Family and Community Health: Pre-natal care

Each woman has her own doctor in our group. This is the doctor you see for your regular pregnancy visits during the second half of your pregnancy. We will be arranging sessions every three months or so to give you an opportunity to meet the other doctors in the call group. We all share deliveries so that each of us is “on call” once per week and one weekend out of every five. For emergencies or for the delivery, you should call either maternal triage at the hospital or the doctor on call.

Yes, that’s right. Most doctors who deliver babies belong to a call group of one sort or another. This is how we can be there for you 24 hours a day, 365 days a year. We believe this kind of structured call group has many advantages.

• One of the doctors in our group will be there for you during your delivery, and you will have the chance to meet all the doctors in the group before you give birth.
• The doctors in the group update each other regularly. This means the doctor who attends the delivery will know about you, and your medical history.
• One of the reasons we came together as a group was because we all approach pregnant women and their families in the same way. We all put safety first, but will do everything we can to follow your birth plan.
• We all work at St. Michael’s Hospital; that means we are all very familiar with the hospital, equipment and other staff.

Yes, residents are doctors who are doing special training in family practice. Our group has a strong commitment to teaching the next generation. After all, pregnancy and birth are a part of normal life and so have to be part of training family doctors.

First trimester: you might be sleeping more (and better), but this is not all. You are likely to have less energy during the day and not be able to do all the things you could previously. Don’t worry … this is temporary but it is your body helping you relax. Simplify your life and don’t ‘burn the candle at both ends’. This is a time to take it easy, shrink your ‘to do’ list and focus on you and the baby.

Second trimester: As the uterus grows, so does the amount of blood in your body (which the baby uses to grow). Your heart is hard at work in moving this fluid. The growing uterus begins to push up on the diaphragm (which is what helps you to take a breath). Finally, your growing body weighs more and more each week (a normal part of second and third trimesters). All of this might make you more tired and less able to move around quickly, lift things and exercise. You may find yourself feeling more ‘faint’ or exhausted after what used to be a normal day. Take it easy and listen to your body. Pregnancy is not a time to push yourself beyond the limits. If you have fainting spells or you feel the fatigue is worrying you, you should talk about this with your doctor or nurse practitioner.

At first, the third trimester feels very similar to the second. But, as your baby grows, there is increasing pressure and discomfort for the pregnant mom. This may seem a negative aspect of pregnancy, but it is necessary. This discomfort makes most mothers ready to experience the delivery by the time they begin to labour. In fact, the fear of the labour goes down (sometimes even goes away) because you cannot wait to feel comfortable again. This lets you participate more fully during your delivery and be as free from fear as possible. Keeping calm during the third trimester and during labour is very important. Your health care provider is here to answer any questions. Always get medical attention if you are worried about your or the baby’s health.

From very early on you may notice that your belly feels and looks bigger, even though the little one is only a few centimetres long. Most women feel at least some nausea and many even have vomiting. You can help this by avoiding a completely empty or a very full stomach; by eating small light meals throughout the day. If you feel as though you cannot keep meals down, your nurse practitioner or doctor can help with medications. The important thing is to keep hydrated (drink small volumes often while awake and keep yourself urinating at least three to four times daily). Nausea tends to get better in the second and third trimesters. If this is still an issue for you, especially if you are still vomiting and having trouble gaining weight, please speak to your provider. You may need extra help to keep you and your baby healthy.

Your bowel movements will likely also change. Most will tend towards constipation but some will experience looser movements. Keep your diet high in fibre (25g of fibre or more per day) in order to keep regular. Whole grains, lentils, bran and apples are all examples of foods with high fibre. Drinking lots of fluid and exercising also helps. When this is not enough, softeners and fibre such as Prodiem, Metamucil or Surfak are safe to take.

If you are healthy, your blood pressure is naturally low and will decrease even further while pregnant. This may result in light headedness when getting up from lying or sitting. Light headedness or even fainting can happen suddenly or with very little emotional upset. Keep yourself hydrated (urinating at least three to four times daily), well-fed and take it easy – this is not the time to start a new intensive workout routine, nor to work 15 hour days.

As the womb grows, there is more pressure in your stomach which causes heartburn (also called acid reflux). You may feel a burning sensation in your throat. There are safe medications to treat this, should this feeling start to bug you. Sleep propped up on pillows if heartburn gets worse at night. Try to avoid a completely empty stomach by eating frequent, small meals and drink water often. Avoid caffeine, alcohol and vigorous exercise to help with this issue. Antacids such as Gaviscon, Tums, Maalox and Zantac may help. Liquid antacids often work better than tablets.

The second trimester comes along with more blood in your system (to feed the growing baby) and a growing womb (where the growing baby is kept). Also, the pregnancy hormones make it more difficult for blood vessels (veins) to move blood towards the heart. All of these factors mean more pressure in the veins of your legs. This can cause hemorrhoids, varicose veins and swelling of the limbs. The swelling in the hands can cause “carpal tunnel syndrome” (numbness or tingling of the hands).

This is what can help:

• keep your legs up when you’re sitting,
• walk and exercise as much as is comfortable (which pumps the extra liquid out of the legs)
• wear pressure stockings

Talk to your provider if swelling becomes bothersome to you or if you have had numbness or tingling. It is important to mention face swelling to your doctor or nurse practitioner if this is happening to you.

Hormones can soften the joints (intersection between bones) and ligaments (strings that connect bones with bones) in the pelvis. This can cause a less stable, less balanced lower back and lower belly. Because of this imbalance in your body, it can put extra stress on your muscles and joints which is felt as pain. Good posture and strong body muscles help prevent and/or relieve this discomfort. There are some exercises you can do at home to improve your posture and muscle strength. When standing, place one foot in front of the other and rock slightly back and forth. Your provider may suggest you see massage and chiropractor services for your back pain. Support belts for the back are also sold in maternity stores.

Leg cramps can be caused by overstretching of the muscles or dehydration. Stand on the affected leg, or stretch your cramped leg. Ask your health care practitioner about hydration, nutrient supplements and other treatments.

You may need to urinate more often throughout the day and night. This can happen for many reasons. When you are pregnant your womb slowly grows into the largest organ in your belly because your baby is growing inside, and presses more and more on your bladder. This makes you feel the need to urinate more and more often. By the end of your pregnancy you may need to empty your bladder every hour. This is perfectly normal for late into your pregnancy and unfortunately there is not much you can do. Try to drink less fluid in the evening to avoid having to get up as many times throughout the night. Ask your doctor or nurse how to do pelvic floor exercises for better control of your bladder.

There are a few warning signs you should watch out for. If you suddenly need to urinate more and more, have burning smelly urine, red urine, or feel fever, nausea, vomiting you should let your provider know as soon as you can. You could have a urine infection.

