Screening tests look for signs of possible problems. The tests help to identify those women who have an increased risk of having an affected baby, but they do not give a ‘yes’ or ‘no’  answer. Those women shown to be at increased risk are then more likely to be offered what is called a diagnostic test. It is the diagnostic test that will give more information about whether the baby really does have the condition.

The diagnostic test you may be aware of is called an amniocentesis. This is where a doctor puts a needle into the womb (uterus) and withdraws some of the fluid that surrounds the baby. The fluid contains unique information about the baby’s ‘make-up’, which is why it is so accurate. There are some conditions that cannot be treated and the effects are ‘life-long’.

The most common conditions that you may have heard of are Down’s  syndrome and spina bifida. However, because of the complexity of early fetal development and the influence from inherited conditions, there are many abnormalities that might be detected by a screening test that can only be confirmed by a diagnostic test. In addition, an abnormality found from the fluid sample mentioned above does not give a complete picture of the degree to which the baby might be affected. If you were to be told that the baby might have a disability, you would naturally want as much information as possible about that condition. Only when you feel better informed, will you be able to decide from the options available, which one is right for you.

What do screening tests tell you?

Screening tests are only able to suggest whether there is an increased risk, therefore, some pregnant women may be told there might be a problem only to find that a diagnostic test shows this not to be the case and their babies are not affected (this is called a false positive result). On the other hand, some women have been told that they are within the ‘normal’ group and that

everything seems all right, but it is later found that the baby was affected (this is called a false negative result). The extent to how useful it is to have a screening test, is often decided by the balance between these false positive and false negative results. Screening tests are unable to pick up all conditions; some problems such as heart defects may not be noticed until the baby is born. In addition, it is important that some tests are performed at a specific time in your pregnancy, therefore, your dates need to be accurate and if you are not sure of them you may be advised to have an ultrasound scan before having a screening test.

Down’s syndrome

Down’s syndrome is a genetic condition caused by an extra chromosome. It can also be called trisomy 21, as this is the chromosome most usually affected. People affected by Down’s  syndrome are likely to have learning difficulties and certain medical problems. There is no way of knowing how serious these problems might be before the baby is born. It is now well recognized that some people with Down’s syndrome will lead semi or completely independent lives, although other individuals may need considerably more support and care.

Is my baby at risk?

Every woman has a slight chance of having a baby with Down’s syndrome. This risk increases with age, therefore, the older you are at the time you become pregnant, the greater your risk. However, the majority of babies who have Down’s syndrome are actually born to women under the age of 35 years (since these women make up the largest number of the childbearing population).

The screening test

The screening test is available at two stages in your pregnancy; between 11 and 14 weeks of pregnancy and then up until the 20th week of pregnancy, or a combination of both.

• Screening at 11 – 14 weeks:

Your midwife or doctor will offer to take a sample of your blood when you are about 11 weeks pregnant. This sample is sent to a laboratory where the levels of various substances in your blood (also known as ‘serum markers’) are measured to work out your risk of having a baby with Down’s syndrome. This test is usually combined with the NT test, see below.

• Nuchal translucency (NT) measurements:

Many hospitals and doctors offer an ultrasound screening test, called a nuchal translucency scan, which measures the fluid at the back of the baby’s neck (the nuchal area); a larger than normal amount of fluid can suggest that the baby has an increased risk of having Down’s syndrome. The scan is normally done between 11 and 14 weeks of pregnancy. In some hospitals the scan and the blood test will be considered together to work out a woman’s risk of having a baby with Down’s syndrome.

You will normally be given the results of your NT measurement at the time of your scan. If the results of your scan suggest that there is an increased risk of your baby having Down’s syndrome, the doctor will explain your scan results and will talk to you about the options available. The diagnostic test that you will usually be offered is called chorionic villus sampling (CVS). This involves using a syringe to withdraw a small sample of tissue from the placenta (afterbirth).This tissue contains unique information about the baby’s ‘make-up’, which is why it is so accurate.

