Σάββατο, 13 Φεβρουαρίου 2010
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Your Pregnancy – a survival guide
Pregnancy and childbirth is an amazing period of your life, with plenty of excitement and worries and eventually some unforgettable memories. We aim to provide careful monitoring and constant reassurance so that will be confident and relaxed to enjoy your pregnancy.
We count a total of 40 weeks, starting on the day that your last actual period began.
You obviously did not get pregnant on that day, but approximately 2 weeks later, upon ovulation, and the actual duration of the gestation is therefore 38 weeks. Still, we use your LMP (Last Menstrual Period) as a defining point, as cycle duration varies and it is frequently impossible for you to know exactly when you conceived.
Your first visit at the Practice is vital. Your period may be late and you are not certain what’s going on. We will confirm your pregnancy status and with pelvic ultrasound (which is absolutely safe) we will make certain that this is a healthy intrauterine pregnancy, thus ruling out a threatened miscarriage or an ectopic.
We will then sit down, take a deep breath and talk about the next 9 months, how your pregnancy will be monitored and exactly which investigations may be needed. We will discuss common pregnancy symptoms and worries, no matter how insignificant they may seem. You will leave the office relaxed, confident and jubilant.
We may need to repeat the scan to confirm that the pregnancy sac keeps growing and eventually the fetal heartbeat becomes obvious. I will also suggest some blood tests that will rule out infections such as rubella (german measles) and hepatitis. Some of those sound strange and offending, such as syphilis and HIV. Trust me, this is a universally accepted screening package in pregnancy and all those diseases, if promptly diagnosed and treated, can save your baby’s life.
An early visit to the Dentist will be advised. Your teeth and gums are sensitive in pregnancy and any kind of oral cavity infection can later be related to premature contractions and labour. Any dental work should therefore be carried out promptly, with the appropriate local anaesthetic. I would only wish to avoid a dental X-ray in pregnancy.
The first trimester, up to 12-13 weeks, can be rather difficult. Headaches, morning sickness and vomiting, swellings, mood swings, you name it. There is also a continuing risk of miscariage, gradually diminishing as your pregnancy progresses, and you might experience abdominal discomfort or even spotting. Your skin may well change while you're pregnant. You might find that it becomes less dry or less oily, or that you get fewer spots, or the opposite could happen. Extra fluid in your face may smooth out any wrinkles, but it may also make you look a bit chubby. Quite early on, you will notice that the area around your nipples is darker and a brown line appears down the centre of your abdomen. You may get brown
patches on your face too, especially if you're in the sun. All these colour changes go away or fade after the baby is born. Stretch marks, may appear on your bump and your breasts from about three or four months. There’s no evidence that these can be prevented. They fade after the baby is born but never disappear.
We will discuss any complaints and exclude potential problems and complications.
The next milestone is the nuchal scan at 12-13 weeks. You will be gradually feeling better and this a good time to enjoy your baby on ultrasound, fully formed and playful and not that big yet. This is also an excellent opportunity to check the space behind the baby’s neck, the nuchal translucency. All babies have a small quantity of luis underneath the skin of the back of the neck. In Down syndrome babies this is found commonly increased. Unfortunately not all Down babies have increased fluid and, vice versa, not all babies with increased fluid have Down’s syndrome. We have therefore monitored several thousands of pregnancies in US and in the UK ten years ago. We checked the nuchal fluid, took into account the age of the mother and obviously the pregnancy outcome. These observations resulted in a screening test, an equation with all the above parameters. This test can pick up more than 90% of Down babies. We will check the nuchal translucency, ask for your age and your last period, and enter all the parameters in a computer software. The computer will alter your basic, age-related risk for Down syndrome, and give you an adjusted risk. If the final risk sounds good, (and we’ll have a long chat about acceptable risks), we may decide to avoid an amniocentesis, even when you are older than 35. An additional, independent parameter that will increase the sensitivity of the test is a hormone blood test (free BHCG and PAPP-A). When your blood result is ready, we shall modify the risk and give you the final result.
