Pregnancy, Labour, Birth and the Early Days of Parenthood Information We recommend that you read the information within this book as your progresses. Mid Cheshire Hospitals Maternity Services Congratulations on your pregnancy. The staff of the Maternity Unit warmly welcomes you and your family. We wish to offer a safe and high-quality service. Our aim is to be sensitive to your physical and emotional needs and to be flexible in our care so that your individual wishes are met. All healthcare professionals you encounter will respect you as an individual undergoing a significant and emotionally intense life experience. You will be in control, listened to and cared for with compassion. We will give you adequate information, so that you can make informed choices and your consent will be sought for any intervention or treatment offered. We hope that this book will be helpful to you during your pregnancy and after your baby is born. At Mid Cheshire Maternity Unit, we have a Consultant Led Unit and Led Unit (MLU) in a semi-rural area undertaking approximately 3000 births per year. Our Maternity Unit provides services for all women. • You will be given the choice of where to their families around problems with drugs, have your baby including; Homebirth, alcohol, mental health, domestic violence Midwifery Led Unit (MLU) or Consultant and abuse. We appreciate it may be difficult Led Unit. During the antenatal period to think about these issues but we are the most suitable place of birth will be committed to making sure you get the help discussed depending on your individual you are entitled to. Your Community needs, medical history and any previous will refer you to this team if they feel that , allowing you to make an you would benefit from additional help and informed choice. You can be referred for support. an appointment at our Birth Choices Clinic • A multidisciplinary diabetic antenatal clinic is if you would like to discuss your options in provided for women with pre-existing diabetes more depth. and those who develop gestational diabetes. • Our Community Team provides antenatal and The team includes a Endocrinologist, postnatal care for all women who live locally Diabetes Specialist Nurse, Midwife and a to the hospital. Care is primarily provided in Dietician for the diabetes clinic. Children’s Centres and GP Practices. • The Labour Ward Suite consists of a • The Maternity Outpatients comprises of Consultant Led Unit, two maternity Theatres two main clinical areas; the Antenatal Clinic and an alongside MLU comprising of three (ANC) and the Antenatal Day Assessment rooms which each have a birthing pool and Unit (ANDAU). The ANC comprises of many are designed to promote normal birth. different types of clinics, from scanning • We also have a Neonatal Unit with clinics for those receiving Midwife Led care experienced Neonatal Nurses and to Consultant Led and specialist clinics Neonatologists if required. for women who have more complex care requirements. We also have Fetal Medicine Students and Twin Clinics which are run by specialist Consultants and . The ANDAU is an • Leighton Hospital provides training for area where we can offer additional pregnancy Student Midwives and Student Doctors. You monitoring in order to prevent unnecessary will be asked if they may participate in your hospital admission. care throughout your pregnancy, birth and the postnatal period as part of their training. Your • A Triage system operates within the Labour co-operation would be appreciated. If you Ward Suite to assess women in order to have any worries, please discuss them with provide appropriate advice and care. your Midwife. The students will be under the • A specialist team of Midwives who provide supervision of a qualified Midwife or Doctor. additional advice and support to women and

2 Pregnancy Information Book Pregnancy Information: If you require any more information regarding your pregnancy or baby please do not hesitate This book provides general information about to ask your Midwife, GP or Health Visitor. your pregnancy, labour and looking after your baby. Leaflets specific to anything that may As well as this Pregnancy Information arise throughout your pregnancy or after birth, Book, you can access the NHS interactive will be given to you as appropriate. pregnancy care planner online, which contains videos and interactive planning tools. It We also have our hospital information leaflets contains all the information you may need to displayed on the hospital website for you to know during your pregnancy. Please see the read or print, please go to: www.mcht.nhs.uk link to the planner below: Then click on: www.nhs.uk/planners/pregnancycareplanner/ 1. The Patient tab Pages/PregnancyHome.aspx 2. Then choose Patient leaflets 3. Click on Maternity Services 4. Pick your chosen leaflet

Clinical Research in Women’s Health at Mid Cheshire Hospitals NHS Foundation Trust

What is Clinical Research? Do I have to take part? Clinical Research helps us understand how It is entirely up to you whether or not to take to diagnose, treat, cure or prevent disease. In part and your care will not be affected if you Women’s Health it may help us to progress decide not to. and develop, leading to providing improved patient care. How can I find out more information? The research could be a drug trial, a screening If you would like to know more about getting study, a questionnaire or a combination of involved in research, please contact the these and participation is entirely voluntary. Research Midwives who are based at Leighton Hospital on 01270 273745. You may be approached by staff during or after your pregnancy regarding studies that you are eligible to take part in.

Pregnancy Information Book 3 Index 1.0 Your pregnancy at a glance...... 8 2.0 Antenatal Care ...... 10 2.1 Your first antenatal appointment ...... 10 2.2 Your named Midwife ...... 10 2.3 Customised antenatal growth charts...... 10 2.4 Importance of Antenatal care: ...... 10 2.5 Appointments at the hospital ...... 10 2.6 Staff Identification...... 11 2.7 Medication ...... 11 2.8 What does having a ‘high risk’ pregnancy mean?...... 11 2.8.1 Planning future births following a previous caesarean delivery...... 11 2.9 Feeding Services...... 11 2.10 Maternity benefits and travelling expenses...... 12 2.11 Car parking ...... 12 3.0 Ultrasound Screening ...... 13 3.1 Screening information...... 13 3.2 Dating scan ...... 13 3.3 Mid pregnancy ultrasound scan...... 13 3.4 Who can come to the scan with you?...... 13 3.5 Photographs ...... 14 3.6 Personal camera/video equipment ...... 14 3.7 Sex of babies...... 14 3.8 Subsequent ultrasound scans ...... 14 4.0 Your health in pregnancy ...... 15 4.1 What should you eat? ...... 15 4.2 Anaemia in pregnancy ...... 15 4.3 Take care with some foods ...... 16 4.4 Vitamins and supplements ...... 17 4.5 Folic acid ...... 18 4.6 Exercise and pregnancy ...... 18 4.7 Pelvic floor exercises ...... 18 5.0 Lifestyle advice ...... 19 5.1 Alcohol ...... 19 5.2 Drug use ...... 19 5.3 Smoking in pregnancy ...... 19 5.4 Nicotine Replacement Therapy (NRT)...... 20 5.5 Carbon monoxide monitoring ...... 20 5.6 Pets ...... 20 5.7 Allergies ...... 20 5.8 Asthma and pregnancy ...... 20 5.9 Sex ...... 22 5.10 Travel ...... 22 5.11 Seat belt advice ...... 22 5.12 Work and benefits ...... 22 5.13 Domestic abuse ...... 22

4 Pregnancy Information Book 6.0 Emotional Wellbeing ...... 24 6.1 Antenatal depression ...... 24 6.2 Baby blues ...... 24 6.3 Postnatal depression ...... 24 6.4 Postpartum psychosis ...... 24 6.5 Partners and postnatal depression ...... 25 7.0 in pregnancy ...... 26 7.1 Chickenpox ...... 26 7.2 Shingles ...... 26 7.3 German Measles/Rubella ...... 27 7.4 Measles ...... 27 7.5 Mumps ...... 27 7.6 Toxoplasmosis ...... 28 7.7 Slapped Cheek/Parvovirus ...... 28 7.8 Hand, Foot and Mouth ...... 28 7.9 Whooping Cough ...... 29 7.10 Influenza/Flu ...... 29 7.11 Hepatitis B ...... 30 7.12 HIV...... 30 7.13 Chlamydia...... 30 7.14 Bacterial Vaginosis during pregnancy...... 30 7.15 Syphilis ...... 31 7.16 MRSA (Methicillin-Resistant Staphylococcus Aureus) ...... 31 7.17 Tuberculosis (TB) ...... 31 8.0 Pregnancy symptoms and complications ...... 32 8.1 Common pregnancy symptoms ...... 32 8.2 Pregnancy complications...... 32 8.3 Blood clots (Deep Vein Thrombosis) ...... 32 8.4 Severe itching and Obstetric Cholestasis ...... 33 8.5 Vaginal Bleeding ...... 33 8.6 Malposition ...... 33 8.7 Blood pressure ...... 33 8.7.1 High blood pressure in pregnancy...... 33 8.7.2 Levels of blood pressure ...... 34 8.7.3 Types of high blood pressure (Hypertension) ...... 34 8.7.4 Pre-eclampsia (previously known as Toxaemia)...... 34 8.7.5 What should I expect during labour and birth? ...... 35 8.7.6 What should I expect after the birth?...... 35 8.7.7 Long Term Health Considerations ...... 35 9.0 Deciding where to have your baby ...... 36 9.1 At home ...... 36 9.2 Hospital Birth...... 36 10.0 Getting ready for birth...... 38 10.1 Parent Education ...... 38 10.2 Young parents group ...... 38 10.3 Preferences for birth ...... 38 10.4 Packing for hospital ...... 38

Pregnancy Information Book 5 11.0 Labour ...... 40 11.1 Signs of labour ...... 40 11.1.1 The show ...... 40 11.1.2 The waters breaking ...... 40 11.1.3 Contractions ...... 40 11.2 Latent phase of labour ...... 40 11.2.1 When to telephone the hospital ...... 41 11.3 Optimal fetal positioning ...... 41 11.4 Initial Assessment of Labour ...... 42 11.5 Monitoring your baby’s heart beat ...... 43 11.6 Established labour...... 44 11.7 First stage of labour...... 44 11.8 Pain relief ...... 44 11.9 Types of pain relief: ...... 44 11.9.1 Self Help ...... 44 11.9.2 TENS ...... 45 11.9.3 Aromatherapy ...... 45 11.9.4 Water ...... 45 11.9.5 Gas and air (Entonox) ...... 45 11.9.6 Pethidine or Diamorphine ...... 46 11.9.7 Epidural anaesthesia for labour ...... 46 11.10 Acceleration labour ...... 48 11.11 Second stage...... 48 11.12 Assisted birth (operative vaginal delivery)...... 48 11.12.1 What happens in an assisted birth?...... 49 11.12.2 What is a ventouse delivery? ...... 49 11.12.3 What is a forceps delivery? ...... 49 11.12.4 What happens when my baby is born?...... 49 11.12.5 Will I need an assisted birth next time?...... 49 11.13 Third stage ...... 50 11.13.1 Physiological Third Stage ...... 50 11.13.2 Active third stage ...... 50 11.13.3 Optimal cord clamping ...... 50 11.14 Postnatal check following delivery ...... 50 12.0 ...... 51 12.1 When might a caesarean section be performed?...... 51 12.2 Planned caesarean section ...... 51 12.3 Emergency caesarean section ...... 52 12.4 Types of Anaesthesia ...... 52 12.5 The operation ...... 52 12.6 In the recovery room...... 52 12.7 After the operation ...... 52 12.8 Looking after your wound ...... 52 13.0 Skin to Skin contact ...... 53

6 Pregnancy Information Book 14.0 Feeding your baby ...... 54 14.1 Putting your baby to the breast ...... 54 14.2 Attaching your baby to the breast ...... 55 14.3 Recognising feeding cues and feeding frequencies...... 56 14.4 How can I tell breastfeeding is going well? ...... 57 14.5 Dummies and teats ...... 58 14.6 Guidance for parents who have chosen to formula feed ...... 59 14.7 Vomiting or posseting following feeds ...... 59 14.8 Expressing milk ...... 60 14.9 Infant Feeding support services ...... 61 15.0 Induction of labour ...... 62 16.0 Pressure ulcers during labour or the immediate postnatal period ...... 65 17.0 Vitamin K ...... 66 18.0 Transferring to the Postnatal Ward...... 67 18.1 Amenity beds...... 67 18.2 Visitors in hospital ...... 67 18.3 Security in hospital...... 67 19.0 After you have had your baby ...... 68 19.1 What to expect ...... 68 19.2 advice...... 68 20.0 Postnatal advice and exercise ...... 69 20.1 Comfort ...... 69 20.2 Caesarean Section ...... 70 20.3 Pelvic floor exercises – all deliveries ...... 71 20.4 Abdominal exercises – all deliveries ...... 71 20.5 Exercises to improve abdominal strength ...... 72 20.7 Exercise ...... 73 21.0 Caring for your baby ...... 74 21.1 Your baby’s health ...... 74 21.2 Newborn hearing screening programme ...... 74 21.3 Newborn blood spot screening ...... 74 21.4 Cord care ...... 74 21.5 Caring for your baby at night ...... 74 21.6 Signs and symptoms of possible illness in your baby...... 75 21.7 Transfer to Community Care ...... 76 21.8 Registration of births ...... 76 22.0 Useful organisations and websites ...... 78 23.0 Glossary ...... 80

Pregnancy Information Book 7 1.0 Your pregnancy at a glance The following section will review the typical progression of your pregnancy. If at any time, you have any concerns, worries or need to talk things over, please see the inside the front page of your Pregnancy Care Records for advice on who to contact at each stage of pregnancy. During your pregnancy you will be given the opportunity to discuss the following with your Midwife: Birth plan, caring for your baby, relationship building and infant feeding. It can sometimes be helpful to write questions down, which you may want to ask at your antenatal appointment.

0-8 weeks qualify for Healthy Start vouchers – whether or not they are on benefits. Vouchers can be • Your Midwife will ask to see you alone for the exchanged for milk, fresh fruit and vegetables. initial five minutes of your first appointment to ask you about any sensitive issues which you • At your booking appointment a Midwife will may not wish to discuss with family or friends discuss your preferences with regards to present. At your first antenatal appointment blood transfusion. If you have any objections with a Midwife, often called your ‘booking to having a transfusion, for personal or appointment’ your Midwife should discuss religious beliefs, a management plan will all the antenatal screening tests that are be made by a Consultant Obstetrician and available to you (see section 3.1 for more Anaesthetist for your pregnancy, labour and details). birth. Please note: Anti D immunoglobulin offered to Rhesus negative (Rh-) women is • At the booking appointment your Midwife a blood product made from plasma collected will discuss regular urine checks during from donors. pregnancy. You will be provided with a sample bottle to take a urine sample with you 11-13+6 weeks to your first scan appointment. • You will be offered an ultrasound dating scan. • A Mid-Stream Specimen of Urine (MSSU) As part of this scan you can opt for screening will be sent to the Laboratory to look for for Down’s syndrome, Edward’s syndrome asymptomatic bacteria. Please provide a and Patau’s syndrome (it is called Combined urine sample at every antenatal appointment Nuchal Translucency Screening, see section which will be tested for the presence of 3.1 for more details). protein (see section 8.7 for more details). • You will be offered blood tests to check your • You should be taking folic acid supplements blood group, iron levels and to check if you (400mcg) and you should try to eat a have HIV, Hepatitis B or Syphilis infections balanced diet. Your Midwife will tell you if you which could affect your baby. need a higher dose. E.g. if you have diabetes (see section 4.5 for more details). • If you are under 25 years of age you will be offered Chlamydia screening. However, you • Contact your GP if you have any medical can have this at any age if you feel you are at conditions e.g. diabetes, epilepsy – as you risk. may require a review of your medication and additional appointments with other specialist • If you have consented to tests, previously teams. discussed with your Midwife at the booking appointments, they will be taken at this • Obtain a Maternity Exemption Certificate appointment. (FW8) from your Midwife or GP. This entitles you to free prescriptions and dental treatment • If you have been feeling sick and tired in from confirmation of your pregnancy until a the early weeks, you may be feeling better year after your baby is born. around this time. • Healthy Start vouchers are available to pregnant women who are on certain benefits. All pregnant women under the age of 18

8 Pregnancy Information Book 16-20 weeks At this stage of pregnancy you should consider: You may start to feel your baby move. • Making arrangements for the birth, whether it • Your tummy will begin to get bigger and you is in hospital or at home. If you have children, will need to wear looser clothing. arrange who will look after them when you • Book onto Antenatal/Parent Education are in labour and during your stay in the classes if you wish to attend. Details about hospital. the hospital classes are on the hospital • Arranging your own transport to the hospital. website (http://www.mcht.nhs.uk/information- Remember, ambulances are for emergencies for-patients/departmentsandservices/ only. maternity/parent-education-and-preparation- for-labour/) and there is further information • Packing a small bag with essentials ready later on in this book. To book a place, please for the hospital (see section 10.4 for more ring 01270 612184 or 01270 273127. details).

18-20+6 weeks 37-40 weeks • You will be offered Fetal Anomaly Screening • If you are having a homebirth, the equipment (a detailed scan). This is an ultrasound will be delivered to your home at 37 weeks. scan that primarily looks for abnormalities • Make sure you have all the important within your baby. You are welcome to bring telephone numbers handy in case labour someone with you to see this. Feel free to starts. ask any questions or concerns you may have. 40-41 weeks • After 20 weeks of pregnancy you can get • You may be offered a membrane sweep your certificate of pregnancy form for your (vaginal examination to stretch and sweep employers (Mat B1) from your Midwife or GP. the neck of womb to stimulate labour) and will be given a date to attend the hospital for 25-28 weeks your labour to be induced if you have not had • If it is your first baby, or you require closer your baby by 42 weeks. monitoring during your pregnancy you will be given an appointment to see your Midwife. • We can listen to your baby’s heart beat from 25 weeks gestation at your antenatal appointment.

28-32 weeks • You will be offered a blood test to check your iron level and antibody levels. • If you are Rhesus negative (Rh-) you will be offered an Anti D injection at 28 weeks.

32-37 weeks • You may be aware of your uterus tightening from time to time. These are mild contractions, also known as Braxton Hicks, and are normal. If they are regular and painful, you should contact the Labour Ward Triage on 01270 273116.

Pregnancy Information Book 9 2.0 Antenatal Care Throughout your pregnancy you will need regular appointments with your Midwife. A list of routine antenatal appointments can be seen in your Pregnancy Care Record (hand held notes) but your care will be designed around your individual needs. These appointments check that you and your baby are well and that any problems can be picked up as early as possible.

2.1 Your first antenatal appointment similar to the slope of the curves of the chart. These measurements will begin to be plotted at It is important that you see a Midwife as early as you first appointment after 26 weeks. possible in your pregnancy. Women have their first and longest antenatal appointment between 2.4 Importance of antenatal care: 6-12 weeks of pregnancy with their Midwife. This is called the ‘booking’ appointment and involves • Regular antenatal care is important for the questions about you and your family’s health, health of you and your baby. any illnesses or previous pregnancies. This • Always bring your Pregnancy Care Record helps us to assess if there may be any possible with you. problems during your pregnancy. During an antenatal assessment the health of 2.2 Your named Midwife you and your baby are checked by: You will have a ‘named’ Midwife throughout • Testing your urine. your pregnancy. Our aim is that for the majority • Measuring your blood pressure. of your appointments in the community you will • Measuring your abdomen to make sure baby see your named Midwife. We operate a buddy is growing well. system to help support this continuity. Each named Midwife has a buddy so that if your • Listening to your baby’s heartbeat from 25 weeks onwards. named Midwife is on holiday or unavailable for one of your scheduled appointments you will • Testing your blood, with your consent, at your see her buddy. You will be given your named first appointment with the Midwife or at your Midwife and her buddy’s contact numbers at dating scan and again at 28 weeks. You may your booking appointment. If your concern is also require blood tests at other gestations urgent however, please use the appropriate dependent on you or your baby’s condition. numbers on the front inner page of your • Discussing any concerns you may have. Pregnancy Care Record. Please keep all antenatal appointments, if If you are unable to contact either of these you have to cancel or rearrange, please tell Midwives then you can contact the Community us as soon as possible so we can give your Team Office on 01270 612177 or if your appointment to someone else and rearrange concern is more urgent, then please telephone yours. Labour Ward Triage on 01270 273116. 2.5 Appointments at the hospital 2.3 Customised antenatal growth Every effort is made to ensure the length of charts time you are waiting in the Antenatal Clinic is It is important that your baby’s growth is as short as possible, please appreciate that monitored accurately during pregnancy. Your medical staff are sometimes called away to baby’s growth is assessed by measuring your deal with emergencies. When this occurs, some abdomen and the measurements taken during delay is inevitable. An appointment system is an ultrasound scan. These measurements are in operation and we would greatly appreciate plotted onto a customised growth chart. The you keeping to your appointment times. Please do not arrive earlier than your appointment as chart is calculated using your height, weight, you will not be seen ahead of schedule. While ethnic origin and details about any previous we try to give you the time that is convenient babies you may have had. The chart shows to you, we hope you appreciate that we can your baby’s expected growth curve and as only make a limited number of early morning your baby grows, the measurements should be appointments. If you are arriving by car, it is 10 Pregnancy Information Book advisable to arrive fifteen minutes before your 2.8.1 Planning future births following a appointment to enable you to park. previous caesarean delivery If you already have children, please bring a Once you have had a caesarean delivery you relative or friend to care for your child during may be anxious as to how you will give birth your appointment. in a subsequent pregnancy. You have two options. You may choose between a Vaginal 2.6 Staff Identification Birth After Caesarean (VBAC) or Elective During your visits to hospital you will meet a Repeat Caesarean Section (ERCS) in the next number of staff who are all part of the team pregnancy. Either choice is safe with different looking after you. All staff should wear a name risks and benefits. For more information about badge with photographic ID to help you identify these risks and benefits refer to the MCHFT them. They should also wear a ‘Hello my name leaflet “Birth after a previous caesarean is…’ badge and introduce themselves by name section” and role the first time you meet them. Obstetric and midwifery staff will be happy to discuss your choices with you at any time. 2.7 Medication Overall, both are safe choices with only very It is important for you to let your GP and small risks. When reviewing these options Midwife know if you are using any type of in a future pregnancy your circumstances, medication whether it is prescribed, purchased concerns, priorities, medical and obstetric from a pharmacy or recreational throughout history will be considered together with any your pregnancy and during breastfeeding. plans for further pregnancies to ensure the To manage your care more effectively whilst in decision made is the correct one for you. hospital, please bring in with you all medication that you are taking in their original containers 2.9 Infant Feeding Services and if possible a copy of your repeat prescription. You can request an appointment with a On admission your medication must be handed member of the Infant Feeding Team at any in to the Midwife looking after you who will point during your pregnancy to discuss any ensure it is safely stored whilst you are on the aspect of feeding your baby. ward. We encourage mothers of babies who are at risk of developing hypoglycaemia (low blood 2.8 What does having a ‘high risk’ sugar levels) e.g. women with diabetes or have pregnancy mean? the potential of feeding problems e.g. cleft lip/ Some women with medical conditions e.g. palate to book an appointment with the Infant diabetes, severe asthma or epilepsy, or who Feeding Team to discuss Antenatal Colostrum have a previous complicated obstetric history Harvesting. This involves expressing and e.g. recurrent , caesarean section, storing colostrum from 36 weeks of pregnancy large or small babies, and premature births, in case your baby needs to be given additional may require extra care during their pregnancy. milk once born. Your Midwife will be able to discuss with you All parents are encouraged to attend Infant whether your pregnancy is straightforward Feeding Workshops, see section 14.0 for more (low risk) or complicated (high risk). If you are details. high risk you may be seen more often and be referred to the hospital Antenatal Clinic where your care will be shared between your Obstetrician, specialist teams and Community Midwife. Your Midwife will discuss an individualised plan of care with you and once you have agreed the pattern of your appointments, your Midwife will let you know how to make these arrangements.

Pregnancy Information Book 11 2.10 Maternity benefits and travelling 2.11 Car parking expenses At Leighton Hospital the car parks are either a Your Midwife can give you advice regarding barrier entry and exit system (Pay on Foot) or maternity benefits and leaflets are available. If pay and display. you receive certain benefits you may be entitled to claim various travelling expenses while Pay on foot attending the Antenatal Clinic. For information The driver will take a ticket on entering the regarding travelling expenses, please visit: car park to raise the barrier. The ticket is http://www.nhs.uk/nhsengland/Healthcosts/ then scanned against the bar code reader on pages/Travelcosts.aspx the Pay Station before they leave where the appropriate charge is displayed. For other maternity benefits, visit: https://www.gov.uk/working-when-pregnant- The ticket is then scanned, barcode facing your-rights upwards, to raise the barrier on exit. Pay Stations are situated outside Macmillan Cancer Centre, Physiotherapy Department, Emergency Department and inside Maternity Outpatients and Treatment Centre.

