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WEIGHT LOSS
•    Find a diet plan that fits your style
•    Keep a dietary diary
•    Eat a high-protein breakfast
•    Use a pedometer to reach 10,000 steps
•    Try Alli (orlistat) for an OTC weight loss crutch
By now you are probably sick and tired of hearing about the obesity epidemic in America. You already know that bigger is not better and that a large waist size increases the risk of diabetes, high blood pressure, and heart disease. But shedding pounds—and keeping them off—is one of the great challenges of modern life.
It’s not that there is any shortage of advice. There are dozens of diet programs and probably hundreds of diet books available to help you shed pounds, preferably painlessly. Effortless weight loss seems to be the perennial American dream. Some of the diets keep popping up like perennials, as well.
One of them, misleadingly titled “the new mayo clinic diet,” has been circulating on the Internet for a decade. Even then, it was a resuscitation of the “old” mayo clinic diet that had been passed from person to person since the 1960s. The actual Mayo Clinic has disavowed this diet in any of its incarnations, but that doesn’t stop enthusiasts from claiming that you can achieve weight loss of 50 pounds in 2 months by following the plan. People are instructed to breakfast upon eggs, bacon, and grapefruit. Lunch consists of salad, meat, and the ubiquitous grapefruit. For dinner, the dieter has (you guessed it) half a grapefruit plus as much meat as he or she wants and a green or red vegetable cooked in butter. People are encouraged to eat until they are
full.
The sad and simple truth is that there are no shortcuts to the shape you want. Taking off pounds requires taking in less energy than you are using up.This equation has two parts: how much you eat and how much you exercise. Changing either part calls for more effort than many of us can muster in an environment that encourages us to eat more and exercise less. No doubt that’s why new diets have such appeal, even though they are often a familiar approach recycled with a new twist.
There are so many diet plans out there that we can’t possibly tell you about each one. Instead, we will stick to some general guidelines that may help you figure out the best approach for you. This is an arena in which one size does not fit all and, sadly enough, there is no magic bullet. Getting weight under control can be quite a challenge, but it is also a great Opportunity to improve your health.
Dietary Approaches
There is no question that diet is crucial to weight loss. You may not want, or even need, to count calories. But even if you take a diet pill, you can’t lose weight without paying attention to what you eat. Dietitians are fond of pointing out that losing weight is a simple matter of using up fewer calories than you take in. “Simple” it may be, but it isn’t easy, as too many of us know! For best results, of course, you need to work on both sides of the equation.
Pick a Plan
Which diet is best for weight loss? That is a difficult question to answer. Most of the popular diets have not been subjected to rigorous study. Even when they have been studied, few of them have gone head-to-head with others to determine the better or best one.
Scientists at Tufts University did undertake a comparison of four popular diets under “real world” conditions. They enrolled people in the trial and then assigned them randomly to the low-carbohydrate Atkins diet, the low-fat Ornish diet, the Weight Watchers diet plan, or the Zone diet. Although there were some interesting differences in the blood fats at the end of the stud
in terms of weight loss, the programs were about the same.People on the more extreme diets—the low-carb Atkins and the low-fat Ornish—lost a bit more weight than those on the more moderate diets. But more people dropped out of those diet groups as well, perhaps because the more extreme diets are harder to follow.
The main trick is to figure out what diet plan you prefer. We don’t mean “what you like to eat”; if you use a diet that focuses heavily on what you like to eat, it will be far too easy to eat too much. No, you need to ask yourself what you are willing to eat. If going without a single piece of cheese for a year will be a major deprivation, you might not want to adopt a super-low-fat approach. If your Italian soul can’t survive without pasta, an ultra-low-carb approach is probably out. But don’t fret too much. Either diet will work, if you stick with it. And so will a lot of the more moderate diet approaches. The social reinforcement built into the Weight Watchers plan can be very helpful for some people; it drives others nuts.
A meta-analysis of diet studies shows that both low-carbohydrate and low-fat diets are about equally effective for weight loss.831 The question is, Do you need to raise good HDL cholesterol and lower triglycerides as well? If so, choose a low-carb diet. But if you really need to get your total cholesterol and your bad LDL cholesterol under control, the low-fat diet is a better way to go.
We have a friend who has managed to lose and keep off about 30 pounds over the years. This weight loss has brought his total cholesterol down so well that he does not need a cholesterol-lowering drug. Mis surprised his doctor, who assumed that he would require a prescription for Lipitor (atorvastatin) or Zocor (simvastatin) sooner or later.
What impresses us is his persistence. He is always very careful about what he eats. We asked him how he manages to keep it up day after day, and he said he makes it like a game with himself. He actually shifts back and forth between a lowcmb pattern and a low-fat pattern, which helps him prevent boredom. But on any given day, he decides which diet he is following and challenges himself to see how closely he can adhere to it. We don’t know if he gives himself points or has a reward system set up. But playing the game of eating right has a lot of rewards built into it, not the least of which is weight control.
If you like the idea of a game, then we have a wonderful “diet” book to recommend: Eat, Drink, and Weigh Less, by the fabulous vegetarian cookbook author Mollie Katzen and the respected nutrition researcher Walter C. Willett, MD, DrPH, MPH. They devised a numeric concept, the body score, that makes it easy to measure how well you are eating and challenge yourself to do even better. 832
Write It Down
Aside from getting you to focus more on low-calorie, high-nutrient vegetables and fruits, calculating your bodV score brings another tool into play: the dietary diary. Even if you do nothing else in your weight loss efforts, do this. Get yourself a portable notebook. It can be as nice as you like, or as inexpensive as a little flip pad. But it does need to -be small, because you should take it with you everywhere you go and write down everything you eat. Not just the menus of your meals, though that is necessary and can be fun. You must also note every tidbit, every nut, every chocolate chip that you eat between meals.
***** Dietary Diary
No matter which diet you plan to follow, this allows you to track your progress. The simple act of writing it down can help you become more aware of what you are eating. You learn to ask yourself, Do I really want this?
In addition, you can analyze the information in your dietary diary to see what circumstances conspire against your sticking to your plan. Try to figure out other ways to deal with problems like having to rush from appointment to appointment and therefore missing lunch, then discovering that you are starving before dinner and gobbling down a bag of tortilla chips with nacho cheese, sauce.
Downside: Inconvenience. But if you stick with it, writing down what you eat and what else is happening can be a great way to reinforce your diet.
Cost: It’s up to you. You could spend as little as 69 cents on a small notebook or as much as $30 on an elegant bound diary.
And don’t forget to write down what you drink as well. Some of us get a lot of calories from sweetened beverages like soft drinks, fruit drinks, or sweet teas. In fact, this makes up 21 percent of our national calorie consumption. 833 Switching to water most of the time could make a substantial difference in energy intake for some people.
Eat Breakfast
It might seem like a good idea to save on calories—and time—by skipping breakfast. You’ve got enough trouble just trying to pull
get dressed, putogether everything you’ll need for the day, and get out the door. If you’re a parent, you may need to do all of that for your children, as well! It’s not easy. But going without breakfast, or grabbing just a cup of coffee and a piece of toast, is a bad idea. A study that has looked at people who have successfully lost weight and kept it off found that most of them make breakfast an important meal, or at least a reliable one.”"
There are probably some breakfast choices that might be worse for dieters than no breakfast at all. Coffee and a Danish pastry come to mind, so do orange juice and a big stack of pancakes dripping with butter and maple syrup. Foods like this are high in sugar and refined flour that are quickly absorbed and push blood sugar and insulin up rapidly. (This can be quantified in scientific terms as the glycemic index of a food, which compares the food’s effect on blood glucose to that of table sugar.) The result, though, may be that your blood sugar level will crash in 2 or 3 hours, resulting in fatigue and maybe even hunger. Instead of these high-glycemic-index treats that will send blood sugar and insulin on a roller-coaster ride—first way up, then down, way down—you want a meal that will carry you through until lunchtime. That way you have a better chance of resisting the midmorning siren call of cookies or pastry. Breakfast is especially important for children, who pay better attention in school with a little nutrition under their belts.
We like a light scramble made of mostly egg whites plus a whole egg. If that’s too much trouble, how about low-fat cottage cheese with some vegetables? Our quickest breakfast, a smoothie, still has a fair bit of protein in it: a frozen banana (peel it before you put it in the freezer!), a couple of scoops of powdered whey protein, a few teaspoons of powdered egg white, a cup or so of frozen fruit or berries, and about 3/4 cup of yogurt and just enough fruit juice to get the blender to work.
With the juice, you don’t need any sweetener; the whey and egg white are good protein, much better than yogurt alone’, and the berries offer all kinds of nutrients as well as fiber. Anyway, the point here is that you should find a breakfast that fits your tastes and lifestyle and satisfies you so you won’t need a snack before lunch.
Keep Moving
As we pointed out earlier, even the most rigorous diet is only half of the story. The other half is increasing your energy expenditure through physical activity. It needs to be tailored to your lifestyle just as carefully as your meal plan.
The majority of Americans just don’t use their muscles very much. If there were games or sports you enjoyed when you were younger, think about whether you might find the time to dust off the rust and go back to playing tennis, say, or dancing. Choosing something you love means you’ll want to do it frequently, and that is more important than the type of exercise. Gardening, swimming, martial arts, yoga, bicycling, or anything else that gets you moving is fair game. There is definitely some activity that will help you use your muscles; it is up to you to figure out what it is and go for it.
If you can’t think of anything else, consider walking. It’s
Pedometer
This gadget is a favorite at our house. It’s small and lightweight, so you can set it to 0, clip it on your belt, and wear it all day long just to see how many steps you take. Of course, if you have a favorite walking or running course, you can measure the distance in miles or kilometers by wearing the pedometer while you traverse it. The goal of taking 10,000 steps a day is definitely doable, but it provides a good challenge. Public health folks offer it as a starting point.
Downside: it can be tricky to figure out the best place to wear this gadget to get an accurate count. Setting the pedometer so it measures your stride is not as hard as programming a VCR, but it can be a challenge.
Cost: Approximately $25 to $30. You can spend more, but you don’t need to.
cheap and readily available, and it’s good exercise. All you need is a pair of decent shoes and about 20 minutes to spare. If you have been very sedentary, you don’t even want to start with 20 minutes. Begin with 5 minutes and gradually work your way up to longer walks. To give yourself something of an extra challenge, get a step-counting pedometer. Then strive for 10,000 steps a day. Write down your step count every night in your dietary diary. When you can get to 10,000 steps reliably, day after day, set yourself a new challenge.
Herbal Disappointment
Dozens of dietary supplements are promoted as weight loss aids, but the science supporting most of them is lacking. Even when a study is done, the difference between those who took the product and those who took placebo is generally quite modest, possibly just a few pounds over several months. So if someone tries to sell you an all-natural supplement from somewhere exotic—whether it’s the Amazon, Outer Mongolia, or the North Pole—be suspicious. If you are told that the agent will turn on your fat burners or turbocharge your metabolism, double your skepticism. People have been selling herbal diet pills for more than 30 years. If they really worked, we’d all be as thin as we’d like to be. In most cases, the only thing that will lose weight is your wallet.
The track record for herbal diet pills is frankly rather discouraging. For quite a while, ephedra (Ephedra sinica) was promoted as a natural weight loss aid. Companies producing ephedra products made a lot of money until, eventually, the FDA reviewed all the reports of problems with this herb. The agency determined that ephedra was associated with a number of strokes, heart attacks, and other serious complications and called for its removal from the market. Aside from being overweight, some of the people who suffered life-threatening or even fatal side effects were otherwise in good health. This Stimulant might have helped people shed pounds in the short term, but it was not safe enough to be used for the long haul.
Ephedra has stimulant properties, which probably account both for its ability to promote some weight loss and for its potential to trigger a dangerous reaction. A couple of other natural products with stimulant activity have beensu ested for use in weight loss. Green tea835 and yerba matAl
have been considered for this purpose, though the research so far is not impressive. Both contain caffeine, along with other compounds that might be relevant.
Another purported stimulant, Garcinia cambogia (hydroxycitric acid), has also been included in a number of herbal weight loss preparations. A 3-month randomized controlled diet did not demonstrate any weight loss benefit beyond that of placebo.837
Q. What is hoodia? I keep getting e-mail messages that this is a wonderful way to lose weight. Does it work? Is it safe?
A. Hoodia is a cactus that grows in the Kalahari Desert in southern Africa. It is being promoted as a marvelous weight loss agent, but there is very little clinical research to support the claims.
One small, unpublished study (18 obese patients) demonstrated some benefit, but we would need to see far more evidence before recommending this plant product. Questions have been raised about the quality control used in manufacturing hoodia products, and long-term safety has not been established.
Nonprescription Help
One of the reasons that ephedra became so popular was that there were only a few other choices available without a prescription. The most popular over-the-counter (OTC) weight loss ingredient was a decongestant called phenylpropanolamine, or PPA for short. In its heyday during the 1970s and 19805, Dexatrim was one of the most popular brands.
PPA was not as safe as most dieters assumed, however. As early as 1980, British researchers had raised a red flag. When they gave PPA to healthy young medical students, they noted side effects such as an alarming elevation in blood pressure along with dizziness, heart palpitations, headache, insomnia, anxiety, and restlessness. By 1990, doctors in the United States had reported 142 bad reactions to PPA, including bleeding stroke, seizure, and even death. But it took the FDA 10 years to make a move. It requested a study of PPNs safety, particularly with respect to bleeding stroke. Yale investigators found that women who took PPA for the first time in a cough or cold remedy tripled their risk of a stroke. Those using the drug as an appetite suppressant appeared to be at 16 times the stroke risk of a woman not taking
the drug. 8-38
Given these data, FDA staffers estimated that PPA might be responsible for 200 to 500 strokes in people under the age of 50 each year. Extrapolating over all the years it was on the market, PPA could have accounted for as many as 10.000 strokes in people who otherwise would not have been vulnerable to that problem. The agency announced in 2000 that OTC weight loss products would need to be reformulated without PPA.This meant that most dieters could no longer rely on a pill to help them. Ephedra had been taken off the market because it was too dangerous. And PPA was removed as well, also because it was not safe enough.
With the approval of orlistat (available by prescription as
Orlistat (Alli)
This weight loss medication is also available by prescription under the name Xenical. It appears to be one of the few weight loss drugs considered safe for long-term use. Orlistat is intended to be used in conjunction with a reduced-calorie, reduced-fat diet. The drug prevents the absorption of fat from the gastrointestinal tract. Nearly twice as many people on orlistat manage to lose 15 percent of their body weight in a year as people on diet restrictions alone.
Side effects: Most of the side effects are gastrointestinal. Because orlistat prevents the absorption of fat, fat is retained in the imeslines. This may result in stomachache, diarrhea, nausea, flatulence, rectal discharge, and fecal incontinence. Headache is also a possible side effect.
Downside: The drug may interfere with the absorption of fat-soluble vitamins. Take a multivitamin either 2 hours prior to or 2 hours after taking Alli.
Cost: Approximately $50 to $60 per month Xenical) to go over the counter under the name Alli, people finally have a tested do-it-yourself option. The company has chosen the name Alli to imply that it will work best if allied with a full program of dietary and behavior modification approaches. The FDA appears confident that this drug does not pose significant safety issues.
Orlistat is a compound that prevents the absorption of fat. It can help people lose weight, but there are some drawbacks. For one thing, there’s the underwear risk: spotting with oily stool. There also may be increased flatulence, sometimes with discharge. Orlistat doesn’t take you off the hook for eating carefully: The 5- to 6-pound weight loss advantage over placebo occurs only when people eat a reduced-calorie, low-fat diet. Unfortunately, once people stop the medication, they often gain back the weight they lost.
Perhaps Alli would be best used as a “jump start” by someone who’s having a hard time pulling together the pieces of a diet plan. Few people will want to take it year after year, although it does appear to be cost-effective.839
Prescription Weight-Loss Drugs
The history of prescription diet pills in the United States is full of woe and intrigue. Starting in the 1950s, millions of overweight Americans were prescribed amphetamines to help them shed a few extra pounds. Such stimulants were supposed to be taken for only a few months at a time, but they were extremely seductive. Many respectable housewives became dependent on “speed.” This made physicians a bit more cautious about prescribing such medications to help people lose weight.
During the 1990s doctors began to combine two diet pills that had been around for decades. The combination of fenfluramine and phentermine (”fen-phen”) seemed to work better than either drug trouble was, the combination led to heart valve complications. At about the same time, a new appetite suppressant, dexfenfluramine (Redux), was approved. It, too, was associated with heart problems and a potentially life-threatening condition called pulmonary hypertension.
In 1997, the FDA asked the manufacturer to withdraw Redux from the market, although it had been approved only the year before. Fenfluramine was also taken off the market. The fen-phen fiasco was certainly a spectacular disaster. Quite a number of people were left with damaged hearts just because they took drugs to help them lose weight.
Despite this uninspired track record, many people were hoping for the FDA to approve a new diet pill. The claims being made about rimonabant (Zimulti) are extraordinary. It is easy to understand why some people might be eager to try it, even if others are skeptical.
The manufacturer, Sanofi-Aventis, is being especially careful to downplay the cosmetic weight-reducing potential of Zimulti. Instead, they are highlighting other benefits, such as the improvement of lipid profiles. In three large clinical trials, Zimulti resulted in promising metabolic improvements.840,841,842
Good HDL cholesterol rose and bad triglycerides dropped. Insulin efficiency improved and blood sugar levels came down. The positive changes were twice what researchers would have anticipated from weight loss alone. Such metabolic effects may be especially beneficial for people with type 2 diabetes.
What really has millions of people excited, though, is rimonabant’s ability to lower weight. After 1 year on the drug, subjects lost approximately 15 pounds, significantly more than those on placebo. In the world of diet pills, such a loss is impressive.
The buzz surrounding Zimulti is enormous. Weight loss and
iW Rimonabant (Zimulti►
Acomplia is different from other prescription diet pills because it works on an entirely new mechanism. It blocks brain CB0) (cannabinoid 1) receptors that respond to natural marijuana-like compounds. It is more effective than any other medication for weight loss, helping people lose more than 15 pounds over the course of a year.
Acomplia also has beneficial effects on good HDL cholesterol, triglycerides, insulin efficiency, blood sugar level, and blood pressure.
Side effects: Nausea, diarrhea, dizziness, headache, sore throat or flu, anxiety, insomnia, and depression. Most of these were mild and transient, although depression is disconcerting and may lead to suicidal thoughts.
Downside: We don’t have much information on the long-term effects of this new medicine.
improvements in blood glucose, blood pressure, and lipids are certainly much needed. In addition, investigators are studying whether rimonabant may help people quit smoking. There is even some hope that the compound may help people deal effectively with other drug dependencies, including the most prevalent one, alcohol.”
The FDA has delayed approval of rimonabant due to worries about anxiety, depression and suicidal thoughts. It could take years to assess whether the drug is safe enough for longterm use.
Conclusions
Losing excess weight is notoriously difficult, but it can have a profound effect on health. Dropping pounds can help lower blood pressure and get cholesterol under control, as well as alleviating the strain on arthritic joints. Weight loss is probably approached best as a long-term change in lifestyle rather than a short-term goal. If Weight Watchers or a similar program that offers social support appeals to you, by all means try it out. Here are some other suggestions that may help.
•    Find a diet plan that appeals to you. The only program that will work is one that you can stick with long-term.
•    Keep a dietary diary. Write down every single morsel that you stick in your mouth and when. Most of the weight loss gurus that we have consulted over the last few decades emphasize that this one behavior is essential for lasting success.
•    Eat a high-protein breakfast. No more bagels and butter. Skip the orange juice and coffee. A low-glycemic-index meal will carry you through to lunch.
•    Find an exercise you like. Get a pedometer and strive for 10,000 steps a day. Plot your progress in your dietary diary or on a computer.
`If you need a pharmacological boost, consider Alli (orlistat). This fat Mocker may help you lose a few pounds, though the side effects might be embarrassing. Don’t forget to take your vitamins if you take this drug.
•    If all else fails, Acomplia (rimonabant) may provide the help you need to lose weight, improve your cardiometabolic risk factors, and quit smoking. Check with your doctor about the benefits and risks of this prescription drug.

