Physical Changes

Key Messages

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These are the main health messages that should be conveyed to all future and new parents. They have been written in the second person and at a reading level appropriate for the general public so that they can be shared with them directly. They are based on a consensus founded in scientific research and professional practice. Clicking an underlined word or group of words in the text will redirect you to the section in Supporting Evidence that deals with that topic.

key message

It is normal to experience a variety of physical changes during your pregnancy while your baby grows and develops.

Pregnancy is a time of change for everyone – mother, baby, partner, and relationships. From conception to the birth of your baby, your body will go through an exciting transformation. Changing hormone levels are responsible for many of the physical and emotional changes that you experience during pregnancy. These changes can start and stop at various times during your pregnancy. Most of these changes resolve after birth.
Pregnancy changes may include:

  • Backache.
  • Nausea and vomiting.
  • Constipation.
  • Heartburn.
  • Hemorrhoids.
  • Frequent urination.
  • Feeling tired.
  • Increase in appetite.
  • Increased vaginal discharge.
  • Tender breasts.

Make sure you speak with your health care provider before taking medications to cope with any pregnancy discomforts.


key message

Understanding these physical changes, and how to cope with them, may help you have a healthy and comfortable pregnancy.

During your first trimester, changing hormones may make you feel tired, have nausea and vomiting, and tender breasts. You may notice a change in your interest in sex.
During your second trimester second trimester, hormone levels even out, any signs of nausea may lessen, and you may feel a heightened sense of well-being. You will start to notice changes in your body’s shape and size. You may have some back and joint aches. You may develop a brownish line down the middle of your belly and uneven brown marks around your eyes, nose, and cheek.
During your third trimester, you will become more visibly pregnant. Your baby may push on your lungs, stomach, and bladder, causing shortness of breath, heartburn, gas, and frequent urination. You may also have difficulty finding comfortable sleeping positions.
To help you cope with some of these changes you can:

  • Rest when you are tired.
  • Accept help from family and friends.
  • Eat small amounts of healthy food many times during the day.
  • Avoid wearing tight-fitting clothes.
  • Participate in physical activities appropriate for your stage of pregnancy and fitness level.
  • Wear comfortable, supportive shoes.
  • Use sunscreen and wear a hat when outdoors.
  • Use extra pillows in bed to increase your comfort.
  • Talk to your health care provider about your concerns.


key message

Discuss any unusual changes or concerns with your health care provider.

Tell your health care provider right away if you have:

  • Unusual or ongoing headaches.
  • Ongoing nausea and vomiting.
  • Changes in eyesight or spots before your eyes.
  • Dizziness or feeling unwell.
  • Vaginal bleeding or leaking of fluid.
  • Regular contractions.
  • Lower back pain/pressure or change in lower backache.
  • Feeling that the baby is pushing down.
  • Any noticeable decrease in your baby’s normal movement.
  • Severe abdominal pain.
  • Sudden swelling of the face, hands, or feet.
  • Calf pain.
  • Unexplained rash.
  • Fever and chills (i.e., temperature above 38.3° C or 101° F).
  • Burning sensation when urinating.
  • Feeling overwhelmed, anxious, or sad.
  • If you are in a motor vehicle accident of any kind, have a fall or any injury to your stomach area.


key message

Learn more about coping with the physical changes in pregnancy.

You can find out more about coping with the physical changes in pregnancy from the following resources. More suggestions can be found in the Resources and Links section.

  • Motherisk Nausea and Vomiting of Pregnancy (Morning Sickness) Helpline
    1-800-436-8477
  • Motherisk Exercise in Pregnancy Helpline
    1-866-937-7678
  • EatRight Ontario
    1-817-510-5102

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Supporting Evidence



The supporting evidence is written in third person and is aimed at prenatal education providers. It is not intended to be shared directly with new and expectant families; it is meant to provide the background information and evidence for the key messages.

About Physical Changes in Pregnancy

Defining physical changes in pregnancy

During pregnancy, a woman’s body goes through various normal physical changes that can be obvious or subtle. These physical changes can affect every body system. Although they may be bothersome, they rarely result in complications. Each pregnancy is unique and women may experience some, all, or none of the physical changes outlined. The majority of these physical changes are normal and when a woman understands what is happening and how to mitigate these changes, she will be better able to cope with them.


Provincial and national statistics

It is normal for the majority of pregnant women to experience a variety of physical changes as their pregnancy progresses due to hormonal fluctuations and the growing fetus. Most physical changes are normal; however, it is important for pregnant women to know how to recognize what is not normal. Some physical symptoms, such as sudden headaches and vaginal bleeding, can be an indication of a pregnancy complication (e.g., pre-eclampsia or preterm labour).1 The percentage of women in Ontario with one or more obstetrical complications increased from 23.6 percent in 2007 – 2008 to 27.6 percent in 2011 – 2012.2
Maternal factors such as age can also increase the chance of experiencing pregnancy complications. Adolescent mothers under 20 years of age have a higher risk of pre-eclampsia and preterm labour.3
Mothers over 35 years of age are at increased risk for many pregnancy complications. The proportion of pregnant women who are over 35 years of age is increasing; almost one in five births in Canada is to a woman age 35 or older.4


Hormones in pregnancy

Changing hormone levels are responsible formany of the physical changes that occur during pregnancy. The following hormones are responsible for some of the physical changes experienced in pregnant women:

Human chorionic gonadotropin (HCG)

HCG is also called the pregnancy hormone. It is the hormone which indicates and confirms pregnancy in early pregnancy tests. HCG is produced by the placenta and is the hormone which can cause nausea.1

Progesterone

Progesterone is produced first by the ovaries and then by the placenta starting in the second trimester. Progesterone keeps the placenta functioning properly and the uterine lining healthy and thick, and it stimulates the growth of breast tissue.1 The higher levels of progesterone during pregnancy may contribute to heartburn, acid reflux, and indigestion.5

Estrogen

Estrogen is responsible for making the uterus grow and increasing its blood supply throughout pregnancy. It also increases vaginal mucous production and stimulates the development of breast ducts in preparation for breastfeeding.1

Relaxin

Relaxin is the hormone that relaxes and softens ligaments and cartilage in the body during pregnancy, including the cervix. It is responsible for expansion of the pelvic joints during labour and birth.1

Oxytocin

Oxytocin is the hormone that causes the uterus to contract during labour.1 Oxytocin stimulates uterine contractions after the baby is born in order to assist with the delivery of the placenta, close off the blood vessels that were attached to it, and begin to shrink the uterus back to its original size. Oxytocin is also responsible for stimulating your breastmilk to flow. This is known as milk ejection reflex (MER), and encourages bonding and attachment.1


Who is at Risk?

The following women are at risk for physical symptoms that are associated with pregnancy complications.

  • Women over 35 years of age.4
  • Women less than 19 years of age. 6
  • Women who have pre-existing health conditions, including:
    • Substance use issues.
    • Living with abuse.
    • Asthma.
    • Diabetes.
    • Eating disorders.
    • Epilepsy.
    • Hypertension.
    • Autoimmune disorders.
    • Heart disease.
    • Pre-pregnancy body mass index (BMI) over 30 or under 18.5

Normal Physical Changes by Trimester

First trimester physical changes

The first trimester is from conception to the end of the 12th week of pregnancy. It is important that a woman understands the physical changes that she may experience and the importance of taking care of herself during this time. A woman’s pregnancy is confirmed by either a urine and/or blood test which tests for HCG.1 Most women will also stop having monthly periods.

