Natal Care And Guidance

This article is intended to provide you with general information. It is not a substitute for advice from your doctor and does not contain all the known facts about travel during pregnancy. If you are not sure about the terms used in this article, ask your doctor.

Read this article, and save it for future reference. Some technical terms are used that may need further explanation by your doctor. Write down questions you want to ask. Your doctor will be pleased to answer them.

Travel advice about insurance, food, water, vaccines, exotic diseases and related issues can be obtained from your doctor and travel clinics. Before booking long distance, overseas or air travel, ask your doctor about the risks of travelling during pregnancy, especially with regard to your pregnancy. Tell your doctor about any medications (including herbal products or vitamins) that you intend to take while travelling.

Seek the opinion of another ;doctor if you are. uncertain about the advice you are given.

Use this article only in consultation with your doctor.

During pregnancy, women need to be aware of the precautions and risk factors associated with long-distance, high-altitude and overseas travel. Tropical regions in developing countries are a particular hazard.

Travel during the last six weeks of pregnancy should be avoided, especially if you have had any health concerns during the pregnancy. Your doctor can advise you.

Carry a brief antenatal history and a letter from your doctor listing any medical problems you may have.

Plan your trip in advance and become well informed about:

• Food and water consumption.
• Risk factors in air travel.
• Risks of nausea and vomiting.
• Vaccines that may be required.
• Risks of disease and the necessary preventative treatments, for example, malaria and anti-malarial drugs.
• The need for caution when engaging in activities such as trekking, skiing and water sports; the College article Exercise during Pregnancy —a guide for women may be helpful.

MEDICAL INSURANCE

Purchase private medical insurance to cover you for accidents or unexpected illnesses. Some policies may deny benefits for pregnancy, especially if it predates the policy. The policy should provide for air ambulance and emergency repatriation. After 24 weeks gestation, obtaining insurance for travel to some countries can be difficult. Ask your travel agent for details.

MEDICINES

While travelling, continue to take any medicines according to your doctor's recommendations. Take a sufficient sup-ply with you and a current prescription. Carry the medications with you rather than putting them into separate luggage that could be lost.

AIR TRAVEL

Most airlines allow women to fly until the 36th week of gestation, provided the pregnancy has been uncomplicated and the woman has no other medical risk factors. However, other airlines advise that air travel should not be undertaken after the 32nd week. Before booking your ticket, check the airline's policy.

Some airlines may require a note from your doctor that gives an opinion whether you can undertake air travel safely. Short flights (less than two hours) are preferred to longer flights.

Problems associated with air travel are:

• Premature labour - In the event of premature labour, adequate facilities for birth or a medical emergency will typi-cally not be available on the aircraft.

• Deep vein thrombosis - Deep vein thrombosis (DVT) is a condition in which one or more blood clots form in the large, deep veins of the legs. In some cases, DVT can be life threatening. Sitting in one position for a long time, dehydration, low humidity in the aircraft, and excess alcohol consumption are some of the risk factors for DVT. It is often called travellers' thrombosis or "economy class syndrome".

  A pregnant woman has an increased risk of DVT due to the pregnancy itself. This adds to the other risks mentioned. The pregnancy-associated risks last for six weeks after the baby is born.

  The risk of DVT may be reduced by:

  • Requesting an aisle seat so you can carefully walk around and move your legs, feet and toes to improve the circulation of blood.
  • Drinking plenty of water, and little or no alcohol or beverages containing caffeine.
  • Wearing well-fitted compression stockings.
• Fetal and maternal oxygenation — when passenger jets cruise at high altitudes, they usually have a cabin pres-sure that equals an altitude of about 1,600 to 2,300 metres. Rarely, this rela-tively low pressure may pose a problem of insufficient oxygen in the blood of both the mother and the fetus. If the mother is anaemic, the risk increases. If anaemia has not been corrected before flying, the woman may need to receive supplementary oxygen.
• Emergencies - Passenger aircraft typically do not bave qualified nursing or medical practitioners among their crew to attend emergency medical situations.