Pressure from the womb slows blood flow from your legs. Blood levels are also more relaxed due to your hormone levels. In some women these natural changes result in varicose veins, leg swelling and hemorrhoids. If your family has a history of varicose veins, it is more likely that you will too. Avoid standing for long periods of time, and walking around throughout the day is even better. Raise your legs many times a day and wear support stockings. This will help with blood flow from the veins. Support stockings are also available by prescription. Constipation can make hemorrhoids worse. To avoid this, eat a high fibre diet (25g/day minimum) to keep your bowel movements regular. Whole grains, lentils, bran and apples are all examples of foods with high fibre.

Large varicose veins may spread to the vulva, which is the area around the female genitals. These will look like big, bluish blood vessels on the area around the vagina. Along with the varicose veins, you may also feel swelling or pressure. If you are feeling uncomfortable, try lying flat on your left side to get some rest. Ask your doctor or nurse about using special padding in your underwear for relief of vaginal pain.

It is common to have trouble sleeping during the third trimester in pregnancy. As your baby grows, you might find it is hard to get into a comfortable sleeping position. The womb and your baby will be pressing on your diaphragm (the muscle that helps you breathe), making it harder to take breaths. The extra weight your body is carrying from your baby might give you pain in your back and legs. You may also have cramping of the legs, especially in the middle of the night.

There are a few things you can do to help you get the best possible sleep. For cramping, massage the area and try to stretch the cramping muscle during the cramp. To prevent cramping drink 2-3 litres of water per day, eat one banana per day and take a calcium/magnesium supplement daily. If cramping is not better address this with your doctor or nurse practitioner at the next available visit.

Most women talk about how both skin and hair become more beautiful during pregnancy, and this may be true! Due to the increased hormones (estrogen and progesterone) in the blood stream, blood vessels in the skin swell and cause a ‘glow’ or flushing which can be very attractive. Hormonal changes also act on hair roots to stop them from dying. This means that women may have more hair during pregnancy.

Hormone changes during pregnancy can also result in acne, coarse hair, or even hair in unwanted places (such as the face or body). If this is you, do not worry too much. Pregnancy is temporary and you have the pleasure of knowing that when it is all over, your own naturally beautiful skin and hair will return.

Skin changes can include: a dark line on the belly (linea nigra), a “mask of pregnancy” or darkening of the facial skin, darkening of the nipples and stretch marks. All skin changes are caused by higher levels of hormones which can make your skin look darker. These changes usually fade after you have your baby. Stretch marks are caused by stretching of the skin but are also influenced by hormones. Some women are more likely to get stretch marks than others. Alhtough there are many creams “against stretch marks”, science has so far found nothing that actually works to stop them. Keeping moisturized with your usual moisturizer is a good way to stop itching and does no harm, though.

You may notice that you are sweating more than usual during your pregnancy. This can become uncomfortable because it makes your skin itchy. If you find you are sweating a lot, try taking showers or bathing more often to soothe your skin. Another good tip is to avoid body lotions that are scented, these can actually make your skin even drier.

Just like the changes to your appearance, libido also changes with the hormones of pregnancy. Early pregnancy can, for some women, mean increased sexual drive as well as increased orgasm. For others however, this time in their lives marks a drop in libido, increased vaginal dryness and more painful intercourse. Part of the pain during intercourse is caused by the enlarging womb. How women respond to their changed libido is a personal, cultural, and emotional issue, it is different for everyone. If any of the above are distressing to you, do not hesitate to bring this up to your healthcare provider during your regular appointments. You may obtain helpful advice on lubricant use, positions to avoid due to discomfort during this time, or support in abstaining from intercourse if that is what you wish. One thing is certain, sex is not dangerous to a normal pregnancy and does not cause miscarriage during the first trimester. Your health care provider will discuss any abnormalities during your pregnancy which may make sex harmful. If the pregnancy is proceeding normally, what you do is your decision and will be supported by your medical team.

Feeling different emotionally during pregnancy is not just a myth. Some, not all, women will find themselves crying unexpectedly, brooding over relationship issues or the general future. On the other hand, you may be lucky enough to find yourself happier than usual, more at peace, or even giddy. Be patient. Give yourself some leeway and encourage those around you to do the same. If you find your emotions interfere with your day, your sleep or your life in general, speak with your healthcare provider to explore if you may be depressed or manic (too emotionally high). Either of these disorders can have serious consequences on your pregnancy and your baby’s welfare. Neither should be ignored.

If you find you have a cold, we have suggested many medicines that are safe for you and your baby. For a minor cold you may take Benylin, Buckley’s or Robitussin cough syrup. If you have nasal congestion you may use Dristan or Otrivin nasal spray. If there is any fever or headache it is okay to use Tylenol. For sore throat, you may use Halls or Bradasol throat lozenges, gargle with salt and water or use Listerine. For allergies, Claritin, Benedril, Reactine and Chlor-Tripolon are safe to use.

Depending on your nausea, and if it’s relieved by food in the stomach, the amount you eat could increase or decrease. Stay away from extreme changes in your diet. This is not time to limit your eating and if you are having a hard time keeping food down see your doctor or nurse practitioner for advice and medicinal relief. Hydration is the most important, as well as taking your maternal vitamins. Eat smaller meals, more often during the day and stay away from fatty foods or foods you have a hard time digesting. If you find yourself losing weight, you should see your health care provider.

Likewise, greatly increasing the calories you ingest is also unhealthy. Too much weight gain puts you at risk for gestational diabetes and obesity in pregnancy, which can harm you and your baby. (See Weight below)

Aim for a nutritious diet and remember that the Canada Food Guide applies during pregnancy just as before or after it. Make sure you get enough calcium (found in leafy green vegetables, dairy products or prenatal vitamins). There are some foods we recommend avoiding, as they may contain toxins or bugs that can hurt the baby. Ask you doctor or nurse for their recommendations on raw or undercooked fish, milk products and predator fish which may contain larger amounts of mercury.

Finally, in the second half of pregnancy the fetus is growing at a faster rate than before, and this requires calories. You could find yourself craving more food in general and certain specific foods. Maintain a balanced diet and do not keep yourself hungry. On average, a pregnant woman in her second and third trimester requires 200- 300 kcal more per day. If you were already overweight it may be better for you to increase your intake by less that this amount and you should speak to your provider for details regarding your diet during this time.

• Daily Bread Food Bank: 416-203-0050
• North York Harvest Food Bank: 416-635-7771
• Yonge Street Mission: 416-929-9614

One of the least fun things about pregnancy is the inevitable weight gain during this stage of life. For some, the losing control of our appearance (especially weight) can be frightening and even depressing. Remember that pregnancy weight is not like weight gained by inactivity or unhealthy diet. Just as the body naturally gains pregnant weight, it also has ways to naturally (and GRADUALLY) shed it off after the pregnancy.