Although a woman may not look pregnant during the first trimester, her body is going through enormous changes as it accommodates a growing fetus. In the first few weeks following conception, her hormone levels change significantly. The uterus begins to support the growth of the placenta and the fetus, and her body adds to its blood supply to carry oxygen and nutrients to the developing baby and her heart rate increases.5

Breast changes

Soon after conception, hormonal changes may make a woman’s breasts tender, fuller, sensitive, or sore. Breasts develop and enlarge under the influence of estrogen, progesterone and prolactin.66  The breast changes during pregnancy occur as the milk ducts are growing in preparation for breastfeeding.7 The increased blood supply a woman has during pregnancy also makes the veins in the breasts become more noticeable. By about 12 weeks of pregnancy, the skin of the nipple and areola may start to darken or pigment. Skin colour changes are very individual to each woman. Women with darker hair and darker complexions tend to notice more colour change than fair-skinned women. The nipples may become more prominent and feel quite sensitive or even sore.1,7

Management
Strategies a pregnant woman can use to cope with breast changes include:

  • Wearing a good-quality support bra or a sports bra.
  • Wearing a bra without underwire.
  • Wearing a bra while sleeping to support the changing breasts.
Fatigue

Sleep needs vary from one individual to the next, and it is estimated that the general population needs approximately eight hours of sleep per 24-hour period (varying between six and nine hours). There is no conclusive data on the number of hours of sleep required during pregnancy. Fatigue is a common, first-trimester symptom. Higher levels of the hormone progesterone lead to an increased desire to sleep. 8 A pregnant woman’s metabolism also increases, and this consumes a lot more of her energy contributing to fatigue.1,8 Pregnant women are also more likely to experience occasional sleep disturbances. Psychosocial factors may also affect sleep quality (e.g., ambivalence about the pregnancy or arrival of the child, stress over living conditions, difficult interpersonal relationships).8

If changes in sleep habits are noted but do not affect daytime activities, there is no cause for concern.

Management
Strategies a pregnant woman can use to cope with fatigue include:

  • Paying attention to her body and resting or taking naps as needed.
  • At work, finding a quiet place to close her eyes and relax.
  • Trying not to fight the feeling of tiredness.
  • Eating healthy foods and drinking plenty of water.1,8
Feeling faint, lightheaded, or dizzy

Feeling faint, lightheaded, or dizzy during early and middle pregnancy (up until about 28 to 30 weeks) is a very common experience. A woman’s blood vessels naturally relax and dilate under the influence of the hormone progesterone lowering her blood pressure.5
Feeling faint or lightheaded may happen because:

  • The pregnancy hormone progesterone relaxes the walls of the blood vessels, making blood ‘pool’ more in the woman’s hands and feet and, at times, drain more rapidly away from her head (especially when getting up from a sitting or lying position). The medical term for this is ‘postural hypotension’. Dizziness and fainting can also happen in a hot environment.9
  • A pregnant woman’s blood pressure is naturally in the lower range of normal (around 90/50 to 110/60). Women with a lower blood pressure tend to experience dizziness and fainting more often than women with a higher blood pressure.5,9
  • Blood sugar levels can become low from a lack of food, sporadic meal times, and nausea and vomiting. Pregnant women can be more susceptible to drops in blood sugar levels as a result of an increased metabolic rate. Metabolic rates can increase by about 20 percent during pregnancy (meaning they process the food in their body more rapidly).5,9

Sometimes dizziness and fainting can be due to a combination of all the above.

Prevention
Strategies a pregnant woman can use to prevent feeling faint or lightheaded include:

  • Slowly getting up from a sitting or lying position.
  • Eating small, frequent, nutritious snacks throughout the day.
  • Eating iron-rich foods.1,5

Management
Strategies a pregnant woman can use to cope with feeling faint or lightheaded include:

  • Sitting down and putting her head between her knees.
  • Loosening tight clothing and placing a cool cloth on her forehead or back of her neck.1,5
Headaches

Headaches during the first 12 weeks of pregnancy may be caused by hormonal changes, but they may also be due to the normal increase in blood volume circulating in the woman’s system.9 Adjusting to a new pregnancy can also be a stressful time for many women. Therefore, headaches caused by tension may also be experienced. A woman who is prone to headaches or migraines may find she does not experience them as often during pregnancy while others may find they are worse.5 It is always important for women to check with their health care provider to have the headaches assessed. It is important that pregnant women avoid self-medicating for headaches and should always consult their health care provider before taking any medication.1

Management
Strategies a pregnant woman can use to cope with headaches include:

  • Lying down in a cool, dark room with a cool cloth on her head.
  • Asking her support person(s) for a massage of her neck or back.
  • Practicing good posture.
  • Eating small, frequent meals if the headache may be linked to low blood sugar.
Increased vaginal discharge

Increased vaginal discharge is a normal part of pregnancy. Normal vaginal discharge during pregnancy is called leukorrhea, which is thin, white, milky, and mild smelling. If the discharge has an odour, is green or yellow, or there is pain, itching, or soreness in the vaginal area, women should consult their health care provider for assessment. During pregnancy, women should not use tampons and douches as they can interrupt the normal balance and lead to a vaginal infection. Women should never assume it is a vaginal infection and treat it themselves.

Management
Strategies a pregnant woman can use to cope with increased vaginal discharge include:

  • Wearing breathable, unscented panty liners.
  • Notifying their health care provider of any changes in vaginal discharge.
Nausea and vomiting

Nausea and vomiting of pregnancy (NVP) is a very common medical condition affecting up to 85 percent of all pregnant women.10 It is frequently referred to as morning sickness; however, women can experience symptoms throughout the day and night. Nausea and vomiting generally start between the fourth and ninth week of pregnancy, and symptoms increase between 7 to 12 weeks and typically subside by 12 to 16 weeks. Mild symptoms of NVP do not have serious impacts on the pregnant woman or baby.

Many studies have shown that NVP can be an indicator of good pregnancy hormone levels, which may have a protective effect on the pregnancy, including:

  • Lower risk of miscarriage and stillbirth.
  • Lower risk of having a baby with birth defect(s).
  • Increased chance of a healthy child.10

Some women will experience these symptoms for a longer period of time.11 Women who experience constant, severe symptoms with weight loss and dehydration are said to suffer from hyperemesis gravidarum (HG). Every year, a large number of women have one or more hospital admissions requiring intravenous fluids and medication (as many as 14 hospitalizations/1000 births).10 Early recognition and management of NVP can have a profound effect on a woman’s health and her activities of daily living during pregnancy.

What causes NVP?
At this time, the causes of NVP are not known. NVP is more severe in:

  • Twin pregnancies with more than one placenta.
  • Conditions where the placenta is larger than usual.
  • Pregnancies where the mother is obese, has high blood pressure, diabetes, or other untreated or poorly-managed health conditions.10

Other risk factors may include:

  • Genetics.
  • Previous history of hyperemesis gravidarum.
  • Carrying a female fetus.10

Prevention
Strategies a pregnant woman can use to prevent NVP or HG include:

  • Taking a multivitamin with folic acid (ideally before conception). This not only reduces the risk of fetal birth defects but also decreases the frequency and severity of nausea and vomiting during pregnancy. In addition, it could optimize the pregnant woman’s nutrition and metabolism.11

Management
There are various ways pregnant women can reduce nausea and vomiting depending on the severity of the symptoms, impact on their quality of life, and potential health effects on the unborn baby. Changes in eating habits are not supported by conclusive data. Despite the lack of conclusive data, dietary changes may provide relief from NVP for some women.11

Strategies a pregnant woman can use to cope with NVP or HG include:

  • Eating before feeling hungry to avoid having an empty stomach.
  • Eating a little bit before getting up in the morning (e.g., crackers, toast, etc.).
  • Eating a snack such as nuts, yogurt, and cheese before bedtime.
  • Eating small, light, frequent meals (i.e., every two to three hours) and not skipping meals.
  • Avoiding overly fatty or spicy foods.
  • Choosing cold, acidic beverages (e.g., lemonade) or aromatic beverages (e.g., mint or orange herbal tea).
  • Drinking between meals instead of while eating.
  • Getting plenty of rest.
  • Avoiding certain environmental stimuli (e.g., strong odours, heat, humidity, noise, etc.)
  • Getting out of bed or up from a chair slowly and avoiding sudden changes in position.

