Pregnancy Care

NSW HEALTH DEPARTMENT This work is copyright. It may be reproduced in whole or in part for study training purposes subject to the inclusion of an acknowledgement of the source and no commercial usage or sale. NSW Health Department 2001 SHPN: (HPA) 970085 ISBN: 0 7313 0649 X For further copies please contact: Better Health Centre Publications Warehouse Locked Mail Bag 5003 Gladesville, NSW 2111 Tel. (02) 9816 0452 Fax. (02) 9816 0492 A full copy of this report and others in this series can be downloaded from the NSW Health Web site: http://www.health.nsw.gov.au Reprinted June 1997 Reprinted June 2001

Contents
INTRODUCTION ......................................................................................................1 1. PLANNING A HEALTHY PREGNANCY.........................................................1 PREPARING FOR PREGNANCY..............................................................................1
General checkup Diet rich in folate Dental check Check your immunity to rubella Give up smoking Limit alcohol intake Limit caffeine intake
Care with drugs

Keep cool Hazards at work

RISKS FOR OLDER WOMEN ..................................................................................8 2. PROGRESS OF PREGNANCY ..........................................................................9 FIRST SIGNS ..............................................................................................................9 PREGNANCY TESTS...............................................................................................10 UNPLANNED PREGNANCY ..................................................................................10 HOW THE BABY GROWS ......................................................................................11
Stages of development Development of the senses

DURATION OF PREGNANCY................................................................................13 MULTIPLE PREGNANCY .......................................................................................13 YOUR EMOTIONS...................................................................................................14 3. WILL THE BABY BE NORMAL?...................................................................15 GENETIC COUNSELLING......................................................................................15
Cystic fibrosis (CF) Thalassaemia

PRENATAL DIAGNOSTIC TESTS..........................................................................16

Ultrasound Chorionic Villus Sampling (CVS) Amniocentesis Alpha Fetoprotein Test (AFP)

CHROMOSOMAL ABNORMALITIES ...................................................................18

4. ANTENATAL CARE ..........................................................................................19 THE FIRST VISIT .....................................................................................................19 LATER VISITS ..........................................................................................................20 SEXUALLY TRANSMISSIBLE DISEASES (STDs) ..............................................21
Chlamydia Gonorrhoea Genital herpes Genital warts

HIV/AIDS ..................................................................................................................22 CHOICES IN CHILDBIRTH ....................................................................................22

Hospital birth Birth centre Homebirth

GOING HOME EARLY ............................................................................................24 5. TAKING CARE ..................................................................................................25

What to wear Work Parental leave Childcare Exercise/sport Overheating Infections Dental check Bathing Sex

TRAVEL.....................................................................................................................27
Car Air

HEALTHY EATING ..................................................................................................28

Food plan Suggested meal Snacks Vitamin supplements Caffeine Fluids Salt Takeaway foods Weight gain Foods to avoid Teenage pregnancy Vegetarian diet Changing your diet

BREAST CARE.........................................................................................................32
Preparing nipples

II

6. COMMON COMPLAINTS ...............................................................................34

Backache Bleeding gums Breathlessness Constipation Cramps Feeling faint Food cravings Frequent urination Headaches Heartburn Itching Morning sickness Nose bleeds Piles (haemorrhoids) Saliva Skin Sleeping problems Stretch marks Swollen ankles Tiredness Vaginal discharge Varicose veins

7. COMPLICATIONS IN PREGNANCY ............................................................39 WARNING SIGNS ....................................................................................................39 COMPLICATIONS ....................................................................................................39

Bleeding and miscarriage Bleeding after week 20 Diabetes Ectopic pregnancy High blood pressure Rubella

8. PREPARING FOR CHILDBIRTH...................................................................43 ANTENATAL COURSES .........................................................................................43 RELAXATION AND BREATH AWARENESS........................................................43
Learning to relax Recognising tension Breath awareness When to use breath awareness Practising breath awareness Massage Positioning

III

ANTENATAL EXERCISES ......................................................................................46

Exercises for abdominal muscles Exercise for pelvic floor muscles Back-mobility exercise Posture check Stretching Summary

9. CHILDBIRTH.....................................................................................................51 PREPARATION .........................................................................................................51

What you need Other children Stocking up Housework Making new friends

CHANGES IN YOUR BODY ...................................................................................52 WHEN TO GO TO HOSPITAL ................................................................................52 WHEN DOES LABOUR BEGIN?............................................................................53
Contractions A show Breaking of the waters

AT THE HOSPITAL ..................................................................................................53 LABOUR ...................................................................................................................53

First stage - external monitoring - internal monitoring Transition period Second stage Third stage

POSITIONS FOR GIVING BIRTH ..........................................................................57 PAIN RELIEF ............................................................................................................57

Self-help Relaxation/breath awareness Heat and water Massage Visualisation Groaning Staying active Changing positions

DRUGS IN LABOUR ...............................................................................................59

Sedatives and tranquillisers Gas Pethidine Epidural

SUPPORT PERSONS ROLE ...................................................................................60

IV

MEDICAL INTERVENTION....................................................................................60
Induction Episiotomy Forceps delivery Stirrups Vacuum extraction (ventouse) Caesarean section

10. COMPLICATIONS IN LABOUR....................................................................63

Premature labour Slow progress Babys position Fetal distress Retained placenta Multiple birth

DEATH OF A BABY.................................................................................................64 BABIES WITH PROBLEMS ....................................................................................64 11. AFTER THE BIRTH .........................................................................................66 YOUR BODY ............................................................................................................66
Your breasts Bleeding Stitches

POSTNATAL EXERCISES .......................................................................................66

Abdominal muscles Pelvic floor muscles Back muscles After a Caesarean Back care Summary

POSTNATAL CHECK...............................................................................................69 YOUR EMOTIONS...................................................................................................69 FATIGUE....................................................................................................................69 YOU AND YOUR BABY .........................................................................................69 CIRCUMCISION.......................................................................................................69 TESTS TO PROTECT YOUR BABY.......................................................................70 BREASTFEEDING ...................................................................................................70
Breast milk production When to feed How much is enough? Extra help Mastitis What can affect breast milk?

BOTTLEFEEDING ...................................................................................................73
Milk allergies

PRACTICALITIES ...................................................................................................73

Rubella immunisation Weekly checks Six-week check Personal Health Record Maternity Allowance and other financial assistance Registering the birth Australian Childhood Immunisation Register

12. COPING AT HOME .........................................................................................75 POSTNATAL BLUES ...............................................................................................75

Causes

SEX AND CONTRACEPTION ...............................................................................76

The Pill IUCD or IUD Condoms Diaphragm or cap

FOR MORE INFORMATION ...............................................................................77 APPENDIX A ..........................................................................................................78

Pregnancy Care Registered Midwives Aboriginal Health Services Womens Health Centres Community Health Centres Early Childhood Health Centres Genetic Counselling Services Prenatal Diagnosis & Related Counselling Services Drugs and Pregnancy Miscarriage, Stillborn Support HIV Counselling Services Postnatal Depression Support Services Breastfeeding & Motherhood

APPENDIX B ...........................................................................................................82
NSW Area & Rural Health Services

INDEX .......................................................................................................................84

VI

Introduction
Whether you are pregnant already or just thinking about starting a family, you are bound to have lots of questions. How can you make the pregnancy and birth as safe and as satisfying as possible? What can you (and your partner) do before conception to give your baby the best possible start in life? What are the choices in how and where you have your baby? How do you prepare for parenthood? This book aims to provide some of the answers. Knowing what is involved in pregnancy, birth and life after birth will help you to make informed decisions, cope with problems and get the most out of pregnancy and early parenthood.

Planning a Healthy Pregnancy

The first twelve weeks after conception are very important to your babys development. This is when all the babys organs are formed, including the heart, the brain and the nervous system. Yet it is also the time when you may not realise you are pregnant. That is why it makes sense to prepare your body for a healthy pregnancy before conception. If you or your partner are concerned that you might pass on an inherited disorder to your baby, now is the time to talk to a genetic counsellor (see Chapter 3, Will the Baby be Normal?). A genetic counsellor can assess the risk and provide information and support. In some cases, a simple test can determine whether you or your partner carry the gene for a specific disorder.

Preparing for Pregnancy

General checkup
A general checkup can spot any conditions that might cause problems in pregnancy. It is particularly important for women over the age of 30 who are planning to have a child. Your blood pressure should be checked - this makes it easier to detect any changes in blood pressure during pregnancy. It is also a good idea to have a Pap smear test at this visit (you should have one every two years). A Pap smear detects early changes in the cervix (the neck of the uterus) which could, if untreated, lead to cancer.

Diet rich in folate

A diet rich in the vitamin folate is good at all times for everyone. For most women a diet rich in folate for the month before as well as for the first three months of pregnancy will help to prevent neural tube defects, including spina bifida, in their babies. Neural tube defects occur very early in pregnancy. Aim to eat at least two serves of fruit (particularly oranges, berries and bananas), five serves of vegetables (especially green leafy vegetables) and seven serves of bread or cereals every day. Folate is easily destroyed by prolonged storage and cooking so it is wise to eat fruit and vegetables that are fresh, raw or lightly cooked.

Many babies with these defects die and others have problems with walking and with bowel and bladder control. About two in every thousand babies in Australia have a neural tube defect, caused when part of the backbone, spinal cord, skull and brain does not form properly. If you have had a baby with a neural tube defect your chance of having another affected baby is about one in 25. You are also more likely to have an affected baby if a close relative has had a baby with a neural tube defect. Genetic counselling before pregnancy is strongly recommended in such instances. There is no substitute for a good diet but taking a low dose folic acid tablet (0.5mg) as a supplement to the diet will ensure that you have a satisfactory intake of folate. These tablets are available from your chemist. If you are taking other medication regularly, check with your doctor before taking folic acid tablets. Supplementation with other vitamins in pregnancy is not recommended.

Dental check
Visit your dentist for a checkup to ensure that your teeth and gums are in top condition. If there are any problems, it is best to have the work done before you fall pregnant. For instance, your wisdom teeth may need extracting - some people may need to have this procedure performed in hospital.

Check your immunity to rubella

Although rubella (German measles) isnt a serious disease, even a mild attack can harm an unborn baby, especially in the first three months. It can cause damage to the brain, sight and hearing of the unborn baby and increase the risk of miscarriage or stillbirth. A stillbirth is when a fetus is expelled after the 20th week of pregnancy. Even if you have been vaccinated against rubella as a teenager, ask your doctor for a blood test to check that you are immune. If you are not immune, you can be immunised before you become pregnant. This must be done at least three months before you become pregnant.

Give up smoking
It is best to quit smoking before you fall pregnant. If you can stop smoking at any stage during the pregnancy it will be good for you and the baby. There is no safe level of smoking. Smoking during pregnancy increases the risk of: having a premature birth (giving birth before the end of the 37th week); delivering a low birthweight baby. When you smoke, carbon monoxide flows into your babys bloodstream. This means the baby gets less oxygen and cannot grow as well as it should. This can also happen to a lesser degree if you live or work in a smoke-filled environment. A lighter baby has an increased chance of having complications after birth, such as difficulty in maintaining body temperature, and lack of energy; respiratory problems in baby. If you smoked during pregnancy, your baby has a higher risk of respiratory (chest) problems; S.I.D.S. (Sudden Infant Death Syndrome).

If you would like to quit smoking but are not sure how to get started, here are a few ideas that might help: If you can stop smoking at any stage during the pregnancy, it will be good for you and the baby. Do not let other people smoke around you and your baby. If both you and your partner smoke, giving up together improves your chances of succeeding. Current advice from QUIT utilises the 4Ds delay, deep breathe, drink water and do something else.

For more information on how to quit smoking, contact the Quit Information line on 13 1848. It can be dialled anywhere in Australia for the cost of a local call.

Alcohol intake
Alcohol passes into your bloodstream and then into the babys bloodstream. Not drinking at all is the safest approach. Medical researchers now know that alcohol can harm the unborn baby. Alcohol use during pregnancy has been linked with a higher risk of: pregnancy complications including miscarriage, stillbirth and premature birth; babies born with intellectual disabilities; poor coordination and movement skills; defects to the face, heart and bones; slow physical growth. The most severe form of this problem is known as fetal alcohol syndrome. Other babies may have milder signs, described as fetal alcohol effects.

Withdrawal symptoms have been observed in the babies of mothers who are heavily dependent on alcohol. These symptoms can include: tremors; irritability; fits; bloated stomach. Is there a safe level of drinking during pregnancy? Unfortunately, we still dont know. Medical researchers are not sure about what amount of drinking by the mother can cause harm to the baby. They are also not sure at what stage in the pregnancy the harm can occur. It appears that drinking even a small amount of alcohol (eg one or two drinks), daily or regularly, such as several times a week, can have an undesirable effect on the baby. The harm can occur throughout the pregnancy. Certainly, the risk of harm increases the more the mother drinks. Also, a drinking binge (a heavy drinking session) is harmful, at any time during the pregnancy, but particularly during the first three months. The leading medical research organisation in Australia, the National Health and Medical Research Council, advises women that it is best to stop drinking altogether during pregnancy. They say this is the sensible way to act, given that we still dont know enough about the effects of alcohol on the baby. For more information, contact the ADIS Alcohol and Drug Information Service, a 24 hour counselling and information line for anyone who wants assistance or information about their alcohol or drug use. The contact phone number is 9331 2111 (Sydney), or 1800 422 599 (from anywhere in NSW). Booklets and information on pregnancy and drugs can be obtained from CEIDA (Centre for Education and Information on Drugs and Alcohol), Ph: (02) 9818 5222.

Limit caffeine intake

Coffee, tea, chocolate, cola (and some other soft drinks) all contain caffeine. There is evidence that a high intake of caffeine increases the risk of miscarriage and premature birth. It is a good idea for pregnant women to limit themselves to 200mg of caffeine daily. This equals: 2 cups ground coffee (100mg per 250ml cup) or 2 1/2 cups instant coffee (75mg per 250ml cup) or 4 cups medium-strength tea (50mg per 250ml cup) or 4 cups cocoa or hot chocolate (50mg per 250ml cup) or 6 cups cola (35mg per 250ml)

Care with drugs

Many women take painkillers for all kinds of minor discomforts and it can be a hard habit to break during pregnancy. However, some painkillers can be harmful. For example, aspirin taken in late pregnancy can interfere with the bodys ability to control bleeding after delivery of the placenta. It is best to try other methods of pain relief in pregnancy (see Chapter 6, Common Complaints; Chapter 8, Relaxation and Breath Awareness; Chapter 9, Pain Relief) or ask your doctor to suggest a brand and a dose which is safe to use. If you take any medication regularly, see your doctor before conceiving and ask whether the medication should be changed. It is best for women who dont take medication regularly to avoid all drugs before conception and throughout pregnancy, unless prescribed by a doctor. If you are trying to conceive or if there is a chance you may be pregnant, tell your doctor before he or she prescribes any drugs for you. For information on drug use in pregnancy, phone ADIS (Alcohol and Drug Information Service) on (02) 9331 2111 or 1800 422 599. Tranquillisers If you use tranquillisers during pregnancy, your baby may experience withdrawal symptoms at birth. These may include sleeplessness, restlessness, shakiness and feeding problems. If you take tranquillisers and are trying to conceive or are already pregnant, tell your doctor. It is important not to stop taking them immediately. Your doctor can explain how to cut back safely.

Marijuana It is best not to smoke marijuana while you are pregnant - it can affect the baby in the same way as tobacco (see this chapter, Give Up Smoking). Cocaine, Crack Cocaine is one of the most dangerous drugs you can use in pregnancy because it can seriously affect the baby at any stage. Besides increasing the risk of miscarriage and stillbirth, cocaine can reduce the babys blood supply and cause death, blockages in the bowel or a brain condition similar to a stroke in an older person. The baby may also suffer withdrawal symptoms at birth, including sleepiness and lack of responsiveness. Heroin Heroin can cause complications such as miscarriage, toxaemia infections, premature breaking of the waters and pre-term labour. There is also a higher risk of stillbirth or delivering a low-birthweight baby. Heroin use in pregnancy can also have possible effects on the mother: Poor nourishment, with vitamin deficiencies, and deficiencies in iron and folic acid. Medical problems associated with unclean needles (other than those already listed) of abscesses, ulcers, thrombophlebitis, bacterial endo carditis and urinary tract infections. Hypertensive disorder.

NARCAN (or any narcotic antagonist) should never be given to a pregnant substanceusing woman, except as a last resort to reverse severe narcotic overdose. It could result in spontaneous abortion, premature labour, and/or stillbirth. If you share needles, you risk catching HIV (the virus which causes AIDS) or hepatitis B and C, and infecting the baby. If you use heroin during pregnancy, your baby may experience withdrawal symptoms at birth, including sleeplessness, shakiness and feeding problems. Other effects on the baby include: neonatal abstinence syndrome (withdrawal), the withdrawal symptoms can include irritability, hyperreflexia, abnormal suck, poor feeding, diarrhoea and vomiting; S.I.D.S. (Sudden Infant Death Syndrome).

Methadone Replacing heroin with methadone as soon as possible in pregnancy reduces the risks to the baby. The baby may still have withdrawal symptoms at birth, including sleeplessness, shakiness and feeding problems. The baby may also be of low birth weight and have higher risk of S.I.D.S. (common to all opiates). Replacing heroin with methadone as soon as possible in pregnancy also improves the health status of the mother and: improves maternal nutrition, increasing the weight of the newborn. improves the womans ability to participate in prenatal care. reduces obstetrical complications and lessens possibility of fetal death.

improves overall lifestyle. reduces risk of HIV infection.

Some women may need their dose of methadone increased in the third trimester. Medical withdrawal from methadone is not advised during pregnancy. Amphetamines (speed) Amphetamines (speed) slightly increase the risk of birth defects if taken in early pregnancy. If you take speed close to delivery, the baby may be born high and hyperactive and may suffer withdrawal symptoms later. These withdrawal symptoms may make the baby sleepy during the first three weeks after birth. The baby may also be undernourished. Barbiturates Barbiturates can cause withdrawal symptoms in the baby at birth, including sleeplessness, feeding problems and shakiness. If a pregnant woman is using barbiturates and would like to stop, they should see their doctor or a drug and alcohol unit. Withdrawal of barbiturates during pregnancy can be very dangerous to the mother and baby and requires careful supervision. It is important never to suddenly stop taking benzodiazepines when pregnant. LSD LSD obtained illegally is usually mixed with other drugs. These mixtures can cause miscarriage, damage to your chromosomes and damage to your immune system, making you susceptible to disease. They may also injure the baby. Ecstasy Ecstasy has stimulant and psychedelic effects which are similar to those induced by speed. Because these drugs produce a rise in pulse rate and blood pressure with a rise in body temperature and increased muscle tension, they may cause serious side-effects in pregnancy resulting in adverse fetal and maternal outcomes. They should be avoided entirely, especially during pregnancy.

Keep cool
There is some evidence from studies in animals that a rise in core body temperature (the temperature inside the body) in the early months of pregnancy may increase the risk of birth defects in the baby. Although this risk has not been confirmed in humans, it is wise to avoid a rise in core body temperature. Core body temperature can be increased by: sitting in a hot tub or a sauna for more than 10 minutes fever with a sustained temperature over 38.50 C heavy work or excessive exercise.

For more information about heat stress in pregnancy see Chapter 5, Exercise/Sport, or discuss it with your doctor.

Hazards at work
Some people work with substances and equipment that may be harmful to an unborn baby. Some of these may affect both men and women, so it is important to find out what the risks are before conception. Hazards include: Exposure to radiation Exposure to ionising radiation, such as X-rays, or radioactive material may be harmful to an unborn baby. Radiation levels from VDUs (computer screens) are NOT believed to pose any health risks to you or the unborn baby (see Chapter 5, Work). Lead All people absorb small amounts of lead from the environment, either by ingesting or breathing it in. Children and pregnant women are at an increased risk to the effects of lead. A child absorbs more lead than an adult does, and the lead absorbed is more harmful to a childs developing brain, nervous system and other body functions. Low levels of lead can pass through the placenta and can affect the developing baby, particularly the developing nervous system. Low levels of lead in the blood can adversely affect intellectual development in young children. It may also impair growth, reduce hearing and is linked to behavioural problems. We do not yet know whether these effects are reversible. The main sources of lead in and around the house are lead in soil and dust, which mainly come from lead-based paint and leaded petrol. Advice needs to be sought when renovating an older house which may have lead-based paint, as improper removal will result in the dispersal of lead dust in the home (lead-based paint was available until about 1971, and one per cent of lead was still permissible in residential paint until March 1989). It is especially important that pregnant women and children are not present during renovations which disturb lead-based paint. It is also vital to ensure that children do not have access to peeling paint or chewable surfaces painted with lead-based paint. Particular attention should be paid to cots, windowsills and windows. Other sources of lead include: lead industries such as vehicle battery recyclers; clothes and dust on lead workers; hobbies which use lead such as lead-lighting, fishing (sinkers), pottery (lead glazers); some traditional medicines such as Pay-loo-ah, Bali goli, rueda and azarcon; lead crystal glassware; and pottery used for food and drink storage which comes from developing countries (lead leaches from glaze if not fired at high enough temperatures). In areas near lead smelters or mines, lead contamination in the environment and the house will be higher than in most urban areas. Further information on the sources of lead, minimisation of exposure to lead and safe removal of lead-based paint can be obtained from your local Public Health Unit (under Health in the White pages), the NSW Community Lead Advisory Service on 1800 626086, or the NSW Environment Protection Authority on (02) 9325 5555.