Pay and display Some of the smaller car parks have a pay and display machines installed. The machines are easy to operate with instructions on each machine. The pay and display machines will not accept notes. Three machines can accept debit and credit card payments. Please see the hospital website for up to date charges and further details about parking and travelling to the hospital, including how to obtain a weekly ticket. www.mcht.nhs.uk/information-for-patients/ travel-and-parking/ There is an intercom fitted to each car park barrier which is linked directly to the Security Control Room at Leighton Hospital. Please press the intercom for security and car parking assistance. For car parking assist and support, please telephone 01270 273792.

12 Pregnancy Information Book 3.0 Ultrasound Screening Ultrasound scans use sound waves to build a picture of your baby. To date, there is no evidence that ultrasound scans such as those used during pregnancy, does any harm to the baby or mother. The Maternity Ultrasound Scan Department offers every pregnant woman a scan at around 12 weeks (dating scan/nuchal translucency) and 20 weeks (Fetal Anomaly Scan) of pregnancy.

3.1 Screening information different test, called the quad test at around 15- Screening information, including screening 16 weeks of pregnancy. This test can give you tests for Down’s syndrome, Edward’s syndrome the risk of your baby having Down’s syndrome and Patau’s syndrome is contained in the or Edward’s syndrome by looking at different ‘Screening Tests for You and Your Baby’ leaflet markers in your blood. You will not be offered a (Public Health England) which your Midwife will further scan appointment. give you at your first antenatal appointment. 3.3 Mid pregnancy ultrasound scan Your Midwife will discuss this with you but it is important that you read and understand this This scan may also be called a Fetal Anomaly information so that you can make an informed Scan or detailed scan. It is done at around 20 choice. If you are considering chorionic villus weeks of pregnancy and takes approximately sampling or , detailed leaflets 30 minutes. are available from the hospital website in the The purpose of the scan is to look at your baby patient information section. in detail to check if your baby is developing normally. In most cases the scan confirms that 3.2 Dating scan nothing unusual can be seen and most women This scan checks the number of babies, the are reassured to see the normal development heartbeat and your baby’s measurements to of their baby. Please take into consideration give a better idea of when your baby is likely to the scan is a screening test which looks for be born. Ideally this scan is completed between abnormalities in your baby, therefore if you do approximately 12-14 weeks pregnant and not wish this scan to be carried out you can takes approximately 20 minutes. However the decline. appointment will take longer than this in total as you will be offered blood tests following your The success of the scan is affected by the scan. of the baby and the size of the mother and in some cases cannot be fully done. Some The scan does not attempt to examine your scans can be difficult to interpret and this could baby in detail, but as a screening test, it may cause anxiety. If a problem is found, you will be sometimes detect abnormalities of your baby. referred to a Consultant for further explanation If this is the case you will be informed, and discussion. whether you have opted for screening tests or not. You will need a full bladder at the dating About 80% of problems are picked up by scan, scan to get good images of your baby but it will however rarely; some babies are born with not be necessary for the mid pregnancy scan. problems that the scan was unable to pick up. If you have opted for screening for Down’s syndrome, Edward’s syndrome or Patau’s 3.4 Who can come to the scan with you? syndrome, then it will be offered and carried out Two adults and your own children may come at this appointment. However, sometimes the with you to the scan. Please remember, baby is not in a good position and the nuchal however, that although the scan is an exciting translucency (fluid filled space at the back of event for the family the purpose is to identify the baby’s neck) cannot be measured at this any problems which can be picked up on an appointment. If this happens you may be asked ultrasound scan. to go for a walk and they will try again but if it is still not possible then you will be offered a Pregnancy Information Book 13 Please understand that the Sonographer 3.8 Subsequent ultrasound scans or Doctor scanning you may not be able to Sometimes ultrasound scans are performed discuss things during the scan. They need later in pregnancy and are used to look at the to concentrate on getting the correct views. growth of the baby and assess if any problems However, once your scan is completed they will are developing. We are not looking for answer any concerns. abnormalities during these scans, however very occasionally something may be discovered that 3.5 Photographs has not previously been seen. You can buy photographs of your baby’s scan at any routine scan appointment throughout your pregnancy. Please ensure that you have enough loose change to purchase a token from the token machine, which is situated in the waiting room in the Antenatal Clinic. Current prices are displayed on the token machine Please ensure you tell the Sonographer prior to the scan that you would like a photograph. Scan photographs cannot be laminated but they can be photocopied. They should be kept in a dark place, but will still fade with time. If you are not happy with the quality of the picture you must mention this to the Sonographer at the time, for another photograph to be taken at this appointment. Scans cannot be repeated for this purpose, as we must reiterate that the purpose of the scan is for medical reasons.

3.6 Personal camera/video equipment This equipment cannot be used in the ultrasound room as they are likely to distract the Sonographer and detract from your personal involvement in the examination.

3.7 Sex of babies Informing you of the sex of your baby is not offered routinely. If you wish to know the sex of your baby you need to make it clear to the Sonographer at that time of your anomaly scan (approximately 20 week scan) but it may not always be possible to determine the sex of your baby. You should be aware that the findings from an ultrasound scan are not a definite indication of the sex of your baby.

14 Pregnancy Information Book 4.0 Your health in pregnancy This section describes some of the things you should think about to ensure you and your baby stay healthy during pregnancy.

4.1 What should you eat? • Fish contains the important Omega 3 essential fatty acids which are needed for a A healthy diet is an important part of a healthy baby’s development and is also a rich source lifestyle at any time, but particularly if you are of Vitamin B12. pregnant or planning a pregnancy. Eating healthily during pregnancy will help your baby 4.2 Anaemia in pregnancy to develop and grow and will help keep you fit and well. Make sure that you eat a variety Iron is essential for the production of of different foods every day in order to get the Haemoglobin (Hb), which helps store and carry right balance of nutrients that you and your oxygen in red blood cells. Without enough iron, baby need. your blood cells will carry less oxygen around your body to your organs and tissues. This Your Midwife will work out your Body Mass condition is called anaemia. Index (BMI) (your weight in relation to your height) at your first appointment. This During pregnancy your Hb levels will be lower information will be recorded in your notes and than usual. This is normal and is due to the fact used to help guide and plan your care. If your that your blood volume increases. However, if BMI is below 18 or 30 and above you will be your iron levels fall too low you may look pale, offered advice and guidance. feel tired, have shortness of breath and feel faint. Your Hb levels are normally checked at • Eat plenty of fruit and vegetables and aim for your booking appointment or anomaly scan and at least five portions a day. Pure fruit juice again when you are 28 weeks pregnant. can only count once towards the five a day. If your Hb level is below 10.5 grams per • Starchy foods like bread, potatoes, rice, decilitre (g/dl) or your iron store levels (ferritin) pasta, chapattis, yams and breakfast cereals are low, you may be advised to take iron are an important part of any diet. They supplements but this will be discussed with you contain important vitamins and fibre. Try on an individual basis. Taking iron supplements eating wholemeal bread and cereals when will turn your stools black and some women you can. find they have digestive problems such as • Lean meat, fish, poultry, eggs, cheese, beans nausea, diarrhoea and constipation. If the and pulses are good sources of nutrients. iron supplements are causing you discomfort, • Dairy foods like milk, cheese and yoghurt please talk to your Midwife who may suggest contain calcium and other nutrients needed an alternative iron supplement. for your baby’s development. Choose low fat It is also important to make sure that your diet varieties wherever possible. contains lots of iron-rich foods, such as those • Try to cut down on sugar and sugary foods – listed below: sugar contains calories without providing any • Dark green leafy vegetables such as spinach, other nutrients. broccoli, cabbage and watercress. • Cut down on fat and fatty foods. Fat is very • Lean meat – especially red meat. Avoid liver high in calories and can contribute to weight and liver products as they contain high levels gain and increase the risk of heart disease. of vitamin A which could harm your baby. Avoid fried foods and go easy on foods like • Fish, particularly oily fish and can be canned pastry, chocolate and chips which contain a (such as mackerel, sardines and pilchards). lot of fat. • Eggs. • Citrus fruit, tomatoes, broccoli and potatoes are goods sources of Vitamin C which you • Pulses – such as chick peas, canned baked need to help you to absorb iron. beans and lentils.

Pregnancy Information Book 15 • Bread, especially wholemeal. Eggs • Dried fruit such as apricots, prunes and To reduce the risk of salmonella food raisins. positioning, make sure eggs are thoroughly • Cereals fortified with iron. cooked until the whites and yolks are solid. Salmonella is unlikely to cause harm to your Vitamin C helps the body absorb iron, so to get baby but can be associated with severe nausea the most from the food you eat, have Vitamin and vomiting. C rich foods with meals; e.g., fresh vegetables, fruit or drinks such as fresh orange juice. Tea Avoid foods that contain raw or undercooked and coffee may reduce the absorption of iron eggs such as homemade mayonnaise. from foods so avoid drinking them directly Mayonnaise bought in a jar is fine as it is made before, during or after meals. with pasteurised eggs. Meat 4.3 Take care with some foods Raw or uncooked meat is risky in pregnancy Cheese due to the potential risk of Toxoplasmosis. There are some varieties of cheese we would Cook all meat and poultry thoroughly so it is advise you to avoid in pregnancy due to the piping hot, has no trace of blood and does not higher risk of Listeria. from Listeria appear to be pink. Toxoplasmosis is caused is rare, however even in mild cases of the by a parasite and although it is very rare it can illness there is an increased risk of , damage your baby. and severe illness in a newborn. Wash all surfaces, utensils and your hands Varieties of cheese to avoid in pregnancy: thoroughly with warm soapy water after the preparation of or contact with raw meat, to • Mould ripened unpasteurised cheeses such avoid the spread of harmful bacteria. as brie and camembert or soft mould ripened goats cheese such as Chevre. Toxoplasmosis can also be found in cured meats such as: pepperoni, chorizo and parma • Blue veined cheeses such as gorgonzola, ham. Be cautious with cold cured meats as Roquefort (except for stilton, see below). many have not been cooked, they have only However the above varieties of cheese are been cured and fermented. It is best to check safe if they have been cooked thoroughly. It is the packaging to see if the meat needs to important to make sure the cheese is cooked be cooked or is ready to eat. For ready to until it is piping hot all the way through. eat cured meat, you can reduce the risk of parasites by freezing it for four days prior to Varieties of cheese that are safe in pregnancy: eating it. If you are planning to cook the cured Hard varieties of cheese such as cheddar, meat you do not need to freeze it. parmesan and stilton even if they are made Prepacked meat, such as ham and corned with unpasteurised milk. Whilst Listeria can still beef, is safe to eat in pregnancy. occur in these cheeses, in comparison to soft cheeses there is less water so bacteria is less Liver can harm your baby due to the high likely to grow. Vitamin A content. Do not eat liver or products containing liver such as liver pâté, liver sausage Soft varieties of cheese (as long as they are or haggis. made with pasteurised milk) such as cottage cheese, mozzarella, feta, cream cheese, Game is best avoided in pregnancy as it is hard paneer, ricotta, halloumi, goats cheese and to detect whether it has been shot with lead processed cheeses such as cheese spreads pellets. If you are purchasing game always are safe to eat. check with the retailer to ensure that the game has been farmed and contains no or very low Pâté levels of lead. Examples of game meats are: Avoid all types of pate, including vegetable, as pheasant and venison. they can contain Listeria.

16 Pregnancy Information Book Fish You do not need to cut caffeine out completely Most fish is safe to eat and advisable to eat as but do not have more than 200mg a day. The it is good for your health and the development approximate amount of caffeine found in food of your baby. and drinks is: • One mug of instant coffee: 100mg. Fish to avoid: shark, swordfish and marlin. • One mug of filter coffee: 140mg. Fish to limit: no more than two tuna steaks or four medium sized cans a week. This is due to • One mug of tea: 75mg. the higher mercury content found in these fish. • One can of cola: 40mg. Avoid more than two portions of oily fish a week • One can of energy drink: 80mg. such as salmon, trout, mackerel and herring. • One 50mg bar of plain dark chocolate (most Shellfish should always be cooked to avoid UK brands contain less than 25mg). harmful bacteria and viruses. Cold pre-cooked prawns are fine to eat. • One bar of milk chocolate (most UK brands contain less than 10mg). Sushi is fine to eat during pregnancy providing any raw wild fish used to make it has been Do not worry if you occasionally have over the frozen first to kill any parasitic worms. If the fish recommended amount as the risks are small is farmed then it no longer needs to be frozen but do try generally to keep your caffeine intake beforehand as it is very unlikely to contain down. parasitic worms. If you are in any doubt avoid Herbal or green teas eating sushi. There is little information known about the The safest way to enjoy sushi is to choose fully safety of herbal or green tea in pregnancy so it cooked or vegetarian varieties. is best to drink them in moderation. The Food Peanuts Standards Agency (FSA) advise no more than four cups a day during pregnancy. Bear in mind Unless you are allergic to peanuts, then green tea also contains caffeine. peanuts or products containing peanuts are safe to eat in pregnancy. The advice regarding 4.4 Vitamins and supplements the safety of peanuts has recently changed as It is advisable to take Folic acid for the first research shows no clear evidence that eating 12 weeks of pregnancy and a vitamin D peanuts during pregnancy is harmful. supplement throughout your pregnancy. Milk and yogurts Avoid general adult multivitamins or vitamins • Only have pasteurised or Ultra Heat Treated with a high Vitamin A content or fish liver oil (UHT) milk. supplements. • All types of yogurt, including bio, live and low Vitamin D fat, are fine. It is important that you get enough Vitamin Soft ice creams should be fine to eat during D during your pregnancy and while you are pregnancy as they are processed products breastfeeding. The best source of Vitamin D is made with pasteurised eggs and milk. sunlight but having a Vitamin D rich diet also helps – oily fish, eggs, meat, fortified cereals Hygiene and margarine. Wash any fruit or vegetables thoroughly if they To ensure adequate levels of Vitamin D have any signs of dirt, soil or contamination on it is recommended that all pregnant and them. breastfeeding women take a daily supplement Always practice good hygiene when preparing of 10mg Vitamin D. food. It is especially important to take Vitamin D Caffeine supplements if: High levels of caffeine in pregnancy are linked • Your family origin is South Asian, African, to lower babies and an increased Caribbean or Middle Eastern. risk of miscarriage. Pregnancy Information Book 17 • You stay indoors for long periods of time and 4.7 Pelvic floor exercises if you usually cover your skin when outdoors. The pelvic floor is a group of muscles which • You have a diet that is low in vitamin D. span the area underneath the pelvis. During • Your pre-pregnancy Body Mass Index (BMI) pregnancy it is under great strain, which if not is above 30. exercised, could result in you leaking urine after pregnancy. Women from these groups are at a greater risk of having lower levels of Vitamin D, therefore How to do pelvic floor exercises: taking a Vitamin D supplement is important. • First squeeze the muscles that you use to However, if you wish to take a pregnancy prevent a bowel movement. related multivitamin this will contain the • At the same time squeeze the muscles you required amount of Vitamin D. use to stop the flow of urine. 4.5 Folic acid • Do this exercise quickly tightening and releasing the muscles straight away. From the time you stop using contraception and for the first 12 weeks of pregnancy, it is • Next do this slowly trying to tighten the recommended that you take a supplement muscles and counting up to 10 before of 400 micrograms (mcg) of folic acid each releasing. Repeat up to 10 times. day (available from any chemist and some • Try and do three sets a day. supermarkets) as well as eating plenty of folate- • Make sure you continue doing your pelvic rich foods such as green leafy vegetables, floor exercises following birth (see section pulses and fortified breakfast cereals. This is to 20.3 for more details). help prevent neural tube defects such as spina bifida. Current national guidelines recommend If you need any advice or have any lasting that you take a higher level of 5mg of folic acid if urinary problems following birth, please contact you have a family history of spina bifida, multiple your Midwife or GP as you may need referral to pregnancies, have diabetes, have other certain a Physiotherapist. medical conditions or if your BMI is above 30. However, if you wish to take a pregnancy multivitamin this will contain 400mcg of folic acid.

4.6 Exercise and pregnancy It is important to keep active during your pregnancy to keep you healthy, control weight gain, help you cope in labour and to get back into shape after birth. If you did not do a lot of exercise before you became pregnant it is advisable not to start strenuous exercises during pregnancy. Exercise tips • Try and be active on a daily basis. • Ensure you warm up and cool down. • Drink plenty of fluids. • Avoid contact and others sports where there is a risk of being hit or falling e.g. Kick boxing, horse riding and gymnastics. • Make sure you tell your teacher or instructor that you are pregnant if you attend any classes.

18 Pregnancy Information Book 5.0 Lifestyle advice There are a number of things you can do to stay healthy while you are pregnant.

5.1 Alcohol It is ok to ask for help so you and your baby In December 2015 the Chief Medical Officer receive the best care by helping you to advised that it is safest to avoid alcohol stabilise, stop or reduce your use. completely whilst pregnant or planning a 5.3 Smoking in pregnancy pregnancy, to keep risks to your baby to a minimum. • Cigarettes contain around 4000 chemicals and at least 80 of them are known to cause cancer. Drinking alcohol in pregnancy can lead to long- term harm to your baby, the more you drink the • Smoking during pregnancy exposes the baby greater the risk. to these harmful chemicals. At a vital time in their development and because cigarettes The risk of harm to your baby is likely to be restrict their oxygen supply, causing their low if you drank only small amounts of alcohol tiny heart has to beat harder each time you before you knew you were pregnant or during smoke. pregnancy. • This can result in higher risk of stillbirth, If you found out you were pregnant after miscarriage, cot death, premature birth already having drunk during early pregnancy, and problems with the baby’s growth and you should avoid further drinking, but should development, including cleft lip. Babies who be aware that it is unlikely in most cases that have been born too early or are underweight your baby has been affected. If you are worried are more likely to face problems with about how much you have been drinking when breathing, feeding and infection. pregnant, talk to your GP or Midwife. • Smoking in pregnancy can cause permanent Alcohol reaches your baby through the cardiovascular damage to children putting and because your baby cannot process alcohol them at a higher risk of cardiovascular as fast as you do, your baby is exposed to disease (heart disease) in later life. alcohol for a longer period of time. Too much alcohol can harm your baby’s development and • Smoking in pregnancy has been linked to the in excessive cases the baby may have physical development of Attention Deficit Hyperactivity or mental problems known as Fetal Alcohol Disorder (ADHD) in children. Syndrome (FAS). FAS can affect your baby • Second-hand smoke is also very harmful, as at any time during your pregnancy and binge up to 75% of the cigarette is expelled into the drinking is especially harmful. air. This can cause babies to be more prone If you have difficulty in reducing or stopping to respiratory and ear infections and cot your alcohol intake, a referral can be made to death. an alcohol specialist service, who can provide • Smoking cannabis can increase the risk of additional help and support. a low birth weight. The amount of carbon monoxide inhaled when smoking cannabis 5.2 Drug use can be 10 times greater than a normal Some women continue to use illicit drugs whilst cigarette. This reduces the amount of oxygen pregnant. your baby can get. Types of illicit drugs are: • Stopping smoking at any time during your pregnancy will increase your chances of • Cannabis having a healthier baby. • Certain pain killers Cigarette smoking is the single largest risk • MDMA / Ecstasy factor for pregnancy related complications and • Heroin mortality. If you smoke while you are pregnant, • Cocaine it is very important to stop, for your own health and the health of your baby. Every cigarette • Stimulants you smoke harms your baby – stopping

Pregnancy Information Book 19 smoking will benefit both you and your baby 5.6 Pets immediately. If you or your partner smokes There is no reason not to have a pet at home and would like help to stop smoking, or a have whilst you are pregnant; however there are a chat about what support is available, speak certain precautions you should take with certain to your Midwife who can refer you to the Stop animals. Smoking Service. Cats It is important that you inform your Midwife or Obstetrician if you start smoking again at Cat faeces can contain an organism that any time during your pregnancy. This is so causes toxoplasmosis. This can be harmful to your baby’s growth can be monitored more your unborn baby. closely. To minimise the risk you should ideally avoid E- Cigarettes cleaning litter trays or use disposable rubber gloves. Very little is known about the use of e-cigarettes during pregnancy. Although some are sold Care should also be taken when handling soil as nicotine free, the sale of e-cigarettes is or sand in the garden. currently unregulated so the amount of harmful Sheep chemicals within the e-cigarette is unknown. To benefit the health of you and your baby it is Lambs and sheep can be a source of an preferable to not smoke any type of cigarette organism called Chlamydia Psittaci which is during pregnancy, including e-cigarettes. known to cause miscarriage and Toxoplama in ewes. You must avoid lambing and milking 5.4 Nicotine Replacement Therapy ewes and all contact with new born lambs. (NRT) 5.7 Allergies Ideally, pregnant women should stop smoking It is important you inform us of any known without using Nicotine Replacement Therapy allergies you have as it may affect your (NRT) but, if this is not possible, NRT may be pregnancy or the way we deliver our care. recommended to help you stop smoking. If you have routinely taken medication for You can also find useful information on the allergies in the past, please discuss this with dangers of smoking during pregnancy and your GP. tips for quitting at the following website: www. smokefree.nhs.uk 5.8 Asthma and pregnancy 5.5 Carbon monoxide monitoring During pregnancy your body goes through many changes and this can affect your asthma At your booking appointment your Midwife will in different ways. measure your carbon monoxide level with a Pregnancy is not likely to bring on asthma if simple breath test. This may also be repeated you did not already have it. However, if you at subsequent antenatal appointments. have asthma, being pregnant can make the As a non-smoker you would expect a reading effects of asthma unpredictable. of below 4 parts per million (ppm). If you have Around a third of women will see an a higher reading than this it could be due to improvement in their asthma especially toward car exhaust fumes, a faulty gas fire or boiler, the third trimester, one third will see little or smoking or passive smoking. If you have a no change and one third may experience reading above 4ppm and you do not smoke you worsening symptoms. should get your car and gas appliances checked for defects urgently. You should consider fitting It is vital that you inform the Midwife at your a carbon monoxide alarm in your home. first booking appointment that you suffer from asthma, as you may need extra appointments depending on the severity of your asthma.

