Pregnancy
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Your Team 

Your CVFHT

Our team of residents, family doctors and doctors trained in obstetrical practice all work together to provide you with care that is centered around you, your needs and your wishes. We aim to listen to your concerns, address your questions and provide you the comfort you require during this special time.

During this period you will be cared for by a family doctor and/or an Obstetrician. Your doctor will review your family and personal medical history. You should expect to see your doctor according to the following guidelines:

• Up to 28 weeks in your pregnancy: every 4 weeks
• From 28-36 weeks in your pregnancy: every 2 weeks
• From 36 weeks to birth: every 1 week

At around 20-24 weeks of gestation, you will be referred to our obstetrical practice, led by a delivering physician at Credit Valley Hospital, Dr. Robert Cho. However, your family doctor will continue following your pregnancy while you're under obstetrical care. If you go past your due date, you will be assessed more frequently. If you or your baby are deemed to be requiring increased monitoring, you may be referred to the High Risk Clinic.

Who Will Be Attending My Delivery? 

The delivering doctors at the hospital you choose to have your baby at will be performing the delivery and potientially our obstetrics specialist. If you are a patient of a resident, the resident on call will attend your delivery. All the residents update each other regularly on prenatal patients, hence the resident physician will be informed of your medical history and ready to help you bring your baby into the world. 

What Happens When My Baby is Born? 

Within a couple days of leaving the hospital, it is strongly recommended that you be seen by your family physician for a newborn appointment. 

Pregnancy

Pregnancy Tests

Pregnancy tests measure the level of human chorionic gonadotropin (hCG)  in your urine or blood. Pregnancy tests can detect this pregnancy hormone in your blood as early as 6-8 days after conception, but only in your urine until a day or so before your missed period. To avoid a false negative test, it is recommended that you wait until you have missed your period and then test. Some tests recommend you repeat the pregnancy test a week later if you still have not gotten your period.

If the test was positive, it is most likely your pregnant. False positives are extremely rare as it only detects hCG in the blood or urine if it is actually there. The next step following a pregnancy is to book an appointment with your family physician. In the meantime it is advised that you avoid alcohol, drugs and  tobacco, as well as begin taking a folic acid prenatal supplement if you have not already.

Due Date Calculator

Prenatal Genetic Screening

Prenatal genetic screening can provide critical information about the health of your pregnancy as well as help emotionally prepare you for what the future holds. However, it can also bring many difficult decisions and questions. If you are accompanied by your partner during your pregnancy, it may also require some discussions as to your joint plan in the event of any outcome. It is important to note that screening tests will not find every kind of birth defect, but it may find conditions other than down syndrome, trisomy 18 and open neural tube defects but these are most common.

Integrated Prenatal Screening

Integrated prenatal screening (IPS) can screen your baby for a lower or higher chance than usual of having a baby with one of the three medical conditions: down syndrome, trisomy 18 or an open neural tube defect. It is your choice whether you want to have IPS. Talk to your health care provider before deciding if IPS is right for you. For women over 35 years of age at their due date, they can elect to skip the screening process and advance directly to diagnostic testing (i.e chorionic villus sampling or amniocentesis) to guarentee a more conclusive result.

IPS is only one route that you can take when undergoing prenatal genetic screening. Genetics Education Canada has provided a table that compares patient options, allowing you to make an informed decision regarding prenatal genetic screening for your child.

What is Down Syndrome?

Baby's born with Down syndrome have mental handicaps and some have physical handicaps. These individuals are more likely to have medical problems. However, Down syndrome is a spectrum and it cannot be determined how severe the mental handicap will be. While there is no cure for Down syndrome, there are many community resources to assist individuals and their families. Higher maternal age is the most well established risk factor for infant Down syndrome.

What is Trisomy 18?

Trisomy 18 is a chromosomal condition associated with  abnormalities in various parts of the body and severe intellectual disability. It is often characterized by intrauterine growth retardation, heart defects, organ abnormalities, abnormally shaped head, small jaw and overlapping fingers. Most do not survive beyond one year of age. The chance of having a baby with trisomy 18 also increases with maternal age.

What are Open Neural Tube Defects?

Open neural tube defects occur when the skull or spine does not develop properly early in pregnancy. The two classifications of open neural tube defects are spina bifida and anencephaly. Spina bifida refers to an incomplete closing of the spine and membranes around the spinal cord during early development in pregnancy, which often presents as physical and mental handicap. While there is no cure for spina bifida, there are surgical approaches that improve quality of life. Anencephaly is the incomplete development of the brain and skull. Unlike the previous two conditions, the likelihood of open neural tube defects does not increase with a woman's age.

What does a Screen Positive Result Mean?

About 4 in 100 women will have a screen 'positive'. A positive result means there is a chance that your baby may have Down syndrome, trisomy 18 or an open neural tube defect. However, most of these positive results tend to be false, hence most women with a postive result do not have a baby with Down syndrome, trisomy 18 or an open neural tube defect.

Routine Ultrasound

The Society of Obstetricians and Gynaecologists of Canada recommend that all women have two ultrasounds: one 'dating' ultrasound at 11-14 weeks and one 'anatomic' ultrasound between 18-20 weeks.

An ultrasound can provide a wealth of information surrounding the health of the fetus, your health and the progression of the pregnancy throughout all of its stages. Specifically, it can  determine:

• If the pregnancy is viable
• If there are multiple fetuses
• The gestational age of the baby
• If the baby is typically sized for their age
• The development of the baby's internal organs
• The location of the placenta
• The position, activity and the amount of fluid surrounding the baby
• The possibility of genetic/other abnormalities
• The possibility of an ectopic or molar pregnancy

Dating Ultrasound

A dating ultrasound estimates the gestational age of your baby, based on the size of your fetus. Dating ultrasounds are most accurate when they are peformed around 7 -12 weeks, and are calculated by measuring the fetus' crown-rump length. Most often these assessments can predict the birth date within 5 days. Knowing the age of your fetus is critical to accurately monitoring the progression of your pregnancy and ensuring all prenatal care is performed on time.

Anatomic Ultrasound

This ultrasound is generally offered in the second trimester, in between 18 - 22 weeks of gestation. If you are at high risk for fetal abnormalities, an anatomic ultrasound may be performed during early pregnancy (11-16 weeks). This type of ultrasound can be used to assess:

• The number of fetuses and their sex
• Gestational age
• The location of the placenta
• Brain, face, heart, spine, chest, major organs, feet and hand development
• Position of your placenta
• Vessels of the umbilical cord
• The amount of fluid surrounding the baby
• The state of your cervix, uterus, ovaries and bladder

Non-invasive Prenatal Screening 

Non-invasive prenatal screening is a blood test that measures cell-free fetal DNA present in the mother's blood. It is a highly effective method of screening for Down Syndrome, paternal genetic abnormalities, an Rh positive fetus in an Rh-negative mother, as well as identifying fetal sex. However, inconclusive results, false postives and false negatives do occur, therefore all positive results require confirmation via more invasive diagnostic testing.

What is an Amniocentesis?

An amniocentesis is a procedure in which a doctor uses an ultrasound guided needle to extract fetal-cell containing amniotic fluid, usually at around 15-20 weeks. The amniotic fluid is mostly comprised of the fetus' urine, which the baby will replace in a few hours. An ultrasound provides visualization to ensure the needle does not go anywhere near the fetus. In addition to genetic testing, an amniocentesis is performed for fetal lung maturity testing, diagnosis of fetal infection, draining of amniotic fluid and paternity testing. The accuracy of amniocentesis in detecting chromosome abnormalities is 99.9%, however the amniocentesis cannot be used to test a specific gene for a genetic condition. It also cannot detect other aspects of your baby's development, such as mental retardation.

