Topic: Gynaecology

Nutrition for Pregnancy


Nutrition for Pregnancy


Pregnancy is a time when what you eat and drink becomes even more important. It’s no excuse to eat for two – the food and the nutrients food provides, will help with the baby’s growth and development as well as keeping you in the best possible shape. That’s why you need to focus on eating a variety of nutritious foods, particularly those that pack a strong nutritional punch!

In some instances it will be challenging to meet the nutritional demands of pregnancy without the use of supplements. This is where it is beneficial to consult a dietitian to discuss your individual needs.

Let’s have a look at the nutrients you need to focus on, the foods that you need to eat a little more of, as well as giving you a heads up on what you need a little less of to ensure (as best that we can) the health of you and
your baby.

What nutrients you need more of:

NUTRIENT WHAT DOES IT DO? HOW MUCH? WHERE FROM?
Folate ( Folic Acid – A B group Vitamin) Healthy development of babies in the first trimester. Reduces risk of abnormalities such as Spina Bifida(where baby’s spinal cord doesn’t form properly) At least 400 micrograms daily at least 1 month before conception and 3 months following.
Ask your doctor for advice, especially if you have a family history of neural tube defects.
Green leafy vegetables (bok choy, broccoli, spinach and salad greens)
Some fruits.
Fortified cereal, fruit juice, bread.
Vitamin supplements.
Iron Helps form red blood cells that carry oxygen needed for baby to grow. Much more than when you were not pregnant –27mg.
Absorption of iron is lower in vegetarians so intakes may need to be 80% higher.
Liver, lean(particularly red)meats.
Fortified cereals.
Green leafy vegetables, legumes. (note that iron is less readily absorbed through leafy vegetables, therefore vegetarians may need to consult a dietitian to ensure adequate iron intake).
Calcium Bone mineralisation, nerve and muscle function, Blood Pressure control. 100mg per day.
At least 3 serves of calcium-rich food each day.
Milk, Cheese, Yoghurt or Soy and other non-dairy milks with added calcium.
Vitamin D Bone and Growth Development. Immune system development. 5 micrograms (200IU) per day.
Some studies are suggesting at least 35 micrograms (1400-2000 IU) per day.
Safe sun exposure. Oily Fish. Full dairy diet. Egg Yolk. Fortified foods.
Omega 3 (DHA & EPA) Baby’s brain, eye and central nervous system, development of the growing baby.
In high-risk pregnancies a higher intake of DHA has also been shown to reduce the risk of premature births (less than 34 weeks).
At least 200mg per day. 2-3 serves of oily fish weekly, apart from varieties high in mercury.

What foods should be eaten during pregnancy?


FOOD GROUP NUMBER OF SERVES EACH
DAY
SAMPLE SERVING SIZES
Bread, cereals, rice, pasta & noodles 4-6, at least half should be wholegrain 2 slices of bread
1 medium bread roll
1 cup cooked rice, pasta or noodles
1 & 1/3rd cups of breakfast cereal flakes.
Vegetables and Legumes 5-6 1 sml potato
1 cup salad vegetables
½ cup cooked vegetables
½ cup cooked legumes
Fruit 4 1 medium fresh fruit (apple, pear, orange, banana)
1 small fresh fruit (apricots, plums, kiwi fruit)
Dairy 3-4 250ml milk or yoghurt drink, 200g yoghurt, 2 Slices (40g) cheese
Meat, fish or poultry 1-2 ½ cup lean mince, 2 small chops, ½ cup legumes, 1 small fish fillet, 2 small eggs.
Extra foods 0-2 ½ 2 tbsp cream or mayonnaise, 4 plain sweet biscuits, 1 tbsp oil or margarine, 1 can soft drink.

While pregnant, try to avoid:


Too much caffeine: Caffeine takes longer to break down in the body during pregnancy, and high intakes may increase the risk of miscarriage and your baby having a low birth weight. Caffeine is found in coffee, tea, chocolate, some soft drinks, energy drinks and some medicines.
Aim for no more than:

  • 1 regular espresso style coffee; or
  • 3 cups of instant style coffee; or
  • 4 cups of tea.

