What is breech?

Babies lying bottom first or feet first in the uterus (womb) instead of in the usual head-first position are called breech babies. Breech is very common in early pregnancy, and by 36-37 weeks of pregnancy, most babies turn naturally into the head-first position.

Towards the end of pregnancy, only 3-4 in every 100 (3-4%) babies are in the breech position.

Why is my baby breech?

It may just be a matter of chance that your baby has not turned into the head-first position. However, there are certain factors that make it more difficult for your baby to turn during pregnancy and therefore more likely to stay in the breech position. These include:

- If this is your first pregnancy

- If your placenta is in a low-lying position (also known as placenta praevia);

- If you have too much or too little fluid (amniotic fluid) around your baby

- If you are having more than one baby

Very rarely, breech may be a sign of a problem with the baby. If this is the case, such problems may be picked up during the scan you are offered at around 20 weeks of pregnancy.

What if my baby is breech towards the end of my pregnancy?

If your baby is breech at 36 weeks of pregnancy, your healthcare professional will discuss the following options with you:

• Trying to turn your baby in the uterus into the head-first position by external cephalic version (ECV)

• Planned caesarean section

• Planned vaginal breech birth.

What does ECV involve?

ECV involves applying gentle but firm pressure on your abdomen to help your baby turn in the uterus to lie head-first.

Relaxing the muscle of your uterus with medication has been shown to improve the chances of turning your baby. This medication is given by injection before the ECV and is safe for both you and your baby. It may make you feel flushed and you may become aware of your heart beating faster than usual but this will only be for a short time.

Before the ECV you will have an ultrasound scan to confirm your baby is breech, and your pulse and blood pressure will be checked. After the ECV, the ultrasound scan will be repeated to see whether your baby has turned. Your baby’s heart rate will also be monitored before and after the procedure. You will be advised to contact the hospital if you have any bleeding, abdominal pain, contractions or reduced fetal movements after ECV. ECV is usually performed after 36 or 37 weeks of pregnancy. However, it can be performed right up until the early stages of labour. You do not need to make any preparations for your ECV.

ECV can be uncomfortable and occasionally painful but your healthcare professional will stop if you are experiencing pain and the procedure will only last for a few minutes. If your healthcare professional is unsuccessful at their first attempt in turning your baby then, with your consent, they may try again on another day.

If your blood type is rhesus D negative, you will be advised to have an anti-D injection after the ECV and to have a blood test.

Why turn my baby head-first?

If your ECV is successful and your baby is turned into the head-first position you are more likely to have a vaginal birth. Successful ECV lowers your chances of requiring a caesarean section and its associated risks.

Is ECV safe for me and my baby?

ECV is generally safe with a very low complication rate. Overall, there does not appear to be an increased risk to your baby from having ECV. After ECV has been performed, you will normally be able to go home on the same day.

When you do go into labour, your chances of needing an emergency caesarean section, forceps or vacuum (suction cup) birth is slightly higher than if your baby had always been in a head-down position.

Immediately after ECV, there is a 1 in 200 chance of you needing an emergency caesarean section because of bleeding from the placenta and/or changes in your baby’s heartbeat.

ECV should be carried out by a doctor or a midwife trained in ECV. It should be carried out in a hospital where you can have an emergency caesarean section if needed.

ECV can be carried out on most women, even if they have had one caesarean section before.

ECV should not be carried out if:

- you need a caesarean section for other reasons, such as placenta praevia;

- you have had recent vaginal bleeding

- your baby’s heart rate tracing (also known as CTG) is abnormal

- your waters have broken

- you are pregnant with more than one baby

Is ECV always successful?

ECV is successful for about 50% of women. It is more likely to work if you have had a vaginal birth before. Your healthcare team should give you information about the chances of your baby turning based on their assessment of your pregnancy.

If your baby does not turn then your healthcare professional will discuss your options for birth. It is possible to have another attempt at ECV on a different day.

If ECV is successful, there is still a small chance that your baby will turn back to the breech position. However, this happens to less than 5 in 100 (5%) women who have had a successful ECV.

Is there anything else I can do to help my baby turn?

There is no scientific evidence that lying down or sitting in a particular position can help your baby to turn. There is some evidence that the use of moxibustion (burning a Chinese herb called mugwort) at 33–35 weeks of pregnancy may help your baby to turn into the head-first position, possibly by encouraging your baby’s movements. This should be performed under the direction of a registered healthcare practitioner.

What are my options for birth if my baby remains breech?

Depending on your situation, your choices are:

Planned caesarean section- If your baby remains breech towards the end of pregnancy, you should be given the option of a caesarean section. Research has shown that planned caesarean section is safer for your baby than a vaginal breech birth. Caesarean section carries slightly more risk for you than a vaginal birth. Caesarean section can increase your chances of problems in future pregnancies. These may include placental problems, difficulty with repeat caesarean section surgery and a small increase in stillbirth in subsequent pregnancies. If you choose to have a caesarean section but then go into labour before your planned operation, your healthcare professional will examine you to assess whether it is safe to go ahead. If the baby is close to being born, it may be safer for you to have a vaginal breech birth.

Planned vaginal breech birth - After discussion with your healthcare professional about you and your baby’s suitability for a breech delivery, you may choose to have a vaginal breech birth. If you choose this option, you will need to be cared for by a team trained in helping women to have breech babies vaginally. You should plan a hospital birth where you can have an emergency caesarean section if needed, as 4 in 10 (40%) women planning a vaginal breech birth do need a caesarean section. Induction of labour is not usually recommended.

While a successful vaginal birth carries the least risks for you, it carries a small increased risk of your baby dying around the time of delivery. A vaginal breech birth may also cause serious short-term complications for your baby. However, these complications do not seem to have any long-term effects on your baby. Your individual risks should be discussed with you by your healthcare team.

Before choosing a vaginal breech birth, it is advised that you and your baby are assessed by your healthcare professional. They may advise against a vaginal birth if:

• Your baby is a footling breech (one or both of the baby’s feet are below its bottom)

• Your baby is larger or smaller than average (your healthcare team will discuss this with you)

• Your baby is in a certain position, for example, if its neck is very tilted back (hyper extended)

• You have a low-lying placenta (placenta praevia)

• You have pre-eclampsia or any other pregnancy problems

There are benefits and risks associated with both caesarean section and vaginal breech birth, and these should be discussed with you so that you can choose what is best for you and your baby.

What can I expect in labour with a breech baby?

With a breech baby you have the same choices for pain relief as with a baby who is in the head-first position. If you choose to have an epidural, there is an increased chance of a caesarean section. However, whatever you choose, a calm atmosphere with continuous support should be provided.

If you have a vaginal breech birth, your baby’s heart rate will usually be monitored continuously as this has been shown to improve your baby’s chance of a good outcome. In some circumstances, for example, if there are concerns about your baby’s heart rate or if your labour is not progressing, you may need an emergency caesarean section during labour. A paediatrician (a doctor who specialises in the care of babies, children and teenagers) will attend the birth to check your baby is doing well.

What if I go into labour early?

If you go into labour before 37 weeks of pregnancy, the balance of the benefits and risks of having a caesarean section or vaginal birth changes and will be discussed with you.

What if I am having more than one baby and one of them is breech?

If you are having twins and the first baby is breech, your healthcare professional will usually recommend a planned caesarean section.

If, however, the first baby is head-first, the position of the second baby is less important. This is because, after the birth of the first baby, the second baby has lots more room to move. It may turn naturally into a head-first position or a doctor may be able to help the baby to turn.

If you would like further information on breech babies and breech birth, you should speak with your healthcare professional.

Reference- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/breech-baby-at-the-end-of-pregnancy-patient-information-leaflet/

Why isn’t a caesarean offered to every woman? 

Most women in the UK give birth vaginally, recover well and have healthy babies. 

Most women who have a planned caesarean birth will also recover well and have healthy babies. However, there are risks for both you and your baby if you have a planned caesarean birth and it may take longer to recover after your baby is born. Having a caesarean birth is a major operation with risks that should be compared with your risks of a planned vaginal birth. 

Your healthcare professional will not usually recommend a caesarean birth unless there are specific issues complicating your pregnancy. However, there are many factors that can influence how you feel about the way you give birth. The risks of caesarean and vaginal births will also depend on your individual circumstances. Your personal feelings, concerns, interpretation of risks and opinions are all important and will be respected when you speak with your healthcare professional about your birth plan. 

I am considering a caesarean birth. Who should I speak to? 

You should tell your healthcare professional you are considering a caesarean birth as early as possible in your pregnancy.  Your healthcare professional will need to discuss this with you, including the reasons for your choice. They do this to ensure that you have accurate information, and to offer further support or options that you may find helpful. Some maternity units may offer peer support, group information sessions, or appointments with specific healthcare professionals (e.g. anaesthetists, mental health professionals, specialist midwives) who can offer you information to prepare for birth. 

It is important to consider the benefits and risks carefully. People view risk differently and how you view risk depends to a large extent on your own preferences and experience. 

If your healthcare team are not able to offer you a planned caesarean birth they should refer you to a different team who can offer this choice to you. 

Why do some women consider a caesarean birth? 

Women consider a caesarean birth for many reasons. Your thoughts and feelings about giving birth will be influenced by the culture you grew up in, your previous experiences, and the experiences of the people around you.  

- You may have had a difficult vaginal birth in the past. 

- You may have concerns about damage to your pelvic floor during a vaginal birth. 

- You may think that a planned caesarean birth is safer for your baby. 

- You may have anxieties about having a vaginal birth for the first time, including about how you might react to vaginal examinations and labour pain. 

- You may want to avoid the chance of needing an emergency caesarean or an assisted vaginal birth. 

- You may want to avoid having an induction of labour. 

- You may feel that a planned caesarean birth gives you a better sense of control. 

- You may have had a previous traumatic experience or sexual abuse. 

- You may be concerned as many of your family members have required emergency caesarean births. 

- You have considered the benefits and risks and have decided you would prefer a caesarean birth. 

Your healthcare professional may offer you support from specialists with experience supporting women with anxieties and other mental health issues in pregnancy. If you had a difficult vaginal birth previously, discussing your birth with a healthcare professional to understand what happened may help. Many complications that happen during one birth do not, or are unlikely to, happen again. Even if you had a complicated assisted vaginal birth in your first pregnancy, your chance of having a vaginal birth with no assistance is more than 4 in 5 (80%) in your next birth. 

Discussing your options for pain relief might be helpful. Safe and effective options for pain relief including epidural analgesia are available. You may wish to talk about your options with an anaesthetist. 

Your maternity unit may also be able to offer you care from a small group of midwives that will look after you throughout your pregnancy, during labour, and visit you at home after birth. Building a relationship with the same midwives who will look after you in labour may give you more confidence. Some maternity units can offer a birth planning appointment with a senior midwife to explore and discuss other aspects of birth in more detail. Ask your healthcare professional for more information if any of these options seem attractive to you. 

If you are anxious about the need for vaginal examination or about any other aspect of birth, your healthcare professional may offer ways of caring for you in labour that may be more acceptable to you and offer referral to a specialist to explore the underlying reasons for your anxiety. There are tools available to help you feel more in control when you are in stressful situations (during birth and beyond). There is a chance that vaginal examinations may be needed even after a caesarean birth (for example if you have heavy bleeding afterwards). 

If you are concerned about the timing of labour and its unpredictability (for example, if your planned birth partner is going to be away for work or if you need childcare for an older child), you can ask to have your labour started in a controlled way. This process is called an ‘induction of labour’. If you would like to discuss this option alongside the option of a planned caesarean birth, let your healthcare professional know. 

What is the safest way for my baby to be born? 

Giving birth in the UK is extremely safe whichever way your baby is born. The safest way for your baby to be born will depend on your own individual circumstances and you should discuss this during your pregnancy with your healthcare professional.  

There is a chance of your baby being cut during a caesarean birth. This happens in 1–2 out of every 100 babies born by caesarean, but usually heals without any long term problems. 

What will a caesarean birth mean for me? 

The benefits of having a planned caesarean birth include: 

• Minimising the chance of needing an assisted vaginal birth or an emergency caesarean birth. 

• Avoiding the chance of tears to your vagina or perineum. Perineal tearing is very common during a vaginal birth. The chance of long term complications following a tear is small. Further information, including how to reduce your chance of tearing, can be found on the RCOG patient information. 

• Reducing the chance of you having urinary incontinence (leaking urine). The chance of longer term urinary incontinence is lower whichever way you give birth and pelvic floor exercises can help. 

• Having a planned date for the birth and reducing the uncertainties of going into labour naturally. 

The risks of having a planned caesarean birth include: 

• Although you should not feel any pain during the caesarean (because you will have an anaesthetic), the wound will be painful while you recover. You will be given pain relief in hospital and to take home.  The recovery period after a caesarean birth is usually about 6 weeks, but this can vary. 

• Infection – this can be of your wound or your uterus (womb). It is common and can take several weeks to heal. You will be offered antibiotics through a drip at the start of your caesarean to reduce this risk. 

• Developing scar tissue (adhesions) internally when you heal from the operation. This can cause pain and can make any operations you might need later in life more difficult. 

• Serious complications are more common if you have had previous operations to your abdomen such as previous caesarean births. Serious complications are not common if you are having your first caesarean birth, if it is planned and if you are fit, healthy and not overweight. 

  You can choose to breast feed your baby after having a caesarean birth and are no more likely to experience difficulties with this than if you have had a vaginal birth. You can have skin-to-skin contact with your baby during a caesarean birth. 

What about the effect of having a caesarean for me in the future? 

The risks associated with surgery increase with the number of caesarean births you have. Once you have had a caesarean birth: 

You have a higher chance of a serious complication called placenta accreta in any future pregnancy (1 in 1000 women compared with 1 in 2500 women who have had vaginal births). Placenta accreta is where the placenta does not come away as it should when your baby is born. If this happens, you may lose a lot of blood and need a blood transfusion, and you are likely to need a hysterectomy. The chance of placenta accreta increases with every caesarean birth.

If you have a vaginal birth with your next pregnancy, there is a higher chance of having a uterine rupture (1 in 98 women after a previous caesarean compared with 1 in 2500 with no previous caesarean). This usually only happens if you go into labour, and is less likely to happen if you plan another caesarean birth. It is an uncommon but serious complication that can lead to very heavy bleeding. 

What does having a vaginal birth mean for me? 

If you have a vaginal birth, you will usually have: 

• A shorter stay in hospital after your baby is born (on average 1 and a half days shorter than women having a caesarean birth). Women having straightforward vaginal births can often be discharged the same day. Women having straightforward caesarean births are usually discharged after an overnight stay (24–36 hours). 

• A faster recovery. You should be able to get back to everyday activities more quickly and you should be able to drive sooner. Standard advice for women having a caesarean birth is to allow 6 weeks for physical recovery and not to plan to drive during this time. 

• A much shorter labour in the future, with a low chance of harm to you and your baby. 

• It is common for the area between your vagina and anus (perineum) to feel sore and uncomfortable for a while after you have given birth. This is because this area will have stretched as your baby is born and you may have stitches. 

Complications can also happen during a vaginal birth, especially with first births. These may include: 

The need for forceps or ventouse to help your baby to be born. For more information, see RCOG patient information.  Vaginal or perineal tears and needing an emergency caesarean birth. 

I have been offered an induction of labour but I would rather have a caesarean. Is this possible? 

If you have been offered an induction of labour for a specific reason, but you do not want this, you can choose to wait for natural labour or plan a caesarean birth instead. Speak with your healthcare professional as early as possible to discuss your options. 

What anaesthetic will I have during a planned caesarean birth? 

There are two types of anaesthetic. You can be either awake (with a regional anaesthetic) or asleep (with a general anaesthetic). Most women having a planned caesarean birth will have a regional anaesthetic (a spinal anaesthetic or an epidural, or a combination of the two). You will not feel pain although you may feel nausea, experience vomiting, and have a pulling sensation or pressure in your lower body. There are medicines that your anaesthetist can give you to help with discomfort or nausea during the procedure. A regional anaesthetic is usually safer for you and your baby than a general anaesthetic and allows you and your partner to experience the birth together. Your partner will not be able to be with you in the operating theatre if you have a general anaesthetic. 

