Prenatal and Postnatal Care

The gynecology department is by consult only.
Hours Mon-Fri 8:00-4:30.

Prenatal Information Sheet

Congratulations on your pregnancy.

The McPhillips Medical Clinic has a group of obstetricians and gynecologists that work within the ‘Manitoba’ call group at the Health Science Centre’s Women’s Hospital (665 William Avenue). There is always an experienced and well-trained physician in the building on call every 12-24hr.

First Trimester (first 12 weeks):

The important aspects of first trimester include dating the pregnancy and healthy nutrition. We date pregnancy by the first day of your last menstrual period. If you had uncertain dates, we try to get an ultrasound to accurately find out when your due date is.

We recommend that you take folic acid 1 mg/day in the preconception (before pregnancy) and for at least the first 12 weeks. Folic acid lowers the chances of cardiac and neural tube defects (i.e.spina bifida) for the baby. Taking vitamin D 1000 in units a day is recommended during the pregnancy and postpartum while breastfeeding.

The first prenatal visit includes a complete history and physical exam. As well, we do routine blood tests including checking for chicken pox immunity, rubella, blood type (rh status), blood levels and hepatitis B and syphilis. We recommend that all women get tested for HIV. If an HIV test is positive, we can give you medications to decrease the transmission to your baby. We also check your urine for bacteria. We also ask if you have ever had genital herpes and if so we can give you an antiviral medication at 36 weeks twice daily till delivery to lower chance of fetal transmission.

We expect women to gain 25-35lbs if they are at their normal weight at the beginning of pregnancy. Moderate exercise is healthy and can be continued throughout pregnancy in most situations. An extra 300-350 calories a day is needed for your baby. As long as your uterus/ womb is growing each visit, you do not need to be too worried about your weight on the scale. Exercise is very important in pregnancy. Try to do something active every day for 30 minutes even just going for a walk.

We recommend that you eat healthy meals according to Canada’s food guide and wash fruits and vegetables well to avoid listeria. Caffeine in no more than 1- 2 cups a day is acceptable. Please do not have pop or beverages high in simple sugar. It is also recommended not to smoke, drink or do drugs during your pregnancy. Check with your physician or pharmacist regarding medications that are safe. Tylenol, gravol, diclectin, and benadryl are common medications that can be taken in pregnancy. Advil is a common medication that should not be taken.

An ultrasound of the baby’s neck called a nuchal scan can also be done between 11- 13 weeks gestation if you are over the age of 35

There is another test that is only available commercially called a Non Invasive Prenatal test (NIPT) that can be done as early as 11 weeks. It measures the fetal cells in the maternal circulation and gives the actual genetics of the baby with 99% accuracy.

Patients of certain ethnic backgrounds may also have genetic testing done. Patients of Ashkenazi Jewish descent may have genetic testing for Tay-Sachs disease, Canavan disease and familial dysautonomia. Other specific genetic testing can be offered to any patients with a positive family history of certain conditions (i.e. cystic fibrosis).

Second Trimester:

The next visit will be around 16-19 weeks. We then do another ELECTIVE blood test called the “maternal serum screen” which tests hormones in your blood to assess the risk of having a baby with Downs Syndrome (DS), other fatal genetic syndromes (trisomy 18) and neural tube defects. This test picks up around                                                                                                            65- 70% of patients with a DS baby and will give you a risk number. Sometimes the test is incorrect based on the wrong due dates or twins and thus we try to correlate with ultrasound dating. If your risk is higher than expected and the right dates, we offer you an amniocentesis or the NIPT.

This is when a needle under ultrasound guidance takes some fluid from around the baby. This fluid is cultured to find out the baby’s genetics and to decide if a baby has DS. There is a chance of 1/200 of losing a pregnancy from the amniocentesis. Women have the option of terminating the pregnancy if the amniocentesis shows a genetic problem.

We also arrange an anatomy screening ultrasound for all pregnant women. This looks at the baby’s organs and placenta location.

