Get Dr Jasmine Mohd's opinions on your questions! Only approved questions are displayed.
In general the risk of pregnancy loss increases when maternal age approaches her late 30s and beyond. Without knowing the details of your circumstances, general advice would be to maintain an normal BMI as maternal obesity or being significantly underweight is associated with obstetric complications. Also avoid excessive alcohol consumption and exposure to cigarette smoke.
For the male partner, watch issues like smoking, alcohol consumption , exercise habits and body weight as these can affect sperm quality.
You have not mentioned whether there was any histological or chromosomal analysis of the pregnancy tissue at the time of miscarriage. If done, it could possibly give a reason for the miscarriage eg trophoblastic change/molar pregnancy, or a chromosomal disorder. Most chromosomal abnormalities in the conceptus are sporadic and not recurrent.
Please do have a pelvic ultrasound to check for any problems that may have arisen since your last pregnancy which could impact on uterine anatomy eg. endometrial polyps or fibroids.
I would suggest screening for thromobophilia in particular antiphospholipid syndrome if you have not already done so, as low molecular weight heparin and aspirin supplementation started at date of a positive pregnancy test does improve birth outcomes.
I would also recommend screening for subclinical hypothyroidism and presence of thyroid autoantibodies as again supplemetation with levo-thyroxine in these circumstances might improve birth outcomes.
I suggest vitamin D supplementation due to the significant prevalence of Vit D deficiency in women with recurrent pregnancy loss.
The use of progesterone is often used in first trimester to prevent miscarrige but the evidence is mixed. The best data is for the use of oral dydrogesterone (Duphaston). There is no strong data for use of progesterone supplementation for luteal phase deficiency for prevention of miscarriage.
There is no clear evidence for the use of immunotherapy, intravenous immunoglobulin or glucocorticoids in recurrent pregnancy loss.
A significant proportion of cases of recurrent pregnancy loss remain unexplained despite detailed investigation. Do not give up! Please be reassured that the prognosis for a successful future pregnancy with supportive care alone is in the region of 75%.
It is not possible to comment accurately on your sister’s labour as we will not be privy to the exact circumstances of what happened.
In general though, the nurses in all labour wards will help the patient arrange for pain relief if it is required, whether it is in the form of epidural, entonox gas or painkiller injections.
All nurses in labour wards are also highly trained to assess patients in labour and their progress (degree of dilation and descent down the birth canal).
Generally the obstetrician is well aware of the progress of the patient as well, as well as whether she had an epidural placed, via regular checks in person and/or communications with nurses.
Vacuum assisted delivery is not uncommon because of an abnormal fetal heart rate trace at the end, and this can be due to a variety of reasons, prolonged labour being one of them.
It can very well also occur because of the umbilical cord or head compression at the end stage of labour.
The length of labour is variable among individual women, and factors that affect these include:
Possible is one thing, but the risk of rupture is higher than for one previous CSection. Uterine rupture is generally rare, but unpredictable and catastrophic.
The likelihood of successful VBAC would increase if you were in labour and dilated to a significant degree in the earlier pregnancy.
Technically the term natural vaginal delivery in obstetrics refers to the spontaneous birth of a fetus as opposed to an assisted vaginal birth, which means being assisted with forceps or vacuum.
However in common usage these days, a natural birth generally refers to an unmedicated birth, or at least a birth with as minimal intervention as possible. Women who are keen on “natural birth” also tend to decline pain relief options in labour.
This desire for such a birth has in the past two decades or so might represent a push back by some women against what they feel is the over medicalisation of a “natural process”.
For many women who are relatively young, fit, and healthy, birth is generally smooth and uneventful. However we have to bear in mind that “naturally”, things may go awry and very rapidly as well. That's where medical staff have to step in and intervene in order to prevent bad outcomes for mother and/or child.
Of course.. you can change your mind anytime! Should you feel you need pain relief at any point in labour, it can and will be offered to you. The pain relief options in labour include nitrous oxide gas, intramuscular opioid injections as well as an epidural. They are all safe and do not result in any significant risk to the baby and mum unlike what is commonly perceived.
Generally, I tell my patients to come in should they develop regular intense contractions that last for approximately one minute and at a frequency of every five minutes or so; secondly if they develop any significant large amount of bleeding or if their waters break in particular if they have tested positive for group B Streptococcus colonisation.
Yes you can eat small snacks and drink in labour to keep your energy up. However I would avoid having heavy meals as you might feel nauseous and be more prone to vomiting when you do start bearing down in the second stage.