You will have an opportunity to discuss your anaesthetic with an anaesthetist. 

If I choose to give birth by caesarean, when will it be done? 

You will usually be offered a date at or soon after 39 weeks of pregnancy. Babies born by caesarean earlier than this are more likely to need admission to the neonatal unit for help with their breathing (1 in 24 babies at 38 weeks compared to 1 in 56 babies after 39 weeks). Even a short stay in the neonatal unit can be very stressful for new parents, and rarely babies can be affected in the longer term as well. This is why your healthcare professional will recommend planning for your caesarean to take place after 39 weeks, unless there are other reasons why your baby may need to be born earlier. 

The planned date of your caesarean may change because of emergency situations on the day of your operation. It is uncommon for this to happen, but if it does your healthcare team will arrange a new date with you as soon as possible. 

I’ve thought about it carefully and I want to plan for a caesarean birth. 

If you are certain that you do not want to plan for a vaginal birth and understand the risks of a caesarean birth you can choose this option for the birth of your baby. Your healthcare team will make arrangements for this to happen and will give you the information you need to prepare for your caesarean birth. 

There is a chance that you may go into labour before the date of your planned caesarean (1–2 in 100 women). It is important to discuss your preferences should this happen. Complication rates for caesarean birth are higher when they are performed during labour (about 1 in 4 women experience complications) compared with during a planned procedure (about 1 in 6 women experience complications). Complication rates are higher when a woman is in the active stage of labour where contractions are regular and the cervix is dilated (1 in 3 women may have complications) compared with when she is in early labour and the cervix has not dilated much (1 in 6 women may have complications). If you do go into labour before the date of your planned caesarean you will be offered a choice of continuing with labour or of having a caesarean birth as planned. Uncommonly, labour may be so advanced that it is not safe for you or your baby to have a caesarean, but your healthcare team will discuss your options depending on your individual situation. 

Reference-  https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/considering-a-caesarean-birth-patient-information-leaflet/ 

What are corticosteroids?

Corticosteroids are a type of medication that may be offered to you to help your baby if there is a chance that you may give birth early. Steroids are given by an injection into the muscle usually of your thigh or upper arm. A single course can consist of two to four injections usually over a 24–48-hour period.

Why are corticosteroids helpful?

Premature babies may have a range of health problems, which tend to be more serious the earlier they are born. Giving you steroid injections shortly before your baby is born reduces the risk of them having serious complications including:

Problems with their breathing

Bleeding into their brain

Developmental delay

If steroids are given within seven days of your baby being born prematurely there is a reduced chance of them dying around the time of birth.

Who should be given corticosteroids in pregnancy?

Babies born between 24 and 35 weeks benefit most from steroids.

You will be offered steroids if there is an increased chance that your baby will be born before 35 weeks of pregnancy. This includes:

• if you are in suspected or confirmed premature labour.

• if your waters break early even if you are not having contractions.

• if it may benefit you or your baby for them to be born early. This may be because your baby is not growing well or because you have developed a problem in your pregnancy such as severe pre-eclampsia.

  If you are likely to give birth between 35 weeks and 37 weeks, or are having a planned caesarean birth before 39 weeks you should have an individualised discussion with your healthcare professional about the risks and benefits of steroids for your baby. There is less evidence that steroids are helpful after 35 weeks.

The benefits of steroids in twin and triplet pregnancies are less certain, but it is still recommended that should be offered steroids if you are likely to give birth early.

Steroids may be given if your baby is expected to be born between 22 and 24 weeks, but this will require an individualised discussion with your healthcare team about the risks to your baby of being born so prematurely.

How long are corticosteroids effective for?

Steroids are of most benefit if the last dose is given to you between 24 hours and 1 week before the birth of your baby. There may still be some benefit even if your baby is born within 24 hours of the first dose. The benefits of steroids are likely to be significantly reduced if your baby is born more than 7 days after the treatment. Therefore, it is important to try to give steroids at the right time.

Can corticosteroids harm me or my baby?

A single course of steroids is safe for you. You may experience some minor side effects such as pain at the injection site. If you have pre-existing or gestational diabetes steroids can affect your blood sugar control.

If you have diabetes, you will need increased monitoring of your blood sugar levels while you have the steroids and may need to be admitted to hospital to be offered additional insulin treatment.

Treatment with steroids between 22 and 35 weeks pregnant is likely to be safe and beneficial for your baby. No long-term harm has been shown although there have been no large studies.

If you are given steroids and are more than 35 weeks pregnant there is a chance that your baby may have low blood sugar levels after they are born. Low blood sugar can be harmful for babies if it is not treated and can mean your baby needs to be admitted to the neonatal unit. Your baby will be monitored for this and offered treatment if needed.

Can I have more than one course of corticosteroids in this pregnancy?

If you have had a course of steroids and you do not give birth in the next 7 days then a second course might have some beneficial effects on your baby’s breathing if they are still expected to be born prematurely.

Your healthcare professional will advise you of the risks and benefits of a repeat course of steroids depending on your individual situation.

When are corticosteroids not necessary?

If you are unlikely to give birth in 7 days, you should not receive steroids. Even if you are at higher risk of giving birth early you won’t be given steroids unless you are likely to give birth in the next 7 days.

Reference- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/corticosteroids-in-pregnancy-to-reduce-complications-from-being-born-prematurely-patient-information-leaflet/

Cytomegalovirus (CMV) is a common virus that is usually harmless. Sometimes it causes problems in babies if you get it during pregnancy (congenital CMV).

What is cytomegalovirus (CMV)?

CMV is related to the herpes virus that causes cold sores and chickenpox. Once you have the virus, it stays in your body for the rest of your life. Your immune system usually controls the virus and most people do not realise they have it. But CMV can cause serious health problems in some babies who get the virus before birth, and in people who have a weakened immune system.

CMV does not usually cause symptoms. Some people get flu-like symptoms the first time they get CMV, including: a high temperature, aching muscles, tiredness, skin rash, feeling sick, sore throat or swollen glands.

If you do have symptoms, they usually get better without treatment within about 3 weeks

How cytomegalovirus (CMV) is spread

CMV is mainly spread through close contact with someone who already has CMV. It can be passed on through sexual contact and contact with other body fluids including saliva, blood, breast milk, tears, urine and faeces.

CMV can only be passed on when it's "active". The virus is active when:

- you get CMV for the first time – young children often get CMV for the first time at nursery

- the virus has "re-activated" – because you have a weakened immune system

- you've been re-infected – with a different type (strain) of CMV

Pregnant women can pass an "active" CMV infection on to their unborn baby. This is known as congenital CMV.

How cytomegalovirus (CMV) is treated

If CMV is not causing symptoms, you or your baby may not need any treatment. There's currently no treatment for CMV in pregnancy, but in most cases the virus does not cause any problems for your baby.

Antiviral medicine may be used to treat:

Babies diagnosed with congenital CMV after they're born

People with a weakened immune system

People who have a stem cell transplant

Treatment weakens the virus and reduces the chance of serious problems, but it does not cure the CMV infection. Babies born with congenital CMV may have tests to check their kidneys, liver, brain, eyes and hearing, and regular follow-up appointments until they're around age 5.

How to reduce the chance of getting cytomegalovirus (CMV) in pregnancy

The best way to reduce the chance of getting CMV during pregnancy is to:

• wash your hands using soap and water – especially after changing nappies, feeding young children or wiping their nose

• regularly wash toys or other items that may have young children's saliva or urine on them

• avoid sharing food, cutlery and drinking glasses or putting a child's dummy in your mouth

• avoid kissing young children on their mouth

  There's currently no vaccine for CMV.

Reference- https://www.nhs.uk/conditions/cytomegalovirus-cmv/

An ectopic pregnancy is when a fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes. The fallopian tubes are the tubes connecting the ovaries to the womb. If an egg gets stuck in them, it won't develop into a baby and your health may be at risk if the pregnancy continues.

Unfortunately, it's not possible to save the pregnancy. It usually must be removed using medicine or an operation.

Most ectopic pregnancies develop in the fallopian tubes (tubal pregnancy) but, rarely they can occur in other places.

What is pregnancy of unknown location (PUL)?

A pregnancy of unknown location (PUL) means that you have a positive pregnancy test but there is no identified pregnancy on an ultrasound scan.

This may be due to three possible reasons:

1- you may have a very early pregnancy within the uterus that is too small to be seen on a scan

2- you may have miscarried; your pregnancy test can remain positive for up to 2–3 weeks following a miscarriage

3- you may have an ectopic pregnancy.

Uncertainty about your pregnancy can be very stressful for you and your family. While it may take time, it is important to reach the correct diagnosis before your doctor discusses your treatment options with you. With a PUL, you will be advised to have regular blood tests to measure your pregnancy hormone levels and your treatment plan will be based on the results of these blood tests, ultrasound scan reports and clinical features.

What are the symptoms of an ectopic pregnancy?

Each woman is affected differently by an ectopic pregnancy. Some women have no symptoms, some have a few symptoms, while others have many symptoms. Most women get physical symptoms in the 6th week of pregnancy (about 2 weeks after a missed period). You may or may not be aware that you are pregnant if your periods are irregular, or if the contraception you are using has failed.

Because symptoms vary so much, it is not always straightforward to reach a diagnosis of an ectopic pregnancy.

The symptoms of an ectopic pregnancy may include:

• Pain in your lower abdomen. This may develop suddenly for no apparent reason or may come on gradually over several days. It may be on one side only.

• Vaginal bleeding. You may have some spotting or bleeding that is different from your normal period. The bleeding may be lighter or heavier or darker than normal.

• Pain in the tip of your shoulder. This pain is caused by blood leaking into the abdomen and is a sign that the condition is getting worse. This pain is there all the time and may be worse when you are lying down. It is not helped by movement and may not be relieved by painkillers. You should seek urgent medical advice if you experience this.

• Upset tummy. You may have diarrhoea or feel pain on opening your bowels.

• Severe abdominal pain/collapse. If the fallopian tube bursts (ruptures) and causes internal bleeding, you may develop intense abdominal pain or you may collapse. In rare instances, collapse may be the very first sign of an ectopic pregnancy. This is an emergency, and you should seek urgent medical attention.

Should I seek medical advice immediately?

Yes. An ectopic pregnancy can pose a serious risk to your health. If you have had sex within the last 3 or 4 months (even if you have used contraception) and are experiencing these symptoms, you should get medical help immediately. Seek advice even if you do not think you could be pregnant.

You can get medical advice from:

your GP or midwife

the A&E department at your local hospital

an Early Pregnancy Assessment Unit (EPAU); details of the unit nearest to you can be found at: www.aepu.org.uk/find-a-unit

NHS 111 (England and Wales) and NHS 24 (Scotland) on 111; support is available 24 hours a day, 365 days a year, by dialing 111; calls are free from landlines and mobile phones.

Am I at increased risk of an ectopic pregnancy?

Any woman of childbearing age could have an ectopic pregnancy. You have an increased risk of an ectopic pregnancy if:

- you have had a previous ectopic pregnancy

- you have a damaged fallopian tube; the main causes of damage are:

- previous surgery to your fallopian tubes, including sterilisation

- previous infection in your fallopian tubes

- you become pregnant when you have an intrauterine device (IUD/coil) or if you are on the progesterone-only contraceptive pill (mini pill)

- your pregnancy is a result of assisted conception, i.e. in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI)

-you smoke

How is it diagnosed?

Most ectopic pregnancies are suspected between 6 and 10 weeks of pregnancy. Sometimes the diagnosis is made quickly. However, if you are in the early stages of pregnancy, it can take longer (a week or more) to make a diagnosis of an ectopic pregnancy.

Your diagnosis will be made based on the following:

Consultation and examination. Your doctor will ask about your medical history and symptoms and will examine your abdomen. With your consent, your doctor may also do a vaginal (internal) examination. You should be offered a female chaperone (someone to accompany you) for this. You may also wish to bring someone to support you during your examination.

Urine pregnancy test. If you have not already had a positive pregnancy test, you will be asked for a urine sample so that this can be tested for pregnancy. If the pregnancy test is negative, it is very unlikely that your symptoms are due to an ectopic pregnancy.

Ultrasound scan. A transvaginal scan (where a probe is gently inserted in your vagina) is known to be more accurate in diagnosing an ectopic pregnancy than a scan through the tummy (transabdominal scan). Therefore, you will be offered a transvaginal scan to help identify the exact location of your pregnancy. However, if you are in the early stages of pregnancy, it may be difficult to locate the pregnancy on scanning and you may be offered another scan after a few days.

Blood tests. A test for the level of the pregnancy hormone βhCG (beta human chorionic gonadotrophin) or a test every few days to look for changes in the level of this hormone may help to give a diagnosis. This is usually checked every 48 hours because, with a pregnancy in the uterus, the hormone level rises by 63% every 48 hours (known as the ‘doubling time’) whereas, with ectopic pregnancies, the levels are usually lower and rise more slowly or stay the same.

Laparoscopy. If the diagnosis is still unclear, an operation under a general anaesthetic called a laparoscopy may be necessary. The doctor uses a small telescope to look at your pelvis by making a tiny cut, usually into the umbilicus (tummy button). This is also called keyhole surgery. If an ectopic pregnancy is confirmed, treatment may be undertaken as part of the same operation. This would be discussed with you before surgery, unless surgery is necessary due to an acute emergency.

What happens when an ectopic pregnancy is suspected or confirmed?

When an ectopic pregnancy is suspected or confirmed, your doctor will discuss your treatment options with you. The options usually depend on where the ectopic pregnancy is suspected or located.

Make sure that you fully understand all your options, ask for more information if there is something you do not understand, raise your concerns, if any. Understand what each option means for your fertility and have enough time to make your decision.

What are the options for treatment of tubal ectopic pregnancy?

Because an ectopic pregnancy cannot lead to the birth of a baby, all options will end the pregnancy to reduce the risks to your own health.

Your options depend upon:

1- how many weeks pregnant you are

2- your symptoms and clinical condition

3- the level of βhCG

4- your scan result

5- your fertility status

6- your general health

7- your personal views and preferences – this should involve a discussion about your future pregnancy plans

8- the options available at your local hospital.

The treatment options for tubal ectopic pregnancy are listed below – not all may be suitable for you, so your healthcare professional should guide you in making an informed decision.

Expectant management (wait and see)- Ectopic pregnancies sometimes end on their own – similar to a miscarriage. Depending on your situation, it may be possible to monitor the βhCG levels with blood tests every few days until these are back to normal. Although you do not have to stay in hospital, you should go back to hospital if you have any further symptoms. You should be given a direct contact number for the emergency ward or gynaecology ward at your hospital.

Expectant management is not an option for all women. It is usually only possible when the pregnancy is still in the early stages and when you have only a few or no symptoms. Success rates with expectant management are highly variable and range from 30% to 100%. This mainly depends on your pregnancy hormone levels, with higher serum βhCG levels associated with a lower chance of success.

Medical treatment - In certain circumstances, an ectopic pregnancy may be treated by medication (drugs). The fallopian tube is not removed. A drug (methotrexate) is given as an injection – this prevents the ectopic pregnancy from growing and the ectopic pregnancy gradually disappears. Most women only need one injection of methotrexate for treatment. However, 15 in 100 women (15%) need to have a second injection of methotrexate. If your pregnancy is beyond the very early stages or the βhCG level is high, methotrexate is less likely to succeed. Seven in 100 women (7%) will need surgery even after medical treatment.

Many women experience some pain in the first few days after taking the methotrexate, but this usually settles with paracetamol or similar pain relief. Although it is known that long-term treatment with methotrexate for other illnesses can cause significant side effects, this is rarely the case with one or two injections as used to treat ectopic pregnancy. Treatment of ectopic pregnancy with methotrexate is not known to affect the capacity of your ovaries to produce eggs.

You may need to stay in hospital overnight and then return to the clinic or ward a few days later. You will be asked to return sooner if you have any symptoms. It is very important that you attend your follow-up appointments until your pregnancy hormone levels are back to normal. You are also advised to wait for 3 months after the injection before you try for another pregnancy.

