Posts Tagged ‘health visitor’

Practical Advice for
Nine to Twelve Months
Psychomotor development
Once the child has learnt to crawl estrogen testosterone imbalance in women . the next stage is when she starts standing up provera primolut . Often, a child of nine to ten months will start by standing on her knees, holding onto to the bars of the playpen lithium induced acne . From ten or eleven months, she may be able to stand on her own feet, supported by the playpen or a chair wellbutrin addiction and withdrawl timeline . This is a great triumph! Statistically, the age of twelve months is characterized by the first independent steps maximum dose viagra . Often the child has already taken steps holding on to her parent’s hand during the previous months zoloft and withdrawl . Therefore a one-year-old child has a (vague) awareness of her own body for the
first time and is also able to start relating freely to space and gravity naproxen for headaches .
In fact, it is important to remember that the development described here in stages is based on averages brethine side effects attorneys . Virtually no child follows these statistics citalopram ssris snorting effects . Some children are faster, others slower wellbutrin and dreams . Sometimes a child will do something, which ’should’ happen later, or will miss out a certain stage analgesic effects of lamictal . This should not usually be a cause for concern info on cipro . If you have any worries, discuss them at the baby clinic with the health visitor avandia and blindness .
Apart from clinging to one person, the child may now also start to become frightened of separation atomic emission spectrum lithium . She will be aware of her mother moving away for a minute and will NINE TO TWELVE MONTHS
start to cry testosterone shots for arthritis . At night, this can give rise to sleeping problems non perscription citalopram .
Sleeping and waking
At the beginning of this period, the rhythm of sleeping and waking is usually the same as for the previous period prevacid vs prilosec side effects . By the end of the first year, many children are only taking one nap a day in the daytime wellbutrin and hair loss .
This transition can be a difficult period, with a loss of the familiar pattern for both the child and parents viagra no prescripsion . The child is too small for one nap and too big for two allegra d 308 av . It may be a month or more before a new pattern is established, both with regard to the nap, and with regard to feeding times risperdal side affects .
Care
Brushing teeth
It is advisable to start brushing the child’s teeth during this stage, once she has teeth, although you cannot expect too much of this at first imipramine is an ssri or maoi . Choose a soft brush for your child and brush her teeth, or let her do this herself fibromyalgia celebrex elavil oxycodone . If your child absolutely refuses to have her teeth brushed, this may be because of painful gums because teeth are still coming through nolvadex deutsche beschreibung .
Regularly brush your own teeth in the presence of your child and she will follow your good example celebrex tendon repair . In our opinion, it is not necessary
to use toothpaste at this stage metformin er side effect . After brushing the teeth, give the child a sip of water, as this also cleans out the mouth azithromycin chlamydia .
The playpen
By about nine months, when the child is standing and crawling, the urge to explore the whole world is often so great that she will reject the playpen as a frustrating restriction dosing prilosec . If you manage to persevere at that moment, you will benefit a great deal in the next few months bupropion and ephedrine . A safe place can then be guaranteed for at least one or two hours per day and that is a great advantage in a period when the child is sleeping less and is increasingly active, able to reach almost everything and throw things about doxycycline side effects anxiety .
When a child suddenly stops being a baby, the parents may find they have problems with upbringing that were inconceivable only a month before amoxicillin dosage treatment course for pneumonia . Should I forbid this, should I punish my child if she touches the plants, or tears the covers off the books? The playpen imposes a clear boundary for the child and means that for while, you don’t have to impose this boundary yourself ibuprofen alert .
In the playpen, the child learns to play with whatever is there at the time fluticasone propionate nasal spray walmart . This limitation means that it often plays in a more concentrated way than outside the playpen, where the range of interesting objects is so much larger brand name for lovastatin .
Another advantage of the playpen is that other children in the fam-child cannot easily stop doing this by herself buy claritin d online dream pharmaceutical . At a certain point, you will have to indicate that enough is enough; for example, by no longer picking the object up getting off synthroid to natural supplements .
Towards the end of the first year, we see that the child imitates everything that is happening around her: she likes to stir a spoon around a bowl when she sees father or mother doing this caffeine good tremors . Or she wants to eat by herself because older brothers or sisters do ivermectin 1 .
Safety
The most common accidents are the same as those described for six to nine months cipro kills prostate cancer . However, during this stage, the child starts moving about more and can do much more, so that the risks increase carisoprodol in mexico . Impose clear boundaries with the use of stair gates, harnesses in the high chair, and the playpen unprescribed clomid . Make sure you have an age-appropriate car seat, or if you cycle, a safe bicycle seat and cycle helmet canine dosage of tramadol . Adapt the situation in the house to this age by placing dangerous or vulnerable objects out of reach or putting them away zoloft buy . Give the child her own shelf or cupboard where she can do her own thing kamagra uk . Always remove the child from places where she can be `naughty atenolol by sandoz .’ Forbidding anything at this age is pointless do caffeine pills make you see . Make sure that there are no loose objects around the child, that she could choke on; marbles, beads and nuts area common source of danger masturbation testosterone hair loss .
Feeding
During this stage a child often clearly indicates that she wants to join in zantac overdose . At this age, this means that she wants to enjoy the domestic togetherness at the table even though she does not have to eat the same food as the others yet soma in europe .
Therefore, times have been left out in the summary of meals given below and the meals are indicated as breakfast, dinner, etc depakote to treat anxiety . However, lunch is usually much earlier than the time lunch is normally eaten because this is more suitable for the sleeping pattern statin drugs cause low testosterone .
Breakfast excessive clomid use safe for babies .- a bowl of porridge and some bread and drinking from a beaker if necessary lithium cell phone batteries transportation .
Possibly a snack in between meals with a drink dog prednisone and lysodren .
Lunch: vegetables and dairy pudding Teatime: fruit and possibly a drink Dinner: porridge and some bread and a drink if necessary claratin d loratadine .
During this period, the bottle usually gradually disappears from the scene lipitor side effects pdr . Porridge is eaten from a bowl and the baby can often manage to drink from a beaker quite successfully rebate for naproxen .
Porridge
You can give the porridge or cereal flakes, described for six to nine months (see p aceon generic name .73) or prepare porridge with flour is bupropion same as buspar .
Bread
This is the age at which a child often starts to chew cialis viagra packs cheap fast . If she has few or no teeth, she will do so with her gums vasotec and tbi . Therefore, the child can start to chew its bread, rather than merely sucking on it as in the previous stage dxm zoloft interaction . To eat a real sandwich, it is important for a child to sit up so that she does not choke so easily dean ornish zocor . The bread will gradually replace the porridge, though usually not before the first year information on medicine seroquil and depakote . At first, bread is a good way to introduce food which can be chewed cocaine counteract impotence with viagra . Start with light brown bread and go on to wholemeal bread at about one year paxil vs cymbalta .
Spreads
Unsalted butter, nut paste (if no parents with a nut allergy), cream cheese and fruit compote testosterone testing isotope yam .
Peanuts are not nuts, but pulses difference between zocor and lopid . Therefore it is best to not give peanut butter caffeine and post op breast augmentation . It is heavier to digest and leads more often to allergies than nuts do (see Pulses, pp cats and ibuprofen .43f) fioricet and effexor interactions .
Drinking
As the food becomes more solid the child needs extra drinks, particularly when the weather is hot viagra available at boots online . However, the total amount of moisture per day should not be more than one litre / quart does diovan cause hair loss .
Herbal tea, fruit juice or apple
FEEDING 81
juice are suitable drinks heart health caffeine . However, try to prevent a one-sided pattern from developing, for example, only giving apple juice bapapendin and bupropion . Large amounts of juice should be avoided because of the sugar content safety of coreg . Milk does not quench thirst, but is a form of food risperdal is very good . Whether you give milk with a meal depends on the rest of the eating pattern; a child needs about 450 to 500 ml (about half a quart) of dairy products per day viagra car .
Bottles
Some children will not be parted from their bottle allegra 64 r centrifuge . They would like to drink all day if possible atenolol gynecomastia . We advise that you do not give into this because drinking too much diminishes the appetite is risperidone the same as risperdal . This applies particularly if you give squash or another such drink claritin prostate cancer .
