Patient support and advice

Mental health services

There is a dedicated midwife who leads an Parent Emotional Antenatal Clinic for Health. She can arrange support for any on-going or potential emotional problems during your pregnancy by referring you to a specialist service if necessary. The dedicated midwife can be contacted via your GP, health visitor or midwife or you can make your own appointment by telephoning 01782 672113.

Vulnerable women services

There is a dedicated midwife for vulnerable women who is able to offer support and treatment if you need assistance with specific problems during your pregnancy. The dedicated midwife can be contacted via your GP, health visitor or midwife or you can make your own appointment by telephoning 01782 672181.

Stopping smoking

Smoking in pregnancy can cause many problems including miscarriage, low birth weight, premature delivery, cot death, asthma and stunted intellectual and physical growth of your baby. Your named midwife can put you in touch with the Quit Smoking in Pregnancy service or you can contact the North Staffordshire Stop Smoking Service.

Maternity information Leaflets

Translated maternity leaflets

New parent advice

New parents advice

Videos for Video for self administration of Fragmin

Videos for VTE:

For all pregnant women to reduce the risk of VTE if they are not as active as usual as they are stuck at home due to the COVID situation: Click here

The second is an instructional video on how to self administer LMWH – BWCH deliver the drug and sharps box from pharmacy and send them the video to watch: Click here

Anti D information

Understanding NICE guidance
Information for people who use NHS services

Routine antenatal anti-D prophylaxis for women who are rhesus D negative

NICE ‘technology appraisal guidance’ advises on when and how drugs and
other treatments should be used in the NHS.

This leaflet is about when routine antenatal anti-D prophylaxis should
be used to treat pregnant women who are rhesus D negative in the NHS in
England and Wales. It explains guidance (advice) from NICE (the National
Institute for Health and Clinical Excellence). It is written for pregnant
women who are RhD negative (rhesus D can be shortened to RhD) but it
may also be useful for their families or anyone with an interest in how
being RhD negative can affect pregnancy.

It does not describe pregnancy or the treatments for RhD-negative
pregnant women in detail – your midwife or doctor should discuss these
with you. Some sources of further information and support are on the
back page.

This may not be the only treatment option for pregnant women who are RhD negative. Your healthcare team should talk to you about whether it is
suitable for you and about other treatment options available.

What has NICE said?

Routine antenatal anti-D prophylaxis is recommended as a treatment option for all pregnant women who are RhD negative and who are not known to be ‘sensitised’.

When a decision has been made to give routine antenatal anti-D prophylaxis, the treatment with the lowest cost should be used. This should take into account the costs of both obtaining and giving the treatment.

Pregnancy in RhD-negative women

People who are RhD positive have a substance known as D antigen on the
surface of their red blood cells, whereas RhD-negative people do not. A
woman who is RhD negative can carry a baby who is RhD positive if the
baby’s father is RhD positive. During pregnancy, or when giving birth, small amounts of the baby’s blood can enter the mother’s bloodstream.

This can cause the mother to have an immune response to the D antigen – that is, she produces antibodies against it. This usually doesn’t affect the existing pregnancy, but the woman becomes ‘sensitised’. This means that if she falls pregnant with another RhD-positive baby, the immune response will be quicker and much greater. The antibody produced by the mother can cross the placenta and attach to the D antigen on the baby’s red blood cells. This can be harmful to the baby as it may result in a condition called haemolytic disease of the newborn, which can lead to anaemia and jaundice.

Routine antenatal anti-D prophylaxis

Prophylaxis is the word given to a treatment that is used to prevent
something from happening. Antenatal anti-D prophylaxis can reduce the
risk of an RhD-negative woman becoming sensitised, by preventing her
immune response to the D antigen in the baby’s blood. It is routinely given between 28 and 34 weeks of pregnancy, in one or two doses, to pregnant RhD-negative women who are not already sensitised (this can be confirmed with a blood test).

What does this mean for me?

When NICE recommends a treatment, the NHS must ensure it is available to those people it could help, normally within 3 months of the guidance being issued. So, if you are pregnant and are RhD negative, you should be able to have routine antenatal anti-D prophylaxis on the NHS. If your doctor thinks this is the right option for you, you should be offered the type of treatment that is considered to be the least expensive.