Surgical treatment - An operation to remove the ectopic pregnancy will involve a general anaesthetic.

The surgery will either be:

Laparoscopy (known as keyhole surgery). Your stay in hospital is shorter (24–36 hours) and physical recovery is quicker than after open surgery. Laparoscopy might not be an option for some women and your doctor will discuss this with you.

Open surgery (known as a laparotomy). This is done through a larger cut in your abdomen and may be needed if severe internal bleeding is suspected. You will need to stay in hospital for 2–4 days. It usually takes about 4–6 weeks to recover.

The aim of surgery is to remove the ectopic pregnancy. The type of operation you have will depend on your wishes or plans for a future pregnancy and what your surgeon finds during the operation (laparoscopy).

To have the best chance of a future pregnancy inside your uterus, and to reduce the risk of having another ectopic pregnancy, you will usually be advised to have your affected fallopian tube removed (this is known as a salpingectomy).

If you already have only one fallopian tube or your other tube does not look healthy, your chances of getting pregnant are already affected. In this circumstance, you may be advised to have a salpingotomy that aims to remove the pregnancy without removing the tube. It carries a higher risk of a future ectopic pregnancy but means that you are still able to have a pregnancy in the uterus in the future. You will be advised to have blood tests for checking your pregnancy hormone levels after salpingotomy as part of follow-up. Some women may need further medical treatment or another operation to remove the tube later if the pregnancy has not been completely removed during salpingotomy. The decision to perform salpingectomy or salpingotomy may sometimes only be made during laparoscopy under anaesthetic. There are risks associated with any operation: from the surgery itself and from the use of an anaesthetic. Your surgeon and anaesthetist will discuss these risks with you.

What are the options for treatment of non-tubal ectopic pregnancy?

The treatment of a non-tubal ectopic pregnancy depends on where the pregnancy is growing (refer to the various sites of non-tubal ectopic pregnancy in the leaflet). Your doctor will discuss the available treatment options with you based on a number of factors, including the location of the ectopic pregnancy, the levels of the pregnancy hormone βhCG in your blood and the ultrasound scan report.

Treatment options may include expectant management, medical treatment with methotrexate or surgical operation.

In an emergency situation

If the tubal or non-tubal pregnancy has burst, emergency surgery is needed to stop the bleeding. This operation is often life-saving. It is done by removing the ruptured fallopian tube and pregnancy. Your doctors will need to act quickly and this may mean that they have to make a decision on your behalf to operate. In this situation you may need a blood transfusion.

What happens to your pregnancy remains?

To confirm that you have had an ectopic pregnancy, tissue removed at the time of surgery is sent for testing in the laboratory. The healthcare team will discuss with you (and your partner) the options around what happens to your pregnancy remains afterwards.

What happens next?

Follow-up appointments - It is important that you attend your follow-up appointments. The check-ups and tests that you need will depend on the treatment that you had. If you had treatment with methotrexate, you should avoid getting pregnant for at least 3 months after the injection.

How will I feel afterwards?

The impact of an ectopic pregnancy can be very significant. It might mean coming to terms with the loss of your baby, with the potential impact on future fertility, or with the realisation that you could have lost your life.

Each woman copes in her own way. An ectopic pregnancy is a very personal experience. This experience may affect your partner and others in your family, as well as close friends.

If you feel you are not coping or not getting back to normal, you should talk to your GP and/ or Chana for support.

It is important to remember that the pregnancy could not have continued without causing a serious risk to your health.

Before trying for another baby, it is important to wait until you feel ready emotionally and physically. However traumatic your experience of an ectopic pregnancy has been, it may help to know that the likelihood of a normal pregnancy next time is much greater than that of having another ectopic pregnancy.

What about future pregnancies? The chances of having a successful pregnancy in the future are good. Even if you have only one fallopian tube, your chances of conceiving are only slightly reduced.

For most women an ectopic pregnancy is a ‘one-off’ event.

You should seek early advice from a healthcare professional when you know you are pregnant. You may be offered an ultrasound scan at between 6 and 8 weeks to confirm that the pregnancy is developing in the uterus.

If you do not want to become pregnant, seek further advice from your doctor or family planning clinic, as some forms of contraception may be more suitable after an ectopic pregnancy.

References- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/ectopic-pregnancy-patient-information-leaflet/

https://www.nhs.uk/conditions/ectopic-pregnancy/

Folic acid is the synthetic version of the vitamin folate, also known as vitamin B9. Folate helps the body make healthy red blood cells and is found in certain foods.

Folic acid is used to:

• Treat or prevent folate deficiency anaemia

• Help your baby's brain, skull and spinal cord develop properly in pregnancy, to avoid development problems (called neural tube defects) such as spina bifida

• Help reduce side effects from methotrexate, a medicine used to treat severe arthritis, Crohn's disease or psoriasis

Folic acid is available on prescription. It comes as tablets or as a liquid you swallow.

You can also buy lower dose tablets from pharmacies and supermarkets.

Folic acid can also be combined with: ferrous fumarate and ferrous sulphate, to treat iron deficiency anaemia , other vitamins and minerals, as a multivitamin and mineral supplement

Key facts

You'll usually take folic acid once a day, but sometimes you'll only need to take it once a week. Your doctor will explain how often to take it. Most adults and children can take folic acid.

If you're pregnant or trying to get pregnant, it's recommended you take folic acid until you're 12 weeks pregnant. It helps your baby grow normally.

You're unlikely to get side effects with folic acid, but some people feel sick, lose their appetite, get wind or feel bloated. These side effects are usually mild and do not last long.

It's best not to drink alcohol while taking folic acid, as it can stop your folic acid from working as well.

If you or your child have been prescribed folic acid, follow your doctor's instructions about how and when to take it.

If you have bought folic acid from a pharmacy or shop, follow the instructions that come with the medicine.

Dosage

How much folic acid you take and how long you take it for depends on why you need it.

Dose before and during early pregnancy - It is recommended to take folic acid while you're trying for a baby (ideally for 3 months before) and during the first 12 weeks of pregnancy. The usual dose if you're trying to get pregnant and during the first 12 weeks of pregnancy is 400 micrograms, taken once a day. Your doctor or midwife may recommend taking folic acid throughout pregnancy, particularly if you are at risk of anaemia or are anaemic. If you have a higher chance of having a baby with a neural tube defect your doctor will recommend an increased dose of 5mg, taken once a day.

Dose for treating folate deficiency anaemia - To treat anaemia, the usual dose for adults and children over 1 year old is 5mg, taken once a day. Sometimes the dose is increased to 15mg a day. If your child is under 12 months old, the doctor will use your child's weight to work out the right dose. You'll usually take it for 4 months. But if your folate deficiency anaemia is caused by a long-term problem, you may have to take folic acid for longer, possibly for the rest of your life. Do not stop taking folic acid without talking to your doctor.

Dose for preventing folate deficiency anaemia - To prevent anaemia, the usual dose for adults and children aged 12 years and over is 5mg, taken every 1 to 7 days. The dose may vary depending on your age, diet and any other health conditions you have. For children under 12, the doctor will use your child's age or weight to work out the right dose.

Dose if you're taking methotrexate - The usual dose for adults and children is 5mg once a week, on a different day of the week to your methotrexate. Some people take 1mg to 5mg once a day, apart from the day when they take their methotrexate. You'll usually take folic acid for as long as you take methotrexate. You may have to take it for a long time, possibly for the rest of your life. Do not stop taking it without talking to your doctor. Stopping means you'll be more likely to get side effects from methotrexate, such as being sick (vomiting) and diarrhoea.

Changes to your dose

Usually your dose will stay the same. Your dose may go up, however, if you're taking folic acid to prevent or treat anaemia and blood tests show you need a higher dose.

How to take it

You can take folic acid with or without food. Swallow the tablets whole with a drink of water.

If you're taking folic acid as a liquid, it will come with a plastic syringe or spoon to help you measure out the right dose. If you do not have one, ask your pharmacist for one. Do not use a kitchen teaspoon as it will not measure the right amount.

If you forget to take it

Missing 1 or 2 doses probably will not matter. But if you keep forgetting to take your folic acid, or you do not want to take it, speak to your doctor. If you forget to take folic acid, what to do depends on how often you take it:

once a day – take your missed dose as soon as you remember, unless it's nearly time for your next dose. In this case skip the missed dose and just take your next dose at the usual time. If you remember on the day you take your methotrexate, wait a day and take your missed dose the following day

once a week – take your missed dose as soon as you remember, unless you take methotrexate that day. If you remember on the day you take your methotrexate, wait a day and take your missed dose the following day. After this, go back to taking your weekly dose on your usual day

Never take 2 doses to make up for a forgotten one.

If you often forget doses, it may help to set an alarm to remind you. You could also ask your pharmacist for advice on other ways to help you remember to take your medicine.

If you take too much

Folic acid is generally very safe. Taking too much is unlikely to cause any harm. If you're worried, speak to your pharmacist or doctor.

Side effects of folic acid

Like all medicines, folic acid can cause side effects in some people. But many people have no side effects or only minor ones.

There are things you can do to help cope if you get these side effects of folic acid:

Feeling sick (nausea)

Loss of appetite

Bloating or wind

Serious allergic reaction - In rare cases, folic acid can cause a serious allergic reaction (anaphylaxis).

These are not all the side effects of folic acid. For a full list, see the leaflet inside your medicine packet.

Speak to a doctor or pharmacist if the advice on how to cope does not help and a side effect is still bothering you or does not go away.

Pregnancy, breastfeeding and fertility while taking folic acid

It's recommended you take folic acid as soon as you start trying for a baby (ideally for 3 months before) and during the first 12 weeks of pregnancy. This will help your baby's brain and spine to develop normally.

You can take folic acid after 12 weeks too. It helps make blood cells. Your doctor or midwife may recommend that you keep taking folic acid throughout pregnancy if you are anaemic or at risk of anaemia. You'll usually take 400 micrograms a day. Your doctor may advise you to take a higher dose of folic acid (usually 5 mg) if you have a higher chance of having a baby with a neural tube defect (a problem with the brain and/or spine, such as spina bifida).

It's OK to take folic acid while you're breastfeeding. Folic acid is a normal part of breast milk. When taken as a supplement it passes into breast milk in amounts that are too small to harm your baby.

There's no evidence that folic acid reduces fertility in either men or women. Folic acid does not help you get pregnant, but it's recommended while you're trying to get pregnant and in the first 12 weeks of pregnancy.

Cautions with other medicines

There are some medicines that may affect how folic acid works.

Folic acid can also affect the way other medicines work. Do not take your folic acid within 2 hours before or after taking indigestion remedies (antacids containing aluminium or magnesium), as they may stop the folic acid being properly absorbed.

Tell your doctor if you're taking any of these medicines before you start taking folic acid:

- methotrexate, a medicine used to treat rheumatoid arthritis, Crohn's disease, psoriasis and some types of cancer

- phenytoin, fosphenytoin, phenobarbital or primidone, medicines used to treat epilepsy

- fluorouracil, capecitabine, raltitrexed or tegafur, medicines used to treat some types of cancer

- antibiotics, medicines used to treat or prevent bacterial infection

- medicines that contain zinc (including throat lozenges and cold remedies)

- a medicine used to treat the inflammatory bowel conditions ulcerative colitis and Crohn's disease

- cholestyramine, a medicine used to reduce cholesterol

Taking folic acid with painkillers

You can take folic acid at the same time as everyday painkillers such as paracetamol.

Paracetamol is the first choice of painkiller if you're pregnant or breastfeeding.

If you're taking folic acid with methotrexate, talk to your doctor before taking any non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or aspirin.

Mixing folic acid with herbal remedies or supplements

Talk to your pharmacist or doctor before taking any herbal remedies or supplements together with folic acid. Some vitamin and mineral supplements already contain folic acid. It's important not to take more than the recommended daily amount. Tell your pharmacist or doctor if you take any supplements or remedies that contain zinc. Folic acid can stop zinc working as well as it should.

Common questions asked about folic acid

How long does folic acid take to work?

Folic acid usually starts to work in a few hours. But if you're taking it for folate deficiency anemia, it may be a few weeks before you start to feel better. It's important to keep taking your folic acid for as long as it's recommended.

Are there other sources of folate?

Folate is found naturally in foods, and some foods are fortified with folic acid, which means the vitamin is added to it. Good sources of folate include: spinach, kale, asparagus, brussels sprouts, cabbage and broccoli, peas, lentils and beans, including chickpeas and black-eyed beans, yeast and beef extracts, including Marmite and Bovril, oranges and orange juice, wheat bran and other wholegrain foods, poultry, liver fortified foods with added folic acid, including some brands of breakfast cereals

Do I need to take folic acid in pregnancy if I already eat foods that contain folate?

Yes, you still need to take folic acid. You need up to 10 times more folate in pregnancy to help your baby grow. It's unlikely that you would be able to have this much through diet alone.

What happens if I do not take folic acid before getting pregnant or during early pregnancy?

Do not worry if you have not taken folic acid before conceiving or in the first 12 weeks of pregnancy. It is still likely that your baby will develop normally. Routine ultrasound checks at around 12 and 20 weeks will detect if there are any concerns. Your midwife will discuss folic acid with you at your first booking appointment and will be able to advise if you need it or not.

Will it affect my contraception? Folic acid will not stop any type of contraception working, including the combined pill and emergency contraception.

Can I drink alcohol while taking folic acid?

It's best to avoid drinking alcohol with folic acid as alcohol may stop folic acid being absorbed. Your folic acid may not work as well. It's safer not to drink any alcohol if you're pregnant or trying to get pregnant because it can damage your baby's growth.

Is there any food or drink I need to avoid?

You can eat and drink normally while taking folic acid.

What’s the difference between folate and folic acid?

Although the terms “folate” and “folic acid” are often used interchangeably, they are different forms of the same vitamin: vitamin B9. Folic acid has a different structure than folate and has slightly different effects in your body. “Folate” is the generic name that encompasses all forms of vitamin B9, including folic acid and 5-MTHF. Folic acid is a specific synthetic form of this vitamin.

What does the body use folate for? Make and repair DNA, help cells grow, divide, and work properly , produce certain proteins and help red blood cells mature.

Folate deficiency can lead to many health problems, including

anemia

an increased risk of heart disease and certain cancers

developmental irregularities in infants if pregnant people don’t get enough folate

Folate deficiency can happen for many reasons. Some possible causes of folate deficiency are

a lack of folate in your diet

diseases or surgeries that affect how your body absorbs folate, including celiac disease, short bowel syndrome, and gastric bypass surgery

no stomach acid (achlorhydria) or low stomach acid (hypochlorhydria)

drugs that affect folate absorption, including methotrexate and sulfasalazine (Azulfadine)

alcohol use disorder

pregnancy

hemolytic anemia

dialysis

Consuming too little folate can cause complications such as anemia, fetal development issues, mental impairment, impaired immune function, and depression.

Preventing birth defects and pregnancy complications

Folic acid supplements can help to prevent neural tube irregularities, including spina bifida and anencephaly. Getting enough folic acid during pregnancy can reduce the chance that your baby will be born with one of these conditions.

Folic acid supplements not only help prevent fetal development issues but also help lower the risk of pregnancy complications such as preeclampsia.

Folic acid supplements may also help with these other health conditions:

• Diabetes. Folate supplements may help improve blood sugar regulation and reduce insulin resistance in people with diabetes. Because the diabetes drug metformin can lower folate levels, you may need a supplement if your levels are low.

• Fertility issues. Folate can improve egg quality and help eggs grow and implant in the uterus. Taking folate may increase the chance of getting pregnant and carrying a baby to term. People who use assisted reproductive technology to conceive may be more likely to have a baby if they have a higher intake of supplemental folate.

• Inflammation. Inflammation plays a role in many diseases. Folic acid and folate supplements have been shown to reduce markers of inflammation such as C-reactive protein.

• Kidney disease. The kidneys usually filter waste out of the blood, but when the kidneys are damaged, homocysteine can build up. About 85% of people with chronic kidney disease have too much homocysteine in their blood. Folic acid supplements may help reduce homocysteine levels and heart disease risk in people with kidney disease.

This list doesn’t include every possible benefit of folic acid. There are many other reasons people may use folate-based supplements.

