Pregnancy, Labour & Birth How to care for yourself in your pregnancy: THE FIRST TRIMESTER (0-13 weeks) EXERCISE: We strongly encourage an active lifestyle and exercise during pregnancy. Being in good physical shape will help you meet the demands of pregnancy and labour. It is also an excellent way to reduce stress. Swimming, walking, bicycling, and prenatal yoga are good ways to exercise during pregnancy. Use your legs, not the car! Some worry about overexertion; if you are working out, you should be able to carry on a conversation (the “talk test”). We discourage you from lying flat on your back to do abdominal exercises after the first trimester, particularly if this makes you feel dizzy or lightheaded. If your have more specific questions, talk to your midwife.

NUTRITION:

Eating well when you are pregnant is crucial. We encourage you to eat when you are hungry. We suggest that you eat several small healthy meals throughout the day to ensure that the baby receives a steady supply of nutrients. Pregnancy requires an extra 300 calories in addition to your non-pregnant diet, which means about one extra snack a day. Trying to avoid refined sugars found in white bread, pasta, and sweets (including pop and juice) is recommended. Your baby will receive more nutrients from whole foods. Plenty of fluids are essential for hydration. Limit the amount of coffee, tea or juice you drink and aim for 8 glasses of water a day. Do not exceed two measured cups of coffee per day. A prenatal vitamin is not necessary for all women. However, pregnant women need adequate calcium, magnesium, iron and protein. If you have concerns that your diet is lacking in any of these, talk to your midwife for more detailed information.

IRON:

Iron is the most common nutrient deficiency in pregnancy. Iron is necessary for increasing the quantity of red blood cells, which carry oxygen. The amount of needed iron doubles during pregnancy to meet the needs of your placenta and growing baby. Signs of iron deficiency includes fatigue, shortness of breath, pale skin, increased susceptibility to infections, brittle nails, heart palpitations and dizziness. Your midwife will check your iron levels in the first and third trimester. For some women, increasing their dietary iron is adequate to maintain their levels. Iron is available in meat and non-meat sources. Meat sources generally have the most iron and it is in a form that is easily absorbed. A supplement is likely more beneficial for women who eat minimal or no meat. The best sources of iron (because they are most easily absorbed) are found in meat such as beef, chicken, lamb, pork and veal. Other good sources included beans, eggs, tuna, lentils, pumpkin seeds, sunflower seeds, sesame seeds, nettle tea, quinoa grain, dried fruits, cooked oatmeal, pistachios, prune juice, cooked oysters, molasses, whole grain breads, leafy greens, iron-fortified cereals and bran muffins.

After reviewing your blood work, your midwife may recommend that you take an iron supplement. Ferrous Gluconate 300 mg is taken one to three times per day, and Ferrous Fumarate 300 mg (Euro-Fer or Palafer) is taken once per day (either one capsule or five millilitres of oral suspension). HVP (Hydrolyzed Vegetable Protein) chelated iron 30 mg is taken one to three times per day, and is more easily absorbed than a non-chelated type. Ferrous Gluconate and Ferrous Fumarate can be purchased at most pharmacies. You may need to ask the pharmacist for it as it is typically kept behind the counter. The HVP chelated iron is found in health food and bulk food stores which carry vitamins. Like all medications, they should be stored in a safe place as it is toxic if ingested in high doses, especially in young children.

Taking an iron supplement may cause nausea, bloating, constipation or diarrhea, and may make your stools turn black. These side effects will often decrease as your body adjusts to the iron. Increasing your fluids and fibre and avoiding taking iron in the morning when your blood sugars are low should help minimize these side effects. Iron is best absorbed on an empty stomach; however, if this causes nausea, try taking it with a meal. For best absorption, iron should be taken with a source of Vitamin C, like orange juice or a Vitamin C supplement of 250 to 500 mg. Tea, coffee or caffeinated sodas should be avoided a few hours before taking a supplement. If you take a thyroid medication, it should be taken at a different time as it will bind to the iron and inhibit absorption. Avoid taking calcium supplements, calcium-containing medications (such as antacids like Tums or Rolaids), or calcium-containing foods with your iron supplement, as these will also inhibit iron absorption.

