Category: 36 Weeks

Regular antenatal care is a key component of a healthy pregnancy and provides an opportunity to receive advice, information and support, while engaging in shared decision making about your  pregnancy that is designed to suit your individual pregnancy needs.

KEY POINTS

Antenatal care should be woman centred acknowledging pregnancy is a normal life event for most.

Antenatal care improves pregnancy outcomes for both mother and baby by recognising potential problems in pregnancy early.

The range of routine antenatal care visits range from 7 – 12 throughout the course of pregnancy with the average being around 10 visits.

During each visit your midwife or doctor will discuss screening test and arrange these as required.

It’s good if your partner, a friend or a family member can go with you to antenatal appointments.

Antenatal appointments keep track of your health and your baby’s health and are a great time to ask questions, discuss concerns and get health and lifestyle support throughout your pregnancy.  All antenatal visits require a directed clinical assessment at each visit, with a focus on general wellbeing and early diagnosis of pregnancy complications.

The clinical assessment should include a –

• blood pressure check
• urine dip stick, usually you do this yourself
• weight and how you can achieve a healthy weight gain
• measure your tummy, otherwise called a symphysis-fundal height (SFH) measurement
• listen to your baby’s heartbeat using a handheld doppler, this is always lovely to hear
• and ask about your baby’s movements from approximately 20 weeks of pregnancy onwards.

The midwife or doctor may also

• recommend blood tests, screening tests and other tests when appropriate and talk about test results.
• discuss healthy eating options and foods that aren’t recommended in pregnancy.
• ask about your lifestyle and help you get support for lifestyle changes like quitting smoking, or giving up alcohol or other drugs
• ask about your work and home environment and your family situation and support throughout your pregnancy.

Many women attend antenatal visits every 4-6 weeks until 28 weeks of pregnancy, then every 2-3 weeks until 36 weeks of pregnancy. After this, you’ll probably have weekly or fortnightly visits until birth.  The number and timing of pregnancy appointments could be more or less than this, depending on your health and your baby’s health. For example, if you have a high-risk pregnancy you might have more pregnancy appointments. Your midwife or doctor will talk with you about the appointments you need and why.

Having access to maternity care that is culturally appropriate and personally acceptable is important throughout antenatal care. Your midwife or doctor will ideally provide informed choice, and where possible include you in both the planning and monitoring of your pregnancy care.

Choice in pregnancy care is important and your midwife or doctor will provide access to appropriate information about the benefits and potential risks of each and every option of your pregnancy care as it applies to yours and your baby’s individual needs at each antenatal visit appointment. Be sure to ask questions at each visit too.

 

The position of your baby in your uterus later in pregnancy can have an influence on how your labour starts and how well it progresses.

***Key Points***

When your baby is head down, with their back on your left and their head down so their chin is on their chest this is considered the optimal position for labour and birth.

This position makes their journey as they descend and rotate through the pelvis the easiest as the smallest dimensions of the baby’s head leads the way.

There are things you can do to help your baby into a good position during pregnancy and during your labour and birth.

***Key Points***

***Preparing during pregnancy***

There are things you can do during pregnancy to encourage baby into the best position for labour.

How you sit and move your body in late pregnancy can affect the position of your baby in the uterus.

There are some exercises you can practice for short periods each day to help get your baby in a good position and these encourage alignment and mobility in the mothers pelvis in preparation for labour and birth

• On your hands and knees, sometimes referred to as on all fours
• Sitting on a ball or stool, like you were in a squat
• Sitting with your hips higher than your knees and your back straight,
• Walking briskly with good posture
• Pelvic rocking or tilting.
• You can rest lying on your left side with a pillow between your legs.

During pregnancy you can practice positions to keep active during labour such as: kneeling, rocking, squatting -using a ball or stool, walking, dancing, sitting backwards on a chair, lunging or kneeling on hands and knees.