Reference- https://www.nhs.uk/medicines/folic-acid/about-folic-acid/

https://www.healthline.com/nutrition/folic-acid#benefits-uses

What is gestational diabetes?

Diabetes that develops during pregnancy is known as gestational diabetes. It happens because your body cannot produce enough insulin (a hormone that helps to control blood glucose) to meet the extra needs of pregnancy. This results in high blood sugar levels (blood glucose).

Gestational diabetes usually starts in the middle or towards the end of pregnancy.

How common is gestational diabetes?

Gestational diabetes is common. It affects at least 4-5 in 100 women during pregnancy. You are more likely to develop gestational diabetes if you have any of the following risk factors:

your body mass index (BMI) is 30 or higher

you have previously given birth to a baby weighing 4.5 kg (10 lbs) or more

you have had gestational diabetes before

you have a parent, brother or sister with diabetes

your family origin is South Asian, Chinese, African-Caribbean or Middle Eastern.

How will I be checked for gestational diabetes?

If you have any of the above risk factors, you should be offered a glucose test during your pregnancy. This may be a simple blood test in early pregnancy and/or a glucose tolerance test (GTT) when you are between 24 and 28 weeks pregnant. A GTT involves fasting overnight (not eating or drinking anything apart from water):

In the morning, before breakfast, you will have a blood test. You are then given a glucose drink. The blood test is repeated 1–2 hours later to see how your body reacts to the glucose drink.

If you have had gestational diabetes in a previous pregnancy, you will be offered either a kit to check your own blood glucose levels or a GTT in early pregnancy. If these are normal, you will be offered a GTT again at 24–28 weeks.

During your routine pregnancy care, your urine is tested for glucose. If glucose is present in your urine, then your healthcare team may recommend that you have a GTT.

What does gestational diabetes mean for me and my baby?

Most women who develop gestational diabetes have healthy pregnancies and healthy babies but occasionally gestational diabetes can cause serious problems, especially if it is not recognised or treated.

If your blood glucose levels are high, the chances of you having an induced labour or a caesarean birth are increased.

The risks to your baby are:

• being bigger than average

• shoulder dystocia (where your baby’s shoulder gets stuck during birth)

• stillbirth or the baby dying at or around the time of birth. This is uncommon.

• needing additional care once they have been born, possibly in a neonatal unit

• being at greater risk of developing obesity and developing type 2 diabetes in later life.

Controlling your levels of blood glucose during pregnancy and labour reduces the chances of these complications for you and your baby.

What extra care will I need during pregnancy?

If you are diagnosed with gestational diabetes, you will be under the care of a specialist healthcare team and will be advised to have your baby in a hospital with a consultant-led maternity unit and a neonatal unit.

Your healthcare team may include a doctor specialising in diabetes, an obstetrician, a specialist diabetes nurse, a specialist diabetes midwife, a dietitian and your community midwife. You should start receiving extra antenatal care as soon as your gestational diabetes is diagnosed. Having gestational diabetes will mean more contact with your healthcare team.

Healthy eating and exercise

The most important treatment for gestational diabetes is a healthy eating plan and exercising regularly. Walking for 30 minutes after a meal can help with controlling your blood glucose levels. Gestational diabetes usually improves with these changes. You should have an opportunity to talk to a healthcare professional about choosing foods that will help to keep your blood glucose at a healthy and stable level.

Monitoring your blood glucose

After you have been diagnosed with gestational diabetes, you will be shown how to check your blood glucose levels and told what your ideal level should be. If it does not reach this level with healthy eating and exercise, or if an ultrasound scan shows that your baby is larger than expected, you may need to take tablets or give yourself insulin injections. If your glucose level is very high at the time of diagnosis, then you may be offered treatment straight away, in addition to making changes to your diet and exercise.

Monitoring your baby

You should be offered extra ultrasound scans to monitor your baby’s growth more closely.

Advice and information

During your pregnancy, your healthcare professionals will give you information and advice about:

planning birth, including timing and types of birth, pain relief and changes to your medications during labour and after your baby is born

looking after your baby following birth

care for you after your baby is born including contraception.

Will I need treatment?

Some women with gestational diabetes will need to take tablets and/or have insulin injections to control their blood glucose during pregnancy. Your healthcare team will advise you what treatment is best for you and your baby.

If you do need insulin, your specialist healthcare team will explain exactly what you need to do. This will include showing you how to inject yourself with insulin, how often to do it and when you should check your blood glucose levels.

When are my birth options?

You will have discussions about your options for birth with your healthcare professionals throughout your pregnancy. Your options include waiting for labour to start, having an induction of labour or having a planned caesarean birth. This will depend on your individual circumstances and preferences and your healthcare professional will discuss the risks and benefits of each option with you.

You will be advised to have your baby before 41 weeks of pregnancy and if there are pregnancy complications affecting either you or your baby, your healthcare team may recommend birth earlier than this.

What happens in labour?

It is important that your blood glucose level is controlled during labour and birth and it should be monitored to ensure it is not too high. You may be advised to have an insulin drip to help control your blood glucose level

What happens after my baby is born?

Your baby will stay with you unless they need extra care. You can usually have skin-to-skin contact with your baby straight away if you choose this. Occasionally they may need to be looked after in the neonatal unit if they are unwell or need extra support. Your baby should have their blood glucose level tested a few hours after birth to make sure that it is not too low.

Gestational diabetes usually goes away after birth and therefore you will be advised to stop taking all diabetes medications immediately after your baby is born. Before you go home, your blood glucose level will be tested to make sure that it has returned to normal.

You should be offered a fasting blood glucose test 6 - 13 weeks after the birth of your baby. A small number of women continue to have high blood glucose levels and will be offered further tests for diabetes. You should be offered information about your lifestyle, including diet, exercise and watching your weight, to reduce your chance of type 2 diabetes in the future.

Up to 50% of women who have had gestational diabetes develop type 2 diabetes within the following 5 years. You will therefore be advised to have a test for this every year.

What are my options for feeding my baby?

Breastfeeding is safe if you have gestational diabetes and your healthcare team will support you in feeding your baby. Whichever way you choose to feed your baby, you should start feeding as soon as possible after birth, and then every 2–3 hours to help your baby’s blood glucose stay at a safe level. Babies born to mothers with gestational diabetes have a high risk of low sugar levels after birth, so you may be advised to hand express and give your baby this early breast milk (also called colostrum) in addition to breastfeeding directly. Your healthcare team will advise you how to do this.

It is safe to express colostrum in pregnancy, from 36 weeks onwards and to store it for use after giving birth. This can be helpful to supplement breastfeeding and expressing if you experience difficulties in breastfeeding after giving birth. Your healthcare team will be able to advise you about how to store breastmilk safely.

You should inform a member of your healthcare team if you have any concerns about your baby’s wellbeing.

What do I need to know about future pregnancies?

Having a healthy weight, eating a balanced diet and taking regular physical exercise before you become pregnant can reduce your risk of developing gestational diabetes again. As soon as you find out you’re pregnant, contact your healthcare team for advice about your antenatal care as there is a chance you may develop gestational diabetes again (more than 1 in 3 women will get gestational diabetes again).

Reference- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/gestational-diabetes/

Hyperemesis gravidarum is severe vomiting in pregnancy.

Sickness in pregnancy (sometimes called morning sickness) is common. Around 8 out of every 10 pregnant women feel sick (nausea), are sick (vomiting) or both during pregnancy. This does not just happen in the morning. For most women, this improves or stops completely by around weeks 12 to 20, although for some women it can last longer.

Some pregnant women experience very bad nausea and vomiting. They might be sick many times a day and be unable to keep food or drink down, which can impact on their daily life. This excessive nausea and vomiting is known as hyperemesis gravidarum (HG), and often needs hospital treatment. If you have this level of vomiting tell your midwife or doctor, or contact the hospital as soon as possible. There is a risk you may become dehydrated, and your midwife or doctor can make sure you get the right treatment. Anti nausea medication should only be prescribed by a doctor to ensure they are safe for pregnancy and specific to HG.

Symptoms of hyperemesis gravidarum

Signs and symptoms of HG include:

• Prolonged and severe nausea and vomiting

• Dehydration – symptoms include feeling thirsty, tired, dizzy or lightheaded, not urinating very much, and having dark yellow and strong-smelling urine

• Weight loss

Unlike regular pregnancy sickness, HG may not get better by 16 to 20 weeks. It may not clear up completely until the baby is born, although some symptoms may improve at around 20 weeks. HG is much worse than the normal nausea and vomiting of pregnancy.

See your GP or midwife if you have severe nausea and vomiting. Getting help early can help you avoid dehydration and weight loss. There are other causes that can cause nausea and vomiting so it’s best to see a GP to rule them out before assuming help for HG.

What causes hyperemesis gravidarum?

It's not known exactly what causes HG, or why some women get it and others do not. There is evidence that it is linked to the changing hormones in your body that occur during pregnancy. There is also some evidence that it runs in families, so if you have a mother or sister who has had HG in a pregnancy, you may be more likely to get it yourself.

If you have had HG in a previous pregnancy, you are more likely to get it in your next pregnancy than women who have never had it before, so it's worth planning in advance.

Treating hyperemesis gravidarum

There are medicines that can be used in pregnancy, including the first 12 weeks, to help improve the symptoms of HG. These include anti-sickness (anti-emetic) drugs, steroids, or a combination of these. You may need to try different types of medicine until you find what works best for you. Anti nausea medication should only be prescribed by a doctor to ensure they are safe for pregnancy and specific to HG.

If your nausea and vomiting cannot be controlled, you may need to be admitted to hospital. This is so doctors can assess your condition and give you the right treatment to protect the health of you and your baby. Treatment can include intravenous fluids, which are given directly into a vein through a drip. If you have severe vomiting, the anti-sickness drugs may also need to be given into a vein or a muscle.

The charities Pregnancy Sickness Support and HGhelp have information and tips on coping with nausea and vomiting, including HG.

Pregnancy Sickness Support are a charity that help woman coping with the everyday effects of pregnancy sickness. This includes HG. To get support you can contact them via WhatsApp on their website, their helpline- 024 7638 2020 or requesting a call back

https://www.pregnancysicknesssupport.org.uk/.

HGhelp is a Jewish UK organisation that has been set up to help women in the community with HG. They support women with HG by providing extra help with matters such as household, childcare, cleaning and advice. They are not medically trained therefore someone with HG should also be contacting their GP or Pregnancy healthcare team during this time. Their contact details are support@hghelp.co.uk

https://hghelp.co.uk/support/

Will hyperemesis gravidarum harm my baby?

HG can make you feel very unwell, but it's unlikely to harm your baby if treated effectively. However, if it causes you to lose weight during pregnancy, there is an increased risk that your baby may be born smaller than expected (have a low birthweight).

How you might feel

The nausea and vomiting of HG can impact your life at a time when you were expecting to be enjoying pregnancy and looking forward to the birth of your baby. It can affect you both emotionally and physically. The symptoms can be hard to cope with. Without treatment HG may also lead to further health complications, such as depression or tears in your oesophagus.

Severe sickness can be exhausting and stop you doing everyday tasks, such as going to work or even getting out of bed.

In addition to feeling very unwell and tired, you might also feel:

• Anxious about going out or being too far from home in case you need to vomit

• Isolated because you do not know anyone who understands what it's like to have HG

• Confused as to why this is happening to you

• Unsure about how to cope with the rest of the pregnancy if you continue to feel very ill

If you feel any of these, do not keep it to yourself. Talk to your midwife or doctor, and explain the impact HG is having on your life and how it is making you feel. Bear in mind that HG is much worse than regular pregnancy sickness. It is not the result of anything you have or have not done, and you do need treatment and support.

Another pregnancy

If you have had HG before, it's likely you will get it again in another pregnancy. If you decide on another pregnancy, it can help to plan ahead, such as arranging child care so you can get plenty of rest.

You could try doing things that helped last time and talk to your doctor about starting medicine early.

Blood clots and hyperemesis gravidarum

Because HG can cause dehydration, there's also an increased risk of having a blood clot (deep vein thrombosis), although this is rare.If you are dehydrated and immobile, there is treatment that you can be given to prevent blood clots.

Do not feel like you are going through this journey alone. We at Chana are here to support you and guide you through your pregnancy.

Reference- https://www.nhs.uk/pregnancy/related-conditions/complications/severe-vomiting/#:~:text=This%20excessive%20nausea%20and%20vomiting,to%203%20in%20every%20100.

What is pelvic girdle pain?

The pelvic girdle is a ring of bones around your body at the base of your spine. PGP is pain in the front and/or the back of your pelvis that can also affect other areas such as the hips or thighs. It can affect the sacroiliac joints at the back and/or the symphysis pubis joint at the front. PGP used to be known as symphysis pubis dysfunction (SPD).

PGP is common, affecting 1 in 5 pregnant women, and can affect your mobility and quality of life. Pain when you are walking, climbing stairs and turning over in bed are common symptoms of PGP. However, early diagnosis and treatment can relieve your pain. Treatment is safe at any stage during or after pregnancy.

What causes PGP?

The three joints in the pelvis work together and normally move slightly. PGP is usually caused by the joints moving unevenly, which can lead to the pelvic girdle becoming less stable and therefore painful. As your baby grows in the womb, the extra weight and the change in the way you sit or stand will put more strain on your pelvis.

You are more likely to have PGP if you have had a back problem or have injured your pelvis in the past or have hypermobility syndrome, a condition in which your joints stretch more than normal.

Can PGP harm my baby?

No. Although PGP can be very painful for you, it will not harm your baby.

What are the symptoms of PGP?

PGP can be mild to severe but is treatable at any stage in pregnancy and the sooner it is treated, the more likely you are to feel better. It is more common later in pregnancy. Symptoms include:

• Pain in the pubic region, lower back, hips, groin, thighs or knees

• Clicking or grinding in the pelvic area

• Pain made worse by movement, for example:

  Walking on uneven surfaces/rough ground or for long distances

  Moving your knees apart, like getting in and out of the car

  Standing on one leg, like climbing the stairs, dressing or getting in or out of the bath

  Rolling over in bed

  Pain during sexual intercourse.

How is PGP diagnosed?

Tell your midwife or doctor about your pain. You should be offered an appointment with a physiotherapist who will make an assessment to diagnose PGP. This will involve looking at your posture and your back and hip movements and ruling out other causes of pelvic pain.

What can I do to help my symptoms?

The following simple measures may help:

- keeping active but also getting plenty of rest

- standing tall with your bump and bottom tucked in a little

- changing your position frequently

- try not to sit for more than 30 minutes at a time

- sitting to get dressed and undressed

- putting equal weight on each leg when you stand

- trying to keep your legs together when getting in and out of the car

- lying on the less painful side while sleeping

- keeping your knees together when turning over in bed

- using a pillow under your bump and between your legs for extra support in bed.

You should avoid anything that may make your symptoms worse, such as: Lifting anything heavy, for example heavy shopping , going up and down the stairs too often, stooping, bending or twisting to lift or carry a toddler or baby on one hip, sitting on the floor, sitting twisted, or sitting or standing for long periods and standing on one leg or crossing your legs.

What are my treatment options?

Your physiotherapist will suggest the right treatment for you. This may include:

Advice on avoiding movements that may be aggravating the pain. You will be given advice on the best positions for movement and rest and how to pace your activities to lessen your pain.

Exercises that should help relieve your pain and allow you to move around more easily. They should also strengthen your abdominal and pelvic floor muscles to improve your balance and posture and make your spine more stable.

Manual therapy (hands-on treatment) to the muscles and joints by a physiotherapist, osteopath or chiropractor who specialises in PGP in pregnancy. They will give you hands-on treatment to gently mobilise or move the joints to get them back into position, and help them move normally again. This should not be painful.

Warm baths, or heat or ice packs

Hydrotherapy

Acupuncture

A support belt or crutches.

For most women, early diagnosis and treatment should stop symptoms from getting worse, relieve your pain and help you continue with your normal everyday activities. It is therefore very important that you are referred for treatment early. PGP is not something you just have to ‘put up with’ until your baby is born.

I’ve tried these measures but I’m still in pain. What are my options?