The following non-pharmacological treatments may be used if the pregnant woman is able to eat adequately and stay hydrated.

  • Vitamin B6 (pyridoxine)may be used in consultation with a health care provider. Studies have shown its probable efficacy at reducing nausea without side effects. It is not effective for vomiting.10,12
  • Ginger taken in forms such as lozenges or drinks. It is best to avoid ginger in large quantities or in tablets since few studies have been conducted thus far to establish the safety and efficacy of this food.13
  • Acupuncture and acupressure, including bracelets used for sea sickness (e.g., Sea-Band®).10

Pregnant women may take antiemetic drugs such as Gravol® on the advice of their doctor. Drugs which have shown to be effective with no risk to the development of the pregnancy have been studied.10 In Canada, Diclectin® (the brand name of doxylamine-pyridoxine) is an example of a prescription drug available for the treatment of NVP.14 With continuous use of Diclectin®, the rates of hospitalization for morning sickness have been dramatically reduced. 15 It is most effective when taken regularly at the same time of day, and dosages can be adjusted in consultation with the woman’s health care provider to achieve maximum relief.9

Please refer to How to Survive Morning Sickness Successfully for more suggestions  for managing NVP and for treating morning sickness.

Sexual Changes

A woman’s desire for sex will vary considerably throughout the pregnancy. Genital vasocongestion is intensified in the first and second trimester, which can increase sensitivity, sexual arousal, and the desire for sex.16 Some women find that tiredness, nausea, and/or vomiting during the first 12 – 14 weeks of pregnancy decreases their interest in sex.17 Orgasm in the third trimester may cause discomfort. Positional difficulties may also require adjustment in the third trimester.

In most cases, having intercourse will not harm the pregnancy in any way, although occasionally it can cause bleeding. The thick plug of mucous sealing the cervix helps to prevent infection. The amniotic sac and the muscles of the uterus also protect the baby. Sometimes there is increased movement from the baby after an orgasm but this is only because of the woman’s increased heart rate at this time and not because the baby is aware of what is happening or because it has felt any pain.16,17

If a couple is uncomfortable with sexual relations during pregnancy they can make time for other forms of intimacy such as cuddling, massage, and hand holding. Couples should take care not to blow any air into the vagina during oral sex as a burst of air might block a blood vessel (air embolism) which could be fatal to both the woman and baby.1

Your health care provider may advise you to limit intercourse in certain situations such as:

  • History of miscarriage.
  • Unexplained discharge or cramping.
  • An incompetent cervix.
  • An infection.
  • Vaginal bleeding.
  • Leaking amniotic fluid.
  • Breaking of the amniotic sac.1

In certain circumstances and relationships, pregnant women should continue to use condoms for protection from sexually-transmitted infections.

Vaginal bleeding

Bleeding or spotting in the first trimester is common and can occur in up to 20 percent of pregnancies. Although frightening, vaginal bleeding is not always a serious problem. Any vaginal bleeding should be medically assessed immediately.

Bleeding or spotting in the first trimester may be caused by:

  • Having sex.
  • Implantation bleeding when the fertilized egg implants in the uterus. This occurs about 10 to 14 days after conception, when the woman usually expects to get her period.
  • Hormone changes.
  • Other factors that will not harm the woman or baby.9,5

More serious causes of first-trimester bleeding include:

  • A miscarriage (also known as a spontaneous abortion) which is the loss of the pregnancy before the embryo or fetus can live on its own outside the uterus. Almost all women who miscarry will have bleeding before a miscarriage.
  • An infection.
  • An ectopic pregnancy, which may cause bleeding and cramping.
  • A molar pregnancy, in which the pregnancy does not form properly.5,9


Second and third trimester physical changes

The second trimester of pregnancy (from week 13 to week 27) is the time when most women start to look pregnant.1 By 16 weeks, the top of the uterus (called the fundus), will be about halfway between the pubic bone and navel. By 27 weeks with a single pregnancy, the fundus will be about 5 cm (2 in) or more above the navel.5 Some women may find that the second trimester is the easiest part of pregnancy.1 The placenta, which has been developing in the uterus, has taken over most of the hormone production and the hormone levels begin to even out. For some women, the breast tenderness, NVP, and fatigue of the first trimester ease up or disappear during the second trimester, while the physical discomforts of late pregnancy have yet to start.1 In the third trimester, which is from 28 weeks’ gestation until birth, many women will begin to feel uncomfortable and tired as their baby grows in size placing pressure on the internal organs, including the lungs and bladder.

Back pain and ligament pain

The growing baby will cause a woman to lean back to find the center of gravity, which can cause strain on the lower back. The weight of the growing uterus in the pelvis, together with the joint movement, hormonal changes, and softening can also contribute to low back pain, including sciatica.1 Ligament pain when walking is caused by stretching of the ligaments supporting the uterus as it adjusts to its increasing size and weight.18 One of the benefits of physical activity during pregnancy is a decreased risk of musculoskeletal pain, especially the lower back. Canadian guidelines for physical activity during pregnancy are 30 minutes or more three to four days per week.19 Please refer to the Active Living file for more information on exercise in pregnancy. If back pain persists or causes severe symptoms such as weakness or numbness in the legs or changes in bowel or bladder function, a health care provider should be consulted.

Management
Strategies a pregnant woman can use to cope with back and ligament pain include:

  • Using good posture.
  • Using a cushion for back support.
  • Avoiding wearing high-heeled shoes.
  • Wearing low-heeled (not flat) shoes with good arch support.
  • Using good body mechanics. To lift something from the floor, place feet hip-distance apart, bend knees with the back straight, keep the load close to the body at waist level and do not twist/rotate.
  • Avoiding heavy lifting when possible.
  • Limiting standing for long periods of time. Keep weight equal to both legs (not shifted to one leg).
  • Accessing services such as a massage therapist or physiotherapist.
  • Using relaxation, yoga, and/or stretching exercises.
  • Practicing pelvic rocking to keep the spine flexible.1,20
Breast changes

The breasts may not be as tender as they were in the first trimester, but they will continue to grow and prepare for breastfeeding.1 By about mid-pregnancy, under the combined effects of many hormones, yellowish or clear fluid called colostrum is produced in the breasts. It may leak from the mother’s nipples from this point on. Colostrum will be the first food the baby receives shortly after birth. The amount of colostrum leakage varies from woman to woman. This does not affect the success of breastfeeding.21

Management
Strategies a pregnant woman can use to cope with breast changes include:

  • Wearing a good-quality support bra or a sports bra with no wires.
  • Increasing bra size.
  • Wearing breast pads if breasts are leaking and changing them when wet.
Contractions (Braxton Hicks)

Braxton Hicks contractions are contractions of the uterus that occur during the third trimester of pregnancy. They are perfectly normal and have been said to represent contractions that occur as the uterus is preparing to give birth. In some women, they occur as early as the second trimester. Sometimes, Braxton Hicks contractions have been referred to as false labour.1,9 Common events can sometimes trigger Braxton Hicks contractions, such as increased activity of mother or baby, touching the mother’s abdomen, dehydration, sexual intercourse, or having a full bladder.5

Braxton Hicks contractions become more obvious and frequent as the pregnancy progresses occurring several times an hour and/or several times a day and do not lead to cervical changes. Although these contractions are pain-free in the majority of women, painful Braxton Hicks contractions have been reported in some cases.