An amniocentesis is recommended if:

• You are 35 years or older
• You've had positive results from a prenatal screening test
• You had a chromosomal condition or neural tube defect in a previous pregnancy
• You or your partner have a family history of a genetic condition
• You have abnormal ultrasound findings

As with any procedure, there are risks involved. The risk of miscarriage is 0.1 -0.3% (mostly if done before 15 weeks). There are also the small chance of a transfer of infection (HIV/AIDS, Hepatitis B and Hepatitis C), Rh sensitization (in which you produce antibodies that attack your babies red blood cells), uterine infection and needle injury to the baby. If it is known that you are Rh negative, you will receive rhogam immunoglobin injections at the time of the procedure to prevent the production of these antibodies.

If the fetus is diagnosed with a genetic abnormality, you have the choice to continue with the pregnancy or terminate. Regardless of your personal decision, your health care provider is there to support your choice, prioritize your health care and ensure you possess complete and thorough information to help you as decisions arise.

What is Chorionic Villus Sampling?

Chorionic villus sampling is a prenatal test in which a sample of placental tissue is taken through the cervix or through the abdomen and is then tested for genetic abnormalities. The advantage of this test is early diagnosis, with results 5-7 weeks before an amniocentesis can be performed. The risk of miscarriage with this procedure is slightly higher than an amniocentesis.

What is Nuchal Translucency?

Nuchal translucency is a test that measures the thickness of the fluid underneath the skin of all fetus' necks. An elevated thinkness could indicated down syndrome or other genetic abnormalities, however this test is not a diagnosis.

For more information regarding genetic screening and conditions, see here:

• Canadian Association of Genetic Counsellors or 905-849-8299 provides a list of genetic centres across Canada
• The Genetics Home Reference - Your Guide to Understanding Genetic Conditions
• Mount Sinai: The Genetics Education Project
• Prenatal Screening Ontario Genetics Education Canada
• March of Dimes
• Canadian Down Syndrome Society
• S.O.F.T Support Organization for Trisomy 18, 13 and Related Disorders
• Spina Bifida and Hydrocephalus Association of Canada

Advanced Fetal Imaging

Advanced fetal imaging, sometimes called a targeted fetal ultrasound, is when a highly trained fetal medicine specialist examines your fetus' organs, placenta, amniotic fluid volume and cervix in high detail. It also involves the use of a Doppler ultrasound, which allows the visualization of blood flow in the fetus. Advanced fetal ultrasounds are typically ordered for fetuses that are determined to be at high risk for fetal abnormalities ( i.e suspicions of growth, placenta or amniotic fluid problems, shortening of the cervix, certain multiple pregnancies, or have a clincal history of high risk pregnancies) or have already been diagnosed. Concerns with maternal health may also warrant the ordering of advanced fetal imaging, including diabetes, high blood pressure, heart, kidney problems, or a pregnancy with an immune disorder.

A targeted fetal ultrasound is usually performed in the second trimester of pregnancy (18-20 weeks), however advanced fetal ultrasound machines can allow diagnosis of fetal abnormalities as early as the first trimester.

Screening For Infections

Hepatitis B Screening

Hepatitis B is a viral infection of the liver. The issue for concern with hepatitis B contraction during pregnancy is that when infants contract Hepatitis B, they, unlike adults, cannot clear the virus and become carriers for life. Hepatitis B is screened for using a blood test. If you test positive for hepatitis B, it is highly likely that you will transmit the infection to your baby during the delivery, especially if you deliver via ceasarean. However, in most cases, if your baby receives the hepatitis B vaccine within their first 12 hours of life, at one month old and at 6 months, the infection can be prevented. You can receive the hepatitis vaccine while pregnant, however if vaccinations can be avoided during pregnancy they usually are. If you and your infant are travelling to a hepatitis B endemic country, it is recommended that both mother and infant are vaccinated after birth.

You are at high risk for contracting hepatisis B if you:

• Have unprotected sexual intercourse with an infected person/multiple partners
• Have a sexually transmitted infection
• Were born to a Hepatitis B infected mother
• Use injection drugs and share contaminated materials
• Receive a tattoo or piercing with unsterilized equiptment

Screening for HIV

All Canadian provinces currently recommend prenatal HIV screening to all pregnant women. HIV is found in an infected person's bodily fluids: semen, blood, vaginal secretions and breast milk -- that is why it is imperative for pregnant women to get screened. Many people infected with HIV do not know they are infected. Depending on the type of screening test, it may be up to 12 weeks after exposure before an infected person tests positive for HIV. Hence, if you are at risk, you may be tested several times over the course of your pregnancy.

Other infections that you will be screened for during pregnancy include:

• Gonorrhea
• Chlamydia
• Syphilis
• Hepatitis C
• Rubella
• Chicken pox
• Urine infections

Vaccinations During Pregnancy                                        

If you are pregnant or thinking of becoming pregnant, your physician will review your immunization status amd recommend a strategy to get you up to date. It is recommended that all women, regardless of immunization records, receive the Tdap vaccine (tetanus toxoid, reduced diphtheria toxoid and reduced acellular pertussis) between 21 and 32 weeks of gestational age (third trimester). This recommendation stands with subsequent pregnancies. Pertussis ("whooping cough") is a transmissable respiratory illness that poses the greatest risk to infants.                     

'Live' or 'live-attenuated' vaccines are typically avoided in pregnancy and are ideally given 4 weeks prior to conceiving due to the risk posed to the developing fetus. For this reason, it is recommended that, if you're planning to conceive, you schedule a pre-conception visit with your doctor or nurse practitioner where the following vaccines can be discussed:

• Tetanus, pertussis, chickenpox/varicella, rubella (MMR - measles, mumps, rubella vaccine)  

Flu Shot

Pregnant women are more vulnerable to developing serious illness in response to contact with the influenza virus, relative to nonpregnant women. Immunization of pregnant women has been shown to reduce respiratory illnesses not only in vaccinated women, but also in infants born of owmen who received influenza vaccine during pregnancy. It is with this reason that receiving the flu shot during pregnancy is strongly recommended to protect you and your baby from serious complications of influenza. Remember, being vaccinated while pregnant also protects your baby for up to 6 months after birth.

Group B Streptococcus

Group B streptococcus is a bacteria that grows around your vagina, anus and bladder. Most women who have group B streptococcus are asymptomatic. However, during vaginal delivery your baby will experience the protective process of being coated with bacteria from surrounding areas. The prescence of GBS poses a risk to your baby as the minority of infants that do contract an infection from this bacteria can become dangerously ill.

Hence, at around 36 weeks of pregnancy, a swab of your vagina and anus will be taken and then cultured in a lab to detect the prescence of this bacteria. If the specimen is positive for GBS then you will simply receive IV antibiotics during labour as a preventative approach. Since doctors have implented this protocol, the number of sick newborns with GBS infections decreased and less babies die from GBS.

Making Sure You're Healthy

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

Glucose Testing

Gestational diabetes occurs when the concentration of glucose in your blood exceeds the production of insulin. Gestational diabetes can alter the placenta and development of the fetus. Untreated gestational diabees increases the likelihood of having a large baby, can increase the risk of stillbirth late in pregnancy and pose health risks for the newborn, including preeclampsia and shoulder dystocia. Furthermore, women who develop gestational diabetes are at a higher risk for developing type 2 diabetes in the future.

How do I Screen for Gestational Diabetes?

All pregnant women are offered a blood glucose screening between 24-28 weeks of pregnancy, however this screening is expedited for those determined to be at risk. Risk factors include:

• Being older than 35
• Obesity (pre-pregnancy BMI greater than 30)
• Aboriginal, African, Asian, Hispanic or South Asian ethnicity
• Family history of diabetes
• Polycystic ovarian syndrome or acanthosis nigricans
• Corticosteroid use during pregnancy
• Previous pregnancy with gestational diabetes
• Previous delivery of a baby larger than 4 kg ( 8.8 lbs)

What to Expect from a Blood Glucose Test?

