Pregnancy
 
Antenatal care means "care before birth". Antenatal care aims to monitor and promote the wellbeing of a mother and her developing baby. Midwives, health visitors and doctors provide information, advice and reassurance as well as monitoring, screening and treatment where necessary.

Who provides antenatal care?

Care from an obstetrician is recommended for women with medical problems that could affect, or be made worse by, their pregnancy, or for women who have previously had difficulties with a pregnancy or delivery.

Antenatal tests

Many routine tests are offered to women during the course of their pregnancy. Blood tests are offered early on to screen for infections that could affect the baby and to check the woman´s blood group. Urine tests check for infections, protein and sugar. Ultrasound scans determine the position of the placenta and look for any physical problem that could affect the baby or delivery. Women may also be offered a variety of other screening tests.

Enjoying a healthy lifestyle

A pregnant woman herself plays the most important role in preparing for the arrival of her new baby. Pregnancy is a good time to concentrate on your health, eat nutritiously, take regular gentle exercise, reduce your alcohol intake to a minimum and stop smoking.

Smoking

Smoking while pregnant is proven to harm the developing baby. In particular, the baby´s growth is likely to be affected and the baby´s birth weight reduced. Smoking during and after pregnancy may also increase the risk of cot death (sudden infant death syndrome, SIDS).

Diet

Eating a healthy diet during pregnancy means that both mother and baby receive all the vitamins and minerals they need. A nutritious, well-balanced diet is one that is varied and includes a wide range of foods including:
 
 - starchy foods such as cereals, bread, potatoes and pasta 
 - plenty of fruit and vegetables that supply vitamins and fibre 
 - foods rich in protein such as meat, fish, eggs and pulses 
 - dairy foods which supply calcium 
 - foods rich in polyunsaturated fats, such as oily fish like salmon and trout

It is best to avoid a lot of sugary, salty or fatty foods. A well-balanced vegetarian diet should provide all that is needed, but vegans may need to take advice from their obstetrician about supplements such as calcium, vitamin D and vitamin B12.

Folic acid

Folic acid is the only vitamin supplement that is recommended for women who are otherwise eating a balanced diet. Folic acid is needed for the development of healthy red blood cells, and taking enough of it decreases the chance of a baby being born with neural tube defects. A baby´s brain and spinal cord are formed from the neural tube very early in pregnancy. One example of a neural tube defect is spina bifida, where an area of spinal cord is not properly enclosed. This can cause problems such as paralysis of the legs and incontinence.

It is best to start taking folic acid before pregnancy (ideally about three months before trying to conceive), or as soon as the woman realises she is pregnant. It should be continued for at least the first 12 weeks. Folic acid is found naturally in fresh dark green vegetables such as broccoli, peas, green beans and spinach. Many breakfast cereals and some breads are fortified with folic acid.

What to avoid eating

Some infections can be picked up by pregnant women and transferred to the developing baby via the placenta. Examples include toxoplasmosis, listeria and salmonella. Even though these infections are not common, they could lead to premature labour, problems with the development of the baby or illness of the baby after birth. Pregnant women are therefore advised to avoid the following foods:
 
 - unpasturised dairy products 
 - soft or blue-veined cheeses 
 - soft-whipped ice-cream 
 - raw or undercooked eggs or shellfish 
 - undercooked chicken 
 - undercooked meat products in general

Women are also advised to avoid eating liver, liver pâté and cod liver oil in pregnancy as these contain high levels of vitamin A. Excess amounts of vitamin A can cause abnormalities in the developing baby.

Toxoplasmosis

Toxoplasmosis can be caught from cat faeces. Pregnant women should avoid handling cat litter, wear gloves when gardening and wash hands afterwards.

Alcohol

Alcohol can cause risk to the baby suffering from a collection of mental and physical problems known as "fetal alcohol syndrome".

