Woman Standing on Scale
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Woman Standing on Scale

It is really encouraging that I now see lots of patients in the pre-conception stage. We have a long chat about trying to conceive, healthy lifestyles, and how they feel about becoming parents overall. I think it’s a great opportunity to build a relationship with a GP who will look after you throughout pregnancy and beyond – including helping you with postnatal problems and becoming your baby’s GP.

When I looked up a Cochrane review on routine pre-pregnancy health promotion, however, I was disappointed with the conclusions that “there is  little evidence on the effects of pre-pregnancy health promotion” on pregnancy outcomes. Was I doing all this pre-conception counseling in vain?

A more recent study of over 5000 women was more encouraging. The researchers identified the factors that led to a decreased risk of a complicated pregnancy. That is, what makes for a healthy pregnancy – one without complications like diabetes, poor fetal growth, prematurity etc. The factors that lead to an uncomplicated pregnancy are:

  • not being overweight (BMI < 25)
  • not taking recreational drugs
  • no alcohol while pregnant
  • normal blood pressure
  • pre-pregnancy fruit intake of at least 3 pieces daily.

Interestingly, maternal age was not associated with increased risks in pregnancy, despite the current thinking.

Perhaps the problem is not that health promotion is not useful, but it currently isn’t effective in normalizing these risk factors – such as weight and diet. In particular, advice on how to lose weight is vague and not evidence-based.

However, planning a pregnancy can be a powerful motivator for change. Not only will a healthier lifestyle improve chances of falling pregnant and having a healthy pregnancy, but parents can begin to set good examples for their children to follow.

Photo credit: http://www.dailyhiit.com/hiit-blog/hiit-diet/diet-tips/youre-dieting-wrong/

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I kept as active as I could during pregnancy, trying for 2.5 hrs a week of aerobic exercise – up til the last few heavy weeks anyway! I ran, swam, and walked a lot. Here’s how exercise helped, or didn’t help, during my pregnancy, the labour and birth and the postpartum period.

Pregnancy

Gentle swimming helped boost my energy levels during the first trimester, but vigorous exercise tended to make me exhausted and hungry. I sometimes woke up from a nap to go for a walk, only to return to bed afterwards!

During the second trimester, I felt fabulous while exercising and managed to run until 6 months. It also gave me a sense of strength and achievement to feel so fit and active.

In the third trimester, I just tried to maintain a modicum of fitness – and waddling around the block in the last few weeks during maternity leave gave me something to do at least.

I gained exactly the weight that I should have, no more and no less. I felt good about myself and the way I looked. It didn’t help morning sickness and I still got pelvic and back pain and some insomnia, but overall I had a fairly uneventful pregnancy. I didn’t have any medical complications such as preeclampsia or gestational diabetes.

Labour and birth

I’d read about how babies born to very active mothers tended to be born earlier (around 1 week before the due date) although the evidence for this is a bit weak. My baby came exactly on her due date! I also kept up the walking in the last few weeks of the third trimester to try and “bring on the labour” but I’m not sure if this helped. I think babies just come when they’re ready!

I was hoping for an uncomplicated labour and birth (though I think from memory the evidence for a lower rate of assisted birth or Caesarian sections in active women is not convincing). As it turned out, labour did start spontaneously but became obstructed because my baby was in the posterior position (which also made for a very painful labour!)

There have been reports that keeping active during pregnancy reduces the need for painkillers during labour. Not for me! I asked for an epidural early on as the contractions were so intense.

The postpartum period

I returned to my prepregnancy weight very quickly, although I don’t know if this was all to do with being active during pregnancy. I found the early weeks quite stressful and I think the kilos fell off because of this. Later on, as it became clear that my baby was a particularly poor sleeper, I found myself walking for hours and hours every day just to get her to sleep – and I dropped below my prepregnancy weight when she was 2 ½ months old. Not how I would recommend other mothers to lose weight, but the walking was a necessity for me, and I guess at least it gave me back my fitness and my prepregnancy body!

I was assessed by a physiotherapist a few days after the birth and didn’t suffer from any DRAM (Diastasis Rectus Abdominus muscle) which is the separation of the muscles of the abdomen. I was also able to return to walking within a couple of weeks, and by about 3 or 4 weeks I was back to walking 40 minutes daily. 10 weeks later I went for my first run.

It’s difficult to tell if being fit during pregnancy helped energy levels in the postpartum period as this depends so much on how sleep deprived you are!

