After the first trimester of pregnancy
Anatomy Ultrasound (18-20 week Ultrasound)
The ultrasound at 18-20 weeks of pregnancy is really important. It is where we check that your placenta is located in a safe position, your babies anatomy again appears normal, and that your babies growth are in the normal range. Benchmarking the babies growth at this point also allows for later comparisons. The length of your cervix is now routinely recommended at the time of your anatomy scan to identify pregnancies that may be a risk of preterm birth.
Growth of baby during pregnancy
The symphysio-fundal height is the measurement between your pubic bone and the top of your uterus. It is used to estimate appropriate growth of your baby where the length measured in centimetres is supposed to approximate the gestational age of your pregnancy in weeks. It is notoriously inaccurate as a measure of your baby’s size, as maternal tissues, amniotic fluid around the baby and a large variation in observer measurements results in inconsistencies. The change in this measurement over a period of time can be more helpful in assessing the appropriate growth of your baby, but is still associated with significant error.
If your practitioner has been trained in obstetric ultrasound, this allows for the most accurate predictor of your babies growth. Changes in your babies measured growth over time help us to ensure your placenta is working well and your baby is continuing to grow appropriately.
Foetal movements
By 23 weeks of pregnancy you should have started to feel your baby moving. If you have an anterior placenta (on the front wall of your uterus) this can affect the sensation of your babies movements. There are no good quality studies indicating an acceptable frequency of fetal movements. However, it is a common story that women who have experienced poor outcomes in pregnancy commonly remember reduced or absent fetal movements. It is therefore recommended if you feel your babies movements are reduced, to take action and seek obstetric advice.
Some well-regarded professional organisations recommend to take a lie down and concentrate on feeling your baby move for a 30 to 45 minute period. If you are still worried that your baby is still quiet, make no hesitation in contacting your health provider, and certainly do not leave your concerns till the next day. You should never feel, or be made to feel, that your concerns are unwarranted, and you should be supported to seek out appropriate care from your health provider to ensure that your baby is healthy and well.
Diabetes screening in pregnancy
It is normal for your blood sugar levels to rise in response to pregnancy hormones. However, excessive increases in your blood sugar levels (gestational diabetes), or high blood sugar levels to start with (pre-existing diabetes), can increase the risks to you and your baby during pregnancy, birth and can have a lasting impact on your child’s health into adulthood. This is why we recommend screening for diabetes in pregnancy. The standard time to screen is between 26-28 weeks. However, women who are at high risk of pre-existing or gestational diabetes will be recommended screening much earlier in pregnancy. The earlier we detect abnormal blood sugar levels, the sooner we can correct it and improve the health of you and your baby.
Routine antenatal visits
Much of your pregnancy care is about screening for problems that commonly arise in pregnancy so that we can prevent poor outcomes.
Occasionally I am asked why we always check your blood pressure, urine protein or tissue swelling. This is to check that you are not developing high blood pressure and/or preeclampsia (pregnancy toxaemia). These are high-risk conditions that arise in 5-7% of pregnancies that can have catastrophic consequences for mother and child. By screening frequently we can help to detect these problems early, prevent poor outcomes and optimize the valuable time that your baby can spend in your womb.
Symptoms that often arise with preeclampsia include headaches, changes to your vision (commonly described as spotty vision), abdominal pain, chest pain, nausea, vomiting, recent onset excessive tissue swelling (especially facial swelling) and just feeling generally unwell. If you develop these symptoms it is very important you check in to be assessed by your doctor.
Intimacy in pregnancy
During pregnancy your sex drive may increase, decrease or stay the same. Not surprisingly your partner may feel scared about hurting the baby during intercourse. These are very common concerns in pregnancy that you may not have the confidence to ask your practitioner about.
Your baby will not get “hurt” as a result of sexual intimacy as it is well protected inside the womb. However, there are some circumstances in which intercourse should be avoided, one of which includes a low-lying placenta. This is where your placenta lies in close proximity to, or covers, the cervix. Your doctor can discuss more about these and other circumstances where sexual intimacy requires careful consideration in pregnancy.
Most importantly however, open communication with your partner about how you feel toward physical intimacy can really help strengthen your relationship and avoid frustration and misunderstandings.
Whooping cough and Influenza vaccines
It is recommended to be vaccinated every pregnancy for whooping cough and influenza, unless you have an allergy to these preparations.