Please see www.nice.org.uk/aboutguidance if you appear to be eligible for the treatment but it is not available.

More information

The organisations below can provide more information and support for
pregnant women who are RhD negative.

Please note that NICE is not responsible for the quality or accuracy of any information or advice provided by these organisations.

• The Miscarriage Association, 01924 200 799
www.miscarriageassociation.org.uk

• NCT (National Childbirth Trust), 0300 33 00 772
www.nct.org.uk

• Sands, 020 7436 5881
www.uk-sands.org

NHS Direct online (www.nhsdirect.nhs.uk) may be a good starting point for finding out more. Your local Patient Advice and Liaison Service (PALS) may also be able to give you further advice and support.

About NICE

NICE produces guidance (advice) for the NHS about preventing, diagnosing and treating different medical conditions. The guidance is written by independent experts including healthcare professionals and people representing patients and carers. They consider all the research on the disease or treatment, talk to people affected by it, and consider the costs involved. Staff working in the NHS are expected to follow this guidance. To find out more about NICE, its work and how it reaches decisions, see www.nice.org.uk/aboutguidance

Birth options after previous caesarean section

About this information

This information is for you if you have had one caesarean section and want to know more about your birth options when having another baby. It may also be helpful if you are a relative or friend of someone who is in this situation.

How common is it to have a caesarean section?

More than one in five women in the UK currently give birth by caesarean section. About half of these are as a planned operation and the other half are as an emergency. Many women have more than one caesarean section.

What are my choices for birth after one caesarean section?

If you have had a caesarean section, you may be thinking about how to give birth next time. Planning for a vaginal birth after caesarean (VBAC) or choosing an elective repeat caesarean section (ERCS) have different benefits and risks.

In considering your options, your previous pregnancies and medical history are important factors to take into account, including:
• the reason you had your caesarean section
• whether you have had a previous vaginal birth
• whether there were any complications at the time or during your recovery
• the type of cut that was made in your uterus (womb)
• how you felt about your previous birth
• whether your current pregnancy has been straightforward or whether there have been any problems or complications
• how many more babies you are hoping to have in future; the risks increase with each caesarean section, so if you plan to have more babies it may be better to try to avoid another caesarean section if possible.

To help you decide, your healthcare professionals will discuss your birth options with you at your antenatal visit, ideally before 28 weeks.

What if I have had more than one caesarean section?

If you are considering a vaginal birth but have had more than one caesarean section delivery, you should have a detailed discussion with a senior obstetrician about the potential risks, benefits and success rate in
your individual situation.

What is VBAC?

VBAC stands for ‘vaginal birth after caesarean’. It is the term used when a woman gives birth vaginally, having had a caesarean section in the past. Vaginal birth includes normal delivery and birth assisted by forceps or ventouse (vacuum cup).

What is an ERCS?

ERCS stands for ‘elective (planned) repeat caesarean section’. You will usually have the operation after 39 weeks of pregnancy. This is because babies born by caesarean section earlier than this are more likely to need to be admitted to the special care baby unit for help with their breathing.

What are my chances of a successful VBAC?

After one caesarean section, about three out of four women with a straightforward pregnancy who go into labour naturally give birth vaginally.

A number of factors make a successful vaginal birth more likely, including:
• previous vaginal birth, particularly if you have had previous successful VBAC; if you have had a vaginal birth, either before or after your caesarean section, about 8–9 out of 10 women can have another vaginal birth
• your labour starting naturally
• your body mass index (BMI) at booking being less than 30.

What are the advantages of a successful VBAC?

Successful VBAC has fewer complications than ERCS. If you do have a successful vaginal birth:
• you will have a greater chance of a vaginal birth in future pregnancies
• your recovery is likely to be quicker, you should be able to get back to everyday activities more quickly and you should be able to drive sooner
• your stay in hospital may be shorter
• you are more likely to be able to have skin-to-skin contact with your baby immediately after birth and to be able to breastfeed successfully
• you will avoid the risks of an operation
• your baby will have less chance of initial breathing problems.

