Vomiting in early pregnancy: when it isn't normal

By Dr. Goh Shen Li
Obstetrician & Gynaecologist
MBBS, FRCOG (London), FAMS (Singapore)

The majority of pregnant women experience some degree of nausea and vomiting (70–80%) in the first trimester of pregnancy. Its severity can vary from person to person and even during different pregnancies in the same woman.

When the vomiting is severe

Hyperemesis gravidarum (HG) is a condition in pregnancy characterized by extreme nausea, excessive vomiting, weight loss and dehydration, and even fluid and electrolyte imbalances. It affects up to 2–3% of pregnant women.

People don't get HG very often, but nausea and vomiting are common during pregnancy, so it can be hard to tell the difference between this and the more common pregnancy sickness.  (PRODIGY 2008, Festin 2009, HER 2010, Matthews et al 2010, Ogunyemi and Fong 2009) HG usually begins at between 6 and 7 weeks of pregnancy (HER 2010), easing off at 14 to 16 weeks of pregnancy. In many cases, HG will end by 20 weeks of pregnancy. Very few sufferers have symptoms that last the whole pregnancy.

How do I know if this is normal or not?

If you have HG, self-help treatments cannot help much and you feel miserable. You are exhausted and are unable to enjoy the pregnancy. You struggle with day-to-day life and are unable to eat and drink. You find it difficult to swallow your own saliva without vomiting (Ogunyemi and Fong 2009, Suzuiki et al. 2009, HER 2010). You vomit several times a day, and you are losing weight.

Recognise the following signs and symptoms - (HER 2010)

• Loss of 5% or more of pre-pregnancy body weight
• Dehydration, causing metabolite disturbances and constipation
• Nutritional disorders such vitamin deficiencies
• Physical and emotional stress of pregnancy on the body
• Difficulty with activities of daily living
• Severe nausea and vomiting
• Food aversions
• Decrease in urination
• Headaches
• Confusion/ fainting
• Jaundice
• Extreme fatigue
• Low blood pressure
• Rapid heart rate
• Loss of skin elasticity
• Secondary anxiety/depression

Hunger, tiredness, prenatal vitamins (especially those with iron), and diet can all make symptoms worse. Some women with HG lose as much as 10% of their body weight. They are also very sensitive to smells around them, and some smells can make their symptoms worse.

Morning Sickness:	Hyperemesis Gravidarum:
Nausea sometimes accompanied by vomiting	Nausea accompanied by severe vomiting
Nausea that subsides at 12 weeks or soon after	Nausea that does not subside
Vomiting that does not cause severe dehydration	Vomiting that causes severe dehydration
Vomiting that allows you to keep at least some food down	Vomiting that does not allow you to keep any food down at all

Why does this happen?

There are theories that suggest HG is due to a combination of factors, which may vary among women and include genetics, body chemistry, and overall health.

One theory is an adverse reaction to the hormonal changes of pregnancy. This would explain why HG happens most often in the first trimester (often between 8 and 12 weeks of pregnancy), when the levels of the pregnancy hormone (hCG) are the highest. Another postulation is an increase in maternal levels of female hormones in the body, leading to slower digestion and delayed passage of food from the stomach to the intestines, thus increasing the nausea and vomiting.

Risk factors for HG

• Hyperemesis gravidarum during a previous pregnancy
• Being overweight
• Having a twin pregnancy
• Being a first-time mother or young mother
• Being prone to motion sickness or migraines
• Pre-existing liver disease
• The presence of trophoblastic disease, which involves the abnormal growth of cells inside a woman's uterus e.g. molar pregnancy

Will my baby be in danger?

HG is physically and emotionally stressful, but it is also important to know that if it is treated, it is extremely unlikely that your baby will be malnourished or harmed (PRODIGY 2008, Festin 2009). Most studies show no health or developmental differences between infants of women who experienced the condition and those who did not.

If you lose weight during your pregnancy, there is an increased risk that the birthweight of the baby may be less than average. However, almost all women regain the weight they had lost in the early stages of pregnancy, usually during the second trimester, and go on to put on enough weight by the time of delivery.

Management of HG - what can be done?

• There is no known prevention of HG but you can take comfort in knowing that there are ways to manage it. All drugs should be used with care in pregnancy, especially in your first trimester, but many anti-nausea medications have a good safety record and have not been shown to have ill-effects on babies (PRODIGY 2008). Consider asking your doctor for anti-nausea medications to help you cope.
• Mild cases are treated with dietary changes, rest and oral medications. More severe cases often require a stay in the hospital so that the mother can receive fluid and nutrition through an intravenous line (IV).

Treatment depends on how ill a woman is and might include:

• Trying vitamin B6, and/or ginger.
• Small frequent meals—Nausea and vomiting might be treated with dry foods (such as crackers), small frequent meals and emotional support.
• Intravenous (IV) fluids—It is important for a pregnant woman to maintain her fluid intake. IV fluids might be needed if a woman continues to vomit throughout the pregnancy or does not improve with oral medications. In severe cases, hospitalisation is required for continued IV fluids and vitamins can be added into the IV fluids. IV fluids might be discontinued when a woman is able to take in fluids by mouth.
• Medicines — Medication to reduce nausea is used when vomiting is so persistent that it may pose possible risks to the mother or baby. If a woman cannot take medicines by mouth, the drugs can be administered through an IV or a rectal suppository. Common medicines used to alleviate nausea include promethazine, metoclopramide, prochlorperazine, and dimenhydrinate. If you are also heaving gastric reflux, anti-reflux medications can be given together as well. (HER 2010)
• Doing urine and blood tests to monitor the degree of dehydration and electrolyte levels e.g. sodium and potassium, and if abnormal, corrected with supplementation.