Screening between 12-20 weeks:

Your midwife or doctor will offer to take a sample of your blood between 15 and just under 19 weeks of pregnancy, but this is usually done around 16 weeks when blood may also be taken to check that your baby’s spine is developing properly. An ultrasound scan is normally performed before the blood test is taken to make sure that the results of this screening test are accurate.

A woman’s chance or risk of having a baby with Down’s syndrome is based on her age when she

became pregnant and the levels of various substances (serum markers) within her blood. In many hospitals you will be told your risk factor using numbers, for example, a 1 in 175 chance that your baby is affected. In most hospitals, a chance of 1 in 250 is counted as high-risk. If the screening test shows that you have more than a 1 in 250 chance of carrying an affected baby, then you will be offered the diagnostic test, amniocentesis.

How exact is the test?

At the moment the screening tests for Down’s syndrome vary in their accuracy:

• 1 in 3 cases of Down’s syndrome are not picked up by screening;
• 1 women in 20 is classed as high-risk and is offered an amniocentesis. But, on average, even if you are high-risk there is only a 1 in 60 chance that your baby is affected.

The amniocentesis result will say definitely whether your baby does or does not have Down’s syndrome. Where you are told that your baby has Down’s syndrome there is usually advice and support readily available, so that you can discuss the future.

Spina bifida and problems with the baby’s spine (neural tube defects – NTDs)

Sometimes an unborn baby’s spine, skull or brain does not develop properly during the early weeks of pregnancy. This can result in a condition called spina bifida – where part of the baby’s spinal cord is malformed ‘open’ or ‘closed’, or a condition called anencephaly – where part of the baby’s brain does not grow. Babies born with anencephaly are not able to survive and die soon after birth. People born with spina bifida may show a wide range of physical disabilities, but many lead full and active lives.

Is my baby at risk?

The baby’s development in pregnancy is a very complex process, so any baby could develop a neural tube defect (NTD).They actually occur in about 1 in 400 births. They are not linked to a woman’s age, though women who have given birth previously to a baby with an NTD may be at increased risk of having another affected pregnancy. There is also thought to be an increased risk

in women taking some types of anti-epileptic drugs. If you are concerned about any drugs that you are taking at the time you become pregnant, do talk to your midwife or GP.

Taking folic acid tablets just before you get pregnant and in early pregnancy has been shown to reduce the numbers of babies born with NTDs. For further information see the Informed Choice article,’ Diet and nutrition in pregnancy’.

The screening test

Your doctor or midwife will offer to take a sample of your blood when you are around 15-20 weeks pregnant. The blood sample is sent to a laboratory where the level of a substance called maternal serum alpha-fetoprotein (AFP) is measured. You may be advised to have an ultrasound scan before the blood test is taken to check that your dates are correct and to improve the accuracy of the screening test.

How exact is the test?

The alpha-fetoprotein (AFP) test is quite good at finding open neural tube defects, but it is not perfect. The ultrasound scan will detect almost all instances of anencephaly, but the results for spina bifida are not quite so good. It can also detect other conditions that cause women to be placed in the high-risk group. Some of these conditions can be treated with an operation

once the baby is born.

Your choice

It is your decision whether to have screening tests during your pregnancy and this article will help you to decide what is best for you and your baby. Most women will choose to have screening tests because they want to be sure that their baby is alright. However, being told that you are in a ‘high-risk’ group can cause a lot of anxiety – and in most cases the amniocentesis or scan will give you much more information, and most times will reassure you that the baby does not have these problems. Before you decide whether to have the screening

tests ask yourself:

1. Do I want the information offered by the screening tests?
2. What would I do if my baby had Down’s syndrome or an NTD?
3. How do I feel about having a child with a disability?

How to find out more

If you want to talk more about screening tests, you can discuss this information with your midwife or doctor.

