Conditions After Pregnancy

Diastasis of the Rectus Abdominis Muscles (DRAM)

DRAM is a separation of the connective tissue joining the two strips of muscles down the middle of the abdomen. This is also known as abdominal muscle separation or Rectus Abdominus Diastasis (RAD). As the foetus grows, the abdominal wall muscles and their connective tissue attachments stretch to accommodate the growing foetus. DRAM occurs when the linea alba, the connective tissue joining the two rectus muscles, widens and splits. This separation can affect the stability of the trunk and may contribute to pelvic floor dysfunction, back and pelvic pain during pregnancy post-natally.

The abdominal wall has 3 layers of muscle. The most superficial muscle layer is the external oblique, the middle layer is the internal oblique and the deepest layer is the transverses abdominis muscle. DRAM can affect the function of all of these muscles of the abdominal wall as their connective tissue contribute to the linea alba. Stable tendinous attachments are required for the abdominal muscles to transmit forces in the desired direction. The disruption of these attachments of the abdominal musculature reduces this ability of the abdominal muscles to stabilise the spine.

DRAM can have a number of implications for the post natal woman. Alterations of a muscle’s angle of insertion will change the muscles function. Changes in rectus abdominis length, width and angle of insertion seen after delivery, which are associated with a reduction in the ability to stabilise the lumbopelvic area (Gilleard & Brown, 1996). A separation persisting after 4 weeks post-natally is likely to disrupt the function of the abdominal musculature. This may be a factor in persistent post natal lumbar, pubic symphysis and sacroiliac pain and even incontinence due to the interaction of the pelvic floor and abdominal musculature as a stabilising unit.

Treatment consists of retraining the action of the various layers of the abdominal wall. It is crucial the exercise program does not further compromise the abdominal wall. Exercising too strongly or in an incorrect way can further increase DRAM. This is commonly seen when women do sit ups after delivery. A sit up is a poor way of improving abdominal muscle function after delivery.

To facilitate your recovery, wearing SRC Recovery Shorts will provide gentle compression to your abdominal muscles. This will complement your exercise program designed for your recovery by your Women’s Health Physiotherapist. This level of compression stimulates your muscles to be continuously active which encourages them to come back together and heal. Please see a summary of the SRC Recovery Shorts results from our pilot studies where patients were referred by Obstetricians and Physiotherapists.

Please note: A garment that is tight and restrictive should not be worn for recovery after delivery as it places too much compression on your muscles and does not allow them to work. This ultimately causes further muscle weakness.


Perineal trauma post episiotomy and post 2nd and 3rd degree tears

An episiotomy is a full thickness cut (midline/ mediolateral) through the perineal tissues to widen the vaginal opening as the baby’s head is crowning. Perineal trauma/tears occur when the perineal tissue is unable to stretch to accommodate the crowning head.

Episiotomy is performed during birthing as prophylaxis against soft-tissue-trauma. Vaginal tears can occur during childbirth, most often at the vaginal opening as the baby's head passes through, especially if the baby descends quickly. Tears can involve the perineal skin or extend to the muscles and the anal sphincter and anus. The midwife or obstetrician may decide to make a surgical cut to the perineum with a scissors (episiotomy) to make the baby's birth easier and prevent severe tears that can be difficult to repair. The cut is repaired with stitches. Some childbirth facilities have a policy of routine episiotomy.

Perineal trauma can affect women's physical, psychological and social wellbeing in the immediate postnatal period as well as in the long term.

  • It is estimated that 85% of women having a vaginal birth sustain perineal trauma and 60–70% receive stitches. Complications depend on the severity of perineal trauma, and on the effectiveness of treatment.  (Sleep J, et al BMJ 1984; 289:587-690)

Following a tear or surgical intervention to the area, histamines are released and subsequent swelling to the surrounding are occurs. Swelling can impair wound healing, and while the exact mechanism is unknown, healing may be impaired by increased distance from capillary bed to cell, restricted ability to remove metabolites and cell debris, deposition of fibrin around the capillary bed, and plugging of capillaries by leukocytes. It has been demonstrated that reduction of swelling by the use of intermittent mechanical compression reduces pain and improves wound healing.

 Treatment for trauma to the perineum includes rest, ice, elevation and compression. The gusset panel within SRC Recovery shorts provide constant gentle compression to the perineal area. It is important to note that if you have had stitches to the perineum you should change your maternity pad every 2 hours. DO NOT wear a pad that has a plastic backing. This may cause the area to sweat which will increase the risk of infection. Wash the area with salt water and dry well following each pad change. Wear your SRC Recovery Shorts during the day only while your perineal stitches are healing. Once the area is fully healed you can wear your Recovery Shorts both day and night.


