Delivery and post delivery

Frances Perry House conducts childbirth education and early parenting classes. Information about how to book in is provided by Frances Perry House when you receive your hospital registration paperwork. Fees for private classes are usually covered by your health fund although there may be some out of pocket expense.

Antenatal classes are an excellent way to prepare for labour, delivery, breast feeding and early parenting and are therefore strongly encouraged. Several of these classes are available as an online program which may be more convenient. 

Frances Perry Hospital tours are also available. 

Please go to http://www.francesperryhouse.com.au/Maternity-Education-and-Tours/Childbirth-and-Early-Parenting-Program for more information.

For those based on the other side of the city Cabrini Malvern also offer antenatal classes to all pregnant women regardless of where they have booked. With various options available at: https://www.cabrini.com.au/patients-and-families/services/new-redirectorpage-2/tours-and-childbirth-education/ 

The hospital also runs a Mums in Training Program which is a one hour weekly training program run by Physios. 

Fees for private classes at Cabrini are usually covered by your health fund though there are some exceptions when attending a hospital you are not booked at.   

Group B streptococci (GBS) are bacteria that occur naturally in the vagina and bowel in about 15% of women. Carrying GBS is normal and rarely harmful to healthy, non-pregnant women. However, the bacteria can pass to a baby in the birth canal during labour and there is a small chance a baby who contacts GBS during labour will develop an infection and become seriously ill. Giving antibiotics to the mother during labour reduces the risk of a baby developing a GBS infection soon after birth. Because of this risk screening with the GBS swab test is offered at 35-36 weeks. 

A number of steps are taken to reduce the risk of transmission to your baby:

• If you are GBS positive you will be given antibiotics in labour. 
• If you have a urinary tract infection caused by GBS it is treated and you will be given antibiotics in labour
• If you have had a baby previously with a GBS infection you will be given antibiotics in labour
• If you are GBS positive at term (after 37 weeks), and your waters break before you go into labour, you will be advised to have your labour induced to reduce the risk of an ascending infection

Gestational Diabetes Mellitus (GDM) is a specific type of diabetes that occurs due to pregnancy. It affects about 15% of pregnancies. It occurs due to increased insulin resistance because of hormones produced by the placenta. Insulin normally moves sugar out of the blood stream into the cells of the body, reducing blood sugar levels. When GDM occurs the body cannot produce enough insulin to achieve this and blood sugar levels may run high. Identifying and treating Gestational Diabetes reduces risks to you and your baby. 

Most women undergo testing for Gestational Diabetes at 26 to 28 weeks. In certain high risk groups testing will occur earlier in the pregnancy after 10 weeks. 

The test is called the oral glucose tolerance test (GTT) which is a fasting test. This normally needs to be booked with pathology providers: 

• Fasting is required for a period of 8-10 hours prior to the test. (No food or fluids such as tea, coffee or fruit juice.) 
• You may drink water at any time prior to and during the test. 
• Testing is generally conducted in the morning. 

 During the test: 

• First a fasting blood sample is collected.
• You will then be given a 75g bottle of glucose to drink within 5 minutes.
• A 1 hour post glucose blood sample collected.
• A 2 hour post glucose blood sample collected.
• You will be at the collection centre for around two and a half hours. 

Current evidence suggests that there is a benefit of reduced perinatal morbidity, with the use of screening programs for GDM, and treating women who are diagnosed with it. For over 20 years, the diagnosis of GDM has been derived from an ad hoc consensus, based on very limited data available at that time.1 When screening for GDM, there should be uniformity in the testing used and the subsequent follow-up management. The landmark observation trial HAPO, 20082 and other important randomised trials (Crowther et al. 20053 Langdon et al. 20094) have led to recommendations for new criteria for the diagnosis of GDM2, which have been endorsed by the World Health Organisation (WHO)5. 

The following is recommended: 

Biochemical screening for Gestational Diabetes should be performed at 26-28 weeks of gestation. Earlier testing performed in women at particularly high risk should be repeated at 24-28 weeks gestation to test for GDM, if a negative result is obtained at the earlier testing time point. 

RANZCOG recommended screening regimen is a 75gram two-hour Pregnancy Oral Glucose Tolerance Test (POGTT). A two-step procedure involving an initial one-hour non-fasting oral Glucose Challenge Test (GCT) is no longer recommended. 

