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CONSIGLIO
REGIONALE
DEL PIEMONTE
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Consulta Femminile
Regionale
del Piemonte
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SOROPTIMIST
INTERNATIONAL
Club di Torino
Pregnancy
and childbirth
some useful information
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Produced by
the Department of Gynaecological and Obstetrical Disciplines
Turin University of Studies
Copyright Consiglio Regionale del Piemonte
Turin - 2009
Studio R. Patrucco - Torino - Italia
We thank the Health Authority of the Piedmont Region
for its collaboration in the dissemination of information
about the project and promotion of its awareness
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Pregnancy is a period in life characterized by important physical and
psychological changes during which dreams, hopes, fear and doubts
alternate.
Usually, a woman in good health and with a correct lifestyle does not
have to modify her personal habits too much. Nevertheless, she should
take a series of precautions that were not necessary before.
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Diet
A correct diet contributes towards making the progress of the pregnancy and the growth of the fetus smooth. For this reason, the quantity and
quality of food and drink must be scrupulously checked.
Broadly speaking, if a woman starts the pregnancy with a normal
body weight, an increase of 200/300 calories a day from the third month
is sufficient to guarantee fetal growth and adaptation of the maternal
organism to pregnancy. However, bearing in mind reduced physical
activity, she should not exceed 2,500 calories a day.
At the end of pregnancy, the increase in maternal body weight
should be between 9 and 12 kg.
Be careful, though: weight increase is not constant in the course of
pregnancy. Weight usually remains stable until the third month, increases by about 1.5 kg a month between the fourth and the seventh month
and by about 2 kg a month in the last 3 months.
She needs to get into the habit of always weighing herself on the same
scales, at the same time of day, preferably in the morning, on an empty
stomach, after emptying her bladder.
An excessive weight increase
can create health problems for
both the mother and the child.
If she is already overweight
when she starts the pregnancy, it will be a good idea to limit
calorie intake under medical
supervision, in order to avoid
weight increase or reduce it to a
minimum.
During pregnancy, it is important to follow a healthy, balanced
and varied diet. It will be up to
the gynaecologist to suggest,
from time to time, foods to be
avoided or preferred and any
nutritional supplements.
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In general, it is advisable to:
• make sure of having an adequate intake of vitamins, mineral salts and
fibres, by eating fresh seasonal fruit and vegetables
• split meals up (breakfast/snack/lunch/snack/dinner)
• avoid being on an empty stomach and unusually heavy meals
• drink a lot of water, especially outside meals
• limit the consumption of fats, sugar, salt, excessively processed foods,
chocolate, coffee and tea
• increase protein intake by not more than 30g a day, preferably taking
in the animal proteins found in fish, meat, milk, egg and cheese
• give preference to the consumption of slow absorption sugars, such as
those present in bread, pasta and rice, rather than the rapid absorption
sugars contained in sweet things
• give preference to polyunsaturated fats (oil) and reduce saturated fats
(butter, margarine, lard and pork fat) to a minimum.
NO!
YES!
YES!
If you are not immune to toxoplasmosis:
• avoid the consumption of sausages, raw or slightly cooked meat and
raw eggs
• wash very carefully, possibly with special disinfectants (bicarbonate of
soda, or Amuchina), greens, vegetables, aromatic herbs (for example
parsley and basil) or fruit, because they could have been contaminated by cat faeces or by the products of decomposition of infected animals. Away from home, as a precaution, it is best to eat cooked vegetables and peeled fruit
• drink only pasteurized milk.
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Physical activity
Physical activity is advisable because:
• it has a positive effect on the future mum’s psychological state of mind
• it helps prevent and reduce typical ailments of pregnancy like constipation, backache, haemorrhoids, and swelling of the ankles
• it contributes to improving perception of her own body, in spite of the
changes it undergoes.
Obviously, sport and physical activity must be right for the state of
health of the expectant mother and the child.
What to do
• “gentle” gymnastic exercise
to keep the muscles of the
abdomen, back and legs in
shape
• water gymnastics or stretching to acquire muscular elasticity and guarantee good
blood circulation
• birth preparation exercises
(generally these are done at
the same hospital where it
has been decided she will
give birth)
• swimming, long walks, exercise bike, yoga and dance.
