Posts Tagged ‘period’

•    Exercise regularly to keep bones strong
•    Take vitamin D along with your calcium supplements
•    Experiment with Menostar (estradiol) instead of hormone replacement therapy
•    Consider Evista (raloxifene) to reduce risks of spinal fracture and breast cancer
•    Ask your doctor about the benefits and risks of Fosamax (alendronate)
•    Make Miacalcin (calcitonin) an option if back pain from fractures is an issue
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We tend to think of our bones as hard and unchanging, like the bones we find on our dinner plate. But actually, they are living tissues that undergo constant change and renewal, just like our other organs. Cells called osteoclasts break bone down, and cells called osteoblasts build it back up, just as if you were remodeling your house a room at a time. The osteoblasts build up living tissue and reinforce it with minerals like calcium, magnesium, boron, and manganese.
Normally, these two processes—resorption and formation of bone—are closely linked so that bone stays strong. Quite a few factors can upset the balance, though. If the osteoclasts race far ahead of the osteoblasts, bone density can drop and eventually the bones are not strong enough. A minor fall can result in a broken hip, which can be catastrophic for an older person.
OStevporosis a condition of weakened bone, is responsible for 1.5 million fractures each year, including 300,000 hip fractureS.71 The National Institutes of Health (NIH) estimates that 10 million Americans currently have osteoporosis. Two million of them are men. While osteoporosis is thought of as a women’s issue, it is not limited to women.
There’s no shortage of controversy surrounding osteoporosis. Perhaps the first issue is just how many people should be RISK FACTORS
•    Female
•    Increased age
•    Shortness and thinness
•    White or Asian
•    Family history of bone loss
•    Sedentary lifestyle
•    Irregular menstrual periods
•    Early menopause
•    Low testosterone (men)
•    High level of thyroid hormone
•    Low-calcium diet
•    Low level of vitamin D
•    Cigarette smoking
•    Alcohol consumption
•    Prednisone or similar drugs (long-term use)
•    Certain anticonvulsants
•    Celiac disease
concerned about it. According to the NIH, 34 million people have low bone density. Add that to the 10 million who have been diagnosed with osteoporosis, and you come up with 44 million Americans for whom “osteoporosis is a major public health threat .,,767 That’s more than half of the population over 50 years of age.
Lumping those 34 million who have low bone density together with those who have already been diagnosed with osteoporosis certainly makes for a larger potential market for the drugs that have been developed to prevent or treat bone loss. Some public health researchers have criticized this tactic by calling it “disease-mongering.’,768 Instead of characterizing osteoporosis or low bone density as a risk factor for fracture, calling it a disease implies that it requires treatment. 769 The critics claim that this tactic mobilizes fear (and helps sell IS IT CELIAC DISEASE?
Anyone can break a bone by falling off a horse or out of a tree. But some people break bones without even trying. If you have experienced fractures for no logical reason, you and your doctor may want to figure out why your bones are not as strong as they should be.
One possible explanation is celiac disease. It should be investigated in young people with low bone density measurements. Celiac disease is due to gluten intolerance. If it is not diagnosed and a gluten-free diet is not followed, the resulting damage to the small intestine can interfere with proper absorption of the nutrients needed to build bone.
drugs) rather than promoting understanding and positive action.
The availability of bone density screening is a two-edged sword in this respect. On the one hand, it is helpful for those who are truly at risk to find out before they break a hip or develop debilitating back pain from vertebral fractures. Unfortunately, many of those being screened are not those who need it most. An analysis of nearly 44,000 women on Medicare found that the oldest women, ages 81 to 85, were only half as likely to be screened as women ages 66 to 70.770 The older women, however, are far more likely to have reduced bone density, even osteoporosis, putting them at risk of a fracture.
Increasingly, middle-aged women are being screened for bone density. The scoring system is a bit complicated, since it is based on standard deviations below the bone density of a young person at peak bone mass. Most of us don’t have the grounding in statistics to make much sense of “standard deviations,” so if the doctor does not explain carefully what the numbers mean, women often end up confused and alarmed. Critics point out that defining osteoporosis as bone density that is 2.5 standard deviations (T score –2.5) below the mean for a young person practically guarantees that approximately 30 percent of postmenopausal women will be diagnosed with this condition, whether they are truly at risk for osteoporosis or not.”Reducing the Risk of Fracture with Nondrug Approaches
Although osteoporosis treatment now includes many more options than it did just 10 years ago, each drug that is prescribed for weakened bones has some drawbacks. That’s why it makes sense to start with nondrug approaches and see how far they will take you. If you begin early enough, you may be able to slow bone loss and prevent a fracture. But even if you already have osteoporosis, these tactics may be a good addition to pharmacological treatment to make it more effective.
Exercise
Your doctor may not be accustomed to prescribing a walk around the block,. but getting more exercise should be just what the doctor orders. In so many cases nowadays we must go out of our way to work up a sweat. Few of us do manual labor to earn a living; walking to our jobs or just to the store is almost as rare, especially in many suburbs. So instead of incorporating physical movement into everyday life, we need to find time—and funds—to go “work out” somewhere.This may be too inconvenient for many people.
It has become clear that our bodies adapt to the demands we make of them. Weight-bearing exercise like walking, running, or mowing the lawn encourages bones to grow stronger.
***** Exercise
Moving your bones helps strengthen them. Doing something enjoyable on a regular basis—walking, gardening, dancing, or another weight-bearing activity—acts to delay bone loss as well as strengthen muscles, benefit cardiovascular health, improve mood, and reduce the risk of dementia. Exercise alone may not be enough to reverse bone loss, but it can improve the effectiveness of other treatments.773
Side effects: Sore muscles
Downside: If the exercise program is overly ambitious or too dangerous, a person with reduced bone density may experience injuries, including fracture.
Cost: Too variable to estimate Sitting in front of a computer screen, sadly, does nothing to stress our bones in a healthy way. In fact, differences in traditional patterns of activity may explain why women usually have less bone mass than men, even as young, healthy adults. In the past, boys were expected and encouraged to be active by playing sports and helping with strenuous chores. Girls, by and large, were not. Although these differences are diminishing among today’s children, physical activity has been declining across the board.
A lifetime of activity is ideal for the strength of the skeleton, but it may never be too late to benefit from more exercise. Anyone who has already experienced fractures from osteoporosis should check first with his or her physician, but appropriate weight training or walking may be helpful even for those who are quite elderly or a bit debilitated. The, exercise program should be carefully designed, of course, so that it does not put the person at a higher risk for fracture from a fall or injury.
The Calcium Craze
Calcium supplements are the first thing most people think of for preventing or treating osteoporosis. Although an adequate calcium intake is necessary to maintain strong bones, just taking calcium doesn’t seem to help very much once bone density has begun to decline. Calcium supplementation can make a difference in young people, whose bones are still developing. But in postmenopausal women, the evidence is murky. Some studies have shown that 500 to 1,000 milligrams of calcium a day together with 700 to 800 IU of vitamin D can reduce the number of fractures (though this benefit does not extend to
the spine ).774,175.776
The results of the Women’s Health Initiative on this issue were less encouraging. The study was very large, involving more than 36,000 postmenopausal women. Though supplements of 1,000 milligrams of calcium and 400 IU of vitamin D daily improved the density of bone in the hip, it did not
3    777
reduce the number of hip fractures, Scientists have tried to explain the disappointing results: The women were not in the oldest age category at highest risk for fracture; the women on placebo pills could take calcium on the side if they chose to; many of the women in the active supplement group did not take their calcium and vitamin D, every day.
Calcium is important for preventing and treating osteoporosis—but by itself it isn’t enough. Taken together with adequate vitamin D, it may help reduce the risk of falling as well as improve bone mineral denSity.77,44
Most of the experts who do research on osteoporosis agree that a calcium-rich diet (or a supplement of around 1,000 milligrams daily) and 15 to 20 minutes of sun exposure 3 or 4 days a week (or a supplement of 800 to 1,000 IU of vitamin D3, also known as cholecalciferol) are a sensible approach. Take no more than 500 or 600 milligrams of calcium at a time for better absorption.
Calcium also works with dietary protein to benefit the skeleton.779 Make sure you are getting enough protein.
Side effects: Gas, intestinal bloating, constipation Downside: Too much calcium increases the risk of kidney stones.
Cost: $6 to $10 per month for a supplement that contains both nutrients
In addition, 400 IU of vitamin D, just may not be enough. An analysis of a number of studies concluded that it takes at least 700 IU of vitamin D, a day to make a difference in fracture risk .780 Lower dosages simply aren’t effective.
Human skin can make vitamin D when it is exposed to sunlight. but older people are often careful not to go out in the
VITAMIN D PARANOIA
The recommendation for supplementing with vitamin D. has been set at 400 IU a day because of worries that a person could get too much. Vitamin D in excess is toxic, so taking more than 2,000 IU a day would be foolish. Most people don’t need a lot more than 1,000 IU daily, but that seems to be a more sensible level to aim for than the currently sanctioned 400 IU. That is especially true for older people at risk for osteoporosis, who may be avoiding sun exposure for fear of skin cancer.
sunshine without their sunscreen. Aging skin is less efficient at making vitamin D, so a health-conscious older person may actually be making very little of it. If this is true for you, a supplement may be advisable.
We weren’t as surprised as others may have been at the lackluster results seen with calcium supplements in the Women’s Health Initiative. Walter Willett, MD, DrPH, MPH, the Frederick J. Stare Professor of Nutrition and Epidemiology and chair of the department of nutrition at the Harvard School of Public Health, had told us years earlier that calcium is not the whole story. Women in Scandinavia have the highest calcium intake in the world, but they also have the highest rates of osteoporosis. Women in some parts of Africa get very little calcium in their diets yet rarely have trouble with fractures as they age. Sun exposure is one obvious difference that might account for women having relatively low levels of vitamin D in Scandinavia.
Clearly, other factors are at work here. That doesn’t mean you should cut down on calcium. But don’t count on it to do the job alone.
If you do choose a calcium supplement, keep in mind that calcium citrate may be taken with or without food, but calcium carbonate is absorbed best if taken at mealtime. 783 Many sources recommend taking 300 to 500 milligrams of magnesium with the calcium supplement.
Drugs to Treat Osteoporosis
Calcium supplements may be necessary but not sufficient against bone loss. Joel Finkelstein, MD, of Massachusetts General Hospital, has suggested that supplements of calcium plus vitamin D should be thought of as the ante for a poker game: It’s the bare minimum if you are going to play.784 Most of the drug treatments for osteoporosis work best if a person gets adequate amounts of these nutrients as well.
Low-Dose Estrogen (Menostar)
Women used to be told that once they reached menopause, they needed to take hormone replacement therapy to keep their bones strong. The idea was that they would be on estrogen (plus progesterone, unless they had undergone a hysterectomy) for decades and that this would prevent osteoporosis and the resulting fractures.
The findings of the WHI threw the wisdom of that simple approach into question. Although hormone replacement therapy (HRT) did cut the risk of hip fracture by more than 30 percent, it increased the risk of coronary heart disease, stroke,
785
and breast cancer. After these findings were released, many women decided that they were more concerned about heart attacks and strokes than broken bones. So they stopped taking their HRT.
Since then, clinicians have been trying to find a way to get the benefits of HRT without all the risks. One way to do that is Menostar is a relatively new ultra-low-dose transdermal estrogen patch. It can increase bone mineral density and has been approved for preventing osteoporosis in postmenopausal women. Menostar comes as a patch applied to the belly. Each one lasts a week.
Side effects: Redness or irritation under the patch. Estrogen has a number of side effects, such as blood clots, stroke, increased risk of breast or endometrial cancer, and gallstones. It is not clear to what degree Menostar will cause estrogenic side effects.
Downside: No evidence that Menostar will prevent fractures; no long-term data on cardiovascular safety
Cost: About $50 a month