INSOMNIA
• Avoid late-night TV, alcohol, and caffeine
• Exercise during the day
• Take a hot bath 1 hour before bedtime
• Listen to soothing music or a relaxation CD
• Seek cognitive behavioral sleep therapy ***
• Eat a high-carb snack before bedtime
• Take magnesium before bedtime ***
• Scent your bedroom with lavender or jasmine
• Try melatonin
• Use acupressure
• Consider valerian ***
• Ask your doctor about Ambien CR (zolpidem) **
• Check with your doctor about Lunesta (eszopiclone) **
• Inquire about Rozerem (ramelteon)
• Ask your doctor about Sonata (zaleplon)
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At the other end of the life span, sleep problems are just as common side effects plavix . Older people frequently have trouble getting to sleep wellbutrin xl effecacy . Another common complaint is that they wake up far too early nabumetone arthritis medicine . Some have to get up to visit the bathroom and then have diffi-culty falling back to sleep tizanidine vs lorazepam for muscle spasm . Others find that they are wide-awake at 3:00 a bactrim ds package insert .m coumadin risks for taking . and toss and turn until mornin~ i Up to half of all elderly people report trouble with insomnia
Babies and senior citizens are not the only ones who suffer aripiprazole product monograph . The number of people who have intermittent or chronic sleep problems is enormous, perhaps as many as 70 million 672 That means that one in five of us is all too familiar with sleeplessness chloresterol drug tricor . 673
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Think about a sleep debt as you would a financial debt omeprazole is the generic for .The more it grows, the harder it is to pay oft Eventually your body rebels nexium blood sugar . Chronic sleep deprivation is associated with high blood pressure, weight gain, diabetes, reduced immunity, daytime drowsiness, poor performance, traffic accidents, falls, memory problems, and cognitive impairment sustention testosterone despo . But lying awake in bed worrying about these possible consequences won’t help parlodel treatment in ivg .
NIGHT LIGHT
Epidemiologists have found that too much light at night may increase a woman’s risk of breast cancer discount vardenafil hydrochloride .”‘ Light
suppresses the production of a natural brain hormone called melatonin xenical acne . Blood levels of this hormone naturally rise at night purchase celecoxib on the net . When you are exposed to a computer screen or bright light at night, the body cannot make enough melatonin metformin 500 mg half . A low level of melatonin is associated with cancers of the prostate, lung, stomach, and breast ivf protocol estrace mid-cycle .675 To minimize disruption of melatonin, body-clock researcher William Hrushesky suggests the following sensible guidelines:
• Have a consistent bedtime generic mestinon .
• Darken your bedroom remeron tab .
• Get regular exercise during the day alternative health caffeine .
• Abstain from alcohol before bed (it blocks melatonin) prothombin time coumadin .
Inviting Sleep
Have you ever climbed into bed exhausted after a stressful day, only to discover that your brain won’t slow down? The events of the day just keep replaying like an endless movie perscription drug stores ultram tramadol . Figuring out how to let go of those worries can be challenging preventive treatment doxycycline . Watching the clock tick off the minutes or the hours just makes things worse glimepiride allergy sulfonamide . The later it gets, the more anxious you become, especially if you are concerned about being fresh the next day evista benefits com .
It’s hardly any wonder that so many people get into the habit of reaching for a sleeping pill “just in case generic allegra online .” They assume they will have difficulty falling asleep and pop a pill to prevent trouble cyclophosphamide and pulmonary hypertension and denton . Of course, this leads to an endless cycle keyword prozac controversy . Without the sleeping pill, they have rebound insomnia, which reinforces the fear of not being able to fall asleep, which triggers another round of pills zanax and buspar . What else can you do to avoid tossing and turning for hours?
Cut Out Caffeine
Most people know that caffeine is a stimulant that can keep them awake maker of flomax . They avoid that evening cup of coffee, thinking that will solve the problem diflucan over . But some people are so sensitive to the effects of caffeine that they should stay away from coffee, tea, and caffeinated soft drinks at any time in the afternoon discontinuation of bupropion . And don’t assume that decaffeinated coffee is the solution to your insomnia problems evista cod . If heartburn is contributing to your nighttime sleep woes, the culprit could be decal coffee, which can trigger acid reflux that may wake you up ic tramadol hlc .
Beware Drugs That Can Keep You Awake
Caffeine is not the only drug that can interfere with aood night’s sleep lithium polymer batteries uk . A surprising number of prescription and
over-
the-counter medications can contribute to nightmares, insomnia, or disrupted sleep using hibiclens while on accutane . Many of these drugs would not necessarily be expected to cause problems crestor vs zocor . Beta-blockers such as atenolol, metoprolol, and propranolol, which are prescribed for high blood pressure or heart trouble, may cause nightmares and insomnia lipitor child labor . The osteoporosis medicine Actonel (risedronate) can interfere with sleep vitamin b 12 deficiency nexium . So can many antidepressants, such as Effexor (venlafaxine), Prozac (fluoxetine), Wellbutrin (bupropion), Zoloft (sertraline), and others, and allergy medicines that contain decongestants such as phenylephrine and pseudoephedrine long term luvox use .
The list of drugs that can cause sleeplessness is so long that we cannot possibly include it in its entirety here guarana seed caffeine content . If you suspect that your medication may be interfering with restful sleep, discuss this issue with your pharmacist and your physician what is a cyclosporine challenge test . There may be alternatives avalide while pregnant .
Forgo the Nightcap
And don’t forget alcohol getting a tattoo on penicillin . An evening glass of wine or a nightcap may seem relaxing and even make you drowsy solubility cefuroxime acetone . But alcohol can affect melatonin levels and interfere with dreaming sleep ship free viagra sample . Waking too early is a common consequence of having an evening cocktail dristan sinus pain with ibuprofen .677 If you’re having trouble sleeping, don’t drink after dinner meloxicam for tendonitis .
Exercise
Exercise is not only good for the heart and bones, it is also a great stress reliever will prednisone make blood sugar elevate . If you can take a brisk walk, play a couple of sets of tennis, or play a round of golf (without the golf cart), you will find that your level of anxiety will diminish allergic reactin prednisone . Do it in the afternoon and you may get some sun on your face sore leg muscles and lipitor . Bright light combined with exercise can relieve depression and insomnia buy soma online usa .678 The sun exposure can also affect melatonin levels that have an impact on sleep quality and could reduce the risk of breast cancer in women tried both diflucan and vaginally . 79
Tai chi is an ancient Chinese exercise program can you get preganant taking provera . This gentle form of activity is actually quite beautiful to watch risperdal zoloft interaction . Researchers at the Oregon Research Institute in Eugene recruited 118 men and women over 60 years old importation viagra . Half were taught tai chi and the other half had a low-impact exercise session tramadol apap opinion . The tai chi students reported that after 6 months, it took them less time to fall asleep (18 minutes less on average) and they slept longer (48 minutes longer) ivermectin injection scabies .’
Timing is everything when it comes to exercise and sleep aleve drug interaction . If you exercise in the morning or early in the day, you should have less trouble sleeping amoxicillin bloating side effect . But if you exercise in the evening, just before bedtime, you’re likely to have more trouble sleeping clavulanic acid ampicillin oral dose .681
Hot Bath
Another simple, inexpensive, and pleasant way to ward off insomnia is to take a hot bath viagra us drugs stors . Here again, though, timing is critical clindamycin for prostatitis . A hot bath or shower just before bedtime could be counterproductive naproxen complications . The trick is to schedule it about an hour before you plan to go to bed risperdal children anger .(’82 A hot bath raises the core body temperature viagra after prostrate surgery . As it drops, the signal that goes to the brain is “sleepy time dipyridamole shortage .” Body temperature normally drops in the first part of a night’s sleep, so pushing it up with a 30-minute soak, then allowing it to fall tricks the body into thinking it may already be asleep zoloft versus efflexor side effects . Combined with a regular bedtime ritual, this can really help monohydrate in cephalexin .
Winding Down
Turning off the internal dialogue is especially hard for some folks cabergoline studies . “If only” is a dangerous game effects imitrex side . People who replay the day’s events, complaining to themselves that they should have done things differently, are destined to toss and turn lamictal side effects in children . How can you stop obsessing? One way is to set aside time specifically for worrying much earlier in the day lipitor and diarrea . It sounds odd, but some people find that it helps tavist smiley atlanta .
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Cognitive Behavioral Therapy
People who have persistent problems with insomnia may find it well worth their while to consult a counselor who offers cognitive behavioral therapy (CBT) genetic viagra mastercard . A study compared this nondrug approach to a sleeping pill similar to Lunesta (eszopiclone) that is commonly used in Europe motrin coupon . Investigators found that CBT was more effective than either the placebo or the sleeping pill mucinex vs claritin .’ The intervention included instruction on using the bedroom only for sex and sleeping, sticking to a regular schedule for rising and retiring, avoiding naps during the day, progressive relaxation, and discussion of beliefs and fears about sleep loss recurrent utis and macrobid .

