acids, as these are thought to play an important part in the development of the brain They can be found in oily fish such as mackerel and salmon (limit to one or two portions a week) ; omega-3 supplements designed to take in pregnancy are available.
When will my baby’s face be formed?
The development of the face starts as early as the sixth week of pregnancy, when grooves that
will form the structures of the face and neck start to grow. A week later, the eye starts to develop and a primitive mouth and nose are evident. By the end of the first trimester the face is well formed and has a definite human appearance, although the skin is still transparent By the 24th week of pregnancy, the eye is fully developed, the eyebrows and lashes have formed, and the skin becomes less transparent, but the eye remains fused shut and does not open until around the 28th week of pregnancy
During the last trimester, your baby’s hair begins to grow on the head and fatty deposits give your baby rounded cheeks
I would like to communicate and bond with my baby before the birth. Is there anything I can do?
As your pregnancy progresses, there are many ways to focus on your baby and communicate with him, and these occasions area chance for you to relax and take time out, too.
* Relax in a warm bath and concentrate on feeling your baby’s movements, imagining what he is doing inside you.
* Talk to your baby. Your baby can detect sounds from outside the womb by the second trimester and is especially likely to tune in to your voice. You can give a running commentary on your activities, or even read to your baby Get your partner to chat too! * Rub or massage your bump. You may find that your baby responds by kicking; it’s almost like having a conversation!
* Spend some time making plans for your baby’s arrival, for example, choosing colours for the nursery
or even just buying a few sleepsuits
* Sign up for birth preparation classes for you and your partner This will give you both a chance to think about labour, birth, and your baby
* Start reading through a book of baby names and make a list of those you and your partner like * Some couples enjoy taking regular photographs of their growing bump
I’ve got a full-on career and have hardly thought about the baby. Will this stop us bonding?
Even if you work full time during pregnancy, this doesn’t have to have a negative effect on your relationship with your baby. As your baby grows, you will probably find that you start to develop a relationship with your ”bump” as you anticipate your baby’s movements and perhaps talk to your baby Make sure you plan enough maternity leave before your due date as this gives you time for practical and emotional preparations, as well as time to rest There is some evidence to suggest that too much stress in a mother can affect her unborn baby’s brain development although this is not conclusive. However, it does highlight the importance of regular opportunities to relax during pregnancy
I’m trying to get my partner involved; I keep letting him feel the baby move, what else can I do?
This is a common concern Feeling the baby move inside you is a great way for your partner to begin to connect with the baby as a separate person and seeing the baby on an ultrasound scan can help too, as can hearing the heartbeat.
It is often difficult for partners to feel involved with a pregnancy since it is not physically happening to them and can feel quite an unreal experience Try to spend time together finding out about pregnancy labour, and birth as this will help your partner to feel as informed as you and discover ways to help -you during the labour and birth and care for the baby after the birth. Some of the suggestions in the box above may also help.
My husband didn’t talk about the baby before the scan. Now he is over-protective. Is this normal?
Many fathers-to-be find it difficult to come to terms with the fact that their partner is carrying their baby, and that the baby will eventually be born and bring all the joys, trials and responsibilities of parenthood. This is all even harder to envisage when they are not physically experiencing the changes that pregnancy brings - not feeling the symptoms or feeling the movements. The ultrasound scan is often a pivotal point for partners - suddenly they are ”face to face” with their baby, and it becomes more real Perhaps your partner is now realizing his responsibilities and affection for the baby and is showing these feelings by taking care of you. If you are finding that his cosseting of you is a little too much, you might want to discuss other ways he can feel involved with the pregnancy and prepare for the baby (see box, above)! Try to embrace his involvement and enthusiasm for the pregnancy - it is a great way for you to strengthen your relationship as a couple and prepare to face parenthood together.
When can a baby first suck its thumb?
Ultrasound scans have shown unborn babies sucking their thumbs from as early as 12 to 14 weeks of pregnancy However, this is likely to be a reflex at this stage as the brain does not have any conscious control over movement until the fetus is much more developed later on in pregnancy,
Some research has suggested that if an unborn baby shows a preference for sucking, for example its right thumb, then it will prefer to lie with its head turned to the right after the birth The same research also suggested that this preference in the womb could be used to predict right or left handedness in the baby as it grew older
When will the midwife be able to hear my baby’s heartbeat?
Your midwife should be able to hear your baby’s heartbeat by the time you are around 12 weeks pregnant using a hand-held device called a sonicaid”. The heartbeat sounds rather like a galloping horse, and the rate is usually somewhere between 120 and 140 beats per minute — around double the rate of your own pulse.
There are factors that can influence whether or not the baby’s heartbeat can be picked up. For example, if you are overweight, or the baby is in an awkward position, it may be harder to hear the heart. If your midwife is unable to locate the baby’s heartbeat at 12 weeks, try not to worry, At this stage, the baby is only about 5cm (2in) long, so it’s still very tiny’ Your midwife will try again in a few weeks. Certainly by 16 weeks it should be easier to pick up and listen to the heartbeat.
When will I first feel my baby move?
Although ultrasound scans have shown that babies may start to move slightly from around 6 weeks, it is not usually until the second trimester (13-26 weeks) that the fetus will make active movements. The sensation known as ”quickening” is described as a fluttering type of feeling usually felt by mums between 16 and 20 weeks, although exactly when a movement is felt can vary from woman to woman and may be affected by various factors. If it is your first baby, you may not notice any movement until later as you won’t know what to expect. Also, if you are an active person, these slight flutters may be missed. Women with an anterior placenta (lying at the front of the womb) may feel movements later, as may larger women, as there is more flesh for the movement to be felt through.
It is not until around 28 weeks that it becomes more important to monitor the pattern of movements. From this stage, the amount your baby moves, as well as the type of movement and the time it happens, are relevant as these indicate that the placenta is sustaining the pregnancy and your baby’s muscles are developing. If you are concerned about lack of movement, contact your midwife or hospital.
What sounds can my baby hear in the uterus?
The baby’s outer ear is visible at around eight weeks and the first reaction to loud noises has been recorded at nine weeks. This has been measured in studies by playing a range of sounds through the mother’s abdomen and recording any responses, such as movement, through ultrasound scans. It is thought that babies start off hearing low tones and then higher tones are heard later on as the hearing system continues to develop.
Studies also suggest that a fetus can determine
its mother’s voice and the voices of close friends and family significantly during pregnancy One study revealed that not only did the fetus hear its mother’s voice, but its heart rate decreased, indicating that her voice had a calming effect. By 16-20 weeks, hearing is considerably developed. Premature babies born at this time react to sounds, so they are living proof that babies inside the womb at that gestation can hear Research also suggests that babies respond to stories read to them or music played during pregnancy after the birth
I’m 25 weeks’ pregnant, and my baby seems to “jump” when it hears loud noises - is this likely?
Babies born prematurely react to sounds, and loud sounds will produce a ‘’startle reflex’, so this provides strong evidence that babies inside the womb at that gestation will hear and react to loud sounds too, possibly with sudden movements
As mentioned above, studies have shown that a baby can react to sounds in the womb from as early as nine weeks’ gestation. As the fetus grows, the hearing develops, with babies responding to a greater range of sounds.
My tummy measurement has been the same for three weeks. Why isn’t my baby growing?
In pregnancy, your abdomen is measured to establish the height of the top of the womb, which indicates how the baby is growing It is important
to know whether the same person is measuring you, as there is an element of subjectivity depending on techniques. In early pregnancy, it is not necessary to measure you as this doesn’t give an indication of fetal growth, but from 26-28 weeks, growth can be assessed this way. However, even with your own personalized growth chart and with the same person measuring you at the correct time, on their own these are not an accurate means of estimating your baby’s growth. If there are any concerns, you will probably be referred to a consultant to decide whether you need further investigations, for example ultrasound scans. If you are at the end of your
pregnancy, one possible explanation may be that your baby’s head is engaging into the pelvis, so although your baby is still growing, some of his head has not been measured due to its position If you are worried, talk to your midwife and, if necessary, she can refer you for a ”growth scan”,