Exercise

Moderate exercise that makes you feel warm and slightly out of breath is beneficial, especially if your body is already used to it. Being fit is very good preparation for the exertion required in labour. It is not wise to start a new, intensive exercise programme, but gentle exercise can be built up. Overheating through exercise, saunas or hot tubs should be avoided. Women´s joints become looser during pregnancy in preparation for childbirth so jerky or violent impacts should be avoided in favour of gentler exercise such as walking or swimming.

Travel

Most airlines prevent pregnant women from flying after 34-36 weeks of pregnancy. From around 28 weeks, airlines may request a letter from a woman´s doctor confirming that she is fit to fly.

The main hazard is the risk of deep vein thrombosis (DVT). The risk of getting a DVT is already increased by pregnancy and the individual risk could be higher for some pregnant women, so you should discuss this issue with a doctor before flying.

When travelling by car, pregnant women are still required by law to wear their seatbelts. A normal three-point seatbelt is worn with the cross strap lying between the breasts. The lap belt should be placed beneath the bump of the baby and across the thighs.
It is important to check that you have a travel insurance policy that covers you while you are pregnant.

Sex

There is no need to avoid sexual intercourse unless there are specific problems and your doctor or midwife has advised against this.

Pregnancy symptoms

During pregnancy a woman´s body undergoes a number of changes to allow the fetus to develop inside the womb. These changes can cause various symptoms, but these are not usually serious and tend to disappear without any treatment during pregnancy or soon after the birth.

Nausea and vomiting

Widely known as morning sickness, feeling or being sick during pregnancy normally occurs from about the sixth until the fourteenth week of pregnancy. However it can start as early as the first missed menstrual period and continue until later into the pregnancy. Although the name suggests nausea and vomiting occur only in the morning, they often occur throughout the day.

The exact cause is unknown, but it is thought to be linked to hormone changes. It is rare for vomiting to cause a serious medical problem.

Nausea and vomiting usually stops by about week 14 of pregnancy, without the need for any medical treatment.

Any woman with severe sickness that does not stop should seek medical advice. Severe vomiting can interfere with nutrition and can cause dehydration. The medical term for it is hyperemesis gravidarum, and it may require hospital treatment.

Urinary symptoms

In the first three months of pregnancy, many women find that they need to pass water more often than normal. This is a result of hormonal changes, and because the enlarging womb pushes on the bladder resulting in a smaller bladder capacity. This frequent need to urinate is also common in the four weeks before the birth, as the baby´s head enters the pelvis and further presses on the bladder.

During the rest of pregnancy, there is an increased risk of developing a urinary infection. This is because hormones and the enlarging uterus can slow the passage of urine out of the body.

To help prevent urinary infections, women should drink plenty of fluids and not delay when they get the urge to pass water.

If a urinary infection is not treated, it may spread upwards to the kidneys and damage them, so it is important not to ignore any pain or burning sensation on passing water. If the symptoms continue, a doctor may need to prescribe antibiotics.

Fatigue

Extreme tiredness is very common in pregnancy, especially during the first 12-15 weeks, because the woman´s body is under extra strain.

To help cope with this, women may want to take naps whenever possible, and try to go to bed earlier.

Extreme fatigue can sometimes be a symptom of anaemia. Any woman who is worried about this should speak to her doctor, midwife or obstetrician.

Constipation

Constipation is common in pregnancy for several reasons. Hormone changes slow the passage of food through the gut, while the growing uterus can put pressure on the rectum. Iron supplements, often given to prevent or treat anaemia in pregnancy, can also make constipation worse.

Drinking adequate amounts of water and eating a diet rich in fresh fruit and wholegrain foods can help prevent or relieve constipation.

Breast soreness

Sensitive, tender or sore breasts are commonly one of the first signs of pregnancy. This usually improves after the first trimester. Wearing a comfortable, supportive maternity bra should help.

Itchy skin

About 20% of pregnant women get some kind of skin itchiness. When this occurs over the abdomen, it is probably caused by the skin stretching. But it´s also common to have itchy palms and soles of the feet, which is thought to be caused by increased hormone levels.

Itchiness can usually be relieved by applying a simple moisturiser such as aqueous cream, which is available inexpensively from pharmacies.