Cognitive Behavievai ‘Therapy
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• • •

They said I need a Caesarean
all about Caesarean births
What’s the difference between an emergency and elective Caesarean?
Caesareans are classified as elective or emergency An elective Caesarean indicates that a pre-planned decision was made during pregnancy to deliver the baby by Caesarean before the onset of labour. An emergency Caesarean is when a situation arises, usually in labour, that means the safest route for delivery is by Caesarean section.
Is it fair to say that most doctors prefer Caesarean deliveries these days?
Although the Caesarean rate has risen over the years, it would be unfair to say that this is due to doctors’ personal preferences; it is more likely to be due to over-caution on the part of the medical staff. NICE guidelines on Caesareans are quite specific on the reasons why a Caesarean should be considered and offered as an alternative to a vaginal delivery However, they also recommend that as currently one in five women will have a Caesarean section, all women should be offered some information about the procedure in antenatal classes If a Caesarean section is considered to be the most appropriate mode of delivery for you, then you should also be made aware of the benefits and the risks to you and your baby and of the possible implications on future pregnancies before you give your consent
Are there any factors that might reduce the likelihood of having a Caesarean?
Research shows there are certain factors that decrease the likelihood of having a Caesarean section and these include!
* Having one-to-one support from another woman
during labour; whether a midwife, a doula, or a supportive friend or relative. This is thought to reduce your chances of having a Caesarean.
* Waiting until after 41 weeks to have an induction of labour, if your pregnancy has been uncomplicated. * Having a home birth reduces the likelihood of a Caesarean if you have had an uncomplicated pregnancy. * Having appropriate tests during labour, such as a fetal blood sample and fetal electronic monitoring, will confirm any indications that your baby is distressed before going ahead with a Caesarean
I’ve got a small pelvis; I’m not too posh to push, but they said I may need a Caesarean. Is this right?
Cephalopelvic disproportion (CPD) is the term used to describe a labour that is not progressing due to the size or shape of the mother’s pelvis in relation to the size and position of the baby entering it. Problems may occur if a baby is unusually large or a mother unusually small. True CPD is rare and even if it is a concern in pregnancy, it is often thought best to give labour a try, although you may be cautioned that a Caesarean is a possibility. Certain signs signify CPD in labour; for example if the baby does not descend through the pelvis, or the cervix does not dilate; in these situations, a Caesarean would be necessary.
The midwife wrote LSCS in my notes - what does that mean?
The most common type of Caesarean section is a lower segment one (LSCS). This refers to the 12-15cm (5—bin) cut made along the bikini line The other type of incision is a “classical” or vertical cut, although this is extremely rare nowadays and would only be used if, for example, there was a vertical scar from a previous Caesarean, or in an emergency situation, such as a haemorrhage, although even then it is rare.