Braxton Hicks contractions are different from true contractions. Braxton Hicks contractions:

  • Occur infrequently and often just a few times per day.
  • Are irregular and do not increase in frequency or intensity.
  • Resolve with walking and moving around or a change in activity.1,9
  • Do not change the cervix.

Contractions that lead to labour have the following characteristics:

  • May start as infrequently as every 10-15 minutes but usually accelerate over time increasing to contractions that occur every two to three minutes.
  • Tend to last longer and are more intense than Braxton Hicks contractions.
  • Lead to cervical change.1,9

Management
Strategies a pregnant woman can use to cope with Braxton Hicks contractions, if they are uncomfortable, include:

  • Changing positions such as taking a walk or lying down.
  • Drinking a glass of water.
  • Practicing relaxation exercises such as deep breathing or meditation.
  • Eating a snack.
  • Having a warm bath.1,9

If a woman is unsure about her contractions she should contact her health care provider to rule out preterm labour.

Constipation and hemorrhoids

Constipation is common during pregnancy as bowel movements slow down.22 During pregnancy, food moves more slowly through the bowels which can lead to constipation. Taking iron supplements can also cause constipation and black stool. Constipation affects up to 50 percent of pregnant women.22 It is most often observed in the first and third trimesters.

Symptoms of constipation include:

  • Abnormal consistency of stool (stool too hard and dry).
  • Decreased amount of stool or frequency of bowel movements (less than three times per week).
  • Difficulty expelling stool.1,22

Hemorrhoids are dilated veins that form in the wall of the rectum and anus. They can be caused by constipation and increased pressure on the rectal veins during pregnancy. Hemorrhoids have no negative effects on the health of a pregnant woman or her unborn baby, but they are uncomfortable.1,23

Symptoms of hemorrhoids include:

  • Itchiness or pain in the anal area.
  • Minor bleeding with bowel movements.

Although they usually go away after the baby’s birth, hemorrhoids remain an issue for approximately 15 percent to 24 percent of new mothers.23

Prevention
Strategies a pregnant woman can use to prevent constipation, which will in turn reduce the possibility of developing hemorrhoids, include:

  • Drinking plenty of fluids (aim for 2.3 L (9.5 cups of water per day).24
  • Eating high-fibre foods. Foods high in fibre include ground flaxseed, fresh fruits and vegetables, whole-grain breads and cereals.
  • Engaging in moderate physical activity such as walking or swimming.22,23

Treatment
It is advised that women do not take any medication for constipation unless recommended by their health care provider. A health care provider may recommend a bulk-forming agent or stool softener.

The following measures are useful for treating hemorrhoids:

  • Clean the anal area thoroughly after each bowel movement.
  • Have a warm sitz bath three to four times a day for 15 – 20 minutes.
  • Consult with a health care provider about applying hemorrhoid cream or ointment locally as this may help to reduce the symptoms of hemorrhoids (i.e., pain, inflammation, burning sensation, itching, discomfort, and irritation).23
Fatigue/sleep disturbances

The second trimester is often a period of improved daytime energy and a reduced need for naps.1 The third trimester is a time to expect increasing insomnia and night waking.1 Strange dreams are also common in the last few weeks of pregnancy.25 The need to take daily naps returns as the due date approaches.1 Insomnia is one of the most common sleep disorders for pregnant women.

Symptoms of insomnia include:

  • Difficulty falling asleep.
  • Frequent night waking.
  • Early waking.
  • Variable sleep quality (i.e., several nights of poor-quality sleep followed by a night of good-quality sleep).
  • Fatigue or sleepiness during the day.
  • Difficulty concentrating.
  • Forgetfulness.
  • Irritability.
  • Decreased level of motivation or energy.
  • Concern about amount and quality of sleep.26

Management
Strategies a pregnant woman can use to encourage good-quality sleep include:

  • Sleeping as long as necessary to feel rested.
  • Keeping regular sleep hours such as going to bed and waking up at the same time every day.
  • Avoiding stimulants (e.g., coffee; chocolate; caffeinated, carbonated beverages), especially in the hours before bedtime.
  • Creating an environment conducive to sleep (e.g., turn off inside and outside lights and electronic devices, control surrounding noise and temperature).
  • Avoiding use of the bedroom for non-sleep-related activities (e.g., studying, eating).
  • Resolving problems and daily concerns before bedtime or making a list of these for the next day.
  • Incorporating regular physical activity into the day, preferably more than four hours before bedtime.26

Pregnant women should avoid self-medication to assist with sleep issues and should always consult their health care provider before taking any over-the-counter, prescription, or natural sleep aid.

Obstructive Sleep Apnea

Obstructive sleep apnea is a sleep disorder in which one’s breathing is repeatedly interrupted during sleep due to decreased oxygen intake. A noticeable feature of obstructive sleep apnea is heavy snoring accompanied by long pauses and then gasping or choking during sleep. Overweight or obese women who become pregnant, women who gain excessive weight, and women who report snoring should be evaluated for obstructive sleep apnea.27 Continuous positive airway pressure (CPAP) is a safe and effective treatment for obstructive sleep apnea during pregnancy. A health care provider may refer a pregnant woman to a sleep clinic for evaluation. Obstructive sleep apnea among obese pregnant women is associated with higher rates of pre-eclampsia, neonatal intensive care unit admissions, and caesarean birth.27

Frequent urination

Frequent urination is a normal physical change caused by the growing uterus putting pressure on the bladder and the kidneys which causes an increased production of urine.5 This pressure may cause the woman to leak out urine when she coughs or sneezes. When the baby drops or engages into the pelvis as labour is approaching, the woman will have more frequent urination. If a woman feels any pain or burning when she urinates, she may have an infection and should speak to her health care provider.1

Management
Strategies a pregnant woman can use to cope with frequent urination include:

  • Drinking less in the evening.
  • Going to the bathroom every time she feels an urge to urinate.
  • Making sure her bladder empties completely.
  • Requesting a referral to a physiotherapist that deals with pelvic floor issues.
  • Doing Kegel exercises.1,9

For more information on Kegel exercises see the Active Living file.

Gastroesophageal reflux

Gastroesophageal reflux, commonly called heartburn, occurs when the contents of the stomach rise back up into the esophagus or mouth. Since stomach contents are acidic, reflux causes a burning sensation in the abdomen and a taste of acid in the throat. During pregnancy, the decreased tone of the lower esophageal sphincter, increased level of progesterone, and expanded uterus (which increases pressure on the abdomen) are factors that contribute to reflux.28 Gastroesophageal reflux affects approximately 30 percent to 80 percent of pregnant women.28

Symptoms of gastroesophageal reflux, which often appear after a meal, include:

  • Burning sensation in the stomach.
  • Pain in the upper abdomen.
  • Regurgitation.
  • Acidic or bitter taste in the throat.
  • Indigestion.
  • Nausea and vomiting.27

Management
Strategies a pregnant woman can use to cope with gastroesophageal reflux and relieve the symptoms include:

  • Elevating her head 10 cm to 15 cm off the bed (using pillows) so that her head and shoulders are higher than her stomach (gravity will help prevent reflux).
  • Avoiding lying down after eating.
  • Eating small, light, frequent meals (e.g., every two to three hours).
  • Avoiding foods/drinks that promote reflux such as coffee, tea, chocolate, carbonated beverages, mint, fatty, or spicy foods.
  • Avoiding eating or drinking before bedtime.
  • Chewing gum to increase saliva production (this can help neutralize gastric acid).
  • Avoiding clothes that are too tight as they may put pressure on the abdomen.29

If these measures are not effective or more intervention is needed, certain pharmacological treatments can be used during pregnancy.