Being in severe pain and not being able to move around easily can be extremely distressing. Ask for help and support during your pregnancy and after the birth. Talk to your midwife and doctor if you feel you are struggling. If you continue to have severe pain or limited mobility, it is worth considering:

• regular pain relief. Paracetamol is safe in pregnancy and may help if taken in regular doses. If you need stronger pain relief, your doctor will discuss this with you.

• aids such as crutches or a wheelchair for you to use on a short-term basis. Your physiotherapist will be able to advise you about this. Equipment such as bath boards, shower chairs, bed levers and raised toilet seats may be available.

• changes to your lifestyle such as getting help with regular household jobs or doing the shopping.

• if you work, talking to your employer about ways to help manage your pain. You shouldn’t be sitting for too long or lifting heavy weights. You may want to consider shortening your hours or stopping work earlier than you had planned if your symptoms are severe.

• If you are in extreme pain or have very limited mobility, you may be admitted to the antenatal ward where you will receive regular physiotherapy and pain relief. Being admitted to hospital every now and then may help you to manage your pain.

Can I have a vaginal birth?

Most women with pelvic pain in pregnancy can have a normal vaginal birth. Make sure the team looking after you in labour know you have PGP. They will ensure your legs are supported, help you to change position and help you to move around.

You may find a birthing pool helps to take the weight off your joints and allows you to move more easily. All types of pain relief are possible, including an epidural.

Do I need to have a caesarean section?

A caesarean section will not normally be needed for PGP. There is no evidence that a caesarean section helps women with PGP and it may slow down your recovery.

Will I need to have labour started off (be induced) early?

Going into labour naturally is better for you and your baby. Most women with PGP do not need to have labour started off. Being induced carries risks to you and your baby, particularly if this is before your due date. Your midwife or obstetrician will talk to you about the risks and your options.

What happens after the birth of my baby?

PGP usually improves after birth although around 1 in 10 women will have ongoing pain. If this is the case, it is important that you continue to receive treatment and take regular pain relief. If you have been given aids to help you get around, keep using them until the pain settles down. If you have had severe PGP, you should take extra care when you move about. Ask for a room where you are near to toilet facilities, or an en-suite room if available. Aim to become gradually more mobile. You should continue treatment and take painkillers until your symptoms are better.

If your pain persists, seek advice from your GP, who may refer you to another specialist to exclude other causes such as hip problems or hypermobility syndrome.

Will it happen in my next pregnancy?

If you have had PGP, you are more likely to have it in a future pregnancy. Making sure that you are as fit and healthy as possible before you get pregnant again may help or even prevent it recurring. Strengthening abdominal and pelvic floor muscles makes it less likely that you will get PGP in the next pregnancy. If you get it again, treating it early should control or relieve your symptoms.

Is there anything else I need to know?

Pregnant women have a higher risk of developing blood clots in the veins of their legs compared with women who are not pregnant. If you have very limited mobility, the risk of developing blood clots is increased. You will be advised to wear special stockings (graduated elastic compression stockings) and may need to have injections of heparin to reduce your risk of blood clots.

Reference- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/pelvic-girdle-pain-and-pregnancy/

What is placenta praevia?

The placenta develops together with the baby in your uterus during pregnancy. It attaches to the wall of your uterus and provides a connection between you and your baby. Oxygen and nutrients pass from your blood through the placenta into your baby’s blood. The placenta is delivered shortly after the baby is born and it is sometimes called the afterbirth.

In some women, the placenta attaches low down in the uterus and may cover part of or all the cervix (the neck of the womb). In most cases, the placenta moves upwards and out of the way as the uterus grows during pregnancy. For some women, however, the placenta continues to lie in the lower part of the uterus as the pregnancy continues. This condition is known as low-lying placenta if the placenta is less than 20 mm from the cervix or as placenta praevia if the placenta completely covers the cervix.

Placenta praevia is more common if you have had one or more previous caesarean births, if you had had fertility treatment to fall pregnant, or if you smoke.

What are the risks for me and my baby?

There is a risk that you may have vaginal bleeding, particularly towards the end of the pregnancy, because the placenta is low down in your uterus. Bleeding from placenta praevia can be very heavy, sometimes putting both you and your baby’s life at risk.

Your baby may need to be born by caesarean because the placenta may block the birth canal, preventing a vaginal birth.

How is placenta praevia diagnosed?

A low-lying placenta is checked for during your routine 20-week ultrasound scan. Most women who have a low-lying placenta at 20 weeks will not go on to have a low-lying placenta later in the pregnancy. If you have previously had a baby by caesarean, the placenta is less likely to move upwards. Placenta praevia is confirmed by having a transvaginal ultrasound scan (where the probe is gently placed inside the vagina). This is safe for both you and your baby and it may be used towards the end of your pregnancy to check exactly where your placenta is lying.

Placenta praevia may be suspected if you have bleeding in the second half of pregnancy. Bleeding from placenta praevia is usually painless and may occur after having sexual intercourse.

Placenta praevia may also be suspected later in pregnancy if the baby is found to be lying in an unusual position, for example bottom first (breech) or lying across the womb (transverse).

What extra antenatal care can I expect if I have a low-lying placenta?

If your placenta is low lying at your 20-week scan, you will be offered a follow-up scan at 32 weeks of pregnancy to see whether it is still low lying. This may include a transvaginal scan. You should be offered a further ultrasound scan at 36 weeks if your placenta is still low lying.

The length of your cervix may be measured at your 32-week scan to predict whether you may go into labour early and whether you are at increased risk of bleeding.

If you have placenta praevia, you are at higher risk of having your baby early (less than 37 weeks) and you may be offered a course of steroid injections between 34 and 36 weeks of pregnancy to help your baby to become more mature.

If you go into labour early, you may be offered a type of medication (known as tocolysis) that is given to try to stop your contractions and to allow you to receive a course of steroids.

Additional care, including whether you need to be admitted to hospital, will be based on your individual circumstances. Even if you have had no symptoms before, there is a small risk that you could bleed suddenly and heavily, which may mean that you need an emergency caesarean.

If you know you have a low-lying placenta, you should contact the hospital straight away if you have any vaginal bleeding, contractions or pain. If you have bleeding, your doctor may need to do a speculum examination to check how much blood loss there is and where it is coming from. This is a safe examination and you will be asked for your consent beforehand.

You should try to avoid becoming anaemic during pregnancy by having a healthy diet and by taking iron supplements if recommended by your healthcare team. Your blood haemoglobin levels (a measure of whether you are anaemic) will be checked at regular intervals during your pregnancy.

How will my baby be born?

Towards the end of your pregnancy, once placenta praevia is confirmed, you will have the opportunity to discuss your birthing options with your healthcare professional.

Your healthcare team will discuss with you the safest way for you to give birth based on your own individual circumstances.

If the edge of your placenta is less than 20 mm from the entrance to the cervix on your scan at 36 weeks, a caesarean will be the safest way for you to give birth. If the placenta is further than 20 mm from your cervix you can choose to have a vaginal birth. Unless you have heavy or recurrent bleeding, your caesarean will usually take place between 36 and 37 weeks. If you have had vaginal bleeding during your pregnancy, your caesarean may need to take place earlier than this.

If you are having a caesarean, a senior obstetrician and anaesthetist should be present at the time of birth and you should give birth in a hospital with facilities available to care for you if you experience heavy bleeding. This is particularly important if you have had one or more caesareans before. Your anaesthetist will discuss the options for anaesthesia if you are having a caesarean birth. During your caesarean, you may have heavier than average bleeding. There are many different things that your doctors can do to stop the bleeding, but if it continues and cannot be controlled in other ways, a hysterectomy (removal of your uterus) may be needed.

If you have heavy bleeding before your planned date of delivery, you may be advised to have your baby earlier than expected.

If you have placenta praevia, you are more likely to need a blood transfusion, particularly if you have very heavy bleeding. During a planned caesarean, blood should be available for you if needed. If you feel that you could never accept a blood transfusion, you should explain this to your healthcare team as early in your pregnancy as possible. This will give you the opportunity to ask questions and to discuss alternative plans as necessary.

What is placenta accreta?

Placenta accreta is a rare (between 1 in 300 and 1 in 2000) complication of pregnancy. This is when the placenta grows into the muscle of the uterus, making delivery of the placenta at the time of birth very difficult.

Placenta accreta is more common in women with placenta praevia who have previously had one or more caesarean births, but it can also occur if you have had other surgery to your uterus, or if you have a uterine abnormality such as fibroids or a bicornuate uterus. It is more common if you are older (over 35 years old) or if you have had fertility treatment, especially in vitro fertilisation (IVF).

Placenta accreta may be suspected during the ultrasound scans that you will have in your pregnancy. Additional tests such as magnetic resonance imaging (MRI) scans may help with the diagnosis, but your doctor will only be able to confirm that you have this condition at the time of your caesarean. If you have placenta accreta, there may be bleeding when an attempt is made to deliver your placenta after your baby has been born. The bleeding can be heavy and you may require a hysterectomy to stop the bleeding. There is a risk of injury to your bladder during the delivery of your placenta, which depends on your individual circumstances.

If placenta accreta is suspected before your baby is born, your doctor will discuss your options and the extra care that you will need at the time of birth. It may be planned for you to have your baby early, between 35 and 37 weeks of pregnancy, depending on your individual circumstances. You will need to have your baby in a hospital with specialist facilities available and a team with experience of caring for women with this condition. Your team may discuss with you the option of a planned caesarean hysterectomy (removal of your uterus with the placenta still in place, straight after your baby is born) if placenta accreta is confirmed at delivery.

It may be possible to leave the placenta in place after birth, to allow it to absorb over several weeks or months. Unfortunately, this type of treatment is often not successful and can be associated with very serious complications such as bleeding and infection. Some women will still go on to need a hysterectomy.

Your healthcare team will discuss a specific plan of care with you depending on your individual situation.

What is vasa praevia?

Vasa praevia is a very rare condition affecting between 1 in 1200 and 1 in 5000 pregnancies. It is where blood vessels travelling from your baby to your placenta, unprotected by placental tissue or the umbilical cord, pass near to the cervix. These blood vessels are very delicate and can tear when you are in labour or when your waters break. This is very dangerous as the blood that is lost comes from your baby.

If your healthcare professional suspects that you may have vasa praevia when you go into labour or when your waters break, your baby needs to be born urgently. Usually an emergency caesarean would be recommended. If your placenta is low, if you are carrying more than one baby or if your placenta or umbilical cord develops in an unusual manner, you are at higher risk of having vasa praevia. You may be offered an extra scan during your pregnancy to check whether you have this condition.

If you are found to have vasa praevia before you go into labour, you should be offered a planned caesarean at around 34–36 weeks of pregnancy. As this would mean that your baby is being born preterm, you would be offered a course of steroids (two injections, 12–24 hours apart) to help mature your baby’s lungs and other organs.

Reference- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/placenta-praevia-placenta-accreta-and-vasa-praevia/

What is pre-eclampsia?

Pre-eclampsia is a condition that typically occurs after 20 weeks of pregnancy. It is a combination of:

• raised blood pressure (hypertension)

• protein in your urine (proteinuria).

The exact cause of pre-eclampsia is not understood. Often there are no symptoms and it may be picked up at your routine antenatal appointments when you have your blood pressure checked and urine tested. This is why you are asked to bring a urine sample to your appointments.

Why do I need to know if I have pre-eclampsia?

Pre-eclampsia is common, affecting between two and eight in 100 women during pregnancy. It is usually mild and normally has very little effect on pregnancy. However, it is important to know if you have the condition because, in a small number of cases, it can develop into a more serious illness. Severe pre-eclampsia can be life-threatening for both mother and baby.

Around one in 200 women (0.5%) develop severe pre-eclampsia during pregnancy. The symptoms tend to occur later on in pregnancy but can also occur for the first time only after birth.

The symptoms of severe pre-eclampsia include:

- Severe headache that doesn’t go away with simple painkillers

-Problems with vision, such as blurring or flashing before the eyes

-Severe pain just below the ribs

-Heartburn that doesn’t go away with antacids

-Rapidly increasing swelling of the face, hands or feet

-Feeling very unwell.

These symptoms are serious and you should seek medical help immediately. If in doubt, contact the maternity unit at your local hospital.

In severe pre-eclampsia, other organs, such as the liver or kidneys, can sometimes become affected and there can be problems with blood clotting.

Severe pre-eclampsia may progress to convulsions or seizures before or just after the baby’s birth. These seizures are called eclamptic fits and are rare, occurring in only one in 4000 pregnancies.

How may pre-eclampsia affect my baby?

Pre-eclampsia affects the development of the placenta (afterbirth), which may prevent your baby growing as it should. There may also be less fluid around your baby in the womb.

If the placenta is severely affected, your baby may become very unwell. In some cases, the baby may even die in the womb. Monitoring aims to pick up those babies who are most at risk.

Who is at risk of pre-eclampsia and can it be prevented?

Pre-eclampsia can occur in any pregnancy but you are at higher risk if:

• your blood pressure was high before you became pregnant

• your blood pressure was high in a previous pregnancy

• you have a medical problem such as kidney problems or diabetes or a condition that affects the immune system, such as lupus.

If any of these apply to you, you should be advised to take low-dose aspirin (75 mg) once a day from 12 weeks of pregnancy, to reduce your risk.

The importance of other factors is less clear-cut, but you are more likely to develop pre-eclampsia if more than one of the following applies:

This is your first pregnancy

You are aged 40 or over

Your last pregnancy was more than 10 years ago

You are very overweight – a BMI (body mass index) of 35 or more

Your mother or sister had pre-eclampsia during pregnancy

You are carrying more than one baby.

If you have more than one of these risk factors, you may also be advised to take low-dose aspirin once a day from 12 weeks of pregnancy.

How is pre-eclampsia monitored?

If you are diagnosed with pre-eclampsia, you should attend hospital for assessment. While you are at the hospital, your blood pressure will be measured regularly and you may be offered medication to help lower it. Your urine will be tested to measure the amount of protein it contains and you will also have blood tests done. Your baby’s heart rate will be monitored and you may have ultrasound scans to measure your baby’s growth and wellbeing.

What happens next?

You will continue to be monitored closely to check that you can safely carry on with your pregnancy. This may be done on an outpatient basis if you have mild pre-eclampsia. You are likely to be advised to have your baby at about 37 weeks of pregnancy, or earlier if there are concerns about you or your baby. This may mean you will need to have labour induced or, if you are having a caesarean section, to have it earlier than planned.

What happens if I develop severe pre-eclampsia?

If you develop severe pre-eclampsia, you will be cared for by a specialist team. The only way to prevent serious complications is for your baby to be born. Each pregnancy is unique and the exact timing will depend on your own situation. This should be discussed with you. There may be enough time to induce your labour. In some cases, the birth will need to be by caesarean section.

Treatment includes medication (either tablets or via a drip) to lower and control your blood pressure. You will also be given medication to prevent eclamptic fits if your baby is expected to be born within the next 24 hours or if you have experienced an eclamptic fit. You will be closely monitored on the labour ward. In more serious cases, you may need to be admitted to an intensive care or high dependency unit.

What happens after the birth?

Pre-eclampsia usually goes away after birth. However, if you have severe pre-eclampsia, complications may still occur within the first few days and so you will continue to be monitored closely. You may need to continue taking medication to lower your blood pressure. If your baby has been born early or is smaller than expected, he or she may need to be monitored. There is no reason why you should not breastfeed should you wish to do so.

You may need to stay in hospital for several days. When you go home, you will be advised on how often to get your blood pressure checked and for how long to take your medication.

You should have a follow-up with your GP 6–8 weeks after birth for a final blood pressure and urine check. If you had severe pre-eclampsia or eclampsia, you should have a postnatal appointment with your obstetrician to discuss the condition and what happened. If you are still on medication to treat your blood pressure 6 weeks after the birth, or there is still protein in your urine on testing, you may be referred to a specialist.

Will I get pre-eclampsia in a future pregnancy?

Overall, one in six women who have had pre-eclampsia will get it again in a future pregnancy.

You should be given information about the chance, in your individual situation, of getting pre-eclampsia in a future pregnancy and about any additional care that you may need. It is advisable to contact your midwife as early as possible once you know you are pregnant again.