This screening test is a two tiered test. The first step involves a measurement taken an hour after you consume a special glucose drink. If your blood sugar falls within normal range, no further testing is required. If your blood sugar falls within a cautionary range, you will be advised to advance to a second round of testing that entails fasting for 8 hours (nothing consumed except water) and getting a blood test before and after consumption of a glucose drink. See the screening guidelines below for abnormal glucose concentration ranges.

What if I am Diagnosed with Gestational Diabetes?

If you are a diagnosed with gestational diabetes, you will work closely with you healthcare provider to ensure your blood sugars are kept within an acceptable range. This requires ensuring you are abiding by a healthy diet, gaining the healthy amount of weight during pregnancy, excersising regularly and, if prescribed, being compliant with medication to lower your blood sugar. Your baby's health will be monitored by regularly measuring their growth and amniotic fluid volume. By 38-40 weeks, an induction of labour may be recommended. Post-partum care involves repeating a glucose tolerance test between 6 weeks and 6 months post partum to determine if you are prediabetic or diabetic. It is also strongly recommended that you breastfeed your infant, if possible.

Your Blood Type: Rh Incompatibility

As many know, every individual has a specific blood type that is predetermined by their genetics. Your blood type is identified by  2 variations - your lettered blood type and if you are Rh positive or negative. All pregnant women are tested for their Rh status during routine bloodwork taken early in pregnancy.

There are some special measures taken if you are Rh-negative and your baby is potentially Rh-positive. Due to the absence of this protein in the mother's blood, her immune system will automatically perceive your baby's Rh-positive blood as foreign and her body will create antibodies that can 'attack' the Rh protein (Rh sensitization). If these antibodies cross the placenta and enter the fetal blood stream, it will result in a serious condition called fetal anemia. This is clinically remarked by a jaundiced newborn, which is caused by an abundance of bilirubin - the by-product of red blood cell breakdown.

In most cases, the sensitization will only occur at delivery, thus subsequent pregnancies are the concern. However, contact between your baby's blood and your blood can also occur during amniocentesis, chronic viillus sampling, bleeding during pregnancy, attempts to reposition a baby from a breech position and trauma to the abdomen during pregnancy.

To prevent this, you will receive an injection of Rh immunoglobulin at approximately 28 weeks gestation. This prevents sensitization in 99% of women. If your baby is found to be Rh positive, you will be given an  Rh immunoglobulin injection again within 72 hours post-delivery.

For more information, you can visit The American College of Obstetricians and Gynecologists. 

What To Expect During Pregnancy

Fatigue

• First trimester: During the first trimester you may be having longer and higher quality sleep. Despite this you may find it increasingly difficult to get through your daily routine and keep up with your days like you used to. It is important to keep in mind that this is the time to relax and focus on you and your baby.
• Second trimester: As you uterus grows, the amount of blood supplying your important reproductive organs increases. Your heart is working extra hard to circulate this surplus of blood. Your growing uterus begins to push up on your diaphragm, making it more difficult to fully expand your lungs. All of this will decrease you stamina significantly. You can expect to feel more tired and less able to move around quickly, lift things and excersise. This is the time to prioritize your health and listen to your body in order to meet the physiological demands of growing another human being.
• Third trimester: As your baby grows to their birth weight, there is increasing pressure and discomfort for the pregnant mom. However, this discomfort prepares pregnant women for birth. They're so excited to meet their baby and begin to feel like themselves again. This excitement will allow you to participate more fully in the delivery and be as free from fear as possible. Keeping calm during third trimester and labour is crucial. The time you decide to go on maternity leave is a very personal decision and depends purely on how you feel and what you believe is best for you and your baby.

Nausea, Constipation and Heartburn

Nausea, or 'morning sickness', is a common and normal symptom of pregnancy, especially during the first trimester. Despite its common nickname, this nausea can occur throughout the day. It usually begins around the 6th week of pregnancy and eases up by the end of the first trimester. Here are some tips you may find helpful in curbing your nausea:

• Avoid smells that bother you
• Sniffing lemons or ginger can sometimes help
• Try to get enough rest as nausea is exacerbated by fatigue
• Some women find eating a few dry crackers or salty potato chips prior to a meal helps
• Try to get up slowly and not lie down too soon after eating
• Eat small meals or snacks often so you stomach does not get empty
• Don't skip meals
• Keep hydrated with small amounts of fluid
• Try temporarily substituting iron-containing vitamins for folic acid or vitamins low in iron
• Try pharmaceutical grade ginger ( i.e Gravol Natural Source Ginger) at a minimum of 250 mg four times a day
• Other safe medications include dimenhydrinate (Gravol), metoclopramide and phenothiazines.
• Your doctor may also be able to prescribe some anti-nauseas medication

Most women also tend to experience a noticeable difference in the frequency of their bowel movements during pregnancy. To avoid constipation, a diet high in fibre ( over 25 g of fibre a day) is recommended. Foods high in fibre include whole grains, lentils, bran and apples. Drinking lots of fluid and excersising also aids bowel movements. When this is not sufficient enough to relieve constipation, softeners and supplementary fibre such as Prodiem, Metamucil and Surfak are safe to take.

With a growing womb placing pressure on your stomach, it is no wonder that women experience heartburn, also known as acid reflux. This is characterized by a burning sensation in your throat. It is recommended that you sleep propped up on pillows and avoid a completely empty stomach by drinking water often and eating small, frequent meals. Avoid caffeine, alcohol and vigorous excersise to alleviate this issue. Antacids such as Tums, Gavison, Maalox and Zantac may help, especially liquid antacids.

Urination

Your growing womb will inevitably place pressure on your bladder, significantly decreasing the volume of urine it can store. By the end of your pregnancy, you may need to empty your bladder every hour. It is recommended that you avoid drinking too much fluid in the evening so that you can sleep through the night. You can also ask your doctor how to do pelvic floor excersises to maintain better control of your bladder.

It is important that you are educated about the symptoms of a urine infection. These include burning smelly urine, red urine, fever, nausea, vomiting. If you experience any of those symptoms, you should let your provider know as soon as possible.

Back pain

Pregnancy hormones soften the joints and ligaments in the pelvis to provide the necessary mobility to birth your baby. This reduces the support and creates a less stable, less balanced lower back and lower belly. This imbalance places extra strain on your muscles and joints, experienced as pain. Good posture and strong muscles can prevent or relieve discomfort. If your back pain is impeding your daily activities, your family physician may suggest chiropractor services for your back pain. Support belts are also sold in maternity stores.

Leg Cramps

Leg cramps can be caused by overstretching of the muscles or dehydration. The best way to get rid of leg cramps is to stand on the affected leg, stretch it out and massage the cramp. To prevent cramping, drink 2-3 litres of water, eat one banana and take a calcium/magnesium supplement daily.  

Hemorriods and Varicose Veins

The surplus of blood that accompanies the second trimester combined with pregnancy hormones that make it difficult for veins to pump blood towards the heart result in pressure on the veins of your legs. This can result in hemorrhoids, varicose veins and swelling of the limbs. The swelling in hands can cause 'carpal tunnel syndrome' (numbness or tingling on the hands). Large varicose veins may spread to the area surrounding the female genitals and are often accompanied by swelling and pressure. If you are experiencing discomfort or pain, ask your doctor about special padding in your underwear for relief of vaginal pain. You can also try sleeping flat on your left side. Here are some more tips to provide relief for hemorriods and varicose veins:

• Avoid standing for long periods of time
• Gentle excersise/ walking to stimulate muscles to push excess fluid out of legs
• Raise your legs multiple times a day
• Wear pressure stockings

Why is my Skin and Hair Different?

The hormone changes during pregnancy can result in noticeable alterations in your appearance. Due to the increase in estrogen and progesterone in the blood, blood vessels swell and produce the commonly referred to 'pregnancy glow'. These hormone fluctuations can also result in acne, coarse hair or hair growth in unwanted places. Skin changes can include: a dark line on the belly (linea nigra), darkening of the facial skin, darkening of the nipples and stetch marks. These differences are typically temporary. Although there are many creams on the market deemed to prevent stretch marks, there is no scientific evidence to support their conclusions. However, these creams can maintain the skin's moisture and reduce the urge to itch your skin. Another irritant to your skin during pregnancy is the excess sweating many women experience. Hence, if you find yourself sweating a lot, try taking showers with scent-free body lotion.