Giving birth

Labour

Labour usually begins by exhibiting one or more of the following signs or symptoms. For some, it is when the membranes of the amniotic sac rupture (also known as your 'waters breaking'), while others will experience a 'show'. This is a small amount of pinkish (slightly blood-stained) mucus that comes from your vagina as your cervix softens for birth. You may also experience the onset of regular contractions. 

There is no order to which one you will experience first, and how long it will take your baby to reach the outside world once labour begins.

Your labour may take many hours or may be over within a few. Good distractions during this time include walks or having warm baths. Heat packs, showers and rest are also very helpful. In early labour it is important to provide your body with energy (small snacks) and water. Different forms of pain relief that are generally used during labour are nitrous oxide gas, Pethidine injections, and an epidural. These are usually available in all hospital maternity units.

Nitrous oxide is inhaled through a mask or mouthpiece during a contraction. It works quickly and has minimal side effects. Some women state that it can make them feel nauseous but you can be nauseated during labour anyway. Nitrous oxide generates a "happy" feeling and can cause short-term dizziness, but it may help with pain during the contractions.

Pethidine (a narcotic analgesic) given via injection into the muscle during labour reduces pain associated with contractions. The effect of this drug can last for a number of hours. This drug can sometimes cause nausea and vomiting so an anti-emetic can be given with it. This drug also crosses the placenta therefore if Pethidine is given too close to the birth, a reversal drug (Narcan) may be given to the baby to prevent any adverse effects on the baby’s breathing.

An Epidural injection (local anesthetic) is given into the epidural space. It blocks the nerve impulses from the lower spinal segments resulting in decreased sensation in the lower half of the body. A needle will be inserted into the epidural space between two vertebrae in the lower back. A small tube or catheter is threaded through the needle into the epidural space. The needle is carefully removed leaving the catheter in place so medication can be given through periodic injections or by continuous infusion. The catheter will be taped to your back to prevent it from slipping out. You may experience a severe headache caused by leakage of spinal fluid. Less than 1% of women experience this side effect from epidural use. If symptoms persist, a special procedure called a “blood patch”, an injection of your blood into the epidural space, can be done to relieve the headache.

Giving birth vaginally may require you to have an episiotomy as you may tear while pushing.


Urinary Incontinence during and after pregnancy

During pregnancy, many women experience at least some degree of urinary incontinence, which is the involuntary loss of urine. The incontinence may be mild and occasional for some women and more severe for others. Incontinence can continue after pregnancy and may not be present right after childbirth.

The kind of incontinence experienced during pregnancy is usually stress incontinence. Stress incontinence is the loss of urine caused by increased pressure on the bladder. In stress incontinence, the bladder sphincter does not function well enough to hold in urine.

Urinary incontinence during pregnancy can also be the result of an overactive bladder. Women who have an overactive bladder need to urinate more than usual because their bladders have uncontrollable spasms. In addition, the muscles surrounding the urethra -- the tube through which urine passes from the bladder -- can be affected. These muscles are meant to prevent urine from leaving the body, but they may be "overridden" if the bladder has a strong contraction.

The bladder sphincter is a muscular valve that lies at the bottom of the bladder. It works to control the flow of urine. In pregnancy, the expanding uterus puts pressure on the bladder. The muscles in the bladder sphincter and in the pelvic floor can be overwhelmed by the extra stress or pressure on the bladder. Urine may leak out of the bladder when there is additional pressure exerted -- for example, when a pregnant woman coughs or sneezes.

After pregnancy, incontinence problems may continue because pregnancy and childbirth weaken the pelvic floor muscles. Damage to the nerves that control the bladder may also contribute to incontinence.

Behavioural methods such as timed voiding and bladder training can be helpful in treating urinary incontinence during and after pregnancy. These techniques are often used first and can be done at home. The changes in habits that behavioural methods involve do not have serious side effects.

To practice timed voiding, you use a chart or diary to record the times that you urinate and when you leak urine. This will give you an idea of your leakage "patterns" so that you can avoid leaking in the future by going to the bathroom at those times.

In bladder training, you "stretch out" the intervals at which you go to the bathroom by waiting a little longer before you go. For instance, to start, you can plan to go to the bathroom once an hour. You follow this pattern for a period of time. Then you change the schedule to going to the bathroom every 90 minutes. Eventually you change it to every two hours and continue to lengthen the time until you are up to three or four hours between bathroom visits.

