A Healthy Pregnancy

It is important to make sure you eat a variety of foods to get the right balance of nutrients for yourself and your growing baby. You should eat a healthy balanced diet which is low in fat and sugar. Your midwife will give you information on healthy eating in pregnancy. As you probably know, being underweight or overweight can have a negative impact on your general health and this is the same in pregnancy. Cooking and food preparation is also important to prevent food poisoning. Take care - some foods need to be cooked well, such as ready meals, meat, poultry and eggs. Pate, mould-ripened soft cheeses, liver, liver products, unpasteurised milk, marline, swordfish and shark should be avoided.

For further advice talk to your midwife or visit the NHS website www.nhs.uk/conditions/pregnancy-and-baby/pages/healthy-pregnancy-diet

If you are on any regular medications please discuss this with your GP/midwife.

If you are taking thyroxine you will need a review of medication as early as possible. Please see your GP.

Folic acid has been shown to help prevent abnormalities in babies, e.g. spina bifida. The recommended dose is 0.4 mg per day for at least eight weeks before pregnancy (pre-conception), and for up to 12 weeks into the pregnancy. If you have diabetes, or have a family history of fetal abnormalities, the recommended dose is 5mg per day.

Other vitamin supplements should only be taken after checking with your midwife or GP.

Vitamin A should NOT be taken in pregnancy.

We get a small amount of Vitamin D from our diet, but the best source of Vitamin D is from exposure to sunlight. Your midwife or GP will give you information on getting enough Vitamin D in your pregnancy.

Caffeine is a stimulant that can be found in tea, coffee and cola drinks. Too much caffeine should be avoided as it is passed through the placenta and may affect your baby.

Pregnant women and women planning a pregnancy should avoid drinking alcohol in the first three months of pregnancy if possible because it may be associated with an increased risk of miscarriage. If you choose to drink alcohol during your pregnancy you should drink no more than one to two UK units once or twice a week (one unit equals half a pint of ordinary strength lager or beer, or one shot (25ml) of spirits. One small glass of wine is equal to 1.5 UK units). There remains uncertainty regarding a safe level of alcohol consumption in pregnancy, but at this low level there is no evidence of harm to the unborn baby. If you get drunk or binge drink (more than five standard drinks or 7.5 UK units on a single occasion) this may be harmful to your unborn baby and may lead to Fetal Alcohol Syndrome (FAS).

If you are pregnant or are planning to have a baby, knowing the effects of drinking alcohol on your baby’s development in the uterus (womb) may be helpful. For more information please read the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines on Alcohol and pregnancy here

Recreational drugs should not be taken during pregnancy as they may seriously harm you and your baby. Over the counter medicines should also be avoided, but you can discuss these with your pharmacist.

Cannabis smoking can have similar effects on the lungs as smoking tobacco and may also be harmful to your baby.

When you smoke tobacco, carbon monoxide, nicotine and other toxic chemicals cross the placenta directly into your baby’s blood stream - so your baby smokes with you! This will reduce your baby's oxygen and nourishment and put your baby at risk of low birth weight, premature birth and other problems. The sooner you stop smoking the better, to give your baby a better healthy start in life.

North Bristol NHS Trust has a no smoking policy within our premises and grounds. Your midwife can refer you to your local stop smoking service or call the NHS Pregnancy Smoking Helpline for advice and support on 0800 1690169.

National guidance is that all women who smoke are referred to local support to stop smoking.

For more information visit:

www.rcog.org.uk

Carbon monoxide screening

Having a smokefree home

The harms of smoking in pregnancy

When you travel by car you should always wear a three-point seatbelt with the diagonal strap across your body between your breasts and the lap belt over your upper thighs. The strap then lies above and below your ‘bump’, not over it. Also, make sure all baby/child seats are fitted correctly according to British Safety Standards. If you are planning to travel abroad, you should discuss flying, vaccinations and travel insurance with your midwife or doctor. Travel by air and any long distance travel when pregnant can increase the risk of deep vein thrombosis. You may be able to reduce the risk by wearing correctly fitted compression stockings.

For health advice on returning from a country or area with risk for Zika virus transmission visit assets.publishing.service.gov.uk

Some women find pregnancy to be a time of increased stress and physical discomfort. It can greatly affect your emotional state, your body image and relationship with others. If you feel anxious or worried about anything, or if you have in the last month felt down, depressed or hopeless, or been bothered about having little interest or pleasure in doing things, discuss this in confidence with your midwife or GP.