20 Pregnancy Information Book Managing your asthma whilst pregnant What should I do if I have an asthma attack It is very important to ensure that you keep while I’m pregnant? your asthma under control throughout your Having an asthma attack when you are pregnancy. pregnant is an emergency. Here are the steps It is advisable to continue with your prescribed of what to do if you have an asthma attack: asthma medication. 1. Take one to two puffs of your reliever inhaler Medication includes reliever inhalers, preventer (usually blue), immediately. inhalers, long-acting relievers, theophyllines 2. Sit down and try to take slow, steady and steroid tablets. There are more risks to breaths. both you and your baby if you do not take your 3. If you do not start to feel better, take two medicines and your asthma gets worse. Your puffs of your reliever inhaler (one puff at a GP or Practice Nurse should give you a self- time) every two minutes. You can take up to management plan to assist you in managing 10 puffs. your asthma. 4. If you do not feel better after taking your Leukotriene receptor antagonists (Montelukast inhaler as above, or if you are worried at or Zafirlukast) is the only group of asthma any time, telephone 999. medications which are not prescribed before or during pregnancy. However, if you were taking 5. If an ambulance does not arrive within 10 Montelukast or Zafirlukast before you became minutes and you are still feeling unwell, pregnant, and it is working well for your asthma, repeat step 3. If your symptoms improve you will probably be advised by your GP to and you do not need to telephone 999, continue taking it, however we recommend that you still need to see your GP or asthma you discuss this with your GP. specialist within 24 hours. Ways to keep your asthma under control: What if I have an asthma attack when I’m in labour? • Avoiding smoking or stop smoking. Please ensure that you have your inhalers • Avoiding allergic triggers e.g. pet fur. with you during labour. • Controlling of hay fever with antihistamines – Asthma attacks during labour are very rare take advice from your GP or Pharmacist as to because your body produces extra natural which are safe in pregnancy. steroid hormones (cortisone and adrenaline), • Avoiding fever triggers e.g. mowing the lawn. which help to prevent asthma attacks. What happens if my asthma gets worse? If you do find yourself getting asthma symptoms Take your preventer inhaler or reliever to help during labour (e.g. coughing, wheezing, any worsening symptoms and seek medical shortness of breath, tightness in the chest), use advice from your GP. your reliever inhaler as normal. It will not harm your baby in any way. Signs to watch out for are: Drawing up a birth plan and discussing it with • A cough that is worse at night or in the early your Midwife can help to reduce any fears you morning, or when you exercise may have about giving birth. • Wheezing What about other complications during • Breathlessness labour? • Tightening of your chest Pain control during labour, including pethidine and epidurals, are safe for women with asthma. Acid reflux can also be symptomatic of If you need to have an operation, it will not pregnancy, and this can often make asthma cause problems provided your asthma is well worse. controlled and the Anaesthetist knows that you Should you have any of the above symptoms, have asthma. contact your GP or asthma specialist for advice.

Pregnancy Information Book 21 Can I breast feed whilst on medication? 5.11 Seat belt advice Yes, continue with your prescribed medication as normal. Will my baby develop asthma? We do not know the exact cause of asthma, but we do know that the tendency to develop asthma often runs in families. Research has shown: • If both parents have asthma, the chances of the baby developing asthma are increased. • If only one parent has asthma, the baby has a greater chance of developing asthma if it is • All pregnant women by law must wear the mother who has asthma rather than the a seatbelt for protection of the baby and father. themselves. • The correct way is with the lap strap across Where else can I go for information? the hip below the bump and the diagonal • Asthma UK: www.asthma.org.uk strap between the breasts, above the bump. • NHS Choices: http://www.nhs.uk/Livewell/ • Wearing the lap strap alone, or across the asthma/Pages/Asthmaattacks.aspx bump, is not advised as this can cause harm • NHS 24 – Health, information and self-care to you or your baby. advice for Scotland 5.12 Work and benefits 5.9 Sex If you are an employee, you have the right to It is perfectly safe to have sex during your take reasonable time off work for your antenatal pregnancy. It will not harm you or your baby. appointments, including antenatal classes, However, you should refrain if you have had without loss of pay. any bleeding or your waters have broken, or https://www.gov.uk/working-when-pregnant- you have been advised not to for any other your-rights reason by your Midwife or Obstetrician. It is usually safe to continue working whilst For further help and advice you are pregnant but your employer should www.thecoupleconnection.net carry out a risk assessment at your workplace and do all that is reasonable to remove any 5.10 Travel risks to your or your baby’s health. If you are If you are planning to travel abroad during at all concerned, please discuss this with your your pregnancy you need to discuss flying, Midwife – any potential risks to your pregnancy vaccinations and travel insurance with your must be discussed with your employer. The Midwife or GP. Health and Safety Executive (www.hse.gov.uk) can provide further information. There is evidence to suggest that periods of inactivity such as long journeys will increase Your employer may ask about your Mat B 1 the risk of developing blood clots. It is form. Your Midwife can provide you with this recommended that you do some leg exercises after 20 weeks of pregnancy. You should to encourage blood circulation and wear be routinely provided with the form at your compression stockings/tights on long drives or appointment after your anomaly scan but if you flights. Drink plenty of fluids and walk around require this sooner please contact your Midwife the cabin to encourage good blood circulation. directly. Please contact the airline company to be made 5.13 Domestic abuse aware of their policy regarding the maximum gestation at which they will allow you to fly. Pregnancy can be the happiest time of a woman’s life but for some women it is the most If you need a ‘fit to fly’ letter for travel please vulnerable. Domestic violence is the largest consult your GP. unreported crime, affecting 1 in 4 (25%) women

22 Pregnancy Information Book at some point in their lifetime. More than 30% • You cannot change an abuser’s behaviour. of domestic abuse starts in pregnancy and Only they can do that if they choose to do so. existing abuse may worsen during pregnancy Getting help or after giving birth. Ignoring abuse is dangerous so it is important Domestic abuse during pregnancy puts you to talk to someone about what is happening to and your unborn child in danger. It increases you. the risk of miscarriage, infection, premature birth, and injury to or death of the baby. Keeping Safe – you and your children have a right to be safe. How do I know if I am experiencing abuse? • In an emergency ring 999. You may not recognise you are being abused. • If you are pregnant it is advisable to talk to If you answer yes to one or more of the your Midwife. following questions, you may be in an abusive • Talk with a specialist domestic violence relationship. professional. They can work with you to • Are you ever scared of your partner or do you reduce the risk of harm to you and your feel like you’re walking on ‘eggshells’? children. • Has your partner ever hurt or threatened you • Ask your Midwife for a copy of the MCHFT or your children? Domestic Abuse patient leaflet which has • Has your partner been in a violent useful advice, information and local contact relationship before? numbers. • Has your partner tried to discourage or stop • You could also talk to your GP, Health Visitor, you from seeing your friends/family, going to Social Worker. work or studying? Being safe in hospital • Does your partner constantly check up on It is important to be aware that you can inform you or follow you? your Midwife if you are involved in an abusive • Is your partner jealous? Does your partner situation. This way, security can be informed accuse you unjustly of flirting or of having if you do not want contact with your partner or affairs? abuser whilst you are in hospital. • Has your partner ever kept you short of money or restricted your access to money? BE SAFE… • Does your partner belittle or humiliate you? Does your partner criticise or insult you in GET HELP WITH DOMESTIC ABUSE. front of other people? Independent Domestic Violence Advisor, • Has your partner ever forced you to do based at Leighton Hospital – 01270 278087 something that you really did not want to do, (9.00am-5.00pm, Monday-Friday, excluding including sexually? Bank Holidays) • Does your partner blame you or others for Domestic Abuse Family Safety Unit their behaviour? (Cheshire East area) – 0300 123 5101 • Does your partner tell you no one else would (24 hour helpline) want you? Do they threaten that if you leave Domestic Abuse Family Safety you will be unable to cope, that they will take (Cheshire West area) – 0300 123 7047, the children, they will kill themselves? Option 2 (9.00am-5.00pm, Monday-Friday, excluding Accepting that you are not to blame Bank Holidays) It may be difficult for you to understand the National 24 hour FREE Domestic Abuse abusive behaviour and you may be feeling helpline – 0808 2000 247 ashamed or blame yourself, however: • No one should be frightened.

Pregnancy Information Book 23 6.0 Emotional Wellbeing

6.1 Antenatal depression During pregnancy it is not uncommon to 6.3 Postnatal depression experience changes in your emotions. This may include feeling moody and tearful, and you may Postnatal depression affects approximately 10 to 15 in every 100 women (10-15%) after feel very tired, especially in the first few weeks. . Postnatal depression is more If these emotions continue, and you begin to common than many people realise and cases lose interest in yourself, your pregnancy, and may often go undiagnosed. the things that usually make you feel happy, If a woman experiences persistent and then it is possible that you could have antenatal prolonged symptoms of the baby blues, it could depression. well be the result of postnatal depression. All too often women are worried about letting Postnatal depression usually develops in the first people know how they feel, and fear that they four to six weeks after childbirth, although in some will be judged adversely, as pregnancy is cases it may not develop for several months. usually associated with feelings of happiness and excitement. But early diagnosis of There are many symptoms of postnatal antenatal depression can minimise the risk of depression, such as: postnatal and on-going depression. • Low mood. It is really important that you talk to your • Feeling unable to cope. Midwife if you are experiencing any of • Difficulty sleeping. these symptoms, to ensure that you can receive the appropriate care and support Many women are not aware they have the condition. throughout your pregnancy. It is important for partners, family and friends 6.2 Baby blues to recognise signs of postnatal depression as • Over half of new mothers will have the baby early as possible and seek professional advice. blues. It is very important to understand that postnatal depression is an illness. It does not mean you • This usually starts three to four days do not love or care for your baby. after birth. Postnatal depression can be lonely, distressing • You may have mood swings or burst into and frightening, but there are many effective tears easily. treatments available. As long as postnatal • You may feel irritable, low or anxious at times depression is recognised and treated, it is a and you may also over-react to things. temporary condition that you can recover from. These are a normal reaction to motherhood as It is very important to seek treatment if you think you (or your partner) have postnatal you adapt to less sleep, hormonal changes and depression. new responsibilities. The baby blues usually stops by the time your 6.4 Postpartum psychosis baby is about 10 days old. You should not need Postpartum psychosis (or puerperal psychosis) treatment for baby blues. is less common than the baby blues or The baby blues does not tend to last very long postnatal depression. It occurs in about 1 in and can be helped by talking to your partner, every 1000 women (0.1%) who have a baby. family, friends and Midwife or Health Visitor. Postpartum psychosis is a severe episode of However, if these feelings continue longer than mental illness which begins suddenly in the a week or worsen, you may be experiencing days or weeks after having a baby. Symptoms something other than the baby blues. Speak to vary and can change rapidly. They can include your GP, Midwife or Health Visitor as you may high mood (mania), depression, confusion, need further support or treatment. hallucinations and delusions. Symptoms can

24 Pregnancy Information Book change very quickly from hour to hour and from her to work out what needs doing now and one day to the next. what can wait. Postpartum psychosis is a psychiatric Practical things you can help with emergency. You should seek help as quickly as • Cook a meal. possible. • Keep visitors to a minimum if they are adding Postpartum psychosis can happen to any to the distress. woman. It often occurs out of the blue to women who have not been ill before. It can • Encourage your partner to take rest and time be a frightening experience for women, their out for herself. partners, friends and family. Women usually • Help with night feeds. recover fully after an episode of postpartum psychosis. • Offer to take the baby out for a walk or round to friends. If you, your partner or family think that you have symptoms of postpartum psychosis, you • Remember to tell your partner of your love will need to be seen urgently. You should see and give hugs. your GP the same day or attend your local • Try not to make too many sexual demands – A+E department. If you are told you do not allow time for recovery. have postpartum psychosis but your symptoms worsen, you should make sure you are seen Your emotional wellbeing as a partner is again. important too Partners can also suffer from depression Most women with postpartum psychosis need following the birth of a baby. This is more likely to be treated in hospital. Ideally you should be to happen if you are already experiencing offered a bed in a Mother and Baby Unit (MBU). depression, if you have previously experienced This is a specialist psychiatric unit where depression, or if you are a first time parent. mothers with mental illness are admitted with their babies. You will be supported in caring Remember, as a parent it is important that you for your baby whilst you have the care and look after your own physical and emotional treatment you need. wellbeing, so that you can look after your family as well as yourself. If you are concerned about It can take 6-12 months or more to recover your own mental health, please discuss this from postpartum psychosis. The most severe with your GP or Health Visitor. symptoms tend to last 2-12 weeks. The vast majority of women will recover fully. For further help and information There are many organisations which offer 6.5 Partners and postnatal depression further support and information for people Looking after the mother’s mental health who are affected by postnatal depression. If your partner is experiencing mental health See Section 22.0 for more details of Useful problems and is not already doing so, you must Organisations. encourage her to seek immediate professional help. The sooner she does this the quicker she will recover. • Listen to her and be there when she needs you. • Understand that this is not her fault or yours, but a real illness. Remind her that she will get better soon. • Be involved with your partner’s care to gain understanding. • Be patient and kind. • Help her to organise her time and encourage

Pregnancy Information Book 25 7.0 Infections in pregnancy If you come into contact with or develop any infectious disease, including tuberculosis, or develop a rash please seek advice.

7.1 Chickenpox If you catch Chickenpox: Chickenpox is an infectious illness that most • Up to 28 weeks of pregnancy people in the UK get in childhood, when it There is no evidence that you are at an is a mild infection causing very itchy spots increased risk of early miscarriage because and blisters. However, if you are infected for of Chickenpox. the first time as an adult, it tends to be more Damage can occur to the eyes, legs, arms, serious and can cause a type of Pneumonia. brain, bladder or bowel in 1-2 of every 100 9 out of 10 pregnant women (90%) in the UK babies (1-2%). You will be referred to a Fetal are immune to Chickenpox even if they cannot Medicine Specialist for discussion about remember having had it. possible tests. You can catch Chickenpox from someone who • Between 28 and 36 weeks of pregnancy currently has it. A person is contagious from The virus stays in your baby’s body but will two days before the rash appears to when all not cause any symptoms. The virus may the blisters have crusted over. become active again causing Shingles in the If you come into contact with Chickenpox first few years of the child’s life. If you have had Chickenpox, you are immune • After 36 weeks of pregnancy, to birth and there is nothing to worry about. You do Your baby may become infected and could not need to do anything. If you have never be born with Chickenpox. had Chickenpox, or are not sure, see your • Around the time of birth GP or Midwife as soon as possible and they can arrange a blood test to find out if you are If your baby is born within seven days of your immune. If you develop a rash in pregnancy Chickenpox rash appearing, your baby may always contact your GP. get severe Chickenpox. Your baby will need to be treated. If you are not immune • Up to 7 days after birth If you are not immune to Chickenpox and you Your baby may get severe Chickenpox and come into contact with Chickenpox during will need to be treated. Your baby will be pregnancy, you may be given an injection of monitored for 28 days after you became Varicella Zoster Immune Globulin (VZIG). This infected. is a human blood product which strengthens the immune system for a short time but does It is safe to breastfeed if you have had not necessarily prevent Chickenpox developing. Chickenpox during pregnancy. VZIG can make the infection milder and not If you catch Chickenpox in pregnancy or last for as long. The injection can be given for when you are trying to become pregnant, up to 10 days after you come into contact with you should avoid contact with other pregnant Chickenpox and before any of your symptoms mothers and new babies until all your blisters appear. VZIG does not work once you have have crusted over. blisters. 7.2 Shingles Effects on your baby Shingles is related to Chickenpox. After you Only a very small number of women, 3 in every have had Chickenpox, the virus stays in your 1000, (0.3%) catch Chickenpox in pregnancy body and can become active again later in the UK. Even fewer babies are affected causing a patch of itchy blisters on the skin that in the uterus. The risk of a baby catching dry out and crust over in a few days. It can be Chickenpox depends on what stage in very painful, but if you get Shingles while you pregnancy you catch it. are pregnant, it is usually mild and there is no risk for you or your baby.

26 Pregnancy Information Book If you come into contact with someone who 10 days (this is called the incubation period). has Shingles you do not need to worry if you Early symptoms of Measles are like a cold with are immune to Chickenpox. If you are not a fever, cough, red eyes and tiny spots in the immune, then the risk of getting Chickenpox mouth. A red-brown spotty rash appears two to from someone with Shingles present on a four days later and lasts for up to eight days. covered part of the body is very small. If the If you catch Measles during pregnancy and Shingles is widespread or exposed (such as you are not immune, this may result in a the face or eye) there is a risk of being infected miscarriage, stillbirth or preterm (early) delivery. with Chickenpox when the blisters are active and until they are crusted over. See your GP for If you know you have not been vaccinated advice about treatment. against Measles, or are not sure, and you think you have been in contact with someone with 7.3 German Measles/Rubella Measles you should see your GP immediately. Your GP may treat you with Human Normal Rubella or German Measles is an illness Immunoglobulin (HNIG). This may reduce causing a mild fever and a widespread rash. the severity of your Measles, but there is no All children are now offered a vaccine against evidence that it prevents miscarriage, stillbirth Rubella through the Measles, Mumps and or preterm delivery. Rubella (MMR) immunisation. If you are planning on getting pregnant and you If you catch Rubella in the first four months of are not sure if you have had Measles or the pregnancy it can seriously affect your baby’s Measles vaccination, your GP may suggest you sight and hearing and cause brain and heart have a blood test to check if you are immune, defects. and if you are not, offer the MMR immunisation If you are unsure if you are immune and think to make sure you are immune. you may have been in contact with Rubella or You cannot have the immunisation while you develop any rashes, you should see your GP pregnant because the vaccination contains a or Midwife as soon as possible. A blood test will live virus, which could cause infection in the show whether you have been infected and you baby. For the same reason, you should not may be referred to a Fetal Medicine Specialist for become pregnant for at least a month after discussion about possible further tests. having the MMR immunisation. We no longer routinely screen to check whether you are immune to Rubella therefore we 7.5 Mumps strongly advise that if you have not had the Mumps is not known to cause any problems disease previously or had two vaccinations in unborn babies, but there may be a small in your lifetime or were born outside of increased risk of miscarriage (as a result of the the UK, that you ask for a copy of your illness and fever). vaccination history from your GP. If there is no documentation to suggest you are immune or Mumps is caused by a contagious virus, which had previous vaccinations, then you should is transmitted through airborne droplets from arrange with your GP to get vaccinated after the coughs and sneezes of infected people. you have had your baby. Mumps mainly affects children between 5 and 15 years of age, but can be caught at any age 7.4 Measles if you have not been vaccinated against it with the MMR immunisation. Measles had become quite rare since the introduction of vaccination programmes, but Mumps is normally a mild illness, although there have been recent large outbreaks since in a minority of cases there can be severe levels of immunisations have dropped. The complications, such as meningitis. The virus is very easily spread in droplets from symptoms of Mumps are: coughs and sneezes in the air. It can also be • Fever. caught from contact with the skin of an infected • Headache. person. You may not show symptoms until 6-21 days after being exposed to Measles, • Swelling of the cheeks or jaw. but most people show symptoms after about • Swollen glands, which can last up to 7-10 days.

Pregnancy Information Book 27 Pregnant women who develop Mumps in the • Do not handle stray cats. first 12-16 weeks of pregnancy may have a • Avoid eating raw or undercooked meat or slightly higher risk of miscarriage as a result of poultry. the illness and fever, but there is no evidence that Mumps can cause defects in the unborn • Peel or wash fruits and vegetables before child. eating, and wash your hands and all utensils, chopping boards, plates, and surfaces Although there is no cure for Mumps, if you that have been in contact with raw meat, think you have been infected your GP will poultry and seafood, or unwashed fruits and be able to suggest treatment to relieve your vegetables. symptoms. • Wear gloves when you are gardening or 7.6 Toxoplasmosis handling soil or sand. Afterwards, wash your hands thoroughly. When you are not pregnant Toxoplasmosis does not usually cause problems. But if you are 7.7 Slapped Cheek/Parvovirus pregnant, it can cause serious health problems for your unborn baby. Parvovirus B19 infection is common in children and causes a characteristic red rash on the If you catch it during pregnancy, or in the three face, so it is often called ‘slapped cheek months before you conceive, the infection can disease’. pass to your baby. Most women are immune to this infection, but it Not all babies get infected but babies who do is very infectious. If you come into contact with get infected in early pregnancy are more likely someone who is infectious you should see your to have serious health problems and it can GP who can check with a blood test to see if cause miscarriage. you are immune. In most cases the baby is not Most healthy people, including pregnant affected when a pregnant woman is infected women, do not have any symptoms from with Parvovirus. However, if the baby is Toxoplasmosis. Some people have a mild flu- infected during the first 20 weeks of pregnancy like illness for a few weeks. it can cause severe complications such as If you are pregnant and think you may have heart failure or anaemia. become infected, you can have a blood test. If you test positive for Parvovirus B19, you If your test shows you have Toxoplasmosis, you will have ultrasound scans throughout your will be referred to a Fetal Medicine Specialist to pregnancy to monitor your baby. If your baby discuss possible further tests and treatment for develops evidence of complications, they your infection. may need a blood transfusion while still in the womb. There’s no evidence that infection Toxoplasmosis is caused by a parasite that can with Parvovirus B19 during pregnancy causes be carried by lots of animals, but commonly pet birth defects or development problems later in cats. It can also survive in infected soil and dirty childhood. cat litter. It can be caught by humans in the following ways: 7.8 Hand, Foot and Mouth • Eating or handling soil, water or food that has Hand, Foot and Mouth disease is a viral been contaminated by cat faeces. infection, usually caused by Coxsackievirus • Eating or handling under-cooked or raw meat A. It is very infectious and spreads through which is infected – mainly pork and lamb. coughs, sneezes and contact with infected stools (faeces). • From mother to baby in the womb. Hand, Foot and Mouth is not the same as Ways to avoid catching Toxoplasmosis: ‘Foot and Mouth’ disease which can only affect • If you have a cat, avoid changing its litter if animals. possible – ask if someone else can do it. Hand, Foot and Mouth disease is common in • If you have to do it yourself, use gloves and children but rare in healthy adults. Most adults then wash your hands thoroughly. The litter are immune to the virus because they had box should be changed daily. contact with it as a child. 28 Pregnancy Information Book Hand, Foot and Mouth disease causes a causes Whooping Cough will have gone by fever and sore throat, followed by sores or this time so you will no longer be infectious and blisters in your mouth and on your hands and antibiotics will not make a difference to your feet. The incubation period (the time between symptoms at this stage. catching the disease and showing symptoms) In the UK, all pregnant women are now offered is three to six days. During this time, the virus a vaccination against Whooping Cough from 20 can be passed on. weeks of pregnancy. Getting vaccinated while There’s normally no risk to your unborn baby if you are pregnant could help to protect your you catch Hand, Foot and Mouth disease while baby from developing Whooping Cough in its you are pregnant. However, if you catch the first few weeks of life prior to starting their own virus shortly before you give birth, the infection sequence of vaccinations. can be passed on to your baby. Most babies This is the case even if you were vaccinated born with Hand, Foot and Mouth disease have as a child, or have been told you have had only mild symptoms. Whooping Cough before. Protection from the 7.9 Whooping Cough childhood vaccine lays dormant in the immune system so this immunity will not be passed onto Whooping Cough is a highly contagious your baby. Immunity can also fade overtime so bacterial infection of the lungs and airways. The the vaccination will boost your own immunity medical term for Whooping Cough is Pertussis. to reduce the chances of you contracting It is caused by a bacterium which can be Whooping Cough and passing it onto your new passed from person to person through droplets born baby. in the air from coughing and sneezing. The vaccine is safe to use in pregnancy and It begins with a persistent dry and irritating there is no evidence that it causes any harm to cough that will progress to intense bouts of the unborn baby. coughing followed by a distinctive ‘whooping’ noise, which is how the condition gets its name. 7.10 Influenza/Flu Other symptoms include a runny nose, raised temperature and vomiting after coughing. The The flu is caused by a family of viruses and coughing can last for around three months causes a feverish illness (a high temperature of (another name for Whooping Cough is the or above 38oC/100.4oF), plus two or more of the ‘Hundred Day Cough’). following symptoms: There is no evidence that Whooping Cough can • Unusual tiredness. cause any specific problems during pregnancy. • Headache. However, if you are infected with Whooping Cough around the time your baby is born, • Runny nose. you could transmit the infection to your baby. • Sore throat. Whooping Cough can be much more serious in young babies. • Shortness of breath or cough. If you or any member of your family develop • Loss of appetite. symptoms suggesting Whooping Cough, or • Aching muscles. you are told that you have been in contact • Diarrhoea or vomiting. with someone who has since been diagnosed with Whooping Cough, please see your Pregnant women are more likely to catch the GP. Whooping Cough can be treated with flu because their immune system is slightly antibiotics if it is diagnosed during the first suppressed during pregnancy. Most pregnant three weeks of the infection. This will prevent women will have only mild symptoms and the infection being passed on to others (as a recover within a week. However, there is precaution, household members of someone evidence from previous flu pandemics that with Whooping Cough may also be given pregnant women are more likely to develop antibiotics and a booster shot of the vaccine). complications. If Whooping Cough is not diagnosed until the later stages of infection, antibiotics will not usually be prescribed. The bacterium that

Pregnancy Information Book 29 Possible complications include: You will be offered a blood test for Hepatitis B • Pneumonia (an infection of the lungs). at the start of your pregnancy and if you are infected you will be referred for further tests • Difficulty breathing. and possible treatment. Your baby should then • Dehydration. be immunised at birth and followed up to look for any evidence of infection. In pregnant women, these are more likely to happen in the second and third trimester. 7.12 HIV If a pregnant woman develops a complication Human Immunodeficiency Virus (HIV) is the of flu, such as pneumonia, there is a small virus that causes Acquired Immune Deficiency chance this will lead to premature labour or Syndrome (AIDS). If you are infected it can miscarriage. pass to your baby during pregnancy, at delivery, Vaccination and pregnancy or after birth by breastfeeding. As part of your routine antenatal care you will be offered a You are advised to take the seasonal flu HIV test at the start of your pregnancy. If you vaccination, whatever the stage of your are HIV positive you and your baby can have pregnancy, even if you are not in a high-risk treatment that reduces the risk of your baby group. becoming infected. The seasonal flu vaccination offers protection against the swine flu virus, as well as other 7.13 Chlamydia strains of flu virus. Sexually Transmitted Infections (STls) are on There is no evidence that inactivated vaccines, the increase. The most common is Chlamydia. such as the seasonal flu vaccine, will cause Most women and up to half of men who have any harm to you or your unborn baby. Every Chlamydia show no symptoms so you may year, the seasonal flu vaccine is given to a not know if you have it. However, untreated large number of pregnant women. Chlamydia can have long term effects on your health, particularly your future fertility, and can When to see your GP also cause serious eye infections in your baby Most cases of flu are relatively mild and most at the time of birth. women recover within a week. As it is caused If you are under 25 years of age you will be by a virus, antibiotics will not help and do not routinely offered screening for Chlamydia in make any difference to your recovery. The best pregnancy and if you are carrying it, it can be advice is to drink plenty of fluids, take regular safely and easily treated. paracetamol to help with the fever, headaches and aching limbs, and rest in bed until you are If you have any reason to believe that you or feeling better. your partner has an STI you should go for a check-up at a Sexual Health Clinic or with your If you develop any complications such as GP as soon as you can. difficulty breathing or chest pain, or feel you are becoming dehydrated if you are unable to 7.14 Bacterial Vaginosis during drink you may need to see your GP. In some circumstances they may prescribe you antiviral pregnancy treatments or arrange for you to be admitted to During pregnancy your natural vaginal discharge hospital. can change. For most women this is normal, but in others this can be a sign of an infection. 7.11 Hepatitis B If your vaginal discharge changes you should Hepatitis B is a virus that infects the liver and tell your GP or Midwife. You can also get help can cause long term liver damage. Many at your local Sexual Health Clinic where they people with Hepatitis B will have no signs of can often do an instant test, and provide free illness themselves but they might infect others. treatment. If you have Hepatitis B or are infected during A common cause of a change in your natural pregnancy you can pass the infection to your vaginal discharge is Bacterial Vaginosis – or BV baby at the time of birth. for short.