Another method is to try to postpone a visit to the bathroom for 15 minutes with the first urge. Do this for two weeks and then increase the amount of time to 30 minutes and so on.

In certain cases, devices can be used to block the urethra or to strengthen the pelvic muscles. In addition, medications also can be helpful in controlling muscle spasms in the bladder or strengthening the muscles in the urethra. Some drugs can help to relax an overactive bladder.

Pelvic Floor or Kegel exercises are another method that can be used to help control urinary incontinence. These exercises help tighten and strengthen the muscles in the pelvic floor. Strengthening the pelvic floor muscles can improve the function of the urethra and rectal sphincter.

For expert advice/information on incontinence please contact the Australian Continence Foundation (1800 33 00 66) for a list of pelvic floor or Women’s Health physiotherapists.


Study by Australian College of GP’s Western Australia.

This longitudinal study was undertaken to determine the prevalence of stress incontinence amongst women during pregnancy, early post-partum (six weeks), and the late post-partum period (six months), and identify determinants of the disappearance or persistence of stress incontinence after childbirth. Also considered were the obstetric variables predictive of an onset of urinary stress incontinence post-partum. The research team utilised a self-administered questionnaire and State-based Midwife Notification data with women recruited from public and private maternity hospitals, and private obstetricians and GPs, in Perth and Melbourne.

Urinary incontinence in pregnancy was reported by 79% of 736 women participating in the study at 36 weeks gestation, with most experiencing stress incontinence. Mixed incontinence, i.e. symptoms of both urge and stress incontinence, were present in 40% of participants. Of the 432 women who remained in the study at six months post-delivery, the level of stress incontinence had reduced to 21%.

If you would like a copy of this report please contact continence@health.gov.au

Reference

Royal Australian College of General Practitioners WA Research Unit (2003). Stress Incontinence in Pregnancy. Final Report prepared for the Australian Government Department of Health and Ageing.

More information on related medical issues

Please be aware that these articles are provided for information purposes only. Should you experience any of the symptoms described in these articles we recommend you see your MD (medical doctor) or GP (general practitioner).

 

Anaemia

Anaemia in pregnancy is usually caused by a decrease in number of red blood cells (RBCs) or less than the normal quantity of haemoglobin in the blood.

Blood is made up of a number of cells and the plasma that they travel in. RBCs contain a chemical called haemoglobin. Haemoglobin is attracted to oxygen and the two substances can bind together. This allows oxygen to be transported by red blood cells from the lungs to all parts of the body.

An increase in plasma volume disproportionate to the increase in RBCs causes haemodilution in a pregnant woman. This lowers the haemoglobin levels.

Symptoms may include breathlessness and increased fatigue. Most doctors’ recommend taking an iron supplement during pregnancy and increasing the foods that have high iron levels e.g. red meat and leafy greens. Iron is an important factor in anaemia because this mineral is used to make haemoglobin. The component of red blood cells that attaches to oxygen and transports it. Red blood cells exist only to oxygenate the body and have a life span of about 120 days.

Braxton Hicks

In 1872, John Braxton Hicks investigated the later stages of pregnancy and found that many women felt contractions without being near birth. Braxton Hicks contractions are usually painless tightening of the uterine muscle and can generally be felt at the top of the uterus from about the second trimester. It is thought that they aid the body to prepare for birth. Not all expectant mothers feel these contractions.

Carpal Tunnel Syndrome

During pregnancy carpal tunnel syndrome is most likely caused by swelling, when the main nerves (ulna and radial) in the wrist become compressed by fluid. This condition is more often seen in the late second and third trimesters of pregnancy. Carpal tunnel syndrome symptoms will usually disappear, along with the swelling, after delivery.

Some women find it helpful to wear wrist splints at night to maintain a specific position of the wrist relative to the hand. Elevating your hands/arms will also allow some of the fluid to drain back into the central system.

Colostrum

Colostrum is the first milk that is produced by the breasts in late pregnancy or just after birth. It is high in protein, low in fat and has protective antibodies for your baby.

Colostrum has a mild laxative effect, encouraging baby’s first bowel motion. Baby’s first bowel movement is called meconium. Meconium also gets rid of excess bilirubin, a waste product of dead red blood cells, which is produced in large quantities at birth due to blood volume reduction. This helps prevent jaundice.