CALCIUM:

Another important mineral during pregnancy is calcium. Calcium is necessary for healthy bones and teeth and the development of your baby’s skeletal system. Calcium also plays a role in regulating blood pressure. It may also decrease leg cramps, although excessive calcium can also cause leg cramps. When pregnant women have insufficient calcium intake, whether by diet or by supplement, the fetus will take calcium from the maternal bones. Fortunately, during pregnancy the body is twice as efficient as absorbing calcium as when you are not pregnant.

Pregnant women need 1000 to 1200 milligrams of calcium per day. If dairy is a normal part of your diet, three to four dairy servings per day will meet your needs. Dairy sources include milk, cheese (especially Swiss) and plain yogurt. Other non-dairy sources include tofu, soy milk, sesame seeds, sardines, canned salmon, evaporated milk, broccoli, oranges, legumes, almonds, kale, oysters and bok choy. In general, vegetables sources have less calcium and are not as well absorbed, especially when cooked. Where possible, try to eat vegetables raw.

For women with lactose sensitivity or those who do not regularly eat dairy, a supplement may be necessary. We recommend a Calcium citrate preparation with Vitamin D and Magnesium to increase absorption. This preparation also causes less constipation and bloating. If you are also taking a prenatal vitamin with iron or an iron supplement, avoid taking it within two hours of taking your calcium supplement to improve absorption of both minerals. Also avoid taking more than 500 milligrams of calcium at one time as absorption will also be decreased. Finally, like any supplement, too much is not good. High doses of calcium (i.e. more than 2500 mg) can increase the risk of urinary tract infections and kidney stones.

THE SECOND TRIMESTER (13-28 weeks) Preterm Labour Definition of Preterm Labour: Preterm labour is labour that starts before 37 weeks of pregnancy. Preterm labour can happen to anyone. The reasons why it happens are not well understood. You may be more at risk if you have had a preterm baby before, smoke, are underweight, are not getting enough healthy food, have lots of stress, or have had several miscarriages.

Effect on Baby Preterm babies may: Have trouble breathing Have trouble feeding Have trouble keeping warm (temperature instability) Have an increased risk of infection Need special care in the hospital and may need to stay in the hospital for a longer time Some preterm babies are very small and may not be strong enough to live. Warning Signs: Cramps, contractions or pains that come at regular intervals (i.e. that are getting longer, stronger and closer together) Lower back pain or dull aching that comes in waves Pressure as if the baby is pushing down Bleeding from the vagina A trickle or gush of fluid from the vagina A feeling that something is not right Page your midwife if you are less than 37 weeks and think that you may be in preterm labour. GESTATIONAL HYPERTENSION Definition of Gestational Hypertension: Gestational hypertension (GH), also known as Pregnancy Induced Hypertension (PIH), is a serious condition that happens in about 5% of pregnancies in Canada. It is more common in first time mothers and in women pregnant with a new partner. It usually happens at the end of your pregnancy. Going to prenatal visits is important. We see you more frequently at the end of your pregnancy to check your blood pressure and to check if there is protein in your urine. Stress may play a role in hypertension. Know how to manage yours with exercise, support and a healthy diet. Effect on Baby: Gestational hypertension may lead to preterm birth, growth restriction, and/or stillbirth (death) for the baby.

Warning Signs: Some possible signs of gestational hypertension include:

Elevated blood pressure Protein in your urine Severe abdominal pain under your right breast (liver pain) Severe headache (usually frontal) that doesn’t resolve with the usual remedies Blurry vision Seeing flashing lights before your eyes Severe nausea and vomiting If you develop these symptoms, please page your midwife.

THE THIRD TRIMESTER (28 weeks-delivery) Fetal Movement Counting: Over time you will become an expert on your baby’s movements. Often babies have predictable times when they are more active (e.g. after dinner). As you approach the end of your pregnancy, the baby may change his/her movements as there becomes less room for big kicks. This change in the quality (strength) of movement is normal, but the quantity (number) of movements should stay about the same.