with an estrogen-receptor modulator such as Evista (see page 517). Another way might be with a different form of estrogen. In 2004, the FDA approved a low-dose estrogen patch to prevent osteoporosis, This transdermal patch, called Menostar, releases 14 micrograms of estrogen as (17-beta)-estradiol a day. This form of estrogen is different from the mixture found in Premarin or Prempro but the same as that found in some other estrogen pills for postmenopausal women. Estrogen is absorbed well through the skin, so the dosage delivered in a skin patch can be a lot lower than the dosage in a pill.This dose is quite a bit lower than those of other commonly prescribed estrogen patches used to treat menopausal symptoms.”
Menostar is not for treating menopausal symptoms such as hot flashes or vaginal dryness. It is not for use by women who already have osteopOCOSis with vertebral fractures. But for women whose bone mineral density is low or who are at risk for developing osteoporosis, Menostar might be one way to try to get the bone benefits of estrogen while sidestepping the cardiovascular risks.
The research done on Menostar indicates that it is not likely to cause problems in the uterus, even though there is no progesterone in the regimen to protect the uterine lining.” It does increase bone mineral density, particularly in the spine, better than placebo. 718 There are not enough data to indicate whether women using Menostar are less susceptible to fractures, either of the spine or of the hip.
The bottom line on Menostar is that women who choose to use it at this time should recognize that in some respects they are experimenting. There are still some important facts about its potential long-term benefits and risks that need to be clarified.
Raloxifene (Evista)
Raloxifene (Evista) was specifically designed to be as much like estrogen as possible in its effects on bone and unlike estrogen in many other ways. The researchers who developed this selective estrogen receptor modulator, or SERM, were hoping that it would strengthen bone and prevent fractures as hormone replacement therapy seems to, but that it would not increase the risk of uterine or breast cancer as HRT does. They were largely successful in their efforts. This medication does reduce the risk of fractures in the spine, although it does not seem to have much impact on hip fractureS.719
Because any osteoporosis drug must be taken for many years, a study considered the safety of raloxifene over a period of 8 years and found that it did not increase the risk of heart attack, stroke, uterine cancer, or ovarian cancer.7 90 Like HRT, raloxifene increases the risk of blood clots forming in
.,
**** Raloxifene (Evista►
This pill strengthens bone and is especially effective at preventing fractures in the spine. It is approved both for preventing and for treating osteoporosis. In addition, raloxifene can reduce the risk of invasive breast cancer in high-risk (postmenopausal) women by approximately 50 percent.
Side effects: Blood clots, vaginal dryness, hot flashes, joint pain, leg cramps
Downside: Raloxifene does not appear to have a significant effect on hip fractures. In addition, it does not reduce the risk of noninvasive breast cancer.
Cost: Approximately $75 for a month the veins. In fact, this drug increases the risk of fatal strokes as well as dangerous blood clots.19′ As a result, doctors and patients need to weigh its benefits—reducing the risk of spinal fractures and of invasive breast cancer—against the possibility of a blood clot or a stroke.
In the spring of 2006, scientists announced that Evista had performed well in the STAR trial, the Study of Tamoxifen and Raloxifene for preventing breast cancer.The women who had volunteered for this National Cancer Institute–sponsored study were at increased risk of developing breast cancer. Both drugs reduced their likelihood of a breast cancer diagnosis by about 50 percent. Women who took raloxifene were less likely to experience blood clots, cataracts, or uterine cancer than those given tamoxifen.
‘Me investigators concluded that women who had already taken tamoxifen for 5 years following treatment for breast cancer would get no further benefit from taking raloxifene. Women who had not taken tamoxifen but were at high risk of breast cancer could get two benefits—breast cancer prevention and osteoporosis treatment—in one pill if they took raloxifene instead.
Actonel, Boniva, and Fosamax
All three of these osteoporosis drugs fall into the category called bisphosphonates. Alendronate (Fosamax), ibandronate (Boniva), and risedronate (Actonel) work by slowing down bone resorption. They zip to places where bone remodeling is going on and mess with the osteoclasts so that these bone-wreckers work more slowly. Usually, that is enough to give the osteoblasts a chance to catch up a bit on bone formation.
Fosamax was the first bisphosphonate to be developed and approved by the FDA for treating osteoporosis. It has been available for more than 10 years in this country. Women who have taken it for that long have Continued to increase their bone mineral density. Although it was originally prescribed as a once-daily pill, the inconvenience of getting up early enough to take it an hour before breakfast or even coffee and juice, as advised, cut down on its popularity.Taking Fosamax with anything other than plain tap water reduces the amount that is absorbed and lessens its effectiveness. Changing the regimen so that it is taken only once a week, and only half an hour before breakfast, has made it easier for women to follow the doctor’s orders.
The effectiveness of all of the bisphosphonate medicines is clearest in people who are at highest risk: those who already have osteoporosis, particularly those who have experienced one or more fractures. The bisphosphonates are not hormones and don’t work through the same mechanisms as hormones. As a result, presumably they would be equally effective for men and women with osteoporosis.
Many of the studies that have been done on the bisphosphonates involved only women. Among a group of women who’d already had one vertebral fracture, Fosamax cut the number of hip fractures in hal E792 A head-to-head trial of Fosamax against Actonel showed that Fosamax had a slight edge. Subjects taking once-a-week Fosamax had higher bone
*** Alendronate (Fosamax)
Alendronate works by slowing bone resorption. It is commonly given once a week. It must be taken with 8 ounces of plain tap water, not mineral water, at least 30 minutes before eating or drinking anything else. The patient must remain standing or sitting during that time to keep the pill from lodging in the throat, where it can cause damage.
Side effects: Digestive disturbances, including heartburn, esophageal irritation or inflammation that can become severe, stomachache, and diarrhea; severe bone, joint, and muscle pain; osteonecrosis of the jaw, a rare but serious complication following tooth extraction, root canal, and other significant dental procedures; inflammation of the eye, resulting in blurred vision, eye pain, conjunctivitis, uveitis, or scleritis
Downside: Although alendronate has been around for more than 10 years, some of the more worrisome side effects are just now coming to light. No one knows how this drug will affect bone in the long term. Could the increased mineralization of bone end up making bones more brittle instead of stronger? As yet, there are no good answers to this ques- tion.’93
Cost: Approximately $77 per month, a little more than Actonel ($72) and Boniva ($74)
mineral density scores and were less likely to have lost bone than subjects taking once-a-week Actonel. ‘9′
A 3-year study of more than 9,W) women with osteoporosis found that Actonel reduced hip fractures significantly, from 3.2 percent in the placebo group to 1.9 percent in the Actonel group!95′Ibis study found no significant benefit among women who did not actually have osteoporosis but were included because of their age or other risk factors. Boniva, which is given just once a month rather than once a week, can increase bone mineral density. In a study that included nearly 3,000 women with at least one vertebral fracture, Boniva significantly reduced the number of new vertebral fractures.7 It did not reduce the rate of hip fractures or fractures elsewhere besides the spine, however.
A few complications of bisphosphonates that are especially worrisome have been getting significant attention lately. Some people taking Actonel or Fosamax have developed osteonecrosis of the jaw, a condition in which part of the jawbone dies. This seems to be an uncommon side effect, but it is frightening because there is no good treatment for it. Most of the cases reported so far have occurred after tooth extraction or some other major dental procedure. There is no indication that Boniva would be exempt from this issue.
If you are taking any of these drugs for osteoporosis, be sure to tell your dentist and your endodontist about it. We don’t know yet if discontinuing the medication for some months before a dental intervention would reduce the risk of this unusual adverse reaction.
TWo other concerns that have come up with the bisphosphonates are severe joint, bone, or muscle pain, and eye inflammation. ‘Me eye inflammation may affect vision. In one case, 7 the only way to control it was to discontinue the medica- tion. 97 Be sure to discuss your osteoporosis medication with your eye doctor, particularly if you notice any problems with ynx VWion.
The joint or muscle pain required narcotic pain relievers in some cases. The confirmation that it was related to the osteoporosis drug came when drug treatment was stopped and the pain went away—but when the drug was restarted, the pain returned.
Teriparatide (Forteo)
Currently, there is no other osteoporosis drug like teriparatide (Forteo). It is a genetically engineered copy of the active part of parathyroid hormone. This hormone, which is produced by a gland in the neck right next to the thyroid, governs the body’s utilization of minerals such as calcium. Like most of the human endocrine glands, it operates on a feedback system and shuts down when it senses there is enough calcium in circulation. If it senses too little, it stimulates bone breakdown to liberate calcium.
If the hormone stimulates bone breakdown, how can it help treat osteoporosis? Forteo—which is given by injection—is active for only a short time, reaching maximum concentration after about 30 minutes and disappearing completely within about 3 or 4 hours. 799 When the hormone is administered in this kind of short pulse, the body responds by building bone. Forteo is the only osteoporosis drug currently in use that stimulates bone formation.
Studies have shown that Forteo can increase bone mineral density in the spine and the hip. It also reduces fractures in the spine and elsewhere. It performs significantly better than placebo in men as well as women. In a small head-to-head trial against Fosamax, Forteo increased the bone mineral density of the spine by about twice as much and reduced fractures in places other than the spine significantly more than Fosamax did.8w
The FDA has approved Forteo to treat osteoporosis in men and women. It sounds great, but of course there are drawbacks. Side effects with Forteo are mostly mild: nausea, dizziness, headache, and leg cramps. It is given by injection, so redness and swelling may rarely occur at the injection site. A patient just starting on Forteo may experience “orthostatic hypotension,” or dizziness if she stands up suddenly. Fortunately, this side effect usually goes away within a couple of hours.
The big worry with Forteo involves its long-term use. Studies in rats have shown that this drug increases the rate of a bone cancer called osteosarcoma. This may have factored in to the FDA’s decision to limit use of Forteo to 2 years. The medication is so new that no one has a good handle on what the long-term. effects will be, but so far no cases of osteosarcoma have been reported in humans using the drug. 801
Another disadvantage of Forteo is that it must be in-jected every day. It comes in a self-injectable “pen,” and the shot is administered in the thigh or belly. Each pen lasts for a month and needs to be kept in the refrigerator.
In comparison to other treatments for osteoporosis, Forteo is extremely expensive. A single month’s treatment can cost $750 to $800. Given all these negatives, we think Forteo might best be reserved for people whose risk for adverse events with other osteoporosis treatments is too high.
Calcitonin (Miacalcin)
Another hormone that may be prescribed to treat osteoporosis is calcitonin. It, too, is made by the thyroid gland. It binds to osteoclasts and slows down their bone munching. It also helps regulate the action of vitamin D and works together with parathyroid hormone to control the balance of calcium and phosphorus within the body.
Salmon calcitonin can be given either as an injection or in a nasal spray. It can reduce fractures of the vertebrae significantly more than placebo. Some scientists have suggested that it may relieve back pain, which is frequently a serious problem for women whose osteoporosis has caused numerous fractures of the vertebrae. There is no solid consensus on this issue, however. 802,803
** Calcitonin (Miacalcin)
Calcitonin is given not to prevent but to treat osteoporosis. In women who already have at least one fractured vertebra, Miacalcin is significantly better than placebo at preventing additional spinal fractures. Some studies suggest that it helps alleviate back pain by stimulating production of beta-endorphins, the body’s natural opiates.
Side effects: Nausea and vomiting, flushing, redness or soreness at the injection site, rash, reduced appetite, severe allergic reaction; runny nose and nosebleed may occur with the nasal spray
Downside: Expensive. It does not appear to have a substantial effect on preventing hip fractures.
Cost: Nasal spray, $95 per bottle; injection, $45 for 2 milliliters (a 4-day supply)
Conclusions
When it comes to preventing broken hips and painful spinal fractures, there is no single treatment that stands head and shoulders above the rest. Each has benefits and disadvantages. People at risk for osteoporosis will need to think about the issues that might affect their treatment and their ability to stick with the program.
Even when the primary goal is prevention by getting adequate calcium and vitamin D together with exercise (and we strongly encourage that for everyone who can do it), the studies show that nutritional supplements are effective only if people actually take them all the time. Surprise! So consider whether you will take a pill or an injection every day, or if you’re better off with once-a-week or even once-a-month therapy.

