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Episode 12 Content and Overview

In episode 12 of the Pregnancy and Childbirth podcast, Dr Greg Jenkins, obstetrician and gynaecologist, discusses the recovery process after a caesarean section.

The recovery process is important because it allows you to heal physically and emotionally after your caesarean. It is also an opportunity for you to learn about your own body and how to care for yourself following surgery. The recovery process will vary from woman to woman, but there are a few things that are common to most women, and these will be covered in this episode.

Listen in as Dr Jenkins discusses pain relief options, the healing process, guidelines for discharge from the hospital, dressing your wound, what activities you can and should do as you recover and more. Whether this is your first or second caesarean, you will find this podcast informative and helpful as you navigate the road to recovery. So, tune in now for all the information and advice you need to make your recovery as smooth and easy as possible.

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Transcription

00:00:00 

Hi I'm Greg Jenkins. Welcome to my pregnancy and childbirth podcast. Today we're going to talk about recovery after your caesarean. This topic was suggested by the partner of one of my patients. If you have any suggestions for podcast topics, please let me know. 

00:00:18 

There are two types of caesarean. There's the caesarean that's performed during labour, where there was a plan to aim for a vaginal birth but something happened during the course of labour to change direction and move towards a caesarean. The second type of caesarean is where there was always the intention to carry out a caesarean. 

00:00:36 

Now the recovery for both of these and the post caesarean care is very similar for both. Really, the only difference is that if you laboured for some time before you had a cesarean, there may be a little bit more recovery needed in the first couple of days as you will be recovering from the labour as well as recovering from the caesarean itself. 

00:00:57 

We'll start by talking about what to expect immediately at the end of your cesarean. So you'll usually have either a spinal or epidural type of anesthetic, in some instances they might leave an epidural catheter in your back and give you some anesthetic down the epidural immediately following your caesarean. 

00:01:17 

Some will give you some medication, some long acting medication through the epidural or the spinal to help with your pain relief for the 1st 12 hours or so after the caesarean and on other occasions you might have a drip with a push button that'll give you small amounts of pain relief as you need it. 

00:01:35 

Whichever approach it is, the anaesthetist will ensure that you have some good quality pain relief to get you through the 1st 12 hours or so after your caesarean. The same thing would apply if you had a general anesthetic or a go to sleep anesthetic for caesarean. So you have some good quality pain relief. 

00:01:55 

You'll also have an intravenous drip, and drip will stay there usually until the following day, and that enables you to have some intravenous fluid, you might need some extra antibiotics and that just helps to keep you well hydrated and keep you well during your post operative recovery. 

00:02:15 

You'll have a catheter in your bladder. It's important that your bladder is able to be emptied following caesarean and you might not be able to do that yourself. So the catheter will usually stay there until the following day. 

00:02:28 

In terms of the skin closure from your caesarean, we'd usually use the dissolving stitches in the skin so it would be unusual to have a stitch which required removal so they'll usually be a dissolving skin stitch, and then there'll be a waterproof dressing over the top of the skin stitch and I would usually use a clear dressing so that we can see the wound quite clearly through the dressing. 

00:02:52 

If the caesarean is fairly straightforward and there were no other complicating factors, it'll usually be ok for you to have something light to eat and something to drink, within the first few hours after your caesarean. And this is actually a good thing to do because it helps to speed up your recovery. 

00:03:10 

Now, there may be occasions where this is not advisable, in which case we'll be sure to let you know that's the case. Generally, on the first day of your caesarean, we wouldn't expect you to be getting up out of bed. This is generally a rest day where you'll be resting in bed. 

00:03:25 

The exception might be if you had your caesarean very early in the morning, in which case we might have you sitting out of bed by later in the day, but usually you'd expect on the day of your caesarean, pretty much a day where you're going to be resting in bed. 

00:03:37 

The midwives will give you lots of assistance with caring for your baby, and if you're breastfeeding, assisting with breastfeeding, and all of those kind of things. And usually your partner is, very much encourage your partner to be involved in all of these activities as well. 

00:03:54 

So we managed to get through the day of your caesarean and the night following, and hopefully this has been a fairly comfortable time with plenty of pain relief, lots of time spent cuddling your baby and helping to get the breastfeeding started, if that's what you're wishing to do. 

00:04:10 

So the following day we plan to get you up and about. So generally speaking the catheter will be removed first thing in the morning and at some time during the day, preferably the morning time, the midwife will help you to get out of bed and get showered, and most women find this is a nice experience and makes them feel a lot fresher and a lot more back to normal, being able to have some breakfast in the morning and get up and have a shower and not be connected to a catheter anymore. 

00:04:38 

We'd usually be able to cap off your intravenous drip so that you're not connected to a drip now, and if everything goes well during the day, then you're intravenous drip would usually removed from your hand or your arm that day as well. Making some changes to your pain relief today, so any pain relief that you had through either your epidural or through the drip would now be removed and we'd be relying on tablet form of pain relief going forward now. 

00:05:07 

And most commonly this would be a combination of three tablets that you're given regularly. So one of these would be paracetamol, which is Panadol, and then usually another drug, which is what we call an anti-inflammatory drug. So the two most common ones would be things like Nurofen or Voltaren. 

00:05:25 

We'll give these in quite a good dose regularly, generally 3 times per day. That of course assumes that you're not allergic to either of these medications, in which case we find other alternatives. And the third regular type of drug you have to manage the pain relief in these early days is a slow release, stronger pain relief style medication. It's a little bit like Endone nor Oxycodone, and it's a slow release form which causes less side effects, which means you only have to take it twice a day and gives you a nice long lasting pain relief across the day. 

00:06:01 

So they'd be the regular pain relief medications that you get. Now on top of these there would usually be some pain relief that you would ask for if you need some extra pain relief. But most women will have a bit of extra pain relief in the first couple of days, and this would most commonly be a medication like oxycodone or endone, which you can have as an extra if you need it. 

00:06:25 

So on the first day after your caesarean, you're mostly going to spend the day in your room unless of course your baby is in the nursery, in which case you'd usually wheelchair up to the nursery to visit your baby. So, day one, mostly in your room sitting out of bed, spending some time in bed and gently mobilizing back and forth to the bathroom as you need to. And that's about all you need to be doing on the 1st day after your caesarean. On the second day, we continue the same plan in terms of your pain relief medication, but on the second day, you'd be doing a little bit more moving around, so spending more time out of bed, more time walking around and able to venture out into the ward to walk around the ward a little bit, and it's important on Day 2 to venture out of your room and it's good for your well-being generally to expand your horizons beyond your hospital room so some little walks around the ward with some assistance is a good way to help your recovery progress. 

00:07:26 

There's plenty of evidence that women who take lots of pain relief and mobilize actively early in their recovery make a faster recovery than women who spend a lot of time sitting in a chair or sitting in bed and not taking pain relief and experiencing more pain. So take plenty of pain relief and gently progress your mobilization over the first couple of days after your caesarean and this will lead to a better recovery. 

00:07:55 

Timing of discharge is going to vary from hospital to hospital and you may want to be somebody who's discharged from hospital quite early, and it's certainly possible to go home on day two or day three after your caesarean if everything is going smoothly and you're feeling confident. Most women will stay a little bit longer than that. Now what you'll need in terms of pain relief once you get home will depend on how soon after your caesarean you go home. 

00:08:20 

Now the main stay your pain relief once you go home will be things like Pandadol and Nurofen or Voltaren, and you should take these regularly in quite good doses and your doctor or midwife will explain to you the sort of dosing you can be looking at once you go home and you should take these medications regularly for as long as you need to, and then gradually reduce them once you feel you're not needing them anymore. 

00:08:44 

Now if you discharged early, you might need some stronger pain relief to go home with, in which case we might give you a prescription or a small supply of of the medication we mentioned earlier, you've got oxycodone or endone. Now this is a very strong pain relief tablet. It will help with your pain relief in the first few days after you're home, if you need it. 

00:09:06 

We do need to be careful with this medication because it's extremely addictive and the longer you're taking it for the harder it's going to be to stop. So if we do give you some endone or some oxycodone, it's the same drug, to take home, we generally only give you a very small supply and we wouldn't expect you to require any more than the supply that you've been given. 

00:09:30 

In terms of the dressing, so as I mentioned earlier, there's a clear waterproof dressing covering your wound. Now this can actually stay on for several weeks, and some women find the dressing is quite comfortable. It provides an extra layer on top of the wound so their underwear doesn't rub around the sensitive skin on the incision. So there's a degree of flexibility or personal preference whether you would prefer the midwives to take the dressing off before you go home, or whether you prefer to leave the dressing on. 

00:10:01 

It's a clear dressing so you can see the incision quite clearly underneath and see how everything is healing. So if you prefer to leave the dressing intact, it's generally something we would talk about as your discharge approaches, and I've had someone leave the dressing intact for six weeks and we take it off when they come back for their six week checkup. 

00:10:21 

It is important to be aware of constipation after caesarean section. It is quite common to have some difficulty opening your bowels in the first week or two after the caesarean. So it's a good idea to have something that you could take at home in a form of a laxative to help your bowels along. Now, most laxatives are completely safe during breastfeeding, if you are breastfeeding, so make sure that you talk to your doctor or midwife about what you might want to take as a laxative if you're having difficulty with your bowels after you leave hospital. 

00:10:54 

In terms of activity, you should be pretty much fine to do most normal day-to-day things once you're discharged from hospital. People worry about maybe lifting their other children or going up and down stairs or just doing gentle day-to-day activities. Now, generally those things are all going to be fine. The caesarean section incision is inherently quite a strong, incision just because of where it's placed on the abdomen and the type of incision that it is. 

00:11:25 

It's very unlikely that you're going to do anything that will really disrupt the healing process. So the advice we generally give is that if something feels comfortable, it's ok to do. And if you go to do something and it's painful around the area of the incision, then you're probably not quite ready to do that yet. And we'd certainly suggest that any heavy or strenuous activity or strenuous exercise, for example, should be delayed until at least after six weeks. 

00:11:55 

In terms of driving, there aren't any clear guidelines around when you should drive after a caesarean, but a common sense approach suggests that when you can stomp your foot on the brake really hard, then you will be safe to drive. And most women will reach this point by about three weeks after your caesarean. So what I'd suggest is that you sit in a straight back chair and stamp your right foot on the ground really hard. And when you can do that without doubling over and discomfort, then you'll know that you're ready to be able to drive. And as I say, that's generally at about 3 weeks. 

00:12:37 

So what do you need to look out for after your caesarean? You should keep an eye on how the incision is healing. If it becomes red and swollen and increasingly painful, this could be the indicator that you might be developing a wound infection. This is not especially common. If it's going to occur, it occurs most commonly within about the first two weeks after the caesarean. And it might mean that you need some antibiotics. 

00:13:04 

If this happens then you should get in touch with your doctor or midwife or your general practitioner to get them to have a look at the incision and see whether antibiotics are needed. Now because you've had a catheter in your caesarean, there's a possibility of developing a bladder infection, and if this happens you might experience a lot of frequency, so needed to go to the bathroom to empty your bladder very frequently, and you might experience burning or stinging when you're passing water. And if this is the case, again you should seek advice from your pregnancy care provider so that you can have a urine test performed and you might need some antibiotics. 

00:13:41 

Now, very occasionally we see women who develop a fever or an infection in the uterus after caesarean. This can happen after normal birth as well, but it's a little bit more common after caesarean. And again, it commonly happens around the 7 to 14 days after the caesarean. And if this happens you'd be likely to develop fever and lower abdominal pain. So you might feel hot and sweaty, you might have a raised temperature and feel a bit unwell with pains in your lower abdomen, your lower tummy. 

00:14:13 

And if this is the case, again, you should seek a review by a pregnancy care provider or your GP, as you might need some antibiotics. Generally we'd book in a six week check up for you to come along at six weeks and see how your recovery from your caesarean, your recovery from childbirth is going and how you're coping with motherhood. And we'd have a careful look at the caesarean incision and make sure that everything is healing nicely and talk about family planning and all those other things that we do at the six week check up. 

00:14:45 

So this is very general advice about caesarean section recovery and what would apply to most women who had a caesarean. There will be specific circumstances that may be particular to you, in which case your obstetrician or midwife will explain those to you before your discharge, so if there are special things you need to be looking out for, then you're well aware of those things. Don't be shy to ask all of the questions you have in the time leading up to discharge so there's an opportunity for all of those questions to be answered for you. 