There is no evidence that sexual activity is harmful while you are pregnant, unless you are advised otherwise.

Keep up your normal daily physical activity or exercise for as long as you feel comfortable. Don’t exhaust yourself and remember that you may need to slow down as your pregnancy progresses or if advised to do so by your midwife or GP. Some vigorous activities such as contact sports, racquet games and scuba diving should be avoided. Bristol Girls Can is a local campaign with the aim of breaking down the barriers around exercise and inspiring more women to get active in the city. Visit www.bristolgirlscan.co.uk or find them on facebook at www.facebook.com/BristolGirlsCan

Bristol City Council has generously donated some of its inspiring collection of images from the Bristol Girls Can campaign to North Bristol Trust. Bristol Girls Can celebrates some of the amazing ways women in our city fit exercise into their lives, no matter how they do it, how they look or how sweaty they get! The selection in the Percy Philips ward and Quantock corridor shows how local women are managing to exercise ante-natally, post-natally and what good role models they are for their children. Meet the women, read their stories and be inspired at: www.bristolgirlscan.co.uk

For more information on physical activity during pregnancy download 

Although you will be putting on weight in pregnancy as your baby grows, limiting the amount of extra weight gain in pregnancy will improve your health and your baby's, both now and in the future. Visit www.tommys.org for more information.

Doing pelvic floor exercises through pregnancy, especially if it is your first pregnancy, can help reduce the likelihood of you leaking urine after you have had your baby. You can get more information from your midwife, physiotherapist or visit www.tommys.org/pregnancy-information/im-pregnant/exercise-pregnancy/pelvic-floor-exercises.

One in four women experience domestic abuse at some point in their lives, and many cases start during pregnancy. It can take many forms, including physical, sexual, mental or emotional abuse. Where abuse already exists, it has been shown that it may worsen during pregnancy and after the birth. Domestic abuse can lead to serious complications which affect you and your baby. You can speak in confidence to your healthcare team who can offer help and support. You may prefer to contact a support agency such as Women’s Aid telephone 0808 2000 247.

Contact your local DSS office for a booklet on the government’s latest provision on maternity rights and benefits and discuss your options with your personnel officer or employer early in pregnancy; ensure everything is in writing prior to commencing your maternity leave. Your midwife will supply you with a maternity certificate after 21 weeks of pregnancy (Mat B1) to allow you to claim your entitlement. This will need to be photocopied if needed for other agencies. An FW8 certificate will be issued in early pregnancy entitling you to free prescriptions and dental treatment. Please speak to your midwife regarding other benefits you may be entitled to.

For more information visit www.gov.uk/employers-maternity-pay-leave

Pregnant employees have 4 main legal rights:

• paid time off for antenatal care
• maternity leave
• maternity pay or maternity allowance
• protection against unfair treatment, discrimination or dismissal

For more information visit:

www.gov.uk

www.maternity action.org.uk

On advice from the Department of Health we and your GP recommend all pregnant women to have the seasonal influenza vaccination. The reason for this advice is that we know that when pregnant women catch influenza they are more likely to develop severe symptoms and complications and more frequently require admission to hospital than women who are not pregnant.

It is safe to give seasonal flu vaccine at any stage of pregnancy. Having the vaccination whilst you are pregnant will also protect your baby for the first four to six months of their life, as the protective antibodies you produce will also be transferred to your baby.

Vaccinations for pregnant women are available in Antenatal Clinic. Please ask at reception for more details when you check in for your appointment.

For more information visit www.nhs.uk/conditions/Flu-jab/Pages/Introduction

You can help protect your baby by getting vaccinated against Whooping Cough – ideally from 16 weeks up to 32 weeks pregnant. Vaccination will be available at Antenatal Clinic after your 18 - 20+6 week scan. For more information visit www.nhs.uk/conditions/pregnancy-and-baby/pages/whooping-cough-vaccination-pregnant

A pressure injury, also referred to as a pressure ulcer or bed sore, is an area of damaged skin or underlying tissue that develops when constant pressure on a part of the body shuts down the blood vessels feeding that area.

Simple steps to help you to prevent pressure injuries:

Skin inspection: Check every day for marks, especially your bottom, heels and bony parts. Let the staff know if you have any existing skin problems or damage.