The full set of criteria can be viewed at the following link:

Going past your due date? 

It is common for pregnant women to go beyond their due date and only about five per cent of babies arrive on the day itself. Going post term is more common in first pregnancies. Most babies tend to arrive between 37 weeks and 41 weeks of gestation, usually within a week either side of their due date. Twins and triplets often arrive early. 

During your pregnancy your preferences around birth and when you would like to deliver will be covered in depth.  In low risk pregnancies you will be offered induction of labour at or just prior to your due date. You will also be given the option of going up to 10 days over. 

In those opting to wait, an ultrasound is performed in the rooms at 41 weeks and fetal heart monitoring will be conducted to check the well-being of your baby. There is a significant increase in complications from the start of the 42nd week therefore induction of labour is offered again in the 41st week if you are yet to labour.  Alternatively, for those not wishing to have an induction regular fetal monitoring will be arranged. 

Why offer induction at term? 

In the last few years new evidence has arisen about the when the ‘safest’ time for low risk women to deliver is at or after your due date. A number of large studies (e.g. ARRIVE) have pointed towards the safest course being induction of labour at 39-40 weeks resulting in a lower rate of caesarean and stillbirth. Understandably this has caused a lot of controversy. 

The reality is that patients can be safely managed in a variety of ways, it’s important that you know all the facts and can make a properly informed decision. 

What are the facts?

Evidence now suggests that in low risk women delivery just prior to or at term (39-40+0 weeks) reduces the risk of the death of a baby by about 2/3rds. That said the overall rate of still birth is very low. At 39 weeks it is 0.14 babies per 1000, at 40+0 it is 0.33 babies per 1000 and at 41+0 it is 0.80 babies per 1000. To put that in perspective one Danish study showed 754 inductions would have to be performed to prevent one perinatal death. 

What effect does routine induction have upon other important outcomes for low risk women at term?

• Caesarean section: likely small reduction in the rate of caesareans
• Pre-eclampsia: a small but significant reduction in rate in the development of pre-eclampsia
• Pain: in one large trial there was a reported reduction in pain levels though epidural use was not measured (the evidence is unclear)
• Instrumental delivery: no significant difference

What are the downsides? 

The major downside of induction is that it requires more intervention. On average women spend more time in hospital, require more interventions during the labour (e.g. monitoring and use of oxytocin) and potentially have reduced mobility in labour. 

This above discussion points do not readily apply to women with additional risk factors in their pregnancy. 

Genetic screening

The last decade has seen a leap in the complexity of pre-pregnancy and pregnancy related genetic screening for conditions such as Down syndrome. These tests aim to give parents more information about their unborn baby. Discussion about which tests are relevant and suited to you is an integral part of both pre-pregnancy and antenatal care. Screening tests are optional and it is best to be informed about the nature of the test and possible results before they are performed. 

Screening tests in pregnancy determine a level of risk to your baby but it is important to note they are not diagnostic. If an initial screening test is abnormal further definitive testing will be offered. Screening tests are safe and pose no risk to you or your baby. 

Screening falls into two main categories: 

• Pre-pregnancy screening or testing very early in the pregnancy
• Antenatal tests (performed at certain times during your pregnancy)

Pre-pregnancy tests

Pre-pregnancy genetic screening is aimed at identifying couples who may be silent carriers of certain conditions that could affect the health of their future children. It is offered to all couples considering trying for a pregnancy and also in early pregnancy (prior to 12 weeks). This form of testing can be carried out once and in most cases the results can be used for all future pregnancies.

The standard testing option is the triple test prepair™ for the relatively common but potentially severe conditions: Cystic Fibrosis (CF), Spinal Muscular Atrophy (SMA) and Fragile X syndrome (FXS). This is a single blood test. About 1 in every 1000 pregnancies is affected by one of these three conditions. prepair™ identifies around 90% of CF carriers, 95% of SMA carriers and 99% of FXS carriers. prepair™ costs $385 with no medicare rebate available. The fee is billed directly to you by the Victorian Clinical Genetics Service (VCGS).

The standard testing option is the triple test prepair™ for the relatively common but potentially severe conditions: Cystic Fibrosis (CF), Spinal Muscular Atrophy (SMA) and Fragile X syndrome (FXS). This is a single blood test. About 1 in every 1000 pregnancies is affected by one of these three conditions. prepair™ identifies around 90% of CF carriers, 95% of SMA carriers and 99% of FXS carriers. prepair™ costs $389 with no medicare rebate available. The fee is billed directly to you by the Victorian Clinical Genetics Service (VCGS).