30 Pregnancy Information Book BV is an imbalance of the natural bacteria and long term health problems if your baby which usually live in the vagina. The cause survives. is not known, but BV can occur when using Syphilis is safely treated with antibiotics once scented soaps or bath products, excessive it has been diagnosed and this can help vaginal washing, or after sex. BV is not a STI. protect your unborn baby from developmental Most women with BV will usually notice an problems. unusual smell (sometimes a fishy smell) All pregnant women are offered a blood test and have a watery white/grey colour vaginal to check for Syphilis as part of their antenatal discharge. The symptoms of BV can sometimes care. feel like a yeast infection (called Thrush or Candida). It is also possible to have BV and not 7.16 MRSA (Methicillin-Resistant experience any vaginal symptoms at all. Staphylococcus Aureus) Testing for BV is very simple and is done by Staphylococcus Aurous is a bacterium that taking a swab from the vagina by your GP or lives harmlessly on the skin and in the nose of Midwife. It is usually recommended that when 30% of the UK population (this is called being you have a test that the Midwife, GP or nurse colonised). also advises you about having a test for STI’s at the same time, especially if you have not had a Staphylococcus Aurous can cause an infection test recently or if you have changed your sexual if it enters the body, for example, wound partner since your last test. Blood tests cannot sites. Staphylococcus is usually treated test for BV. with Flucloxacillin but MRSA is resistant to Flucloxacillin and some other antibiotics. BV can be safely treated during pregnancy. The treatment is often antibiotic tablets or antibiotic In order to reduce the risk of MRSA being vaginal gel/cream. Your sexual partner does not spread in hospital, women who are booked for need treatment. an Elective Caesarean Section will be screened from 34 weeks by offering a nasal swab and You do not need a test to make sure BV has treated as appropriate. gone after you have been treated. However, it is common for BV to re-occur and many 7.17 Tuberculosis (TB) women will need treatment again. If you have reoccurring BV you may be advised to talk to a Tuberculosis (TB) is still prevalent in many specialist Doctor for advice at your local Sexual countries. As a result some parents are more Health Clinic. at risk of contracting this disease, which therefore increases the risk to babies. TB is a BV can be linked with miscarriage, low birth difficult infection to catch and usually requires weight and premature labour, however in the prolonged or repeated contact with someone majority of women BV is not usually a serious who is infectious. problem and does not usually cause any serious harm to you or your baby. A risk assessment will be completed at your booking appointment and if it is felt your baby is If you would like to know more about BV or at high risk of contracting TB then a vaccination other infections ask your GP or Midwife for will be offered soon after birth for your baby. information or visit www.fpa.org where you can also find details of your local sexual health and For further information: www.hpa.org.uk contraception services. Additional information on infections can be found in the National Screening Committee’s 7.15 Syphilis ‘Screening Tests for You and Your Baby’ Syphilis is another STI. It used to be very rare (Public Health England). but the number of people infected by this is increasing. Most infected people do not have any obvious symptoms but it can cause severe problems for your baby if it is present and untreated in early pregnancy. There is a large risk of stillbirth, as well as various deformities

Pregnancy Information Book 31 8.0 Pregnancy symptoms and complications

8.1 Common pregnancy symptoms 8.3 Blood clots (Deep Vein Thrombosis) As your body changes in pregnancy, you can Risk factors experience some minor problems which can There are certain factors which might increase cause irritation and some discomfort. a woman’s risk of developing a blood clot If you are at all concerned, please discuss during pregnancy and afterwards. These these with your Midwife or GP. include: Common symptoms can include: • Previous history or family history of a blood clot. • Nausea. • Severe varicose veins. • Tiredness. • Being overweight (BMI of 30 or above). • Backache or other mild aches and pains. • Prolonged immobility. • Heartburn. • Aged 35 or more. • Constipation. • Having an operative birth. • Haemorrhoids (piles). • Having more than one baby. • Swelling in hands or ankles. • Smoking. • Varicose veins. • Long distance travel including air travel. These are common symptoms that your Midwife • Some blood disorders. or GP can offer guidance on and can be rectified or improved with simple treatment or advice. Pregnancy itself is an associated risk factor because pregnancy hormones relax the 8.2 Pregnancy complications muscles in the veins and can reduce good blood circulation. Blood clots can develop from With some complications in pregnancy we the beginning of pregnancy until well after the would want you to seek immediate guidance. baby is born. If you are less than 16 weeks pregnant seek this guidance via your GP or A+E if it is an You can reduce the risk of having a blood clot emergency. If you are more than 16 weeks during pregnancy and afterwards in a number pregnant, please contact the Labour Ward of different ways. These include: Triage on 01270 273116. The numbers • Wear compression stockings if you have are located on the first inner page of your varicose veins. These are available free on Pregnancy Care Record. prescription from your GP. Examples of these complications include: • You will be given compression stockings • Vaginal bleeding. and/or medication if you are in hospital and • Recurring headaches. are immobile for a long period of time or if you have an operative birth. You will be • Blurred or altered vision or flashing lights. encouraged to get up and about as soon as • Abnormal swelling of the face, hands or feet. you are able. • Abdominal pain. • See travel section if making long journeys or • Pain in your calf or chest pain. travelling by air. • Feeling unwell. • Try to stop smoking. • Reduction in your baby’s movements (see • Avoid dehydration by drinking plenty of water. Your Baby’s Movements in Pregnancy leaflet). Signs and symptoms of a blood clot in the • Your waters break. leg include: • Itching to hands and feet. • Swollen and/or painful calf or thigh. More advice can be found on the inside • Redness over the area. of the front cover of your Pregnancy Care Record. If you need urgent help phone the • The area may feel hot. Labour Ward Triage on 01270 273116 32 Pregnancy Information Book Sometimes part of the blood clot breaks free For further information please ask for our ECV from the veins and can cause a pulmonary information leaflet or view it from the hospital embolism in the lungs. website under patient information. Signs and symptoms of a blood clot in the 8.7 Blood pressure lung include: Blood pressure is the force of blood pumping • Chest pain. around your body, and is measured by a • Shortness of breath. machine on your upper arm with an inflatable cuff. A slight tightening on the arm occurs in If you experience any of these symptoms, order to obtain the reading. contact your A&E or GP urgently. With prompt treatment any complication arising • The pressure is recorded as two numbers from the blood clot can be reduced. e.g. 120/80. • The first number e.g. 120 is the systolic and 8.4 Severe itching and Obstetric shows the pressure of the heart pumping. Cholestasis • The second number e.g. 80 is the diastolic It is not uncommon to experience some itching and shows the pressure as the heart relaxes. in pregnancy. Severe itching of the hands and feet, particularly in the last four months of Blood pressure: pregnancy, may be the sign of an uncommon • Varies between people. condition called Obstetric Cholestasis. If you do experience troublesome itching please contact • Changes with the time of day and activity. your Midwife, GP or Labour Ward Triage • Can increase in times of worry and stress. on 01270 273116. To exclude this condition • A persistent reading of 140/90 or greater a blood test is performed and if necessary is a cause for further investigation by your treatment may be required. Midwife or Obstetrician. 8.5 Vaginal Bleeding 8.7.1 High blood pressure in pregnancy It is important to report any bleeding to your During your pregnancy, with your consent, you Midwife or GP, as bleeding in pregnancy will have your blood pressure monitored at requires investigation by an Obstetrician. In early every antenatal check and your urine will also pregnancy it could be a sign of miscarriage, be tested. Regular checks help keep you and although many women who do bleed go on your baby safe. to have successful pregnancies. Bleeding in later pregnancy can indicate problems with the Some women may develop high blood pressure placenta or trauma to the cervix (e.g. erosion). A during pregnancy and others may already have minor blood loss mixed with mucous is referred high blood pressure before conceiving. to as a ‘show’ and is normal in late pregnancy. Raised blood pressure can be a sign of a It is important to identify the cause so that pregnancy problem called Pregnancy Induced appropriate care can be given. Hypertension (may be called Gestational Hypertension see section 8.7.3 for more 8.6 Malposition details). By the time you reach the 36th week of If you have raised blood pressure and protein pregnancy your baby should be in a cephalic in your urine you may be developing Pre- position which means it is lying head down. eclampsia (see section 8.7.4 for more details). However, occasionally your baby may be lying in If protein is found in your urine, a Protein a different position (breech) which may increase Creatinine Ratio (PCR) test will be sent to the risk of complications during labour and birth. the laboratory to check the level of protein in If this happens you will usually be offered the your urine. If this level is found to be normal, option of External Cephalic Version (ECV). This routine monitoring of your urine will continue. If is where an Obstetrician will put pressure on the level was higher than expected you will be your abdomen to try and turn your baby to a asked to attend the hospital for review. head down position. If this does not work then you will be offered a caesarean section. Most women with Pre-eclampsia feel perfectly well, that is why these checks are important. Pregnancy Information Book 33 8.7.2 Levels of blood pressure Pre-eclampsia have a lot of protein in their There are three levels of blood pressure: urine (known as proteinuria). Extra medical care is needed with this condition. • Mild – defined as a reading between 140/90 and 149/99. Your blood pressure may be What is Pre-eclampsia? checked regularly but usually does not need It is an illness you can get during pregnancy or treatment. straight after your baby is born, and it can affect • Moderate – defined as a reading between you and your baby. 150/100 and 159/109. What happens to you? • Severe – defined as a reading of 160/110 or Pre-eclampsia involves changes in the blood higher. vessels all over the body – as a result: 8.7.3 Types of high blood pressure • Blood pressure rises (Hypertension) • Protein from the blood leaks into the urine There are different types of high blood pressure. • Water can leak out of the blood vessels and cause sudden swelling (oedema) in the Chronic (or essential) high blood pressure hands and face Chronic (long term) high blood pressure may be developed before pregnancy or in its It is important to attend all your antenatal early stages (before 20 weeks). There are two checks as some women can become seriously types of chronic high blood pressure: ill with this condition. Pre-eclampsia can also cause problems in the liver, brain, lungs or – • Primary chronic high blood pressure blood clotting system. where the cause is not known. This is the most common type. What happens to the baby? • Secondary chronic high blood pressure Your baby may grow too slowly because not – which has a medical cause e.g. kidney enough blood is getting to the placenta – which disorder can lead to health problems. If you have secondary chronic high blood You are more likely to get Pre-eclampsia if: pressure your Obstetrician should offer to refer • This is your first pregnancy. you to a specialist for additional care during your pregnancy. • This is your first baby. • You are 40 years or over. Gestational hypertension (pregnancy induced) • Your last pregnancy was more than 10 years ago. Gestational hypertension is a type of high blood pressure that develops in the later stages (after • You are overweight (BMI > 30). 20 weeks) and goes away within six weeks of • If you have a family history of pre- eclampsia. the baby’s birth. • You are carrying more than one baby. If you have high blood pressure, the type of • You have high blood pressure before becoming treatment you receive will depend on what pregnant (chronic high blood pressure). type of high blood pressure you have and how • You had high blood pressure during a high it is. If you were already taking medication previous pregnancy. for high blood pressure prior to becoming • You have a chronic kidney disease, diabetes pregnant, it is important to check with your GP or an inflammatory disease that affects the that the medication you are taking is safe to immune system such as lupus. continue during pregnancy. Symptoms of Pre-eclampsia 8.7.4 Pre-eclampsia (previously known • Severe headache. as Toxaemia) • Problems with your eye sight e.g. blurring or Pre-eclampsia is a type of high blood flashing before your eyes. pressure which develops in the latter stages • Severe pain just below your ribs. of pregnancy but can start as early as after 20 weeks pregnancy and goes away within six • Vomiting. weeks of the baby’s birth. Women with • Sudden swelling of your face, hands or feet.

34 Pregnancy Information Book If you have Pre-eclampsia 8.7.6 What should I expect after the • You may be admitted to hospital for tests and birth? treatment. All women who have had high blood pressure • Your blood pressure may be monitored after the birth, and wish to breast feed will be several times a day. advised on the best blood pressure drugs/ tablets to take. • You may be offered a drug to help lower your blood pressure – this will not harm your baby. Your blood pressure will continue to be • Your baby’s heart rate will be monitored. monitored and you should be offered a check up with a GP at your postnatal appointment six • You may be tested for liver, kidney and blood to eight weeks after the birth. clotting problems. Women with chronic high blood pressure will • You may be advised to have your baby early be checked two weeks after the birth to ensure by having your labour induced or by having that they are on the correct treatment. a Caesarean section – whichever is best for you and your baby. Women who had gestational high blood pressure and are still taking blood pressure In rare cases, some women with Pre-eclampsia drugs two weeks after leaving hospital, should have one or more convulsions or seizures be offered a check-up by the GP to see if the before or just after the birth. These are called treatment needs to be stopped or amended. If eclamptic fits. after six weeks of the birth you are still taking If you are at a high risk of this or your baby is the high blood pressure drugs, you should be expected to be born within 24 hours, you may referred to a specialist to check your high blood be given a drug to prevent or stop seizures pressure treatment. (Magnesium Sulphate). 8.7.7 Long Term Health Considerations After the birth, you should be offered a postnatal six to eight weeks check up with your All women who have had high blood pressure Obstetrician. during the pregnancy should try and stay within a healthy weight range to help reduce the risk If you are still requiring drugs to treat your of high blood pressure problems in the future. blood pressure – your Obstetrician should refer you to a specialist. If you had Gestational High Blood pressure: Urine and blood tests may be taken. If there is • You may develop it again with a future still protein in your urine you should be offered pregnancy. another appointment four to six weeks later to • There is a small risk that you may develop check how well your kidneys are working. Pre-eclampsia with a future pregnancy. Following this you may be referred to a kidney • You may develop high blood pressure and its specialist. complications in later life. 8.7.5 What should I expect during If you had Pre-eclampsia: labour and birth? • You may develop gestational high blood You should continue to take your blood pressure or Pre-eclampsia in a future pressure drugs and your blood pressure will be pregnancy. (Your risk depends on how many monitored every hour or continually if high. weeks pregnant you were when your baby was born). If your blood pressure is very high, your Obstetrician may advise you have an operative • There is a risk of developing Pre-eclampsia in birth (a birth with instruments to help the baby a future pregnancy is greater, if there is a gap be born). These may be forceps (tongs to of 10 years or more between pregnancies. cradle the baby’s head) or ventouse (a cup • The risk of kidney problems in later life is fitted onto the top of the baby’s head and uses small if your blood pressure is normal and suction) or you may be offered a caesarean there is no protein in your urine at your section. postnatal check-up. • You may develop high blood pressure and complications in later life.

Pregnancy Information Book 35 9.0 Deciding where to have your baby It is important for you to have all the information you need so that you can decide where you would like to give birth. Do not hesitate to ask your Obstetrician or Midwife any questions if you do not understand something or if you think you need to know more. Talk things over with your partner and your Midwife. Your Midwife will be able to offer you advice based on your individual needs, your medical history and any previous pregnancies you may have had. It is always possible to change your mind at any time during your pregnancy.

You should be offered a choice of where you can have your baby: • At home OR • In the hospital

9.1 At home Disadvantages: Homebirth is becoming increasingly popular. • You may have to transfer to hospital should For women experiencing a straightforward problems arise. You should be given pregnancy with no major complications information about the likelihood of this during anticipated during the birth, the option of having your labour and an estimate of how long this a homebirth is a real alternative to going into should take. The most common reasons for hospital. transferring to hospital are when your labour does not seem to be progressing or if there Giving birth at home is generally very safe for is concern about you and/or your baby. If you both you and your baby. Research has also need to transfer to hospital, an ambulance shown that those women who plan to have a will be arranged for transport by the Midwife. homebirth are more likely to have a normal vaginal birth, with less intervention. • Some women may wish to go into hospital for further pain relief. Some women want to have their babes at home because: If you are considering a homebirth, talk to your Midwife who will be able to give you more • They will feel happier, more in control and information. If you have had no complications more able to cope in a place they know with during your pregnancy, homebirth may be an their family around them. option you would like to consider and is suitable • They will be looked after by Midwives in the for first time pregnancies too. comfort and relaxation of their own home. • They feel they will have more freedom to do 9.2 Hospital Birth as they wish rather than having to fit into a Midwifery Led Unit (MLU) hospital routine. Women experiencing a pregnancy with no • They feel they will have more privacy. major complications anticipated during the birth • If they have other young children, there may give birth in the MLU. This is generally would be no need to leave them to go into very safe for you and your baby. Research has hospital, although we would still encourage also shown that women who plan to give birth that you have someone on standby to in an MLU are more likely to have a normal provide childcare should it be needed. vaginal birth, with less intervention. • They do not have to decide when to go into hospital. Pain relief available includes gas and air (Entonox) and water immersion. If you are considering a water birth at home please discuss this with your Midwife.

36 Pregnancy Information Book Advantages: If you require further information about the • Relaxing ‘home from home’ rooms with mood outcomes for you and your baby depending lighting and availability of a birthing pool for on where you give birth, please speak to your pain relief and/or delivery. Midwife or see NICE guideline Intrapartum care; care of healthy women and their babies • Access to medical staff and further pain relief during childbirth. if required. www.nice.org.uk/guidance/cg190 • Pain relief available also includes gas and air (Entonox) and Pethidine. • You can go home following the birth of your baby without needing to be transferred to the Postnatal Ward; however it is still available if requested. Disadvantages: • Epidural anaesthesia cannot be offered on the Midwifery Led Unit. • Only two birthing partners allowed in each birthing room. Consultant Led Unit Women can choose to give birth in the Consultant Led Unit or this may be advised due to previous complications during pregnancy or birth or due to a pre-existing medical condition. Advantages: • Direct access to Obstetricians, Anaesthetists and Neonatologists. • A birthing pool is available for women with high risk pregnancies. • The option of having an epidural for pain relief. An epidural is a special type of local anaesthetic into your back which can numb the feelings of pain. It is only available on the Consultant Led Unit. It needs to be given in hospital, as it involves an Anaesthetist and means you have to be closely monitored during your labour. • You will not need to transfer if there are problems during the labour. Disadvantages: • Women may not be relaxed as not in their own environment. • Women’s expectations are not always achieved resulting in reduced satisfaction in their birth experience. • Only two birthing partners allowed in each birthing room.

Pregnancy Information Book 37 10.0 Getting ready for birth

10.1 Parent Education Remember to be flexible, especially if this is In order to prepare you for labour, birth and your first baby. What might appeal to you now the early days of parenthood, we offer a range might not be what you actually want when you of classes in various locations to meet your are in labour. needs. 10.4 Packing for hospital For further information you can look at our web page: www.mcht.nhs.uk/pregnancy. To Below is a general guide of items you will book a class, please telephone 01270 612184 require during your stay in hospital. It is best to (Monday-Friday, 9.00am-4.00pm). pack two medium sized bags – one for you and one for baby. Remember to book your classes to commence from when you are approximately 32 weeks as We advise you to leave valuables such as places are limited. handbags and credit cards at home as we cannot accept responsibility for loss or damage. We will give you adequate information to Mobile phones may only be used in the enable you to make informed and appropriate designated areas and outside the hospital as choices. Our aim is to give individualised care they may interfere with patient care. that is sensitive to both your emotional and physical needs. For you: • Wash bag with toiletries such as – soap/ 10.2 Young parents group shower gel, toothbrush and toothpaste, Parent education groups designed to meet deodorant, shampoo, etc. the needs of young parents are provided on a • Towels group or individual basis. For more information, contact your named Midwife. • Underwear (at least 6 pairs) old or disposable. 10.3 Preferences for birth • Sanitary pads for heavy/maternity use (NOT It is a good idea to write a birth plan, which is a tampons). written record of what you would like to happen • Light and comfortable day clothes. during your labour and after birth. Thinking about your birth preferences can encourage • Two to three nighties or pyjamas, if you are you to look at all the birth options available, breastfeeding it may be best to choose front- and you can include anything you feel strongly opening nighties. about. Your birth plan will be discussed with • Dressing gown and slippers (ensure they still you throughout your pregnancy. Please use the fit at the end of your pregnancy as your feet birth plan within your Pregnancy Care Record may be swollen). to record your preferences. Your Midwife will discuss this with you at your antenatal • One or two feeding bras. appointment at approximately 36 weeks of • Breast pads. pregnancy. It is also a good idea to discuss this with your birth partner. • Camera. When writing your birth preferences, it is • Any medication you normally take (such as important to take into account your medical asthma inhalers or tablets). Please ensure to history and the facilities available at your home let your Midwife know of any medication you or in hospital. Once in labour, the Midwife who are taking. cares for you will discuss your preferences • Books or magazines. and agree a plan of care with you. However, if complications arise, your Midwife and • Money and loose change/cash. Obstetrician will discuss these with you and will be able to let you know your options in these particular circumstances.