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Magnesium is another mineral that is frequently overlooked and in short supply in the diet buspar and substance abuse . People on diuretics may be especially low in this crucial nutrient health net viagra non-formulary cost . Not only is magnesium essential for normal muscular contraction, it also plays a crucial role in heart health, blood pressure control, and hundreds of enzymatic reactions in the body captopril time to lower hypertension . It also helps reduce the risk of kidney stone formation enzyme immunoassay celecoxib .
People have been using magnesium for decades (as milk of magnesia) to counteract constipation amoxicillin causes liver . The normal dose ranges between 300 and 500 milligrams daily dosage for lexapro . One study demonstrated moderate effectiveness in battling nighttime leg cramps at 300 milligrams” Pregnant women are especially vulnerable to leg cramps adderall aciphex zoloft heartburn . Another study concluded that “magnesium supplementation seems to be a valuable therapeutic tool in the treatment of pregnancy-related leg cramps maxolon side effects .”"‘ Be aware that too much can cause diarrhea, and people with kidney problems should take magnesium only under medical supervision hair loss and cymbalta .
Some people are equally enthusiastic about calcium for preventing leg cramps panasonic br2330 lithium cell . The research that has been done on this remedy has been equivocal lithium manganese oxide . In one study, pregnant women with nighttime leg cramps were given calcium supplements or vitamin C as a “control paroxetine brain zapps .” Since there is no evidence that vitamin C can reduce leg cramps, it seemed that the difference between the two groups would be readily apparent if calcium worked well nasal decongestant risperdal . Both groups did equally well, however, suggesting that
715
calcium really didn’t make much difference ipratropium bromide long acting . A systematic review of the research on calcium for nocturnal leg cramps concluded that the evidence for its effectiveness is weak, at least in pregnant women how amoxicillin is produced . The reviewers found more support for supplemental magnesium tofranil pm for fibromyalgia . 716
One way to get extra minerals is with a special pediatric formulation called Pedialyte avandia problems . It was developed to “quickly replace fluids and electrolytes lost during diarrhea and vomiting to help prevent dehydration in infants and children quitting effexor weight .” Pe-Pedialyte
This rehydration solution for babies and children provides a balance of electrolytes that may help adults avoid muscle cramps trazodone and lung problems . Drinking about 4 ounces after exercising should help,
Downside: Somewhat expensive
Cost: Approximately $8 for a liter, or about $1 per “dose”
diatricians frequently recommend this ready-to-use liquid for sick children instead of juice or other beverages effect of clomid on progesterone . Ingredients include water, dextrose, potassium citrate, sodium chloride, sodium citrate, and citric acid zyprexa anorexia . Pedialyte is sold in drugstores and supermarkets in the baby section cyclosporine lipid emulsion . One athlete offered an amazing testimonial for its benefits against leg cramps coumadin interaction with foods and vitamins .
I have experienced a fair amount of cramping in my legs at night after I play tennis man dies from viagra overdose . The cramps occur more during the hot summer months when I perspire more melatonin while on zoloft .
I tried a lot of the sports drinks, but they didn’t seem to help with the cramping methotrexate ectopic . Someone suggested that I either eat bananas or drink tomato juice doxazosin mesylate msds . Unfortunately for me, I don’t like either food blood cozaar pressure .
I was told that the cramping was due to a loss of potassium in the body hsv i treating with valtrex . An assistant tennis pro suggested I try drinking the infant solution called Pedialyte rimonabant indication confusion . I thought that was a crazy idea, but I tried it because I didn’t like waking at midnight with a leg cramp depot provera pregnancy . To my surprise, the Pedialyte has worked like a charm and has eliminated my cramping micronase diabeta .
Pedialyte has one other unexpected benefit I usually play singles tennis, and I am usually pretty worn out after / play order viagra without prescription . Like a lot of people my age, my middle-aged body is usually pretty darn sore after playing, particularly the next day national geographic caffeine . Like everyone else, I take Morin for sore muscles phenergan injection adverse reaction . The Pedia(yte has substantially reduced The Soreness that I experience, and I don’t need to take Motrin the next day n1 3 lithium battery tester 3v .
B Vitamins
B vitamins have become the superheroes of nutrients cefuroxime axetil and symptom relief . Not only do compounds like folic acid, B6, and B12 have cardiovascular benefits, folic acid and niacin may help reduce the risk A combination of B vitamins may reduce nighttime leg cramps relicore zantac dieting combo . Keep the dose of vitamin B trileptal withdrawal how to .,below 100 milligrams per day to avoid nerve damage from long-term use cocaine and lexapro .
Downside: The B-complex formulas available are not specifically designed to prevent leg cramps generic viagra available .
Cost: Approximately $11 for 100 tablets, or a 3-month supply
of Alzheimer’s disease paroxetine and 5ht . One study from Taipei offers evidence that a B-complex vitamin formulation can reduce nighttime leg cramps tranny taking viagra . “After 3 months caffeine drinks . 86 percent of the patients taking vitamin B had prominent remission of leg cramps, whereas those taking placebo had no significant difference from baseline,”71 reported the study’s authors lipitor zocor news . This study used a formulation that is not available in the United States fosamax d generic . It contained vitamins B, (50 milligrams), B, ~5 milligrams), B6 (30 milligrams), and BIZ (250 micrograms) fda topamax warning .7 8
My husband has suffered horrible leg cramps at night all his life kidney infection and ibuprofen . He would writhe in pain amiodarone blood levels .
/ read that 8 vitamins might help uk imitrex . He now takes multiple B-100s every day and has no leg cramps naproxen and nursing babies .
We found a “dose-response curve caffeine makes me panic now .” With B-50s, he’d still have cramps, but they were less severe toradol and orange urine . With B-75s, he wouldn’t have cramps, just twinges in his legs ultram the medicine . At the 100 level, he has not even a twinge how to make prednisone .
A B-complex with 100 milligrams of vitamin B6 may be too much zetia buyback . We worry that regular consumption of th, s nutrient may lead to nerve damage lamisil side effects for women . Anyone who contemplates taking, more than 50 milligrams of vitamin B, should be under medical supervision synthroid phentramine .
Quinine
If you tell your physician that you suffer from frequent leg cramps at night, you may be offered a prescription for quinine depakote with tramadol . This botanical medicine (derived from the bark of a South American tree) has been used against malaria since a monk
B Vitamins sent a sample to Spain in 1633 avapro with dieuretic . (At that time, the diagnosis was probably “fever” or “the ague” rather than malaria gi lithium batteries .)
Doctors began using quinine against leg cramps in 1940 experience with lexapro . Despite this long history, there is still some controversy over whether its effectiveness outweighs the risks of side effects 19 In the 1990s, the FDA determined that the possibility of a susceptible individual experiencing a life-threatening blood reaction (idiopathic thrombocytopenic purpura, or ITP) was just too great cheapest diflucan online w o prescription . OTC sale was banned home coumadin testing . Now the FDA has forbidden doctors to prescribe quinine for leg cramps rifampicin isoniazid pyrazinamide ethambutol . One reader reported that a single glass of tonic water (which contains quinine) put her in the hospital with an almost fatal anemia flomax dosages .
It is hard to predict ahead of time whether a person might react to quinine by developing severe anemia erythromycin resistance peptide . Pregnant women should stay completely clear of quinine (even though they may suffer leg cramps) because it could cause birth defects and induce premature labor about penicillin capsules . Other side effects from quinine include ringing in the ears, rash, changes in color vision, headache, nausea, diarrhea, liver damage, low blood sugar, life-threatening anemia (ITP), vomiting, and trouble breathing prescribed premarin . Anyone experiencing such symptoms should get medical attention promptly meloxicam tab .
The amount of quinine in tonic water may vary from one brand to another discount digoxin . Some brands contain as much as 80 milligrams in a quart of tonic pseudoephedrine hydrochloride tablets canada . The dose that proved effective in preventing muscle cramps in one placebo-controlled study was 400 milligrams cialis tadalafil cialis tadafil tal .720 That suggests that a person would have to drink more than a gallon to get an effect, but many readers report that they notice a benefit from one or two glasses of tonic why hairloss with zetia . The
* Quinine
This traditional prescription for leg cramps is probably effective zocor causes ed . One or two glasses of tonic water may contain enough gui(xi(
Downside: Tinnitus (ringing in ears), rash, changes in color vision, headache, nausea, diarrhea, liver damage, low blood sugar, life-threatening anemia (ITP), vomiting, and trouble breathing are possible reactions atomic model of lithium .
Cost: Approximately $65 in the United States for 100 pills or $33 from a Canadian pharmacy prescription dose used to be 260 to 300 milligrams-, older people should generally start with a’lower dose warfarin graph .
I used to take quinine, but then it became unavailable over the counter My doctor recommended that I drink a glass of Schweppes Tonic Water lasix diabetes . It has enough quinine that it might help long terra omeprazole .
I tried it and it works methanphetamine ephedrine or pseudoephedrine . I have recommended this to others bothered with cramps after exercising, and they have been pleased procardia sr .
One word of caution is probably unnecessary triamcinolone .1 . Even though some people are accustomed to putting gin in their tonic water, the alcohol does nothing to prevent leg cramps resonance caffeine . If it is taken shortly before bedtime, alcohol can disrupt sleep—the last thing a sufferer wants swelling that is helped by prednisone .
Conclusions
Health care professionals generally consider leg cramps more of a nuisance than a serious health problem free live online zoloft help . Nonetheless, anyone who suffers from nighttime leg cramps knows that they can disrupt sleep, and that can eventually have consequences for health as well as mood is prazosin compatable with prozac . Finding the remedy that suits you best may require some trial and error increase free testosterone females . Don’t be afraid of the home remedies: They may seem silly, but since the only prescription treatment, quinine, can have such serious adverse effects, we think they are worth considering teva pantoprazole december .
I had terrible leg cramps, and nothing helped prozac action . Then my husband got some liquid calcium, and that worked immediately olympus li 10b lithium batteries . I have not had another leg cramp women’s international testosterone .
He decided to try mustard for leg cramps, but he still had leg cramps and really did not savor the mustard cat soma . He decided to try turmeric, an ingredient in mustard lithium batteries for electric automobiles . He took’/, teaspoon at bedtime and ‘/;, teaspoon at breakfast xenical side efftects . BINGO! This worked great price of prevacid . Not only did it cure his leg cramps, but it also eased the pain in his hip and feet
He recommended I try it for my awful loot problems valtrex capl . It felt like an ice pick was stuck in the ball of my foot As soon as I started taking the turmeric, I had no more pain ephedrine caffeine stack . I can now wear my lovely high-heeled shoes on Sunday without suffering celebrex qoclick .
e Ibck a bar of ordinary soap under the bottom sheet when you make the bed tricor side . It should be near your legs, and may need to be replaced every 6 weeks or so buying generic zoloft . We don’t know why it would prevent leg cramps, but many readers report success—and we know of no side effects naproxen and methylprednisolone .
• Swallow a teaspoonful of yellow mustard—the inexpensive kind sometimes dispensed in individual packets cyclosporine ointment . We think it may be the turmeric in the mustard that helps lexapro peak . This remedy can work very quickly, though some readers have reported heartburn as a result wellbutrin xl prozac weight loss .
• Sip about an ounce of pickle juice medroxyprogesterone acetate anorexia . Some pickles may contain turmeric, so perhaps that explains why this helps some people fight off muscle cramps so quickly procardia sr . Or, it may provide some missing minerals salbutamol inhaler medication information . Pickle juice is high in sodium, so this home remedy is not for anyone on a low-sodium diet buy viagra on line .
• Baking soda, ‘44 teaspoon in 8 ounces of water, is reputed to fight painful leg cramps quickly prozac video for dogs . Baking soda contains sodium, so it is not for anyone on a low-salt regimen viagra sports .
• Pinch your upper lip firmly between your thumb and forefinger until the cramp eases veterinary ranitidine pricing . This may have the effect of providing a distracting pain that is under your control testosterone injections chronic fatigue . Many readers claim it is helpful, although we have not been impressed information lipitor prescribing .
• Stretch leg muscles for several minutes before bedtime toprol xl 50 mg .
• Consume plenty of potassium-rich vegetables, especially low-sodium V8 juice doctors give shots of penicillin . Increasing potassium intake seems to help prevent leg cramps hydrid technologies lithium power .
• Take a supplement of 300 to 500 milligrams of magnesium a day atacand picture . Reduce the dose if this gives’you diarrhea viagra gif . Avoid magnesium if you have kidney disease can i take accutane and bactrim .
• Try 4 ounces of Pedialyte after vigorous exercise to replenish minerals and prevent muscle cramps decadron vs prednisone .
• Consider B-complex vitamins to prevent cramps oxycoton compared to tramadol . Keep the dose of vitamin B,, under 100 milligrams per day to avoid nerve damage cialis patent expiration wikipedia .
• Ask your doctor about quinine beers effect on levitra . it is available by prescription (or at low doses in some brands of tonic water) how long before wellbutrin kicks in . Severe side effects are uncommon but may be life-threatening, especially a blood disorder called ITP carafate suspension pets .