00:15:18 

I hope this has been a helpful discussion around the things to expect following recovery from caesarean section, and as I mentioned earlier, if you have any suggestions regarding topics for future podcasts, please let me know. Bye for now. 

   

 

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Episode 11 Content and Overview

In episode 11 of the Pregnancy and Childbirth podcast, Dr Greg Jenkins, obstetrician and gynaecologist, talks about what happens if you catch COVID-19 whilst you're pregnant. Dr Greg provides advice specific to where we are in the pandemic at the present time, so it's important to note that this podcast was recorded in mid January 2022 and in Sydney where Dr Greg is based.

Listen to this episode to learn about:

• What to do if you catch COVID-19 during pregnancy

• Effects of COVID-19 illness on vaccinated and unvaccinated pregnant women

• What symptoms you are likely to experience and how to manage them

• What happens if you're in late pregnancy and your waters break? Or you go into labour before you've been able to deisolate?
  

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Happy listening and don’t forget to subscribe to the Pregnancy and Childbirth podcast with Dr Greg on Apple Podcasts to get new episodes as they become available.  

Transcription

00:00:00 

Hi, I'm Greg Jenkins, obstetrician. Welcome to my podcast. Today we're going to talk about what happens if you catch COVID whilst you're pregnant. The advice I'm going to give is specific to where we are in the pandemic at the present time, so it's important to note that this podcast is being recorded in mid January 2022 and in Sydney where I'm based. We're in the midst of a rather large outbreak of Omicron COVID. 

00:00:32 

At the outset, I should mention that this advice is of a very general nature only, and it assumes that you are basically a healthy person with a healthy pregnancy. If you have any pre-existing medical problems or any significant issues during your pregnancy, it's very important that you seek immediate advice from your pregnancy care provider if you're diagnosed with COVID. That's because the advice I'm going to provide here may not be particularly applicable to you. 

00:01:03 

Now for every pregnant woman who catches COVID during pregnancy, they should make early contact with their pregnancy health care provider so that they can obtain a specific advice to their particular needs. 

00:01:16 

Now if you catch COVID during pregnancy, it matters whether you're a vaccinated or unvaccinated person. We're seeing significantly milder illness in vaccinated pregnant women are with unvaccinated women a bit more likely to experience a more significant illness. And we're seeing a very small number of unvaccinated women admitted to hospital with very severe, and in some cases critical illness, requiring intensive care support. 

00:01:45 

So I would just reiterate the advice from one of my earlier podcasts around vaccination, if you haven't accessed COVID vaccination up to this point, I would strongly encourage you to do so at the earliest opportunity. 

00:02:00 

This is also useful opportunity to reflect on the public health advice, so follow whatever public health orders happen to be in place, but we do know that masks significantly reduce the transmission of COVID. So when you're in a crowded public indoor areas, it's very helpful to be wearing a mask, to maintain social distancing wherever possible, and to practice good hand hygiene, and of course if you have symptoms then isolate at home until your symptoms have resolved and get a COVID test, of course. 

00:02:40 

It's very possible that you've done all those things extremely well, and that you're a double vaccinated person, but now you find yourself having contracted COVID. So what does that mean? Well, the first thing to say is that you're very unlikely to experience a significant illness, and by a significant illness I mean an illness that's significant enough for you to require care in hospital. 

00:03:03 

The symptoms can be quite bothersome and you may well feel quite unwell for a few days. Most women will experience a sore throat, often described as a scratchy throat, a cough for a couple of days, maybe a sense of chest tightness, fatigue, fevers, and generalised muscle aches and pains, and headaches would be the most common symptoms that we're seeing during COVID illness. 

00:03:33 

The respiratory symptoms, the sore throat, and a cough and the chest tightness usually pass fairly quickly, and most commonly only last a few days. Some people with COVID will experience significant nausea and vomiting, and if you're a woman in early pregnancy who catches COVID, if you're in early pregnancy and you're already experiencing our troublesome early pregnancy, nausea and vomiting, it's possible that COVID might make this worse. 

00:04:02 

If you reach a point where you're not able to keep all fluids down, without vomiting, then this would be a trigger for you to go to hospital at your local emergency department to seek medical advice, as you may require, intravenous fluids and medication to help manage the nausea and vomiting. 

00:04:22 

In terms of the other, more common symptoms, cough medicines are fine to help manage the cough, although sometimes are limited benefit, but they are safe medications in pregnancy. We would recommend regular Panadol as this will help with any fever and will help with the generalised muscle aches and pains and the headaches which often accompany COVID. 

00:04:44 

It's important to keep up your fluids, so make sure that you're drinking plenty and taking on adequate nutrition, so even if you're feeling sick, please try to eat well during your period of illness. 

00:04:57 

Now, in terms of the baby, if you're above 25 weeks gestation we'd be expecting her baby to be moving actively every day, and that continues during the period of your COVID illness. So you should continue to notice your baby moving actively every day. 

00:05:14 

If you find that there's a significant reduction in your baby's movements or an absence of movement, then it's important that you contact the birth unit at the hospital where you’re booked in to have your baby or make contact with your pregnancy care provider so that they can arrange for an assessment of your baby’s well being or further explore the change in movements that you have noticed. 

00:05:39 

I should stress that the likelihood of your COVID illness causing a significant problem for your babies well being is very unlikely, but monitoring foetal movements and during a period of illness is a very important thing to do. 

00:05:54 

Now as I said most women are not going to be unwell enough to need to seek care in hospital. Vaccinated women tend to have a shorter and more mild cause of illness than unvaccinated women, but you should be aware of the things that would lead to a need for you to present to hospital. 

00:06:13 

So if you are becoming increasingly short of breath such that you would have trouble walking up a flight of stairs uninterrupted or speaking in a long sentence without taking a break to catch your breath, then this will be a trigger for hospital presentation and you should call an ambulance. 

00:06:31 

Sometimes COVID can cause very high fevers, and if you have persistent fevers above 38.5 degrees Celsius, if you have a thermometer at home to measure your temperature, and if those fevers don't reduce with Panadol or paracetamol, then you should contact either the birth unit at the hospital where you were booked or your pregnancy care provider, because again, this may be a reason to present to hospital for review. 

00:07:00 

So what about deisolation? So the criteria around deisolation are the same for pregnant women as for the rest of the population. So if you're a fully vaccinated person, provided you have become asymptomatic for 24 hours by day seven of your illness, then you are allowed to deisolate. 

00:07:22 

So the criteria that we are using around duration of illness is the onset of symptoms, which will usually be a sore throat or cough or a positive COVID test, whichever of those things happened first. 

00:07:39 

So the first day of your symptoms or the day you get a COVID test will become day one of your illness, and if you reach day 7 and you have no respiratory symptoms for the 24 hours preceding day 7, you can then deisolated. And by respiratory symptoms we mean a persistent cough, a sore throat, runny nose or a fever. And you may find that you still have some persisting tiredness and lethargy, so that the tiredness can persist for a while, and we may have quite significant muscle aches and pains and headaches as well. 

00:08:14 

Now those symptoms are ok and they can last for a while and you can still deisolate in the presence of those symptoms, provided you don't have any respiratory symptoms. 

00:08:27 

Now, if you're an unvaccinated person and you need to isolate for 14 days. If you are a vaccinated person and you get to day 7 and you still have a cough and sore throat and a runny nose, you need to isolate for a further 3 days and you can't deisolate until day 10. 

00:08:45 

Now, what happens if you're in late pregnancy and your waters break? Or you go into labour before you've been able to deisolate? Now not all hospitals are able to look after COVID positive woman during labour and birth. Now this is something that's changing fairly quickly so keep abreast of what's going on with your local hospital, and your pregnancy care provider will be able to provide you with the latest information around this. 

00:09:13 

Most women with COVID are remaining quite well as we have discussed and having COVD during the time of labour and birth shouldn't impact significantly on the care that you receive during your labour and birth and shouldn't impact on the birth itself, but it might result in a change in the hospital where you need to give birth and of course all of the staff looking after you will be wearing PPE, so they'll be wearing eye protection, a gown, gloves and a special type of mask during the care that you receive during your labour and birth. 

00:09:56 

Now in many hospitals it's possible for your partner to still be with you as a support person during labour and birth, but this is going to vary from hospital to hospital. And it will depend on whether your partner is COVID positive and whether or not they have significant symptoms. So again, this is something you can explore with both the birth unit at the hospital and your pregnancy care provider. 

00:10:21 

We would expect that as a well, COVID positive woman, who gives birth to a healthy term baby that your baby will remain with you during your hospital stay and you would be encouraged to breastfeed and have close contact with your baby just as would normally occur. 

00:10:41 

Finally, we are seeing lots of pregnant women are being diagnosed with COVID, and in the vast majority of cases we're seeing most of those women have a mild illness not requiring hospitalisation, being cared for safely in the community, and being deisolated fairly quickly, and continuing on with their pregnancies in a normal way. 

00:11:03 

I hope you found this podcast informative. Just one final reminder if you are an unvaccinated person, please consider getting a COVID vaccination as soon as you are able. Many thanks for listening. Bye for now. 

 

   

 

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Episode 10 Content and Overview

In episode 10 of the Pregnancy and Childbirth podcast, Dr Greg Jenkins, obstetrician and gynaecologist, talks about breech presentation; when your baby is trying to come out bottom first instead of head first.

Listen to this episode to learn about:

• When does breech position matter?

• Three options for giving birth if your baby is breech coming into the last month of pregnancy: external cephalic version (ECV), vaginal breech birth and elective caesarean
  

Subscribe

Happy listening and don’t forget to subscribe to the Pregnancy and Childbirth podcast with Dr Greg on Apple Podcasts to get new episodes as they become available.  

Transcription

00:00:00 

Hi, I'm Greg Jenkins and welcome to this edition of my pregnancy podcast. Today we're going to talk about breech presentation. So breech presentation is when your baby is trying to come out bottom first instead of head first. 

00:00:14 

This issue matters because delivering your baby as a vaginal breech birth is a little bit more risky for the baby and a bit more complicated than delivering your baby vaginally from a head first position. 

00:00:29 

So when does breech position matter? We know that at 30 weeks gestation, so 30 weeks into your pregnancy, that about one in three babies are in a breech position. 

00:00:39 

We also know that by the time you get to 37 weeks gestation that only about 3% of babies remain in a breech position. So if your baby is breech at 30 or 32 weeks, we don't need to be too worried about this because we know that 90% of these babies are going to turn around all by themselves by the time you get to 36 or 37 weeks. 

00:01:02 

Now, if it's your first baby and your baby breech at 36 weeks, the chance of it turning around on its own after that are quite small. Similarly, if it's your second or subsequent baby, we tend to give baby another week to turn on its own. But if your baby is still breech at 37 weeks, then it's probably not going to turn around on its own after that. 

00:01:25 

So, depending on whether or not this is your first pregnancy, 36 to 37 weeks is the time when we become really interested in the position of your baby in terms of whether your baby is head first or bottom first. 

00:01:38 

Even if your baby is breech at 36 to 37 weeks, there is still a small chance your baby will turn around on its own, and most babies don't. If your baby is breech coming into the last month of pregnancy, we need to make some decisions about how you're going to give birth. There are three options. 

00:02:00 

We can do a procedure called an ECV, which is an external cephalic version, and that's where we attempt to turn the baby around from a breech position into a head first position and we'll talk about that in a bit more detail in a minute. 

00:02:16 

The second option would be to leave your baby in a breech position and attempt a vaginal breech birth and we'll talk about that also. And the final option would be to do an elective caesarean, and if all else is well with your pregnancy and assuming that you don't come into labour prior, this would usually be done close to 39 weeks gestation. 

00:02:38 

It's worth mentioning that this decision is very much a shared decision made between you, your partner and your pregnancy care provider, and in my podcast on birth after caesarean section I spend a little bit of time talking about the process of shared decision making. 

00:02:56 

Let's start by talking about ECV or external cephalic version. So this procedure is generally done at around 37 weeks gestation. It's done in a supervised environment, such as in a birth unit environment or similar, somewhere where we have an ultrasound so we can verify the baby's position and somewhere where we can continuously monitor the baby's heartbeat throughout the procedure to make sure that we're not doing anything that's going to compromise the baby's well-being. 

00:03:26 

So what do we know about ECV? We know that if it started around 37 weeks gestation, that it's a safe procedure, so the risks associated with ECV are really very small provided it's done in those circumstances I mentioned previously. We know that it doesn't always work. 