What next?

After IV rehydration is completed, you can progress to frequent small liquids or bland meals. Treatment then focuses on managing symptoms to allow normal food intake. However, cycles of dehydration can recur, making continuing care or repeated hospitalization necessary. (NHS 2010)

• Stay hydrated by taking small sips of fluid, or by sucking ice cubes (NHS 2010) or lollipops.
• Eat whatever you can manage or like. Do not worry if it is not a balanced diet or your regular meal. You can always catch up on good nutrition later, as your baby will get her nourishment from your body’s current reserves.
• Tweaking your diet to eliminate fatty and spicy foods, which are more likely to cause nausea
• Avoiding smells or tastes that tend to set you of.
• If you do not have severe anemia, wait until the nausea has improved before starting iron supplements.
• Try natural remedies such as ginger and peppermint alongside medical treatments (NCCWCH 2008, Festin 2009)
• Get as much rest as you can. Tiredness can make nausea and vomiting worse (NHS 2010), and make you feel unable to cope with the pregnancy. (PRODIGY 2008)

The gift of life

By Dr. Choo Wan Ling
Consultant, Obstetrician & Gynaecologist
MBBS (Singapore), M.Med (O&G), FAMS

From conceiving to delivering

Having a baby is truly remarkable. From mutual love that creates new life, to the very first kick in your belly, and ultimately to the climacteric birth of your baby, the journey is nothing short of a miracle. While your joy is immense, it is only natural to have concerns at any point during this life-changing experience. For instance, you may be anxious to conceive or be apprehensive about childbirth.

Difficulty in conceiving: are there simpler treatments before in-vitro fertilization (IVF)?

As a woman ages, her chances of conceiving are slimmer, particularly above the age of 35.

For women, the common causes of infertility include ovulation problems, blocked or unhealthy fallopian tubes, and endometriosis.

For men, problems with hormones and genes, heavy smoking, varicocele, and infections can all cause sperm to be missing, too few, or not work right.

Treatment would involve resolving the abnormalities and individualising therapies to obtain the simplest, cheapest, and safest modality with reasonable success.

Options would include:

1. Better understanding of the fertile period

• Knowledge and timing of the fertile period is essential, coupled with frequent sexual intercourse. Timed sex with ovulation – predicted from urine tests and a good menstrual calendar – may improve conception rates.

2. Treating underlying hormonal disorders

• 80-90% of women achieve ovulation once hormonal abnormalities are corrected, increasing the chance of conception
• This can be achieved with fertility drugs ranging from oral medications to injections to boost ovulation.

3. Intrauterine insemination

• Chances of conception can be further improved with intrauterine insemination in cases where there is mild sperm defect. This is a simple procedure where washed sperms are flushed into the womb at the time of ovulation.

4. Corrective surgery

• Depending on the damage to the fallopian tubes, tubal surgery may be helpful. Success of pregnancy following tubal surgery is variable. Compared to IVF, surgery is a one time treatment with a higher potential for long term fertility. Surgery in endometriosis improves fertility rates but not back to normal levels.

5. IVF

• Simpler options should be considered first before IVF but it may be needed for severely damaged fallopian tubes, significant endometriosis and considerable sperm abnormalities. Concerns surrounding IVF include cost, psychological, emotional and physical stress, higher risk of multiple pregnancies and premature birth.

Successful conception hinges on a myriad of factors concerning both partners. Do talk to a doctor if you and your partner have been having regular, frequent, unprotected sex for a year and still can't get pregnant.

Is my baby normal?

With increasing educational and socio-economic status, there is a trend towards deferred child bearing. The problems associated with late maternal pregnancy include maternal and fetal problems.

Firstly, there is an increased risk of miscarriage. There is also an increased risk of chromosomal abnormalities. The most common chromosomal abnormality is Down’s syndrome, which can be screened for in all pregnant women.

This screening test can be done between 11 and 13 weeks of pregnancy via a blood test and an ultrasound scan to measure the neck fold thickness and look for the nasal bone. It does not carry any risks to the fetus. This allows mothers the time to make an early choice about the pregnancy should an abnormality be detected. Confirmatory tests for Down’s syndrome include amniocentesis, which can be performed between 16 and 20 weeks of gestation, or chorionic villus sampling, which can be performed from the 11^th week.  Both confirmatory tests, however, are associated with a small risk of miscarriage.

Medical conditions like gestational diabetes and hypertension are more common in older mothers. Older mothers may also tend to have more problems in labour.

Even though having a baby when a mother is older poses more risks to the pregnancy, these risks can be managed by keeping a close eye on the mother during pregnancy and labor to reduce the chances of complications.

