Weeks 33 – 36 - MAMA Maternity

Your baby: By the end of week 36 will measure approximately 50cm, about the same length as she will be at birth, and will weigh around 2.4 – 2.8kg. Your uterus and abdominal cavity will be very full of baby.

During the next three weeks your baby will probably gain more weight than at any other time during the pregnancy. Her face will now be softly rounded both because of the fat that has been deposited under her skin and also because the suckling/pumping muscles in her cheeks and jaws are now nearly fully developed. She may have been exercising these muscles for a few months now, by sucking on her thumb or fist.

If this is your first baby, her head will probably “engage”/enter your pelvis this month both in effort to get more room and in preparation for his birth journey. If your baby enters your pelvis feet or bottom first (breech) your LMC midwife or doctor may suggest, exercises that will encourage your baby to turn; that you start a course of acupuncture to encourage your baby to turn before she becomes too big; or refer you to a specialist obstetrician for a procedure called External Cephalic Version (ECV). This procedure is usually performed at around 37 – 38 weeks by an obstetrician who uses ultrasound to see exactly where your baby and placenta are located and attempts to “massage” your baby around into a head-down position.

Your baby is now shedding the soft hair (lanugo) that has covered her body since the beginning of the second trimester. By the time she is born all that may be left is a small amount of hair across the top of her shoulders, on the tips of her ears and possibly a small amount on her forehead. Instead, the waxy vernix that her skin secretes to protect itself will become thicker this month, although most of this too, will be absorbed in the last few weeks before he is born.

Your body: The end of your pregnancy and the birth of your baby will now feel more real. As well as coping with the physical stresses of late pregnancy, there are practical things you should organize to help ensure that your labour and birth progresses efficiently. You will maybe need to find solutions to any of the worries you are feeling about labour and birth, or parenting your baby “on the outside”, so that these anxieties don’t inhibit the onset or the progress of your labour.

Your whole body is likely to be feeling a bit stressed and tired and possibly achey, from carrying so much extra weight and mass – a whole new person inside! Your lungs and stomach will be pushed up making your breathing more rapid and shallow and the pressure on your stomach may mean that even though you are eating smaller portions you are still experiencing indigestion and heartburn. You will feel some relief as your baby “drops” down into your pelvis.

It is usual for you to see your LMC midwife or doctor for check-ups every fortnight during this month.

Optimum Fetal Positioning: If this is your first baby he will probably enter your pelvis head-down this month. Once he has “engaged” into your pelvis there is not much room to move. He’ll still wriggle and kick and rotate a bit, but there is not much room for changing position. Whatever number of pregnancy this is for you, you can help your labour to be as efficient as possible by encouraging your baby to enter your pelvis in the “optimum” position i.e. with her neck “well-flexed” and the back of her head “anterior” (towards the front) to your body. This involves spending as much time as possible in positions that tilt your pelvis forward. For more information about what you should do to help ensure that your baby settles into your pelvis in the most efficient position for getting out, go to www.homebirth.org.uk/ofp.htm

Birthplan: If you haven’t already started to discuss and document your birthplan with your LMC now is the time to do it. A birthplan outlines your wishes for your labour and birth. This includes your ideal birth environment e.g. home, maternity hospital, obstetric hospital etc as well as things within that environment e.g. low light, aromatherapy, music etc. Your birth plan details how you would like to manage your labour e.g. natural labour using labour coping techniques. How you feel about the use of pain relieving drugs and medical interventions. For more information about your options for maternity care during labour and birth go to www.maternity.org.nz/labour-and-birth.shtml You also need to decide how you want to meet your baby immediately after birth e.g. skin to skin contact immediately (before cleaning and dressing), low light, cuddling baby until after the first breastfeed or baby cleaned and examined and dressed then breastfed. You may also have some requests for emotional support or to accommodate religious or cultural practices that are important to you. Discuss your expectations for the progress of your labour with your LMC, also discuss how you might manage and the support you might need if your labour is proceeds differently from your ideal scenario e.g it is longer or slower or you or your baby can’t cope. Ask your LMC midwife or doctor about the monitoring and procedures that are a normal part of the care that they provide during labour and birth and decide whether or not you are comfortable with these. A birthplan probably will not change your LMC’s usual style of practice, but communicating and documenting your birthplan with your LMC will let you know whether or not your LMC is willing and/or able to support the choices you make. If you discover that your ideal birth and your LMCs preferences for managing labour and birth are very different, you should consider, even at this late stage of your pregnancy, changing to another midwife or doctor.