Results take around 10 working days to be processed following collection and you will be contacted with the results.

There are a few extended testing options that you can perform before you’re pregnant or in early pregnancy. These tests are only normally taken up by certain at risks groups but as prices come down over time their use will become more common.

It should be noted that most of the conditions tested for are very rare and the likelihood of both partner’s having them extremely low. Testing and interim results can cause anxiety hence the necessity for counselling.

• Prepair Plus (prepair+ TM) expanded carrier screening that looks at over 250 genetic conditions. Both partners are screened at the same time with saliva swab. This test is also run by the VCGS and costs $900. Turn around time can be up to 5 weeks.
• EugeneTM test covers 301 recessive and X-linked conditions from a saliva sample. It Costs $549 for an individual and $750 for a couple. Pre and post-test genetic counselling is included for every patient with before, during and after in 1 hour secure video consultations. Turn-around time is 3-4 weeks so the test is suitable for pre pregnancy screening or early pregnancy.
• Counsyl Foresight™ which includes these conditions and 175+ rare genetic disorders is also available. Price per person tested is $579.

Cystic fibrosis

Cystic Fibrosis is an inherited condition that primarily affects the lungs and digestive system.  1 in 25 people are unaffected carriers and it affects 1 in 2500. Individuals with CF develop an abnormal amount of thick mucus within the lungs and gut. In the lungs, this mucus traps bacteria resulting in recurrent infections. Within the gut, the mucus impairs digestion of food. Infants, children and adults with CF require daily chest physiotherapy to clear the mucus from the lungs and enzyme replacement medication to aid in food digestion. CF is a serious condition and there is no cure. Individuals with CF have a shortened life span with lung failure being the major cause of death.  A couple is only at risk of having a child with CF if both parents are carriers of the condition. If the tests show that you are a carrier for CF, your partner will be offered testing to clarify the risks for your child / children. 

Fragile X syndrome

Fragile X syndrome is the most common cause of inherited intellectual disability. 1 in 250 people are carriers with 1 in 4000 affected. People with FXS can have developmental delay, learning difficulties, anxiety, autism, epilepsy as well as some physical characteristics. The features of FXS vary from mild to severe and males are more likely to be severely affected than females. There is no cure for FXS although some educational, behavioural and medical interventions can improve outcomes. Some females who are carriers are at risk of developing fertility problems and going through the menopause early. Only female carriers of FXS are at increased chance of having a child with FXS. Therefore, your partner does not need to be tested.

Spinal Muscular Atrophy

Spinal muscular atrophy is a condition that affects nerves in the spinal cord and causes muscles to get weaker. 1 in 40 people are carriers with 1 in 6000-10000 affected. There are four types of SMA, with SMA type 1 being the most common and the most severe. prepair™ only looks for genetic causes of SMA type 1 which will identify around 95% of SMA carriers. Babies with SMA type 1 have weak muscles from birth and usually do not live past two years of age. There is no cure for SMA, however there are treatments and interventions available aimed at managing symptoms and improving quality of life.  If the tests show that you are a carrier for SMA, your partner will be offered testing to clarify the risks for your child / children.

Testing during pregnancy
(Prenatal screening)

Every baby has a small chance of having a chromosomal or genetic condition. Prenatal screening is primarily aimed at identifying babies with the more common specific chromosomal or genetic conditions such as Down Syndrome (Trisomy 21), Edward Syndrome (Trisomy 18), Patau Syndrome (Trisomy 13) and Turners Syndrome (Monosomy X). Early structural abnormalities may also be identified on ultrasound.  Screening poses no risk to your baby. 

Prenatal screening is entirely voluntary and is offered so as to give patients more information about their unborn baby. Where a result is abnormal the next step is to decide whether to proceed with definitive invasive diagnostic testing such as chorionic villus sampling (CVS) or amniocentesis. These tests pose a small risk to the baby. Where a serious abnormality is confirmed patients have the option of terminating the pregnancy. Alternately patients can continue with the pregnancy with the additional information aiding preparation, planning and care. You will be supported and assisted with your decision either way. 