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What not to do
• all sports that involve the risk of falls or blows to the abdomen and/or
require a particular ability to keep ones balance and be coordinated
(martial arts, skiing, tennis, riding, cycling, football, diving and all socalled “extreme” sports)
• overdo things and end up breathless during physical activity: a pregnant woman should be able to talk during exercise
• carry out exercises (for example jumping) that subject the ligaments to
particular strain; during pregnancy they become less resistant and are
more susceptible to injury
• lift excessive weights.
Working
If the pregnancy proceeds normally, work activity can be continued at
least until the time specified by law (1-2 months before the birth).
Nevertheless, it is best to
stop excessively heavy or
psycho-physically stressful
work.
Moreover, any exposure to chemo-physical
agents in the work environment that could be
harmful for the fetus must
be careful assessed right
from the beginning of the
pregnancy.
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Travelling about and making long journeys
If the pregnancy is following a normal course, there is nothing against
travelling about and making journeys.
Nevertheless, it is advisable to take some precautions and avoid means
of transport considered risky.
From the beginning of third trimester onwards, it is best to avoid travelling about on mopeds, motorcycles or bicycles. In fact, the excess
weight and the changes the body has undergone could cause problems
of balance.
Journeys by car should not be too long or should be broken up by
a number of rests.
As far as long journeys are concerned, it is advisable to avoid excessive strain and discomfort. The best time to set off is during the second
trimester when the body has already had chance to adjust to the
changes.
At any rate, before making a journey, it would be prudent to have a
check-up.
It is advisable not to travel when it
is excessively hot: preferably in
the morning or the evening.
The length of the journey must
not be excessive and the means of
transport chosen must guarantee
the pregnant mother the best possible comfort.
If it is anticipated that the stay in
the chosen place may continue for
some time, it is useful to take with
you your medical documentation
with all the checks and examinations carried out up to that time.
Travelling by train is less risky
than travelling by car.
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For long distances, the aeroplane is without doubt the most convenient
means.
If the destination is a tropical country, where the risk of contracting
infectious intestinal diseases is high, you need to pay great attention to
what you eat, and avoid drinking tap water or drinks with ice in them, or
eating unpeeled fresh fruit, ice-cream and raw meat.
!
Please be careful
Many vaccines, required by some Countries are contraindicated
during pregnancy!
If you need preventive anti-malaria treatment the use of mefloquine
and doxycycline is contraindicated, while taking chloroquine and paludrine is acceptable. Therefore, journeys to malarial zones are inadvisable where there is the risk of forms resistant to chloroquine (especially sub-Saharan Africa, the Amazon area, and Southeast Asia).
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Vaccinations
Vaccinations containing deactivated viruses or other substances
with an antigenic effect can be given.
The following vaccines belong to this group:
• desensitizers specifically for the treatment of allergies
• anti-flu
• anti-hepatitis A
• anti-hepatitis B
• intramuscular anti-poliomyelitis
• anti-whooping cough
• anti-pyogenic
• anti-pneumococcal
• anti-haemophilic
• anti-rabies
• anti-tetanus.
Vaccines containing attenuated live viruses are contraindicated.
The following vaccines are in this group:
• oral anti-typhus
• anti-yellow fever: this should not be given in the first three months of
pregnancy.
The following vaccines for which there is no conclusive data are also
advised against:
•
•
•
•
•
•
•
•
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anti-rubella
anti-mumps
anti-measles
anti-diphtheria
anti-smallpox
anti-chickenpox
anti-tuberculosis
anti-cholera.
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Smoking and alcoholic drinks
Smoking
The negative impact of smoking on the progress of the pregnancy, the
wellbeing of the fetus and the future health of the baby is considerable:
from this point of view, smoking can be considered to be the most
important and the simplest cause of easily avoidable obstetric
pathologies.
NO!
Smoking reduces fertility, increases the incidence of extra-uterine pregnancy and doubles the risk of miscarriage in the first trimester.
The most serious harm caused by smoking is however the result of the
effects of nicotine on the placenta and on the fetus. The circulation of
blood and oxygen through the placenta, which guarantees the nourishment and therefore the growth of the fetus, is seriously damaged by nicotine: for this reason, the children of women who smoke have a reduced
intra-uterine development and are usually born with a lower weight
than those of women who do not smoke. The effect is dose-dependent,
i.e. the more cigarettes are smoked per day, the more serious it is.