Surface: Surfaces you are sitting on should not be hard or causing marks, again let the staff know if you are starting to see marks.

Keep moving: Keep changing position, let the staff know if require help to move.

Moisture: Sweat or moisture can damage the skin, please ask the staff if you feel you need clean pads.

Nutrition/hydration: Eat and drink well.

Remember

Any concerns please speak to a member of staff.

For more information visit www.nbt.nhs.uk

When pregnancy is confirmed, or if you have had a baby in the last 12 months, you may get free prescriptions. However, you must have a valid maternity exemption certificate before you are entitled to free prescriptions.

Group B Streptococcus (GBS) in pregnancy and newborn babies

• Group B Streptococcus (GBS) is one of the many bacteria that normally live in our bodies and which usually cause no harm.
• Screening for GBS is not routinely offered to all pregnant women in the UK.
• If you carry GBS, most of the time your baby will be born safely and will not develop an infection. However, it can rarely cause serious infection such as sepsis, pneumonia or meningitis.
• Most early-onset GBS infections are preventable.
• If GBS is found in your urine, vagina or rectum (bowel) during your current pregnancy, or if you have previously had a baby affected by GBS infection, you should be offered antibiotics in labour to reduce the small risk of this infection to your baby.
• The risk of your baby becoming unwell with GBS infection is increased if your baby is born preterm, if you have a temperature while you are in labour, or if your waters break before you go into labour.
• If your newborn baby develops signs of GBS infection, they should be treated with antibiotics straight away.

The full Royal College of Obstetricians and gynaecologists (RCOG) has guidelines and current UK recommendations for preventing Group B Streptococcus (GBS) infection in newborn babies.

What is anaemia?

Anaemia is the result of either not having enough red cells to take oxygen around the body, or having faulty red cells that are unable to carry enough oxygen. It is measured in the blood by the level of haemoglobin, sometimes called ‘Hb’.

Blood is a complex fluid containing lots of proteins and a number of different types of cell to help our body to function correctly. These cells include white cells to help fight infection, platelets to help form clots when we bleed and red cells to carry oxygen. Oxygen is carried by the red cells to all our organs, such as the brain, heart, kidneys, liver and tissues such as muscle, to convert food into energy for the body to work. Red blood cells last about 120 days so the body has to constantly make new ones in the bone marrow to replace them.

What are the signs and symptoms of anaemia?

The following can be features of anaemia:

• Fatigue/tiredness
• Shortness of breath
• Dizziness
• Fast or irregular heartbeat
• Pounding or “whooshing” in your ears
• Headache
• Cold hands or feet
• Pale or yellow skin
• Chest pain
• Lack of concentration.

Are there different types of anaemia?

Yes, there are many different types of anaemia and they require different treatments. Some of the commonest types are listed below.

Anaemia due to an under-production of red cells can have different causes including:

• A shortage of iron or vitamins: Iron deficiency anaemia is common. It is caused by a lack of iron in the body. There might be a problem with not having enough iron in your diet or in absorbing it from your diet or you might have used it all up during pregnancy, surgery or because of bleeding
• Vitamin B12 or Folate deficiency: this is usually as a result of inadequate intake in food or more commonly the inability of the body to absorb it. Examples of the latter include pernicious anaemia and coeliac disease
• Anaemia of chronic illness: this is also sometimes called ‘functional iron deficiency’. In this case the body has plenty of iron in stores but inflammation caused by chronic illnesses or infections can block access to the iron, so that the bone marrow does not have enough iron available to produce good quality red blood cells. This is more common as we get older.

Anaemia due to a problem in the bone marrow, where red cells are made: this can be caused by many different diseases, for example:

• Patients with kidney failure may be unable to produce the hormone erythropoietin which is the messenger telling the bone marrow to produce more red cells
• Cancer may invade the bone marrow or some drugs such as chemotherapy may also slow down the rate at which red cells are made
• There are other types of bone marrow disease that can cause anaemia such as myelodysplastic syndrome or aplastic anaemia
• Infections can also reduce red cell production.

Anaemia due to inherited disorders: these can affect haemoglobin production, for example thalassaemia.

Anaemia due to excessive destruction of red cells which occurs in immune haemolytic anaemia and inherited disorders such as sickle cell anaemia and sometimes an adverse reaction to certain medications.