Possible food poisoning: As hormone changes may weaken your immune system, avoid Listeria containing foods (mostly chilled, ready to eat foods):

  • Soft cheeses (e.g. ricotta, brie, camembert)
  • Take away chilled cooked chicken (e.g. chicken sandwiches)
  • Cold meats
  • Pre-prepared salads
  • Paté
  • Raw or smoked seafood (e.g. smoked salmon) – canned seafood is safe.
  • When eating out, avoid food served lukewarm choose hot foods only.

Foods and drinks that prevent your body absorbing iron:

  • Too much tea/coffee (especially with meals) and unprocessed bran.
  • Avoid taking iron supplement with a meal containing milk, cheese and yoghurt.

Mercury in fish: Some fish may accumulate levels or mercury that may be unsafe for your baby’s development. Food standards Australia New Zealand (FSANZ) recommends the safe fish intake for pregnant women and women planning pregnancy where 1 serve = 150g:

  • 1 serve per fortnight of shark (flake) or billfish (swordfish/broadbill and marlin) and no other fish that fortnight.
  • OR
  • 1 serve per week or orange roughy (deep sea perch) or catfish and no other fish that week.
  • OR
  • 2-3 serves per week of any other fish and seafood not listed above.

What can help:


Nausea and vomiting:

  • Eat small, frequent, regular meals and have small frequent drinks between meals.
  • Avoid foods if their smell, appearance or taste makes you feel sick.
  • Food has a stronger smell when it is heated, that may make nausea worse. Prepare you food during times that you feel better, or ask others to help with the cooking.
  • Limit fried, fatty and spiced foods.
  • Eat more nutritious foods, such as dry toasts, crackers, breakfast cereals or fruit, and less sugary and fatty foods.

Reflux:

  • East small, regular meals and snacks.
  • Avoid fatty, fried or spicy foods.
  • Separate eating from drinking. Drink in between meals or snacks instead.
  • Avoid tea, coffee, cola drinks, chocolate drinks and alcohol.
  • Sit up straight whilst eating and avoid bending after meals.

Constipation:

  • Have enough fibre (from vegetables, fruit, wholegrains, nuts, seeds and legumes).
  • Keep up your fluid intake.
  • Keep physically active.

Keep weight in check:

Even though obesity negatively affects pregnancy outcomes for both mother and baby, weight loss is safer before or after pregnancy:

  • Try to minimise weight gain during pregnancy if you are overweight or obese; aim to only gain a little in the first trimester, most in the last when the baby gains most weight.
  • Depending on your pre-pregnancy weight, aim to only gain.
  • Between 10-13kg if you are in the healthy weight range.
  • No more than 10kg if your BMI greater than 30.
  • No more than 7kg if your BMI is greater than 40.

Manage your weight by:

  • Exercising throughout your pregnancy, particularly during the first two trimesters.
    Seek advice from your doctor to ensure there are no medical reasons to limit activity – but walking, swimming, low impact exercises and many other activities are safe for most pregnant women.
  • Consulting an accredited practicing dietitian, your doctor or midwife for assistance with weight management.

Keep weight in check:

It is vital to eat healthy, nutritionally – balanced food, and to look after yourself so you can provide the best care for your baby. Producing breast milk increases appetite and nutritional requirements (such as kilojoules, protein, zinc, iodine, omega 3 fatty acids and vitamin B12) for the mother.

  • Limit caffeine to 1 regular expresso style coffee, or 3 cups of instant style coffee or 4 cups of tea a day.
  • Better not to drink alcohol, at least for the first month. If you have a drink, aim for no more than 2 standard drinks a day, and drink after a breastfeed. (it can take more than 3 hours for alcohol from 2 standard drinks to be cleared from breast milk, so try to plan ahead and express some breast milk to feed your baby before you drink).
  • Keep exercising regularly: Choose something you enjoy and can combine with your busy day or with your baby: walking, an exercise DVD or resistance activities.
  • Get enough rest and if you have any problems, ask for help and advice.