I want to be asleep during the Caesarean section. Will I have that option?
It is preferable that you are awake in the operation as most surgeons and anaesthetists agree that it is safer for mothers and babies to have an epidural or spinal anaesthetic. Also, you will be able to have your
partner with you, and will see and hold your baby straight away. In addition some women even manage to breastfeed while the operation continues or straight after the operation in the recovery room There are also greater post-operative risks for the mother and baby with general anaesthesia, including respiratory problems. If you are afraid of the operation talk to your midwife or doctor You may be able to visit an operating theatre and discuss the procedures.
I haven’t had problems, but I just don’t want to go through birth. Can I opt for a Caesarean?
If there are no medical grounds for a Caesarean and this is purely down to your fear of labour pains, then to opt to have a Caesarean is a drastic decision A Caesarean is major abdominal surgery, and although it is sometimes preferable, it is not a favoured method for many reasons, such as the risk of post-operative problems occurring as a result of surgery; a higher risk of secondary fertility problems, or the second baby being born by Caesarean; and an increased risk of postnatal depression It would be better to talk to your midwife about the pain-relief options available and ensure you receive the most effective type for
you. Having somebody you know and trust with you in labour can reduce your anxiety levels greatly. If you still feel that you cannot go through with labour, you may need to talk to your consultant obstetrician as the final decision will probably be his or hers.
I’ve had two Caesareans and now have been advised to have an elective one. Is this necessary?
It is common practice to advise women who have had more than one Caesarean section or operation involving cutting the womb to have an elective Caesarean This is because the risk of the womb rupturing during labour is slightly higher with each of these procedures. Usually, women who have had one previous Caesarean can have a ”trial of labour’ (see p. 182), but this will depend on the reason for the last Caesarean and how your current pregnancy is going If you do have a trial of labour, this will be carefully monitored and any indications that may suggest a rupture beginning would result in a Caesarean without question It is usual to prepare the mother for a Caesarean in case an urgent one is required by having an epidural anaesthetic in place, as this will reduce the time delay if intervention is needed. Ultimately, whether you opt for an elective Caesarean or for a trial of labour is your decision and the consultant will be able to advise on the risks and benefits of each method.
I heard that Caesarean babies are brighter because they don’t have a traumatic birth. Is this true?
No. this is not the case at ail Full term, healthy babies are designed to cope with the stresses of a natural labour and birth and should not be affected in any way by this experience The type of birth on its own does not affect a baby’s abilities, although if a baby becomes” distressed” during the delivery, on rare occasions this can cause problems that persist into later life (although usually the baby is born fit and well) It is the case that you can help your baby by staying healthy in pregnancy, for example by eating well and not smoking or binge drinking.

A Caesarean birth is when your baby is born during an operation in which the surgeon lifts out your baby through a short incision made through your abdomen (generally below the bikini line) and through the wall of your womb. This operation is carried out under anaesthetic, which could be spinal anaesthesia, epidural, or occasionally by general anaesthetic. There are many different reasons why a Caesarean birth happens. Sometimes the decision can be made during the pregnancy, which is called an elective Caesarean, and sometimes the decision is made during labour, which is known as an emergency Caesarean.
Today the Caesarean birth rate is 25 per cent
in the UK and rising. Look at the statistics from your local hospitals to see what their Caesarean rates are to help you decide where to have your baby. If you are considering an elective Caesarean, you should bear in mind that this is not without risks to you or your baby, or even to your next pregnancy, The decision to have a Caesarean section should be made by weighing up all the risks and then making a decision that is right for you
Can I avoid a Caesarean? There area few things you can do to help prevent a Caesarean section, for instance having someone with you throughout your labour, especially a midwife; having a homebirth (if you have no risk factors like high blood pressure); having an external cephalic version (turning your baby while you are about 37 weeks pregnant) if your baby is in a breech position (their bottom coming first); having a senior obstetrician involved in the decision not to have a Caesarean; and, if it is thought your baby is distressed, taking a fetal blood sample before deciding to carry out an emergency Caesarean.
What type of anaesthesia will I have? There are different types of anaesthesia for Caesareans all of which prevent you from feeling the operation General anaesthetics (which make you go to sleep) are only used if your baby needs to be born quickly or you have a rare blood disorder with low levels cf platelets (these help your blood to clot) Vlore offer_, an injection is put into your back, which is either a spinal block, when the drug is injected into the spinal fluid, an epidural, or a combined spinal epidural; you are awake to experience your baby being born and there are fewer complications this way

Caesarean, and these will stay in place for about 24 hours. If you wish to breastfeed, you can feed as soon as the baby is born, while the operation is still happening It is important that you are pain-free after your Caesarean, so ask the midwives for more pain relief if you need it, ideally before the pain builds up. To prevent blood clots forming in your legs, you will be given an injection and after 24 hours or preferably sooner, you will be encouraged to get up and walk around
How much can I do after a Caesarean? Once you get home, take it easy and let the pain guide you as to how much you do. You can start gently exercising as soon as you want and most hospitals give you information as to which exercises you can do safely. Using your vacuum cleaner, driving, and strenuous exercise are definitely not recommended You can drive again after six weeks, depending on your insurance company.
Will I have to have a Caesarean next time? The reason you had a Caesarean this time will determine the advice from your doctor as to whether you have a VBAC (vaginal birth after Caesarean) or have further Caesareans for subsequent babies. If you feel negative about the birth of your baby, you should try talking to your doctor or hospital and get expert help, as it is common to feel unhappy if you had an emergency Caesarean when you were expecting a vaginal birth.

What type of pain relief will I be given before the operation?
There are two main types of anaesthesia, or pain relief, prior to a Caesarean section! general and regional. A general anaesthetic is the procedure whereby the mother is put to sleep before the
Caesarean. Although this is a relatively quick
and safe method for the mother and baby, it is not common practice as it is thought preferable for the mother to be awake during the operation so that she is able to expereince the birth of her baby, rather than having to wait until she recovers from the anaesthetic and is possibly too groggy to respond to her baby. There is also a slight risk of the mother inhaling vomit during the operation and the possibility that the anaesthetic will affect the baby’s responses after the birth (see p.207).
A regional anaesthetic is given either as an epidural (see p 176), a spinal block, where the anaesthetic drug is injected into the fluid surrounding the spinal cord, or a combined spinal epidural. In both cases, a needle is inserted into the back and medication is given through a narrow tube to numb the abdomen downwards Although this takes longer to perform than a general anaesthetic, the anaesthetist will be very skilled at inserting the needle He or she will use a cold spray to ensure that you are totally numbed and the procedure will not start until the anaesthetist is completely happy that this is the case. On very rare occasions when the procedure can be felt, a general anaesthetic will be given straight away. The regional option is safer and
the birth experience is not missed The choice will ultimately be yours, unless certain conditions dictate the safest option
Who will be in the operating theatre?
Although it may seem like a crowd, all of the people in the operating theatre have a role. An anaesthetist will be present to make sure you do not feel the procedure and he or she will be helped by an operating department assistant. The main surgeon and his or her assistant will be performing the Caesarean section A midwife and sometimes a paediatrician will receive the baby A scrub nurse will pass the instruments to the surgeon and a runner’ will be there to fetch things and count the instruments with the nurse Your permission must be gained for students to be present You may wish to have your husband partner friend, or a family member present with you, which is usually agreed with the team leader in advance (although it is very common for your partner to be there).
How will I be stitched and how long will my scar be?
If you have the most common type of Caesarean, a ”lower segment Caesarean section”, a 12-1 Scm cut is made along the bikini line. The other, less common, type is a ‘classical” or vertical incision. During a Caesarean, the surgeon needs to cut through several layers of fat and tissues before making an incision in the uterus These internal layers will then be restitched after the operation using soluble stitches and then the layer of skin will be stitched or clipped at the end. Clips, or staples, are usually removed about three days after the operation whereas stitches are left in for about five days. The removal of clips or stitches is usually a fairly painless procedure.
Can my partner still cut the cord?
It is important during a Caesarean section that the procedure is carried out under sterile conditions. This means that all of the staff around the operating table, and the instruments, will be sterile (the highest level of cleanliness). The staff have to undergo a specialized washing technique called ‘’scrubbing” and then use a gown that has been washed and packed to certain standards This is to reduce the risk of infection to the mother and baby. If your partner was allowed to cut the cord, this would mean that the same principles would apply. It would therefore not be practical or possible to ensure that every partner was trained in this technique However, it may be possible for your partner to “trim’ the cord away from the table as an alternative. This is sometimes necessary when the midwife has cut the cord and applied the cord clamp; but there is still too much cord length, and it is often a good opportunity to involve dads
Will I be able to watch my Caesarean section operation if I want to?
Usually the mother is fully awake for her Caesarean section, with the exception of some emergency situations when it might take too long for the anaesthetist to insert the spinal anaesthetic, in which case a general anaesthetic will be given However, whether the mother would literally be able to watch the Caesarean section is a different matter. During
•    Caesarean when the mother is awake, it is usual for
•    screen to be erected to stop her and her partner from seeing anything. To see the operation, the screen would have to be taken down. You would also need to have your head raised, which would present difficulties for the surgeon, as the operation requires that the mother lies fairly flat so that the surgeon can get to the baby and the abdomen. Although the operation itself may sound thrilling, you may not be thinking this when it is actually happening to you On occasion, even a planned Caesarean section can run into difficulties, and in the worst case scenario, the mother will have to be given a general anaesthetic.
Many obstetricians, however, do drop the screen, if you wish, at the point of your baby being delivered from the abdomen, and the parents are shown the baby so that they can see what the baby looks like.
Is a baby born by Caesarean section any different to a baby born vaginally?
The condition of a baby following a Caesarean section depends greatly on the reason for the operation. If the Caesarean section is being performed as an emergency situation because the baby’s wellbeing is in question, there will be differences between this baby and one born by
a planned Caesarean section or vaginal birth. For example if the baby is distressed, its skin colour, activity levels, and breathing rate may all be affected Each baby is assessed, initially by the midwife and/ or a paediatrician, and is then given a score out of 10, known as the Apgar score (see p.217).This looks at the baby’s colour, heart rate, stimulation response, how the baby is breathing and the muscle tone, and the midwife will perform a detailed examination of the baby a little later to examine the baby’s skin, fontanelles, ears, eyes, mouth, nose, body, genitals, spine, anus, and heart and breathing. A baby born by a planned Caesarean will have a nice rounded head as it hasn’t been pushed through the birth canal, and about and this will. in itself, speed up recovery and reduce the risks resulting from immobility such as deep vein thrombosis.
Will I still be able to hold my baby straight after the birth?
In most units, the midwife or paediatrician will show you your baby quickly before reviewing your baby’s condition (see p.217) Once the paediatrician and the midwife caring for you are happy that your baby is well, she will be well wrapped and placed across your chest while you are on the operating table. Although it might be hard for you to hold your baby at this point due to your position, this will be the first opportunity for you to feel and see your baby.
Once you have been transferred to the recovery area after the operation, the midwife will first make sure that you are well by checking your pulse, breathing, and blood pressure, and by looking for any signs of heavy bleeding She will then attempt
to get you into a comfortable position, probably lying on your side, to enable you to enjoy some skin-toskin contact with your baby and to breastfeed your baby should you so wish.
How soon will I be able to go home after a Caesarean section?
Only a relatively few years ago, women who had had a Caesarean were kept in hospital for around five to seven days, and a few years before that, 10 to 14 days was the average amount of time spent in hospital Nowadays, mainly due to the recognition that women do recover much better in the comfort of their own homes — where they are likely to get more sleep and rest as they are not being disturbed by other babies — and also sometimes due to economics, lack of space, and reduced maternity staffing levels, women are usually discharged from hospital at around two or three days after their Caesarean operation.
There are individual circumstances when this might not be the case, for example if the mother is not coping well after the birth, if she is on her own at home, or if she is having problems breastfeeding her baby, then her discharge home may be delayed. If a baby has been admitted to the special care unit in the hospital, many maternity units will allow the mother to stay for up to 10 days.