Colds During Pregnancy

Below are some suggested medications that are safe for you and your baby.

• For a minor cold: Benylin, Buckley's or Robitussin cough syrup
• For nasal congestion: Dristan or Otrivin nasal spray
• For fever or headache: Tylenol
• For sore throat: Halls or Bradasol throat lozenges, gargle with salt water and listerine
• For allergies: Claritin, Benedril, Reactine or Chlor-Tripolon

Mental Health During Pregnancy

Pregnancy can be an overwhelming and turbulent time during a women's life. It's accompanied by rapid changes in your appearance, your emotions and your life. That is why it is essential to practice self-forgiveness and encourage others to give you some leeway during your pregnancy. Be patient with yourself. It can be difficult to gain perspective when your mind is enveloped by emotions with no explaination as to why you're feeling a certain way. However, it is important to note there is no 'normal' way to feel when you're pregnant, despite social and cultural pressures telling you otherwise.

If you are at risk for poor mental health during pregnancy, meaning you have experienced physical or sexual abuse, have a history of depression, stress and/or have little or no social support, and you have concerns about your mental health during pregnancy, it is important you address these concerns with your family physician. Severe mental illness (bipolar affective disorder, severe depression, psychosis) may worsen during pregnancy and postpartum. Women with these illnesses should consider having a discussion with their health care provider prior to becoming pregnant, especially if you rely on medications to treat your illness. Some medications will cross into the fetal system and are not necessarily safe for a developing baby, however a discussion with your doctor will clarify the risks and benefits associated with your situation, as well as any alternate care plans that can be explored.

Excersise During Pregnancy

Maintaining an active lifestyle during pregnancy is an excellent way to alleviate many of the pregnancy symptoms and ease the challenges associated with pregnancy. The benefits of excersise include:

• Strengthening your body for labour
• Improving your quality of sleep
• Prevention of excess weight gain
• Elevate your mood and energy level
• Alleviating constipation
• Reducing backache
• Reducing the likelihood of developing gestational diabetes

Unless you have a complication that prevents you from excersising, achieving at least 150 minutes of moderate intensity excersise every week is definitely recommended. Recommended excersises include walking, swimming, low-impact aerobics, stationary cycling, moderate strength training, yoga, stretching and pelvic floor excersises. Choose excersises that minimize the risk of falling or contact with others.

Complications that can prevent pregnant women from excersising include:

• Ruptured membranes
• Preterm labour
• High blood pressure
• Weakened cervix
• Growth-restricted fetus
• Preeclampsia
• Multiple pregnancy of triplets or more
• Placenta previa after the 28th week
• Severe anemia
• Other diseases (uncontrolled type 1 diabetes, thyroid disease, heart disease, lung disease)

Nutrition During Pregnancy

Vitamin and Mineral Supplements

Growing a baby is energy consuming. To ensure that both you and your baby recieve sufficient nutrients, a daily prenatal vitamin is strongly recommended.  Folic acid is particularly important and is naturally found in foods such as dark leafy greens, fruits, nuts, beans, peas, dairy products, meat, eggs, and grains. It is required for the cell generation and the synthesis of DNA. Scientific evidence has revealed that adequate levels of folic acid prevent neural tube defects (when the fetal spinal column does not close completely or the brain/skull does not develop normally). Other defects such as cleft palate and heart defects have been linked to insufficient folic acid intake. It is recommended that you take folic acid supplements at least three months prior to conception if you are trying to get pregnant. For more detailed recommendations that fit your needs, including timelines and dosages, please see the chart below.

Diet and Nutrition

When you're pregnant, what you choose to eat is also what your baby 'eats'. It is important to keep in mind that pregnancy is not the time to loose weight, nor is it the time to overindulge. The phrase 'eating for two' is a myth. In reality, women who were a normal weight pre-pregnancy only require an additional 200-300 kcals in their second and third trimester. However, the demands for nutrients are higher in pregnant women. This means paying special attention to the quality of your diet, rather than the quantity. Overall, a varied, nutrient-dense diet, as recommended by Canada's Food Guide, will help ensure the nutritional requirements of both you and your baby are met.

Iron

It is recommended that you increase your daily iron intake to 27 mg during the final six months of pregnancy to meet the demands of multiplying red blood cells and growing fetal tissues.

Fibre

To ease constipation and reduce the risk of developing high blood pressure, a daily fibre intake of 28 g is recommended.

Omega-3 Fatty Acids

Omega-3 fatty acids are essential for fetal eye and brain development. Food sources are typically preferred over supplements. Fish, particularly organic salmon, is an excellent source of omega-3 fatty acids. DHA, one of the three omegas found in fish, is the best source. Aim for 1.4 g daily.

Iodine

Iodine is a mineral involved in the synthesis of the thyroid hormone. The thyroid hormone is important for muscle contraction, promoting bone development, the break down of fats, and stimulating nutrient absorption. Aim to consume 250 mcg daily.

Choline

Choline intake above 450 mg a day is linked to improved fetal stress responses and a reduced risk of neural tube defects. This vitamin may not be included in your daily prenatal vitamin, however it can be found in vegetables, meat, poultry, fish, eggs and peanuts.

Vitamin D

You may want to take an extra 1000 units vitamin D to protect your bones during pregnancy.

Foods to Avoid

While pregnant, it is important to eat healthy, well balanced meals. However, there are certain foods that you should try to avoid while pregnant.

• Consuming raw or undercooked meat and seafood poses a risk of contamination with coliform bacteria, toxoplasmosis and salmonella
• Consuming deli meats, smoked seafood, soft cheeses, unpasteurized milk, and refrigerated pate poses a risk of contamination with listeria, which can cause miscarriage
• Consuming fish with mercury poses a risk of developmental delays and brain damage
• Consuming fish exposed to industrial pollutants (mainly regading fish caught in local waters)
• Consuming raw shellfish
• Consuming raw eggs poses a risk of salmonella infection
• Caffeine consumption should be limited to fewer than 300 mg per day during pregnancy. Some research shows that large amounts of caffeine consumption is associated wiht miscarriage, premature birth, low birth weight and withdrawal symptoms in infants.
• No amount of alcohol is known to be safe during pregnancy; consumption of alcohol can lead to Fetal Alcohol Syndrome.
• Consumption of unwashed vegetables poses a risk of toxoplasmosis.

Weight Gain

Pregnancy is notorious for a loss of control in a women's appearance, particularly in terms of weight. It is inevitable that you will gain weight during pregnancy, but it is important to remember that pregnancy weight is different that weight gained from an unhealthy diet and sedentary lifestyle. Your body has ways of naturally and gradually shedding the weight from pregnancy. Also, your baby is not the only change contributing to your weight gain. Your placenta, increased blood volume, larger breasts and fat stores to support breastfeeding also contribute. Gaining weight within the recommended targets reduces your risk of gestational diabetes, preterm birth, and having a large baby. Your baby will also less likely to be overweight later in life. Gaining too little weight can also bring forth challenges, such as a greater risk of low birth rate, preterm birth and difficulty breastfeeding.

It is important to be patient with yourself and hold realistic expectations admist the societal pressure to snap back in shape immediately after your baby arrives. You will recognize your body as yours eventually.The amount of weight deemed healthy or 'normal' to gain during pregnancy depends on your pre-pregnancy weight and body mass index.

Use the Government of Canada's online calculator to determine a healthy amount of weight gain to expect during your pregnancy.