Drinking sweet juice from a bottle can also lead to problems if the child develops a sweet tooth, and can lead to dental decay in the front teeth lipitor atorvastatin nebraska . In our view, using a beaker with a spout as a transition from the bottle to the beaker is not desirable, because the child may want to suck on this all day mixing sotalol with rimadyl for dogs . It is best is to go from a bottle directly to a nor-
L,
mal cup, because this is best for the mouth muscles in relation to speech development course of naproxen .
Snacks
Suitable snacks are toast or crisp-baked biscuits, a crust of bread, Ryvita, rice cakes, bread sticks prescription medication atrovastatin . Never give the child these snacks without supervision because of the danger of choking rechargeable 1000 mah lithium ion battery .
Vegetables
The vegetables can be mashed or cut up more coarsely viagra vs levitra vs . Instead of adding oil you can also add some butter or cream to the vegetables action of ciprofloxacin . The flakes can be alternated with wholemeal macaroni or spaghetti apartments near lenor nc .
It is still too early for whole grain rice, barley etc health and fitness caffeine .
Fruit
The fruit should be sufficiently nutritious to help the child get through the afternoon how to remove viagra official site . On the other hand, it should not be so tilling that it takes away the child’s appetite for dinner pseudoephedrine water . Therefore, depending on the child, it could consist of pur6ed fruit with or without flakes and/or dairy products celexa message boards .
Aspects of Care for the Small Child
Tests, vitamins and development
The PKU and CHT test
Depending on where you live, the midwife, health visitor, obstetrician or sometimes your doctor will visit between the fifth and the seventh day after the birth to give the child a ‘heel test viagra sublinqual .’
A few drops of blood are collected from a small prick in the heel taking bactrim for staph . This blood is examined for PKU (phenylketonuria, a metabolic disorder) and CHT (an adrenal hormone, of which there may be a deficiency) lopressor 100 mg . Both these rare diseases can cause brain damage, but can be treated at an early stage through diet and medicines respectively zoloft with hydrocodone .
Make sure that the baby’s feet are warm for the prick in the heel pharmicudical info on penicillin . This makes it easier to take blood paxil for ibs .
Vitamin K
In recent years, parents have been advised to give babies extra vitamin K what bacteria does bactrim fight . The advice applies to the period that the body does not produce suffi-
cient vitamin K itself, that is, during the first three months generic dutasteride . The aim is to prevent some babies from developing serious — and in some cases fatal — bleeding (for example, in the brain) paroxetine iv iv . These cases are extremely rare and are attributed to slow coagulation of the blood, a complicated system with many different ‘coagulation factors information on focalin and risperdal .’ By giving vitamin K, the aim is to accelerate the development of the coagulating mechanism and thus reduce the chance of bleeding viagra equivelent .
In a number of countries, including the UK, a vitamin K injection is usually administered to newborn babies immediately after birth jems ondansetron . An alternative option, is to give vitamin K orally at birth, followed by further doses on days 4 to 7, and a third dose at one month can you filter cyclophosphamide .
In our opinion, there is a great deal to be said for giving a breast-fed child extra vitamin K for the first three months, in view of the seriousness of the complications concerned, the small amounts of the vitamin given for an extremely short period, and the absence of side effects gneric for drug lipitor .
Vitamin D and rickets
Nowadays, rickets is mostly a serious problem among immigrant populations lithium ion battery first charge . Rickets can be seen as a disease in which the body is not sufficiently connected with the earth erythromycin newborn . This is expressed in a developmental disorder and problems with calcium, particularly in the skeletal structure domperidone summary . The ‘earthly’ character of the body is related to the development of bones and calcifying processes lexapro recreational use . These processes give the body a more solid character and also help it to develop generic cialis pills generic or overseas . For example, the late appearance or non-appearance of teeth or a slow motor development in the case of rickets can be ‘made up’ at an accelerated rate with the help of vitamin D metformin reproductive problems .
However, in children who would not get rickets, the vitamin D stimulates accelerated development under normal circumstances who manufactures aciphex . These children mature earlier and are therefore also intellectually stimulated purchase doxycycline online . You must make a conscious choice whether you want this or not, because accelerated development is not always harmless prozac and extasy . It can take vital forces from the body, which are really needed for the body to develop over a longer period allegra j smith . Therefore giving vitamin D as a matter of course does not seem desirable toprol sleep apnea .
However, devoting attention to preventing rickets is important for all children prednisone and dog and dosing . How rickets can be prevented must be determined by the doctor at the baby clinic for each child individually cymbalta weight gain .
Rickets can be prevented by ensuring there is enough contact with sunlight and outside air or by giving vitamin D inderal dosages .
Therefore it is a good idea for the child to spend at least an hour and half per day in direct contact with the outside air or with daylight hatori soma . This is even possible in autumn, winter and spring, whatever the weather, in a pram that has been heated with hot water bottles and removed before the child is placed inside regulating coumadin therapy factors .
Children with dark skin are at greater risk, and the doctor at the health centre should keep an eye on them celebrex prescription .
Vitamin D is added to formula milk as a standard supplement; therefore, this will have to be taking into account when you are making a choice buy tramadol hcl .
In some countries all children are checked for symptoms of rickets at the baby clinic, or at least, an attempt is made to do so can i snort wellbutrin . It is advisable to be aware of the vitamin D policy and to discuss it with a doctor at the baby clinic of tadalafil . Although it is a rare disease, rickets can have a number of unpleasant symptoms, which are not always predictable lowering testosterone levels . It is also difficult to predict who is and who is not susceptible to rickets minocyline minocin .
This makes it more difficult to adopt an individual policy zoloft and hot flashes . Nevertheless it is worth trying to do so veterinary sertraline .
Development of the teeth — fluoride
It looks so ordinary, but is actually quite extraordinary depo provera used in chemical castration . We are born without visible teeth caffeine and effects . During the course of the first three years, the n1ilk teeth appear, and at the age of about six, the teeth simply fall out to be replaced with the permanent teeth soma mineral makeup . These permanent teeth and molars are only formed after birth who makes depo provera .
It is quite remarkable that this development can indicate the actual state of the development of the organism as a whole diflucan 150 mg tablet . At birth, the ,milk organism’ is still unfinished to a great extent; it needs time to develop levofloxacin gum infection . In addition, the whole organism must be transformed in the first seven years to produce a permanent organism the drug risperdal .
Because of their enamel, teeth are the hardest organs we possess, and are harder than bone does caffeine affect fibermylagia . When the milk teeth appear — a process that takes place on average between the ages of six months and two and a half years — it marks the development of a weak, not very robust baby into a toddler with an independent relationship to space, and his first independent thought processes pariet aciphex .
We have already seen that the sense of self and starting to use the word ‘l,’only appear when the child has learnt to walk, talk and think
(p cheap dilantin prescriptions .20); it is fascinating to see that the development of the teeth takes place in parallel with this buy cod tramadol ultram . Perhaps it is understandable: the hard crystalline elements that form the teeth are formed under the influence of very specific forces, and these forces are released when they have completed their task evenessence lithium .
In the anthroposophical view of the human being there is a connection between the forces which are released to form the teeth and ,earthly’ thought processes testosterone before after puberty graph . Earthly thinking refers to the clear ’solid’ thought processes, which are more or less strongly developed in adults, but are completely absent in a newborn child amoxicillin dosage 875 mg . A child can only develop this way of thinking when the body, and in particular the milk teeth, have developed to some extent levaquin substitute .
One problem which affects virtually everyone nowadays is caries, that is, holes in the teeth albuterol proair hfa side effects . The hard enamel dissolves because bacteria in the plaque on the teeth produce acid augmentin ibuprofen . Scientists have discovered that giving fluoride in the form of tablets, toothpaste or as a coating, can harden the enamel and therefore help to prevent caries famvir versus valtrex .
Fluoride is found naturally in the teeth enamel, and in the bones prednisone and bladder side effects . It has a binding, formative effect, inhibiting life forces and hardening the tissues pseudoephedrine use signs of .
Dentine, the tissue under the enamel is a very different substance switching to lexapro .