You may think that there is little a
partner can do during a Caesarean, but this is not the case as your birth partner still has the important job of supporting you during the operation.
* If the Caesarean is an emergency procedure, partners can make sure that the reasons why this is necessary are clear. * If you are awake for the procedure, your partner can remain in the theatre, sitting by your head and offering you reassurance throughout the operation.
* Once your baby is born, you and your partner can welcome her together,
and its gender Then the screen is put back up to deliver the placenta and stitch up the incision. If you do wish to watch more of the operation, you should discuss this with the surgeon and the anaesthetist prior to the operation Likewise, if you don’t want the screen to be lowered at all, make this clear to the operating team beforehand.
What are the reasons for Caesarean sections?
There are various reasons why a Caesarean section might be carried out. You may be advised to have a Caesarean if the baby cannot enter the pelvis due to the baby’s size or position or the shape and size of the pelvis; if you have a low-lying placenta; for a multiple pregnancy or breech baby, if your labour is not progressing; if you had a previous Caesarean section or traumatic birth: if you have severe pre-eclampsia; if the baby’s growth is severely reduced; if you have had heavy bleeding in pregnancy; and for certain other medical conditions The doctor will advise you of the reasons why a Caesarean section may be the safest option.

Recovering from a Caesarean
Although you should remain mobile after a Caesarean operation,
it is also important that you get plenty of rest A Caesarean is major surgery so you will need to avoid lifting and carrying heavy loads for the first few weeks. As this may be difficult if you have other small children or are at home alone, you should try and recruit as much help as possible after the operation You should avoid doing any shopping, which usually involves lifting, or driving for a few weeks Check with your insurance company when they are happy for you to drive again and make sure that you feel comfortable wearing a seatbelt and doing manoeuvres, including emergency stops. It is generally thought to take up to six weeks to fully recover.

Where should I give birth?
home or hospital?
Do I have options for where I can give birth?
Yes you do Choosing where to have your baby is
a personal choice and knowing all the relevant facts can help you to make an informed decision. You can contact an organization called BirthChoiceUK for more information (see p.310) and talk to your midwife and other mothers in your area to widen your perspective. Where you live will affect your choice, as will the decision to have NHS care, go to a private hospital, or hire an independent midwife, who can arrange to deliver your baby in the local maternity unit If your pregnancy has been straightforward, you should be offered the option of delivering your baby at home, in a birthing centre (if one is available in the vicinity), in a hospital birthing unit (see p 154), or in the hospital obstetric unit itself
Is it safe to have my baby at home?
Research has shown that for healthy women who have had a normal pregnancy. a planned home birth attended by an experienced caregiver is as safe as giving birth in hospital. There are similar findings for
birth centres and GP units. Statistically, women who have home births are less likely to use drugs to cope with the pain and less likely to have an assisted delivery or Caesarean, even if they have to be transferred to hospital during labour. They are also more likely to use upright positions for giving birth compared to hospital births. Likewise, women who give birth in a birthing centre (see p 154) are less likely to use drugs for pain relief and less likely to have their labour speeded up artificially. They are also more likely to be satisfied with the care they receive.
Can I choose which hospital to give birth in or does it have to be the one nearest to me?
Although, technically, you have a right to choose any hospital in which to give birth, you should consider the practicalities of distance for attending antenatal appointments and scans at the hospital you choose, as well as thinking about how far you want to travel while in labour. A local facility is therefore probably the most sensible choice. You may have a variety of services nearby, including hospitals, GP units, or birthing centres Discuss all your options with your midwife and doctor and try to talk to other mothers locally to see if they have recommendations.
My pregnancy hasn’t been straightforward. Will I have to give birth in hospital?
There are several reasons why you may be advised to deliver in hospital. If this is a second baby and there were complications before, such as bleeding in pregnancy or a Caesarean, your midwife might suggest you deliver in hospital. Or if this is your first baby and there are complications, such as diabetes or high blood pressure, or it is a multiple pregnancy, you may be advised to have your baby in hospital

What additional things do I need to think about if I’m having a home birth?
It may be worth having all the items you need for the labour and birth gathered in the place you intend to deliver, and it can also be helpful to organize your items separately from the baby’s items As well as practical items, such as clothing, toiletries, and sanitary pads, you may also want to have to hand music phone numbers, and a camera It’s a good idea to have a well-stocked fridge to ensure that you have nutritious snacks to hand during labour as well as helping you and your partner in the first few days after the birth. Your baby will need nappies, cotton wool, vests, clothing sheets and blankets If you have other children, you may need to make arrangements for them with family friends, or neighbours, or have meals planned for them in advance and plenty of activities to occupy them.
Even though you are planning a home birth, there are occasions when things don’t go quite as you wish and you need to be transferred to hospital. This can happen before, during, or after labour and so even though you may not wish to contemplate this outcome, it’s a good idea to have an emergency bag packed for such an occasion.