Care
Boundaries
Birth is an immense change for the baby. Her whole physiology changes fundamentally and she experiences a completely new environment. The boundaries of the womb are left behind and she enters a ‘boundless’ world. In the womb, the child was able to grow harmoniously, protected from the world.
This reveals that everything that is developing requires a protective environment. With a newborn baby, and actually throughout childhood, this protective environment is constantly provided to establish firm foundations for later life. Unconsciously, the child is constantly reminded of the situation in the womb, which is related to an experience of security, safety, protection and fundamental confidence.
Warmth
The womb not only protects the embryo from the world; it also surrounds it with an even temperature of 37°C (98.6°F). A ‘warm environment’ is provided in the best possible way.
After birth, a child has to learn to maintain her own body temperature at a constant level, at first with the help of adults. She must interrelate the warm and cold parts of the body. This is achieved by means of a sensitive metabolic process which generates heat.
Normal growth and the development of the normal physical processes are also dependent on this metabolism. All the heat which the baby does not have to produce herself in order to maintain her temperature at the right level will benefit growth.
It takes the child a long time to regulate her own temperature; the normal difference of PC (2°F). between the body temperature during the night and the day is achieved by most children between their fifth and ninth months. Up to that time they are extremely dependent on the extra warmth provided in the form of good physical care, clothes, and hot water bottles used to warm the cradle before they are placed in it.
The ability to distinguish whether something is hot or cold is learnt during the initial period. The better this ability has been developed by providing sufficient warmth in childhood, the better the child can use it at a later age.
Cold feet are an important sign that extra attention should be devoted to regulating the child’s temperature. A baby should have warm feet, warm legs, a warm body and warm arms.
Special attention to warmth also has another significance. A warm environment helps the child to ‘warm up’ for life on earth. However, our motto is not ‘the warmer, the better,’ because always being dressed in too many clothes or being covered up can actually make a child either drowsy or very restless, and overheating can be very dangerous. Detailed research has revealed that there is a relationship between overheating and cot death. Duvets and synthetic materials can especially cause overheating. Therefore we certainly advise against using these.
In our view, the important thing is to learn to observe the needs of the child with regard to warmth, and to read the signs when more or less warmth needs to be provided in the form of clothes, bedding or ambient heating. The body temperature of the child is the most important thermometer, and in a healthy baby, this fluctuates around 37°C (98.6°F). You can learn to take the baby’s temperature with your hands so that you can literally feel how the child is regulating its own temperature. In the first week or two after birth, take the baby’s temperature every day, as well as feeling how warm she is. Then start testing yourself: feel how warm the baby is, then predict her temperature and check with the thermometer for a few days. If your predictions are correct, you will only have to take the baby’s temperature when you are doubtful or if she is sick.
Impressions
Everything we do, feel and think around the child is assimilated by the child. She is still completely open and has a boundless trust in the environment. The buffer which
we have between ourselves and the world as adults is formed by recognising and understanding that world. A small child is not yet able to do this. Up to about the third year, the child identifies with the environment in which she is living in a very natural way. This is followed by a stage in which thinking gradually assumes set patterns, and the child leans to distinguish herself from the outside world. For the first time, she makes a distinction between her own individuality and the world which is perceived. In this light it is understandable that first memories only go back to the third year, and there are no, or very few, memories before this.
The child is one big sensory organ. Up to the third year, all impressions are assimilated in an uninhibited way and disappear into the subconscious. There they are combined with other physical processes, and a sort of print is made; it is as though the child models the influences of the environment in its own `clay.’ Therefore, it is important that we are aware of what ‘goes into’ the child — also for later on.
Example. A child in a boat on the water, experiences the swell, feels the sunlight on her skin and the wind in her hair, smells the odour of water and fish, is taking in healthy impressions which build up the whole organism. The situation is quite different for a child at a department store who is placed in a rotating ship, which goes round and round when a coin is placed in the machine. The child will enjoy both these experiences, but they affect the organism in significantly different ways. The ‘boat on the water’ situation sounds idyllic; this is usually a vacation experience. However, there are also impressions closer to home, which can be constructive and have the above-mentioned character
Positive, constructive impressions are those impressions in which the natural origin of materials, sounds etc, can be perceived by the child. For hearing, these are the sounds of people and animals, and natural sounds such as the rustling of the wind. For sight, they are natural colours. For the sense of touch, they are materials such as wool, cotton, silk, wood, sand and water.
Many domestic appliances such as vacuum cleaners, washing machines, radio, television and plastic toys were created as a result of human technical ingenuity. For children, these are actually an abstraction, lacking in natural connection.
Radio, television and plastic toys are things you can consciously choose to have or not to have in a small child’s immediate environment. With household appliances, you can take care to minimize the sound in the baby’s immediate environment. So-called ‘white noise’
from household appliances is not a good idea for the young child as it blocks out normal impressions. Autistic children can also become obsessed by white noise. Playing a lyre, humming or singing are better background sounds for the child.
Simple actions such as washing hands, or sweeping up with a dustpan and brush in the child’s presence show how things are done. These actions are enjoyable and you can invite children to imitate them.
The feelings of people around the child also have an effect. It is obvious that a child will thrive best in a genuine atmosphere of joy and warmth. This has a positive effect. But there is not a parent in the world that is always cheerful and relaxed at every moment of the day (and night). It is worth aiming to achieve these qualities, but at times when you do not succeed, you must take them for what they are — also real human emotions. In every family there are days when everything goes pear-shaped and the ideal image of a happy family seems a long way off. Humour is always a good remedy. It can be a relief if you can laugh about yourself and the situation.
The needs which were mentioned above — that is, the need for boundaries, warmth and positive impressions — make great demands on the environment. It means that parents must have clear insight and a good level of empathy to get things right: too cold or too warm, too many im-pressions or too quiet, well-protected or not enough room to breathe?
From this point of view, we would like to discuss a number of practical aspects of childcare.
Clothes
Clothes are like a second skin, which support the functions of the skin. The skin helps to regulate body temperature and protects us from infections. In addition, the skin is a sensory organ with which we perceive the environment. These three functions are most effectively supported with clothes made of wool, silk, cotton or hemp. These fibres are preferable as they provide sense impressions from a natural source via the skin, which help the child to build up its body. Other fibres are more alien, and even viscose, which is made from cotton or wood, is processed quite strongly, in a way which is now known to be quite polluting.
Wool
Sheep’s wool protects the sheep from heat and cold, rain and toxic waste. The curls trap the warm air around the sheep’s skin. The wool keeps out the rain, and waste products are absorbed and emitted through the wool via perspiration.
All these qualities are found in woollen clothes. The warmth of the wool protects the child from cooling down too quickly and supports her unstable heat regulation system which cannot yet retain body heat.
Its absorbent capacity (30 to 40%) ensures that the child remains comfortably dry. The quality of the wool depends on the age of the sheep, the animal’s diet and health, as well as the way in which the wool was turned into clothing.
Finely knitted woollen vests are available, which forma soft, flexible outer skin. Woollen jumpers and cardigans should be loose fitting so that they are easy to put on and take off. Woollen pants are wonderful to use over cotton nappies. They can be knitted easily, preferably from slightly greasy sheep’s wool, and are ideal for absorbing moisture and neutralizing the waste products in urine.
A woollen shawl will keep the baby warm when there are fluctuations in temperature. Woollen socks will also keep the feet nice and warm. Furthermore, wool does not attract dirt, and therefore woollen clothes do not have to washed as often as cotton clothes, though they do have to be aired regularly.
Silk
The silkworm spins its cocoon of silk thread, in which the worm is sealed off from any negative external influences. The silk is made under the influence of sunlight — at sunset, the silkworm stops spinning, and at sunrise, it starts work again.
If you use silk in clothes, you will feel its enclosing qualities. Furthermore, silk can absorb 30% of its weight in moisture without feeling damp. In addition, silk retains heat when it is cold and releases heat when it is warm. That is why silk is worn especially in summer. Silk and, in particular, knitted silk is an excellent basic material for vests, but it is advisable to put a woollen vest over the silk vest as well.
Children who are sensitive to wool against the skin, and children who are very sensitive to impressions and consequently become restless, will benefit from wearing a silk vest.
Cotton
Cotton is widely used nowadays for children’s clothes, especially as this material can be washed so easily in the washing machine. At the same time, it should be said that it actually has to be washed often because it attracts dirt easily. Cotton can absorb 20% of its own weight in moisture.
As cotton cannot absorb heat, this passes easily through the material to the outside air. Consequently, this material is not the best choice for a child’s underclothes throughout the year. Furthermore, the way in which cotton is grown is not particularly environmentally friendly, and chemical products are often used in the treatment of the material. Fortunately, there are several eco-cotton projects which now promote its environmentally-friendly cultivation and processing, and eco-cotton is becoming increasingly available in shops and over the internet.
We suggest dressing the baby in at least two layers of clothing, covering the whole body, including the arms, legs and feet. This produces a layer of air between the two layers which retains heat. In a temperate climate, a long-sleeved woollen vest — or a vest of wool and silk — can be worn for most of the year.
In practice, we regularly find that babies are not dressed warmly enough, and they are often restless and troubled by stomach cramps, or they are constantly crying. The simple remedy of dressing the child more warmly, in better fitting clothes, will do wonders for this.
Bonnets
Unfortunately, bonnets are no longer in fashion. In comparison with the rest of their bodies, little babies often have an enormous — and sometimes rather bald — head. The head is constantly losing heat, which should really be retained for the development of the brain and organs. On the one hand, a silk bonnet will retain the baby’s heat, and oil the other hand, it protects the head and the open fontanel from a restless environment. It is important for the forehead to be free, because this part of the body acts as a sort of thermostat for regulating body heat. Where it is often windy, it may also be necessary for the baby to wear a second bonnet made of wool. There are wonderful bonnets on sale, or they can be knitted in material which is so soft that it is like a second skin.

