Pregnancy- What happens during my care
What is my approach to your pregnancy?
I understand that pregnancy is both a major exciting change in your life and also a venture into the unknown, with some anxiety. My role is to guide and support you through the pregnancy, delivery, and afterwards. I will provide you with the highest quality medical care, and keep you informed. I am more than happy to answer any questions. Overall, my view is that it is your body and pregnancy and I will, with clarification and the provision of appropriate knowledge, support you in your decisions. Overall I will assume that you are aiming for a natural delivery, unless medical events or your preferences dictate otherwise. I am happy to let nature takes its course but do have the knowledge, experience, and skills to be able to intervene appropriately in order that yourself and baby are protected.
Dr Bell would like to see you for your initial consultation quite early in pregnancy. Our reception staff will endeavour to book this visit for you to be seen at about 7-10 weeks gestation. However, if you are worried then please come in at around 6 weeks.
When you first attend our secretarial staff will collect your administrative information, previous medical history, and details of any previous pregnancies, and will explain our costs structure based upon your particular medicare and insurance status . All information is strictly confidential. If you dont want to write something down, dont worry- just wait until you see Dr Bell and tell him.
At your first visit you will meet me. I will clarify and assist with any of your particular concerns as well as performing an ultrasound in order to determine the well being of your pregnancy and confirm your due date. Based on your medical history, any previous pregnancies, and any particular wishes you may have Dr Bell will develop a plan for the care of your pregnancy, organise your hospital booking in form, and order any appropriate blood tests. I will also discuss more complex screens such as the optional cell free DNA analysis (eg. GeneSyte (Genea), Harmony (Douglass Hanly), etc) or an NT scan.
You will be asked to attend on a regular basis during the pregnancy. These visits are to check the well being of you and your baby. There is always scope for additional visits if required, either because Dr Bell wants to more closely monitor your pregnancy or because you have concerns. Please do not hesitate to ask if you have any concerns or queries. Do not feel you are wasting my time or that it is unimportant. I would prefer to know if you have any concerns. The best thing to do is make a list and bring this along on the day of your visit, or phone if it cannot wait. If you have any urgent problems between visits you may contact me in the rooms. After hours any of the Labour Wards would be happy to advise you and if they feel it necessary ask you to attend for evaluation. If necessary the hospital staff can contact me 24x7.
The frequency of visits will vary from patient to patient according to whether or not any problems are apparent. In all cases the frequency of visits increases as the pregnancy becomes more advanced. In general, visits for a first pregnancy, are every 4 weeks until 28 weeks, then every 2 weeks until 36 weeks, and then weekly thereafter. In general, second (or more) time mums have fewer visits.
At or around 28 weeks I will give you an ante-natal card. This card will have a duplicate record of the results of your investigations and findings at each visit. Your antenatal card will assist our midwifery staff when you are eventually admitted to the Labour Ward. At or around 37 weeks any aspects of a delivery plan will be further discussed. Generally, if you do not labour spontaneously (unless there are other indications), induction at or around 41 weeks is recommended.
There is a set of scales in the waiting area. Please weigh yourself before the consultation and record your weight on the antenatal card (or tell Dr Bell your weight if you have not yet received your card). Weighing is not compulsory.
Routine weighing of pregnant women at each visit has not been shown to be of benefit in relation to pregnancy outcomes and is therefore not a necessary part of your pregnancy care. We are happy to record your weight at each visit if you wish and provide advice on ideal target BMI weight gain if desired.
There are a routine selection of tests, which are performed in the first few months of the pregnancy. There is a blood test and a urine test. The blood test checks for your blood group and any unusual blood group antibodies, full blood count (to check for anaemia), Rubella immunity (German Measles) and a check for Hepatitis B, C, Syphilis and HIV. Immunity to Chicken Pox and Parvovirus may be checked. The urine test is checking for bacteria in your urine.
A detailed ultrasound examination of the pregnancy is recommended at around 19 weeks gestation. The main purpose of this examination is to ensure as far as possible that your baby is developing normally. It is not possible to identify all abnormalities on ultrasound, but more than 50% of significant abnormalities will be identified. See here for a list of local ultrasound providers who specialise in obstetric scanning.
The above outside ultrasound examinations is the only ones that is routinely offered. Sometimes indications arise to perform additional ultrasounds (eg. double check any possible problems, make sure the placenta has moved out of the way, twins, check that the placenta is working adequately, etc). High quality outside scans cost you time and money, I try not to order them unnecessarily.
Diabetes of pregnancy- Gestational diabetes
It is recommended that all pregnant women be checked for pregnancy (Gestational) Diabetes. This usually does not have any symptoms. A blood test is performed at about 28 weeks gestation. Fasting overnight is required for this test. The pathology staff will give you a drink which contains a standardized amount of glucose (it is sweet!). Your blood is then tested for 2 hours after this drink.