So what is the SHOULD of weight gain in pregnancy? The medical truth is that it depends on your pre-pregnancy weight and body mass index. Pregnancy is not the time to lose weight, nor is it the time to become obese or diabetic.

There are many resources to help you figure out the right amount of weight gain during your pregnancy. Here is a reliable resource published by Health Canada:
www.hc-sc.gc.ca/fn-an/nutrition/prenatal/bmi/index-eng.php

During pregnancy your growing baby will need lots of nutrients to make them healthy. Your baby will get these nutrients from your body. Depending on your nutrition, this may leave you with too little for yourself. Prenatal vitamins make sure that you have enough of all vitamins and minerals to continue to have a healthy body and a healthy baby. During the first trimester, the folate in prenatal vitamins helps avoid spina bifida (a birth defect). Also, you may take extra vitamin D (1000 units daily) to help protect your bones.

Vitamins/supplements for ODP recipients

• Special funding for prenatal ODP recipients

Exercising during a healthy pregnancy is not harmful. This is not the time to start high endurance training, but keeping up your usual pre-pregnancy routine is generally safe. Due to the changes in your body, you may find yourself getting tired more easily, having pain or even feeling new problems during your routine (such as nausea, lightheadedness, bleeding, cramping in the abdomen). Listen to your body. Lighten your exercise and do not push yourself if you feel unwell. Review all your exercise related symptoms with your doctor or nurse practitione to make sure nothing harmful is happening.

As your pregnancy progresses remember that your growing womb in becoming an important, ever larger part of your belly. It is no longer protected by the bones of your pelvis. Avoid contact sports, that may expose you to falls, always wear your seatbelt (whether pregnant or NOT) and avoid heavy lifting or straining. If you have had what may be trauma to the belly (motor vehicle accident, fall, hit to the belly) please report to your nearest obstetrical hospital for a checkup.

• Canada’s Physical Activity Guide to Healthy Active Living
• Canadian Society for Exercise Physiology

Working or physical activity are healthy for a normal, uncomplicated pregnancy. There are some problems (discomfort, fatigue and stress) that can happen from this activity. All of these possible problems are more likely as the pregnancy grows. Feeling well is very important during this time in your life. Let yourself a pause when needed and limit yourself when you feel strained (whether physically or emotionally). Speak to your health care provider when you feel your level of work is more than you can handle. They can tell you how much is too much for you and your specific pregnancy.

On the other side, travel can be risky when it involves prolonged sitting. The chance of blood clots is greater during pregnancy due to the increased levels of Estrogen in your system. So it is important to speak to your provider before you travel to review how to do it safely. It is important to decrease immobility as much as possible by getting up for small walks in an airplane or train, taking frequent breaks from a car ride and even exercising your legs while sitting (ex. pointing your feet and squeezing your calf muscles repetitively every hour or so). This activity will also decrease the amount of leg swelling which can develop in pregnancy.

Other risks of airplane travel involve the radiation from being high up and closer to the sun For this reason, plane travel is best avoided during the first three months if possible. Finally, travel involves contact with a totally new environment. Speak to your healthcare provider or go to a travel clinic for advice on how to minimize risk of infections, sun exposure, irritants etc.

Being pregnant with HIV can happen in a healthy way that avoids harm to the mom or baby. The St. Michael’s Family Health team provides a positive space for positive pregnant moms. Please see below some helpful tools to educate yourself on pregnancy care and speak with your doctor or nurse practitioner about how to care for you and your baby during this special time.

• Ontario AIDS Hotline: 1-800-668-2437 (English and 15 other languages) 1-800-267-7432 (French) Toronto: 416-392-2437
• Service Ontario INFOline: 1-866-532-3161 (Toll-free) Toronto: 416-314-5518 TTY: 1-800-387-5559

Throughout your pregnancy the little one is developing inside your body, especially during the first third of pregnancy when he/she is forming all of the vital organs which will be with him/her during their entire lifetime. Everything you ingest during this time is used in part to make your baby and it is important to be very aware and careful about what enters your pregnant body. Smoking and street drugs should be avoided completely. The safe level of alcohol to drink is as of yet unknown, so the safest amount is none.

Since what you ingest can also get passed to your baby, any medication taken should be reviewed for safety in pregnancy. Be sure to let your health care provider know of any medications you are ingesting, whether over the counter, supplement or prescription. The Hospital for Sick Children has an excellent website to help give you pregnant mothers safety information about specific products/supplements/medications during pregnancy (and breastfeeding):

When taking ANY medications or using any drugs, please inform the prescriber that you are pregnant. For some women, and for many reasons, this is very difficult or nearly impossible. Please speak to your doctor or nurse practitioner about safer ways to reduce harm to your baby in pregnancy.

Substance Use in Pregnancy Program: This is available through our family medicine obstetrical group. Call us if you think we can help.

• Alcoholics Anonymous: 416-487-5591
• Centre for Addiction and Mental Health: 416-535-8501
• Health Canada/Go Smoke-Free
• March of Dimes
• PREGNETS

Screening for infections

HIV, gonorrhea, chlamydia, syphilis, hepatitis B and possibly hepatitis C may all be tested to try to protect the growing baby from these infections. We will also check that you are immune to (cannot be infected by) common infections that can be dangerous to the developing fetus or the pregnant mom: rubella, possibly hepatitis B and chickenpox. Finally, we will check for urine infections so we can treat them before they spread which is more common in pregnancy.

Making sure you’re healthy

It’s important to check for thyroid disease, anemia (low blood), vitamin B12 deficiency or abnormal cervix cells (PAP). All of these conditions can be treated if needed, to keep you healthier during pregnancy.

Your blood type

We always test your blood type. Everyone knows that there are different blood types (A, B, O or AB) but few know that for each of these types there is a POSITIVE and NEGATIVE state (i.e. A positive or A negative). Regardless of your lettered blood type, if you are NEGATIVE status there are some special treatments for you while you’re pregnant. You will need specific injections to ensure that your blood does not react to the baby’s blood. This is necessary if you ever bleed during your pregnancy, if you have certain procedures (ex. therapeutic abortions), at approximately 28 weeks of gestation, and after delivery. This injection contains antibodies to the POSITIVE component of blood typing which will glue onto the baby’s blood if he/she is POSITIVE status. These antibodies effectively hide the baby’s POSITIVE status and make sure that your blood will not react against the baby’s blood.

Before these injections were invented, some mothers with NEGATIVE blood would become ‘immune’ to babies with POSITIVE blood and not be able to carry such a pregnancy to term ever again. So It is very important to be treated in order to prevent future miscarriages.

Non-stress test

This test involves going to the hospital and having a probe on the belly which monitors the baby’s heart and uterine contractions for 20-40 minutes. It is done in all sorts of situations to check that the baby is well. This test is rarely done before 28 weeks of pregnancy. Someone from our team will explain both the reason for doing this test as well as the result as it applies to your particular situation.