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I’m a huge fan of physical activity overall, and I didn’t want to stop being active during pregnancy. Fortunately, we know now that exercise during pregnancy is safe and carries many benefits for mother and baby. Research suggests that exercise during pregnancy can:

  • reduce the risk of developing gestational diabetes mellitus by 50%
  • reduce the risk of pre-eclampsia
  • ensure weight gain is healthy and not excessive
  • improve maternal well-being
  • reduce physical complaints such as back pain and insomnia
  • reduce the risk of premature birth
  • reduce the risk of operational delivery
  • shorten labours, including the pushing stage
  • decrease the need for pain relief during labour
  • decrease risk of maternal cardiovascular disease in the long term
  • decrease post-partum Body Mass Index.

It seems that regular aerobic exercise, the kind that gets you breathing faster, helps to build a healthier and more efficient placenta.

Babies born to mothers who exercised during pregnancy are also thought to settle more easily and be more intelligent at 5 years.

Personally, I couldn’t have got through my pregnancy without exercise. I made exercise a priority because (1) I wanted to maintain my fitness so I could get back into running post-partum; (2) I wanted to gain weight in a healthy weight and not “balloon out”; (3) I wanted a healthier baby. Exercise improved my mood and self-esteem, often increased my energy levels, allowed me to connect with nature, improved back pain, helped my sleep, helped me keep weight gain slow and steady as is recommended, and generally made me feel and look fabulous during pregnancy. I think it’s vital that you have a set of personal reasons as to why you want to continue on with physical activity during pregnancy, or perhaps start doing some if you are currently inactive. Do consult with your health provider as soon as you know you are pregnant, and read on about safety of exercise during pregnancy.

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For many of us, the thought of going without alcohol for nine months is daunting. After all, drinking is such a social activity and wine is such a lovely accompaniment to a good meal…

I certainly found that avoiding alcohol was one of the most challenging aspects of being pregnant. I certainly loved my cocktails with the girls, bubbly for any occasion, beer on a hot summer’s day, and a crisp glass of sauvignon blanc with seafood – before pregnancy, that is. I chose not to drink at all during pregnancy, and while this was difficult, it is what is currently recommended by the experts (that is, there is no safe level of drinking during pregnancy).

Alcohol passes straight into your unborn baby’s bloodstream and is toxic to her brain and other cells. Babies born to mothers who drink at high levels during pregnancy suffer from Fetal Alcohol Syndrome, which is characterised by facial abnormalities, growth retardation in utero, and a range of effects on the brain including small brains, mental retardation, learning disabilities, seizures and ADHD (Attention-Deficit Hyperactivity Disorder).

Given that alcohol can readily induce these effects in a baby, and that nobody can guarantee that even small amounts of alcohol are not harmful, I found it easier on my conscience to abstain completely – and this is what I recommend to my pregnant and preconception patients.

When you are stone cold sober and others around you are imbibing in alcohol, you get to make some interesting observations – such as how silly you might have looked at times when you were inebriated, or how you may have relied on alcohol as a relaxant after work or on weekends. It makes you more self-sufficient – you have to find other ways to relieve stress and have a good time.

Do try not to fall into the trap of having calorie-laden soft drinks as an alcohol substitute. I certainly went through a lot of ginger beer and lemonade initially because I just wanted to nurse a drink in my hand! This can predispose you to excessive weight gain and gestational diabetes. Try half strength fruit juices or just plain water instead. I did love sparkling mineral water but this could deplete your calcium stores and gives you a whacking dose of sodium, so it’s to be enjoyed in small quantities.

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This is a fantastic book that doesn’t dumb down the importance of being active during pregnancy, and goes into great detail about the safety and appropriateness of many different sports and activities. It explains the benefits of exercise during pregnancy, precautions, and has recommendations as to what to start if you were fairly inactive before getting pregnant. It then discusses a whole heap of different activities (including hiking, surfing, swimming, snowboarding, horseriding…) and whether or not they are appropriate in pregnancy depending on the trimester you are in and your current level of expertise. No absolute recommendations are made (except, notably, for diving, which is not recommended at all during pregnancy) – just levels of risk to consider ie low, medium or high. I really like the fact that it allows you to make an informed decision about what you want to do during pregnancy and gives plenty of practical advice about making exercise safer and more comfortable. It doesn’t just tell you that walking, swimming and yoga are excellent exercise during pregnancy and leave it at that. As with many books that I recommend, I like the fact that it’s written by a medical doctor and hence, in my opinion, gives a balanced view to the picture. I highly recommend this inspiring book to all women, even those who didn’t do any exercise before pregnancy.

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One of my biggest fears was developing “cankles” in pregnancy. You know, when you don’t know where the calf ends and the ankle begins? I felt there was enough to deal with having a giant bump, bigger boobs and thighs and bum that are definitely more generous than before. I didn’t need my body image completely shattered by developing cankles as well!

Well, I was lulled into a false sense of security because for the first 36 weeks of pregnancy I was cankle-free. My feet remained slim, my ankles svelte, and my ego huge. Then suddenly, for no reason (apart from my ballooning uterus obstructing blood flow back to the heart, I suspect) I suddenly turned into the Elephant Woman. I had joined the 75% of women who develop the dreaded cankle during pregnancy.

