Delivery planning

At 28-32 weeks gestation Dr Matt Thyer discusses your delivery planning and expectations about birth. Dr Matt will also offer a discussion about birthing expectations with Tracey Steele (Midwife and Lactation Specialist) in his rooms at 32 weeks to help you understand what is likely to happen during labour and birth, or at Caesarean section, and to help you decide on your preferences for birthing such as, but not limited to, analgesia, mobility, access to shower and bath for example. Open channels of communication about your desires and concerns are key to your sense of satisfaction about the events surrounding the birth of your child. You are encouraged to discuss these issues at any point in your pregnancy 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 and 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 the potentially life-threatening complications of a VBAC.

As a general approach, provided the risks are considered acceptable to patient and practitioner, 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 and TENS machines, however overall they have not been shown to be effective 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.

Rarely 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.

Caesarean Section

The majority of patients express a preference for a planned vaginal birth unless there are strong and compelling reasons to birth via Caesarean section. Sometimes Caesarean section is medically necessary from the outset, for example where the placenta or babies umbilical cord covers the cervix. However I find it increasingly frequent, although still overall a smaller proportion, for women to elect for Caesarean section from the outset. The very personal reasons for this are varied and reflect a well thought through and considered decision as much has been documented in the literature about the risks and benefits of planned Caesarean section vs Vaginal birth. 

Dr Matt feels a Caesarean section birth need not be a cold and depersonalised experience for parents whether it be elected or required. Dr Matt Thyer has developed a sterile process of allowing parents to first see their baby delivered, and then accept baby into their arms at Caesarean section provided baby has transitioned well and there are no compelling medical reasons to do otherwise. 90% of Dr Matt’s Caesarean births are conducted in this way and Dr Matt feels it really “makes the moment” and gives the parent that first touch, the skin-to-skin that is so important for bonding and breastfeeding.

Whichever birthing option you elect for Dr Matt Thyer Perth Private Obstetrician and Gynaecologist is there to listen to your desires and concerns leading up to delivery, and to help achieve a delivery that its safe for mother and baby. 

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.

Early Pregnancy

Congratulations, you are pregnant!
Below are some of the important issues and concerns that should be considered in early pregnancy.

Lifestyle

A healthy but moderated exercise regime bears no significant risk to you or your pregnancy provided there are no medical or obstetric reasons that preclude such activity. The Royal Australian College of Obstetricians and Gynaecologists Guideline [PDF Download] endorses and details general advice about what would be considered a healthy exercise regimen to help regulate your metabolism and encourage a healthy weight during pregnancy.

Diet and food preparation

There are foods that are encouraged and discouraged in pregnancy, but the general advice is to ensure your diet is well balanced, healthy, is safely stored and prepared and does not include potentially dangerous foods.

Fresh foods (mainly fruit and vegetables) should be handled with washed hands, kept separate from meats when prepared and stored in the fridge, and washed well before consumption.

Use gloves when gardening and handling kitty litter and cat faeces. This is to avoid contamination of foods and food-borne infections.

Food types that should be avoided in pregnancy include unpasteurized dairy products such as soft cheeses, smoked salmon, cold meats, pates and fresh ciders. Undercooked meat should also be avoided, while meat that has been cooked through well is safe to eat. Likewise food that has been refrigerated should be re-heated till piping hot before consumption. Foods that have not undergone a heating or pasteurizing process may harbor potentially dangerous microorganisms that can cause infections that affect your unborn child.

Foods very rich in Vitamin A, such as liver, should be avoided during pregnancy due to concerns about Vitamin A teratogenicity, especially in the first trimester.

Seafoods such as clams, oysters, muscles, abalone, other sea-living crustaceans, and shark, swordfish, king mackereal, marlin, orange roughy and big eye tuna (other tuna’s are ok) may be high in heavy metals, such as mercury and can affect your child’s neurological development. Most other fish may be consumed but no more one to two servings per week for the same reasons.