Screening during pregnancy

Down Syndrome has been the focus of screening during pregnancy for many years as it is the most common chromosomal cause of intellectual disability in children and adults. This condition is caused by the baby having three copies of chromosome 21, instead of the usual two copies. It is usually a random as opposed inherited condition. Its frequency in the population is about 1 in 800 and it has effects on both health and learning. The chromosomal conditions Edwards syndrome (trisomy 18) and Patau syndrome (trisomy 13) are also screened for. These conditions are associated with disability, pregnancy loss or death in the newborn. With the advent of non-invasive pre-natal testing (NIPT) the chromosomal condition Turner’s syndrome (Monosomy X) is also screened for. This is a condition that affects girls and can result in short stature, under-developed ovaries and other potential health problems. 

Screening options:

Ultrasound and nuchal translucency scan 

This is an ultrasound scan conducted between 11 and 14 weeks of your pregnancy. It provides an excellent early assessment of the baby’s anatomy in addition to measuring the nuchal translucency. Nuchal translucency is the thickness of a fluid filled space in the soft tissue at the back of a baby’s neck. An increased nuchal translucency is often normal but can also signify an increased risk of genetic abnormalities such as Down syndrome and certain structural abnormalities. If an increased nuchal translucency is identified further testing is then offered. This would take the form of amniocentesis or chorionic villus sampling (CVS) depending on gestation. It is recommended that all patients have this ultrasound in addition to any other screening tests performed. 

Non-invasive prenatal testing (NIPT or NIPS)

NIPT is a maternal blood test that is collected from 10 weeks onward during your pregnancy. A small amount of a baby’s genetic material makes its way into the maternal circulation during pregnancy (cell free DNA). This test assesses that genetic material to detect Trisomy 21 (Down syndrome), Trisomy 18 (Edwards syndrome), Trisomy 13 (Patau syndrome) and Turner syndrome (Monosomy X). It also identifies the gender of your baby. The test is highly sensitive with a >98% detection rate for Down Syndrome, Edwards Syndrome, and Patau syndrome and a >95% detection rate for Turner syndrome. There are two main providers of the test in Melbourne – Percept™ and Harmony™ with a cost of $449 and $425 respectively. Unfortunately, this test is not currently covered by Medicare or private health insurance. Results take up to 5 business days to return. In the event of an abnormal result further diagnostic testing in the form of amniocentesis or CVS is offered to definitively assess if the baby is affected.  

First Trimester Combined Screening (FTCS)

FTCS is the older first trimester screening option that is still in wide use. It combines the results of the nuchal translucency ultrasound scan with a blood test performed between 11 and 14 weeks. The result is further adjusted by the patient’s age.  FTCS aims to detect Down syndrome, Edwards syndrome and Patau syndrome. Unfortunately, it is less likely to detect all of these and has a higher false positive rate than NIPT. An approximate out of pocket cost for the blood test after Medicare is $70, which is added to the cost of the ultrasound. Results of this testing are reported as low risk or increased risk. In most cases where a result suggests increased risk (>1:300) the baby will be normal. Nonetheless further testing is offered and this may be via NIPT (further screening) or a diagnostic test such as amniocentesis or CVS. 

Quadruple Test
(Maternal Serum Screening Test)

The quadruple test is an older second trimester screening test that is preformed between 15 and 20 weeks assessing the risk of baby having Down Syndrome, Edward Syndrome or a Neural Tube defect. It consists of a single blood test. The out of pocket cost after Medicare rebate is $70 and results take about one week to return. This test is significantly less likely to detect Down Syndrome than both NIPT and FTCS and for this reason is not recommended. 

Positive predictive value (PPV): if the screening test result is abnormal the PPV is the probability that the baby actually has that abnormality. 

Diagnostic Testing

Invasive tests such as amniocentesis or chorionic villus sampling, are used to definitively diagnose genetic or chromosomal conditions in unborn babies. These tests are normally performed where a increased risk screening result has been returned. 

Chorionic villus sampling (CVS)

CVS involves passing a needle under ultrasound guidance into the placenta between 11 and 13 weeks gestation. A small amount of placental tissue is collected for testing. A full chromosomal analysis is performed which takes 8-14 working days to complete.  A more rapid FISH test is also conducted identifying a specific set of conditions including trisomies 21, 18 and 13, with results available after 24-48 hours. The sensitivity of CVS for detection of Down syndrome is almost 100%. Very occasionally a technical problem growing the placental cells in the laboratory can occur. If so, an amniocentesis may be required later in pregnancy. The risk of miscarriage from the procedure itself is 0.2-1% (the risk of spontaneous miscarriage at this gestation is approximately 2%).