00:03:46 

If it's your first baby, the success rate is probably around about 30%, and if it's your second or subsequent baby, then success rates of over 50% would usually be expected. We also know that if the ECV works, your baby is very unlikely to turn back, so less than 5% of babies will spontaneously turn back to breech position if the ECV was successful. And for those women where the baby remains in a head first position, the pregnancy can then be allowed to continue on with labour managed just as per normal. 

00:04:25 

So what would happen if you decided to have an ECV? So the procedure would generally be booked in with your birth unit at the hospital where you're having your baby. You would come in on the designated day. The midwife in birth unit would attach a CTG or a foetal heartbeat monitor, and we'd run that monitor for a while before we do anything, just to make sure that your baby is happy and in good condition before we attempt the ECV. 

00:04:52 

We would often give you an injection of a drug called terbutaline and this helps to slow down uterine contractions. So in the background, your uterus is tightening all the time, particularly in the last month of pregnancy. And if we go poking around our new uterus, we stimulate some tightening of the uterus and those tightenings make it a little bit harder to turn the baby around. So there is some quite good evidence that if we use a drug like terbutaline, it helps to relax those contractions and makes the success of the procedure a little bit higher. 

00:05:30 

What does this mean for you? Terbutaline has a common side effect of making your heartbeat race a little bit, but otherwise it's a very safe drug and it's very unlikely to have any other significant side effects for you, and it's very safe for your baby. So once we've given you some terbutaline, and we've done a CTG to make sure that your baby is happy, we will then do an ultrasound just to confirm the position of your baby. We'd get you laying quite flat. 

00:05:57 

Probably a bit more flat than you would usually be comfortable lying during pregnancy and then by massaging your tummy we can gently but firmly try and assist your baby to rotate to do a somersault either forwards or backwards into a head first position. So the process of actually doing the ECV doesn't usually take more than five to 10 minutes. 

00:06:20 

It is mild to moderately uncomfortable, but should always be done within the limits of what you're able to comfortably tolerate and it's not a procedure that would use pain relief medication for. 

00:06:34 

We will monitor the baby's heartbeat during the ECV to make sure that the baby stays happy during the procedure and if at any time the baby seems to be unhappy, we can turn the body back to its original position. 

00:06:46 

We can use ultrasound also to monitor our progress and to verify the position of the baby at the conclusion of the ECV procedure. 

00:06:55 

Once the ECV has been completed, whether successful or unsuccessful, it would then be placed back on the foetal monitor for a period of time to ensure that we haven't done anything that's going to cause the baby any concern or distress. Once we're happy that the CTG monitoring is fine at the end of the ECV you would then be able to go home.  

00:07:15 

We would advise you that if you have any vaginal bleeding, if you have any abdominal pain or if your waters break to call up the birth unit and come back for assessment. 

00:07:27 

ECV does not appear to increase the likelihood of labour happening in the days following the procedure. There's good evidence that ECV is a safe and reasonable way to approach babies that are breech in the last few weeks of pregnancy. And if we offer every woman with a breech in the last part of pregnancy, we do reduce the number of breech babies presenting in labour at the end of pregnancy. So it is a worthwhile intervention to consider. 

00:07:54 

An alternative to this, or an option if your ECV is not successful, would be to consider a vaginal breech birth. Fundamentally, the concerns around vaginal breech birth relate to the fact that for most babies, the head is the largest part of the baby and with a breech birth, the baby's head is the last thing to emerge. And if we have difficulty in delivering the baby's head, that can be very serious in terms of the outcome for the baby. 

00:08:24 

Now there was a very large study published in medical literature in the year 2000 which aimed to solve the question as to whether vaginal breech birth was safe or not. Now, this study, known as the Turnbridge trial, drew some conclusions that have subsequently been questioned. However, the Turnbridge trial concluded that planned caesarean section was safer for the baby when compared with vaginal breech birth. 

00:08:55 

It's reasonable to say that a number of subsequent analyses have identified some shortcomings with this trial, and have called into question the conclusions that were drawn. So we now believe that for a selected group of women who are motivated to water attempted vaginal delivery that this can be done in a reasonably safe way. 

00:09:19 

It's also worth mentioning that vaginal breech delivery is a bit more risky for the baby than a vaginal birth of a head first baby. There are a number of factors that influence this risk, such as whether you've had a successful vaginal birth in the past, the size of your baby, the type of breech presentation that your baby's in, whether the feet are under the bottom, or whether the feet are sitting up in front of the baby's face. And these are all issues that need to be discussed on an individual basis with yourself and your pregnancy care provider. 

00:09:57 

It's also important to realise that some clinicians feel more comfortable with attempting vaginal breech birth than other clinicians. So if your clinician is not somebody who's comfortable considering a vaginal breech birth and this is something you're wishing to pursue, there are resources available which can guide you to clinicians who have some interest and expertise in managing vaginal breech birth. 

00:10:26 

Another thing to consider, if you are contemplating vaginal breech birth is to seek out a hospital that supports vaginal breech birth and has the necessary support mechanisms and structures in place to ensure this can be carried out for you in the safest way possible. 

00:10:45 

Finally, there is the option of elective caesarean section. Some women are not keen on the idea of ECV and this is very much an individual decision. 

00:10:57 

In the setting of an elective caesarean just for the reasons of breech presentation, as I mentioned earlier, this will usually be done as close to 39 weeks as possible, accepting that there is a small chance that your labour may begin spontaneously before 39 weeks, in which case there will usually be ample time to arrange a caesarean with the onset of labour. When it comes to breech presentation in the last few weeks of pregnancy, those are the available options. 

00:11:29 

Information I've discussed today is of a very general nature and there will often be things that are quite specific to you, to your baby, or to your pregnancy that will have an important bearing on the applicability of these options to your circumstance. So it's really important that if your baby is breech in the last month of pregnancy that you have a discussion with your pregnancy care provider about how these options can be applied to you and come to a decision that is in the best interests of the things that you want to achieve and also the health and well-being of your pregnancy and your baby.  

00:12:13 

I hope you have found this content informative and enjoyable. If you have any feedback or suggestions for future episodes, please get in touch and bye for now. 

 

   

 

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Episode 9 Content and Overview

In episode 9 of the Pregnancy and Childbirth podcast, Dr Greg Jenkins, obstetrician and gynaecologist, talks about birth following caesarean section.

Listen to this episode to learn about:

• Why birth following caesarean section is an issue

• The principles of making important decisions around medical care or shared decision making

• The risks versus benefits and the framework that sits around that decision making for each individual woman

• Special circumstances that arise on occasions

• Care during labour if you are pursuing a vaginal birth after caesarean
  

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Happy listening and don’t forget to subscribe to the Pregnancy and Childbirth podcast with Dr Greg on Apple Podcasts to get new episodes as they become available.  

Transcription

00:00:00 

Hi, I'm Greg Jenkins and welcome to my pregnancy podcast. Today we're going to talk about birth following caesarean section. This is commonly known as VBAC or NBAC. NBAC stands for next birth after caesarean and VBAC stands for vaginal birth after caesarean. 

00:00:21 

I'm going to cover a few different areas. The first thing we'll talk about is why is this an issue? The second thing we'll talk about is the principles of making important decisions around medical care or shared decision making. Next, we’ll cover the risks versus benefits and the framework that sits around that decision making for each individual woman. We’ll then cover some of the special circumstances that arise on occasions and then finally talk about care during labour if you were pursuing a vaginal birth after caesarean. So let's hop into it. 

00:00:57 

The first thing is why is this an issue? Well, if you've had a caesarean before, then you're faced with the choice as to whether you want to have a caesarean again, or whether you'd like to attempt a vaginal birth. Now this is an important decision because unlike your first pregnancy or the pregnancy which ended up with a caesarean, you now have a scar on your uterus and that poses some particular concerns around things that might happen during labour. 

00:01:26 

For some women this decision making is very clear. Some women come to pregnancy with a very clear idea of how they would like to approach the process of birth for their next pregnancy. But for many women this is a challenging decision which is made across the course of their pregnancy. 

00:01:46 

Let's talk about shared decision making to begin with. This is something that not only applies to decisions around caesarean section, but applies to most significant decisions in pregnancy and in fact across medical care generally. 

00:02:01 

So there's an acronym called SHARE which I think outlines very nicely the process of shared decision making and I think it helps both sides, both the medical practitioner or the health care provider and the patient, or in this case the pregnant woman, in understanding the framework that we work through in making this decision. 

00:02:24 

So, I would see my role very much as not telling you what to do but participating in a decision-making process with you. 

00:02:34 

So the first step, the S in SHARE, is about seeking your participation. So how we agreeable, that this is the process that we're going to work through together. 

00:02:44 

The second thing is helping to provide you with the information that you need to help guide your decision making and ensuring as far as possible that that's accurate and reliable information that's pertinent to your particular circumstance. 

00:03:00 

The A in SHARE is about assessing your values and preferences and bringing the information that we have into line with your preferences and values so that we can move towards making a decision. 

00:03:15 

The R is to reach an outcome. So to reach a decision about what you would prefer to do. And the E at the end is my evaluation of your decision. Evaluation is mostly going to mean that we reflect on the process that we've gone through and we feel satisfied that we've achieved an outcome that's being respectful of your personal autonomy to make an informed decision about the aspects of care that intimately affect you and your pregnancy and your baby. 

00:03:50 

However, there might be occasions where we don't come to complete agreement, but nevertheless I will still respect your choice to make an informed decision about your care. 

00:04:03 

The other useful thing to mention is that over the course of pregnancy, this is a conversation which happens rather than being a specific decision point. Meaning that we have time to think over these issues to digest them to see how pregnancy progresses and see how the progress of pregnancy sometimes influences the decisions which are arrived at at the end of pregnancy, which might be a little bit different to the decisions which could have been right at the beginning of pregnancy. 

00:04:35 

With all that out of the way, let's talk about how we make a decision. There are three things that I see as being major influences over the decision to attempt a vaginal birth, or to choose for a repeat planned caesarean. 

00:04:53 

The first is the likelihood of success, so is this attempt at a vaginal birth likely to be successful, and if so, how likely? 

00:05:03 

The second is what maybe the risks associated with attempting a vaginal birth after a caesarean in your particular circumstance. And the third is to acknowledge the framework with which you make those decisions. So, what are the things that are really important for you? What are your main priorities. 

00:05:26 

When it comes to assessing success or the likelihood of success in attempting a vaginal birth, there are characteristics about your past pregnancy histories that are very important. 

00:05:40 

So, for example, if you've had a successful previous vaginal birth already, whether that was prior to your past caesarian or following your past caesarian that increases your success rate quite substantial. 

00:05:54 

The other thing will be the circumstances around your caesarean. So why did you have a caesarean? So we know that for women who had a caesarean for what we call a nonrecurring indication, meaning something that was particular to that particular pregnancy, the likelihood of success for vaginal birth in a subsequent pregnancy is higher. So one of the examples around this would be a caesarean that was done for a breech presentation, so a baby that was coming bottom first. If your next baby is not breech, then there's quite a high likelihood that if you attempt to vaginal birth, you'll be successful. 

00:06:34 

There are other reasons for a caesarean. The most common reasons for a caesarean being performed during labour would be lack of making adequate progress during the course of labour or the baby showing signs of compromise in labour. 

00:06:48 

Now, if your previous caesarian was for a lack of progress in that the baby appeared to get stuck and was unable to fit through, then the likelihood of success for a subsequent vaginal birth is a little bit lower than for some of what are called nonrecurring indications. 

00:07:07 

There's also some personal characteristics around the mother. So we know that for women who have a higher BMI or a higher weight are the likelihood of success is it is a little bit lower. 

00:07:20 

It can also be a bit lower if you've had some other pregnancy complications, and if you're having a large baby. So, for example, a baby estimated to be greater than 4 kilograms, the success rate is likely to be lower. 

00:07:35 

In order to assist with these calculations, there are online VBAC success calculator. And if you Google VBAC success calculator, you'll come across some algorithms for which you can enter a number of your characteristics and they will give you some estimate of success. 

00:07:55 

Bearing in mind, these are just estimates and there may be things that are particular to you or to your pregnancy that you're a pregnancy care provider could guide you on a little bit more specifically than an online calculator will be able to. Nevertheless, they do provide some really helpful ballpark information. 

