Your health care team

Throughout your pregnancy, you may see a number of different professionals as part of your care. Your carers may be:

Midwives

Midwives will be your lead professional if you are noted to have a low risk pregnancy and birth. They will be there ensuring you can make informed choices throughout all aspects of your care. During and after your pregnancy they will be seeing you in the Community Clinics, in the Children’s Health Centre.

Obstetricians

Obstetricians will be your lead professional if you have a high-risk pregnancy and/or birth. If required you will be booked into their Antenatal Clinic. This referral to their care may happen at your first ‘booking’ appointment or at any point in the pregnancy if a problem was to arise. They will then plan, discuss and agree on a management plan and your care will be a “shared care” between the consultants and the midwives. An obstetrician may also be called to your delivery if the situation deviates away from the normal, which may result in them having to deliver your baby rather than a midwife.

Sonographers

Sonographers are those professionals who will be performing all your Ultrasound scans during your pregnancy. They will be the ones performing your routine 12 and 20-week scan, along with any further necessary scans in which the midwife/doctor may request.

General Practitioner (GP)

GP’s are community based doctors, who deal with all aspects of minor or chronic health problems for you and your family. GHA GP’s can be found at the Primary Health Care Centre situated at the entrance to St Bernard’s Hospital. (See front page for details)

Paediatricians

Paediatricians will attend to do your baby’s first newborn examination once your baby is over 24 hours old. They may also attend your delivery if needed.

 Health Visitors

The Health Visitors will take over once you and your baby have been discharged from the community midwives. They will usually get into contact with you around day 10-14 to arrange your first appointment with them.

Antenatal care plan

(see the full table on the Guide)

It is important to bear in mind that not all of your antenatal, labour and/or postnatal care may end up being carried out in Gibraltar.

Here in St. Bernard’s Hospital we are a small Maternity unit with no Neonatal Unit, and it is due to this that at some point we may decide that the safest place for you to deliver your baby is in Spain and in some cases, the UK. If this is the case, we will arrange the transfer and we will stay in contact with you throughout your stay at the assigned hospital

Routine blood tests

Screening tests are available during your pregnancy to help detect some of the conditions that may affect either you or your baby. You can choose whether to have these tests and the information in this leaflet will help you decide. Your midwife and doctor can help discuss any concerns you may have.

Full Blood Count

To check for anaemia and on occasion can detect other problems that may need more investigation. The common reason for anaemia is lack of iron, which can usually be treated easily with iron tablets and/or an iron-rich diet. At 28 weeks, this test will be repeated.

Blood Group and Antibodies

This test is required in case of you requiring a blood transfusion. It will determine your blood group. For those women, who are Rhesus Negative, they will require Anti-D in their pregnancy. (You will be provided with more information on this once you are informed of your blood group. Sometimes the test finds other rare blood factors. It is important to know about these so you and your baby can be given specialist care. At 28 weeks, this test will be repeated.

Rubella

If caught in the first 12 weeks of pregnancy, your baby has around 9 in 10 chance of problems such as heart defects, cataracts and deafness. This is lowered if rubella occurs in later pregnancy. If you have had Rubella in the past or had a Rubella vaccination, you are likely to be immune. About 5 % of people who have been vaccinated are not immune. A blood test is offered and if the test shows you are not immune, you will be offered a Rubella vaccine once your baby has been born, to protect you in any future pregnancies.

Hepatitis B

This virus infects the liver. Many people who have Hepatitis B are not aware they have it and a small number become ‘carriers’ of the virus. If you have Hepatitis B, your baby can be exposed to the virus during delivery. A baby who catches the virus may have the infection for life and may be at risk of liver disease. Testing is important because a course of vaccinations started soon after birth can help stop the baby contracting the virus. The vaccinations protect most babies from developing Hepatitis B.

Syphilis

This is a serious sexually transmitted bacterial infection. Most people who have Syphilis are unwell for only a short time at first, and they may not be aware they have it. If Syphilis is not treated, it can cause you serious problems later in life. If you have Syphilis when you are pregnant, it can harm your baby. Treatment with antibiotics during your pregnancy will help you, and usually stops your baby catching Syphilis. Once your baby arrives, s/he will need another course of antibiotics.