Substance Use During Pregnancy

Everything that enters your body also enters the little one that is inside you. However the difference between you and your unborn child is that their organs are still undergoing development. Exposure to harmful substances can severly impede and alter the delicate cellular construction occuring during your pregnancy. That is why caution and vigilance should be excersised when it comes to what enters your body. Smoking, street drugs and alcohol should be avoided completely. E-cigarettes and cannabis are also strongly advised against due to a significant amount of scientific evidence associating usage with adverse and fatal outcomes. For more information surrounding the risks of drug use during pregnancy, please visit the Society of Obstetricians and Gynaecologists of Canada website.

Any medications, regardless whether its over the counter, supplements or prescriptions, should be reviewed for safety and risks during pregnancy. It is paramount that you inform the prescriber that you are pregnant.

Fetal Movements and Kick Counts

The strongest sense of your baby's wellbeing comes from your perception of your baby's movements. Mothers know their baby's best, so you should always trust your gut feeling if you have an unfaltering worry about your baby's wellbeing. If you ever have concerns regarding your baby's movement pattern, you should have your baby assessed as soon as possible. Kick counts are one tool used to assess fetal movements.

When Will I Feel my Baby's Movements?

In the beginning, it may be difficult to distinguish between fetal movement and intestinal gas. But after a while, you will find a pattern in the movements. First time mothers may not feel movement until 18-20 weeks. However, some may feel movement as early as 13-16 weeks from the start of their last period. By 24 weeks, almost all women feel their baby's movements in a predictable way. A very small percentage of women do not feel their baby's movements.

How Do I Perform a Fetal Kick Count?

It is recommended that you be observant of  your baby's typical activity of level and any changes to your baby's behavior in utero, especially during the third trimester. If you have any pregnancy risk factors (e.x high blood pressure, gestational diabetes, etc.), you should do a kick count every day, starting at 26-32 weeks.  Most babies tend to become more active when you're winding down, during the evening. You may be able to feel the movements better if you lie down. To do a kick count, count your baby's movements for 2 hours. If you don't feel 6 movements, such as kicks, flutters or rolling movements) within those 2 hours, you should contact your healthcare provider as soon as possible. Try to count movements at the same time every day.

You can download the Baby Movement App to help track your baby's movements, help you feel more connected to your baby and reduce anxiety.

Sex and Pregnancy

One's inclination towards sex during pregnancy is highly individual and subject to variation throughout your pregnancy. Early pregnancy can, for some women, produce an increase in libido and increased orgasm. For others, it may be marked by a drop in sexual drive, increased vaginal dryness and painful intercourse (due to an enlarging womb). If you have concerns about your sex life during pregnancy, do not hesitate to bring it up during your prenatal visits. You can receive helpful advice on lubricant use, positions to avoid and support in abstaining from intercourse if that is your desire.

One common misconception is that sex during pregnancy can result in miscarriage during the first trimester. This is false. However if you are at risk for preterm labour (multiple pregnancy or high blood pressure), it is best to abstain from intercourse. It is important to clarify your risk with your doctor before proceding.

Work and Travel

As a working mother to be, it is important to prioritize your wellness and not overstrain yourself. Most women, bearing uncomplicated, low-risk pregnancies, work as long as they like. However, as your pregnancy progresses, you can expect physical limitations. Your employer should have policies to accomodate you with a modified work load. Moreover, if you are exposed to certain chemicals, solvents, fumes or radiation, you might need to avoid contact with some of these workplace hazards. When you decide to stop working is entirely up to you and how you feel. Some women choose to enter maternity leave several weeks before their due date while others will be at work even in early labour.

Pregnancy and Maternity Benefits

In Canada, federal Employment Insurance (EI) provides temporary financial assistance to Canadians who are sick, pregnant or caring for a newborn or adopted child. To qualify for these maternity, parental or sickness benefits, you must have worked 600 hours within the past 52 weeks. For more detailed information, please visit Service Canada.

Maternity Benefits

The EI program provides maternity benefits of up to 15 weeks to a mother for the birth of a child. These benefits can be collected any time during a period that begins eight weeks before your expected due date and ends 17 weeks after the birth.

Parental Benefits

In addition to the 15 weeks of maternity benefits, the EI program provides parental benefits to either parent for up to 35 weeks. These benefits can be claimed by either parent, concurrently or consecutively. For employer benefits, it is advised you contact your employers human resources department.

Travel

During pregnancy, your elevated estrogen levels make you more prone to developing blood clots. This risk can be exacerabated by periods of prolonged sitting during flights or car rides. Hence it is important to limit your periods of immobility by walking up and down aisles during your flight or stopping frequently during road trips. You can also try sitting leg excersises, such as pointing your toes and contracting your calf muscles and thighs. This activity can decrease the amount of leg swelling which can develop during pregnancy.

Any major travel plans should be discussed with your health care provider as you may need vaccinations and other precautions while you are gone. If you are travelling internationally, check the Public Health Agency of Canada website for travel health and safety. Most airlines allow pregnant women to fly up to and including the 36th week of pregnancy. It is recommended that you investigate the coverage provided by your travel insurance. It is also a good idea to ask your caregiver for a copy of your prenatal record in case you need to seek care while you are away.

Preparing for Birth

Prenatal Classes

You and your partner may consider taking prenatal classes in your third trimester, especially if this is your first child. Feeling prepared and knowing what to expect will ease the anxiety that comes with a large impending change to your life.

To learn more about prenatal classes offered in Peel, click here.

Birth Plan

A birth plan can indicate clear instructions to your team of nurses and physicians on the care you would like to receive during labour. Your health care providers will try their best to abide by your wishes and preserve the essence of the plan but it is important to keep an open mind due to the potentially changing needs of your baby. Ultimately the wellbeing of you and your infant are the utmost priority. Click here to access a fill in the blank birth plan.

Childproofing Your Home

The first few months of being a mother will be hectic and exhausting.  Having the neccessary safety precautions in place prior to the arrival of your baby will grant you peace of mind and reduce the worry and anxiety that you will keep as a new parent.

To make your home safe for an infant, it is recommended that you:

• Keep poisons, chemical cleaners and other toxic substances up high or in an inaccessible location
• Move small objects that pose a choking hazard to an out of reach location
• Lock away any sharps or powered hand tools
• Securely fence your pool and install a self-locking gate
• Read the safety features of all baby furniture and equipment you purchase.
• Ensure second hand furniture meets current safety standards according to Health Canada
• Keep stuffed toys and blankets out of the crib
• Use furniture safety straps to secure shelves, book cases and bureaus to the wall
• Cover your electrical outlets with plug covers
• Check if your smoke detector and carbon monoxide detector are functional

Labour and Delivery

What to Pack

Here is a downloadable checklist for the recommended essentials to bring for you, your partner and your newborn.

Early Signs of Labour

As you near the term of your pregnancy (your baby is at term after 37 weeks and before 42 weeks), there will be indications that labour and delivery are imminent.

Firstly, within the last several weeks before delivery, your baby will drop, meaning your infants head will descend into your pelvis. This is marked by a markedly lower belly, easier breathing and more frequent urination. For some women this doesn't happen until just before labour.

The release of the mucus plug means your baby will be arriving in the next couple days. The mucus plug is a palm sized clear-reddish jelly material which sits on the cervix and protects the uterus/placenta/baby from infections that may enter through the vaginal opening. Shortly before delivery, this drops out form the cervix as it softens and becomes more open. The mucus plug can fall out all at once or gradually.

Finally, your water may break, meaning the fluid surrounding your baby in utero is released. While this can occur as a large gush of fluid, it can also happen as a gradual leakage. If your underwear feels wetter than usual, you should report to your delivery hospital at maternal triage to be checked to see if your water has broken.

Stages of Labour

All labour proceed through the same stages. For your first child, labour usually lasts around 12-14 hours once regular contractions are established. For your subsequent children, labour is usually shorter.

Stage 1 of Labour

You will know labour is beginning when you begin to feel irregular, increasingly frequent contractions that feel like period cramping in your lower abdomen and back. These contractions thin and open your cervix to allow passage for your fetus. It is clinically marked by a cervical dilation of 0 - 4 cm. This phase, called the latent phase, is the longest stage of labour and is usually experienced at home.