Constipation

Constipation is a common complaint during pregnancy and can begin early and be a problem for some women throughout pregnancy. It is thought that the cause of this is due to hormones such as Progesterone slowing down the motility of the intestines. The longer it takes for digested food to pass through the bowel the more water is reabsorbed within the large intestine and the harder the stool. Also be aware that straining leads to haemorrhoids forming.

During late pregnancy, constipation can also be caused partly by direct pressure on the intestines from the growing baby.

There are a number of things that you can do to possibly alleviate or reduce the effects of this condition. Drink 2-3 L of water per day the first one of the day warm with a squeeze of lemon juice, this is very cleansing to both the liver and the intestines. Increase your fruit, vegetable and fiber intake. Try having muesli made from raw oats, nuts and seeds with a few prunes on top in the morning for breakfast. Dried prunes should be soaked in water overnight in the fridge.

Cystic Fibrosis

Cystic fibrosis is a serious inherited genetic disease which mainly affects the lungs and pancreas, but can involve other organs. Normally, cells in these parts of the body make mucus and other types of secretions. In people with cystic fibrosis, these cells make mucus and secretions which are much thicker than normal. With cystic fibrosis, a specific pair of genes on chromosome 7 does not function properly. These genes help to control the way the cells handle sodium and chloride ions. Cells in affected organs function abnormally in that too much sodium travels into the cell. Because water molecules are attracted to the sodium molecules water also travels into the cell leaving the substances outside the cell more viscous or thick.

Symptoms usually arise in early childhood and include persistent cough, wheeze, repeated chest infections, malabsorption of food, and general ill health. Treatments include antibiotics, physiotherapy, mucus thinning drugs, pancreatic enzyme replacements and other lifestyle therapies.

Dizziness

Hormones that cause your blood vessels to relax and widen during pregnancy is one of the main reasons for dizziness. This helps increase the blood flow to your baby, but it slows the return of the blood in the veins to you. This causes your blood pressure to be lower (hypotension) than usual, which can reduce the blood flow to your brain, temporarily causing dizziness.

Women who are anaemic or who have varicose veins may be more susceptible to dizziness than others.

Down’s syndrome

Down syndrome (DS), also called Trisomy 21, is a condition in which extra genetic material causes delays in the way a child develops, both mentally and physically. In most cases of DS, a child gets an extra chromosome 21resulting in a total of 47 chromosomes instead of 46. It's this extra genetic material that causes the physical features and developmental delays associated with DS.

The physical features and medical problems associated with Down syndrome can greatly vary from child to child. While some kids with DS need a lot of medical attention, others lead healthy lives with little medical intervention.

Down syndrome can't be prevented; it can be detected using nuchal translucency and or Chorionic Villus Sampling (CVS) at around 11-13 weeks of pregnancy.

Women age 35 and older have a significantly higher risk of having a child with DS. At age 30, for example, a woman has about a 1 in 900 chance of conceiving a child with DS. Those odds increase to about 1 in 350 by age 35. By 40 the risk rises to about 1 in 100.

Eclampsia

Eclampsia is a fit (convulsion or seizure) which can be a life-threatening complication of pregnancy. Less than 1 in 100 women with pre-eclampsia develop eclampsia. Generally most women with pre-eclampsia do not have eclampsia. The treatment and care of women with pre-eclampsia is to prevent eclampsia and other potential complications. Your obstetrician and or general practitioner will be monitoring you for symptoms of such conditions.

Gestational Diabetes

Gestational diabetes is high blood sugar that starts or is first diagnosed during pregnancy. Around the 24th week approximately 18% of pregnant women develop gestational diabetes. A diagnosis of gestational diabetes doesn't mean that you had diabetes before you conceived, or that you will have diabetes after giving birth.

Placental hormones can block the action of the mother's insulin (insulin is used by the body to convert glucose to energy) in her body. This condition is called insulin resistance. Insulin resistance makes it difficult for the mother's body to use insulin. She may need up to three times as much insulin.

Gestational diabetes starts when your body is not able to make and use all the insulin it needs for pregnancy. Without enough insulin, glucose cannot leave the blood and be changed to energy. Glucose builds up in the blood to high levels. This is called hyperglycaemia.

Even though insulin does not cross the placenta, glucose does. This gives the baby a high blood glucose levels and causes the baby's pancreas to make extra insulin in order to maintain normal blood glucose levels. Your baby is getting more energy than it needs to grow and develop, the extra energy is stored as fat.

Gingivitis

When you have Gingivitis your gums become swollen and bleeding is common. This can be a very unpleasant condition and is often assumed to be one of the natural consequences of increased oestrogen and progesterone.