You will be contacted if this test is elevated. Dont worry if the test is positive. When managed diet controlled gestational diabetes is more a pain in the finder than anything serious. (the NDSS website has useful information. There telephone number is 1300-136-588).
If your Pap smear is due it will usually be performed at the time of the 6-week postnatal check up. It is sometimes performed during the first half of pregnancy if there is a specific reason to do so.
Urine testing used to be performed on all pregnant women at each checkup. Recent studies have demonstrated this to be unnecessary for the majority of women. The purpose of testing urine is to check for changes, which may occur in association with a pregnancy disorder called pre-eclampsia. Under some circumstances, testing of urine is necessary; you will be advised if this applies to your pregnancy.
Down syndrome and other abnormal chromosome testing
Optional testing is available. It is a complex topic, please read here for further information.
Group B Streptococcus (GBS)
This is a bacteria, which commonly occurs in the vagina. It occasionally causes serious infection in the newborn. One of the recommended approaches to prevent this is to identify pregnancies that are at risk and to treat the mother with antibiotics during labour. There are a number of factors, which identify at risk pregnancies. Some practitioners perform a swab on all pregnant women in late pregnancy. This is an alternative approach. Both approaches are considered acceptable strategies in the prevention of GBS infection in newborns.
Dr Bell prefers that a swab be collected at 36 weeks for DNA analysis to see if you are carrying the GBS bacteria in the vagina. The justification for GBS testing is described here.
Medications in pregnancy
Please ask if not sure. The following are considered safe
Pain relief: Paracetamol +/- codeine e.g. Panadol or Panadeine or equivalent
Cough suppressant Benadryl or Duratuss
Constipation: all laxatives safe. Try Metamucil or Fybogel first
Heartburn: all antacids safe e.g. Mylanta, Gaviscon, Rennie
Vaginal thrush: vaginal creams and pessaries all safe e.g. Canestan, Nilstat, Monistat
Haemorrhoids: all creams safe e.g. Proctocedyl, Rectinol
Antihistamines: older ones are known to be safe e.g. Polaramine, Phenergan
Throat lozenges: all safe e.g. Strepsils, Difflam
Iron tablets: all safe but may cause constipation (recommend fefol)
Vitamin supplements: Elevit or Blackmores pregnancy & breastfeeding
Antibiotics: Amoxil, Keflex commonly prescribed and are safe.
Nasal sprays: temporary relief of congestion e.g. Saline, Sinex, Drixine
Dermatitis/skin rashes hydrocortisone cream e.g. Sigmacort
Dental local anaesthetic is safe
Other medications: if in doubt or concerned phone us to check
Mothersafe is a free telephone service (9382 6539) in NSW for women concerned about exposure to medications and other toxins during pregnancy and breastfeeding. This includes, prescribed medication or over the counter medicines. They are available Monday to Friday 9am to 5pm.
Nutrition, Vitamins, weight gain, and exercise
I encourage you to have a very sensible diet. Meat, vegetables, fruit and dairy products in moderation are desirable. Restrict carbohydrates and sugar foods to a reasonable extent. Excess sugar (either as the obvious, or thru sweet fruits) may cause the baby to be larger than otherwise.
Some foods contain significant iron but the body is unable to absorb it. Beef, lamb, fresh and tinned fish, pork, and chicken are good sources of absorbable iron. Iron (food or tablets) is best absorbed if taken with vitamin C (eg. Orange juice). If you require an Iron supplement, I recommend Fefol Iron supplement (87mg iron compared to 12mg in its multivitamin form).
Restrict your alcohol to a minimum and try to discontinue smoking if possible. If you can’t stop, at least aim for less than 5 cigarettes per day.
If you wish to read more, please see general purpose information on healthy eating.
Fish & Seafood. Fish are rich in protein, minerals, and important fatty acids. However, some fish contain mercury levels that may be harmful to baby. A serve for an adult is 150gms, for a child up to 6 years it is 75gms. The following fish should be limited to no more than one serve per fortnight; Organge Roughy (Sea Perch), Catfish, Shark (Flake), or Billfish (Swordfish, Broadbill, or Marlin). Any other fish may be eaten 2-3 times per week.
Because of Listeria (see below), raw seafood such as oysters, sashimi, smoked salmon should be avoided (canned oysters are safe).
Should I restrict my activity? Normally there is no restriction except that you should avoid potentially dangerous contact sports. Antenatal classes are available through the hospital. You can enquire about these classes when you book in.
Normally I do not insist that you give up work during pregnancy. If you are coping there is no reason why you can not continue working until the end.
You will need to accept that your exercise tolerance level will fall and tiredness will increase as the pregnancy advances. I will let you know of any special consideration that may apply to your work or physical activity. There are usually no restrictions on sexual intercourse during pregnancy.