Support groups

Association for Spina Bifida and Hydrocephalus (ASBAH) www.asbah.org

Down’s Syndrome Association www.dsa-uk.com

Antenatal Results and Choices (ARC) www.arc-uk.org
2012 Hulda Thorey/ Article based on Midirs database

I am not making a lengthy blog about this today, but I wanted to just raise a few points.

First of all, not all babies grow the same.  There is no particular advantage of being  “average” or above the 50th percentile.  Even if your baby is bigger or smaller, as long as it grows, this is fine.

Second, the breast milk production changes over time, over days and between the hours of the day.  It is also greatly affected by your sleep, food and drink intake, stress levels, outings, guests, travels, illness etc.  So there will be swings.  And similarly, baby’s need for milk changes through the day, between days and as it grows.

The great thing is that the two usually sync beautifully, if you just stay calm and let things happen.  After a few weeks of breastfeeding, there is harmony in this for most women but in the meantime, it is sometimes hard to stay patient, or even to believe that the day will come when everything is in balance.  But it makes no sense that there would not be enough milk for some babies, if everything is done “correctly” (why I put this this way is because correct can be many different ways).

Also, hard core breastfeeding support is sometimes a bit too hardcore.  Us that work in this field are always staying very optimistic and telling the women to be patient, everyone can breastfeed etc.  But sometimes we fail to akcnowledge that there are women out there that for one reason or another will always have a harder time breastfeeding than others.  They can still breastfeed but it must be admitted and they must not be made to feel bad when it is obvious that they do in fact never have but just about the amount that the baby needs, or if they are ones that always have massive overflow of milk.

I will continue with this later.  But if you are one that produces more milk than makes you feel comfortable, or less milk than it seems that the baby wants,  be comforted by the fact that you are first of all not alone, this happens to many women but also, with time things always settle and you will find a pattern to feed your baby that suits both of you best.

As for my involvement, I must just say that i admire all of you ladies out there, you really make me feel proud of the strength that I see within you all.

A baby that is exclusively breastfeeding can have everything from stools 10 times a day or up to 10 days between with out anything being abnormal. When the baby starts to have solid foods, especially when dairy products are on the menu, the digestion changes and then the baby usually has more frequent stools, or else feels rather uncomfortable.

Color
Breastfeed babies usually have very loose stools that are orange or mustardy color and sometimes with little seed like bits in it. It can also go quite olive in color and even brown for a few days.
Formula fed babies have thicker stools, they smell strong and are usually from dark orange color to green.
And once the baby is having solid food, expect darker and thicker, – and unfortunately more smelly stools.

Constipation
Firm stools that can cause a lot of discomfort for the child is quite common amongst babies that are formula fed. Sometimes giving a little of well dilated prune juice to get things moving again. If the baby is already having some solids, it is important to give high fibre food as well as water regularly. The baby can have cereals twice a day, plus vegetables and fruits but it is important to keep dairy products, such as yogurts at balance. It is not necessary to stop giving all dairy though, but give a lot of other fluids – mainly water.

Diarrhea
During the first year, digestive discomforts are rather common. Usually we are seeing cases of mild cases with a bit of diarrhea for one to two days. In those cases it is important to give plenty of fluids to replace what got lost with the loose stools. Otherwise you can feed the baby normal solid food if the baby is happy to eat. Breastmilk can always be given and can often be the only source of nutrition, even if the baby has gone onto solid foods, – in case of a sick baby.

If a baby gets severe diarrhea, does not want to drink, does not urinate and is otherwise lethargic and very sick, you should always get in contact with your family doctor or a pediatrician.
In some cases, babies have really loose stools and even diarrhea for a long time. If the baby gains weight normally ad thrives as usual, loose stools are in it self nothing to worry about but you must pay attention to if the baby looses weight as well and respond by seeing a doctor if this is the case.

Occasionally babies have a long term diarrhea due to not enough fat in food, for example if they have skimmed milk or too many juices and never get fat as a part of their solid foods. As soon as those children get fat back into their diet, the diarrhea is no longer a problem.