00:08:18 

So what about the risks of having a VBAC? There's a lot of focus around risk of VBAC, so this is something we need to focus our attention on. If you're a pregnant woman who's making a decision to undergo VBAC it, it is important that you are aware of the potential risks. 

00:08:37 

So what are the risks? So having had previous caesarean you know how to scale on the lower part of your uterus. This does not usually present a problem during the course of pregnancy, however, during labour when your uterus contracts, you generate very large pressures inside the uterus and the scar on leaders from your previous area is a potential weak point in the wall of the uterus. 

00:09:01 

Therefore, there's a small risk of this scar separating, or in fact bursting open or rupturing during the course of labour. So I should stress this is for the most common type of caesarean that's performed. This is extraordinarily uncommon to happen prior to the onset of labour. 

00:09:22 

We know that of the women who attempt a vaginal birth after a caesarean, there's approximately a 1 in 200 risk of some type of scar separation or scare rupture occurring during labour and in most of these instances that's not going to be a terribly serious event. The team of midwives and doctors that are looking after you will most likely recognise that there seems to be a problem occurring and will recommend the caesarian be carried out and provided this is done in a fairly prompt way, it's unlikely that there will be any serious outcome for either you or your baby. 

00:10:01 

You'll notice that I did say mostly, and we do have some fairly specific and fairly reliable numbers around the potential risks associated with VBAC in terms of a serious outcome for mother and baby. So it's important that we talk about those numbers. 

00:10:20 

So if you are attempting a VBAC, there's something like a 1 in 1000 or 1 in 1500 chance of something really serious going wrong that will have really major long term consequences for your baby and when we talk about major long term consequences we mean stillbirth, or your baby not surviving, or a brain injury to your baby due to lack of oxygen that will lead to a permanent disability. 

00:10:50 

Now something that happens to around 1 in 1000 women who are attempting a VBAC is certainly not a common event, but nevertheless it is something that does occur, and for those women where it happens and it is a tragic and catastrophic event. 

00:11:08 

The other thing that can occur if the scaling uterus ruptures is to cause some serious risks to the mother. So this can lead to significant bleeding into the abdominal cavity, so into the tummy, and can result in the need for a blood transfusion. There can be injury to other things so you can get a tear extending into the bladder, which can be quite challenging to repair. And if it's a really bad rupture, sometimes the only way to stop the bleeding is to do something as drastic as a hysterectomy. Now this is not common and this will occur in significantly less than 1 in a 1000 women who attempt a vaginal birth after caesarean, but nevertheless they are things that we need to be aware of and take these into account in making our decisions. 

00:12:01 

I also think it's very important that we keep these risks in some degree of perspective. For a woman who's not had a caesarean before, who's a low-risk woman in labour, there's also about a 1 in 1000 chance of something seriously going wrong during the course of labour that might have a significant impact on the long-term health and well-being of the child. 

00:12:26 

So, no matter which way we approach childbirth, there are always some types of small risks associated with the decisions that we make. Those figures that I quoted in terms of risks associated with vaginal birth after caesarean section apply to women who've only had one previous caesarean, and I'll talk about women who've had more than one caesarean a little bit later. 

00:12:51 

There are also some factors that are associated with an increased risk of scar rupture during labour. One of those things would be that if we use drugs to stimulate the contractions of your uterus.In other words, if we did an induction of labour, then we would use a drug called oxytocin to stimulate your uterine contractions. And we know that if we use oxytocin in somebody who's had a previous caesarean the risk of rupture and the risk of something serious going on goes up by a factor of about two times, so it doubles. 

00:13:25 

We also know that, or we think we know, that if there's a short interval between your pregnancies, risk of rupture increases. Now we would consider a short interval as an interval of less than 18 months between births. So this would mean if you had an interval of around 12 months since the birth of your last child until you get pregnant again, that you're in a safe interval in terms of your risk of VBAC, but if your pregnancies have occurred very close together such that the births are likely to be less than 18 months apart, there is probably an increased risk of scar rupture during labour in your subsequent pregnancy. 

00:14:07 

It can also be things about your previous caesarean that might increase your risk of scar rupture. So mostly with a caesarean it'll be performed through the lower part of the uterus without any of the incision on the uterus extending into the upper half of the uterus. 

00:14:25 

If there's been an incision or a tear extending into the upper part of the uterus during your previous caesarean then firstly the medical team will very likely have informed you about this event because it is quite uncommon. And secondly, if this has happened it changes the risk profile quite significantly, in that it increases the risk of rupture quite a lot for your subsequent pregnancy. 

00:14:51 

And that's why if you've had a caesarean before, we're quite keen on delving into some of the details and circumstances around that caesarean. So that's about sharing information with you about the risks and benefits of attempting vaginal birth after previous caesarean. The thing that's potentially going to be very important for you is the framework that you bring to that decision making. So what are your priorities? 

00:15:17 

Some women will come very much with the priority of maximising the chances of attempting a virginal birth because that's something they feel is very important for them. Other women or couples might come from a much more safety conscious perspective. 

00:15:36 

So, the information is the information, but how you process that information in a way that's most relevant to you and helps to guide you to the most appropriate decision for you and your pregnancy and your baby will vary greatly from individual to individual. 

00:15:54 

There may be additional information which is particularly pertinent to you, and we'll call these special circumstances. One of these I alluded to before, was women have had more than one previous caesarean. 

00:16:07 

The information to help guide our decision making around this is not quite as strong as for women who have only had one caesarean, so we do know that if you've had two previous caesareans, the risk of uterine scar rupture goes up quite significantly compared with one estimated probably to about double the risk. 

00:16:25 

Once we moved women who've had three or four previous caesareans, the risks become extremely difficult to calculate but the information we have suggests that the risks probably become quite high, and this would need to be discussed in an individualised way. 

00:16:44 

Finally, assuming that we've made a decision that we're going to go down the pathway of attempting a vaginal birth after your caesarean, what does your care during labour look like? 

00:16:55 

So firstly, we're going to try and avoid doing an induction of labour because we know that induction of labour doubles the risk of things going wrong. 

00:17:05 

Secondly, there are no limitations around your pain relief in labour. So you can access whatever form of pain relief you like. So an epidural is fine, you can breathe on gas, you can use morphine or pethidine if you wish. 

00:17:20 

Next, we'd like to see you reasonably early in the course of labour. This enables us to assess your baby’s well-being and assess the progress of your labour, both of which are important factors in attempting a VBAC. So, once you start to develop regular painful contractions, or your waters break, it's a good idea to call up the birth unit and make your way into hospital, probably a little bit earlier than you might otherwise do if you hadn't had a previous caesarean. 

00:17:53 

Another aspect of your care that will be a little bit different is if you're attempting a vaginal birth after a previous caesarean, then we like to continuously monitor your baby's heartbeat during the labour. This is because the baby's heartbeat tracing gives us the most reliable indicator of how things are progressing with the scar on your uterus. So, you remember that we talked about uterine scar rupture has domain risk associated with vaginal birth after caesarean, so the baby's heartbeat tracing is the most reliable indicator that there might be a problem developing with the scar.  

00:18:34 

Now for some women continuous monitoring can be an issue in that you may want to mobilise actively during labour. You might want to be in the shower. And most birth units nowadays will have telemetry monitoring systems, which means that state you can be hooked up to a fetal monitor without the need for wires and cables, and be able to mobilise and hop in the shower and move around the room reasonably comfortably without the encumbrance of being physically connected to a monitor. Otherwise your care and assessments during labour will be carried out in a in a fairly routine way. 

00:19:13 

Finally, I think it's important to say that there's very often no clear cut right or wrong answer around the questions involved in decision making for attempting vaginal birth after a previous caesarean, and it's important that you have an individualised discussion with your pregnancy care provider and come to a decision that you and your partner feel comfortable with. 

00:19:37 

Thank you for listening. I hope you found this information informative and enjoyable. We would welcome any feedback and if you have any suggestions for future episodes please reach out. Bye for now. 

   

 

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Episode 8 Content and Overview

In episode 8 of the Pregnancy and Childbirth podcast, Dr Greg, obstetrician and gynaecologist, provides an update on the developing COVID-19 situation (as at 29 August 2021).

Listen to this episode to learn about:

• What's happening with COVID-19 in Western Sydney

• New recommendations regarding COVID vaccination and pregnancy

• New recommendations regarding COVID vaccination in breastfeeding
  

Additional Resources

• Pregnancy and Childbirth podcast episode 6: COVID-19 and Pregnancy

Subscribe

Happy listening and don’t forget to subscribe to the Pregnancy and Childbirth podcast with Dr Greg on Apple Podcasts to get new episodes as they become available.  

Transcription

00:00:00 

Hi, I'm Greg Jenkins and welcome to this episode of My Pregnancy Podcast. Today is the 29th of August 2021 and this episode is going to be an update on COVID and pregnancy. Now if you haven't had to listen to my previous episode on pregnancy and COVID. 

00:00:20 

It would be worthwhile doing so because I'm not going to recap on the things that I discussed in that episode, but I'm going to provide an update with respect to things that have changed since I recorded that episode. So what has changed in a few weeks since I recorded my episode on COVID and Pregnancy? 

00:00:43 

There are 3 things that I'm going to touch on today. One is what's happening with COVID in Western Sydney, which as you may be aware, is where my work is based. The 2nd is the new recommendations regarding COVID vaccination and pregnancy, and the 3rd relates to COVID vaccination in breastfeeding where there are some new recommendations as well. 

00:01:07 

So firstly, what's happening with COVID in Western Sydney at the moment, as you may be aware, Western Sydney is pretty much the epicenter of COVID in Australia at the present time, and unfortunately we're seeing lots of pregnant women being diagnosed with COVID. 

00:01:24 

Now, as we're seeing and as I mentioned in my previous episode, most of these women are experiencing quite a mild illness, are and are not requiring hospitalization. However, we are seeing quite a number of women admitted to hospital and a small number of women admitted to intensive care and occasions have even occurred where pregnant women have required ventilation. 

00:01:50 

As the number of pregnant women diagnosed with COVID in Western Sydney continues to increase I expect that we will see a greater number of hospitalizations and unfortunately we will probably see a greater number of women admitted to intensive care with severe COVID illness. 

00:02:08 

For any women who are pregnant or wishing to become pregnant, my advice to you would be to get vaccinated as soon as you possibly can. And the other really important piece of advice, whether you're vaccinated or not vaccinated is to ensure that you are complying with the public health recommendations. 

00:02:28 

So, with respect to vaccination in pregnancy, what's changed in the last few weeks? Well, at the time when I recorded my previous episode, the Moderna vaccine was not available in Australia at that time. 

00:02:40 

Now the Moderna vaccine is similar to the Pfizer vaccine in that it is an mRNA vaccine. It's not identical to the Pfizer vaccine, there are some slight differences, but it is a vaccine which has also now been approved by ATAGI and recommended by RANZCOG as being safe for use in pregnant women. 

00:03:04 

So as a pregnant woman or a woman who is trying to fall pregnant, either the Pfizer or Moderna vaccines would be suitable. 

00:03:14 

In terms of evidence supporting the safety of COVID vaccination in pregnancy, there have been some new studies published looking at quite large numbers of women are again confirming the vaccine is safe in pregnancy based on all the information that we have currently available with no serious adverse pregnancy events associated with mRNA vaccination that is either Pfizer or Moderna are when given in pregnancy. 

00:03:44 

The other new piece of information which has come out since I recorded my previous episode relates to COVID vaccination in breastfeeding. So at the time of my last episode, the recommendation from RANZCOG and ATAGI was that Pfizer was the preferred vaccine for our breastfeeding women. This is now being expanded to include the AstraZeneca vaccine. 

00:04:10 

I should state that at the time I recorded the previous episode, there were no safety concerns around the AstraZeneca vaccine for breast feeding. It was felt at that time that there wasn't sufficient information available to make clear judgment. 

00:04:25 

Since then, further information has become available and both ATAGI and RANZCOG have supported the AstraZeneca vaccine as being safe and effective for women who are breast feeding. So if you're a breastfeeding woman, any of the 3 available vaccines would be perfectly suitable for you, either AstraZeneca, Pfizer or Moderna. 

00:04:48 

And as mentioned in the previous episode, once you are vaccinated and you have antibodies, there's good evidence that those antibodies pass through your breast milk to your baby. So they are likely to be beneficial for your baby as well as for yourself. 

00:05:02 

That's all I wanted to say for this update on COVID in pregnancy and COVID vaccination in pregnancy and breastfeeding. I hope you found this information useful and helpful. Please keep safe, get vaccinated and follow the public health orders. Bye for now. 

