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Heart health in pregnancy

Heart health in pregnancy

Graphic of red heart with a jigsaw shaped piece missing Chest pain in pregnancy and/or afer your baby’s birth should never be ignored. Some chest pain can be serious and can lead to a heart attack, heart failure, cardiac arrest or even death. Most women do not suffer from these conditions during or after pregnancy but it is important to recognise the symptoms and, if you have any of them, to seek treatment quickly.

Pre-existing heart conditions

If you have a known heart condition, were born with a congenital heart defect or have been diagnosed with heart disease, you should tell your midwife/GP/cardiologist and they will monitor your heart health before, during and after pregnancy and your health.

Symptoms of health attack can include:

  • Central chest pain
  • Arm pain or numbness
  • Pain in the jaw, back or shoulders
  • Nausea
  • Sweating/clamminess
  • Breathing difficulties
Some people experience indigestion-like chest or throat pain that does not respond to indigestion remedies.

When should I contact the midwife or doctor?

If you feel unwell, contact your midwife or GP for guidance. If you experience some/all of the above symptoms, dial 999 and ask for an ambulance as your heart health needs to be investigated quickly. An ECG monitor and a troponin blood test should be carried out to find out if you have had a heart attack.

When am I more likely to have a heart attack?

You are more likely to have a heart attack if you:
  • have a family history of heart problems
  • have high blood pressure
  • have high cholesterol
  • smoke
  • drink excessively
  • are obese
Rarely, women with no risk factors or history of heart disease in their family will experience heart attack symptoms. Heart attack symptoms in pregnancy should never be ignored. Contact your midwife or GP for further advice.
Pregnancy and heart conditions Misdiagnosis of heart attacks in women Heart disease in pregnancy
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Spontaneous Coronary Artery Dissection (SCAD) in pregnancy

Spontaneous Coronary Artery Dissection (SCAD) in pregnancy

Pair of hands supporting a graphic of a heart rate trace SCAD is a rare but serious heart condition that causes a tear or bruise to develop in a coronary (heart) artery resulting in a blockage that prevents normal blood flow. It can cause heart attack, heart failure or cardiac arrest and can be fatal. SCAD can happen during pregnancy and during the weeks and months after you have given birth. Symptoms can include:
  • central chest pain
  • arm pain or numbness
  • pain in the jaw, back or shoulders
  • nausea
  • sweating/clamminess
  • breathing difficulties
Some people experience indigestion-like chest or throat pain that does not respond to indigestion remedies. If you experience some/all of these symptoms, call 111 or 999 and say you are worried about your heart.
Beat SCAD charity – What is SCAD? Beat SCAD charity Beat SCAD YouTube channel
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Preventing and managing common complaints during pregnancy

Preventing and managing common complaints during pregnancy

Close up of pregnancy bump with woman supporting her arched back with her hands

What complaints are common during pregnancy?

Pregnant women may experience one or more of the following symptoms:
  • back, pelvic, buttock or hip pain
  • rib pain
  • leakage of urine when coughing or sneezing
  • aching legs/cramps/varicose veins/swollen ankles
  • numbness and tingling in the hands
  • fatigue (extreme tireness)

Why am I more likely to experience these common complaints during pregnancy?

Hormonal changes

From early on in your pregnancy your body produces high levels of certain pregnancy hormones (called ‘relaxin’ and ‘progesterone’). These work to soften ligaments and muscles, especially around your lower back and pelvis, preparing your body for pregnancy and labour.

Weight gain and postural changes

Your body adjusts to the weight gain during pregnancy by changing your posture, for example, the way you stand. This can result in increased strain through some areas of your body. Strain is often felt around your lower back or pelvis.

Muscular changes

Your abdominal (tummy) muscles act like a corset to support your spine. During pregnancy, they soften and stretch slightly to allow your baby to grow. This can make them less effective in supporting your back and pelvis. Other muscles may also stretch or weaken during pregnancy, including your pelvic floor muscles which help to control your bladder and bowels. All of these changes are normal and allow your body to adapt to being pregnant, but they can make you vulnerable to aches and pains. The advice on the following pages will help you to be aware of the changes occuring and how to take care of yourself during pregnancy.

What can I do to help prevent aches and pains?

Look after your back

Think about your posture Doing this throughout your pregnancy can help to avoid and reduce pain.