Reference- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/pre-eclampsia-patient-information-leaflet/

First trimester

Week 1-2 - In weeks 1 and 2 of pregnancy — the week of and immediately following your last menstrual period  your body is working hard to gear up for the event that paves the way for baby: ovulation. Right now, your uterus has begun preparing for the arrival of a fertilized egg, though you won't know for sure if that egg has successfully matched up with sperm until next month.

During the past few days, an increase in oestrogen and progesterone prompted the lining of your uterus to thicken to support a fertilized egg. At the same time, in your ovaries, eggs were ripening in fluid-filled sacs called follicles. Once you ovulate, an egg erupts from its follicle and is swept from your ovary into a fallopian tube. (Ovulation doesn't necessarily occur right in the middle of your cycle. For example, it could happen any time between days 9 and 21 for women with a 28-day cycle.)

During the next 24 hours, that egg will be fertilized if one of the nearly 250 million sperm in an ejaculation manages to swim from your vagina through your cervix, up through your uterus into the fallopian tube and penetrate the egg. About 400 sperm survive the 10-hour journey to the egg, but it's usually only one that succeeds in burrowing through its outer membrane. During the next 10 to 30 hours, the sperm's nucleus merges with the eggs and they combine their genetic material. If the sperm carries a Y chromosome, your baby will be a boy. If an X chromosome, you'll be carrying a girl. The fertilized egg is called a zygote

The egg takes three or four days to travel from the fallopian tube to your uterus, dividing into 100 or more identical cells along the way. Once it enters the uterus, it's called a blastocyst. About 6 days after fertilization, the blastocyst attaches to the lining of the uterus, usually near the top. This process, called implantation, is completed by day 9 or 10. The placenta produces several hormones that help maintain the pregnancy.

Week 3 - Your developing baby is a tiny ball of several hundred cells that are multiplying and burrowing into the lining of your uterus. The cells in the middle will become the embryo. The cells on the outside will become the placenta, the pancake-shaped organ that delivers oxygen and nutrients to your baby and carries away waste.

The cells that will become the placenta are pumping out the pregnancy hormone hCG (human chorionic gonadotropin). It tells your ovaries to stop releasing eggs and keep producing progesterone, which prevents your uterus from shedding its lining – and its tiny passenger. Once there's enough hCG in your urine, you'll get a positive pregnancy test result. Amniotic fluid is beginning to collect within the amniotic sac. This fluid will cushion your baby in the weeks and months ahead. Your little blastocyst is receiving oxygen and nutrients (and discarding waste) through a primitive circulation system made up of microscopic tunnels that connect your developing baby to the blood vessels in your uterine wall. The placenta will eventually take over this task.

Symptoms - Some women feel pregnant even before the test is positive, but most don’t notice anything yet. If you have symptoms this week some of them may feel like PMS (Bloating and cramping, Sore breasts, Spotting, Basal body temperature stays high)

Week 4 -Your baby is about the size of a poppy seed. Your embryo consists of two layers called the hypoblast and the epiblast, from which all of your baby's organs will begin to develop over the next six weeks. This is the time when she'll be most vulnerable to anything that might interfere with her development. Your embryo's outer cells are tunneling into the lining of your uterus. Spaces form within this layer for your blood to flow into so that you'll be able to provide nutrients and oxygen to your growing baby. The amniotic sac contains amniotic fluid and will enclose your baby and cushion her as she grows. The yolk sac will produce your baby's first red blood cells and blood vessels.

Symptoms- Don’t worry if you don’t feel anything yet this week. Most early pregnancy symptoms don’t start until about 6 weeks.

-Breast tenderness can be one of the earliest signs of pregnancy. It usually starts around 4 to 6 weeks and lasts through the first trimester.

-For many women, exhaustion is one of the first signs of pregnancy. But other women hardly slow down at all.

-Morning sickness can happen at any time of day. It usually starts around 6 weeks of pregnancy but can begin as early as 4 weeks.

-Cramping can happen

Week 5 - Your baby is about the size of a sesame seed! Deep in your uterus your tiny embryo is growing at a furious pace and looks more like a tadpole than a human. Your embryo is now made up of three layers – the ectoderm, the mesoderm, and the endoderm – which will later form all of the organs and tissues.

Your baby's brain, spinal cord, and nerves form from the neural tube, which is starting to develop from the top layer – the ectoderm. This layer will also give rise to skin, hair, nails, mammary and sweat glands, and tooth enamel.

The heart and circulatory system begin to form in the middle layer, or mesoderm. (This week, in fact, the tiny heart begins to beat and pump blood.) The mesoderm will also form your baby's muscles, cartilage, bone, and the tissue under the skin.

The third layer, or endoderm, will become the lungs, intestines, and early urinary system, as well as the thyroid, liver, and pancreas. In the meantime, the primitive placenta and umbilical cord, which deliver nourishment and oxygen to your baby, are already on the job.

Week 6 - Your baby is the size of a lentil! Your baby's heart is beating almost twice as fast as yours. You'll see it if you have an ultrasound at 8 weeks. Or hear it with a Doppler at 10 to 12 weeks There are dark spots where your baby's eyes and nostrils are starting to form. Emerging ears are marked by small depressions on the sides of the head. Inside the tiny mouth, the tongue and vocal cords are beginning to develop. Your baby's arms and legs begin as tiny paddles. The backbone extends into a small tail that will disappear within a few weeks.

Symptoms - Early pregnancy symptoms tend to start this week -

Nausea or vomiting, frequent urge to pee, Mood swings, Tender or swollen breasts, Fatigue

Week 7 - Your baby is the size of a blueberry! The main parts of the eye that allow your baby to see – the cornea, iris, pupil, lens, and retina – start developing this week, and they're almost fully formed just a few weeks later. Your baby's stomach and esophagus start to form. The esophagus is the tube that moves food from your baby's mouth to her stomach. Your baby's liver and pancreas are starting to develop this week.

Symptoms - Heightened sense of smell, Food aversions, Frequent urge to urinate, Mood swings

Week 8 - Your baby is the size of a kidney bean! The heart rate can be heard as early as 8 weeks on a Doppler in the doctor's office, but more likely closer to 12 weeks. Your baby has fingers and toes now – and they're webbed! Her hands are flexed at the wrist and meet over her heart. She now has knees, and her legs may be long enough that her feet meet in front of her body.

Your baby's respiratory system is forming. Breathing tubes extend from her throat to the branches of her developing lungs. A network of nerves is spreading through the body making connections not only with each other but also with muscles and other tissues, as well as organs like the eyes and ears. At 8 weeks of pregnancy, the placenta and fetus have been developing for 6 weeks. The placenta forms tiny hairlike projections (villi) that extend into the wall of the uterus. A thin membrane separates the embryo's blood from the mother's blood that flows through the space surrounding the villi. This allows materials to be exchanged between the blood of the mother and that of the embryo and prevents the mother's immune system from attacking the embryo because the mother's antibodies are too large to pass through the membrane. The embryo floats in amniotic fluid, which is contained in an amniotic sac. The amniotic sac is strong and resilient.

Symptoms - Growing breasts, Abdominal bloating

Week 9 - Your baby is about the size of a grape. Ten tiny tooth buds are developing within each band of gums. (They'll transform into the 20 "baby teeth" that eventually fall out during childhood.) Next week, the teeth start to harden and connect to the jaw. The four chambers of  your baby's heart have formed. The placenta is developed enough now to take over most of the critical job of producing hormones but will only fully develop between 18 and 20 weeks.

Symptoms - Food cravings, Food aversions, heightened sense of smell

Week 10 - Your baby is the size of kumquat! Eyelids now cover the eyes – they'll stay fused shut until 27 weeks. Teeth start to harden and connect to the jaw bone. Your baby's forehead temporarily bulges with her developing brain and sits very high on her head, which measures half the length of her body.

Symptoms - A thickening middle, Excess saliva, Vaginal discharge

Week 11 - Your baby is the size of a fig! Your baby is no longer called an embryo. This week is the beginning of the fetal period. All vital organs should be in place, and many have already started to function. By the end of this week, your baby's external genitals will start developing. In a few weeks, you'll be able to see on an ultrasound whether you're having a girl or a boy.

Symptoms - Constipation, heartburn

Week 12 - Your baby is the size of a lime! She is now big enough to fill the entire uterus. Your baby's fingers will soon begin to open and close, her toes will curl, her eye muscles will clench, and mouth will make sucking movements. Your baby has ten fingers and ten toes (no more webbing), and peach-fuzz hair begins to grow on tender skin.

Her intestines, which have grown so fast that they protrude into the umbilical cord, move back into her abdominal cavity now.

Symptoms - Growing uterus- your uterus has grown to the extent that your healthcare provider can now feel the top of it low in your abdomen above your pubic bone.

Worries- Don’t be surprised if you and your partner are feeling stressed out these days. Many pregnant couples worry about their baby’s health and how they will handle the changes ahead. Coping with stress can trigger depression which is common during pregnancy.

Week 13 - Your baby is about the size of a peapod! Your baby has started swallowing amniotic fluid and excreting urine, which she then swallows again, recycling the full volume of fluid every few hours. She's also producing meconium. This black, sticky substance will accumulate in her bowels, and you'll see it in her first dirty diaper. Prints are forming on your baby's tiny fingertips.

Symptoms - Feeling better soon- next week marks the beginning of your second trimester when many women see early pregnancy symptoms such as morning sickness and fatigue subside.

Making colostrum- you can’t feel it but your breasts may have already started making colostrum, the nutrient-rich fluid that feeds your baby for the first few days after birth, before your milk starts to flow.

Cramping- a little bit of pain with cramping in early pregnancy is common. But call your healthcare provider if your pain doesn’t go away after several minutes of rest.

Second Trimester

At the beginning of the second trimester, babies are about 3 1/2 inches long and weigh about 1 1/2 ounces. Tiny, unique fingerprints are now in place, and the heart pumps 25 quarts of blood a day. As the weeks go by, your baby's skeleton starts to harden from rubbery cartilage to bone, and he or she develops the ability to hear. You're likely to feel kicks and flutters soon if you haven't already.

Week 14 - Your baby is about the size of a lemon! From roughly this week the gender can be identified. Your baby can now squint, frown, and grimace. Thanks to brain impulses, her facial muscles are getting a workout as her tiny features form one expression after another. Your baby also starts to make sucking and chewing movements. And if her thumb happens to be near her mouth, she may latch onto it. Her body's growing faster than her head, which now sits upon a more distinct neck. Her arms are growing more in proportion to the rest of his body. (Her legs still have some lengthening to do.). Though you can't feel her tiny punches and kicks yet, your little one's hands and feet are more flexible and active. Fingernails and toenails start to form this week.

Symptoms - Your energy is likely returning, your breasts may be feeling less tender, and your queasiness may have eased by now. If not, hang on – chances are good it will soon be behind you (although an unlucky few will still feel nauseated months from now).

The top of your uterus is a bit above your pubic bone, which may be enough to push your tummy out a tad. Starting to show can be quite a thrill, giving you and your partner visible evidence of the baby you've been waiting for.

About half of pregnant women have swollen, red, tender gums that bleed when flossed or brushed. This gum inflammation is partly caused by hormonal changes that make your gums more sensitive to the bacteria in plaque.

Week 15 - Your baby is about the size of an apple! Your baby's legs are growing longer than her arms now, and she can move all of her joints and limbs. There's not much for your baby to taste at this point, but she is forming taste buds, and nerves begin connecting them to the brain. If you have an ultrasound coming up, you may be able to find out your baby's gender – if you don't know already.

Symptoms - Congestion - If your nose is stuffed up you can probably chalk it up to the combined effect of hormonal changes and increased blood flow to your mucous membranes. This condition is so common there's even a name for it: rhinitis of pregnancy. Nose bleeds- Some pregnant women suffer nosebleeds as a result of increased blood volume and blood vessel expansion in the nose.

Week 16 - Your baby is the size of an avocado! In the next few weeks, your baby will double their weight and add inches to their length. Her legs are much more developed, and her head is more erect. The patterning of your baby's scalp has begun, though their locks aren't recognizable yet. Your baby's heart is now pumping about 25 quarts of blood each day, and this amount will continue to increase as your baby develops.

Symptoms -The top of your uterus is about halfway between your pubic bone and your navel, and the round ligaments that support it are thickening and stretching as it grows. Less nausea, fewer mood swings, and "glowing" skin contribute to an overall sense of well-being. Soon you'll be feeling your baby move. While some women notice "quickening" this early, most don't feel their baby move until 18 weeks or more. (If this is your first baby, you may not feel movements until 20 weeks or so.) The first movements may feel like little flutters, gas bubbles, or even like popcorn popping, but they'll grow stronger and more frequent.

Week 17 - Your baby is about the size of a turnip! Your baby's skeleton is changing from soft cartilage to bone. The umbilical cord – her lifeline to the placenta – is growing stronger and thicker. Sweat glands are starting to develop.

Symptoms - Unsteadiness- Starting to feel a bit off balance? As your belly grows, your center of gravity changes, so you may begin to occasionally feel a little unsteady on your feet. Try to avoid situations with a high risk of falling. Wear low-heeled shoes to reduce your risk of taking a tumble; trauma to your abdomen could be dangerous for you and your baby. Dry eyes- You may also notice your eyes becoming drier. Using over-the-counter lubricating drops may help. If your contact lenses become uncomfortable, try wearing them for shorter stretches of time. If you still have discomfort, switch to glasses until after you give birth.

Week 18

Your baby is about the size of a bell pepper! Your baby's ears are now in their final position, although they're still standing out from their head a bit. In the lungs, the smallest tubes (bronchioles) start to develop at the tips of the branches. At the end of these tiny tubes, respiratory sacs begin to appear. By the time your baby is born, these sacs will become enmeshed with tiny blood vessels and allow oxygenated blood to circulate to all of the body's organs and tissues. If you're having a girl, her uterus and fallopian tubes are formed and in place. If you're having a boy, his genitals are noticeable now, but he may hide them from you during an ultrasound. The placenta is fully formed between 18 to 20 weeks but continues to grow throughout pregnancy. At delivery, it weighs about 1 pound.

Symptoms - Ravenous hunger-

An increase in appetite – and specific food cravings – are pretty common about now. Dizziness- Your cardiovascular system is undergoing dramatic changes, and during this trimester your blood pressure will probably be lower than usual. Don't spring up too fast from a lying or sitting position, or you might feel a little dizzy.

Week 19 - Your baby is about the size of a tomato! Your baby's sensory development is exploding! Her brain is designating specialized areas for smell, taste, hearing, vision, and touch.

Her arms and legs are in proportion to each other and the rest of her body now. A waxy protective coating called the vernix caseosa is forming on your baby's skin to prevent it from pickling in the amniotic fluid.

Symptoms - Lower abdominal pain- Your belly will start growing even faster in the weeks to come. As a result, you may notice some achiness in your lower abdomen or even an occasional brief, stabbing pain on one or both sides – especially when you shift position or at the end of an active day. Most likely, this is round ligament pain. The ligaments that support your uterus are stretching to accommodate its increasing weight. Skin changes- Are the palms of your hands red? It's from the extra estrogen. You may also have patches of darkened skin on your upper lip, cheeks, and forehead – that's called chloasma, or the "mask of pregnancy." Extra pigment may cause some darkening of your nipples, freckles, scars, underarms, inner thighs, and vulva. That darkened line running from your belly button to your pubic bone is called the linea nigra, or "dark line."

Week 20 - Congratulations! You're halfway through your pregnancy Your baby is about the size of a banana! No, your baby didn't really grow 4 inches since last week. He's just being measured differently. For the first half of pregnancy (when a baby's legs are curled up against his torso), measurements are taken from the top of her head to her bottom, or from "crown to rump." But starting at 20 weeks, she's measured from head to toe.

Many of your baby's taste buds can now transmit taste signals to her brain, and he's swallowing molecules of the food you eat that have passed through your blood into your amniotic fluid. Researchers aren't sure if he can taste these molecules, but some research indicates that what you eat during pregnancy can influence the foods your baby will prefer later.