Do babies have hiccups in the womb? I’m sure I can feel them.
Babies hiccup from early in the third trimester. This is a normal phenomenon that is usually short-lived but often recurs at similar times each day It feels like a quick, spasmodic sensation in your abdomen. Hiccups are not harmful to the baby and in fact are a sign that your baby is healthy, in the same way that your baby’s movements are a positive sign.
It is thought that the hiccups may be caused when, occasionally, babies take a deep breath in and ingest the amniotic fluid that surrounds them. The sudden change in chest cavity pressure when they take in fluid can cause the hiccups, just as when we drink something fast. These deep breaths help to exercise breathing muscles and stimulate their lungs to produce “surfactant”, which is essential for the lungs to function. The baby cannot drown, as it receives its oxygen supply from the placenta.
When will my baby grow fingernails?
Babies begin growing fingernails from the end of the first trimester and the nails reach the fingertips between 34 and 36 weeks of pregnancy It is possible for babies to scratch themselves inside.
After birth, cutting a baby’s nails can be a cause of concern for parents. Newborn nails grow rapidly and the best time to shorten them is after a bath, when they are at their softest and the baby is more relaxed. There is some controversy over whether to use scissors, clippers, or simply bite them off. Scissors and clippers may easily cut the skin, but biting carries a higher risk of infection if the skin is broken. Pressing the nail helps to distinguish nail from skin. Using emery boards or simply peeling them off can be slightly safer options, or put your baby in scratch mittens.
At what stage could my baby survive outside of the womb?
Until relatively recently, babies born under 28 weeks’ gestation often did not survive Today, with medical advances in special care baby units, babies of 22 weeks’ gestation have survived outside the womb, although this is still very rare. The guidelines for most hospitals is that 24 weeks is the earliest point at which they will resuscitate a baby, unless the baby shows signs of life at birth.
Extremely premature babies have an increased risk of disability, even with the best medical care, and often the delivery itself can put an enormous strain on the baby.
Very experienced doctors, midwives, and nurses will be involved in the care of extremely premature births If possible, the delivery should take place in a hospital with a dedicated special care baby unit (SCBU) If this is not possible, babies are often transferred to a specialist centre when they are stable enough to be moved.
As each day and week is a milestone for your baby, the nearer to your due date you deliver, the better the chances for your baby.
I like to rub my tummy and talk to my baby as even now I feel like my baby is here - is this daft?
No, this is perfectly normal and may be soothing for him as babies can determine their mother’s voice in the womb and sometimes their heart rate decreases in response. However, I wouldn’t recommend that
you rub your tummy too vigorously or too often as, in some cases, this can cause contractions and may trigger a premature labour if you are around 37 weeks’ gestation.
Many women feel that the mother-child bond
is there before the baby is born. It is good that you are having these positive thoughts during your pregnancy, as this is an excellent foundation for your future relationship with your baby
Can my baby see bright lights? I’m 32 weeks’ pregnant.
A baby’s eye structures begin to develop from as early as 4-5 weeks, with the eyelids forming at around 8 weeks and closing between 9 and 12 weeks. By 24 weeks, all of the eye structures are fully developed and at around 28 weeks, the eyelids start to open and shut Although we tend to presume the uterus is dark, this is not so Between 30 and 32 weeks, the baby experiences light and dark environments, depending on where the mother is and the time of day. It has even been reported in studies that not only do babies react to light, but have been seen on ultrasound scans trying to grasp at the light source. When a baby is born, he reacts to lights by frowning or blinking and can see to a distance of around 15-20cm (6-8m) (the same distance to mum’s face from the breast!).
Is it normal for babies to stop moving around so much towards the end of pregnancy?
Towards the end of pregnancy, your baby’s range of movements may change as there is less room for him to extend his limbs and trunk However, you should still be aware of a regular pattern of movement. Over the last 30 years, women have been actively encouraged to count how much their babies kick However, in 2003, the National Institute for Clinical Excellence (NICE) recommended that this practice of counting movements stopped, as counting how many kicks a baby makes is not an accurate indication of whether the baby is well and each baby makes a different number of kicks Nowadays, women are encouraged instead to tune in to their babies’ pattern of activity, including the type of movement they make and the periods when they are most active. Studies have shown that over 50 per
cent of women who had a stillbirth noticed a change in the pattern of movement. The general advice is, if -you are worried about your baby’s movement pattern you should speak to your midwife or hospital.
When will my baby’s head engage?
Engagement, when your baby’s head moves from higher in your abdomen down into your pelvis in preparation for the birth, can happen at any time from 36 weeks until the onset of labour (see p 148). The head tends to engage earlier in a first pregnancy
Can my baby’s position in the womb affect when his head engages?
A baby’s position can affect how it engages into the pelvis. For example, if the baby is lying in a ”back-to-back” position, with his back lying along the mother’s back; this can make it more difficult for the baby’s head to move through the pelvis. Similarly, if the baby is in a breech, feet first, position or a transverse position (see p. 145), then engagement will not be possible unless the baby moves and a Caesarean delivery may be necessary.
It is thought that the mother’s level of activity and the positions she adopts can influence the position of the baby in the womb. Nowadays, it is more common for babies to lie in a back-to-back position and it is thought that this may be due to people leading a more sedentary lifestyle. In the past, when women were possiby more active, perhaps performing tasks such as scrubbing the floor on their hands and knees, there was less incidence of this position
Will my baby develop much in the last month of pregnancy?
During the final month of pregnancy, your baby is busy preparing for birth. He will be practising breathing movements and sucking, and will start to turn towards light. You may notice that there are fewer vigorous movements now — this is natural as there is less space within the uterus. However, you should still be noticing plenty of nudges and wriggles.The downy hair that covered your baby’s body starts to disappear and the hair on the head and your baby’s nails continue to grow Meconium, the waste product that will be your baby’s first poo, starts to form in the bowels at this time. During this last month, most of your baby’s organs are fully mature and the lungs will continue to develop. ”Full term’ is considered to be from 37 weeks.
I feel very emotional at times and am scared that I won’t love my baby - is this normal?
The feelings you have are not uncommon An increase in hormones during pregnancy can cause some extreme and deep feelings, some of which are irrational Pregnancy is a major life event and, as well as the physical changes that are going on in your body, the emotional pressures are vast. There may be a range of pressures that are adding to how you are feeling, such as relationship problems, financial pressures, caring for other children, lack of space in your house, or returning to work after the birth. It is fine if these are occasional feelings, but if you find
that you are constantly snapping or crying, tired, having difficulty sleeping and eating, or sleeping and eating too much, are unable to concentrate, feel reluctant to leave the house, feel sad and anxious most of the time, or have developed obsessive compulsive disorder (OCD), then you need to speak to your midwife or doctor for help and advice as these are all symptoms of depression.
I’ve recently lost a parent and am very traumatized. Can stress affect my baby’s development?
This is a major life-changing event and with the additional fluctuation in hormone levels and the physical changes that are occurring in pregnancy you are obviously under a great deal of stress However, it may be helpful to bear in mind that your body is designed to deal with episodes of stress
There are studies that have suggested that women experiencing long-term stress may have an increased risk of pre-eclampsia (see p.89) and premature birth, although how reliable this evidence is has been questioned It has also been suggested that there may be a link between extreme stress in pregnancy and children becoming hyperactive, but again this is inconclusive The most important thing to do, now that you have recognized you may be at risk of long-term stress, is to speak to your doctor or midwife, particularly as there has been a recent increase in levels of support and treatment offered
to pregnant and new mothers in your situation, which may help to limit any adverse effects of stress.
YOUR BABY’S MOVEMENTS
First kick
The moment when you feel your baby’s first movements is a truly emotional experience, as you start to become completely aware of, and connect with, the baby growing inside
you. Usually, the first movements are felt as a fluttering sensation, or a ”quickening”, as your baby starts to stretch and turn. This can be felt from around 18 weeks, although for some women it is much later; if you have had a baby before you are likely to be aware of these movements earlier, but for a first baby, awareness of the baby’s movements is usually later, around 22 weeks It is not until about 24 weeks that you will really start to feel regular, more definite movements and you will soon become accustomed to your baby’s activities.