Anaemia due to bleeding: this can be severe and sudden such as bleeding from a gastric ulcer or blood loss may be at a slower rate such as due to heavy periods or hidden blood loss from the bowel. When blood loss is slow, the anaemia develops gradually and is often associated with a shortage of iron as the iron is lost from the body.

Am I at risk of anaemia?

Anaemia can be caused in many ways. You are at a higher risk if you are young and have not built up a store of iron, essential vitamins and minerals, have a diet lacking in iron, essential vitamins and minerals, or suffer from certain diseases such as inflammatory bowel disease, bone marrow disorders, chronic illnesses such as rheumatoid arthritis, heart disease, chronic liver diseases or severe infections.

You would also be at risk if you have bowel cancer or have recently had major surgery.

Girls and women having periods can also become anaemic. Pregnant women may become anaemic as the developing fetus takes essential iron for their own development from their mother.

The risk of anaemia also increases with age as our stores of vitamins and minerals decrease.

What tests are done to see if I am anaemic?

Blood Tests

• Full Blood Count – checks the number and quality of red cells in your blood and also measures the haemoglobin
• Vitamin B12 and Folate levels – checks to see if you have enough vitamin B12 and folate in your body to help make red cells
• Ferritin and Iron Saturation levels – checks the amount of iron you have in store (Ferritin) and the amount available to use (Iron Saturation)
• Direct Antiglobulin Test (DAT) demonstrates whether the body’s immune system might be breaking down its own red cells
• Blood chemistry tests to demonstrate whether organs such as the liver and kidneys are working well

Bone marrow biopsy

• This is rarely required and will only be carried out by a specialist in a hospital.

Other investigations

These may include tests to see if there is bleeding somewhere for example:

• Bowel investigations such as colonoscopy (examination of the bowel)
• Endoscopy (examination of the gut)
• Gynaecological (female reproductive system)
• Urinary tract investigations such as cystoscopy (examination of the bladder).

What treatments are available?

There are two general approaches to the treatment of anaemia:

1. Replacement therapy: there are several different types of treatment available which might include oral iron tablets, intravenous iron, iron injections and blood transfusion.
2. Treatment of the underlying problem or disease: these treatments include:

• Drug therapy such as steroids or immunoglobulins to treat an immune problem
• Antibiotics for infections
• Surgery and/or chemotherapy for cancer
• Surgery for example to treat a bleeding problem.

You may wish to discuss which is the best treatment for you with your doctor, nurse or midwife.

Can I help myself?

There are several things you can do to help yourself. These include:

• Eat a healthy diet including fruit, vegetables, eggs, fish or meat and carbohydrates such as potatoes, pasta, rice or bread. NHSBT provide a Patient Information Leaflet called ‘Iron in Your Diet’ to assist you with this, it can be found at the web addresses below
• Talk to your doctor, nurse or midwife if you think you have any of the symptoms of anaemia listed in this leaflet or have noticed blood in your bowel motions or urine or have persistent heavy periods
• Always discuss any alternative medicine, herbal preparation or over the counter treatments for anaemia with a healthcare professional before taking them, as they may react with any prescribed medications.

Patient Blood Management (PBM)

PBM is a new standard of care that focuses on measures to reduce or avoid the need for a blood transfusion if possible. However, if a transfusion is needed, PBM makes sure that patients are given only what they really need and that the transfusion is given safely. There is a NHSBT PBM Patient Information Leaflet available that explains things in more detail so please ask your nurse or doctor for a copy.

Recent studies suggest that if PBM is followed and transfusion is reduced or avoided, patients have fewer complications, faster recoveries and shorter stays in hospital.

During your treatment, a transfusion of red cells or other blood component such as platelets may be required. If so, there are other patient information leaflets available from NHSBT such as “Will I need a blood transfusion?” that may help explain things for you. Please ask your doctor or nurse for a copy of the other leaflets that are suitable for your proposed treatment pathway.

Additional Information

As a precautionary measure to reduce the risk of transmitting variant Creutzfeldt-Jakob Disease (vCJD), people who have received a transfusion of blood or any blood component since 1980 are currently unable to donate blood or blood components.

You may also find the following websites useful:

www.nhs.uk

www.nhsbt.nhs.uk

Why is iron important?

Iron is important because it helps your body to make haemoglobin. Haemoglobin, or ‘Hb’, is the protein found in red blood cells that carries oxygen around your body and gives blood it’s red colour.