What are the disadvantages of VBAC?

• You may need to have an emergency caesarean section during labour. This happens in 25 out of 100 women. This is only slightly higher than if you were labouring for the first time, when the chance of an emergency caesarean section is 20 in 100 women. An emergency caesarean section carries more risks than a planned caesarean section. The most common reasons for an emergency caesarean section are if your labour slows or if there is a concern for the wellbeing of your baby.
• You have a slightly higher chance of needing a blood transfusion compared with women who choose a planned second caesarean section.
• The scar on your uterus may separate and/or tear (rupture). This can occur in 1 in 200 women. This risk increases by 2 to 3 times if your labour is induced. If there are warning signs of thesecomplications, your baby will be delivered by emergency caesarean section. Serious consequences
for you and your baby are rare.
• Serious risk to your baby such as brain injury or stillbirth is higher than for a planned caesarean section but is the same as if you were labouring for the first time.
• You may need an assisted vaginal birth using ventouse or forceps. See the RCOG patient information An assisted vaginal birth (ventouse or forceps) (www.rcog.org.uk/en/patients/patientleaflets/assisted-vaginal-birth-ventouse-or-forceps).
• You may experience a tear involving the muscle that controls the anus or rectum (third or fourth degree tear). See the RCOG patient information A third- or fourth-degree tear during birth for more information.

When is VBAC not advisable?

VBAC is normally an option for most women but it is not advisable when:
• you have had three or more previous caesarean deliveries
• your uterus has ruptured during a previous labour
• your previous caesarean section was ‘classical’, i.e. where the incision involved the upper part of the uterus
• you have other pregnancy complications that require a planned caesarean section.

What are the advantages of ERCS?

• There is a smaller risk of uterine scar rupture (1 in 1000).
• It avoids the risks of labour and the rare serious risks to your baby (2 in 1000).
• You will know the date of planned birth. However, 1 in 10 women go into labour before this date and sometimes this date may be changed for other reasons.

What are the disadvantages of ERCS?

• A repeat caesarean section usually takes longer than the first operation because of scar tissue. Scar tissue may also make the operation more difficult and can result in damage to your bowel or bladder.
• You can get a wound infection that can take several weeks to heal.
• You may need a blood transfusion.
• You have a higher risk of developing a blood clot (thrombosis) in the legs (deep vein thrombosis) or lungs (pulmonary embolism). See the RCOG patient information Reducing the risk of venous thrombosis in pregnancy and after birth
• You may have a longer recovery period and may need extra help at home. You will be unable to drive for about 6 weeks after surgery (check with your insurance company).
• You are more likely to need a planned caesarean section in future pregnancies. More scar tissue occurs with each caesarean section. This increases the possibility of the placenta growing into the scar, making it difficult to remove during any future deliveries (placenta accreta or percreta). This can result in bleeding and may require a hysterectomy. All serious risks increase with every
caesarean section you have.
• Your baby’s skin may be cut at the time of caesarean section. This happens in 2 out of every 100 babies delivered by caesarean section, but usually heals without any further harm.
• Breathing problems for your baby are quite common after caesarean section but usually do not last long. Between 4 and 5 in 100 babies born by planned caesarean section at or after 39 weeks have breathing problems compared with 2 to 3 in 100 following VBAC. There is a higher risk if you have a planned caesarean section earlier than 39 weeks (6 in 100 babies at 38 weeks).

What happens when I go into labour if I’m planning a VBAC?

You will be advised to give birth in hospital so that an emergency caesarean section can be carried out if necessary. Contact the hospital as soon as you think you have gone into labour or if your waters break.
Once you start having regular contractions, you will be advised to have your baby’s heartbeat monitored continuously during labour. This is to ensure your baby’s wellbeing, since changes in the heartbeat pattern
can be an early sign of problems with your previous caesarean scar. You can choose various options for pain relief, including an epidural.

What happens if I do not go into labour when planning a VBAC?

If labour does not start by 41 completed weeks, your obstetrician will discuss your birth options again with you. These may include:
• continue to wait for labour to start naturally
• induction of labour; this can increase the risk of scar rupture and lowers the chance of a successful VBAC
• ERCS.