Birth after Caesarian Section


Birth after Caesarian Section


50% of women will attempt a VBAC and 50% will be successful.

Factors associated with successful VBAC-a previous vaginal birth, especially previous VBAC, are associated with 87% to 90% BVAC success.

Risk factors associated with unsuccessful VBAC are:

a. Induced labour
b. No previous vaginal birth
c. BMI greater than 30
d. Previous caesarian section for dystocia

When all of these are present successful VBAC is less than 40%.

Other factors associated with a decreased likelihood of VBAC:

a. VABC at or after 41 weeks
b. Birth weight greater than 4kg
c. No epidural anesthesia
d. Previous pre-term caesarian birth
e. Cervical dilatation at admission less than 4cm
f. Less than 2 years from previous caesarian birth
g. Advanced maternal age
h. Non white ethnicity
i. Short stature
j. Male infant

Contra indication to VBAC:

a. Previous uterine rupture
b. Previous high vertical classical caesarian section, 2-9% risk of uterine rupture
c. 3 or more previous caesarian sections.

No significant difference in the rate of uterine rupture in VBAC with 2 or more previous caesars but hysterectomy rate x 3 transfusion requirements x 2.

Specific risks of VBAC:

a. Rupture rate 0.2 – 0.7%
b. No risk of rupture with ERCS, uterine rupture in an unscarred uterus is 0.005 – 0.02%

RISK’S BACV ERCS
Blood Transfusion 10.7% 1%
Endometritis 2.9% 1.8%
Hysterectomy 0.23% 0.30%
Thrombosis 0.04% 0.06%
Maternal Death 17/10 to the five 44/10 to the five

The increased risk of successful verses unsuccessful VBAC.

RISKS UNSUCESSFUL VBAC SUCESSFUL VBAC
Uterine rupture 2.31% 0.11%
Uterine dehiscence 2.0% 0.14%
Hysterectomy 0.46% 0.14%
Transfusion 3.2% 1.2%
Endometritis 7.6% 1.2%

Women considering a planned VBAC have a 2-3 out of 10,000 additional risk of birth related perinatal death when compared to ERCS. This is equivalent to a first delivery.

RISKS VBAC ERCS
Perinatal mortality 0.32% 0.13%
Still birth greater than 37 weeks 0.19% 0.08%
Delivery related perinatal death 0.04% 0.14%
Respiratory distress symptom 2-3% 3-4%

VBAC carries an 8/10,000 risk of baby developing HIE. Approximately 50% of the increased risk is caused by uterine rupture.

The risks of ERCS. There are minimal risks for a 2nd or 3rd caesarian section but risk increases with the number of caesarian sections.

a. Placenta accreta
b. Injury to bladder, bowel or ureter
c. Ileus
d. The need for post operative ventilation
e. ICU admission
f. Hysterectomy
g. Blood transfusion requiring more than 4 units
h. The duration of operative time and hospital stay

Number of previous C/S Hysterectomy Rate Placenta Accreta Accreta with Placenta Previa Bladder Injury Transfusion Requirement
1 0.65% 0.24% 3%
2 0.42% 0.13% 11% 0.3% 7.2%
3 0.9% 0.57% 40% 0.8% 7.9%
4 2.41% 2.13% 61% 14.1%
5 3.49% 2.33% 67% 2.4%
6 or more 8.99% 6.74% 67%

Healthy Pregnant or Postpartum Women


Healthy Pregnant or Postpartum Women


Is it ok to be physically active while I’m pregnant and after I have my baby?

Yes! If you are a healthy pregnant or postpartum woman, physical activity is good for your overall health. For example, moderate-intensity physical activity, such as brisk walking, keeps your heart and lungs healthy during and after pregnancy. Physical activity also helps improve your mood throughout the postpartum period. After you have your baby, exercise helps maintain a healthy weight, and when combined with eating fewer calories helps with weight loss.