Active labour is beginning when your contractions are becoming increasingly frequent, intense and regular. This is your cervix dilating more rapidly, with most women progressing at least 0.5 cm per hour. This active phase of labour is regarded as a cervical dilation of 4-8 cm. Hospital admission usually occurs at the beginning of this phase, when you are dilated at 4 cm. In the hospital you will be placed in a private room for delivery. In the delivery room you will continue to be monitored (fetal heart rate, blood pressure, contractions) or you may be free to walk around. It is recommended to have someone you trust, who makes you feel safe and, most importantly, someone who eases any anxiety or fear you may have. For more information on how your health care team will monitor your baby, click here.

The transition phase is the end of stage 1 and involves the maximum dilation of your cervix to 10 cm. At this point, your contractions are strong, intense and frequent being around 3-4 minutes apart and lasting from 60-90 seconds. You may feel the natural urge to push or strong pressure as you approach maximum dilation.

Stage 2 of Labour - Push!

When your health care provider has confirmed a fully dilated cervix, you will be instructed to push. As your baby descends you will feel a natural urge to push. If you receive an epidural, your sensation will be reduced and you may need to be coached when to push. This stage takes an hour for the first baby but only 15 minutes for subsequent deliveries.

After your baby is quickly assessed by your health care provider, your baby will be placed on your chest for warmth and skin to skin contact. Delaying clamping the cord will provide your baby with a surplus of iron-rich blood. The cord can be cut by your partner or health care provider.

Stage 3 of Labour - Delivery of the Placenta

After your baby has been welcomed into the world, your placenta will follow. The mild contractions that you will experience following the delivery of your baby will aid in the removal of your placenta. The routine administration of oxytocin will stimulate these contractions to reduce the chance of major bleeding after delivery.

Induction of Labour

Induction is the process fo preparing your cervix for delivery and prompting uterine contraction to begin labour. Induction is typically recommended as you approach 41 weeks. Induction of labour may be discussed for other reasons such as:

• Rupture of membranes with no labour (water has broken)
• Medical reasons that may affect you or your baby

Risks Associated with Induction

• Increased risk of vaccuum or forceps delivery
• Cesarean delivery
• Abnormal fetal heart rate

If induction is recommended for you, your obstetrician will decide the most appropriate method of induction at the time of your induction appointment.

Out-Patient Methods of Induction: Cervical Ripening Methods

• Stretch and sweep of the membranes: Performed during a vaginal exam, a stretch and sweep entails separation of the amniotic sac from the lower part of the uterus to increase prostaglandin production in preparation of labour.
• Prostaglandin administration:  Prostaglandin is a hormone endogenously produced during labour. It is administered exogenously, using a small plastic applicator inserted into the vagina, to stimulate contractions.
• Foley catheter: A mechanical method of opening the cervix.

Out patient methods may take a few days and, for this reason, you will be discharged home 1-1.5 hours following the procedure to await active labour.

In-Patient Methods of Induction

• Amniotomy: An amniotomy entails the mechanical breaking of your water using a safe plastic hook. You and your baby will be monitored during this procedure.
• Oxytocin: Oxytocin administered intravenously stimulates uterine contractions.
• Misoprostol: Misoprostol is a medication administered orally or vaginally that also initiates contractions.

If you need to contact the Labour Assessment Unit on the day of your induction please call the location you are registered to deliver at:

Credit Valley Site - 905-813-1100 x 4127

Mississauga Site - 905-848-7385

Pain Management During Labour

Many women worry about how they will handle the pain and agony typically associated with labour. Your concerns and questions surrounding pain management during delivery will gladly be addressed by your family physician. There are many options that can provide you with relief. 'Natural' or endogenous pain management methods include peanut balls, yoga balls and the use of the shower and jaccuzi. Below are your options for pain relief medications.

Nitrous Oxide

This gas is a 50/50 mix of nitrogren and oxygen and is also called the 'laughing gas'. The gas works rapidly and is out of your system just as fast, hence it has no lasting effect on you or your baby. The gas does not necessarily provide pain relief, but 'lifts' you above it so that you can pass through the contractions. A benefit to this method is it can be self administered so you can use it when you need it most.

Intravenous Medication

Medications given into the muscle, subcutaneously or intravenously are called narcotic pain medication. This is a more effective method of pain relief, however the downside is that, since it crosses the placenta, it will enter your baby. This poses the risk that your baby will be sleepier after birth and hence you may be refused this medication close to delivery. There has to be a sufficient window for your body to clear the medication to ensure the strength of your baby's respiratory system upon delivery. Potiential side effects to yourself include itching, nausea, vomiting and fatigue.

Epidural Medication

Epidural medication is a common route of pain relief chosen by expecting mothers. During an epidural, you will recieve a mix of local anesthetic and narcotics into your spinal column. This is the only medication that can stop contraction pain. A small tube left in your back will provide access for medication to be continously delivered throughout labour. After an epidural, you will be non-weight bearing and will require a catheter to empty urine from your bladder. This is all normal and expected as apart of an epidural. Despite many misconceptions surrounding the safety and long term effects of receiving an epidural, you can be rest assured that the likelihood of any of the risks  occuring (such as severe headache, infection and bleeding) is extremely low. The anesthetist performing the procedure will discuss with you any risks in detail if you request an epidural.

Cord Blood Options

Umbilical cord blood is a rich source of blood-forming stem cells. Stem cells are special because they can differentiate into a variety of cells, while other cells can only replicate themselves. Blood stem cells can become red blood cells, white blood cells and clotting cells.

These stem cells can be used in the treatment of blood disorders including leukemia, lymphoma, aplastic anemia, adrenoleukodystrophy, Krabbe's disease, sickle-cell anemia. Scientists are also developing stem cell applications in treating heart disease, diabetes, Parkinson's and Alzheimer's.

Your umbilical cord blood can be donated, free of charge, through Canadian Blood Services. Upon donation, your umbilical cord blood becomes a public good. Another option is banking your umbilical cord blood for your personal use later in life, should the need arise. This must be done through a private blood bank and can be expensive ($1200 processing fee and annual $100 storage fee). Here are some facts that may educate you on this option as the delivery of your baby approaches.

• Due to the link between many of blood disorders and genetics, the use of an infant's own cord blood to treat his/her own disease is rare ( i.e if a child develops lymphoma, their own cord blood will become unusable for transplant due to the risk of 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 their own cord blood transplant is 1/2700 or less

Ask your family physician on the benefits and drawbacks for this procedure in your case. Here are some resources for your own research:

Ceasarean Section

According to the Canadian Institute for Health Information, 28.2% of births in Canadian hospitals were performed via C-section. A C-section is the delivery of a baby through a surgical opening in the lower abdomen, as opposed through the vaginal canal. The practice of performing C-sections has saved many lives of mothers and their children, decreasing the maternal and infant mortality rate worldwide.

There are many instance in which a C-section may be required, some of which are involving the baby and some involving the mother. The practice of performing C-sections has saved many lives of mothers and infants from avoidable causes of death and illness. The circumstances in which a C-section may be performed include:

• Abnormal fetal heart rate
• Poor fetal position. including some breech positions
• Abnormalities in the fetus that make it unsafe for labour
• Slow or difficult delivery
• Undilating cervix
• Advised against vaginal delivery following previous C-section (although vaginal birth after Caesarean has a high success rate)
• HIV positive (without suppression of viral load) or active herpes infection
• The placenta is positioned so that it blocks the cervix (placenta previa)

Risks and Benefits Associated with C-sections

If you have been prepared by your health care team for the possibility of a C-section, it is likely they informed you of the risks and benefits associated with this procedure. They will also detail special considerations of your case that led to their recommendations for the safest method of delivery. The large distinctions between C-sections and vaginal deliveries are the longer recovery times, the scar and loss of sensation, as well as the special consideration for your next labour. Infection of the incision or uterus, bleeding, blood clots, urinary tract infections and decreased bowl function are also risks associated with C-sections.  You can be rest assured that you and your baby's wellbeing will always be put first.