In rare cases, generalised itchiness in the third trimester can be a sign of a liver problem called obstetric cholestasis. Any woman with widespread itching should consult her obstetrician.

Backache

Backache can occur in pregnancy owing to the increasing size and weight of the womb and the breasts, and because pregnancy hormones loosen the ligaments that attach the spine to the pelvic bone.

Backache may be relieved by resting, having warm baths, or massage. If pain is severe, a doctor may prescribe some forms of painkillers that are safe to take in pregnancy.

Leg cramps

Leg cramps can occur during pregnancy. The exact cause of these is unknown, but doctors think they may be related to changes in the blood circulation in the legs, and the extra weight being carried. Leg cramps are most likely to happen in the second and third trimesters of pregnancy.

Leg cramps may be relieved by stretching, walking, warm baths and massage.

Swollen ankles

Swelling (oedema) can affect the extremities, especially the ankles and toes, often later in pregnancy. The swelling happens when the enlarged womb presses on the veins that come up from the legs, leading to accumulation of fluid around the ankles.
Swollen ankles may be relieved by elevating them when sitting, wearing waist-high support tights and exercising.

Pins and needles

Pins and needles, especially in the hands, can be accompanied by some pain or numbness and occasionally weakness in the fingers. Usually this is caused by fluid build-up around the wrists, which compresses the nerves that run to the hand muscles and skin. This is known as carpal tunnel syndrome and tends to occur when there is also swelling in the ankles.

If finger pain or numbness is an ongoing problem, a doctor may suggest wearing a moulded wrist splint, especially at night.

Varicose veins

These are enlarged veins, usually in the legs. They often develop or become worse during pregnancy because the growing uterus puts extra pressure on the veins in the pelvis and legs, and because hormones cause the walls of blood vessels to relax.
Pregnant women can help to relieve the symptoms or reduce the risk of getting varicose veins by getting regular gentle exercise, not crossing their legs when sitting, putting their feet up when possible, and putting on support tights or stockings before getting out of bed in the morning.

Varicose veins often improve or disappear after the baby is born.

Piles

Piles (haemorrhoids) may first appear or become worse during pregnancy and result from changes in the circulation of blood around the pregnant woman´s body. They may also develop during labour when the woman is pushing.

Women can reduce the risk of getting piles by making sure they don´t become constipated, and not ignoring the urge to open their bowels. Piles can be relieved with over-the-counter creams, available from pharmacies. Taking warm baths is helpful for some women.

Like varicose veins, piles often improve or disappear completely after the baby is born, but occasionally surgery is needed.

Medical problems

The symptoms described so far are common in a normal pregnancy and generally clear-up without medical treatment. However, there are a number of less common pregnancy-related conditions that may need medical treatment. Some examples include Anaemia, Pre-eclampsia, DVT and Diabetes in pregnancy.

Identifying problems

Pregnant women should attend regular antenatal appointments so that any problems with the pregnancy are picked up. The obstetrician will ask about any symptoms, and conduct a number of tests. These include:
 
 - monitoring blood pressure 
 - monitoring weight, which can increase more than expected if a woman retains a lot of fluid 
 - taking a urine sample which can help identify an infection 
 - a blood test, which is taken at the start of pregnancy and then as required during pregnancy to check for anaemia

Any woman who is worried about her symptoms can seek advice from her antenatal care provider at any time.

Diabetes in pregnancy

Diabetes can develop during pregnancy in a woman who hasn´t previously had the condition. This is called gestational diabetes, which affects two to three per cent of pregnant women. If it is not properly controlled, it can lead to problems for the mother or her baby.

What is gestational diabetes?

Gestational diabetes develops in women during pregnancy because the mother´s body is not able to produce enough insulin. Insulin is a hormone that enables the body to break down sugar (glucose) to be used as energy. Without sufficient insulin the amount of sugar in the blood rises.

High blood sugar levels in the mother´s body are passed through the placenta to the developing baby. This can cause health problems.