These hormones influence kidney function in that all cells of the body retain more fluid which causes them to become swollen. Avoid vigorous brushing as this will increase the risk of damage and potential infection.

Haemophilia

Haemophilia is a genetic blood disorder that affects the blood’s ability to clot and bleeding can occur both externally and internally. Usually internal bleeding occurs around joints and muscle. Symptoms include pain, swelling and stiffness. Over time joint damage can occur.

The two most common types of haemophilia are haemophilia A and haemophilia B.

Both types have the same symptoms. However, the two types are caused by problems with different clotting factors and have slightly different treatments.

There is no cure for haemophilia. Due to the creation of genetically engineered clotting factors since 1990 this condition can now be well managed. The clotting factors can be given by regular injections.

Haemorrhoids (Piles)

Haemorrhoids are swellings that can occur in the anus and lower rectum.

There is a network of small veins within the lining of the anus and lower rectum. These veins sometimes become engorged with more blood than usual. These engorged veins and the overlying tissue may then form into one or more small swellings called haemorrhoids.

Haemorrhoids are common during pregnancy usually due to the effects of pregnancy hormones on the walls of the veins. Haemorrhoids usually settle after the birth of your baby.

A number of ointments and creams are available over the counter from your pharmacist to assist in decreasing discomfort.

Huntington’s disease (chorea)

Huntington's disease (HD) is named after George Huntington who first described it in 1872. HD is an inherited, genetic condition that affects the brain and nervous system. It interferes with the movements of your body, can affect your cognition (your perception, reasoning, awareness, thinking and judgement) and can lead to a change in your behaviour. It progresses slowly. Symptoms occur because of damage and death to some of the brain cell in specific parts of your brain. At present there is no cure for HD. Until recently HD was known as Huntington’s chorea. Chorea means a jerky, involuntary movement.

HD is caused by an inherited defective gene. This gene is carried on chromosome 4 and is responsible for making a protein called huntingtin.

Treatment is aimed at trying to control symptoms as much as possible when they develop.

Hypoglycemia (low blood sugar)

Hypoglycemia occurs when blood sugar levels drop too low and there is not enough glucose in the system to provide for your body enough energy.

The signs of hypoglycemia in pregnancy do not vary that much from the symptoms associated with hypoglycemia associated with diabetes. These symptoms include shaking, profuse sweating, nervous and anxiety attacks, intense hunger, dizziness, extreme headache, confusion, changes in vision and sudden irritability.

Pregnant women are more prone to hypoglycaemia since their bodies have increased energy requirements and may burn through stores of glucose much faster than a normal person. It is important for pregnant women to eat small amounts every 2-3 hours so that your body has adequate fuel.

Hypotension (Low Blood Pressure)

Blood pressure is a measurement of the pressure in your arteries during the active and resting phases of each heartbeat.

Systolic pressure. The first (top) number in a blood pressure reading, this is the amount of pressure your heart generates when pumping blood through your arteries to the rest of your body.

Diastolic pressure. The second (bottom) number in a blood pressure reading, this refers to the amount of pressure in your arteries when your heart is at rest between beats.

Low blood pressure during your pregnancy is common and caused by a number of factors. Because a woman's circulatory system expands rapidly and blood volume increases along with blood vessels dilating, blood pressure is likely to drop. Symptoms include sudden dizziness when you get out of bed or stand up quickly (postural hypotension). Lying on your back may cause supine hypotension because of pressure on the vena cava (main vein returning blood back to the heart). Blood pressure usually returns to your pre-pregnancy level after you've given birth.

When you become dehydrated, your body loses more water than it takes in. Even mild dehydration can cause low blood pressure, dizziness and fatigue. Maintaining adequate hydration will help to reduce symptoms of low blood pressure.

Hypertension (High Blood Pressure)

Most women will not develop any problems with their blood pressure during pregnancy. However, in some women, high blood pressure (hypertension) can develop. It is often mild and not serious. But in some cases, high blood pressure can become severe and can be harmful to both the mother and baby. Some women with high blood pressure may develop pre-eclampsia which is a more serious condition. Sometimes high blood pressure is present before pregnancy. In other cases, high blood pressure develops during pregnancy.

Chronic hypertension If high blood pressure develops before pregnancy, during pregnancy but before 20 weeks or lasts more than 12 weeks after delivery, it's known as chronic hypertension.