What happens if I have an ERCS planned but I go into labour?

Let your maternity team know what is happening. It is likely that an emergency caesarean section will be offered once labour is confirmed. If labour is very advanced, it may be safer for you and your baby to have
a vaginal birth. Your maternity team will discuss this with you.

Key points

• If you are fit and healthy, both VBAC and ERCS are safe choices with very small risks.
• 3 out of 4 women who have had one caesarean section and then have a straightforward pregnancy and go into labour naturally give birth vaginally.
• 9 out of 10 women will have a successful VBAC if they have ever given birth vaginally. Successful VBAC has the fewest complications.
• Giving birth vaginally carries small risks for you and your baby but, if you have a successful vaginal birth, future labours are less complicated with fewer risks for you and your baby.
• Having a caesarean section makes future births more complicated.
• Most women who have a planned caesarean section recover well and have healthy babies, but it takes longer to get back to normal after your baby is born.

Making a choice

If you are asked to make a choice, you may have lots of questions that you want to ask. You may also want to talk over your options with your family or friends. It can help to write a list of the questions you want answered and take it to your appointment.

Ask 3 Questions

To begin with, try to make sure you get the answers to three key questions if you are asked to make a choice about your healthcare.

1. What are my options?
2. What are the pros and cons of each option for me?
3. How do I get support to help me make a decision that is right for me?

Further information

• NICE guidance on caesarean section
• RCOG patient information A third- or fourth-degree tear during birth
• RCOG patient information An assisted vaginal birth (ventouse or forceps)

Sources and acknowledgements

This information has been developed by the RCOG Patient Information Committee. It is based on the RCOG Green-top Clinical Guideline Birth after Previous Caesarean Birth

This leaflet was reviewed before publication by women attending clinics in Raigmore Hospital, King’s College Hospital, Queen’s Hospital, St Mary’s Hospital, University Hospital Lewisham and Wrexham Maelor Hospital,
by the RCOG Women’s Network and by the RCOG Women’s Voices Involvement Panel.

The RCOG produces guidelines as an educational aid to good clinical practice. They present recognised methods and techniques of clinical practice, based on published evidence, for consideration by obstetricians and gynaecologists and other relevant health professionals. This means that RCOG guidelines are unlike protocols or guidelines issued by employers, as they are not intended to be prescriptive directions defining a single course of management.

A glossary of all medical terms is available on the RCOG website.

Low lying Placenta (placenta previa)

Placenta praevia, placenta accreta and vasa praevia

About this information

This information is for you if you have placenta praevia (a low-lying placenta after 20 weeks of pregnancy) and/or placenta accreta (when the placenta is stuck to the muscle of your womb). It also includes information on vasa praevia. It may also be helpful if you are a partner, relative or friend of someone in this situation.

A glossary of all medical terms used is available on the RCOG website

Key points

• Placenta praevia happens when your placenta (afterbirth) attaches in the lower part of your uterus (womb), sometimes completely covering the cervix (neck of the womb).
• This can cause heavy bleeding during pregnancy or at the time of birth.
• If you have placenta praevia, your baby will probably need to be born by caesarean.
• Placenta accreta is a rare but serious condition when the placenta is stuck to the muscle of your womb and/or to nearby structures such as your bladder. This is more common if you have previously had a caesarean. It may cause heavy bleeding at the time of birth.
• Vasa praevia is a very rare condition where blood vessels travelling from your baby to your placenta, unprotected by placental tissue or the umbilical cord, pass near to the cervix. If these blood vessels tear, this can be very dangerous for your baby.

What is placenta praevia?

The placenta develops together with the baby in your uterus during pregnancy. It attaches to the wall of your uterus and provides a connection between you and your baby. Oxygen and nutrients pass from your blood through the placenta into your baby’s blood. The placenta is delivered shortly after the baby is born and it is sometimes called the afterbirth.