Fetal biophysical profile

This is another test which is used in similar situations as the non-stress test. This time, the baby is watched on ultrasound and specific factors are looked at to assess baby’s well-being (ex. movements, fluid volume). Again, there are lots of reasons for ordering this test, and the interpretation of what the results may mean are different. Your provider will answer questions around why it is being done and what the results mean in your individual situation.

Glucose tolerance test + gestational diabetes

Higher blood sugars in pregnancy can happen just like in Type 2 diabetes. The higher sugar changes the pregnancy by changing the placenta as well as how the baby develops. These changes can harm the baby, the mother and the upcoming labour. So, it is important to notice diabetes in pregnancy and to treat the sugars so we can stop these changes.

The glucose tolerance test is performed between the 25th and 28th week of gestation. It is a NON FASTING test which takes an hour to finish. You will go to the lab, drink a container of sweet juice (called the “glucose challenge”) and an hour later have a blood test. If this test is abnormal you will do the main diabetes test which is a FASTING test (nothing to eat or drink except water for eight hours prior). You will go to the lab and have a blood test, drink a larger sweet juice bottle, and have blood tests one and two hours later. If this set of testing is abnormal it means you have gestational diabetes and will be referred for treatment by your provider.

Group B streptococcus test

GBS is a type of bacteria that can grow on the around your vagina and bum. It usually just lives there peacefully and, apart from the rare urine infection, does not harm you. During vaginal delivery your baby passes through the vagina and gets coated with bacteria from the surrounding areas. This is for the most part a protective process, during which the skin of the baby gets filled with ‘friendly’ bugs and is made unavailable for ‘unfriendly’ bugs who are more likely to cause infection. When GBS is on your skin, it also can be transferred onto the baby. Most babies who end up with GBS on their skin are fine, without any infections. A very few of these unfortunately do get infections from GBS and, when this occurs, the infection can be dangerous (even life-threatening).

At around 36 weeks of pregnancy, we will do a swab of your vagina and anus. If we find this bug to be growing there, we will give you antibiotics during labour (through the IV) and kill GBS before it gets onto your baby. Since doctors have started doing this, the number of sick newborns with GBS infections decreased and less babies die from GBS.

Vaccines, if they can safely be avoided, usually are in pregnancy. For this reason, it is ideal to have a pre-conception (pre-pregnancy) visit with your doctor or nurse practitioner, where the following vaccines can be discussed:

• tetanus, pertussis, chickenpox/varicella, rubella (given as the MMR or mumps, measles, rubella vaccine), and influenza

While you’re pregnant, it is important to protect yourself and your baby from getting the flu.  This is why we advise all our patients (especially pregnant moms) to get their flu shots at the beginning of each flu season.  We also suggest having a pertussis (“whooping cough”) booster in your third trimester and this will be reviewed in detail with you when you reach this stage.  Finally, if you or your baby is travelling early in life to a hepatitis B endemic country we recommend vaccinating yourself and your baby after birth.

Keep in mind that vaccinations and vaccine schedules are an ever-changing part of medical care. Advice on immunizations during, and outside of, pregnancy changes quickly and your provider can explain any new recommendations if they apply.

There are a few different types of genetic tests which are time-sensitive (meaning they have to be done at specific times during the pregnancy). They try to tell us the risk of the fetus having certain genetic problems: such as Down syndrome and spina bifida. These tests are called: first trimester screening, integrated prenatal screening, maternal serum screening or the non-invasive prenatal testing. The best explanation of these tests is on the Mount Sinai Hospital website. Please refer to the link below:

• ontariofetalcentre.ca

Prenatal Diagnosis Program
Mt. Sinai Hospital
700 University Avenue – Hydro Building, Toronto, ON M5G 1Z5
416-586-4946

As you near the term of your pregnancy (your baby is at term after 37 weeks and before 42 weeks) there may be some new things going on with your body which tell you that your body is getting ready for delivery. The first is called ‘nesting’ and happens when you feel the need to get your home ready for the baby. You may feel like cleaning the house, getting the baby room organized and prepared, or even wishing to stay close to home rather than leave on a trip ‘in case the baby comes’. Although all of the above may seem to be ‘just normal thinking when you’re having a baby’, some women start to truly focus on these things in the two to three weeks before delivering.

Secondly, the uterus may move lower in the tummy. This is what some people call ‘your stomach dropping’ and happens so that the baby’s head is down inside the pelvis to get ready for delivery. Although not exact (nothing is 100 per cent predictable in pregnancy medicine) this may happen one to two weeks before delivery, however some women experience this much earlier on. As the uterus lowers you may feel that breathing becomes easier for you and that your need to urinate increases. This is because your baby (inside the uterus) is moving farther away from the muscles that help you breathe and closer onto your bladder. Feeling the need to urinate more often is normal and, (unless you are also experiencing painful urination, fever, nausea, vomiting, mid-back pain) not a sign of a urinary infection. Thirdly you may ‘lose your mucus plug’ several days before your labour begins. The mucus plug is a palm-sized clear-reddish jelly material which sits on the cervix and protects the uterus/placenta/baby from infecting organisms which may otherwise move up from the vagina. The plug acts like a protective barrier between the external surface of the vagina and your insides of your uterus and baby. Shortly before delivery, this drops out from the cervix as it softens and becomes more open. The mucus plug may come out all at once and be visible as a jelly clump in the toilet or bathtub, or otherwise may come out bit by bit and be very small or it might even happen without you realizing it.

Finally, your ‘water may break’ which happens when the balloon of fluid around the baby develops a hole through which fluid flows into the vagina and, eventually, into the underwear. This also may happen as a large fluid gush from the vagina, which is unmistakable and will not be missed. However, if the hole in the ‘balloon’ is very small, the leaking from the vagina will be in very little amounts and may be hard to notice. If your underwear feels wetter than usual (ex. as though someone keeps pouring water over them) change your underwear, dry yourself off and check again in one to two hours. Should you, once again, notice wet underwear that are soaking through to your pants you should report to your delivery hospital (at maternal triage) to be checked to see if your water has broken.

If you think your water may have broken, by a small leak or a large gush, you should report to your delivery hospital to be checked and managed appropriately.

As your pregnancy nears its end you (and perhaps your partner) may find yourself worrying about when to go to the hospital. Will you know when? Is this a false alarm? What if you wait too long and don’t make it to the hospital in time?