Pregnancy and dental health

By Dr. Tan Su Wee

While it is an old wives' tale that calcium is lost from a mother's teeth and "one tooth is lost with every pregnancy", changes experienced in your oral health during pregnancy may dramatically affect the way your dentition looks, feels, and functions. This is chiefly due to a surge in hormones; particularly an increase in oestrogen and progesterone, which can exaggerate the way gum tissues react to plaque.

How does a build-up of plaque affect me?

Poor oral hygiene results in a steady accumulation of plaque. The bacterium it brings about irritates our gum tissues, causing gum disease. In pregnancy, the effects of gingivitis are more pronounced. “Pregnancy gingivitis” causes red, swollen, tender gums that are more likely to bleed. Also, gum disease moves faster from gingivitis to periodontitis, which is an advanced form of gum disease that causes damage to our teeth and their supporting structures that can't be fixed.

Pregnancy Gingivitis might surface as early as the second month of pregnancy and can lead to significant discomfort and pain. Potential gum problems should be combatted with meticulous cleaning habits.

Pregnant women are also at risk for developing pregnancy epulis, an inflammatory, non-cancerous fleshy growth that develops when swollen gums become irritated. They do not usually require treatment and will shrink on their own after delivery. However, if it interferes with chewing, brushing, or other oral hygiene procedures, your dentist may decide to remove it.

How can I prevent these problems?

Brush with fluoride toothpaste twice daily and floss thoroughly. If you experience morning sickness and bouts of frequent vomiting, rinse your mouth with fluoride mouthwash followed by a generous application of re-mineralising tooth mousse afterwards to prevent erosion of your tooth structure. These products are available at your dentist. Regular checks (each trimester) and cleanings at the dentist during the 2nd trimester will also help control plaque, prevent gingivitis, and detect dental problems early. Good nutrition—particularly plenty of vitamin C and B12—will help keep the oral cavity healthy and strong.

When should I see my dentist?

If you are planning to become pregnant, schedule a routine check with your dentist. He/she will assess your oral condition and treat all dental problems prior to pregnancy.

If you are pregnant, make sure to let your dentist know prior to any dental visit. It is best to have a routine visual exam every trimester to check for any problems and to clean during the second trimester of your pregnancy. This is because the first three months of pregnancy are thought to be of the greatest importance in your child's development. Stress associated with dental visits may increase the incidence of prenatal complications during the last trimester.

Inform your dentist of all the names and dosages of drugs you are taking, including medications and prenatal vitamins prescribed by your doctor. Any specific medical advice your doctor has given you should also be communicated. Your dentist may need to alter your dental treatment plan based on this information. Certain drugs, such as tetracycline, can affect the development of your child's teeth and should not be given during pregnancy.

Do not skip routine dental checks because you are pregnant. Because of the way hormones change during pregnancy, it's important to get regular periodontal (gum) exams to stop gum problems from getting worse quickly. Pay particular attention to any changes in your gums during pregnancy. If tenderness, bleeding, or gum swelling occurs at any time during your pregnancy, seek help from your dentist as soon as possible.

Are there any dental procedures I should avoid?

The best time for routine dental treatment is the fourth through sixth months. Dental emergencies that cause a lot of pain can be treated at any point during a woman's pregnancy. However, your obstetrician should be consulted if you need anaesthesia or if you are given medicine. Treatments that aren't necessary, like getting your teeth whitened or getting other cosmetic work done, should wait until after the baby is born. It is best to avoid cosmetic dental work while pregnant to keep the developing baby from being exposed to any risks, no matter how small.

Routine x-rays (radiographs) taken at yearly intervals to screen for cavities should be postponed until after birth. In certain dental emergencies, such as extractions, radiographs might be necessary for diagnosis and treatment of the pregnant patient. According to the American College of Radiology, no single diagnostic x-ray has a radiation dose significant enough to cause adverse effects on a developing embryo or foetus.

Some tips to make your dental visits comfortable

• Maintain healthy circulation by keeping your legs uncrossed while you sit in the dental chair
• Take a pillow to help keep you and the baby more comfortable
• Bring headphones and some of your favourite music

Can oral health have an effect on pregnancy?

There is increasing evidence supporting a link between gum disease and premature, underweight births. Pregnant women who have gum disease may be more likely to have a baby that is born too early and too small. More research is needed to confirm how dental diseases affect pregnancy outcomes.

Eating right for your teeth and baby

Although cravings for sugary snacks and treats are common during pregnancy, they should be avoided as much as possible. Keep in mind that the more frequently you snack, the greater the chances of developing tooth decay. Also, many studies have shown that the bacteria that cause cavities are passed from the mother to the child. Your baby's first teeth begin to develop about three months into pregnancy. Therefore, a healthy and balanced diet will ensure your baby has strong, healthy teeth. Well-balanced meals comprising dairy products such as cheese and yogurt are a good source of the essential minerals needed for a baby's developing teeth, gums, and bones.

After you have had your baby

If you had gum problems during your pregnancy, see your dentist as soon as possible after giving birth to have your entire mouth examined and your periodontal health evaluated.

Putting more focus on dental health and good oral hygiene habits during pregnancy will help both mother and child have healthy smiles for the rest of their lives.