What can happen if I have low iron levels?

If the level of iron in your body falls, your red blood cells may not contain enough haemoglobin. At first, you may not notice any difference; however, if the amount of haemoglobin falls further, you may start to feel tired. If the shortage of haemoglobin is more severe, you may feel unusually weak or breathless.

This is called anaemia. There are different types of anaemia but, the most common type is caused by a shortage of iron and called Iron Deficiency Anaemia. Getting enough iron will help your body to work more efficiently and may speed up your recovery following an operation.

Where does iron come from?

You can usually get enough iron from a balanced diet, as it is found in a variety of foods. In the UK the main sources of iron in our diet are cereal, cereal products, meat, meat based foods, and vegetables. We need a regular supply of iron in our diet as it is not easily absorbed by the body.

What causes low iron levels?

If you do not eat enough foods containing iron, your iron levels may be low. Vegans and vegetarians need to take particular care to ensure that they get enough iron in their diet; sources, of iron, other than meat are less easily absorbed by the body.

Sometimes blood loss, for example during an operation, will result in a loss of iron. Girls and women who have heavy periods are more at risk of low iron levels because of their monthly blood loss. Pregnancy can also cause women to have low iron levels. Young children can also sometimes have low iron levels. Please speak to a healthcare professional if you have any questions or concerns about your baby or child.

Which foods are good sources of iron?

A varied and balanced diet should provide an adequate iron intake. The following foods are particularly good sources of iron:

• Lean red meat
• Turkey and chicken
• Liver is rich in iron, but it is NOT recommended for pregnant women because of its high Vitamin A content
• Fish – particularly oily fish which can be frozen or canned (such as mackerel, sardines, and pilchards). Note: Although eating fish is a good source of vitamins and minerals, during pregnancy or breast feeding you should avoid eating some types of fish and limit the amount you eat of others.
• Eggs
• Breakfast cereals – some cereals have been ‘fortified’ with iron
• Pulses and beans – in particular, canned baked beans, chickpeas, and lentils
• Nuts (including peanut butter) and seeds
• Brown rice
• Tofu
• Bread – especially wholemeal or brown bread
• Leafy green vegetables – especially curly kale and broccoli
• Dried fruit – in particular, dried apricots, raisins, and prunes.

What if I am vegetarian or vegan?

Although iron from sources other than meat is more difficult for the body to absorb, if you are following a well-balanced diet you should be able to get enough iron in your diet. Your healthcare professional can give you further advice and, if needed, you can be referred to a dietician.

What can I do to boost my iron levels?

• Try to eat a well-balanced diet, especially if you are pregnant or if you are waiting for an operation
• Vitamin C (sometimes called ascorbic acid) may help the body to absorb iron. To get the most iron from the food you eat, have Vitamin C rich foods with meals; for example, fresh vegetables or fruit, or drinks such as fresh orange juice.

A note about tea! Tea may reduce the absorption of iron from foods. Avoid drinking tea directly before, after, or with meals. Only drink tea in between meals.

If you know you have had low iron levels in the past, tell your healthcare professional so they can arrange a blood test, if necessary, to check your haemoglobin and iron level.

Correcting a shortage of iron may reduce the chances of you needing a blood transfusion.

Do I need to take iron tablets?

Most people should be able to get all the iron they need by eating a varied and balanced diet and should not need to take iron supplements or iron tablets. If the level of iron in your body is very low your doctor may recommend you take a tablet containing iron.

• Iron tablets should only be taken if your doctor has advised you to do so
• Iron tablets can cause constipation or nausea (feeling sick) in some people. Speak to your healthcare professional if you experience any side effects, an alternative treatment may be available. These side effects should settle down over time although, if they are severe, you may be advised to take the tablets with food or shortly after eating to help minimise side effects,. You may also be advised to take less tablets, if you are finding the side effects difficult to cope with.

Additional Information

If you are interested in finding out more about Anaemia please ask your healthcare professional for a copy of our leaflet ‘Anaemia – Patient information’.

You may also find the following websites useful:

www.nhs.uk

www.nhsbt.nhs.uk

For more information on healthy pregnancy visit:

• www.tommys.org/pregnancy
• www.nhs.uk/Conditions/pregnancy-and-baby/pages/pregnancy-and-baby-care
• www.saferpregnancy.org.uk/
• Newborn Immunisations