HIV

HIV is a virus that attacks your immune system. The virus can lead to acquired immune deficiency syndrome (AIDS). A person infected with HIV can look and feel well many years. They may not even know they are infected. If you have the HIV virus, treatment can dramatically lower the chances of you passing HIV to your baby. You will be given specialist treatment and care.

NIPT/SAFE Test

The SAFE test is a non-invasive test that evaluates whether a pregnancy is at risk of certain chromosomal conditions. It can be performed following your 12-week scan and is sent off to St Georges Hospital, London for testing. Your midwife should have provided you with an Official SAFE Test at your first appointment.

Scans

All women here at St. Bernard’s will be offered two routine scans. If any problems during your pregnancy are detected, you may then be advised on further scans.

• Dating Scan

This scan will be performed when you are around 12 weeks pregnant. The purpose of this scan is to confirm your pregnancy, determine the number of babies you are carrying and exclude some major abnormalities that can be seen at this stage of your pregnancy. The Nuchal Translucency (an area at the back of baby’s neck) is also measured and this is used to assist in determining abnormalities. They will also measure the length of your baby to check your due date. Occasionally, it is not possible to see the baby well enough and an internal scan may need to be carried out instead.

• Anomaly Scan

This scan is carried out as close to the 20^th week of your pregnancy. The sonographer will look at your baby in detail to check how it is developing. The areas they look at include the structure of some parts of the brain, the heart, stomach, kidneys and bladder, the spine and the umbilical cord.

For both of these appointments you are advised to attend with a full bladder and you may bring one adult and your children to see the scan with you. The scan will be performed on the 4^th floor, in Maternity, but we remind you to please report to Radiology department (Ground Floor) first.

• Glucose Tolerance Test (GTT)

A GTT is a blood test to find out if you have developed gestational diabetes (high blood sugar levels in pregnancy). This is test is generally performed at 24-28 weeks and at 16 weeks if you have been diagnosed with gestational diabetes in a previous pregnancy.  However, this is NOT a routine test and only offered to those pregnant women with risk factors: –

1. Certain ethnic groups (Middle Eastern, Black Caribbean or South Asian)
2. A Body Mass Index(BMI) of over 30
3. A previous baby of over 4.5kg
4. A first degree relative with diabetes
5. Polycystic Ovaries

• MRSA Screening

MRSA is a type of bacteria that is resistant to a number of widely used antibiotics. MRSA bacteria usually spread through skin-to-skin contact with someone who has an MRSA infection or has the bacteria living on their skin. The bacteria can also be spread through contact with contaminated objects such towels, sheets, clothes, dressings, surfaces, door handles and floors. If you are a hospital worker, it is recommended that you be screened for MRSA. Those women having a planned Caesarean Section will also be advised to be screened as per our protocol.

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When to call a Midwife

You should call your midwife or maternity unit if

• your waters break, or
• you’re bleeding, or
• your baby is moving less than usual, or
• you’re less than 37 weeks pregnant and think you might be in labour

Baby Movements

Feeling your baby move is a sign that they are well.

You usually begin to feel your baby move between 16 and 24 weeks of pregnancy. A baby’s movements can be described as anything from a kick, flutter, swish or roll. The type of movement may change as your pregnancy progresses.

How often should my baby move?

There is no set number of normal movements. From 16 to 24 weeks on you should feel your baby move more and more up until 32 weeks, then roughly stay the same until you give birth.

DO NOT WAIT UNTIL THE NEXT DAY TO SEEK ADVICE IF YOU’RE WORRIED ABOUT YOUR BABY’S MOVEMENTS – please the GHA if you are concerned about your baby’s movements

It is not true that babies move less towards the end of pregnancy or in labour.

You should continue to feel your baby move right up to the time you go into labour and whilst you are in labour too.

Why are my baby’s movements important?

A reduction in a baby’s movements can be an important warning sign that a baby is unwell. Around half of parents who had a stillbirth noticed their baby’s movements had showed slowed down or stopped.