Fibroids and pregnancy

By Dr. Wee Horng Yen
Obstetrician and Gynaecologist
MB BCh BAO (Dublin), MRCOG (London), FAMS (Singapore)

What are fibroids? 

Fibroids are non-cancerous tumours that grow in or around the womb (uterus) and are very common. The growths are made up of muscle and fibrous tissue and vary in size from under 1 cm to over 20 cm. Fibroids are sometimes known as uterine myomas or fibromyomas.

Many women are unaware that they have fibroids as they do not have any symptoms. This often means that fibroids are diagnosed by chance during a routine gynaecological examination, test, or scan.

However, larger fibroids may cause swelling in the lower tummy, pain, difficulty passing urine, a feeling of bulge while bending or constipation.  If the fibroid impinges on the uterine cavity (the area where the baby grows), it may cause difficulty conceiving, miscarriage, or heavy and painful periods. 

Fibroids that cause difficulties in conceiving require treatment.  Surgery is the mainstay of treatment. Surgery can be performed using a keyhole or a traditional open (bikini line cut).  If the fibroids are only in the uterine cavity, a hysteroscope can be used to remove them through the vaginal route without leaving any scars.

Patients whose fibroids are not too large may be offered keyhole surgery.  Rarely in Singapore do patients present with fibroids that are very large, over 15 cm; occasionally a midline scar is needed for access to the tumour.

Keyhole surgery has the advantages of less pain, a shorter stay in hospital, and smaller scars.

After surgery, the surgeon will advise the patient on the duration of rest before they may conceive.  This may be any time after three months post-surgery.  Some patients will require a caesarean section for all future deliveries after fibroids are removed.  This is to prevent rupture of the uterine scar during labour.

In the longer term, fibroids may recur, requiring future surgery.

Fibroids during pregnancy

One of the more common complications of large fibroids in pregnancy is “red degeneration”.  This can cause moderate to severe pain and may be hard to tell apart from contractions of the uterus.  When blood goes to the growing baby instead of the fibroid, red degeneration can happen.  The reduction in blood and oxygen to the fibroid causes pain and the fibroids may shrink.

Rarely, fibroids within the uterine cavity may cause miscarriage. Very large fibroids may be associated with preterm birth. The majority of fibroids remain about the same size throughout pregnancy and do not cause major complications.

As long as the fibroid is not physically obstructing the passage of the baby, women with fibroids may undergo natural birth.

Fibroids noted at caesarean section 

It is not routine to remove fibroids at caesarean delivery.  This is because of the increased risk of bleeding in doing so. The exception is when the fibroids are “sticking out” or at the surface.  In these cases, the base of the fibroid is much smaller and it may be safely removed.

Reducing breast engorgement with cabbage leaves & gel packs

By Dr Wong Boh Boi

Founder and Senior ParentCraft Consultant

Wong Boh Boi Pte Ltd 

Breast engorgement is one of the common problems experienced by mummies after the birth of their children. It is the feeling of tightness in your breast that can result in hardness and pain. There are multiple theories behind this phenomenon, and the most popular belief is that there is an increase in milk production. If you have it, you are not alone. In fact, studies have found that 20–70% of women experience breast engorgement.^1,2 

There have been many traditional methods that have been explored in the past, including methods like breast massage.

To help relieve these common symptoms, Dr Wong experimented with the use of cabbage leaves and cold gel packs.³ The study was published in the top international nursing journal (International Journal of Nursing Studies). We would like to share the findings of the study in this article.

How was the study conducted?

A randomised controlled trial was conducted, and 227 mothers were divided into three groups:

Group 1: Cold cabbage leaves application plus routine care by the hospital
Group 2: Cold gel packs application plus routine care by the hospital
Group 3: Control group which received routine care by the hospital only

*Routine care includes education on breastfeeding during antenatal classes, daily in-house postnatal teaching classes, and during rounds conducted by lactation consultants. Lactation consultants also help to rectify problems during breastfeeding. Pain management may include: 1) Paracetamol 500mg (two tablets of 250mg) three times a day; 2) Synflex 550mg (2 tablets of 275mg) two times a day; or 3) Ponstan 500mg (2 tablets of 250mg) three times a day.

This was the study flow and data collection point

The first application of cabbage leaves or gel pack
a. Data collection after 30 minutes
b. Data collection after 60 minutes
c. Data collection after 120 minutes

The second application of cabbage leave or gel pack
a. Data collection after 30 minutes
b. Data collection after 60 minutes
c. Data collection after 120 minutes

Results

Cabbage leaves were found to be most effective in relieving pain and hardness. Gel packs were also helpful to some extent. Mothers who used cabbage leaves were most satisfied, followed by those who used gel packs.

Total scores for the 3 groups:
Cabbage leaves – 4 points
Gel packs – 2 points
Routine care – 0 point

Now we know that cabbage leaves are most effective, let us teach you how to apply the cabbage leaves.

1. The cabbage leaves can be the common green cabbages (Brassica oleracea).
2. Remove the hard stem of the cabbage leaves.
3. Rinsed the cabbage leaves in cold water and chill in the freezer for 15 minutes in a zip lock freezer bag or in the fridge for 1 hour before application.
4. Apply 3 big leaves (preferably the outmost leaves) on top of each other on each breast, and cover the entire breast with the leaves. Support the leaves by wearing a bra.
5. Leave it on for two hours, or until the cabbage loses its coldness. You may use a new set of cabbage leaves thereafter.
6. Eat the rest of the cabbage! ?