Bonnets can be removed when the child is in the cot as long as the baby is well protected.
Wraps and swaddling
Because of the need for boundaries, it is understandable why many babies, as well as older children, calm down and fall asleep easily when they are firmly tucked in, or if they are wrapped up or swaddled.
Usually, babies have a flannel sheet wrapped around them, during the postnatal period, but this often disappears, to be replaced by a babygro/sleepsuit. We recommend continning to use a swaddling cloth and wrapping it firmly around the babygro/sleepsuit before putting the baby to bed (see illustration). As the baby still lies with its arms and legs bent, it should be swaddled in this position, to increase the sense of security. The baby can now relax and will fall asleep warm and snug. However, you must make sure that the baby is not wrapped up too warmly (see p.25).
The woollen wrap can serve as a blanket outside the cot for when the baby is fed. When the woollen cloth is no longer sufficient, use a (woollen) baby sleeping bag for in bed.

Children who remain restless and have difficulty falling asleep despite being wrapped up, as well as babies who do not establish a good rhythm of drinking/sleeping, may benefit from the old-fashioned method of swaddling in which the arms are also wrapped up so that the child cannot flail about. Flailing is often a response to crying, cramps or fright, but because it is involuntary, it can cause new restlessness. Swaddling can help to break this vicious circle.
Many parents find it difficult to restrict their baby in this way; in our age of boundless freedom, it is not so easily accepted. However, parents usually overcome their resistance when they see how the baby responds to swaddling. For most babies, it results in a much greater sense of peace, and consequently they sleep well and establish a pattern of sleeping and feeding every few hours. Nowadays, two methods of swaddling are recommended: either ready-made swaddling blankets or swaddling wraps, or using the method shown at the back of this book (see p.108). (See also Blom, Crying and Restlessness in Babies.)
The cradle
The cradle is an important successor of the smallest home in which the baby lived before birth. You can opt for a basket cradle (Moses basket), a wooden (rocking) cradle or
a cot. For safety considerations, the baby’s feet should always be placed at the end of a cot, with its head halfway down. Tuck in the blanket in such a way that the head is free and the shoulders are covered. A hood or canopy over the cradle or cot makes the space more intimate, so that the child is not distracted by the environment and can sleep more peacefully.
For the canopy, it is best to use plain materials in soft colours. A canopy made of light blue silk combined with a layer of pink silk gives a very subtle calming colour.
The mattress must be absolutely flat, providing good support, and it must be well-ventilated and warm. Our preference is for a mattress of kapok, cotton or another natural material. A sheep’s fleece can be placed on the mattress. The fleece is soft and gives a beneficial warmth so that the newborn baby is protected from cooling down too quickly. Make sure that the fleece is not too large and lies on the mattress without any folds. Cover the fleece with a sheet. The bedding should be made of cotton and wool. Do not use synthetic materials. The sheets and blankets should be big enough to tuck the baby in quite firmly. The fleece and the mattress should be regularly aired. If you use a woollen wrap there are likely to be patches of damp under the mattress. If necessary, use a waterproof sheet. There are cotton sheets available that are impregnated with rubber and do not feel clammy. We do not recommend the use of duvets, even those made of wool, because of the risk of suffocation.
If the cradle is next to the window, watch out for overheating in the sun. A baby can easily become too hot in a heated room when the sun shines through the window.
The playpen
Up to the age of four months, it is not really necessary to have a playpen. Nevertheless, when the baby is downstairs, it is a good idea to have a safe place to place it. A wicker basket with a soft cover, or the bed of a pram, are quite suitable.
We do not recommend the frequent use of a baby seat or recliner, as the baby is stimulated by the ac-
tion of sitting in an upright position at a stage when he is still physically immature. The baby can only lie passively in a baby seat, which does not matter for a short period, but is harmful to physical development in the long term.
This objection does not apply so much to the use of a recliner, but there are other objections; when the baby discovers that he can bounce the recliner with one leg, he often finds it difficult to stop, even when he gets tired of the mechanical movement.
When the baby starts to reach out for things and becomes more active in its motor development, it is time for a playpen. Quite apart from the fact that this provides a safe place for the child to learn to sit and stand, it is often a favourite place for being quiet and for playing undisturbed. A cloth cover, like a curtain, along three sides of the playpen will increase the sense of security, and is not to be confused with cot bumpers, which are not recommended as they pose a suffocation risk for the young child. For motor development, it is important that the floor of the playpen is sturdy and not too smooth (for example, a cloth folded double), so that the child can roll over and can put pressure on it.
Walkers and baby bouncers
We emphatically advise against the use of walkers and baby bouncers. These are ‘aids’ which speed up the child’s motor development in an unnatural way. Children certainly like to use these things — especially if they can move around in them quickly — and want to use them more and more. However, it is much better for a child to learn to stand and walk at his own pace. In this sense, walkers and baby bouncers do not help healthy development in any way, and are actually more of a deterrent to healthy development.
Prams and baby carriers (slings)
The pram can be a safe and sheltered place in which the baby can sleep outside during the first few months. For walking, a baby carrier is often a better alternative because it means
that the baby moves in time with the pace at which the adult is walking, and is not shaken about so much as in a pram, as it goes up and down the pavement. The child is carried in a natural position in a baby carrier (sling), (see the illustration on p. 106).
However, at this point a warning should be given. It has been shown that babies can become too hot and stuffy, particularly if carried under a coat. Unfortunately, there are even a few cases, which resulted in a baby’s death. We recommend that you keep a careful eye on a baby in a baby carrier, and if possible carry it on top of a coat rather than underneath, with, if necessary, a woollen cloth around the baby.
The disadvantage of a baby carrier in which the baby is in a vertical position is that the baby did not take up this position itself. In this sense, the baby carrier is not for babies until they reach the age of nine months. A sling is preferable, as the whole back and head are supported, although it might be tiring for the mother to carry.
When a baby has reached the age for a pram, the best model is one in which the baby faces the parent. In this way, the baby constantly has the comforting face of its father or mother in front of it, and can find out from that face what is happening in the big wide world. A traditional pram has the advantage that the child lies flat, as at this age the baby’s head is still relatively heavy and the neck cannot keep the head in a stable position. We recommend a buggy only from the age when the child is able to sit unassisted.