Amniocentesis

Amniocentesis is performed from 15 weeks gestation. It involves taking a small sample of amniotic fluid from around the developing baby using a needle under ultrasound guidance. A full chromosomal analysis is performed and takes 8-14 working days to complete.  A more rapid FISH test can be performed on the sample identifying a specific set of conditions, including the trisomies 21, 18 and 13, with results available after 24-48 hours. The sensitivity of amniocentesis for detection of Down syndrome is almost 100%. Occasionally there can be a technical failure to grow the cells in the laboratory but this is very uncommon. The risk of miscarriage from the procedure itself is approximately 0.1-0.5%. 

• Dating scan: this is performed between 6 and 9 weeks to determine your due date, confirm an intra-uterine pregnancy and ascertain whether you have a singleton or twin pregnancy. 
• Nuchal translucency ultrasound scan: this is performed between 11 and 14 weeks. This is an early but often detailed assessment of your baby’s anatomy in addition to being a part of the first trimester combined down syndrome screen. It is recommended in all pregnant women, even those having NIPT for their antenatal genetic screening. 
• Morphology scan: this is performed between 18 and 22 weeks and assesses the anatomy of your baby, the location of your placenta and the length of your cervix.
• Growth scans: additional ultrasound scans after the morphology ultrasound may be organized to formally assess the growth and well being of your baby as the pregnancy progresses. 
• A bedside ultrasound will be performed at every antenatal appointment to assess the wellbeing of your baby. 

As you near your due date it’s normal for your baby to be positioned in the womb head first toward the birth canal. This is often referred to as a cephalic presentation.

Some babies can be positioned bottom or feet first (breech) and more rarely lying sideways (oblique or transverse). These presentations occasionally result in problems in women aiming for a vaginal birth, in late pregnancy and sometimes at caesarean section. Breech babies can be frank (extended legs), complete (sitting cross legged) or footling (feet first). 

How common are breech babies? 

• At 30 weeks about 20% of babies are breech. 
• At term only about 3% are. 

What causes it? 

Often a specific cause can’t be found but certain factors may contribute such as:

• An abnormally shaped uterus
• Fibroids in the uterus
• A low-lying placenta
• A higher or lower than normal level of amniotic fluid
• A previous breech
• Having had babies before slightly increases your risk
• A short cord 
• Twin pregnancy
• An abnormality with the baby – this is rare

What are the risks and complications? 

The risks of a breech vaginal delivery are contentious but there is now a relatively large body of evidence from which we draw conclusions.

There is a very small but significant increase in the risk of babies being unwell or passing away during vaginal breech birth when compared to other types of delivery (Cochrane 2015). Because of this, the rate of caesarean delivery is much higher with breech presentations and most practitioners are relatively unfamiliar with Breech vaginal births- but they do still occur from time to time. There is also a small risk of complications with the umbilical cord when the waters break in the late pregnancy and during labour. 

What are the management options?

As you approach term you have three options: 1) Caesarean section, 2) External cephalic version (ECV) or 3) Breech vaginal birth. 

Generally vaginal birth with a breech baby is discouraged but may be offered in certain circumstances with careful discussion prior. 

The two preferred options are either an elective caesarean section or an attempt at spinning your baby around also known as external cephalic version (ECV) so that you can go on and attempt a vaginal birth. 

External Cephalic Version (ECV)

ECV involves an Obstetrician massaging your baby round to the correct position with their hands. This can be attempted in suitable pregnancies following careful review. An ultrasound and fetal heart rate monitoring (CTG) are performed before and after the procedure to check on your baby’s well-being and its suitability to proceed. Factors such as the baby’s position, the location of the cord and the fluid level will be checked. 

Most doctors administer a medication prior to commencing to relax the uterus to ease the turn. 

ECV is successful roughly 50% of the time with slightly lower success rates in those having their first baby. 

Risk considerations with ECV: 

• About 1 in 200 attempts results in serious fetal compromise requiring immediate caesarean section. 
• Minor complications such as breaking the waters, a small amount of bleeding or transient fetal heart rate abnormalities occur in about 1 in 25 attempts.