It is generally considered that up to 200mg/day of caffeine is safe in pregnancy. Some guidelines allow for up to 300mg per day. Higher doses of caffeine are potentially associated with poor reproductive outcomes though the overall quality of evidence is poor. 

Rough estimates of caffeine content for certain drinks:

• Instant coffee - 80-120 mg per 250 ml
• Drip or percolated coffee - 150-240 mg per 250 ml 
• Espresso coffees such as espresso or latte - 105-110 mg per 250 ml
• Decaffeinated coffee 2-6 mg per 250 ml 
• Black tea 65-105 mg per 250 ml
• Cola drinks - 40-49 mg per 375 ml 
• Red Bull energy drink 80 mg per 250 ml
• Dark chocolate - 40-50 mg per 55 g serve
• Caffeine tablets - such as No-Doz - 100 mg per tablet.

Exercising in pregnancy is beneficial for both mother and baby. For those already exercising some adjustment may be required for your growing bump and it is always best to avoid significant physical discomfort. It is recommended that all pregnant women continue to partake in aerobic and strength-conditioning exercise as part of a healthy pregnancy. The UK Chief Medical officer’s recommendation is to aim for 150 minutes of moderate intensity exercise per week. 

Benefits of exercise include: 

• Improved sleep
• Improved mood
• Reduced rate of diabetes in pregnancy
• Avoidance of excessive weight gain in pregnancy
• Reduction in musculoskeletal  and back pain
• Potential reduction in the length of labour
• Decreased constipation 

Recommended exercise options include: 

• Walking
• Swimming (avoid heated spas and hot hydrotherapy pools >35C )
• Jogging (if you jogged prior to pregnancy)
• Gentle spin
• Light to moderate strengthening
• Modified Pilates, Yoga
• Pelvic floor exercises

Activities it is best to avoid: 

• Extreme, prolonged exercise and exercise in high temperatures (>32C)
• Activities with an increased risk of trauma : skiing, water skiing, surfing, off-road cycling, gymnastics, horse riding and contact sports such as ice hockey, boxing, football or basketball
• Scuba diving, Sky diving or vigorous exercise above 6000ft 
• Activities involving lying in supine positions after the 1st trimester: e.g. yoga or pilates or exercise classes in supine positions. Most pregnancy specific yoga or pilates classes are safe as they do not include these positions and adjust accordingly. 
• Hot yoga and pilates
• Heavy weight lifting and straining
• Sit ups after the first trimester. 

When to stop exercising and seek review:

• Vaginal bleeding
• Regular painful contractions
• Leakage of amniotic fluid 
• New shortness of breath before exercise
• Dizziness
• Headache
• Chest pain
• Muscle weakness affecting balance
• Calf pain or swelling

There are certain food safety precautions that you should take while pregnant to avoid placing your baby at risk of harm.  

Listeria

Listeria is a bacteria present in some foods that can cause a rare but dangerous infection called listeriosis. If Listeria is transmitted to your unborn baby it can lead to miscarriage, premature labour, or stillbirth. 

Salmonella

Salmonella is a bacterial infection that can cause gastroenteritis like symptoms. This can be severe in pregnancy and in rare cases it may trigger a miscarriage.

Steps to reduce the risk of Listeria and Salmonella:

• Eat only freshly cooked food and well washed, freshly prepared fruit and vegetables. Leftovers can be eaten if they were refrigerated promptly and kept no longer than a day 
• Avoid foods that may have been made more than a day in advance, for example pre-made and pre-packaged salads, sandwiches and wraps
• Avoid soft and semi-soft cheese such as brie, camembert, ricotta, fetta, bocconcini and blue (unless thoroughly cooked to >75C and eaten soon afterward). 
• Avoid soft serve ice-cream
• Drink only pasteurised milk
• Avoid raw egg in food (e.g. home made mayonnaise, aioli, chocolate mousse)
• Avoid pre-prepared or pre-packaged salads including fruit salad 
• Avoid eating all bean sprouts unless thoroughly cooked (e.g. alfalfa, broccoli, snow pea sprouts)
• Avoid eating processed deli meat such as ham, salami, chicken (unless thoroughly cooked to at least 75C and eaten soon afterwards). 
• Avoid eating any raw meat
• Avoid eating cold meats 
• Avoid eating pate
• Avoid eating raw seafood and ready to eat chilled peeled prawns 
• Avoid eating store bought Sushi