The next important scan is the anomaly scan, or b-level scan. This will take place at 22-23 weeks of gestation. It is a thorough scan, checking number of fingers, heart valves and other important details of the baby’s anatomy. A normal result is reassuring but bear in mind that some minor abnormalities may still be missed, even in expert hands.
From 14 weeks onwards, you will also probably feel much better, with plenty of energy to do things and appetite. Take it easy and keep an eye on your scales. You will be free to have a holiday as long as you do not stress yourself too much and avoid exposure to the sun. You will be able to swim and take sport activities. Sex will also be part of the agenda, unless advised otherwise.
We will have regular visits in our Practice, every four weeks, and more frequently should any problem arise. We will be checking the blood pressure, the urine and your weight and we will do regular scans to check the baby’s growth. I will be checking on you overall welll-being, including the psyhological aspect and see that your pregnancy progresses smoothly. Our midwife will be advising on breast preparation for lactation and nipple care.
At 28 weeks I will ask you to have a glucose tolerance test, in order to exclude gestational diabetes.
At 32 weeks a Doppler scan will reassure us that the placenta remains healthy and that the blood flow and the oxygen supply to the baby is adequate.
At 37-38 weeks, in addition to ultrasound, we will do a cardiotocogram (CTG), checking the baby’s heart rate variation in relation to uterine contractions. This is an additional reassuring test to check fetal well-being.
From 36 weeks onwards, we will be prepared for labour. Early labour signs include regular contractions and the rupture of membranes. If your waters go, it will be easy to tell, there is usually plenty of it and you will get soaked. You must immediately get going for the hospital. If you start having painful contractions, check how frequently they come and whether they are regular or not. Genuine labour pain, as opposed to Braxton-Hicks contractions, comes and goes at regular intervals, initially every 20-30 minutes, gradually getting more frequent. When not certain, you ring me or my midwife and we tell you what to do. Another early sign is the ‘show’, a mucous, thick, vaginal discharge, occasionally mixed with small amount of blood. This is the cervical ‘plug’ that kept the cervix tightly sealed throughout pregnancy and prevented micro-organisms from ascending into the cavity of the womb. A couple of days prior to onset of labour, this, having served its purpose, will pop out. It is a fairly accurate sign that labour is imminent, so don’t panic, don’t rush to the hospital, just have your things ready.
When the time comes, be it regular pain or the waters, you ring me or the midwife and we all meet in Labour Ward. We will remain with you throughout the whole labour and keep you informed and so that you remain confident and reassured.
Epidural anaesthesia is strongly recommended, but obviously you are the one to decide. An epidural will completely stop any painful sensation without making you drowsy. You will be alert, yet relaxed. You will not be stressed and you will be breathing better and that helps the oxygen supply
to the baby. There are no significant recognised side-effects apart from a transient headache.
An epidural will not affect the labour outcome and will not increase the possibility for
I will guide through the stages of labour, aiming towards a straightforward vaginal delivery, and I am keen to persist and wait, as long as it is safe, in order to get there. However if any complication arises, or if the baby simply gets ‘stuck’ within the pelvis, we will be ready to proceed, with your consent, to a safe instrumental delivery or caesarean section. The Labour Ward at Iaso is perfectly organised and the staff are trained to assist in any kind of emergency. In the end of the day what we must have is a healthy mother and a healthy baby and I am keen to pre-empt problems and advocate safe, standard practice.
Once the baby is born, we will give you to hold and hug for as long as you like, early bonding between the two of you is essential. In the meantime, I will remove the placenta and may need to put a couple of stitches in the vagina. You will then be able to rest for a couple of hours in Labour Ward Recovery before you are transfered to your bed in the Ward.