The first point of reassurance is that labour is never hard to miss – no matter whether it’s your first or your tenth baby, your labour will never go unnoticed. The true question is now long to wait with discomfort at home before driving into St. Michael’s to be assessed for admission. If this is not your first baby then you already may remember how you feel when in labour and, as soon as you feel this way you should drive to the hospital to be checked out. Generally, if it’s not your first, every labour lasts shorter than the one before and so you should speak to us about when you should head to hospital (ex. If last labour lasted three hours from feeling strong pains to the baby coming out, then it will likely be even shorter this time). The following is for information on labour in a first time mom:

The beginning of labour is called LATENT LABOUR and during this stage you will have irregular contractions which over time get stronger and closer together (ex. at first you may notice that every 15 minutes you feel period cramping in your lower belly and your lower back. As the time goes on, you feel the pains getting stronger and there is less time between pains). These cramps are slowly softening and stretching your cervix (the doorway to the womb). Once your cervix is 3-4 cm open you have begun ACTIVE LABOUR. If laboring mothers are admitted to the ward before they are in active labour, they are overtreated and are more likely to end up having a C-section. Because of this, we do not admit mothers in latent labour to the ward. This can be frustrating when you are experiencing pain and distress, however it is in your best interest and done for you and your baby’s protection.

So how do you know at home if you are in latent labour or active labour? The general rule is that if you are having strong contractions every four to five minutes or less, when these contractions are lasting one or more minutes, and when this is happening for one or more hours, you should drive to hospital to be checked for how open your cervix is. Also, if you are having any bleeding from the vagina (which can be a normal), any leaking of water into your underwear, or any symptoms not generally part of normal labour (fever, jaundice, rashes, diarrhea, difficulty breathing, etc..) you should go to St. Michael’s to be checked. After being checked your first time at the hospital, we will tell you when you should come back, or will admit you to the hospital if it is time for the baby to come.

If a pregnancy reaches 42 weeks gestation it is called post-term. After this age, life for the baby becomes more dangerous inside the womb than outside. Because of this, pregnancies are not recommended to continue beyond 42 weeks, and an INDUCTION of labour is offered between 41 and 42 weeks’ gestation. During this last week, we also monitor the baby more closely. Should your pregnancy reach post-term, your doctor or nurse practitioner will explain the risks and benefits of inducing (medically starting) your labour.

You will know when to come to maternal triage to start your induction (bring your bags and be ready to be admitted to the delivery floor). Inducing a pregnancy usually involves checking your cervix to see how ready it is for labour. Depending on how ready it is (how soft, open etc.) the doctor may insert a medication (or a catheter) to get the cervix softer and more open. The doctor taking care of you in the hospital will explain to you exactly how it will be done.

Once you do arrive at the hospital you will have to report to the triage desk on the maternity wardlocated on 15th floor of Cardinal Carter South. If you do not know where this is you can ask at any desk and you will be directed. The nurse is the first to see you and get an idea of what brings you in. She will ask you about how frequent your pains are, what they feel like, and if you’ve had anything unusual coming out of the vagina. She will put you in a bed and ask you to change your underwear (even to put a gown on in some cases). She will put a baby monitor on your belly to measure the baby’s heart rate as well as your contractions. She may check your vagina to see how dilated you are and if the doctor needs to check you right away. She will also take your blood pressure, temperature and pulse. Depending on how you are feeling she may ask you to do other tests and even start some blood work or an IV.

Once you are in active labour you will be admitted to the ward and put into your own private room for the delivery (if you’re being induced you are already there). This room has a private shower and some have jacuzzis for your use if it’s safe to do so. You will stay in this room until one to two hours after having your baby. After, you’ll be transferred to a semi-private or private room depending on availability and your insurance coverage.

In the delivery room, you may continue to be monitored (fetal heart rate, blood pressure, contractions) or you may be free to walk around. Your supports can come in with you, however there is a limit of two helpers in your room at one time. During the contractions, it will help to have someone with you. This person should be someone you know, you trust, who makes you feel safe and most importantly someone who relieves stress and fear. It has even been proven in research that having such a person with you helps the progress of your labour.

You will be taken care of by a nurse who has special training and experience in deliveries. From time to time a doctor may examine you and discuss your progress as well as any worries as they arise. Worries do sometimes arise during delivery and most of the time there is ample time to explain interventions with you, so that you understand and consent to any procedure (knowing how you will benefit from it and what the risks are). There are unfortunately some instances where something happens quickly (with you or with the baby) which requires fast treatment. If this happens, the medical team will have to treat quickly and will explain the situation later.

Research has proven that good support (from family, partner, friend, doola) improves the progress in labour and decreases the amount of medication given for pain during labour. This could mean that less pain is felt by you or that you simply deal better with it. In fact, your ability to remain under control and not panic is vital to good labour (both in terms of oxygen delivery to the baby and the speed/ease/flow of labour itself). Choose someone who you trust, has the ability to make you feel assured/safe/less anxious/more brave. It is okay to have loving, intimate family members wait outside the room if they do not have this effect, and especially if they have the opposite effect.

Pain during labour is one of the things most patients ask about when talking to their practitioner about the actual delivery.  It’s important to remember that there are good pain relieving options that are not medications: peanut balls, yoga balls and the use of the shower or Jacuzzi really does help us to cope with the pain.  One can never understate the importance of your helpers for this support as well. The following are the medication aids that are available to you during your labour at St. Michael’s.

This medication is on the labour floor at St. Michael’s. It comes in a pressurized container with a mouthpiece. You will hold the mask over your mouth and nose as the contraction builds, and breathe through it to the end of the contraction. The gas works so fast, that as soon as you stop breathing it, it’s out of your body. This means it has no effect on how the baby will breathe/ cry/ eat after birth. Nitrous oxide doesn’t stop pain, but lifts you above it so that you can cope with the tough contractions as you become fully dilated and are ready to push.

Medications given into the muscle, fat under the skin or intravenously are called narcotic pain medication. They are more effective than nitrous oxide in decreasing pain. They do not stop pain altogether but they do decrease it which allows you to relax a little (side effects include itching, nausea, vomiting, and fatigue). They do enter the blood, cross the placenta, and enter into the baby. Because of this there is a risk that the baby will be sleepier after birth. This is why, once you are close to delivering, we may not be able to give them to you. There needs to be enough time for your body to get rid of the medication so that your baby can breathe well once he/she comes out.

Epidural medications are usually a mix of local anesthetic and narcotic. They are injected in a space around the spinal column and are the only medication that can stop contraction pain. After the first injection of medication, a small tube is left inside the space so that more medication can drip in to keep your pain away for the remainder of the labour. Once the epidural is running the baby has to be monitored continuously, you may have to have a tube into your bladder to empty it, and your legs will not be strong enough for you to walk. None of this is dangerous but it does mean you will have to stay in bed until the epidural is switched off and you have recovered from the leg weakness.