Nutrition... Folate, Iodine, and Vitamin D. Folate is a B vitamin needed for healthy growth and development. A baby's growth is most rapid in the first weeks of life - often before you even know you are pregnant. Folate is especially important for women at least one month before pregnancy and for the first three months of pregnancy to help prevent birth abnormalities like Spina-Bifida in babies.
It is recommended that all pregnant women ensure adequate iodine intake throughout the duration of pregnancy and especially in the first trimester. Iodised table salt is a good source of iodine. There are also a number of vitamin supplements that contain iodine.
Maternal Weight Gain. Weight gain in the pregnancy, if excessive may impact on your comfort and mobility in later pregnancy as well as your longer-term health. Assessment of ideal weight gain in pregnancy is best based on a woman's pre-pregnancy body mass index (BMI, a measure of height in relation to weight). In general, leaner women are advised to gain more pregnancy related weight, and heavier women are advised to gain less.
Infectious Diseases and Pregnancy
The following sections cover prevention of Influenza and whooping cough, Listeria, and Zika. There are many other situations that may be of concern (eg. exposure to slapped cheek or chicken pox). If you are not sure then please ask me (the CDC is also an excellent resource).
Vaccinations in pregnancy
It is highly recommended that you receive a Flu vaccination, and it can be given at any stage in pregnancy. See here for the Australian government recommendation, and here for information about the vaccination.
It is also recommended that pregnant women receive a whooping cough (Pertussis) vaccination at around 28 weeks in every pregnancy. Partners and care givers should receive a booster shot every 10 years. See here for more information.
Listeria monocytogenes is a type of bacteria, which can be found in some foods. It causes few or no symptoms in healthy people, but can be very dangerous to pregnant women and babies. Hormonal changes during pregnancy have an effect on the mother's immune system that makes the mother more vulnerable to Listeria. Listeria, although rare, can be transmitted to an unborn baby, and may lead to miscarriage, stillbirth, or premature birth. About 22% of cases with perinatal Listeriosis result in stillbirth or neonatal death. Early treatment may prevent fetal infection and fetal death.
Listeria has been found in uncooked meats, uncooked vegetables, un-pasteurised milk, foods from unpasteurised milk and processed foods. Listeria is destroyed by pasteurisation and conventional cooking (if at a high enough temperature), but can grow in refrigerated food. Ideally, eat only freshly cooked food and well-washed freshly prepared fruit and vegetables. Leftovers can be eaten if they are refrigerated promptly and kept no longer than a day. It is important not to eat food if there is any doubt about its hygienic preparation or storage. There is a chance that contamination may occur in ready-to-eat foods such as hot dogs and deli meats because contamination may occur after cooking and before packaging.
Symptoms of Listeriosis may show up 2-30 days after exposure. Symptoms in pregnant women include mild flu like symptoms, headaches, muscle aches, fever, nausea and vomiting. If the infection spreads to the nervous system it can cause stiff neck, disorientation or convulsions. Infection can occur at any time during pregnancy, but it is most common during the third trimester when your immune system is somewhat suppressed.
Listeriosis is treated with antibiotics during pregnancy. These antibiotics, in most cases, will prevent infection to the fetus and newborn. These same antibiotics are also given to newborns with Listeriosis.
Following these guidelines can greatly reduce your chances of contracting Listeriosis.
For more information on food safety and prevention of food borne illnesses refer to food standards or NSW health or the Center for Disease Control (the previous link also gives information about other pregnancy infection risks) or the NSW food authority.
The Zika virus is a newly identified problem for pregnant women. Knowledge is evolving. What is known is that
Zika virus can be passed from a pregnant woman to her fetus.
Infection during pregnancy can cause certain birth defects
Pregnancy, birth and early motherhood for most women is a very positive experience. However, it may not be totally what you expected. This is a time of transition for you and your partner and it may be difficult to adjust. Depression may affect up to one in seven women, either during the pregnancy or after birth. There is help available and I have listed some contact numbers for you.
Emergency Telephone Support
Dona Maria Support Line. 1300 555 578
Lifeline. 13 11 14
Karitane. 1800 677 961
Tresillian. 9596 5733
Karitane Jade House
Local Community Womens Health Centres
(Hills Community Health Care) 8853-4500
Karitane Cottages 9399 6999
Karitane Residential Unit 9794 1800
Tresillian Residential Unit 9569 5773
Parent Support Line 9832 8081
Parent Line 13 20 55
Home Start Program 9310 5885
Australian Psychological Society 1800 333 497
Perinatal Mental Health Services
RHW (Randwick) 9382 2796
King George V (Camperdown) 9515 8165
Liverpool Hospital 9827 8070
Nepean Hospital 4724 2585
St John of God (Burwood) 9747 5611
Relationships Australia 1300 364 277
Domestic Violence 9382 6539
How long will my pregnancy be?