Waterbirth: Immersion in water is one of the most effective means of managing pain in labour. Women typically report that being in a birth pool reduces their perception of the intensity of the contractions by up to 50%. If you are interested in the possibility of using immersion in water as a labour coping skill you will need to discuss this with your LMC and if you are planning to give birth in a hospital, check that hospital policy allows planned waterbirths. Most LMC midwives are happy for women to labour in a pool but not all midwives offer waterbirth. If you like the idea of giving birth in water, make sure that your LMC midwife or doctor is comfortable and experienced with monitoring and assisting a woman to labour and give birth in water. If you are planning to give birth at home, either your midwife or your local Homebirth Association may hire out birth pools, if not there are a couple of on-line businesses that sell birthing pools. (e.g. www.h2ohbaby.co.nz or www.nurturenz.com)

Homebirth: If you are planning to give birth at home there are a few extra things that you will probably need to organize. Your midwife will bring all the supplies and equipment she needs to do her job but she will probably have some suggestions for things that you could have on hand that will be useful during your labour and birth. Your midwife should visit you at least once at your home so she knows how to get to your place and can see what you’ve got and what you might need to make your homebirth experience go smoothly. Your local Home Birth Association or Home Birth Support Group will also be a good source of information and support. For more information about homebirths in NZ/Aotearoa go to www.homebirth.org.nz

Hospital Tour: If you are planning to give birth in a hospital, maternity unit or birthing unit and you haven’t already taken a tour of the facility, you should phone to find out if they run tours and if they do book yourself onto one. Even if you can’t tour the labour and birth ward (as is the case at Auckland City Hospital) you and your partner/support person should drive to hospital to work out the best route; to check out the hospital parking; to find our how to get into the building day or night; and find out where the labour and birthing ward or rooms are. Attending a Labour and Birthing ward tour will also give you an opportunity to find out about hospital policies and protocols and also see what birthing aids and equipment (e.g. labour balls, birthing pools, birthing stools, bean bags etc) are available in the labour rooms.

NB National Womens at Auckland City Hospital does not provide a tour of their birthing facilities. You can find a virtual tour at www.adhb.govt.nz/NWHealthInfo

Postnatal Care Plan: It can be hard to focus on anything past the labour and birth before your baby is actually born. However, you do need to discuss your postnatal care with your LMC midwife or doctor.

Ask your LMC how often s/he will visit you after your baby is born. Find out about the schedule and purpose of home visits and make sure you know how to contact your LMC in between visits if you have questions or concerns. Your LMC midwife or doctor is required to monitor your recovery from labour and birth: to help you to establish breastfeeding; to teach you basic parentcraft; and to monitor the growth and development of your baby. S/he is required to visit you regularly until your baby is 4 – 6 weeks old and make referrals to any other medical or health services that you or baby need during this time, then make a formal handover of your care to both your family GP and your chosen Well Child provider. There are a range of screening tests and treatments that available to your baby in the first few hours, days and weeks of his life. You need to gather information about the following treatments & tests before your baby is born, so that you can make informed decisions about whether or not you will consent to your baby having them.

Signs of Labour: If this is your first baby and you have attended a Birth Preparation Course you should be aware of the signs of labour. If not you need to talk to your LMC midwife or doctor about these signs at you next pregnancy check-up. You also need to ask your LMC about when to contact her/him when you are in labour.

Exercise: Join or continue to attend a regular pregnancy yoga, aquanatal or pilates class. Not only will regular exercise help reduce the likelihood that you’ll experience the discomforts listed below but regular exercise will also help keep your stamina up for labour and birth as well as mothering your baby 24/7.

Backache: You whole body is continuing to soften and loosen in preparation for your labour.

Check your posture when standing and sitting.

Join or continue to attend a regular aquanatal, pregnancy yoga or pilates class and continue to exercise regularly and appropriately.

Have regular massages either from a massage therapist or your partner.

Try a warm bath (< 38.4ºC) with Epsom Salts dissolved in the water.

Hot compresses – use a hottie in a cover or a grain sack etc.

Ask your LMC midwife or doctor for a referral to a physiotherapist.

Pelvic Pain: All your pelvic joints are softening and opening to allow your baby’s head to fit into your pelvis. Your ligaments are likely to be very soft by now so all your pelvic joints, centre front (symphysis pubis), at the back (sacro-iliac), as well as around your hips will move a little when you move. Any activity that involves lifting one leg at a time or parting your legs e.g lifting your legs to put on clothes, getting out of a car, turning over in bed or getting out of bed, walking up stairs, standing on one leg, lifting (especially toddlers), and walking in general, can be painful. This pain usually ocurs in the last trimester with a first pregnancy but can occur earlier in a second or subsequent pregnancy and for most women is relatively mild. The number of women experiencing moderate to severe pelvic pain in their first pregnancies is growing. Many women (pregnant or not) spend a lot of time each day sitting – at desks, in the car, in front of the TV or computer at home. If you have a sedentary lifestyle your muscles, including your lower back, pelvic and core muscles will be less toned and strong, so less able to compensate for the normal ligament softening that occurs in late pregnancy. Some fit and active women also experience pelvic pain so there is possibly a genetic predisposition for some women i.e. their bodies may be more responsive to the effects of pregnancy hormones, relaxin and progesterone also, some women have naturally hyper-mobile joints and the relaxing hormones of pregnancy may increase this mobility leading to pelvic pain and instability. Previous trauma or accidents involving damage to the pelvis may increase the risk of developing pelvic pain during pregnancy.