In some women, the placenta attaches low down in the uterus and may cover part of or all of the cervix (the neck of the womb). In most cases, the placenta moves upwards and out of the way as the uterus grows during pregnancy. For some women, however, the placenta continues to lie in the lower part of the uterus as the pregnancy continues. This condition is known as low-lying placenta if the placenta is less than 20mm from the cervix or as placenta praevia if the placenta completely covers the cervix.
Placenta praevia is more common if you have had one or more previous caesarean births, if you had had fertility treatment in order to fall pregnant, or if you smoke.

Normal placenta

Low-lying placenta (less than 20mm from the cervix)

Placenta praevia (completely covering the cervix)

What are the risks to me and my baby?

There is a risk that you may have vaginal bleeding, particularly towards the end of the pregnancy, because the placenta is low down in your uterus. Bleeding from placenta praevia can be very heavy, sometimes putting both your and your baby’s life at risk.

Your baby may need to be born by caesarean because the placenta may block the birth canal, preventing a vaginal birth.

How is placenta praevia diagnosed?

A low-lying placenta is checked for during your routine 20-week ultrasound scan. Most women who have a low-lying placenta at 20 weeks will not go on to have a low-lying placenta later in the pregnancy: 9 out
of 10 women with a low-lying placenta at their 20-week scan will no longer have a low-lying placenta when they have their follow-up scan, and only 1 in 200 women overall will have placenta praevia at the end of
their pregnancy. If you have previously had a baby by caesarean, the placenta is less likely to move upwards.

Placenta praevia is confirmed by having a transvaginal ultrasound scan (where the probe is gently placed inside the vagina). This is safe for both you and your baby and it may be used towards the end of your
pregnancy to check exactly where your placenta is lying. Placenta praevia may be suspected if you have bleeding in the second half of pregnancy. Bleeding from placenta praevia is usually painless and may occur after having sex.

Placenta praevia may also be suspected later in pregnancy if the baby is found to be lying in an unusual position, for example bottom first (breech) or lying across the womb (transverse).

What extra antenatal care can I expect if I have a low-lying placenta?

If your placenta is low lying at your 20-week scan, you will be offered a follow-up scan at 32 weeks of pregnancy to see whether it is still low lying. This may include a transvaginal scan. You should be offered a further ultrasound scan at 36 weeks if your placenta is still low lying. The length of your cervix may be measured at your 32-week scan to predict whether you may go into labour early and whether you are at increased risk of bleeding.

If you have placenta praevia, you are at higher risk of having your baby early (less than 37 weeks) and you may be offered a course of steroid injections between 34 and 36 weeks of pregnancy to help your baby to become more mature.

See the RCOG patient information Corticosteroids in pregnancy to reduce
complications from being born prematurely (www.rcog.org.uk/en/patients/patient-leaflets/corticosteroids-inpregnancy-to-reduce-complications-from-being-born-prematurely/).

If you go into labour early, you may be offered a type of medication (known as tocolysis) that is given to try to stop your contractions and to allow you to receive a course of steroids. Additional care, including whether or not you need to be admitted to hospital, will be based on your
individual circumstances. Even if you have had no symptoms before, there is a small risk that you could bleed suddenly and heavily, which may mean that you need an emergency caesarean.

If you know you have a low-lying placenta, you should contact the hospital straight away if you have any vaginal bleeding, contractions or pain. If you have bleeding, your doctor may need to do a speculum examination to check how much blood loss there is and where it is coming from. This is a safe examination and you will be asked for your consent beforehand. You should try to avoid becoming anaemic during pregnancy by having a healthy diet and by taking iron supplements if recommended by your healthcare team. Your blood haemoglobin levels (a measure of
whether you are anaemic) will be checked at regular intervals during your pregnancy.

How will my baby be born?

Towards the end of your pregnancy, once placenta praevia is confirmed, you will have the opportunity to discuss your birthing options with your healthcare professional. Your healthcare team will discuss with you the safest way for you to give birth based on your own individual circumstances.