High-Risk Pregnancy FAQ

The midwife says I’m “high risk” because of my blood pressure. What does this mean?
Blood pressure is monitored in pregnancy as raised blood pressure can be a sign of pre-eclampsia (see p39) At your first antenatal visit, your midwife will record your blood pressure and assess your risk of pre-eclampsia based on the blood pressure reading, your medical history and family medical history Certain factors increase your risk These include: * High blood pressure.
* Pre-eclampsia or raised blood pressure in previous pregnancies, or having a mother or sister who had pre-eclampsia.
* Being aged over 40 years and this being your first pregnancy.
• Being significantly over- or underweight
• Having a multiple pregnancy.
If your midwife thinks you are ”high risk”, she will refer you to a consultant obstetrician and discuss a plan of care for your pregnancy Many women who are assessed as high risk have pregnancies that progress without complications, but they are monitored a little more closely
I’ve been told that because of my diabetes I have to go to the hospital clinic - why is this?
Whether you develop diabetes in pregnancy (known as gestational diabetes), or have pre-existing diabetes, you will require special care with support from a diabetic health care team and a consultant obstetrician. This is because diabetes poses risks in pregnancy if there is poor control of blood glucose levels In the mother, these include hypertension (high blood pressure), thrombosis (blood clots), pre-eclampsia, diabetic kidney disease, and diabetic retinopathy a condition that affects the retina in the
eye. For the baby, there is an increased risk of congenital abnormalities and growth may be too fast or too slow. It is important that your care is tailored to you, taking into account any other complications you may already have from diabetes.
The key to a healthy pregnancy and baby when you have diabetes is good blood glucose control as your insulin requirements will change throughout pregnancy Controlling blood glucose levels reduces the risk of birth defects and stillbirth, or a larger than expected baby, which can present problems during birth. If you have gestational diabetes, you will need to adapt your diet to include carbohydrates and fibre and reduce fats and sugar: you may also need insulin injections to help control blood sugar levels
I have epilepsy - will I need special care in pregnancy?
Ideally, women with epilepsy should discuss their situation with their doctor prior to conception. Epilepsy and the medication used to control it do carry some risks in pregnancy but there are ways to minimize these. Some anti-epileptic drugs (AEDs) are thought to be more harmful to a developing baby than others, so your doctor may wish to change your medication before you become pregnant. Although
most women taking AEDs have healthy babies, taking any type of AED increases the risk of birth defects, so you will probably be offered extra scans. The aim is to control your seizures on the minimum dose AEDs also restrict your body’s absorption of folic acid, which reduces the risk of an unborn baby developing neural tube defects such as spina bifida, so your doctor will probably discuss taking a higher dose of folic acid. Once your baby is born, you will generally be advised to breastfeed if at all possible, as any risk to the baby from AEDs is outweighed by the many health benefits of breast milk
I’m 28 weeks and have been having contractions. Is my baby going to come early?
From early pregnancy, the uterus ‘practises` contracting in preparation for labour. A mother is usually unaware of these practice contractions, known as ”Braxton Hicks”, until later in pregnancy, when they can be felt as a hardening of the ”bump’ Each contraction lasts from a few seconds to a few minutes before the uterus relaxes and becomes soft
again. These contractions are painless (although
they can feel quite uncomfortable!), follow no regular pattern, and having them does not necessarily mean that your baby is going to be born early
However, if you experience painful contractions -described as being like strong ”period-type” pains -and they seem to increase in strength and frequency, you should contact your hospital as you could be
going into labour. You should also seek medical advice if you leak any fluid or blood from the vagina
My last baby was premature -is this likely to happen again?
Having one premature baby, born before 37 weeks of pregnancy, means that you have about a 15 per cent chance of having a second preterm birth, although this also depends on why you had a premature birth originally, Reasons why babies are born prematurely include
Infection in the mother
Early rupture of the membranes (’waters breaking”)
• Multiple pregnancy.
• Weak, shortened cervix (neck of the womb).
• Unusual shaped womb, for example, a bicornuate uterus (heart-shaped womb).
* A medical condition in the baby, for example if the baby is not growing as expected, which means that labour has to be induced early.
* A medical condition in the mother, such as pre-eclampsia (see opposite). which also means that labour has to be induced early.
Although most of the causes of premature
birth cannot be prevented, there are steps you can take to reduce the risk of premature labour. These include not smoking, avoiding being under- or overweight. and avoiding extreme stress In addition, it is essential that you attend all your antenatal appointments so that the wellbeing of both you and your baby is constantly assessed You should discuss whether there was an obvious reason for your last baby being premature. and if there are any specific preventative measures you can take to help avoid a reoccurrence this time round.
I’m expecting triplets. Will I be treated as “high risk”?
Yes, you will be classed as having a high-risk pregnancy as all the usual risks are increased for women with twins and multiple pregnancies This is partly because hormone levels are higher when there is more than one baby and partly because it is hard work for your body to carry and nourish three little lives! There will be an increased risk of miscarriage; severe pregnancy sickness (hyperemesis gravidarum); raised blood pressure/ pre-eclampsia: anaemia (iron deficiency), diabetes: and premature and/or low birth weight babies There is also an increased, although small, risk that one or more of the babies will die during the pregnancy With triplets, you will almost certainly need to give birth by Caesarean section Although considered a very safe operation, this is still major surgery and carries the associated risks.
You can expect to be referred to an obstetrician, who will plan your antenatal care with you and you will probably have more frequent checkups and scans. If you attend all your appointments and look after your health, it is likely that you will have three healthy babies at the end of your pregnancy. For more information about multiple pregnancy and details of local support groups, contact the Twins and Multiple Births Association (TAMBA) (see p.310).
I have lupus - how will this alter my care during pregnancy?
Lupus is an autoimmune disease that causes inflammation in the bone joints, blood, kidneys,
and skin and sufferers often find that symptoms flare up due to certain triggers. The condition is more common in women than men, especially women of childbearing age Some women find that pregnancy aggravates lupus, causing a flare-up, probably due to the hormonal changes that occur, while others find that pregnancy eases the symptoms. As lupus can affect an unborn baby, increasing the risk of stillbirth, miscarriage, premature labour, and slow growth, your pregnancy will be monitored very closely, especially when checking your blood pressure and
urine However the likelihood is that you will have a completely healthy pregnancy resulting in a healthy baby You can contact Lupus UK for support and information (see p.310)
I’ve had a few small bleeds during pregnancy - will my baby be OK?
Bleeding in early pregnancy is not uncommon Usually, the reason is unknown, but there is a theory that although the hormones of the menstrual cycle are suppressed, variations in the cycle continue. This could explain why some women have light “spotting” around the time a period would be due. If the bleeding is light, and not accompanied by abdominal cramping or pain, then it is unlikely that there is anything wrong
Bleeding after early pregnancy can be due to
a cervical ectropian, when the surface of the cervix becomes ‘raw’. This results from hormonal changes and is not harmful to the baby. Sexual intercourse can aggravate a cervical ectropian, stimulating bleeding.
Bleeding in late pregnancy may be more serious as it can be due to the placenta partially, or totally,
detaching from the wall of the uterus, known as placental abruption, or to a low-lying placenta, known as placenta praevia (see below and p.92).
If you have a mucus discharge tinged with blood in late pregnancy, this may be a ‘’show” when the plug of mucus sealing the cervix comes away. This is normal and can indicate that labour isn’t far away
It is important that you seek advice for any type of bleeding at any stage of pregnancy, as serious causes for bleeding must always be ruled out
We know our baby has Down’s syndrome. How can we best prepare ourselves?
On a practical level, you can prepare in much the same way as every parent, thinking about your preferences for labour, attending antenatal classes, and buying baby equipment Knowing in advance that your baby is going to be born with a condition such as Down’s gives you time to adjust and find out as much as possible about what to expect. You may wish to tell family and friends too, to give them time to prepare. Ask your health visitor for details of local support groups and contact the Down’s Syndrome Association for more information (see p.310).
I had an emergency Caesarean last time. Now the doctor says I’ll have a trial of labour, what is this?
This means labour after a Caesarean section. Another term is VBAC (Vaginal Birth After Caesarean section). Until relatively recently, most doctors
advised women who had had a Caesarean to have a planned Caesarean for the next baby to avoid uterine rupture, where the Caesarean scar tears in pregnancy or labour. Although serious this is rare, and it is now thought to be preferable for both the mother and baby to have a natural vaginal delivery if possible. Even so, if you want a vaginal delivery, it would be wise to opt for a unit that has fetal heart monitoring and that can carry out Caesareans if one turns out to be required.
Your chances of having a successful labour depend partly on why you had a Caesarean section. If it was because the baby was breech or you had a low-lying placenta, -your chances of a natural labour this time are higher If it was due to complications in labour, such as slow cervical dilatation, then the problem may recur Overall, about half of women have natural deliveries after a Caesarean You can contact the Caesarean organization for more information (see p.310).
My friend had placental abruption. Is this serious?
Placental abruption means that the placenta has started to come away from the wall of the uterus before the pregnancy has reached full term. This is a potentially serious condition that may mean the baby needs to be delivered as soon as possible by Caesarean section. If there is persistent pain in the abdomen during pregnancy which may be accompanied by fresh, bright red bleeding and/or a change in the baby’s movements, then medical help should be sought straight away
I have had three miscarriages -will my antenatal care be different because of this?
While one or even two miscarriages are relatively common, three is less so. If you have had recurrent miscarriages, you will be offered extra antenatal care. You may be advised to take low-dose aspirin if there is evidence that you have a blood-clotting condition called anti-phospholipid syndrome (aPL). A vaginal scan may also be offered to check if you have a ”weak cervix”, where the cervix is unable to support the growing baby. If a weak cervix is diagnosed, you may be given a stitch during pregnancy to hold the cervix shut. There is some evidence that taking the hormones progesterone or human chor 4 onic gonadotrophin in early pregnancy can reduce the risk of miscarriage.
My baby is very small for her dates - can anything be done about this?
From 25 weeks, your midwife will measure and palpate your tummy to estimate the fetal size If she thinks you are ‘’small for dates” she may refer you for a scan for a more accurate assessment of the baby’s size and of the efficiency of the placenta You may be offered a repeat scan in a week or so to measure growth over time. If babies do not grow as they should, this is called intra-uterine growth restriction (IUGR). This can be due to a problem with the baby or the placenta, affecting the amount of oxygen and nutrients reaching the baby, Pre-eclampsia can cause IUGR, as can smoking, drinking alcohol, and
recreational drugs. If your baby is very small and the rate of growth drops off considerably, it may be necessary to deliver the baby early
My friend had hyperemisis gravidarum in her pregnancy -can you tell me more about this?
Hyperemesis gravidarum (HG) is severe pregnancy sickness, a debilitating condition affecting around one per cent of women. The woman is unable to keep down food or fluids without vomiting and becomes clinically dehydrated. This can begin at around week 6 of pregnancy and may last until 16-20 weeks (although some women suffer
throughout pregnancy). Sufferers may need hospital treatment with intravenous fluids, and medications to control the vomiting may be given, but their success varies No-one is sure what causes the condition,
but it is thought that high levels of the hormone hCG, fluctuations in thyroid levels, and changes in liver function may all be involved Sometimes the condition runs in families. There is a support group that provides information and tips (see p.310).