Exposure to infection Exposure to viruses, such as rubella (if you are not immune), the Human Immunodeficiency Virus (HIV, the virus which causes AIDS) or hepatitis B and C may be harmful to an unborn baby. If you think you are at risk, or if you want to make sure the substances or equipment you work with are safe, talk to your doctor, union representative or employer. You can also contact the WorkCover Authority of NSW, 400 Kent St, Sydney NSW 2000. Ph: (02) 9370 5000

Risks for Older Women

More women now choose to have their first baby between the ages of 30 and 40. It is true that the risks of complications in pregnancy increase with age (especially after 35), but statistics show that with good antenatal care, a healthy diet and exercise, the odds are still very much in favour of having a successful pregnancy.

Progress of Pregnancy
First signs
The first signs that you are pregnant may include: A missed period A missed period is usually the first clue you may be pregnant. The medical term for this is amenorrhoea. However, some women who are pregnant have a very slight period, losing just a little blood. Changes in your breasts Your breasts may become bigger and feel tender. You may feel a prickling, tingling sensation in them. The veins may show up more and nipples may darken. Nausea Feelings of nausea are common in the morning just after you get out of bed, but they can happen at any time of the day. For advice on coping with morning sickness, see Chapter 6, Morning Sickness. Fatigue You may have feelings of fatigue. Frequent urination Needing to urinate more often is normal during pregnancy. However, if there is any pain on passing urine, see your doctor immediately. Constipation Symptoms of constipation include a reduction in the frequency of bowel motions, and pain or difficulty in emptying your bowel. Stools are usually hard and small. Talk to your doctor/midwife about prevention of constipation. Odd taste You may have a slightly metallic taste in your mouth. Going off food You may go off food or beverages, such as tea or coffee. Changes in your genitals Two or three weeks after a missed period, you may notice changes in your genitals. The external genitals become bluish in colour. The vagina feels moist and you may have more vaginal discharge.
The reproductive system in a teenage girl or woman.

Pregnancy Tests
Most pregnancy testing is done by checking the urine or sometimes the blood to see if it contains a particular hormone. Depending on the type of test used, pregnancy can be detected from 10 days after conception to one or two weeks after the first missed period. The test may be done by your doctor, a Family Planning Clinic or a womens health centre. When you go for a pregnancy test, you will need to take a small amount of earlymorning urine in a clean, freshly washed (or sterilised) container. Alternatively, you may choose to buy a home pregnancy test kit ($10 to $20) from a pharmacy. The kit includes a container for your early-morning urine sample, equipment (such as a small test tube and testing solution) and easy-to-follow instructions. Some kits have two of everything so you can do a follow-up test at a later date. The tests claim to be up to 99 per cent accurate, and can be used as early as the day after a missed period. However, the instructions must be followed carefully for a reliable result. If you believe the result of the test may be incorrect, go to your doctor to be tested again.

Unplanned Pregnancy
If your pregnancy is unplanned, you may be wondering whether you should keep the baby, have it adopted or have a therapeutic abortion (also called a termination of pregnancy). Although this is very much your decision, it may help to talk it over with your family and friends. It might also help to talk it over with someone who is not so close to you, such as a social worker or a counsellor. Counselling services are listed in Appendix A. If you choose to have the baby, counselling services can put you in touch with other services you may need during pregnancy and after the birth. They can help with accommodation, special benefits or advice on support from the father of the child. If you are thinking about having the baby adopted, you will be referred to an approved adoption agency. If you decide to terminate the pregnancy, there are some health risks. However, a termination is usually safe as long as it is done by an experienced doctor in proper conditions with the right equipment. In the first eight weeks of pregnancy, a termination is usually quite straightforward - in fact, it can be done without too much difficulty up to 12 weeks into the pregnancy. After this, terminating a pregnancy can be dangerous. Termination is legal in NSW, provided certain conditions are met. Firstly, the termination must be performed by a registered doctor who believes the termination is essential to maintaining your health. Social or financial problems may also be taken into account. Secondly, the risk of continuing the pregnancy should outweigh the risks in a termination. If you prefer not to see your family doctor, you may choose to attend a special clinic which conducts termination procedures and provides counselling. For further advice on termination, contact your doctor, a Family Planning Clinic or a Community Health Centre (see Appendix A).

10

How the Baby Grows

Pregnancy begins when an egg (ovum) is shed from your ovary and is fertilised by a sperm. This usually happens towards the outer end of the Fallopian tube, and about midway between menstrual periods. As the egg moves down the Fallopian tube, it divides into two cells. The cells keep dividing until a solid ball of cells has been formed. When it reaches the uterus, this ball of cells attaches to the wall of the uterus. Once the ball of cells is attached, the tissue surrounding it produces hormones which help the pregnancy to continue. This happens before your next period is due, and stops the bleeding. However, you may still get a light period or, less likely, what appears to be a normal period. The outgrowth of cells which develops into the baby is referred to as the embryo at this stage. That part of the ball of cells which attaches to the wall of the uterus becomes three things - the umbilical cord, the placenta and the amniotic sac. The placenta absorbs oxygen and nourishment (as well as nicotine and other drugs) from your blood and these are carried to the baby by the cord. Waste materials from the baby are carried back by the cord to the placenta and are disposed of by your body. The amniotic sac is filled with fluid which protects the baby while it is in the uterus.
Fertilisation

Stages of development
Week 6 At six weeks, the embryo is about 5mm long, from its head to its bottom, or a bit smaller than your little fingernail. Its brain, stomach and intestines are developing and the heart is starting to beat. Little dimples on the head mark where the eyes and ears will be. Arms and legs are starting to bud. Week 8 - 9 At 8 - 9 weeks, a face is forming, the eyes and ears are developing and the embryo has a mouth and tongue. The heart, brain, lungs, kidneys, liver and intestines are all developing. Limbs are growing and the hands show signs of fingers.
Fertilisation usually happens towards the outer end of the Fallopian tube, and about midway between menstrual periods.

Week 6

11

Week 12 At 12 weeks, the embryo is now called a fetus. It is about 5cm long, from its head to its bottom, or about the size of your little finger. It has a nose and a neck, and all its organs and parts have been formed, including ovaries or testicles. From now on, the fetus grows and parts of its body mature.
Week 12

Week 16 At 16 weeks, the fetus is about 10cm long, from its head to its bottom, or about the size of your palm. At 16-20 weeks, you feel the baby move (it feels like fluttering). The top of your uterus is about level with your navel. Week 24 At 24 weeks, the fetus is about 21cm long, from its head to its bottom, or about the length from your elbow to your wrist. Week 32

Week 16

At 32 weeks, the fetus is about 25cm long, from its head to its bottom, or about the length from your elbow to the base of your fingers. Week 40 At 40 weeks, your baby is about 33cm long, from its head to its bottom, or about the length from your elbow to the tips of your fingers. Your uterus has increased in size to almost fill your abdomen. You are said to be at term and your baby is ready to be born. (NB We will refer to the embryo and fetus as the baby in the rest of the text.)

Development of the senses

Week 24

Sound The baby can hear the thud of its mothers heart and the grumble of air passing in her intestine. However, although the baby is used to noise, it will still react to a loud noise outside the uterus by moving. Once the baby is born, being held on the left breast is often more calming than being held on the right. This is probably because the baby can hear the mothers heartbeat - the familiar sound it heard in the uterus.

12

Touch Once the hands and feet are formed, the baby can touch other parts of its body with them. Early in pregnancy, the baby tends to move away from anything it touches; later on, it moves towards it. If a finger gets into its mouth, the baby will suck it. Movement Although you dont usually feel movement until the 16th to the 20th week, the baby actually begins moving in the ninth week. Some movements happen in a regular pattern which may be related to when the baby sleeps. The baby tends to be more active if you are stressed, tired or have recently had a meal. Pain The babys heart rate and movement increase if it is touched (this may happen during amniocentesis, see Chapter 3, Amniocentesis) but will return to normal within a few minutes.

Duration of Pregnancy
Pregnancy ends and labour begins about 280 days after the first day of your last period. One way to estimate your expected date of delivery is to add seven days to the date of the first day of your last menstrual period. Count back three months, and you have the Expected Date of Confinement (EDC). Example: Your last period started on the 7th February. Add seven days: 14th February. Count back three months: 14th January, 14th December, 14th November. Your baby is due about the 14th November. Pregnancy lasts about 40 weeks from the first day of your last period. Conception usually occurs about two weeks after this time, and pregnancy can be confirmed shortly after your next period would have been due. This means that, for example, at six weeks from your last period, your doctor or midwife will say that you are six weeks pregnant, even though the pregnancy actually started four weeks before. This is a convention that has been used for a long time, but some people find it confusing. If you have a menstrual cycle that is shorter or longer than 28 days, your doctor or midwife may change the Expected Date of Confinement from what was worked out using the date of your last period.

Week 32

Week 40

13

If labour starts early, before the end of the 37th week, the baby is pre-term and may have problems and require special care in the early days or weeks after birth. If pregnancy lasts more than 42 weeks, the baby is postdates. Unexplained problems are more common after this time. This is why it is important to know the date of your last period. If you are in any doubt, tell your doctor or midwife at your first antenatal visit. Your doctor or midwife can estimate the date of delivery by monitoring the growth of the baby in the uterus, conducting an internal examination or an ultrasound (see Chapter 3, Ultrasound).

Multiple Pregnancy
Twins happen about once in every 100 births. There is a greater chance of having them if you or your partner have twins in your family, or if you are more than 35 years of age, or undergoing fertility treatments. Identical twins result from one fertilised egg splitting into two separate cells. Each cell then develops into a baby. Because they have come from the same egg, the babies have the same genes. They are the same sex and they look very alike. Identical twins usually share one placenta but have separate cords. Non-identical (fraternal) twins develop when two eggs are fertilised by two sperm. They will resemble each other only as other brothers and sisters do. Each twin has its own placenta. Triplets are rare and quads (four babies) rarer still, although the use of infertility drugs is making multiple births more common. Signs that may indicate a multiple pregnancy include fast weight gain or a uterus that is larger than usual for your particular stage of pregnancy, or exaggerated nausea, or urinary frequency. In later pregnancy, the doctor may be able to feel the head, back or limbs of more than one baby. Sometimes, an ultrasound (see Chapter 3, Ultrasound) is needed to confirm a multiple birth.

Your Emotions
Pregnancy can affect your feelings and behaviour. Whether you are having your first baby or your fifth, it means that your life is about to change. That can mean extra stress, especially if you are having problems with your partner or are worried about money. If the first few months of pregnancy, in particular, hormone changes can make you moody. On top of this, there may be feelings of fatigue and nausea - so dont be surprised if you feel irritable and depressed occasionally. Towards the end of pregnancy, you may feel bulky and your morale may sink. You may also feel anxious about the birth, wondering how you will cope and whether the baby will be all right. All these fears and feelings are a normal part of pregnancy. Talking to your partner or someone else close to you may help. If you are worried about some aspect of your pregnancy or the birth, talk to your doctor or midwife.

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Will the Baby be Normal?

Although most babies are born without serious abnormalities, some couples have a higher risk than others of having a baby with a birth defect.

Genetic Counselling
Ask your doctor or midwife to refer you for genetic counselling if: you have already had a child with a serious disorder; you or your partner have a serious disorder which may be passed on to the baby, or you have a relative with a serious disorder or an affected child; you have a family history of a disorder which affects boys only. Women in the family may be carriers of a disorder, such as haemophilia (where the blood is slow to clot after an injury); your partner is a close relative; you are having (or planning) a baby (not necessarily your first) and are in your mid-30s or older.

By talking to you about you and your partners family history, a genetic counsellor can assess your risk of having a child with a particular disorder. This may involve having tests before pregnancy to find out if either partner is carrying the gene for a particular disorder. These disorders include cystic fibrosis and thalassaemia. For Genetic Counselling Services, see the contacts listed in the Appendix.

Cystic fibrosis (CF)

Cystic fibrosis is the most common, life threatening, inherited disorder in Australian children. About one in every 2000 children is born with the disease. It affects the lungs and digestive system, and children with the disease used to have a shortened life span, however treatment has now considerably increased the lifespan. One in 25 people whose ancestry is European or Anglo-Saxon are carriers of the faulty CF gene. If two people with the CF gene have a child together, there is a one in four chance their child will have CF. It is now possible to test a person to see if they are a carrier of a faulty CF gene. Genetic counselling is recommended if there is a family history of CF (see Appendix A). For more information, contact the Cystic Fibrosis Foundation (NSW), PO Box 149, North Ryde, NSW 2113. Ph: (02) 9878 2075

Thalassaemia
Thalassaemia is a blood disorder which can be passed on from one generation to another. There are two kinds of thalassaemia. The common, mild type is called thalassaemia trait or thalassaemia minor. People with this disorder usually have very mild anaemia. This does not stop them from being healthy. The second type is thalassaemia major. This is a life-long condition which often causes a serious form of anaemia.

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Anyone can inherit thalassaemia minor (or trait). However, it is more often found in families originating from the Mediterranean, the Middle East, South East Asia, Africa or the Pacific. It is less common for Australians of Northern European or Anglo-Saxon background to have thalassaemia minor. Testing for thalassaemia minor should ideally be completed by couples well before planning to have children. These tests are provided free by most major hospitals in NSW through their haematology departments. If both parents are found to have thalassaemia minor, genetic counselling is recommended (see Appendix A). If one parent has thalassaemia minor, there is a one in two chance the baby will inherit thalassaemia minor. However, two parents with thalassaemia minor face a one in four risk of having a baby with thalassaemia major. If you have tested positive for thalassaemia minor during pregnancy, your partner should be tested as soon as possible. The unborn baby can be tested for thalassaemia major 1018 weeks into the pregnancy. For more information about thalassaemia, contact the Thalassaemia Centre of NSW, Royal Prince Alfred Hospital, Level 5, Queen Mary Building, Grose St, Camperdown NSW 2050, Ph: (02) 9550 4844.

Prenatal Diagnostic Tests

Prenatal diagnostic tests, conducted during pregnancy, may determine whether the baby has a particular problem. If you are concerned that your child may have a serious disorder (see this chapter, Genetic Counselling), ask your doctor if tests can be conducted. It is important to remember that prenatal tests do not guarantee a perfect baby. They can only test for specific problems.

Ultrasound
Besides revealing the babys age and whether or not you are carrying twins, ultrasound can also detect some physical abnormalities. The doctor rubs a jelly-like substance onto your abdomen before pressing an instrument like a microphone against your skin. Sound waves pass into the uterus, bouncing off the baby. The sound waves are translated by a computer into a picture on a television screen. The test is believed to be harmless to you and your baby.

Chorionic Villus Sampling (CVS)

This test must be done in the 10th to 12th week after the first day of your last period. If you think you need this test, it is vital to see a doctor as soon as you think you may be pregnant. By testing cells from tissues surrounding the baby, CVS can detect chromosomal abnormalities such as Down syndrome and inherited abnormalities such as cystic fibrosis and thalassaemia (see this chapter, Genetic Counselling). Results are usually available in two to three weeks. CVS uses ultrasound to locate the tissue needed for testing. A fine tube then goes through the cervix into the uterus to remove a tiny amount of tissue (it is a bit like having a Pap smear taken). Sometimes the tissue is removed by passing a needle through the abdomen.

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You dont need an anaesthetic. When the test is carried out by a doctor experienced in CVS, the risk of miscarriage from the test is about one in 50 pregnancies, (including miscarriages in those women who may have miscarried without the test).

Amniocentesis
Amniocentesis is done in the 14th to 18th week of pregnancy. It can detect chromosomal abnormalities, inherited disorders and neural tube defects such as spina bifida (where the babys spinal cord doesnt develop properly). Results take about three to four weeks. For amniocentesis, an ultrasound is used to locate the amniotic fluid. This is the fluid inside the amniotic sac, the balloon-like bag of waters in which the baby floats. A hollow needle then goes into the abdomen and draws out a small sample of fluid. When amniocentesis is done by an experienced doctor, the risk of miscarriage from the test is one in 100 pregnancies or even lower, (including miscarriages in those women who may have miscarried without the test).

Alpha Fetoprotein Test (AFP) or Maternal Serum Test

This blood test is done in the 16th to 18th week of pregnancy and can provide you and your doctor with an estimate of the risk (or chance) that your baby has certain birth defects. It checks the level of hormone called alpha fetoprotein (AFP) in your blood. Too much AFP in the blood occurs in three in 100 pregnant women. It may mean the baby has a neural tube defect, such as spina bifida or anencephaly (where the skull and brain dont develop properly). However, if there is a high level of AFP in your blood, dont panic. There can be other causes. It could mean you are having twins, for instance, or that your pregnancy is further along than you thought. It doesnt necessarily mean the baby is affected in any way. If this happens to you, your doctor may suggest an ultrasound examination (see this chapter, Ultrasound) to check whether there is a neural tube defect. If the level of alpha fetoprotein (AFP) in the blood is found to be very low (this happens in less than five in 100 pregnancies), the levels of two other hormones in the blood may also be measured. This is called a triple screening, and is done through your doctor or hospital. By looking at the levels of these three hormones and considering other factors such as your age, weight and how many weeks pregnant you are, triple screening can assess your risk of having a baby with Down syndrome or certain other chromosomal abnormalities. If the result shows a high risk for the condition, you can then decide whether to have an amniocentesis, (see this chapter, Amniocentesis), to determine for certain whether your unborn baby has Down syndrome.

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Chromosomal Abnormalities
Chromosomes are tiny structures present in every cell of your body. Each chromosome contains thousands of genes (the instructions that decide how each of us will look and develop). Birth abnormalities may result if a baby has too many or too few chromosomes. The most well-known chromosomal disorder is Down syndrome which occurs when a baby has an extra chromosome. What if a test shows an abnormality? The chances are it wont. However, if an abnormality is diagnosed, parents will be given the necessary information to make a choice about whether to continue with the pregnancy. For parents who are unsure about their decision, support and counselling are available (see Appendix A).

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Antenatal Care
During pregnancy, you should have regular checkups at an antenatal clinic or with your general practitioner, an obstetrician (you will need a referral from your general practitioner), or a midwife. Antenatal clinics may be run by hospitals, Community Health Centres or private organisations. Another increasingly popular model of care is shared care between your general practitioner and the hospital clinic. With this system, you see your local family doctor for most of the visits and only attend the hospital for three to four visits during the pregnancy. You can also receive antenatal care through midwives clinics, operated in some major hospitals or through a Hospital Birth Centre. Usually, you will be seen at the booking visit by an obstetrician (a doctor who specialises in caring for women during pregnancy and child-birth). If your pregnancy is expected to be trouble-free, you may be offered the option of attending the midwives clinic. You will be cared for by the midwives at the clinic, although an obstetrician may see you at different stages of your pregnancy. Antenatal care ensures the pregnancy is progressing smoothly and that any problems can be spotted and treated early. It also gives you the opportunity to discuss how and where you would like to have your baby. You can also contact your doctor or midwife in between regular visits if you have concerns about your health or the health of your baby, For local Aboriginal Medical Services, see Appendix A.

The First Visit

The best time for your first antenatal visit is as soon as you know you are pregnant. The baby is most easily damaged during the first 12 weeks and medical advice can help you avoid possible dangers. At the first visit, you will be given an antenatal record card. The first visit will usually include a general physical examination to check your heart, lungs and blood pressure. There will be a urine test to make sure your kidneys are coping with the demands of pregnancy and to rule out kidney infection. Your urine sample will be checked for glucose. You will also have an internal examination to check the size and position of the uterus. If you did not have a Pap smear in the three months before falling pregnant, it may be included it the examination. The first visit also provides the opportunity for you to talk to your doctor or midwife about your plans for your babys birth and any concerns that you may have about your pregnancy. A blood sample will be taken to check for the following: Your blood group It is important to know this in case a blood transfusion is needed and to find out if your blood group is Rhesus negative. If you are Rhesus negative, this is not a problem for your first baby. However, if you are Rhesus negative and you are pregnant with a Rhesus positive baby, you will need an injection after the birth (or miscarriage or termination of this pregnancy) to protect your next baby from severe anaemia.

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Immunity to rubella (See Chapter 1, Check Your Immunity to Rubella.) Anaemia There is a greater risk of anaemia during pregnancy because your body uses extra iron to make the babys blood. Anaemia makes you tired and less able to cope with any blood loss during delivery. Pregnant women may need to take iron tablets daily to prevent anaemia from developing. Your doctor or midwife can advise you on this. Syphilis The symptoms of syphilis include painless sores in and around the vagina and rashes on the hands, feet or other parts of the body. However, most pregnant women with syphilis have no symptoms. Early treatment can prevent the baby from becoming infected. (See this chapter, Sexually Transmissible Diseases, STDs, for more information on STDs and pregnancy.) Hepatitis B The symptoms of hepatitis B include jaundice (a yellow tinge to the skin and whites of the eyes, dark urine and pale stools), fever, loss of appetite, lethargy and joint pains. However, most infected people get no symptoms. Hepatitis B can be transmitted during sexual intercourse, by an infected mother to her baby at birth, by sharing needles and by close household contact. Carriers of hepatitis B can have the virus without being sick themselves, but may still infect others. If you suspect you may have been infected, tell your doctor. Babies and mothers who carry hepatitis B and babies from certain ethnic groups are immunised against the infection at birth. Groups where the risk of hepatitis B is higher than average include Aboriginal people, Maori people, Pacific Islanders and people from Cambodia, Chile, China, Cyprus, Egypt, Greece, Hong Kong, India, Southern Italy, Laos, Lebanon, Malaya, Malta, Papua New Guinea, the Philippines, Sub-Saharan Africa, Taiwan, Turkey, Vietnam, and former Yugoslavia. HIV/AIDS You may consider having a test for the Human Immunodeficiency Virus (HIV, the virus which causes AIDS). If you wish to have the test, be sure that a counsellor/doctor fully informs you first about what the test is and what positive and negative results mean. A HIV test is not a routine antenatal test.