   

 

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Episode 7 Content and Overview

In episode 7 of the Pregnancy and Childbirth podcast, Dr Greg, obstetrician and gynaecologist, discusses induction of labour.

Induction of labour involves using medical treatment to artificially stimulate the commencement of labour.

Labour induction may be recommended when your pregnancy care provider feels that it is in the best interest of either you or your baby for birth to be brought on sooner, rather than waiting for labour to begin naturally.

When considering labour induction, it is important to be aware of the benefits and risk so that you can decide what is best for you and your baby.

Listen to the podcast to have your questions answered:

• What is induction of labour?

• Why do we induce labour?

• What are the risks?

• When shouldn’t we do an induction of labour?

• How do we induce labour?

• What are the myths around induction of labour?

If you've reached a point in your pregnancy where you're having a discussion around induction of labour with your pregnancy care provider, there are three important questions that should be addressed:

1. Why are we doing an induction of labour? Part of that why question should involve a balancing of the risks and benefits

2. When will we induce labour? Are we going do an induction of labour just after 39 weeks, or are we going to wait until 41 to 41+ weeks?

3. How will we induce labour?

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Happy listening and don’t forget to subscribe to the Pregnancy and Childbirth podcast with Dr Greg on Apple Podcasts to get new episodes as they become available.  

Transcription

0:00
Hi, I'm Dr. Greg, obstetrician, and welcome to this episode of my pregnancy podcast. Today, we're going to talk about induction of labour.

0:11
Induction of labour, also known as induction, or IOL, is one of the commonest interventions performed in the latter part of pregnancy. Recent studies suggest that as many as 40%, and in some hospitals, perhaps even more than 40% of women will undergo induction of labour in the latter part of their pregnancy.

0:31
The frequency of induction of labour has increased in recent years. And we'll come to some of the reasons for that a little bit later. So why don't we start with defining what it is we're talking about. So what is induction of labour? Induction is when we make a decision to artificially stimulate the commencement of labour. And we'll talk about some of the ways that we do this a little bit later as well.

0:58
So why do we do induction of labour? And why has it become more common? Induction of labor is done either for the benefit of the mother, or for the benefit of the baby, or perhaps a combination of the two. Essentially, the decision that we're making is that we feel it would be in the best interest of either mother or baby, for the pregnancy to come to an end and the baby to be born, rather than for the pregnancy to continue.

1:26
So what are some of the common reasons where we might perform an induction of labour? It might be considered because the pregnancy has continued for a bit too long. We used to think that it was perfectly reasonable to allow pregnancies to continue to 42 weeks and beyond. We now know that once we go beyond 41, to 41 and a bit weeks, the risks to the baby, even in what appears to be a low risk pregnancy, do start to increase a little bit as we move closer to 42 weeks. So most people would now agree that induction of labor is a reasonable thing to consider.

2:03
Once we get to the 41 to 41 and a half week stage of pregnancy, there are other reasons for considering an induction of labour other than being overdue. For example, if we feel that your baby is not growing well, in the latter part of pregnancy, we might consider that it's a little bit safer to deliver the baby rather than to allow the baby to remain in the uterus.

2:26
There are other medical conditions such as pregnancy diabetes, and high blood pressure or preeclampsia, which are also some of the common medical reasons while we might have a discussion around induction of labour. And there's an increasing amount of evidence to suggest that if your baby appears to be very large, that induction of labour a little bit before the due date, probably results in a greater likelihood of a good outcome for you and your baby, compared with allowing the pregnancy to go beyond the due date.

3:01
Sometimes induction of labour is performed for reasons of maternal preference. For example, there can sometimes be a lot of discomfort associated with the latter part of pregnancy. And for some women having their baby just prior to the due date rather than having to endure another week of pregnancy can be highly preferable. Sometimes for matters of convenience, organisation of work, organisation of childminding, and various other activities of daily life can be more easily planned, if there's a scheduled date for delivery of the baby. So maternal preference can certainly come into the equation when making decisions around induction of labour.

3:45
Now, there's one other factor which we need to talk about in any discussion around induction of labour. And that's the risk of stillbirth. There's an initiative launched in Australia in the last 12 months called the safer baby bundle, which is about implementing measures to try and reduce the rate or the likelihood of stillbirth in the latter part of pregnancy. Whilst this is not a common occurrence, all of us would agree that any initiatives that can be undertaken to help reduce this tragic occurrence would be worthwhile. So part of the initiatives in the safer baby bundle is to think carefully about each woman's pregnancy and to think about the risk factors that may exist for the risk of stillbirth as we approach the due date.

4:39
And whilst we don't always understand the exact reasons for stillbirth in the later part of pregnancy, we are aware of some of the risk factors that increase the likelihood of this tragic occurrence. By identifying women with risk factors and discussing these risk factors. We can come to a plan for the timing and safe delivery of your baby. I should reiterate that the likelihood of stillbirth occurring in the latter part of pregnancy is very low and Australia does have one of the lower rates of near term stillbirth of most of the developed countries in the world.

5:21
So when shouldn't we do an induction of labour? Well, again, there was another initiative launched a few years ago by New South Wales Health, called every week counts. And this highlighted the fact that if baby's healthy and well inside the uterus, that there are a lot of very important developmental things that occur for your baby up to 39 weeks gestation. So unless there's a very clear medical indication for delivery prior to 39 weeks, a strong preference for the benefit of your baby is to keep baby inside your uterus until at least 39 weeks gestation.

6:03
Well, what do we know about induction of labour? We know that if we induce labour after 39 weeks gestation, that there doesn't seem to be any increased risk to mother or baby of having a bad outcome because of the induction of labour. We also know that induction of labour from 39 weeks on does not appear to be associated with an increase in likelihood of having a caesarean birth and we can be reasonably reassured about the reliability of this information based on a very large trial that was conducted and published within the last couple of years. It's called the arrive trial and it showed quite clearly, that induction of labour from 39 weeks on was not associated with any harms for either mother or baby.

6:55
Now, that doesn't mean that induction of labour is completely risk free. We do know that induction of labour is an artificial way of commencing labour. And we know that when we induce labour, or move from a situation where there are essentially no uterine contractions, to a situation where there are very frequent and painful, strong uterine contractions, and this transition happens much more quickly with an induction of labour than happens for women whose labour starts naturally. So with naturally occurring labour, there are often several hours of pre-labour where the contractions will be fairly spaced out and fairly mild, and will gradually progress to those more frequent, strong and regular contractions. And that certainly happens much more quickly in the presence of an induction of labour. Now for some women, this can make the contractions seem much more painful, and seem more difficult to cope with. So whilst not everybody who has an induction of labour has an epidural, if we look at epidural rates amongst women who are induced, they are a little higher compared with women whose labour has started spontaneously.

8:14
Having an epidural is not necessarily a problem. But if you've had an opportunity to have a listen to my podcast on epidurals, and I'll give it a plug if you hadn't, it's well worth a listen, you would know that whilst epidurals are safe, there is an increased likelihood of having either a vacuum or forceps assisted birth, if you have an epidural compared with women who labour without having an epidural.

8:41
Now, because we're using drugs to artificially stimulate the uterine contractions, there is a need for continuous fetal monitoring or CTG monitoring during labour. Whereas if you had a naturally occurring labour and you didn't have an epidural or oxytocic drugs to stimulate your uterine contractions during labour, you wouldn't necessarily need to have continuous fetal monitoring. And this can make mobilising and labour a little more difficult if you're connected to a monitor. You can still mobilise and be active in labour with a monitor, but it is one of those things that does tend to get in the way a little bit.

9:21
The other thing about using oxytocin drugs to stimulate uterine contractions, we are a little more likely to have abnormalities of your baby's heart rate during labour. This occurs a bit more often in induce labour's compared with naturally occurring labour's provided we manage this carefully during the labour, it doesn't seem to result in an increase of the need for a caesarean birth, or an increase in the likelihood of your baby becoming compromised during labour.

9:55
I guess that brings us to some of the commonly held myths around induction of labour. So as we've already said, induction of labour is not associated with an increased likelihood of a caesarean birth. Induction of labour is not dangerous for the health or well-being of your baby. It's commonly said that induction of labour is more painful than naturally occurring labour and we've addressed the reasons why that may be the case. It's often said that if you have an induction, you'll have an epidural. And that certainly doesn't need to be the case. I've cared for many, many women who've had induction of labour and not had an epidural. But epidurals are more likely in women who have an induction of labour compared with those that don't.

10:46
So what about the issue of induction of labour purely for reasons of maternal request? Well, as we've heard, if we're looking at induction of labour, anytime from 39 weeks on, this is not associated with any harm for either mother or baby. So I think we should be open to the idea of having an informed discussion with the women we look after, so that they're in the best position to make a decision about whether induction of labour electively after 39 weeks is something that they feel comfortable with. And if they do, the preference of the pregnant woman, and or her partner should be respected.

11:27
Well, what if you want to avoid having an induction of labour? Is there anything that you can do to help bring on the labour naturally? There isn't a lot of good quality evidence or information to guide us in this area. One thing that has been shown to be beneficial is a vaginal examination involving a strip and stretch, or a sweep of the membranes. This involves your pregnancy care provider, doing a gentle internal examination and if your cervix is a little bit dilated already, as it often is, after 39 weeks gestation, it's possible to give the cervix a gentle stretch, or to sweep the membranes away from the inside of the cervix. It's thought that this stimulates release of natural prostaglandin, which is a hormone released by your cervix, the membranes and the lining of the uterus. And prostaglandins are thought to play an important role in the initiation of labour. So this examination can be a little uncomfortable but there is some evidence that there's an increased likelihood of labour occurring within a few days of this examination, compared with women who have not been examined.

12:40
If you Google natural methods for induction of labour, you'll come up with a long list of suggestions for things like castor oil, which will probably just give you a nasty case of diarrhea, spicy food, exercise, sexual intercourse, nipple stimulation, herbal remedies, such as raspberry leaf tea, and also acupuncture. Now, it's not to say that none of these things are going to cause initiation of labour in some women. But the available evidence we have does not support any of these things being effective in initiation of labour. So not to say you shouldn't try them but you should be aware that there really isn't any evidence to show that they work.

13:27
If you've reached a point in your pregnancy where you're having a discussion around induction of labour with your pregnancy care provider, there are three important questions that should be addressed and which you should have an answer to. The first is why you're doing an induction of labour and part of that why question should involve a balancing of the risks and benefits. So the risks of continuing with the pregnancy, compared with the risks of doing an induction of labour, versus the benefits of doing an induction and the benefits of continuing with the pregnancy. And the decision, by and large should be based around a balancing of those risks and benefits.

14:07
The second question is when, so timing of induction of labour is critical, are we going do an induction of labour just after 39 weeks, or are we going to wait until 41 to 41+ weeks? Obviously, the longer we wait, the greater the likelihood that your labour will occur spontaneously in the meantime.

14:26
And the final question should be the how. What methods are going to be used to induce your labour? How is this going to occur? We've already spoken a little bit about risks and benefits, and we've spoken a bit about timing. So let's move on to the how are we going to do an induction of labour. So before having an induction of labour, you will need to have a vaginal examination to assess your cervix. And we rate your cervix as either being favourable or unfavourable. And this means how ready is your cervix for the onset of labour.

15:03
Now, if your cervix is not very ready for labour or unfavourable, then we will usually recommend some cervical ripening techniques. So these are techniques to help get your cervix ready for labour. So there might be two steps in doing an induction of labour for you if your cervix is not ready. The first step will be about getting your cervix ready for labour and the second step will be actually getting you into labour. Now, if your cervix is already ripe, in other words, if it's ready for labour, you don't need to do the first step so it's going to be just about getting you into labour.

15:40
So what if your cervix is not ripe or not ready for labour, then how will we approach this? So generally, you'll come into hospital the day prior to the induction and depending on which methods are used, you might stay in hospital overnight prior to your induction, or you might be able to go home and come back the following day.