Toxoplasmosis

Toxoplasmosis is an uncommon parasitic infection that can be harmful to your baby.  It can occur if you eat undercooked meats, or unwashed fruit and vegetables, particularly from gardens with household cats. Most commonly, however, infection is caused by contact with cat faeces or contaminated soil in the garden. 

Steps to reduce the risk of Toxoplasmosis:

• Avoid undercooked or raw meat
• Avoid raw oysters, clams or mussels
• Avoid unpasteurised goat’s milk
• Always thoroughly wash fruit and vegetables
• Always wear gardening gloves when gardening
• Always wash your hands after touching animals, especially cats
• Avoid handling cat litter or animal faeces where possible (if necessary, wear gloves)
• If swimming in a lake or river, avoid swallowing the water
• Avoid tap water when travelling overseas

Fish and pregnancy

Eating fish in pregnancy is beneficial to mother and baby as a dietary source of omega 3 fatty acids which are important for fetal visual and brain development.  It is recommended pregnant women eat 2 to 3 serves of fish per week. You should, however, be careful about which fish you choose as some species contain high levels of mercury.  It is safest to consume only cooked seafood.  

Recommendations:

• Avoid – billfish (swordfish, broadbill and marlin) and shark (flake)
• Limit to one serve (150g) per week – orange roughy (deep sea perch) or catfish, with no other fish eaten that week.
• Eat 2–3 serves per week – of any other fish or seafood (for example, salmon or tuna).

There is no need to worry if the occasional meal with fish containing high mercury levels has been consumed. It becomes a problem where that type of fish is eaten regularly resulting in high accumulated mercury levels. 

An extensive list of what is safe and what to avoid is available from the US FDA: https://www.fda.gov/downloads/food/resourcesforyou/consumers/ucm536321…

Sexual activity and female orgasm are safe in pregnancy. It is not unusual for a small amount of vaginal spotting to occur after penetrative intercourse. If bleeding is heavy or recurrent it is best to seek review immediately. Penetrative intercourse should be avoided in patients with a low lying placenta (placenta praevia). 

More information: 

https://www.nhs.uk/conditions/pregnancy-and-baby/sex-in-pregnancy/

Flying

Flying itself does not have any affect on pregnancy. Long haul flying due to immobility and dehydration does increase the risk of deep venous thrombosis (blood clots) for all travellers. This risk is especially high in pregnancy but can be reduced.

Restrictions on pregnant women flying vary between airlines and their policies are usually available online.

Qantas and Virgin allow women with uncomplicated pregnancies to travel on flights greater than 4 hours up to the end of their 36th week. For flights less than 4 hours women may travel up to the end of the 40th week. Earlier restrictions apply to women with multiple pregnancies.

All airlines require women travelling after 28 weeks of pregnancy to carry a doctor’s note confirming their dates and clearance to travel. This should be written within 10 days of departure.

Recommendations for flying:

• Assess the availability and quality maternity facilities at your destination
• Assess the risk of infections disease at your destination: https://www.smartraveller.gov.au
• Confirm your travel insurance cover’s pregnancy related conditions (the costs of international delivery especially if the baby is born preterm can be enormous).
• Reduce your risk of deep venous thrombosis by staying well hydrated, reduce caffeine intake, mobilise during the flight and wear compression stockings
• Wear your seatbelt when seated, it fits below your bump
• Carry a copy of your pregnancy information with you (hardcopy or USB)

Zika Virus

Zika virus is a mosquito born disease present in certain regions of the world. It can also be transmitted from an infected partner during sex. Zika poses serious risks to unborn babies including:

• Microcephaly (an abnormally small head due to the brain not developing properly)
• Intellectual disability
• Developmental delay
• Hearing and visual problems
• Seizures

Only 1 in 5 patients that are infected with Zika will develop symptoms. These may include a mild fever, conjunctivitis, headache, joint pain and a rash. 