If you think your baby’s movements have slowed down or stopped please ring central labour suite it immediately on 01244 365026 or 365028. Midwives are available 24 hours a day, seven days a week. There is always a midwife available even at night. Do not put off getting in touch with your maternity unit. Do not worry about phoning, it is important to talk to your maternity unit for advice even if you are uncertain. It is very likely that they will want to see you straight away.

What if my baby’s movements become reduced again?

If after your check-up you are still not happy with your baby’s movements, you must contact your maternity unit straight away, even if everything was normal last time.

NEVER HESITATE TO CONTACT THE MATERNITY UNIT FOR ADVICE NO MATTER HOW MANY TIMES THIS HAPPENS

DO NOT use handheld monitors, dopplers or phone apps to check your baby’s heartbeat. Even if you detect a heartbeat this does not mean your baby as well.

Staying Active

Check the guide infographic.

• shows at a glance how much exercise women can do during pregnancy
• gives exercise suggestions
• shows the benefit of exercise for pregnancy, labour and birth
• lists the exercises to avoid.

Smoking in Pregnancy

The PCC offers smoking cessation sessions, you can self-refer by calling 200 52441.

The Risks:

The Royal College of Obstetricians & Gynaecologists state that smoking whilst pregnant can increases the risks of:

• Miscarriage
• Ectopic Pregnancy(where a pregnancy occurs outside of your womb)
• Your baby dying in the womb (stillbirth) or shortly after birth – one-third of all deaths in the womb or shortly after birth are thought to be caused by smoking
• Your baby being born with abnormalities, for e.g. face defects, such as cleft lip and palate, are more common because smoking affects the way your baby develops
• Your baby’s growth and health being affected – the more you smoke, the less healthy your baby will be, and a baby that is small due to smokingis more likely to have health problems when young and also later in life
• Bleeding during the last months of pregnancy, which is known as an abruption (when the placentacomes away from the wall of the womb) – this could be life threatening for you and your baby
• Premature birth, when you have your baby before 37 weeks of pregnancy.

At your booking appointment the midwife will ask if you are a smoker, what it is you smoke and how often. It is important that you answer honestly in replying to these questions. They will also ask if anyone else at home smokes. This question, is asked as passive smoking can be just as harmful your baby, so even if you don’t smoke your baby could still be at risk. Passive smoking can increase:

• Stillbirths or Neonatal Deaths
• Premature delivery
• Poor Growth

Stopping Smoking

Stopping smoking will help both you and your baby. We understand that stopping smoking can be difficult to do. However, it is one of the best things that you can do to give your child a healthy start to life. Reducing the amount of cigarettes you smoke is a positive step in the right direction, however there is no ‘safe level’ of smoking. Therefore, both you and your partner, if necessary, will be encouraged to stop smoking completely.

STOPPING SMOKING AND ENSURING YOU ARE IN A SMOKE FREE ENVIRONMENT WILL REDUCE ALL THE ABOVE RISKS!

Alcohol in Pregnancy

The Chief Medical Officers for the UK recently altered the guidance advice for consumption if pregnancy. It is recommended, that the safest approach is NO alcohol whilst pregnant in order to minimise the risks to your baby. Alcohol consumption during pregnancy can lead to long-term effects to your baby.

THE MORE YOU DRINK, THE GREATER THE RISK!

When you drink alcohol whilst pregnant, it will cross from your blood through to the placenta and to your baby. Your baby cannot process alcohol like you can and too much exposure can lead to some serious damage.

The Risks

Alcohol in the 1^st 3 months can increase the risk of miscarriage, premature birth, placental abruption, birth defects and your baby being underweight at birth.

Continuing to drink further into your pregnancy may cause problems once your baby has been born such as learning and behavioural problems. Excessive drinking throughout the pregnancy can cause your baby to develop Fetal Alcohol Spectrum Disorder (FASD).

FASD can cause:

• Poor growth
• Facial Abnormalities
• Learning and behavioural problems

What is a unit of Alcohol?