Healthy women should get at least 150 minutes per week of moderate-intensity aerobic activity, such as brisk walking, during and after their pregnancy. It is best to spread this activity throughout the week.

Healthy women who already do vigorous-intensity aerobic activity, such as running, or large amounts of activity can continue doing so during and after their pregnancy provided they stay healthy and discuss with their health care provider how and when activity should be adjusted over time.

10 minutes at a time is fine. We know that 150 minutes each week sounds like a lot of time, but you don’t have to do it all at once. Not only is it best to spread your activity out during the week, but you can break it up into smaller chunks of time during the day. As long as you’re doing your activity at a moderate or vigorous effort for at least 10 minutes at a time.

Aren’t there risks involved with physical activity and pregnancy?

According to scientific evidence, the risks of moderate-intensity aerobic activity, such as brick walking, are very low for healthy pregnant women. Physical activity does not increase your chances of low-birth weight, early delivery, or early pregnancy loss. It’s also not likely that the composition or amount of your breast milk or your baby’s growth will be affected by physical activity.

What are some things to keep in mind when I do physical activity during and after my pregnancy?

Unless you have a medical reason to avoid physical activity during or after your pregnancy, you can begin or continue moderate-intensity aerobic activity. If you begin physical activity during your pregnancy, start slowly and increase your amount gradually over time. While pregnant, you should avoid doing any activity that involves lying on your back of that puts you at risk of falling or abdominal injury, such as horseback riding, soccer, or basketball.

Pre Conception check


Pre Conception check


Before attempting to conceive it is desirable that all women have a pre-conception check to ensure that cautions are taken to improve the chances for a successful outcome of pregnancy. Usually 3 months before attempting to conceive is adequate, but women with PCOS or endometriosis may need to increase this time because help may be required in achieving a pregnancy.

Either a GP who is interested in women’s health or an Obstetrician Gynaecologist can perform the assessment at this stage.

The rationale behind this consultation is to discuss lifestyle factors that can have an impact on the pregnancy and also ensure that the appropriate pre-pregnancy investigations have been performed.

Smoking

Smoking should definitely be discontinued before a pregnancy. Smoking is associated with an increased risk of fetal mortality, pre-term labour and small growth retarded babies. It also increases the risk of infertility, placental separation, premature rupture of membranes and placenta previa. Of course there are the long term maternal risks such as heart disease, lung disease and an increase in numerous cancers.

It is also known that children who inhale smoke have a higher incidence of SIDS, chronic respiratory conditions, including asthma, Atherosclerosis and middle ear disease. Essentially they grow into unhealthy adults.

Nicotine patches are not recommended during pregnancy but are probably safer than smoking during pregnancy. Ideally smoking should be ceased before the pregnancy is conceived.

Alcohol

It is known that excessive alcohol intake can produce fetal abnormalities, but the exact safe level of alcohol intake during pregnancy has not been determined. Binge drinking has a higher risk than a small amount of alcohol on a regular basis. It is important that women, once they start attempting to conceive, avoid the possibility of binge drinking, especially over the Christmas period, when this seems most likely to happen.

The occasional glass of alcohol, however, is unlikely to cause any problems to the baby, but this can not be guaranteed. I will add that 1 standard drink is 100mls of wine.

There is no exact dose response relationship between the amount of alcohol consumed during the prenatal period and the extent of damage caused by the alcohol and the infant, abstinence is recommended.

Diet

Obviously a healthy diet will help grow a healthy baby. It is recommended that women taken pregnancy vitamins for 3 months prior to conception. There are a range of these on the market and it is important to choose 1 with Iodine. For example: Elevit with Iodine, Blackmores Gold with Iodine, Pregnacare with Iodine.

Folic acid deficiency has been shown to increase the risk of Spina Bifida and related abnormalities, and the addition of folic acid either by folic acid tablets alone or in the multi vitamins, can significantly reduce this risk.

The makers of Elevit claim a reduced risk of miscarriage.

Another issue to be concerned about is ones BMI.

