Some medical conditions show up later in pregnancy, even if women are healthy at the beginning of their pregnancy. In the case of a woman who is under the care of a midwife or General Practitioner (GP,) she will end up being transferred to an obstetrician (OB) should she be diagnosed with certain medical conditions. This means that an OB is now in charge of all medical decision making, even if her midwife or GP continues to provide supportive care. Each situation is different, so it’s important to have open communication and ask lots of questions.
The following is a list of a number of medical conditions or issues that pregnant women can experience. Note that in some cases, these do not require a transfer of care.
Preeclampsia is a rare, but very serious condition that only develops in pregnancy; it is characterized by elevated blood pressure, swelling (fluid retention) and the secretion of protein in the urine. It is important to attend regular prenatal check-ups with your care provider, as blood pressure and urine tests will help to determine if preeclampsia has developed. Make sure to inform your care provider if you experience sudden swelling, severe headaches, vision problems, or severe pain just below your ribs. The treatment for preeclampsia is to give birth, and an induction of labour will be necessary.
Most placentas grow within a safe distance from the neck of the womb (or cervix,) so that babies can exit the birth canal. However, sometimes placentas will grow over the opening of the birth canal, either partially or fully covering it. The distance of your placenta is measured during an ultrasound, and a care provider will monitor with frequent ultrasounds if the placenta is found to be too close to the opening. In some cases, a cesarean section is necessary if the placenta does not move away from the neck of the womb.
A breech baby is one that lies in the womb in a different position other than “cephalic,” or head down. Some babies can lie bum first, feet or foot first, and even transverse (sideways.) Years ago a breech presentation meant an automatic cesarean. However, new studies have shown that some breech presentations can be safely delivered vaginally. Your care provider will palpate your belly during the third trimester, in order to assess baby’s position. If they are unclear, an ultrasound will be ordered. The option for vaginal delivery for a breech baby depends on the way the baby is lying, hospital protocols, and whether there is a care provider trained to deliver breech babies. Currently there are a small number of midwives who will perform vaginal breech deliveries.
Intrauterine Growth Restriction (IUGR)
IUGR is a condition in which the placenta ages prematurely and stop functioning effectively. This leads to a decrease in the nutrients your baby receives, and their growth is restricted. Placental function and growth restriction can be assessed through ultrasound, and if any red flags show up, further monitoring will be necessary. Women with IUGR will require the care of a high-risk obstetrician, and the care plan varies from hospital to hospital. Many women with IUGR are induced at the point when doctors determine that baby will have a better outcomes if delivered.
Premature Rupture of Membranes (PROM)
PROM refers to a woman who is full term (>37 weeks pregnant) and has her water break before any contractions have begun. This is generally not a cause for alarm. Contrary to what we see in Hollywood movies, only 10-12% of women have their membranes rupture before labour begins; this typically occurs in the middle of the night or early morning.
If your water breaks, give your care provider a call to let them know. Each hospital and care provider will have different policies relating to PROM – some will want to induce labour within 18 hours, and others will wait 24 hours to see if your body will go into labour on its own. Risk of infection in the uterus (called chorioamnionitis) increases with the amount of time the membranes have been ruptured.
Group B Streptococcus (GBS)
GBS is a transient bacteria that lives in the vagina and rectum, and 10-35% of pregnant women will have GBS at any one time. Babies are exposed to the bacteria as they move through the birth canal, and a very small percentage of babies can become sick from GBS. Women are tested between 35-37 weeks of pregnancy, and if found to be positive, will be offered IV antibiotics during labour. Some women choose not to receive antibiotics, unless they are also dealing with another risk factor – premature labour, PROM, or fever in labour. Being positive for GBS does NOT require a transfer of care.
Premature labour occurs when women go into labour before 37 weeks of pregnancy. Signs and symptoms can include lower abdominal pain/cramps, contractions, low back pain, bleeding, and leaking of amniotic fluid. If you suspect that you are in labour, it’s very important to get in to see your healthcare provider immediately. Early intervention is key and there are medications that will improve outcomes if labour cannot be stopped or slowed down.
Just as there are some women who go into labour before 37 weeks, there are also women who go into labour after 41 weeks gestation. At 10 days after the due date (referred to as “post-dates”) women will be schedule for an induction to artificially start their labour. This policy is due to the (very slight) increased risk in stillbirth after 42 weeks of pregnancy. An induction will require a transfer of care if women are being cared for by a GP or midwife – however, many low-risk practitioners will continue to care for the woman once the induction is successful and she is in labour.
It’s always a stressful situation to deal with a transfer of care, as women have become comfortable with their primary care provider and are not keen to make a switch. To maintain some continuity of care, consider hiring a birth doula for support. And remember that many low-risk care providers will offer supportive care during labour by staying in the room and providing physical and emotional support.