Basic guidelines and do’s and dont’s for your pregnancy
Any medication use should be discussed with us, particularly during the 1st trimester. You may take paracetamol tablets (Depon, Panadol), up to 3 a day, if you have a headache or a flu, and Buscopan tablets for the occasional tummy ache, but other than that talk to us and double-check.
The only strict prohibition in pregnancy is smoking and if you do smoke we will advise to give it up promptly. Smoking has been related to high risk of miscarriage, prematurity, placental abruption, high blood pressure. Maternal smoking has also been incriminated for cot death in infancy.
You may have sexual intercourse throughout pregnacny, unless otherwise indicated. Always make certain that this is not painful or uncomfortable and you may want to try different, more comfortable positions We obstetricians tend to advise against it during the last 4 weeks of gestation, but even then there is no harm you can do apart from initiating labour.
Try to keep away from stray cats and if you have a cat yourself, have someone else to collect its faeces. Avoid fresh salads if the greenery has not been thorougly cleaned.
Dring plenty of milk – at least two full glasses a day. You may opt for semi-skimmed milk, with less fat but same amount of calcium and vitamins. Make sure that your milk is pasteurised- avoid fresh goat milk from your village! Avoid evaporated milk – most of its vitamins have been affected.
Avoid nuts during pregnancy. Recent studies relate maternal consumption in pregnancy with subsequent allergy to nuts of the offspring.
You may use hair dye and nail polish, as this has not been found to have any detrimental effect whatsoever to your pregnancy.
You may drive your car up to the end of gestation, as long as there are no pregnancy complications. Always wear your seatbelt, with the the horizontal part underneath your belly and the transverse part crossing above it.
It is safe to work long hours in front of a computer screen, as it is established to be absolutely safe.
FOODS TO AVOID
• Soft cheese, such as Brie, Camembert, however, cottage, gruyere and feta cheeses are fine. Blue-veined cheeses, such as Danish Blue or Stilton should also be avoided.
• Unpasteurised goat's, cow's, or sheep milk. • Ready-prepared coleslaw. •Raw shellfish. •Raw eggs (in mayonnaise, mousses, cake-icing or cheesecake). •Paté (any type) •Raw or undercooked meat. •Liver (unacceptably high levels of vitamin A). •Peanuts or peanut butter (if there's a family tendency to allergies).
Common concerns and issues to discuss
Nearly 80% of women experience pregnancy sickness - and not just in the morning. Some women will just feel a bit nauseous. Others will feel sick every day and may actually vomit. An unlucky few will be so unwell that they need to take time off work. The good news is that most women start to feel a lot better at about 14 weeks. Hormonal changes may be the cause: the pattern of sickness seems to follow the ebbs and flows of human chorionic gonadotrophin (hCG), the hormone that orchestrates the production of other pregnancy hormones. Levels rise rapidly during the first six weeks, peak at eight to 10 weeks, and begin to fall at 11-13 weeks. Some people believe that pregnancy sickness protects your baby from harmful substances, this may be why so many women can't bear coffee, alcohol, cigarette or petrol fumes at this crucial time. Snacking can help reduce morning sickness. Some women are really helped by sucking lemons or peppermints, others swear by crisps, bananas or breakfast cereals. Nibble something at night if you wake up. It may stop you feeling so sick in the morning. Homemade, day-old popcorn is said to reduce nausea. Keep crackers by the bedside to nibble before you get up in the morning. Try ginger biscuits or ginger ale, or make ginger tea by infusing a little grated ginger root with boiling water in a teapot. You can add lemon or honey to taste and drink hot or cold. A supplement of vitamin B6 with magnesium may help if you are vomiting a lot. Foods rich in B6 include cereals, bananas, baked potatoes, lentils and tinned fish. Sea sickness acupressure bands, which are available from pharmacies, may also be helpful. You should also try to rest as much as you can.
