Consultant Obstetrician & Subspecialist in Maternal Fetal Medicine
"We were impressed by your excellent attention to details combined with your friendly and personal nature."
".... you truly are a beautiful person. I couldn't have got better without you"
This is your first antenatal visit with Dr Hunter. This involves an ultrasound scan and discussing the care plan and options available during the pregnancy. Your past medical and obstetric history will be discussed.
Details of previous pregnancies are relevant when making decisions about the care you receive. Some of the main topics are described below. If there is anything else you think may be important, please tell us.
This is a term which describes how many babies you already have. Usually early pregnancy losses are also listed after a 'plus' sign. For example, the shorthand for two previous births and one miscarriage is '2 + I'.
High blood pressure and/or pre-eclampsia.
If you had this condition last time, you are more likely to have it again, although it is usually less severe and starts later in pregnancy. It is more likely to happen again if you have a new partner.
This means any birth before 37 weeks but the earlier the baby is born, the more likely that it will have problems and need special or intensive neonatal care. The chance of premature birth is increased because of smoking, infection, ruptured membranes, bleeding, or poor growth. Having had a baby prematurely increases the chances of it happening again.
Small babies (fetal growth restriction).
If one of your previous babies was growth restricted, there is a chance of it happening again. Arrangements will be made to watch this baby's growth more closely, offering ultrasound scans and other tests as necessary.
Big babies (macrosomia).
A baby over 4.5 kg is usually considered big - but this also depends on your size and how many weeks pregnant you were when the baby was born.You may be offered a blood test to check for high blood sugar (diabetes), which may be linked to having big babies.
Previous caesarean section.
If you have had one caesarean section in the past you have a good chance (40-70%) of having a vaginal birth this time. I will discuss with you the reason for your last caesarean and the options for childbirth this time. Labour after a previous caesarean section is monitored more closely, to make sure the old scar does not tear, although in over 99% of cases this does not happen. If you have had two or more caesarean sections in the past, you will be advised to have your next baby(ies) by caesarean section.
Bleeding after birth.
Postpartum haemorrhage (PPH) means a significant loss of blood after birth (usually 500 ml or more). Often this happens when the womb does not contract strongly and quickly enough. There is a chance of it happening again, but your midwife will make sure they are prepared for this eventuality.
The postnatal period lasts up to 6 weeks after the birth and it is during this time your body recovers. However, for some women problems can occur, including feeding difficulties, slow perineal healing, or concerns with passing urine, wind and/or stools. If you have experienced these or any other complications, talk to your doctor or midwife.
It is quite common to feel low for a little while after having a baby because of the huge emotional change and tiredness. However, some mothers do become seriously depressed. This can carry on for months or even years and may require help, counselling and/or medication. Depression can happen again, so it is important that we know about it. We can then discuss any special worries or anxieties you may have and arrange counselling and help to suit your needs.
A miscarriage is usually thought to happen because of a one-off problem with the baby's chromosomes, causing an abnormality. After one miscarriage, the chances of a successful next pregnancy are as good as before. If you have had three or more miscarriages, there is still a good chance that this pregnancy will go well, but special tests may be required.
What if I've had a termination (abortion) but do not want anyone to know?
This information can be kept confidential between Dr Hunter, yourself and your doctor and can be recorded elsewhere.
The first half of pregnancy is a time when various tests are offered to check for potential problems, by blood tests and ultrasound scans. The tests listed here are the ones usually recommended in the UK by the Royal College of Obstetricians and Gynaecologists. We can list only brief points here, but further information can be found on www.preg.info.
Do not hesitate to ask what each test means.
Blood Tests and Investigations
Blood group & antibodies. This test tells us your blood group; whether your blood is Rhesus Positive (Rh +ve) or Negative (Rh-ve); and whether you have any antibodies (foreign blood proteins). If you are Rh-ve, you will be offered blood tests to check for antibodies. If your baby has inherited the Rh +ve gene from the father, antibodies to the baby's blood cells can develop in your blood. To prevent this, you will be advised to have 'anti-D' injections whenever there is a chance of blood cells from the baby spilling into your blood stream (e.g. due to miscarriage, amniocentesis or CVS, vaginal bleeding, a blow to the abdomen, and after the birth of the baby). It is recommended that Anti-D is given routinely to all Rh -ve mothers at 28 and 34 weeks of pregnancy (however, by autumn 2008 this may be reduced to one injection at 30 weeks).
Rubella (German Measles). Rubella infection early in pregnancy can damage your baby. A test is offered to check your immunity (ability to fight infection). Most women are protected by routine rubella vaccinations given in childhood, but if you are not immune, you will be advised to be immunised after the birth. Inform your midwife or GP if you develop a rash.
Hepatitis B is a virus which infects the liver. If you are a carrier of the virus or have become infected during pregnancy, you will be advised to have your baby immunised at birth to avoid infection.