If you become concerned that your baby has not been as active as usual, we suggest that you do a fetal movement count as detailed below. Please note that this criteria applies after 32 weeks gestation.

Drink something cold and sugary to wake up the baby, then lie on your left side with your hands on your abdomen. Try to avoid other distractions such as watching TV or reading a book. Count your baby’s movements (i.e. kicks, jabs, punches, twists and turns.) You should feel at least six movements in two hours. Page your midwife if you felt no movement in one hour or if you counted less than six movements in two hours.

GBS Information: Here is some information on Group B Streptococcus (GBS) infections in pregnancy, and the relevance to your newborn. The information will help you decide if you would like to have a vaginal/rectal swab for GBS, usually done at thirty-five to thirty-seven weeks of pregnancy.

GBS is a type of bacteria that normally lives in the bowels, and is found in the vagina in ten to thirty-five percent of pregnant women. In healthy adults, GBS does not typically cause problems.

If a pregnant woman has GBS and is not treated, it may be transmitted to the baby during the birth, as bacteria can travel upward from the mother’s vagina into the uterus. 40-50% of infants born to mothers who are GBS positive will be positive for GBS themselves (i.e. will be colonized with GBS) if the mother is not treated. Fortunately, most babies who acquire GBS from their mothers do not get sick; however, 1-2% of babies who become colonized with GBS will go on to develop GBS infection/disease, or about 1 in 200 babies. Infant GBS infection is treated with admission to the neonatal intensive care for seven to ten days (though it can be longer) where babies are given antibiotics through an IV. For babies thirty-seven weeks gestation or older (term babies), the prognosis is very good, with approximately ninety percent of infected babies responding to treatment.

Do I have GBS? During your pregnancy, we will offer you a vaginal/rectal swab at thirty-five to thirty-seven weeks gestation, to determine whether or not you carry GBS. It is your choice whether to have the swab or to decline it. Currently, family physicians, obstetricians, and recent research from the Centre for Disease Control and the Society of Obstetricians and Gynecologists, support routine swabbing of all pregnant women.

What happens if my swab is positive? Women who swab positive for GBS are offered treatment with antibiotics through an IV during labour (usually penicillin, unless the woman is allergic). As previously stated, if a woman is GBS positive, the chances of her baby developing GBS infection is approximately 1 in 200. This risk decreases to approximately 1 in 2000 if the woman receives IV antibiotics at least four hours prior to delivery. Taking antibiotics by mouth during or before labour does not prevent GBS infection in the newborn.

IIt is recommended that newborns of GBS positive women who are untreated or partially-treated remain in the hospital for twenty-four hours after the birth to be monitored for signs of infection, and so the baby can receive a blood test to rule out any infection. If you choose to go home before twenty-four hours, your midwife will educate you on the signs and symptoms of an infection.

If I am positive for GBS, do I need to have antibiotics? As midwives, we provide information and offer treatment options. It is your decision to accept or decline treatment.

If you have GBS and no antibiotic treatment, there is a 1 in 200 chance that your baby will develop an infection. If you have GBS and antibiotic treatment, there is a 1 in 2000 chance that your baby will develop the infection. The risk of GBS infection increases when other risk factors are present. These risk factors are:

Preterm delivery (delivery at less than thirty-seven weeks) Fever during labour (greater than or equal to thirty-eight degrees Celsius) If your waters have been broken for eighteen hours or more before the birth Having had a previous baby with GBS disease/infection Having GBS bacteria found in your urine during the pregnancy Some women choose to treat with antibitoics only if a risk factor comes up during their labour.

Possible Risks of Taking Antibiotics Possible side effects of treating with antibiotics include:

Allergic reaction in the mother (i.e. anaphylaxis) – very rare Yeast infections or thrush in mom and/or baby A potential for antibiotic resistance What if I don’t swab? If we don’t know whether or not you have GBS, antibiotics would be recommended and offered in labour if you develop a risk factor (as listed above).