One unit is 10ml or 8g of pure alcohol. A unit is a way of telling us how strong your drink is. For further information on how many units are other varieties of alcoholic drinks please visit:  www. Drinkaware.co.uk

Drugs in Pregnancy

Illegal drug use in pregnancy can be harmful to your baby. It is extremely important for you to inform your midwife/GP if you are using any illegal drugs, so we can adapt and provide you with the best care possible along with being able to help support and advise you accordingly.

If taking Illegal drugs, you are exposing yourself to risks for anaemia, blood and heart conditions, skin infections, hepatitis and other infectious diseases.

Your drug use during the pregnancy can affect both yourself and your baby. Most drugs pass across through the placenta to your baby. Some of these drugs can cause toxic effects and even drug dependency to your baby, meaning that once your baby is born they will be addicted to the substance and will show signs of withdrawal once born.

In general, the side effects of illegal drug use in pregnancy on you, (the mother), is:

• Poor appetite
• Difficulty in sleeping
• Premature labour
• Poor decision making
• Increased risk of infections
• Waters breaking prematurely
• Sudden bleeding

Drugs can also affect your unborn baby:

• Underweight at birth
• Premature delivery/miscarriage
• Slow growth/development
• FAS
• Learning difficulties
• Heart problems
• Birth defects
• Death

On the guide, you will find a table showing some illegal drugs and the complications they can cause to the pregnancy and your baby.

Weight in Pregnancy

The midwife will calculate your Body Mass Index (BMI) at one of your 1^st appointments. Your BMI calculates whether your weight is in proportion to your height, along with whether your health is at risk by being underweight or overweight. It is calculated by dividing your weight in kilograms by your height in metres squared.

Being overweight can increase the risk of complications for pregnant women and their babies. A BMI of 25 or above is associated with risks for you and your baby.  If your BMI is over 30 you will be referred to one of our obstetric consultants.

The risks associated with a raised BMI according to the Royal College of Obstetricians & Gynaecologists are:

Risks to the pregnancy:

Thrombosis

As a pregnant woman, you are already at an increased risk of developing a blood clot, but having a raised BMI increases this risk even further.  You may be offered injections, of a medication called low molecular weight heparin to reduce these risks. Your consultant will discuss this with you.

Gestational Diabetes

When your BMI is 30 or over, you are over 3 times more likely to develop gestational diabetes than those women with a BMI under 25. You will be offered a test for gestational diabetes at around 28 weeks.

High Blood Pressure and Pre-Eclampsia

Having a BMI of over 30 can increase your risk of developing high blood pressure. Pre-eclampsia is a condition involving a combination of hypertension and proteinuria (Protein in your urine). Your risk of being diagnosed with pre-eclampsia is doubled if you have a BMI >35 compared to those women with a BMI <25.

Risks for your baby:

• BMI >30 before pregnancy or in early pregnancy, can affect the development of your baby.
• The general risk of miscarriage under 12 weeks is 20%, but a BMI>30 increases this risk to 25%
• If your BMI is >30 the likelihood of your baby weighing over 4kg (8lb 14oz) is doubled from 7% (BMI 20-30) to 14%
• The risk of stillbirthis also doubled
• By being overweight yourself, your baby will also have an increased risk of obesity and diabeteslater on in their life.
• In view of the above risks associated with baby, if your BMI is over 35, you will be offered an additional 2 growth scans. You may need extra scans on top of these, as it can be more difficult to assess your baby’s growth or feel if your baby is in the right position.

Risks during labour and delivery (Especially if your BMI is over 40):

• Increased risk of premature delivery– Baby is born before 37 weeks
• Increased risk of having a long labour
• Increased risk of your baby’s shoulders becoming stuck during delivery– known as a shoulder dystocia (an obstetric emergency)
• Increases risk of delivering your baby via a caesarean section. A raised BMI may then cause problems with anaesthetic, especially a general anaesthetic and bring a further increased risk of complications following the caesarean.
• Increased risk of heavy bleedingafter delivery or during, if a caesarean (A postpartum haemorrhage)