Later Visits
For most women, antenatal visits are usually every four to six weeks initially. They become increasingly frequent in the last 12 weeks of pregnancy. At each visit, the doctor or midwife will check your weight, urine and blood pressure and feel your abdomen to check on the babys development and position. These visits also give you the opportunity to talk about any concerns. Prenatal tests (Chapter 3, Prenatal Diagnostic Tests) may be conducted at various stages throughout the pregnancy. Some doctors will advise you to be tested for gestational diabetes at 26 to 30 weeks into the pregnancy (see Chapter 7, Diabetes).

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Sexually Transmissible Diseases (STDs)

It is important to know which Sexually Transmissible Diseases (STDs) can affect the baby either before or after birth. Besides syphilis and hepatitis B (see this chapter, Syphilis and Hepatitis B), the following STDs can also cause problems. Any woman who is pregnant (or planning to fall pregnant) and suspects she may be infected should be tested.

Chlamydia
Many women have Chlamydia and dont know it, although some women may notice extra vaginal discharge or irritation when urinating. Although Chlamydia is easily treated with antibiotics, an untreated infection can be passed on to the baby and cause eye infection or pneumonia. It can also lead to pelvic inflammatory disease (PID) in the mother - this can damage the Fallopian tubes and affect fertility. Chlamydia during pregnancy may increase the risk of a premature birth. If you or your partner have had a change of sexual partner during the six months before pregnancy or during pregnancy, or you are under the age of 25, you should ask your doctor to test you for Chlamydia.

Gonorrhoea
The symptoms of gonorrhoea can include extra vaginal discharge and irritation when urinating. If you are infected and not treated adequately, the infection can put your babys eyesight at risk. If you are treated promptly, the outlook for the baby is excellent.

Genital herpes
Genital herpes is caused by a virus. The symptoms include painful, tingling or itchy blisters or ulcers in the genital area. Some people develop flu-like symptoms as well. However, most people with genital herpes have no symptoms. Although the sores heal themselves, the virus stays in the system. This means that even after the sores have healed, the symptoms can recur. You should tell your doctor if you or any of your partners have a history of genital herpes. If you suspect you may have a recurrence when labour begins, you should go to the hospital as soon as possible in case a Caesarean section is necessary to avoid infecting the baby. However, it is usually women who have or who have just had their first outbreak of blisters who are much more likely to infect the baby. If you suspect a first outbreak of genital herpes, see your doctor immediately. If you have had recurrent outbreaks, your baby is likely to have partial immunity to genital herpes.

Genital warts
Genital warts, usually painless, start as tiny swellings on the genitals, sometimes developing into cauliflower-like lumps. Others are flat and hard to see. Because the response to treatment is poor during pregnancy, treatment of warts is usually deferred until after the baby is born. While genital warts are common amongst pregnant women, babies rarely develop warts.

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HIV/AIDS
HIV (the Human Immunodeficiency Virus), the virus which causes AIDS, damages the immune system so that your body cant fight off other infections and illnesses. For HIV positive women, it is possible that the baby could become infected with HIV during the pregnancy or delivery. HIV positive mothers are strongly advised not to breast feed because of the risk of HIV infection to the baby. You have a greater risk of HIV and should ask your doctor about HIV antibody testing (the AIDS test) if you or your sexual partner have: injected drugs; had unprotected sex with someone you suspect may be infected; had other sexual partners and have not used condoms; have had a blood transfusion in Australia between 1980 and 1985.

You also have a greater risk of HIV and should also be tested for HIV if you have had sex with a man who has had sex with another man, or comes from a part of the world where HIV/AIDS is common. If you are considering a HIV test, you should have counselling both before you have the test and when you get the results. If you are HIV positive or have AIDS when you are pregnant, there is a risk that the baby may be infected too. You should seek specialist advice about treatments which may reduce the risk to your baby. If a mother is infected with HIV, treatment with antiviral drugs and avoiding breastfeeding have also been shown to reduce the transmission of HIV to the baby. See Appendix A for information about AIDS counselling and womens support groups.)

Choices in Childbirth
Depending on where you live, you may be able to choose between giving birth in a hospital, a birth centre or at home. Ask your Health Service or your local Community Health Centre what is available in your area. If you have the choice, find out as much as you can about the different options. This will help you make an informed decision.

Hospital birth
The advantage of a hospital birth is that if a serious problem crops up during or after labour, the equipment and expertise to deal with it are immediately available. Some people believe that too much technology is involved in a hospital birth. However, most hospitals now give you more choice in the way you have your baby. You are usually able to choose the position in which you give birth and can have up to two people of your choice with you during labour. Some hospitals limit the number allowed in the labour ward. Some hospitals allow children into the delivery suite (also called the labour ward). Some hospitals allow independent midwives to attend during the birth, but the midwife must be registered and have visiting rights with that hospital. For more information on registered midwives, see Appendix A.

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It is a good idea to talk to the hospital about its policy on different matters. Some of your questions might include: Does the hospital encourage you to move around during labour? Can you give birth in the position you find most comfortable? What is the hospitals policy on induction, pain relief or any other procedure which concerns you? Will you have access to a shower or a bath for pain relief? Will your baby be allowed to be with you all the time or will the baby stay in the nursery? How many people will be allowed into the delivery suite with you and will they be asked to leave at any stage? Will the baby be put to your breast immediately after birth? Can you visit the delivery suite and postnatal ward before the birth? (Some hospitals arrange regular tours for pregnant women and support people.) What is the hospitals attitude to breastfeeding, complementary feeding and bottlefeeding?

Birth centre
Some hospitals now have birth centres attached to them as safer alternatives to homebirths. These centres offer a midwife-assisted delivery, with minimal use of painrelieving drugs, in a normal bedroom instead of a delivery suite. During labour, you have the freedom to do what feels comfortable - walk around, sit, squat or kneel. Birth centres allow people of your choice to be at the birth, and may allow children too. If there is a complication during labour, you will be transferred to the hospitals delivery suite. Shortly after the birth, you and your baby may be transferred to a postnatal ward (in some cases, you will be free to take total care of your baby and to have meals in a dining room instead of in bed). Alternatively, you may be able to go home early by taking advantage of the domiciliary midwifery program (early discharge program). These options vary from centre to centre - check when you book in. If you decide on a birth centre, it is best to book early. Antenatal care for private patients at a birth centre is usually shared between a midwife and an obstetrician. Public patients usually see a doctor during the first visit and a midwife for the later visits. In some birth centres, women have the choice of a birth-centre midwife or an independent midwife (see Appendix A). Birth centres arent suitable for women with, among other things, heart or kidney disease, diabetes, high blood pressure or complications in previous labours. The guidelines for eligibility can vary from centre to centre.

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Homebirth
Some women choose to give birth to their baby at home. Few births in Australia take place at home, although there are private midwives and doctors who will attend a homebirth. Some women feel more in control of their pregnancy and labour by arranging a homebirth. Services offered by private midwives are not covered by Medicare, although some health insurance funds will give rebates. The midwife supplies all the equipment necessary for a homebirth (including resuscitation equipment). In most instances, you only need to provide sanitary pads and plastic sheets. Midwives give antenatal care and, after the birth, should provide postnatal care for up to 10 days. Some private midwives also provide childbirth education classes. As with birth centres, homebirths are not suitable for women who are likely to have complications during pregnancy or delivery. If you choose to give birth at home, it is strongly recommended that you: have a general practitioner, a private midwife or an obstetrician with you during the birth, and have access to hospital-based health professionals; be booked in at a nearby hospital in case you need to be transferred during the birth. During your pregnancy, it is recommended that you consult with the hospitals obstetric service; have your newborn baby examined by a doctor in the first week after the birth. Your midwife should carry out routine tests on your baby to check for any problems (see Chapter 11, Tests to Protect Your Baby) or refer you to an appropriate health service.

Going Home Early

Going home early is known as the early discharge program or the domiciliary midwifery program. It is available at most hospitals and birth centres and it enables you (providing you and the baby are well) to go home anywhere between four and 72 hours after the birth. Once you and your baby are home, a midwife (one of a special team attached to the hospital) will contact you (telephone or home visit) during the first week following discharge. The midwife does the things that would normally be done in hospital, such as postnatal checks, advising on baby care and self-care (including exercises) and making sure the baby is feeding well. The advantages of this program are that there is less disruption to family life and minimal separation from other children (who then have the chance to become involved with the baby much earlier). It is also easier for you to get into a routine and, providing you have a partner or someone else to help, it is often easier for you to rest. You can ask for details of the domiciliary midwifery program when you book into a hospital or birth centre. An interview will be arranged with a team midwife to take a medical history and other details. For some women, medical problems, such as heart disease or some cases of diabetes, may exclude them from the program.

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Taking Care
What to wear
Wear anything you like as long as it doesnt feel tight around your waist, crotch or the top of your legs. The idea of discarding high heels may make you groan but you will be more comfortable (and less likely to stumble or fall over) in heels no higher than 5cm. If your feet tend to swell, shoes need to be roomy enough not to cut into your feet - but if they are too loose, you might slip.

Work
Unless your job involves heavy physical work or occupational hazards that may affect your baby (see Chapter 1, Hazards at Work), there is no reason why you cant work well into your pregnancy. If you have any doubts, talk to your doctor or midwife. If your job involves standing for long periods of time, make sure you take the chance to sit down during breaks (if it is possible to put your feet up on another chair, so much the better). Standing for long periods may increase your chance of getting varicose veins during the pregnancy (see Chapter 6, Varicose Veins). If you sit at a desk or computer terminal most of the day, take 15 minutes every hour to get up and walk around. Be aware of your sitting posture - use a chair that gives you good back support and sit with your back straight. Keep your chest up - dont slump. You should not do any heavy lifting while you are pregnant. You should also avoid climbing ladders and excessive bending during late pregnancy when changes in the centre of balance make these tasks difficult. You cant work, be pregnant and rush home to cook gourmet meals and clean the house too. Try to spend as much time as you can after work resting with your feet up. The simplest meals (a big salad, bread, lean meat, poultry or fish) are often the healthiest. Do as little housework as possible (the health of you and your baby is more important than a spotless kitchen). This is a time when your partner will have to do a larger share of the housework.

Parental leave
Parental leave includes maternity leave (taken during or after pregnancy), paternity leave (taken at the time of birth, and/or for a further period in order to be the childs primary care giver), and adoption leave. The law in NSW gives parental leave to a parent who has been working with one employer for at least 12 months continuously up until the time the leave is due. To take advantage of maternity or extended parental leave, you need to inform your employer of some details at least 10 weeks before the baby is due. If you are eligible, you can take up to 12 months parental leave. It is a good idea to check the conditions of your award for your parental leave entitlements. (Contact the Award Enquiries Service Centre at NSW Department of Industrial Relations, on 131 628). For more information on parental leave, see the pamphlet, Parental Leave, prepared by the NSW Department of Industrial Relations. These can be obtained from the Womens Equity Bureau, Ph: (02) 9266 8668.

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Childcare
Dont wait until the baby is born to plan your childcare arrangements. Good childcare can be hard to find - put yourself onto the waiting list as soon as you know you are pregnant.

Exercise/sport
If you were active before pregnancy, it is a good idea to stay that way during pregnancy too. By keeping fit, you will cope better when the baby is born. But remember that the aim of exercise in pregnancy is to maintain fitness, not improve athletic performance. If you havent been physically active before pregnancy, now is the time to begin a gentle exercise program suitable for pregnancy. Ask about this when you attend your childbirth education course (see Chapter 8, Antenatal Exercises). If you normally play sport, ask your doctor or midwife if you can continue during pregnancy. Some activities are safe, as long as you take things easy, stop when you feel tired and dont overheat. However, some activities can pose problems - obvious ones are contact sports which can cause injury. Others include scuba diving (excess oxygen or carbon dioxide can harm the baby) and water skiing (water surging into the uterus may cause miscarriage). If you go to exercise classes, check with your doctor or midwife that it is okay to continue. Remember to tell your instructor that you are pregnant. You will need to slow down your pace. Alternatively, you could look for a class that caters for pregnant women. One of the effects of pregnancy is that your bodys ligaments become softer - this makes them more vulnerable to injury. High-impact exercises and repetitive bouncing, jumping or jarring movements are more likely to cause problems, but you can risk injuries with some low-impact exercises too. After the 20th week, it is important not to do exercises lying flat on your back - this can reduce the blood flow to the growing baby. If you are concerned about any of the exercises you do, ask a physiotherapist for advice.

Overheating
It is important to avoid becoming too hot, especially in the first three months of pregnancy, or if you are planning a pregnancy. If you do, your bodys core temperature can rise and this may harm the baby (see Chapter 1, Keep Cool). Playing a sport, running or doing a vigorous exercise class on a hot day can be enough to raise your core temperature. Staying as cool as possible, not exercising too strenuously and drinking fluids during and after exercise will help to keep your core temperature down. Women with certain medical conditions who are likely to have complications during pregnancy or who are having twins should avoid exercise. Check with your doctor or midwife.

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Infections
If you are not immune to rubella (see Chapter 1, Check Your Immunity to Rubella), it is important to keep away from anyone who has it. Also stay away from anyone who has other infections, such as colds or flu. If you do catch an infection, remember not to take any medication unless your doctor prescribes it. Self-medication in pregnancy may have serious consequences for your baby.

Dental check
If you did not have a dental check before falling pregnant, it is wise to have one now to make sure teeth and gums are in good condition. Gums are more vulnerable to infection when you are pregnant. Make sure you tell your dentist you are pregnant.

Bathing
It is probably better not to have baths or showers too hot or stay in too long in case you become overheated and dizzy. Towards the end of pregnancy, you may find it hard to get into and out of the bath by yourself.

Sex
As long as you are well and there are no problems with the pregnancy, you can continue with sexual intercourse. Dont worry if one of you loses interest in sex for a while at some stage - this is normal. There are no rules about sex in pregnancy - there may be times when you prefer just the physical closeness of being held, touched or massaged by your partner, rather than having intercourse. At other times, your enjoyment of sex may be just the same as usual or even increased. Sex is safe during pregnancy for most couples, unless advised otherwise by a doctor or midwife. However, it isnt always easy, especially in the later weeks. You will probably need to use your imagination and try new positions. Be assured that there is no way that the penis can touch or harm the baby in any way. Later in pregnancy, Braxton Hicks contractions (painless contractions which are the bodys way of practising for labour) are often more noticeable after orgasm or intercourse. Dont worry, they are usually harmless, although somewhat off-putting. Around the time of birth, prostaglandins, a substance found in semen, can help ripen the cervix in preparation for birth.

Travel
Car
It is important that you continue to wear a car seatbelt when youre pregnant. Worn properly, a seatbelt can protect both you and your baby if there is an accident. Wear the lap seatbelt as tightly as possible without making you uncomfortable. Fasten the belt buckle over the hips, with the lap section as low as possible, under the bulge of your abdomen. This will help prevent harm to your baby in an accident.

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Air
Airlines rules about flying during pregnancy can vary - contact individual airlines for information. If you are having problems with your pregnancy, talk to your doctor or midwife first about any plans to travel. Generally, air travel is perfectly safe for women.

Healthy Eating
From the moment it is conceived, your baby depends on you for its food. Besides keeping you well, a good diet before and during pregnancy will also provide the baby with the nutrients it needs for healthy development.

Food plan
Try to eat from the following five food groups every day: 1. Breads and cereals

Four servings or more each day of breads and cereals, preferably wholegrain or wholemeal. Besides being a good source of energy and protein, wholegrain breads and cereals contain plenty of fibre. 1 serving = 1 slice bread 3/4 cup ready-to-eat breakfast cereal 1/2 cup cooked rice or pasta 2 plain, wholemeal biscuits or crispbreads 2. Vegetables, salads and fruit

Four servings or more each day. Vegetables and fruit are very important sources of vitamins, minerals and fibre. 1 serving = 1/2 cup cooked vegetables or salad vegetables 1 piece fresh fruit 1/2 cup fruit juice 1/2 cup canned fruit (preferably no added sugar) Include one serving each day of Vitamin C-rich fruit or vegetables (orange, mandarin, grapefruit, lemon, kiwi fruit, strawberries, pineapple, pawpaw, capsicum, tomato, cabbage, cauliflower, broccoli, brussels sprouts and potatoes). Orange, grapefruit and tomato juice are also rich in Vitamin C. Fruit juice drinks and cordials arent good substitutes for fresh fruit. Include one serving of green or yellow vegetables daily, such as beans, peas, spinach, lettuce, carrots or pumpkin. The healthiest way to cook vegetables is to steam or microwave them, or cook them in a little water until they are just tender. Dont add soda to vegetables - it destroys the nutrients.

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3.

Meat, fish, poultry, eggs, cheese, legumes or nuts

Two servings each day. These are good protein foods (protein is important in developing the babys muscles, tissues and bones). Lean meat, poultry and fish are also good sources of iron (iron helps to prevent anaemia). For a main meal, one serving equals 75g to 100g of cooked lean meat, poultry or fish, or one cup of legumes. 4. Calcium-rich foods

1100mg of calcium daily during pregnancy during pregnancy: 1200mg of calcium daily while breastfeeding. Calcium is very important in pregnancy. Besides building the babys bones and teeth, it keeps your bones strong too. The simplest way to boost your calcium intake is to have plenty of milk or dairy products. If you are unable to eat these foods, there are non-dairy sources as well. When you are buying milk or yoghurt, remember that the low-fat versions provide as much, or more, calcium as whole mild or whole-milk yoghurt. Cottage cheese, creamed cottage cheese, cream and ricotta cheese arent good sources of calcium, The following table gives examples of foods you could eat to get your daily allowance of calcium: Food 1 cup (250ml) whole milk 1 cup (250ml) skim milk 1 cup (250ml) reduced-fat milk Calcium content = 300mg = 300mg = 300mg

(Reduced-fat milks vary in their calcium content. You can work out which one has the highest by comparing the calcium content marked on the cartons.) 25g (1 medium slice) cheddar cheese 200g (1 carton) yoghurt 60g (1/2 small tin) canned sardines (bones included) 50g (1/4 cup) canned salmon (bones included) = 200mg = 300mg = 200mg = 100mg

250ml (1 cup) soy milk with = 150mg added calcium (check label to make sure it has added calcium) 80g (1 cup) broccoli 100g (1 small tin) baked beans 100g (1/2 cup) houmus (chick-pea dip) 20g almonds (11 nuts) 25g (1 heaped tblspn) cottage/ricotta cheese 50g (2 heaped tblspn) bean curd or tofu = 100mg = 40mg = 45mg = 30mg = 25mg = 40mg

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The following is an example of a daily food plan that would provide 1200mg of calcium: 2 cups reduced-fat milk 1/4 cup salmon in a sandwich (lunch) 1 slice cheese (afternoon snack) 1 carton low-fat yoghurt (dessert at dinner) Total = 600mg = 100mg = 200mg = 300mg 1200mg

If you dont wish to consume dairy products, you may need to take a calcium supplement. 5. Butter or margarine

15g to 30g each. Day. Butter and margarine are sources of Vitamins A and D.

Suggested meal
Breakfast Wholegrain cereal with unprocessed bran. Egg, cheese. Toast or bread (preferably wholemeal or wholegrain) with butter, margarine or peanut butter. Milk, fruit juice, water, tea or coffee. Lunch Meat, fish, poultry, egg, cheese or legumes. Salad or lightly cooked vegetables. Bread with butter or margarine. Fresh fruit. Milk, water, tea or coffee. Dinner Potato, rice or pasta. Lightly cooked vegetables and/or salad. Fresh fruit. Yoghurt or a milk pudding. Milk, water, fruit juice, tea or coffee. If preferred, the lunch and dinner menus can be swapped.

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Snacks
Have a nutritious snack, such as fruit, milk, nuts, dried fruit, yoghurt or plain wholemeal biscuits with cheese or tomato. Keep cakes and sweet biscuits to a minimum - especially if you are over-weight.

Vitamin supplements
Doctors may recommend iron and folic-acid supplements in pregnancy. Calcium supplements may also be recommended especially if you dont like milk-based products. Other vitamin and mineral supplements arent necessary. Boost your iron intake by eating more iron-rich foods such as liver, kidney, red meats, chicken and fish. Other foods with iron include cereals, green leafy vegetables and legumes. However, our bodies dont absorb this kind of iron easily. If you add a Vitamin C-rich fruit or juice to the meal (eg. a glass of orange juice), this will help your body absorb more of the iron from these foods.

Caffeine
Too much caffeine in pregnancy can cause problems for you and your baby. It is best to limit your intake of drinks containing caffeine, such as coffee, tea, cola or chocolate. See Chapter 1, Limit Your Caffeine Intake.

Fluids
It is important to drink plenty of fluids, especially in hot weather. Water is the best thirst quencher.

Salt
Whether you are pregnant or not, it is important to cut down on salt and high-salt foods.

Takeaway food
The trouble with a lot of takeaway food is that it is too high in fat and salt. If you are away from home, carry a healthy snack, such as fruit, with you. The best choices in takeaway food are wholemeal sandwiches with a nutritious filling and plenty of salad, steak sandwiches, a cheeseburger with salad, a cheese-and-tomato or seafood pizza or Asian dishes (steamed or stir-fried dishes).