WATER AND FOOD

During your travels, be careful to avoid foods and liquids likely to be contaminated. Food should be thoroughly and freshly cooked. Avoid lightly cooked meat, raw meat, and raw foods such as vegetables, salads and unpasteurised milk products (milk, yoghurt, cheese and so on). These foods may contain organisms that can cause disease, especially toxoplasmosis and listeriosis. Avoid foods that have been cooked and left to stand, even if refrigerated.

In some countries, bottled water from a reputable company is the safest. Water that contains too much iodine (used to disinfect water in some countries) can adversely affect the fetus's developing thyroid gland.

Hepatitis E: This is a serious infection of the liver that is contracted through contaminated food and beverages in the same way as hepatitis A. No treatment for hepatitis E is available. Epidemics have occurred in several countries in Asia, Africa and the Indian subcontinent.

NAUSEA AND VOMITING

Travel can provoke persistent nausea and vomiting even in a woman who has been relatively free of these problems during the pregnancy. In addition to causing distress, vomiting can cause dehydration, which can develop into a serious condition for the mother. Rarely, it may provoke miscarriage in severe cases.

Several drugs are effective treatments for motion sickness, but generally they should be avoided during the first three months of pregnancy. If this applies to you, ask your doctor for more details.

VACCINATIONS

As many vaccines are available, pregnant women should seek advice from their doctor about which vaccines are recom-mended for the region they intend to visit. Avoid vaccines in the first three months of pregnancy, and avoid "live" vaccines (which carry a small risk of transmitting a disease to the fetus) throughout the pregnancy. Live vaccines include measles, rubella, BCG (tuberculosis), polio (oral route), and some influenza vaccines.

Some of the safe vaccines after the first three months are for hepatitis A, hepatitis B, meningococcal meningitis, rabies and typhoid fever (typhium Vi). Vaccines should only be used when the benefits outweigh the risks that vaccines may cause to the mother and the fetus.

MALARIA

Malaria is a tropical disease transmitted by the bites of infected mosquitoes. It can result in miscarriage and other chronic health problems, and can be life threaten-ing in some cases. Chloroquine and related drugs can help prevent the type of malaria found in Central America, China and the Middle East. This drug is generally safe to use for prevention of malaria during pregnancy. Chloroquine has been used by a large number of pregnant women without any proven harm to the fetus; it is a "Category A" drug for the prophylaxis of malaria. It must be taken before travelling, during the trip, and for a few weeks after the trip. Pregnant women and children should not travel to areas where resistance to chloroquine and other anti-malarial drugs is significant, such as some parts of Africa, Asia, Thailand, Papua New Guinea, and South America.

Some anti-malarial drugs can usually be safely used during pregnancy, but they may cause serious side effects in some women. No drug ensures complete protec-tion against malaria. The choice of medication to reduce the risk of malaria is best discussed with your doctor.

A good defence is to avoid being Bitten. For example, wear long sleeves and pants, sleep under a mosquito net, and use an insect repellent.

Unless you have an overwhelming need to travel to a malarial area, postpone the trip until after the birth.

OTHER ACTIVITIES

Activities at low altitude (less than 3,000 metres) such as swimming, walking and moderate hiking are acceptable. However, avoid activities at high altitudes such as trekking and skiing. Emergency services are rarely available at high altitudes.

If you are determined to trek or ski, or to undertake similar activities:

• Discuss this with your doctor, who can arrange for you to have at least one ultrasound scan before departure to see whether the pregnancy is progressing normally.
• Make sure you do not have anaemia, high blood pressure or diabetes.
• Drink a lot of clean water (preferably bottled), and rest every time you feel tired. Climb slowly, and be aware of your surroundings.

Scuba diving:

Avoid scuba diving. Diving to depths greater than 18 metres (about 60 feet) is unsafe at any stage of pregnancy because of the excess pressure and the increased risk of vomiting.

Land travel:

Limit travel to five or six hours a day. Avoid long, tiring journeys. Make frequent stops to exercise your legs. In vehicles, always wear a seatbelt that goes across the lap (beneath the tummy and across your hips), with the shoulder strap between your breasts and across your shoulders. Make sure you are comfortable.