How is the C-Section Performed?

During a C-section, your partner can join you in the operating room. There will be a  sheet to prevent you from seeing the operation and you should be able to hold your baby briefly after delivery. A catheter and intravenous (IV) line will be inserted. You will receive either an epidural or spinal anesthetic, however in emergency situations a general anesthetic may be used. Once you are numb, the obstetrician will make an incision through the skin, fatty tissue, the abdominal wall and the uterus. Following the delivery, your umbilical cord is cut and the placenta is delivered. Your uterus is closed with dissolving stitches and your skin will be stitched or stapled. 

Here are some additional resources from the Society of Obstetricians and Gynaecologists for information on a variety of topics surrounding labour and delivery:

• Vaccuum and forceps-assisted birth
• Vaginal birth after Caesarean (VBAC)
• Labour in water and water birth
• Out-of-hospital birth
• Multiple birth
• Breech childbirth
• Delayed cord clamping

After Birth

Your newborn's heart rate, temperature, breathing, colour and circulation will be monitored in the hours after delivery. The nurses in Labour and Delivery will also weight your child and help you breastfeed.

Within the first hour of birth, your newborn will also be administered an injection of Vitamin K in the thigh. This is recommended practise to prevent Vitamin K Deficiency Bleeding. The Vitamin K injection helps initiate the clotting system, which has not yet established in newborns.

Furthermore, your baby will be administered an Erythromycin Ointment, which is an antiobiotic applied to the eyes to prevent infection due to contact with bacteria that may have occured during delivery.

Your newborn will also be screened for at least 27 rare disorders that can cause health problems in babies through a blood sample taken by pricking the baby's heel. The blood is collected between 24 hours and 7 days of age during the baby's hospital stay and sent to the Newborn Screening Program Laboratory for testing.

Eight hours after vaginal birth or Caesarian birth, you should be able to:

• Urinate
• Stand and walk
• Feed your baby at least twice

If you had a vaginal birth, eight to twenty four hours after delivery (and within 48 hours for Caesarian birth) you should:

• Have bathed your baby yourself
• Be caring for yourself
• Know how to hold, diaper, take care of the umbilical cord and position your baby for sleep
• Know how to feed and burp your baby

Discharge

You and your baby will be discharged only when you meet certain discharge criteria. This can occur anywhere between 8-60 hours for vaginal birth and 8-72 hours for Caesarean birth. Please make an appointment for your baby to see your family doctor within 5 days after birth. The nurses will provide you with the necessary government forms, including:

• Child tax credit
• Birth registration
• Ontario health infant coverage

Infant Care and Post-Partum

Tips for Infant Positioning and Development

To reduce the risk of Sudden Infant Death Syndrome (SIDS), infants should be placed on their backs to sleep. To avoid skull flattening and/or weak back muscles, you should:

• Limit the time the baby spends on their back when awake
• Change baby's position often when awake
• Gradually increase baby's supervised time on their tummy when awake

Breastfeeding

Breastfeeding your baby is the most natural and mutually beneficial way to feed your newborn. In the beginning you will produce a substance called colostrum, which is a golden-coloured liquid containing immune factors to protect your baby while their immune system is still undergoing development. Breast milk changes to meet the changing nutritional needs of your infant. Your breast milk is always available at the perfect temperature and is free of cost. Your breast milk production is controlled by the simple idea of supply and demand. The more demand (i.e the more often your baby drinks your breast milk), the more supply that will be produced.

Health Canada, The Canadian Paediatric Society and the World Health Organization all recommend exclusive breastfeeding until 6 months of age and breastfeeding combined with food introduction from six months to two years. Some of the advantages are highlighted below:

• It is a bonding moment with your baby
• It provides protection from diarrhea and pneumonia
• It is always available and the perfect temperature
• It is affordable
• It reduces the mother's risk of breast and ovarian cancer, type 2 diabetes and post partum depression
• Breastfed children are more likely to be a healthy weight
• Children who were breastfed perform better on cognitive thinking tests

It is important to remember that the breastfeeding relationship may take time to develop. You are your baby are learning about each other. As time passes, you and your child will develop a coordinated routine when you both will know what to expect. This relationship may need support at times, however is ultimately highly rewarding.

Formula

While formula is lacking in the immune benefits contained in breast milk, it does provide basic nutrition for your baby. It also may allow your significant other and relatives to assist with feeding, however this can also be achieved through pumping and storage of bottled breast milk. If you choose the route of infant formula, ensure that the formula is being prepared and stored correctly. Feeding equiptment must be sanitized properly. It is recommended that you talk to your health care provider about which feeding method is right for you. Just know your physician will always advocate for you and your child's benefit.

Nutrition for Breastfeeding Women

Practising self-awareness in regards to your nutrition levels and quality of food is imperative to avoid the deprivation of calories, vitamins and minerals needed to produce nutritious breast milk for your baby. It is particularly important that you focus on your sources of vitamin D, omega-3 fatty acids and iron.

Vitamin D

Vitamin D is present in very low quantities in breast milk unless a supplement is taken during pregnancy. It is recommended that you supplement infants with 400 IU of vitamin D daily or you can supplement 2000 IU during the final six months of pregnancy to six weeks postpartum to deliver the vitamin through breast milk.

Omega-3 Fatty Acids

Omega-3 fatty acids are essential for healthy eye and brain development. You can obtain the necessary quantity of omega-3 fatty acids for you and your baby by consuming at least 150 g of fish (preferably salmon). Try to avoid or limit fish with high mercury content. For other food sources of omega-3 fats, please visit the Dieticians of Canada's website.

Caring for Your Breasts

It is important to stay hydrated by drinking lots of fluids and limiting your caffeine intake. Although breastfeeding is demanding, it is important to make an effort to get as much rest as possible. If your nipples get sore or cracked, applying a small amount of lanolin after feeding may provide relief. This soreness should only last for the beginning stages.  It is also a good idea to keep your nipples dry between feedings.

A key component to successful breastfeeding is getting a good latch. All babies are different. Some babies latch on right away while others have more trouble. A good latch involves having most or all of the areola in the baby's mouth. If the latch is poor, break the suction by putting your finger into the corner of the baby's mouth and try again. If discomfort persists or if you feel pain even when the baby is latched properly, you should ask your family doctor for a referral to a breastfeeding clinic.

It is also a good idea to invest in a supportive and properly fitting breastfeeding bra. To prevent your breasts from becoming engorged (full of milk, hard, painful), try breastfeeding as often as possible. It is recommended that you nurse 8 or more times per 24 hours. If you're struggling with engorgement, you can try a warm compress before feeding and gently massaging your breast towards the nipple. Blocked milk ducts, experienced as redness and swelling, are not an uncommon occurence among breastfeeding women. Try breastfeeding often and positioning your baby so that their chin points in the direction of the blockage. If the blockage persists, seek help from a public health nurse, lactation consultant or someone skilled in helping breastfeeding mothers.

Medications and Breastfeeding

Anything you put in your body will end up in your breastmilk, therefore it is important to consult with your physician on safe medications and dosages that you can be taking while breastfeeding. In general, most medications applied to the skin, inhaled, or applied to the eyes and nose are approved for breastfeeding women. Most vaccines are safe and most medications that are commonly prescribed to infants are safe.

Drugs that are typically not suitable for breastfeeding women include anti-cancer drugs, immune suppressants, ergot alkaloids, radioactive medications and anticonvulsants. Newborns and premature infants are most vulnerable to the negative effects of exposure to this medication.