Hulda Thorey

A few thoughts always go through my head when I am fortunate enough to be a part of births like this, although i will still say that many hospital births can be absolutely lovely as well.  The first one is, that at home, the peace and quiet that comes with the environment has such a good effect on everyone.  Also the fact that I am invited to the event, rather than the woman, who sometimes feels quite scared and insecure to begin with, having to be taken to a place where she is less in control.   Also, the father gets to play a host and supporter in an environment where he actually is in control and this gives a whole lot of confidence to him.

Then, once the dilation is full and the baby is moving lower in the pelvis, giving the urge to push, it is just so relaxed and calm.  Instead of the somehow shift in the atmosphere where everyone gets “ready to push” and even stirrups are pulled out, lights come on etc.  – at home nothing really changes other than the woman who slowly starts to put pressure into her breathing and gently bear down.

I can never really resist a few tears and goosebumps when the baby finally arrives, it is just so pure and joyful.  Every time.

Thank you Arden and Michell for allowing me and Sarah to be with you and share the first moments in Shaunyos life outside of the womb.

And here I am, after rather busy days since December,  – one homebirth and another very lovely birth at Union Hospital, – and lots of home visits, i somehow have managed to ignore the fact that my own feeding schedules are all over the place.  And I am really supposed to know about these things.  In any case, I am just about finished with unblocking it by feeding much more frequently and resting in bed for more or less 2 days.  Painful and taking all my energy but worth doing and now feel much better.

So i guess one should never fail to check and feel and listen to the body.  Any changes in the usual daily patterns, more or less feeding, pumping, activities etc. may all lead to troubles if you are not careful.  I just wanted to share this – and finally say that as long as you do catch it in time, it is well worth fixing it by taking it slowly with the baby for a few days – it has been lovely here at home with my little ones.

 We at Annerley wish you all a lovely family time and happy holidays.  We look forward to see you after Christmas.

Hulda, Kristrun, Tamara, Sarah, Eugenie, Donna, Mandy, Ines, Fiona and Kathryn. 

To a certain extend this is correct.  The eyes of newborn babies are not fully developed and for a while after they are born they can not fully see colors.  They also cannot focus far away so only things around 10 – 30 cm away from their eyes are clearly visible.

My baby has got a bit of hair and it is growing fast, but there are some bold areas on the back of his head.  Is this normal?

Yes, and try not to worry about this.  This happens mainly because babies lie on their backs most of the time and the friction between the head and the surface underneath usually causes some of the hair to fall off.  Because of increased risk of cot-death when babies sleep on their front, sleeping on the back is the preferred position so most parents see bold spots on their babies’ heads after a while.  The good thing is that after the hair grows a bit thicker, this bold spot disappears and you never see any signs it was there in the first place.

When is the right time to give solid foods to babies?

The need for solid food differs quite between babies.  They also tolerate new types of food in a different way, so therefore it is important not to start too early and start really slowly.  We recommend parents to take the baby to a baby clinic and get advice from midwives or doctors on what is suitable for each child.  General guidelines from the WHO in 2005 are to wait until the baby is 6 months old and ideally to feed only breast milk until then.

How often do we have to change nappies?

As a rule of thumb, it is good to change nappies every time you feed the baby, ideally in the end of the feed since most babies will urinate/pass stools during the fees or right after.   If your child develops nappy rash, you must change more frequently than this and try and ensure some time every day without the nappy to dry the area.  You do not have to change the nappy every time the baby does a little pee unless the baby seems really sensitive to this.

Is it good or bad to warm up milk in the microwave?

BAD!!  Microwave ovens are designed in the way that temperature of fluids that have been heated can be extremely uneven.  Then when you touch the milk on the outside of the bottle it might seem the right temperature, but inside it might be a lot warmer, causing serious damage to the baby’s mouth and stomach.  Another reason is also that some of the ingredients of the Breast milk can be damaged with microwaves.