How Soon Can I Go Home with My Baby? FAQ
I just want to go home
I hate the thought of being in hospital for long - how soon can I go home with my baby?
In most maternity units, there is a degree of flexibility as to how long you remain in hospital after
the birth If you wish to stay for as brief a period as possible, talk to your midwife about this. In
the past, postnatal stays tended to be longer - in 1997-98, the average stay in England was 2.2 days,
and was 5.5 days in 1981 Nowadays, the minimum length of time in hospital is about six hours and many
mothers just stay overnight to rest and gain some confidence. In some areas, you can move to a doctor’s
unit or birthing centre. To help make the transition home as smooth as possible plan your return,
making sure you have plenty of support in place.
How long you stay in hospital will largely depend on your type of delivery If you have a vaginal
delivery, you should be able to return home fairly soon, but a Caesarean may mean you need to stay in
for about three days Also, if your baby is born early, or is unwell, or struggling to feed or maintain
his temperature, then you will be advised to stay in hospital until your baby is ready When babies are
premature, mothers may have to leave them in the special care unit and visit regularly
Will I have any privacy in hospital? I don’t want to be on a ward.
There is usually an attempt to make maternity wards as cheerful as possible, although the reality is
they are often busy and lacking privacy. Your delivery room is likely to be a single room and may have
ensuite facilities. Postnatal ward facilities vary tremendously in different locations: there may be
single rooms, small rooms, or traditional Nightingale wards with a corridor of beds Each bed will have
curtains to pull around it for extra privacy, and bathroom facilities can vary.
Where will my baby sleep when we’re in the hospital?
Mothers and babies usually remain together for 24 hours a day You should only be separated from your
baby if there is a medical reason for this, for example your baby needs special care, and you should be
fully informed before agreeing to this. Your baby will usually sleep in a cot attached to the bed or
next to it This is recommended by the World Health Organization (WHO) and UNICEF who run a programme
called The Baby Friendly Initiative This works with healthcare systems to ensure a high standard of
care for mothers and babies, and many maternity units are guided by their advice.
My friend’s baby slept almost continuously for the first day or so. Is this normal?
The birth process is tiring for the baby as well as the mother and so it is not unusual for the first
24 hours to be fairly quiet, as your baby rests after the birth Babies are often very alert and ready
for a feed immediately after the birth, but then have a long sleep. Also, if you had drugs such as
pethidine or diamorphine, during labour: these can linger in the baby’s system and contribute to the
drowsiness. If your baby does sleep a lot at first, make the most of the opportunity to rest while
still offering regular feeds — your midwife will advise you. After the first 24 hours, you may still
find that your baby is feeding erratically, maybe every hour for five hours, and then having a
four-hour sleep. Rest assured there is no set pattern in the early days; your baby should feed when she
wants to and you shouldn’t expect any routine to emerge at this stage.
Will the hospital help me with the everyday care of my baby if I’m having problems?
While -you are in hospital there will be midwives and maternity support workers to help you They have
plenty of advice and information to offer so don’t be afraid to ask about anything that is worrying
you, such as specific questions about your baby, or any aspects of baby care (see below). However do
bear in mind that maternity units tend to be extremely
busy and this, coupled with the fact that presently there is a shortage of midwives nationwide, means
you may have to be patient and prepared to wait a while at times before someone is free to help you
Before you go home you will also be given contact numbers in case you need help or advice in between
your postnatal checks.
Once you are home, your community midwife and your health visitor will be available to offer advice and
support They will also be able to give you details of local mother and baby groups, and postnatal
drop-in clinics, all of which offer support and information for new mums and their families and give
you the chance to meet other mums.
Do we need a car seat straight away or can I hold my baby in the car?
If you intend to take your baby home in the car, it is a legal requirement for them to travel in a car
seat appropriate for their age. Indeed, it is illegal for children to travel in a car without a
correctly fitting and fitted car or booster seat until they are over
Getting advice in hospital
Although the arrival of your baby is a time of incredible excitement, it can also seem overwhelming and
you may feel daunted by the enormous task of looking after and meeting the needs of this tiny new baby.
One of the benefits of your stay in hospital, as well as recovering from the birth, is to help you feel
confident in the care of your baby, There are several aspects of baby care and feeding that the
hospital midwives can help with.
* Staff can help you to establish breastfeeding by
guiding you on technique. Some hospitals have a    BATHING HELP: dedicated breastfeeding counsellor on
site.
* The midwives can help you with everyday care by
demonstrating topping and tailing, bathing techniques,
changing a nappy, and dressing and undressing.
Small babies and children need the protection that baby seats and child seats are designed to provide.
So, yes, you do need to get your car seat ready before the birth to take your baby home from the
hospital.
I’m going to be on my own when I go home and I’m worried I won’t manage.
It’s only natural to feel anxious about your new responsibilities when you arrive home with your baby
Being a single parent is increasingly common so don’t be afraid to ask for help. Your midwife and
health visitor will visit you to help with any baby-care problems and you will be given contact
telephone numbers before your discharge from hospital in case you experience problems or need advice in
between postnatal visits and checks
When you are on your own, it’s a good idea to arrange for a group of reliable friends or family members
who are willing to assist you with babysitting, morale boosting, and provide general all-round back-up
in the early days. Over time you
can establish a network of other single parents in your area with whom you can share your problems and
solutions. Also, ask your midwife or health visitor for contact details of local postnatal groups and
organizations that support single parents.
My mum is coming to stay with me but I don’t want her to take over. How should I approach this?
Overbearing mothers and mothers-in-law can be a problem, however well-intentioned they are. You will
find it’s not just mothers who insist on issuing lots of advice and information, but friends and other
relatives can be just as vocal Although this advice is often useful, some of it may be old-fashioned or
simply conflict with -your own ideas on how to care for your baby
Even though -you may be feeling vulnerable after the birth, practise being clear and assertive about
the way in which you want to do things and make sure that people understand and respect your views and
that your partner supports you in this too. It may help to pass on leaflets or books that you have read
so your mother can see how things have changed since she brought up her children, and what advice you
are following. You could suggest other ways in which she could help, such as shopping, cooking, and
cleaning, so that you are left with the care of your baby Most mums just want to help in some way, so
it’s up to you to channel her enthusiasm
Will I get any sleep at all in the early days?
You will get sleep but whether it is of the same quantity and quality that you are used to is
questionable. Although young babies need a lot more sleep than adults, approximately 16 hours each day,
they do not take all of this sleep in one long stretch as they need to wake up for frequent small feeds
Up to the age of three months, babies have ‘’sleep—wake” cycles throughout the day with longer spells
of sleep at night
The length of these cycles varies from baby to
baby, but on average your baby will sleep about two hours at a time in the day, and four to six hours
at night. All babies wake up a number of times throughout the night. The length of time your baby
sleeps for during the night may also be affected by how she is fed. Several studies suggest that
breastfed babies take longer than formula-fed babies to develop a pattern of sleeping through the
night. This is because breast milk is easier to digest than formula milk, so babies get hungry more
quickly and wake more often in the night Most babies are physically capable of sleeping through the
night from the age of six months.
Should my baby be in her own room or in with us and, if so, for how long?
In the early days, when your baby is fed frequently, often every two to three hours, you may find it
more convenient to have her closer to you. UNICEF recommends that babies share their mother’s room for
the first six months of life as this helps to sustain breastfeeding and is also thought to help protect
babies against cot death (see p.276).
As -your baby grows and develops, her needs and sleeping patterns will change One of the main changes
is that your baby will start to sleep longer between feeds at night and often this is the stage that
many parents decide is a good time to move their baby into their own room. You may also find that, if
your baby is a light sleeper, she may sleep better in her own room as she is less likely to be
disturbed by you and your partner
I’m a really deep sleeper and I’m worried that I won’t hear my baby crying. Is this likely?
This is a common worry for many new parents,
but you should rest assured that it is highly unlikely you will sleep through your baby crying Many new
parents find that they do not sleep as deeply following the birth of their baby, which may be partly an
unconscious worry about sleeping too deeply and not attending to their baby’s needs Having your baby
sleep in the same room as you to begin with and using a baby monitor later if your baby moves into her
own room will help you to feel confident about hearing your baby at night It’s a good idea to try to
catch up on some sleep during the day-time and take a nap while your baby is sleeping, as this will
mean that you are not totally exhausted when you go to bed at night. You should also learn to trust the
greatest prompt of all, your natural inbuilt maternal instincts!
Who can I turn to if I have problems with breastfeeding?
Although breastfeeding comes naturally to some mums, for many others it can prove surprisingly
difficult. Initially you will have midwives and maternity care assistants on hand in the hospital to
assist you with breastfeeding. Once you return home, your community midwife and health visitor can
continue to advise you, but obviously they will not be available 24 hours a day If you continue to have
problems with breastfeeding, there are many helplines and local support groups available for which your
hospital, doctor’s surgery, and health centre should have contact details. Also, there are plenty of
Internet sites that have forums, which are useful for discussing problems and comparing experiences.
Some midwives and health visitors run local drop-in breastfeeding sessions, and some breastfeeding
groups meet informally in cafes, so enquire whether there are any of these groups locally The National
Childbirth Trust (NCT) (see p 310) also has a national network of trained breastfeeding counsellors and
a helpline for you to call.