1. When you are standing:

Try to avoid your ‘bump’ pulling you forward and over-exaggerating the curve in your lower back:
  • Tuck your chin in
  • Pull your shoulders back and down
  • Gently draw your tummy button towards your spine
  • Squeeze your buttocks slightly
  • Keep your knees relaxed and soft

2. When you are sitting:

  • Try not to slouch
    • choose a chair that will provide your back with some support and ensure your bottom rests at the back of the chair. You may also wish to place a pillow or rolled up towel in the small of your back.
  • Make sure your feet are flat on the floor
    • try using a foot rest if they don’t quite reach. This will take the pressure off your spine.
  • As you stand up from a chair or bed, try squeezing your tummy and buttock muscles to provide extra support to your pelvis.
Woman shown sitting in chair incorrectly slumped forward then woman shown sitting with a rolled towel supporting her back

3. When you are lying down:

Woman lying on her side with a pillow between her bend legs
  • Lie on your side with a pillow between your knees (bending your knees comfortably).
  • You may find a pillow or small towel placed under your ‘bump’ supportive.
  • When turning from side to side, keep your kneeds bent and together, squeezing tummy and buttock muscle and moving in stages. Alternatively, turn onto all fours, keeping your buttocks clenched as you turn.

4. Geting in/out of bed

  • Bend your hips and knees together and remain on your side.
  • Squeeze your buttock and tummy muscles as you move.
  • Push up with your arms into a sitting position.
  • Do the reverse to get into bed or try climbing into bed on all fours.
Woman semi-reclining on one elbow with her knees and ankles bent demonstrating how to get in and out of bed

5. What about lifting?

  • Where possible, cut down on activities that involve bending, twisting and lifting, such as picking up small children and vacuuming
  • When lifting from the floor, bend down on one knee – see picture opposite
  • Keep a small stool to use in the kitchen to sit on instead of squatting down
  • Avoid lifting excess weight where possible – your body is already working hard to carry your baby
  • Shopping – try to avoid lifting out of deep shopping trolleys. When carrying larger loads, try to distribute the weight equally in each hand, or use a small backpack.
Woman bending down on one knee with her hands supporting a box on her raised bent knee to demonstrate safe lifting

Tips for daily life

  • Footwear
    • avoid heels more than 1 inch in height and try to have flat shoes with a supportive arch as they can encourage good posture.
  • Dressing
    • sit down to get dressed. This avoids standing on one leg, which can aggravate pain.
  • Ironing
    • make sure the board is a waist level to avoid prolonged stooping. Alternatively, sit down to iron if possible.
  • Cooking
    • sit rather than stand when preparing food.
  • Getting into a car
    • sit down first, keep your knees togeher and then swing both legs in at the same time (or slowly move each leg). Reverse this to get out of a car.

Keep your tummy muscles strong

Your tummy muscles stretch during pregnancy to allow your baby to grow and this is normal. The following simple exercises are safe to do during pregnancy and can help relieve back pain and improve the strength and function of your lower tummer muscles. If you are unsure about any of the exercises, please speak to a physiotherapist before starting them.

Transversus abdominus (deep lower tummy muscle)

This muscle wraps around your lower tummy and back like a corset to support the area. To strengthen this muscle:
  • Begin on your hands and knees (all fours), keeping your shoulders over your hands and your hips over your kneeds – try to keep your back flat and still.
  • Breathe in, and as you breathe out, gently draw in your lower abdomen/tummy towards your spine.
  • Hold for 10 seconds, then release.
  • Repeat at least 10 times until fatigued.
  • Try to practice this two or three times a day.
Woman kneeling on all fours demonstrating lower tummy muscle exercise You can also do this exercise lying on your side, or when sitting or standing. You can exercise this muscle effectively when you are walking around or lifting and carrying. Just draw your tummy in as if you were hugging your bump or wearing a bikini!

Pelvic tilting

  • Stand with your back against a wall, with your head, shoulders and bottom touching the wall.
  • Bend your knees, keeping your heels shoulder-width apart, feet slightly sway from the wall.
  • Pull your tummy button back towards your spine and tuck your bottom under until you feel your lower back flatten against the wall.
  • Repeat up to ten times and do the whole exercise three times a day.
Woman sitting on a chair slightly slumped and then woman sitting on a chair with a straight back to demonstrate pelvic tilt exercise Alternatively, you can try doing this exercise in different positions, such as when kneeling, leaning on the bed, sitting (on a chair or exercise ball), or on all fours) see pictures 1-2 and a-c). Woman on all fours demonstrating pelvic tilt exercise by moving from an arched back to a neutral position then to a concave back