Cabbage leaves preparation

How does cabbage leaves help to reduce breast engorgement?

There is no definitive answer to this. However, we hypothesise that it is due to cabbage leaves containing enzymes such as sinigrin and rapine, which have proven to be a good source of antioxidants.^3,4 The sulfur compound in cabbage leaves has antiseptic, disinfectant, antibacterial, and anti-inflammatory properties, which may support their use to ease pain and swelling.⁶ Having the cabbage leaves chilled can also increase its effectiveness.⁷

References

1.Spitz IM, Bardin CW, Benton L, Robbins A. Early pregnancy termination with mifepristone and misoprostol in the United States. N Engl J Med. 1998, 338(18), 1241-1247.
2. Walker M. Breastfeeding and engorgement. Breastfeeding Abstracts. 2000, 20 (2), 11-12.
3. Wong BB, Can YH, Leow MQH, Lu Y, Chong YS, Koh SSL, He H. Application of cabbage leaves compared to gel packs for mothers with breast engorgement: Randomised controlled trial. International Journal of Nursing Studies. 2017; 76: 92-9.
4. Joy J. A study to evaluate the effectiveness of chilled cabbage leaves application for relief of breast engorgement in volunteered postnatal mothers who are admitted in maternity ward of selected hospital in Belgium. 2013. Masters’ thesis. KLE University.
5. Nilnakara S, Chiewchan N, Devahastin S. Production of antioxidant dietary fibre powder from cabbage outer leaves. Food Bioprod Process. 2009, 87 (4), 301–307.
6. Hatfield G. Encyclopaedia of folk medicine: old world and new world traditions. 2004. ABC-CLIO, California. pp. 59-60.
7. Rosier W. Cold cabbage compresses. Breastfeed. 1988. Rev 12, 28-31.

Quick guide to morning sickness in pregnancy

By Dr. John Yam
Obstetrician & Gynaecologist
MBBS, FRCOG, MMED, FAMS

"Morning sickness" is a term used to describe the nausea and vomiting that occur during pregnancy. It affects about 75% of pregnant women and, despite it being called morning sickness, it can happen at any time of the day.

The good news for most expectant moms is that morning sickness is mild and tends to get better during the last 12 to 14 weeks of pregnancy. But there are some women who have it for a longer time, and sometimes they have it the whole time they are pregnant.

Hyperemesis Gravidarum is a severe form of morning sickness that only a small number of women who are expecting get. It is a condition where nausea and vomiting are so severe that they cause dehydration, resulting in the loss of more than 5% of the pre-pregnancy body weight. Hyperemesis gravidarum may require hospitalization and treatment with intravenous (IV) fluids and medications.

In most cases, morning sickness is mild and does not require any treatment. An expectant mother’s experience with morning sickness will vary. The symptoms can vary between pregnancies as well; while you might experience severe symptoms in one pregnancy, the next one might be a breeze!

COMMONLY ASKED QUESTIONS:

1. What causes morning sickness? 

There is no known single cause. Many factors could play a part in triggering the feeling of nausea. Some people think that the rising level of the pregnancy hormone (hCG) is one of them.  Higher levels of the hormones estrogen and progesterone, as well as reduced blood sugar, may also aggravate symptoms.

Other factors and triggers include:

• Sensitivity to smell: you could keep tabs on what triggers your symptoms and try to avoid these triggers
• Pre-existing motion sickness: this could worsen during pregnancy
• Stress can initiate or aggravate digestive issues
• Physical and mental fatigue
• Certain medical conditions could be associated with increased symptoms of nausea, such as thyroid issues, urinary tract infections
• If you are pregnant with more than one baby, chances are you could have more than your share of symptoms than you might have had if you were carrying just one

2. Will that affect my baby's growth? 

You may not be feeling your best, and you may not be eating as much as you did before pregnancy, but this is usually not a problem.

In the first trimester, your baby gets most of her nourishment from your body’s reserves. Retching and vomiting will not cause any physical harm to the baby, and your appetite should improve by the end of the first trimester.

However, if you have lost more than 5% of your pre-pregnancy weight and your appetite has not picked up (not able to eat or drink anything), it is imperative to consult your doctor.

3. Any tips to cope with it? 

Every woman has a different experience with morning sickness. There is no one-size-fits-all solution. However, lucky for you, there are some ways to alleviate the symptoms.

a. Diet

• Stick to foods & beverages that appeal to you for now. Avoid eating, smelling or even thinking of foods that may trigger the nausea. Even if that means you might be eating the same few dishes frequently.
• Eating small, frequent meals at regular intervals may help to ease the symptoms.
• Eat early! Morning sickness may kick in the moment you are out of bed or even when you are brushing your teeth in the morning. Nausea is likely to strike when your tummy is empty after a long night’s sleep. Try to stock up some healthy snacks like cereals, crackers or nuts by your bedside so you have something to munch on the moment you open your eyes.
• Try a light, healthy supper before bed. Try snacking on complex carbs and something high in protein – e.g. Whole grain meal, a glass of milk, almond nuts, freeze dried fruits.
• Eat nutrient-dense foods! Plan your diet to include protein and complex carbohydrates.