Syphilis is a sexually transmitted disease and can seriously damage your baby if left untreated. If detected, treatment can be offered with antibiotics to control the infection and to help protect your baby.
HIV (Human Immunodeficiency Virus) affects the body's ability to fight infection. This test is important because any woman can be at risk. It can be passed on to your baby during pregnancy, at birth or through breastfeeding. Treatment given in pregnancy can greatly reduce the risk of infection being passed from mother to child. A negative test does not affect past or future life assurance claims.
Sickle Cell and Thalassaemia are blood disorders that can be passed from parent to child. You will be offered a blood test if you are living in an area with high occurrence of the disorder, or if there is an increased chance of you being a carrier without knowing. This is the case if you or your family come from Africa, the Caribbean, India, Pakistan, Bangladesh, South East Asia, China, the Middle East, or Mediterranean countries (e.g. Greece, Italy, Turkey, Cyprus). The results may require the baby's father to be tested.
Additional tests may be offered as necessary,' for example to check for infections which can cause damage to the developing baby, but rarely cause problems for the mother. Inform your midwife or GP if you develop any rashes or if you think you have been in contact with any of the following:
1. Chicken pox can cause problems to the developing baby if caught before 20 weeks of pregnancy. It can also be passed to the newborn baby if caught within 10 days prior to the birth. Howvever, if you have had chickenpox infection you should be immune as will the baby – if not sure a blood test can be taken to investigate further.
2. Cytomegalovirus (CMV) prevention involves careful hygiene especially thorough washing of hands.
3. Parvovirus (slapped cheek syndrome) often causes a red rash on the face and is mostly seen in children.
4. Toxoplasmosis is caused by an organism that is found in cat faeces, so always wear gloves when gardening or changing cat litter. Also make sure that all food is washed and thoroughly cooked before it is eaten.
Blood pressure (BP) needs to be checked to detect pregnancy induced hypertension or pre-eclampsia. High blood pressure may cause severe headaches or flashing lights. If this happens, tell your midwife or doctor immediately.
Urine tests A mid-stream urine sample (MSU) is collected in early pregnancy to check for infection. You will also be asked to supply a sample of your urine at each visit to check for protein (recorded as + or + + = presence of), which may be a sign of pre-eclampsia or a urine infection but may be completely normal.
Fetal movements (FM or FMF = fetal movements felt). You will usually start feeling some movements between 16 and 22 weeks. Later in pregnancy your baby will develop it's own pattern of movements. This will range from kicks and jerks to rolls and ripples. Sometimes your baby will hiccup. You will very quickly get to know the pattern of your baby's movements. At each antenatal contact we will talk to you about this pattern of movements, which you should feel each day. A change, especially a reduction in movements, may be a warning sign that the baby needs checking by ultrasound and Doppler. Become familiar with your baby's typical daily pattern of movements and contact us or Royal Maternity admissions immediately if you feel that the movements have altered.
Fetal heart (FH or FHHR - fetal heart heard and regular). At our clinic fetal heart will be checked on by ultrasound at each visit.
Liquor refers to the amniotic fluid, the water around the baby. A gentle examination of the abdomen can give an idea of whether the amount is about right (recorded as NAD, no abnormality detected, or just N), or whether there is suspicion of there being too much or too little. The ultrasound will also check the liquor volume.
Lie and Presentation. This describes the way the baby lies in the womb (e.g L = longitudinal; 0 = oblique, T = transverse); and which part it presents towards the birth canal (e.g. head first or cephalic = C, also called vertex = Yx; bottom first or breech = B or Br).
Engagement is how deep the presenting part - e.g. the baby's head - is below the brim of the pelvis. It is measured by the proportion which can be still felt through the abdomen, in fifths: 5/5 = free; 4/5 = sitting on the pelvic brim; 3/5 = lower but most is still above the brim; 2/5 = engaged, as most is below the brim; and 1/5 or 0/5 = deeply engaged, as hardly still palpable from above.
In first time mothers, engagement tends to happen in the last weeks of pregnancy; in subsequent pregnancies, it may occur later, or not until labour has commenced.
Internals / vaginal examinations are NOT usually done at antenatal visits unless there is a specific reason. Please discuss with your midwife or doctor if you have any concerns about this. They may be performed from 39 weeks to check for ripening (opening of the cervix- neck of the womb). If the cervix has started to open at this stage a stretch and sweep examination may be performed to improve the chances of a natural onset of labour.
Assessing Fetal Growth
Fundal height. During the second half of your pregnancy ultrasound will be used to assess fetal growth and wellbeing at each visit.
Growth restriction. If the growth of the baby has slowed then assessment of Doppler flow is recommended, which indicates how well the placenta is managing the blood supply needed for the baby. If there is a serious problem, your obstetric team will need to discuss with you the best time to deliver the baby.