Sea travel:

It would be best to postpone sea travel as it can cause prolonged seasick-ness, especially if you haven't done it before. If you do decide to go, then consult with your doctor and make sure adequate medical cart will be available in case of an emergency. Your doctor can prescribe tablets for motion sickness.

AFTER RETURNING HOME

Some diseases contracted overseas may not cause signs or symptoms for some weeks or months. See your doctor promptly if you develop:

• Fever (above 38°C) or chills.
• Serious nausea, vomiting or diarrhoea.
• Any skin disorder.
• Urinary tract infection or genital infection.
• Any illness that concerns you. Severe acute respiratory syndrome (SARS): If you have travelled overseas during the 10 days before the onset of illness, telephone your doctor and provide details about:
• The name of the country you visited.
• The date of arrival in Australia or New Zealand.
• Whether you have a cough, difficulty in breathing or shortness of breath.
• Your temperature.

Costs

Your doctor can advise you about the costs of examinations, reports, vaccinations, diagnoses, medicines or other treatments that may be necessary for your travel. Due to unexpected tests or treatments, costs may vary from the original estimated cost. It is better to discuss costs with your doctor before receiving tests and treatment rather than afterwards.

Regular exercise is an important part of life for many women, and most wish to continue exercising during pregnancy. Some women feel that pregnancy is a good time to start a gentle program.

An informed and sensible exercise routine can be enjoyable and beneficial during pregnancy. Regular exercise throughout pregnancy helps to keep the heart and blood vessels healthy, improves muscle tone and promotes well-being.

Exercise may help to relieve some discomforts and complications of pregnancy, including tiredness, leg cramps, constipation and excessive weight gain.

A program of back-strengthening exercises for the pregnant woman is desirable because backache is common during pregnancy.

CHANGES DURING PREGNANCY

The body undergoes many physical changes during pregnancy. These changes affect the way a woman's body responds to physical activity, as follows:

• The most obvious changes are increased weight and change of body shape. These can alter a woman's sense of balance and co-ordination, so it is important to avoid activities that increase the risk of falls or injury to the abdomen. Contact sports and some other activities that involve unexpected stress 'tsuch as horse riding and skiing) require caution, particularly after 28 weeks gestation.
• Throughout pregnancy, the body releases a hormone called relaxin. Relaxin softens the ligaments, allowing the pelvis to expand and preparing it for the birth. However, all joints become less stable, and the risk of injury to the joints increases. Strapping or support of a previously injured joint may be helpful.
• Pregnancy places extra demands on a woman's heart. More blood is pumped around the body each minute to ensure an adequate supply of oxygen to the baby. The resting heart rate and exercising heart rate increase throughout pregnancy.
• As pregnancy progresses, the expanding uterus pushes the diaphragm (the large muscle between the chest and the abdomen) upwards. This crowds the chest area and may make breathing more difficult.
• Pregnancy hormones can contribute to breathlessness.
• The body uses carbohydrates more quickly during pregnancy, so more frequent food intake may be necessary.
• Core temperature of the body rises about 1°C during pregnancy. This, coupled with an increase in core temperature during exercise, means pregnant women must be cautious not to overheat. Prolonged and excessive overheating can be harmful to 'the fetus, especially in the first three months. Follow the Exercise Guidelines in this article to reduce the risk of overheating.

Talk to Your Doctor

This article is intended to provide general information. It is not a I substitute for advice from your doctor and does not contain all known facts about exercise during pregnancy.

Read this article carefully. Write down questions you want to ask. Your doctor will be pleased to answer them.

If you are not sure about the benefits, risks and limitations of exercise during pregnancy, ask your doctor. This article should only be used in consultation with your doctor.

When undertaking sports or exercise during pregnancy, it is often helpful to tell your coach or instructor that you are pregnant.

EXERCISING SAFELY DURING PREGNANCY

Women who have not followed an exercise routine before pregnancy should consult their doctor before starting a mild program. Regular exercise (about three times a week) is recommended. Low-impact activities such as walking, swimming, water aerobics, and using an exercise bike are considered safe throughout pregnancy.