Gestational diabetes usually begins in the second half of pregnancy, and goes away after the baby is born. This makes it different to the more common forms of diabetes which, once they occur, are permanent.

What causes gestational diabetes?

The cause of gestational diabetes is unknown. It is thought that the hormones produced during pregnancy may block the action of insulin. Gestational diabetes can happen if the mother´s body can´t produce enough extra insulin to counteract this blocking effect.

Risk factors

Although there is no clear reason why some women get gestational diabetes, women are more at risk if they:
 
 - have a family history of type II (adult-onset) diabetes 
 - are over the age of 35 
 - are obese 
 - have previously given birth to a large baby 
 - have previously given birth to a baby born with an abnormality 
 - have previously had a stillbirth late in pregnancy

Symptoms

In most women, gestational diabetes causes no symptoms. Some women do get symptoms of high blood sugar, such as increased thirst, increased need to pass water and increased hunger, although these are also common later on in pregnancy anyway.

The effects of gestational diabetes

Effects on the fetus during pregnancy

Having high blood sugar can cause the baby to grow larger, which can make delivery difficult and potentially cause injuries to both mother and baby during birth. In some cases a caesarean section is necessary.

Effects on the baby after birth

The baby may have low blood sugar (hypoglycaemia) after birth. This is because the baby´s pancreas makes extra insulin in response to the mother´s high blood sugar levels. Shortly after birth, the baby may continue to make extra insulin even though high levels of blood sugar are no longer present. After a pregnancy affected by gestational diabetes, the newborn baby´s blood sugar level is checked regularly. Sometimes babies are given an early feed of a sugar (glucose) solution through a drip (fed directly into a vein) to correct low blood sugar.

It is more likely that the newborn baby will develop jaundice (yellowing of the skin and whites of the eyes). This is not serious and usually fades over a few weeks, without the need for medical treatment.
There is an increased risk that the baby will be born with congenital problems, such as a heart defect. Sometimes, infants can be born with respiratory distress syndrome, in which the baby has problems breathing because his or her lungs have not matured as normal. This usually clears up with time.

There is also a slightly higher chance of stillbirth or death as a newborn, but if detected and the glucose levels are well managed, death is rare.
There may be an increased risk of the baby developing type II diabetes or being overweight later in life.

Effects on the mother

Gestational diabetes is not an immediate threat to the woman´s health. Most women with gestational diabetes whose blood sugar levels stay within the safe range deliver their babies without complications. However, in some women, it can result in high blood pressure.

Women who get gestational diabetes are more likely to develop gestational diabetes in future pregnancies, and are at a higher risk of developing type II diabetes later in life.

Diagnosing gestational diabetes

Urine is routinely tested for sugar throughout pregnancy, and high blood sugar, if present, is usually detected between 24 and 28 weeks of pregnancy.

The only way to confirm gestational diabetes is with a glucose tolerance test, which needs to be carried out after eight hours without food. The woman is given a solution of glucose to drink, and then blood samples are taken and analysed at different intervals to see how the body deals with the glucose over time.

If a doctor believes a woman is likely to develop gestational diabetes, this test may be carried out earlier than 24-28 weeks. Any woman whose medical history means she´s at a greater risk of diabetes, or is concerned about any symptoms should see her obstetrician.

Treatment

Self-help - The most important part of treatment is to control blood sugar levels. For many women, this means regular testing of blood sugar (glucose) levels, a carefully planned diet and regular exercise.

Home glucose testing kits are available from chemists. These usually involve taking a tiny blood sample with a pinprick device. The blood is put onto a strip and inserted into a glucose measuring device, which gives the blood glucose level.

Doctors usually advise blood glucose testing once a week, although for some women this may need to be more often. Glucose needs to be measured in the morning before breakfast and again two hours after breakfast. Some women may also need to test levels in the mid-afternoon.

A doctor or dietician can give advice about what and how much to eat. A meal plan will probably consist of a variety of foods including plenty of starchy fillers such as bread, pasta, rice and potatoes, and at least five portions of fruit and vegetables each day.