Couples planning pregnancy should take steps to reduce the chance of infection at the time of conception and during the remainder of the pregnancy by: 

• Avoiding travel to affected areas while attempting conception 
• If avoiding travel is not possible, couples should take all precautions to prevent mosquito bites and use condoms consistently and correctly when having sex in that country. 
• Upon return to Australia it is recommended that women wait at least 6 months after leaving an affected area before attempting pregnancy, regardless of the presence of symptoms of Zika virus infection. If the woman’s partner travelled with her, they should also follow the advice below. 
• It is therefore recommended that men wait at least 6 months after leaving an affected area before attempting pregnancy or donating sperm, regardless of the presence of symptoms of Zika virus infection. During this waiting period, the couple should use condoms correctly and consistently.
• If you are unable to wait for the full recommended period before attempting pregnancy a Zika blood sample is taken at least 4 weeks after the last exposure to ensure no infection. 

A list of countries where Zika infection is possible can be found on the Australian Government Smart Traveller website. https://smartraveller.gov.au/guide/all-travellers/health/Pages/infectio…

Driving

It is important to wear your seatbelt and correctly when pregnant with the lap part of your seat belt worn as low as possible, positioned below your baby. It should be over the upper thighs and across the pelvis. The sash part of your seatbelt should pass above the stomach and between the breasts. On long drives stop regularly to stretch your legs and remember to keep hydrated.

Whooping Cough (Pertussis)

Whooping cough is a highly contagious severe respiratory illness characterised by bouts of coughing which make it difficult to breathe. Adults can be vaccinated although babies cannot. In order to protect both mother and baby the current Australian Government guidelines recommend mothers are vaccinated during their pregnancy, from 22 weeks. Your antibodies cross the placenta and provide protection from whooping cough for the baby in its first 8 weeks of life. Protection is not life-long and begins to fade after 6-10 years. The vaccine Boostrix® can be obtained for free for both parents from your local GP. It is safe in pregnancy. It is also recommended that family and anyone else who will have contact with your baby should have the vaccine every ten years.

Influenza (Flu)

Influenza (flu) is a seasonal disease with new strains causing illness each year. Pregnant women are at high risk of severe complications of influenza infection. The vaccines are available in mid-March in Australia and usually consist of protection against 3 or 4 of the most commonly seen strains of virus in the preceding Northern Hemisphere winters. Influenza vaccine is also safe in pregnancy in all trimesters and is recommended. It can also be obtained for free from your GP and it too offers the baby protection after birth, for up to 6 months

COVID-19

As of the 9th of June 2021 RANZCOG and the Australian Technical Advisory Group on Immunisation has recommend that pregnant women are routinely offered the Pfizer mRNA vaccine at any stage of pregnancy. This is because the risk of severe outcomes from COVID-19 is significantly higher for pregnant women and their unborn baby. Global data from large numbers of pregnant women have not identified any significant safety concerns with mRNA COVID-19 vaccines given at any stage of pregnancy. There is also evidence that maternal antibodies in cord blood and breastmilk may offer protection to infants through passive immunity. Women who are trying to become pregnant do not need to delay vaccination or avoid becoming pregnant after vaccination.

In Australia where the risk of Covid-19 infection remains very low it is understandable pregnant patients are taking a cautious approach to vaccination. It is nonetheless great that the option is now available and given recurrent outbreaks uptake is increasing.