  • Over-the-counter antacids (e.g., Rolaids®, Tums®, Maalox®) help relieve symptoms by neutralizing gastric acid for short periods. Therefore, the effect is temporary.29 These are available without a prescription but consultation with a health care provider about usage is recommended.
  • Prescription medication may be an option in consultation with a health care provider.
Leg cramps

Up to 30 percent of women can be affected by leg cramps during pregnancy.30 The cause of leg cramps during pregnancy is not fully known, but they may be caused by reduced levels of calcium or increased levels of phosphorus in the blood. Leg cramps are more common in the second and third trimesters of pregnancy and happen most often at night.30

Management
Strategies a pregnant woman can use to manage typical leg cramps include:

  • Passive stretching and massage of the affected muscle which will help ease the pain of an acute attack (e.g., for calf cramping – straighten the leg with dorsiflexion of the ankle or heel walk until the acute pain resolves).
  • Regular stretching of the calf muscles throughout the day may help to prevent acute attacks.
  • Walking to stretch the calf.31
  • Placing a pillow at the end of the bed to avoid stretching out leg during sleep.
  • If leg cramps are in one leg only and there are signs of swelling and redness of the leg, it is possible that there might be a blood clot present. A health care provider should be consulted.
Nasal congestion

Pregnant women experience nasal stuffiness due to estrogen causing an increased production of mucus. The safest treatment of these symptoms is a saline nasal spray.

Prevention
Strategies a pregnant woman can use to prevent nasal congestion include:

  • Refraining from smoking as well as avoiding second-hand and third-hand smoke.
  • Avoiding antihistamines unless recommended by a health care provider.

Management
Strategies a pregnant woman can use to cope with nasal congestion include:

  • Placing warm, moist towels on her face.
  • Breathing steam from a hot shower, a pot of boiling water, or a vapourizer.
  • Using a cool mist humidifier.
  • Massaging her sinuses by rubbing on the bony ridge above and under the eyebrows, under the eyes, and down the sides of the nose.
  • Drinking water.
  • Using saltwater nose drops made from 1/4 teaspoon of salt dissolved in one cup of warm water or over-the-counter saline drops.32
Quickening

Quickening or first perception of fetal movement varies considerably among pregnant women. It is generally experienced between 16 and 20 weeks of gestation (long before fetal viability).33 In a first pregnancy, this can occur around 18 weeks’ gestation and in following pregnancies it can occur as early as 15 to 16 weeks’ gestation. Early fetal movement is felt most commonly when the woman is sitting or lying quietly and concentrating on her body. It is usually described as a tickle or feathery feeling below the umbilical area (belly button). Placental location can impact the timing of quickening. Sometimes the movement of the fetus is not felt as quickly if the placenta is on the front wall of the uterus.33 As the fetus grows larger, the feeling of fetal movement becomes stronger, regular, and easier to detect. Once fetal movements are established a pregnant woman should be able to detect six fetal movements in an interval of two hours.1

Red, inflamed gums

Dental care during pregnancy is an important part of overall health care. During pregnancy, the gums naturally become more swollen and may bleed after brushing. Hormonal changes during pregnancy can increase the risk of developing periodontal (gum) disease. 34 Poor oral health may also affect the health of the developing baby. Pregnant women with periodontal disease may have a higher risk of delivering a preterm or low-birth-weight baby.34

Prevention
Strategies a pregnant woman can use to improve her oral health include:

  • Avoiding soft, sweet, and sticky snacks that are high in carbohydrates and sugar.
  • Cleaning her teeth after snacking to prevent cavities.
  • After vomiting, rinsing her mouth with water or with fluoride mouthwash as soon as possible.
  • Brushing her teeth at least twice a day using a soft toothbrush with fluoride toothpaste.
  • Flossing regularly.
  • Having regular dental checkups and cleanings by a dental professional to detect and prevent periodontal disease.34
Skin changes

Pregnancy masking called melasma is the darkening of the skin on the forehead and cheeks (looking somewhat like a mask).35 Also common is the development of the linea nigra, which is a dark line from the navel all the way down the abdomen.36 Stretch marks called striae may also develop around the abdomen and other parts of the body.35,36 There is no way to prevent stretch marks. The degree to which a woman experiences stretch marks is determined genetically.36 Due to hormonal changes in pregnancy, dry and itchy skin is common.36

Management
Strategies a pregnant woman can use to manage skin changes include:35,36

  • Soaking in oatmeal baths.
  • Applying cool compresses.
  • Avoiding harsh soaps and bathing in hot water.
  • Consulting with a health care provider about medications that are safe to prevent itching.
  • Practicing sun safety guidelines, including use of sunscreen, wearing a hat, and covering skin when outdoors.37
Shortness of Breath

Shortness of breath is a common complaint in pregnancy.1,9 In the last trimester of pregnancy, the expanding uterus pushes up against the diaphragm resulting in shallow breathing. Near the end of pregnancy, when the baby engages, many women will feel less shortness of breath as there is more room for the lungs to expand. The feeling of breathlessness gets better as labour approaches. As the baby descends into the pelvis, pressure against the diaphragm is somewhat relieved.1

Management
Strategies a pregnant woman can use to cope with shortness of breath include:

  • Practicing good posture.
  • Exercising daily.
  • Avoiding overly strenuous activity.
  • Relaxing.
Varicose Veins

Varicose veins are more common as women age; weight gain, the pressure on major venous return from the legs, and a family history increase the risk of developing varicose veins during pregnancy.38 Varicose veins occur in the legs, vulva, and anus (hemorrhoids).5

Management
Strategies a pregnant woman can use to manage the symptoms of varicose veins include:

  • Avoiding standing for long periods of time.
  • Avoiding sitting with legs crossed.
  • Gaining weight within the recommended limits.
  • Elevating legs whenever possible.
  • Using support hose following discussion about sizing with her health care provider. The cost of these may be covered by supplementary health benefits.
  • Sleeping with legs elevated.
  • Exercising to improve circulation.

Physical Changes or Warning Signs to be reported to a Health Care Provider

Unusual or ongoing headaches

Unusual or ongoing headaches can be a sign of high blood pressure or hypertension. Headache due to hypertension is often associated with visual disturbance. About 10 percent of pregnant women will develop high blood pressure. Some women have high blood pressure prior to pregnancy.39 Hypertensive disorders of pregnancy are classified as pre-existing hypertension (occurring before 20 weeks’ gestation or prior to pregnancy) or gestational hypertension (occurring after 20 weeks’ gestation).39 If there is significant protein in the urine or some adverse symptoms such as headache, it is called pre-eclampsia.

Pre-eclampsia occurs more commonly in the second half of pregnancy. Hypertension and/or pre-eclampsiacan decrease blood flow to the placenta which can reduce the amount of oxygen and nutrients the baby receives, which may slow down the baby’s growth. Decreased placenta function may also lead to lower amounts of amniotic fluid around the baby. Pre-eclampsia also increases a mother’s chance of placental abruption and/or the need to have the baby early. Early birth may be required for the health of mother and/or baby. Birth is the beginning of the cure for hypertension. However, it may still persist for a few weeks postpartum.39

Women at greater risk for pre-eclampsia include those who:

  • Have a past history of pre-eclampsia.
  • Have diabetes or an inflammatory disease that affects the immune system (such as lupus).
  • Are pregnant with two or more babies.
  • Have a family history of pre-eclampsia (i.e., mother or sister had pre-eclampsia).
  • Are experiencing their first pregnancy.
  • Had a body mass index (BMI) above 30 when they became pregnant.39

A pregnant woman needs to get help from a health care provider immediately if she has:

  • A headache that doesn’t go away; it may be constant, severe, or changing.
  • Blurry vision, flashes, or dark spots.
  • Stomach pain, usually in the upper right part of the belly.
  • More nausea, stomach upset, or vomiting than usual.
  • Pain in her chest or shortness of breath.