It´s important to limit consumption of sugary foods like cakes, biscuits and soft drinks. A diet that is low in fat is also desirable. This can be acheived by avoiding full-fat dairy products such as butter and cream, and limiting fatty meat, pies, sausages and burgers. Grilling, steaming or microwaving food rather than frying or roasting means less fat is added during cooking.

Gentle, regular exercise such as walking can help reduce blood sugar levels and promote a sense of well-being. A doctor can advise about suitable exercise during pregnancy.

Medicines

Despite making the above lifestyle changes, a few women´s blood sugar levels remain too high, and they may need daily injections of insulin. The extra insulin will not cross the placenta and will not affect the baby. Any woman who needs to take insulin will be taught how to take it by her doctor or nurse.

It is possible to have too much insulin and this can cause low blood sugar (hypoglycaemia). Common symptoms of this are weakness, shaking, hunger and sweating. For people taking insulin, it is a good idea to keep a snack handy at all times in case low blood sugar develops.

After the birth

In almost every case, gestational diabetes disappears on its own after delivery. To be sure, doctors may check the mother´s blood sugar levels a few times after the birth.

Prevention

To help reduce the risk of getting gestational diabetes, women should make healthy lifestyle choices, such as eating a balanced diet, taking regular exercise and maintaining the correct weight for their height.

Tests in pregnancy

The aim of tests during pregnancy (antenatal tests) is to monitor the health and wellbeing of the mother and developing baby (fetus). Some antenatal tests are routinely offered to all women and others are offered only to certain women because of their age and medical or family history.

Pregnancy tests

The first test of any pregnancy is one that confirms the woman is pregnant. Conception typically takes place midway through a woman´s menstrual cycle. Pregnancy tests are very accurate and can usually detect pregnancy from the time a woman misses her first period - approximately two weeks after conception. Women can buy home-testing kits from a pharmacy, or take a urine sample to their obstetrician surgery.

Check-ups during pregnancy

Once a woman knows or suspects she is pregnant, she can make an appointment with her obstetrician to discuss antenatal care and tests. The obstetrician will ask about any previous pregnancies, general health and whether any close members of the family have a health problem that can be inherited, such as cystic fibrosis.

The obstetrician checks that the woman is taking the right dose of folic acid supplement and gives general advice about pregnancy.

An estimated date is given for when the baby is due. A brief ultrasound scan is performed to confirm that the size of the baby fits with the estimated dates and to check if the woman is expecting more than one baby.

The nurse or doctor takes a blood sample. Although there may be some variation between different healthcare providers, the following are the typical blood tests done at the booking visit:
 
 - blood group and rhesus (Rh) type. Women are either Rh positive or negative. Rh negative women are usually offered an injection after delivery to protect their next baby from the risk of anaemia 
 - haemoglobin to check for anaemia 
 - screening for infections that can affect the mother and baby, such as hepatitis B or syphilis and HIV 
 - immunity to rubella (german measles). Women who are found not to be immune are given advice on how to reduce the risk of catching it and what to do if they catch it

Other blood tests may be offered depending upon a woman´s medical history and ethnic background.

The woman´s height and weight are recorded. Women who are underweight or overweight may need extra care.

A pelvic examination (internal) is not usually needed although women may be offered a smear if this is not up-to-date, or swabs if there have been symptoms of vaginal infection.

Routine tests

At each appointment blood pressure and urine are tested and the baby´s development is checked.

Checking the mother´s health

Blood pressure is monitored as this can rise during pregnancy. Urine is tested for infection and for the presence of protein. Protein in the urine and raised blood pressure are two signs of pre-eclampsia - a symptomless condition that can be harmful to both mother and baby and may mean that the baby needs to be delivered early. Blood is tested again at 28 weeks for anaemia.

Checking the baby´s development

As the baby grows, the uterus rises out of the woman´s pelvis and becomes the "bump". The top of this is called the fundus. The height of the fundus is measured to ensure that the baby is growing.