Leaving hospital

Each hospital varies, but generally, before being discharged from the hospital, several checks take
place. *You will be examined by a midwife or doctor to check that your uterus is starting to return to
its pre-pregnancy size.
* If you had stitches, these will be checked to see if they are healing properly.
*Your baby will undergo various newborn checks (see p.220) and will need to be signed off by a
paediatrician.
* If you need to take any medication home, this will be dispensed and you will be told how to arrange
your postnatal check.

First days at home
Regardless of whether or not this is your first baby, on your return home you are likely to be both
physically and mentally exhausted. If this is your first baby, although the transition to motherhood is
exciting, it can be daunting and, once home, you may be surprised at how big an adjustment this is.
While some families want to share their joy with family and friends as soon as possible, others decide
to have some quiet time together at first to get to know the new arrival and get used to their new
roles Try to put worries about housework and clearing up to the back of your mind – these will keep
Hormonal changes may mean that you feel quite low and weepy about three days after the birth, known as
the ”baby blues” (see p.281). Getting as much rest as possible will help you to recuperate and begin
to feel normal once more.
I don’t want to go home too soon - can I stay in hospital if I want to?
When you leave hospital is something that you will agree with the hospital midwives and doctors, and it
will be dependent on your particular needs and circumstances. Although you obviously can’t remain in
hospital indefinitely, generally you won’t be transferred home until you feel ready to return The
midwife will ensure that you are confident feeding -your baby, whether this be breastfeeding or
bottlefeeding and that you are confident providing everyday care for your baby, which is good
preparation for returning home.
When you go home, your care will be transferred back to the community midwife, so you will continue to
receive support, information, and advice as necessary Also, planning in advance support for when you
return home may help you to feel more confident about leaving the hospital As well as support from your
partner, try to enlist the help of family, friends, and close neighbours to help you cope in the first
few weeks after the birth.

BEING TOGETHER:
We had so many visitors in hospital last time it was exhausting. Can I stop this?
Many people seem to believe that if you are in hospital then they can visit whenever they want to,
whereas most people, even close family. wouldn’t just turn up on your doorstep unannounced if you were
at home with your baby If you know in advance how you will feel then you really need to be assertive
this time and let people know your wishes It is possible to do this in a diplomatic way without
offending people by simply telling friends and maybe family too that you would prefer to have some
quiet time with your partner and children during the first few days to recuperate and get to know your
new baby. Most people will understand this sentiment and will be more than happy to wait for a few days
until you are feeling ready to see them.
If you are discharged fairly early from hospital
it may be easier to control the flow of visitors as you will be able to dictate visiting on your own
terms. You can then take the time that you need to settle down to a new family life.