Most pregnant women can continue established routines but may need to moderate their activities as the pregnancy progresses. During the first trimester (first three months of pregnancy), many women feel tired and unwell, and may feel frustrated when they have the desire to exercise but little energy. These feelings typically pass as women enter the second trimester (the middle months of pregnancy).

EXERCISE GUIDELINES

• Drink plenty of water during and after exercise.
• Be aware of your limitations. Discuss an exercise plan with your doctor.
• Do warm-up and stretching exercises before any vigorous routine. Follow with a gradual cool-down period, keeping the legs moving to help blood return to the heart. Be careful not to over-stretch. It may cause back injury and pain.
• Stop exercising if you start to become breathless or fatigued.
• Exercise cautiously in hot or humid conditions. It is important that you and your baby do not become over-heated.
• To assist cooling of the body, wear clothing that allows evaporation from the skin. A well-fitting bra is also recommended.
• Avoid exercising during the hottest or most humid parts of the day. Exercise in a well-ventilated area.
• Avoid excessively hot tubs, spas and saunas.
• Do not deep-sea dive beyond three metres underwater or water ski.
• Do not exercise if you have a fever or feel unwell.
• After the first 18 weeks of pregnancy, avoid exercises that involve lying flat on your back. The weight of the uterus can put pressure on a major vein in the abdomen and interfere with blood flow back eto the heart; the result is to feel faint.
• Avoid long periods of standing.
• Exercises that involve sudden movements such as bouncing, jumping or changing direction should be avoided, especially in the third trimester (after 28 weeks).
• Avoid exercises where it may be hard to keep your balance.
• Do pelvic-floor exercises. The pelvic-floor muscles support the bladder, the uterus and the intestines. Pregnancy can weaken and stretch these muscles, possibly leading to bladder and bowel-control problems. A physiotherapist with expertise in pelvic-floor exercises may be helpful.
• If playing team sports, substitute and rest frequently. It is a good idea to tell your coach that you are pregnant. Don't put the interests of the team ahead of your well-being, especially during competition.
• Eat nutritious and regular meals.

COMPLICATIONS DURING PREGNANCY

Some complications that develop during pregnancy may affect a woman's ability to exercise. These include:

• Anaemia — usually due to low levels of iron in the blood, resulting in less oxygen being transported around the body. This can cause breathlessness and fatigue while exercising. An iron-rich diet should be followed, with extra vitamin C to help iron absorption. Your doctor may recommend iron supplements.
• Back pain — many women experience back pain during pregnancy. Inappropriate exercise, especially weight-bearing exercise, may increase back pain and place further stress on joints. Swimming and simple yoga exercises may be preferable for women with backache.
• preterm contractions — these increase the risk of premature birth. Avoid exercise if you are prone to preterm contractions.

A woman may be advised not to exercise during pregnancy or may have to limit her activities if she has any of the following conditions:

• The onset of high blood pressure during pregnancy.
• persistent vaginal bleeding .
• Placenta praevia (part of the placenta is covering the opening of the uterus).
• Preterm labour — all exercises should be avoided.
• Poor growth of the baby (intra-uterine growth restriction).
• Twin pregnancy.
• Heart disease .
• Pelvic-girdle laxity.

EXERCISE AFTER THE BIRTH

During the first six to eight weeks after birth, women should follow the same guidelines for exercise as they did during pregnancy.

Women who have had a caesarean section or a difficult birth may take longer to return to exercise. Continue pelvic-floor exercises to strengthen pelvic-floor muscles and prevent bladder-control problems. Start slowly, and delay more vigorous exercise for at least six weeks.

REPORT TO YOUR DOCTOR

Tell your doctor if any of the following occur during or after exercise:

• Blood or fluid leaking from the vagina.
• Shortness of breath.
• Chest pain or rapid heartbeat.
• Headache, feeling faint or dizziness.
• Uterine contractions.
• Abdominal or vaginal pain.
• Decreased fetal movements.
• Any other concerns you may have.

The aim of antenatal care is to safeguard the health and well-being of the mother and baby during pregnancy. Ideally, antenatal care should begin before a woman is pregnant.