Waters Breaking and GBS Once the amniotic sac is broken, bacteria can ascend up the vagina and to the baby.

If you are GBS positive, the community standard is to induce labour soon after the waters are broken and to begin antibiotics at that time. However, other options are also possible – such as treating with antibiotics while waiting for labour to start on its own or declining antibiotics and waiting for labour to start on its own. Your midwife can discuss these options (and the associated risks and benefits) with you in more detail. Research shows it is safe to wait up to 18 hours before choosing to start antibiotics and/or an induction.

If you do not have GBS, you do not require antibiotics. You may choose to have labour induced or wait for labour to start on its own.

If your GBS status is unknown, usually you only receive antibiotics and an induction if a risk factor develops (i.e. if your waters have been broken for more than eighteen hours, if you develop a fever in labour, or if you are preterm). However, other options are also available, such as treating with antibiotics and undergoing induction of labour within 6-12 hours of your waters breaking (similar to if a woman were GBS positive). The community standard (in the obstetrics community) if you are GBS unknown is to induce labour and give IV antibiotics.

Choice of Birthplace Midwives offer the choice of either home or hospital births. Either choice is a safe choice.

The evidence is overwhelming that for low-risk, healthy women, a planned home birth with a midwife is a safe option. Home birth outcomes are just as good as hospital birth outcomes, and the women who give birth at home report higher satisfaction rates, receive fewer interventions, and experience less infection. Birth is a normal process, and midwives are trained to safely and effectively monitor both the mom and baby throughout the labour and delivery process in order to recognize and minimize potential problems. Your midwife comes with all of the medications, equipment, and training necessary to handle emergency situations, and to stabilize and transport you and/or your baby in the unlikely event you need to be moved to the hospital.

Mother’s Responsibilities: You are responsible for your health and childbirth experience. This includes eating a healthy diet, engaging in physical activity, and getting adequate rest. You will benefit from learning about the processes of labour and birth. We have a lending library from which you can borrow books for a small fee of $5.00. The local library is also a good source of information. The internet can be a useful source for information although we caution against ‘Dr Google’ and encourage you to seek out reliable sources. Many women benefit from formalized prenatal education through the Health Unit or a Doula practice. Ask your midwife for prenatal class information. Prenatal visits with your midwife are scheduled during normal business hours on Tuesdays, Wednesdays, and Thursdays, and visits are up to 30 minutes (first and final appointments are sometimes longer). We recognize that your choice of clinic days is limited, however, this is due to the fact that much of our time is spent in the community attending births and conducting home visits. Due to our busy and unpredictable schedule, we may not be able to provide care at a time convenient to your work schedule. It is entirely your responsibility to attend appointments. If you must cancel an appointment, please give us 24 hours notice.

We encourage you to bring questions and concerns you may have to your visits, as this helps us to provide you with effective care.

The home environment should remain smoke-free at all times during the birth and for all midwife visits. All pets need to be secured and away from the midwives, birthing area, and birth equipment. We ask that those planning a homebirth have an adequately clean area for the birth.

If complications or emergencies arise which necessitate transport to a hospital setting we will be discussing this with you. You are asked to be responsible about accepting transport at such time.

If you are planning sibling participation at your birth, you will need someone that you and your child (or children) trust to be present with them during your labour and birth. This person should feel comfortable about the possibility of being present at the birth, but also not attached to the idea, so that your child’s (or children’s) needs at the time may be met.

Labour And Delivery We currently attend birth at Leamington District Memorial Hospital, Windsor Regional Hospital, and at home.

If you wish a hospital tour please call the hospital you wish to deliver at to arrange the tour. If you are planning a homebirth we will provide you with some items and you will be given a supply list of items we want you to have on hand for the home visit at the end of your pregnancy. Sometimes a midwife is in contact with you during early labour, and the midwife will attend you once you are in active labour. During active labour your midwife will remain with you and monitor labour contractions, check the dilation of your cervix, check blood pressure, and monitor the fetal heart rate. Your midwife will provide you with labour support, deliver your baby and the placenta, repair any tears with stitching, perform a full newborn exam, and check all aspects of your and your baby’s wellness. Your midwife is with you during active labour and the second midwife will be called when you are ready to have your baby. Midwives provide skilled support during labour and suggestions for pain relief. However, we cannot replace the important support provided by your partner, Doula, close friends or other family members. In the rare event of births happening at the same time, your midwife may ask you to come to the hospital she is at for assessment or may send another midwife to assess you.