I don’t want to breastfeed
bottlefeeding your baby
I don’t want to breastfeed - can you tell me what to do?
If you do not want to breastfeed, you can either bottlefeed your baby expressed breast milk or formula milk. There are many women who do not breastfeed because they receive a lack of support and find that the advice available is insufficient. However, having a go at breastfeeding, even if this is just for one week, will benefit your baby.
If you have chosen to bottlefeed you will need to decide on a few things. First, you need to work out which type of formula you want to use. Take some time to look at the many brands on the market and opt for one that you feel will be right for your baby Ask your midwife or health visitor for advice if you are not sure You will also need to purchase bottles, teats, and a sterilizing unit. This can be confusing as there are lots to choose from, so you will need to take some time to find out about the available options and which unit will work best for you (see p.239)
Bottlefeeding sounds so complicated. Are there “dos” and “don’ts” to remember?
Yes, it is important to bottlefeed safely. The NHS provides guidelines for safe bottlefeeding
* Always make sure you use a sterilized bottle. cap, and teat for each feed
* Ideally, make up one feed at a time and discard any leftover milk at the end of a feed.
* Use boiled tepid water that has been left to cool for up to half an hour before making up a feed.
Put the water into the bottle before the formula.
Don’t pack the formula into the scoop: instead, level it off gently with a knife.
* Warm the feed — not in a microwave, but in a bowl of hot water — and test the temperature before giving it to your baby
* Avoid swapping scoops from different makes of infant formula milk as different scoops may be different measurements.
I feel guilty for not breastfeeding - should I?
No! The main thing is to ensure that your baby receives the best possible care in life that you are able to provide. If it is not possible for you to breastfeed, then formal milk feeds are a safe option. However, you need to feel comfortable with your decision and not be swayed by others. You may want to look at the advantages and disadvantages of both breast- and bottlefeeding. That way you’ll be sure you’ve made the right decision for you and your baby without feeling guilty Once you have made an informed decision, communicate this confidently to family, friends, and your healthcare provider.
Is formula milk as good as breast milk?
Breast milk is universally considered the ideal nutrition for your baby, and the World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life as it provides all the nutrients a baby needs However,

Bottles and teats
Getting ready to bottlefeed your baby
There area variety of bottles and teats available in different styles.
You will need between four and six bottles and teats As well as larger bottles measuring 250ml (8fl oz), you may also want a couple of smaller bottles of 125 ml (4fl oz). Teats come with different sized holes to make the flow of milk faster or slower to suit your baby’s needs. Some teats are therefore recommended for newborns and some for hungrier older babies,
there area variety of high-quality, nutritional baby formula milks available that scientists and medical experts have spent years developing. Most infant formula milks are derived from cow’s milk, but are modified to resemble breast milk as closely as possible. If you feel confused, discuss the different brands with your midwife or health visitor.
What exactly is in formula milk and how similar is this to breast milk?
If you read the labels on different brands of formula, there are not many variances. The Infant and Dietetic Association website (see p 310) provides a table comparing the contents of the five main brands
available in the UK. Baby milk must provide energy, fat, protein, carbohydrate, vitamins, minerals, and trace elements, and the quantity of each nutrient is specified by law. The proportions of energy supplied by protein, fat, and carbohydrate in infant formulas are similar to those in mature breast milk
* The fat content. In infant formulas this is based on blends of dairy or vegetable fats that are chosen partly depending on their levels of unsaturated fat. Omega 3 fats may be added as these are vital nutrients for growing brains and bodies Formula milk does not have the fat-digesting enzyme, lipase, which accounts for the unpleasant-smelling stools of formula-fed babies.
* The protein source. In formula milk, this is either cow’s milk, in the form of casein or whey, or soya (see p,240) The amino acid content of formula is equivalent to that of breast milk to meet the needs of the rapidly growing baby.
* Lactose. This may be included in formula; mature breast milk contains about 7 per cent carbohydrate in the form of lactose, which is thought to be important for brain development.
* Vitamins, minerals, and trace elements. These are added to formulas to meet the nutritional needs of the baby and to comply with legal requirements. * Iron. This is vital to your baby’s wellbeing, being essential for healthy blood, growth, and development, and this is added to formula brands.
* Other components. Infant formula may contain other components that are found naturally in breast milk, such as long-chain polyunsaturated fatty acids (for brain and membrane development), oligosaccharides (to aid digestion and immunity), or nucleotides (to promote healthy growth and development and to help the immune system).
There are some components of breast milk that cannot be replicated in formulas For example, breast milk contains important antibodies that help protect babies against infection and illness and these are not present in formula milk. However, prebiotics, which are nutrients found in breast milk that strengthen a baby’s natural immune system, may be added to some brands of formula

How to bottlefeed
Preparing and giving feeds
Bottlefeeding, using formula or expressed breast milk, can seem daunting at first, but becomes easier once you get into a routine.
How do I start?You will need at least 4-6 bottles and teats, with at least one or two sterilized and ready. You can sterilize by steaming, microwaving, boiling, or using a sterilizing liquid. Your choice will depend on the cost and what you find easiest. Before sterilizing, rinse a bottle first with warm soapy water using a bottle brush, taking care to clean the top of the bottle and inside the teat.
How do I make up a feed? Wash your hands and make up a feed according to the instructions. Put the correct amount of tepid boiled tap water
into the sterilized bottle first and then add the right number of level scoops of powder, Never add extra powder as this could make your baby ill. Don’t put a half finished feed back in the fridge - throw it away and use a fresh bottle next time
How do I give the feed? Test that the milk is not too hot by putting some on the inside of your wrist (never use a microwave to warm up milk) Find a comfortable position and always hold your baby’s head slightly higher than his body. Put the teat gently into his mouth and slowly tip the bottle so that only milk, not air, gets into the teat You can wind your baby - gently pat or rub your baby’s back - halfway through the feed, or wait until the end. Throw away any milk that is left over.

KEEPING BOTTLES CLEAN:

Sterilizing equipment
Before using new bottles and teats, and each time you use them, wash and sterilize them. Wash them in warm, soapy water with a bottle brush, and rinse thoroughly. Sterilizing methods include: * Electric steam sterilizing, which takes about 10 minutes, plus the time it takes for equipment to cool
* Microwave steamers, which take around 5 minutes. The equipment remains sterile for up to 3 hours if the lid is left on. * Equipment can be sterilized by boiling, which takes around 10 minutes. The pan must not be used for another purpose and you may find that teats wear out more quickly
* Cold water sterilizing tablets can be used either in a special sterilizer, or in a suitable clean container with a lid. This takes around 30 minutes and the equipment can be left in the solution for up to 24 hours; the solution needs to be changed each day. * Dishwashers need to be set on a high temperature and some parents prefer to wait until after a year before using these.
Is it OK to combine breast-and bottlefeeding?
Yes, it is possible to combine breastfeeding with bottles of expressed breast milk or formula, and many women choose to do this rather than stop breastfeeding altogether.You may also decide to do this if you are returning to work.
Feeding from a bottle uses a different technique to feeding from the breast, and your baby may take a little time to get used to it, which can make it quite a struggle to introduce bottles It may help to warm the teat and to get someone else to offer the bottle the first time, as your baby may be able to smell your milk if you hold him and will be likely to want to be breastfed instead Holding him in a different position, such as propped up against your front and facing away from you, may also help
Before deciding to introduce the bottle, it’s worth considering that breastfeeding does get easier and that there is a lot of extra work involved with bottlefeeding in terms of preparing feeds. Also, as your breast milk is produced on a supply and demand basis, introducing bottles for some feeds
will affect your milk production. If you do want to combine the two, talk to your health visitor or a breastfeeding counsellor about how to manage this so that you can maintain breastfeeding
Will people treat me like a failure if I can’t breastfeed and have to use formula?
Many mothers do feel pressure from friends and family to breastfeed their newborns It is unlikely that you will be treated as a failure, as Western society is very accepting of bottlefeeding and, on the contrary, it is a continual effort to try to promote breastfeeding in our society. In November 2007, the Department of Health actually banned baby milk manufacturers from advertising infant formula for children under six months old on television and in parenting magazines.
Guidelines aside, although breastfeeding is a wonderful experience, it can sometimes be very hard work to establish If you find that you are struggling to establish breastfeeding, it’s worth seeking help from your midwife, health visitor, or breastfeeding counsellor before giving up
completely. However, if you find you simply cannot breastfeed, or you choose not to, you should try not to feel guilty as formula-fed babies grow and develop perfectly well. This is your baby and you will have your baby’s best interests foremost whatever action you decide to take.
Which formula milk should I buy?
There area number of brands that have a very similar nutritional content and you may need to chat to your local midwife or health visitor, or even family and friends with little ones, when trying to decide which one to use. Sometimes, babies are born prematurely and may need a special formula, or occasionally may react to a particular brand. If your baby was born full-term and is healthy, it is usually down to personal preference.
Manufacturers modify cow’s milk to make formula for human babies by adjusting carbohydrate, protein, and fat levels, and adding vitamins and minerals. There are two main types of formula milk, which have different ratios of the two proteins in milk: whey and casein. Those that are suitable for babies from birth contain more whey than casein The ratio of whey to casein in these milks is similar to that of breast milk, so it is thought to be easier for new babies to digest Milks that are marketed for the ”hungrier” baby (known as ”follow-on” milk) are casein-dominant and take longer to digest.
Why do some people use soya-based formula and is it safe?
Soya-based formula is made from soya beans, which are modified for use in formula with vitamins, minerals, and nutrients. Some parents consider giving a soya-based formula if their baby has an intolerance or sensitivity to cow’s milk formula. Soya infant formulas are nutritionally similar to cow’s milk-based formulas. The protein used in soya formulas is an extract of the soya bean, which has a high protein content. However, the UK government recommends that you should always seek the advice of a health professional before giving soya-based formula to
your baby. The current Department of Health advice is that soya formula milk should not be given automatically to babies with a sensitivity to cow’s milk, as there are other types of formula that are suitable for most babies with an allergy or intolerance that may be more favourable than soya. So if you are considering soya milk, make sure you seek medical advice first.
The carbohydrates used in soya milk contain glucose syrup, which may damage your baby’s teeth over a period of time, so if you are using soya formula, make sure you take your baby to the dentist once his teeth come through and tell the dentist that your baby has a soya formula. The Food Standards Agency also highlights concerns that soya-based formula could affect reproductive health. This is because soya contains phytoestrogens, substances found naturally in some plants, which may mimic cr block the action of the hormone oestrogen As this is a potentially sensitive time in a baby’s development, it is not clear whether soya-based infant formula could affect a baby’s reproductive development.
How should I hold my baby when I’m giving him the bottle?
Bottlefeeding can be a wonderful time for bonding with your baby by holding him close. Find a position that both you and your baby like — think about whether you are right- or left-handed and the age and size of your baby. You can cradle your baby or simply sit your baby on your lap. You will help reduce wind by giving your baby his bottle in as upright a position as possible. Also take care to tilt the bottle so that the teat and neck are always filled with formula and never leave your baby to feed unattended by propping the bottle up. Ask your midwife or health visitor for further advice
How long do you need to sterilize bottles for?
The recommendation is that you sterilize bottles and teats for at least the first year of your baby’s life. It is during this time that they are most vulnerable to germs and viruses, which if contracted could cause illness and possibly dehydration.
Can I make up feeds in advance?
Ideally, you should make up each feed fresh. The Department of Health and Food Standards Agency’s recommendations on the preparation and storage of formula milk advise that the risks associated with using powdered infant formula milk are reduced if each feed is made up fresh, as the longer the formula is stored, the greater the risk of bacterial growth. They do acknowledge that there are times when this is not practical, for example if you are going to leave the house for an extended period, or if you are dropping off a baby at a childminder’s or nursery. In this case, you should prepare the feeds in separate bottles as instructed and then store them in the fridge (see below). This is a departure from previous information so can seem unusual to mothers who have previously bottlefed Discuss this with your midwife and health visitor
How long can pre-made feeds stay in the fridge?
Although it is not recommended that you make up bottles of infant formula milk in advance to store in the fridge because of the risk of bacteria developing, if you need to do this, store them in the back of the fridge, not the door, to ensure they are below 5°C (4 PF) and never store feeds for longer than 24 hours (although this is considered too long for young babies). Formula milk is not suitable for freezing.
Taking a break
Is it safe to warm a bottle and take it out to use later on?
Carrying warm formula milk in an insulated carrier is not safe, as warm milk is a good breeding ground for bacteria The safer option is to make a feed up fresh for your baby just before it is required If you are out, you can carry boiled water in an insulated container ready to mix with formula powder when you need it Ready made-up milk feeds that come in little cartons are a more expensive option, but are handy for instantly decanting into a sterilized feeding bottle. If your baby is reluctant to take milk at room temperature, you could use a travel bottle-warmer, which can also be used to heat up containers and jars of baby food
What precautions should I take making feeds with bottled water when I’m travelling?
When using bottled water to make up a feed, make sure the seal is still intact. Use still, not sparlding, water, and avoid water with high concentrations of the minerals sodium, nitrate, or flouride. Boil the
One of the major plus points of bottlefeeding is that anyone can feed your baby, allowing you to have some time off and rest.
* Getting your partner involved in feeding is a great way to help him bond with and feel close to your baby
* Sharing feeds gives you a break and you can take it in turns to do night feeds
* If you are switching from breast- to bottlefeeding, it may be easier to get someone else to give your baby the bottle, as your baby may reject the bottle from you wanting to be breastfed instead water in a kettle in exactly the way you would boil tap water at home and wash and sterilize your feeding equipment as usual Large bottles of mineral water should be stored in a fridge after opening For convenience, you may prefer to use smaller bottles of mineral water if you are travelling from place to place. For extra convenience, ready-to-feed milks are available in cartons so you do not have to carry bulky tins of powdered milk with you. Although more expensive, these cut down on the amount of work you have to do and mean that you can be sure of good hygiene in the absence of adequate facilities
I’ve heard that bottlefed babies have smellier poo - is this true?
This does seem to be the case Bottlefed babies may have one bowel movement a day or only have a bowel movement once every three or four days.
Avoiding tummy upsets
Small babies are more susceptible to gastrointestinal infections so it’s important to observe strict hygiene while bottlefeeding. One of the most important aspects while bottlefeeding is to ensure that all the equipment involved in the bottlefeeding process is sterilized properly and spotlessly clean with no trace of old milk. This means sterilizing the bottles, teats, and lids (see p.239). If your baby doesn’t complete a feed, don’t be tempted to give it to him later to finish as germs that are present in the baby’s mouth may have transferred to the bottle and can then breed in the milk When you are travelling or out for the day, you need to take care transporting feeds Ready-made formula is probably the safest way to feed your baby while on the move, or adding formula to the water when you need it. Changes in water in different regions sometimes cause tummy upsets in bottlefed babies.
are normal. A bottlefed baby’s stools are pale brown smelly, and more formed than those of a breastfed baby. Some baby formula milks give a greenish tinge to the stool. It is thought that unabsorbed fat causes the unpleasant-smelling stools in formula-fed babies. Breast milk is better absorbed, which means the stools usually have less odour
Will my baby get more wind if he is bottlefed?
Wind refers to the air in your baby’s tummy. It is swallowed along with milk during feeds, but also when he cries. It will fill his tummy before he has drunk enough milk and be uncomfortable Also the faster flow of milk from a bottle can make babies take in more gulps of air. Some babies suffer with wind and need burping after every feed Breastfed babies tend to get fewer problems with wind than bottlefed ones as they control the flow of milk at the breast and so suck at a slower pace, swallowing less air with the milk They also have smaller and more frequent feeds and may be fed in an upright position, both of which can reduce wind
Some babies have trouble bringing up wind and their discomfort is obvious You can reduce wind by feeding your baby in an upright position and tilting the bottle so that the teat is full of milk and not air. If your baby doesn’t burp after a couple of minutes, he probably doesn’t need to. Wind your baby by gently rubbing his back or placing him over your shoulder Some babies only seem to be able to get rid of wind through hiccuping. If the wind is severe, your health visitor or doctor may suggest medication.
Is it OK to give my baby water as well as milk?
Formula milk does tend to be less thirst-quenching than breast milk as the strength of formula doesn’t vary whereas breast milk varies in consistency, with the beginning of a feed tending to be more watery If your bottlefed baby still seems hungry after a feed, it could therefore be that he is thirsty and some cooled boiled water may help to placate him In hot weather he may need regular top-ups of water.