If you are planning a pregnancy, it’s best see Dr. Suyesha for a check-up. Routine tests are available to detect whether you may have some conditions or illnesses that could affect you or the baby's health during pregnancy.

This is a good time to talk with your doctor about other factors that can pose a risk to the baby, such as alcohol, smoking, prescription medicines and recreational drugs.

If you are being treated for a medical problem (such as epilepsy, diabetes, acne, asthma, high blood pressure, a heart problem, anxiety, depression or other psychiatric problem), talk to your doctor about the effect that medications and treatment may have on your pregnancy.

Genetic counselling: If you have a child with a birth defect or if you or your partner have a family history of a genetic problem, birth defect or intellectual handicap, then your doctor may recommend that you see a genetic specialist or a genetic counsellor. Genetic counselling will help you to assess potential risks and then to make an informed choice about family planning. Genetic counselling requires a detailed family history and sometimes a physical examination and laboratory tests.

The family history and other tests help determine your risk of having a baby with a birth defect.

THE FIRST VISIT TO YOUR DOCTOR

Your first examination should ideally take place during the first six to eight weeks of pregnancy or when your menstrual period is two to four weeks late.

Your doctor will take a full medical and pregnancy history, conduct a thorough physical examination, estimate the date the baby is due, and discuss with you any likely problems.

Information from this initial consultation may greatly influence the management of your pregnancy and healthcare during and after labour.

For many women, this will be the first time they have had such a thorough examination and consultation. A hospital or birth centre booking can be made, but you may wish to visit a number of centers before making a final decision about where you would like to have your baby.

First physical examination

This usually includes recording your height, weight and blood pressure, and examining your legs for varicose veins.

Your teeth, gums, breasts and nipples may also be examined, and the health of your heart and lungs checked. A vaginal examination may be needed to check the size of your uterus (womb) or if you need a Pap smear.

Talk to Your Doctor

This article is intended to I provide you with general information. It is not a substitute for advice from your doctor and does not contain all known facts about antenatal care.

This article should only be used in consultation with your doctor.

If you are not sure about the risks, benefits and limitations of antenatal tests, the consequences of the tests, terms used in this article, or anything else, ask your doctor.

Some technical terms are used in this article, but don't let that stop you from reading it.

Write down, questions you want to ask. Your doctor will be pleased to answer them.

If you are uncertain about your doctor's advice, you may wish to seek the opinion of another doctor.

ANTENATAL TESTS

Some tests are required to detect specific problems in pregnancy. Most tests are routine. Other tests may be needed, depending on your medical history and family background.

Screening tests are ordered to determine if you, or your baby, are at an increased risk of certain conditions. Screening tests performed on blood, urine and the cervix do not give perfect results and do not pick up all problems. Occasionally, tests can raise concern that the fetus may have a certain condition when, in fact, the fetus does not have the condition. If the test result shows an increased risk, your doctor will discuss this with you and implement further testing if indicated. All test results are recorded in your medical notes.

It is possible that a fetus may have a problem that cannot be detected during pregnancy, for example, intellectual impairment.

BLOOD TESTS

The following tests are routine. Almost all pregnant women receiving antenatal care will have them.

Blood group and antibody screen: Your blood group will be determined. It could be A, B, AB or 0. Blood is also tested for the Rhesus (or Rh) factor. If your blood has the Rh(D) factor, it is Rh(D) positive. If not, it is Rh(D) negative. Problems may arise if the mother's blood is Rh(D) negative and the baby's blood is Rh(D) positive. Women who are Rh(D) negative need repeat testing for the presence of antibodies later in pregnancy.

Blood count: This detects whether the amount of haemoglobin in the red cells of the blood is normal; haemoglobin is the iron-containing protein that binds oxygen for use by all cells throughout the body. If the blood cells have too little haemoglobin, the woman is anaemic and may need to take iron tablets and/or vitamin supplements. A blood count will be performed again later in pregnancy to make sure that anaemia has not developed during pregnancy. Women whose ancestry is from a country near the equator may be tested for other genetic disorders of haemoglobin and red blood cells (such as thalassaemia).

