How to keep your baby safe in the last stages of pregnancy

Transcription

1 Maternity Services How to keep your baby safe in the last stages of pregnancy Information for parents after the 20 week scan

2 How to keep your baby safe in the last stages of a normal pregnancy This includes: Going past your due date How we check on your baby Induction or not? What happens if you are induced? This booklet is designed to reassure you and help you make the last few weeks of your pregnancy as safe as possible. The two main issues which worry parents, in a normal low risk pregnancy, are: 1. Is my baby moving enough? 2. What are the risks of going overdue? Movements in the womb The mother s sensation of how much a baby is moving varies enormously from mother to mother and baby to baby. You will be used to what is normal for you, and that is the level of movements which is right for you and your baby. Towards the end of the pregnancy the amount of fluid reduces by about one fifth a week, as your baby grows and fills more of the space in the womb, so the type of movement may change but the periods of activity should not. If you are sitting at home thinking It really hasn t moved very much at all today, please give us a call (useful contact numbers are listed at the back of this booklet). It is difficult to predict which pregnancies are at risk; there is a very small risk of the baby dying in the womb in all pregnancies (less than one in 500 in a low risk pregnancy). Sometimes this can happen with no warning at all. 1

3 There is evidence that encouraging mothers to seek advice when concerned about movements, reduces the chance of such a rare event happening. Kick charts, where the mother has to count the number of movements each day, have been shown to increase anxiety and increase unnecessary intervention, for example caesarean section. So it comes back to what is right for you and your baby. Home monitors to listen to your baby s heartbeat, although reassuring, give no information on the wellbeing of your baby and we do not recommend them. What should I do if I am worried? Please come and see us and use the contact number at the end of the booklet if: you do not feel your baby move at all during a whole day. If this ever happens, never wait until the next day to see advice. your baby moves less and less in the course of a day and you feel less activity compared with normal. you are worried because your baby s movements are becoming less frequent. We will usually see you on the same day. A midwife will check that there are no other problems, such as high blood pressure or a small baby. They will do a heart rate trace for about 30 minutes. If all these are normal, it is a good sign that your baby is fine at that point. However it does not test for long term safety of your baby. Usually the movements pick up again but, if they do not, we would like to do a fuller assessment with an ultrasound scan. When you have the scan, it will check: the growth of your baby the amount of fluid around your baby the blood flow along the cord to your baby if we are concerned about the growth 2

4 if your baby is moving, it is not unusual for us to see lots of kicking and the mum to not be feeling anything! Please expect to be on the Unit for up to four hours. If the assessment on the Day Unit is normal, it means that your baby does not need to be delivered. The chance of the baby dying in the womb in the week after a normal test is no greater than the risk in any pregnancy. An induction would carry a greater risk than awaiting a normal delivery. Going overdue Most parents are very keen for the baby to arrive when the due date is reached. If your baby is overdue, review your dates with the midwife: a few days do not seem very long at 20 weeks; but it often does now. Your due date is best calculated from the scan you had at 12 weeks; this is more precise than the date from your cycle, however sure you may feel. In normal pregnancies about: one in two go to their due date one in four go a week over eight in a hundred go two weeks over three in a hundred go three weeks over if you wait. We suggest you see your midwife around your due date to discuss your options. If you are worried about the movements before this time, please refer to the advice above. Parents often feel that, as the baby is getting bigger, induction will make the pregnancy safer or the delivery easier. There is no truth to this, as induction can mean the baby being in a less favourable position for labour and birth. 3

5 At Hampshire Hospitals NHS Foundation Trust we aim to avoid inductions that are done for reasons that have nothing to do with the risk of the pregnancy, for example social reasons, discomfort, pain in the pelvic girdle, a previous large baby and so on. Induction When induction is appropriate then it is best for the midwife or doctor to check that your baby s head is entering the pelvis, and to do an internal examination. The examination shows how ready the entrance to the womb is, helping to decide how easy an induction is likely to be. If the entrance is favourable then stretching the cervix and sweeping the membrane doubles the chances that you will go into labour yourself, the best outcome of all. If the cervix is closed then massaging it through the vagina can help. We suggest this is done from your due date for first time mums and at 41 weeks for others. If you have had a caesarean section before, you should have received the information leaflet Birth after a previous caesarean. Do a check on the baby and wait Your midwife will arrange for you to come to the unit for an assessment when you are around days overdue. They will do a full check as described above, an internal examination and discuss your options. Again, expect to be at the hospital for up to four hours. If the assessment is normal, the midwife will either refer you back to your community midwife for further management or arrange for you to have a date for induction. In some cases the obstetrician will need to see you at this point. 4