Therefore, as you can see many risks are associated with a raised BMI. By eating healthily and exercising during your pregnancy, you can help lower these risks. At the 1^st appointment, your midwife should offer you a referral to the dietician, in order to support you with healthy eating during your pregnancy. (See next chapter on Pregnancy and Healthy Eating). If exercise is not part of your weekly routine generally, start with including some light exercise (15 minutes, 3 times a week) and then gradually increase it to 30 minutes a day, as your fitness and pregnancy progresses. See page 11 ‘Guide to Staying Active’ for more information on exercising in pregnancy. Ideally, folic acid should have been taken pre- conceptually, with the routine dose being 400mcg, however, if your BMI is over 30 you should have been commenced on (if not already taking it) an increased dose of 5mg folic acid for the 1^st 13 weeks of your pregnancy.

How much weight should I expect to put on?

Weight gain varies and depends on what you weighed before you became pregnant. However, most women put on 10 to 12.5kg (22 to 28lb) over the whole of their pregnancy. If you gain too much weight, this can affect your health and increase your blood pressure. Equally, it is important that you do not try to diet. If you are concerned about your weight, talk to your GP or midwife. Cutting down on fatty and sugary food and drink may help you to avoid gaining excessive weight during pregnancy.

Pregnancy and Healthy eating

It is important to try to eat a variety of foods including:

• Plenty of fruit and vegetables(fresh, frozen, tinned, dried or a glass of juice) – aim for at least five portions of a variety of fruit and vegetables a day.
• Plenty of starchy foods, such as bread, pasta, rice and potatoes.
• Some protein, such as lean meat and chicken, fish (aim for at least two servings of fish a week, including one of oily fish), eggsand pulses (such as beans, peas and lentils).
• Plenty of fibre, found in wholegrain bread, wholegrain cereals, pasta, rice, pulses, and fruit and vegetables– this helps prevent constipation.
• Some dairy foodssuch as milk, cheese and yoghurt, which contain calcium. These are also good sources of protein.

Do I need extra iron?

 Pregnant women can become short of iron, so make sure you choose plenty of iron-rich foods. Try to have some food or drink containing vitamin C, such as a glass of fruit juice, at the same time as an iron-rich meal because this can help your body absorb the iron. If the iron level in your blood becomes low, your midwife may advise you to take iron supplements.

Good sources of iron include:

• red meat (choose lean cuts)
• pulses
• bread
• green leafy vegetables
• wholegrain starchy foodsand fortified breakfast cereals
• dried fruit

Do I need to cut out caffeine?

You should limit the amount of caffeine you have each day, but you do not need to cut it out completely. The current NHS guidelines recommend less than 200mg of caffeine a day. This is because high levels of caffeine can result in babies having a low birth weight. It has also been linked to miscarriage and stillbirth. The amount of caffeine in food and drink will vary, but as a guide, each of these contains roughly 200mg:

• 1 mug of instant coffee – 100mg
• 1 mug of filter coffee – 140mg
• 1 mug of tea – 75mg each
• 1 can of cola – 40mg
• 250ml can of energy drink – around 80mg
• 1 Bar of plain chocolate – around 26mg

Are the any foods I should avoid?

Yes, there are certain foods you should not eat while you are pregnant:

• Liver and liver products. Liver contains very high levels of Vitamin A, which can be toxic to your baby. Also, avoid Vitamin A supplements.
• Make sure all your meat is thoroughly cooked through and avoid raw eggs. This is to avoid the risk of salmonella, which causes a type of food poisoning. You may also prefer to avoid raw cured meat, such as Parma ham, chorizo, pepperoni and salami. Cured meats are not cooked, so there could be parasites in them that cause toxoplasmosis. If you do want to eat cured meat, you can freeze for 4 days at home before defrosting and eating.
• Shark, swordfish and marlin. Tuna should be limited. The amount of tuna to two tuna steaks or four medium sized cans of tuna a week. This is due to the high mercury levels in these fish, which can harm your baby’s developing nervous system.
• Pate – all forms. Pate may contain bacteria called listeria, which can cause listeriosis, and this can harm a baby during pregnancy or cause severe illness in newborns.
• Soft, unpasteurised and blue cheeses, such as brie and camembert. Goats and sheep’s cheese should also be avoided. This is because these cheeses may contain listeria, which can be harmful to your baby. All hard cheeses are safe to eat and soft pasteurised cheeses such as Cottage cheese, cheese spread, mozzarella, feta, halloumi and ricotta. Goat’s cheese without the rind is also classified as safe to eat.