Keep your pelvic floor muscles strong

Your pelvic floor muscles lie between your public bone at the front and your coccyx (tailbone) at the back of your pelvis. They surround your anus, vagina and bladder openings. These muscles are like a platform that helps the pelvis to support the weight of your baby as it grows. They also maintain control of your bladder and bowels, and give support to the pelvic bones. During pregnancy, these muscles can be weakened by the weight of the baby, and are stretched during vaginal birth. Cross-section diagram of a mature baby in the womb to show where the pelvic floor muscles are located Some women may experience leakage of urine when coughing and sneezing (known as ‘stress urinary inconinence’) as a result of weak pelvic floor muscles. This is a common complaint affecting one in three women, but it can be prevented, reduced and even resolved fully with regular pelvic floor exercises. It is highly recommended that all pregnant and postnatal women regularly exercise their pelvic floor muscles even if they have no problems with bladder control, to prevent problems in the future. To begin with, you may have to concentrate while doing the exercises, but as you become more confident, you could do them whilst watching television, standing in a supermarket queue or waiting for the kettle to boil.

Pelvic floor exercises

Imagine you are trying to stop yourself passing wind and then pull forward as though you are also trying to stop your flow of urine. This closes and draws up the back passage and vagina. You need to exercise this muscle in two ways:

1. Slow holds

Hold the muscle in for as long as you can for up to 10 seconds. Release slowly and rest for at least 5 seconds between each one. Aim to do 10 in a row.

2. Fast squeezes

Squeeze the same muscles but quickly, releasing straight away. Aim to do 10 in a row. You can do these exercises almost anywhere and anytime but not when passing urine. In the beginning you will find these exercises easier to do when lying down or sitting. To train these muscles during and after pregnancy, try to get into the habit of doing both of the exercises 3-6 times a day.

Other helpful tips

  • If you have swollen ankles or legs, make sure you spend some time with your feet up every day. Keep your feet moving and avoid crossing your legs. Wearing support stockings may help.
  • Sometimes women experience numbness and tingling in their hands. This can be due to excess fluid retention and often worse at night and first thing in the morning.
  • Try running cold water over your hands for a few minutes when you wake up – this helps improve circulation. Keep your hands moving, and massage your hands in the direction of your elbows. If this remains a problem, ask your midwife or GP to refer you to a physiotherapist.
  • It is hard work being pregnant, so listen to your body and rest when you need to. It is a good idea to spend some time relaxing regularly.

What about lower back and pelvic pain during pregnancy?

Lower back and pelvic pain during pregnancy are very common symptoms and are rarely due to a serious problem. Evidence suggests that 50% of women experience this pain during pregnancy. More than half of these women will complain that the pain impacts on their daily living. If you are starting to suffer from back or pelvic pain, make sure you are following all the advice and exercises previously listed on this page.

Pain relief

If your back continues to be painful, there are a number of other things you can do to help yourself. For example:
  • Put an ice pack (bag of frozen peas wrapped in a damp towel) or hot water bottle on the painful area for 1–15 minutes, several times a day. Avoid placing it directly over your abdomen (tummy) and protect your skin with a towel.
  • Relaxation and massage techniques can also help decrease the pain.
  • Keep active, as staying still for prolonged amounts of time can cause joints to become stiff and painful.
  • Talk to your pharmacist, GP or midwife about suitable pain relief to use during pregnancy.
  • You may like to try this gentle stretch, which may help to relieve your lower back pain.
Woman on the floor sitting back on her heels with her face towards the floor and her arms outstretched in parallel beyond her head Remember – it is not usually the one time we lift awkwardly or stand badly that causes pain; it is often the continual stresses and strains we place on our body during our everyday activities. Therefore, it is important to modify your daily activities using the techniques in this booklet, do some of the gentle exercises we suggest and ensure you pace your activities throughout the day and week. Please ask your midwife or GP to refer you to a physiotherapist if you are still having difficulties with pain.

How can I stay active?

Start by exercising the parts of your body most under strain during pregnancy. your back, tummy and pelvic floor muscles all need regular exercise to remain strong. Gentle low impact exercise, such as walking, swimming, yoga and pilates, is safe and highly recommended during pregnancy. Exercise encourages the release of hormones called ‘endorphins’ which help you to feel good, sleep better and reduce pain. However, there are some rules to exercise during pregnancy:
  • We advise that you avoid contact sports such as hockey/netball.
  • Be sure you warm up and cool down to avoid injury.
  • Make sure you do not get too breathless and can still talk in full sentences.
  • Replace, reduce or stop high impact exercises such as running and jumping.

What is perineal massage and how can it help?