Weight gain
During pregnancy, the average weight gain is 12 kg to 14kg. Pregnant women shouldnt go on a strict diet to lose weight - this is a time when a balanced diet is essential, especially if you are overweight. If you have a weight problem, deal with it after the baby is born. As a guide to weight gain in pregnancy, you can expect to put on about 1 kg to 2kg in the first three months, and then about 1kg to 2kg each month after that. It is not necessary to eat for two. You will find you wont need much extra food - some extra milk or fruit will probably be enough. Your appetite may not always be a good guide, especially if you have strange food cravings.

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Foods to avoid
Try to avoid foods high in kilojoules which have low nutritional value. These include: sugar, glucose, honey, syrup, jam, marmalade, sweet spreads, soft drinks, cordials, effervescent glucose drinks, chocolates, lollies, cakes, pastries, pies, sweet biscuits, fatty/fried foods, dripping, lard, cooking fats and oils, sausage rolls, spring rolls, potato chips and crisps, snack foods and alcohol.

Teenage pregnancy
If you are a teenager, especially if you are under 17 and still growing, you will need more nutrients. Eat three good meals with nutritious snacks in between, as explained in the Food Plan (see this chapter). A pregnant teenager needs about 1300mg of calcium daily (about 1400mg while breastfeeding). Your doctor or midwife may prescribe iron and folic-acid supplements. Include plenty of fresh fruit and vegetables in your diet. Dont try to restrict weight gain at this time - remember that it is normal to put on weight while you are pregnant.

Vegetarian diet
If you are a vegetarian, you will need to plan your diet carefully. Milk, eggs, cheese, dried peas and beans, nuts, wholegrain cereals and bread are good sources of protein. If milk, cheese or eggs are not part of your diet, make sure you get enough protein from dried peas and beans, wholegrain cereals, bread, nuts and seeds. Eaten together, the following foods provide protein in a vegetarian diet: Cereal grains, breads and pasta (preferably wholemeal) with dried peas, beans, lentils or nuts. A light meal might be wholemeal bread with peanut butter or baked beans. Dried peas, beans or lentils with seeds (eg. kidney beans and sesame seeds) in a vegetable casserole, served with brown rice.

Changing your diet

Some disorders, including constipation, piles, morning sickness and heartburn, can be helped by changing what you eat and drink. See Chapter 6, Common Complaints.

Breast Care
Your breasts may need extra support in pregnancy. They increase in size in early pregnancy and, without support, they tend to sag and feel uncomfortable. Wearing a maternity bra will provide support during pregnancy and breastfeeding. Your breasts will also be more likely to return to their original shape after the birth. You will probably need a maternity bra by about the third month of pregnancy. Make sure it feels comfortable, has good support (including extra under-arm support), wider shoulder straps and a wider strap at the back. Extra rows of fastenings allow room for your breasts to grow. A front-fastening bra is usually easier to manage when you start breastfeeding.

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If your breasts leak drops of colostrum (the first milk produced by your breasts, usually a creamy yellow) during pregnancy, you can buy nursing pads from a pharmacy. You can also make little pads of towelling or other absorbent material and put them inside the bra cups. These are handy later on when you are breastfeeding.

Preparing nipples
Nipples are designed for breastfeeding, so if yours are an average shape and size, they probably wont need any preparation. Treat nipples gently - carefully wash off any dried colostrum and pat them dry (no brisk rubbing). Do not use soap on the nipples - it can dry them out. There is no need to put oil or cream on your nipples - they have their own builtin lubricant. Adding anything else may clog the oil producing glands. A flat or inverted nipple is one that doesnt protrude when it is stimulated. This can make it hard for the baby to suck. If you have a nipple like this, tell your doctor, midwife or antenatal clinic staff so that they can organise extra help with your breastfeeding.

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Common Complaints
Pregnancy is a time when many women look and feel particularly well. But it is also a time when your body goes through a lot of changes that can result in some side effects.

Backache
Lower back pain is common in later pregnancy. It is probably caused by the softening of the ligaments of the lower back and pelvis in preparation for childbirth. It might also be caused by the extra weight of the uterus. Back-mobility exercises (see Chapter 8, BackMobility Exercise) can help, as can your other regular exercise, including walking. Try to alternate standing and sitting activities, but dont stand when you can sit. Have a rest each day (preferably lying down) and avoid wearing high-heeled shoes in the second half of pregnancy. Elbow circling helps to relieve pain in the upper back - put your fingers on your shoulders and make circles backwards with your elbows. Tell your doctor or midwife if backache is severe or persistent.

Bleeding gums
Bleeding gums are caused by plaque building up on your teeth and irritating your gums. Gums are more easily irritated during pregnancy so it is very important to keep them healthy and avoid infection. Infected gums (gingivitis) can eventually cause tooth loss. Careful brushing and flossing will help prevent this. Have a dental checkup before falling pregnant or early in pregnancy to make sure teeth and gums are in good shape. See your dentist if bleeding gums persist for any length of time.

Breathlessness
It is normal to feel short of breath when you exert yourself in the last few weeks of pregnancy. It is caused by your growing uterus restricting your breathing. Breathlessness can also happen when you are lying down - sleeping propped up on a couple of pillows should help. Women having their first baby may notice that feelings of breathlessness disappear towards the end of pregnancy. That is because the uterus drops as the babys head moves down into the pelvis. This is called lightening and it takes the pressure off the chest (and often eases any heartburn too). It seldom occurs in subsequent pregnancies. If you have a bad cough or cold, with sudden attacks of breathlessness or breathing problems, tell your doctor or midwife.

Constipation
Hormonal changes can make bowels less efficient during pregnancy. Counteract this with regular exercise (walking is good), plenty of fluids and fibre-rich foods, such as wholegrain bread and cereals, unprocessed bran, vegetables, fresh and dried fruits, nuts, dried beans and dried peas.

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Although it is safe to use a mild laxative or a fibre supplement until diet and exercise begin to take effect, strong laxatives should be avoided. Constipation can sometimes be caused by iron tablets too - ask your doctor about changing to a different type.

Cramps
Muscle cramps in the foot, leg or thigh can strike at night, usually in late pregnancy. Try rubbing the muscle hard or stretching it by walking around for a while. Relieve a foot cramp by bending your foot upwards with your hand. Some doctors think these cramps can be caused by a lack of calcium. Ask your doctor or midwife about taking a calcium supplement.

Feeling faint
Pregnancy affects the circulation. Standing for too long, especially when it is hot, can make you feel faint, or you may feel dizzy if you get up quickly after lying down. Lie or sit down at the first sign of faintness and put your head between your legs until you feel better. Drinking plenty of fluids also helps. Frequent dizziness or fainting early in pregnancy (especially if there is vaginal bleeding or abdominal pain) means you should see a doctor quickly to rule out an ectopic pregnancy.

Food cravings
Sudden urges for lots of sweets, fruit or cereals, or cravings for unusual foods are probably caused by hormonal changes. It is fine to indulge these cravings occasionally, as long as your diet remains healthy and balanced.

Frequent urination
In early pregnancy, frequent urination is possibly caused by hormonal changes, but in later pregnancy, it is probably due to the weight of the uterus pressing on the bladder. You may find emptying the bladder completely more difficult in later pregnancy. In the last few weeks of pregnancy, you may leak a little urine when you sneeze, cough or lift something. This is why it is important to do pelvic floor exercises regularly (see Chapter 8, Exercises for Pelvic Floor Muscles). The condition usually improves a few weeks after the birth. Any pain or scalding when you urinate may mean an infection, so see your doctor promptly.

Headaches
Headaches are more likely in the early months. Rest and relaxation are the best solutions. If headaches are frequent and severe, tell your doctor or midwife. In later pregnancy, this could be a sign of high blood pressure.

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Heartburn
A burning feeling in your chest, sometimes accompanied by a taste of bitter fluid in your mouth, is common in the second half of pregnancy. The best remedy is to sit up for a while and to neutralise the acid with a drink of milk. Preventive measures include: eating slowly; eating frequent, small meals instead of one large one; drinking fluid separately from meals (half an hour before or an hour and a half after); and avoiding foods that make the problem worse (eg. fatty or spicy foods). Sleeping in a semi-upright position, supported by pillows, can also help - this makes it harder for the fluid to spill into the food passage. If these measures dont help, your doctor may prescribe an antacid.

Itching
As your baby grows, the skin of your abdomen gets tighter and may itch a lot. You should tell your doctor about persistent itchiness as it may indicate liver problems. Itchy genitals may mean a thrush infection, so see your doctor.

Morning sickness
Although nausea is more common in the morning, it can happen at any time of the day. It ranges from mild queasiness to actual vomiting. Starting early in pregnancy, it usually continues until the 12th to the 14th week, but there is a lot you can do to prevent or minimise it. Nausea usually strikes when your stomach is either very empty or very full, so it makes sense to eat frequent, small meals rather than large ones hours apart. Nibbling on dry biscuits, dry toast, peppermints or pieces of apple can help, so can dry ginger ale. (If you work, remember to keep a supply of these things with you.) Some find acupressure bands on the wrists helpful. These were originally designed for car sickness and are available from pharmacies. Avoid anything that triggers your nausea - common culprits included fatty or spicy foods, coffee, tea, alcohol or tobacco smoke. If you feel sick first thing in the morning, stay in bed for a few minutes with a dry biscuit and a cup of tea (keep a vacuum flask beside the bed). Sudden movements, such as jumping out of bed, racing to the shower or running to the bus, can make you feel sick too. If nothing works and you feel exhausted, or you are vomiting a lot and losing weight, see your doctor.

Nose bleeds
Nose bleeds can occur because of the increased supply of blood to the lining of your nose during pregnancy. Blowing your nose gently helps prevent nose bleeds. However, if they do occur, try applying pressure or an ice pack. If this fails to stop the bleeding, see a doctor as soon as possible.

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Piles (haemorrhoids)
These are varicose veins in the rectum and anus which cause soreness, itching and slight bleeding. They can be triggered by constipation (see this chapter, Constipation) and/or pressure from the babys head. The best remedy is to avoid straining (squatting rather than sitting on the toilet may help). Ask your doctor or midwife to suggest a soothing ointment or suppository.

Saliva
You may produce extra saliva (and even dribble in your sleep!). This is quite normal.

Skin
The chances are your skin will improve during pregnancy but sometimes acne can develop for the first time or be worse than usual. Dont worry if you develop patches of darker skin on your face. These are called chloasma and will disappear after the baby is born. Oral contraceptives (the Pill) can cause the same thing. If it worries you, disguise it with a cosmetic concealing cream.

Sleeping problems
Insomnia can strike in the last few weeks of pregnancy. At this stage, sleep is easily disturbed by visits to the toilet, heartburn, a kick from the baby or difficulty getting comfortable. Many women experience disturbing dreams or nightmares in the last couple of months which can be due to anxiety about approaching childbirth and parenthood. The relaxation technique described in Chapter 8, Learning to Relax, can help you get back to sleep. Also try sleeping with one pillow under your tummy and another under your top leg, or reading for a while with a drink of warm milk and honey. If nothing works and you feel exhausted, see your doctor.

Stretch marks
Not everyone gets stretch marks - fine, red lines which usually appear on the abdomen and breasts - but they are more likely to appear if you put on weight rapidly. They dont disappear completely after pregnancy, but they do fade to a faint, silvery-white. Although experts say that massaging the skin with oils or creams wont prevent stretch marks, it will help to keep skin in good condition.

Swollen ankles
There is extra fluid in the tissues of your body during pregnancy and some of it collects in your legs. If you stand for long periods, especially in hot weather, this fluid can cause swelling in the ankles and feet. It is more noticeable towards the end of the day and usually goes down at night while you sleep. Wearing comfortable shoes and putting your feet up as often as possible will help. Although this swelling is common, tell your doctor or midwife when you first notice it happening. If the swelling is more than slight, if it is there early in the day and doesnt go down at night or if you notice it in other parts of your body (like hands and fingers), see your doctor or midwife as soon as possible. It could be the first sign of high blood pressure.

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Tiredness
In the first 12 weeks, it is normal to feel tired and lethargic - dont be surprised if your eyelids are drooping at 8pm. The changes going on in your body are probably to blame but it may also be natures way of making you rest while the baby goes through its most important stage of development. After this, your normal energy levels should return until the last weeks of pregnancy when carrying the increased weight of the baby may slow you down again.

Vaginal discharge
During pregnancy, there is usually an increase in normal vaginal discharge (clear mucus). Tell your doctor about any discharge that smells unpleasant, causes soreness, itching or irritation, is discoloured, or is causing you concern.

Varicose veins
As the uterus grows, it presses on the veins of the pelvis and slows down the return of blood from the legs to the upper body. This, plus hormonal changes, is why some women develop varicose veins - a common cause of aching, swollen legs during pregnancy. They are more common in women whose parents have varicose veins. To help prevent varicose veins: avoid wearing tight underwear or anything which fits tightly around the top of the leg it can restrict circulation; change weight frequently from foot to foot when you are standing for long periods of time; put your feet up whenever you can, with your legs supported; speed up circulation with foot exercises - move feet up and down at the ankles and around in circles a few times; put on support pantihose before you get up in the morning and wear them all through the day.

Varicose veins can also develop in the vulva (external genitals), making it sore and swollen. Tell your doctor or midwife he/she may recommend wearing a sanitary pad firmly against the swollen part as a support. Sleeping with your bottom on a pillow may also help.

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Complications in Pregnancy
Although most pregnancies go smoothly, every parent-to-be needs to be well informed about the conditions that complicate pregnancy. This makes it easier to recognise a problem and act quickly.

Warning Signs
Contact your doctor, midwife or hospital immediately if you have any of the following symptoms. While you are waiting for medical attention, rest in bed. Vaginal bleeding (however slight). Very severe nausea or vomiting several times during a short period. Severe abdominal pain. Constant clear watery vaginal discharge. A severe headache that wont go away (especially in the second half of pregnancy). Sudden swelling of the ankles, fingers and face. Sudden blurring of vision. A temperature of more than 37.80C The baby stops moving or has a marked decrease in movement for any 24-hour period from the 30th week of pregnancy onwards. Regular contractions any time before the 37th week.

Complications
Bleeding and miscarriage
Bleeding in early pregnancy (before 20 weeks) is called a threatened miscarriage (the medical term for a miscarriage is spontaneous abortion). In most cases the bleeding ceases and the pregnancy continues. If bleeding is accompanied by pain or discomfort in the lower back or abdomen (perhaps like period pains), the likelihood of a miscarriage is much greater. A miscarriage is inevitable once the cervix (neck of the uterus) is open and some of the pregnancy has come away. Since altered blood clot and pregnancy tissue may be similar in appearance, if possible, try to keep anything so that the doctor can check it. Following a miscarriage a simple procedure called a curette or D & C is usually done. A curette involves scraping the inside of the uterus with a spoon shaped instrument to remove all the pregnancy tissue. This is done to prevent heavy bleeding and infection. It is usually done under a general anaesthetic. Sometimes if an ultrasound scan shows the cavity of the uterus to be absolutely empty, a curette is not done. In this case, the term complete miscarriage may be used. When a baby has died and is born after the 20th week of pregnancy, the baby is called a stillborn baby.

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A miscarriage can be devastating for some women. One of the worst problems can be that other people dont always understand how much grief you can feel when you lose a baby this way. Although you can expect sympathy if your baby is stillborn or dies after birth, many people dont realise that you can still have real feelings for a baby that is not fully formed. It is common for you to feel guilty after a miscarriage you may think the miscarriage was caused by something you did (or didnt) do. This is rarely the case the cause is usually a major chromosomal abnormality. It helps to talk to someone who will understand what you are going through. This could be another woman who has miscarried or a hospital social worker. There are also some parent organisations listed in Appendix A, which can provide information and support.

Bleeding after week 20

Bleeding after week 20 is called antepartum haemorrhage. It is rare and usually means a problem with the placenta. It needs immediate treatment. Sometimes, instead of being attached to the top part of the uterus, some or all of the placenta is located lower in the uterus. This is called placenta praevia. When the uterus stretches in late pregnancy, it can dislodge part of the placenta, causing bleeding. Sometimes, a placenta can separate slightly from the uterus, even though it is located in the correct place. This can cause slight or heavy bleeding and, occasionally, abdominal pain. If the area that separates is large, there exists a major risk to both mother and baby. Immediate medical attention is necessary. Prompt treatment usually saves the baby, although the baby may be born pre-term and a Caesarean section may be necessary. Contact your doctor, midwife or hospital at the first sign of bleeding at any stage of your pregnancy.

Diabetes
Most women with pre-existing diabetes have successful pregnancies as long as the diabetes is kept under strict control. This means careful attention to diet as well as more frequent self-testing of blood glucose levels. You will also need to see your doctor frequently for adjustments to insulin doses. With careful supervision, complications due to diabetes are uncommon. Some women develop what is known as gestational diabetes. Gestational diabetes means diabetes in pregnancy and about 3 per cent of all pregnant women are affected by it. It normally develops 20 to 24 weeks into the pregnancy and usually only lasts for the term of the pregnancy. During pregnancy the placenta produces factors which oppose the action of insulin. This can be understood by thinking of the placenta as trying to reduce the glucose used by the mother so that more is available for the fetus. This makes control of diabetes more difficult in pregnancy and some women not otherwise diabetic become so in pregnancy (gestational diabetes). However, if you have had gestational diabetes once, you will probably develop it in subsequent pregnancies.

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Symptoms of gestational diabetes include increased tiredness, more frequent urination, thirst and recurrent infections (especially thrush). However, some women with gestational diabetes do not have any obvious symptoms. For this reason, some doctors may advise you to be tested for gestational diabetes 26 to 30 weeks into the pregnancy. This involves drinking a glucose mixture and having a blood test one hour later. It can be done by your doctor. Gestational diabetes increases the risk of your baby being born with a problem. However, if gestational diabetes is properly diagnosed, monitored (with regular blood and urine tests) and managed (with diet and sometimes insulin injections), this risk is minimised. Women with gestational diabetes are considered to have high-risk pregnancies. There is a greater chance of developing complications such as pre-eclampsia (see this chapter, High Blood Pressure) or polyhydramnios (over production of amniotic fluid, which can stretch the uterus and bring on premature labour). Regular checkups are needed to find and treat problems early. For more information on diabetes, contact Diabetes Australia, PO Box 9824, SYDNEY NSW 2001. Ph: (02) 9552 9900.

Ectopic pregnancy
Sometimes, instead of moving down to the uterus after conception, a fertilised egg gets stuck in the Fallopian tube and starts to grow there. This is called an ectopic or tubal pregnancy. It is often caused by a narrowing in the Fallopian tube which prevents the egg reaching the uterus. Symptoms include severe pain low down on one side of the abdomen, bleeding, feeling faint or vomiting. The bleeding may be mistaken for a period, especially if you dont know you are pregnant. The baby cannot survive an ectopic pregnancy. An ectopic pregnancy also poses risks to you. It is vital to contact a doctor if you suspect you may have an ectopic pregnancy surgery is needed to stop the bleeding and terminate the pregnancy. After an ectopic pregnancy, you should ask your surgeon whether you are likely to have problems becoming pregnant again.

High blood pressure

The reason why doctors and midwives carefully monitor blood pressure in pregnancy is because high blood pressure (hypertension) can be associated with reduced blood supply to the baby and serious effects on the kidneys, liver and brain of the mothers. Regular checks mean the problem can be spotted early and kept under control. This is another good reason for seeing a doctor as soon as you suspect you are pregnant and for making sure you have regular antenatal care. Raised blood pressure in later pregnancy can be an early sign of a condition called preeclampsia (also known as hypertensive disease in pregnancy or pregnancy-induced hypertension) which needs prompt treatment. Another sign of pre-eclampsia is swelling, especially in the hands, feet and face. Pre-eclampsia can develop into a much more serious, although rare, condition called eclampsia, which is marked by convulsions.

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Some women with high blood pressure may need to spend time in hospital during the pregnancy so that their blood pressure can be monitored and stabilised. Depending on the severity of the problem, the hospital stay may be a matter of days, weeks or months.

Rubella
If a woman is infected with rubella during pregnancy (especially in the first 16 weeks), it can harm the baby (see Chapter 1, Check Your Immunity to Rubella). That is why it is vital to ensure you are immune to rubella before conceiving. It is very important to avoid contact with anyone who has rubella while you are pregnant, unless you are sure you are immune. If you do have contact with someone who has it or who develops it within a few days of contact, tell your doctor as soon as possible. A blood test can be done to find out your current level of immunity. If necessary, another test will find out whether you have been infected. If you develop any kind of rash during pregnancy, tell your doctor immediately. You may need to have a blood test to determine whether you have rubella. If a pregnant woman does catch rubella in the first 16 weeks of pregnancy, the couple may want to have special tests done to see if the baby has been infected, or discuss terminating the pregnancy (see Check Your Immunity to Rubella).

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Preparing for childbirth

Antenatal Courses
There are real advantages in attending special courses designed to offer you physical and emotional advice in preparation for childbirth and parenthood. Besides boosting your confidence and reducing any anxiety you may have, they also give you the chance to ask questions and discuss your feelings about pregnancy and parenthood. It is also a good way of meeting other parents-to-be. The course content can vary, but usually includes: information about labour and birthing procedures; classes on relaxation, breath awareness and other skills to help you during pregnancy and birth; instruction on exercises to strengthen muscles that are stretched in pregnancy and childbirth; information on how to care for your new baby at home; opportunities to discuss how you and your partner feel about pregnancy, childbirth and parenthood.