Whooping cough is relatively common infection in the community, across all ages, and it is easily passed by droplet spread from infected individuals. It can cause a nasty respiratory infection to your newborn requiring hospitalization, and cause long-term lung disease in your child. In severe cases a newborn may not survive the infection.
The good news is that your newborn can be protected by having a whooping cough vaccination, optimally given between 28-32 weeks of pregnancy. The antibodies you produce against this vaccine cross the placenta, enter the babies circulation and protect your baby for the first 3-4 critical months until your child has begun its own vaccinations (the DTTP vaccine). Your partner and any other close contacts with your newborn are also encouraged to have a booster every 5 years in order to create “herd immunity” around your child.
The “flu” is a particularly nasty infection to acquire during pregnancy and pregnant women are considered high risk. Pregnant women have an altered immune system and later in pregnancy have compromised respiratory capacity. If you are pregnant, you should take the “flu” very seriously and check in with your GP or obstetrician.
Fortunately, the flu vaccine is available in Autumn every year and is recommended by Australian medical authorities. Pregnant women may consider receiving the flu vaccine at any gestation during their pregnancy and it bears no harm to you or your baby as it only contains the “dead” influenza virus. Like the whooping cough vaccine, the antibodies you produce against the influenza viral strains will cross the placenta and protect your baby at birth.
Other important precautions that you can take to reduce the risk of acquiring a nasty respiratory infection are regular washing of hands before touching your own, or your child’s, face. Others who clearly have signs of the flu or a respiratory tract infection should ideally not handle the child.
Anti-D
If your blood type is rhesus negative you may need to have anti-D protection during pregnancy. Anti-D is a purified antibody harvested from human blood donors. It may be required when there are risks of blood mixing between you and your baby. For example, as a result of abdominal trauma, bleeding in pregnancy, amniocentesis and after delivery of your baby. It may also be given as a preventative medication at 28 and 34 weeks of pregnancy for further protection. There are some circumstances in which anti-D may not be recommended for a rhesus negative woman, however these exceptions are best discussed with your medical practitioner.
Bleeding and vaginal loss in pregnancy
Bleeding in pregnancy should never be considered normal and a medical opinion should be sought as a matter of urgency. All vaginal bleeding in pregnancy must be fully investigated as some causes may be dangerous for mum and baby. Important information your doctor will require are previous ultrasounds you have had this pregnancy.
The well-being of your baby should be determined as soon as possible with either a cardiotocograph (CTG; a heart beat trace of your baby) and an ultrasound.
Divarication
This is where the muscles of your abdominal wall become spread apart in the midline of your abdomen. It is noticed when you lift your head off your pillow, or sit up from a lying position. If it is associated with pain you should seek a medical opinion as soon as possible, however this is rarely the case. Divarication may get worse with each successive pregnancy.
During and after pregnancy you may wish to help with divarication by wearing an elastic-tube abdominal support. However, there is little evidence it limits the process. After delivery, most cases of divarication repair spontaneously, however if it persists and you are concerned by the appearance, there are conservative and surgical measures that can help.
Optimising iron and haemoglobin before delivery
During pregnancy your haemoglobin (the protein that carries oxygen to your tissues) level naturally decreases in concentration due to the large increases in your blood volume. However, your haemoglobin level must be maintained in the normal range for your health and for the growth of your baby. Your haemoglobin level should also be optimized leading up to delivery.
Iron is a key building block for the synthesis of haemoglobin. If your iron stores are low, your haemoglobin stores will not reach their full potential. Anaemia (low haemoglobin) and low iron stores are best corrected earlier on in pregnancy.
Red meat is the richest source of iron in your diet. If you are vegetarian, leafy green vegetables are also a good source, but they need to be consumed in large quantities to meet daily requirements. An iron supplement is often the simplest method of increasing iron levels and should be taken with vitamin C to optimize uptake of iron. Iron supplements can disturb your bowels, and you may find yourself either constipated of getting diarrhoea. If your iron stores are severely deficient, you cannot take iron supplements or you do not respond to supplements, an iron infusion may be recommended. This would require discussion with your doctor.
GBS screening
Australian guidelines support screening for Group B Streptococcus (GBS) after 34 weeks of pregnancy. This microorganism naturally lives in the bowel and vaginal environment of about 20-25% of women at any one particular time. Its presence should in no way be considered an “infection”. However, where it is present in sufficient abundance, GBS can cause a nasty infection in your newborn after a vaginal delivery or prolonged rupture of your membranes. By treating you with antibiotics during labour we can help to prevent most newborn infections that may otherwise have occurred within the first week of delivery.