Walking, swimming and drinking lots of water have been recommended as good cankle prevention exercises, and they probably helped me up to that point. Beyond 36 weeks, what worked best was compression. I threw my dignity away and wore support stockings – the kind you get from the pharmacy to prevent clots in the leg during air travel. They looked awful but felt good and kept my feet to a manageable size. Putting my runners on and going for a long walk also helped – probably because there was lots of compression happening inside my now snug sneakers. I was already spending lots of time with my feet up and this didn’t make much difference, although spending time with my legs dependent (or below my knees ie sitting or standing for too long) did make the cankles worse.

If you do develop swelling, and this is sudden, or is generalised (eg in the face and hands as well as the legs), or if you feel unwell and “off” with the swelling, get yourself checked out straight away, as it could be a sign of pre-eclampsia – a medical condition during pregnancy that can be very dangerous for both mother and baby. Otherwise, good luck and here’s to your ankles looking lovely during pregnancy ☺

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Let’s face it, pregnancy often feels like an endless list of restrictions, and nine months is a long time. There’s alcohol and smoking and caffeine; modifying your workout routine; “listening to your body”; and all sorts of old wives tales about not having sex, or eating too much, eating too little, not enough fish, too much fish… .It can drive a pregnant woman crazy!

Then there’s the listeria thing, and if you’re like most women, this would create the most restrictions in your life. It can seem at times that there is NOTHING that you can safely eat. Especially at lunch. Take my friend, newly pregnant, who went to a café, and tried to order a meal.

Waiter: “How about a chicken and avocado roll?”
Friend: “Can’t have cold chicken – sorry” (She could have had it toasted, but only if she was sure that it was heated up to the right temperature”
Waiter: “Smoked salmon then?”
Friend: “No can do, no cold seafood either”
Waiter: “Prosciutto and salad?”
Friend: “I love prosciutto, but no cured meats…”

Argh!! Is it worth it? Are  we too paranoid about listeria and other bugs that can “harm our baby”?

I am a strong believer in making informed decisions. This means knowing exactly what you are dealing with and how it works and how to prevent it and what the risks actually are. It’s all our choice in the end – there are no laws about these things. Bear in mind though that this time it doesn’t just affect you, it affects a wee little human inside of you.

Firstly, I’ve seen Listeria in action and it’s awful. Being a doctor, we see the worst case scenarios, but the point is, this actually happened to someone, and she lost her baby.  I wouldn’t wish Listeriosis on my worst enemy.

So how common is it? The Victorian government’s infectious disease website (www.health.vic.gov.au/ideas) says it’s relatively uncommon. Listeriosis is an uncommon disease in humans. In Australia in 2003 the rate was 4.6 infections per 100 000 births per year for maternal-foetal infections. That year there were 250000 registered births which means there were 11-12 cases of Listeria infections in the whole of Australia. So, not common. However, outbreaks do occur, as happened in August 2009 with the tragic case of the contaminated chicken wraps that were served on Virgin blue flights. 13 people developed listeriosis. Of these, 8 were pregnant women, and there were 3 foetal deaths.

What does one do when the risk is low but the consequences potentially fatal? You need to consider the benefits of taking the risk. In other words, is it worth it?

There are great resources on the web regarding advice on how to avoid listeria and other problematic food-borne infections in pregnancy. The Food Standards website had the most informative brochure (see link below). Instead of just following the blanket rules of “no soft cheese, no pate” etc, I found it helpful to learn a little bit about Listeria and how it grows. It made it a bit easier to make food choices when the rubber hit the road. Here are some pointers from their brochure that I wasn’t aware of before:
•    Store leftovers for up to 24 hours only
•    “Processed” (packaged) food may be safer than unprocessed because of the heat treatment required
•    Deli foods are not safe because there is no guarantee as to how long cold foods have been left standing and refrigerated
•    If it’s steaming hot, it is most probably safe

See the brochure for more information.

Basically, if fruits/vegetables/cold meats have been prepared and left to refrigerate for more than 24 hours there is a risk that Listeria may have multiplied significantly. This includes vegetable garnishes, salads, even “fresh fruit” juices at juice bars (Have you ever noticed how the fruit is cut up and left out in a fruit bar before juicing? It also may have been left in the fridge for much longer before being put on “display”).