38 Pregnancy Information Book For baby: • Vests. • Stretch suits or similar. • Cardigans. • Bonnet/hat. • Socks and scratch mitts. • One pack of disposable nappies (no washable nappies please as we have no laundry facilities). • Cotton wool. If you are planning an early discharge you will also need a car seat and a blanket to take your baby home in. The hospital does not routinely supply nappies or sanitary pads. Please ensure you bring your own supply to last you through the length of your stay. Visitors can bring in extra clothing if you find you need it.

Pregnancy Information Book 39 11.0 Labour

11.1 Signs of labour If the water is not clear you may be offered the option of being induced sooner. You are not likely to mistake the signs of labour when the time really comes. If you need advice 11.1.3 Contractions at any time and you are planning to have your baby on: A contraction is when your uterus tightens and your abdomen (tummy) feels hard. The uterus • The Labour Ward Suite, contact the Midwife then relaxes and your abdomen feels soft in Triage on 01270 273116 again. Labour contractions do feel different to • The Midwifery Led Unit on 01270 278063 if Braxton Hicks (painless, irregular tightening), you plan to have your baby there. which you may have felt during your pregnancy. There are three main differences between 11.1.1 The show Braxton Hicks and labour contractions. Labour Either before labour or early in labour, the plug contractions are: of mucus in the cervix, which has helped to • Painful (for most women). seal the uterus during pregnancy, comes away • Regular. and comes out of the vagina. This sticky mucus is called a ‘show’ and it may be mixed with a • Become longer and stronger and more little blood. This can happen several times. frequent. However, if you are losing fresh red blood that is not mucousy please telephone Labour 11.2 Latent phase of labour Ward Triage for advice on 01270 273116. It is In the early stages of labour, often known as possible to have a show and not experience the ‘latent phase’ the contractions are softening contractions immediately. Some women can your cervix (neck of the womb) and making it have a show several days before they start ready to dilate (open up). Some women have labour, or may not have a show at all. backache or have contractions but they may not be regular. They will be sharp but short 11.1.2 The waters breaking lasting, which then stop and start again hours The bag of water which surrounds your baby later. This is perfectly normal. may break before labour starts. This can be Labour can be a lengthy process, so if possible a slow trickle or felt as a gush of water. If you it is best to stay in your own surroundings as think your waters have broken telephone either long as you can during this early part of labour. the Labour Ward Triage for advice on 01270 273116, or the Midwifery Led Unit for advice • Ignore the first signs of labour for as long as on 01270278063 depending on where you possible, carry on with the normal tasks of plan to have your baby. It is useful if you wear the day and rest when you can. a maternity sanitary pad to see if there are • Relax as much as possible. any further trickles and to check the colour of • Have a warm bath that is deep enough to the water. It may also be useful if you bring cover your bump or listen to music. used maternity pads in with you to help with your assessment. The water should be clear. • It is important to make sure you eat and drink If it is not clear you will be asked to attend the little and often and to empty your bladder hospital as soon as possible. regularly. An antenatal check will need to be carried out • Paracetamol can be taken as a simple form and your baby’s heartbeat will be assessed. of pain relief. You can take two (500mg) Not all women start contracting after the waters tablets, every four to six hours. Do not take break. If your contractions have not started more than eight tablets within a 24 hour within 24 hours you will be offered the option of period. induction of labour as there is a small increase in the risk of infection.

40 Pregnancy Information Book If you think your labour is starting then you may 11.2.1 When to telephone the hospital want to seek advice from a Midwife. You can • If your waters have broken. ring Labour Ward Triage on 01270 273116 or the Midwifery led Unit on 01270 278063 at any • You have any fresh red bleeding or you are time for support and advice. Details of your concerned your baby is not moving as much telephone call and the advice that you receive as normal, you need to telephone the hospital will be recorded in case you ring back at a later as soon as possible and they will probably time. You can ring back at any time of the day or advise you come in for a check. night whenever you need further advice. • If your contractions start but your waters have Your birthing partner can help you keep calm not broken, wait until the contractions are and relaxed. It can be helpful if they massage coming regularly, about four minutes apart your back if you have backache, or suggest and lasting for about 60 seconds and have been doing so for at least one hour. Although alternative positions to encourage labour to this is the ideal time to come into hospital, you continue. It is also important to remain active may feel like you want support before this, without exhausting yourself during this time. please telephone at any time. Take a walk with your partner, stopping if you need to during a contraction. Keep upright as If you live far away from the hospital, make sure much as possible as this will encourage labour you leave plenty of time to get there. and gravity helps your baby go down into your Be aware that second and subsequent babies pelvis. Swaying or rocking your hips can also often arrive more quickly than first babies once help. If you have access to a birthing ball, labour is established. use it regularly as this too can alleviate any Do not forget to phone the hospital first and discomfort. You can also try a TENS machine bring your Pregnancy Care Record with you and now if you have one. However, although this your prepacked bags (see section 10.4 for more can be an exciting time, remember to have details). periods of rest and not get overtired as you will need lots of energy later on. It is natural that your family and friends are keen to know what’s happening when you go into The latent or early stages of labour last until hospital. Please tell them not to ring the hospital your cervix is about four centimetres dilated but to wait for you or your birthing partners to and you have regular strong contractions, and ring them with any news. It is important to keep sometimes this can take a long time. the hospital phone line free for emergencies. If you go to hospital before you are in Staff are unable to give out any of your details established labour you may be advised to return to anyone due to confidentiality. home again for a while, as the hormones your body produces to help your labour continue 11.3 Optimal fetal positioning work much more effectively when you are in Optimal fetal positioning is when your baby’s a familiar environment. This decision will be back is forward with the chin tucked in so that it based on the findings of a thorough examination can enter your pelvis. This is a good position for and based on research that suggests that the labour, as it is easier for your baby to birth in hospital is not the appropriate environment this way. for women who are in the latent phase of Modern Lifestyle labour. Being relaxed and confident helps labour to progress but if you are feeling very Today we are less active than we used to be. uncomfortable at this point please discuss this We have more time to recline on furniture designed to enable us to relax. with your Midwife. Additional information can be found in the Be careful how you sit Latent Phase leaflet which is on the hospital When you sit in a soft armchair your pelvis tips website, under patient information. backwards and your baby has no alternative but to lie towards your back, this is known as Sometimes labour starts early before 37 an Occipito Posterior (OP) position. Crossing weeks. If this happens, phone the Labour your legs and long journeys in cars can also Ward Triage immediately on 01270 273116. encourage your baby to stay at your back.

Pregnancy Information Book 41 If your baby stays towards your back this can 11.4 Initial Assessment of Labour mean: Whether you are planning to have your baby at • Increased pain as your baby’s head tries to home or in hospital, your Midwife will: enter your pelvis. • Ask you about what has been happening • Aches and pains due to pressure on during your early labour. ligaments and your bladder. • Take your pulse, temperature and blood • Backache before and during labour. pressure and check your urine. • A long labour whilst your baby turns with its • Feel your abdomen to check your baby’s back towards your front. position and will listen to your baby’s • The need for stronger pain relief which heartbeat. could lead to a loss of control in your birth • Your Midwife may perform an internal experience. examination with your consent to find out • Medical intervention is more likely such as how much your cervix has opened and how the need for an instrumental delivery of baby far your labour has progressed. and possible trauma for you. These checks will be repeated at intervals throughout your labour, with your consent. Postures that may help in the last six weeks of your pregnancy: If you and your birth partner have made a Watching television can be done sitting astride birth plan, your Midwife will discuss this with a chair. you. Any information and discussions you have with your Midwife or Obstetrician about the care offered should include explanations and possible advantages and disadvantages. You can always change your mind about any decisions you make. Once you are in established labour you will receive care from a Midwife. Having discussed your birth preferences, your Midwife will be able to use this information to help and support you Always try to have your knees lower than during labour. You should be encouraged to your hips move around and change position to increase your comfort and assist your labour and birth. Try using these positions as frequently as possible throughout the day as this may help to keep your baby in an optimal position.

Sometimes your baby may remain in an OP position even after doing these exercises but your Midwife will discuss this in more detail with you.

42 Pregnancy Information Book Options for monitoring your baby in labour for all low risk women We need to effectively monitor your baby’s heart rate to establish and maintain fetal wellbeing during labour.

Intermittent monitoring Continuous monitoring Equipment Hand held Doppler or Pinnards Electronic fetal monitoring (EFM) (Using the same device the This method requires you to wear two belts Midwife uses to listen to your around your abdomen with two circular discs baby’s heart beat during your attached to record your baby’s heart beat and routine appointments). any contractions. Frequency NICE recommend every 15 The aim is to get a continuous trace of minutes in the first stage of the heart rate which will be assessed and labour and every five minutes observed by the Midwife. in the second stage. Benefits of Less invasive. Although EFM significantly reduces the risk of this type of Normal levels of mobility. neonatal seizure in high risk women it is not monitoring Can use the birthing pool. the case for low risk women. We have a monitor that can be used in the birthing pool on the Consultant Led Unit. Disadvantages It can sometimes be difficult to EFM increases intervention during labour such of this form of listen to your baby effectively as a caesarean section. monitoring so you may need continuous EFM can restrict mobility in labour as many monitoring. This will mean a women opt to lie down or sit on the bed to transfer to a consultant led make monitoring easier. room. Where this can Midwife Led Unit Consultant Led Unit be done? Consultant Led Unit Homebirth

11.5 Monitoring your baby’s heart beat • Sonicaid – a handheld monitor which can also be used during a water birth. You It is important to monitor the heart rate of your can listen to your baby’s heartbeat too if a baby during labour. The method of doing this Sonicaid is used. will depend on you and your baby’s individual needs. Your Midwife will discuss this with you. These types of monitoring allow you to move Although most babies cope extremely well around freely. during labour, there are a few babies who have Continuous monitoring of your baby’s heart difficulties and the best way to check on how beat they are coping is to listen to their heartbeat. There are different ways of monitoring your If you have had complications during your baby’s heartbeat. pregnancy or if there are any concerns about how your baby will cope with labour NICE Guidelines recommend that there is no (for example, your baby may be premature need for you to be connected to a monitoring or smaller than expected) or you are being machine even for a short period unless there induced, it may be advisable that your baby’s are concerns about your baby. The Midwife heartbeat be monitored continuously. will check your pulse rate to ensure there is no confusion between your heart rate and your Continuous monitoring may also be baby’s. Your baby’s heartbeat will be listened recommended during labour if complications to at regular intervals by one of the following arise. These complications could be for methods. www.nice.org.uk/guidance/CG62 example – abnormal changes in your baby’s heartbeat, if your baby has opened its bowels • Pinnard – Trumpet shaped instrument which (passed meconium) or you start bleeding. helps the Midwife to listen to the heart rate.

Pregnancy Information Book 43 Continuous monitoring is also advisable if 11.7 First stage of labour you need to have Oxytocin to encourage contractions or if you want an epidural for pain How long will labour last? relief. The length of the first stage of labour varies between each woman. On average, established Cardiotocograph (CTG) labour (four centimetres dilated onwards) will An electronic fetal monitoring machine last about 12 hours for women who are having produces a printed recording of your baby’s their first baby, and are unlikely to last over 18 heartbeat and your contractions called a hours. This does not include the early/latent cardiotocograph (CTG) or sometimes called a phase of labour which can take up to 72 hours. ‘trace’. Two small pads held in place with two For women having their second or subsequent elastic straps are placed on your abdomen. baby, labour can take on average five hours Information about your baby’s heartbeat and and is unlikely to last over 12 hours. your contractions will then be printed onto graph paper. The Midwife or Obstetrician can Eating or drinking in labour then interpret the trace to see how well your Eating and drinking regularly is essential to baby is coping with labour. Your ability to move ensure your body has enough energy to get around during labour will be limited but you can you through labour. Where possible aim for still stand or sit in a chair or on a birth ball. high carbohydrate/high energy foods such as pasta, bread, cereals and biscuits or failing • Fetal Scalp Electrode – sometimes it may that whatever you fancy at the time. If you be suggested that a clip is put onto your are unable to eat, high energy drinks, sugary baby’s scalp instead of using one of the pads sweets and glucose tablets may be useful. If on your abdomen, so that the heartbeat you are giving birth in hospital you will need to can be picked up directly. The reasons for bring these with you. doing this should be discussed with you. The electrode is put on during a vaginal You need to empty your bladder regularly examination and the waters are broken if during the first stage of labour to protect it from they have not already done so. Your baby damage and to allow the descent of your baby’s may have a small mark from the clip which head. If you are unable to pass urine your should heal quickly. Midwife may need to insert a catheter to empty your bladder. If there is any concern about your baby’s heartbeat, the Obstetrician may recommend 11.8 Pain relief taking a blood test from your baby’s scalp (called fetal blood sampling). This involves Labour is painful so it is important to find out taking a few drops of blood from your baby’s about all the different ways pain in labour scalp and testing how much oxygen is in it. can be reduced. Talk to your Midwife and you This is a more accurate way of checking your can decide what is best for you. However, be baby’s wellbeing. Your Midwife or Obstetrician flexible as you might find you need more or less will discuss the results and recommendations pain relief than you had planned. depending upon the result with you. 11.9 Types of pain relief: 11.6 Established labour 11.9.1 Self Help Once established, there are three stages to labour: The most important thing you can do to help yourself is learn to relax and have confidence in 1. In the first stage the cervix gradually dilates your body. Being anxious can make pain worse, (opens up) to 10 centimetres. especially when you do not understand what is 2. In the second stage the baby is slowly happening or do not feel in control. Controlling pushed down the vagina and is born. your breathing and the use of massage can 3. In the third stage the placenta comes away help you relax your muscles and help labour to from the wall of the womb and is also progress. delivered out of the vagina.

44 Pregnancy Information Book Your position can also make a difference. Disadvantages Upright positions such as kneeling, sitting, • Only available for women with low risk squatting, walking around, using a birthing labours. ball or sitting in a rocking chair can all help. Changing position not only makes labour less • The use of aromatherapy oils is not advised painful but can also encourage contractions to with some medical conditions or medications. be more effective and helps your baby move • Will not remove all pain and discomfort. down the pelvis. Research has also shown that there is less need for an epidural or pethidine if 11.9.4 Water you are mobile during labour. Being in water during labour; in a bath or 11.9.2 TENS birthing pool is recommended for pain relief. TENS (Transcutaneous Electrical Nerve Advantages: Stimulation) is a gentle electric current that gives • Encourages you to relax and reduces your pain. a tingling feeling through four pads placed on • Makes you feel more in control. your back. TENS stimulates the release of your body’s natural painkiller (endorphins) and also • Gives your body support and means you use reduces the number of pain signals to the brain. less energy during labour. Having your partner, relative or friend to support • You can leave the water at any time. you during labour also helps. Your Midwife is • The buoyancy of the water helps you to move also there to give you the support you need. around freely and adapt positions beneficial Advantages: in labour and birth. • There are no known side effects for you or • The water can soften the vagina and your baby. perineum which can lead to fewer tears. • You control the strength of the current. • Your baby will have a gentle birth as the Midwife will use a ‘hands off’ technique for • Available in many birth environments. delivery. Disadvantages: • Reduces the need for an epidural. • You cannot use it in the birthing pool. • No unwanted side effects. • You need to start using it in early labour • You can use gas and air as additional pain relief. to feel the full effects and may not be as effective during the later stages of labour. • Available in all birth environments. Please be aware that whilst you are in water 11.9.3 Aromatherapy you cannot use other pain relief such as TENS, Aromatherapy is the use of essential oils which Pethidine or Epidural. are concentrated extracts from a number of plants. The oils work in the same way as 11.9.5 Gas and air (Entonox) medicines, and are used in a number of ways This is a mixture of oxygen and nitrous oxide including massage and in a foot bath. gases. It is breathed in via a mouthpiece or Not all oils are suitable for use in pregnancy, so mask which you can hold yourself. it is important for these only to be used on the Advantages: advice of trained professionals. • It is easy to use and starts working quickly. Advantages • You can control it yourself and you can stop if • It promotes relaxation, enhances mood and you do not like it. reduces pain levels. • You can use it at any time during your labour. • There are no side effects for your bab.y • It can be used while you are in water. • Can be administered in a number of ways to • It has no harmful side effects to your baby. suit you. • Available in all birth environments. • Can be used at any point in your labour. Pregnancy Information Book 45 Disadvantages: anaesthesia. The Anaesthetist will come to see • Gas and air will not remove all pain but it you and answer any questions before siting the does reduce it. epidural. It usually takes 20 minutes to set up the epidural and 20 minutes to work. • It may make you feel light-headed, nauseous or dizzy for a short time. You will need to have a drip in your arm so that fluid can be given into your vein. This may To get the best out of using gas and air it is be necessary as 1 in every 50 women (2%) important to breathe it in at the very beginning experience a significant drop in blood pressure. of each contraction when you feel the You will be asked to sit or lie on your side tightening. It takes 15 to 20 seconds to work. curled up. Your back will be cleaned and a local By doing this it will be fully effective when the anaesthetic injection will be injected into your pain is at its worst. skin. Sometimes it can be difficult to site the epidural, as the tip of the needle has to pass 11.9.6 Pethidine or Diamorphine between the bones of your back to find exactly Pethidine and Diamorphine are pain killers the right place. similar to Morphine, and are given as an Once the epidural is in place you will be free to injection into the muscle. It takes approximately move on the bed and pain killing drugs can be 20 minutes to work and the effect usually lasts injected through the small tube to provide you 2-4 hours. with pain relief. These drugs may also affect Advantages: the nerves to your legs making them feel a bit heavy and numb. Some epidurals do not work • Pethidine or Diamorphine can provide gentle fully and/or need to be adjusted or replaced. sedation. Can anyone have an epidural? • Available on the Labour Ward and the Midwifery Led Unit. There are some medical conditions and complications of pregnancy which make an Disadvantages: epidural unsuitable. In particular if you have • Pethidine/Diamorphine can cross over the had major surgery to your back or have a placenta to your baby. bleeding disorder. Tell your Midwife and • Babies whose mothers have had Pethidine Obstetrician who can arrange for you to see in labour may feed less frequently in the first an Anaesthetist during your pregnancy to 48 hours as it can make the baby drowsy for discuss this. several days. An Anaesthetist needs to insert the epidural • Pethidine or Diamorphine can make some and if the Anaesthetic Team has other women feel lightheaded, dizzy, sleepy, emergency commitments they may not always nauseous and experience difficulty in be immediately available. When the Labour concentrating. Ward Suite is very busy it is not always possible to provide an epidural immediately. • You should not use the birthing pool if you have had Pethidine or Diamorphine within the Advantages: previous 3 hours. • Epidural analgesia provides the most effective method of pain relief in labour and 11.9.7 Epidural anaesthesia for labour can be used to provide pain relief over hours An epidural is a method of pain relief for labour, without drowsiness. which involves administering drugs through a • It does not increase the likelihood of a longer small tube that is inserted into the middle of first stage of labour or a caesarean section. your back in order to anaesthetise your nerve endings. Any woman having an epidural will • It can be topped up for a caesarean section if need to be on the Labour Ward Suite in the required. hospital. • In general, epidurals do not affect your baby. The epidural will be sited by an Anaesthetist who is a fully qualified Doctor specialising in

46 Pregnancy Information Book Disadvantages: however this is not common. Sometimes • Restriction of movement – Whilst we use the epidural may numb only one side of the ‘low dose’ epidurals which tend to leave body or there may be a patch that is not fully reasonable feeling in the legs and you will numbed. It may be possible to resolve this by probably be able to move around the bed, adjusting the epidural or re-siting it, but it can we do not allow women to stand or walk with be a persistent problem and you may need epidurals. This is to prevent you falling over some additional pain relief, such as Entonox and suffering an injury. (gas and air). • Having a catheter – You may not feel the • Prolonged second stage – The presence of urge to pass urine and your Midwife may an epidural may prolong the second stage of need to pass a small tube into your bladder labour and reduce the urge to ‘bear down’. to let the urine out (catheterisation). This There is an increased need for the use of should not cause any discomfort with an instruments (including forceps/ventouse) in epidural that is working well. women with epidurals compared to those without (14% vs 7% respectively). • Shivering – Women may feel a shivering sensation but this does not usually last long. • Backache – This is common during and after pregnancy. Localised tenderness at the site • The epidural may not work properly – of the epidural may occur and last for a few Occasionally the Anaesthetist may be unable days, however there is now good evidence to resite an epidural and may advise you that epidurals do not of themselves cause to persist with other forms of pain relief, long term backache.

Other risk factors of epidurals are listed below: How common Type of Risk How often does this happen? is it? Significant drop in blood pressure Occasional 1 in every 50 women (2%)

Not working well enough to reduce labour Common 1 in every 8 women (12.5%) pain so you need other pain relief Not working well enough for a caesarean Sometimes 1 in every 20 women (5%) section so you need a general anaesthetic 1 in every 100 women (1%) (epidural) Severe headache Uncommon 1 in every 500 women (0.2%) (spinal) Temporary – 1 in every 1,000 Nerve damage (numb patch on a leg or foot Rare women (0.1%) or having a weak leg) Effects lasting for more than 6 months Rare Permanent – 1 in every 13,000 women (0.007%) 1 in every 50,000 women Very rare Epidural abscess (infection) (0.002%) 1 in every 100,000 women Meningitis Very rare (0.001%) 1 in every 170,000 women Epidural blood clot Very rare (0.0005%)

Accidental unconsciousness Very rare 1 in every 100,000 women (0.001%) 1 in every 250,000 women Severe injury, including paralysis Extremely rare (0.0004%)

Pregnancy Information Book 47 11.10 Acceleration labour between your vagina and back passage) time to stretch without tearing. Sometimes the skin If your labour is progressing normally and you of the perineum will not stretch enough and and your baby are well, any clinical intervention may tear or if medically necessary, a surgical is not recommended. However, if your labour cut called an is made. is not progressing as expected your Midwife or Obstetrician may recommend that your Once the head is born, most of the hard work labour is accelerated. You will be given a clear is done and you will be asked to give one more explanation of why this has been suggested push to deliver your baby. Your baby will be and your consent will be needed. dried and lifted onto your tummy so that you can hold him/her and be close to each other If your waters have not broken, the Midwife immediately. This is called skin to skin contact or Obstetrician will break them using a small (see section 13.0 for more details). You and plastic hook during a vaginal examination. your baby will be covered with a towel or This is sometime called ‘artificial rupture blanket to keep you both warm. Usually a baby of membranes’. Doing this may make your is very keen to breastfeed at this time and your contractions stronger. Midwife can help you if you wish. If your contractions are not effective, you may It is recommended that any tear or cut to the be offered a hormone (Oxytocin) which will perineum is repaired using dissolvable stitches make the contractions more effective, this (or you may hear them being called sutures) to will be given into a vein in your hand or arm minimise future problems. through a drip. Your baby’s heartbeat will need to be monitored continuously using the CTG This entails numbing the area with either a local machine which also monitors the frequency of anaesthetic or if you already have an epidural your contractions. this might be adequate enough. Your Midwife will observe the area to ensure it is healing well. 11.11 Second stage If you have had stitches you need to keep the This stage begins when the cervix is fully area clean, bathe/shower regularly with plain dilated and your baby’s head starts moving water and dry carefully afterwards. It will also down your vagina. help with healing if you do your pelvic floor exercises. Positions for second stage If you feel that your stitches are sore and Mothers are encouraged to find whatever uncomfortable or swollen, tell your Midwife position feels natural and the Midwife will as you may need treatment to help with the discuss with you which positions are best in healing process. helping you to give birth to your baby. Upright positions such as kneeling, squatting or 11.12 Assisted birth (operative vaginal standing are more comfortable, less painful, pushing may be easier and research has also delivery) shown that there is less chance of needing an Your Midwife will give you care and support to assisted delivery if you adopt these positions. If encourage the normal birth of your baby. Being you feel tired you can always lie on your side. upright or lying on your side during labour and avoiding an epidural will reduce the chance Pushing of needing an assisted birth. However, if your You will feel a strong urge to push with the Midwife has concerns about the progress of contractions and your baby will gradually your labour or the wellbeing of your baby your descend with your pushing efforts. Sometimes care will be discussed with an Obstetrician. The a woman might not have the urge to push and Obstetrician and Midwife will always discuss it is best to wait until your body is ready. Your their concerns with you and it may be that the Midwife will give you lots of help and support. Obstetrician recommends that you are given When your baby is about to be born, the help to birth your baby during the last part of Midwife will tell you to stop pushing. This is so labour when the cervix is fully dilated. that your baby’s head can be born slowly, giving The most common reasons for needing an the skin and muscles of the perineum (the area assisted birth are:

48 Pregnancy Information Book • The baby is not moving down the birth canal. 11.12.3 What is a forceps delivery? • The baby is in distress during the birth. Forceps are smooth metal • You are unable to or have been advised not instruments that look like to push during birth. large spoons or tongs. They are curved to fit around your The purpose of an assisted birth is to mimic baby’s head. The forceps are a normal (spontaneous) birth with minimum carefully positioned around risk to you and your baby. To do this, an your baby’s head and joined Obstetrician uses special instruments together at the handles. (ventouse or forceps) to help your baby to be born. With a contraction and with you pushing, the Obstetrician pulls to help deliver your baby. 11.12.1 What happens in an assisted There are many different types of forceps. birth? Some forceps are specifically designed to turn Before an assisted birth, your Obstetrician the baby round, for example, if your baby has will check to make sure that your baby can be its back to your back. Your Obstetrician will safely delivered vaginally. This involves feeling choose the type of forceps to best suit your your abdomen and performing an internal situation. examination. 11.12.4 What happens when my baby is You should be given pain relief during an born? assisted birth. As your baby is being born, an episiotomy (cut This will either be a local anaesthetic injection to the skin between the vagina and anus) may inside the vagina (pudendal block) or a regional be needed to enlarge the vaginal opening. anaesthetic injection given into the space If you have a vaginal tear or cut, this will be around the nerves in your back (an epidural or repaired with stitches. a spinal). Your bladder needs to be empty for an assisted birth and your Obstetrician may A Paediatrician may attend the birth to check pass a catheter (small tube) into your bladder on your baby’s wellbeing. If your baby does not to empty it. Your legs will need to be supported require additional care, skin to skin contact can by the use of leg rests attached to short poles commence (see section 13.0 for more details). positioned on either side of the bed. The suction cup from a ventouse can leave a If your Obstetrician is not sure that your baby mark on your baby’s head called a chignon. can be born vaginally, your delivery may be The suction cup may also cause a bruise on carried out in theatre so that a caesarean your baby’s head called a cephalohaematoma. section can quickly be undertaken if needed. A Both will disappear with time. Your Midwife will caesarean section is a surgical operation where explain these. Forceps can leave small marks a cut is made in your abdomen and your baby on your baby’s face. These will also disappear. is delivered through that cut (see section 12.0 A catheter from your bladder may be needed for more details). for up to 24 hours after you have given birth while you are recovering. Women who have 11.12.2 What is a ventouse delivery? had an epidural are most likely to need a A ventouse (vacuum catheter after delivery. extractor) is an instrument that uses suction to attach 11.12.5 Will I need an assisted birth a plastic cup on your baby’s next time? head. With a contraction If you need an assisted birth in your first and with you pushing, the pregnancy, it is unlikely that you will need one Obstetrician pulls to help in your next pregnancy. Most women have a deliver your baby. normal birth next time.