Placenta praevia
Placenta praevia means a low-lying placenta, which occurs when the placenta is either partially covering (minor), or completely covering (major), the cervix. In major placenta praevia, the baby cannot be born vaginally Major placenta praevia poses a high risk of heavy bleeding, either in the later stages of pregnancy or during the actual labour, which is treated as an emergency If a low-lying placenta is detected at your 20-week scan, you may be offered
a scan in late pregnancy; this is because the placenta may ”move up” as the uterus grows, and by about 34 weeks may no longer be low. If you have placenta praevia, particularly major placenta praevia, most hospitals admit you for bedrest in the last weeks of pregnancy until the birth so that if you bleed heavily, you can be treated immediately

Cholestasis is a condition in which bile does not flow freely down the bile ducts in the liver, causing bile to leak into the bloodstream. This condition poses serious risks for both the mother and the baby, and so it is important that it is diagnosed with a blood test and managed as soon as possible. Medication will be given to relieve the itching and improve the liver function. The aim of the medication is to stabilize the condition until it is safe for the baby to be delivered. Usually labour is induced between 35 and 38 weeks of pregnancy.

Pre-eclampsia is a condition that affects around 10 per cent of women during their pregnancy (or, rarely, in the first 72 hours after the delivery) The cause is still unknown. although it is thought that it may be caused by a malfunction of the placenta.
What are the symptoms? There are varying degrees of pre-eclampsia, from your blood pressure rising a little bit towards the end of your pregnancy and a small amount of protein detected in your urine (which affects about 1 in 10 pregnant women), to a large rise in your blood pressure and a considerable amount of protein found in your urine (affecting about 1 in 50 pregnant women) Your blood pressure and urine will be checked (and the size of your baby measured) at your antenatal appointments to look for signs of pre-eclampsia and you will be referred to the hospital if necessary. Sudden swelling, headaches, pain =der your ribs, and visual disturbances also indicate pre-eclampsia and you should contact your midwife or doctor straight away if you experience any of these.
What can be done? If you have the milder form of pre-eclampsia, this will only require your blood pressure and urine being tested a little more frequently – perhaps weekly However, the more serious form will require you to go into hospital where you and your baby will be monitored and given medication to lower your blood pressure This is because if you are left untreated it could develop into eclampsia, which is a very serious condition in which you may suffer convulsions, and your and your baby’s lives could be in danger. However, with both types of pre-eclampsia, you will generally need
to be induced early (see p 190) as once your baby is born and the pregnancy is over, this will end the pre-eclampsia.
Who is at risk? Women are at a greater risk of pre-eclampsia if they have had the condition before; are over 40 years old have a body mass index (BMI) over 35; have a family history of pre-eclampsia (mother or sister); had high blood pressure, diabetes, or kidney disease before the pregnancy; or are carrying more than one baby.