Hospital birthing units

Unlike ‘’stand-alone” birthing centres, which may be some way from a hospital unit with emergency equipment a hospital birthing unit is situated in the hospital delivery suite, or nearby, but there is still little medical intervention and doctors are not in the unit. However, if there is an emergency or you want an epidural, instead of having to await transfer to a hospital, the midwife can transfer you rapidly to the delivery suite on site
Do I have a right to give birth at home?
The issue of a legal right to home birth has become a bit complicated recently because there is no right in law for women to give birth at home, and the Department of Health has issued advice to NHS Trusts saying that they should provide a home birth service ‘ where practicable ‘, rather than insisting that they provide one However, the bottom line is that in law no one can be compelled to attend a hospital for treatment or care, and that includes for birth. Your local services are likely to influence your choices greatly and the organization BirthChoiceUK can help to inform your decision (see p 310).
What’s the difference between a birthing unit and a maternity department in a big hospital?
Birthing units are run by midwives and the emphasis is on a natural birth. They can be situated next to a hospital maternity unit or on a completely separate site. Some hospitals have a birthing unit facility in the actual maternity unit, known as a hospital birthing unit (see left), where midwives provide total care in a dedicated area of the maternity unit
As the majority of women give birth without needing medical intervention, these units provide a good alternative to a more medicalized hospital environment. The environment in a birthing unit tends to be more relaxed and flexible, which may appeal if -you want a home birth atmosphere with added support. You will also have continuous support from midwives and may even be attended by the same midwife throughout your labour and birth Furthermore, the midwives in these units are very experienced at handling a birth without medical intervention All of these factors therefore increase your chances of having a straightforward birth.
To be eligible to give birth in such a facility, you would need to have had an uncomplicated pregnancy and be unlikely to require specialized medical care or monitoring in labour and birth. If complications do occur in labour or birth at a birthing unit you would need to be transferred to the nearest maternity unit, although this is a rare occurence as most women in birthing units have been identified as being ”low risk’
If you labour in a standard maternity unit, you can be subject to a range of policies and not enjoy the same degree of flexibility However, you will have access to an epidural and, if emergency intervention is needed, doctors will be close at hand.
I’m booked for a Caesarean as my baby is breech, but I want a natural birth. Is this possible?
You need to discuss this with your midwife and obstetrician and express your preference, as your feelings are an important factor when deciding how to manage your birth. You may be able to have a procedure called external cephalic version (which is usually done around 37 weeks) to try to turn your baby to a head-first position (see p.144) However, if you have this procedure and your baby still remains in a breech position, you may be advised to have a Caesarean, although some obstetricians will support you if you wish to try for a vaginal birth (see p. 183).
I don’t want to be monitored in labour. Will the midwives and doctors listen to me?
Unless there is a medical or obstetric complication, such a previous Caesarean section or high blood pressure, you don’t need to be strapped continually to a monitor to listen to the baby’s heartbeat Instead, a procedure called ”intermittent auscultation’, which means listening in regularly to the baby’s heartbeat with a sonicaid, should be sufficient to monitor the baby’s wellbeing. Ultimately, the choice of monitoring or listening in if all is well, is yours. If a midwife or obstetrician wants to monitor the baby’s heartbeat continuously, they should explain why
It’s a good idea to make a note of your wishes during pregnancy in a birth plan (see p.149) and discuss this with your midwife before you go into labour If you don’t have a chance to discuss this before labour when you do go into labour, the midwife on duty will first take a medical and obstetric history and ensure that you and your baby are well, and will then ask if you have a birth plan, or you can show her the plan.
Can I bring food and drinks into the labour room?
The latest NICE guideline recommends that all women should be able to drink in labour. Water may be refreshing, but isotonic drinks may be more beneficial, as they contain energy-boosting ingredients. If established labour is progressing well and you and your baby are well, you can eat light snacks to give you energy and help labour to progress. However, if you require pethidine or diamorphine, which can make you nauseous or sick, or need an epidural, or other risk factors develop, you may be advised to drink sips of water only. You may also be offered an antacid tablet to reduce acid build-up in your stomach This is a precaution in case you need an emergency Caesarean
Who will be with me while I’m in labour?
If you have a home birth, you will be allocated a midwife who will stay with you throughout your established tabour As you near delivery, she will contact the hospital and a second midwife will be sent to support her and you through the birth. Whoever else you have at your home delivery is
up to you Things may be different in hospital, where it is generally recommended that you have just two birthing partners, simply because the space in most labour rooms is limited. Once in established labour, NICE recommendations are that you are cared for by one midwife throughout labour. In reality although each unit will endeavour to offer one-to-one support, this may not be possible If this is the case, the midwife will be with you as much as she can, will show you how to contact her if she is not in the room, and will be with you for the delivery. It may be wise to organize one or two people such as your partner and a good friend, to support you during labour
and maternity support workers to support midwives Unfortunately, there have been times when maternity units are full If no beds are available, staff will find a bed for you at another hospital: many hospitals have “sister” units, to which they will transfer you. Most
maternity units are not full for long and will organize for you to be transferred back as soon as possible
I keep reading about infections like MRSA and now I’m worried about having my baby in hospital.
Although there is a great deal of media coverage of ‘ superbugs” such as MRSA, most people have
no problems at all with hospital infections. Infections are caused by germs, of which there are four major types: bacteria; viruses; fungi, moulds, and mildew; and protozoa. Hospital infections are bacterial There are thousands of different types of bacteria. Some bacteria, known as helper germs, are friendly or good bacteria, which aid the digestion and absorption of food in the gut. Others can cause infection and illness, methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C difficile) being two notable ones of concern in hospital.
MRSA is a bacterium that can live completely harmlessly on the skin of healthy people, but can lead to serious infection in vulnerable individuals. Good hygiene, particularly in the form of simple precautions such as hand washing, is an effective method in the prevention of MRSA infection and your chances of acquiring this in hospital are low. Even healthy relatives and friends of patients with MRSA
I’ve heard about hospitals
being understaffed and women not getting a bed. Is this true?
There are concerns about shortages of midwives and beds. Many hospitals now employ ancillary staff carry no risk If cutlery and plates are washed using soap and water (preferably hot) this removes MRSA, and the risk of acquiring MRSA through contact with curtains, sheets, and pillows is very low Healthcare workers use antiseptic solutions, such as alcohol hand rubs, and more recently many hospitals have alcohol gels for hand cleaning at the end of each bed.
C difficile is another type of bacterium mentioned frequently in the media Hospitals prevent and control the spread of C. difficile with antibiotics general hygiene measures such as hand washing, and by detecting cases early so that they can isolate affected patients to prevent it spreading further.
What measures can I take to prevent my baby or myself getting an infection in hospital?
Regular hand washing by yourself, staff, and visitors are likely to be adequate measures to prevent infection. Take your own soap, a flannel, and moist hand wipes with you. Always wash your hands after using the toilet and always wash your hands or clean them with a hand wipe immediately before and after eating a meal Make sure your bed area is regularly cleaned and report any unclean toilet or bathroom facilities to staff. Breastfeeding will provide your baby with protection against infection. A new innovation, silver-lined pyjamas designed to protect against MRSA, are now on sale in the UK! Silver is thought to have particular antibacterial qualities and to be an effective agent against infection. Hopefully these measures will help you feel in control You are unlikely to be in hospital for very long, and you and your baby should be safe
My partner can’t drive. Can an ambulance take me to hospital?
An ambulance can transport you to hospital in an emergency for example if you are bleeding heavily As this is an emergency vehicle driven by trained operatives it is expensive to provide. If you call an ambulance for a non-emergency you could be taking it away from an emergency situation and putting others’ lives at risk.
Part of planning for labour is finding out which facilities your local maternity unit provides and what you might need to provide yourself to help you through the labour and birth.
* Check if your local unit supplies
equipment such as birthing balls or TENS machines or whether you need to hire these in advance.
* Check in advance if the hospital has a birthing pool and midwives trained to deliver babies in water.
* Find out if your hospital has a dedicated birthing unit (see p 154)
be on call when you go into labour? Or can you call a minicab in early labour? If you can’t organize transport, discuss this antenatally with your midwife or, once in labour, call the labour ward for advice.
Can I ask for a private room in the hospital for me and the baby after the birth?
Unless you give birth in a private hospital, there are few hospitals that offer private postnatal care Many hospitals have postnatal ”amenity rooms”, which are usually single rooms, with or without ensuite facilities, on the postnatal ward These may be allocated to women who need a private room for medical reasons in which case they are free. Otherwise, they are offered on a first come, first served basis, so state in your birth plan if you wish to have one and remind your midwife after the birth.
The cost of these rooms and their facilities can vary between units and covers the room only The midwifery care is given by the staff on the postnatal ward and, in most units, your partner and visitors will still have to abide by the ward visiting times.

Although there are no guarantees that your labour will proceed in the
way you would like it to and it’s probably best to approach labour with a flexible attitude, there are things you can do to make it more likely that you will end up having the type of experience you would prefer Attending antenatal classes and being as informed as possible about labour and your choices will help you to prepare in advance Other things women find helpful are having a supportive birth partner, making decisions with the midwife, being positive, and using a birth plan.

Water births
Relaxing in labour
Some cultures have used water births for centuries to provide a gentle birthing experience. Today, there is evidence to support the fact that labour may be quicker and less painful in water.
How can it help with the pain? Possibly women feel more comfortable and therefore more confident and in control in water. It is thought that water sets off a surge of oxytocin (the hormone that triggers contractions), making contractions more effective Some women find they can move around more easily in water, which helps them find a good position in which to give birth. Some feel the benefits of immersion in warm water as soon as they get into the pool, but for others it can take 15-30 minutes before they relax. Water can
be a natural aid to relaxation as it soothes muscles and releases tension. When we feel less anxious, our bodies produce fewer ’stress” hormones. This encourages the brain to produce endorphins, the body’s painkillers, and promotes wellbeing Dimmed lights and relaxing music can further aid relaxation. Some studies suggest that women have a shorter second stage of labour in water, and there may be less exertion needed to push the baby out If contractions are too intense you can still use Entonox (gas and air).
Can the baby be monitored in water? Your baby can still be monitored by the midwife using a Pinard (ear trumpet) stethoscope or a waterproof hand-held electronic sonicaid.
Will I be allowed to have a water birth?
You can use a birthing pool providing your pregnancy is normal and there were no problems in previous pregnancies If -you want a water birth in hospital and are going to be induced (without a drip), or there are other complications with the pregnancy, you may need to negotiate this with your doctor or midwife. You can talk to a Supervisor of Midwives (who can be contacted via the maternity unit) during pregnancy to help you to make a plan to meet your wishes
Is it possible to have a water birth in hospital?
This depends on the hospital maternity unit Some units have their own birthing pool; some have facilities for you to hire a pool and bring it in; some units have only room enough for a pool to labour in; and others do not have the facilities for you to bring one in or the structural ability to have one in the unit as the amount of water in the pool would be too heavy for the floor to hold.
If your maternity unit does have a birthing pool. it is possible that the pool might be in use when you go into labour. To improve your chances of being able to use a pool, you may want to consider a home birth and to hire a pool (see p. 153).
Can I use the birthing pool for labour and birth if I’ve had a previous Caesarean?
Unfortunately, it is recommended that if you have had a previous Caesarean section, your baby’s heartbeat and your contractions will need to be continuously monitored throughout a subsequent labour and delivery which cannot be done in a birthing pool The reason for continuous monitoring in this situation is that there is a chance, although quite a small one, that your uterus may rupture. This often causes no pain and the only indication may be a change in your baby’s heartbeat. If you decide you do want to labour and deliver in water after a Caesarean section, this is your choice, but you should be fully aware of the risks.
When can I get into the birthing pool?
You can get into the pool whenever you want, but some midwives suggest that you wait until you are 4-5cm (tin) dilated or in established labour. This is because some people are concerned that the water can be so relaxing that it may cause the contractions to slow down or even stop, although there is little evidence to support this However, if this does happen, getting out of the pool and walking around for a while is likely to increase the strength of the contractions You will need to get out of the pool if your baby passes meconium (see p.252) or if the midwife has any concerns about you or your baby.
The water temperature can be whatever you find comfortable, although 37°C (98 6′n body temperature is usual, especially if you are giving birth in the pool, as babies can get cold quickly once they are born.
Most units have guidelines on this.
Can I deliver my baby in a birthing pool, or are these just for labour?
You should ask your midwife to find out if the hospital that you have chosen to deliver at provides facilities for you to deliver in the water, or just use the pool for most of your tabour This often depends on whether the pool is big enough for the delivery, Occasionally, there may not be a midwife available who has been trained in delivering births under water, in which case you may only be able to labour in water and will have to get out for the delivery.