Pregnancy Information Book 49 11.13 Third stage For preterm (early) babies it decreases the risk of: After your baby is born, more contractions will push out your placenta. This will usually take • Bleeding on the brain. up to 60 minutes. There are two ways in which • Late onset sepsis. your placenta can be delivered: • Infection of the bowel. 11.13.1 Physiological Third Stage • Need for blood transfusion. This is the natural way to deliver your placenta. For the mother: Your baby’s cord will not be clamped or cut until it has stopped pulsating, or until your placenta • Less intervention. is delivered, allowing your baby to receive all • Promotes natural physiology of birth. of his/her blood from the placenta. Research • May prevent complications delivering the has shown that this is of great benefit to babies, placenta. reducing the risk of jaundice and increasing your baby’s haemoglobin levels. You will need For more information visit www.bloodtobaby. to give a few gentle pushes to help push your com placenta out. 11.14 Postnatal check following 11.13.2 Active third stage delivery If you have experienced any problems in your Your Midwife will take your blood pressure, labour or with bleeding later in your pregnancy pulse, and temperature and will also monitor then you may be advised by your Midwife to your blood loss after you have given birth to have an active third stage. Even if your labour your baby. and birth has been without risk, you can still Your baby will be examined and weighed and choose and active third stage if you wish. for security reasons, given two name bands A drug called Oxytocin is given by injection showing his/her date and time of birth hospital into your leg or upper arm to help the uterus number and surname. to contract. This drug will shorten the amount In order to reduce disruption to skin to skin of time taken to deliver the placenta. Up to contact and initiation of breastfeeding, your five minutes will be allowed (depending on the Midwife will discuss the best time to weigh your condition of your baby at birth) for all the blood baby. in the cord to reach your baby, the will then be clamped and cut. The cord will then be gently pulled to deliver the placenta.

11.13.3 Optimal cord clamping Optimal cord clamping and has many benefits for the mother and baby. Your baby: • Receives 30% more blood from the cord and placenta. • Has a reduced risk of anaemia. • May experience an aid to neurological development. • Receives more oxygen to vital organs. • Receives more stem cells which help to build the immune system.

50 Pregnancy Information Book 12.0 Caesarean section A caesarean section involves major surgery where the baby is born through a cut in the mother’s abdomen and uterus. A caesarean section will only be performed when there is concern about you or your baby’s health, as there are risks involved with surgery and having a caesarean section could affect future pregnancies. There are two kinds of caesarean section – an elective or planned caesarean, where the decision is taken before labour begins or an emergency caesarean section. The decision to have an emergency caesarean section usually takes place when you are already in labour and there is an unexpected problem, the Obstetrician will discuss this with you at the time.

12.1 When might a caesarean section • Future pregnancies are at increased risk of be performed? miscarriage, ectopic pregnancy, placental You may be offered an elective caesarean if: problems and unexplained stillbirth. • Your baby is not lying head down at the end • There is a 1.5% chance of the baby having of your pregnancy. superficial injuries such as a small cut when the uterus is being opened. • The placenta lies close to or covers the part or the entire cervix. • You will need more support to establish breastfeeding. • You have had previous caesarean deliveries. • You or your baby has certain medical conditions. 12.2 Planned caesarean section • You are expecting twins, triplets or more – Once you have an agreed date for your you may be offered a caesarean section, if it caesarean section, you will be asked to is not appropriate for your babies to be born come to the Antenatal Day Assessment Unit vaginally. (ANDAU) before your planned caesarean During labour an emergency caesarean may section. An antenatal check will be carried out be needed if there is concern about your baby’s and your blood will be taken for you iron levels and a current blood group. Flowtron boots health or if your labour is not progressing or if are also used, they are to help prevent blood an emergency arises before you are in labour clots in the deep veins of the legs. The devices such as heavy vaginal bleeding. use cuffs around the legs that fill with air and Potential risks of having a caesarean section: squeeze your legs. This increases blood flow through the veins of your legs and helps • It is more likely that women will take longer to prevent blood clots. They remain on you until recover, both physically and emotionally after you are fully mobile again. You will be seen by a caesarean section. an Obstetrician to discuss the operation and • Increased pain from the wound and reduced gain your consent. mobility. On the day of the operation, an Anaesthetist • Developing severe infection. will discuss which type of anaesthetic is best • Developing a blood clot. for you. After the operation you will be offered • Bladder or bowel injury. injections to reduce the risk of blood clots, antibiotics may also be offered to reduce the • Unsightly wound or delayed wound healing. risk of infection. Please let your Midwife or • Increased chance of heavy bleeding and Obstetrician know if you are allergic to any blood transfusion. antibiotics or medication. • Hysterectomy (removal of the uterus) – this is During and after the operation you will be given very rare. fluids through a drip in your arm until you are • Increased risks associated with a general able to eat and drink and a catheter will be anaesthetic, if this is necessary. inserted into your bladder to allow urine to drain • Longer hospital stay. whilst you are immobile. • It may be more difficult to become pregnant Please be aware that although our aim is to again after a caesarean section than vaginal perform your caesarean section on the date birth due to scarring on your uterus. it is booked, it may be necessary to delay the

Pregnancy Information Book 51 procedure if there is another woman with a 12.6 In the recovery room greater need, to prevent possible ill heath to You will be closely observed in the recovery her or her baby. room to make sure you recover from the 12.3 Emergency caesarean section anaesthetic properly and there are no immediate complications. You will be able to In some circumstances a caesarean section have skin to skin contact and breastfeed your needs to be carried out urgently for the benefit baby. Please note, no visitors other than your of you or your baby. The procedures mentioned partner are allowed into the recovery room. before will still need to be carried out, although they will be done very quickly. Everything will 12.7 After the operation be explained to you and your consent will be Once your observations are stable you will be needed to carry out the operation. taken to the Maternity Ward. 12.4 Types of Anaesthesia After a caesarean you will feel uncomfortable for An Anaesthetist will discuss with you the most a few days, as you would expect from any major appropriate type of anaesthesia depending on operation. After 12-24 hours any drips, catheters your circumstances. A caesarean section is or drains are usually removed and after the first usually carried out using a regional anaesthetic day you will be encouraged to get up and move such as a spinal anaesthetic and you will be around. You will be given regular pain relief awake during the operation. If you have an following your caesarean for as long as you epidural in place this can sometimes be topped need it. Ask your Midwife if you require more. up with more anaesthetic. If you are having an elective caesarean section If you have a General Anaesthetic (GA), you will be given an information leaflet about you will be asleep during the operation and enhanced recovery to help you get up and about your partner can wait for you in the waiting more quickly. room until you are fully recovered from the Depending on how you feel and the wellbeing anaesthetic. You will be taken to the recovery of your baby, you will usually be discharged by room and be able to see your baby as soon as day two, following your caesarean. you wake up. A spinal anaesthetic is safer for you than a GA but in an emergency a GA may The stitches are usually dissolvable; however be necessary. some stitches or clips on the wound may need to be removed after five days if healed well. 12.5 The operation You will have to take it easy once you get home A cut is made in the skin; this is usually and you will need help with daily activities. You horizontally below the bikini line. In very rare should not lift anything heavy, e.g. prams and circumstances the cut may be made up and car seats or do strenuous housework for up to down the abdomen. A screen will be put across six weeks. You will not be able to drive for your chest so that you cannot see what is several weeks following the operation – please being done. Flowtron boots will be applied to contact your car insurance company for advice. your legs to help prevent blood clots. If you are For more information see Section 20.0 having a spinal anaesthetic, your partner will be Postnatal Advice and Exercise for more details. able to be with you in the operating theatre and will be given theatre clothes to wear to reduce 12.8 Looking after your wound the risk of infection. You should gently clean your wound with water The Obstetricians and Midwives will talk to and dry the wound with a towel every day. It is you and let you know what is happening. You advisable to wear loose, comfortable clothes and should not feel any pain, just some tugging cotton underwear. If your wound becomes more and pulling, but if you do feel pain let your red, painful and swollen seek advice from your Anaesthetist know immediately. If you continue midwife. If there is a discharge of pus or foul- to feel pain the Anaesthetist might advise a smelling fluid from your wound you may have an general anaesthetic, although this is rare. infection so you must contact your midwife or The operation takes about 30-40 minutes and if GP as soon as possible so that a swab can be you have a spinal anaesthetic you will be able taken and antibiotics started if required. to see and hold your baby as soon as possible after birth.

52 Pregnancy Information Book 13.0 Skin to Skin contact Following birth, all new mothers and their babies should remain together in skin-to-skin contact no matter how you decide to feed your baby. At birth, your naked baby is dried and placed on your naked chest. You will both be covered with a blanket to maintain both of your temperatures.

Benefits of early skin contact: Instinctive Newborn Behaviour • Promotes bonding. As your baby is stimulated by your touch and smell, your baby engages in a series of pre- • Regulates baby’s heart rate. feeding behaviours. These inborn reflexes occur • Regulates baby’s breathing. in stages and will happen without intervention if • Controls baby’s body temperature. your baby remains in skin contact with you. It can be easy to want to help by hurrying your • Emotional benefits for the mother. baby through the stages; however this may • Facilitates breastfeeding. cause further problems with breastfeeding. • Stimulates the baby’s digestive system. The use of certain drugs in labour may affect the ability of your baby to go through these • Introduces the baby to the mother’s friendly stages immediately after being born. bacteria. Also, some mothers and babies may need Skin to skin contact should be initiated in an medical attention immediately after birth. As soon unhurried environment from the moment of birth as this has passed whether it is 20 minutes, two for as long as you wish. Skin to skin contact can hours, two days or two weeks, the two can be be carried out at any time (for example on the brought together and encouraged to enjoy skin to Postnatal Ward or at home) and as often as you skin contact PLEASE NOTE: Your baby will be choose. Both you and your baby will continue to covered with a blanket and a hat applied during gain the hormonal benefits of skin to skin. skin contact to keep your baby warm. Physiological effects of skin-to-skin contact BIRTH CRY Skin to skin contact stimulates your powerful ‘mothering’ hormone prolactin, which is triggered by touch. Prolactin prepares your body for making milk and stimulates intense motherly and protective feelings.  The nearness of your baby also stimulates RELAXATION  Oxytocin which calms you. Skin to skin contact AWAKENING may therefore be of great benefit to all women and their babies, even where the mother decides not to breastfeed. Babies are also calmed and relaxed by being in skin contact with their mother. Rooting and  nuzzling stimulates your baby’s digestion, even ACTIVITY if your baby does not feed.  CRAWLING This calming effect helps your baby to regulate  its heart rate and breathing. A baby in skin RESTING contact with its mother is receiving the best  FAMILIARISATION temperature regulation possible.  Your baby is also colonized by your skin SUCKING bacteria and family bacteria which your baby will be exposed to when they leave hospital. Breast milk contains antibodies to any harmful bacteria, so your baby will receive targeted protection at the same time.  SLEEPING Pregnancy Information Book 53 14.0 Feeding your baby The time when your baby is very young, is brief and very precious. Spending a lot of time close together in the first few weeks helps you get to know one another and builds the love that keeps your baby safe and secure.

Holding your baby next to your skin soon after breastfeed or give as much breast milk as they the birth will help ease the transition into can or as they feel able. independence for your baby and helps calm Infant Feeding Workshops are available to and comfort you. It can also help to get mothers (and their partner/support person) breastfeeding off to a good start. which include information about breastfeeding. Before your baby is born you may not have Information about these classes and how to decided how you would like to feed your baby book can be found on our website: but this does not matter. Hold your baby close http://www.mcht.nhs.uk/information-for-patients/ and see how you feel when your baby responds departmentsandservices/maternity/parent- to the touch of your skin and the sound of your education-and-preparation-for-labour/infant- voice. feeding-workshops/ Breastfeeding can be used to comfort and calm If you choose not to breastfeed for personal your baby as well as to alleviate hunger. A feed or medical reasons, you will be given help and can be initiated when: support with your chosen feeding method in the postnatal period. • Your baby appears lonely or is distressed. Should you decide to formula feed your baby • Your breasts feel full. we would recommend that as many of the feeds • You would like to sit down and rest. as possible are given by you in the early weeks. Mothers and babies benefit from the raised Breastfeeds can be long or short according to hormone levels that occur during closeness and your baby’s needs. A breastfed baby cannot babies in particular benefit from reduced stress be overfed or ‘spoiled’ by too much feeding. hormones when they are close to their mothers. Breastfeeding your baby gives you and your Ideally, as many feeds as possible should be baby many short and long term health benefits. given in skin to skin contact, in the early weeks. Breast milk contains antibodies that protect Skin to skin contact has many benefits for your baby from infection. Babies who are fed all mothers and babies regardless of feeding with formula milk do not receive this protection method (see Section 13.0 for more details). and are therefore more likely to suffer from As you grow more familiar with your chosen diarrhoea and vomiting, urine infections, chest feeding method you will gain confidence and infections and if born prematurely, serious learn to relax and enjoy seeing your baby thrive bowel infections. Research also suggests that and grow. formula fed babies are more likely to suffer from asthma, eczema, obesity, diabetes, high blood 14.1 Putting your baby to the breast pressure and have poorer dental health. Your position For maximum health benefits no other food or drink is required other than breast milk for the It is important that you find a comfortable first six months. position. If you are sitting down to feed, try to make sure that: By following this advice, you will always make the right amount of milk for your baby. • Your back is straight and supported. Breastfeeding is good for the mother’s health • Your lap is almost flat. too. It helps protect you from breast and • Your feet are flat (you may need a footstool ovarian cancer, gives you stronger bones in or a thick book). later life and helps you lose weight. • You have extra pillows to support your We believe that breastfeeding is the healthiest back and arms or to help raise your baby if way for a woman to feed her baby. For needed. this reason all women are encouraged to

54 Pregnancy Information Book Breastfeeding lying down can be very Skin to skin is known to be beneficial in comfortable. It is especially good for night feeds establishing breastfeeding. (See Section 13.0 as you can rest while your baby feeds. for more details) • Try to lie fairly flat with a pillow under your 14.2 Attaching your baby to the breast head and your shoulder on the bed. • Lie well over on your side. A pillow supporting your back and another between your legs can help with this. • Once your baby is feeding well, you will be able to feed him/her comfortably anywhere without needing pillows. Your baby’s position

Remember Lips curled back. Areola is visible more above top lip. Tongue down. Chin in contact with breast like Velcro. Happy mum – pain free – it should not hurt. There are various ways that you can hold your Ever so wide mouth. baby for breastfeeding. Whichever way you Suck swallow ratio (one suck to one choose, here are a few tips to help make sure swallow, or one suck to two swallows). that your baby is able to feed well: It is important to make sure that your baby 1. Your baby should be held close to you. attaches on to the breast properly, otherwise 2. Your baby should be facing the breast, with your baby may not get enough milk during the head,shoulders and body in a straight line. feed and your nipples could become sore. 3. Your baby’s nose or top lip should be • Position your baby as described above with opposite the nipple. your baby’s nose or top lip opposite your nipple. 4. Your baby should be able to reach the breast easily, without having to stretch or twist. • Wait until your baby opens their mouth really wide (you can gently brush your baby’s lips 5. Your baby’s mouth should be wide open with your nipple to encourage your baby to 6. Remember always to move your baby do this). towards the breast rather than your breast • Quickly move him/her on to your breast, so towards your baby. that your baby’s bottom lip touches the breast THINK C H I N as far away as possible from the base of the Close – Baby should be held close. nipple. This way, your nipple will be pointing towards the roof of your baby’s mouth. Head free and tilt back. When your baby is properly attached to your In alignment, head, shoulders, hips in a breast you will notice that: straight line. • Your baby’s mouth is wide open. Nose to Nipple and lead with the chin which should be in contact with the breast. • Your baby has a big mouthful of breast. • Your baby’s chin is touching the breast.

Pregnancy Information Book 55 • Your baby’s bottom lip is curled back. 14.3 Recognising feeding cues and • If you can see any of the areola (the brown feeding frequencies skin around the nipple), more is visible Cues above your baby’s top lip than below his bottom one. Crying is a late sign that your baby needs feeding and if you wait until this point your • The sucking pattern: a baby that is well baby: attached usually starts with rapid short sucks • Will need to be calmed before they will be to long deep sucks with pauses – usually a able to feed. baby will suck one to two times then pause to swallow. • May have tired from crying and not take a full feed. Feeding should not be painful. However, while you and your baby are learning to breastfeed Earlier signs that your baby is ready for a feed you may feel some pain or discomfort when include: your baby first attaches to the breast. This • Restlessness and wakefulness. sensation should fade quickly and then the feed will not be painful. If it continues to hurt, • Making small noises or movements with their this probably means that your baby is not mouth. attached properly. In this case, take your baby • Smacking their lips or sucking their fists. off by gently pressing your breast away from • Rooting or turning towards the breast when the corner of your baby mouth so that the being held. suction is broken and then help your baby to re- attach. If the pain continues, ask a Health Care It is important to keep your baby close both day Professional for help (see section 14.9 for the and night as: feeding support available). • You and your baby will get to know each Information obtained from UNICEF UK baby other. friendly initiative: Breastfeeding your baby • You will recognise your baby’s feeding cues. www.babyfriendly.org.uk • It allows feeding when either mother or baby wants to. • It keeps mum’s breastfeeding hormones high and baby’s stress hormones low. Frequency Frequent feeding is very important in the early weeks and this is especially important in the first few days. This early frequent feeding will ensure that maximum milk production is established. Babies who are over 48 hours old will feed at least eight times in 24 hours – however there is no upper limit and initially many babies will feed more frequently. Babies will also want to feed during the night as mother’s prolactin levels are highest at this time.

56 Pregnancy Information Book 14.4 How can I tell breastfeeding is going well?

Breastfeeding is going well Talk to your Midwife if: when:

Your baby has 8 feeds or more Your baby is sleepy and has had less than six feeds in 24 hours. in 24 hours.

Your baby is feeding for Your baby consistently feeds for five minutes or less at each feed. between 5 and 30 minutes at Your baby consistently feeds for longer than 40 minutes at each each feed. feed.

Your baby appears jaundiced (yellow discolouration of the skin). Most jaundice in babies is not harmful; however, it is important to check your baby for any signs of yellow colouring particularly during the first week of life. The yellow colour will usually appear around the face and Your baby has normal skin forehead first and then spread to the body, arms and legs. colour. A good time to check is when you are changing a nappy or clothes. From time to time gently press your baby’s skin to see if you can see a yellow tinge developing as this will hint to jaundice. Also check the whites of your baby’s eyes when they are open and the inside of your baby’s mouth when open to see if the sides, gums or roof of the mouth look yellow.

Your baby is generally calm Your baby comes on and off the breast frequently during the and relaxed whilst feeding and feed or refuses to breastfeed. is content after most feeds.

You baby has wet and dirty Your baby is not having the number of wet and dirty nappies nappies explained overleaf. (see chart overleaf).

You are having pain in your breasts or nipples, which does not disappear after your baby’s first few sucks. Your nipple comes Breastfeeding is comfortable. out of your baby’s mouth looking pinched or flattened on one side.

When your baby is three to four days old and beyond you You cannot tell if your baby is swallowing any milk when your should be able to hear your baby is three to four days old and beyond. baby swallowing frequently during the feed.

Your baby always falls asleep on the breast and/or never finishes the feed himself.

You feel you need to give your baby formula milk.

You think your baby needs a dummy.

Pregnancy Information Book 57 Nappies

The contents of your baby’s nappies will change during the first week. These changes will help you know if feeding is going well. Speak to your Midwife if you have any concerns. Baby’s age Wet nappies Dirty nappies One to two or more per day. One or more dark green/black One to two days old Urates may be present.* ‘tar like’ called meconium. Two or more, changing in Three or more per day. colour and consistency – Three to four days old Nappies feel heavier. brown/green/yellow becoming looser (changing stool). Two or more yellow; may be Five to six days old Five or more per day. Heavy wet.** quite watery. Two or more at least the 7 days to 28 days old Six or more per day. Heavy wet. size of a £2 coin, yellow and watery, ‘seedy’ appearance.

* Urates are a dark pink/red substance that many babies pass in the first couple of days. At this age they are not a problem, however if they go beyond the first couple of days you should tell your midwife as that may be a sign that your baby if not getting enough milk. ** With new disposable nappies it is often hard to tell if they are wet, so to get an idea if there is enough urine, take a nappy and add two to four tablespoons of water. This will give you an idea of what to look/feel for.