Prescribed bedrest

Towards the end of pregnancy, there are some circumstances when you may need to be admitted into hospital for bedrest and monitoring.
* If you have contractions, but your waters haven’t broken; you may also be given a drug to slow contractions.
* If you develop pre-eclampsia in
pregnancy you may have to stay in hospital and measures will be taken to reduce your blood pressure.
* If you have placental abruption (see p 91), you will be monitored in hospital and early delivery may be needed

THE SIDE EFFECTS OF PREGNANCY

Why does pregnancy make you feel so sick?
Although no one is really clear about the cause of sickness in pregnancy it is thought to be due partly to the hormone human chorionic gonadotrophin (hCG), released early in pregnancy. For most women, symptoms are mild and begin to ease at 12 weeks. For some, the sickness may last throughout the day and continue beyond this time. A small percentage of women experience severe nausea and vomiting, known as hyperemesis gravidarum (see p 92).
There are practical measures you can take to relieve nausea and sickness (see p 82).
I’m two months’ pregnant and feel incredibly tired all the time. Is this normal?
Yes tiredness is a common complaint in pregnancy with most women feeling a sudden loss of energy in the early stages as their body gets used to the changes caused by pregnancy. This often lasts throughout the first trimester, but after about week 13 you should start to feel a bit more energized When you’re not resting, try to stay active and take some gentle exercise.
Another cause of tiredness is anaemia, a common condition in pregnancy that needs to be monitored. Although it’s more likely that your tiredness is due to the pregnancy itself, when you see your midwife you will be offered a blood test to check your iron levels, and if these are found to be low you will be offered supplements. To avoid anaemia, eat iron-rich foods, such as dark green leafy vegetables, red meat, wholegrain cereals, pulses, and prune juice. Vitamin C helps your body to absorb more iron from your diet, so try drinking fresh orange juice with meals, and limit your tea and coffee intake, as caffeine inhibits iron absorption.
I often feel faint - what could be causing this?
Feeling faint or having a dizzy spell is quite common in pregnancy as pregnancy hormones cause your blood vessels to relax and widen Although this improves the blood flow to the baby it also has the effect of slowing down the flow of blood around your body which can lead to low blood pressure, known as hypotension. Although this is unlikely to be a risk in itself, it can cause feelings of faintness, most commonly when you stand up too fast from a sitting or lying position.
Other causes of faintness include lying on your back (as this can put pressure on several large blood vessels involved in returning blood back to your heart, which can cause low blood pressure and in turn make you feel dizzy and faint); a lack of food or drink: getting overheated; and fast breathing (hyperventilating).
Sometimes, feeling faint can be more serious. If the feeling does not pass by eating, drinking water, cooling down, or taking things slowly as you stand up, it may need investigating further and you should seek the advice of your midwife or doctor as this could be due to anaemia (see above) and you may need treatment in the form of iron tablets.
Is it normal to have pelvic pain in early pregnancy?
Pelvic pain is associated with the soft area supporting your pelvis, the symphysis pubic joint. This can swell or separate causing considerable pain, termed symphysis pubis dysfunction, or SPD This is thought to be caused by pregnancy hormones and is quite common in late pregnancy, but can occur earlier. Many women feel most pain when walking or lying Wear comfortable shoes; use pillows to support the hips and legs in bed; keep your legs together when getting out of bed; avoid breast stroke; and get lots of rest. Some women find sitting on a birthing ball helps You may be referred to an obstetric physiotherapist and advised to wear a support belt. In severe cases, crutches may be needed. Most cases resolve after the birth.
I’m embarrassed because I think I’ve got piles. I don’t want to go to the doctor - what can I do?
Haemorrhoids (piles) are swollen veins at or near the anus that can be very uncomfortable, especially during pregnancy. Piles area common feature in
pregnancy, with many women experiencing them at some stage, so your doctor will not be at all surprised You could also speak to your midwife about the problem if this is easier Your doctor or midwife will be able to recommend a treatment, such as a cream or a cooling maternity gel pad.
As piles often develop as a result of straining due to constipation, increasing your fibre and fluid intake may help you to have regular bowel motions, which in turn may help to relieve the problem Eat fresh fruit and vegetables and drink lots of water If you are very constipated, you could ask your doctor to prescribe suppositories I know you may feel embarrassed, but it is best to approach someone rather than to suffer alone.
I’ve been getting regular headaches since becoming pregnant - should I be worried?
Headaches in the early stages of pregnancy are quite normal and are thought to be related to the effects of pregnancy hormones. Headaches can also be caused by other factors such as dehydration, low
blood sugar, a stuffy environment, tiredness, and lack of sleep. Try increasing your intake of water, aiming to drink at least eight glasses of water a day, and have small regular meals to maintain your blood sugar. If you feel a headache coming on, drink two glasses of water and have a rest for 30 minutes. Taking a lose dose of paracetamol is considered safe, although it is best to avoid this if possible
If you are suffering with headaches at around
28 weeks or more, you should inform your doctor or midwife of these, especially if your headaches are accompanied by blurred vision, an inability to focus, or flashing lights, as this may be a sign of pregnancy-induced hypertension (high blood pressure), which could indicate pre-eclampsia (see p.89). Try not to worry, as even though many women complain of headaches and some will have high blood pressure in pregnancy, few go on to develop pre-eclampsia. It is thought that the incidence is somewhere between two and five per cent of all pregnancies.
My gums have started bleeding since I’ve been pregnant -why is this?
It is very common for gums to bleed in pregnancy The pregnancy hormone progesterone causes areas of tissue that connect muscles and ligaments to soften and become stretchier so that your body can make room for the growing baby However, this can affect tissue in other parts of the body, such as in the gums, making them softer and more prone to bleed.
Also, some women crave sweet foods in pregnancy, an excess of which can affect the gums, causing them to become tender, swollen, and more likely to bleed, and increasing the chances of developing gingivitis, a gum infection. Pregnant woman are encouraged to see a dentist early in pregnancy for a checkup (dental care is free up until the baby’s first birthday)
It is important to brush your teeth more than usual and floss regularly when pregnant to minimize the risk of an infection Unlikely as it may sound, it has been suggested that there is a link between premature birth and gum disease
Whenever I sneeze, I leak - is that going to last for ever?
Many women suffer from stress incontinence during pregnancy, which means a leakage of urine when you cough or sneeze The leaks are caused by the loosening of muscles in the pelvic floor - a group of muscles and ligaments that support the pelvic organs - due to pregnancy hormones. Also, as the growing baby puts more pressure on the bladder stress incontinence becomes more likely,
It is recommended that you carry out pelvic floor exercises (see p.57) to reduce the likelihood of leakage. These can be started at any stage of pregnancy, but the earlier you begin the better; once you get the technique right they are simple. As these are such discreet exercises it is easy to practise without anyone else realizing what you are doing
Stress incontinence should improve following the birth, although it can take up to six weeks There is some suggestion that the problem can persist longer depending on the type of birth you have, with a natural vaginal birth more likely to cause ongoing problems than a Caesarean delivery.
I’ve been getting nosebleeds for the first time in my life. Why is this?
It’s not unusual for nosebleeds to occur in pregnancy due to the increased blood supply in the body Nosebleeds are not serious, but if the bleeds are severe, you can ask your doctor for a spray to help the blood to clot. If your nosebleeds are frequent, a simple surgical procedure can cauterize the vessel
When you have a nosebleed, sit for a few minutes with your head upright and apply pressure to the bridge of the nose. To avoid further nosebleeds, make sure you blow your nose gently, drink plenty of fluids to avoid dehydration, use vaseline on dry nostrils, avoid smoky environments, and open your mouth when you sneeze to relieve nasal pressure
I’m 30 weeks’ pregnant and have persistent backache - is there anything that can help?
The weight of your baby and the fact that joints and ligaments soften in pregnancy can cause backache Sometimes sciatica occurs, a sharp pain that travels down the back and leg when the sciatic nerve is
trapped in a joint in the lower back
For lower backache warm baths and a warm compress can help, and gentle massage done by an experienced practitioner Exercise, such as yoga, pilates, or aquanatal classes (see p.55), strengthens back muscles, but check with your doctor before embarking on a new exercise regime. Watch your posture, making sure that you sit upright - you could try using a birthing ball - and wear flat shoes.
If you have sciatica, ask your doctor or midwife to refer you to a physiotherapist to assess your condition and teach you exercises to help relieve the pain and minimize a reoccurrence. Some women have a maternity girdle or back brace fitted.
Little moles are appearing on my skin. Why is this happening?
Skin changes occur frequently in pregnancy due to the effect of pregnancy hormones However, some changes, such as new moles and freckles appearing,
although not usually serious, should be discussed with your midwife or doctor, particularly if new or existing moles seem to change shape, are red or tender or start to bleed
In general, skin either becomes quite oily in pregnancy due to an increase in the production of the skin’s natural oil, sebum or, if skin is prone to dryness, it may become even drier and more sensitive. Many women experience a darkening of the skin, while others notice a pattern on their face that looks like a patchy sun tan, called chloasma (see p. 105). If your skin is sensitive, avoid scented creams and oils, and perfume. Regular cleansing of the skin and avoiding oil-based products may also help
My mum had varicose veins -am I likely to get them in pregnancy?
Around a third of women suffer from varicose veins in pregnancy to some degree (see p.86). These occur because increased levels of the hormone progesterone cause the walls of the veins to become more relaxed; there is also increased pressure within the veins as a result of the enlarged uterus pressing on major veins in the pelvis A family history of varicose veins does increase the possibility of them occurring, but there are several things that you can do to reduce the risk or severity of varicose veins.
If varicose veins do appear during pregnancy, they usually improve within three months of giving birth although unfortunately in subsequent pregnancies they are likely to recur.
My feet are swollen and tight; can I do anything about it?
Swollen feet and ankles, known as oedema, are due to excessive fluid seeping into the tissues because of the increased volume of blood By late pregnancy as blood volume continues to rise, this is a common problem. The swelling is usually worse later in the day and when the weather is warmer There are steps you can to take to help reduce the swelling, such as elevating your legs when sitting, rotating your feet, and lying on the floor with your feet up the wall. Wearing support tights or stockings also improves circulation in the legs. Make sure that you drink plenty of fluids, particularly water, as this improves the kidney function and reduces water retention. Gentle exercise, such as swimming or aquanatal exercises, also increases the efficiency of the circulatory system. There is evidence that reflexology from a registered practitioner may help.
If you also have swelling in your hands or face it is worth having a blood pressure check to rule out pre-eclampsia (see p,89) Most women find that the swelling gradually disappears after they give birth
My fingers are tingling and my midwife said it might be carpal tunnel syndrome - what is this?
Carpal tunnel syndrome occurs when swollen tissues in the wrist compress the nerves and cause pins and needles and numbness. Other symptoms include difficulty grasping with fingers and thumb and a general weakness in the hands. This is common in pregnancy due to the increased volume of blood, which can cause fluid retention
There are ways to reduce the symptoms, such as circling and stretching exercises to improve circulation and increase wrist mobility Wearing wrist splints and elevating your hands on a pillow at night can also help. There is some inconclusive evidence that ultrasound treatment may help in mild cases
I’m 35 weeks and get terrible leg cramp. What can I do?
Leg cramp, where the leg muscles go into a painful spasm, is common in pregnancy, particularly at night, which may be due to the pressure of the uterus on pelvic nerves This usually resolves itself once you are out of bed and using the muscle. However, if the pain doesn’t recede and there is any reddening or swelling in one leg, you should seek medical advice urgently to eliminate the possibility of a clot.
To reduce the incidence of cramp or its severity; drink lots of water to prevent dehydration and try leg stretches and ankle exercises, circling your heel first and then wiggling your toes, before going to bed. Gentle exercise, such as walking or swimming, can also help and getting your partner, friend, or relative to massage your legs, particularly the calf muscle, can improve circulation Some research suggests that taking magnesium supplements reduces the incidence of cramps but further studies are needed.
I’m itching to the point where I’m bleeding. What can I do?
Most itching in pregnancy, especially on your tummy, is due to stretching of the skin, hormonal changes, and heat. However, if you have significant itching, see your midwife or doctor to determine whether you have a condition called obstetric cholestasis, a serious but rare condition that affects the liver and occurs in about one per cent of pregnancies (see p 90) - a blood test can rule out this condition
Using a non-perfumed moisturizing lotion or emoillient cream daily after washing may help, and avoid bathing in very hot water Try not to scratch, as broken skin is vulnerable to infection; wearing cotton gloves at night may stop you scratching in your sleep After 28 weeks, five drops of essential lavender oil in a bath helps to soothe the skin. Antihistamine creams or tablets may be prescribed by your doctor if the itching is severe and other measures aren’t working.
My breasts keep “leaking”. Should this be happening now?
In pregnancy, your body prepares for breastfeeding and some women find that they leak colostrum, the first watery, yellowish milk. as early as 16 weeks Some leak large amounts, some small amounts, and some not at all. The amount you leak has no bearing on the amount of milk produced after the birth or your ability to breastfeed. If you are self-conscious,wear breast pads to protect clothing You may leak more when sexually aroused as oxytocin, one of the hormones responsible for the “let-down” reflex in the breasts, is released at this time.
I’ve got terrible indigestion -why is this?
Progesterone, the hormone that relaxes smooth muscle (muscle that controls unconscious actions) in pregnancy, has the unfortunate side effect of relaxing all smooth muscle in the body, including the whole of the digestive tract. This slows digestion and the ring of muscles called a sphincter at each end of the stomach become less effective, which can cause heartburn and indigestion as acidic juices from the stomach leak back into the oesophagus. In addition, your growing baby is squashing your stomach so that you have a smaller space to digest food.
To relieve indigestion, eat little and often, eat slowly, don’t eat late at night, and cut down on fatty or spicy foods. Rather than lie flat, prop yourself up with pillows Talk to your midwife, doctor, or pharmacist about remedies that are safe to use in pregnancy.