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The placenta can be so badly damaged as to come away from the wall
of the uterus. Detachment of the uterus at the wrong time is a traumatic event that puts the life of the fetus and of the mother herself at very
high risk. In women who smoke the likelihood of this occurring is
increased by 50%.
The risk of placenta previa also increases as a consequence of smoking. In this case, since the placenta is positioned in the lower part of the
uterus, in front of the fetus, birth through the vagina is impossible. Often
because of vaginal bleeding caesarean section becomes necessary long
before the nine months are up, with serious problems for the wellbeing of
the baby because of premature birth.
But the effects of smoking on the incidence of idiopathic (i.e. spontaneous and apparently without cause) premature birth and on the appearance of congenital malformation of the fetus (i.e. anomalous malformations of organs and apparatus, such as the heart and the skeleton) are
still in doubt and the subject of study.
As a consequence of all these harmful effects, habitual smoking brings
about a significant increase in perinatal mortality (fetal death in the
uterus from the 180th day of pregnancy + untimely death of the newborn,
i.e. within the first seven days of life).
!
It has been calculated that if all women who smoke stopped smoking
during pregnancy, perinatal mortality would be reduced by 10%.
The harm done to the fetus by smoking during pregnancy continues
even after birth. The children of women who smoke, besides being born
underweight and sometimes before term, are more easily subject to respiratory disorders, such as bronchitis and asthma, and in the first few
weeks of life they are at greater risk of “cot death” (SIDS: Sudden
Infant Death Syndrome). This traumatic event increases by no less than
3.5 times, if the mum has smoked during pregnancy and it is dosedependent.
It also seems that, if the woman smokes while breastfeeding, her
risk of developing a breast tumour is twice as high.
Finally, some data suggests that even passive smoking is dangerous
for a pregnant woman and her child. Nevertheless, the evidence concerning this is difficult to assess.
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Alcoholic drinks
In high doses, alcohol is a powerful teratogenic agent, i.e. it is capable of causing harm to the developing embryo. For this reason, the consumption of alcoholic drinks during pregnancy is dangerous and must be
reduced to a minimum.
The harm from alcohol is dosage-dependent, i.e. the greater the quantity of alcohol consumed, the greater the harm done. The threshold level
that affects the progress of the pregnancy and the health of the future
child is 30 g of alcohol a day.
Threshold level not to be exceeded during pregnancy
30 g of alcohol a day
corresponding to
2 glasses of wine
or
2 cans of beer
or
2 measures of spirits
If consumption exceeds this level, there is an increased risk of miscarriage, fetal underdevelopment and slight mental retardation.
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The threshold that carries a risk of fetal malformation is in the order of
80-90 g of alcohol a day.
Risk of fetal malformation
80-90 g of alcohol a day
corresponding to
5-6 glasses of wine
or
5-6 cans of beer
or
5-6 measures of spirits
In women who consume this quantity of alcohol during pregnancy the
incidence of fetal malformation reaches 40%.
All the fetal anomalies caused by alcohol considered as a whole are
known by the name “feto-alcoholic syndrome” and it includes fetal
underdevelopment and post-natal growth retardation, neurological problems at birth (tremors, insufficient sucking), mental retardation, malformation of various organs and apparatus among which the skull and the
face are typical.
Some advice…
Pay particular attention to bodily care and hygiene. The bath or shower should be taken avoiding water that is either too hot or too cold. The
right temperature is between 30 and 35°.
Use comfortable clothes that do not constrict the abdomen and that
allow you to move with freedom and agility. At home loose clothes are
recommended, made with natural fabrics, and low-heeled shoes (slippers
or flat broad-soled shoes).
Classic hair colorants based on chemical products are contraindicated as a precaution, especially during the first trimester. In fact, coming into direct contact with the scalp, they can be absorbed and intro14
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duced into the maternal blood, and so they could theoretically have an
effect on the fetus.
But “highlights” are not contraindicated, because they provide for the
use of special papers or plastic skullcaps, provided with small circular
openings, that make it possible to avoid the chemicals coming into direct
contact with the scalp.
To avoid the risk of contracting toxoplasmosis, besides taking
the precautions described in the chapter on diet, it is advisable to:
• wash hands, surfaces and utensils thoroughly after handling raw meat
• wash your hands carefully after being in contact with a cat or other
domestic animals
• use gloves to handle the cat tray, which should at any rate be cleaned
every day (it is better if it is done by someone else)
• avoid giving the cat raw meat and try to limit its movements outside the
home environment
• use gloves if you have to work in the garden or in contact with soil and,
afterwards, wash your hands carefully.