Gestational hypertension If high blood pressure develops after 20 weeks of pregnancy, it's known as gestational hypertension. Gestational hypertension usually resolves quickly after delivery.

Pre-eclampsia Sometimes chronic hypertension or gestational hypertension leads to pre-eclampsia, a serious condition characterized by high blood pressure and protein in the urine after 20 weeks of pregnancy.

Indigestion

Indigestion, also known as dyspepsia, is pain or discomfort in the upper abdomen .If you have indigestion; you may experience a number of symptoms. Heartburn or acid reflux is a burning sensation in the oesophagus that is caused by acid passing from the stomach. Regurgitation of food and bloating is also common.

As many as 8 out of 10 women experience indigestion at some point during their pregnancy. Indigestion tends to become more common as the baby develops. Indigestion during pregnancy is mainly due to rising levels of hormones causing smooth muscle to relax and increased pressure on the abdomen.

A number of lifestyle changes may help improve the symptoms of indigestion, such as eating smaller meals or cutting out certain foods. There are also medicines, such as antacids, that can be taken safely during pregnancy to treat indigestion.

Some women may find that their indigestion gets worse as their pregnancy progresses. However, in most cases, after giving birth, the symptoms disappear. Indigestion during pregnancy rarely causes complications.

Leg Cramps

Almost 50% of pregnant women suffer with lower leg cramps during the second and third trimester of pregnancy. These are sudden painful spasms that occur in the foot, calves or thighs. They are more common in the calf. Leg cramps will usually occur more often at night.

The causes are largely unknown but it is believed to be because of a lack of magnesium, salt and or calcium. There is some evidence to suggest that adequate salt in the diet may improve leg cramps. As blood volume increased by 50% during pregnancy and blood plasma is high in salt this may reduce the ideal levels of cellular salt in the muscle.

Muscular Dystrophy

Muscular dystrophy (MD) is a genetic condition causing muscle weakness. MD is a group of disorders which cause muscle weakness. There are different types of muscular dystrophy, ranging from very mild to severe. The different types also vary as to what age they begin and which muscle groups they affect.

The defective gene in MD affects the production of a specific protein required by muscle cells. The protein will either be deficient, or will be defective which does not work well. This leads to damaged muscle fibres and to muscle weakness. Depending on the exact type of faulty gene and faulty protein, different types of muscle weakness result.

At present, there is not a cure for MD. There are many types of treatment and aids that can help with the effects of the muscle weakness. The treatment needs to be fitted to the needs of each individual and the problems that they have from their MD. Physiotherapy and splinting are very common forms of treatment.

Nausea and Vomiting

Nausea and vomiting is very common during pregnancy. It is probably due to hormonal changes. Nausea and vomiting tend to be worse with twin or multiple pregnancies where hormone changes are more pronounced. In most cases it is mild and does not need any specific treatment. In more severe cases, an anti-sickness medicine is sometimes used. Dehydration is a complication in severe cases. See your medical practitioner if you suspect that you are becoming dehydrated. Severe sickness and vomiting is known as hyperemesis gravidarum. These women often require hospital admission for intravenous fluids and other treatment.

Oestrogen

Following ovulation and fertilisation of the egg, hormones change dramatically. Usually oestrogen and progesterone levels fall at the end of the menstrual cycle. After fertilization these levels rise.

A new hormone, HCG (human chorionic gonadotrophin), produced by the developing placenta, stimulates the ovaries to produce the higher levels of oestrogen and progesterone that are needed to preserve a healthy pregnancy.

As with the hormone progesterone the placenta takes over from the ovaries as the main producer of oestrogen and progesterone. The functions of oestrogen during pregnancy include; contribution to the development of breast tissue during pregnancy, maintenance of the endometrium during pregnancy, increasing joint mobility ( important for pelvic joints and ligaments), increasing mobility of nipple tissue and regulation of bone density within the foetus.

Placenta

The placenta is an organ that connects the developing fetus to the uterine wall to allow nutrient supply and removal of waste products via the mother's blood supply. The word placenta comes from the Latin for cake, from Greek plakóenta/plakoúnta, "flat, slab-like”.

The placenta has two components, the fetal component develops from the sperm and egg and the maternal component develops from the uterine tissue.

The placenta is generally 22 cm long and 2–2.5 cm thick. It weighs approximately 500-650 grams at full term. It has a dark reddish-blue colour. The surface of the placenta looks like a network of vessels a little like a tree structure.