14.5 Dummies and teats • Your breasts may become full and uncomfortable as the milk you make is It is not advisable to use dummies or teats replaced by formula and therefore is not when you are breastfeeding as research shows removed by your baby. that they can interfere with a baby’s ability to feed effectively due to the different sucking • If your breasts are full, it can make it more action used. difficult for your baby to attach to the breast. Their use can interfere with responsive feeding Babies given large amounts of formula may be if they are used to settle or pacify a baby less satisfied with ongoing breastfeeds. rather than a breastfeed being offered, if a Breastmilk provides a protective coating in your feeding cue has been misinterpreted. Frequent baby’s digestive tract and formula milk can baby-led feeding is essential to establish and destroy this. maintain a good milk supply. Anything which interferes with this may result in reduced milk Babies who suck on a bottle teat may find it production. more difficult to breastfeed. This is called nipple teat confusion. Does giving my breastfed baby formula milk Offering formula as a night time feed may make a difference? reduce your milk supply. Yes, it does. We would recommend you view formula as Any amount of formula can trigger allergic a treatment for a problem, for example low sensitisation. blood sugars in your baby and no breastmilk available. Breastfeeding works on a supply and demand basis. Just as we would not give antibiotics in the absence of an infection, we would discourage • If breastfeeding is interrupted by giving the use of formula in the absence of a problem formula your breasts may not make enough in a breastfed baby. milk for your baby.

58 Pregnancy Information Book 14.6 Guidance for parents who have • Let your baby seek the teat. chosen to formula feed • Encourage your baby to take it into their We strongly recommend you use First Milks mouth. only unless you are medically advised to • The feeding should take 15-30 minutes. If change to an alternative. There is no need your baby drinks too quickly, tip the bottle to move onto Hungry Baby, Follow On, Night down or remove it to slow the pace of the Time or Comfort Milks. First Milks are suitable feeding. from birth up to one year. You do not need to continue with the same brand of milk. • You can hold your baby’s ‘cheek to breast’ during a feeding. • Your baby will let you know they have had enough by dribbling the milk, arching their back, slowing the sucking or fidgeting around. • Do not be tempted to try and make your baby finish the bottle if they appear satisfied, unless you have been advised that your baby needs to take a certain amount for example, in cases of low birthweight or jaundice. • If your baby appears unsettled after a feed continue with or start skin to skin contact.

All parents and babies benefit from lots of Please refer to the manufacturer’s guidance for skin contact. Skin contact induces feelings the amount of formula to give your baby. If your of calmness and will also help to regulate baby is taking significantly more or less than your baby’s breathing, heart rate and body the recommended amount then please speak temperature. We recommend formula feeds are to your Midwife. given in skin to skin. 14.7 Vomiting or posseting following In the early weeks we would encourage you to feeds limit the number of people who feed your baby as this will help: It is quite common for babies to bring up milk during or shortly after feeding – this is known • You and your baby to bond. as posseting or reflux. • You to become aware of your baby’s needs. It can occur in at least 40% of babies. It usually • Your baby to feel more secure. begins before eight weeks of age and in 90% of cases it resolves before the baby is one year old. How to bottle feed Reflux is just your baby effortlessly spitting up Always make sure you use sterilised equipment whatever they’ve swallowed. and that the milk has been made up to manufacturer’s instructions. If you need further It’s natural to worry something is wrong with guidance about preparing feeds please ask your baby if they’re bringing up their feeds, your Midwife. Demonstrations on how to make especially if it occurs regularly. 5% of babies up formula feeds are available on the Postnatal can have six or more episodes a day. In the Ward for women who have chosen to formula majority of cases no investigation or treatment feed. is required. Paced Bottle Feeding However it is advisable to see your GP if reflux starts after six months of age, continues • Watch your baby for hunger cues such as beyond one year, or your baby has any of the rooting, smacking lips and wriggling. following problems: • Hold your baby almost upright. • Spitting up feeds frequently or refusing feeds • Hold the bottle horizontally, just filling the teat (this may be resolved by responsive feeding, with fluid. if you are breastfeeding or paced bottle feeding).

Pregnancy Information Book 59 • Coughing or gagging while feeding. • If you are wishing to collect breast milk for • Frequent projectile vomiting. your baby for other reasons such as wanting to build up a stock of milk for your return to • Excessive crying or irritability. work etc., we would recommend waiting for a • Green or yellow vomit, or vomiting blood. couple of weeks and then expressing once a day at your fullest time. • Blood in their poo or persistent diarrhoea. How to express by hand: • A swollen or tender tummy. It is helpful to have your baby close when • A high temperature (fever) of 38oC (100.4oF) expressing or at least have something to or above. remind you of your baby. Gentle breast • Not gaining much weight, or losing weight. massage and nipple rolling can help the milk to • Arching their back during or after a feed, or flow. drawing their legs up to their tummy after feeding (this may be resolved by responsive feeding, if you are breastfeeding or paced bottle feeding). These can be signs of an underlying cause and may mean your baby needs tests and treatment.

14.8 Expressing milk What does ‘expressing milk’ mean? 1. Cup your breast and feel back from the end of the nipple to where the texture of your • Expressing is simply a way of taking milk breast feels different, usually around 2.5 from your breast without your baby suckling. centimetres away from the base of the nipple. • You can express by hand or by using a 2. Using your thumb and index finger, gently manual or electric pump. squeeze this area – this should not hurt. Why express milk? 3. Release the pressure and then repeat again • If your baby is born early or is sick, and again, building up a rhythm. Avoid expressing your milk will enable you to sliding your fingers over the skin. Milk should provide breast milk for your baby and also will start to flow. help to keep your milk supply up until your 4. When the flow slows down, express from the baby is well enough to start breastfeeding. other breast. Keep changing breasts until the • You may wish to provide milk for your baby milk stops or drips very slowly. and keep your milk supply up when you 5. If the milk does not flow, try moving your return to work, expressing may help with this. fingers slightly towards the nipple or further • Your breasts may feel uncomfortably full and away. Or try a gentle breast massage. so expressing will relieve the discomfort. How to store expressed breast milk: When should I express and how often? • Remember to use a sterilised container to put • If you are expressing for a sick or premature the milk in. baby you should start within the first hour • You can store milk in the fridge for up to five or two of your baby being born, you should days at 4°C or lower (usually at the back of then express 8-10 times during each 24 hour the fridge as the temperature in the door is period. At least one of those expressions not consistent). needs to be at night as a hormone essential • Breastmilk can be stored for two weeks in the for milk production (prolactin) is present in ice compartment of a fridge or for up to six high levels at night. It is important not to allow months in a freezer. more than four hours during the day and six hours during the night to pass between • Defrost frozen breastmilk in the fridge and expressions. once thawed use it straight away.

60 Pregnancy Information Book 14.9 Infant Feeding support services Infant feeding support is available for women who are under the care of Mid Cheshire Maternity Unit. This care consists of support from the whole of our Maternity team. We offer: • Antenatal conversations. • Invitation to Parent Education classes. • Initiation of feeding support. • On-going feeding support. CHERUBS breastfeeding support workers are also on hand to provide information and support in the long term, both online through social networking sites such as Facebook and at support groups held at various children’s centres. Our Infant Feeding Lead is available for specialist concerns related to feeding.

Pregnancy Information Book 61 15.0 Induction of labour In most pregnancies, labour starts naturally between 37-42 weeks of pregnancy, leading to the birth of your baby, but it is not known exactly what makes women go into labour. Your body produces a natural hormone called Oxytocin which makes the uterus contract. Sometimes this may need to be given in the form of a drip to help start your labour. Induction of labour is the process used to encourage labour to start artificially. Some of these processes involve giving drugs; all aim to encourage the neck of the womb (cervix) to shorten, soften and open (with the help of contractions) to allow your baby to be born. Labour cannot be ‘switched on’ like a light. Induction of labour aims to tip the balance in favour of labour starting, but occasionally this does not work.

There are two main reasons why induction of starting your labour when you are past your labour is suggested: due date in an attempt to encourage labour to • The pregnant woman or the baby’s wellbeing start naturally. This is the first step before other is causing concern and delivering the baby methods of induction are considered and is early may be beneficial. repeated one week later if required. • A healthy pregnancy has continued for 42 Advantages weeks or more. • A membrane sweep aims to increase the production of the body’s own hormones Women who have had an uncomplicated which can encourage labour to begin. All healthy pregnancy: women who are being advised to have • More than 8 out of 10 (80%) pregnant induction of labour should be offered a women will have given birth by 42 weeks. It membrane sweep as part of that process. is extremely likely that you will go into labour As long as the waters have not broken by yourself before 42 weeks without needing previously, this procedure does not increase an induction. We offer induction of labour to the risk of infection in the mother or the baby. women after this stage because research suggests that the risk of stillbirth increases • It can be performed at the community from 1 in 1000 (0.1%) at 42 weeks to 2 in antenatal appointment, in the Antenatal Clinic 1000 (0.2%) at 43 weeks. or in your own home (depending upon the reasons for suggesting a membrane sweep). • Induction of labour is offered to all women between 40 weeks +10 days to 40 weeks • It reduces the need for other methods of +14 days. This does not increase the induction of labour. likelihood that you will need a caesarean Disadvantages section in labour. • The examination does not involve drugs or Methods used to Induce Labour medical instruments of any kind but may be It is usual to begin with a membrane sweep, uncomfortable; this discomfort should not and then follow this with another method. persist after the examination. The suitability of each depends on what is • Occasionally light ‘spotting’ of blood can happening to the neck of the womb; an internal occur afterwards. Vaginal Examination (VE) is needed to provide Prostaglandin Pessaries this information. In certain situations, some methods are less suitable and your Midwife or These pessaries are a drug called Synthetic Obstetrician will inform you of those which are Prostaglandin E2. You will need an internal not advised in your particular circumstances. vaginal examination to enable the pessary to be put high into the vagina behind the neck of Membrane sweep the womb. The pessary remains in place for 24 At approximately 40 weeks of pregnancy your hours unless you go into labour during that time Midwife will offer you a vaginal examination (if your waters break but you are not in labour, and a membrane sweep, which is a way of the pessary remains in place).

62 Pregnancy Information Book Advantages head to make close contact with the cervix; this further stimulates the release of natural • The pessary encourages the neck of the prostaglandins. These effects may be enough womb to become softer and open; this allows to encourage contractions to start. for your waters to be broken. However, it may take some hours to have • If you have an otherwise low risk pregnancy any effect from the procedure; if this does not and you go into labour following the pessary, start labour you will be encouraged to have you can be cared for on the Midwifery Led Oxytocin augmentation (see below) to stimulate Unit. contractions once your waters have been Disadvantages broken. • You will have your baby’s heart rate Risks continuously monitored for about 30 minutes before the insertion of the pessary. The • There is a small chance that the umbilical frequency and duration of monitoring your cord may slip past the baby’s head (a baby’s heart rate following insertion of the cord prolapse); this is rare but requires an pessary, is dependent upon the reason for immediate caesarean section. The rate your induction of labour. of cord prolapses when the waters break, naturally or artificially, is around 1 in 500 • You will need to stay in hospital from the time that the pessary is given. You can leave the (5%) labours. The risk of cord prolapse is ward if you do not need to be monitored, reduced if the head is engaged in the pelvis however please inform a member of staff. prior to performing an artificial rupture of the membranes. • Period type pains are common and can be managed with pain relief tablets and warm • If the neck of the womb has not opened it baths. may not be possible to break your water. Your Obstetrician will discuss an individual Risks plan with you if this is the case. • Occasionally women deliver the baby Oxytocin Augmentation extremely quickly after the pessary is given. A synthetic Oxytocin drip will be given via a • On rare occasions the womb contracts so vein in your arm/hand. Its action is similar to strongly and frequently in response to the that of the natural hormone (Oxytocin) which is pessary that the baby becomes distressed, produced by the human body in order to make the placenta may start to separate from the uterus (womb) contract. The most common the womb. In these cases an emergency reasons for needing an Oxytocin infusion are: caesarean section may be needed before labour has become established. • To induce labour. A birth partner will be able to stay with you • Because labour has stalled. This is often throughout the Induction process. Your because the uterus has been contracting well second birth partner can attend once you are but the cervix does not continue to open or transferred from the Induction Bay into your natural contractions have not been able to own room. Your Midwife will guide you as to get your baby to turn its head into the pelvis. when to inform your second birth partner. • Because labour has been prolonged due to Artificial Rupture of the Fetal Membranes a long period without contractions. It may be (breaking the waters) decided to speed up your labour to prevent you or your baby becoming unwell. After the pessary has been in place for 24 hours the next step is to break the waters The timing of starting the infusion will around your baby if they have not already done be discussed with you by the Midwife or so naturally. This can only be done when the Obstetrician. neck of the womb has begun to open. When the neck of the womb is open to around Advantages two to three centimetres, it may be possible to • Encourages contractions leading to the neck use a plastic hook to break the waters amniotic of the womb opening more, your baby turning sac. This releases natural hormones called its head in the pelvis and your baby being Prostaglandins and encourages your baby’s moved down in the pelvis.

Pregnancy Information Book 63 • Can help achieve a vaginal birth when labour progress has stalled. Disadvantages • The contractions can be more intense than ones produced without synthetic Oxytocin, so you may find that you start thinking about pain relief sooner, although you may not necessarily have planned this. • Being on a drip and being continuously monitored may limit your ability to move around and to have an active birth. • Uncommon side effects include; nausea, vomiting, a skin rash. Risks • Oxytocin is a powerful drug and its effects must be monitored closely; you will need to have continuous electronic fetal monitoring (CTG). Some babies become distressed when contractions are stimulated and this may lead to an emergency caesarean section. • Women’s bodies respond very differently to Oxytocin; some women will need large doses to stimulate contractions, others show a dramatic response at low doses. On rare occasions, the womb and/or placenta may start to tear, causing distress to the mother and the baby and making an emergency caesarean section necessary. There are some women who seem to be insensitive to Oxytocin and do not have any contractions at all. • When an Oxytocin infusion has been used during labour, the womb is likely to need further encouragement to expel the placenta and to control bleeding afterwards. It is therefore recommended that you have an actively managed third stage of labour (see section 11.13.2 for more details).

64 Pregnancy Information Book 16.0 Pressure ulcers during labour or the immediate postnatal period A pressure ulcer is an area of damage to the skin caused by unrelieved pressure, shear or friction (also known as pressure sores or bed sores). Pressure ulcers can occur on the lower back, buttocks, hips and/or heels.

Most women go through pregnancy without More specifically: developing any pressure ulcers. But, if for • Keep moving/repositioning at least every any reason you are not able to move very hour if you are able – if not, please ask your well during or after labour there is a risk of Midwife to assist you. developing a pressure ulcer, particularly if other risk factors are present. • Check your skin regularly for redness, especially your heels, hips and buttocks – Women at risk: report any redness to your Midwife. • Anyone who is unable to change their own • Keep skin clean and dry. position due to problems such as paralysis or pain, or the use of external equipment e.g. • Change wet sanitary towels regularly (when drips, catheters. your waters have broken) to keep your skin as dry as possible. • Women who have used the birthing pool – this makes the skin more susceptible to • Eating and drinking well is important to breakdown. ensure adequate nutrient intake. • Anyone who cannot feel pain over parts of • Avoid friction by careful transfers, particularly their body due to an anaesthetic, epidural or onto bed and trolleys. Lift your body rather paralysis. than dragging your skin across the bed or chair. • Anyone who has a poor diet and fluid intake. • If you are diabetic, keep your blood sugars • Anyone who is very underweight or stable within the normal range. overweight. • Anyone who has a prolonged established labour (normally over 16 hours). Most pressure ulcers can be prevented through: • Good skin care • Careful moving and handling (transferring from one surface to another). • Repositioning regularly (with assistance if required).

Pregnancy Information Book 65 17.0 Vitamin K As part of your birth plan and after your baby is born you will be asked to decide whether or not you want your baby to have Vitamin K. This Trust recommends the injection preparation, as discussed below. However, Vitamin K can be given orally upon request.

What is Vitamin K? By injection Vitamin K is found in certain foods, but bacteria Research has shown that one intramuscular living in the gut make most of the Vitamin K the injection into the baby’s thigh, given shortly after body needs. Vitamin K is essential to help the birth, prevents bleeding in virtually all babies. blood to clot. If blood does not clot any bleeding It is estimated that less than one baby in a will not stop and is known as a haemorrhage. million given the injection, including those at Why give babies Vitamin K? greater risk of bleeding, will suffer a bleed. Studies have found that babies naturally That means it is very effective. The National have low levels of Vitamin K in their blood. Institute for Health and Care Excellence (NICE) Very occasionally babies can suffer from a guidelines recommend the injection as the best rare but serious and sometime fatal bleeding method to give your baby Vitamin K. disorder known as haemorrhagic disease of By mouth the newborn. This condition is rare – about 1 in If you do not want your baby to have the every 10,000 (0.01%) babies. injection, Vitamin K can also be given by mouth It most commonly happens in the first week (orally) to your baby. of life but it can happen at any time in the first Two doses are given in the first week. If you are six months. Bleeding can occur from the nose, breastfeeding a third dose is given when your mouth or in the brain, which can cause brain baby is four weeks old. Bottle fed babies do not damage or death. need a third dose because Vitamin K is added Which babies are more at risk? to artificial milk. It is estimated that 1 in 300,000 Babies are at greater risk of bleeding who: (0.003%) babies given a full course of oral Vitamin K will suffer bleeding. • Have had a complicated delivery, e.g. forceps delivery. What are the recommendations? • Are premature. NICE advises that all newborn babies receive Vitamin K to prevent the rare, but serious • Are ill for other reasons. disorders of bleeding. • Are failing to take or absorb feeds. They recommend Vitamin K by injection for • Have a liver disease that may show as all babies born after 36 weeks of pregnancy, prolonged jaundice. with the option of Vitamin K by mouth for those parents who chose it. • Are born to mothers taking anti-coagulants (blood thinning drugs), anticonvulsants However, it is also the right of parents to (drugs taken to control epilepsy) or drugs choose no Vitamin K for their baby, but if a taken to treat Tuberculosis (TB). baby is in any of the high risk groups, parents will be strongly advised to allow their baby to Some babies who do not have any of these have Vitamin K by injection. risk factors can bleed unpredictably as there are no ways of identifying these babies. The Parents of babies who do not have Vitamin K most effective way of protecting them is to give need to be especially watchful and seek urgent Vitamin K to all babies. medical attention for: As with any preventative treatment there are Bruising and minor warning bleeds risks and benefits to consider and it is the • Jaundice (when the baby looks yellow) for parent’s decision whether or not they want their more than two weeks in formula fed babies baby to have Vitamin K. and three weeks in breastfed babies. How is Vitamin K given? • Pale stools or dark urine. Vitamin K can be given by mouth or by If you would like more information or if you are injection. The preparation is called Konakion taking any drugs please talk to your Midwife or MM and is the only Vitamin K preparation GP. licensed for use in the UK. It also contains You could also visit www.nice.org.uk/guidance/ Glycocholic Acid and Lecithin. cg37

66 Pregnancy Information Book 18.0 Transferring to the Postnatal Ward If you decided to have your baby in hospital, discuss with your Midwife whether you could go home straight from the Labour Ward, Midwifery Led Unit or be transferred to the Postnatal Ward.

When you and your Midwife are happy for The visiting policy limits the number of people you to be transferred you will be taken to the visiting to four per bed. This is because of Postnatal Ward. security and safety issues and also to reduce On arrival at the ward, as soon as you are the risk of cross infection to new babies. This is ready a member of staff will show you the why no children, other than your own children, layout of the ward and the facilities available. will be allowed on the ward to visit you. Please A Bedside Folder containing useful information ask your visitors to use the hand gel before of the ward and the hospital will be available at entering ward areas and before handling your your bedside to read. baby. You will have an individual bedside locker Your baby’s safety for your personal items, but storage space is Whilst on the ward we ask you to ensure that limited. Please do not bring large amounts your baby is safe. Your baby should be with of money or valuables as Mid Cheshire you at all times, even when visiting the toilet Hospitals NHS Foundation Trust cannot accept and taking a bath or shower. Your baby must responsibility for loss or damage to patients’ be transported in the cot provided and not money or property unless they are locked up for carried around the ward in case you or a visitor safe-keeping and an official receipt obtained. accidently drops your baby. We also advise that All suitcases/holdalls must be taken home and you change your baby’s nappy in the cot and returned only when you are discharged. do not place your baby on the bed at any time. Please ensure that you give ward staff any medication you require so that it may be stored 18.3 Security in hospital safely. We advise parents never to hand over their baby to any person that is not known to them, 18.1 Amenity beds even if they act or look like a member of staff. There are a limited number of amenity beds All staff should be clearly wearing identification available. badges and ‘Hello my name is…’ badges. These are single rooms with en-suite facilities The doors to the Labour Ward Suite, Midwife and are subject to availability. Enquiries should Led Unit, Consultant Led Unit and Postnatal be made on admission. A charge of £34.85 per Wards are kept locked at all times, and require day is made. All fees are used for the continued access is via a video/intercom. All visitors need improvement of our maternity wards. to press the intercom and identify themselves If a single room is required for someone with a to gain access. medical need, you may be requested to move When you have been given access to a Ward, into a bay. Amenity beds are not private beds please do not give anyone else access into the and visitor numbers are four per bed. Ward. They need to gain their own access so staff members are aware of them. 18.2 Visitors in hospital Visiting times are as follows: For partners or birth companions - 8.00am-10.00pm The visiting hours for mothers’ own children and all other visitors -10.00am-8.00pm One adult is welcome to stay on the Postnatal Ward overnight but must sign a ‘Code of Conduct for overnight stay’. A reclining chair is provided.

Pregnancy Information Book 67 19.0 After you have had your baby

19.1 What to expect Breast changes – It is normal to find your Blood loss – You should expect to have some breasts changing size and shape during blood loss after birth from the vagina. This will pregnancy and after birth. They may also be be heavy at first but decreases in the following tender. If you choose not to breastfeed you days. You should wear super absorbent do not need to do anything but your breasts sanitary towels. We suggest you purchase will still fill with milk around the third day after maternity pads that do not contain plastic having your baby. It may help to wear a firm coatings, especially if you have had stitches. supportive bra until the breasts settle down. Do Do not use tampons. not express the milk as this will stimulate them to produce more. If you feel your blood loss is excessive or you are passing large clots, please inform your Your breasts may feel lumpy in the postnatal Midwife. It may be necessary to save your period; especially if you are breastfeeding, pads so the blood loss can be more accurately but if you are worried or they are very painful, assessed. inflamed or have red patches inform your Midwife or GP. Going to the toilet – It is common to have some discomfort when passing urine after 19.2 Family planning advice you have had your baby. It is important that Your Community Midwife will ask if you wish to you pass urine within the first six hours after talk about family planning advice and will inform delivery to prevent any problems in later life. you of the family planning services available to Please ask a Midwife for a bed pan so your you. You will also be advised to attend your 6 urine can be measured after you have given weeks’ postnatal appointment so that you can birth. If you are experiencing difficulty in have a final check ensuring that everything is passing urine or are leaking urine when you normal. This will usually be with your GP. cough or laugh you should inform your GP or Midwife. Bowels – Piles are very common after pregnancy, often they will disappear on their own in the following weeks after having your baby. It will help to have a well- balanced diet and drinking plenty of fluid to prevent constipation. If you are feeling very uncomfortable, your Midwife or GP can give you some ointment to soothe the pain. Perineum (area between vagina and anus) – Your Midwife may check your perineum to see it is healing, especially if you had a tear or stitches. The stitches usually take about two weeks to dissolve and throughout that time your perineum should continue to heal. Regular pain relief will help with any discomfort, try to avoid constipation. It may be easier to lie on your side rather than on your back, especially when you are breast feeding. The perineum is a common area for infection and should be kept as clean and dry as possible.