Antenatal courses are held in most hospitals and some Community Health Centres. Courses are also available through the Childbirth Education Association and other private educators, (see Appendix A).

Relaxation and Breath Awareness

Relaxation and breath awareness are two good self-help techniques for you to use in childbirth. Besides helping to relieve pain, they will keep your body relaxed. This means: your uterus will work more efficiently; you will conserve energy and feel less tired all the time; you and baby will get plenty of oxygen through deep, relaxed breathing; you will be better able to cope with stress, not just during pregnancy and labour but at any time in your life.

The first step in learning to relax is to find a position in which you feel totally comfortable.

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Learning to relax
To relax, you must learn how to recognise physical tension and how to consciously relax your muscles and relieve that tension. This process of letting go not only relaxes you physically, it also induces a feeling of emotional calm as well.

Recognising tension
Practise this technique at home once or twice a day for at least 10 minutes at a time. It is a good idea if your partner or other support person understands the technique as well.
Use a number of positions when you are learning to relax. Try sitting down and leaning forward onto a pillow on a table.

First, sit or lie in a supported position in a quiet room (play some relaxing music, if you like). You should be very comfortable with pillows supporting all body curves. If you must lie on your back, it is better to have your shoulders raised rather than lying flat. This prevents you from feeling faint. 1 Clench your right hand and tense the arm muscles up to your shoulder. Now release the tension, giving a long, sighing, outward breath as you let go and relax. Feel your arm go loose and be aware of how breathing out helps you relax. Relax more with each outward breath. 2 Repeat this with your left hand and arm, followed by your right foot and leg and, finally, the left foot and left leg. When tensing, you prevent cramps by pulling your foot up at the ankle joint and stiffening your knee. 3 Bunch your shoulders up towards your ears. Be conscious of how tense it makes you now relax as you breathe out. 4 Tighten the muscles around your genitals and anus (these muscles are part of your pelvic floor) and squeeze your buttocks together. Then let go as you breathe out. 5 Clench your jaw and frown, tightening your face and scalp muscles. Now breathe out and relax. 6 Once you have learned the difference between a tense muscle and a relaxed one, you can follow these steps without first tensing the muscles. Simply release the tension from all the muscles of your body from your face (including the jaw), arms and legs, buttocks and pelvis. Let go and allow them to rest completely. Feel your body become very heavy or perhaps lighter. Practise relaxing in this way in a number of positions, especially those you may use during the first stage of labour. You could try it sitting down and leaning forward onto a pillow on a table, for example. Once you have learned this relaxation technique, you can use it to cope with stress at any time.

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Breath awareness
Breathing can be used to release tension in labour and help your body stay relaxed. It can also help you resist any premature urge to push which may occur late in the first stage of labour. It helps you flow with contractions rather than tense up or fight against them. Breathing more slowly helps your body relax. Everyones rate of breathing is different (15 to 20 breaths per minute is average), but try to breathe as slowly and deeply as is comfortable for you. Accentuate the outward breath, allowing any tension to flow out with the air from your lungs. It may help to make a steady noise or a groan (aaah or hmmm) as you do this. Pause at the beginning of each contraction to take a cleansing breath. This is a very relaxed breath (like a sigh) designed to cue your body to relax.

When to use breath awareness

During early contractions, relax with normal breathing. It is best to try to ignore contractions at this early stage and get on with your normal routine, moving about as much as possible. When it becomes difficult to relax using normal breathing during first-stage contractions, keep breathing deeply and slowly for as long as possible. Your breathing will become a little faster as the contractions get stronger, but try to slow your breathing down to your normal rate or a little slower.

Practising breath awareness

Imagine you are having contractions (they last from 30 to 60 seconds) and practise breathing slowly and deeply in a variety of positions sitting, standing, kneeling or leaning forward against a support. Always take a cleansing breath at the beginning and end of each contraction, and sigh with each outward breath. If you feel dizzy at any stage, stop. Next time you practise, make sure you breathe more slowly.

Massage
Besides being relaxing for anyone at any time, massage can help to relax and relieve pain in labour. There are no rules experiment and see what feels good for you (but tell the person doing the massage if something doesnt feel good). Using oil makes massage smoother. Massage of the scalp (like shampooing hair, slowly) can also be very relaxing.

Positioning
Changing positions in labour and remaining upright is very useful. However, to feel comfortable about adopting these positions during labour, it is important to practise them in pregnancy.

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Antenatal Exercises
During pregnancy and childbirth, the muscles in your abdomen, pelvic floor and back have to work harder than usual. Antenatal exercises will help to keep these muscles strong. These exercises have been designed to fit into the busiest day. The floor exercises will only take about five minutes once or twice a day. The other exercises can be practised during normal activities at work or home. It is best to start these exercises as early as possible in pregnancy. If you can do them before pregnancy, better still. Check with your doctor first to make sure there are no reasons why you should not do them. Remember: Do the exercises slowly and smoothly. Relax after each one. Dont strain. Repeat each exercise two or three times at first, gradually increasing to six. Practise once or twice daily (unless advised otherwise). Antenatal exercises shouldnt cause pain or make you arch the small of your back. If this happens, stop the exercise and see a physiotherapist for advice.

Exercises for abdominal muscles

Abdominal muscles are stretched in pregnancy to make room for your growing uterus. They usually separate down the middle to allow more room. However, they need to be strong. Besides having to support the uterus and baby and protect your back against injury, you use them to push during the birth. To check that your abdominal muscles have separated, lie on your back with your knees bent and feet flat on the floor. Press the fingers of one hand gently onto the area around your navel. Breathe out and raise your head and shoulders a little. If there is a separation, you will see and feel a bulge and be able to feel the two, separate edges of the muscle. 1. Pelvic tilt

Lie on your back with your head on a pillow, your knees bent up and your feet flat on the floor. Use two or three pillows, depending on their size, under your head and shoulders as the uterus becomes larger. (Lying flat later in pregnancy may make you feel faint.) Put your hands onto your abdomen to feel your muscles tighten. Breathe normally as you pull in your abdominal muscles, then flatten the hollow of your back onto the floor and squeeze your buttocks together. Try to hold this position for six seconds, then slowly relax. Feel the pelvis tilt backwards as you flatten your back. Dont hold your breath. This exercise helps you to maintain good posture. Practise it as often as you can in different positions, eg. lying on your side, kneeling on all fours, sitting in a chair or standing.

Pelvic tilt.

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2.

Raise and lower knees

Lie on your back as for pelvic tilt. Flatten the small of your back onto the floor. Lift one knee towards your chest, keeping it bent, followed by the other knee. Hold it for six seconds, keeping your back flat. Now slowly lower one leg at a time back to the floor, still keeping your back flattened. Relax. Dont hold your breath. Dont do this exercise in later pregnancy if it makes you feel uncomfortable or dizzy. 3. Straight curl up

Lie on your back as for pelvic tilt. Fold arms across your abdomen to support the separated muscles, as usually, to a certain extent, they have separated. Raise head and shoulders as you breathe out until the separation begins to bulge. Hold for six seconds, breathing normally, then lower back slowly. Relax. Dont curl up further than halfway to the knees. Dont do this exercise in later pregnancy if you feel faint or uncomfortable. 4 Isometric abdominal exercise

DONT DO this exercise if your abdominal muscles are separated. Sit in a chair with your back and feet supported. Press the heel of your right hand against the inside of your left knee. Dont let the knee move. Hold for six seconds, feeling your abdominal muscles tighten. Relax slowly. Repeat with the left hand against the right knee.

Exercise for pelvic floor muscles

Pelvic floor muscles form the floor of the pelvis and support the organs inside your pelvis, including the uterus. The following exercises will help prevent leaking of urine when you cough or laugh. Lie back with head and shoulders well supported and raised on pillows. Your knees should be bent up and apart, with feet flat on the floor. Tighten and pull up the muscles around the vagina and anus. Hold, then slowly relax. It feels as if you are trying to stop yourself from urinating or having a bowel movement. Be aware of the released feeling in these muscles around the vagina as you relax them. It will be important for you to try to relax like this during the second stage of labour.
Top: Straight curl up. Bottom: Isometric abdominal exercise.

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Once you have practised this lying down, practise it sitting and standing as well. Try to do up to 50 contractions every day in groups of five. Hold each, tightening for a few seconds at first, gradually building up to six seconds.

Back-mobility exercise
This exercise helps prevent and ease stiffness and aching in the lower back. The position also helps relieve pelvic congestion and discomfort. Kneel on all fours. Round the small of your back and tighten your abdominal muscles at the same time, then relax until your back is straight and not hollowed. This movement tilts the pelvis as in the pelvic tilt exercise.

Posture check
During pregnancy and after birth, you are more likely to have back problems this is because your ligaments are softer and your muscles are weaker. But good posture and back care will help to prevent back pain and fatigue. Good posture needs a lot of practice get used to checking or correcting it at set times of the day. Sit, stand and walk tall. Stretch up tall from the top of your head, chin tucked in and shoulders relaxed. Be aware of the hollow in the small of your back. Correct this by tilting your pelvis forward a little, as in the pelvic tilt exercise. Pull your abdominal muscles in towards the spine. Relax out again slowly. Now pull in again just a little. Try to maintain this tucked in feeling all the time. When standing, your knees should be straight but not braced back hard. Wear low-heeled shoes or no shoes. When sitting, the small of your back should be well supported. Avoid lifting heavy weights. Even when you are lifting light objects, bend your knees, not your back.

Stretching
Stretching exercises can do a lot for you in pregnancy. They: increase the range of movement in your joints; help to make you more relaxed;
Top: Exercise for back mobility - rounding the small of your back. Bottom: Exercise for back mobility - relaxing until your back is straight.

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help you become aware of your body, and of what it can and cant do; encourage good posture and free movement; help you maintain positions in labour without becoming uncomfortable.

You can start stretching exercises any time in your pregnancy. Begin by holding each pose as long a possible (even if it is only for a few seconds). Gradually increase this time until you can hold for two or three minutes. 1. Calf stretch

Stand facing a wall, about 30cm away from it, with one foot about 1m in front of the other. Your arms should be outstretched towards the wall. Lean your upper body forward into the wall and rest your head on your arms. Bend your front knee so that your back leg takes all your weight. Hold for a minute, breathing into the stretch, and then change legs. 2. Shoulder rotations

Sit cross-legged with your back supported against a wall. Place fingers on each shoulder and make circles backwards with your elbows. Stretch your arms over your head to smooth out tightness in the shoulders and upper back to relieve pressure under your rib cage. 3. Leg stretch

Sit upright, legs apart, knees straight, hands clasped behind your back. Slowly move your body forward so that your chest gets closer to your right knee make sure that you keep your back straight. Hold for a minute, breathing into the stretch, then return to the beginning, this time leaning over your left leg. 4. Butterfly sitting

Sit upright, soles of feet together and as close to your body as possible. Clasp your feet with your hands. Gently push your knees toward the floor and hold the position as you breathe into the stretch. Relax and repeat. Make sure your back is always straight. 5. Japanese sitting

Kneel on the floor with your knees as wide apart as possible, your toes pointing towards each other. Slowly move forward from the hips, keeping your buttocks down and your back straight until your hands reach the floor and you feel the stretch in your groin. If you dont feel a stretch, go down further onto your elbows. 6. Squatting

If you have varicose veins in your legs, piles (haemorrhoids) or if you have a cervical stitch, do the dictionary squat only. You can use a low stool instead of books if you prefer. You may need to hold something for support at first. Dictionary squat: Put a few large books under your buttocks and then remove the books one by one as your squatting improves. Squat against a wall, using the wall as a touch of support for your lower back.

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Squat with a firm cushion under your heels. To keep your balance, hold onto a friend, a bath rail or something similar.

Now progress to an unsupported squat: Stand with your feet about 1m apart, toes pointing forward. Keep your back straight and feet flat as you squat. Clasp your hands and spread your knees apart with your elbows. Stay there for a few minutes or as long as you are able.

Summary
Exercises to be practised once or twice daily: Raise and lower knees Straight curl up Isometric abdominal exercise Back-mobility exercise

Exercises to be practised frequently during the day: Pelvic tilt Exercise for pelvic floor muscles Posture check Stretching

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Childbirth
Preparation
What you need
Save a lot of last-minute panic by getting organised a month or so in advance. When you book into the hospital or birth centre, you will be given a list of items to bring. It will probably include: 3-4 nightdresses (front-opening ones are best if you are breastfeeding); dressing gown (you can take some loose, comfortable day clothes to wear as well, if you like); slippers; two nursing bras and nursing pads for your breasts; six (or more) pairs of briefs; sanitary pads; toiletries; clothes for you and the baby to wear when you go home. Your own going-home clothes need to be loose-fitting you wont be back to your usual size.

If you are having the baby at home, your midwife will tell you what you need.

Other children
It is not always easy for children to share their parents with a new baby. If they are old enough to understand, preparing them in advance will help. Small children (especially under-twos) will find it easier to cope with separation if they can visit you in hospital and be reassured how much you love them. You may consider preparing small gifts for any older children for when they first visit the baby in hospital. This can help counteract feelings of jealousy about all the attention paid to the new baby. Arrange for someone to look after the children when you go into hospital and explain the arrangements to children who are old enough to understand. If you have no one to care for the children, there are some community agencies who can help. Ask the social worker at the hospital or a local Community Health Centre (see Appendix A) for advice.

Stocking up
Newborn babies are very demanding in the early weeks so there wont be much time to cook or shop. Organise it so that you and your partner do some shopping in advance, and cook and freeze some meals. Stock up on sanitary pads too you will have a discharge for some weeks after the birth.

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Housework
Now is the time to discuss chore sharing with your partner. Couples who work often share chores, but this arrangement has a habit of changing when a baby comes along. The partner staying at home can end up doing most of the domestic labour. Some women resent this. It makes sense to discuss how you will divide the household chores with your partner beforehand.

Making new friends

Women who work outside the home until their first baby is born dont always have the chance to meet other women with babies and small children. After years of working with other people, suddenly finding yourself at home, alone with your baby, can make you feel unexpectedly isolated. Early motherhood is a lot easier if you have other women to talk to. Pregnancy is a good time to try to get to know other women at home or to find out about playgroups, womens groups or other community activities in the area. Early Childhood Health Centres run first mothers groups where you can meet other women with babies the same age as yours.

Changes in Your Body

In the last few weeks or days of pregnancy, you may notice changes in your body. These may include: more frequent Braxton Hicks contractions a painless tightening of the uterus as it practises for birth; lightening when the babys head moves into the pelvis 2-4 weeks before labour begins (usually later if it is not your first child); pressure in the pelvis; more frequent urination; weight loss of around 1kg about a week before the birth; mild diarrhoea; a spurt of energy and an urge to get things done around the house (this is your nesting instinct showing); feeling anxious or excited.

When to Go to Hospital
Ask about the best time to go to hospital at one of the antenatal visits. If this is your first baby and you are well prepared and confident, you will probably be advised to go to hospital when contractions are at regular five-minute intervals and are moderately strong. On the other hand, if you live some distance from the hospital, it might be best to go into hospital as soon as labour starts. If you feel anxious, no matter how early in labour you are, head for the hospital. Dont worry if you arrive early the main thing is your peace of mind.

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Ring the hospital before you leave and speak to one of the midwives in the delivery suite to let them know you are on your way. If you are travelling to hospital by car and feel as if the baby is about to be born, go to the nearest hospital, even if it is not the one you booked into.

When Does Labour Begin?

Labour can start some days (or one or two weeks) before the due date, or up to two weeks after it. It can start in one of several ways with contractions, a show or breaking of the waters. These can happen in any order.

Contractions
These may be mild at first. Your back may ache or you may notice the sort of aching, heavy feeling you sometimes get with a period. Gradually, these contractions become more regular, closer together, longer and more painful. You will know they are the real thing (and not just Braxton Hicks contractions) when they become stronger and more frequent. You may also feel sick, vomit or have diarrhoea.

A show
During pregnancy, the cervix (neck of the uterus) is partly sealed with a plug of mucus. Before or during labour, this plug comes loose and passes out of the vagina. If this happens before labour, it may appear in the toilet or on your underwear as a small amount of pinkish mucus it is a sign your cervix is starting to stretch. However, it may be several hours or perhaps a day before contractions start or your waters break.

Breaking of the waters

The membrane bag that holds the baby and the fluid it floats in (the amniotic sac) may burst at the beginning of labour or when labour is under way. Fluid may leak or gush from the vagina. As soon as your waters break, contact the hospital or birth centre. Prompt medical attention is required as a safeguard against infection. The hospital or birth centre will ask you to go in even if there is no sign of a show or contractions. Once labour begins, you may be told not to eat or drink anything. This is to prevent you from feeling sick later on in labour. It is also a precaution in case a Caesarean is necessary and you need a general anaesthetic. However, you can keep your mouth moist by sucking ice or barley sugar or having sips of water. If labour starts during the day, continue your normal routine at home until it is time to go to hospital. It is best if you can stay as mobile and upright as possible. If it starts at night, conserve your energy by resting or sleeping.

At the Hospital
What happens on arrival at hospital varies, so this is just a guide. It is a good idea to find out in advance about your hospitals procedure.

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The midwife who admits you may: put an ID bracelet onto your wrist; ask how labour is progressing; check your temperature, pulse and blood pressure; check the babys position by feeling your abdomen; time the babys heart rate; time your contractions; test your urine; do an internal examination to find out how much your cervix has opened, and to confirm the babys position.

Some of these tests and checks are repeated routinely throughout labour. Some hospitals may: shave or trim your pubic hair. (This used to be standard but usually doesnt happen now); ask if you would like a shower.

Although this is rarely carried out some hospitals may also offer you an enema to clear your bowels. The advantage of an enema is that it will remove any fears you may have about emptying your bowels during the birth. However, if you have been to the toilet beforehand and feel comfortable, you may decide not to have one. Some hospitals have a lounge room where you can spend the early part of labour. Other hospitals use a delivery suite from start to finish. If you need a general anaesthetic, blood transfusion, assisted delivery or a Caesarean, the hospital staff should discuss it with you and then obtain your informed consent.

Labour
When your baby is ready to be born, it will usually be curled up with its head down, arms tucked in and knees bent. (Birth is usually head first this is thought to make it easier for the baby to fit through the bones of your pelvis.) There are three stages in labour. The first stage starts with regular contractions and cervical dilation and lasts until the cervix has opened up fully. The second stage is when the baby is pushed down the vagina and is born. They third stage is when the placenta comes away from the uterus and is pushed out of the vagina.

First stage
This is the longest part of labour. Although it is anyones guess how long your labour will last, the average length of the first stage of labour is between 10 and 14 hours for a first baby and about eight hours for subsequent babies.

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During this time, contractions gradually open up the cervix until it is about 10cm wide (this means it is fully dilated). It may not seem much, but it is wide enough for a baby to come through. At this time, it would be best to move around for most of the first stage and use some of the positions described later in this chapter. What do contractions feel like? First, the muscles of the uterus tighten and the pressure slowly builds up to a mild, moderate or strong level of pain (depending on how far labour has gone). Then this feeling of pressure and pain reaches a plateau in other words, it stays briefly at that same level and gradually fades away.

The first stage of labour: Contractions gradually open up the cervix until it is about 10cm wide.

These contractions gradually intensify and come closer together until each one is about a minute long and coming at a rate of one contraction every two to three minutes. There will be a break of one to two minutes between contractions at their strongest. During the first stage, a midwife may do an internal examination regularly to see how far the cervix has opened. The babys heartbeat will be monitored frequently to see how well it is coping with labour. This may be done with a stethoscope or with an instrument held against your abdomen. Sometimes, electronic monitors are used. There are two kinds, internal and external. External monitoring External monitoring involves two belts being attached to your abdomen these belts are wired to a machine that gives a print-out of the babys heartbeat and your contractions. Internal monitoring Internal monitoring provides the same information as external monitoring but via an electrode attached to the babys scalp (to check the heartbeat) and via a tube inside the uterus (to record contractions). These are often used to monitor a babys condition, particularly if the baby is in distress. A mixture of internal and external monitoring can also be used that is, an external monitor to record the contractions and an internal monitor for the babys heartbeat. Towards the end of the first stage of labour, when the cervix is almost completely open, you may feel the urge to push. The midwife will ask you to try not to push until the cervix has opened up fully.

Transition period
There is a transition or changeover period between the first and second stages. It usually lasts five to 45 minutes, and you may feel shaky and nauseous. You may vomit (which will make you feel better), feel irritable, anxious and as if you cant cope one minute longer. Not all women experience these things, but if you do, dont worry it wont last long, and it signals progress towards the birth.

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Second stage
This is much shorter (around 45 minutes to two hours for a first baby; between 15 and 45 minutes for subsequent babies). An urge to push will indicate the second stage. You can then start to push with the contractions. Some women choose to stand, squat, sit on a birthing stool or kneel on all fours. Find the position that feels best for you. Remember, you need only stay in a squat or kneeling position for the duration of each contraction, then you can lie down or lean forward onto a bean bag to rest and wait for the next contraction. You will probably need your partner or support person to physically assist you in changing positions. As each contraction starts and your body signals you to push, you will notice that you hold your breath (for no more than six to seven seconds), your abdomen will tense and your uterus will push your baby down the vagina. Try to keep the muscles of your perineum (the area between the vagina and anus) relaxed as you push. Concentrate on keeping your jaw relaxed, as well as the vagina and pelvic floor. You may find you are making a noise or groaning. This is normal. With each contraction, your body may signal three or four pushes. If it doesnt, you need to change your position and be more upright. You may feel as if you are going to open your bowels at this stage it is caused by the pressure on the back passage as the baby moves down the vagina. When the babys head starts to press against the entrance to the vagina and it opens, you will feel a burning sensation as the skin stretches. The doctor or midwife will try to make sure the head emerges slowly by asking you to pant this helps to prevent the skin of the perineum tearing. You may like to use a mirror to watch the babys head appearing through the vagina. Once the head is through, most of the hard work is over and the baby is usually born quite quickly. After birth, most midwives put the baby onto your abdomen with the cord still attached. Your partner may be given the choice of cutting the cord.