For women in whom it's their first labour (primigravida) there will usually be some degree of tearing. Some first time mums are lucky and have no tear. For multipara (second time mums and above) tearing is usually minimal and some do not tear at all. This is because the soft tissue resistance is less in women have delivered before and secondly the perineum tends to stretch out better in these women as well.
Likelihood of tearing is related to a few factors. These include size of baby, need for assisted delivery with vacuum or forceps, as well as the expulsive forces at the point of delivery itself. Generally slow control pushing right at the point of crowning is preferable as opposed to a sudden strong push.
However during labour it's often difficult for mum to control how she pushes even with guidance. Sometimes the urge to push can be very strong and labour can be precipitate. That means the baby comes out very rapidly and suddenly. The role of the birth attendant, whether it be a midwife or obstetrician, is important in guarding the perineum to control the degree of tearing.
Generally the consensus is that a natural tear is preferable to an episiotomy. In my practice most multiparae do not need an episiotomy. Quite a number of first time mums do not need one if they push well. However natural tears can also be irregular and extensive. In general, with episiotomies, the likelihood of tears around the urethra or clitoris is less.
The overall recommendation is for restricted use of episiotomies. For example it can be useful in women who tend to be very oedematous and swollen at the perineum after prolonged pushing. I also tend to see more frequent vaginal of vulval haematomas in women who have prolonged distension (>20 min) of the perineum by the fetal head in an attempt to avoid a natural tear or episiotomy. Prolonged distension of the perineum is not ideal and may result in tearing of blood vessels within the vagina walls and this may result in severe pain and haematoma collection which requires a surgical procedure to remove the haematoma.
Please do not worry. If you are afraid of pain, there are many good pain relief options that are available to women in labour. The contraction forces in labour can be very intense. Some mums are able to manage this well without pain relief with breathing techniques and keeping calm during labour. Some other pain relief options that my patients use include walking around, water immersion or shower or massage, and working with a birth support person (doulas).
Forceps delivery is sometimes necessary during the second stage when the mum gets too exhausted to push further or if there is significant concern about the baby for example fetal distress which requires the baby to be delivered immediately. I tend to choose forceps when I feel the mum is not pushing well enough or baby is big. If mum is pushing well and there is good descent of the baby but mum still need helps eg with rotation of the foetal head, that's when I decide to use a vacuum extractor instead. Assisted delivery if done by a competent practitioner should not result in trauma to the child.
Therefore the decision for assisted delivery versus Caesarean section in the second stage is a very important one and this depends on the experience and competence of the obstetrician, as well as the mum’s preferences. These discussions should ideally be done prior to the birth during the pregnancy check-ups. This is because during the second stage decisions need to be made very quickly or it may be an emergency situation during which an extended discussion regarding pros and cons of assisted delivery versus Caesarean section may not be possible.
There are a myriad of complications that can occur. Generally the more common ones include
Most women give birth lying down in a supine position (on their back). This is particularly the case if they are on epidural as they will not be able to manage alternative positions well. Some also give birth lying their sides. Alternative birthing positions include squatting and on all fours. These are an option if you are not on epidural as you will be able to maintain your position well. I suggest to explore options with your obstetrician and doing the labour to see what suits you best.
I would recommend birth classes for first-time mums as they would help you be more aware of what to expect doing labour. Secondly, some preparation is of value, as it might help you make better choices during labour.
Bearing down in the second stage will result in you pooping if your rectum is full. To prevent this from happening you can consider having a enema. This is often administered by the nurses when you do present in early labour at the hospital. An enema is safe and it doesn't hurt.
The block from the epidural/spinal should start kicking in within a few minutes of administration of the regional anaesthesia. It is very quick!
Not at all. This is a commonly held misconception. Epidurals are safe and do not result in any long-term or short term risk to mother or child. Sometimes with an epidural you may not have much sensation or urge to push when it comes to the second stage of labour. If this is the case I usually encourage the mum not to bear down until the fetal head has descended passively down the birth canal. Sometimes I may also reduce the epidural infusion rate a little so that the mum can push better.
The other pain relief options include gaseous nitrous oxide (Entonox) and intramuscular opioid injection.
Entonox will make you feel a bit high and takes the edge of the contractions but you will still feel the contractions distinctly.
The injection is more effective than Entonox and is sedating. It lasts for about 3-4 hours. If given too close to the point of delivery it might cause some respiratory depression in the newborn but this is generally rare.
Epidural is the most effective method of pain relief. It is generally administered once you are in active labour and will last all the way through until after delivery when the suturing is completed.
Medisave claim for natural delivery is up to $2550, assisted delivery up to $3050, Caesarean section up to $4400. These are inclusive of a claim of $900 for pre-delivery expenses. Please refer to the Ministry of Health website for further details.
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