68 Pregnancy Information Book 20.0 Postnatal advice and exercise The following information gives you some immediate postnatal advice and will guide you through some exercises which will help you to regain your pre pregnancy health and fitness. Some sections may not be applicable to you as it covers both caesarean section and vaginal delivery.

20.1 Comfort

Sitting

Occasionally pillows may make positioning your baby at the breast a little more difficult. Please ask your Midwife for help if you have any concerns. • Ensure you sit as far back in your chair or bed as possible and use a small pillow or rolled towel in the small • Placing a small pillow or rolled towel in your of your back for increased comfort. lower back may increase your comfort. • Bending one or both knees up from time to time may help to relieve discomfort. • Make sure you are well supported – which is good for your back, and your tummy will not be as sore. • Whether breastfeeding or bottle feeding, pillows on your lap can help you to raise your baby up and will make your stitches/clips more comfortable. Adopt a similar approach when sitting in a chair.

Lying

Plenty of rest is essential • When lying on your back you may find it more comfortable with a pillow under your thighs. • When lying on your side your comfort may be increased by using pillows for support underneath your abdomen and between your legs. • Lying on your side may also be a comfortable position for feeding.

Turning from lying on your back Bend both knees, slowly one at a time so that your feet are flat on the bed. Support your abdomen/wound with your hand, you can also use a rolled up towel or small pillow for support. Move your shoulders and knees at the same time as you roll on to your side.

Pregnancy Information Book 69 Getting out of bed • Turn on to your side as described previously. • Use the hand closest to the mattress to support your abdomen/wound. • Push your body up by pressing down on to the mattress with your other hand, allowing your feet to go down to the floor. • Progress to standing slowly by pushing up through your hands and feet. Use one hand to support your abdomen/wound if needed. • A good posture is essential; it will be more comfortable and will help to protect your back.

Getting into bed

Reverse the previous process. • If sitting is uncomfortable you can get in to bed by kneeling on to the bed and then lowering yourself down on to your side.

20.2 Caesarean Section Breathing exercises Coughing If you have had a caesarean section breathing If you feel the need to cough something up exercises are important to ensure that you use (phlegm), the least painful and most effective your lungs well, especially as you have had an way is to ‘huff’ (a short forced breath out anaesthetic. through your mouth, like steaming up a mirror). • Take a deep slow breath in through your nose. Circulation • Hold for a count of two. • Briskly circle or bend and stretch at the ankle • Sigh the air out through your mouth. for 20 to 30 seconds. Repeat this three times, and continue regularly • Start this exercise immediately and continue until you are up and about. (This exercise also until you are up and about. This helps helps to loosen phlegm). maintain circulation and prevents/reduces swelling. Cough, laughing and sneezing • Do this as often as possible. Supporting your abdomen with both hands may be sufficient. You can also use a rolled towel or small pillow to support your abdomen for additional comfort. Adopting this position will help decrease discomfort.

70 Pregnancy Information Book 20.3 Pelvic floor exercises – all How to exercise Pelvic Floor muscles deliveries Sitting or lying comfortably with knees slightly apart, concentrate on your pelvic floor muscles. Lift and squeeze the front as if trying to stop the passage of urine and at the back as if stopping the passage of wind. Hold contraction for as spine uterus bowel long as you can (at least two seconds increasing bladder as you improve up to 10 seconds). This is a contraction or lift. Rest for an equal number of seconds. Repeat the contraction and relaxation pubic bone as many times as you can, this will be ‘your number’ – aim for 10 contractions. You may not feel that anything is happening at first but keep urethra coccyx trying. pelvic floor anus Also practice the same number of short, fast, muscles strong contractions when you have built up your muscles and confidence. Diagram 1: the pelvic floor muscles Make sure you do not hold your breath, squeeze The pelvic floor consists of layers of muscles your buttocks or tighten your abdominal muscles supporting the contents of the pelvis (bladder, when doing these exercises. womb and bowels). Remember, you must do your pelvic floor They are attached to the pubic bone at the exercises as many times as you can every day, front, and to the base of the spine at the back at least eight times. A good reminder is every (see diagram 1). time you feed your baby, or every time you turn After pregnancy and childbirth the pelvic floor the taps on. It is important to remember that muscles are often stretched and can sag. The pelvic floor exercises can be done anywhere, at nerve supply to them may also be damaged. any time. You must continue with these exercises until the What does the pelvic floor do? pelvic floor is working correctly, this may take up Strong and healthy pelvic floor muscles will to 6 months. After this time look after your pelvic provide support help in the control of bladder floor by exercising it twice every day. and bowels, and also increase the pleasure If symptoms such as leaking of urine or faeces during sexual activity. persists, then make an appointment to see your A weak pelvic floor may lead to prolapse, GP. leakage of urine with cough, laugh, sneeze or physical effort, and reduce sexual sensations. 20.4 Abdominal exercises – all deliveries Remember: After a caesarean section commence once • To start the pelvic floor muscle exercises as your wound has healed and pain has settled. soon as possible after you have had your What do your abdominal muscles do? baby unless advised otherwise. The abdominal muscles form a natural corset that • To do the exercise in varying positions but supports your back and internal organs. As with if you are sore after your delivery, try to do the pelvic floor muscles, these muscles become them on your side. weak and stretched during pregnancy, so it is • To do rhythmic tightening and relaxing of the very important to begin to strengthen them. muscles, this may help discomfort, pain and As your abdomen enlarges in pregnancy, the swelling and can aid healing if you have a muscles stretch and lengthen and can separate tear or stitches. down the centre leaving quite a wide gap. The • To wait until your urinary catheter (if you have gap usually gradually closes up after your baby one) is removed and you are passing urine is born. If the separation persists you should normally before starting these exercises. discuss this with your Midwife or GP.

Pregnancy Information Book 71 The images below show before (left image) 2. Pelvic Tilting and after (right image) separation of the recti muscles.

• Lie on your back with your knees bent and your feet flat on the bed/floor. • Tilt your pelvis as though you are rocking 20.5 Exercises to improve abdominal your lower back down into the bed. strength • Hold that position for a few seconds (do not 1. Abdominal hollowing exercise hold your breath). Start doing the exercise in the most comfortable • Let go gently. position for you – lying on your back or side with your knees bent or sitting with your back • Repeat several times well supported. 3. Knee rolling • Place one or both hands on your abdomen below the level of your umbilicus (tummy button). Breathe in through your nose and as you breathe out slowly pull your lower abdominal muscles away from your hands towards your back and then relax. • You should be able to talk and breathe at the same time and your lower back should stay still. Do the exercise three times a day if you can. • Once you have practiced the exercise you How to get into position? should be able to do it whilst standing. Repeat the sequence above and keep your • Pull in your tummy. muscles drawn in for three seconds whilst • Keeping your knees together, take both you breathe in and out normally. knees gently to the left, back to the middle • Try to increase the number of repetitions to and then to the right ...only as far as it is 10. Try to do these exercises 3 times per day comfortable. or as often as you can. • If possible, do these exercises 10 times at • Use these deep abdominal muscles by doing least twice a day. the hollowing as described above when • Do not exercise when you are really tired and doing any activities which require effort, for remember to have a rest every day. example picking up your baby. It is important not to let your tummy dome or 20.6 Important Advice bulge, due to the separation of the muscles, Going Home while doing any of the above mentioned exercises. If it does, stop the exercise, return • Put a pillow between yourself and the seat to abdominal hollowing and seek advice from belt, this may increase your comfort. your Midwife or ask your GP for a referral to a • Expect to feel tired and take plenty of rest. Physiotherapist for specialist advice. Driving (start gradually)

72 Pregnancy Information Book • When you start driving again will depend • Try to avoid lifting heavy weights e.g. pram, upon your rate of recovery. toddler for two to three months. • Check with your insurance company that you are covered. This will normally be four to six weeks after a caesarean delivery. • Can you concentrate? • Can you look behind you without discomfort? • Can you do an emergency stop?

20.7 Exercise The rules • Listen to your body. • Stop if it hurts. • Stop when you are tired. • Never exercise if you are feeling unwell. • Continue these exercises when you return home. This will depend on your general level of fitness/activity before you became pregnant. • If your caesarean wound is healed, your pelvic floor is strong and your six weeks postnatal check is clear, you can begin a gradual return to exercise. • Avoid strong abdominal exercises and competitive sport for at least three months. • Try to avoid any physical strain for the first six weeks after delivery. Remember the effects of hormones can still affect your joints for up to five months following the birth of your baby, so care should be taken not to start any high impact activity too soon. Always listen to your body and stop if anything hurts. Women with disabilities If your ability to exercise is affected by any health problem, you should contact your Midwife or GP who will be able to offer you advice. Manual handling/lifting • Make sure your legs take the strain and not your back. • Bend your knees – keeping your back straight. • Pull in your tummy and your pelvic floor before you lift.

Pregnancy Information Book 73 21.0 Caring for your baby

21.1 Your baby’s health 21.5 Caring for your baby at night Following birth your Midwife or a Paediatrician Becoming a parent is a very special time and will do a visual examination on your baby at can be one of the most rewarding experiences one and five minutes of age. This is called an of your life as you get to know your baby. It can APGAR score and helps to assess your baby’s also be challenging, especially when you are health by looking at things such as baby’s tired and your baby is wakeful and wanting to heart rate, colour and breathing rate. We would feed frequently during the night. expect a healthy baby to have a score of above It may be reassuring to know that not only is this six, by five minutes of age. normal but it is essential for your baby to feed A full top-to-toe examination of your baby will during the night. Babies grow quickly in the early be carried out by your Midwife shortly after weeks and months of life and they have very birth. small stomachs. Therefore, they need to feed around the clock to meet their needs. We do not Your baby will then have their Newborn and endorse any method of sleep training. Research Infant Physical Examination within 72 hours suggests that a baby’s brain development is of birth. This can be performed by a Midwife, impacted positively by responsive parenting. You Nurse or Paediatrician (Doctor specialising in cannot spoil your new baby by giving them lots children and babies). of hugs and cuddles. Information about screening tests offered Making night feeds easier following birth can be found in the ‘Screening Tests for You and Your Baby’ It is important to create the right environment leaflet (Public Health England). for you and your baby at night for getting as much rest as possible. 21.2 Newborn hearing screening Keep the room fairly dark, it is not usually programme necessary to switch on bright lights to feed or You will be offered a hearing test for your care for your baby. baby. The test is not painful and there are no Keep your baby close, the safest place for your associated risks in having the test. It allows baby is in a cot by the side of your bed. This babies that may have hearing problems, to means you can hear your baby and respond receive early intervention and give parents the to your baby’s needs before your baby starts support they need. crying or becomes distressed. Also you can reach your baby easily without having to get up. 21.3 Newborn blood spot screening Try not to stimulate your baby too much. As When your baby reaches five to seven days soon as your baby demonstrates early feeding old your Midwife will ask to take a spot of blood cues such as restlessness, murmuring sounds from your baby’s heel. This is used to test for and sucking fingers, offer a feed. That way your some rare but potentially serious illnesses. baby will not be difficult to settle. Talk to your 21.4 Cord care baby in a soft quiet voice and only change your baby nappy or clothing if really necessary. The umbilical cord from the placenta to your baby’s navel will be clamped and cut shortly Reducing the risk of sudden infant death after birth. syndrome (sometimes called ‘Cot Death’) It will take about a week for this to dry out and Always make sure: drop off. • You put your baby down on its back to sleep. Whilst this process is ongoing you will need to • The cot is beside the parent’s bed for at least keep the area clean and dry. If you notice any the first six months. bleeding or discharge or there is an offensive • The mattress is firm and flat; waterbeds, smell, please inform your Midwife, Health bean bags and sagging mattresses are not Visitor or GP. suitable.

74 Pregnancy Information Book • Your baby is not overdressed or covered with • Do not sleep with your baby if you have had too much bedding, no more than you would any alcohol or have taken any drugs (legal or use yourself. illegal) that may cause drowsiness. • The bedding is not able to cover your baby’s • Do not sleep with your baby if you or your head. partner are smokers. • The room is not too hot (16-20oC is ideal). • Do not put yourself in a position where you • The room in which your baby sleeps is a could doze off with your baby on a sofa or an smoke free zone. armchair. If you decide to share a bed with your baby: Bed Sharing • Keep your baby away from the pillows. Some parents choose to sleep with their baby in bed and some fall asleep with their baby • Make sure your baby cannot fall out of the during the night while feeding and comforting bed or become trapped between the mattress whether they intend to or not. Therefore, it is and the wall. important to consider the following points: • Make sure bedclothes cannot cover your • It is not safe to share a bed with your baby in baby’s face or head. the early months if your baby was born very • Do not leave your baby alone in the bed as small or prematurely. even very young babies can wriggle into a dangerous position.

21.6 Signs and symptoms of possible illness in your baby Age of Baby Signs and symptoms Who to contact Midwife can be Within the • Baby has not passed urine. contacted 24 first 24 hours • Baby has not passed meconium (baby first stools). hours a day on after birth • Baby skin colour is yellow. 01270 612287 • High pitched or weak cry. • Much less responsive/ active than usual. If your baby has • Floppy baby i.e. head and limbs hanging loosely. any of these signs • Making noises with each breath like sighing or grunting. you will need to • More irritable than usual contact a Health • Not waking for feeds or not interested in feeding once awake. Care Professional • Passing much less urine. immediately Birth – 28 Midwife can be days • Vomiting. • High temperature above 38°C. contacted 24 hours a day on 01270 • With the exception of hands and feet, feels cold when 612287 dressed appropriately for the environment temperature. • Blood in baby’s stools. Contact your own GP / out of hours • Vomits green fluid. service. • Jitteriness – excessive repetitive movements of one or more limbs, which are unprovoked and usually relatively fast. • Stops breathing or goes blue. • Cannot be woken. Urgent medical • Has a fit which would be recognised by a stiff body with attention can be At any time jerky movements. obtained by dialling • Has a rash that does not disappear under pressure, this 999 rash can be anywhere on the body and looks like pin pricks or purple bruises.

Pregnancy Information Book 75 Babies rely on their parents to be aware of The Health Visitor will visit you from signs and symptoms of illness and for their approximately 10 days after the birth. parents to act quickly if they suspect an illness. When you leave the Maternity Unit or following Following the symptom checklist can help you a homebirth you will be cared for by the decide whether medical attention is required for Community Midwives. your baby. Babies can become ill very quickly You will be given your Pregnancy Care Records and it is important to seek medical attention and baby’s ‘My personal child health record’ sooner rather than later. They can also get (the red book). worse very quickly, so it is important to keep Appointments for a hearing test and a newborn checking your baby often when you suspect examination for your baby will be arranged if that your baby may be unwell. If you have any they have not already been performed. concerns contact your GP or Midwife straight away. It is vital that we have your correct contact details. The Midwife will check these with you For more information on how to look after your prior to discharge/leaving your home. baby, please ask your Midwife or Health Visitor. A Midwife will phone you on the day after you 21.7 Transfer to Community Care transfer home. Your on-going care needs, visiting requirements will be discussed and any Routine schedule of Postnatal care questions you may have will be answered. First day home 21.8 Registration of births Telephone call from the Midwifery Team to check that you and your baby are well and You must register your baby within six weeks plan your care. (42 days) of birth. You can either register the birth in hospital or at your local Registry Office. Up to four days following discharge You will be given their contact details after the A home visit from the Midwife to check that birth of your baby. you and your baby are well and to arrange follow up care. If you and your baby’s father were married to each other at the time of the child’s birth, either Five to eight days following the birth parent may register the birth. An appointment with your Midwife at your local Children Centre or Midwives Clinic If you and your baby’s father were not married where the new born blood screening will be to each other at the time of your baby’s birth, you may register your baby without the father performed. Your baby will be weighed and present, however the father’s details can only any concerns or questions will be discussed. be entered in the register if he is also present at Day 10 the time or the mother and father both make a Telephone call from your Midwife to discuss if statutory declaration. any additional visits are required. Please be aware that if you and your baby’s Day 21 father were not married at the time of your An appointment at your local Children’s baby’s birth, the father cannot register your Centre or Midwives Clinic for your Midwife baby’s birth alone. to discharge you from Midwifery care and The implications for you, your child and the transfer your care to the Health Visitor. father if you were not married are: Additional visits may be recommended or • Using the father’s name as a joint registration requested depending on your needs. These cannot ever be changed. will be discussed with you and arranged on an individual basis. • Using your surname as joint registration can only be changed if you marry. Should you require any advice, or if you have any concerns regarding yourself or your baby • Using the father’s name with only your details at any time, please contact: Ward 23 Telephone means the father’s details can be added. 01270 612287 – 24 hours advice. • Using your name with only your details Details of your transfer home will be sent to means the surname can be changed and the your GP. father’s details can be added. 76 Pregnancy Information Book General points for you to think about: • If your current relationship is failing and your child has a different surname to you. • Having different surnames within the family may result in confusion and difficulties at school, at the GP etc. • Future relationships. • The use of the birth certificate as an identification document. • If the name of the child is changed by Deed Poll documents need to be kept together. If you have any queries, please contact the Registrar for help and advice on 0300 123 5019.

Pregnancy Information Book 77 22.0 Useful organisations and websites The section aims to direct you to websites that are correct and active at the time of production

ACAS (Advisory, Conciliation and Local contact: Infant Feeding Lead: Arbitration Service) Tel: 01270 273675 Tel: 08457 474747 Child Poverty Action Group www.acas.org.uk Tel: 0207 837 7979 Offering advice on time off for antenatal care www.cpag.org.uk and on maternity rights, parental leave and Campaigns on behalf of low income families. matters like unfair dismissal. Information and advice for parents on benefits, APEC (Action on Pre-eclampsia) housing and welfare rights etc. Tel: 0208 427 4217 CLAPA (Cleft Lip and Palate Association) www.apec.org.uk Tel: 0207 833 4883 National charity offering support and www.clapa.com information about Pre-eclampsia via its helpline Support for families of babies born with cleft lip and newsletters. and/or palate. Feeding equipment available. Association for Postnatal Illness (APNI) Disability Pregnancy and Parenthood Helpline: 0207 386 0868 International www.apni.org Tel: 0800 018 4730 (freephone) The leading organisation in its field, providing support to mothers suffering from post-natal http://patient.info/support/disability-pregnancy- illness. It exists to increase public awareness and-parenthood-international.htm of the illness and to encourage research into its A charity set up to support and advise disabled cause and nature. people who are already or wish to become parents and their families. It is also for health Association of Breastfeeding Mother and social professionals and other individuals Tel: 08444 122949 and organisations concerned with disability Blood Transfusion Service and/or pregnancy and parenting. Tel: 0300 123 2323 Disabled Parents Network www.blood.co.uk www.disabledparentsnetwork.org.uk British HIV Association Domestic Abuse Partnership Tel: 020 8639 5380 Tel: 0808 2000 247 www.bhiva.org In an emergency telephone 999 Cheshire Really Useful Breastfeeding Down’s Syndrome Association Support (CHERUBS) Tel: 0333 1212 300 http://www.cherubsbreastfeeding.co.uk/ http://www.downs-syndrome.org.uk/ East Cheshire Drink Aware - Drinkline Breastfeeding Support line: Tel: 01270 376641 (Monday – Friday, 9.00am-5.00pm) Tel: 0300 123 1110 https://www.drinkaware.co.uk/ Crewe Leighton Hospital: Tel: 01270 612287 Macclesfield District FRANK General Hospital: Tel: 01625 661153 www.talktofrank.com Support for mothers (and mothers-to-be) with Tel: 0300 123 6600 access to further information and resources Information about all types of drugs and their around breastfeeding. It also allows them to effects. search online for groups they can attend to mix with other mothers and seek assistance from health professionals.

78 Pregnancy Information Book La Leche League: NSPCC Tel: 0345 120 2918 Child Protection Helpline The La Leche helpline is the only 24/7 Tel: 0808 800 500 breastfeeding helpline in Britain. www.nspcc.org.uk 24 hour free helpline for advice and support for Lullaby Trust anyone who is concerned about a child at risk Tel: 020 7802 3200 of abuse. https://www.lullabytrust.org.uk/ The Lullaby Trust provides specialist support The Samaritans for bereaved families, promotes expert advice Tel: 116 123 on safer baby sleep and raises awareness on www.samaritans.org sudden infant death. P.O. Box 90 90, Stirling FK8 2SA Samaritans listen in confidence to anyone in MENCAP any type of emotional distress, without judging Tel: 0808 808 1111 or telling people what to do. www.mencap.org.uk Mencap is the leading UK charity for people Sickle Cell Society with a learning disability and their families. Tel: 0208 961 7795 www.sicklecellsociety.org MIND (National Association for Mental Health) Spinal Muscular Atrophy Support UK Tel: 020 8519 2122 www.mind.org.uk Tel: 01789 267520 www.smasupportuk.org.uk National Breastfeeding Helpline: Tel: 0300 100 0212 or 0300 100 0210 TAMBA (Twins and Multiple Births Association) https://www.nationalbreastfeedinghelpline.org. uk/ Tel: 0800 138 0509 (freephone) www.tamba.org.uk National Childbirth Trust (NCT) UK Thalassaemia Society Helplines:Enquiry line: Tel: 0300 330 0770 Tel: 0208 882 0011 Breastfeeding line: Tel: 0300 330 0771 http://www.ukts.org/ Pregnancy and birth line: Tel: 0300 330 0772 Postnatal line: Tel: 0300 330 0773 Advice, support and counselling on all aspects of childbirth and early parenthood. www.nct.org.uk NHS Choices http://www.nhs.uk/Conditions/pregnancy-and- baby/pages/pregnancy-and-baby-care.aspx NHS 111 Tel: 111 http://www.nhs.uk/NHSEngland/ AboutNHSservices/Emergencyandurgentcare services/Pages/NHS-111.aspx 24 hour nurse- led service providing health information and advice.

Pregnancy Information Book 79 23.0 Glossary The following list is a glossary of all the terms that have been used within this book or you may hear during your hospital appointments and antenatal/postnatal care.

Abbreviation Abbreviation Definition Definition / Term / Term Accident and Emergency Human Normal A+E HNIG Department Immunoglobulin ABV Alcohol by Volume mcg Micrograms Attention Deficit Hyperactivity mg Milligrams ADHD Disorder ml Millilitre Acquired Immune Deficiency MMR Measles, Mumps and Rubella AIDS Syndrome MSSU Mid-Stream Specimen of Urine ANC Antenatal Clinic Methicillin-Resistant MRSA Antenatal Day Assessment Staphylococcus Aureus ANDAU Unit National Institute for Health NICE Artificial Rupture of and Care Excellence ARM Membranes NRT Nicotine Replacement Therapy

BMI Body Mass Index A Doctor specialising in the BV Bacterial Vaginosis care of women during Obstetrician pregnancy and the early cm Centimetres postnatal period. CTG Cardiotograph STI Sexually Transmitted Infection ECV External Cephalic Version Transcutaneous Electrical TENS FSA Food Standard Agency Nerve Stimulation g/dl Grams per decilitre VE Vaginal Examination GP General Practitioner Varicella Zoster Immune VZIG Hb Haemoglobin Globulin o Human Immunodeficiency C Degrees Celsius HIV Virus oF Degrees Fahrenheit

This information is available in large print, The contents of this book is subject to copyright audio, Braille and other languages. To request law and should not be reproduced in any form a copy, please ask your Midwife. whatsoever without prior written approval from Mid Cheshire Hospitals NHS Foundation Trust the Maternity Service at Mid Cheshire Hospital is not responsible or liable, directly or indirectly, NHS Foundation Trust. for any form of damages resulting from the use We would like to acknowledge and thank (or misuse) of the information contained in this Shrewsbury and Telford Hospital NHS Trusts book or found on the web pages linked to by for their input and the format this book has this book. been based upon. At time of printing this document was fully up Date Revised and reprinted: July 2018 to date and in line with hospital and national Review July 2020 Ref: WC/MS/0300718 guidance.

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