The second stage of labour, with the babys head partly outside the vagina.

The second stage of labour, with the babys head fully outside the vagina.

The third stage of labour, when the placenta comes away from the uterus and is pushed out of the vagina.

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Third stage
After the baby is born, contractions will push out the placenta. You will be given an injection just as the baby is being born to help the uterus contract and to help the placenta separate safely from the uterus. This stage is usually over in about 15 minutes, after the baby has been born.

Positions for Giving Birth

Giving birth in an upright position (eg. sitting, straddling a chair, standing, squatting) means you have got the force of gravity on your side this helps the baby out. These positions also increase the pressure of the babys head on the cervix. This triggers the release of a hormone which makes your contractions more efficient. Squatting can help in the second stage of labour because it widens your pelvis. Another advantage of squatting or standing is that it evens out the pressure of your perineum this means you are less likely to tear or need an episiotomy (a small cut made in the perineum to enlarge the vaginal opening and help prevent tearing of the skin). Some women like to give birth kneeling on all fours for the same reason. This position also helps with pain relief because it takes the pressure off your back, but rules out any help from gravity.

Find positions that feel right for you - you may choose to stand, squat, sit or kneel.

Pain Relief
As labour progresses, you will probably find the contractions become painful. During pregnancy, you will need to think about how you will cope with this. Find out what sort of pain relief will be available in your hospital. Try to think about what you might choose and talk it over with your partner or other support person, as well as your doctor or midwife.

Moving around during the first stage of labour can distract you from the pain and keep your circulation going.

Self-help
You will feel much more relaxed if you understand what is happening to you. Anxiety makes muscles tense and increases pain. Dont hesitate to ask questions during labour if there is something you dont understand.

Relaxation and breath awareness

Labour is the time to put the relaxation and breath awareness techniques you learnt in pregnancy to good use. Some women find soothing music helps them to relax, especially any music they listened to while practising relaxation techniques in pregnancy.
Kneeling on all fours during the first stage of labour can help with pain relief because it takes the pressure off your back.

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This music can act as a cue that helps you to relax automatically. Check with the hospital to see if you can take a cassette player with you.

Heat and water

A hot bath or shower may help to reduce tension and ease backache in labour. Alternatively, a well wrung-out, hot, wet nappy or towel, or a hot pack (provided by some hospitals) feels good too, especially along the spine, on the hip joint or the pubic bone.

Massage
Massage reduces muscle tension during labour. Ask your partner or support person to practise massage techniques with you regularly during pregnancy

Adopting an upright position, such as straddling a chair, is helpful during the first stage of labour. It means youve got the force of gravity on your side.

Visualisation
Conjure up a mental picture of your cervix. Imagine it looking like the opening of a polo-neck sweater with the babys head just visible. Imagine the polo neck gradually widening away from the babys head. Some people believe that this technique helps your body to work more effectively during labour. As each contraction begins, imagine the uterine muscles working to pull back the cervix to let the baby be born as you breathe and move through each contraction.

Lie down or lean forward into a bean bag to rest between contractions.

Groaning
Dont feel you have to keep a stiff upper lip. Groaning as an expression of pain or effort is a natural thing to do (if athletes can grunt when they exert themselves, so can you!). Trying to stifle your pain will only make you feel more tense.

Staying active
Walking around during labour can help with pain it can distract you from the pain and keep your circulation going. Staying upright also means you have the force of gravity working for you.

Your support person can help take your weight in some positions.

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Changing positions
Staying in the same position for too long can get uncomfortable and doesnt serve to reduce the pain of contractions. It is best to use a variety of positions in labour. Although you may feel you dont want to move, you will find that changing position frequently can help you cope better with contractions. Your partner or support person can help.

Drugs in Labour
If you have spent your entire pregnancy talking about the drug-free labour you are planning only to find you do need pain relief from drugs, it doesnt mean you have failed. Labour is very unpredictable and it is impossible to anticipate how much pain there will be and how you will react. The length of your labour and the time of day it starts also affect your perception of pain and your need for pain relief. You will probably cope better in a short, day-time labour than a long labour that deprives you of sleep.

Sedatives and tranquillisers

Sedatives and tranquillisers are not used for pain relief, but are sometimes offered at night in early labour to help you sleep (and conserve energy) or calm you down if you are very anxious. They dont usually affect the baby some tranquillisers and sedatives may cause jaundice or sleepiness in the newborn baby, but it depends on the dosage and when they are given.

Squatting can make the second stage of labour easier because it widens your pelvis and evens out pressure on your perineum.

Gas
Gas is usually a mixture of nitrous oxide and oxygen which takes the edge off pain but does not remove it altogether. You breathe it in through a mask which you hold yourself. There is no danger of overdosing yourself (when you feel too whoozy, you drop the mask). Its advantage is that it doesnt accumulate in your body to affect you or your baby. However, it can sometimes make you feel nauseous, drowsy or confused.
Ask your support person to give you a massage to help relieve muscle tension.

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Pethidine
Pethidine is a narcotic given by injection. It lessens pain for two to four hours or more. The disadvantage of this drug is that it can make you feel drowsy, dizzy, nauseous or make you vomit. If the drug is given within an hour or so of delivery, the baby may be a little sleepy and slow to breathe. These effects can be reversed by treatment from the doctor.

Epidural
Epidural is a type of local anaesthetic injected around the spinal cord. It is given by an anaesthetist and blocks pain quickly and safely. For some women, however, it doesnt work completely. Its advantage is that you have excellent pain relief and stay alert. It can be helpful in long labours or if you are very distressed.
A hot bath or shower may help to reduce pain and ease backache in labour. Some hospitals provide these facilities.

The disadvantages are that it may make it harder for you to push during the second stage of labour and this increases the chances of a forceps delivery and episiotomy. It can also cause low blood pressure, headaches or backache. (All of these conditions do not have a long term effect.)

Support Persons Role

Having someone to talk to and give you moral support is a big help during labour. But there are also practical things he/she can do, such as: wipe your face, rub your back, give you sips of water, hold your hand, help your change position; remind you to use relaxation and breath awareness techniques, and actually mimic the breathing for you so you can follow this cue; support your decisions (about pain relief, for example); tell you how well you are coping.

Besides being tiring for you, a long labour can also be tiring for the partner, friend or relative who is with you. Sometimes, it is good to have more than one support person on hand so they can take turns helping.

Medical Intervention
Although it is best to keep medical intervention to a minimum, there are times when it helps. It is a good idea to be well informed about these procedures. Discuss them with your doctor or midwife before going into labour.

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Induction
Induction means starting labour artificially. It is usually done when there is believed to be some risk to the health of you or your baby if the pregnancy is allowed to continue, eg. you have high blood pressure or the baby appears to have stopped growing. Induction is usually planned ahead, so you will be able to discuss the reasons for it with your doctor and find out what is involved. To induce labour, a small quantity of gel containing a hormone (prostaglandins) may be placed in the upper vagina near the cervix. To induce labour, the doctor may also put a drip into your arm. A hormone called oxytocin is added to the drip flask which starts the contractions. The doctor may also insert an instrument through the cervix (providing it has opened up enough) and break the bag of waters. The main risk of induction is that it may fail and you may need a Caesarean. Other problems are that when labour is begun with a hormone drip, it may make your contractions seem more painful. Having a drip in your arm wont hurt but it can tether you to the bed. Ask if your drip can be attached to a portable stand so you can move around.

Episiotomy
An episiotomy is a cut made in the perineum just as the babys head appears. The reason for an episiotomy is to speed up the second stage of labour and to prevent the perineum tearing badly. It is usually done under a local anaesthetic. Healing of an episiotomy can vary from a few weeks to a few months depending on the degree of tissue affected. Sexual difficulties and general pain and discomfort may be felt until healing is complete. See your doctor if problems persist.

Forceps delivery
Sometimes, forceps need to be used to help the baby out of the vagina. This may be because you seem unable to push it out on your own or because the baby is in an awkward position or in distress. Sometimes, the forceps make small marks on the babys head, but they soon disappear. An episiotomy is normally required with a forceps delivery.

Stirrups
Back in the 1950s, babies used to be delivered with the mother in stirrups (a metal support to hold your legs up in the air). Now they are usually only used for forceps deliveries, breech births, multiple births and sometimes for stitching episiotomies after the baby has been born.

Vacuum extraction (ventouse)

Vacuum extraction is sometimes used as an alternative to forceps delivery. The doctor inserts into the vagina a cup made of metal or plastic attached to a pump. The pump makes a vacuum which holds the cup to the babys head and enables the doctor to gently pull the baby out. There may be a slightly raised area on the babys head following a vacuum extraction but this gradually disappears.

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Caesarean section
A Caesarean section is when the baby is delivered by cutting through the abdomen into the uterus. It is usually done with a horizontal cut just below the bikini line so the scar is hidden by pubic hair. Caesareans are done for a lot of reasons sometimes because your pelvis is too small to let the baby through or because either you or your baby is at risk and delivery needs to be quick. Usually, it is done with an epidural anaesthetic, sometimes with a general anaesthetic. After a Caesarean, your baby may need extra care. You will feel uncomfortable for a few days (it hurts to laugh and it is hard to stand up straight) and you may need a little longer in hospital. Postnatal exercises are especially important after a Caesarean to get your muscles working again. A Caesarean section is a procedure which many people believe is done too often so you may want to discuss your doctors policy beforehand. You could also do some advance negotiations with the doctor and hospital staff as to how you would prefer a Caesarean to be managed if you had to have one. You could request: an epidural anaesthetic. This means you are conscious when your baby is born. The other advantage is that, unlike a general anaesthetic, your partner will often be allowed into the theatre so you can both see the baby at birth; that if you do need a general anaesthetic, your partner be allowed to hold the baby and accompany it to the nursery.

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Complications in Labour
No matter how well prepared a woman is for labour, there can be unexpected problems.

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Premature labour
Labour is premature if it starts before the 37th week of pregnancy. It may be due to problems with the placenta, a multiple birth or the mother having high blood pressure. There is also a high risk of premature labour in women who havent had adequate antenatal care. Often, the cause of premature labour is unknown. If any of the symptoms of labour occur before 37 weeks, you should contact your hospital immediately. It is safer for premature babies to be born in large, well-equipped hospitals where there are staff specially trained in looking after small babies (especially those under 1500g). Premature babies often have difficulty breathing and get cold quickly. This is why they go into a special, enclosed crib (a humidicrib) as soon as possible. Sometimes a premature baby may need to be transferred from the hospital of birth to a larger hospital with special neonatal care facilities. Your doctor will organise this if it is necessary.

Slow progress
Sometimes, your cervix may take longer to open up, it opens only part of the way or the contractions stop. The kind of help needed depends on the cause of the problem and whether there are any risks to you or the baby.

Babys position
Some babies adopt positions, such as posterior or breech, that may complicate the birth. Posterior position is when the babys head enters the birth canal facing your front instead of your back. This can involve a longer labour with more backache. Sometimes, an episiotomy is necessary, or the doctor may need to turn the babys head with forceps and/or help it out with either forceps or a vacuum pump (see Chapter 9, Forceps Delivery and Vacuum Extraction). Throughout labour, getting down on your hands and knees and pelvic rocking can relieve the backache and encourage the baby to turn to face your spine. A breech birth is when a baby is born bottom first (you may get advance warning because it can be detected from the 32nd week). Sometimes, a doctor will turn the baby manually through the abdomen, sometimes a Caesarean is done, but often the baby will be born bottom first with or without the help of forceps to deliver its head.

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Fetal distress
A baby may suffer a shortage of oxygen in labour. In such a case, the baby is said to be distressed. Signs of fetal distress are a faster or slower than usual heartbeat or a bowel movement (a greenish-black fluid called meconium that stains the fluid around the baby). If a baby is in fetal distress, its heart rate will usually be monitored (using an internal monitor, see Chapter 9, Internal Monitoring). The baby will be delivered as soon as possible (perhaps by Caesarean or with forceps) if a sample of blood taken from the babys scalp indicates the need for urgent delivery.

Retained placenta
Occasionally, the placenta doesnt come away according to plan after the baby is born, so the doctor or midwife needs to remove it promptly. This is usually done with an epidural or a general anaesthetic.

Multiple birth
When there is more than one baby, labour may be pre-term. When the last baby has been born, the placenta (or placentas) are expelled in the usual way. However, the babies are likely to need extra care at birth and for a few days afterwards.

Death of a Baby
Some babies die either before or during labour, or soon after birth. This is more likely to happen to a low birthweight baby or a baby with a developmental problem. Whatever the reason, you and your partners grief is as real and as deep as if you had lost a child later in life. Most hospitals now have specially trained staff to help bereaved parents. You and your partner are encouraged to hold your baby and to spend time with your baby. If you wish, you can go home and then come back and spend more time with the baby. You are encouraged to have keepsakes of your baby to take photographs, a hair clipping or a handprint, for example. Doing these things can help you cope better with your grief. You may refuse these mementos, but hospital staff sometimes take them and keep them anyway in case you change your mind. It is normal for you and your partner to feel angry and even wonder if you or other people were to blame for your babys death. You may be worried that other pregnancies will end the same way. It will help to talk about these things with a doctor, midwife, grief counsellor or social worker at the hospital. If you dont have anyone to talk to, a Community Health Centre can arrange for you to see a social worker or counsellor. There are also some parent organisations listed in Appendix A, which you might like to contact.

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Babies with Problems

Some babies are born with a condition which may make his or her life different in some ways, at least for a time. These babies include those who are premature and those who have an illness or some other condition which interferes with the way their body or brain works. These babies need special care in hospital care that will be supervised by a paediatrician (a doctor who specialises in caring for babies and children). If your hospital does not have the facilities and equipment needed to give your baby the special care required, your baby may need to be transferred to a different hospital. The Newborn and Paediatric Emergency Transport Service (NETS) coordinates the transfer of sick babies by road or air. It is often possible for you or your partner to travel with your baby to the new hospital. If your baby is affected, there will be many things you will want to discuss with the doctor. What is the cause of the condition and what can be done about it? How will it affect the child? Is there a chance that any other babies you have in the future will be affected in the same way? Dont hesitate to ask questions that are important to you it is a good idea to write your questions down to make sure they all get answered. A lot can be done for many of these conditions. Cleft palate and lip (hare lip) can be corrected, surgery often works wonders for heart problems and many premature babies not only survive, but arent affected by having been born pre-term. Babies with problems usually need to stay in hospital for special attention after the mother has gone home. It is important for you and your baby to get to know each other. You will be encouraged to do this as soon as possible after the birth, even if the baby is in a humidicrib. Some parents know in advance that their baby will have a problem, but whether the news comes before or after the birth, you may have feelings that are hard to cope with. Grief, anger and disbelief are natural reactions. Many parents, especially mothers, are worried that they may somehow be to blame for the problem. These guilty feelings are almost always unjustified. You may hesitate to touch and handle your baby at first. The hospital staff will understand your feelings and try to help you cope with them. You need as much support and information as you can get. Talking to the doctor, hospital staff or hospital social worker may help. So will talking to parents of babies with the same condition. Ask your doctor, hospital or Community Health Centre to put you in touch with the right organisation.

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After the Birth

Your Body
After giving birth, your body will slowly begin to return to normal. Dont worry if your tummy still bulges. Part of the reason is that your uterus is still distended but breastfeeding will speed up the contractions that make it normal again. (You may feel these contractions as pains in the abdomen, especially when the baby is sucking.) Your abdominal muscles also need time to regain their strength after months of being stretched. See this chapter, Postnatal Exercises, for exercises that will get you back into shape. Most women should be able to start gentle exercises 24 hours after the birth. Check with the hospital physiotherapist or your midwife.

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Your breasts
Dont panic if your breasts become huge, lumpy and painful in the first few days. This occurs because they are engorged with milk. It is only temporary and the hospital staff or midwife will show you how to deal with this. You may also find it helpful to read the NSW Health Department booklet, Breastfeeding.

Bleeding
You will bleed from the vagina for a few weeks. This discharge is called the lochia and, for 12-24 hours after the birth, it can be heavier than a normal period. Eventually, the bleeding will dwindle to a brownish discharge. Later, it becomes a clear, yellow-brown fluid. Lochia usually lasts for three weeks or longer. You may find if you are breastfeeding that the bleeding can be heavier at feed times. This is because the hormone that lets the milk down also causes the uterus to contract.

Stitches
Stitches (from an episiotomy or tear in the perineum) may make you feel as if you are sitting on barbed wire. The nursing staff will check the area to make sure it stays clean and dry and that it is healing normally. Most stitches dissolve but others have to be removed this is done in a few days when the area has healed properly. The best remedy is to sit on an air cushion and take warm baths to which salt has been added. To keep the area clean, change sanitary pads frequently and have plenty of showers. if it stings when you urinate the first day after the birth, try standing straddling the toilet bowl so the urine doesnt flow onto the stitches.

Postnatal Exercises
Postnatal exercises will strengthen muscles stretched in pregnancy and labour. Follow the general guidelines in Chapter 8, Antenatal Exercises.

Abdominal muscles
It is important to get these muscles back to their normal strength, not only to regain your shape but also to protect your back and support your abdominal organs.

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1.

Pelvic tilt

See Chapter 8, Pelvic Tilt, for instructions. However, place only one pillow under your head. 2. Raise and lower knees

See Chapter 8, Raise and Lower Knees, for instructions. Place only one pillow under your head. 3. Straight curl up

For abdominal muscles that are separated: See Chapter 8, Straight Curl Up, for instructions. If your muscles are very weak, you may need to start this exercise with your head and shoulders raised on several pillows. Practise straight curl ups frequently every day in the first days after the birth this will quickly close the separation between the abdominal muscles. Then move on to straight curl ups for abdominal muscles that are beginning to close. For abdominal muscles that are beginning to close: See Chapter 8, Straight Curl Up, for instructions. When you can do this exercise easily, do the same exercise with your arms folded across your chest. When this feels easy to do, do it with your hands behind your head, keeping your elbows back and level with your ears. 4. Isometric abdominal exercise

Pelvic tilt.

Straight curl up, for abdominal muscles that are separated.

See Chapter 8, Isometric Abdominal Exercise, for instructions. Dont begin this exercise until your abdominal muscles have begun to close up. When you can do this exercise easily, go on to diagonal curl up. 5. Diagonal curl up
Straight curl up, for abdominal muscles that are beginning to close.

Lie down, with your legs straight and your arms by your side. Slowly curl up to a sitting position as you breathe out, reaching both hands towards the outside of one knee. Hold for up to six seconds, breathing normally. Lie back down slowly and relax. Repeat to the other side. When you can do this easily, try the same exercise with your arms folded across your chest, bringing your elbow towards your knee.

Diagonal curl up.

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Pelvic floor muscles

Pelvic floor muscles are stretched during labour. It is very important to get them back into shape otherwise you risk problems, such as: some loss of control over urine and bowel action. The odd leak when you sneeze, cough or jump might only seem a nuisance to begin with. However, if you dont get it under control early on, you can have more serious problems with incontinence as you get older; prolapse or dropping down of the bladder and uterus; less pleasure during sexual intercourse due to a lax vagina. You may have more difficulty reaching orgasm.

Practise the exercises for pelvic floor muscles explained in Chapter 8, Exercise for Pelvic Floor Muscles. Begin them immediately after the birth.

Back muscles
Lie face down with pillows under hips, shoulders and ankles. Press heels together, then bend your knees, lifting feet about 10cm off the floor. Try to hold for six seconds, then relax slowly.

After a Caesarean
All the above exercises are useful after a Caesarean section. Begin them in the same position described for late pregnancy with head and shoulders well raised and supported on several pillows. Progress slowly. Deep breathing and foot exercises need to be included for the first few days.

Back care
Remember to sit, stand and walk tall. Posture is important (see Chapter 8, Posture Check). Once you are back at home, there will be a lot of lifting and bending to do. Try to avoid lifting heavy weights for the first few weeks until your muscles are stronger. When you do lift, make sure you do it the right way: Bend your knees, not your back, and tighten your pelvic floor muscles at the same time. Keep your feet apart, one in front of the other. Keep the load close to your body. Summary Do the following exercises frequently during the day: Pelvic tilt Raise and lower knees

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Straight curl ups progress by changing arm positions Isometric abdominal exercise progress to diagonal curl up Diagonal curl up progress by changing arm positions Exercise for back muscles Exercise for pelvic floor muscles

Postnatal Check
The abdominal muscles are back to normal strength when you can do a straight curl up with hands clasped behind your back. The pelvic floor muscles are back to normal when you can control the stop and start of the flow of urine, and when you can put pressure on the pelvic floor by skipping or jumping without leaking urine. It will help both your bladder control and your sexual response if you can keep up these exercises for the rest of your life. If backache or bladder problems continue for more than three weeks, talk to your doctor or physiotherapist.