Syphilis: Although syphilis is rare, it can be present without symptoms and may harm the fetus. Syphilis can be treated so that the infection is not passed to the fetus.

Human immunodeficiency virus (HIV): ): HIV is the virus that causes AIDS. Pregnant women may be offered testing for HIV even if they do not have a particular risk factor. If a woman is found to be HIV positive, treatment during pregnancy can reduce the risk of the baby becoming infected by HIV. Counselling, treatment and delivery plans will be discussed with her.

Rubella (German measles): Your blood is tested for antibodies from a previous rubella infection or vaccination. If you have had rubella before, you are not likely to get it again. If you have not had rubella, avoid anyone who has this infection while you are pregnant. Rubella can cause serious problems in a fetus. If the blood test shows that you are not immune to rubella, then it is recommended that you have a rubella vaccine after the baby is born.

Hepatitis B: This is a viral infection of the liver. A woman can be a carrier of hepatitis B without having symptoms. The disease can be passed to the baby. If tests show that the woman has current or recent infection, or is a chronic carrier, then the baby should be vaccinated against `hepatitis B soon after birth. Additional treatment for the baby may be recommended. Hepatitis C: Doctors may recommend a hepatitis C screening test. There is a small risk of transmission of hepatitis C to the baby if the test is positive.

URINE TESTS

Urinary screen: Your urine may be tested for protein, sugar and blood. This test may be repeated at other antenatal visits.

Visits to your doctor as pregnancy progresses.

Visits: : If you are healthy with no complicating risk factors, you can expect to see your doctor every four to six weeks until week 28 of pregnancy, then every two weeks until week 36, then once a week until delivery.

Blood pressure: At each visit, your blood pressure will be recorded. If it becomes elevated, the condition must be closely monitored. Your doctor will discuss monitoring and treatment with you if your blood pressure is elevated.

Abdominal measurement and palpation: : As your pregnancy progresses, your doctor will palpate (feel) your abdomen and may measure the growth of the uterus with a tape measure. The measurement is taken from the pubic bone to the top of the uterus. The baby's heart can be heard using a Doppler instrument or a special stethoscope. Later in the pregnancy, the doctor is usually able to feel the baby's position and whether the head is down in the pelvis.

CERVICAL TESTS

Pap smear: : Unless you have had a streptococcus, which can be treated. Pap smear recently, a Pap smear will These cervical tests do not cause be performed to check for changes in miscarriage. cells on the surface of the cervix. These changes are called dysplasia. If dysplasia is left untreated, it may lead Uterus to cancer.

Cervical swabs: A swab may be taken from your cervix to check for certain infections such as gonorrhoea, gardnerella, chlamydia and Group B streptococcus, which can be treated.

These cervical tests do not cause miscarriage.

OTHER ANTENATAL TESTS

Maternal serum screening: This is a blood test that screens for Down syndrome. It can be performed at 10 to 13 weeks of gestation (combined with a nuchal translucency ultrasound that is performed at 11 to 13 weeks) or at 15 to 17 weeks without ultrasound. This test may not be available in your area.

Ultrasound (US) examination: High-frequency sound waves are used to make a picture of the fetus, uterus and placenta. U.S examinations are performed in most pregnancies. If US examinations are per-formed, the best times are between 11 to 13 weeks for a nuchal translucency-assessment and 18 to 20 weeks for the detailed US scan to assess fetal development. An US examination may also be offered at other times depending on clinical need. Details about US examination and maternal serum screening are avail-able in the College article titled Prenatal Screening Tests for Down Syndrome and Other Conditions.

Amniocentesis and chorionic villus sampling: If you will be older than 35 at your due date or if you have a positive screening test, you may be offered amniocentesis or chorionic villus sampling (CVS). Both detect chromosomal abnormalities in the fetus. Amniocentesis is usually performed from 15 weeks of gestation, and CVS from 11 weeks. For more information, see the College article titled Amniocentesis and Chorionic Villus Sampling.