General Points of View
In this section we describe a number of points of view which serve as a guideline for the way we view, and relate to, young children.
The child’s development and care, sleeping and waking, play and toys, safety and feeding are subjects which will be tackled in this section in terms of content. A practical approach to these subjects can be found under the advice for every stage (see Chapters 3-6).
The child’s development
From the moment the child is born, the parents have the important task of monitoring his or her development. This gives rise to many questions. How can we best prepare for the child’s future? Should we, or should we not, familiarize the child with elements of adult life at an early stage, so that she will be prepared for this later on? The answers to these questions will depend on your view of the child’s developmental stages.
We proceed on the assumption that the more successfully a child is able to fully develop at a particular stage, the more harmonious the development will be. This also applies for future development.
Fora baby and young child, this means that we must create the conditions in which a baby can most successfully be a baby, and a young child can most successfully be a young child.
The first developmental stage after birth is strongly centred on the child’s physical and motor development. Growth is quite exceptional during the first year of life, and is still rather like the growth of the embryo. The development and growth, which takes place outside the womb in humans, takes place completely inside the womb in other mammals. When the child is one year old, the development has reached a level comparable to the birth level of other mammals.
For the baby’s development, it is good if the conditions after birth are still quite similar to the situation in the womb. This particularly concerns the protective cocoon around the child. Warmth, a sense of security and some protection against environmental influences promote the baby’s health. It is extremely important for the baby’s physical development for her to have physical contact — rocking, cuddling or simply holding the baby in your arms. Children who lack this physical contact do not develop well, even if they have ‘the best feeding.’ These babies immediately start to grow again when attention and care is devoted to physical contact. Satisfying the need for physical contact gives the child a basis for the rest of his or her life.
Nevertheless, in humans, a good environment alone does not guarantee development. Every person has his own rate of development and his own way of developing. For example, there are babies who develop motor skills very quickly, sit up at an early stage, roll over, stand and walk. On the other hand, other children appear to ’stand still’ in their development fora long time, then seem to miss out a few stages and can suddenly walk, even though they never crawled. Some children start to develop speech very early, while others remain unintelligible for a long time.
It is important to be aware of a child’s own way of developing. There may be a tendency to a certain one-sidedness. This sort of one-sidedness — for example, the slow development of speech — can be regarded as the child’s own way of developing. It is only when this one-sidedness is particularly strong that it may be seen as a developmental disorder.
Thus, the first year of the child’s development can be seen as a continuation of the embryonic stage.
During this first year of life, the body matures to the extent that the child becomes able to control it for herself. A one-year-old child can stand and go where she likes and move about freely in space. It is as though she is taking charge of her own physical body. This stage of development depends on healthy physical growth and development. Illness and malnutrition will immediately delay the process. Development at this stage is mainly influenced by the physical organism and the care of this organism.
The basis for the later development of speech is laid during the first year of life. Talk to, and with, the baby, and play with her. She sees the gestures which accompany words, and hears the songs. All this contributes to the child becoming increasingly familiar with human language. The clearest sign of this is contented baby talk by the end of the first year of life.
After the first year, the child depends on being able to imitate what she has heard. She will start to copy the words herself, first words of one syllable and then words of several syllables. She then begins to combine words, and finally produces short sentences. In this way, the child enters a second area in which she can move about freely — the field of language. By mastering speech and language, the child takes part in social life in her own way, and becomes able to express herself through the spoken word.

The next stage of development is the time at which the child starts to say ‘U Prior to that stage the child called herself by her own name. This can be seen as an expression of the fact that the child was not yet deeply connected with her own body; thus in a sense the child saw herself from outside, as other people see her.
When she becomes more closely connected with her own body, the first, still primitive, sense of self-consciousness emerges and the child experiences a sense of self; she starts to say ‘F and experiences herself as a centre. As a result of this process, the child may also feel cut off from the world around her.
By the age of three or four, the child has gone through a sort of first cycle of development. By learning to stand and walk, she has achieved a certain degree of freedom in space. By learning to speak and understand, she can develop socially and communicate with others. With the deeper connection of the self and the body, self-consciousness emerges for the first time, and this is expressed when the child uses the word ‘I’ to talk about herself.
Learning to use language independently is an important psychological development, as is developing a sense of individuality. However, healthy physical development is always a prerequisite for this. Motor development is particularly important for the development of psychological functions later on. Playing
THE CHILD’S DEVELOPMENT    21
with bricks, simple ball games, finger games, circle games — in short, everything we do with the physical organism of the child as the point of contact — will have a positive influence on development.
The behaviour of the people in the child’s direct environment is very important for development. A small child learns and develops by imitating what she sees, hears, feels and so on. In this way the child learns to walk, speak and think, and during this first learning process carefully assimilates all the details — particularly during the first three years. This once again underlines the importance of being conscious of our own behaviour as well as the material environment of the child (see also Impressions, p.25).
Admittedly, the aspects of child development described here are very general, but they can still provide a direction for the way in which we behave with the child. The care for the physical processes of growth and development are of central importance. We can measure and weigh growth, while we can assess development from the development of the motor system, the mastery of language, and the birth of the ’self’ when the child starts to say ‘F.
Sleeping and waking
During the course of life a person’s need for sleep undergoes great changes. A newborn baby often sleeps for between eighteen and twenty hours out of every twenty-four. A one-year-old can sleep for fourteen hours, while an adult needs between six and eight hours of sleep. Therefore, in the first year of life, the child should spend a great deal of the time asleep.
We have seen that there are two important things in this first year — growth (a baby’s weight triples in the first year) and development. Growth takes place particularly during sleep, while development is stimulated during the waking hours. The various organs ‘learn’ to operate in a sense, with the use of the body during, the daytime (by eating, moving, etc.). What the organs ‘learn’ during the day continues to have an effect while the baby sleeps, and is assimilated in the body’s growth activity.
A one-sided predominance of growth and excessive stimulation to develop both have a negative effect. There should be a healthy balance between the two processes; an alternation between waking and sleeping which is suitable for each stage. When the child is about one year old, this balance will have become established in the operation of the organs, in a particular day/night rhythm — the biological clock.
For good health and for the child to be able to make use of his physical capabilities properly, it is essential for this day/night rhythm to become well established. Therefore, it is literally of vital importance for a small child to establish a steady pattern during the day with regard to sleeping, eating and waking.

A steady pattern of set times in the life of a child promotes growth and development and helps to establish a healthy rhythm of sleeping and waking. Too much stimulation during the day may prevent the child from falling asleep; however, a completely unstimulating environment, without healthy challenges for the child, can also lead to problems with sleep because the child is not sufficiently tired. A healthy routine in the day, alternating challenges and periods of quiet, being together and being alone, can help to correct sleeping problems. Rituals for going to sleep can also be helpful — rocking, singing lullabies, the use of musical boxes or a prayer for the child are methods used by many families.
Sleeping well means that the child must be able to surrender and ‘let go.’ This is not as easy for some children as for others. It is helpful to give the child a sense of security, for example, in the enclosed space of the cradle (possibly with a hood) or lying against the mother. Warmth promotes a sense of comfort and relaxation; a bonnet, a sleeping bag, some drops of lavender water on the pillow, or a hot water bottle can sometimes help babies who find it difficult to fall asleep. Hot water bottles should always be removed before the baby is placed in the warm cradle. A light silk bonnet is appropriate for indoor use, but be aware of the risk of overheating. Wrapping the child up firmly pro-
SLEEPING AND WAKING    23
vides a sense of security as well as a feeling of warmth.
However, there are babies who assimilate everything that happens around them so greedily that they actively seem to suppress their feelings of tiredness and the need for sleep. The more stimulation they are given, the hungrier they seen to be. They are unable to set their own boundaries. Increasingly, we see babies who spend many hours of the day — and sometimes the night —awake, constantly asking for attention from the environment. For these children, the parents must learn to see when they show signs of being sleepy. The fact that this is quite an art is clear from the many stories told about this problem. If you miss the right moment, the child appears to go past his sleepiness and will keep going for many hours. Signs of sleepiness are restlessness or agitation, looking away, rubbing the eyes and face, warm hands and red ears, grizzling and crying. By responding to these signs of sleep immediately and consistently, by placing the baby in his cot, it is possible to create a healthy need for sleep. By not responding straightaway every time the baby cries, he will learn to resolve minor discomfort for himself. It is important to realize that any attention wakes the baby up. All the extra attention and special behaviour associated with going to sleep often achieve quite the opposite of what the parents hope to achieve.

Breastfeeding your baby
why breast is best
Can I get breastfeeding advice before the birth and will I get help in hospital?
If you are planning to breastfeed, ask about specific breastfeeding support or sessions available in your area prior to the birth (see opposite), as having additional information beforehand is extremely useful and will help you in the first few weeks when you are trying to get breastfeeding established
You should get breastfeeding support while in hospital, both in the delivery suite and on the wards; this may come from a variety of sources, not just from the midwife Many maternity units have

Benefits of breastfeeding
Giving your baby the healthiest start in life
There are several unique advantages to breastfeeding, the main one being that breast milk arrives on demand as the perfect food for your baby. Other benefits of breast milk

include the following:
•    Breast milk protects babies from infection.
•    It reduces the risk of some diseases.
•    Breastfeeding is thought to increase a child’s IQ later in life.
* It can reduce the risk of allergies. It has also been reported that babies who are formula-fed are more likely to have breathing problems such as asthma, and gastric problems
such as colic. Constipation is also more common among formula-fed babies, and hence there are more hospital admissions from bottlefed babies.
* There are greater benefits for the mother if she breastfeeds, such as increased weight loss.
maternity support workers who offer support with breastfeeding. Other units encourage local voluntary breastfeeding support workers to come into hospital to offer women guidance
while they are staying in hospital and then afterwards at home. Some babies will breastfeed well without problems, while others take a little while to learn, so ask for help and
assistance as and when you need it. There are a few tips to remember to help you make a good start: * Skin-to-skin contact at birth is recommended to encourage milk production.
* Good positioning and attachment at the breast is very important Hold your baby close to you and facing your breast, with her head, shoulders, and body in a straight line (see
p.225-229), and make sure that her nose or her top lip is opposite your nipple, so she is able to latch on easily
* Ensure your baby can reach the breast easily, without having to stretch or twist
* Always move your baby towards the breast rather than your breast towards the baby
* Feed your baby on demand, allowing her to feed as often as needed for as long as she wishes * Avoid supplements of water or formula milk unless there is a medical reason for
this that has been fully explained to you.
* Avoid giving your baby bottles or dummies while you are establishing feeding as this can create nipple confusion” as nipples and teats require different sucking techniques.
* Try to relax and enjoy your baby’s feeds
Should I put my baby to the breast as soon as she is handed to me after the birth?
Holding your baby close to you as soon as possible after the birth is recommended, partly to encourage breastfeeding and skin-to-skin contact.