You may be able to reduce pelvic discomfort and pain by: –

Putting a pillow between your legs, under your “bump” and an extra one or two under your head and shoulders when sleeping; (a body pillow can be a great investment especially for women carrying twins).
Sleeping in a pillow supported version of the recovery position so that your weight is concentrated on your thigh muscle rather than you hip joint.
Keeping your knees together when moving or turning in bed, getting out of the car, getting up from the table or desk.
Sitting with your thighs parallel rather than with your legs crossed.
Walk Tall – lengthen your spine and actively “lift” your upper body weight out of your pelvis.
Try swimming or aqua-walking as a form of exercise instead walking.
An ice pack on painful joints may help reduce inflammation; a hot pack may help to relax muscles that have spasmed.
Think before you move – avoid sudden movements.
Ask your LMC for a referral to a physiotherapist.
Get a pelvic support belt – there are several different versions available – a physio might be able to prescribe one or you can buy on-line.
Book a massage or an appointment with an osteopath who has experience in working with pregnant women.

Ligament Pain: You may notice mild stabbing, stitching or pulling pains low down in your pelvis on one side or the other (a bit like “the stitch”). These pains will usually occur when you suddenly change position or start moving after standing still for a while, go from lying to sitting or standing, or from sitting to standing, or if you twist or turn your torso but not your legs. As your uterus grows it stretches the supporting ligaments and their reduced elasticity is what causes these stitch-like pains. This pain is not dangerous but may be reduced by any the self-help tips in the previous section on pelvic pain and by breaking movements down so that you don’t change height and direction at the same time and by using your arms and hands to lever yourself out of chairs etc or better still, get someone/your partner to help you up.

Varicose Veins: Your blood vessels will have softened and stretched to cope with your extra blood volume. In addition, the valves that flick the blood back up the veins in your legs will also be softer and less efficient causing a slower flow of blood. The extra weight of blood in your veins can cause these valves in the veins to fail, allowing the blood to pool and further distend the veins, causing them to become varicosed.

It seems that some women have a genetic tendency to develop varicose veins during pregnancy. However all women can help prevent varicose veins or limit their severity by exercising their legs and ankles regularly. If you have a sedentary job, you should try to get up and walk around every hour and do ankle and leg exercises to assist the circulation in your legs. Sitting for long periods and sitting with your knees crossed will inhibit the circulation in your legs. If your leg veins have varicosed you can wear support stockings to assist the circulation in your legs and to reduce the pain. You should put these stockings on while you’re still lying in bed each morning, before you stand up.

Haemorrhoids: are varicosed veins in your rectum and are caused by a combination of:-

Your increased blood volume.
The continuing increase in your production of softening hormones that (a) cause the walls of your blood vessels to be softer slowing the flow of blood and allowing blood to pool and (b) slow the passage of waste through your bowel contributing to constipation that can cause women to strain to pass to bowel motion – a manoeuvre that can cause the rectal veins to form swollen pouches inside or outside the rectum.
Iron supplements that cause or exacerbate constipation.
Increased pressure on the rectal vein from the growing weight of your uterus.

You can help prevent haemorrhoids by ensuring that you eat fibre rich foods (raw fruits, vegetables and wholegrain foods) and drink sugar-free drinks especially water at regular intervals throughout the day. Regular exercise also assists digestion and excretion and pelvic floor exercises can help to keep the muscles around your anus and rectum firm, preventing the veins from popping through.

If, despite your best efforts, you develop haemorrhoids, you can try sitting on an ice pack for immediate relief and ask your LMC midwife or doctor for a prescription for a haemorrhoid ointment that will help reduce the swelling and relieve the itching and pain. If you are unable to cure constipation with diet etc and it is causing painful haemorrhoids, your LMC can prescribe a stool softening medication.

Insomnia: A significant number of pregnant women either find it difficult to fall asleep or difficult to get back to sleep once they have woken (for yet another trip to the toilet!). Sleeping issues at this stage of pregnancy can be caused by physical discomfort, stress or an overactive mind. Physical discomfort can be reduced by exercising regularly so your muscles remain strong and toned, altering your sleep position (modified recovery position can be good), and supporting your body with pillows. If your life, relationship and/or work is stressful you need to work out some stress management strategies and make time each day to relax – lie down and listen to music or a relaxation tape, have a bath or a massage using relaxing essential oils (aromatherapy), see a counselor or therapist etc. If it’s an overactive mind that is keeping you awake – again you need to put in place some management techniques like a bedtime ritual where you work on winding down, with a massage or bath, a few chapters of an easy reading novel etc before you go to bed. Make a list of any tasks or concerns that you are likely to turn over and over in your mind instead of relaxing and sleeping and leave the list somewhere away from your bedroom to be dealt with tomorrow. Similarly, if you wake and cannot get back to sleep, don’t lie in bed worrying about it – read something non-stressful or get up and make a cup of herbal tea (chamomile, passionflower, valerian etc), write a letter to a loved-one or an entry into a late pregnancy diary/journal, do some knitting or stroke the cat while you listen to relaxing music, then go back to bed. If you’re working you may need to cut back your hours to compensate for the lost of sleep and to allow you time for a daytime nap – you will be able sleep when you need to.