Chicken Pox (Varicella Zoster)

Chicken pox is a viral infection that is highly contagious. It is spread via respiratory droplets (cough, sneeze etc.) and results in a characteristic blister like rash. Many Australian women (90%) have had either infection as a child or been vaccinated. Vaccination is not safe in pregnancy. Occasionally, at times of stress or fatigue, the virus can reactivate and cause ‘shingles’. This is less severe and can only be caught via direct contact with the lesions on a person’s skin. Infection confers lifelong immunity which can be detected through a blood test, usually done at the beginning of pregnancy. If you are immune you are not at risk of re-infection. If you are not immune and you come into contact with chickenpox, you need to contact Jonathan immediately and he will arrange for you to have an injection (ZIG) within 96 hours of contact to reduce your risk of infection. If you are non-immune and planning a pregnancy vaccination pre-pregnancy is ideal. You should avoid pregnancy for 4 weeks after completing the vaccine schedule and avoid contact with non-immune pregnant women should a post-vaccination rash occur.

Hand foot and mouth

Hand, foot and mouth disease is an illness caused by a virus called Coxsackie virus. It is very common in children under 8 and, being highly contagious, frequently seen in children who attend day care. It is characterised by sores (rash) on the child’s hands, feet and sometimes in the mouth. Most adults have had hand, foot and mouth disease as children. If they do contract it as an adult it is often very mild. It is not known to cause any problems in pregnancy.

Parvovirus (Slapped Cheek)

Parvovirus is another common viral illness of childhood. 70% of adults in Australia have had parvovirus as a child which gives them lifelong immunity, easily detected by a blood test. When children have parvovirus they commonly are unwell with a high fever and then develop bright red cheeks (hence the name ‘slapped cheek’ disease). Adults though are usually only mildly affected. In pregnancy parvovirus can cause anaemia in the developing fetus which can lead to heart failure. If you come in to contact with parvovirus during your pregnancy, contact the practice so that your risk level can be assessed and immunity checked.

Constipation and bloating are very common during pregnancy and in the post-partum period. Up to 40% of pregnant women are affected. Hormonal changes, in particular increased progesterone levels, result in the slower transit time of food in the gut.

Certain medications such as oral iron, anti-nausea medication and strong pain relief can worsen constipation.

Staying mobile, keeping up your fluids and optimising your diet will often alleviate most cases of constipation.  A high fibre intake (e.g. whole grains, rice, bran, beans, lentils, nuts, dried fruit, fresh fruit and vegetables) is essential. These foods should be introduced gradually if they’re not normally a part of your diet as bloating and flatulence may occur. 

There are a number of laxatives that are safe to use in pregnancy while others are best avoided if possible. Common laxative types are listed below starting with the safest options at the top:

1. Bulk forming laxatives. First line option and safe. These are effective but take a few days to work. Examples include:

• Psyllium (Metamusil® capsules or powder)
• Ispaghula (Fybogel® oral granules).

2. Osmotic laxatives. Second line. These should be used with caution in pregnancy but the following are considered safe.

3. Stool softeners. Third line and used in combination with other therapy.

4. Stimulatant laxatives. These should be avoided except for occasional doses. They are not teratogenic but have other adverse effects. They are safe while breastfeeding. Examples include:

• Bisacodyl (Bisalax)
• Senna (Senekot, sennetabs)
• Sodium Picosulfate (Ducolax)

Eating a healthy, varied diet in pregnancy will help you to get most of the vitamins and minerals you need. Nonetheless, it is important to take some additional supplements before and during your pregnancy to ensure the needs of your growing baby are met.

The following supplements are recommended during the pre-pregnancy and pregnancy period.

Folic acid

Folic acid 400 micrograms (mcg) daily should be taken from at least a month before you know you’re pregnant until beyond 12 weeks of pregnancy. This helps prevent birth defects known as neural tube defects, including spina bifida.