Underweight women who have a BMI of less than 18.5 have an increased risk of spontaneous preterm birth. Small babies (less than 2500 grams), and have increased risk of perineal tearing during labour. Women who have a raised BMI, however, have an increased risk of gestational diabetes, hypertension during pregnancy, the need for induction of labour, caesarian section and large babies. There is also an increased risk of fertility issues, often because a raised BMI is associated with the presence of PCOS.

A sensible eating plan should be commenced before conceiving and should be incorporated with exercise. It is possible, of course, to continue this eating program during a pregnancy to help minimise the risks.

Medical Conditions

Medical conditions such as Thyroid Disease, Auto Immune Diseases, Hypertension and Heart Disease need to be discussed and medications evaluated before conception occurs. It is vital to ensure that these drugs are safe during pregnancy and, if the preconception assessment occurs in time, there is time to change to safer medications if necessary.

Some blood tests are best performed before pregnancy. These include Rubella (German Measles) and Varicella (Chicken Pox). An infection with German Measles during the first 12 weeks of pregnancy can produce significant fetal abnormalities including deafness and blindness. A Chicken Pox infection during pregnancy can cause the mother to become very unwell with the risk to the baby being significantly less.

There are vaccinations for both of these viral infections but they need to be given 3 months before conception occurs.

Blood Group

It is also good to know your blood group before conceiving in the event of an early miscarriage. If the woman is rhesus negative she may require an Anti-D injection to protect against future pregnancy problems.
Cystic Fibrosis

Another test that we are now doing is for Cystic Fibrosis. Cystic Fibrosis is a genetic condition that occurs in approximately 1/25 people in the community who are carriers of the abnormal gene. There is a 1/625 chance of 2 carriers conceiving together and that couple has a ¼ chance of having an infected baby.

Cystic Fibrosis causes major lung problems, malabsorption and pancreatic damage and is often associated with a shortened life span.

There is a test available to check the presence of the carrier state so that appropriate advice can be provided if necessary. This is a test that only needs to be performed on the mother in one pregnancy in most circumstances.

Pap Smear

It is always advisable to check on a pap smear during a preconception check. If a pap smear is taken during pregnancy it often shows low grade changes that can be worrying but are usually not significant and therefore it is desirable to avoid taking a pap smear when pregnant.

The preconception check is also a time to discuss period regularity, whether there are signs of ovulation, period pain or other symptoms that could suggest that there may be factors that could hinder conception. A preconception check is one way of making sure that everything is in order before a baby is conceived.

What is the Pelvic Floor?


What is the Pelvic Floor?


The pelvic floor is the “floor of the core”, like an internal “hammock” in your pelvis between your “sitting bones”. It stretches from the pubic bone at the front to the coccyx (tail-bone) at the back.

What do the Pelvic Floor Muscles (PFMs) do?

Why are these muscles important?

  • They work with your deep abdominal (tummy), back muscles anddiaphragm (breathing muscle).
  • They help control the pressure inside the abdomen to deal with the pushing-down force when we lift or strain, helping to control the bladder and bowel.
  • They hold up the bladder and bowel, plus the uterus (womb) in women.

If your PFMs are not working well, you might leak urine when you exercise, cough, sneeze, laugh or lift – and you might pass wind unexpectedly. The PFMs play a role in sexual sensation and function too.
Protect and strengthen your Pelvic Floor.

Strengthening your PFMs (Pelvic Floor Muscles)

Can you make your PFMs stronger? Yes! By training with special PFM exercises and by protecting your PFMs to prevent straining and weakening.

Using overly-heavy weights or gym machines, high impact exercise sand straining with constipation can weaken the PFMs.

Be aware of protecting your pelvic floor with any physical activity. Talk to your fitness professional about this important aspect before you begin any exercise program.

The PFM exercise routine.

  • Relax your thigh, bottom and lower tummy muscles
  • Draw in (lift and tighten) the muscles around your front and back passages and hold for a second or two (while continuing to breathe normally)
  • Relax all the muscles
  • 3 quick squeezes to finish, relaxing fully between each one
    (lift UP: don’t push out or downwards!).