Another hypertensive disorder of pregnancy that is less common is HELLP Syndrome. HELLP syndrome is a group of symptoms that occur in pregnant women who have:

  • H – hemolysis (breakdown of red blood cells).
  • EL – elevated liver enzymes.
  • LP – low platelet count.39


Changes in eyesight

Vision changes can be a sign of pre-eclampsia. Pre-eclampsia is marked by high blood pressure and the presence of protein in urine. Vision changes typically include temporary loss of vision, light sensitivity, blurry vision, auras, and the appearance of flashing lights. See the above section on unusual or ongoing headaches for more information about pre-eclampsia.39 Women should contact their health care provider if they experience these symptoms.


Ongoing nausea and vomiting

A small number of women (between 0.5 percent and 2.0 percent) suffer from a more severe and persistent form of nausea and vomiting, called hyperemesis gravidarum (HG).10 This condition often requires hospitalization because it is associated with daily persistent vomiting, a loss of more than 5 percent of pre-pregnancy weight, severe dehydration, and an electrolyte imbalance.10

The following are associated with more severe morning sickness or HG:

  • A multiple pregnancy (i.e., twins, triplets).
  • A placenta that is too big.
  • Molar pregnancy (a rare, abnormal, non-viable pregnancy).
  • Certain thyroid problems (such as hypothyroidism or hyperthyroidism).
  • Certain digestive problems (such as acid reflux, heartburn, Crohn disease).
  • Stress, depression, and other psychological problems.
  • Certain viral or bacterial infections (such as cough and cold, flu, sinus infection).
  • Active headaches or migraines.
  • Diabetes or gestational diabetes.
  • Obesity.
  • High blood pressure.10

Severe nausea and vomiting of pregnancy (NVP) or HG can lead to dehydration and malnutrition.

A pregnant woman should contact her health care provider if she:

  • Is not able to keep food or fluid down for a period of 24 hours or more.
  • Feels weak or lightheaded.
  • Has dry lips or mouth.
  • Is producing much less urine than normal.
  • Has urine that is dark and has an odour.
  • Is passing urine less than three times a day.
  • Does not gain weight or has a weight loss of five or more pounds over a one- to two-week period.10


Vaginal bleeding

Vaginal bleeding in pregnancy is any discharge of blood from the vagina during pregnancy. As many as one in four women will experience vaginal bleeding at some time during their pregnancy. It can happen any time from conception (when the egg is fertilized) to the end of pregnancy. A small amount of bleeding (referred to as spotting) in early pregnancy is quite common and rarely represents a serious problem, although a woman should be medically assessed.5 With bleeding, as opposed to spotting, a woman will need a liner or pad to keep the blood from soaking her clothes. This type of bleeding requires immediate medical assessment.5

What causes vaginal bleeding?

During month’s four to nine, bleeding may be a sign of:

  • The placenta separating from the inner wall of the uterus before the baby is born (placental abruption).
  • Pregnancy loss.
  • Placenta previa, where the placenta covers all or part of the opening to the cervix.40

Other possible causes of vaginal bleeding during pregnancy include:

  • Cervical polyp, growth, or degenerative uterine fibroid.
  • Early labour (bloody show).
  • Ectopic pregnancy.
  • Infection of the cervix.
  • Trauma to the cervix from intercourse (small amount of bleeding) or recent pelvic exam.5,40


Leaking or gushing of fluid

Leaking or gushing of fluid is often a sign of rupture of membranes. If this occurs after a woman is 37 weeks’ gestation it is called pre-labour rupture of the membranes (PROM); if it occurs before 37 weeks’ gestation, it is preterm PROM and may lead to preterm labour.41 Term PROM occurs in 2 percent to 10 percent of pregnancies and preterm PROM occurs in two percent to three percent of pregnancies.42

Regardless of when PROM occurs, there is an increased risk of infection to mother and baby once it happens. The time between the rupture of the membrane and onset of labour is called the latent period. Approximately 90 percent of women will go into labour spontaneously within 24 hours of PROM. For women who are earlier on in their pregnancy, the latent period will be longer, for example, at 28 – 34 weeks’ gestation 50 percent of women will go into labour within 24 hours after rupture of the membrane.41,43

Potential complications of term PROM include:

  • Fetal or neonatal infection.
  • Maternal infection.
  • Umbilical cord compression or prolapse.

Potential complications of preterm PROM include:

  • Preterm labour and birth.
  • Fetal or neonatal infection.
  • Maternal infection.
  • Umbilical cord compression or prolapse.
  • Increased cesarean section rate.42


Regular contractions before 37 weeks' gestation

Regular contractions before 37 weeks are a sign of preterm labour. Preterm labour is also called premature labour. In 2010 – 2011, the Canadian in-hospital preterm birthrate was 7.9 percent. This rate remained fairly stable since 2006 – 2007 (8.1 percent).2 Premature babies are more vulnerable and can have lifelong problems related to their prematurity. In general, the more premature a baby is, the more severe the problems.44

Babies who are born prematurely have problems because their organs are not ready to work on their own. A baby’s lungs are not ready to be used until the end of the pregnancy, and the baby may suffer mild to severe breathing concerns since surfactant is not made until the end of pregnancy. Surfactant is a coating on the inside lining of the alveoli. This coating makes it easier for the alveoli to expand during breathing. It also keeps the alveoli from collapsing and sticking together when air leaves the lungs. Surfactant is naturally made in the lungs. An immature stomach and bowel can result in feeding issues. There is an increased risk of infections with an immature immune system.45

Babies born early are more likely to be delivered by caesarean section. Babies born before the 25th week usually do not survive without problems.44 It is important to know early whether premature labour is occurring as it sometimes can be stopped or delayed. This can provide time to give a woman in preterm labour steroids, which may assist with the baby’s lung maturity, treat any underlying causes if possible, and permit transfer of mother to appropriate health care facility if necessary.45

About half of all premature labours begin for unknown reasons to women whose pregnancies were otherwise normal.46,47

The following women are at higher risk for preterm labour or birth:

  • Women who have previously delivered preterm or who have previously experienced preterm labour.48
  • Women who are pregnant with twins, triplets, or a pregnancy resulting from assisted reproductive technology. One study showed that more than 50 percent of twin births occurred preterm compared with only 10 percent of births of single infants.49
  • Women who have a short cervix or whose cervix shortens in the second trimester (month’s four to six) instead of the third trimester. This can sometimes be diagnosed by a vaginal examination or by measuring the size of a cervix by ultrasound.50
  • Women with an incompetent cervix.50

Certain medical conditions, including some that occur only during pregnancy, also place a woman at higher risk for preterm labour and birth. Some of these conditions include:44

  • Urinary tract infections.
  • Sexually-transmitted infections.
  • Certain vaginal infections, such as bacterial vaginosis or trichomoniasis
  • High blood pressure.
  • Bleeding from the vagina.
  • Certain developmental abnormalities in the fetus.
  • Being underweight or obese before pregnancy.
  • A short time period between pregnancies (i.e., less than six months between a birth and the beginning of the next pregnancy).
  • Placenta previa, a condition in which the placenta grows in the lowest part of the uterus and covers all or part of the opening to the cervix.
  • Being at risk for rupture of the uterus (when the wall of the uterus rips open). Rupture of the uterus is more likely if you have had a prior cesarean birth or have had previous uterine surgery such as removal of a fibroid.
  • Diabetes (high blood sugar) and gestational diabetes (which occurs only during pregnancy).
  • Periodontal disease.
  • Blood clotting problems.