Student Involvement in Your Care From time to time there will be students placed at our practice, and it will be expected that the student will be involved in your care. Should you have concerns with this, please do not hesitate to let us know. Senior students take pages and report to their teaching midwife. Students may not enter a house of woman in labour without a midwife, ever.

Infant Care NEWBORN MEDICATIONS: In the first hours after birth, the following medications are routinely given to all newborns. Erythromycin is administered by law; however, some clients choose to refuse erythromycin administration following an informed choice discussion. It is also your choice whether or not your baby will receive Vitamin K.

Erythromycin This clear antibiotic ointment is administered into each eye. This ointment does not sting; it may cloud the baby’s vision for a brief period of time. Erythromycin effectively destroys gonorrhea and is somewhat effective against chlamydia. These are two bacteria that may be present in your baby’s eyes after passage through the birth canal. Both organisms may lead to blindness if symptoms of eye infection are ignored in the newborn period.

Vitamin K In humans, Vitamin K is produced primarily by bacteria in the bowel. Babies are born naturally deficient in Vitamin K, as only a small amount is transferred across the placenta in utero and the bowel is sterile at birth.

There are only small amounts of Vitamin K in breast milk. Cow’s milk is high in Vitamin K. Vitamin K is essential in blood clotting.

Vitamin K is administered by intramuscular injection (IM) to the thigh of the newborn. It is effective in preventing a condition called Vitamin K deficiency bleeding (VKDB), formerly known as hemorrhagic disease of the newborn (HDN). The incidence of VKDB in breastfed babies who do not receive Vitamin K after birth is about 1 in 50 to 1 in 250. The benefit of administering Vitamin K after birth is that the occurrence of VKDB is virtually eliminated.

Risks of Vitamin K IM injection include pain, bleeding, and possible infection at the injection site. Skin-to-skin and/or breastfeeding during Vitamin K administration may help to reduce the pain of the injection. Over thirty years of experience in administering IM Vitamin K in the early hours of life has not identified adverse effects related to this medication.

Baby FEEDING: Your baby will hopefully feed at birth—we will help you if you need help with the first latch. After the first feed, most babies will have a long sleep of 4-6 hours. After the first big sleep, your baby should nurse 8 times in 24 hours and should be awakened every 3 hours to nurse. If your baby’s eyes are open in the first 2 -3 days then you should be feeding your baby. Do not introduce a pacifier or soother until breastfeeding is well established.

CORD CARE: The cord should be kept clean and dry. It should be out of the diaper and the diaper folded down enough in front to keep the belly button free of it. There may be a small amount of blood oozing from the cord but there should be no active bleeding. Before the cord stump falls off, it normally begins to smell very strongly. As the cord stump starts to separate, and even once it falls off, you may see a small amount of blood or yellow oozing where the diaper or clothing rubs.

STOOL and URINE: At first a newborn’s stool, meconium, is the colour and texture of tar. Using Vaseline on the baby’s bum will help make cleanup easier. Within a few days, the baby’s stool changes to a very loose mustard yellow with little white ‘seeds’. The frequency of bowel movements in a breastfed baby varies a great deal from many times a day to once every week. Both are normal if the baby is eating only breast-milk. If the baby has not urinated or passed meconium after 36 hours of birth contact your midwife. Place a piece of tissue in the diaper as a liner to look for urine if unsure.

Baby’s urine output is:

Day 1 – 3 1 – 3 Diapers

Day 3 – 4 3 – 4 Diapers

Day 5 -6 5 -6 Diapers

JAUNDICE: If the baby becomes yellow or orange-looking (jaundiced) within the first 24 hours of life, page your midwife. This is an urgent matter, so page if unsure in the first 24 hours. Most babies become jaundiced on day 3 or 4. This is a normal process and should gradually resolve over time.