The average length of pregnancy is 40 weeks from the first day of your last normal period, but this varies considerably from one pregnancy to another. We will always describe any particular stage of pregnancy as so many weeks as opposed to months. This avoids confusion between calendar months and groups of four weeks. All other factors being equal it is safe to let a pregnancy go to about 41½ weeks before induction is necessary.
Twins are a special case, and generally will deliver at around 37 weeks if labour has not started naturally.
I think I am in labour !!!!
If you think that your are in labour, that your waters have broken or if you have had a "show" then telephone the delivery suite directly and the midwife will tell you what to do. The midwife will inform me of your admission and keep me informed of your progress in labour.
While it is not possible for me to be present during the whole of your labour, I am personally responsible for the care and well-being of you and your baby. That is, the midwives will keep me informed throughout your labor and I will respond with appropriate instructions and/or attend personally.
I will come to Delivery suite immediately if there is a significant problem or when delivery is close. If in the unlikely event that I am unavailable when you are ready to deliver (eg. Attending a conference or attending an emergency) then a trusted specialist colleague will attend you (you will not be charged by that specialist, I will take care of his payment).
SHAVES, ENEMAS, LABOUR POSITION?
I do not insist that you have a shave or an enema, however you can if you prefer. I try to keep delivery as natural as possible. If all is well I do not have strict views about the birthing position and do not insist on the use of drapes. I encourage you to adopt the most efficient position during the second stage of labour and this will vary from one labour to the next.
I do not routinely perform episiotomies (cutting the vagina prior to delivery) and will only perform one if I judge that overall any perineal tear will be smaller if I do one. Obviously I prefer you to have no tear or a small one.
Pain varies enormously from person to person. All popular modern methods of pain relief are available in the hospital. This includes gas (nitrous oxide and oxygen mix), Pethidine injection, and epidural block. Most people will wait until labour starts before stating their preference. Some labours will generate intense pain signals, others will not. For some patients their cervix will dilate very quickly, others will not. Keep an open mind. If you have questions please ask.
An epidural may be required for pain relief in labour, to allow comfortable delivery by forceps, for an elective or emergency caesarean, or sometimes to aid control of blood pressure in labour for pre-eclampsia.
An epidural is an injection of local anaesthetic into the epidural space deep inside the back. Initially a needle is inserted but then a fine catheter is threaded through the needle and the needle withdrawn. The soft catheter stays in place so that further injections may be given as the first dose begins to wear off.
All procedures carry risks, just as getting in your car carries a risk, however you can be assured that there is no safer place in the world to have an anaesthetic than Australia. Major complications are very rare. Common side effects are an initial fall in blood pressure, shivering, temporary loss of bladder sensation (requiring a catheter to empty the bladder), or a headache which lasts some days. The chance of long term back problems from the epidural is either zero or very small. Your anaesthetist will be able to provide further information and/or clarification.
Cost of an epidural?. Your anaesthetist is an independent specialist. He or she will charge according to the type of procedure, time taken, out of hours, etc. I am unable to state what the ‘out of pocket’ will be if you have an anaesthetic in labour and/or for delivery.
My aim is that you should experience a natural birth. However, if circumstances arise that place you or your baby in jeopardy then forceps or caesarean section delivery may be required. If that is the case, I will of course be discussing that in more detail with you and your partner.
After delivery I will place your baby on your abdomen. If you wish you can put your baby to the breast as soon as delivery is completed. I encourage you to breast feed.
Your partner is encouraged to stay with you during the labour and the delivery. This includes the situation where forceps are needed. I will try and keep your partner involved. I have no objections to other support staff being present, but you should discuss this with the labour ward midwives beforehand.
BREAST FEEDING. See below
The hospital will routinely arrange for your baby to be checked and cared for by a Specialist Paediatrician. If you have a special request for a particular paediatrician then please let me know.
Breast feeding is preferable to bottle feeding. To prepare for this some suggest that whilst in the shower or bath that you pluck the nipples with a slightly soapy thumb and first two fingers five times. Then rub with a soft towel. Finally rub with a moisturising cream (eg. Wool at, Lanolin, or Ego skin cream). I dont feel strongly that preparation makes a massive difference, but it doesnt do any harm.
It is important to make sure that your baby attaches properly. If the baby is feeding and it is uncomfortable then break the suction and call the nursing staff to show you how to attach the baby to feed comfortably. Most mothers do not get milk for 3-4 days and it can take up to 4-6 weeks for lactation to settle.
I won’t go into all the details of breast feeding. It is one of the major tasks of the nurses on the post natal ward to assist you in establishing comfortable effective breast feeding. Continued support after discharge from hospital is available.
Good luck with breast feeding – it is not for everyone. If you cannot do it you are not a failure.