Thinking ahead being practically and emotionally prepared
It’s wise to think about how to prepare for breastfeeding before the birth. * Address your perceptions about breastfeeding and those of your partner and family, and deal with
negative stories This is because some of the problems associated with breastfeeding include embarrassment and a lack of confidence in your ability to produce enough milk.
* Purchase nursing bras and try to attend your antenatal classes, where breastfeeding will be discussed. The National Childbirth Trust (NCT) and La Leche League (LLL) also run
classes on breastfeeding (see p 3 10).
that your baby is close to the breast. Your baby may root for the nipple and some babies will latch on instinctively, while others may just sniff and lick the nipple. Don’t be
worried if your baby does not latch on straight away as babies are born with enough nutrients to last several hours before getting hungry.
What is colostrum?
Colostrum, commonly called the first milk or premilk, is a watery, white/yellow substance produced by the breasts for the first few days. Most women do not notice it until after
the birth, although it starts being produced from as early as 20 weeks in pregnancy and may leak during pregnancy. Although colostrum is not abundant, it has a high
concentration of nutrients. It is high in protein and vitamin K and it also contains antibodies and white blood cells to protect your baby against infection. Colostrum helps
your baby to excrete waste products and lines the stomach with a protective layer that helps fight against foreign substances, such as bacteria, in the body. It is also thought
that colostrum helps to prevent allergies
Help! My breasts are like huge beach balls. Will they stay like this if I carry on breastfeeding?
Between three and six days after birth, your breasts prepare to increase their milk production and may be tender, throbbing, lumpy, and uncomfortably full This is due to the
blood and lymphatic flow to the breasts increasing and a larger volume of milk being produced This is normal, but if milk isn’t effectively removed at each feed, breasts can
become swollen, or engorged. This should be a temporary condition, as long as your baby latches on well and feeds on demand for as long as she needs. Some mothers find it
helpful to massage the breast during feeds to encourage milk flow Wearing a supportive feeding bra and alternating hot and cold flannels can relieve the discomfort
When will my milk come in?
After the birth, your body produces the hormone prolactin, which tells your brain to produce milk, and most women start to produce breast milk between days three and six Which
day your milk comes in may also depend on the type of birth you had, as some studies suggest that milk production is delayed if you have a Caesarean. A delay can also occur if a
woman is on medication, such as insulin, to control blood sugar levels. Also, although this is a natural process, certain factors can affect when, and how much, milk is
produced, such as a woman’s thoughts on breastfeeding and how relaxed she feels, and if a mother is undergoing any stress or anxiety.
There are so many different formula feeds around nowadays - is breast really still the best?
It’s true that there are many types of formula milk, with each one striving to be as close to breast milk as possible. However, there are some nutrients and bacteria-fighting
cells present in breast milk that cannot be artificially produced. Breast milk contains everything a baby needs for at least the first three months As well as promoting the
benefits of their own brand, all formula brands also acknowledge that breastfeeding is the best option.

Establishing breastfeeding
Each mother has a different experience when starting to breastfeed Both you and your baby
will be learning and practising together, which can seem quite strange for something that is supposed to be so natural. Some babies will simply attach themselves onto the nipple
(”latch on”) straight away, while others will take longer and may need help from a midwife Sometimes, the type of labour and birth that you experienced can affect how quickly
you establish breastfeeding.
a store of water and fat in her body to provide nourishment until milk is available She will. however, have a strong urge to suckle.
How should I position myself for feeds? For subsequent feeds, it is worth taking the time to check that you are in a comfortable position (see below, right). It might help if
someone holds your baby while you make yourself comfortable -perhaps with cushions behind your back, or a cushion to lie your baby on.
How should I start the first feed? Many babies begin to breastfeed if left ‘’skin-to-skin”, lying directly on you near your breasts, for about 45 minutes Your baby can smell
your milk and will naturally start to make mouthing movements and turn her head to your nipple At first, your baby will need only a small amount of food because she has
Latching on
How should I position my baby? The key to successful breastfeeding is ensuring that your baby is in the right position and has a good ”latch”. Move your baby so that her nose
is opposite your nipple and “tummy to mummy” (your baby’s tummy is lying across your tummy) in a straight line and held close to you (see below). Wait until she opens her mouth
Structure of breasts really wide (this ensures that her tongue is in the right
position) and then move her mouth onto the breast.
How do I know if my baby has latched on properly? It is important to make sure that the whole of the nipple and areola are in your baby’s mouth. This enables your baby to get a
good sucking action and prevents your nipples from getting sore or cracked. The baby’s bottom lip should be curled back, and sucking will be long and deep (rather than little
chomping movements). You may also notice that her ears move
as she sucks. When your baby has latched on correctly,    I fatty tissue
you shouldn’t feel any pain (or, possibly, only a slight
During pregnancy pain when she first starts to suck). If it still hurts after she
has begun sucking, she is not latched on correctly and
you should ease her off the breast and start again after adjusting her position
How do I take my baby off the breast? Do this by sliding your finger gently inside your baby’s mouth - this will break the seal it forms around your breast
I’m expecting twins - can I still breastfeed?
Lots of women successfully breastfeed with twins, although it may take extra planning, as life is easier if both babies adopt the same routine and are fed together. Most women
think that they won’t produce enough milk to satisfy twins; however, milk production works on on a supply and demand basis, so the more your babies suckle, the more milk you
produce You can either fully breastfeed with both babies latching on. or express milk (see p 234-235) and alternate when each baby latches on Expressed milk may be cup-fed to
minimize the risk of a baby taking to a teat and possibly preferring this to the nipple The Twins and Multiple Births Association has plenty of advice on caring for twins (see
p.310).
I’ve heard that it’s harder to breastfeed straight after a Caesarean - is this true?
Women who undergo a Caesarean are likely to be
in more pain than those who have had a vaginal birth, and studies have also shown that postoperative pain
can affect breastfeeding. Also, following major surgery, it’s not easy to move around for a day or so These factors make feeding more challenging initially. However, most
hospitals provide good post-delivery pain relief, which helps women to breastfeed Adopting feeding positions that don’t
put pressure on your stitches also helps (see below). Even if breastfeeding does not happen in the first 24 hours, it is important to allow skin-to-skin contact between you and
your baby as soon as possible.
Will I need a special bra?
It is important that your breast is free during feeding With a normal bra, you would have to remove a garment, so yes, it is advisable to purchase at least two nursing bras.
Nowadays there are lots of attractive bras available. The bra should have a zip or drop-cup fastening to allow one cup at a time to be undone. Ask a trained assistant to measure
you, as a poorly fitted bra can contribute to problems such as mastitis (see p.233) It’s best to wait until 36 weeks before choosing a bra as your breasts continue to grow, The
average increase is around two cup sizes.
Breastfeeding after a Caesarean
Breastfeeding after a Caesarean section can be more challenging than following a vaginal birth as your baby may be sleepy from the effects of the drugs and you will be feeling
uncomfortable from the stitches. If your baby is asleep most of the time, do encourage her to wake for a feed every couple of hours Finding a comfortable position to feed is
important for the let-down reflex.You may find lying on your side facing your baby easier and this is a recommended position after a Caesarean In the days following the
operation, when you are more mobile, you can try feeding sitting up with your baby lying on a pillow to alleviate pressure on your wound.
Breastfeeding is such a struggle. What are we doing wrong?
Although breastfeeding is supposed to be a natural process, for some mothers and babies it can be a challenge. There are a few basic guidelines to help you relax your baby and
get her to latch on properly (see p.228). First, try not to force the nipple into your baby’s mouth. Instead, wait for your baby to lean towards the nipple. For this to happen,
your baby must be turned towards you with her head, shoulders, and body in a straight line (see p,229). Your baby’s lower lip should be below your nipple. To soothe your baby,
you can try stroking her lip with your nipple, or squeeze a few drops of milk onto her lips If your baby wants to feed, she will open her mouth to receive the nipple If so. draw
her closer so that she can latch on across the nipple and around the areola (the darker skin around the nipple) Once she is in the right position, you shouldn’t be able to see
any of your nipple, just a small area of the areola. It should also feel comfortable. Although you shouldn’t force the nipple on your baby you can move her towards the breast so
that her mouth touches the nipple and is encouraged to open wide. Avoid bending forwards, as this can give you backache and may encourage a poor feeding technique.
There are key signs that your baby is properly latched on. These are that the bottom lip is curled back, the chin touches the breast, the mouth is wide open, your areola shows
more above her top lip than under her bottom lip, and the sucking pattern changes to long deep sucks.
How often should I breastfeed my baby?
This is commonly asked by mothers as they feel that the baby should have a routine or pattern. However, it is best not to schedule feeding times and force your baby into a
pattern of, say, every 3-4 hours All babies, but particularly breastfed ones, should be fed on demand. All babies are different and you will soon become familiar with your
baby’s signs of hunger. For example, your baby may ”root”, or search, for the nipple, may not settle, and may make crying or
Troubleshooting
Sore, cracked nipples area common complaint among breastfeeding women and a source of great distress, often leading women to abandon breastfeeding altogether. Knowing what steps
you can take to prevent this happening, or how to alleviate any discomfort, will help to make breastfeeding a more relaxing experience. * Make sure your baby latches on properly
and is removed from the breast gently (see p 228). If your breasts are engorged, expressing some milk first helps your baby to latch on more easily
* Keep your nipples dry between feeds Let the air get to your nipples and use breast pads to soak up leaks of breast milk.
* Relieve sore nipples with a chilled cabbage leaf. You can use a nipple cream if necessary, although most midwives suggest avoiding these if possible.
whimpering sounds. A baby can only hold about 1-2 ounces of milk in their stomach, so some babies may be hungry after an hour, while others may hold out a bit longer. If your
baby dirties a nappy just after a
feed, it is likely that she will become hungry again sooner, usually within an hour of the feed It is also important to allow your baby to feed for as long as possible on each
breast before changing side, to
ensure that she gets the full benefits of the milk
What can I do to help my baby get enough milk?
There are steps you can take to ensure successful breastfeeding and that your baby gets enough milk. * Hold your baby close to you as soon as possible after the birth She will
start to ”root” for your nipple when she is ready to feed.
* Feed your baby as often as she demands in the first few hours and days after the birth This will enable your body to synchronize with your baby’s needs. Feeding on demand in
this way also helps your milk to come in around days 3-5.
* Check that your baby is latched on correctly (see p.228). When your baby is in the correct position, you will both feel comfortable and relaxed. If the baby is not latched on
correctly, it may become painful for you, and you are more likely to stop breastfeeding earlier.
* Allow your baby to feed on one side as long as possible This is because the consistency of breast milk changes during the feed The first part, or foremilk, is lower in fat
compared to the hindmilk The longer she feeds, the more milk you will produce. * Avoid giving your baby a bottle and/or a dummy until feeding is established as this may lead to
nipple confusion. In some cases, a baby may find it hard to latch on, or reject the nipple in favour of a teat. If this continues, your milk production will fall significantly *
Some women believe they should not exercise as it may affect milk production, but this is not the case Studies have revealed that even high-intensity exercise does not affect
breast milk production.
How will I be able to tell that my baby has had enough milk?
Although you can’t measure the exact amount of milk your baby gets, the breasts work on a supply and demand basis, so your body responds to your baby’s sucks and the amount of
milk she takes and produces more according to her needs. Usually, babies feed for at least 10 minutes each feed in the first few days after the birth and you may need to offer
both breasts before she is satisfied. You can tell that your baby is feeding well as her lower jaw will move steadily while she is on the breast. When she is full, she will fall
asleep or release the nipple and be contentedly awake. You should not break the feed, even to change breasts. Your breasts may feel softer and less tense after a feed. Another
sign that your baby has enough milk is the amount of wet and dirty nappies she produces (Breastfed babies tend to have runnier poo than bottlefed ones, see p 242) If you think
that your baby is not satisfied, ask your midwife or health visitor for advice and support before using formula milk.
I get wet patches on my clothes and find breastfeeding so messy. Do you have any advice?
Your breasts leak when they are full and overflow, or when the let-down reflex kicks in, for instance when another baby in the room cries or when you feed from the other breast.
To avoid this, try expressing to stop your breasts becoming too full. Breast pads can help there are disposable and washable ones available. If one breast leaks when your baby
feeds on the other, put a plastic, washable breast shell inside your bra before you start to feed. If the shell
is sterilized, you can save the milk that it collects and freeze it This can be given to your baby at a later date or donated to a milk bank at your local hospital, if you have
one. When you’re out, carry a change of clothes, bra, and breast pads. If you feel a let-down, cross your arms and hug yourself, pressing gently against your breasts, which may
stop the flow. You will probably leak most in the first few weeks of breastfeeding, while you are establishing the right supply for your baby Many women find that the problem
disappears after the first six weeks
Do I have to watch what I eat and drink if I’m breastfeeding?
Yes. Generally, it is important to remember that your baby receives all the nutrition she needs through your breast milk, so having a well-balanced diet is really important (see
p.50). However, there are certain foods and drinks that will affect your baby’s digestion. For example, if you eat lots of fruits, such as grapes and oranges, it can cause loose
stools or diarrhoea in your baby You are advised to avoid high amounts of salt as this can cause your baby to become dehydrated It is also advisable to avoid alcohol Not only
can it make your baby quite sleepy, but there have been studies linking this to cot death
Can all women breastfeed? My mum says she wasn’t able to.
The majority of women are able to breastfeed. You may find that the system of maternity care hindered your mother’s breastfeeding, as there was a time when mothers were told to
feed only every four hours. Learning as much as -you can about breastfeeding in advance makes you more likely to succeed. A common myth is that breast size affects the ability
to feed, but this is not the case. Breast surgery may affect breastfeeding, but even after the most invasive surgery, it is possible that a portion of the original glands and
ducts remain intact. Hopefully you will feel confident enough to give breastfeeding a try.
I want to go back to work six weeks after the birth. Is it worth starting to breastfeed?
Yes, most certainly. Even if you only breastfed for the first week, your baby would benefit from the colostrum. So continuing breastfeeding up to six weeks is good It is
estimated that around 40 per cent of women stop breastfeeding at around six weeks, which may also coincide with the fact that they are no longer receiving visits from a midwife
or health visitor and therefore have a lack of support. Once back at work, you can express your milk, either at work, depending on the facilities, or in the mornings and
evenings at home
What are the benefits of expressing milk?
Expressing breast milk (squeezing milk out of your breasts, see left) enables your baby to receive all the benefits of breastfeeding if you are unable to be with your baby for
every feed. Mothers express their milk for many reasons Some like to give their baby breast milk from a bottle if they are going out when a feed would normally take place, while
others who are going back to work express several feeds’ worth so they can continue to breastfeed their baby, Mothers of premature babies being cared for in a special care baby
unit might express all their baby’s feeds
When can I start expressing?
You can start expressing as soon as is practical after your baby is born. Also, studies have shown that expressing as soon as possible can greatly increase long-term milk
production. For mothers who breastfeed and are returning to work, expressing should start at least a week before so that the baby can get used to receiving the milk from a
bottle or cup. Once you start expressing, if possible, you should express around every three hours, including once in the night when prolactin levels are highest, aiming to
express 6-8 times in a 24-hour period. As breast milk is made on a supply and demand basis, the better your baby feeds, or the more often you express, the more milk you will
make for your baby. An Australian study found that women who express milk are more likely to continue breastfeeding for up to six months.