Symptoms - Weight gain- Feeling cramped? It's no wonder: The top of your uterus is now about level with your belly button, and you may have gained around 10 pounds. Expect to gain another pound or so each week from now on. If you started your pregnancy underweight, you may need to gain a bit more; if you were overweight, a bit less. See if you're on track. Itchy skin- You may feel especially itchy around your belly and breasts as your skin stretches to accommodate your growing baby. Use cold packs and slather on moisturizer for relief. (Scratching can make it worse!) Get more tips on easing the itch, and find out when it could be the sign of a problem. Restless sleep- Short on sleep? Do you shift around all night trying to find a comfortable sleeping position? These suggestions may help: Lie on your side, with your knees bent and a pillow between your legs. For extra comfort and support, arrange other pillows under your belly and behind your back. You could also try using a contoured maternity body pillow.

Week 21 - Your baby is about the size of a carrot! You may soon feel like she's practicing martial arts as her initial fluttering movements turn into full-fledged kicks and nudges. You may also discover a pattern to her activity as you get to know her better. Your baby's eyebrows have grown in. Behind her eyelids, her irises still lack pigment.

Symptoms - Varicose veins- You're more prone to varicose veins now. As your pregnancy progresses, there's increasing pressure on the veins in your legs. Higher progesterone levels, which may cause the walls of your veins to relax, can make the problem worse. Spider veins- You may also notice so-called spider veins (a group of tiny blood vessels near the surface of your skin), particularly on your ankles, legs, or face. They may have a spider- or sunburst-like pattern with little branches radiating from the center, they may look like the branches of a tree, or they may be a group of separate thin lines with no particular pattern.

Week 22 - Your baby is about the size of a spaghetti squash! Your baby may be able to hear sounds faintly from inside your body, such as your breathing, your heartbeat, and your digestion. These sounds will grow louder as your baby's hearing improves.

If you could see inside your womb, you'd be able to spot the fine hair (lanugo) that covers his body and the deep wrinkles on her skin, which he'll sport until he adds a padding of fat to fill them in.

Symptoms - Acne- Increased oil production may cause you to develop acne. Stretch marks- You may start to notice stretch marks on your abdomen as it expands to accommodate your growing baby. These small streaks of differently textured skin can range from pink to dark brown (depending on your skin color). Although they most commonly appear on your tummy, stretch marks may also show up on your buttocks, thighs, hips, and breasts.

Start doing Kegel exercises Kegels can help prevent urine leaks during and after pregnancy, keep hemorrhoids at bay, and improve the muscle tone of your vagina, making sex more enjoyable.

Week 23 - Your baby is the size of a large mango! Your baby can hear sounds from outside your body now, such as a dog barking. At first, your baby's ears can hear only low-pitched sounds, meaning she can hear male voices more clearly than female voices. With her sense of movement well developed by now, your baby can feel you dance. And you may be able to see her squirm underneath your clothes. The wave-like movements that propel food along the digestive tract (peristalsis) begin. As with swallowing, it's just practice for your baby's system at this point since there's no actual food to move.

Symptoms - Swollen ankles- You may notice that your ankles and feet start to swell a bit in the coming weeks or months, especially at the end of the day or during the heat of summer. Sluggish circulation in your legs – coupled with changes in your blood chemistry that may cause some water retention – may result in swelling, also known as edema. Swollen hands and face- While a certain amount of edema in your lower extremities is normal during pregnancy, excessive swelling may be a sign of a serious condition called preeclampsia. Be sure to call your midwife or doctor if you have severe or sudden swelling of your feet or ankles, more than slight swelling of your hands, swelling in your face, or puffiness around your eyes.

Week 24 - Your baby is the about the size of an ear of corn! Respiratory sacs at the tips of the smallest branches of your baby's lungs are growing and multiplying, adding more surface area for the exchange of oxygen and carbon dioxide once your baby is born. Your baby cuts a pretty lean figure at this point, but her body is filling out proportionally, and soon she'll start to plump up. Her skin is still thin and translucent, but that will start to change as well.

From this week the fetus has a chance of survival outside of the uterus.

Symptoms - Growing uterus- The top of your uterus has risen above your belly button. It's now about the size of a soccer ball.

Worries are normal- It's normal to worry a bit now and then, but try to focus on taking care of yourself and your baby – and have faith that you're well equipped for what's ahead.

Know the signs of preterm labor-

If you don't already know how to spot the signs of preterm labor, now's the time to learn. Contact your doctor or midwife immediately if you notice any of them.

Week 25 - Your baby is about the size of a rutabaga! Your baby will soon exchange her long, lean look for some baby fat. As she does, her wrinkled skin will begin to smooth out, and she'll start to look more and more like a newborn. She's also growing more hair – and if you could see it, you'd be able to discern its colour and texture

Symptoms - Thicker hair- Your locks may look fuller and more lustrous than ever. It's not that you're growing more hair, but thanks to hormonal changes the hair that you'd normally shed is sticking around longer than usual. Enjoy the fullness while you can – the extra hair will fall out after you give birth.

Pale skin- Pale skin is a sign that you may have iron-deficiency anemia. It's pretty common during pregnancy, so you'll be tested for it around this time.

Week 26 - Your baby is about the size of a scallion! Your baby may now be able to hear your voice. She can hear a broader range of sound and can respond with changes in heartbeat, breathing, and movement. He has started to inhale and exhale small amounts of amniotic fluid, which is essential for the development of the lungs. These so-called breathing movements are also good practice for when she's born and takes that first gulp of air.

If you're having a boy, his testicles have begun to descend into his scrotum – a trip that will take about two to three months.

Symptoms - Lower-back pain- If your lower back seems a little achy lately, you can thank both your growing uterus – which shifts your center of gravity, stretches out and weakens your abdominal muscles, and may be pressing on a nerve – as well as hormonal changes that loosen your joints and ligaments.

Know the signs of preeclampsia-

Preeclampsia – a serious condition characterized by high blood pressure – most often shows up after 37 weeks, but it can happen earlier, so it's important to be aware of the warning signs. Call your healthcare provider if you have swelling in your face or puffiness around your eyes, more than slight swelling of your hands, excessive or sudden swelling of your feet or ankles, or rapid weight gain (more than 4 to 5 pounds in a week).

Week 27 - Your baby is about the size of a cauliflower head! Your baby's eyelids, which have been fused shut, can now open and close, and she may blink in response to light. If you shine a flashlight at your tummy, you may feel her respond with a burst of flutters and wiggles. Chalk up any tiny rhythmic movements you may be feeling to a case of baby hiccups, which may be common from now on. Each episode usually lasts only a few moments, and they don't bother her, so just relax and enjoy the tickle.

Symptoms - Extra body hair- Your facial and body hair may grow faster when you're pregnant, possibly because of an increase in hormones called androgens. Restless legs- Around this time, some women feel an unpleasant "creepy-crawly" sensation in their lower legs and an irresistible urge to move them while trying to relax or sleep. If this sensation is at least temporarily relieved when you move, you may have what's known as restless legs syndrome.

Third Trimester

Babies weigh about 2 1/4 pounds by the start of the third trimester. They can blink their eyes, which now sport lashes. And their wrinkled skin is starting to smooth out as they put on baby fat. They're also developing fingernails, toenails, and real hair (or at least some peach fuzz), and adding billions of neurons to their brain. Your blossoming baby will spend his or her final weeks in utero putting on weight. At full term, the average baby is more than 19 inches long and weighs nearly 7 pounds.

Week 28 - Your baby is about the size of a large eggplant! Your baby's brain is adding billions of new nerve cells. Her senses of hearing, smell, and touch are developed and functional. During the third trimester, the brain triples in weight, and the cerebrum develops deep, convoluted grooves that provide extra surface area without taking up more room in the skull. A protective covering of myelin begins to form around her nerves during this trimester, a process that will continue for a year after he's born.

Symptoms Baby kicks- Your baby's very active now. Your healthcare provider may ask you to spend some time each day counting kicks and will give you specific instructions on how to do this. Leg cramping- Leg cramps are more common at night but can also happen during the day. Your legs are carrying extra weight, and your expanding uterus is putting pressure on the veins that return blood from your legs to your heart as well as on the nerves leading from your trunk to your legs. Nail changes- Some pregnant women develop harder nails, but others find that their nails are softer or more brittle.

Week 29 - Your baby is the size of a butternut squash! Your baby's bones are soaking up lots of calcium as they harden, so be sure to drink your milk (or find another good source of calcium, such as cheese, yogurt, or enriched orange juice). About 250 milligrams of calcium are deposited in your baby's skeleton each day.

The respiratory sacs at the tips of your baby's lung branches have begun making a substance called surfactant, which keeps them inflated when there's not a lot of air in the lungs (when exhaling, for example). While her lungs are still immature, they would be capable of functioning – with a lot of medical help – if she were to be born now.

Symptoms - Gas and bloating- The pregnancy hormone progesterone relaxes smooth muscle tissue throughout your body, including your gastrointestinal tract. This relaxation, coupled with the crowding in your abdomen, slows digestion. Sluggish digestion can cause gas and heartburn – especially after a big meal – and contribute to constipation. Hemorrhoids- Your growing uterus may also be contributing to hemorrhoids. These swollen blood vessels in your rectal area are common during pregnancy. Fortunately, they usually clear up in the weeks after giving birth. Lightheadedness- Some women get something called "supine hypotensive syndrome" during pregnancy. This happens when lying flat on your back causes a change in heart rate and blood pressure that makes you feel dizzy until you change position. You might also notice that you feel lightheaded if you stand up too quickly.

Week 30 - Your baby is about the size of a large cabbage head! About a pint and a half of amniotic fluid surrounds your baby. The amount will peak around 34 to 36 weeks. Your baby may now be able to see dim shapes. Her pupils are able to constrict and expand, allowing her eyes to let in more or less light

Symptoms - Fatigue- You may be feeling a little tired these days, especially if you're having trouble sleeping. Growing feet- The relaxation of your ligaments can cause your feet to spread permanently, so you may have to invest in some new shoes in a bigger size. Mood swings- The combination of uncomfortable symptoms and hormonal changes can result in a return of mood swings. It's normal to worry about what your labor will be like or whether you'll be a good parent. But if you can't shake the blues or feel increasingly irritable or agitated, you may be among the 1 in 10 expectant women who battle depression during pregnancy. Also let your healthcare provider know if you're frequently nervous or anxious.

Week 31 - Your baby is about the size of a coconut! She can turn her head from side to side, and her arms, legs, and body are beginning to plump up as needed fat accumulates underneath her skin. Your baby's probably moving a lot, so you may have trouble sleeping with all the kicks and somersaults keeping you up. Take comfort: All this moving is a sign that your baby is active and healthy.

Symptoms - Braxton Hicks contractions- Have you noticed the muscles in your uterus tightening now and then? Many women feel these random contractions – called Braxton Hicks contractions – in the second half of pregnancy. Often lasting about 30 seconds, they're irregular, and at this point, should be infrequent and painless. Leaky breasts- You may have noticed some leaking of colostrum, or "premilk," from your breasts lately. If so, try tucking some nursing pads into your bra to protect your clothes. (If not, it's nothing to worry about. Your breasts are making colostrum even if you don't see any.)

Week 32 - Your baby is about the size of a jicama! Your baby can focus on large objects that are not too far away, and this ability to focus will stay that way until birth. You're gaining about a pound a week, and roughly half of that goes right to your baby. She'll gain a third to half of her birth weight during the next seven weeks as she fattens up for survival outside the womb. Her toenails and fingernails have grown in, along with real hair (or at least respectable peach fuzz).

Symptoms - Shortness of breath- To accommodate your and your baby's growing needs, your blood volume has increased 40 to 50 percent since you got pregnant. And with your uterus pushing up near your diaphragm and crowding your stomach, the consequences may be shortness of breath and heartburn. Lower-back pain- You may have lower-back pain as your pregnancy advances. If you do, let your doctor or midwife know right away, especially if you haven't had back pain before, since it can be a sign of preterm labor. Baby movement- Keep monitoring your baby's kicks, and let your healthcare provider know immediately if you notice a decrease. Though your baby's quarters are getting cozy, he should still be as active as before.

Week 33 - Your baby is about the size of a pineapple. The bones in your baby's skull aren't fused together, which allows them to move and slightly overlap, making it easier for her to fit through the birth canal. (The pressure on the head during birth is so intense that many babies are born with a cone-head-like appearance.) These bones don't entirely fuse until early adulthood, so they can grow as the brain and other tissue expands during infancy and childhood.

Your baby is rapidly losing that wrinkled, alien look, and her skin is less red and transparent. It's becoming soft and smooth as she plumps up in preparation for birth. It's getting snug in your womb, so your baby isn't doing as many somersaults, but the amount of kicking should remain about the same.

Symptoms - Trouble sleeping- Finding an easy position to sit in – let alone sleep in – is becoming more of a challenge. Wrist pain-You may be feeling some achiness and even numbness in your fingers, wrists, and hands. Like many other tissues in your body, those in your wrist can retain fluid, which can increase pressure in the carpal tunnel, a bony canal in your wrist. Increased libido- You may need to make some adjustments, but for most women, sex during pregnancy is fine right up until their water breaks or their labour starts.

Week 34 - Your baby is about the size of a cantaloupe! Your baby's fat layers – which will help regulate his body temperature once she's born – are filling out, making her rounder. If you've been nervous about preterm labor, you'll be happy to know that babies born between 34 and 37 weeks who have no other health problems generally do fine. They may need a short stay in the neonatal nursery and may have a few short-term health issues, but in the long run they usually do as well as full-term babies.

Symptoms - Fatigue- By this week, fatigue has probably set in again, though maybe not with the same coma-like intensity of your first trimester. Your tiredness is perfectly understandable, given the physical strain you're under and the restless nights of frequent pee breaks and tossing and turning while trying to get comfortable. Dizziness- If you've been sitting or lying down for a long time, don't jump up too quickly. Blood can pool in your feet and legs, causing a temporary drop in your blood pressure when you get up that can make you feel dizzy. Itchy rash- If you notice itchy red bumps or welts on your belly, and possibly your thighs and buttocks as well, you may have a condition called pruritic urticarial papules and plaques of pregnancy (PUPPP for short). Call your caregiver if you feel intense itchiness all over your body, even if you don't have a rash. It could signal a liver problem.

Week 35 - Your baby is about the size of a honeydew melon. Most babies have settled into a head-down position by this point. By this time, you baby is floating in about a quart of amniotic fluid. It will now gradually decrease until you give birth. Her kidneys are fully developed now, and her liver can process some waste products. Most of her basic physical development is now complete. She'll spend the next few weeks putting on weight

Symptoms - Heartburn and bloating- Your uterus now reaches up under your rib cage. Your ballooning uterus is crowding your other internal organs too, which is why you probably have to pee more often and may be dealing with heartburn and other gastrointestinal distress. Clumsiness- You might feel clumsier than normal, which is perfectly understandable. Not only are you heavier, the concentration of weight in your pregnant belly causes a shift in your center of gravity. Plus, thanks to hormonal changes, your ligaments are more lax, so your joints are looser, which may also contribute to your balance being a bit off.

Week 36 - Your baby is about the size of a head of romaine lettuce Your breathing may become easier as the baby starts to descend towards the birth canal. Weight gain accelerates-Your baby is still packing on the pounds – at the rate of about an ounce a day. Your baby's shedding most of her downy covering of hair (lanugo), as well as the waxy substance (vernix caseosa) that protected her skin during her long amniotic bath. He swallows both of these substances, along with other secretions, resulting in a blackish mixture called meconium that will form the contents of her first bowel movements.

Most likely your baby is already head-down. But if not, your caregiver may suggest scheduling an external cephalic version in which pressure is applied to your abdomen to try to manipulate your baby into a head-down position.

Symptoms - Decreased appetite- Now that your baby is taking up so much room, you may have trouble eating a normal-size meal. Smaller, more frequent meals are often easier to handle at this point. Breathing easier- You may have an easier time breathing when your baby starts to "drop" down into your pelvis. This process – called lightening – often happens a few weeks before labor if this is your first baby. (If you've given birth before, it probably won't happen before labor starts.) Lower abdominal pressure- If your baby drops, you may feel additional pressure in your lower abdomen, which may make walking increasingly uncomfortable. You'll probably find that you have to pee even more frequently. If your baby is very low, you may feel lots of vaginal pressure and discomfort as well. Some women say it feels as though they're carrying a bowling ball between their legs!