There are many misconceptions about the epidural, some of which are explained below. If after reading you still have questions please ask your doctor or nurse practitioner, so as to understand this tool for pain relief before the time when you may need/want it. Many believe that epidurals cause long-term back pain after delivery, however they definitely do not. (Pregnancy for nine months, breastfeeding for long periods and carrying an ever increasing bundle of joy cause back pain after delivery). Secondly, patients tend to worry about damage to the spinal column during the procedure. Although this risk exists, it is extremely rare (you are more likely to win the lottery). Epidurals are done safely and without harming patients a minimum of ten times/day in any major hospital across the world. The main risks to an epidural are severe headache (which is very unlikely with the small needle size used nowadays), infection, and bleeding all of which are very rare. The anesthetist performing the procedure will discuss with you any risks in detail if you request an epidural.

The option to collect cord blood is a new, and for some exciting, possibility for pregnant parents to consider while expecting their baby’s arrival. There is a free public cord blood bank available for donation through the Canadian Blood Bank Services (compared to the private cord blood banking companies which charge a $1-2000 fee for collection alone, followed by $1-200 yearly cost thereafter for a maximum of 18 years). It is important to do your research before investing in this interesting, expensive and very very rarely beneficial procedure. The following facts may be of interest:

• cord blood is used mostly in transplanting patients with blood borne diseases such as leukemias, lymphomas, haemoglobinopathies (all scary but thankfully very rare conditions). Treating Diabetes, Parkinson’s disease and acquired brain injuries are all just dreams for the future.
• due to the link between many of these diseases and genes, the use of an infant’s own cord blood to treat his/her own disease is rare (ex. if a child develops lymphoma, his/her own cord blood will become unusable for transplant due to the risk of the developing this disease again after transplant.)
• although difficult to calculate, the likelihood of needing a stem cell transplant is 2-10/1000
• the likelihood your child will benefit from his/her own cord blood transplant is estimated at 1/2700 or less

Ask your provider for patient information on the pros and cons of this procedure. Here are some resources for your own research:

• www.blood.ca/en/cordblood
• www.insception.com/cord-blood-101/
• www.cellsforlife.com
• www.createcordbank.com/
• www.healthcord.com/

• Your birth plan and prenatal medical records
• Robe, dressing gown, wrap sweater. This will be useful if you end up pacing hospital corridors in early labour and you’ll need one for after if you’re staying overnight. Hospitals can be very warm, so a lightweight one may be better.
• Slippers
• Socks. Believe it or not, your feet can get cold during labour.
• Massage oil or lotion if you would like to be massaged during your labour.
• Lip balm (believe it or not people find this soothing during labour)
• A headband or elastic. If you have long hair, you might want it tied up.
• Toiletries
• Music to listen to: Make sure your batteries are charged, as some hospitals won’t let you plug things in.

• Water spray, or a hand-held fan to keep cool down the mom-to-be while she’s in labour.
• Comfortable shoes. You may be pacing the corridors!
• A change of clothes
• Watch with a second hand, to time contractions.
• Address book or a list of phone numbers. You and your partner will be able to use a mobile phone in parts of the hospital, but bring lots of change or a prepaid phone card just in case, for all the calls you may want to make.
• Snacks and drinks. You don’t want a dehydrated, hungry birth partner looking after you and if you take some with you, they can stay with you rather than leaving the room to search for food!

• A going-home outfit: You’ll need loose comfortable clothes to wear while you’re in hospital and for the journey home. It will take a while for your belly to go down, so you’ll be still wearing maternity clothes when you come home – sorry!
• Nursing bras: Take two or three.
• Breast pads
• Maxi pads: Bring a couple of packs.
• Nightshirt wrap or T-shirt. Front-opening shirts are useful in the early days of breastfeeding.
• Toiletries
• Towels, hairbrush, toothbrush and toothpaste.
• Old or cheap underwear, or disposable panties. Don’t bring your best ones as they will get messy.
• Ear plugs, in case you end up in a crowded room!

• An infant car seat: Some hospitals won’t let you leave by car without one.
• One outfit for the trip home (all-in-one stretchy outfits are easiest). Two or three sleepers for baby to wear while you are in hospital.
• Baby blanket. Take a warm one if the weather is cold.
• Diapers
• One pair of socks or booties
• Hat
• Jacket or snowsuit for winter babies

We have many breastfeeding supports at St. Michael’s.  Every one of our obstetrical providers has training to support you on your journey to feeding your newborn. Our nurses have special training for assessing and managing breastfeeding.

Other clinics/classes

• La Leche League Breastfeeding Hotline: 416-483-3368
• Public Health Nurse: 416-338-7600
• Toronto East General Hospital: 416-469-6667: 825 Coxwell Ave.
• Breastfeeding | ontario.ca
• Health811online or call 811 (TTY: 1-866-797-0007)

Breast pump rental

• Shoppers Home Health Care: 416-236-1201
• St. Michael’s Hospital: 416-864-5252
• Sunnybrook Hospital: 416-323-6526

Herbal remedies

• Milk Supply/Candida Protocol: 416-498-0002
• Jack Newman: drjacknewman@sympatico.ca, www.drjacknewman.com
• Edith Kernerman: breastfeeding@sympatico.ca

Recovering from a vaginal or surgical delivery happens gradually during the first six weeks of the baby’s life. Depending on how intense this time in your life is, this part of you may go completely unnoticed, because you’re so focused on the baby. This is why we put it first on this list. Try to take time for yourself, because caring for yourself makes caring for your baby possible. This is no cliché: your baby and your family need your well-being to thrive.

The muscles of your back, lower belly and pelvis (the muscles between your legs) are all recovering from carrying a growing baby inside for nine months and from the stretching during delivery. If you’ve had a Cesarean section, your lower belly muscles have been cut through. They must now re-attach and gain their strength back. Here are some patient resources for exercises to decrease pain, improve strength and get yourself back.

• Exercise after pregnancy

A baby is an injection of love and fear. Parenting is something we feel our way through much more than an inborn talent or something we study for and ‘pass’. Figuring it out takes a lifetime and involves stumbling along the way. It is natural to feel overwhelmed, extreme emotions (good and bad) and even lost. So when is what you’re feeling abnormal? When could you be depressed? When do you need help?

The first layer of answering these questions is this: if you feel that your answer to any of these questions could be yes see your doctor or nurse practitioner and ask their opinion. Diagnosing yourself is difficult, but if you’re worried we should check. If you’re not sure what your answers to these questions are here are a few signs of abnormal depression:

Feeling like you can’t sleep even though you’re exhausted and the baby is sleeping
Not ever feeling joy during your day with the little one
You cannot get worries out of your mind and these thoughts are stopping you from sleeping, taking care of the baby or yourself
People who are close to you and love you have told you they’re worried about you
Thoughts of harming the baby: these do NOT mean you’re a bad person or a bad parent, they mean you’re depressed and need help to get things back on track
The above is not a complete list, nor do these symptoms have to be there for depression to exist… if you’re thinking you may be depressed let us know.