Screening for diabetes: Diabetes can be brought on by pregnancy. it can Intel-Jere with fetal growth and can affect up to one in 10 pregnant women. Testing, if recommended, is done between 24 and 28 weeks. The testing can be a glucose challenge test or a glucose tolerance test. If diabetes is diagnosed, a management program will be established.

Screening for Group B streptococcus: Group B streptococcus (GBS) is a bacterium often found in the bowel, genital tract or urinary tract. It does not usually cause serious illness. GBS is not a sexually transmitted disease.

About one in four women have GBS without being aware of it. If GBS bacteria pass from a woman to the baby during pregnancy' or delivery, the baby may develop GBS infection. This happens in about one of every 200 babies whose mothers have GBS. GBS infection in an infant can be life threatening.

Swabs may be taken from the vagina (and sometimes the perianal region), and tested for GBS three to five weeks before the due date. A positive result means that GBS is in the vagina or anal region but does not mean that you or the baby will become ill. If GBS is present, antibiotics will be recommended as a preventative treatment during labour or when your waters break.

Your Health During Pregnancy

Pregnancy is a great opportunity to make changes to improve your health. Looking after your health can make a big difference to you and your baby.

Smoking: Smoking has adverse effects on the well-being of the fetus. If you are a smoker, you are encouraged to inquire about the quit-smoking programs that may be available at the hospital where you are going to have your baby. State health departments and some general practices run "Quit" programs. Your doctor has details.

Smoking: Smoking has adverse effects on the well-being of the fetus. If you are a smoker, you are encouraged to inquire about the quit-smoking programs that may be available at the hospital where you are going to have your baby. State health departments and some general practices run "Quit" programs. Your doctor has details.

A healthy diet: A well-balanced diet that provides all the daily nutrients should consist of servings of the following foods:

• Vegetables.
• Grains and Cereals.
• Fruit.
• Dairy.
• Meat.
• Fish and Poultry.

One to two servings of protein-rich foods (red and white meat, fish, eggs, dairy products, nuts and legumes) should be eaten daily. Calcium is found in dairy foods. The best source of iron is red meat. In smaller amounts, iron is also found in chick-en, fish, green leafy vegetables, cereals, nuts and legumes.

Allowing for differences among women's tastes, the following daily diet serves as a general guide for adequate nutrition during pregnancy:

• Four servings of vegetables.
• Three servings of fresh fruit.
• Three servings of milk or dairy products (low fat is better).
• Several servings of rice, pasta, breads or cereals.
• Two or three servings of lean fish, meat, poultry, eggs, nuts or beans.
• Six to eight glasses of water.

Cleanliness and food preparation: To avoid bacteria in food that can pose risks to you and the fetus, wash your hands carefully before and after preparing food. Refrigerate fresh and cooked foods. Pregnant women appear to be at particular risk of bacterial infection from contaminated food. Avoid those foods that are particularly prone to bacterial contamination, such as pate, prepared salads with mayonnaise, soft-serve ice cream, precooked and undercooked meats and chicken.

Kitty litter: Ask someone else in the household to clean the cat's. tray. Cat droppings can transmit toxoplasmosis, an infection linked to birth defects. Toxoplasmosis can also be contracted by eating raw or undercooked meats. Always wear gloves in the garden to prevent contact with cat droppings, and wash your hands when finished.

Prescription and over-the-counter medicines: Some medicines have been linked to birth defects, especially during the first three months of pregnancy. If you are taking an conventional, traditional or alternative medicine, tell your doctor.

Weight gain: SIf you are concerned about weight gain, discuss this with your doctor. You may find that a visit with a dietician is helpful. It is very important that you do not gain excessive weight in pregnancy, for the health of both you and your baby.

Oral health: The increase in hormone levels during pregnancy is associated with an increase in gum disease. Tooth decay may be a problem. Brushing your teeth two to three times daily and flossing once daily helps to reduce the build-up of plaque on teeth and gums and reduces the risk of tooth and gum disease. Some simple'rules that can help with oral hygiene during pregnancy are:

• Always use a soft toothbrush and brush frequently; floss daily.
• Immediately after morning sickness, rinse several times with water to help rid the mouth of stomach acid; this can prevent erosion of tooth enamel.
• Avoid sweet and sticky foods.