Week 37 - Your baby is about the size of a bunch of Swiss chard Your due date is getting close now, but doctors don't consider your baby "full term" until 39 weeks. Spending the next two weeks in the womb allows your baby's brain and lungs to fully mature. So if you're planning to have a C-section, for example, your doctor will schedule it for no earlier than 39 weeks, unless there's a medical reason to intervene earlier.

Many babies have a full head of hair at birth, with locks from 1/2 inch to 1 1/2 inches long. Of course, some babies sport only peach fuzz. Don't be surprised if your baby's hair isn't the same color as yours. In any case, it may all fall out and grow back a different color.

Symptoms - Braxton Hicks contractions- Braxton Hicks contractions may be coming more frequently now and may last longer and be more uncomfortable. Vaginal discharge or spotting- You might notice an increase in vaginal discharge. If you see some "bloody show" (mucus tinged with a tiny amount of blood) in the toilet or in your undies, labor is probably a few days away – or less. (If you have heavier spotting or bleeding, call your doctor or midwife immediately.) Lots of kicking- Keep monitoring your baby's movements, and let your healthcare provider know immediately if you notice a decrease. Though your baby’s quarters are getting cozy, he should still be as active as before.

Week 38 - Your baby is about the size of a leek. Your baby’s brain is developing deep, convoluted grooves-extra surface area for neurons

Symptoms - Swollen ankles- Some swelling in your feet and ankles is normal during these last weeks, but call your doctor or midwife without delay if you notice excessive or sudden swelling of your feet or ankles, more than slight swelling of your hands, any swelling in your face or puffiness around your eyes, or have a sudden weight gain. These are symptoms of a serious condition called preeclampsia. Trouble sleeping- It may be harder than ever to get comfortable enough to sleep well at night. If you can, take it easy during the day – this may be your last chance to do so for quite a while. Crazy dreams- While you're sleeping, you're likely to have some intense dreams. Anxiety both about labor and about becoming a parent can fuel a lot of strange flights of unconscious fancy.

Week 39 - Your baby is about the size of a watermelon . Your baby is full term this week and waiting to greet the world! Full term is 39 to 40 weeks. Babies born before 37 weeks are preterm, 37 to 38 weeks is early term, 41 weeks is late term, and those born after 42 are post-term. Your baby continues to build a layer of fat to help control her body temperature after birth, but it's likely that your baby already measures about 20 inches and weighs a bit over 7 pounds. (Boys tend to be slightly heavier than girls.)

Symptoms - Kicking- Keep paying attention to your baby's movements. Let your doctor or midwife know right away if they seem to decrease. Your baby should remain active right up to delivery, and a noticeable slowdown in activity could be a sign of a problem. Ripening cervix- At a prenatal checkup, your provider might do an internal exam to see whether your cervix has started ripening: softening, effacing (thinning out), and dilating (opening). But even with this information, there's still no way to predict exactly when your baby is coming. Leaking fluid- Call your provider if you think your water may have broken. Sometimes there's a big gush of fluid, but sometimes there's only a small gush or a slow leak. (Don't try to make the diagnosis yourself. Call even if you only suspect you have a leak.) If your water breaks but contractions don't start soon, you'll be induced.

Week 40 - Your baby is about the size of a small pumpkin. Babies of all ethnicities are born with reddish-purple skin that changes to pinkish-red in a day or so. The pink tint comes from the red blood vessels that are visible through your baby's still-thin skin. Because your baby's blood circulation is still maturing, her hands and feet may be bluish for a few days. Over the next six months, your baby's skin will develop its permanent color.

Symptoms - After months of anticipation, your due date rolls around, and ... you're still pregnant. It's a frustrating but common situation. You may not be as late as you think, especially if you're relying solely on a due date calculated from the day of your last period. (That's because sometimes women ovulate later than expected.) But even with reliable calculations, some women have prolonged pregnancies for no apparent reason. Ripening cervix- Your healthcare provider will check your cervix to see if it's "ripening." Its position, how soft it is, how effaced (thinned out) it is, and how dilated (open) it is can all affect when and how your labor is induced. If you don't go into labor on your own, you'll be induced, usually sometime between 41 and 42 weeks.

40 weeks + - For safety reasons, your doctor or midwife will talk with you about inducing labor if your baby isn't born in the next week – or earlier if there are any problems. Most providers won't let you wait more than two weeks past your due date to give birth because it puts you and your baby at increased risk for complications.

References-https://www.babycenter.com/32-weeks-pregnant

https://www.msdmanuals.com/home/women-s-health-issues/normal-pregnancy/stages-of-development-of-the-fetus

Labor is a natural process. Here's what to expect during the three stages of labor and birth — and what you can do to promote comfort.

Labour is a unique experience. Sometimes it's over in a matter of hours. In other cases, labour tests a mother's physical and emotional stamina. You won't know how labor and childbirth will unfold until it happens. However, you can prepare by understanding the typical sequence of events.

Stage 1: Early labor and active labor

Cervical effacement and dilation

The first stage of labour and birth occurs when you begin to feel persistent contractions. These contractions become stronger, more regular and more frequent over time. They cause the cervix to open (dilate) and soften as well as shorten and thin (efface) to allow your baby to move into the birth canal.

The first stage is the longest of the three stages. It's actually divided into two phases — early labour and active labour.

Early labor

During early labour, your cervix dilates and effaces. You'll likely feel mild, irregular contractions.

As your cervix begins to open, you might notice a clear pink or slightly bloody discharge from your vagina. This is likely the mucus plug that blocks the cervical opening during pregnancy.

How long will it lasts?

Early labour is unpredictable. For first-time moms, the average length varies from hours to days. It's often shorter for subsequent deliveries.

What you can do?

For many women, early labor isn't particularly uncomfortable, but contractions may be more intense for some. Try to stay relaxed.

To promote comfort during early labour:

• Go for a walk

• Take a shower or bath

• Listen to relaxing music

• Try breathing or relaxation techniques taught in childbirth class

• Change positions

If you're having an uncomplicated pregnancy, you may spend most of your early labor at home until your contractions start to increase in frequency and intensity. Your health care provider will instruct you on when to leave for the hospital or birthing center. If your water breaks or you experience significant vaginal bleeding, call your health care provider right away.

Active labor

During active labor, your cervix will dilate from 6 centimeters (cm) to 10 cm. Your contractions will become stronger, closer together and regular. Your legs might cramp, and you might feel nauseated. You might feel your water break — if it hasn't already — and experience increasing pressure in your back. If you haven't headed to your labor and delivery facility yet, now's the time.

Don't be surprised if your initial excitement wanes as labour progresses and your discomfort intensifies. Ask for pain medication or anaesthesia if you want it. Your health care team will partner with you to make the best choice for you and your baby. Remember, you're the only one who can judge your need for pain relief.

How long will it last?

Active labour often lasts 4 to 8 hours or more. On average, your cervix will dilate at approximately 1 cm an hour.

What you can do?

Look to your labour partner and health care team for encouragement and support. Try breathing and relaxation techniques to relieve your discomfort. Use what you learned in childbirth class or ask your health care team for suggestions.

Unless you need to be in a specific position to allow for close monitoring of you and your baby, consider these ways to promote comfort during active labor:

• Change positions

• Roll on a large rubber ball (birthing ball)

• Take a warm shower or bath

• Take a walk, stopping to breathe through contractions

• Have a gentle massage between contractions

If you need to have a Cesarean delivery (C-section), having food in your stomach can lead to complications. If your health care provider thinks you might need a C-section, he or she might recommend small amounts of clear liquids, such as water, ice chips, popsicles and juice, instead of solid foods.

The last part of active labor — often referred to as transition — can be particularly intense and painful. Contractions will come close together and can last 60 to 90 seconds. You'll experience pressure in your lower back and rectum. Tell your health care provider if you feel the urge to push.

If you want to push but you're not fully dilated, your health care provider will ask you to hold back. Pushing too soon could make you tired and cause your cervix to swell, which might delay delivery. Pant or blow your way through the contractions. Transition typically lasts 15 to 60 minutes.

Stage 2: The birth of your baby

It's time! You'll deliver your baby during the second stage of labor.

How long will it last?

It can take from a few minutes to a few hours or more to push your baby into the world. It might take longer for first-time moms and women who've had an epidural.

What you can do?

Push! Your health care provider will ask you to bear down during each contraction or tell you when to push. Or you might be asked to push when you feel the urge to do so. When it's time to push, you may experiment with different positions until you find one that feels best. You can push while squatting, sitting, kneeling — even on your hands and knees.

At some point, you might be asked to push more gently — or not at all. Slowing down gives your vaginal tissues time to stretch rather than tear. To stay motivated, you might ask if you could feel the baby's head between your legs or see it in a mirror.

After your baby's head is delivered, the rest of the baby's body will follow shortly. The baby's airway will be cleared if necessary. If you've had an uncomplicated delivery, your health care provider may wait a few seconds to a few minutes before the umbilical cord is cut. Delaying clamping and cutting the umbilical cord after delivery increases the flow of nutrient-rich blood from the cord and the placenta to the baby. This increases the baby's iron stores and reduces the risk of anemia, promoting healthy development and growth.

Stage 3: Delivery of the placenta

After your baby is born, you'll likely feel a great sense of relief. You might hold the baby in your arms or on your abdomen. Cherish the moment. But a lot is still happening. During the third stage of labor, you will deliver the placenta.

How long it will last?

The placenta is typically delivered in 30 minutes, but the process can last as long as an hour.

What you can do?

Relax! By now your focus has likely shifted to your baby. You might be oblivious to what's going on around you. If you'd like, try breastfeeding your baby.

You'll continue to have mild, less painful contractions that are close together. The contractions help move the placenta into the birth canal. You'll be asked to push gently one more time to deliver the placenta. You might be given medication before or after the placenta is delivered to encourage uterine contractions and minimize bleeding.

Your health care provider will examine the placenta to make sure it's intact. Any remaining fragments must be removed from the uterus to prevent bleeding and infection. If you're interested, ask to see the placenta.

After you deliver the placenta, your uterus will continue to contract to help it return to its normal size. A member of your health care team may massage your abdomen. This may help the uterus contract to decrease bleeding.

Your health care provider will also determine whether you need repair of any tears of your vaginal region. If you don't have anesthesia, you'll receive an injection of local anesthetic in the area to be stitched.

Now what?

Savor this special time with your baby. Your preparation, pain and effort have paid off.

Reference- https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/stages-of-labor/art-20046545

What is the umbilical cord?

The umbilical cord connects the baby from its umbilicus (tummy button) to the placenta inside the womb (uterus). The cord contains blood vessels that carry blood, rich in oxygen and nutrients, to the baby and take waste products away.

After the baby is born, the cord is clamped and cut before the placenta is delivered.

What is an umbilical cord prolapse?

An umbilical cord prolapse happens when the umbilical cord slips down in front of the baby after the waters have broken. The cord can then come through the open cervix (entrance of the womb). It usually happens during labour but can occur when the waters break before labour starts.

It is important to remember that: cord prolapse is uncommon, occurring in between 1 in 200 and 1 in 1000 births. When it does happen, it usually occurs close to the end of pregnancy (after 37 weeks). A prolapsed cord is an emergency situation for the baby.

Why is it an emergency?

When the umbilical cord prolapses, it can be squeezed by the baby or the womb during a contraction. This can reduce the amount of blood flowing through the cord and so reduce the oxygen supply to the baby. The baby may need to be delivered immediately to prevent the lack of oxygen causing long-term harm or death of the baby.

Can a cord prolapse be predicted?

It is not possible to predict a cord prolapse. An ultrasound scan does not show which women will have a cord prolapse, as the cord and the baby change position during the pregnancy.

When is a cord prolapse more likely to happen?

When the baby is engaged (moves down into and completely fills the pelvis), the cord cannot usually prolapse. However, if the baby is not engaged, there is space for the cord to slip past and prolapse.

The chance of cord prolapse is higher if:

- your baby is not in the head-first position, particularly if the baby is breech (bottom first) or transverse (lying sideways)

- your waters break early or you go into labour prematurely

- you have more than one baby (such as twins or triplets)

- you have more water than usual surrounding your baby (polyhydramnios)

- you are having a small baby

- you have a low-lying placenta

- your waters are broken by a doctor or midwife (artificial rupture of membranes or ARM) when the baby’s head is higher up in your pelvis. Your doctor or midwife will usually only break your waters if the baby’s head is low down in your pelvis to try to avoid cord prolapse.

If there is uncertainty, your doctor or midwife might break the waters in an operating theatre. If there is a cord prolapse, you would then be in the best place to have your baby quickly.

Your obstetrician or midwife will give you full information about your own situation if any of these conditions are suspected.

Can a cord prolapse be prevented?

Umbilical cord prolapse cannot be prevented. However, if you are at increased risk, you may be advised to be admitted to hospital – then immediate action can be taken if your waters break or you go into labour.

Your doctor will discuss with you the option of being admitted to hospital from 37 weeks if your baby is lying in a transverse position or is changing position frequently (unstable lie). This is because you are more likely to go into labour after this time.

What are the signs of a cord prolapse?

• You can feel something (the cord) in your vagina

• You can see the cord coming from your vagina

• Your obstetrician or midwife can see or feel the cord in your vagina

• The baby’s heart rate slows (bradycardia) soon after your waters break. This can mean that the baby’s cord has been squeezed and the baby is not getting enough oxygen.

In some women there are no signs.

What should I do if I am at home or at work?

If you think you can feel the cord in your vagina or you can see the cord: Phone 999 for an emergency ambulance immediately

Say that you are pregnant and you think you have a prolapsed umbilical cord

Do not attempt to push the cord back into your vagina

Do not eat or drink anything in case you need an operation.

To reduce the risk of the cord becoming compressed, you will be advised to get onto your knees with your elbows and hands on the floor, and then bend forward (as shown in the diagram below). You should remain in this position until the ambulance or midwife arrives.

The ambulance will take you to the nearest consultant-led maternity hospital or unit that can provide full care. In the ambulance it is safer for you to lie down on your side.

What happens next?

As your baby needs to be born as soon as possible, it is likely that you will be advised to have an emergency caesarean section but a vaginal birth may also be possible. Your doctor or midwife will explain the situation and what needs to be done.

A midwife or doctor may gently insert a hand in your vagina to lift the baby’s head to stop it squeezing the cord. Sometimes a tube (catheter) may be put into your bladder to fill it up with fluid. This will help to hold the baby’s head away from the cord and reduce pressure on the cord. You may be given oxygen through a mask and fluid from a drip.

Emergency caesarean section

If a vaginal birth is not possible quickly, you will be advised to have an emergency caesarean section.

You may need to have a general anaesthetic instead of a spinal or epidural anaesthetic for your caesarean section, so that the baby can be born quickly.

Vaginal birth

If your cervix is fully dilated, you may be able to have a normal birth or an assisted birth (forceps or ventouse) but only if this can happen quickly. A vaginal birth is less likely than a caesarean delivery when you have a cord prolapse.

A doctor or midwife trained in caring for newborn babies should be at the birth.

This situation can feel frightening for you and your partner but the midwives and doctors will explain what is going on. Every effort will be made to keep you fully informed.

What could a cord prolapse mean for my baby?

For most babies, there is no long-term harm from cord prolapse. However, even with the best care, some babies can suffer brain damage if there is a severe lack of oxygen (birth asphyxia). Rarely, a baby can die.

If your baby has come to harm, your baby’s doctor should provide you with full information about how this will affect him or her.

You should also be given information about support groups if you need them.

How will I feel after the birth?

For most babies, the outcome is good. However, the experience can be frightening for you, your partner and your family. Talking to your midwife, obstetrician or GP about what happened can help.

It is important to remember that the chance of having a cord prolapse in your next pregnancy remains very low.

Reference- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/umbilical-cord-prolapse-in-late-pregnancy-patient-information-leaflet/