If you wish to warm up milk, we suggest to put hot water (30 – 40 degrees) in a small bowl and then to put the bottle in there for a few minutes.  The milk will warm up quickly without any risk to the baby.  Make sure to test the milk before feeding it, by putting a drop on the inside of your arm/wrist.  It should not feel hot.

Colic – what to do?

Babies often get the occasional colicky period, without developing“every day” colic.  Best way to deal with it is to try different advice and see what seems to suit your child.  You might want to try and have the baby lie flat on the stomach on your forearm and walk around like this.  Also you can make chamomile tea and cool it down until around room temperature, and then give around 2 teaspoons.  This often soothes the stomach and lasts for a few hours.  If the baby does not seem to be calmed in any way, call a midwife or a doctor to get advice.  Another treatment that has proven both very popular and useful is to have osteopathic treatment.  At Annerley, Ines De Beer is our in-house osteopath.

When can I give my child normal cow’s milk?

In the first year, if the baby is not given the breast milk, formula powder is the second best option.  When the child has been given food from all food groups and has gotten used to those, he/she can have cows milk.  This is usually around 12 months of age.  We recommend delaying giving other types of dairy, such as cheese and yogurt until 9 – 11 months, or at least give them sparingly.

How can I prevent nappy rash?

Most babies get nappy rash sometime in their early months.  Here are some tips about how to prevent it:

Clean the bottom carefully with only cotton wool and water and dry well with a cloth.

Leave the baby with no diaper on for a while every day, or even every time when you change a nappy.

Change nappies as soon as they get dirty.

If none of this works, a nappy rash cream might be helpful, especially the ones with zinc oxide in.

Just pregnant – public and private maternity services

In Hong Kong, every person with an ID card has the right to use the government hospital maternity services and the cost will be minimal.  The maternal health clinics generally give really good service, although sometimes English is not perfect and communication aims more for being efficient and medical than “consumer friendly”. However, in terms of staff, equipment, safety and resources, clinics and hospitals are perfectly up to standards and Hong Kong is one has one of the lowest morbidity and mortality rates in the world.

When people have insurance cover or simply chose to pay for private maternity services, there is a variety of hospitals to choose from and most of them offer all basic care, emergency cover for operation theatre and paediatric backup.  Choosing this, you will often have more choices in terms of the birth itself; less policies to worry about and can decide more who is with you during the labour.  You will also both be pampered more and given more privacy than public hospitals can offer.  I also find that after the birth, women that have stayed in some of the private hospitals will have more success with breastfeeding, mostly because the staff seems to have more time to help with initial challenges.

Private hospitals are usually also well equipped but it is important to know that they not be able to take care of seriously ill newborn and premature babies before week 34 of pregnancy are taken to a public hospital for intensive care.

Maternity checkups

In the beginning, you are advised to see a midwife or doctor around every 4 weeks for routine checkups and screening of risks/abnormalities.  Luckily most women come away from those without complications but depending on circumstances, some women would be recommended or offered the following screening tests and scans:

• 6 – 10 weeks:  Early ultrasound scan to confirm pregnancy and possible due date.
• 11 – 14 weeks:  Nuchal Translucency Scan.  This is a risk assessment to screen for Downs syndrome.  The test is often combined with a blood test to give more accuracy and if the result indicates a high risk, you might be offered amniocentesis, which then would be done around week 15-18.
• 18 – 20 weeks:  Ultrasound to confirm due date and to check with accuracy for any physical abnormalities with the baby.  Also to check the lying of the placenta and to confirm singleton/twin pregnancy.
• 24 – 28 weeks:  Glucose tolerance test to exclude diabetes during pregnancy.  Usually good to check iron levels at the same time (Hb and/or Ferritin).
• 34 – 36 weeks:  A scan to confirm that baby is growing and developing well.

When the pregnancy progresses, you will see the doctor/midwife more frequently, or around every 2 – 3 weeks.  The visits are routine health checkups for you and the baby, but you can try and use the time to get to know your caregiver and introduce to her/him the ideas you might have about the birth itself.  That way you will slowly find a way to try to fulfil the wishes you have and minimize fears that sometimes arise when communication is not good.