The umbilical cord is around 55-60cm in length and connects the foetus to the placenta. It contains one vein and two arteries. Deoxygenated fetal blood is transported through the umbilical arteries to the placenta. Where the umbilical cord meets the placenta the arteries begin to branch until an arteriocapillary venous system is formed. This is where the gaseous exchange takes place between mother and baby without any direct contact between their blood.

Pre-Eclampsia

Pre-eclampsia is a complication of pregnancy. Symptoms of this pregnancy complication include high blood pressure, protein in urine and swelling of hands and feet. The greater the severity of these symptoms, the greater the risk of serious complications to both mother and baby. The exact cause of pre-eclampsia is uncertain but it is thought to be due to a problem with the placenta. Signs of pre-eclampsia include persistent headache, blurred vision, right sided upper abdominal pain and sudden weight gain. The only way to cure pre-eclampsia completely is by delivering your baby. Medication may be advised to help prevent complications of pre-eclampsia.

Should you develop signs and symptoms of preeclampsia, you and your baby will be closely monitored. Sometimes bed rest or hospitalization is recommended.

Premature Labour

Your baby is premature if it arrives before you are 37 weeks pregnant. Although the specific causes of premature labour are not known certain factors may increase a woman's risk of having premature labour. Women most at risk of are those who are pregnant with multiples, had a previous premature birth or they have certain uterine or cervical abnormalities.

About one baby in every 13 will be born before the 37th week of pregnancy. In most cases labour starts by itself, either with contractions, the sudden breaking of the waters, or a show.

If your baby is likely to be delivered early, you will be admitted to a hospital with specialist facilities for premature babies.

Should contractions start prematurely you will probably be given injections of steroids which will help to mature your baby’s lungs so that your baby is better able to breathe after the birth. This treatment takes about 24 hours to work.

Multiples births (Twins, triplets or more) are usually premature. The average delivery date for twins is 37 weeks, and for triplets around 33 weeks.

Progesterone

Progesterone is first produced by the corpus luteum of the ovary during the first 8 weeks of pregnancy. Following implantation of the embryo and up to delivery, the placenta takes over the production of progesterone. The levels increase dramatically all throughout pregnancy being at their highest just pre delivery. Progesterone is necessary for the preservation of pregnancy and all pregnancies will fail if progesterone production is too low. It is reduction in the levels of progesterone secreted by the placenta that stimulates the beginning of the contractions that will lead to the birth of your baby.

The function of progesterone during pregnancy is to keep the endometrium thickened, prevent the uterus from contracting, stimulate breast tissue production and prevent lactation pre-birth,

Rising progesterone levels are responsible for much of the symptoms associated with pregnancy. These include constipation, heartburn, headaches, food cravings or increased hunger, mood swings, bloating, nausea, breast tenderness and blurred vision.

Relaxin

Relaxin is a protein hormone first described in 1926 by Frederick Hisaw.

It is produced by the corpus luteum of the ovary, the breast and, during pregnancy, also by the placenta, chorion and endometrium.

Relaxin is produced mainly by the corpus luteum, in both pregnant and nonpregnant women. Its levels increase approximately 14 days of ovulation, and then declines in the absence of pregnancy, resulting in menstruation. In early pregnancy, levels rise and additional Relaxin is produced by the endometrium.

During pregnancy the hormone Relaxin influences collagen remodelling and softens all ligaments of the body along with the ligaments around the birth canal to prepare for delivery.

Concentrations of Relaxin during the two days immediately preceding delivery (parturition) are significantly greater than all other days. Relaxin is no longer manufactured in large amounts in the postnatal period, however the effects of the hormone on the ligaments are still evident until about five months post birth.

Rapid Eye Movement Sleep (REM sleep)

Rapid eye movement sleep (REM sleep) is a normal stage of sleep characterized by the random movement of the eyes. Tonic and phasic phases make up the two categories of REM sleep. REM sleep was first identified and defined by Nathaniel Kleitman and Eugene Asenirsky in the early 1950s. Rapid eye movement, low muscle tone and a rapid- low-voltage EEG are measures for REM sleep.

In adults REM sleep takes up between 20–25% of total sleep. During a normal night of sleep, humans usually experience about four or five periods of REM sleep. They are quite short at the beginning of the night and longer toward the end. REM sleep varies considerably with age. A newborn baby spends more than 80% of total sleep time in REM. Intensely recollected dreams generally happen during REM sleep.

Round Ligament Pain

Round ligament pain is most common during the second trimester and is generally refers to as a brief, sharp, stabbing pain or a longer-lasting dull ache that pregnant women generally feel in the lower abdomen or groin. Pain can occur suddenly when you change position e.g. rolling over in bed, coughing/sneezing.