b. Fluid

It is important to get sufficient fluids. Drink plenty of fluids at regular intervals to avoid dehydration. If water is not appealing to you, try sucking on a popsicle instead. Fruit juices are a tasty alternative too.

c. Supplements

Take your prescribed prenatal vitamins. These will help compensate for any nutrients that may be lacking.

d. Ginger

A traditional folk remedy that has stood the test of time. Sucking on fresh or preserved ginger slices, sipping on ginger ale, or even a cup of ginger tea might ease the queasiness.

e. Acupressure wristbands

Some pregnant women swear by the effectiveness of these. This drug-free solution has no side effects and is available at most pharmacies.

 f. Get plenty of rest

Nausea gets worse with fatigue and stress.

g. Get help from your obstetrician

Keep anti-sickness medicine on standby in case you feel unwell.

4. Is my pregnancy normal if I have no morning sickness?

Not all expectant mums experience morning sickness, so lucky for you. There is no way to tell if a pregnancy is normal based on whether or not a woman has morning sickness.

How to choose a maternity insurance plan?

Every couple wishes for a smooth, safe pregnancy and delivery of their baby. However, they might be worried about the complications at birth and other concerns that may instill the purchase of maternity insurance. Here is a list of some information that you might find useful in the course of finding a suitable one.

What is maternity insurance and are there different types?

There are basically two types of maternity insurance that will cover an expectant mother during her pregnancy journey:

1. Covers the costs of delivery
   Maternity insurance covers the costs of delivery. However, the coverage varies from individual to another individual. You would expect to pay a hefty price tag for one that requires higher coverage, such as a rider or an international medical plan for expats. Comparing this to our local integrated plans (IP) or group insurance provided by your employers, prices would be more affordable. However, do take note that the coverage does differ.
   
2. Covers the costs of specific pregnancy complications and congenital conditions
   Larger life insurers such as AIA, AXA, GE and Prudential would be able to cover mothers for pregnancy complications and congenital disorders. Alternatively, you automatically receive such free coverage if you decide to store your child’s cord blood with Cordlife.

What does maternity insurance cover?

1. Common conditions
   Maternity insurance covers common complications and conditions for both mother and child that will require treatments which are not normally covered by their personal medical insurance or employee benefit insurance. The common child congenital conditions are Down syndrome, cerebral palsy or cleft lip. As for mothers, the common complications covered are pre-eclampsia/eclampsia and amniotic fluid embolism.
   
2. Common pregnancy complications 
   Maternity insurance also covers common pregnancy complications like pre-eclampsia, which accounts for 63% of pregnancy complication claims and 16% for abruptio Placentae. Moreover, not only are mothers covered under maternity insurance, your little one will be covered for common child congenital conditions such as heart conditions which makes up 40% of the claims.

What are the considerations in choosing maternity insurance plans?

The plans available in the market are generally similar, below are some of the considerations:

1. Coverage:
   a. Sum assured: Most plans cover between $5,000 to $10,000, except for AIA which you can choose coverage of up to $25,000.
   b. Scope of cover: Most plans cover 7-10 types of pregnancy complications and 17-18 types of child congenital conditions, but again AIA covers up to 14 and 25 conditions, respectively. Most plans will come with a hospital cash benefit, that will pay $100 per day of hospital stay.
   c. Length of cover: All plans start the coverage from 13 to 18 week of pregnancy and terminates when your child turns 2 to 3 years old.
   
2. Premium:
   a. The premium costs hover around the same range: Starting from the lowest $315 to $395. A $5,000 coverage is for options that require you to purchase a regular premium whole life plan or investment link plan. GE is the only insurer with a plan that does not require a client to get a whole life plan and premium starts from $542. Cordlife’s plan is complimentary if you decide to sign up their cord blood banking services.
   
3. Other features:
   a. Underwriting: All plans require the insured individual to complete health declarations and scans of foetus, except for Cordlife’s. Their coverage will start automatically after 18 weeks of pregnancy and as soon as you enrol in their services.
   b. IVF pregnancies and babies are only covered by AIA and Cordlife’s plan.

Which plan should I pick? 

Everyone's perspective and situation would be unique. Here’s our friendly advice—select a plan based on these two options: 

1. Plans with the best value
   The plans are complimentary if you have decided to sign up for Cordlife’s cord blood banking service. This makes it the best bang for buck. The coverage may not be one of the highest in the market, but a coverage of six months is more than sufficient as most congenital conditions would be diagnosed by then. In addition, with no underwriting as a requirement, it would be a useful and convenient feature as it could be time consuming to submit all medical requirements. 
   
2. Plans with the highest coverage
   Go for AIA’s Mum2baby, as it has the highest sum assured option – $25,000. Furthermore, it covers the most type of pregnancy complications and congenital conditions.