16:02
Fundamentally, there are two techniques for preparing your cervix for labour. The first is what's called a balloon catheter. So this is a rubber or latex tube, which is inserted through your cervix with an examination a little bit like a pap smear, and the balloon is blown up on the inside of your cervix. The balloon is about as big as a 50 cent piece approximately when fully inflated. The examination to put the balloon in is usually quite well tolerated. It's a little uncomfortable. Most women tolerate this really well. The balloon causes some irritation to your cervix and to the membranes, and causes release of natural prostaglandins and as we mentioned earlier, prostaglandins play an important role in not only in the initiation of labour, but also in the ripening of the cervix. And the benefit in using a balloon is that there's quite a low likelihood of you coming into labour from this technique. It doesn't stimulate uterine contractions, so it's very safe for your baby and therefore, if you've had a balloon inserted, it is safe for you to go home and come back the following morning for your labour to be induced.

17:15
The second technique is to use a vaginal medication called prostaglandin and this can be either administered as a gel or as a vaginal tablet. Before insertion of either the gel tablet or balloon catheter, you will have a fetal monitoring or a CTG carried out and you'll have another monitoring following the procedure.

17:39
Now, if you're having gel or vaginal prostaglandin tablet, you will need to remain in hospital overnight, because these medications can cause uterine contractions, and some women, although it's not the intent of the medication, some women will come into labour in the few hours following the administration of this medication. So some additional fetal monitoring is required if you've been given prostaglandin medication vaginally. The aim of both of these approaches is that by the following morning, your cervix will be more ready for labour than it was before and this will make initiation of your labour easier and make the induction more effective.

18:22
So hopefully by the following day, your cervix will now be a little bit more dilated, perhaps two to three centimeters dilated, and the next step in initiating labour will be most likely to break your water. So doing a vaginal examination, and using an instrument a little bit like a crochet hook to break the waters in front of baby's head. This is a little uncomfortable, but it's a very safe thing to do. And then we initiate the uterine contractions, so the labour contractions, with a medication called oxytocin. And this is just like the hormone that your body releases to sustain labour. And this is given as an intravenous infusion, so it's given through a drip. Now once you're on the oxytocin infusion, we started at a low rate and we increase it gradually, and it will be necessary to continuously monitor your baby's heart rate through the duration of labour. If we commence oxytocin, it'll usually be necessary to continue that medication right through until the end of the labour.

19:23
Now, if your cervix was ripe or ready for labour, you don't need the vaginal medication or the balloon catheter. And you're most likely just come in to the birth unit on the morning of your induction to have the waters broken, which is an artificial rupture of membranes or ARM, and commencement of the oxytocin infusion through a drip. Sometimes if your cervix is very favourable, meaning it's very ready for labour, and if the baby's head is sitting quite low, it's possible that we could commence an induction just by breaking your waters and allowing you to hop up and mobilise and walk around, and that might be enough to initiate the onset of labour.

20:04
However, once we've broken your waters, there's no going back from that point. So if your labour contractions don't come on in the next couple of hours, we will be committed to needing to put in a drip and commence an oxytocin infusion. Although in that setting is light that only a very small amount of oxytocin will be required to initiate the onset of the labour contractions.

20:26
That covers off most of the things I was wanting to say about induction of labour. So just to reiterate, the advice contained here is of a very general nature and I think it's really important that if induction of labour is something that's been suggested, or something that you're contemplating, then it's really important that you have an individualised discussion with your pregnancy care provider. And I think, thinking about those questions around induction of labour, so why am I having an induction, or why am I requesting an induction, and what are the risks and benefits associated with that decision? And if we're doing an induction, how do we think about the timing, so choosing the right time in pregnancy is critical to making sure that it's a good decision to go ahead with an induction and then finally having a good plan in place for exactly how your induction is going to be carried out. I think if you've got all of that information, then you're in the best possible position to make a good decision for both yourself and for your baby.

21:32
So hopefully, you found that information interesting and informative. As always, we will be very interested to receive any feedback or suggestions for future episodes and bye for now.

   

 

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Episode 6 Content and Overview

In episode 6 of the Pregnancy and Childbirth podcast, Dr Greg discusses COVID-19 and pregnancy.

When the pandemic first started, there were many questions surrounding Coronavirus (COVID-19) and pregnancy, with very little research or information to answer them. Over 12 months later and we now have some answers.

Join Dr Greg, Head of Department of Obstetrics at Westmead Hospital, the designated COVID-19 obstetrics and gynaecology hospital for Western Sydney, as he reveals the implications of COVID-19 and pregnancy. With pregnant women now eligible for the Pfizer mRNA COVID-19 vaccine, Dr Greg also shares his thoughts and recommendations regarding vaccination.

Listen to the podcast to learn about:

• The impact that pregnancy has on COVID-19 illness (how is COVID-19 illness different if you develop a COVID-19 infection and you happen to be pregnant)

• The impact that COVID-19 can have on the progress and outcome of your pregnancy

• The implications for the baby if you have COVID-19 during pregnancy, or if you happen to be COVID-19 positive around the time of birth

• COVID-19 vaccination in relation to pregnancy

Additional Resources

• Click here to read Dr Greg’s ‘COVID-19 and pregnancy’ blog

• Pregnancy and Childbirth podcast episode 8: COVID-19 and Pregnancy update

Subscribe

Happy listening and don’t forget to subscribe to the Pregnancy and Childbirth podcast with Dr Greg on Apple Podcasts to get new episodes as they become available.  

Transcription

0:00
Hi, I'm Dr. Greg, and welcome to this edition of my pregnancy and childbirth podcast. This edition is about pregnancy and COVID. It's an episode I've been thinking about doing for quite some time, but I've been putting it off because I felt that the information was still evolving in such a way that the content could well be redundant within a few weeks of me releasing a podcast. So it's probably worth date stamping this episode, I think. So today is the 25th of July 2021, we're in the midst of a fairly significant wave of Delta variant COVID virus spreading across Sydney and it's having a wide variety of impacts.

0:43
So I'm not really going to talk about COVID in general. I'm going to talk about the implications around COVID and pregnancy. And of course, I'm going to talk about COVID vaccination in pregnancy. I appreciate for a lot of pregnant women and their partners, the big question is going to be, should I get COVID vaccinated during pregnancy? It is the issue that I'm going to talk about in more detail at the end of this podcast, there are a few things that I think provide useful background that I'm going to go through first. But if vaccination is what you want to hear about, feel free to jump to the end of the podcast. Or I can tell you now that my recommendation is going to be that all pregnant women and women planning pregnancy should get a COVID vaccination.

1:33
Now, as well as the Delta variant sweeping across Sydney at the present time, there's a couple of other things that have changed in the last few weeks that make me think that this is a good time to put out a podcast around COVID and pregnancy. The first of these was a few weeks ago, when ATAGI, which is the advisory group on vaccination in Australia, and RANZCOG which is the College of Obstetricians and Gynecologists for Australia and New Zealand put out a joint statement recommending that Pfizer vaccination in pregnancy and breastfeeding should be considered safe and that pregnant women should consider vaccination.

2:13
The other thing that's happened just in the last few days, is that pregnancy is now considered part of the eligibility criteria for vaccination. So regardless of your age group, regardless of your health status, and regardless of anything else, just being pregnant, makes you eligible for Pfizer vaccination in Australia. So I think both of those things are really important developments and they have changed the discussions around COVID and COVID vaccination with regard to pregnancy.

2:49
In this podcast, I'm not going to talk about COVID in general, but I'm going to talk about the impact that pregnancy has on COVID illness. So how is COVID illness a little bit different if you develop a COVID infection and you happen to be pregnant. Then I'm going to talk about the impact that COVID could have on the progress and outcome of your pregnancy. I'll say a few words about the implications of this for the baby, if you have COVID during pregnancy, or if you happen to be COVID positive around the time of birth. And then finally, I'll be saying a few things about COVID vaccination in relation to pregnancy.

3:30
So what do we know about the impact of pregnancy on COVID illness? So we know that pregnancy does not make you more susceptible to acquiring COVID. So there's no greater likelihood of you developing a COVID infection, whether you're pregnant or not pregnant. The early symptoms of COVID are very similar, again, whether you're pregnant or not pregnant. Now, in the early phases of the pandemic, it appeared that pregnant women didn't do particularly worse in terms of their health outcomes than women who were not pregnant. Now, this was a little surprising, because we knew that with several other severe respiratory viruses, that pregnant women were more likely to develop severe illness, and were more likely to have significant adverse health consequences, compared with non-pregnant women of around the same age have the similar health status. So early in the pandemic, we thought that COVID wasn't such a big problem.

4:38
We now know that if you're a pregnant person who gets COVID there is a significantly greater likelihood of you having a bad health outcome compared with a non-pregnant woman with a similar health status of around the same age. So in real terms, what does this mean? It means If you get COVID and you're pregnant, you've got about double the chance of developing severe illness, meaning that you have double the risk of being admitted to intensive care and you have about double the risk of requiring ventilation.

5:16
So what are we seeing around Sydney at the moment? All of the major obstetric hospitals around Sydney are seeing pregnant women being admitted with COVID related illness. I work at Westmead Hospital and for the entirety of last year, the entire first phase of the pandemic, we did not have a single pregnancy admission with COVID. In the last few weeks, we've had several women admitted with COVID. And just like other hospitals across Sydney, some of these pregnant women with COVID have become severely unwell, and have required admission to our intensive care service.

5:56
We also know that there are some risk factors in pregnancy that make it more likely that you will get severe illness. So if you're a pregnant woman over the age of 35, if you're a pregnant woman who's overweight, or if you're a pregnant woman who has other significant medical problems, then it's more likely that you will develop severe illness, it's more likely that you'll require intensive care admission and require ventilation.

6:22
So what about the impact of COVID on the cause of pregnancy? So we know that there is about a 50% increase of having a preterm birth if you develop COVID during pregnancy, particularly if you develop COVID in the last third of your pregnancy or after 28 weeks gestation, and there also appears to be a significant increase in the risk if you're developing a condition called preeclampsia, which is a blood pressure disorder of pregnancy. Some of the studies have shown an increase in the likelihood of stillbirth and this does seem to be related to the severity of maternal illness. So particularly women who become severely or critically unwell, there does appear to be some increase in the likelihood of stillbirth.

7:12
So what about the outcome for the baby? If you develop COVID during pregnancy, we do know that there is a small chance that COVID might be passed on to your baby and your baby might be born with the COVID virus. This can happen around the time of birth, or there have been cases reported where this has occurred during the course of pregnancy, even when the baby was born after the illness had passed.

7:40
Now, if you’re COVID positive around the time when you give birth, the recommendations are that we will try and keep your baby with you. So avoiding separation or breastfeeding is encouraged, however, with precaution, so the mother should wear a face mask and should practice good hand hygiene. In terms of COVID, the other risks to the baby seem to relate to the increased risk of being born preterm. So there don't seem to be any other significant adverse consequences for the baby from the mother developing COVID during the course of pregnancy.

8:16
So let's talk about vaccination for COVID in pregnancy. Now, I think all of the things that we've spoken about so far, can help to inform our decision-making around COVID vaccination in pregnancy. So what do we know about COVID vaccination? So we're going to talk just about the mRNA vaccine, which is the Pfizer vaccine in Australia. And at the present time, it's the only mRNA vaccine that's available in Australia. And for pregnant women who are wanting to be vaccinated, the Pfizer vaccine is the recommended vaccine to have. So firstly, should there be any health concerns about administering an mRNA vaccine during pregnancy? So the evidence is incredibly reassuring. So there aren't any similar vaccines which have been given which have been associated with any sorts of pregnancy harms or any harms related to the baby. And there isn't any reason why we would expect that there would be any harms associated with the administration of this vaccine had any time during pregnancy. So that's the best expert advice we have about the likely safety of this vaccine.

9:35
Now, it's true to say that pregnant women were not involved in the clinical trials which were conducted and which led to these vaccines being approved, and in retrospect, that probably was a significant oversight. Nevertheless, that's the information that we have to move forward with. We know that around the world 10s of 1000s of women have received mRNA vaccines during pregnancy, with no significant case reports of adverse outcomes for either mother or baby. The CDC, which is the Centre for Disease Control in the United States of America, has recently published data on over 90,000 pregnant women who received mRNA vaccines during pregnancy with no adverse events reported.

10:24
Now it's true to say that only a small number of women have completed their pregnancy and gone on to deliver a baby, so the long-term outcomes for their babies are yet to be known. But I come back to the point I made earlier about vaccination; there is absolutely no reason to believe that mRNA vaccines should cause any long-term health consequences for the baby if administered during the pregnancy.

