The end of the pregnancy is now in sight and by now you might be feeling uncomfortable. Your baby bump is getting bigger. It’s more difficult to do the normal things like getting in and out of a chair or your car or picking things up from the floor. It’s especially important to protect your joints and back as your ligaments are lax and your centre of gravity is changed by your baby bump. You will probably be more comfortable in looser clothing and flat shoes at this stage. Ankle swelling is also common at this time, but swelling of your fingers and needing to remove your rings can be a sign of pre-eclampsia. Pre-eclampsia is a blood pressure complication of pregnancy. Your obstetrician will have been checking your blood pressure and urine test at every visit throughout pregnancy. The frequency of visits will increase to monitor you more closely in case you develop this uncommon but serious condition.
You will be having more regular visits with your obstetrician as your pregnancy progresses. You will probably see your doctor every two weeks from 28 weeks and then every week from 36 weeks. Your doctor will be checking that the baby is growing as it should and may recommend extra growth scans.
At 28 weeks you will have routine blood tests. This is to check that you aren’t anaemic and you don’t have any blood group antibodies. You may also be offered a glucose tolerance test to screen you for diabetes known as GDM (or gestational diabetes mellitus). This is offered to all women unless they are already known to be diabetic. [Hyperlink to complications section]
You will also be offered a Tdap booster vaccination between 28 and 36 weeks. This vaccination provides a tetanus booster, diphtheria vaccine and most importantly pertussis or whooping cough vaccine. This booster ensures that you have antibodies in your blood to whooping cough. These will cross the placenta into your baby’s circulation. This provides your baby with immunity against whooping cough infection for the first three months of their life. Whooping cough is always a nasty infection but it especially serious for newborn babies. So the immunity that you pass on to your baby is very important.
It is also recommended that pregnant women have a flu vaccination. They are more vulnerable to catching flu and being seriously unwell than non-pregnant adults. Seasonal flu vaccination is offered in October to November before the flu season starts. Flu vaccine is safe at all stages of pregnancy. Have the flu vaccine as soon as it becomes available regardless of how far along your pregnancy is.
You will continue to see your obstetrician every 2 weeks until you reach 36 weeks of pregnancy. They will check your blood pressure and wellbeing and will be monitoring your baby’s growth.
You will be offered a swab test at approximately 36 weeks. This is to screen you for a vaginal infection called Group B Strep if you are planning a vaginal birth. Women carrying this infection usually don’t have any symptoms. But this can cause a rare but serious infection in the newborn baby. So if you do test positive, you will be offered antibiotics in labour.
It’s good to pack your baby bag early for when you go into labour. A small number of babies are born before 37 weeks. Either because or pre-term labour of due to pregnancy complications. [hyperlink to complications] Even if you are having a planned caesarean section, it’s still worth being prepared in case your baby decides it wants to make an early entrance into the world. [hyperlink to baby bag].
The Baby’s Head Engaging
Towards the end of the pregnancy your baby should have turned to be in the correct position. This is head down and the head should start to descend into the pelvis, known as the head engaging. Your obstetrician will check that the head is engaging when they examine your abdomen. The baby’s head may press on your bladder. This can make you need to pass urine more frequently and the head can put pressure on your pelvic bones. For some women this discomfort is severe and is known as symphysis pubis dysfunction. In those cases a physiotherapist may be able to help you with positioning, posture and exercises.
In a small number of pregnancies (four in 100) the baby doesn’t turn. They may remain bottom down or breech presentation. If this happens your obstetrician will discuss a number of options with you. This may include trying to turn the baby or caesarean birth. A large international study done in 2000 showed that the risks to the baby are increased in vaginal breech delivery. Overall, the risks remained small but the chance of brain damage or the baby dying was increased compared to a caesarean section or a baby born head first. The two options to avoid a vaginal breech birth are turning the baby or caesarean section. Turning the baby is a safe procedure and is successful in about half of cases. You may be offered immediate induction of labour if your obstetrician thinks there is a risk of your baby turning back to breech again. But in most cases it’s safe to wait until you go in to natural labour. A small number of women aren’t diagnosed with a breech presentation until they go into labour. If they are making rapid progress they may go on to have a vaginal breech birth. All obstetricians are trained in delivering babies breech first.
Induction of Labour
Normal pregnancy is 40 weeks long. But some women don’t go into labour naturally, even at 40 weeks. In that situation your obstetrician will discuss with you the options of induction of labour. Or more intensive monitoring for you and your baby. You may be offered vaginal examinations (stretch and sweep of the cervix) from 38 weeks gestation. This is to encourage your body to go into natural labour. While these examinations can be uncomfortable, they can stimulate the release of your own natural hormones thus avoiding the drugs and procedures of a medical induction of labour.
There are some conditions in pregnancy that increase the risk of problems. This may mean that induction of labour may be considered before 40 weeks. This includes gestational diabetes, pre-eclampsia and maternal age of 40 years or more. If your obstetrician thinks your pregnancy is higher risk, they will discuss induction of labour or delivery options with you.
There are a number of ways that labour can be induced. If your cervix has already started to open up but you haven’t got regular contractions your waters can be broken by doing a vaginal examination and using a small device to puncture the bag of waters. This isn’t painful, just a bit uncomfortable like any internal examination is. Breaking the waters usually starts contractions as the natural labour hormones are released. If you don’t get regular contractions after breaking the waters, you will be prescribed a drip containing a hormone (Pitocin). This will stimulate contractions and labour should start.
If the cervix is still closed you may be given a hormone gel or pessary in the vagina. This should soften the cervix and start to open it so that your waters can be broken. For some women the hormone gel can start regular labour contractions. But for others they will need the Pitocin drip as well. An alternative to the hormone gel or pessary is passing a tube or catheter through the cervix and inflating a balloon. The catheter is then put under tension and the balloon gently dilates the cervix.
Choosing Your Birth Team
You will have chosen your obstetrician months ago. But now is the time to choose the hospital where you would prefer to deliver and the paediatrician to be there at your baby’s birth. Don’t forget to tell your obstetrician about your choices. This means make the relevant calls when you go into labour or agree a date for a planned caesarean section. [hyperlink to choosing your birth team]