SLEEPING: Leave your baby on the back to sleep. The current advice is to avoid a belly down position or side lying position when you are not awake and with the baby.

SKIN CARE: Babies do not need a bath every day to be clean. The first bath can be done anytime in the first days of life, but it is recommended to wait at least 24-48 hours. Limit the use of soaps and lotions because these can be drying and irritating to the skin.

CONCERNS: If the baby has a fever (temperature under the arm of > 37.5 degrees Celsius), or is gasping and/or grunting with each breath, page your midwife as these are urgent concerns. Normal baby temp. is 36.5-37.5 degrees Celsius.

Mother REST: After having your baby, adequate rest is very important; your midwife will encourage mostly staying in bed for the first 3 days, a walk outside around day 5, and then gradually increasing your activity over the next two weeks. Accept help from others for cleaning, cooking, and childcare – you should focus on rest and feeding your baby.

BLEEDING: To decrease the bleeding you experience in the first days, we will teach you to check for the hardness of the uterus. Rubbing the uterus will help your uterus to contract. Ensuring that your bladder is empty will give your uterus the space it needs to contract. Whenever you stand up, any blood that has collected in the back of the vagina may come out, sometimes in a large clot. Nursing makes your uterus contract, and you may feel cramps and/or a gush of blood. If you completely soak 1 pad in half an hour you should page your midwife and save the pads in case she wants to look at them. Passing the odd large blood clot is normal, if your bleeding is minimal prior to and after losing the clot; a large clot followed by heavy bleeding is not.

SELF CARE: Your whole vaginal area should be kept clean. Many women find that soaking in a clean warm bath several times a day eases the discomfort of abrasions or stitches. A cold pack applied after birth will help the swelling and bruising. Ice will be your friend; make ice packs to apply as needed for pain and swelling. If it burns when you urinate, you can use your squirt bottle with lukewarm water as you urinate. Try to keep your bowels loose by drinking plenty of water and eating foods high in fiber. Pain killers can help you cope with the pain; Advil (Ibuprophen) 400mg every 4-6 hours and Tylenol 500mg every 6 hours can help.

INFECTION: Preventing infection by good self care is the key to feeling well. Take your temperature every day in the first week following birth; a temperature above 38.0 degrees Celsius could indicate an infection, so page your midwife. Your bleeding should smell like a period. If it smells foul, if there is any pus in the discharge, or if you have an area of uterine tenderness, you may have an infection and you should page your midwife. BREASTFEEDING: When your milk comes in, your breasts may feel uncomfortably full and hard. Hot or cold compresses applied to the breasts, or standing in the shower and allowing warm water to run over your breasts, will provide some comfort and may speed up the letdown of milk. Alternatively, cabbage leaves from the fridge placed in your bra can help with the engorgement pain. If you feel hard lumps or hot-red painful areas in your breasts, warm compresses, massage, bed rest and keeping the baby nursing frequently is beneficial in preventing breast infection (mastitis).

SUPPORT: When possible, it is helpful to have support of family and/or friends to assist you as you adapt to early parenting. Women can experience varying degrees of emotional instability, particularly in the first week following the baby’s birth. This may range from weepiness to feeling extremely agitated or depressed. If you feel that you are unable to cope or if you feel that you want to harm yourself or your baby, page your midwife immediately.

No OHIP Required What does it cost to use a midwife? Midwifery services are completely funded by the Ministry of Health and Long-Term Care, so women do not pay for care out-of-pocket. Women who are not currently covered by OHIP can still receive free midwifery care. All you require is a residence in Ontario. The services that are not funded for women without OHIP are laboratory tests, ultrasounds, care involving a physician, and hospital fees; these services require payment by the woman. If you do not have OHIP and wish to have a hospital birth, you will be required to pay for your hospital stay and/ or any hospital assessment; you are responsible for setting up a payment schedule with the hospital.