Third Trimester

The next important visit is between 26- 29 weeks. We do a screening blood test for Hemoglobin (blood count, iron check), blood antibody test and a test for gestational diabetes. The diabetes test involves an orange drink and then a blood test 1 hour later. You do not have to be fasting. You can get the drink before the visit and then be seen and have the blood drawn 1 hour from then.

If you are Rh negative without antibodies, your WhinRo injection will be given at around 28 weeks at Women’s Hospital.

We recommend some vaccinations in pregnancy. This includes the flu shot at any gestational age. This also includes the whooping cough vaccine called tdap (tetanus diphtheria and pertussis) that is recommended at each pregnancy. It is a safe vaccine and recommended after 26 weeks GA. Of course the covid

vaccination is recommended for all trimesters in pregnancy if needed and boosters when appropriate.

At 35 weeks, we screen for Group B Strep bacteria (GBS). This is a bacteria that lives in the vagina and bowel in 30% women. It is harmless to both you and your baby unless your water is broken. Approximately 50% of babies born to mothers who carry GBS will pick up the bacteria during birth and about 1% of these babies will become seriously ill.

GBS can be detected by a vaginal and rectal swab that is done around 36 weeks. If you are a carrier of GBS, you will receive Penicillin through an intravenous in labor. The antibiotics prevent the baby from getting a GBS infection.

We also screen for high blood pressure (hypertension/ preeclampsia/ toxemia of pregnancy) in the pregnancy. If you have high blood pressure, we might get you to purchase a blood pressure cuff for at home. There is also an antenatal home care program where nurses come to your home and monitor you if blood pressures are concerning.

If you and your baby are healthy without concerns, then the total number of appointments may be around 10 if this is your first baby or 7 if you have had a baby before.

Fetal movement

The baby likely will move most of the day. After 36 weeks, routinely do a check in with baby after meals and ensure moving. A baby can sleep for 1 hour but there should not be a prolonged interval of no movement. If you are ever worried then go into triage at Women’s Hospital that is open 24/7.

Induction

There are a few reasons to induce patients. It is usually to prevent any bad outcomes to mothers or babies. We induce often for high blood pressure at the end of pregnancy, diabetes or in mothers over the age of 40. This is a process where you get called into the hospital on the induction day. Sometimes we start with a gel called prostin or a string called cervidil to soften and open the cervix (the opening of the womb). These agents are called prostaglandins. Sometimes we also use a foley balloon to open the cervix mechanically. Then you often go on to get a synthetic version of a natural hormone called oxytocin to make contractions come. Induction is safe and does not increase your CS rate and we only do this if we feel there is a good reason. Most people do not need induction.

Labor

You may not have the obstetrician who sees you for your Prenatal Care Consultant Winnipeg visits at your delivery.

We want your labor to occur as naturally as possible. We expect you to come to hospital when you are having regular contractions every few minutes over a few

hours. If this is your first baby then this process may be longer. If you are having pains for more that 24 hours that are keeping you awake, then go to the hospital as this is not a normal labor pattern.

Most people have changes to their cervical dilatation and we assess the baby’s heart rate when you are actively laboring with external heart rate monitors. If you are coping well then sometimes you do not need any medicine for pain. If the pain is too long or too much, you can request pain options including epidurals.

Sometimes we have to augment labor with breaking your water or giving you a medicine called oxytocin to make contractions stronger. We get you to start pushing when you are 10 cm and feeling the urge to do so. Most people push for less than 1-2 hours with their first baby but it can be up to 3 hours with an epidural. Most second baby’s come with only a few pushes less than 30 minutes. We do NOT do routine episiotomy. Delayed cord clamping is the standard of care as is skin to skin with the baby immediately after delivery.

Pain in labor

Labor is associated with pain and there are many treatment options available to patients. The new hospital has large private rooms with bathtubs/ showers in all the attached bathrooms to use heat for pain relief. Having supportive partners and family is welcomed. Our nurses offer 1:1 care and also offer position changes and techniques to improve tolerance of contractions. The options of nitrous gas, narcotics and epidural are available. We have in house dedicated anesthetists at the hospital.