The round ligaments surround your uterus in your pelvis. As your uterus grows during pregnancy, the ligaments stretch and thicken to accommodate and support it. These changes can occasionally cause pain on one or both sides of your abdomen. Round ligament pain is considered a normal part of pregnancy as your body goes through many different changes.

Rest is one of the best ways to help with this kind of pain. Changing positions slowly allows the ligaments to stretch more gradually and can help alleviate any pain. If you know that you are going to sneeze or cough bending and flexing your hips may reduce the pull on the ligaments.

Sickle cell anaemia

Sickle cell anaemia is the most common form of sickle cell disease (SCD). SCD is a condition where red blood cells (RBCs) are sickle-shaped or crescent like. Sickle cell anaemia is an inherited, lifelong disease.

RBCs are disc-shaped and look like doughnuts without holes in the centre. They move easily through your blood vessels. RBCs contain an iron-rich protein called haemoglobin (HB). This protein carries oxygen from the lungs to the organs and tissues of the body.

Sickle cells contain abnormal HB called sickle HB or haemoglobin S. Sickle HB causes the cells to develop a sickle, or crescent, shape.

Sickle cells are stiff and sticky. They tend to decrease blood flow in the blood vessels of the limbs and organs. Obstructed blood flow can cause pain, serious infections, and organ damage.

In sickle cell anaemia, the number of red blood cells is low because sickle cells don't live very long. Sickle cells usually die after only about 10 to 20 days. The bone marrow can't make new red blood cells fast enough to replace the dying ones.

Sickle cell anaemia has no widely available cure. Blood and marrow stem cell transplant may offer a cure for a small number of people.

Sickle cell anaemia varies from person to person. Some people who have the disease have chronic pain or fatigue. However, with proper care and treatment, many people who have the disease can have improved quality of life and reasonable health much of the time.

Stretch marks

A large percentage of women during pregnancy develop stretch marks (striae gravidarum). These occur because (CKS 2007) your skin is stretching as your baby grows and as you gain weight in pregnancy. They usually look like pinkish, or sometimes red, lines on your belly, breasts, legs, thighs and hips.

Stretch marks are permanent, although they do fade to a dull, silvery colour sometime after your baby is born.

If you put on a lot of weight during pregnancy or you are expecting more than one baby, you are more likely to develop them than if you remain very slim (Atwal et al 2006; Osman et al 2007).

Women complain that their skin becomes itchy as it stretches. Applying a moisturiser reduced this symptom. Vitamin E cream may reduce the ultimate severity.

Thalassaemia

This disorder is an inherited blood disorders. Haemoglobin is located in cells called red blood cells which are part of the blood. Haemoglobin is made out of different parts. The main parts are called 'alpha chains' and 'beta chains' which are put together to make the haemoglobin molecule. Alpha or beta chains of the globin content of haemoglobin (Hb) are either reduced or absent. As a result, there is not enough normal haemoglobin and the red blood cells break down easily.

There are different types, which vary from a mild condition with no symptoms, to a serious or life-threatening condition. Thalassaemia is most common in people whose family origins are Mediterranean or Asian. It can be diagnosed from a blood test. Women who are carriers of thalassaemia, may be asymptomatic when not pregnant but more anaemic than usual during pregnancy.

Chorionic villus sampling in the first quarter of pregnancy and fetal cord blood sampling under ultrasound guidance in the second quarter can be used to detect B2-thalassaemia major.

Urinary tract infection (UTI)

A urinary tract infection (UTI), also called bladder infection, is a bacterial infection within the urinary tract. Pregnant women are at higher risk of developing a UTI's because the uterus sits directly over the bladder. As the uterus grows, its increased size can reduce the drainage of urine from the bladder. This can cause stasis of urine within the bladder and an infection can develop.

The most common symptoms are a feeling of wanting to go to the toilet a lot without passing much urine and during micturition you may experience a burning sensation.

UTI's can be safely and commonly treated with a 5-7 day course of antibiotics during pregnancy.

Vaginal discharge

It's quite common to have more vaginal discharge (leukorrhea) during pregnancy. This is not cause for concern unless associated with pain and or odour which may indicate UTI.

The odourless or milky discharge that you may have noticed in your underwear before you were pregnant has now increased. Due to higher oestrogen production and increased blood flow to the perineal area this discharge is usually greater. This discharge contains old dead cells and secretions from the cervix and vagina.