10:53
We also know that the vaccine works during pregnancy this has been extensively studied, and pregnant women produce the same antibody response as non-pregnant people do. We also know that those antibodies cross through the placenta and go to the baby. So the baby is born with some of these antibodies on board which will give the baby some protection from COVID illness in probably the first three to four months of life if this behaves in a similar way to things like influenza vaccine in pregnancy, for example. The antibodies derived from vaccination also pass through breast milk. It's unclear how beneficial this is to the baby, but it provides some reassurance to know that if you've been vaccinated, and you're breastfeeding your baby, that your baby may well derive some benefit from the antibodies that go across through the breast milk. The other point to make is that the best available evidence we have suggests that COVID vaccination is completely safe to give at any time during pregnancy, or whilst breastfeeding.

12:01
So if I could sum up, at the present time, the likelihood of a pregnant woman developing a COVID infection is significant. The Delta variant is circulating in our community and it is highly transmissible. We know that if you develop COVID during pregnancy, most likely you will have a fairly uneventful illness, and your pregnancy will progress along smoothly. Though we also know that there's a possibility that you will develop severe illness and require admission to tensive intensive care, and maybe end up being put on a ventilator. And we know that if you get COVID whilst you're pregnant, the risk of that happening to you is twice as high as somebody who gets COVID who is not pregnant. We also know that if you get COVID during pregnancy, that there's a greater likelihood of an adverse pregnancy outcome, particularly things like preterm birth, and pre-eclampsia, and maybe a small increased risk of stillbirth. And about the vaccine, we have really good evidence to say that the Pfizer vaccine is safe to administer at any time during pregnancy and whilst breastfeeding.

13:18
So to me, the argument is pretty clear. If you're a pregnant woman or are contemplating pregnancy or a breastfeeding woman, you should seriously consider going out and getting access to a Pfizer vaccine at the earliest available opportunity. Now, this of course, is very general advice. There may be people who have other particular health issues that need to be taken into consideration when it comes to decisions around vaccination and it's very important that you discuss these things with either your general practitioner or your pregnancy healthcare provider.

13:54
So that's a wrap for this episode. Please stay safe. Please follow the public health advice. Please raise your concerns with either your GP or your pregnancy health care provider. And I hope you found this episode informative and helpful. As always, we will be very keen to hear your feedback and if you have any suggestions regarding future episodes, please let us know. Bye for now.

   

 

Podcast: Pregnancy and Childbirth with Dr GregNever miss an episode. Subscribe on Apple Podcasts to get new episodes as they become available.

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Episode 5 Content and Overview

In episode 5 of the Pregnancy and Childbirth podcast, Dr Greg discusses reproductive carrier screening.

Carrier screening involves testing parents prior to pregnancy, or in the early stages of pregnancy, to determine whether or not they are at risk of having a baby with a serious genetic condition.

It is recommended that all couples in Australia who are contemplating pregnancy, or who are in the early stages of pregnancy, are informed about their options in regard to reproductive carrier screening.

In this podcast you’ll discover how carrier screening works, what conditions we can test for and what your options are if your baby is found to be affected by any of these conditions.

Additional Resources

• Mackenzie’s Mission will provide reproductive genetic carrier screening to 10,000 Australian couples who are either planning to have children or are in early pregnancy

• Sonic Genetics gives doctors and patients access to an extensive range of genetic tests, provided through Sonic Healthcare’s network of Australian and international laboratories

• NSW Health reproductive genetic carrier screening fact sheet

Transcription

0:01
Hi, I'm Greg Jenkins, and welcome to this edition of my pregnancy podcast. Today we're going to be talking about a thing called reproductive carrier screening. This is testing that can be carried out, either prior to pregnancy or during the early stages of pregnancy to determine whether you and your partner, may be a risk of giving birth to a child, who could have a potentially serious genetic condition. It is recommended that for all couples in Australia who are contemplating pregnancy, who or who are in the early stages of pregnancy, that they be informed about their options in regard to reproductive carrier screening. You may choose not to pursue testing in this area but it is important part of your decision making to be informed about this and to give it some consideration.

0:53
So before we can talk about reproductive carrier screening, we need to understand a little bit about what it is that we're talking about. So this is not about testing for conditions like Down Syndrome, for example, these are chromosome conditions rather than genetic conditions. So what we're talking about in this case, is conditions that would usually be inherited from the parents. And the way that these are inherited is that in most instances, one or both of the partners are a carrier for this condition, and they pass the condition on to some of their children. There are quite literally 1000s of these conditions. And it's estimated that there may be something like a million people living in Australia, who are affected by a genetically inherited condition.

1:44
Some of these conditions are very serious, and have a major impact on both duration and quality of life. And some relatively minor with minimal impact on quality of life. The commonest of these conditions is something that you might be familiar with, is a condition called Cystic Fibrosis. Now in order to understand how this works, we need to have a bit of a chat about genetics. So genes generally occur in pairs. In order to inherit a genetic condition, you generally need to have both pairs of the gene for that condition. Now, we all carry faulty genes, on average, most of us carry at least two faulty genes. Now, if you happen to be having a baby with somebody who has the same faulty gene as you, then there's a possibility that some of your children will get both of your faulty genes, and therefore will actually have the condition that's related to these genes, and this is called autosomal recessive inheritance. So these genes are recessive. And in order to get the disease, which the gene is particular to, you need to have both of the faulty genes.

3:01
There's another way of inheriting a genetic condition, and that's called an X linked recessive condition. In these conditions, the faulty gene resides on the X chromosome. Now, you're probably aware that females have 2x chromosomes and males have an X chromosome and a Y chromosome. So for an X linked condition provided there is a normal X chromosome to balance out the gene on the faulty X chromosome, the condition won't generally occur. However, in boys, if they inherit the X chromosome with the faulty gene, they don't have an extra another X chromosome with a normal gene to cancel it out. So in X linked conditions, we normally say the visible nature of this disease, are much more predominantly in boys than in girls. I mentioned that because in the most commonly performed test to look for reproductive carrier screening, it involves a combination of autosomal recessive conditions, and an X linked recessive condition also.

4:16
So what does it mean to be a carrier of one of these conditions? Well, usually it won't have any health implications at all. But for some conditions, it might mean that you have some mild features of the actual disease itself. But in most instances, it will have minimal implications to your health if you are a carrier of one of these conditions. The most commonly performed testing option available tests for three of the more common genetic conditions. These three conditions are cystic fibrosis, which occurs around about 1 in 3000 children born, spinal muscular atrophy, which occurs between 1 and 5000 and 1 in 10,000 children and fragile X syndrome, which occurs between 1 in 5000 and 1 in 10,000 children. So as you can see, even when we add these three conditions up, they don't occur particularly commonly, however, they are particularly important.

5:20
You might have heard of some publicity surrounding Mackenzie's mission. This is about a baby that was born with a condition spinal muscular atrophy. The baby died at around seven months of age, and her parents who unbeknown to them at the time were both carriers of this condition, decided that other parents should be educated and informed about the issues surrounding serious genetic conditions and the potential for passing these conditions on to the children.

5:58
So as I mentioned, the most common panel of tests that's available is a test to check for those three conditions. There are, however, what are called expanded carrier screening tests that test for quite literally hundreds of conditions. And it's quite possible that we'll see in the next few years government funding testing available, which will test for up to 700 to 1000 different genetic conditions. If you're interested in pursuing expanded carrier screening, then you should talk to your health care provider about how to access these options. Now, I should also mention that this testing can be done prior to pregnancy as well as during the early phases of pregnancy. And there is an excellent website. If you Google search, Mackenzie's mission, there's some very good information there about reproductive carrier screening, and some more detail about Mackenzie's mission itself.

7:01
The other thing to mention is that this test at the present time unless you're enrolled in a study is not accessible for Medicare rebate or Medicare funding. So it is reasonably expensive. The three panel tests looking at cystic fibrosis, spinal muscular atrophy, and fragile X is in the order of $350 per partner, the general process would be that the woman gets tested first and if she's found to be a carrier for one of these three conditions, then her partner would usually then undergo follow up testing.

7:41
So what if you decide to pursue this testing? And what if you're both found to be a carrier for the same condition? Say, for example, you're both carriers for cystic fibrosis, or you're both carriers for spinal muscular atrophy. This means that there's a likelihood that one in four of your children will actually have this condition. If you happen to be pregnant once the testing is done, and this information is now available to you during pregnancy, then further testing options would involve tests that that take a sample of the baby's cells so that the baby's genetics can be determined. So this would usually be either an amniocentesis, which involves putting a needle into your tummy and taking a sample of the amniotic fluid, or a test called a CBS, which also involves putting a needle into your tummy, and taking a sample of the baby's placenta. From these tests, it can be determined with quite a high degree of reliability, whether your baby actually has the condition or doesn't have the condition.

8:49
The third condition, which I mentioned is fragile X syndrome. If the mother happens to be a carrier for fragile X syndrome, and if the child is a boy, then there is a 50% chance that he will be affected by this condition. Now, if you determine that you are both carriers, and your baby is affected by the condition, and this has been confirmed with what we call invasive testing, then unfortunately, this condition cannot be rectified and your options would then relate to whether you wanted to continue with the pregnancy, or whether you chose to not continue with the pregnancy on the basis of the new information that you now have.

9:36
If you had these tests carried out before becoming pregnant, then there's another management option available. And that option would be to have IVF treatment and have your embryos tested for these conditions before the embryos are placed back into your uterus. So for couples who've had a baby with one of these conditions in the past whether it continued to full term or whether it didn't, many of these couples will choose to go down the pathway of having IVF and what's called pre-implantation genetic testing with future pregnancies.

10:15
So in summary, I know this is all a bit complicated. This testing is available to all couples who are thinking about having a baby or who are in early pregnancy. The commonest test that's done is the test to check for three genetic conditions. But there is testing available for a much wider panel, it is more expensive, but it is available. The majority of couples that I see don't tend to go down the pathway of undertaking this testing, but it definitely is available and it certainly can be facilitated if you're wanting to do it. The conditions that we're testing for are uncommon, but they are potentially very serious. And if you and or your partner were found to be carriers for these conditions, then further testing would be necessary in order to determine whether your baby was affected by this condition or not.

11:13
If you're interested in finding out more about genetic carrier screening, you should definitely talk to your health care provider. And if you're interested in pursuing testing, similarly, talk to your health care provider and this can be very easily arranged. I have included some links to additional resources in the show notes for this episode. Thanks for listening. I hope you found this episode informative and I would welcome any feedback or suggestions regarding future episodes. Bye for now.

   

 

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Episode 4 Content and Overview

In episode 4 of the Pregnancy and Childbirth podcast, Dr Greg discusses pregnancy related nausea and vomiting.

Nausea and vomiting are common symptoms that affect many pregnant women, particularly during the first trimester. This condition is often referred to as morning sickness, although this is misleading as symptoms can occur at any time. Join Dr Greg as he discusses how to manage pregnancy nausea and vomiting so that they have a minimum impact on your day-to-day function and on your general well-being.  

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Happy listening and don’t forget to subscribe to the Pregnancy and Childbirth podcast with Dr Greg on Apple Podcasts to get new episodes as they become available.

Transcription

0:01
Hi, I'm Greg Jenkins and welcome to this edition of my pregnancy podcast. Today, we're going to be talking about nausea and vomiting in pregnancy. This is a really common symptom. It affects a large proportion of women and predominantly is confined to the first trimester or the first 12 weeks of pregnancy. It's also commonly referred to as morning sickness, although typically for a lot of women, the symptoms are not confined to the morning and can occur at any time during the day.

0:34
In most women, the symptoms are bothersome, but not a major concern to their health. However, for a small group of women, they develop a more severe version of nausea and vomiting in early pregnancy, and this is called hyperemesis gravidarum, or often referred to as HG. In the symptoms are severe enough to cause significant weight loss and or dehydration. In these women, periods of hospitalisation may be required for administration of intravenous medications and intravenous fluids. And at the more severe end of the spectrum, this can have a significant impact on health and well being.

1:19
For most women however, their symptoms are more mild than this and can be managed without the need for admission to hospital. And there are usually measures involving lifestyle and dietary modification and simple medications, which will keep the symptoms reasonably well controlled.