Tips for pregnant mothers during the COVID-19 pandemic

 By Dr Ng Ying Woo

Obstetrics & Gynaecology

SBCC Women’s Clinic

Pregnancy is often a joyous event in our lives. However, this has been dampened by the recent COVID-19 pandemic. The disease has spread to almost every part of the world, including Singapore. Drastic measures such as circuit breaker and social distancing have been implemented in our country. These measures have brought stress and uncertainty to our expectant mothers. Thus, it is natural that most mothers have questions about the disease and how it impacts their pregnancy.

Here are some tips that may help you to ride safely through this pandemic:

Is it safe to go for my prenatal check-ups?

These check-ups are essential during your pregnancy. The risk of contacting the virus is probably low as hospitals and clinics scan the temperature of every visitor, and there are hand sanitisers at almost every counter. Wearing masks, keeping a safe distance from others, and driving directly to the hospital instead of taking public transportation may help reduce the risk of contact even more.

What should I do as a pregnant mother to keep myself safe from COVID-19?

Stay home to minimise the risk of infection. Going out to shop for baby stuff like we used to may not be advisable. Pregnant mothers may need to adjust their preparation and make purchases online instead.

You might have to do most of your prenatal workouts at home if you want to stay healthy and fit before giving birth. Precautions like these should help pregnant mothers to stay safe and well from COVID-19.

How will the new precautionary measures in place at hospitals affect me?

Congratulations! You and your loved ones have gotten through the circuit breaker period safely. From June 2, 2020, Singapore has entered Phase One of reopening:

Husbands with negative contact history will continue to be allowed to accompany their wives during active labour. However, everyone in the labour room will still have to wear masks.

In Phase 1, a maximum of five pre-designated visitors will be allowed to visit inpatient wards. However, only one person will be allowed to visit the patient at a time. Children below 12 years old are still prohibited from visitation. Though the family may be excited to visit the new mother and baby, be sure to remind them of this visitation restriction.

Is it still safe to give birth in a hospital with the current situation?

The hospital has strict rules about keeping people from getting sick and keeping infections under control. Measures such as temperature scans, health declarations, mask wearing at all times, frequent use of sanitisers, restriction of visitation, etc. help to keep the risk COVID-19 spreading to our mothers to a minimum.

How should I prepare for my stay in the hospital? Are there additional items I should pack in my hospital bag?

Simple preparations such as clothing for yourself and the baby should suffice. Your husband can help to prepare the required documents and other miscellaneous items, e.g. camera, mobile phone charger, etc.

With consideration of COVID-19, a small bag of masks and hand sanitiser may be useful.

Stay strong and stay together

Use a positive outlook and attitude to deal with the worries and fears that this pandemic has caused. With that in mind, we can safely welcome our little one into our family.

Essential birth planning tips

Written By: Dr. Edwin Thia

Senior Consultant

The Prenatal Consultants

Mount Elizabeth Novena Specialist Centre

You are now in the third trimester. This is the best time to talk about birth plans with your doctor. Birth planning includes discussing about your preferred mode of delivery, what forms of pain relief available during delivery, how you want to approach your delivery, the immediate after care for you and your newborn baby, whether you would like to store your baby’s cord blood etc.

Mode of delivery 

We start by discussing the two modes of delivery – vaginal delivery and caesarean section.

All women are encouraged to have a vaginal delivery if there are no medical or obstetrical reasons to exclude this. Most women will go into labour on their own around week 39, and they will have a normal vaginal delivery that goes well.

Labour

Labour is traditionally divided into three stages:

Stage 1

The cervix begins to dilate and is made up of two phases—a latent phase and an active phase. The latent phase is when the cervix dilates and thins out to about 3 cm. This stage is often very variable in duration and can last from a few hours to a few days. The symptoms are usually not specific and can range from mild abdominal cramps, backaches, or the passing of some bloody mucus discharge (show). Some women may not have any symptoms at all.

The active phase is when the cervix continues to dilate and thin out to be fully dilated (about 10 cm). The typical rate of dilation in the active phase is about 1 cm per hour, and hence the average duration is about 8 to 10 hours. This phase is when you have painful, regular contractions. The contractions are much more painful and more frequent, and each contraction usually lasts for up to 30 to 45 seconds. Your uterus is actively working to dilate and thin out the cervix.

Stage 2

This stage involves the delivery of your baby. This is when you have to work the hardest to push your baby out. This stage may last from 30 minutes to up to 2 hours. You will usually have a sensation and an urge to bear down due to the pressure of the baby’s head on your perineum. Your legs may be raised to allow more room for the baby. An episiotomy may sometimes be needed to increase the space.

Stage 3

The placenta is expelled at this stage. This usually lasts between 5 and 30 minutes. Your uterus continues to contract and will squeeze out the placenta after it detaches from your uterus.

Pain relief during labour 

Pain is expected during labour, and there are various methods of pain relief available to you. The three most common pain relief methods are Entonox gas, opioid injections, and epidurals.

Entonox is an inhalational form of analgesia. The mother breathes in a gas mixture of 50% nitrous oxide in oxygen. Entonox doesn't get rid of pain; it just changes the way you think about it so that it hurts less. The effectiveness is about 50%.

An opioid injection is a type of drug that is injected into the muscle of the thigh and provides pain relief for about 3 to 4 hours. It cannot be given too close to the delivery of the baby because it can make the baby drowsy at birth and cause temporary breathing problems. It can reduce pain by up to 70%, but only for a short duration of about 3 to 4 hours.