The perineum is the area between the vagina and the anus (back passage). Perineal massage is used to stretch the perineal tissue and scar tissue during late pregnancy. It may help to desensitise the area and reduce any pain. This may also help with a return to sexual relations. Diagram demonstarting hand positions when performing perineal massage

How to perform massage

Prepare

A mirror can help you to locate the area between the vagina and the anus so you know what you are doing. Imagine your perineum represents a clock face. Hands should be clean with nails clipped. Make sure your bladder is empty. Some women find having a warm bath beforehad can help relax and soften the tissue.

Position

Position yourself so that you are comfortable. You could try:
  • Squatting down (supporting yourself by leaning back against a wall or forwards on a bed or chair)
  • Sitting on the toilet
  • Standing with one foot raised on a chair/toilet
  • Leaning back or kneeling on all fours.

Technique

Lubricate your fingers well using a vegetable oil (such as almond or olive oil). Insert one or two fingers up to 2 to 5 centimetres into the vagina. Massage the oil into the tissues of the perineum and inside the vagina. To prepare the tissues, start by pressing towards the anus and then use a firm sweeping movement down and to the back. Imagine your fingers are sweeping like clock hands from 3 to 9. Continue this for 2 minutes maintaining pressure throughout. Clock face Following this, apply a firm pressure at 5, 6 and 7 on the imaginary clock. Hold each stretch until you feel a burning, stinging sensation for approximately 2 minutes. This technique may be painful/cause stinging sensation – this is normal. Try working in a circular montion with your thumb or fingertip across the scar and concentrate on one area of the scar at a time. Begin with a gentle pressure and build up as you feel comfortable. Massage can also be performed in the bath without addition of any oils.

Frequency

Aim to practice the techniques 3-4 times per week for between 5-10 minutes. Massage may be continued until the area is desensitised and less painful.

Further information

NHS Choices – exercise in pregnancy

Help and advice

If you have any concerns, or would like further advice, contact yoru local antenatal clinic, your community midwife or GP.

Acknowledgement

This content has been produced by the Department of Women’s Health Physiotherapy, Imperial College Healthcare NHS Trust and is used with permission.
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Sepsis during pregnancy

Sepsis during pregnancy

Sepsis infection particles under a microscope Infection in pregnancy and/or after your baby’s birth should never be ignored. Some infections can progress to a more serious situation known as sepsis, where the infection spreads to the blood stream and through the whole body. If left untreated sepsis can lead to shock, organ failure and death. Whilst most women do not suffer from infection or sepsis during or after pregnancy, it needs to be recognised and treated quickly if they do.

Signs of sepsis

The first signs of sepsis are usually a rise in your temperature, heart rate and breathing. You may also feel unwell, have chills and flu-like symptoms and a worrying pain in your tummy and/or diarrhoea. This can progress very quickly so it is important to seek advice if you are concerned about your health.

How can infection in pregnancy or after childbirth be prevented?

Good personal hygiene helps. This can include: daily showers/baths, proper hand washing and drying, perineal hygiene to include keeping the perineal area (between the vagina and back passage) clean, dry and frequent changes of maternity/sanitary pads. It is important to wash your hands before and after going to the toilet and changing maternity/sanitary pads.

When am I more likely to get an infection or sepsis?

Sepsis may happen in pregnancy or after your baby is born. The risk of getting an infection is increased in the following circumstances:
  • After having a miscarriage or an ERPC (ERPC – evacuation of retained products of conception is a surgical procedure to remove tissue from the womb)
  • Premature rupture of membranes (when your waters break long before your baby is due)
  • If your waters break more than 24 hours before your baby is born
  • If you develop a urine infection (UTI)
  • If your baby was born prematurely/early (before its due date)
  • After you have had your baby – this is the most common time for serious infection to develop; especially if you had your baby by an emergency caesarean section, by forceps or vacuum delivery, or if you had a perineal wound or an episiotomy).

When should I contact the midwife or doctor?

You should contact your GP or the maternity unit if you are worried, unwell and/or if you notice any of the following:
  • Pain/burning on passing urine or struggling to pass urine, this could be a symptom of a urinary tract infection
  • Vaginal discharge which may be foul smelling and/or an unusual colour, this could be a sign of a genital tract infection (vaginal/womb infection)
  • Abdominal pain that does not seem to be getting better with simple analgesia, this could be a sign of womb/wound infection or abscess
  • Chills, flu type symptoms or feeling faint and unwell
  • Fast breathing or shortness of breath
  • Fast heart rate
  • Persistent cough with or with sputum, shortness of breath or chest pain could be a sign of chest infection or pulmonary embolism (blood clot in the lung)
  • A wound that is not healing well, broken down or is red
  • Severe pain in one area of breast
  • Diarrhoea
  • Sudden increase in vaginal bleeding (after your baby is born).
Contact the maternity unit where you gave birth, your midwife or GP for urgent advice. For more information:
UK Sepsis Trust
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Female Genital Mutilation (FGM)

Female Genital Mutilation (FGM)

Graphic of four identical female silhouettes with one of them highlighted to stand out from the other three

What is FGM?