1:40
So what causes nausea and vomiting in early pregnancy? Well, it's undoubtedly related to pregnancy hormones. And the higher the pregnancy hormone levels, for example, in multiple pregnancies, women tend to have more severe symptoms than in women with single pregnancies. It's not clear, however, why some women develop quite severe symptoms, and other women very mild symptoms, and some women no symptoms at all. The trajectory of symptoms does, however, follow reasonably well, the rise and fall in the pregnancy hormone level through the first trimester of pregnancy. So it's reasonably predictable, that symptoms of nausea and vomiting and pregnancy reached their worst by about 9 to 10 weeks. And after this time, in the vast majority of women, they gradually improve over the next few weeks. There are, however, a small group of women who experienced persistent nausea and vomiting for much longer than the first trimester, and very occasionally, throughout the entire duration of pregnancy.

2:47
So how do we manage nausea and vomiting and pregnancy? Well, unfortunately, the bad news is, there isn't anything we can do that's going to make it go away. So the key is to find a way to manage the symptoms, so they have a minimal impact on your day to day function, and on your general well-being. Now the majority of women find that the longer they go without having anything to eat or drink, the worse they tend to feel. So it's a little bit paradoxical. In order to not feel sick, you need to eat or drink something. Most women this is reasonably predictable. Now it doesn't really matter what you eat or drink. However, most women find that foods that are fairly bland, are carbohydrate rich, and easily digestible, are the things that work best. Similarly, with fluid, it doesn't especially matter what you drink. Some women find water to be not particularly palatable in the early trimester of pregnancy, and things like dilute fruit juice, even soft drinks, sports drinks, Hydralyte, any of those sorts of things can help to manage the symptoms and also provide carbohydrates that provide fuel and energy for your body. In terms of foods, small bland snacks, so crackers, sugary lollies, sometimes, dry toast, all of those things can be helpful, and it's a matter of experimenting with a few things and see what works best for you. You might even find that carrying snacks around. Some women find that having a snack by their bedside. So as soon as they wake up in the morning, they can have something to eat before they get out of bed that can help with the feelings of nausea and vomiting first thing in the morning.

4:33
You need not be too worried about your nutritional status during the first trimester of pregnancy unless you're experiencing severe vomiting with significant weight loss. Generally by the strategy of small frequent snacks and keeping up your fluids. You will maintain adequate nutritional status. And don't be concerned about the nutritional status of your baby. Your baby will require all it needs through the first trimester provided you're not on the brink of starvation, which happens in very, very few women in the early part of pregnancy. The other aspect is, of course, you'll be wanting to try and keep down your pregnancy vitamins, particularly in the first trimester, when you should be taking a folic acid supplement or perhaps a pregnancy multivitamin. You could try experimenting with a couple of different multivitamins if you are taking a multivitamin, as they contain different amounts of vitamins and minerals. And sometimes that can impact on your nausea vomiting in early pregnancy as well. So you might experiment with some different brands and different combinations to see whether that's more palatable for you. And obviously, there might be times of the day where you're more likely to be able to keep your pregnancy multivitamin or your folic acid tablet down, and you can tailor the timing of your tablet to the time when you're less likely to be vomiting.

5:57
Now there are some over the counter medications, which have been shown to be beneficial in helping to manage the symptoms of nausea and vomiting in pregnancy. The first line tends to be bigger vitamin so there's a vitamin called pyridoxine or vitamin B6. And there's quite a lot of evidence that pyridoxine can help to reduce nausea in early pregnancy, it probably doesn't have a huge effect on vomiting. But for a lot of women, it can result in a significant improvement in nausea.

6:30
Now ginger is a natural antiemetic. And there's a number of combination, early pregnancy multivitamins out there specifically for the purposes of managing nausea and vomiting in early pregnancy, which contain a combination of pyridoxine and ginger. And those will be available from your local chemist. For a lot of women, these combination supplements can be very beneficial in helping to manage their symptoms.

7:03
The next step beyond there is a medication called Doxylamine, the commonist over the counter version of this in Australia is a medication called Restavit. Now, it's a very safe medication to take in pregnancy, it can cause some drowsiness, and a lot of women who will help to reduce the nausea and the vomiting in early pregnancy. So it's a very simple first line approach and something that you can buy over the counter at the chemist.

7:34
Most commonly prescribed medication that I see for the treatment of nausea and vomiting in pregnancy is a medication called Metoclopramide, which the most common trade name is Maxolon. Now it's quite popular, because it's a category A medication for pregnancy, meaning there's very clear evidence that is completely safe, and is not likely to have any harmful effects whatsoever on the baby or the pregnancy. It can however, cause some sedation. And there's a bit of evidence to suggest that it doesn't work particularly well for nausea and vomiting in pregnancy. So it might be something that you try but don't be surprised if it's not especially helpful. I have seen some women where it helps. But I would say that the majority of women that I see are Maxolon it hasn't helped them particularly much. And there is of course the problem with Maxolon that it comes as a tablet, meaning that you have to swallow the tablet and keep the tablet down in your stomach for a period of time in order for it to be absorbed and in order to obtain the benefit from the medication.

8:51
The medication that I prescribe most often for women that need medication to manage the nausea, vomiting and pregnancy is a medication called Ondansetron. And the commonest trade name for this is Zofran. Zofran is unique amongst the medications for nausea and vomiting in pregnancy, in that it comes not only as a tablet, but it also comes in a form called a wafer, which is a very tiny lozenge which you dissolve in your mouth. So you don't have to rely on swallowing the medication and waiting for it to absorb in your stomach before it works. So you can just suck on it. It absorbs through the lining of your cheek, goes straight into your bloodstream and is effective very quickly. So that's one benefit to Ondansetron. The second benefit is it's an extremely effective nausea and vomiting medication and tends to work better than anything else. Now in terms of its safety in pregnancy is generally considered to be extremely safe in pregnancy. There's no evidence that it causes harmful effects on the pregnancy or on the baby and its classification is Category B1. And we'll use lots of Category B1 medications at various stages in pregnancy. Those women who don't like the taste of the wafer or the lozenge, it does come as a tablet. But as I said, one of the limitations of a tablet is that you have to retain it in your stomach long enough for it to be absorbed in order to get the benefit of the medication. The other good thing about Ondansetron is that you can just take it as you require it, it's not something that you need to take every day and you can adjust the dose depending on whether you're having a good day or a bad day, you can adjust the timing and you can dose it multiple times per day, if you're having a particularly challenging day. However, if you're one of those women that has really bothersome symptoms that occur on the vast majority of days, it's very safe to continue it for extended periods of time. In terms of side effects, it's generally very well tolerated. The most troublesome side effect, which occurs with Ondansetron is constipation. And most women who are taking Ondansetron for any extended period of time, will have some issues with constipation. So it's worth thinking about how you'll manage that, if that particular symptom occurs.

11:25
Now, there are other medications available. But in my experience, the vast majority of women can be fairly effectively managed using a combination of dietary advice, careful management of oral fluid, and the supplements and medications which we've just discussed.

11:45
So what if you're one of those women that has really quite severe symptoms, where you're at risk of becoming dehydrated and you're experiencing significant weight reduction. So it's important to have a plan in place so that you know, when the trigger points are reached, for your need to present to hospital for intravenous fluids, possibly intravenous medication as well. And you should discuss these things with your pregnancy care provider, whether that be your GP in early pregnancy, or whether it be the obstetrician or midwife that's involved in your pregnancy care. And you should have a plan as to how you will access the hospital whether that be through the emergency department, or whether special arrangements can be made for your presentation to the Birthing Unit, or for direct admission to the ward. Most women do not require extended periods of hospitalization. And in fact, women who require extended hospitalisation, on the whole tend to do a bit worse than women who are managed predominantly as an outpatient. So the principle that we try to stick to is we try really hard to keep women out of hospital to keep their symptoms well managed. And when it gets to the point where they're becoming dehydrated, or they're becoming more unwell, then a brief admission to hospital to rehydrate with intravenous fluids, to top up with intravenous medications, get them feeling as well as possible and get them back home again.

13:23
Now, for women with significant weight reduction, and persisting symptoms, the involvement of a dietitian can be extremely helpful in looking after your nutritional status during the early part of pregnancy, particularly for women where their symptoms are progressing into the second trimester.

13:42
Now, I should say that most women are going to experience pretty much a complete resolution of symptoms by about 15 weeks. It'll most commonly be a slow, steady improvement in symptoms between 10 and 15 weeks. However, in some women, the symptoms disappear very quickly. There'll be a smaller group of women whose symptoms persist beyond that, most will get better between 15 and 20 weeks, and a small number will persevere between 20 and 25 weeks. The bad news, unfortunately, is if you've still got symptoms by about 25 weeks, that's going to be pretty much how it is for the remainder of your pregnancy. So it's important if you are one of those small group of women, that you have a strategy to help maintain your nutritional health, maintain the nutritional health for your baby, and also maintain your general well being through the remainder of the pregnancy because this can be both physically and mentally a very challenging situation to manage.

14:41
It's reassuring to know that in the vast majority of women who have nausea vomiting in pregnancy, even women with fairly severe symptoms and women with hyperemesis gravidarum that pregnancy outcomes are not impacted on by this condition. So you can expect that you will have a healthy pregnancy and a healthy baby at the end of this. The only exception to that is a woman who becomes severely nutritionally unwell during the pregnancy, and hence the need for involvement with a dietitian.

15:16
So what about if you've had nausea and vomiting or hyperemesis gravidarum in a previous pregnancy? What can you expect in your next pregnancy? Well, unfortunately, the symptoms tend to be fairly similar, and tend to last for a fairly similar duration. Now there can be some variation, some women's symptoms will be a bit less severe, or maybe a bit more severe. And this seems to be fairly random occurrence. There's no particular association with the gender of your baby or with any other variables that we can predict or identify. But generally speaking, if your symptoms were at the more severe end of the spectrum, they're likely to be there again. And they're likely to last for about the same duration into your pregnancy. If your symptoms were fairly mild, they will probably be fairly mild again. And if you're a woman who had no nausea or vomiting in her pregnancy, then that will probably be what happens to you in your next pregnancy as well.

16:17
If you're somebody who did experience significant symptoms in a previous pregnancy, is there anything that you can do before you get pregnant, to help to improve the symptoms? So there are a couple of things, you can make sure that you're nutritionally well before you get pregnant. That will help you to sustain yourself and sustain the well being of your pregnancy throughout the early part of the pregnancy. The second thing you can do is to start your pregnancy multivitamins two to three months before you become pregnant. There's a little bit of evidence to say that women who've been taking a pregnancy multivitamin in a couple of months prior to pregnancy, might have less severe symptoms than women who have not done so.

17:05
And the other piece of evidence out there is for women who have significant symptoms of reflux, or indigestion or heartburn prior to pregnancy. There's some evidence that for those women being on treatment, that has effectively reduced those symptoms before they become pregnant, that the nausea and vomiting through the first trimester of pregnancy may be significantly improved.

17:33
The other thing to consider is your general well-being and support during early pregnancy. So if you're a woman who has experienced quite severe nausea and vomiting in a previous pregnancy, then you want to try make sure that you have as much support around you as possible. So given that you've had a previous pregnancy, there's going to be a toddler or a small person in your life that's going to require care during the time in pregnancy where you might be feeling particularly unwell. So making sure that you have some sort of support strategies in place can help to make life a lot easier for everybody, including yourself during the early part of pregnancy at that time, when you're feeling unwell and maybe struggling to manage things on a day to day basis.

18:24
Also talking to either your GP or your pregnancy care provider to make sure that you can get access to medications early in pregnancy, when your symptoms begin. If you're somebody who feels they might need prescription medication to manage their symptoms in early pregnancy, that is a good strategy.

18:46
So I hope you found some of that information useful, helpful and informative. I do have the greatest sympathy for women who experienced significant nausea or vomiting in early pregnancy, it can be unrelenting and it can be psychologically and physically very challenging. And I think part of what we can do as healthcare providers is offer as much support as possible for you in helping you get through that challenging part of the pregnancy. And particularly for that very small group of women whose symptoms persist for the duration of pregnancy. Having a relationship with a pregnancy care provider that provides you with support at lots of different levels can help to make things a bit easier on the journey of your pregnancy.

19:31
So that's it for now. Again, if you have any feedback, you would like to leave or you have any suggestions for future topics to cover, they would be very warmly received. Bye for now.

   

 

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Episode 3 Content and Overview

In episode 3 of the Pregnancy and Childbirth podcast, Dr Greg talks all about epidurals. An epidural is a local anaesthetic, injected into the spinal nerves of your lower back. Its purpose is to block the pains associated with labour and birth. Join Greg and discover what it’s like to have an epidural, what the procedure involves, what the pros and cons are and how it can impact labour and birth.  

   

 

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