Repeat this set of movements 3 times. Rest between each set.

  • Once you can do this set confidently:
    Hold the lift-and-tighten for longer, say, 3-5 seconds.
  • Build – up slowly over time – to a 1- second hold: feel the muscles “let go” each time.
    Don’t hold your breath; breathe normally throughout.
  • Don’t press out OR down – lift UP and tighten.
  • Do this exercise routine 2-3 times a day.
  • You can build this routine up to 10 times in a row.

Put your Pelvic Floor first with this helpful checklist.

10 tips to make exercise “Pelvic Floor safe”.

1. Keep it “comfortable”: Don’t lift weights that are too heavy or make you hold your breath. Aim to lift from waist height rather than from ground level. If your PFMs are weak, keep your weights to a minimum until your pelvic floor muscle strength improves.

2. Lift your PFMs before and during your strength-training. Relax fully between steps or repetitions. The goal is for your pelvic floor to be working immediately before and then as you lift/lower/push or pull any weight.

3. Keep good posture by maintaining that normal inward curve in your lower back during every exercise you do – whether you’re sitting, standing or lying on your back. That way, your supportive deep abdominal and pelvic floor muscles are more involved (instead of the stronger outer abdominal muscles).

4. Breathe out with a push, pull or lift and never hold your breath or pull your stomach in strongly during exercise. This strategy helps you to avoid unwanted strain and (bad) downward pressure on your pelvic floor.

5. Choose sitting or lying down positions wherever possible to reduce pelvic floor strain. Sitting on an exercise ball while you perform your strength exercises is helpful too. Your deep abdominal muscles support your pelvic floor so involving these more decreases the likelihood of strain. It will also be easier to feel your pelvic floor muscles working.

6. Keep your feet close together: Avoid wide-leg standing positions. It’s easier to activate your pelvic your PFMs when your feet are together and your pelvic floor openings are less exposed. If you’re performing a standing resistance (strength) exercise, try to keep your feet no further apart than your hips (your knees about a fist-width apart).

7. Strengthen gradually and exercise correctly: Start with very light resistance. Be aware of how you are performing each movement. To reduce your risk of injury, gradually increase your load only when you are (a) very confident of your technique and (b) when you have good pelvic floor and abdominal muscle control.

8. Take care when tired, injured, unwell or have lower back pain: Your pelvic floor and deep abdominal muscles may not work as well and you’ll be more prone to symptoms and injury. Take a break and recover before returning to resistance training.

9. Rest between sets for a couple of minutes between each set of exercises. This gives your muscles (including the PFMs) time to recover before your next lift.

10. Be aware of your bodies reactions while exercising. If you experience any pain or strain, or you hold your breath with a specific exercise: (a) modify the exercise – change it to protect your pelvic floor (b) leave it out of your program, or (c) get advice about another exercise to replace it.

Resistance (Weights/Strength)
Abdominal exercises (e.g. sit-ups, curl-ups, crunches, double-leg lifts, exercises on machines)Medicine ball rotations (swinging a medicine ball around from side to side).Deep lunges or side lunges (bending your knee deeply either front-on or to one side).Wide-legged or deep squats.Jump Squats.Lifting or pressing heavy weights.Lateral pull-down with heavy weights. Legg press machine with heavy weightsDead lifts (weights lifted from a still position on the floor)High bench, step up/step down.Exercises with both feet off the ground (e.g. chin-ups, triceps dips).Full push-ups (i.e. from the toes, rather than from the knees which is less of a strain).Exercises where there is a direct downward pressure on the pelvic floor.

Cardio(Aerobic)
RunningJumpingStar jumpsSkippingBoxingHigh impact exercise classes that involve jumping and running Sports with start-stop running and quick changes of direction (e.g. tennis, netball, basketball, hockey, touch football)

Exercises to avoid.

If you have symptoms of a weak pelvic floor or are in a high-risk group:

Do NOT do any type of exercise that causes a downward push, pain or feeling of pressure on your pelvic floor muscles (PFMs)