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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.

Related Posts

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Letter to Obstetric Patients Regarding COVID-19

Dear Patients,

My thoughts are with you during this stressful time. At this moment of great joy, excitement, and anticipation, instead you may be experiencing worry and fears about how COVID-19 will affect your pregnancy care, and the health of yourself and your baby. Firstly I want to reassure you that the health of you and your baby is my highest priority, and I want to encourage you to contact my rooms if you have questions, symptoms, or worries. 

You may wish to read through some resources that have been put together by Queensland Health:

COVID-19 and pregnancy

COVID-19 and breastfeeding

I have had requests to provide advice about whether you should take early leave from your occupation to reduce your chances of a COVID-19 infection. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists is currently recommending that pregnant women work from home where possible. While there is currently no specific advice for pregnant women to stop working or take leave from work, there are general recommendations to avoid larger groups and practice social distancing, along with advice about hygiene practices.

My advice specifically for pregnant women is upgraded in order for you to stay as safe as possible and stay ahead of the wave of COVID-19 transmissions that seem to be escalating rapidly.

The following recommendations reflect my advice based on reading health guideline updates, my own observations, and after discussion with colleagues:

  • Work from home if at all possible. 
  • You are within your rights to request early leave from work especially where you may be exposed to large groups of people (at work or getting to/getting home from work); I would encourage you to negotiate this with your employer.
  • If you have children, whether or not to remove them from school is a controversial decision. School is a “large group” environment likely to accelerate spread. If you are trying to protect yourself, this would be an effective way to limit your exposure.
  • If you cannot stop attending your workplace, limit your exposure to colleagues and others by maintaining appropriate social distances >1.5m, wash hands regularly (especially before eating), avoid contact such as shaking hands, avoid touching your eyes/nose/mouth/face etc.
  • Partners and household family members are advised similarly as above in points 2, 3 and 4. Furthermore, household members are encouraged to be vigilant by heeding precautionary measures with social distancing, hygiene measures, and washing hands when arriving home. Isolation and seeking medical advice should be sought if partners or other members of your family develop worrying symptoms.

Contact me if you feel you have a confirmed exposure, or suspected/confirmed infection so I can help arrange appropriate care and follow up. I will be assessing antenatal appointments ahead of time from this week onwards to determine if we can look at the option of telephone consultations to reduce the need to attend the surgery in person. There will still be a requirement for reviews “in house” so that we can check baby’s ongoing growth and well being, the frequency of which will be determined on a case by case basis depending on your pregnancy and circumstances.

My hope is that by limiting your risk of exposure, you will continue to be safe in pregnancy, delivery and back at home afterwards.

Kind regards and yours sincerely,

Dr Matt Thyer 

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Perinatal Anxiety and Depression

Pregnancy, childbirth and parenthood are exciting and special human experiences. However, it can be difficult to adjust to the pressures associated with these life-changing events. For those that have good supports, helpful family and friends and the good fortune of placid newborn this adjustment is made much easier. However, for some a difficult adjustment can turn to despair, anxiety and depression.

80 % of women will experience anxious and depressive symptoms shortly after giving birth. Commonly referred to as “the baby blues”, you may be teary, despondent and feel inadequate to care for your baby. These feelings are short-lived by most, but for a sizeable proportion of women they persist.

Up to 20% of women and 10% of men will experience perinatal anxiety or depression.

Depression is typified by one or more of the following symptoms and behaviours that persist for more than 2 weeks, can occur at any time during pregnancy and up to a year after delivery, and interferes with your normal function and relationships:

  • Depressed mood and persistently negative thoughts
  • Loss of interests or a sense of indifference or feeling numb
  • Difficulty concentrating, remembering things or getting things done Irritability, agitation or a “short fuse”
  • Feeling out-of-control
  • Feelings of guilt, shame, anger, inadequacy or hopelessness
  • Thoughts of harming oneself or the baby
  • Extreme lethargy and tiredness a lot of the time
  • Teary and upset a lot of the time
  • Social withdrawal
  • Sleeping problems; difficulty going to sleep or waking early
  • Change in appetite, weight gain or loss
  • Palpitations, headaches, sweaty hands

Anxious thoughts to some degree are a normal part of everyone’s life, however an anxiety disorder involves a persistent impairment of one’s normal function, relationships and work and may present in the following ways;

  • Generalized anxiety
  • Worry
  • Fears
  • Panic attacks

Anxiety and anxious behaviours in this case may be considered excessive or irrational to someone impartial.

These feelings should be taken extremely seriously, especially where they persist beyond two weeks an occur on a daily basis. It is a desperately sad fact that perinatal anxiety and depression are the leading causes of maternal mortality in the developed world. A parent in this state may lose hope and perspective, and this is a dangerous combination.

Several factors put people at higher risk of developing perinatal anxiety and depression including:

  • Past mental health illness including past perinatal depression/anxiety
  • Perfectionist and vulnerable personality type
  • Recent big life changes; financial pressure, loss of work, bereavement
  • Emotional stresses; estranged family or strained relationships
  • Social isolation: rural women, migrants and refugees
  • Domestic violence
  • History of physical or sexual abuse
  • Difficult birth

During and after pregnancy it is recommended to screen women for anxiety and depression. The Edinborough Post-Natal Depression Questionnaire produces a score (EDPS) that estimates your risk of being depressed. It is not diagnostic, but a screening tool. About 70% of women that screen positive to this questionnaire will be diagnosed with perinatal depression, so it is a reasonable screening tool. Equally however it is not 100% accurate and some people may screen negatively but still have depression. This is why a medical professional must be sensitive to these conditions and revisit screening on multiple occasions during and after pregnancy.