The baby´s heartbeat is not routinely checked, but some mothers may ask to listen to it for reassurance. The midwife or doctor may use a device placed on the abdomen to amplify the heartbeat.

At around 19-20 weeks, women start to feel the baby moving. Babies have active and restful times. In the early months, they have plenty of room and may move around a lot. As the pregnancy progresses, the midwife or doctor will ask about the baby´s movements and try to determine the position of the baby by feeling the mother´s abdomen. Towards the end of pregnancy, the head usually drops down into the pelvis into a position ready for delivery (when the head is said to be engaged).

Checking for abnormalities

The majority of pregnancies result in the birth of a healthy baby. However, if there are any problems, knowing about them in advance can help parents and doctors plan for the baby´s future and assess any special requirements for the birth and aftercare.

Various tests may be offered to check the health of the baby. Screening tests assess the risk of the baby being born with certain conditions, such as spina bifida or Down´s syndrome, but cannot give a definite "yes" or "no" diagnosis. The overall calculation of risk may include more than one type of screening test plus the woman´s age.

Other tests can confirm whether the baby has a certain condition.

For many women, the decision to have these tests is a difficult one: it´s important to consider what it would mean if the results were abnormal.

Blood tests

Blood tests are offered from 11-20 weeks. The levels of a number of chemicals can be measured in the mother´s blood to help estimate the risk of the baby suffering from certain conditions, such as spina bifida or Down´s syndrome.

Different tests measure different hormones or proteins, or combinations of these, including alpha-fetoprotein (AFP), human chorionic gonadotrophin (hCG), oestriol and inhibin A. If hCG and AFP are used as a screening test, this is often called the "double test". If oestriol is added to the double test, this is known as the "triple test". If inhibin A is added to the triple test, it becomes the "quadruple test".

Ultrasound scanning

In early pregnancy, as well as checking the size of the fetus and looking for more than one baby, ultrasound is used to diagnose early complications such as miscarriage.
At 18-20 weeks of pregnancy, most women have a more detailed ultrasound scan. The ultrasonographer makes sure the right amount of fluid surrounds the baby, examines the baby´s head, heart, spine, limbs and internal organs in detail and checks the position of the placenta (which joins the mother and fetus and allows exchange of nutrients and waste products between them). This scan can identify some physical abnormalities, such as cleft lip or skeletal abnormalities, and can confirm spina bifida if blood tests have shown the baby is at high risk. It cannot diagnose Down´s syndrome.

Nuchal translucency scan

This is a screening test for Down´s syndrome that´s usually offered at 11-14 weeks. It involves an ultrasound scan to measure the thickness of the layer of fluid at the back of the baby´s neck. Babies with Down´s syndrome have a thicker layer. If it is thicker than average, women are usually offered an amniocentesis for diagnosis.

Amniocentesis

Amniocentesis is a diagnostic test that some women choose to have, usually between 15 and 19 weeks of pregnancy. A fine needle is inserted into the amniotic fluid surrounding the baby. Ultrasound is used to guide the positioning of the needle. The amniotic fluid contains some cells from the baby that are cultured in the laboratory and then analysed in detail. Full results can take up to four weeks.

This is an accurate way of finding out whether the baby has a number of genetic or inherited disorders, such as Down´s syndrome or cystic fibrosis. Amniocentesis carries a 0.5 -1% risk of harming the baby or causing a miscarriage. It is usually only offered to women when screening tests show they may be at a higher risk of having a baby with a genetic disorder, or to women over 35 years old.

Chorionic villus sampling (CVS)

For CVS, a fine instrument is inserted through the woman´s cervix into the uterus and a sample of the chorionic villi (tiny fingerlike projections found in the placenta) is removed. These have the same genetic material as the baby.

This test looks for similar problems as amniocentesis, although it does not test for neural tube defects. CVS is performed earlier - usually between 10 and 12 weeks of pregnancy, and the results are usually available within a few days. The results are not quite as accurate as amniocentesis, the procedure is technically quite difficult and it is not always successful. There is a slightly higher risk of miscarriage with CVS - approximately 1-2%.