Operative delivery

The goal is never to have pull out a baby with a vacuum or forceps.

Operative delivery is only done when there is a reason such as the baby’s heart rate is worrisome and we need to get the baby out quickly OR the mother is exhausted and can no longer push.

If you need an operative delivery, we usually discuss the reasons why and the risks and alternatives. If the baby’s heart has suddenly dropped and needs to urgently come out, then we sometimes just have to act quickly for a safe delivery. These cases are VERY rare.

We may do a trial of operative delivery in an operating room as a “double setup” meaning we might do a cesarean section if the baby does not come with a vacuum or forceps. The risks to an operative delivery are small but include baby and mother issues. The baby risks are rare significant bleeding in the baby’s head (uncommon 5-60/10,000), facial nerve injury from forceps (rare and reversible). The maternal risks are vaginal tears extending to the rectus muscle or anus 1-2/100. The alternative to doing an operative delivery is a cesarean section, which also has risks to the mother of increased blood loss, risk to future pregnancies with a CS scar and injury to other organs.

The above is only mentioned for discussion and knowledge before labor.

Ultimately very few operative deliveries are done overall as the goal is for mothers to push babies out on their own with different changes in position and pushing when ready.

Overdue!

The average pregnancy is 40 weeks but “term” is 37-41 weeks. Only 10% of women have their baby on their due date. While 15% of women will still not have had their baby by 41 weeks, only 3% will be undelivered by 42 weeks.

If you go over 41 weeks, we arrange for an ultrasound (fetal assessment) to ensure that the baby is well and that there is adequate fluid around the baby. If this is reassuring, then we wait till 41.5 to 42 weeks to induce you. Waiting allows most women to safely go into labor.

When to go to the hospital: (Women’s Hospital Triage)

If you have regular contractions every 5 minutes that are getting stronger

If your water breaks (usually a gush or increased leaking clear fluid) and you are GBS positive even if labor has not started yet

If you are GBS negative and your water breaks, you can stay home till labor starts for 12-24 hours if:

The fluid is clear (no meconium or green staining) The baby is moving with no concerns

There is no bleeding

You are not having painful regular contractions or constant abdominal pain If you are not feeling the baby move over 1-2 hours

If you have bright red bleeding Any other concerns

Phone numbers to know at hospital

HSC Paging: “Manitoba Group” Obstetrician On call 204-787-2071 (weekends/ night)

Women’s Hospital Triage 204-787-4201

Please see our website for other valuable resources.

PostPartum

You will schedule a visit at 6 weeks from delivery to do possibly a Pap smear and pelvic exam and assess any other issues (contraception) at the clinic.

If any problems should arise from delivery till then (ie concerns of breast infection, bleeding too heavily) then call the office to come in sooner. If there are any urgent issues in the evening or weekends, you can go to triage at Women’s hospital up till 6 weeks postpartum.

Your baby will see a baby doctor at 2 weeks and you make that appointment with your own family doctor or a pediatrician.

We recommend breastfeeding.

However, if breastfeeding is not successful, it is important just to feed your baby and formula is totally adequate as well.

Let us know if you need a breast pump as many drug plans cover them as medical devices. There is a breastfeeding clinic in the city that takes referrals if you need additional supports. A public health nurse visits you at home after the baby comes as well and many have lactation experience.

POSTPARTUM DEPRESSION

This is a common problem. The combination of lack of sleep and increased anxiety from a new baby are challenging. Having some sad moments in the first few weeks or feeling overwhelmed is normal.

However if you continue to lose function after 6 week this may be a sign of depression.

Let us know at your 6-week visit how you are doing so we can try to help you and your family.

Other resources Include

www.ppd.manitoba.ca

Mobile crisis unit if there is an acute risk and you want someone to come to your house 204-940-1781

You can also come to Women’s Hospital triage if any acute issues up to 6 weeks after delivery.