Large baby (macrosomia). The ultrasounds may sometimes detect that the baby is large for dates. Occasionaly very big babies may cause problems either before or during birth (obstructed labour, shoulder dystocia etc.). However, most often they are born normally. Research has shown that there is no definite advantage in inducing women early who have a big baby.
High blood pressure. You need to tell us or RJMH immediately if you get headaches or spots before your eyes, as these can be signs that your blood pressure has risen sharply. If there is also protein in the urine, you may have pre-eclampsia which in its severe form can cause blood clotting problems and fits. It is also often linked to restricted growth and other problems for the baby.
Diabetes may be present before pregnancy, or may only happen during pregnancy (gestational diabetes). It can show as sugar in the urine, when blood sugar levels become high due to a lack of insulin. High sugar levels cross the placenta and can cause the baby to grow large (macrosomic). The baby gets used to these high sugar levels and sometimes can have difficulty getting used to managing without them - causing it to have low blood sugar (hypoglycaemia) after birth. If you have or develop diabetes you will be looked after by a specialist team who will check you and your baby closely throughout the pregnancy. Gestational diabetes usually settles after pregnancy but can happen again in future pregnancies.
Itching. Severe itching, especially on the hands and feet, can be caused by a liver condition known as Obstetric Cholestasis.Cholestasis can affect the baby and may result in complications including a slight, but rare, increase in stillbirth if not treated. Blood tests can check to see if you have the condition. If you do, you may require tablets and the baby will require careful monitoring. The timing of delivery should be discussed with you by your doctor according to your individual needs.
Thrombosis (clotting in the blood). Your body has naturally more clotting factors during pregnancy to stop the bleeding as quickly as possible once the 'afterbirth' is delivered. However this also means that all pregnant women are at a slightly increased risk of developing blood clots during pregnancy and in the first weeks thereafter. The risk is higher if you are over 35, overweight, smoke cigarettes, or have a family history of thrombosis. You are advised to go to RJMH admissions immediatelyif you have pain or swelling in your leg, or pain in your chest, or cough up blood.
Vaginal bleeding. Bleeding may come from anywhere in the birth canal, including the placenta (afterbirth). Occasionally, there can be an 'abruption', where a part of the placenta separates from the uterus, which puts the baby at great risk. If the placenta is lying low in the uterus, tightenings or contractions may also cause bleeding. Any vaginal blood loss should be reported immediately to RJMH. You will be asked to go into hospital for tests, and advised to stay until after the bleeding has stopped or until the baby is born. If you are Rh -ve, you will require an Anti D injection.
If the waters break. Spontaneous rupture of the membranes (SROM) is followed by a gush, leak or trickle of amniotic fluid. You are advised to call RJMH to check whether you are in labour, and to make sure that the baby's cord has not slipped down. If you are not in labour, swabs will be taken to check for infection.
Prematurity. labour may start prematurely (before 37 weeks), for a variety of reasons. Before about 34 weeks, most maternity Units have a policy of trying to stop labour for at least a day or two, whilst giving steroid drug injections (e.g. betamethasone) to help the baby's lungs to mature. However once labour is well established, it is difficult to stop.
Breech. If the baby's presentation is not head first (cephalic), there is an increased chance that labour will not be straightforward. It is now usually recommended to try to turn the baby before labour commences (ECY = external cephalic version). However, the procedure is not always successful. Your midwife and obstetrician will discuss with you the options on how best to deliver a baby that stays in the breech position: delivery by a planned (elective) caesarean section is now recommended.
Multiple pregnancy. Twins, triplets or other multiple pregnancies need close monitoring, and more frequent tests and scans are recommended. Further details about the special needs of multiple pregnancies can be found on www.preg.info
Parentcraft Education Day - Antenatal Classes from 352
Parentcraft (or Antenatal) classes for prospective “new” and maybe “not so new” (who require a wee refresher session) mothers and fathers are an important part of antenatal care. They help prepare you for some of the more exciting, but equally daunting, times ahead!
The NHS provides parentcraft classes over 6 successive weeks from about 24 weeks onwards in the hospital. However, many mums/dads find this level of commitment difficult to get to and have found these Saturday sessions extremely useful and good fun. The day starts at 0945 and ends at 1600hrs.
These parentcraft days occur every 6 weeks and are run by 2 experienced parentcraft midwives, at the Wellington Park Hotel, Malone Road, Belfast BT9. For more information, contact Margaret Boyd: 02890634896(Voicemail) or 02890633293 (Direct Line). Parking is on site and please present your ticket to reception to receive a reduced parking ticket.
The includes a lunch of soup and sandwiches, which is the same, regardless of whether the partners attend or not. If the partners do attend, I am reliably informed that the bar does good Guinness!
It is best to book these sessions for between 24 and 32 weeks of the pregnancy.