Varicose veins
how can I avoid them
Self-help measures to avoid the risk of varicose veins include:
* Wearing support hosiery - this is one of the best ways to avoid varicose veins All pregnant women are entitled to two free pairs of compression tights
* Doing regular ankle and foot exercises to reduce swelling and cramp
• Avoiding standing for long periods.
• Raising your legs when sitting down
• Getting up to take regular walks if you have to sit for long periods.
* Avoiding high-heeled shoes, which reduce the work done by the calf muscles, to maintain blood flow in the legs.
Sleeplessness
You are often very sleepy at the beginning and end of pregnancy, and towards the end of pregnancy you may find it increasingly difficult to sleep restfully in the night as your bump makes it hard to find a comfortable position, pressure on your bladder causes you to get up frequently to use the toilet and your baby may not share the same sleeping pattern as you and wakes you frequently with his kicking. Coupled with the fact that your body is working extremely hard, a poor night’s sleep adds to your general levels of fatigue. If possible. try to compensate for broken night-time sleep by catnapping in the day, or find time to sit down and put your feet up

Coping with morning sickness
To alleviate feelings of nausea and sickness in pregnancy, try eating little and often, and sip water continually during the day Some women find ginger helps, so you could try nibbling ginger biscuits, perhaps before you get out of bed. Acupressure bands worn on the wrists and available from most chemists are also thought to relieve the symptoms.
Fatigue

One of the most cited complaints in pregnancy, particularly in the first trimester, is extreme tiredness as your body deals with its extra workload. Accepting this and adapting your routine accordingly can help you cope. * Slow down and take a break, or even a catnap, whenever possible.
* Eat small, healthy snacks throughout the day and drink plenty of fluids to maintain energy levels
• Whenever possible go to bed earlier.
• Take regular, gentle exercise to relieve stress and improve your fitness and stamina.

Who will handle my care?
a guide to antenatal care

What types of antenatal care are available to me?
The options for antenatal care in the UK vary from one region to another, and sometimes according to the hospital you choose. so it’s worth asking your doctor or midwife early on about your choices. There are four main types of care (see p.76) The most common is shared care, where you are cared for by your doctor and community midwife with visits to the hospital limited to scans or investigations. In some areas, midwifery care is offered where you are looked after by a midwife or a team of midwives, sometimes called one-to-one care or team midwifery care. Women with pre-existing medical problems, or a more complicated pregnancy, such as a multiple pregnancy, may have consultant-led care with visits to a hospital-based consultant If you opt for private care, you will be cared for by an independent midwife Appointments will be timed to suit you and scans may be with a private obstetrician. The midwife will be on call for the birth, which may be at home, in a birth centre, or at the local hospital.
How many antenatal appointments will I need?
The exact number of appointments and how often you have them depends on your individual situation Usually, if this is your first pregnancy, you will have up to 10 appointments, whereas if you have had a baby before, you should have around 7 appointments.