Medications that decrease milk production (as listed below) should not be used by breastfeeding mothers:

• Antihistamines
• Sedatives
• Some decongestants
• Some weight loss medications
• Diuretics
• High doses of vitamin B6
• Nicotine
• Ergot alkaloids

Alcohol

Alcohol distributes into milk and will be ingested by nursing infants, hence consumption should be avoided. Optimally, nursing should be held off for at least 2 hours per drink to avoid infant sedation and impairment of motor skills.

Caffeine

Consumption of caffeine in moderate amounts (maximum of two cups per day) is not harmful to your nursing infant.

Cigarette Smoking

Smoking while breastfeeding has been linked to infantile colic and lowered maternal prolactin levels, which leads to earlier weaning. Furthermore, infants should not be exposed to second hand smoke as their lungs are still growing and are more vulnerable to toxic exogenous substances.

Postpartum Health Care

You and your newborn should be seen by your family physician within a week from delivery. This will be your first postpartum and wellbaby visit. During this visit, the health of both you and your baby will be assessed. You can expect the following to be discussed at your visit:

• Weigh and measure the newborn
• Your baby's intake and soiled diapers
• Breastfeeding questions and concerns
• Breast health
• Any bowel or bladder issues
• Assess C-section incision
• How your perineum healing
• Bleeding
• Your mood and wellness
• Screening for postpartum depression
• Birth control options
• Any need for bloodwork or glucose test
• Any need for a PAP test

Taking care of and attending to a new life can be a mentally, emotionally and physically exhausting period. It is important to not forget to take care of yourself as a new parent and to practise self forgivness.

Your baby and your family need your well-being to thrive. You are not perfect and it is normal to feel surprised by the demands of caring for your first child. This is a period of adjustment.

Regardless of if you gave birth vaginally or via caesarean section, giving birth is a traumatic experience. The muscles of your back, lower belly and pelvis are all in repair during your post partum recovery. Here are some patient resources for excersises to decrease pain, improve strength and get yourself back.

• Exercise after pregnancy

Feeling Sadness After Having a Baby

It is normal to experience a rollercoaster of emotions after giving birth. For one, your hormones are beginning to adjust to prepregnancy levels. 1 in 5 mothers will experience depression and/or anxiety after giving birth. These mood changes can be experienced in three different ways.

Baby Blues

• Affects up to 85% of new mothers
• Crying spells, feeling sad or irritable
• Emotional changes worsen after giving birth
• Symtoms improve on their own within approxiametely two weeks post-partum

Post-Partum Depression

Postpartum depression is diagnosed if a woman experiences the following symptoms nearly every day for two weeks to the extent that it interferes with her ability to care for herself and her children.

• Depressed mood or extreme sadness
• Crying spells for no logical reason
• Guilty thoughts
• Feelings of worthlessness
• Restlessness or lack of energy
• Anxiety or panic attacks
•  Difficulty concentrating
• Changes in sleep or appetite
• Withdrawing from family and friends
• Thoughts of harming herself or others

As soon as you recognize that you or your loved one may be suffering from postpartum depression, you should voice these concerns to your family physician immediately. If you are still unsure if you or a loved one is suffering from post-partum depression, you can fill out the Edinburgh Post-natal Depression Scale and bring your results to your family physician.

Post-Partum Psychosis

• Have thoughts of harming yourself or the baby
• Hear or see things that are not there
• Believe people or things are going to harm you or your baby
• Feel confused or out of touch with reality
• Requires immediate help

Who is at risk?

You may be at risk if you:

1. Experienced depression and anxiety in pregnancy
2. Experienced recent stressful life events
3. Have a lack of social support
4. Have a personal history of postpartum depression or mental illness

What Can Help?

• Recognize the symptoms and ask for help from health care providers/programs available near you
• Prioritize self care
• Do not blame yourself
• Pregnancy/breastfeeding safe medication may be prescribed for moderate to severe conditions

Resources Available in Peel

• Hospital Emergency Department
• Distress Line Peel - 24 hours: 905-278-7208
• Mobile Crisis Team Peel - 24 hours: 905-278-9036
• Telehealth: 1-866-797-000
• Peel Public Health Healthy Babies Healthy Children Program: 905-799-7700
• Canadian Mental Health Resources Peel Branch: 905-804-0123

Vaginal Recovery

Your perineum (the skin between your anus and vagina) is likely to be swollen, tender and bruised for up to 6 weeks after birth. Acetaminophen and ibuprofen is safe to use for pain relief while you're breastfeeding. Below are some tips that may provide relief from vaginal pain and swelling:

• Use a pillow or inflatable ring (sold at most drug stores) when sitting
• Use a peri-bottle or a spray bottle to rinse off the perineum after using the toilet and blot dry
• Apply ice packs wrapped in a towel to the perineal area for the first 24 hours. These should be removed every 10 to 20 minutes and reapplied every hour as needed
• Women can use a frozen, water-soaked maxi-pad to provide cold relief
• Let the perineum air-dry while resting
• Soak the perineal area in warm water; if using the bathtub ensure that it is cleaned first and that someone is present to help you in and out of the tub

Postpartum Bleeding

You will have heavy vaginal bleeding and clotting that will subside around 6 weeks postpartum. After 10 days postpartum, the heavy bleeding should become light-coloured pink or brown discharge.

Normal Newborn Behavior

Irregular breathing from your baby, for example fast and shallow vs deep and slowly, is normal. Your baby may even stop breathing for about 10 seconds or so. Blotchy, red skin and bluish hands and feet can be expected in the first few days of life.

In terms of feeding, your baby should start to feed every 2 to 4 hours (8-12 times per day) fairly quickly. Your baby should have one wet diaper the first day, two on the second day and three on the third. Once your baby begins to feed regularly, you can expect six to eight wet diapers a day.  Your baby's first few poops will be black/dark green -- this is called meconium. After a few feeds, your baby's bowel movements will become fluid yellow, green or brown. Their stool might even look seedy- this is also not an issue of concern.

Newborns sleep for about 16 hours a day. This will most likely be done as scattered naps. Your baby's umbilical cord should fall out within their first two weeks of life. You may see some blood because the umbilical cord is much like a falling scab. However, if your baby's stomach becomes red and inflamed or the area develops a pink moist bump, you should contact your baby's family physician.

Pregnancy Loss

Miscarriages 

Miscarriages are a severely underdiscussed issue despite their high prevalence. Spontaneous pregnancy loss occurs in 25 of 100 pregnancies, usually within the first 8 weeks. Sometimes it happens so early in the pregnancy that women do not even know they're pregnant yet. After a miscarriage, many women have feelings of guilt, questioning what they did wrong. Just know, the answer is nothing. A miscarriage is the body's natural mechanism of preventing an unviable pregnancy from fully developing. This may be due to a poor attachment to the uterine wall or genetic mutations.

How you decide to cope with the emotional aftermath of a miscarriage is a very personal decision. Some may seek comfort in confiding in others and hearing about other women's experiences. Others may decide they do not wish to reveal to others that they had a miscarriage and cope best by continuing with their daily life as best as they can. However, one thing that all women should do is prioritize their wellbeing during this sensitive time. You should ensure you're recieving good nutrition by eating a variety of foods, as well as excersising regularly. If you're having issues sleeping, it is advised you bring this up to your doctor in the context of your recent hardship. Try your best to resume your normal routine and look forward to your next pregnancy. If you're finding it increasingly difficult to get back to your 'normal' as time passes, let your health care provider know.

Vaginal Bleeding and Pregnancy 

Vaginal bleeding during pregnancy can be cause for concern. You should contact your healthcare provider if you experience any bleeding. About one-third of pregnant women have some bleeding before the 20th week and around half of these pregnancies continue healthily. Common signs of a miscarriage include vaginal bleeding, the passage of clots and tissue and cramping and pain in the lower pelvis or back. If your healthcare provider confirms your miscarriage, then you may be referred to receive a  dilation and curettage (D&C) to help clear out any remaining tissue in your uterus. 

Information is provided by The Society of Obstetricians and Gynaecologists of Canada.