Exercise: An exercise program can be helpful. Swimming and walking are excellent exercises during pregnancy. If playing sports, use common sense, and do not take unnecessary risks. To reduce the risk of overheating while exercising:

• Drink plenty of water.
• Eat nutritious and regular meals.
• Avoid exercise in the hottest or most humid times of the day.
• Indoor exercise spaces should be cool and well ventilated.
• When playing a team sport, rest or substitute frequently
• During the last three months of pregnancy, limit participation in sport to three sessions or less each week.
• Reduce exercise intensity as the pregnancy progresses.

Sauna and spa: It is not advisable to use the sauna because of the potential increase in your core body temperature. Use a spa with care and common sense, being careful not to overheat.

Sex during pregnancy: Sexual activity may continue according to the wishes of you and your partner, unless you have complications and are advised otherwise. Sexual desire may change at different times during pregnancy. Comfort may also be a factor, especially in late pregnancy.

Rest and sleep: Rest and sleep are important. Some women find that they feel more tired during certain stages of pregnancy. Your doctor may advise extra rest, for example, if you are carrying more than one baby or if you have a medical problem.

Common discomforts: Many women have one or more of the following discomforts during pregnancy. If any are persistent or cause particular distress or illness, discuss them with your doctor:

• Morning sickness (nausea and vomiting).
• Constipation.
• Heartburn.
• Anxiety or depression.
• Bleeding gums.
• Urinary frequency A haemorrhoids.
• Leg cramps.
• Sore joints.
• Swelling (oedema) of the legs.
• Tiredness.
• varicose veins.
• Vaginal thrush infection.

Vaginal bleeding: A small amount of vaginal spotting or bleeding in the first trimester is common. This causes worry for most women, but a little "spotting" is unlikely to be a sign of impending miscarriage. If bleeding is persistent or becomes painful, contact your doctor at once. Heavy bleeding must be investigated but does not mean that a miscarriage is likely or that the fetus has an abnormality.

Fetal movements: The woman usually starts to feel kicks and similar movements at about 20 weeks. The nature of the movements will change as the baby grows.

Preparation and Planning for Your New Baby

As well as looking after your baby's health during pregnancy, you need to plan for the physical and emotional needs of the baby and yourself after birth. Consider the changes in lifestyle that the birth means for you and other family members. In particular, your partner may need to make adjustments to prepare for the changes that will inevitably occur in your relationship and family life.

Antenatal classes: Most women find that antenatal classes are valuable, especially with a first pregnancy. Classes help you to know more about your body during pregnancy. You will learn how to prepare yourself for labour so that you work with your body. Your doctor can advise you about classes that are available for you and your partner.

Information and education: It is important to get as much information as possible about health and well-being during pregnancy. Many excellent books, videos, CDs and DVDs have been prepared about pregnancy, labour and parenting skills. Your antenatal teacher and doctor can recommend titles they have found helpful.

Report to Your Doctor

Tell your doctor at once if you have any of the following complications of pregnancy:

• Persistent or severe nausea and vomiting.
• Blood or fluid coming from the vagina (a little, infrequent spotting is common in the first trimester; bleeding late in pregnancy must be reported promptly to your doctor or the hospital you will be attending).
• Pain or cramps in the abdomen, if they are persistent or severe.
• Noticeable decrease in fetal movements, especially if fewer than 10 movements in 12 hours after 26 weeks of gestation.
• Burning when passing urine.
• Sudden or excessive swelling of the fingers, face or legs.
• Dizziness.
• Blurring or poor vision.
• Fever or chills.
• Any illness or infection.

Costs

Your doctor can advise you about the services and models of care that are available. If you are seeing a private doctor, she or he will discuss private health insurance and out-of-pocket costs. You may want to ask for an estimate that lists the likely costs. This includes medical and hospital fees, and other items. Ask which costs can be claimed on private health insurance. Due to unexpected tests or treatments, the final account may vary from the estimate. It is better to discuss costs with your doctor before receiving tests and treatment rather than afterwards.