When will I have my first antenatal appointment?
Your first ”booking’ appointment should be between 8 and 12 weeks, depending on the midwives’ preferences in your area. This is often the first time you will meet the midwife who will be organizing, and in most cases providing most of, your care.

I’m going for my first appointment next week - what will happen there?
The purpose of your first appointment with your local midwife is for her to obtain your medical history and exchange information so that your future care during the pregnancy and birth can be planned. This is also an opportunity for you and your midwife to get to
know each other and for you to ask any questions you may have and discuss the schedule for appointments, blood tests, scans, and antenatal classes. You will also be given booklets, information leaflets, and important contact telephone numbers
Your midwife will ask you about your medical history; your family’s medical history; your partner and your partner’s family’s medical history; about any previous pregnancies you have had; and how this pregnancy has been so far Your answers to these questions will help your midwife to build up a picture of your current state of health, and will also help identify any factors that may affect your pregnancy, for example if there is a family history of pre-eclampsia (see p.89).
Your midwife will also take your blood pressure, weigh you, test your urine (see below), and listen to the baby’s heartbeat if you are 12 or more weeks pregnant. She may also take some blood tests (see opposite). These observations provide a useful baseline for future antenatal checks

Why do I have to bring a urine sample to the clinic each time?
Your midwife is looking for the presence of protein in your urine. If protein is present, this could indicate that you have a urine infection that may need a course of antibiotics After around 24 weeks of pregnancy, protein in the urine is an indication of pre-eclampsia (see p 89), a potentially serious condition that needs close monitoring.
If you have a body mass index (BMI) (see p 18) over 35, you will be offered a glucose tolerance test, also done by testing -your urine. Glucose in the urine is a sign of gestational diabetes (see p.87) If glucose is present, you may be referred for blood tests to analyse your sugar levels. If diabetes is diagnosed, you would receive care and advice accordingly.

Why are some of my appointments with my doctor and others with the midwife?
The type of antenatal care you receive can vary slightly between different areas. If your pregnancy is straightforward, your care is usually shared between your doctor and midwife, or in some areas all your appointments are with your midwife. If you feel more comfortable with your midwife, you should be able to arrange to have the majority of your appointments with her, and the same applies if you feel happier seeing your doctor. Whichever way, it is important that -you feel able to ask any questions or discuss any issues, which may be personal or sensitive

Will I have to have an internal examination at my first antenatal appointment?
It is unlikely that you will have an internal examination at your first antenatal appointment. Twenty years or so ago, when home pregnancy tests weren’t as reliable and ultrasound scans were not so accurate or widely available, an internal examination was the
best way to confirm and ‘date” a pregnancy The midwife or doctor placed two fingers into the vagina, and pressed on the lower abdomen with the other hand to judge the size of the uterus
Nowadays, there are a few instances when an internal examination may be recommended during early pregnancy. If you have an infection, such as thrush, an internal examination enables the vagina to be visualized to check for any signs of infection and for a tissue sample to be taken with a swab (like a long cotton wool bud). The swab is sent to the hospital for testing so that the appropriate treatment can be offered
If -you have vaginal bleeding, you may have an internal examination with a speculum (an instrument shaped like a duck’s bill, used for smear tests) to allow the cervix to be seen: a small erosion on the surface is a common cause of bleeding in pregnancy Although internal examinations are not enjoyable, it is important to try and relax to help the muscles of the vagina to relax and loosen, which may prevent discomfort. Many women find it helpful to breathe slowly and steadily during the examination.

I’m very small and have tiny feet - will that be a problem when I give birth?
In the past, doctors used to measure a pregnant woman’s feet to assess her likelihood of needing a Caesarean section, as small feet were thought
to indicate a narrow pelvis Although there is some truth in the fact that small feet generally indicate that a woman is small-framed and therefore likely to have a small pelvis, small women also tend to grow small babies in proportion to their pelvic size. True cephalo-pelvic disproportion (CPD), where the baby’s head is too large to fit through the pelvis and be born vaginally is relatively rare
During labour there are other factors that help you to deliver your baby. The pelvis is not a fixed structure and the hormone relaxin helps to soften the ligaments that hold the pelvic bones together to help the pelvis to stretch and accommodate the baby
Also, your baby’s head is designed to mould into shape. The skull is made up from separate bones that are able to overlap each other slightly in order to reduce the overall size of the head as it travels through the pelvis during labour This is a normal part of the birth process. Labour positions also affect the dimensions of the pelvis. For example, squatting can increase the internal measurements of the pelvis by around 30 per cent. Sitting, or lying on your back can actually reduce these measurements by restricting the natural backwards movement of the tailbone (coccyx) during birth.

My midwife is lovely but she’s always in a hurry - how can I get her to answer my questions?
This is a common problem. Antenatal clinics are often very busy, with lots of women for the midwife to see. Asa  result, most clinics allow only a 10- to 15-minute appointment for each woman – barely enough time to go through the basic physical checks However, it is important that -your questions are addressed and it may be helpful to write them down so that you remember what you want to ask. If your midwife doesn’t have time to discuss the issues during your appointment, ask her to arrange to talk to you at a mutually convenient time This could be in the form of a phone call, or another appointment at the clinic Or she may be able to direct -you to other sources of information such as books, leaflets, websites, or other healthcare professionals.
It is a crucial part of your antenatal care that you feel comfortable with your caregivers and are given the opportunity to discuss any questions you have or issues that arise, and this is recognized by the National Institute for Clinical Excellence (NICE) in their guidelines for antenatal care (see p.310).

I’m four months’ pregnant and haven’t had many appointments. Will they get more frequent?
Yes, you will find that your antenatal appointments become more frequent as the pregnancy progresses. With your first pregnancy, you can expect a total of about 10 appointments but if you have had a baby before, you may only have 7. If you develop any complications, additional appointments would be arranged according to your needs. The schedule of antenatal appointments differs slightly from area to area, but as a general rule you can expect an appointment at the following stages of pregnancy: one to two appointments by 12 weeks of pregnancy, and then appointments at 16 weeks, 25 weeks, 28 weeks, 31 weeks, 34 weeks, 36 weeks, 38 weeks, 40 weeks, and if, your baby is overdue, 41 weeks If you are expecting your second or subsequent baby and the pregnancy is straightforward, you may miss out appointments at 25 weeks, 31 weeks, and 40 weeks.

I want a home birth. Will this make a difference to my antenatal appointments?
Usually women planning a home birth will have the same type of antenatal care as any another healthy pregnant woman in regards to frequency and location of antenatal appointments Midwives in some areas may provide a home visit towards the end of
the pregnancy if a woman is planning a home birth This is helpful as it offers an opportunity to discuss the preparations for labour and birth, such as what equipment to have ready and the intended place for the actual delivery. If your midwife cannot offer a home visit to discuss the arrangements for your home birth, you should be given an opportunity to talk about it together during one of your usual antenatal appointments.

Is it OK to bring my partner with me to the antenatal appointments?
It is absolutely fine to bring your partner with you to some or all of your antenatal appointments It is a good way for him to feel involved in the pregnancy, and also gives him an opportunity to ask questions that he may have. It is a legal requirement that you are allowed paid time off work to attend antenatal appointments, but your partner does not have this right, which may pose a problem as most antenatal clinics are during the day. Another way to involve your partner in the pregnancy is to attend birth preparation classes together Classes are often held at the weekends or in the evenings to make it easier for partners to attend This gives you both a chance to find out more about labour and birth and about babycare after the birth.