Here are some resources for support:

Partners for Health (East End): 416-469-7608
St. Joseph’s (West End): 416-530-6850
Our Sister’s Place: 416-486-7432
New Parent Support Line: 905-897-6262, open 9 a.m. to 9 p.m.

The Department of Childbirth and Family Life Preparation
Sunnybrook Hospital, M-wing, 5th floor, room 102
Email: prenatal.classes@sunnybrook.ca
Phone: 416-480-5368
Website: www.sunnybrook.ca/prenatalclasses

Toronto Public Health:

• Downtown Health Area: 277 Victoria St., 416-392-7641
• Northeastern Health Area: 235 Danforth Ave., 416-392-6958
• 40 St. Clair Ave. E, Suite 201, 416-392-0962
• Western Health Area: 1115 Queen St. E, 416-392-0888
• 2340 Dundas St. W, 416-392-0985

Breastfeeding

• St. Michael’s Breastfeeding Clinic

Children’s aid services

• Toronto Children’s Aid Society: 416-924-4646
• Catholic Children’s Aid Society: 416-925-6641
• Jewish Family Services: 416-638-7800
• Native Child and Family Services: 416-969-8510
• Peel Children’s Aid: 905-363-6131, 1-888-700-0996

Child safety

• Canadian Paediatric Society: www.caringforkids.cps.ca

Health Canada

Information and Education Unit
613-952-1014 (Ottawa)

Canadian Foundation for the Study of Infant Deaths (SIDS)

• 1-800-END-SIDS (1-800-363-7437)
• www.babysbreathcanada.ca

• Toronto Health Connection:  416-338-7600
• Car seats, information standards, rentals, sales
  • Car Seats: 1-800-566-9278, 905-568-8442
  • Consumer and Business Services: 416-326-8555
  • Easter Seal Society: 416-421-8377
  • Ontario Safety League: 905-625-0556
  • Canadian Automobile Association (CAA): 905-771-3170

• St. Michael’s Hospital – 61 Queen St. E
  • Pediatrics – up to one month old or 10 lbs.
  • 416-864-6060 ext. 6560
  • Can be done at time of delivery
  • $300 – $150 to doctor (cash), $150 to hospital (debit or credit)

• Michael Garron Hospital
  • 416-469-6580 ext. 6616
  • $250

• Dr. Aaron Jesin, North York General
  • 4256 Bathurst St. #203, Toronto, ON
  • 416-635-5012
  • Maximum age six months
  • $150 + every four weeks of age by $100

• Canadian Paediatric Society
• Canadian Immunization Coalition for Awareness and Promotion
• World Health Organization

• St. Joseph’s Health Centre: 416-530-6611, 30 The Queensway
  Just for Kids Clinic: Monday to Friday, 11 a.m. – 9 p.m.; weekends 10 a.m.– 2 p.m.
• North York General Hospital: 416-250-5000, 1100 Sheppard Ave. East, Suite 100
  Children’s After-hours Clinic: Monday to Friday, 6 – 10 p.m.; weekends/holidays 9 a.m.– 7 p.m.
• Scarborough Hospital – General campus: 416-439-3424, 3050 Lawrence Ave. E
  After-hours Clinic: Monday to Friday, 5 – 10 p.m.; weekends/holidays 10 a.m. – 10 p.m.
• Scarborough Hospital – Birchmount campus: 416-492-6666, 3030 Birchmount Rd.
  After-hours Clinic: Monday to Friday, 5 – 10 p.m.; weekends/holidays 10 a.m.– 10 p.m.
• Michael Garron Hospital: 416-461-3000, 235 Danforth Ave.
  Children’s After-hours Clinic: Monday to Friday, 6 – 9 p.m.; weekends/holidays 10 a.m.– 6 p.m.
• MCI The Doctor’s Office: 416-598-1703, 595 Bay St.

• The Hospital for Sick Children: 416-813-1500, 555 University Ave
  Medical Information Line: 416-813-5817
• Poison Control: 416-813-5900, 1-800-268-9017, 24 Hour Info Line: 416-813-6245
• St. Michael’s Hospital: 416-864-5094, 30 Bond St.
• St. Joseph Health Centre: 416-530-6003, 30 Queensway
• Michael Garron Hospital: 416-469-6435, 825 Coxwell Ave.
• North York General Hospital: 416-756-6001, 4000 Leslie St.
• Scarborough Hospital – Birchmount campus: 416-495-2550, 3030 Birchmount Rd.
• Scarborough Hospital – General campus: 416-438-2911 ext. 6300, 3050 Lawrence Ave. E
• Rouge Valley Centenary: 416-281-7270, 2867 Ellesmere Rd.

• Electronic Child Health Network
• Toronto Community Services – Children’s Services: 416-392-5437
• Community Information Centre – daycare locations: 416-392-0505
• Ontario Early Years Centre Info Line: 1-866-821-7770
• Family Daycare Services: 416-922-9556
• Visiting Homemakers Association: 416-489-2500
• Applying for daycare subsidy:
  • Kidsline (for placement of wait list): 416-392-KIDS
  • Children Services Department: 416-392-5437
  • VON – Peel Region only: 905-821-3242

• 519 Church Street Community Centre – Family Resource Centre: 416-392-6878 ext. 108
• Gerrard Resource Centre: 416-925-4363, 349 Ontario St. (Gerrard and Paliament)
• Parent Resources – St. Lawrence: 416-941-9248, 92 Front St. East
• Regent Park Community Health Centre
• Parents for Better Beginnings: 416-362-0805
• Growing Up Healthy Downtown: 416-595-9230 ext. 328
• Hincks Dellcrest: Growing Together: 416-921-8716
• School readiness programs
  • City of Toronto: Getting ready for kindergarten
  • Ready for School Connects (for newcomer families)

• Association of Parent Support Groups: 416-223-7444
• Jennifer Kolari, Masters of Social Work, www.connectedparenting.com
• Beverly Cathcart-Ross, certified patient educator, www.parentingnetwork.ca
• Parent Talk – Parenting Workshops, www.practicalparenting.ca

• Scadding Court: 416-392-0335 x 225, Brenda Morse (coordinator), 707 Dundas St. W
• The Gerrard Resource Centre: 416-972-1319, 444 Sherbourne St.