Other factors that may increase the risk for preterm labour and premature birth include:

  • Ethnicity.
    • Preterm labour and birth occur more often among certain racial and ethnic groups. Infants of African American mothers are 50 percent more likely to be born preterm than are infants of Caucasian mothers.45 Many First Nations, Inuit, and MĂ©tis have poor access to high-quality and culturally-appropriate maternal health care and are more at risk of poor maternal health outcomes, including higher rates of low- and high-birth-weight babies, preterm birth, gestational diabetes, caesarean section birth, and poor access to specialist care due to geographic location.51
  • Age of the mother.
    • Women younger than age 18 are more likely to have a preterm birth.6
    • Women older than age 35 are at risk of having preterm infants as they are more likely to have other conditions (such as high blood pressure and diabetes) that can cause complications requiring preterm birth.4
  • Lifestyle and/or environmental factors.
    • Late or no health care during pregnancy.
    • Smoking.
    • Drinking alcohol.
    • Using illegal drugs.
    • Domestic violence, including physical, sexual, or emotional abuse.
    • Lack of social support.
    • Stress.
    • Long working hours with long periods of standing.
    • Exposure to certain environmental pollutants.48

Women under 37 weeks’ gestation should watch for the following symptoms and go to a hospital immediately if they experience:

  • Regular contractions for an hour.
  • Leaking or gushing of fluid from the vagina.
  • Pain that feels like menstrual cramps (with or without diarrhea).
  • A feeling of pressure in the pelvis or lower abdomen. Feeling like the baby is pushing down.
  • Dull aching in the lower back, pelvic area, lower abdomen, or thighs that doesn’t go away.
  • Not feeling well, including having a fever.48


Decreased fetal movement

Timely intervention for decreased fetal movement results in a substantial reduction in the rate of stillbirth.
The Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends that all pregnant women follow these guidelines:

  • With pregnancy risk factors, women should monitor fetal movements daily starting at 26 – 32 weeks.
  • Without risk factors for adverse perinatal outcomes, women should be made aware of the significance of fetal movements in the third trimester and asked to perform a fetal movement count if they perceive decreased movements.52

Women who do not feel six movements in an interval of two hours should be assessed.


Calf pain

Calf pain in pregnancy could be related to deep vein thrombosis (DVT). This is a serious condition where a blood clot develops, often in the deep veins of the legs but occasionally in the pelvis. It can be fatal if the clot dislodges and travels to the lungs. Due to hormonal changes causing an increase in blood volume and pressure on the veins from the enlarging uterus, DVT in pregnancy generally occurs in the lower extremities with a tendency for the left leg.53 Pregnant women are more likely to develop thrombosis than non-pregnant women of the same age. A clot can form at any stage of pregnancy and up to six weeks after the birth.

Risk factors for developing deep vein thrombosis include:

  • Having had thrombosis (clot) before pregnancy.
  • Being over 35 years old.
  • Having thrombophilia (a condition that makes clots more likely).
  • Being obese (with a BMI of 30 or more).
  • Carrying more than one baby.
  • Having fertility treatment during pregnancy.
  • Sitting still for long periods of time, including long-distance travel of more than four hours.
  • Being a smoker.
  • Dehydration.

The symptoms of DVT usually, but not always, occur in one leg only. Seek advice from a health care provider immediately with one or more of the following symptoms:

  • Swelling.
  • Pain.
  • Warm skin.
  • Tenderness.
  • Redness, particularly at the back of the leg below the knee.

To reduce the risk of DVT, a pregnant woman should drink extra fluids such as water; avoid caffeinated drinks; wear loose-fitting clothes that are not tight at waist and legs; and get up and move every 30 minutes to 60 minutes.

A pulmonary embolism (PE) is when a blood clot travels to the lungs. It can be fatal.

A woman should receive medical attention by calling 911 immediately with one or more of the following symptoms:

  • Sudden difficulty breathing.
  • Chest pain or tightness.


Unexplained rash

Some women experience a skin condition specific to pregnancy called Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP). Women with PUPPP develop small red bumps and hives and when severe the bumps form large patches.35 This rash usually starts on the abdomen and spreads to the thighs, buttocks, breasts, and arms, and is extremely itchy.

Some pregnant women experience severe itching during the third trimester of pregnancy. This symptom can be due to a condition called intrahepatic cholestasis of pregnancy (ICP).54 Mild jaundice (yellow colouration of skin and eyes) can also occur with this condition. ICP is the most common liver disease during pregnancy. It is largely a benign maternal condition, although the intense itching can result in sleep deprivation and disruption in activities of daily living. Serious effects have been reported, including an increased incidence of preterm birth, meconium staining of amniotic fluid, abnormal fetal status requiring birth, postpartum hemorrhage, and late intrauterine fetal death.55 The itching may increase as the due date approaches, but usually disappears a few days after the birth.

To soothe intense itching, a health care provider may recommend:

  • Taking prescription medication to decrease the level of bile in the mother’s bloodstream to relieve itchiness and reduce complications for the baby.
  • Soaking itchy areas in lukewarm water.


Fever and chills (i.e., temperature above 38.3° C or 101° F)

A fever is a sign of infection. Common infections in a pregnant woman can include vaginal, cervical, kidney, or bladder infections. Women may have a fever that accompanies these infections. If it is a bladder or kidney infection, symptoms may include fever, pain when urinating, urinating more often, urinating with only a small amount of urine coming out. If a woman has an infection in the vagina or cervix, there may be unusual vaginal discharge, pain in the pelvis or groin area, or a fever. With any of these symptoms, it is important to see a health care provider right away to seek treatment.56

In Canada, there is a 14 percent rate of bacterial vaginosis in pregnancy.57 Symptoms may include green and yellow discharge, fever, itching, and sometimes pain. Bacterial vaginosis has been associated with poor birth outcomes such as preterm labour and birth, preterm premature rupture of membranes, spontaneous abortion, and uterine infections.58 Bacterial vaginosis can be treated with both oral and topical antibiotics.

During pregnancy, a woman’s immune system is lower making her more susceptible to colds, upper respiratory infections, and gastrointestinal viruses. Women should seek help from their health care provider if they have a fever at any time in their pregnancy.

Prevention
Strategies a pregnant woman can use to prevent infections include:

  • Eating properly.
  • Getting plenty of rest.
  • Ensuring good hand washing.
  • Eating foods that are properly washed and cooked.
  • Obtaining the flu vaccine.


Burning sensation when urinating

A burning sensation when emptying the bladder may be a sign of a urinary tract infection (UTI). It is estimated that between 2 percent and 20 percent of women experience UTIs during pregnancy.59 Often UTIs are asymptomatic.

When symptoms are present, they include:

  • Pain or burning when urinating.
  • A persistent feeling of needing to urinate.
  • An increase in urination frequency and a fever.
  • An unpleasant odour that emanates from the urine.
  • Pressure or pain in the abdomen.
  • A presence of blood in urine.60

Possible health consequences of UTIs include:

  • Preterm labour.
  • Poor intrauterine growth.59

Prevention
There are different ways to prevent urinary tract infections. As the main source of contamination is E. coli (which comes from the bowel tract) it is important to follow good hygiene measures.