When will I hear my baby’s heart beat?
Your baby’s heart starts beating around 20 days after conception, and can be seen on an ultrasound scan at about six weeks of pregnancy It is usually not until around 12 weeks of pregnancy that it is possible to hear the heartbeat with a hand-held monitor, known as a sonicaid, as it is around this time that the uterus starts to grow upwards out of the pelvis, making it easier to detect the heartbeat When the heartbeat can be heard also depends a bit on your build; if you are very slim, it is usually easier to find the baby’s heartbeat than if you are overweight

Will I have my own midwife?
Midwives realize that it is important for a woman to develop a relationship with them so that they feel supported and able to ask questions, and continuity of care is provided if possible However, how many midwives you meet in pregnancy, labour, and birth and the postnatal period depends on how services are arranged in your area Generally, the midwife linked to -your doctor’s surgery provides the majority of care. Depending on your situation and common practice in your area, you may also meet other midwives if some of your appointments are at the hospital. When -you go into labour, you are usually cared for by hospital-based midwives who you may not have met In some areas, community midwives look after women in hospital. If this is the case, you may be familiar with the midwife caring for you in labour Midwives working on a labour ward work shifts, so it is likely that you will meet more than one midwife during your labour and birth. Your postnatal care is usually carried out by community-based midwives. This may include the midwife you saw for antenatal appointments at the surgery
I’ve only just found out I’m pregnant and I must be at least four months. What should I do?
One of the first things you need to do is to contact your local maternity unit and inform them of your pregnancy Women can refer themselves, although many still approach their doctor first. If you inform your doctor, he or she will send a referral to the hospital or to a midwife to arrange a booking appointment as soon as possible. You should also review your diet (see p.50) Depending on the number of weeks of your pregnancy, you may be due a scan, which may need to be done before the booking appointment Most units offer a scan around 10-14 weeks, and a second one around 20 weeks. You will be offered a range of blood tests (see p. 117) and should be aware of their purpose before consenting Each unit may have a slightly different schedule for care. The earlier you book in the better, so that you do not miss out on any aspects of antenatal care.

Antenatal jargon
Understanding your notes
Once your midwife has compiled your notes, you will be in charge of these and will need to take them to appointments. Abbreviations will be used for much of the medical information.
• BP Blood pressure.
• Hb Haemoglobin levels.
• Primagravida A first pregnancy
• Multigravida A subsequent pregnancy
• NAD Nothing abnormal detected (usually referring to urine sample).
FHHR Fetal heart heard and regular.
FHNH Fetal heart not heard.
FMF Fetal movements felt.
EDD Estimated date of delivery
iIc Ceph or Vx Baby head down
Br Baby is breech - feet down.
Eng/E Baby’s head is engaged for delivery * NE Baby’s head is not engaged.
* SFH Symphysis fundal height, size of the womb

Rhesus negative
Each person’s blood carries a Rhesus factor (Rh-factor), which is positive or negative Problems arise if a Rh-negative woman carries a Rh-positive baby who has inherited the status from the father. If the mother’s blood comes into contact with the baby’s blood during delivery, she may produce antibodies against the baby This does not usually affect a first baby. but may cause problems in subsequent pregnancies when a mother’s antibodies attack the cells of another Rh-positive baby
Preparing for visits
Getting ready for your antenatal appointments
Knowing what to expect at your antenatal appointments and having the necessary information to hand for the midwife will mean the allotted time is used efficiently.
At your first antenatal appointment, your midwife is gathering as much information about you as possible to build up a picture of your health and consider the most appropriate type of care for you. Make sure you have the date of your last menstrual period, as well as the dates of any previous pregnancies, including ones that ended in miscarriage You will also need to be clued up on your family’s medical history and your partner’s medical history, including any inherited abnormalities, so check before the appointment if you are unsure about anything Read any information sent by the hospital and make a list of any questions so that you don’t forget them.
Antenatal care options
Wno provides your care
The options for antenatal care in the UK vary from area to area, so this section will provide a general overview You will find out more when you go for your booking-in appointment, usually around 8-12 weeks Midwives are specialists in providing maternity care where there are no complications and they provide the majority of antenatal care to women. As they are specially trained to look after normal births, women should only have to see a doctor if a problem arises, or if they are at a higher risk of complications. Within the NHS there are three main types of care: shared care, midwifery care and consultant-led care. The Association for Improvements in Maternity Services (AIMS), has a useful website that provides plenty of support, advice, and information on maternity choices in the UK (see p. 310)
What is shared care? Most women have their antenatal appointments with their doctor or community midwife during pregnancy, with visits to the hospital only for routine scans or for investigating problems. Care is then transferred to the hospital midwives and obstetrician, if required, for the birth and postnatal stay
How does midwifery care work? In some areas, teams of community midwives provide continuous care throughout pregnancy, birth, and the postnatal period, and when this type of care
is available it tends to be a popular choice in low-risk pregnancies as it enables women to build up a relationship with their midwives The community midwives are responsible for your antenatal care, your care in hospital during the labour and birth, and then for home visits after the delivery. It is not guaranteed that you will have the same midwife all the way through your pregnancy and birth. For this reason, it’s a good idea to request antenatal appointments with different midwives within the team, so that you meet as many members of the team as possible during your pregnancy, and it will therefore be more likely that you will know the midwife who is with you for the actual labour and delivery of your baby,
When might you have consultant-led care? Women with pre-existing medical conditions, such as hypertension, or those with more complex pregnancy issues, such as twins or multiple births, may have the majority of antenatal care with an obstetrician. Most of their appointments may be carried out in hospital There are other conditions, such as diabetes or epilepsy, which may require the care of two specialists: an expert in the medical condition as well as an obstetrician. A hospital midwife will usually participate in this care too.
What about independent midwives? Outside the NHS, there is also the option of independent midwives Independent midwives are midwives who have chosen to work in the private healthcare sector. They charge a fee to provide antenatal care, care during labour and the delivery, and postnatal care Because they only look after small numbers of women, independent midwives can provide a continuity of care that is not always available on the NHS and they will also tailor care to suit your individual needs, for example timing antenatal appointments when most convenient for you You can find out more details by visiting the wesbite of the Independent Midwives Association (see p.310)
Does my care change if I’m having a home birth? As well as hospital delivery in a birthing or delivery unit, there is also the option of having a home birth within the NHS framework (see p 153). When a pregnancy is straightforward, research hasn’t found any difference in the safety of having a baby at home or in
hospital If you are having a home birth, your antenatal care will be provided by community midwives who are attached to a maternity unit. Once in labour, your midwife will stay with you until your baby is born, and she will visit regularly for between 10 and 28 days after your baby has been born, or you can attend a postnatal drop-in centre in your local area.
How will I choose my antenatal care? This may be partly dictated by the type of care that is available in your area. It’s worth talking to other local mothers with young children to see if they have any advice or recommendations. The type of care you receive may also depend on where you choose to give birth. If you have a low-risk pregnancy and decide to have a homebirth or to deliver in a birthing unit, then you will probably just see midwives and your doctor in your own home or the doctor’s surgery If there are complications, your care may be shared between your midwives and doctor and a hospital obstetrician.
Blood tests
How these contribute to your antenatal care
You will be offered quite a few blood tests during pregnancy and the results provide vital information that may affect your pregnancy and help your caregivers to plan your care. At your hooking appointment, you will be offered blood tests to check for the following:
• Anaemia (low iron levels).
• Your blood group
• Your Rhesus status (see p 79).
• Hepatitis B.
• Your rubella (German measles) immunity.
• HIV and syphilis
These are usually taken at the same time, so you won’t need a separate test for each!