These positions restore balance in the body creating space for your baby

Always follow the ‘No Pain’ rule. If you are experiencing any pain always consult your doctor or midwife

***Preparing during pregnancy***

Resources

Queensland Government – journey of labour

Why may a Caesarean section be suggested for you and your baby

Approximately  one third of women have an induction of labour. An induction of labour involves your Doctor or Midwife encouraging the process of labour to start artificially before your body starts labour naturally.

***Key Points***

During your pregnancy appointments your midwife or doctor will be monitoring you and your baby to make sure you are well and your baby is well and growing as expected.

If there is something that indicates concerns for you or your baby, they may suggest induction of labour.

That may involve the insertion of a hormone or catheter into your cervix, breaking your waters, or starting a hormone drip – it is usually a combination of these interventions.

There are risks with these procedures, make sure you are informed and ask lots of questions before you make your decision.

***Key Points***

 

***Reasons an induction may be suggested***

If your doctor is recommending induction of labour ask questions to ensure you understand why they they are suggesting it.

It might be because they consider you to be ‘overdue’ or past 41 weeks of pregnancy, or you have high blood pressure or other illness or concerns about you. There might be concerns about your baby or that the placenta is not functioning as expected or if your baby is not moving normally for your baby. If your waters have broken but contractions have not started this may also be a reason for an induction of labour.

The most common reasons for an induction of labour are:

• Pregnancy has gone on longer than 41 weeks without signs of spontaneous labour
• Waters have broken bu labour has not started naturally
• Baby is not well, not moving normally or growing well
• Mother is unwell or has specific medical conditions.

 

Some women may not want to be induced because they have reached 41 weeks of pregnancy, especially if there are no signs that the baby is unwell, speak to your Midwife and Obstetrician about your choice.

These may include

• Monitoring you baby via a CTG to check the baby’s heart beat
• An ultrasound to check that the blood flow to and from the placenta is functioning properly, providing oxygen to the baby and taking waste products away and to check the amniotic fluid levels are within the normal range.

If no abnormalities are found, you can discuss with your doctor the option to delay the induction for a few days.

***Reasons an induction may be suggested***

***How is labour induced?***

Usually the first thing the doctor will do is to do a vaginal examination to check your cervix, they are trying to feel whether it is opening, if it is firm or soft or thinning out. Depending on the findings most women will need a combination of these steps to induce labour.

• A prostaglandin
• A balloon catheter
• Artificially breaking your waters
• A synthetic oxytocin drip

***How is labour induced?***

***The experience for you***

The method of induction will depend on how ready your cervix is for labour to begin.

A prostoglandin is a gel or tablet that is inserted into your vagina to soften the cervix. You will usually need to lie down for around 30 minutes and the have your baby’s heart rate monitored and most likely stay in hospital now until labour begins. You may feel

• Mild cramping sensations
• vaginal soreness
• a small number of women  feel nauseas or experience diarrhoea or vomiting
• Very occasionally the prostaglandin gel may stimulate the uterus to contract strongly too quickly. This can be treated with further medication to assist the uterus to relax

A balloon catheter is an alternative option to help prepare the cervix for labour. This involves a thin rubber tube called a catheter with a balloon on the end being inserted into your cervix. the balloon is inflated with a small amount of water and applies gentle pressure to your cervix.

The next step during an induction of labour is to

Break your waters, this is usually done with you lying down, the Midwife or Doctor will place a small instrument inside your vagina and through the cervix, to break the bag of water surrounding your baby. This may be uncomfortable during the examination. You will usually experience a gush or trickle of fluid once the bag of forewater has been punctured.

After that is done the Midwife will start an intravenous drip with a hormone called syntocinon. This will start your uterus contracting. A pump will control the amount of medication you are given. They start on a low dose, then increase the amount of medication every 30 minutes until you are experiencing a pattern of contractions that are about three or four in a ten-minute period lasting about one minute, making sure there is enough rest in between each contraction. They will need to monitor your baby’s heart-rate continuously with a CTG (cardiotocograph) throughout your labour when you are being induced. That means you may not be able to move around as much as you would like as you will have a IV drip and are attached to a CTG machine.