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Try to find yourself in the privacy of your own home some time for yourself and your partner establishing further emotional and sexual involvement with him.
If the pregnancy proceeds normally, sexual intercourse can be maintained with the frequency the couple prefer.
Penetration and ejaculation do not transmit any kind of disease to the
child if the mum and dad are healthy. Furthermore, sexual activity
towards the end of pregnancy seems to facilitate labour making the neck
of the uterus softer.
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To get yourself
good sleep
A few tricks and some
small precautions before
going to sleep are all
you need.
What to do
• have a light and balanced evening meal bearing in mind that some
foods help to induce sleep (milk, yoghurt, bananas, wholemeal cereals,
lime, valerian or mallow-based herbal tea)
• relax and engage in an activity that is rewarding for yourself, your body
and your mind (read a good book, watch a film, chat with your partner…)
• have as regular a routine as possible: always going to bed and waking
up at the same time helps find your own waking/sleeping rhythm
• use firm, but not hard, mattresses, in latex or with springs, resting on
wooden staves.
What not to do
• have a long snooze during the day, so as not to run the risk of being
too well rested by evening
• any physical activity or effort in the evening, since it could cause an
increase in neurotransmitters that make you more wide awake
• consume stimulant foods that contain caffeine or theine (tea, coffee,
coca-cola, chocolate…) in the evening and, in any case, before going
to sleep.
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Medical examination during pregnancy
Pregnancy, even though it is a normal physiological event in the life of
a woman, needs careful medical supervision and periodic examinations
aimed at assessing the state of health of the mum and the future baby.
Periodic medical examinations are necessary in order to assess on
each occasion the clinical situation and prescribe whatever action is considered appropriate.
It is important to remember that pregnancy is often a useful time to
identify any disorders the mother may have, that she is not aware of.
Sometimes conditions are also discovered that predispose a person to illnesses that can appear in pregnancy and/or become chronic later on.
On the whole, it is advisable
• Periodically to check arterial blood pressure (even at home, at the
pharmacy or at your own doctor’s), especially where there are risk factors like: the first pregnancy, being overweight, being over 40, pregnancy with twins, kidney trouble, cases of hypertension in the family,
chronic hypertension, previous pregnancies complicated by hypertension, fetal underdevelopment, endo-uterine death.
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• To check your weight increase, especially if there are conditions that facilitate the onset
of diabetes: obesity, having
diabetes in the family, glycosuria, hypertension, previous
pregnancies complicated by
miscarriage, polyhydramnios,
or fetal macrosomia.
• To carry out haemato-chemical tests and any in-depth
investigation prescribed by
your gynaecologist.
• To undergo periodic obstetric
scans, with the main objective of dating the pregnancy,
studying fetal anatomy, and
assessing fetal growth and
presentation of the fetus.
• Based on what the couple
choose and the age of the
woman, possibly to carry out
prenatal diagnosis checks,
that consist of non-invasive
screening tests (Tritest, Integrated Test) and invasive
tests to study fetal chromosomes (villocentesis, amniocentesis).
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Sponaneus labour
Labour can be considered to be physiological if its onset is spontaneous, at the end of pregnancy (between 37 and 41 weeks), in the presence of normal maternal and fetal conditions. In this case, assistance
during labour is aimed at safeguarding maternal and fetal wellbeing and
the natural progress of the birth. However, even in normal physiological
conditions, risk situations can suddenly arise for the expectant mother
and the fetus that make it necessary to take therapeutic action.
The active stage of labour, which starts when the neck of the uterus is
dilated by at least 2 cm and uterine contractions are regular and painful,
is preceded by a period, called prodromic, during which contractions
are irregular and the neck of the uterus is preparing for active labour. For
this period, that can last up to 8-12 hours, no particular assistance is
anticipated.
Physiological labour and childbirth is attended by the obstetrician, who
in case of necessity can be assisted by the gynaecologist, the anaesthetist and the neonatologist.
The expectant mother can, if she wishes, have her partner or a person
she is happy to have present alongside her. In labour, she will be able to
assume the position she thinks is the most comfortable and feed herself
with light and easily digestible foods.