FGM is sometimes called female genital cutting or female circumcision. The definition of Female Genital Mutilation is “any cutting or damage to the external female genitalia that was carried out for non-medical reasons”. It is a form of child abuse and is a cultural practice that is illegal in the UK. FGM is carried out in many parts of the world including Africa, Asia, the Middle East as well as among certain ethnic groups in Central and South America. Through migration of peoples it is also found in Europe, USA, Canada, Australia and New Zealand.

What are the different types of FGM?

The World Health Organisation (WHO) estimates that 200 million women and girls worldwide have been affected by FGM. WHO has classified 4 Types of FGM: Type 1: part or all of the clitoris and/or clitoral hood has been removed. Type 2: part or all of the clitoris and/or clitoral hood has been removed, as well as the inner labia (lips that surround and protect the urine hole and vaginal opening). Type 3 (pharaonic circumcision): the labia or inner lips have been removed and the remaining edges are then sewn together or fuse together forming a layer of scar tissue with a small single opening at one end. Type 4: any other harmful practices to a woman’s genitals such as pricking, piercing, stretching or burning.

Possible health problems resulting from FGM

  • urinary infections
  • vaginal infections
  • painful periods
  • painful sex
  • feeling sad, anxious or depressed
  • problems during childbirth.

FGM and pregnancy

In pregnancy all women will be asked about FGM. Women with FGM should have a appointment with a specialist midwife or doctor in order to make a personalised plan of care as FGM may have physical and/or psychological consequences that can affect your pregnancy or labour. A safeguarding risk assessment will be carried out to ensure that, if you have a baby girl, she will be protected from FGM.

FGM and UK law

In the UK, it is against the law:
  • for anyone to carry out FGM
  • to take girls or women who live in the UK to another country to carry out FGM
  • to help someone else carry out FGM (this includes making travel arrangements)
  • to sew women up after childbirth (known as reinfibulation).

Women with FGM

If you thing you have FGM tell your midwife. She will refer you to a clinic where you will be given support by a FGM specialist midwife.

How can I protect my daughter/s?

The following resources are helpful:
NSPCC/FGM Helpline: 0800 0283550 Police (emergency): 999 Non emergency: 101 Foreign and Commonwealth office (if abroad): 00 44 207 0081500
Female genital mutilation FGM patient information leaflet
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Placenta accreta

Placenta accreta

Illustration of baby in the womb with the placenta implanted abnormally into the womb wall The placenta can also sometimes implant abnormally into the wall of the womb. This is a rare condition known as placenta accreta. The risk of having placenta accreta is higher if there is a previous scar on the womb, such as from a previous caesarean section, as the placenta can invade into the previous scar. This is a very serious condition that can be challenging to manage and a hysterectomy (operation to remove the womb) is sometimes needed at the time of delivery.
Placenta accreta
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Placenta praevia

Placenta praevia

Graphic of baby in the womb with a low lying placenta This can be picked up on an ultrasound scan as a low lying placenta in mid pregnancy. This is when the placenta is covering all or part of the entrance to the womb. If you are found to have a low lying placenta you will be rescanned between 32-36 weeks. The majority of low lying placentas will move to the upper part of the womb by 36 weeks, however 10% of low lying placentas remain low. This can cause bleeding in pregnancy that is sudden and severe. A caesarean birth may be recommended in cases of severe placenta praevia, and the likelihood of needing a blood transfusion can be higher.
Placenta praevia: Frequently asked questions
Placenta praevia Placenta praevia, placenta accreta and vasa praevia
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Intrahepatic cholestasis of pregnancy (obstetric cholestasis)

Intrahepatic cholestasis of pregnancy (obstetric cholestasis)

Close up of woman's hand scratching her bare foot This is a liver disorder that can develop in pregnancy, usually after 30 weeks gestation, but which sometimes develop as early as 8 weeks, affecting up to one in every 140 pregnant women. Symptoms can include:
  • itching, usually on the hands and feet but which can be anywhere on the body
  • dark urine, pale stools
  • yellowing of the skin and whites of the eyes.
Intrahepatic Cholestasis of Pregnancy (OC): Frequently asked questions
Intrahepatic cholestasis ICP support Obstetric cholestasis