Home birth
Planning a birth at home

Although only around two per cent of women in the UK choose to give birth in their own home, this number is increasing. Research has shown that mothers may have shorter and less painful labours in their own home. It is not known why this is, although it may be due to them feeling more confident and comfortable in their surroundings. You will generally have at least one midwife with you constantly once you are in established labour during a home birth. Many women hire a pool for use during labour at home, and this may progress to a water birth.
Will I be allowed a home birth? If your pregnancy has been classed as ”low risk’ - you are healthy and have not had any complications in this or any previous pregnancies - then a home birth is a definite option If you desire a home birth and have experienced some complications during the pregnancy, talk to your midwife or contact a Supervisor of Midwives at your local maternity unit who will be able to advise you.
How do I plan for a home birth? If your midwife is happy for you to deliver at home, you need to talk to her about the type of home birth you wish to have, for example do you want a water birth (see p.156) or to use a birthing ball, and how do you plan to manage the pain? If you would like a water birth, you will need to hire a birthing pool in advance You may want to set up a special area in your home to have your baby, which ideally should be near bathroom facilities. Plastic sheeting and old sheets are advisable to protect your flooring, and shower curtains make a good surface for giving birth You will also need a supply of dustbin bags for waste.
What will happen? Most community midwives carry a homebirth pack with them, which they will bring along when you go into labour The kit includes a blood pressure monitor; a stethoscope and/or sonicaid; a thermometer; gloves; a gas and air cylinder; pethidine; scissors; antiseptic solutions; and emergency equipment Some midwives like you to provide towels and plastic sheets. You can use your TENS machine, and the midwife will arrange for gas and air (Entonox) to be delivered The midwife can also ask your doctor or obstetrician to prescribe pethidine or diamorphine if you wish.
What if there is a problem? If the midwives are concerned about you or your baby’s health, they will discuss this with you and it may be necessary to transfer you to hospital. This transfer is usually done by ambulance, accompanied by paramedics, your midwife, and your birth partner.

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.

High-Risk Pregnancy FAQ

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

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

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

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

Prescribed bedrest

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

Glossary
Abruption The detachment of part of the placenta from the wall of the uterus during late pregnancy, which may result in bleeding. Accelerated labour The artificial augmentation of contractions, after the cervix has started to dilate, by the injection of oxytocin through an intravenous drip Often used to speed up a long labour. Active birth An approach to childbirth that involves upright positions and movements during labour.
Active management of labour The constant monitoring and technical control of labour to monitor its duration
Alphafetoprotein (AFP) A substance produced by the embryonic yolk sac, and later by the fetal liver, which enters the mother’s bloodstream during pregnancy Alveoli Milk glands in the breasts, which produce a flow of milk when they are stimulated by prolactin and the baby’s sucking.
Amniocentesis The surgical extraction of a small amount of amniotic fluid through the pregnant woman’s abdomen. This procedure is usually carried out as a test for fetal abnormalities.
Amniotic fluid The fluid that surrounds the fetus in the uterus. Ultrasound scans may be done in late pregnancy to ensure that enough is present
Ammotomy The surgical rupture of the amniotic sac, often done to speed up labour This is referred to as ARM (artificial rupture of the membranes).
Anaemia A condition in which there is an abnormally low percentage of haemoglobin in the red blood cells, it is treated by iron supplements
Anaesthetic Medication that produces partial or complete insensibility to pain Anaesthetic, general Anaesthetic that affects the whole body, with temporary loss of consciousness.
Anaesthetic, local Anaesthetic that affects a limited part of the body
Analgesics Painkilling agents not inducing unconsciousness
Antenatal Before the birth
Anterior position See Occipital anterior Antibiotics Substances capable of
destroying or limiting the growth of micro-organisms, especially bacteria Antibodies Protein produced naturally
by the body to combat any foreign bodies, germs or bacteria
Anti-D An injection of antibodies given to women who have a Rhesus negative blood group if it is thought they may have been exposed to Rhesus positive fetal blood cells
Antihistamines Tranquillizers that are used in the treatment of nausea vomiting and certain allergies.
Apgar scale A general test of the baby’s wellbeing given shortly after the birth to assess the heart rate and tone respiration blood circulation, and nerve responses. Areola The pigmented circle of skin surrounding the nipple.
ARM See Ammotorny
Bile pigment See Bilirubin.
Bilirubin Broken-down haemoglobin, normally converted to nontoxic substances by the liver. Some newborn babies have levels of bilirubin too high for their livers to cope with See also Jaundice, neonatal. Birth canal See Vagina
Blastocyst An early stage of the developing egg when it has divided into a group of cells. Braxton Hicks contractions Practise contractions of the uterus that occur throughout pregnancy, but which may not be noticed until towards the end. Breast pump A device for drawing milk from the breasts.
Breech presentation When the position of the baby in the uterus is bottom down rather than head down
Caesarean section The delivery of the baby through an incision in the abdominal and uterine walls
Candida See Thrush,
Cardiotocograph (CTG) An electronic monitor that is used to measure the progress of the mother’s contractions and the baby’s heartbeat during labour.
Carpal tunnel syndrome Numbness and tingling of the hands arising from pressure on the nerves of the wrist In pregnancy it is caused by the body’s accumulation of fluids
Catheter A thin plastic tube that is inserted into the body through a natural channel to withdraw fluid from, or introduce fluid into, a particular part of the body This can be used to draw off urine from the bladder after an operation, or to maintain a constant input of fluids into a vein, or to introduce anaesthetic into the epidural space.
Cephalic presentation (Vertex presentation) The position of a baby who is head down in the uterus The most common presentation. Cephalopelvic disproportion A state in which the head of the fetus is larger than the cavity of the mother’s pelvis Delivery must therefore be by Caesarean section
Cervical dilatation See Dilatation.
Cervical incompetence A disorder of the cervix, usually arising after a previous mid-pregnancy termination or damage to the cervix during a previous labour, in which the cervix opens up too soon, resulting in repeated mid-pregnancy miscarriages. It is sometimes treated by suturing to hold the cervix closed. Cervix The lower entrance to the uterus, or neck of the womb
Chloasma Skin discolouration during pregnancy, often facial.
Chorion The outer membranous tissue that envelops the fetus and placenta
Chorionic gonadotrophin See Human chorionic gonadotrophin (HCG).
Chorionic villus sampling A method of screening for genetic handicap by analysis of tissue from the small protrusions on the outer membrane enveloping the embryo that later form the placenta.
Chromosomes Rod-like structures containing genes occurring in pairs within the nucleus of every cell. Human cells each contain 23 pairs. See also Gene
Cleft palate A congenital abnormality of the roof of the mouth
Club foot A congenital abnormality in which the foot is painlessly twisted out of shape. Colostrum A kind of milk, rich in proteins, formed and secreted by the breasts in late pregnancy and gradually changing to mature milk some days after delivery
Conception The fertilization of the ripened egg by the sperm and its implantation in the uterine wall.

Congenital abnormality An abnormality or deformity existing from birth, usually arising from a damaged gene, the adverse effect of certain drugs or the effect of some diseases during pregnancy
Contractions The regular tightening of the uterine muscles as they work to dilate the cervix in labour and press the baby down e birth canal
Cordocentesis A fine needle is passed trough the mother’s abdomen into the fetal –vein in the umbilical cord. The technique allows fetal blood to be tested, facilitates intra-urine blood transfusions, and enables drugs to be injected directly into the baby Corpus lutuem A glandular mass that forms n- the ovary after fertilization It produces progesterone. which helps to form the placenta, and is active for the first 14 weeks of pregnancy
Crowning The moment when the baby’s head appears in the vagina and does not slip back again.
CVS See Chorionic villus sampling.
D and C The surgical dilatation (opening) of the cervix, and curettage (removal of the contents) of the uterus
Dehydration A physical condition caused by the loss of an excessive amount of water from the body, often resulting from severe vomiting or diarrohea
Depression, respiratory Breathing difficulties in the newborn baby
Diabetes Failure of the system to metabolize glucose, traced by excess sugar in the blood and urine.
Diamorphine A narcotic opium derivative used as an analgesic.
Dilatation The progressive opening of the cervix caused by uterine contractions during labour.
Distress See Fetal distress
Dizygotic See Twins
Domino scheme A scheme operated by some hospitals in which community midwives provide antenatal care and are present at hospital for the delivery.
Doppler A method of using ultrasound vibrations to listen to the fetal heart
Doula A supportive woman helper who provides physical and emotional support during childbirth
Down’s syndrome A severe congenital abnormality caused by an incorrect number
of chromosomes that produces physical abnormalities and reduced intelligence. Drip See Intravenous drip.
Eclampsia The severe form of pre-eclampsia, which is characterized by extremely high blood pressure, headaches, visual distortion, flashes, convulsions and, in the worst cases. coma and death The condition is now rare since the symptoms of pre-eclampsia are treated immediately See also Pre-eclampsia.
Ectopic (Tubal pregnancy) A pregnancy that develops outside the uterus, usually in one of the Fallopian tubes. The mother has severe pain low down on one side in her
abdomen at any time from the 6th to 12th week of pregnancy. The pregnancy must be surgically terminated.
EDD The estimated date of delivery Electrode A small electrical conductor used obstetrically for monitoring the fetal heartbeat during labour.
Electronic fetal monitoring The continuous monitoring of the fetal heart by a transducer placed on the mother’s abdomen over the area of the fetal heart, or by an electrode inserted through the cervix and clipped to the baby’s scalp
Embryo The developing organism in pregnancy from about the 10th day after fertilization until about the 12th week of pregnancy, when it is termed a fetus Endometrium The inner lining of the uterus. Engaged (Eng/E) The baby is engaged when it has settled with its presenting part deep in the pelvic cavity. This often happens in the last month of pregnancy
Engorgement The over congestion of the breasts with milk. If long periods are left between feeds, or the baby is not well latched on painful engorgement can occur. This can be relieved by putting the baby to the breast or expressing the excess milk Entonox A mixture of 50 per cent oxygen and 50 per cent nitrous oxygen, breathed in through a mask during tabour, that gives pain relief as contractions peak
Epidural (Lumbar epidural block) Regional anaesthesia used during labour and for Caesarean sections, in which an anaesthetic is injected through a catheter into the epidural space in the lower spine. Episiotomy A surgical cut in the perineum to enlarge the entrance to the vagina.
External version (External cephalic
version, or ECV) The manipulation by gentle pressure of the fetus into the cephalic position This may be done by an obstetrician at the end of pregnancy if the baby is breech or transverse
Fallopian tube The tube into which a ripe egg (ovum) is wafted along after its expulsion from the ovary along which it travels on its way to the uterus
False labour Braxton Hicks (rehearsal) contractions, which are so strong and regular that they are mistaken for the contractions of the first stage of labour,
Fertilization The meeting of the sperm with the ovum or egg to form a new life See also
Conception.
Fetal distress A shortage in the flow of oxygen to the fetus, which can arise from numerous causes
Fetus The developing child in the uterus, from the end of the embryonic stage at about the 12th week of pregnancy until birth FH Fetal heart.
Fibroid A benign (non-cancerous) muscle growth in the uterus.
Forceps Metal tong-like instruments placed either side of the baby’s head during labour to help deliver the baby
Hormone A chemical messenger in
the blood that stimulates various organs to action.
Human chorionic gonadotrophin (HCC) A hormone released into the woman’s bloodstream by the developing placenta from about six days after the last period was due. Its presence in the urine means that she is pregnant
Hyperemesis gravidarum Almost continuous vomiting during pregnancy Hypertension (High blood pressure) During pregnancy this can reduce the fetal blood supply.
Hypnosis A state of mental passivity with a special susceptibility to suggestion. This can be used as an anaesthetic, and can be self-induced.
Hypotension Low blood pressure.
Identical twins See Twins
Implantation The embedding of the fertilized ovum or egg within the wall of the uterus
Induction The process of artificially starting off labour and keeping it going.