When you have the syntocinon drip, they will also start some plain intravenous fluids. The midwife will closely monitor the intravenous fluid and medication, as well as your baby’s heart-rate and your observations [such as pulse, blood pressure and contraction pattern] will be regularly observed. The doctor or midwife caring for you may also want to perform a vaginal examination every four hours or so to check to see that your cervix is opening.

Because your body is not naturally going into labour, it can be more painful than natural labour and some women ask for pain relief more quickly than if they weren’t being induced.  If you have an epidural, it might stop you from feeling the sensations of your body and you might need some help to get the baby out. The doctor may need to use forceps or a vacuum. If you have an epidural you will most likely be confined to the bed, however you can still change positions using the functions of the bed to support you. Your midwife should be able to help with position changes.

***The experience for you***

***The risks of an induction of labour***

For some women, an induction does not result in labour starting and you need to have a caesarean.

You are at a higher risk of your uterus being over stimulated from the synthetic hormones used during an induction. There are risks to the baby including a lack of oxygen due to the strength and frequency of the contractions. Talk to your care provider for risks specific to you and your baby. It is always important to balance the risks and benefits of an induction of labour and make a decision in collaboration with your doctor or midwife

***The risks of an induction of labour***

References

Pregnancy Birth Baby – induced labour

Pregnancy Birth Baby – induced labour what are your options?

RANZCOG – induction of labour

 

Between 10-30% of women normally have GBS in their vagina and bowel. Approximately 20% of women will test positive to Group B streptococcus [GBS] during pregnancy. GBS is a transient bacterium, that means it is there sometimes and other times is not.

***Key Points***

If Group B strep is present during pregnancy, labour or birth, it does not affect you but if your baby is exposed to it during birth, for example if your waters break some time before birth, there is a chance your baby can become unwell.

You will be offered a test to see if the bacteria are present in your vagina at around 36 weeks of pregnancy. If positive, you will be offered antibiotics during labour. There is a small chance that your baby can develop an infection if exposed to GBS

***Key Points***

***Testing for GBS Streptococcus***

The GBS swab is a test that you can do yourself – you insert a swab (a bit like a cotton bud) into your vagina (only about one centimetre) and around your anus, then you put the swab into a tube that comes with the swab. Usually your midwife or doctor will give you the kit to do the test yourself and you complete it in the bathroom during one of your antenatal appointments.

***Testing for GBS Streptococcus***

***I have tested positive – what does this mean?***

If the test results are positive, it means that when your waters break in labour or before labour, you will be offered antibiotics (usually penicillin) to help protect the baby from becoming unwell. A very small number of babies exposed during labour may develop a serious infection such as meningitis, pneumonia or blood poisoning. This is thought to affect about 1 to 2 babies in every 1000 live births. When the infection occurs during labour it is called ‘early-onset GBS disease’ and may happen up until about 6 days after the birth. When it happens later, up until 3-6 months after the birth, it is called ‘late-onset GBS disease’.

Some hospitals offer the test to everyone who is pregnant, others will offer it only to people who are considered high risk, this is called routine testing and risk-based testing respectively. Antibiotic treatment for women who screened positive to GBS has been shown to be effective in reducing the chance of the newborn developing early onset GBS disease in 86-89% of cases. There is no high level evidence to support screening to prevent GBS disease but some other studies have shown some benefits of screening in the reduction of GBS transmission.

***I have tested positive – what does this mean?***

***Is my baby at risk?***

You might be considered high risk if you have had GBS in a previous pregnancy, or a previous baby with a GBS infection, or you are at a higher risk of having a pre-term birth. Your baby might also be at higher risk of being infected with GBS if your waters are broken for a long time [18 hours] before the birth, if you give birth or your waters break before you are 37 weeks pregnant or you have a high temperature during labour.