Your Emotions
For some women, the elation of giving birth overrides the discomfort of prickly stitches and sore breasts. But it is also normal to feel low sometimes, especially if you are tired or if your first attempts at breastfeeding dont go smoothly. Some women also worry if they dont feel instant love for their babies but that is not unusual either. Motherhood doesnt automatically mean love at first sight. Give yourself time and dont expect too much of yourself. Bursting into tears and feeling depressed is common around the third or fourth day so dont be surprised if you are weepy and over sensitive. The cause is probably partly to do with hormonal changes as well as lack of sleep. If the feelings persist, you may be suffering from postnatal depression and you should contact your doctor, an Early Childhood Health Centre or Community Health Centre for help (see Appendix A).

Fatigue
The combination of childbirth and broken sleep is very tiring so try to get as much rest as you can. Investing in earplugs and an eye mask can make it easier to sleep or at least doze. Sleep through the day when your baby does dont worry about the housework.

You and Your Baby

If you are both well, you will be encouraged to look after your baby as much as possible in hospital, especially if it is your first. The staff will show you how to bath the baby, change a nappy and how to keep the stump of the umbilical cord clean. These might seem like very basic tasks, but dont be surprised if you are a bit clumsy or inefficient at first. It can take a while to get things right (especially when you are tired).

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Circumcision
Boys have a piece of skin called the foreskin covering the tip of the penis. Removing this skin surgically is called circumcision. However, unless there are religious or cultural reasons for doing it, or there is some medical problem with the foreskin, most health professionals believe the operation is unnecessary. As with all operations, there are risks associated with this procedure. These include infection, severe bleeding, injury to the penis and narrowing of the opening at the tip of the penis (which may need more surgery). Most doctors no longer circumcise babies. If you are concerned about whether or not your boy should be circumcised, discuss it with your doctor or nurse. There is no need to retract the babys uncircumcised foreskin it will roll back by itself when the child is about three or four years old. If the tip of the penis is soiled with faeces, just wipe it off with a wet face cloth and leave the foreskin alone.

Tests to Protect Your Baby

While the baby is still in hospital, a few drops of blood are taken from the heel to test for a number of rare medical disorders. Early diagnosis means treatment can be started early and serious disabilities prevented. For more information about these and other tests, read the NSW Health Department publication, Tests to Protect Your Baby. This is available from hospitals, Early Childhood Health Centres or Community Health Centres.

Breastfeeding
Breastfeeding is a good experience for many women, but the skill often needs to be learnt. The following are some of the advantages of breastfeeding: The ingredients in breast milk are tailored to the rate of growth and development of your baby. Throughout breastfeeding, the milk changes according to what your baby needs. Breast milk is more easily digested because the curds it forms are smaller and softer than those of untreated cows milk. It also contains many enzymes these are substances which help the body digest food. They make it easier for the baby to absorb nutrients. Breast milk, particularly colostrum (the early form of breast milk) has special properties which help protect the baby from problems like diarrhoea and respiratory infections. Allergy to breast milk is rare. You dont have to worry about breast milk being too strong or too weak it is always just right. You have to hold your baby to you to breastfeed. This close contact can make it easier for both of you to develop a special attachment to each other. Because no preparation is needed to sterilise bottlefeeding equipment, breastfeeding is more convenient, especially for night feeds or when travelling. It is cheaper too.

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It helps you get back into shape faster. Besides helping the uterus to return to its normal size after birth (the babys sucking makes the uterus contract), it also uses up the fat your body stored during pregnancy.

The size or shape of your breasts has nothing to do with your ability to breastfeed. Although your breasts are bigger while you are pregnant and breastfeeding, they usually return to their normal shape and size afterwards. If you would like to talk to a breastfeeding mother and dont have one among your friends, ring the Nursing Mothers Association of Australia (Ph: (02) 9639 8686).

Breast milk production

After your baby is born, a special hormone causes your breasts to make milk. When your baby sucks at the breast, another hormone causes the milk to be squeezed into the ducts and reservoirs which lie just under the darker skin around your nipple. This process is called the let down. Your body continues producing milk as your baby continues to suck regularly. When the baby sucks, nerves in the nipple pass a message on to the pituitary gland. This message alerts the gland to make more of the hormone which is responsible for milk production. The more often your breasts are emptied, the more milk they produce.

When to feed
In the first few days, it is usually best to let the baby feed as often and as long as he or she wants. If this is your first baby or if you had problems with previous babies, ask the hospital lactation consultant or midwife to make sure the baby is attaching properly at the breast. If the baby isnt properly attached, it can make your nipples sore. Remember to alternate the breast you start with at each feed in other words, if you began the last feed with the left breast, begin the next one with the right. This makes sure both breasts get the stimulation and emptying they need to keep up the milk supply. The number of feeds each day can vary. At this time, the baby is usually hungry every time he/she cries, so accept that the need for feeding is as urgent as it sounds. It will be a few months yet before your baby can wait even a little while for food without getting upset.

How much is enough?

A baby is getting sufficient breast milk if he/she: gains weight satisfactorily; is wet when you change the nappy; has bright eyes and good skin tone; settles between feeds.

Sometimes your baby may fuss at the beginning of a feed because your let down is slow. The let down can be affected by pain, feeling tired or anxious or by an emotional upset. Try relaxing for a short time before feeds. Make sure you are in a comfortable position when you are feeding, and try not to rush things.

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Extra help
Some babies need help to feed. They are often small or sleepy or both, or they may be rather unsettled and fuss when they are being fed. Some suck for a minute and then fall asleep. Whatever the problem, it doesnt mean youve failed. Some babies take a while to get the knack of breastfeeding. If you need extra help when you are at home, contact an Early Childhood Health Centre or the Nursing Mothers Association of Australia (Ph: (02) 9639 8686). Some hospitals have lactation clinics which can provide assistance.

Mastitis
The signs of breast infection include breasts which are painful, hard and red. You will also feel sick, feverish and generally unwell. Warmth applied to the breasts (a clean cloth wrung out in warm water or a warm shower over the infected breast) works well, as does feeding your baby frequently. See your doctor as soon as you notice signs of mastitis early treatment means you can continue breastfeeding uninterrupted. Some authorities also recommend putting a cabbage leaf inside the bra. It is believed that the properties of a cabbage leaf (which is a good source of Vitamin A) help to soften the breast and relieve engorgement. The coolness of the leaf is also believed to be soothing. Ice packs may also be used.

What can affect breast milk?

There are a number of substances which can get into breast milk. These include: Medications Most Medications get into breast milk. However, if you take them in the amount prescribed by your doctor, the quantity in your milk will be safe for the baby. There are a few drugs which can get into breast milk and cause problems for the baby. Always remind your doctor that you are breastfeeding if he or she prescribes medication for you. Ask the doctor to look up a drug reference book to be sure the drug is safe for breastfeeding mothers. Laxatives also pass into breast milk. Strong laxatives are likely to give the baby diarrhoea. Substances from cigarettes Substances from cigarettes pass into breast milk. If you dont give up smoking, at least limit yourself to as few cigarettes as possible. Alcohol Like other drugs, alcohol passes into breast milk. If you dont want to cut out drinking alcohol completely, try to keep it to an absolute minimum. HIV (the Human Immunodeficiency Virus) HIV, the virus which causes AIDS, is present in breast milk in HIV-infected women. It is possible for a baby to become infected with the virus through breastfeeding. It is recommended that women with HIV bottlefeed their babies.

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Contraceptive Pill A normal-strength contraceptive Pill can get into your breast milk. However, you can take a low-dose mini Pill which should not affect your milk supply. The mini Pill does have a slightly higher failure rate than the normal-strength contraceptive Pill so it is important to remember to take it at the same time every day.

Bottlefeeding
Some women cannot breastfeed (eg. they are unwell or have had plastic surgery on their breasts) or they prefer not to breastfeed. Bottle-fed babies grow and develop just as well as breast-fed babies, and mothers who bottlefeed can be just as loving and effective as breastfeeding mothers. Babies need to feel the warmth of your body, so hold your baby close to you each time you give a bottle. Remember: Boil or sterilise the babys bottles and teats, and boil the water used for the milk mixture. Use a commercial infant formula. These formulas are designed for babies of different ages, and some are not suitable for babies in the first six months, so check with an Early Childhood Health Centre (see Appendix A). Read the label carefully before making up the feed and follow the manufacturers instructions. Never leave the baby alone and dont prop up the bottle while feeding. A baby could choke on the milk or the milk might trickle into the babys ear and cause an ear infection. Young babies normally take about 60ml to 120ml at each feed. They usually feed about every three or four hours about five to six bottles every 24 hours. As your baby gets older, gradually more and more milk will be taken until he or she is drinking about 180ml to 250ml at each feed, usually about three to four bottles every 24 hours. Your baby doesnt have to finish all the milk at each feed babies need different amounts at different times. When your baby has finished feeding, usually about 15 to 30 minutes, throw away any leftover milk, then rinse the teat and bottle with cold water. Do this immediately because germs can grow very fast in leftover milk.

Milk allergies
A small number of babies are allergic to milk formulas and need to be given a substitute. If you think your baby has this problem, talk to your family doctor or an Early Childhood Health Centre (see Appendix A).

Practicalities
Rubella immunisation
If the blood tests done in early pregnancy showed you had little or no immunity to rubella, it is a good idea to be immunised before leaving hospital. Remember, it is important not to become pregnant for three months after vaccination.

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Weekly checks
It is recommended that you take your newborn baby to an Early Childhood Health Centre each week, at least for the first few months. There, a trained nurse will check the height, weight and general health of your baby. He or she will give you the opportunity to raise any problems you are having. The Centre also arranges new mothers groups, so you can meet other women with babies of a similar age.

Six-week check
Before you leave hospital, an appointment will be made for you to have a checkup about six weeks after the birth. If not, you should see your Obstetrician or General Practitioner. This includes an internal examination to make sure everything is back to normal, as well as a Pap smear if you didnt have one at the beginning of the pregnancy.

Personal Health Record

Before you leave the hospital, your new baby will be issued with a blue, plastic folder which will provide a complete record of your childs health from birth until the teenage years. By taking the record with you every time you take your child to visit a hospital, doctor or nurse, any important details can be added to it. These details include records of immunisation and information about any health problems. The Personal Health Record also contains information for parents on child development, First Aid and safety.

Maternity Allowance and other financial assistance

If you have children, you can lodge a claim for the family allowance. This allowance is geared to the number of children you have and is means (income) tested. A supporting parents benefit is paid to sole parents who look after children without help from a partner. A Maternity Allowance is also available. Forms are available from the Department of Social Security or from post offices. The Department of Social Security can post the forms to you, if you prefer. The Maternity Allowance is also available to parents of babies who are stillborn or who die in the first few days or weeks of life. For a detailed list of Commonwealth Government family services and payments, phone 131 305.

Registering the birth

The hospital will give you a form so you can register your babys birth. By law, this must be done within one month of the birth.

Australian Childhood Immunisation Register

It is very important that your baby is registered with Medicare as soon as possible after birth. This ensures that your baby will be on the Australian Childhood Immunisation Register and that you receive reminder notices when immunisations are due or overdue.

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12

Coping at Home
Having a small baby to look after doesnt mean you should forget your own needs. Try to find as much time for yourself as you can you will cope better and enjoy your baby more. Consider these energy savers: Sleep or rest whenever you can. You can lie down to breastfeed if you like and both nod off together afterwards. Dont try to win any housekeeping awards. Do as little housework as possible. If you are worried about appearances, try keeping just one room in the house tidy for visitors. Dont be tempted to fly around the house cleaning when the baby sleeps put your feet up. Just because you are a mother doesnt mean you have to assume all childcare chores yourself. Besides enhancing the relationship between the parents, sharing childcare can bring fathers closer to their children too. Remember your relaxation techniques (see Chapter 8, Learning to Relax) they are good for when you feel tense and edgy. Accept all offers of help and ask for assistance if you need it the chances are friends and neighbours will be happy to give you a hand.

Postnatal Blues
If you experienced the three-day blues mentioned in Chapter 11, Your Emotions, you are not alone. It happens to about 80 per cent of women who have just had babies. But there may also be days when you are at home with the baby when you feel depressed. It is hardly surprising lack of sleep, the round-the-clock demands of a baby, adjusting to a new role at home (especially if you have been used to going out to work), even adjusting to living on one income instead of two, can make you feel overwhelmed at times. If this happens, consider: talking to someone who will understand your partner, a friend or a health professional such as your doctor or an Early Childhood Health Centre nurse; going out and seeing friends and/or making new ones your Early Childhood Health Centre is a good place to find out about mothers groups in your area; planning special things for yourself. Ask your partner or a friend to baby sit, or inquire about occasional-care services in your area (this is short-term childcare often run by local councils which gives mothers a few hours to shop or do something for themselves); going out with your partner.

However, some women (about 20 per cent) feel low all the time. Feelings of being overwhelmed, inadequate and unable to cope just wont go away. When this happens, the problem is called postnatal depression. Other symptoms may include: exhaustion problems with sleeping not as a result of caring for the baby;

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crying, feeling low; difficulty making decisions; a change in ability to cope with any aspect of life; not enjoying the baby or life in general; feelings such as guilt, shame, isolation; anxiety, anger and persistent worry about the labour, baby or self; perceive own self as not a good mother; frightening thoughts, sometimes about taking own life or harming the baby or other children.

The sooner a woman with postnatal depression gets help, the faster she will recover. For most women, self-help groups or counselling are the answer. Contact your doctor, Early Childhood Health Centre or Community Health Centre for advice, or contact one of the self-help groups listed in Appendix A.

Causes
No one really knows what causes post-natal depression, but there is a belief that it is linked to hormones, your environment or life stresses (such as a lack of support from family and friends or a deteriorating relationship). There is a feeling in our society that having a baby brings instant happiness. But looking after a newborn can also mean hard, tiring work. Some women feel they are inadequate mothers because they dont cope as well as they thought they would. Some women become postnatally depressed if their plans to have a natural birth, with no pain-relieving drugs or medical intervention, dont work out. They may feel they have failed if, for example, they required a Caesarean. This, of course, is not the case. There are counselling services available to help women through these feelings (see Appendix A). Postnatal depression isnt the same as a more serious problem called postpartum psychosis. This causes delusions, hallucinations, manic-depression and suicidal tendencies. Although it is not common, it needs immediate treatment mothers with this problem are in danger of hurting themselves or their baby.

Sex and Contraception

It is best to wait until the lochia (vaginal discharge) has cleared up before you begin having sexual intercourse again. If you had a forceps delivery, stitches or a Caesarean section, wait until everything has healed check with your doctor before you leave hospital. For the first eight or 10 weeks, you may find your vaginas natural lubrication isnt as good as it used to be. You may also lubricate less while you are breastfeeding. You may need to use a lubricating jelly such as KY Jelly or Lubafax (available from pharmacies). If you have had stitches, the entrance to the vagina may seem a bit tight and this can make intercourse uncomfortable at first. If this continues for more than a month, see your doctor.

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Fatigue can be another problem nights of broken sleep dont do much for anyones libido. But these are all temporary problems you will soon get back to normal. Dont forget contraception. If you are bottlefeeding, it is possible to conceive again as early as four weeks after the birth. If you are breastfeeding, your chances of falling pregnant again are reduced for some months (providing you are giving four-hourly feeds, including through the night). But breastfeeding isnt a reliable form of contraception. The six-week check is a good opportunity to talk about contraceptive methods with your doctor or Family Planning Clinic. Contraceptives include: The Pill If you are not breastfeeding, you can go back to taking your usual contraceptive Pill. But remember, it is not reliable for the first 14 days of taking it, so you will need to use another method, such as condoms, until you are protected. If you are breastfeeding, you can take a progestogen-only (mini) Pill which should not affect your milk supply. IUCD (also known as an IUD or Intra Uterine Contraceptive Device) The IUCD can be inserted at your six-week check. However, it is not the best choice for women who havent completed their families. It is also not suitable for women who either have more than one sexual partner themselves or whose partners have other sexual partners. Condoms Condoms may be the simplest choice during the early weeks. If you need to use a lubricant, make sure it is water-based, such as KY Jelly or Lubafax. Dont use petroleum jelly, baby oil or hand lotion they can perish the rubber. Diaphragm or cap If you used a diaphragm or cap before pregnancy, you may need a different size now that you have had a baby. Ask your doctor to check your size when you have your six-week check (a diaphragm that doesnt fit properly is as reliable as not using one at all!).

For More Information

There are a number of NSW Health Department publications, available free, that provide more information about family planning, pregnancy health, having babies or looking after them. These include: Choices in Family Planning Pregnancy and Birth Breastfeeding Tests to Protect Your Baby

Ask for copies of these at a Community Health Centre, Early Childhood Health Centre or hospital, or contact the Better Health Centre (02) 9816 0452.

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Appendix A
These numbers and addresses are correct at the time of going to print but are subject to change.

OR 38 Arthur Street CABRAMATTA NSW 2166 Ph: (02) 9726 1016 Fax: (02) 9728 7312

Pregnancy Care
Pregnancy tests, contraception, referrals & advice
For information on pregnancy tests, contact your local doctor, a Family Planning Clinic (listed in the main section of the White Pages telephone directory, under Family Planning NSW), or the outpatients section of a maternity hospital. Some pharmacies also provide information on pregnancy tests. Family Planning Association Health (FPA Health) (For pregnancy tests, information & referrals) 328-336 Liverpool Road ASHFIELD NSW 2131 Ph: (02) 8752 4300 FPA Health - Multicultural Services 356 The Horsley Drive FAIRFIELD NSW 2165 Ph: (02) 9754 1322 Pregnancy Help Centres (Non-government) Armidale Ph: (02) 6772 7100 Bathurst Ph: (02) 6332 4866 Beacon Hill, Ph: (02) 9413 1341 Bellingen Ph: (02) 6655 0042 Blacktown Ph: (02) 9671 5844 Campbelltown Ph: (02) 4625 8028 Canberra Ph: (02) 6247 5050 Coffs Harbour Ph: (02) 6658 0370 Doonside (Mt Druitt) Ph: (02) 9622 8219 Liverpool Ph: (02) 9602 6543 ManlyWarringah Ph: (02) 9905 1974 Maxville Ph: (02) 6568 1046 Milton / Ulladulla Ph: (02) 4455 5607 Newcastle Ph: (02) 4969 6675 Parramatta Ph: (02) 9635 4449 Young Ph: (02) 6382 6660 Womens Health Advisory Service Childbirth Education Association of Australia (NSW) LTD (Prenatal classes for couples in Sydney) 15 The Strand PENSHURST NSW 2222 Ph: (02) 9580 0399 Fax: (02) 9580 9986 Email: jennyf_r@cea-nsw.com.au Immigrant Womens Health Service (Information, referral, advice on pregnancy & other womens health matters) 92 Smart Street FAIRFIELD NSW 2165 Ph: (02) 9726 4044 4/18 Little Street CAMDEN NSW 2570 Ph: 4653 1445 Centacare Pregnancy Support Services (Non-government support services, for counselling during pregnancy. See local White Pages telephone directory under Centacare for a service in your area) Polding House 276 Pitt Street SYDNEY NSW 2000 Ph: (02) 9283 3099 Fax: (02) 9261 0510

Care during Pregnancy

Any large public hospital specialising in women will have social workers experienced in assisting with pregnancy, childbirth and adoption. Also see Womens Health Centres (under Womens Health Centres in the White Pages telephone directory), Community Health Centres (under Community Health Centres in the White Pages telephone directory), and Aboriginal Health Services (see list later in Appendix). Other services are listed below.

Registered Midwives
For details of registered midwives, contact: The NSW Midwives Association (INC) 77-89 Jones Street ULTIMO NSW 2007 Ph: (02) 9281 9522

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Fax: (02) 9726 4928

Aboriginal Health Services

Dharruk Aboriginal Medical Service 2 Palmerston Road MT DRUITT VILLAGE NSW 2700 Ph: (02) 9832 1356 Pius X Anne Street MOREE NSW 2400 Ph: (02) 6752 1099 Redfern Aboriginal Medical Service 36 Turner Street REDFERN NSW 2016 Ph:(02) 9319 5823 Riverina Aboriginal Medical & Dental Corporation 14 Trail Street WAGGA WAGGA NSW 2650 Ph: (069) 21 7292 South Coast Aboriginal Medical Service 51-53 Berry Street NOWRA NSW 2541 Ph: (02) 4421 5099 Tharawal Aboriginal Co-op 187 Riverside Drive, Airds CAMPBELLTOWN NSW 2560 Ph: (02) 4628 4837 Thubbo Aboriginal Corporation 133 Bourke Street DUBBO NSW 2830 Ph: (02) 6884 8211 Tingha Aboriginal Corporation 4 Amethyst Street TINGHA NSW 2369 Ph: (02) 6723 3535 Tingha Health Centre Inverell Road TINGHA NSW 2360 Ph: (02) 6723 3096

Walgett Aboriginal Medical Service 37 Pitt Street WALGETT NSW 2832 Ph: (02) 6828 1798 Walhallow Aboriginal Health Post PO Box 3 CAROONA NSW 2343 Ph: (02) 6747 4853 Weigelli Centre Aboriginal Corporation Po Box 6 COWRA NSW 2794 Wellington Aboriginal Corporation Health Service 68 Maugham Street WELLINGTON NSW 2820 Ph: (02) 6845 3545

Womens Health Centres

For Womens Health Centres, see the main section of the White Pages telephone book, under Womens Health Centres.

Community Health Centres

Community Health Centres are listed in the main section of the White Pages telephone book under Community Health Centres.