Varicose veins are caused by a combination of factors. Pregnancy hormones relax the muscular walls of the veins, while at the same time there is more blood for your circulation to pump around. This makes it more difficult for the muscle tissues and the valves in the veins to pump the blood back up to the heart, which means that some blood pools in the lower body. Another factor is the weight of your enlarging uterus that puts extra pressure on the veins of the legs and pelvic region. Some women feel no discomfort, but others suffer a mild ache, or a heavy feeling in their legs, or even acute pain. Those who are expecting twins or multiples, or those for whom varicose veins run in the family - are more at risk. You can avoid trouble by: • Walking and swimming more, to pump the blood around; • Doing specific exercises to prevent the blood pooling - frequent ankle flexions and rotations, at least 30 seconds at a time, with the feet elevated; • Doing frequent pelvic floor exercises (see below); • Never sitting with your knees crossed, or thighs pressing against the edge of a chair; • Always resting with your legs raised; • Trying not to stand for long periods of time; If you are already suffering from varicose veins, the measures above can help, but also try wearing support tights and raising the foot of your bed to help the blood drain back to the heart. For maximum effect they should be worn right from the start of your pregnancy.
Pelvic floor exercises
Our pelvic floor muscles hold all the abdominal contents in place and keep us continent, that is, they stop urine and faeces escaping when we cough, laugh, sneeze or lift. Exercising your pelvic floor muscles now will tone them up so they give support to your growing baby and uterus and help you feel more comfortable during the pregnancy. After pregnancy, pelvic floor exercises will encourage healing and recovery in that area.
Imagine you are desperate to empty your bladder, but when you get to the lavatory it's occupied. Instinctively, you will do a pelvic floor contraction and squeeze to stop wetting yourself. Try doing it now - pulling up around the front passage as if to stop yourself leaking, hold for a count of four and then release. You should feel the difference when you let go. Repeat the exercise in batches of six to eight as often as you can during the day. As well as holding for a count of four, try doing some where you squeeze, release, squeeze, release, quite quickly. Remember to keep breathing normally throughout. Once a week, while sitting on the loo, you can try to stop in midstream while peeing to check that you are doing the exercise correctly.
Your own breastmilk is exactly the right food for your baby. There's strong evidence that babies do best if they have nothing but breastmilk for about the first six months of life. This may be important if you have any diabetes or allergies in your family as the use of formula milk increases the risk of diabetes, asthma or eczema. Breastfeeding protects your baby from infections, including sickness and diarrhoea, ear infections and chest infections. For some infections this protection continues even after you stop breastfeeding. Exclusive breastfeeding - giving nothing except breastmilk - is more likely to reduce the risk or severity of allergies and provides the best protection. However, combining breastmilk with some formula still helps to reduce the risk of infections. Women who breastfeed have less risk of pre-menopausal breast cancer, ovarian cancer and broken bones due to osteoporosis in later life. If you choose to combine formula feeding alongside breastfeeding, you can increase your chances of maintaining a good milk supply if you only introduce formula once breastfeeding is well established. Your midwife, health visitor or breastfeeding counsellor can help you work out when – and how - to do this. But if you start to bottle feed from the beginning it can be very hard to change to breastfeeding. If you are undecided, it's therefore best to start breastfeeding. Your baby will benefit from even a few feeds of colostrum - which is the first milk that your breasts produce, rich in antibodies and other substances that protect against illness and infections.
If you worry about the ‘day-after’, when you go home with your baby, have a chat with our Paediatrician, Dr Amalia Michaelidou. She is a Consultant Neonatologist at Iaso Neonatal Unit and a Member of the Royal College of Paediatrics in London. She will guide you through the basic do’s and dont’s and reassure you.
Above all, don’t worry. Pregnancy is a normal process and all problems and complications are very rare. Enjoy your pregnancy and don’t listen to horror stories and scenarios. We will be monitoring your pregnancy closely and keep you well informed and reassured.
Dr Alexandros Kalogeropoulos
Member of the Royal College of Obstetricians & Gynaecologists, London