• Robertson House: 416-392-5662
• Toronto Community Hostel: 416-925-4431
• Anduhyaun Residence for Native Women: 416-920-1492
• Nellie’s Hostels for Women: 416-461-1084
• Family Residence: 416-397-1318
• YWCA Women’s Shelter: 416-693-7342

• St. Michael’s Hospital, Social Work Department: 416-864-5090
• Distress Centre (24 Hours): 416-598-1211
• Assaulted Women’s Help Line: 416-863-0511
• Toronto Rape Crisis Centre: 416-597-8808

Bereavement

• Bereaved Families of Ontario: 416-440-0290
• Perinatal Bereavement Services: 905-472-1807

Multiple births

• Toronto Parents of Multiple Births Association: 416-760-3944
• Multiple Births Canada: 1-866-228-8824

Parent programs

• Healthy Babies Healthy Children Program: 416-338-7600
• Parents Helping Parents: 416-392-7451
• Metro Mothers Network: 416-487-MUMS
• Mothercraft: 416-920-3515
• Visiting Homemakers Services: 416-489-2500

Teenagers

• Jessie’s Centre for Teenagers: 416-365-1888

Toronto services

• Downtown Legal Services: 416-978-6447
• Family Services Counseling: 416-595-9618
• Toronto Social Services: 416-392-8623

Chinese community

• Scadding Court Community Centre: 416-392-0335
• Centre for Information and Community Services: 416-292-7510

Native community

• Native Women’s Resource Centre: 416-963-9963

Somali community

• Canadian African Newcomer Aid Centre: 416-658-8030
• Somali Immigrant Aid: 416-653-8602

Sri Lanka Singhalese community

• South Asian Family Support: 416-431-4847

Vietnamese community

• SEAS Centre: 416-362-1375

• Birth Registration (Birth Certificate Info): 416-392-7036
• Community Information: 211
• Canada Customs and Revenue Agency (Child Tax Benefit): 1-800-387-1193
• Emergency: 911
• Employment Insurance Canada-benefits: 1-800-206-7218
• Health card: 416-327-7567, 1-800-664-8988
• OHIP: 416-314-5518, 1-800-268-1154
• Parent Books/ Mother’s Allowance: 416-537-8334, 1-800-209-9182
• Passports and Birth Certificates: 416-973-3251, 1-800-567-6868
• Product Safety – Health Canada: 416-973-4705

• Encyclopedia on Early Childhood development
• Canadian Council on Learning
• Centre of Excellence for Early Childhood Development
• University of Toronto – Children’s Programs

You’ve done the test… twice… your health care practitioner has confirmed it: you are pregnant! You are excited and happy and looking forward to creating a new life. So when to tell the world? Other than cultural, personality and relationship factors, here are a number of medical aspects to consider:

Firstly, you will not begin to show your pregnancy until sometime during your mid to late second trimester (that is about 20 weeks into your pregnancy). There may be some bloating of the abdomen or breast enlargement, however for most women these can be hidden under clothes. This means that you have time to decide when to make your pregnancy public knowledge.

Secondly, until the end of the first trimester, spontaneous pregnancy loss occurs in one quarter of all pregnancies (for every 100 pregnancies, 25 will be lost during this time). This is usually a result of an abnormal sperm – egg combination which would otherwise result in a very sick infant. A pregnancy loss can be stressful, understandably sad and, once the pregnancy has been made public, the loss will also have to be out in the open. This can be very tough for you to deal with. Therefore, until the end of the first trimester (12-14 weeks), it may be advisable to only break the good news to those you wouldn’t mind breaking the bad news to should a miscarriage occur.

Pregnancy loss is common and, although you may not know it, many of the women around you have gone through it. Miscarriage during the first 14 weeks happens in one quarter of all pregnancies. It usually happens after natural mistakes in the making of the fetus. This abnormal fetus would make a very sick baby. Thankfully, our bodies recognize this and end the pregnancy early on. There are a few preventable reasons for early pregnancy loss such as smoking, cocaine, or heavy alcohol use.

Should this unfortunate outcome happen to you, please keep in mind that it was likely a natural process, which saved a very sick baby from being born. Remind yourself that this is common and that many of the women around you have gone through it at least once. If you have told people about your pregnancy you may start hearing the miscarriage stories of many women. If you find this distressing, tell these women gently that you would rather not talk about this issue. Try to relax, get back to your normal routine, and look forward to the next pregnancy. If you find yourself having a very hard time getting back to ‘normal’, let us know. We are here to help and to keep you safe during this difficult time.

Lower belly or back pain (especially if it feels like your periods) may mean contractions of the womb. Most women who have these symptoms end up with normal pregnancies, but they all need to be examined by one of our obstetrical providers. If you have not yet had an ultrasound during your pregnancy, it is important you consult your provider the same day.

Spotting from the vagina (red or dark brown in colour) can happen normally after Pap testing, after sex or even with physical exercise. Always mention vaginal bleeding to your health care provider. If you’re bleeding like a heavy period, you need to be seen by your provider the same day. There are many non-urgent reasons which could be causing your bleeding, but it is important to first be seen by a medical professional in this context.

There are many reasons to feel belly pains in pregnancy, not least of which is an ever larger, heavier womb with a kicking baby inside of it. Contractions, however, tend to have a waxing and waning quality, tend to be felt at the front lower belly and at the lower back, and tend to feel similar to the cramping during your periods.

Review any pain in your belly with your healthcare provider to see if they could be contractions. If these pains do not get worse into stronger and/or more often pains it is something to bring up at your regular appointments, and may be normal during this stage of pregnancy. If however, the pains come along with bleeding from the vagina, are increasing, getting longer in length, or happening more often, do not wait for your next appointment and call your nearest obstetrical hospital to be seen.

During the second and third trimester of pregnancy it is possible to develop preeclampsia. This usually starts with increased blood pressure, headache, blurred vision, swelling of the face or even seizures. If you are having a headache, this is common during pregnancy and does not necessarily mean you have preeclampsia. It is important to mention the headaches to your doctor or nurse practitioner, who will be checking your blood pressure and for other signs of this disease. If you are having severe headache, blurred vision, high blood pressure or increasing swelling of the face it is important to see a professional the same day.

As your pregnancy grows beyond 26 weeks, the baby’s movements change. They feel different and come less often than before. If you notice that the baby’s movements are less that their normal for that time of day: lay down, drink a sweet drink and count all the movements you feel. If you count six or more within two hours you can be reassured. If you get to two hours without counting six movements, call maternal triage at St. Michael’s Hospital (416-864-5252). If you are at all worried, call the resident on-call for family practice to review the details with them.

This happens when the balloon of liquid around the baby breaks. The liquid pours into the vagina and then into your underwear. This can happen as a large fluid gush from the vagina, which is unmistakable and has inspired many Hollywood films. However, if the hole in the ‘balloon’ is very small, the leaking from the vagina will be very little and may be hard to notice. If your underwear feels wetter than usual (ex. as though someone keeps pouring water over it) change your underwear, dry yourself off and check again in one to two hours. If you again notice wet underwear you should call maternal triage (416-864-5252) to be checked.

It doesn’t matter if it is a large or a small leak. If you think you’ve broken your waters you should call us to be checked. The answering service pages the resident who will get back to you right away.

Information the on-call resident will need:

• Your name
• Your family doctor
• Your resident doctor (if any)
• Your situation

The resident gives all this information to the doctor on-call, who will call you right back.