6 Referral to the Day Assessment Unit is not always to arrange induction, but to support you to make a decision that is as safe as possible about the next few days. If you wish to wait until your own labour starts, we will continue to assess the pregnancy in the Day Unit every three to four days, to maximize safety for the baby. Parents often worry that the reserve of the placenta will run out. The fact is that this is a very rare event. Evidence shows that these risks increase slightly after 42 weeks and therefore most parents choose to have their baby induced before this time. Should you prefer not to be induced we are happy to discuss this and support your choice and increase the level of surveillance. These risks are increased a bit if mothers are over 40, have high blood pressure, smoke and so on. If you go a long way overdue in a first pregnancy the chances of having a normal delivery decreases, as it does as you get older, and we really do not understand why. What we do know is whether you wait or are induced it does not seem to change the outcome. Induction process During induction, you will be given drugs called prostaglandins which act like the natural hormones that kick start labour. They are inserted into the vagina as a gel or tablet. Your cervix should be re examined about six hours later. Your baby s heartbeat should be checked again when contractions begin. Your midwife may then switch to using a small hand held device to check your baby s heartbeat at regular intervals. 5

7 In general we admit women who have had a baby before in the morning and those who have not in the afternoon, as the process takes longer, with the first prostaglandin working overnight. We sometimes use a slow release 24 hour pessary. The process is very variable in the time it takes. Some women are very insensitive to the hormone. Sometimes the induction has to be delayed due to activity in the unit. We would encourage you to remain mobile, eat and drink regularly and rest when you are able. Amniotomy or artificial rupture of the membranes (ARM) is a method of induction in which healthcare professionals break the sac of waters around the baby. You will not normally be offered an amniotomy unless your obstetrician or midwife thinks there may be specific problems with using prostaglandins, such as very frequent or very long contractions. Amniotomy is usually used later in the induction process or if the neck of the womb (cervix) is opening. This aims to trigger natural contractions, but a high number of such inductions need a drug given into your arm to stimulate contractions. This also happens in normal labours and the midwife will explain this to you further. It does make the labour more medical and continuous monitoring of your baby s heart beat is needed at this time. However, it is normally still possible to remain mobile with continuous monitoring and we would encourage this. Pain relief Induced labours are more painful than spontaneous labours. You will be offered support and whatever pain relief is appropriate to you in the same way as if your labour had not been induced. You will be encouraged to use your own coping strategies for pain relief as well. 6

8 If you do not go into labour after induction, your midwife or obstetrician will check on you and your baby thoroughly and discuss the options. We would usually review the situation if after two applications of prostaglandins, you are not in labour. Depending on your wishes and circumstances, we may offer you the option of waiting (as long as you and the baby are well), another dose of prostaglandins or, very rarely, a caesarean section. Further information Royal College of Obstetricians and Gynaecologists health/patient information We hope this booklet has given you the information to help make your decisions in your pregnancy, and will make your discussions with your midwife and doctor as helpful as possible. Any suggestions or feedback are always welcome. Useful contact details Basingstoke and North Hampshire Hospital (central contact number 24/7) Royal Hampshire County Hospital, Winchester (central contact number 24/7) Copies of all maternity patient information leaflets are available on the Trust s website at Michael Heard, Consultant Obstetrician, edited from the 2011 RCOG information leaflet Layout by Paula Searle, Macmillan Health Information Manager August, 2013 Review August, 2016 FCS/ 065/ 2013 (previously 0374/ PB00143) Hampshire Hospitals NHS Foundation Trust