Insulin A hormone produced by the pancreas that regulates the level of carbohydrates and amino acids in the system. It may be used as a means of controlling the effects of diabetes.
See also Diabetes.
Internal monitoring See Electronic fetal monitoring
Intravenous drip The infusion of fluids directly into the bloodstream by means of a fine catheter introduced into a vein Intravenous injection An injection into a vein
Invasive techniques Any medical technique that intrudes into the body
In vitro fertilization (IVT) A type of assisted conception where fertilization occurs outside of the womb and fertilized embryos are tranferred back into the womb.
Jaundice, neonatal A common complaint in newborn babies which is caused by the inability of the liver to break down successfully an excess of red blood cells See also Bilirubin
Lanugo The fine soft body hair of the fetus Lateral position Transverse lie or horizontal position of a fetus in the uterus (sometimes occurring if the mother has a large pelvis), where the presenting part is either a shoulder or the side of the head
Let-down reflex The flow of breast milk into the nipple.
Lie The position of the fetus within the uterus Linea nigra A line of dark skin that appears down the centre of the abdomen over the rectus muscle in some women during pregnancy
Lochia Postnatal vaginal discharge Longitudinal lie The position of the fetus in the uterus in which the spines of the fetus and the mother are parallel
Low-birthweight baby A baby who weighs below 2,5 kg (57 lb) at birth.
Meconium The first contents of the bowel, present in the fetus before birth and passed during the first few days after birth The presence of meconium in the amniotic fluid before delivery is usually taken as a sign of fetal distress
Miscarriage The spontaneous loss of a baby before 24 weeks of pregnancy
Monitoring See Electronic fetal monitoring Monozygotic See Twins.
Morula A stage in the growth of the fertilized
egg when it has developed into 32 cells. Moulding The shaping of the bones of the baby’s skull, which overlap to allow the baby to pass through the birth canal.
Mucus A sticky secretion.
Multigravida A woman in her second or subsequent pregnancy
Multiple pregnancy The development of two or more babies, See also Twins Mutation A damaged genetic cell. This can occur naturally or more commonly as an effect of outside agents, such as radiation. Neural tube defects Abnormalities of the central nervous system See also
Anencephaly, Hydrocephalus Spina bifida. Nicotine A highly poisonous substance that is present in tobacco During pregnancy this can enter the bloodstream of a woman who smokes and may affect the efficiency of the placenta, which often results in a lowbirthweight baby
Nucleus The central part or core of a cell, containing genetic information.
Occipital anterior The position of the baby in the uterus when the back of its head (the crown or occiput) is towards the mother’s front (anterior)
Occipital posterior The position of the baby in the uterus when the back of its head (the crown or occiput) is towards the mother’s back (posterior)
Oedema Fluid retention, which causes the body tissues to be puffed out.
Oestriol A form of oestrogen.
Oestrogen A hormone produced by the ovary
Opioids (Narcotics) Painkilling drugs that induce drowsiness and stupor,
Ovary One of the two female glands, set at the entrance of the Fallopian tubes, which regularly produce eggs until the menopause Ovulation The production of a ripe ovum or egg by the ovary
Oxytocin A hormone secreted by the pituitary gland that stimulates uterine contractions during labour and stimulates milk glands in the breasts to produce milk Palpation Feeling the parts of the baby through the mother’s abdominal wall. Pelvic floor The springy muscular
structure set within the pelvis that
supports the bladder and the uterus, and through which the baby descends during tabour,
Pelvis The pelvis is a solid ring of bone at the base of the abdomen: it shields the bladder and portions of the genital tract. Perinatal The period from the 24th week of gestation to one week following delivery Perineum The area of soft tissues surrounding the vagina and between the vagina and the rectum.
Pethidine See Analgesics
Phototherapy Treatment by exposure
to light, which may he used when a baby has jaundice
Pituitary gland A gland set just below the brain that among other functions, secretes various hormones controlling the menstrual cycle. In late pregnancy it releases a hormone, oxytocin, into the bloodstream, which stimulates uterine contractions and also the milk glands.
Placenta The organ that develops on the inner wall of the uterus and supplies the fetus with all its life-supporting requirements and carries waste products to the mother’s system.
Placental insufficiency A condition in which the placenta provides inadequate life support for the fetus, often after 40 weeks, resulting in a baby at special risk.
Placenta praevia A condition in
which the placenta lies over the cervix at the end of pregnancy. This part of the uterus stretches in the last few weeks of pregnancy, but the placenta cannot stretch, so it may separate, the result is bleeding during late pregnancy, A woman with a complete placenta praevia is delivered by Caesarean section
Posterior See Occipito posterior
Postnatal After the birth.
Postpartum After delivery.
Post-traumatic stress disorder Panic and anxiety experienced by some women after traumatic and disempowering childbirth Pre-eclampsia (Pre-eclamptic toxaemia or PET) An illness in which a woman has high blood pressure, oedema, protein in the urine, and often sudden excessive weight gain See also Eclampsia.
Premature A baby born before the 37th week of pregnancy and weighing less than 2.5 Ing (5 lb)
Presentation The position of the fetus in the uterus before and during labour,

lying directly over the cervix
Preterm See Premature
Primigravida A woman having her first pregnancy.
Progesterone A hormone produced by the corpus luteum and then by the placenta Progestogen A synthetic variety of the hormone progesterone used in oral contraceptives.
Prolactin A hormone that stimulates milk production for breastfeeding Prostaglandins Natural substances that stimulate the onset of labour contractions. Prostaglandin gel may be used to soften the cervix and induce labour
Proteinuria The presence of protein in the urine, which may be a sign of pre-eclampsia. See also Pre-eclampsia
PTSD See Post-traumatic stress disorder Pubis The bones forming the front of the lower pelvis.
Quickening The first noticeable movements of the fetus felt by the mother.
Respiratory depression See Depression, respiratory.
Rhesus factor A distinguishing characteristic of the red blood corpuscles. All human beings have either Rhesus positive or Rhesus negative blood If the mother is Rhesus negative and the fetus Rhesus positive, severe complications and Rhesus disease (the destruction of the red corpuscles by antibodies) may occur, unless prevented by anti-D gamma globulin.
Rooting The baby’s instinctive searching for the breast
Rubella (German measles) A mild virus that may cause congenital abnormalities in the fetus if it is contracted by a woman during the first 12 weeks of pregnancy
Scan (Screen) A way of building up a picture of an object by bouncing high-frequency soundwaves off it. The sonar or ultrasound scan is used during pregnancy to show the development of the fetus in the uterus. See also Transducer.
Show A vaginal discharge of bloodstained mucus occurring before labour, resulting from the onset of cervical dilatation. A sign that labour is starting
Small-for-dates Babies who are born at the right time but who for a range of reasons have not flourished in the uterus. See also
Placental insufficiency
Sperm (Spermatozoon) The male reproductive cell that fertilizes the female ovum or egg.
Spina bifida A congenital neural tube defect in which the fetal spinal cord forms incorrectly, outside the spinal column Spinal anaesthesia An injection of local anaesthetic around the spinal cord.
Steroids Drugs used in the treatment of skin disorders, asthma, hay fever, rheumatism, and arthritis. Because they alter the chemical balance of the metabolism they may very rarely cause fetal abnormalities if used extensively during pregnancy
Stillbirth The delivery of a dead baby after the 24th week of pregnancy
Streptomycin A broad-spectrum antibiotic that should not be taken in pregnancy See also Antibiotics
Stretch marks Silvery lines that sometimes appear on the skin after it has been stretched during pregnancy
Supplementary feeding Additional bottles given to a breastfed baby.
Surfactant A creamy fluid that reduces the surface tension of the lungs so that they do not stick together when deflated. Preterm babies may have breathing difficulties if surfactant has not developed sufficiently Suture The stitching together of a tear or a surgical incision.
Syntocinon A synthetic form of
oxytocin, which is used to induce or accelerate labour.
TENS machine See Transcutaneous electronic nerve stimulation
Term The end of pregnancy this is measured at 38-42 weeks from the first day of the last menstrual period. Tetracycline A wide-spectrum class of antibiotic that should be avoided during pregnancy. because it can affect the development of the fetal teeth and hones See also Antibiotics.
Thrombosis A blood clot in the heart or blood vessels.
Thrush A yeast infection that can form in the mucous membranes of the month, genitals, or nipples.
Toxoplasmosis, congenital A parasitic disease that is spread by cat faeces. If it crosses the placenta during pregnancy, it can cause eye or central nervous system damage in the baby
Transcutaneous electronic nerve stimulation A method of pain relief that uses electrical impulses to block pain messages to the brain.
Transducer An instrument that translates echoes of very high-frequency soundwaves bounced off the developing fetus in the uterus to build up an ultrasound image on a monitor. See also Scan.
Transition A phase between the first and second stages of labour when the cervix is dilating to between 7 and 10 cm
Trial of labour A situation in which, although a Caesarean section may be necessary, the mother labours in order to see if a vaginal delivery is possible
Twins The simultaneous development of two babies in the uterus, either after two eggs are fertilized independently by two sperm - dizygotic or fraternal twins - or, more rarely, after one fertilized egg divides to produce monozygotic or identical twins.
Ultrasound See Scan, Transducer.
Umbilical cord The cord connecting the fetus to the placenta
Uterus (Womb) The hollow muscular organ in which the fertilized egg becomes embedded, where it develops into the embryo and then the fetus
Vacuum extractor An instrument, used as an alternative to forceps which adheres to the baby’s scalp by suction and with the help of the mother’s bearing down, can be used to guide the baby out of the vagina
Vagina The canal between the uterus and the external genitals It receives the penis during intercourse and is the passage through which the baby is delivered
VE Vaginal examination.
Vernix A creamy substance that often covers the fetus in the uterus
Vertex presentation (VX) See Cephalic presentation.
Vulva The external part of the female reproductive organs, that includes the labia and the clitoris
Water birth Birth of a baby under water.