In certain cases a higher dose of folic acid (5mg per day) is required:

• where there is a personal or family history of neural tube defects
• women with a previously affected pregnancy
• diabetic women
• women with a BMI above 30
• women on certain antiepileptic medications.

Iodine

Women who are pregnant, breast feeding or trying for a pregnancy should take an iodine supplement of 150 micrograms each day. Iodine is important for the normal functioning of both the maternal and fetal thyroid in addition to the normal development of the baby’s brain. Iodine deficiency is increasing due to a reduced population intake of traditional generic products such as iodised table salt, bread and milk. Good daily sources of iodine include many dairy products, seafood, seaweed, eggs, bread (non-artisan), some vegetables and iodised table salt.

Vitamin B12

Vegetarians and vegans should be should supplement with Vitamin B12 during pregnancy and breastfeeding. This reduces the risk of certain neurological consequences in exclusively breast fed infants.  Recommended daily intake is 2.6 mcg/day in pregnancy and 2.8 mcg while breastfeeding.

Iron

During pregnancy, a woman’s requirement for iron increases due to an expanded blood volume in addition to the needs of a developing baby and placenta. Iron is essential for red blood cells to transport oxygen around the body.

Not all women require iron supplementation though it is generally recommended for women at particular risk of iron deficiency including vegetarian women and those with a twin pregnancy.

It is important for all pregnant women to eat iron-rich foods every day, such as meat, chicken, seafood, dried bean, lentils, and green leafy vegetables. Animal sources of iron are readily absorbed by the body. Iron from plant sources is not absorbed as easily, but absorption is helped when these foods are eaten together with foods that contain vitamin C.

The recommended daily intake (RDI) of iron during pregnancy is 27 mg a day (9 mg a day more than for non-pregnant women). Most pregnancy multivitamins contain a sufficient daily dose.

Calcium

Calcium is vital for making your baby's bones and teeth. It is also important for your long term musculoskeletal health. Due to increased maternal absorption of calcium a healthy balanced diet will ensure sufficient intake in pregnancy. Sources of calcium include: milk, cheese and yoghurt, green leafy vegetables, tofu and certain calcium fortified foods (e.g. breakfast cereals, fruit juices and bread). Certain at risk women will require additional supplementation.

Vitamin D

In pregnancy, vitamin D is essential for the normal development of your baby’s bones. Vitamin D also helps maintain your muscle and bone strength. Vitamin D deficiency can make it hard for your body to absorb adequate levels of calcium from food. Therefore your levels will be tested in pregnancy and supplementation is commenced where deficiency is identified.  

https://www.betterhealth.vic.gov.au/health/healthyliving/pregnancy-and-…

A number of skin changes occur during pregnancy in response to elevated levels of hormones such as oestrogen and progesterone.

Increased pigmentation

Many women have a range of pigmentation related changes during the pregnancy. These include: 

• Birth marks, moles and freckles that may darken
• Increasing freckles or brown patches on the face (Melasma)
• The area of skin around the nipples (areola) may go darker
• Some women develop a dark line down the middle of the stomach 

It is important to protect your skin from the sun while pregnant as it is more sensitive and excessive sun exposure may increase these changes. Most changes will fade after the birth of your baby.

Sun Sensitivity and Sun Screen

It is important to protect your skin from the sun while pregnant as it is more sensitive and excessive sun exposure may increase pregnancy related changes mentioned above. You will find that your skin will burn more easily. Most skin changes will fade after the birth of your baby but not always. 

There is no direct risk posed to your baby from sun exposure though it is important to stay well hydrated, avoid sun burn and overheating. 

It is safe to use most sunscreens in pregnancy but some are potentially safer than others. Overall the quality of evidence is poor. That said there are two main types of commercially available sunscreens: physical barrier (aka mineral) or chemical. As per usual the higher the SPF rating the better. 