Expressing breast milk
Providing additional milk supplies
You can express breast milk as soon as you feel ready after the birth, although some women prefer to wait until breastfeeding is established, at around four weeks. Expressing
milk means your partner can start to help with feeds and you may be able to get out for periods.
How is it done? Most women use a pump to express their milk There are many different types available, ranging from manual to electric ones. The other way to express your milk is
manually. To do this, support your breast with one hand, making a c-shape towards the back of your breast and gently squeeze in a downward motion, moving towards the nipple;
stop, and then repeat until you have enough milk You will soon learn where the
best place is to put your finger and thumb. Sometimes it is difficult to get a”let-down reflex” when you are expressing – try thinking of your baby and you should soon be making lots of milk.
How should breast milk be stored? It is important that you put the expressed breast milk into a sterile bottle liner or a sterile bottle. This can then be stored in the fridge
for 24 hours, or in the freezer for up to three months Label each bottle or container with your name (if your baby will be with others at a nursery), and the date and time you
expressed it. To defrost the milk, warm it gently in a bowl of hot water – don’t use your microwave Do not keep milk in the fridge door, as the temperature fluctuates.

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

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

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

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

Who will handle my care?
a guide to antenatal care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

NOW YOU’RE PREGNANT
My test is positive
-what happens next

We’ve confirmed the pregnancy - when should we tell everyone?
This is down to personal preference. Many women wait until after their first scan at around 12 weeks before announcing their pregnancy This is mainly because the chances of miscarriage are at their highest during the first trimester. This avoids having to break the news if you do miscarry On the other hand, you may value others’ support Circumstances may dictate that you tell people earlier for example, if pregnancy symptoms are pronounced. Some couples find that waiting to share the news allows them to adapt to the idea of parenthood without constant ”advice” from others.

It’s what we wanted, but now I feel unsure - am I just scared?
Finding out you are pregnant, even if it was planned, can feel overwhelming and what you are feeling is perfectly normal. The hormonal changes you are experiencing can also give you highs and lows, which you have to handle along with the physical changes of pregnancy. Talking to your partner, a trusted family member or a friend, or confidentially to your midwife, about how you are feeling may help relieve your anxiety It’s important to acknowledge that pregnancy is a period of enormous change —physically, emotionally, socially, and financially — and it takes time to adjust to these changes.
I want the baby but my partner doesn’t - can he force me to have an abortion?
No, whether or not you proceed with the pregnancy is your decision. Your partner may simply need more time to adjust, but if he remains adamant that he doesn’t want the baby you need to decide about the future of your relationship.

My mum has strong opinions about pregnancy - how can I tell her I want to do it my way?
You could take your mother to an antenatal appointment so she can see how things have changed and your midwife can explain the reasoning behind your care. If she still interferes, have a frank talk Tell her that although you love her and know she wants to help, you want to make your own decisions. Hopefully she will come round to your point of view

We don’t feel ready financially -how will we cope?
There are ways to cut costs when preparing for your baby, Although some items should be new, such as mattresses and car seats, many things can be bought second-hand or passed on from friends and relatives, who may also wish to buy an ”item’ There is a range of monetary and health benefits that you may be entitled to (see pp.62-3). Also some families are eligible for a Sure Start Maternity Grant, a one-off payment that doesn’t have to be paid back, and child benefit is paid to all people bringing up children A child trust of E250 is also available for each baby born in the UK (see p 6 1). Your midwife can give you contact details for any benefits you are entitled to

I’m pregnant by IVF - is there anything different I should do?
Some experts believe that once pregnant, providing there are no other risk factors. you should be treated the same as unassisted low-risk pregnancies. Others believe that you are already a higher risk because
you needed help to conceive. Recent research suggests a link between IVF and growth problems, so regular scans may be sensible. Your hospital may have a policy for IVF pregnancies and you could speak to your midwife about consultant care.

wnen will I have my first antenatal appointment and how many can I expect?

Your first appointment with the midwife, known as the “booking appointment”, usually takes place between 8 and 12 weeks. This tends to be the longest one as its purpose is to obtain your medical history and carry out a series of checks (see p.74) so that your care during pregnancy and birth can be planned.For a first pregnancy with no complications, 10 appointments are usual, and for subsequent pregnancies, 7 visits are adequate. You can contact your midwife between appointments if you have any concerns or questions.

I got pregnant straight away - are we super-fertile?If you have intercourse around ovulation time and neither of you has fertility problems, you have a 25 per cent chance of conceiving. So I’m afraid this just indicates that intercourse was well timed!

My partner treats me as if I’m made of glass. How can I show him that this isn’t necessary?
Discuss your feelings and allow him to voice his concerns. Ask him to come to an appointment, as the more he understands, the better equipped he will be to provide more appropriate support when needed.