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.

What do I tell my boss?
your rights and benefits
My manager said I can’t have time off for my antenatal clinic, is this true?
All pregnant women are entitled to paid time off to attend antenatal appointments as required by a registered medical practitioner, midwife, or health visitor. The employee must show a certificate issued by one of the above professionals to confirm they are pregnant, together with proof of the appointment. You are not expected to do this for the first appointment as this will be when you ask for the documentation Antenatal appointments include childbirth preparation or relaxation classes, as these are an important part of your care. If your employer is refusing to allow you time off, start by talking it through with him or her. If this doesn’t help, seek advice from your human resources department or another senior member of staff You can also contact trade union representatives, the Advisory, Conciliation, and Arbitration Service (ACAS), or the Citizens’ Advice Bureau (see p 310).
When is the best time to tell my employer that I’m pregnant?
As soon as your employer knows that you are pregnant, the employment laws that protect you will apply, so it’s a good idea to tell him or her straight away. It is recommended that you inform your employer in writing with details of your expected due date. Your employer should then conduct a risk assessment for you in your working environment. Any risks identified should be removed or, if this is not possible, alternative arrangements should be made for you. You can also discuss when your maternity leave will start, when you can take any outstanding holidays, and if there are any other entitlements If your baby is born early or your maternity leave starts earlier than planned due to illness, the arrangements can be altered at short notice. Your employer should respect
your right to confidentiality, so by telling them, this should not mean that everyone else at work will know. If you wish the issue to remain confidential until a certain date, you could add this to your letter.
Can you tell me about the new baby funding from the government?
The government introduced the Child Trust Fund for children born after the 1st September 2002. This is a voucher of E250 that is to be used to set up a tax-free savings account. The account will be for the child
alone and can only be accessed by them when they reach the age of 18, although they can start to plan what to do with the money from the age of 16. Once the account has been set up, family and friends can add to the savings to a maximum of £1,200 each year. When your child is 7 years old, a second payment of £250 is made and children of low-income families will receive an additional E250 around the same time that will be paid directly into their bank account. There are three types of account that you can choose to set up for your baby a savings account, an investment account, or a stakeholder account. Talk to a bank or building society about which account they would recommend.

Since I told my boss I’m pregnant he has been really dismissive - what should I do?
The law protects you from being unfairly treated as a result of you being pregnant. This includes dismissal on the grounds of being pregnant or a reason that is connected to pregnancy, If you feel that your boss is treating you unfairly, try to resolve this with him first.
To protect yourself, it is advisable that you keep your manager informed of your maternity leave, return date, and antenatal appointments. Always confirm appointments in writing or provide official documents that show appointment times You should also ask your manager about any additional benefits the company may have and when you will have your risk assessment. If your manager does not respond satisfactorily to these requests, seek advice from your human resources department, a senior member of staff trade union representative, ACAS or the Citizens’ Advice Bureau.
Am I sure to get my job back after having my baby?
The law states that all employees on ordinary maternity leave (52 weeks) are entitled to return to their original job. This is regardless of how long they have worked there or what hours they work. Exactly the same terms and conditions should also apply. If a member of staff returns after parental leave (see right), then they should return to the same job where possible, if not a suitable alternative should be given. You have to notify your employer, usually in writing, when your maternity leave is planned to start. When they receive this letter, they have 28 days to write and confirm your return date. You do not need to give notice if this is the date you plan to return, but if the planned date is different or changes, eight weeks’ notice is required. You cannot work for the first two weeks (or four weeks if in a factory) following the birth of your baby.
How long can I stay at home after I’ve had my baby?
The law changed in April 2007. All pregnant women. can now take up to 52 weeks as maternity leave, regardless of their length of continuous service at their place of work. Notification to your employer must be given before the 15th week before the baby is due (25 weeks’ pregnant).
Statutory maternity pay is paid for 39 weeks to pregnant women earning at least £87 per week with 26 weeks continuous service into the 15th week before the baby is due You need to give written notice to your employer 28 days before the start of statutory maternity pay. If you do not qualify for this benefit, you may receive maternity allowance for 39 weeks (see p.62).
Am I allowed to take additional time off unpaid after my paid maternity leave ends?
You can take parental leave after maternity leave and will be entitled to the same terms and conditions as if you were taking ”additional” maternity leave of 52 weeks (see above). This means you can return to the same job, where possible, or a suitable alternative should be found. Parental leave is a separate entitlement for employees who have worked for the company for one year and must be used to care for the child or to find suitable childcare arrangements. Each parent can take 13 weeks for each child and it is unpaid If you have twins, this means you will get 13 weeks for each twin. If you do not qualify for parental leave, you could take paid holiday or ask your employer for unpaid leave. It may be worth discussing flexible working options with them, too.

Can I refuse to do tasks during pregnancy if they might put my health or the baby’s health at risk?
An employer has a duty to comply with health and safety laws, and when you are pregnant your employer must carry out a risk assessment for you within the workplace. The sooner you tell your employer in writing that you are pregnant, the sooner this check will be conducted Your employer has an obligation by law to tell you of any risks known to the company that may affect your pregnancy, Common risks to you or your unborn child are exposure to toxic or harmful substances; lifting heavy loads; standing, sitting, or twisting for long periods of time; long working hours; or certain shift patterns Your employer has a duty to either remove the risk or, if this is not possible, remove you from exposure to the risk. This may involve a suitable alternative job or suspension on full pay.
The company is talking about redundancy - can they get rid of me when I’m on maternity leave?
Your employer is breaking the law if they make you redundant because you are pregnant or taking maternity leave This is an example of sexual discrimination, as they could not treat a man in the same way, However, if the reason is a legitimate one unconnected with your pregnancy, and they have not treated you any less favourably because you are pregnant, then this is allowed.
Apart from unfair redundancy, how else can I be discriminated against during pregnancy?
Other discriminatory issues during pregnancy include giving you unsuitable work (you should have had a risk assessment carried out, see above), changing your hours of work without your agreement, using pregnancy-related illness as a disciplinary issue, and giving you poor staff reports because you are pregnant
My friend came back to work and was demoted - are they allowed to do that?
Under the Sex Discrimination Act (1975) it is against the law for an employer to discriminate against an employee on the grounds of gender, marriage, pregnancy, or maternity leave This can be classified as direct or indirect discrimination. An example of indirect sex discrimination may be less favourable treatment of part-time workers, which may affect women in particular as more women tend to work part time than men. All employees on ordinary maternity leave (52 weeks) are entitled to return to their original job, however long they have worked at the company. If an employee returns after additional parental leave, they should return to the same job where possible, or if not to a suitable alternative. If it is felt that an employee has been demoted due to maternity leave, advice should be sought by the human resources department, a trade union representative, ACAS, or the Citizens Advice Bureau.