Preparing for the birth 

When it comes to preparing for the actual birth, in some ways it can be best to not have any set ideas about how you want it to be, to avoid a complete shock or disappointment if it does not turn out the way you had planned it to.  There is, however, a great difference between preparing and detailed planning.

The birth is a journey

It is in a way similar to prepare for a marathon hike that you don’t know how long is, or where it is taking place.  You gather general information, try and think about different scenarios and how you think you would respond to those.  Other than that, the preparation is mostly about staying fit, feeling psychologically well, eating a balanced diet, drinking plenty of water and making sure you get plenty of rest.  This sounds familiar, since, this is what all pregnant women are advised to do anyway.

Sometimes, when planning for the birth, people tend to think that all of a sudden some new powers start to work on the body to change the way it functions, and therefore they need to learn a totally new technique to deal with this.  In my experience as a midwife, this is not the case; there are surely physical challenges that are new, but mostly you rely on already established methods that you just don’t know that you have!

What do I need to know?

To help yourself to feel more in control when you are in labour, it is useful to gather some information about the process and what to expect from the hospital staff.  Reading, talking to friends and family and discussing with your doctor or midwife is all a part of this.  If you want to go one step further, antenatal classes might be an option.  In Hong Kong, the Queen Mary hospital offers English speaking classes for parents that plan to give birth there, as well as a tour of the labour ward.  Some private hospitals also offer this, and in most cases you will find them to be specially aimed for presenting each hospitals ideology and protocols, often involving the staff of the actual labour ward – which is useful.

When deciding on preparation classes you might want to ask yourself:

1.     What do you want from the classes?
2.     Who is teaching them and what background do they have?
3.     Do they follow any special philosophy?
4.     Are they mainly giving practical information or is there any training also involved?
5.     How many couples will there be in the classes?
6.     Is there a chance for questions and discussions?

Private midwives, such as here at Annerley offer childbirth preparation classes that usually aim for more independent view, meaning that parents are encouraged to rather follow their own intuition than the hospital protocols.  This sometimes can be a challenge for parents if the staff at the hospital does not have the same ideas about what are reasonable demands and what is too independent.  Luckily though, most of us are being realistic and we help parents to find a way that suits everyone without any dilemmas.  With parents being more demanding, there have been a lot of changes towards more modern attitude in the labour room, including the option of mothers using different positions when giving birth, use of birth ball and less routine use of episiotomy and medical pain relief.

Minimizing interventions

Most antenatal classes have one of their aims to minimize the chances of negative birth experience caused by unexpected events.  A part of this is to encourage the parents to be actively involved in the process of making decisions, and being informed.  To decrease chances of medical interventions, it is also important to find a balance between physical activity and relaxation, and be upright and mobile to speed up the process of contractions.

Sometimes, however, it is necessary to step in the process and use medical interventions, such as emergency C-section, vacuum extraction or forceps.  For parents that are well prepared, this is usually not a desired outcome but it should not have to be too shocking, given that communication channels are kept open and people feel informed at all stages in the process.  This is why it is important in the preparation of the birth to not have a rigid plan, but rather ideas that then get developed when you actually feel what it is like to be in the process.

You just have to go with the flow

When I started doing antenatal classes, I soon found that parents often walked away with too unrealistic image of what might happen during the labour, so I added a private lesson into the antenatal package.  This, I found, helped greatly to clear out misunderstandings or dilemmas that often rise in group lessons and also gave the parents a chance to write down their ideas of the birth with some private guidance.  I find that most midwives and doctors will give you the chance of something similar if you ask for it, and actually value your involvement when it not too unrealistic.  In the end of the day, you just have to go with the flow, trust your instincts and make sure you at all times make your wishes clear to the ones around that are trying to help.

Hulda Thorey 2011

Best,
Hulda midwife-in-constant-training