Epidural is the most effective and reliable pain relief method. This is done injecting an anaesthetic medicine into a space within the spinal canal. This is done by a trained anaesthetist. The epidural can last throughout the entire duration of the labour. If an emergency caesarean section is required, it can also be used for the operation.

Instrumental delivery 

Instrumental delivery is sometimes needed to help a vaginal delivery go smoothly. This can be done either using a vacuum suction device or forceps. There can be many reasons for needing help with the birth of your baby. Some common reasons are if you are not able to push well during the second stage of labour or if there are concerns with the well-being of your baby.

Caesarean section 

If you can't give birth through the birth canal, you will need a caesarean section. Depending on your situation, you can choose to have a planned caesarean section or you may need an emergency caesarean section.

A planned elective caesarean delivery is often done because the baby is in the wrong position or the placenta is low. Reasons for an emergency caesarean delivery include fetal distress during labour or slow progress of labour.

Caesarean delivery is considered a major operation. Although generally a safe operation, there are some risks involved, like any other major surgical operation. Most women who have a caesarean section will recover well. However, there are risks for both you and your baby, and it may take longer for you to get back to normal after your baby is born. Having a caesarean section also makes future births more complicated. The main risks associated with having a caesarean section include wound infection, more bleeding than expected, and blood clots in the legs (deep vein thrombosis) that can travel to the lungs (pulmonary embolism). Future pregnancies will be seen as higher risk, which may change how your next pregnancy is cared for.

Deferred cord clamping 

After your baby is born, the umbilical cord is clamped and cut before the placenta is expelled. Deferred or delayed cord clamping provides the newborn baby with an additional 80-100 mL of blood. The cord is not clamped in the first 60 seconds, except where there are concerns about the cord integrity or if the baby’s heart rate is abnormal. This additional blood improves the iron stores in the baby’s infancy.

Cord blood banking 

If you choose cord blood storage, it will be collected after your baby is born but before the placenta separates from your womb. Cord blood collection does not interfere with delayed cord clamping.

Some of your baby’s cord blood will also be collected for specific laboratory testing like blood grouping, thyroid function tests, and glucose-6-phosphate dehydrogenase (G6PD) deficiency testing. After that, cord blood can then be collected for cryogenic storage.

Cord blood banking is the process of storing your baby’s umbilical cord blood in the umbilical vein. Your baby’s umbilical cord blood stem cells are a rich source of haematopoietic stem cells (HSCs), which are responsible for replenishing the blood and regenerating the immune system.

In addition, HSCs are also known as naive precursor cells as they have a unique ability to differentiate into the different types of cells found in the body, namely: red blood cells, white blood cells, and platelets.

When parents decide to store their baby’s cord blood stem cells, they will be availing their baby (and family) of the following possible benefits:

1. Mainstream treatment of over 80 diseases ranging from leukaemia, lymphoma, thalassaemia as well as metabolic and immune disorders.¹ There are currently clinical trials underway for the possible treatment of Cerebral Palsy, Autism, Type 1 Diabetes, Alzheimer’s disease and spinal cord injury and many more.²

2.A sure match for autologous (donor and recipient are the same person) transplants. Since cord blood stem cells are "naive," they can change into different types of cells and do not need to be a perfect match like bone marrow transplants do. There is also a 40–60% chance of a match between siblings.³ So, parents are strongly encouraged to save for each child because it makes it more likely that they can cover each other if they need to.

3. Lower risk of Graft-versus-Host Diseases (GvHD) for autologous transplants, which makes it less likely that a stem cell transplant will be rejected.

4. A ready supply of life-saving stem cells that can be used quickly in a transplant situation where time is of the essence. Unlike bone marrow, which requires a perfect match between donor and patient, the probability of finding a match among family members using cord blood stem cells is higher.

When it comes to collecting your baby’s cord blood, it will be done by your OBGYN doctor. This process usually takes less than 5 minutes and is a safe and risk-free procedure for both mother and child.

Skin to skin contact 

After your baby has been cleaned up, he/she can be laid directly on your bare chest, and both of you are then covered with a warm blanket. This helps to calm and relax both you and your baby. It also helps to regulate the baby’s heartbeat and breathing, helping them better adapt to life outside the womb.

Conclusion

You should be all ready for the birth of your baby. Your doctor will now continue to monitor your pregnancy's well-being. Your doctor will also be doing a vaginal swab soon to check for the presence of Group B Streptococcus and will continue to monitor the growth and well-being of your baby.

Keep going to your regular appointments, and here's hoping that your birth plans go as planned.

References:

¹ For the full list of treatable diseases and references, please refer to  https://www.cordlife.com/sg/treatable-diseases.

² Diseases and Disorders that have been in Clinical Trials with Cord Blood or Cord Tissue Cells page. Parent’s Guide to Cord Blood Foundation website.  https://parentsguidecordblood.org/en/diseases#trial.  Accessed March 8, 2021.

³ Beatty PG, Boucher KM, Mori M, et al. Probability of Finding HLA-mismatched Related or Unrelated Marrow or Cord Blood Donors. Human Immunology. 2000; 61:834-840.