Early Childhood Health Centres

Listed in the main section of the White Pages under Early Childhood Health Centres.

Genetic Counselling Services

Genetic Counselling Services are available at the following major hospitals: Liverpool Hospital Department of Clinical Genetics LIVERPOOL NSW 2170 Ph: (02) 9828 4665 Royal Prince Alfred Hospital Department of Molecular and Clinical Genetics Missendon Road CAMPERDOWN NSW 2050 Ph: (02) 9515 5080

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Sydney Childrens Hospital Department of Medical Genetics High Street RANDWICK NSW 2031 Ph: (02) 9382 1708 The Childrens Hospital at Westmead Department of Clinical Genetics Hawkesbury Road WESTMEAD NSW 2145 Ph: (02) 9845 3273 Hunter Genetics Cnr Turton and Tinonee Roads WARATAH NSW 2298 Ph: (02) 4985 3100 Other metropolitan and country outreach services can be contacted at: Royal North Shore Hospital, ST LEONARDS Ph: (02) 9926 7111 Nepean Hospital, PENRITH Ph: (02) 4734 2000 Bathurst Community Health Centre Ph: (02) 6331 5533 Broken Hill Community Health Centre Ph: (02) 8087 5800 Cessnock Community Health Centre Ph: (02) 4991 0438 Coffs Harbour Community Health Centre Ph: (02) 6659 1424 Dubbo Community Health Centre Ph: (02) 6885 8999 Child Development Unit, GOULBURN Ph: (02) 4827 3950 Public Health Unit, OURIMBAH Ph: (02) 4349 4845

Lismore Base Hospital Ph: (02) 6621 8000 Mudgee Community Health Centre Ph: (02) 6372 6455 Muswellbrook Community Health Centre Ph: (02) 6543 1777 Port Macquarie Community Health Centre Ph: (02) 6588 2882 Tamworth Community Health Centre Ph: (02) 6766 2555 Taree Community Health Centre Ph: (02) 6551 1315 Wagga Wagga Community Health Centre Ph: (02) 6938 6411 Wollongong Community Health Centre Ph: (02) 4274 0281 Canberra Hospital, ACT Ph: (02) 6244 3466 For further information on services and locations, contact: Genetic Education Program of NSW PO Box 371 ST LEONARDS NSW 2065 Ph: (02) 9926 7324 AGSA (Association of Genetic Support Australasia) 66 Albion St SURRY HILLS NSW 2010 Ph: (02) 9211 1462

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Prenatal Diagnosis & Related Counselling Services

Fetal Medicine Unit King George V Hospital CAMPERDOWN NSW 2050 Ph: (02) 9515 8258 Fetal Medicine Unit Liverpool Hospital LIVERPOOL NSW 2170 Ph: (02) 9828 4191 Prenatal Diagnosis Unit John Hunter Hospital NEWCASTLE NSW 2300 Ph: (02) 4921 4694

Fetal Medicine Unit The Canberra Hospital WODEN ACT 2606 PH: (02) 6244 3079 Iffa-Induction for Fetal Abnormality (Parent support, counselling & newsletter) PO Box 39 WARATAH NSW 2298 Ph: (049) 677 413 SAFDA (Support After Fetal Diagnosis of Abnormality) c/- NSW Genetics Education Program PO Box 317 ST LEONARDS NSW 2065 Ph: (02) 9926 7324 Abiding Hearts

Centre for Fetal Medicine Royal Hospital for Women PADDINGTON NSW 2021 Ph: (02) 9382 6098 Fetal Medicine Unit Nepean Hospital PENRITH NSW 2750 Ph: (02) 4734 2578 Department of Medical Genetics Sydney Childrens Hospital RANDWICK NSW 2031 Ph: (02) 9382 1708 Maternal and Fetal Medicine Unit Royal North Shore Hospital ST LEONARDS NSW 2065 Ph: (02) 9926 7099 Fetal Welfare Department Westmead Hospital WESTMEAD NSW 2145 Ph: (02) 9845 6802 Department of Clinical Genetics The Childrens Hospital at Westmead WESTMEAD NSW 2145 Ph: (02) 9845 3273

(For parents continuing pregnancies prenatally diagnosed with fatal birth defects like anencephaly. Support before and after birth) Box 5245, Bozeman MT 59717, USA Ph: 0011 1 (406) 587 7421

Drugs and pregnancy

Smokers Quitline Ph: 131 848 (from anywhere in NSW)

ADIS Alcohol and Drug Information Service (Also provide contacts for local Drug Use in Pregnancy Services) Ph: (02) 9361 2111 or 1800 422 599 (from anywhere in NSW).

Miscarriage, Stillborn Support

For more information about support after miscarriage, and for details on miscarriage support groups in your area, contact a Community Health Centre. See following for Stillbirth support and other services. Stillbirth and Neonatal Death Society (SANDS) 322 Railway Toe GUILDFORD NSW 2161 Ph: (02) 9721 0124

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Pen-Parents of Australia (A correspondence network of parents who have experienced pregnancy loss or the death of an infant) PO Box 574 BELCONNEN ACT 2616

Breastfeeding & motherhood

Nursing Mothers Association of Australia Breastfeeding Help Line (Sydney) Ph: (02) 9639 8686 Karitane

National Association For Loss and Grief (NALAG) (Assistance to those suffering the effects of loss and grief) PO Box 379 DUBBO NSW 2830 Ph: (02) 9976 2803

cnr The Horsely Drive & Mitchell Street CARRAMAR NSW 2163 Ph: 9794 1852 (within Sydney) or 1800 677 961 24 hr helpline (Free call from anywhere in NSW) Tresillian Family Care Centres

HIV Counselling Services

To find out about HIV and AIDS counselling services for women, contact: Albion Street AIDS Centre 150-154 Albion St SURRY HILLS NSW 2010 Ph: (02) 9332 4000 AIDS Council of NSW - HIV & Women Support, Ph: 9206 2012 - HIV/AIDS Family Support, Ph: 9206 2079

2 McKenzie Street BELMORE NSW 2192 Ph: (02) 9787 5255 (within Sydney) or 1800 637 357 24hr helpline (Free call from anywhere in NSW)

Appendix B
NSW Area Health Services
CENTRAL COAST Gosford Hospital Cnr Holden and Racecourse Roads GOSFORD NSW 2250 Ph: (02) 4320 2111 Fax: (02) 4325 0566 CENTRAL SYDNEY Queen Elizabeth II Building Level 1, Royal Prince Alfred Hospital Missenden Road CAMPERDOWN NSW 2050 Ph: (02) 9515 9600 Fax: (02) 9515 9611 HUNTER Rankin Park Hospital Lookout Road NEW LAMBTON HEIGHTS NSW 2305 Ph: (02) 4921 4960 Fax: (02) 4921 4969

Postnatal Depression Support Services

An Early Childhood Health Centre can also provide advice or details on support groups in your area. Tresillian Family Care Centres 2 Shaw Street Petersham NSW 2049 Ph: (02) 9787 5255 (within Sydney) or 1800 637 357 24hr helpline (Free call from anywhere in NSW) Karitane cnr The Horsely Drive & Mitchell Street CARRAMAR NSW 2163 Ph: (02) 9794 1852 (within Sydney) or 1800 677 961 24 hr helpline (Free call from anywhere in NSW)

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ILLAWARRA Public Works Department Building 33 Five Islands Road PORT KEMBLA NSW 2505 Ph: (02) 4275 5111 Fax: (02) 4276 1447 NORTHERN SYDNEY Royal North Shore Hospital Executive Offices, Lv 4 Pacific Highway ST LEONARDS NSW 2065 Ph: (02) 9926 8418 Fax: (02) 9926 6025 SOUTH EASTERN SYDNEY Primrose House Cnr Russell Avenue and Malua Street DOLLS POINT NSW 2219 Ph: (02) 9382 9898 Fax: (02) 9382 9891 SOUTH WESTERN SYDNEY Eastern Campus, Liverpool Hospital Elizabeth Street LIVERPOOL BC NSW 1871 Ph: (02) 9828 5700 Fax: (02) 9828 5769 WENTWORTH The Nepean Hospital Derby Street PENRITH NSW 2750 Ph: (02) 4734 2120 Fax: (02) 4734 3737 WESTERN SYDNEY Westmead Hospital Level 3, Dental School Cnr Darcy and Hawkesbury Roads WESTMEAD NSW 2145 Ph: (02) 9845 7000 Fax: (02) 9689 2041

NSW Rural Health Services

FAR WEST 176 Thomas Street BROKEN HILL NSW 2880 Ph: (08) 8080 1682 Fax: (08) 8080 1333 GREATER MURRAY 63-65 Johnston Street WAGGA WAGGA NSW 2650 Ph: (02) 6933 9185 Fax: (02) 6922 9188 MACQUARIE 23 Hawthorn Street EAST DUBBO NSW 2830 Ph: (02) 6841 2222 Fax: (02) 6841 2225 MID NORTH COAST The Parsonage, Albert Street TAREE NSW 2430 Ph: (02) 6551 5111 Fax: (02) 6552 1798 MID WESTERN 175 George St BATHURST NSW 2795 Ph: (02) 6339 5500 Fax: (02) 6339 5521 NEW ENGLAND Tamworth Base Hospital PO Box 83 TAMWORTH NSW 2340 Ph: (02) 6768 3222 Fax: (02) 6766 6638 NORTHERN RIVERS Lismore Base Hospital Cnr Uralba and Hunter Streets LISMORE NSW 2480 Ph: (02) 6620 2100 Fax: (02) 6621 7088 SOUTHERN City Link Plaza Building 24 Morisset Street QUEANBEYAN NSW 2620 Ph: (02) 6299 6199 Fax: (02) 6299 6363

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Index
Abdominal muscles 46, 66, 69 - separated 46-48, 67 - unseparated 46-48, 67 Abdominal pain 35, 39-40 Aboriginal Health Services 79 Abortion - spontaneous 5, 39 - therapeutic 10 Acupressure bands 36 Adoption 10, 25 AIDS 5, 7, 20, 22, 72 - counselling 82 Alcohol 3, 4, 6, 32, 36, 72, 81 Allergies, milk 73 Alpha fetoprotein test 17 Amenorrhoea 9 Amniocentesis 13, 17 Amniotic sac 11, 17, 41, 53 Amphetamines (speed) 6 Anaemia 15, 16, 19, 20, 29 Anaesthetic - general 39, 53, 54, 62, 64 - local 60, 61 Anencephaly 17 Antenatal - care 8, 13, 19, 20, 23, 24, 41, 52, 63 - clinic 19, 33 - courses 43 - exercises 26, 46, 66 Antepartum haemorrhage 40 Anxiety 37, 43, 57, 76 Back care 48, 68 Backache 34, 58, 60, 63, 69 Barbiturates 6 Baths/showers 27, 66 Birth - centres 23, 24 - defects 6, 17, 81 Birthweight, low 2, 64 Bladder 2, 35, 68, 69 Bleeding, vaginal 35, 39 Blood pressure - high 6, 23 ,35, 37, 41, 42, 61, 63 - low 60 - tests 1, 19, 20, 23, 41, 42, 54

Blood - tests 2, 10, 17, 19, 40, 41, 42, 70, 73 - transfusion 19, 22, 54 Bottlefeeding 23, 70, 73, 77 Breaking of the waters 5, 53 Breastfeeding 22, 23, 29, 32, 33, 51, 66, 69, 70-73, 76 - benefits of 66, 70-71 - extra help 33, 66, 71, 72 - quantity 71 - when to feed 71 Breast milk - effects on 70, 72, 73, 77 - production 33, 66, 70-71 Breasts - care of 32, 33, 51, 66, 71-72 - changes in 9, 32, 33, 36, 37, 66, 71-72 - infection 72 - tenderness 9, 33, 66, 69, 72 Breath awareness 4, 43-44, 45, 5758, 60 Breathlessness 34 Breech birth 5, 61, 63 Caesarean section 21, 40, 62, 68, 76 Caffeine 4, 31 Calcium supplements 31 Cap 77 Cervical - cancer 1 - dilation 54 Cervix 1, 17, 27, 39, 53, 54, 44, 57, 58, 61, 63 Checkups - before pregnancy 1, 2, 34 - during pregnancy 19, 34, 41 - six-week 74 Childbirth - choices in 22 - education 24, 26 - positions 44, 46, 49, 55, 56, 59, 63 - preparation 34, 43-54 Childcare 26, 75 Children, other 51 Chlamydia 21 Chorionic Villus Sampling (CVS) 16 Chromosomal abnormalities 16, 17, 18

Circumcision 70 Cleansing breath 45 Cleft palate 65 Chloasma 37 Clothing 51 Cocaine 5 Colds 27, 34 Colostrum 33, 70 Community Health Centres 79 Complementary feeding 23 Conception 1, 4, 7, 10, 13, 41 Condoms 22, 77 Constipation 9, 32, 34, 35, 36 Contraception 76, 77 Contractions 27, 39, 45, 48, 52-57, 59, 61, 63, 66 - Braxton Hicks 27, 52, 53 Convulsions 42 Core body temperature 6 Counselling 2, 3, 10, 15, 16, 18, 22, 76, 78-82 Cramps 35, 44 Cravings 31, 35 Curettage 39 Cystic fibrosis 15, 16 Death of baby 2, 5, 6, 39, 40, 64, 74, 81 Delivery suite (labour ward) 22, 23, 53, 54 Dental check 2, 27, 34 Depression 69, 75, 76, 82 Development, baby - of senses 12 - stages of 11 Diabetes 20, 23, 24, 40, 41 Diaphragm 77 Diarrhoea 5, 52, 53, 70, 72 Diet - changes to 1-2, 28-32 - fluids 26, 31, 34, 35 - nutrition 1-2, 28-32, 35 - requirements 1-2, 28-32, 34, 35 - salt 31 - snacks 31 - takeaway food 31 - vegetarian 32 Dizziness 27, 35 Domicilliary midwifery program 23

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Down syndrome 16, 17, 18 Dribbling 37 Drip, intravenous 61 Dropping down 68 Drugs (see also tobacco, alcohol) - during pregnancy 3-6, 11, 22, 23, 81 - in labour 59-60, 78, 81 - while breastfeeding 72-73, 78, 81 Early Childhood Health Centres 52, 69, 70, 72-79 Early discharge program 23, 24 Eclampsia 41, 42 Ectopic pregnancy 35, 41 Embryo 11, 12 Emotions 14, 69, 75 Enema 54 Engorgement 72 Epidural 60, 62, 64 Episiotomy 57, 60, 61, 63 Exercise 6, 8, 24, 26, 34-35, 38, 43, 46-51, 62, 66-69 Exercises - antenatal 46-51 - postnatal 66-69 Expected date of confinement 13 Eyesight, blurring 21 Faintness 35, 41, 44, 46, 47 Fallopian tubes 11, 21, 41 Family allowance 74 Fertilisation 11 Fetal distress 63 Fetus 2, 12, 40 Financial assistance 74 Flu 27 Folic-acid supplements 1, 31-32 Forceps delivery 60-61, 63, 76

Haemophilia 15 Haemorrhage, antepartum 40 Haemorrhoids 36, 49 Hare lip 65 Headaches 35, 60 Heartburn 32, 34, 35, 37 Heart disease 24 Hepatitis 5, 7, 20, 21 Heroin 5 Herpes 21 High blood pressure 6, 23 ,35, 37, 41, 42, 61, 63 HIV/AIDS 5, 6, 7, 20, 22, 72, 82 Homebirth - guidelines for 23, 24 Home pregnancy tests 10 Hormones, changes in 11, 17, 76 Hospital birth 22, 23 Housework 25, 52, 69, 75 Humidicrib 63, 65 Hypertension 41 Hypertensive disease 41 Incontinence 68 Induced labour 23, 61 Inherited disorders 17 Insomnia 37 Internal examination 13, 19, 54, 55, 74 Intervention, medical 60, 76 Inverted nipples 33 Iron supplements 20, 29, 31, 32 Itchiness 36 IUD or IUCD 77 Jaundice 20, 59 Joint pains 20 Kidney disease 23

Lightening 34, 52 Liver problems 36 Lochia 66, 76 Low birthweight baby 2, 64 LSD 6 Lubrication 76 Marijuana 5 Massage 27, 45, 58 Mastitis 72 Maternity - Allowance 74 - bra 32 - leave 25 Meconium 63 Menstruation 11, 13 Methadone 5, 6 Midwives - clinics 19, 78 - independent 22, 23, 78 - registered 22, 78 Milk allergies 70, 73 Miscarriage - support 39, 40, 81 Monitor - external 55 - internal 55 Moodiness 14, 44, 69, 75 Morning sickness 9, 32, 36 Mothers groups 52, 74, 75, 76, 78 Movements of the baby 3, 13, 39 - decrease in 39 Multiple pregnancy 13-14 Nausea 9, 14, 36, 39 Needle sharing 5, 20 Neural tube defects 1, 17 Nipples 9 - care of 33, 71 - inverted 33 Nitrous oxide 59 Nursing Mothers Association of Australia 82 NSW Health Services 82-83 Nose bleeds 36 Nursing pads 33, 51 Nutrition 1-2, 28-32, 35

Gas 59 Genetic counselling 2, 15, 16, 79 Genitals, changes in 9, 36, 38 Genital warts 21 German measles 2 Gestational diabetes 20, 40, 41 Gingivitis 34 Gonorrhoea 21 Groaning 56, 58 Growth, of baby 11-14 Gums 2, 34 Labour - first stage 44, 45, 54-55 - transition period 55 - second stage 56 - third stage 57 Labour ward (see delivery suite) 22, 23, 53, 54 Lactation consultant 71 Laxatives 35, 72 Let down 71

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Obstetrician 19, 23, 24, 74 Oral contraceptives 37 Overheating 26, 27 Oxytocin 61 Paediatrician 64 Pain - abdominal 34, 38, 40, 41, 46, 47, 66, 67 - during intercourse 76 - in labour 23, 53-60 - in passing urine 9, 34, 66 - relief 23, 34, 43, 45-50, 58, 66 Painkillers 4, 59 Pap smear 1, 17, 19, 74 Parental leave 25 Partners role 1, 44, 51-52, 56, 57, 58, 60 Pelvic - floor muscles 35, 47, 50, 58, 59 - inflammatory disease 21 - tilt 46, 64 Perineum 54, 56, 59, 66 Periods, missed 11 Personal Health Record 74 Pethidine 60 Piles 32, 36, 49 Pill, the contraceptive 37, 73, 77 Placenta 56 - praevia 40 - retained 64 Polyhydramnios 41 Position, the babys - breech 5, 61, 63 - posterior 63 Positions in labour 44, 49, 59 Postnatal - blues 72 - care 24 - check 24, 68 - depression 68, 75, 76, 82 - exercises 62, 66 - ward 23 Post-partum psychosis 76 Posture 25, 47, 48, 68 Pre-eclampsia 41 Pregnancy - complications in 39 - duration of 24, 26

- in older women 8 - signs of 9 - teenage 32 - tests 10 - work and 25, 26 Pregnancy-induced hypertension 41-42 Premature labour 41, 63 Prenatal diagnostic tests 16, 20 Pre-term baby 40 Prolapse 68 Prostaglandins 27, 61 Quit Smoking Services 3, 81 Radiation 7 Rashes 20 Registering the birth 74 Relaxation 43, 44, 46, 57 Rhesus factor 19 Rubella 2, 7, 20, 27, 42 Saliva 37 Sedatives 57 Sex 21, 22, 24, 26, 27, 68, 69, 76, 77 Shave, pubic hair 54 Show 53 Six-week check 74 Skin 36, 37 Sleeplessness 4, 5, 6, 37 Smoking 2, 3, 81 Speed (see amphetamines) 6 Spina bifida 1, 17 Sport 26 Stillbirth 2, 3, 5, 81 Stirrups 61 Stitches 66, 69, 76 Stocking up 51 Stress 43, 44, 72 Stretch marks 37 Stretching 48, 49 Support pantihose 38 Support persons role 60 Supporting parents benefit 74 Swelling - face 39, 41, 42 - feet/ankles 37, 39, 41, 42 - hands 39, 41, 42 Syphilis 20

Teenage pregnancy 32 Tension 59 - recognising 44 - relieving 43-46 Termination 10, 19 Tests - blood 2, 10, 17, 19, 40, 41, 42, 70, 73 - blood pressure 1, 19, 20, 23, 41, 42, 54 - for newborn babies 68 - for pregnancy 10 - prenatal diagnosis 13, 14, 20 Thalassaemia 15, 16 Thirst 31, 41 Thrush 36, 41 Tiredness 9, 14, 37, 41, 48, 69, 77 Tobacco 2, 3, 36, 72, 81 Tranquillisers 4, 59 Travel - air 28, 65 - car 27, 65, 70 Triple screening 17 Tubal pregnancy 41 Twins 13, 14, 16, 17, 26 Ultrasound 13, 14, 16, 17, 39 Umbilical cord 11, 69 Unplanned pregnancy 10 Urination - frequency 9, 41, 52 - leaking 35, 48, 68 Urine tests 41 Vacuum extraction 61, 63 Vaginal - bleeding 11, 35, 38, 39, 40, 41, 66 - discharge 9, 20, 38, 39, 51, 66, 76 Varicose veins 25, 36, 38, 49 Ventouse 61 Visualisation 58 Vitamin supplements 30 Vomiting 5, 36, 39, 41 Vulva 38 Weekly checks 74 Weight - gain 14, 30, 31, 32 - loss 52 Womens Health Centres 79 Work - hazards 7, 25

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SHPN: (HPA) 970085