Fetal wellbeing will be checked by means of intermittent listening to the
fetal heartbeat or through cardiotocographical monitoring.
Although pain is an unavoidable part of labour, the obstetrician will be
able to bring relief through non-pharmacological methods (e.g. massage, appropriate breathing and relaxation positions and techniques).
Should non-pharmacological methods not suffice, recourse can be
made to epidural analgesia. In some hospitals, this is carried out by the
anaesthetist at the patient’s request and/or as indicated by the obstetricgynaecological team. The medications injected in the epidural area do
not reach the fetus and in the case of urgent Caesarean section, the
catheter already in position is used for the epidural anaesthetic.
During the dilation period, if uterine contractions are inadequate to
guarantee the dilation progress, the administration of an intravenous
injection of oxytocin may be suggested that may involve rupture of the
amniotic sack (amniorrhexis).
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When dilation of the neck of the uterus is complete, the expulsion period begins, lasting about 1 hour, during which the fetus makes its
progression through the birth channel thanks to the help of maternal
pushing.
When the fetal head arrives almost at the level of the external genitals,
its expulsion can be facilitated, in a minority of cases, by the execution of
a small incision (episiotomy) under local anaesthetic.
Under normal physiological conditions, expulsion of the placenta
(called “secundines expulsion”) takes place a short time after the birth.
If the birth has taken place without complications, the newborn can be
placed on the mum’s abdomen to make the materno-fetal detachment
less abrupt. The obstetrician will then see to the first care of the newborn:
assessment of its condition at birth, clamping the umbilical cord, any necessary aspiration of mucous material from the primary air passages,
maintaining body temperature, applying the identification bracelet,
administration of antibiotic eye-drops to prevent eye infection…
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Caesarean section
Caesarean section is an operation in which the birth takes place by
extracting the fetus through a surgical incision made to the abdominal
wall and the uterus. The operation becomes necessary on all those occasions where birth through the vagina is impossible or presents greater
risks, for the mother or for the baby, than Caesarean section.
Indications that the operation is necessary may be fetal and/or maternal. Some of the main ones are mentioned as follows: fetal distress,
anomalous presentation of the fetus, feto-pelvic disproportion, fetal malformations, placenta previa, untimely placental detachment, uterine rupture, previous operations on the uterus, anomalies of the maternal pelvis,
serious preeclampsia and its complications, maternal pathologies that
contraindicate vaginal birth, etc.
The usual technique provides for a horizontal incision to the abdominal wall, 2-3 cm above the pubic bone, and an incision, once again horizontally, to the lower part of the front wall of the uterus. In this place, the
scar on the uterus gives the greatest guarantee of resistance in the case
of a new pregnancy. Only in particular situations, such as for example
previous surgical operations, may it be necessary to make a vertical ,
navel-pubic incision, to the abdominal wall.
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After the operation: the patient can get up, with the help of hospital
staff, after a few hours. The post-operative pain will be lessened with the
use of specific medications. The urinary catheter will be kept for 24-36
hours and liquids will be administered for 24-48 hours. Use of an abdominal bandage is advised.
In later pregnancies, the woman who has undergone a caesarean
section can go into normal labour, if there are no contraindications for a
vaginal birth. The risk of the previous scar on the uterus opening fluctuates around 1-1.5% of cases: careful supervision of labour generally
allows timely intervention.
Anaesthesia
Until a few years ago, the caesarean was usually carried out under a
general anaesthetic.
Currently, the most commonly used method is peripheral anaesthesia
(subarachnoid, epidural or combined subarachnoid-epidural).
This consists in injecting anaesthetic medications into the lumbar
region, directly, into the subarachnoid space, or through the insertion of
an extremely fine plastic tube (catheter) into the peridural space, where
they can act upon the nerve fibres that transmit pain, eliminating it.
Peripheral anaesthesia offers the advantage of not subjecting the newborn’s breathing to the possible depressive effect of general anaesthetic
medications during the operation. As well as this, it allows the mother to
stay awake and therefore to see her baby straightaway.
The epidural catheter
can be kept after the operation for the administration of pain relieving medicines.
However, it should be
mentioned that some conditions exist, such as the
presence of coagulation
pathologies or the taking of
anticoagulant medicines
that contraindicate the use
of peripheral anaesthesia.
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