***Is my baby at risk?***

***After birth***

After the birth, if you were positive to GBS your baby will be monitored for the first couple of days to make sure they are not becoming unwell

Although rare, some babies become very unwell from exposure to GBS in the weeks after the birth. If you notice your baby seems unwell, is lethargic or sleepy, the legs and arms look floppy, appears to be having difficulty breathing or not feeding well you should seek help urgently. Call triple zero [000] or go to your local emergency department.

***After birth***

References

Pregnancy Birth Baby – Group B strep test

Queensland Health – GBS

RANZCOG – Group B Streptococcus

Department of Health – Group B Streptococcus

The muscles and skin that make up the area between your vulva and rectum are called the perineum. 

KEY POINTS

There are some things you can do to prepare the area for birth, including

• pelvic floor exercises
• perineal massage

There is a risk that the skin and muscle may tear during the birth of the baby.

Some pregnant women choose to massage their perineum in the last month of pregnancy to prepare for the stretching and pressure that will occur during the birth process.

It has been shown to be most effective in first time mothers in reducing the rate of significant perineal tears.

What is a third or fourth degree perineal tear?

A perineal tear is an injury to the perineum, which is the area between the vagina and anus. Tears are usually graded by ‘degrees’ – you may hear terms such as first, second, third or fourth degree tears.

Third and fourth degree perineal tears are more serious tears – they extend from the perineum to the anus or rectum and include the muscle that controls the opening and closing of the anus (anal sphincter).

First and second degree tears may need stitches, but women tend to recover within a few weeks or months. Third and fourth degree perineal tears need surgical repair and may be associated with short- and long-term complications for women, affecting their physical, psychological and sexual wellbeing.

Most women who sustain a third or fourth degree perineal tear recover well with appropriate treatment and support, although some will need specialised care to optimise their recovery.

About 3% of all Australian women who have a vaginal birth, and 5% of women having their first vaginal birth, will experience a third or fourth degree perineal tear.

The effects associated with third and fourth degree tears can be considerable and may include complications such as: perineal pain, faecal and flatus incontinence and painful sexual intercourse. There may also be ongoing psychological effects.

It is not possible to prevent all third and fourth degree perineal tears, but there are ways to reduce their likelihood.

Perineal self-massage (or with help from your partner) after 34 weeks of pregnancy can help protect your perineum and reduce the risk of third and fourth degree perineal tears.

It is recommended to commence perineal massage after 35 weeks of pregnancy. Practising can help you to become more in tune with that area of your body, help you to relax as you feel the baby is putting pressure on the area and to alleviate some of the extreme sensations of the baby’s head passing through as it is being born.

a warm bath or warm compress on the perineum for 10 minutes may help to relax this area prior to massage.

• Massage a good quality vegetable oil, not mineral or baby oil, into the perineal area
• Place thumbs inside your vagina.
• Press gently downwards towards your rectum and to the sides at the same time
• Hold the pressure for one minute breathing deeply and slowly. Keep pressing with your thumbs and then slowly and gently massage back and forth over the sides of your vagina in a “U” movement for 3 minutes.

You should not do perineal massage if you are 34 weeks pregnant or less, if you have any problems with your placenta or any vaginal bleeding or if you have any vaginal infection such as thrush or herpes that may be worsened or spread by massaging the area.

Pelvic floor muscle training may help prepare you for labour and birth and reduce the possibility of a third or fourth degree perineal tear. – See out content page on pelvic floor exercises

During a vaginal birth:

• Applying warm compresses to the perineum during the second stage of labour can significantly reduce the risk of a third or fourth degree perineal tear.

REFERENCES

ACSQHC – Clinical Care Standard 

Cochrane – antenatal perineal massage for reducing perineal trauma

Pregnancy Birth Baby – anatomy of pregnancy and birth, perineum and pelvic floor

Queensland Clinical Guideline – perineal care

Mater brochures – perineal massage