For me personally, the benefits of avoiding Listeria as much as I can far outweigh the small pleasures I might gain from having a cold chicken sandwichor the convenience of a pre-prepared salad. I try to focus on what I can have in pregnancy (even though at times this seems like very little…) and eat at home as much as I can. If I’m out I can still enjoy a dining experience – grilled wagyu beef at a Japanese BBQ restaurant was one recent guilt-free gastronomic adventure. I also have a little book in which I have written down all the things I’m going to eat as soon as this baby is born. Some examples are a ham sandwich with mustard, sushi, potato salad, poached eggs with hollandaise sauce… you get the drift. Eventually these nine months will be but a memory and I’ll be able to eat all the sushi I can muster. Bring on the post partum seafood buffet!

Food Standards Australia

New Zealand Food Safety Authority

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More like my Whole Pregnancy Bible! I came across this book before I fell pregnant, and it has seen me through the preconception period and entire pregnancy. If patients come in to see me and are thinking of conceiving or are pregnant, I always refer them to this handbook. I refer to the chapters on nutrition extensively during my consultations with pregnant or preconception patients.

I really admire Joel Evans. He’s an obstetrician who adopts a truly holistic approach to his practice which incorporates nutrition, mind-body medicine, and complementary therapies. He comes across as an extremely gentle, caring and nurturing caregiver from his writing. I also like the fact that he is an obstetrician and hence all his advice is very safe.

The handbook explains mind-body medicine, and covers pre-conception and pregnancy health comprehensively, with chapters devoted to nutrition, living and working while pregnant, exercise during pregnancy, medical complications of pregnancy, and common symptoms during pregnancy. The pregnancy timeline was particularly useful, as are the chapters on early pregnancy and late pregnancy. Dr Evans also provides suggestions for treating common pregnancy ailments using both safe Western medical treatments, gentle changes in lifestyle, and safe complementary treatments where appropriate (such as acupuncture or herbal treatments).

I cannot recommend this book highly enough to anyone who is thinking of falling pregnant or is already pregnant. It is a wonderful read and contains so many pearls of wisdom.

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When I fell pregnant I was prepared for so-called “morning sickness”, but nobody warned me about the fatigue. And what fatigue it was! It came on at about six weeks and finally lifted just before thirteen weeks. I felt as though I had the “flu” for all this time, and developed a newfound empathy for patients who suffer from Chronic Fatigue Syndrome. I felt unwell and sedated for most of the first trimester.

Like everything else, “hormones” are blamed, namely progesterone, which does make a woman more placid and drowsy than usual. Apparently the body takes three months to adjust to higher levels of hormones, which is why doctors often tell women that their Pill side effects may disappear after three months of use.

Blood sugar levels also tend to fall during the first trimester, which I believe exacerbates the fatigue (and led to me never leaving the house without a peanut butter sandwich in my handbag for those two-hourly hypoglycemic attacks). Something else is happening that your body hasn’t done for a long time – it’s building a whole new organ “from scratch”. The placenta, which is the connection between you and your baby, starts to form in the first days after conception, and is completed pretty much by the thirteenth week.

There were days I could barely drag myself out of bed, even after marathon 10-12 hour sleeps (I often passed out on the couch by about 8:30pm – my poor husband had little of a social life in those weeks!) The fatigue was overwhelming, worse as the day wore on, and over the weekend I seemed to spend all of my time sleeping – and yet woke up feeling no better. I remember crying one morning during the tenth week as I woke up to my fourth day of terrible fatigue. My obstetrician called it “my version of morning sickness” – not that I was spared the nausea, mind you, just that the fatigue was much more prominent than the nausea.

As I bumbled along in first trimester, I learned a few things that helped (sometimes):

  • I needed to eat every 2 or 3 hours, without fail. Low-GI carbohydrates (I went through loaves of wholegrain bread and craved pasta) plus protein helped the most.
  • The support from V was immensely helpful. He told me to take it easy, never complained when I fell asleep during dinner, put up with my lacklustre cooking efforts (if I made the effort that night), and twice I woke up after having put laundry in the washing machine and falling asleep, to see him put the laundry out in the middle of the night. Your partner needs to honour the immense work your body is doing on your baby’s behalf.
  • Gentle exercise helped – a lot. Swimming was wonderful as I felt buoyant and wasn’t worried about passing out. Always have a snack before and after exercising.
  • Overdoing the exercise and exertion resulted in days of awful fatigue. I went surfing on a cold day at 7 weeks and the experience was just too intense. The following week was one of the worst weeks.
  • Take your antenatal vitamins religiously.
  • Take it easy and remember “this too shall pass”. For the vast majority of women, they feel “normal” again by 14-16 weeks. I remember gradually feeling like myself again during the thirteenth week, and voila! One morning I woke up and said to V, “I’m Back!”

Your body is doing a huge job – creating a new organ AND a new human being. Your baby is fully formed by 12 weeks – with ears and nose and fingers and toes and everything in its place. Your body did this from a microscopic sperm and egg. Respect the enormity of what it sets out to achieve in those first three months and good luck!

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