Eggs

You also need to be careful with eggs. If eating Red Lion stamped eggs, they have been certified as less likely to have salmonella, so can be eaten runny or raw. If not a Red Lion egg, please make sure they have been cooked thoroughly before consumption.

Shellfish

Raw shellfish can cause food poisoning so is recommended to be avoided during pregnancy. Cooked shellfish is safe to eat.

Sushi

Sushi is generally safe to eat. If it contains raw uncured fish, you need to ensure it has been frozen first. Avoid any sushi containing raw shellfish.

On the following page, there is an information leaflet about a general healthy diet in pregnancy.

Infection During Pregnancy

Pregnant women and women who have just had a baby are at risk of developing genital tract infections (infection in the vaginal area). In some cases, these infections can be very serious and even life threatening.

Bacteria, such as Streptococcus A, that causes sore throats and respiratory (airway) infections, can be spread from the throat and mouth and transferred to the vagina and perineum via the hands.

Prevention:

Genital tract infections can be prevented very easily, simply by having good personal hygiene and through careful hand washing.

This is particularly important if either you or a member of your family have had a sore throat or a respiratory (airway) infection.

To prevent the transfer of infection from mouth to the genital area, it is strongly advised that you remember to wash your hands thoroughly before and after:

•  Using the toilet
•  Changing your sanitary towels
•  Changing your baby’s nappy

Signs of infection:

Contact your GP or Midwife for advice if you develop signs of an infection. For example:

• Sore throat
• Fever
• Shivering
• Fast heart rate
• Abdominal pain
• Unpleasant vaginal discharge

Speak to your midwife for further information.

Infectious Illnesses

Some infectious illnesses can cause problems for you whilst pregnant. Please inform you Midwife/Doctor if you have any concerns regarding any of the following illnesses.

Seasonal Flu

Evidence has shown that pregnant women have a higher chance of developing complications if they get flu, particularly in the later stages of pregnancy. One of the most common complications of flu is bronchitis, a chest infection that can become serious and develop into pneumonia. If you get the flu whilst you are pregnant, this could cause your baby to be born prematurely, have a low birthweight, and may even lead to stillbirth or death. This is why the flu jab is recommended in pregnancy as will help protect both you and your baby.

Covid

You are at higher risk of getting seriously ill from COVID 19 whilst pregnant. If contracted in the later stages it could put your baby at risk. It is been strongly recommended that you be vaccinated to protect you and your baby. If you test positive for COVID19 at any stage during your pregnancy please call the Maternity Ward and inform one of the members of our team and they will advise you accordingly.

Whooping Cough

Whooping cough is a serious bacterial infection and can be very dangerous for newborn babies. They cannot be vaccinated against it until they are at least 2 months old. During this period, they are vulnerable and depend only upon the immunity that they receive from their mother. Therefore, being vaccinated during your pregnancy is recommended as it can help you protect your baby from developing whooping cough in this period. Your immunity will pass to the baby through the placenta during pregnancy and through breast milk after delivery. (See whooping cough leaflet for further details)

Rubella (German Measles)

At your blood appointment, all women are offered to check their rubella immunity. If you are immune, there is no need to worry about contact. However, if not immune, and you are exposed to Rubella you should advise a midwife or doctor.

Parvo Virus (Slapped Cheek)

If you are in contact with someone who has Parvo Virus, or who develops the rash a few days after you’ve been in contact with them you should call and report this to your midwife/doctor. A blood test to see if you are immune to this infection can be done and a plan for further investigations put in place if you are not immune.

Chicken Pox

If you have had chicken pox, you are immune and there is nothing to worry about. You do not need to do anything. If you are not sure about having had chicken pox or have never had it, you may be at risk. So if this is the case and you have come into contact with it you should report it to a midwife/doctor. You will need a blood test to find out if you are immune. If not immune, preventative treatment may be offered