• Physical or mineral sunscreens are generally considered safer in pregnancy. These sunscreens contain zinc oxide or titanium dioxide and work by literally blocking the sun. 
• Chemical sunscreens contain compounds such as benzophenone-6, oxybenxone, dioxybenzone, mexenone, octinoxate, octisalate, avobenzone. There is some (weak) evidence that these compounds effect hormonal function and are therefore best avoided if possible. 

DEET: certain sunscreens contain the pesticide DEET. This should only be used if necessary (in areas where mosquito born disease is present) and it is best to use products that contain low concentrations of  5-20%. Overall, given the very small amounts absorbed it is thought that when it is required the benefits of protection will outweigh the risks. 

Stretch Marks

Stretch marks or striae gravidarum are very common and occur due to changes in the connective tissue of the skin secondary to the hormonal changes of pregnancy. They are not harmful. Stretch marks usually begin as pink or purple lines on the skin. These change to slightly sunken lines or streaks of a lighter colour than the surrounding skin (faded silver grey).  They usually occur on the abdomen, thighs and breasts and may occur on other areas such as the back and buttocks. Stretch marks normally start to form in the late second or early third trimester of pregnancy. Women with a family history of stretch marks are more likely to develop them. Stretch marks normally fade over the year after the pregnancy but will not completely disappear. 

There are no proven treatments for stretch marks and those that exist are should only be used after delivery (e.g. laser). Most strategies focus on prevention. Evidence for preventative treatments is also limited. Creams containing Vitamin E or Tretinoin have shown promise though the safety of topical Tretinoin use in pregnancy is not entirely clear.

Hair growth

Hair growth can increase in pregnancy and you may notice your hair is greasier. About three months after the birth most women notice hair loss from the scalp. Hair usually grows back completely and will return to normal within 6 months of giving birth.

Difficulty sleeping

It’s common for many women in late pregnancy to experience poor quality sleep. Sleep is lighter and often more interrupted at this stage. This can be for a number of reasons such as restless legs, feeling anxious, increased frequency of urination, reflux, anxiety and the musculoskeletal discomfort that often occurs later in pregnancy. Thankfully a lack of sleep poses no risk to your baby.

Addressing difficulty sleeping involves first treating any apparent underlying cause. Having done this start with the basics such optimising your sleep environment and avoiding stimulants like tea, coffee or other caffeinated drinks in the afternoon. Improving your sleeping position with support pillows (between the legs, behind your back and under your bump) can also help.

Gentle exercise, antenatal pilates and yoga are often beneficial for sleep quality.

Occasionally medication may be required and sedating anti-histamines such as Doxylamine (Restavit®) can be used safely for short periods.

Sleeping position

From the 28th week of your pregnancy it is best if you can sleep lying over on either your left or your right side. This is because the weight of baby and the womb when flat can compress the large blood vessels at the back of the abdomen effecting the return of blood to your heart. This results in less overall blood flow to the womb and reduced oxygen delivery to your baby. Accordingly, research has shown that the risk of stillbirth may increase slightly in later pregnancy in women that regularly go to sleep lying flat.

Lying on your side also improves your breathing and keeps up adequate oxygen intake.

There is no need to worry if you wake up on your back as the relevant research looked at the way you fall asleep which is usually your most common sleeping position. If this occurs just roll over on to your side as you go back to sleep.

Sleeping on your side can be difficult if you’re not used to it but there are specific aids and wide range of maternity pillows available designed to help you stay comfortable.

Every labour is different as are every patient’s preferences when it comes pain relief. To ensure you can make an informed decision about what suits you best and understand why clinicians may offer certain options a discussion with your obstetrician well before the day of delivery is ideal.

A lot of the information regarding pain relief in labour is vague and can be delivered in emotive terms so that patients can feel pressured in their decision making. Thankfully there are number of excellent objective resources that make for ideal reading. Some of these are listed below:

• Australian and New Zealand College Anaesthetists pain relief in labour Summary
• Royal Women’s Pain Relief in Labour summary
• Royal Women’s Epidural Patient Sheet