I want to work part time after my baby is born - do I have that right?
Currently the law states that parents of children under the age of 6, or disabled children under the age of 18, have the right to apply for flexible working, which can include different shift patterns, when -you work, how long you work, and where. You must make your request in writing. Your employer is duty bound to consider your request and must be able to demonstrate why this is not possible if it is refused. You are entitled to take a colleague with you to any meetings regarding this issue, which may be your trade union representative if you have one.
If at any point you feel that your employer has not reasonably demonstrated why the company cannot accommodate your request, you can seek the advice of a trade union representative, the human resources department, or another senior member of staff. Also, as previously mentioned, organizations such as ACAS and the Citizens’ Advice Bureau may be able to offer advice and information.
What is maternity allowance and will I be eligible for it?
Maternity allowance is a benefit for women who have changed jobs during pregnancy, are self-employed, or who have had low earnings or unemployment during their pregnancy (see p 63). Your midwife should be able to advise you on what you are entitled to and can give you a certificate to confirm your pregnancy, which is known as a maternity certificate or Mat B1. which you will need to claim your maternity allowance.
What happens if I decide to be a stay-at-home mum - do I have to give my maternity pay back?
If you decide that you don’t want to go back to
work after the birth, you must give your employer at least the amount of notice your contract requires for leaving your job, and more notice if possible. You are still entitled to receive your maternity pay for up to
39 weeks even if your employment ends, and as long
as you do not begin another job, and you do not have to pay any of this back. However, if you had additional maternity pay or benefits, you may be required to pay some or all of these back.
I want to work right up to the birth - is that allowed?
Yes, you can do this, but you may need a doctor’s medical certificate to confirm that -you are fit to do so, and you should tell your employer at least 15 weeks before your baby is due when you want to start your maternity leave. Think carefully before making this decision Late pregnancy is extremely tiring and, if your job is mentally and/or physically taxing, it may be better to begin your leave a few weeks before your due date. You will also need time to prepare for the arrival of your baby
I want to go back to work very quickly - how soon can I start?
Legally, you can return to work anytime from two weeks after the birth, or four weeks if you work in a factory However, on a practical and emotional level returning so soon may not be a good solution Most women find that it takes around six weeks to recover after the birth Breastfeeding takes around six weeks to become established too Even if you bottlefeed, it is probable that your hormones, together with the natural exhaustion that follows having a baby, prevent you from concentrating. You may find that it is hard to be apart from your baby for long periods and -you need to think about your baby’s needs too.

Maternity benefits
Your rights in pregnancy
There is a range of benefits available to pregnant women and what you are entitled to depends upon your individual circumstances and your employment status These benefits have improved considerably over the years Check your company’s policy, as individual companies may also offer their own, more generous, maternity package.
Ordinary maternity leave All pregnant employees are entitled to take 52 weeks of maternity leave, regardless of the amount of time they have worked for an employer and their salary You can start your leave up to 11 weeks before the baby is due You can choose to work up to your due date, although if you take any time off sick in the four weeks before your due date, your employer can start your leave from that date
You are obliged to give your employer a minimum of four weeks’ notice of when you intend to start your leave and a minimum of four weeks’ notice of when you plan to return. You are also legally obliged to take a minimum of two weeks’ leave after the birth of your baby You may need to inform your employer in writing of your intention to take leave Tell them the date when the baby is due and the date you want to start your maternity leave. If you meet certain criteria (see right), you may be entitled to statutory maternity pay for 39 weeks of your maternity leave, after which time you will be taking unpaid maternity leave.
What are my rights while I’m on leave?
You have the same employment rights and benefits (with the exception of your wages) while you are on maternity leave However, while on additional maternity leave, some of your rights, such as contributions to a pension, may be temporarily
suspended. While on leave, you are also entitled to build up your minimum holiday entitlement, which you can add on to your leave either at the beginning or the end
Statutory maternity pay If you have been in full-time employment, or work part-time or on a fixed contract for over six months, you are entitled to receive statutory maternity pay (SMP).You are eligible for this benefit if you have worked for the same company for 26 weeks, by the end of the 15th week before the expected week of the birth. This is paid at 90 per cent of your weekly earnings for the first six weeks and then at the lesser of £112,75 or 90 per cent of your weekly average for the next 33 weeks. This is not dependent on whether or not you plan to return to work, and you do not have to return the money if you change your mind about returning to work. Your employer will deduct your tax and National Insurance contributions, and then your employer reclaims around 90 per cent of your pay from the Inland Revenue.
Maternity allowance If you are self-employed have changed your job, or have had periods of unemployment during pregnancy, you are entitled to maternity allowance, which is a tax-free benefit from the government that is also dependent on your National Insurance contributions
Maternity allowance is paid for 39 weeks at a rate of £112.7 5, or 90 per cent of your average weekly earnings if your earnings are below this figure To be eligible for maternity allowance, you will need to have been working for at least 26 weeks out of the 66 weeks before your baby’s estimated due date, and have average weekly earnings of around £30. You can begin to claim your maternity allowance up to 11 weeks
before your baby is due, and the latest you can claim this allowance is the day after your baby is born.
Time off for antenatal care Your employer is legally obliged to allow you to take a reasonable amount of time off to attend any antenatal appointments, which can include time off to attend antenatal relaxation classes or hospital antenatal classes.
Additional benefits There is a range of other benefits that are not linked to employment, which pregnant women are entitled to claim. All pregnant women are entitled to free NHS dental care during pregnancy They are also entitled to free eye treatment and free prescriptions. You continue to be entitled to free dental care and prescriptions for you and your baby for a year after the birth.You will need to obtain your exemption certificate from your health authority and your midwife or doctor will give you the application form when you have your booking in appointment.

Paternity leave
Rights for fathers
Paternity leave can be granted for an employee who is the biological father or the partner or person who will be responsible for the child’s upbringing.
To qualify for paternity leave, an employee must have had 26 weeks’ continuous service at the end of the 15th week before the baby is due and the employer should be notified, in writing, by the end of the 15th week before the baby is due. The amount of leave granted is usually around one or two weeks, which can be taken together, but not as separate days This time off must be taken within 56 days after the birth Statutory paternity pay will be paid if an employee earns at least 87 pounds per week It will be worked out as the lesser of £112.75 a week or 90 per cent of the average weekly earnings. This is the standard paternity leave package, but individual companies may offer more generous terms and conditions.