There are effective ways to treat perinatal anxiety and depression and they include a range of counseling modalities through to psychiatric and medical treatments. Your doctor is trained to help facilitate this where they can play a central role in directing you towards effective treatments that are appropriate given your conditions and circumstances.

There is no shame in seeking and receiving help for anxiety or depression as it shows you care about your pregnancy, baby, family, friends and yourself. That makes you a decent and caring person.

People do find their way through perinatal anxiety and depression. It is important to hold onto this fact during recovery.

The following helpful links are provided for your assistance in understanding more about perinatal anxiety and depression and the supports available to parents experiencing these conditions.

Life should be enjoyed.

The Gidget Foundation

Beyond Blue

Lifeline

PANDA – Perinatal Anxiety and Depression Australia

St John of God Raphael Services

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Delivery planning

At some stage during your pregnancy it is worthwhile discussing your delivery planning and expectations about birth. Open channels of communication about your dreams and concerns are key to your sense of satisfaction about the events surrounding the birth of your child. You are encouraged to bring up this topic when you feel ready, otherwise it is discussed as a matter of routine as you progress toward your due date.

Vaginal birth after caesarean section (VBAC)

VBAC is supported by obstetric guidelines around the developed world provided it meets patient-based, institution-based and practitioner-based safety requirements. Decisions around whether or not to try for a VBAC can be highly emotive. A reasonable plan for one patient may be very different to another a the circumstances and risks can differ substantially. For this reason it is important to seek the advice of a practitioner that has seen the risks play out during pregnancy and labour, and knows how to deal with potentially life-threatening complications of a VBAC.

As a general approach, provided the risks are considered acceptable, every chance should be given to help you achieve a natural vaginal birth under the careful and watchful guardianship of your practitioner

Education and support including breastfeeding after delivery

Your midwife is invaluable in helping you to establish good breastfeeding habits after delivery. This will usually start with encouragement of skin-to-skin contact and breastfeeding as soon as possible after birth. Even at caesarean section it is possible to achieve this with the help of your midwife and other theatre staff. Occasionally your paediatrician may need to keep a very close eye on your baby in the nursery after delivery. However every effort is made to allow you a first contact as soon as possible after your delivery.

A strong focus on breastfeeding is currently adopted as there are evidence-based benefits to breast-feeding your child for at least 6 months. Breastfeeding reduces your child’s risk of developing metabolic and weight issues later in life, and there is early research showing breastfeeding can “reverse” these risks for babies that were “programmed” for metabolic impairment during the pregnancy. These are amazing benefits, however sometimes it feels like there is a lot of pressure around this issue after the birth. Again, open channels of communication with the team including your midwife, lactation consultants, obstetrician and paediatrician are key to working through these issues. Your voice is most important in this process and everyone is there to support you. It is worth remembering that breastfeeding is a partnership between you and baby, and it is not always the best thing for you both especially where the difficulties outweigh the benefits.

Analgesia in labour

There are some effective options for analgesia in labour that are supported by good evidence.

The epidural provides hands-down the best possible pain relief you can be offered in labour. Unfortunately, however, epidurals are not risk-free, they affect your mobility in labour, and can increase the duration of pushing and the risk of instrumental deliveries. They do not increase the risk of a caesarean section, and this detail is well supported by good evidence. The specific risks of an epidural should be discussed with you prior to labour so that you are not making decisions for the first time under the duress of labour.

Entonox or nitrous oxide (laughing gas) can provide some mild pain relief in labour. For some it is also a great distraction from labour. However many people experience intolerable effects including dizziness, nausea and sometimes vomiting. It is an option certainly worth considering for pain relief in labour where an epidural is considered undesirable.

Warm water immersion, or a warm shower, may provide good pain relief in labour. It is also relaxing. So where it is possible, is considered safe and does not pose a danger to yourself, baby or staff, it is a great option to consider.

Other than those above, there are no known reputable alternative sources of pain relief in labour. Some people have had good experience with morphine or pethidine, however overall it has not been shown to work well for the majority of people and is poorly supported by the evidence.

Analgesia at Caesarean Section

Caesarean sections require very effective and reliable pain relief. Spinal or epidural aneasthesia provide a regional nerve blockade so that your sensation is impaired below your waist thereby allowing your obstetrician painless access to deliver you child.

A spinal anaesthetic is introduced via a very fine needle through your lower spinal vertebrae and into the fluid bathing your spinal cord. The effect is very fast and effective. Conversely an epidural is introduced via a larger catheter, but stops short of entering the spinal canal, and relies on the diffusion of anaesthetic across tissue membranes to enter the spinal fluid that bathes the sensory nerves of your spinal cord. Occassionally your anaesthetist will combine these two methods to get a faster and more complete acting regional block, but also the benefit of an epidural catheter placement that can deliver anaesthetic following your operation. Each method has its benefits, limitations and risks and should be canvassed with the anaesthetist.

Sometimes a general anaesthetic will be required to provide adequate analgesia for a caesarean section where a spinal or epidural cannot be sited or where it is considered the safest means given the circumstances. In this situation you will be put to sleep and kept safe under the watchful eye of your anaesthetist while your baby is delivered. You are asleep for a short time and woken soon after your wound is closed and dressed. Recovery after a general anaesthetic can take some time as you may feel a bit drowsy, but generally after a few hours you are back to normal.