When to book in to see the GP

Once you have found out that you are pregnant it is important to book an early appointment with your GP. Your GP will usually recommend early pregnancy blood tests that confirm the pregnancy hormone level in your blood (bHCG), and will recommend an early pregnancy ultrasound to date and locate your pregnancy. This is to ensure that your pregnancy is viable with a heartbeat and is safe and sound inside your uterus.

1-2% of pregnancies are ectopic, meaning they fall outside the womb and pose a significant risk to the mother. This risk increases for women who have had a previous ectopic pregnancy, pelvic infections in the past (most commonly sexually transmitted infections that have infected the fallopian tubes), endometriosis, previous pelvic surgery, cystic fibrosis sufferers, pregnancies conceived by IVF and smokers.

Pregnancy Dating

Accurately dating the gestational age of your pregnancy with an early pregnancy ultrasound allows for a true assessment of your babies growth and wellbeing throughout pregnancy. In turn it enables you and your doctor to help make good decisions about the safe planning and timing of delivery and can help to reduce unnecessary intervention. An optimal gestation to date your pregnancy with a specialist pelvic ultrasound is between 8-12 weeks of pregnancy.

The “expected due date” (EDD) of delivery is the date at which you would be 40 weeks pregnant. This has traditionally been thought of as the median gestational age at which babies will deliver spontaneously. The EDD is used as a yardstick to calculate the gestational age of your pregnancy. It is important to note that the EDD may not necessarily be the optimal time for your baby to be delivered. In fact the optimal time for your baby to deliver may be earlier, may be later or when the “baby decides” depending on your specific circumstances.

Special tests in early pregnancy

Blood tests
When you visit your GP in early pregnancy, they will order a host of blood tests to check on your health and fitness for your pregnancy. This will include a check on your immune status for important infections, type of blood group, liver kidney and blood health and fasting blood sugar levels.

Urine checks
Your GP will check to make sure your urine contains no infection. Infections in your urine can cause early pregnancy loss and can cause your baby to be born prematurely. If infection in your urine is found your doctor will treat it with antibiotics. Sometimes it is recommended to check that the infection has been cleared.

Screening for Down’s syndrome and other chromosomal disorders
There are two common tests that your doctor will offer if you wish to screen your pregnancy for common chromosomal disorders including Down’s syndrome.

1. The “First Trimester Screen” includes blood tests, best done at 10 weeks, and an early ultrasound at 12-13 weeks. These results are combined to calculate a risk of your baby being affected with some of the most common chromosomal disorders including Down’s syndrome. It is not a diagnostic test, so a “high risk” result means the pregnancy needs further assessment. Apart from screening for chromosomal disorders, the purpose of this ultrasound is to get an early look at your babies basic anatomy, investigate the placenta(s) of twins/multiple pregnancies, and date the pregnancy, should this have not been done previously.

Non-Invasive Prenatal Testing (NIPT) is another screening test for common chromosomal disorders such as Down’s syndrome. Some pathology laboratories also offer specific tests for chromosome aneuploidies and other genetic mutations. They all can detect whether your baby is a male or female, but you have the option as to whether or not this information is disclosed. NIPT is a much more accurate screening test than the first trimester screen. It involves a maternal blood test after 10 weeks of pregnancy. A very small fraction, less than 5%, of tests will fail. Unfortunately at this time NIPT is not Medicare subsidized and the patient bears the cost of this test. The cost however is continuing to decrease as the technology becomes less expensive.

Like the first trimester screening test, NIPT is not a diagnostic test, so if it comes back as high risk, the pregnancy will need further diagnostic testing. At this point it is best to discuss what this means for your pregnancy and where to from here with your doctor.

Bleeding in early pregnancy

Reassuringly most bleeding in early pregnancy will resolve and your pregnancy will continue on to be normal. However bleeding should never be ignored and must be investigated as soon as possible. If your doctor is accessible they will request an urgent ultrasound to ensure your pregnancy is safe and sound within your uterus. If there are delays you should attend a hospital emergency centre to investigate.