Strategies for good hygiene that a pregnant woman can use to prevent a UTI include:

  • Wiping or washing the genital area from front to rear.
  • Urinating after sex.
  • Washing the genital area daily as well as before and after intercourse.61

In addition, a systematic review noted that regular consumption of cranberry juice helps to decrease the number of symptomatic UTIs in women over a 12-month period.62 Pregnant women with a history of urinary tract infections (i.e., more than three episodes per year) may benefit from prophylactic treatment throughout pregnancy and up to four weeks to six weeks postpartum.5

Treatment
Any urinary tract infection in a pregnant woman should be treated, even if it is asymptomatic. There are many safe antibiotics that can be prescribed by a health care provider. Urinary tract infections are the most common bacterial infections during pregnancy.

Group B Streptococcus (GBS) causes about 10 percent of cases of acute pyelonephritis, mainly in the second trimester. Women with documented bacteriuria caused by GBS should be treated at the time of labour or rupture of membranes with appropriate intravenous antibiotics for the prevention of early-onset neonatal group B.63 Please see the Routine Prenatal Care file for more information on GBS.


Blunt trauma during pregnancy

Motor vehicle crashes (including snowmobiles, all-terrain vehicles, and boats) domestic violence, and falls are the most common causes of blunt trauma during pregnancy.64 All pregnant women with significant injury should be assessed immediately by their health care provider to rule out any signs of placental abruption. Trauma or blunt force can present with symptoms or no symptoms. Symptoms may include uterine bleeding, abdominal pain, uterine contractions, dizziness and shortness of breath, leaking of vaginal fluid, and decreased fetal movement.

Prevention
Strategies a pregnant woman can use to prevent blunt trauma during pregnancy include:

  • Wearing the three-point harness system for seatbelt usage.65 The lap belt should be placed under the pregnant woman’s abdomen and snugly over the thighs with the shoulder harness off to the side of the uterus between the breasts and over the midline of the clavicle.65 Seat belts placed directly over the uterus can cause fetal injury.65 Airbags should not be disabled during pregnancy.65
  • Wearing good supporting shoes when walking outside especially when wet or slippery and when doing physical activity.
  • Using handrails when going up and down stairs.
  • Using a rubber bath mat in the shower or tub to avoid slipping.
  • Seeking help if in an abusive relationship. Health care providers should screen all women for domestic violence and be aware of community resources for referral resources and support.

Referrals

When to refer

Women with the above-mentioned physical symptoms will need to be assessed by their health care providers. In addition, women with the following difficulties should be referred to specialized services by their health care provider.

  • Women who have severe, unexplained rashes; unusual lumps; or persistent breast pain.
  • Women who are experiencing persistent and/or severe reflux.
  • Women who are under severe stress and not coping well with the physical changes associated with pregnancy.
  • Women with chronic back pain.
  • Women with severe gum disease.


Where to refer

Women with the above-mentioned difficulties can be referred to the following specialists after assessment from their health care provider.

  • A dermatologist who offers treatment for unexplained rashes such as PUPP or ICP.
  • An internist for a woman experiencing persistent and/or severe reflux.
  • A psychologist or psychiatrist for women not coping well with the physical changes associated with pregnancy.
  • An orthopedic surgeon, physiotherapist, chiropractor, or massage therapist.
  • A dentist or periodontist. Women who do not have a dental plan should contact their local public health department to ask about subsidized oral programs. Often local colleges offer dental cleaning/checkups through their dental hygiene program. If a pregnant woman is receiving financial assistance (e.g., Ontario Works), oral health care may be covered.

Additional referrals:

  • Motherisk Nausea and Vomiting of Pregnancy (Morning Sickness) Helpline
    1-800-436-8477
  • Motherisk Exercise in Pregnancy Helpline
    1-866-937-7678
  • Diclectin® Surveillance Program
    1-888-744-0020

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Resources & Links



Please note this is not an exhaustive list of available resources, nor should any of these resources be used in place of seeking professional advice. The resources cited throughout this resource are not necessarily endorsed by the Best Start Resource Centre or the Government of Ontario. When in doubt, professionals should contact the organization responsible for issuing a specific recommendation/practice guideline.

Professional Guidelines

Professional Associations

Websites

Helplines

  • Diclectin® Surveillance Program
    1-888-744-0020
  • Motherisk Exercise in Pregnancy Helpline
    1-866-937-7678
  • Motherisk Nausea and Vomiting of Pregnancy (Morning Sickness) Helpline
    1-800-436-8477

Prenatal Education Provider Tools

Client Resources and Handouts

Apps

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References

  1. Society of Obstetricians and Gynaecologists of Canada. (2009). Healthy beginnings giving your baby the best start from preconception to birth 4th edition. Mississauga, ON: John Wiley & Sons.
  2. Better Outcomes Registry and Network Program Report (BORN). (2012). Perinatal health indicators for Ontario. Retrieved from http://www.bornontario.ca/assets/documents/specialreports/Perinatal%20Health%20Indicators%20for%20Ontario%202012.pdf
  3. Ganchimeg, T., Ota, E., Morisaki, N., Lumbiganon, P., Zhang, J., Yamdamsuren, B., … WHO Multicountry Survey on Maternal Newborn Health Research Network. (2011). Pregnancy and childbirth outcomes among adolescent mothers: A World Health Organization multicountry study. BJOG: An International Journal of Obstetrics & Gynaecology, 121(S1), 40-48. DOI:10.1111/1471-0528.12630
  4. Canadian Institute for Health Information. (2011). In due time: Why maternal age matters. Ottawa, ON: Author. Retrieved from https://secure.cihi.ca/free_products/AIB_InDueTime_WhyMaternalAgeMatters_E.pdf
  5. Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2014). Maternal child nursing care. Louis, MO: Mosby.
  6. Kingston, D., Fell, D., & Chalmers. B. (2012). Comparison of adolescent, young adult and adult women’s maternity experiences and practices. Pediatrics,129(5), e1228-1237. doi:10.1542/peds.2011-1447
  7. Walker, M. (2011). Breastfeeding management for the clinician, using the evidence (2nd ed.). Boston, MA: Jones and Bartlett.
  8. Facco, F. L., Kramer, L., Ho, K. H., Zee, P. C., & Grobman, W. A. (2010). Sleep disturbances in pregnancy. Journal of Obstetrics and Gynecology, 115(1), 77-83. doi:10.1097/AOG.0b013e3181c4f8ec
  9. Mattson, S., & Smith, J. (2004). Core curriculum for maternal-newborn nursing. Louis, MO: Elsevier Saunders.
  10. Koren, G., & Maltepe, C. (2014). How to survive morning sickness successfully. Toronto, ON: Best Start Resource Centre. Retrieved from: http://www.motherisk.org/women/morningSickness.jsp
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Health Before Pregnancy

Health Before Pregnancy

Routine Prenatal Care

Routine Prenatal Care

Physical Changes

Physical Changes

Healthy Eating & Weight Gain

Healthy Eating & Weight Gain

Active Living

Active Living

Alcohol

Alcohol

Smoking

Smoking

Medications & Drugs

Medications & Drugs

Safety During Pregnancy

Safety During Pregnancy

Abuse

Abuse

Mental Health

Mental Health

Pregnancy & Infant Loss

Pregnancy & Infant Loss

Preterm Labour

Preterm Labour

Labour Progress

Labour Progress

Labour Support

Labour Support

Interventions in Labour

Interventions in Labour

Pain Medications in Labour

Pain Medications in Labour

Caesarean Birth

Caesarean Birth

Vaginal Birth After Caesarean

Vaginal Birth After Caesarean

Breech Birth

Breech Birth

Newborn Care

Newborn Care

Newborn Safety

Newborn Safety

Breastfeeding

Breastfeeding

Recovery After Birth

Recovery After Birth

Transition to Parenthood

Transition to Parenthood