If the edge of your placenta is less than 20mm from the entrance to the cervix on your scan at 36 weeks, a caesarean will be the safest way for you to give birth. If the placenta is further than 20mm from your cervix
you can choose to have a vaginal birth. Unless you have heavy or recurrent bleeding, your caesarean will usually take place between 36 and
37 weeks. If you have had vaginal bleeding during your pregnancy, your caesarean may need to take place earlier than this. If you are having a caesarean, a senior obstetrician and anaesthetist should be present at the time of birth and you should give birth in a hospital with facilities available to care for you if you experience heavy bleeding. This is particularly important if you have had one or more caesareans before. Your anaesthetist will discuss the options for anaesthesia if you are having a caesarean birth.

During your caesarean, you may have heavier than average bleeding. There are many different things that your doctors can do to stop the bleeding, but if it continues and cannot be controlled in other ways, a hysterectomy (removal of your uterus) may be needed. If you have heavy bleeding before your planned date of delivery, you may be advised to have your baby earlier than expected. If you have placenta praevia, you are more likely to need a blood transfusion, particularly if you have very
heavy bleeding. During a planned caesarean, blood should be available for you if needed. If you feel that you could never accept a blood transfusion, you should explain this to your healthcare team as early in your pregnancy as possible. This will give you the opportunity to ask questions and to discuss alternative plans as necessary. For more information, see the RCOG patient information Blood transfusion, pregnancy and birth (www.rcog.org.uk/en/patients/patient-leaflets/blood-transfusion-pregnancy-and-birth/).

What is placenta accreta?

Placenta accreta is a rare (between 1 in 300 and 1 in 2000) complication of pregnancy. This is when the placenta grows into the muscle of the uterus, making delivery of the placenta at the time of birth very difficult.
Placenta accreta is more common in women with placenta praevia who have previously had one or more caesarean births, but it can also occur if you have had other surgery to your uterus, or if you have a uterine
abnormality such as fibroids or a bicornuate uterus. It is more common if you are older (over 35 years old) or if you have had fertility treatment, especially in vitro fertilisation (IVF).

Placenta accreta may be suspected during the ultrasound scans that you will have in your pregnancy. Additional tests such as magnetic resonance imaging (MRI) scans may help with the diagnosis, but your doctor will only be able to confirm that you have this condition at the time of your caesarean. If you have placenta accreta, there may be bleeding when an attempt is made to deliver your placenta after your baby has been born. The bleeding can be heavy and you may require a hysterectomy to stop the bleeding. There is a risk of injury to your bladder during the delivery of your placenta, which depends on your individual circumstances.
If placenta accreta is suspected before your baby is born, your doctor will discuss your options and the extra care that you will need at the time of birth. It may be planned for you to have your baby early, between 35
and 37 weeks of pregnancy, depending on your individual circumstances.

You will need to have your baby in a hospital with specialist facilities available and a team with experience of caring for women with this condition. Your team may discuss with you the option of a planned caesarean hysterectomy (removal of your uterus with the placenta still in place, straight after your baby is born) if placenta accreta is confirmed at delivery. It may be possible to leave the placenta in place after birth, to allow it to absorb over several weeks or months. Unfortunately, this type of treatment is often not successful and can be associated with very serious complications such as bleeding and infection. Some women will still go on to need a hysterectomy. Your healthcare team will discuss a specific plan of care with you depending on your individual situation.

What is vasa praevia?

Vasa praevia is a very rare condition affecting between 1 in 1200 and 1 in 5000 pregnancies. It is where blood vessels travelling from your baby to your placenta, unprotected by placental tissue or the umbilical cord, pass near to the cervix. These blood vessels are very delicate and can tear when you are in labour or when your waters break. This is very dangerous as the blood that is lost comes from your baby. Babies only have a small amount of blood in their bodies so they don’t need to lose much to become very unwell or even die. Up to 6 in 10 affected babies can die if this happens.

If your healthcare professional suspects that you may have vasa praevia when you go into labour or when your waters break, your baby needs to be born urgently. Usually an emergency caesarean would be recommended.

If your placenta is low, if you are carrying more than one baby or if your placenta or umbilical cord develops in an unusual manner, you are at higher risk of having vasa praevia. You may be offered an extra scan during your pregnancy to check whether you have this condition.

If you are found to have vasa praevia before you go into labour, you should be offered a planned caesarean at around 34–36 weeks of pregnancy. As this would mean that your baby is being born preterm, you would be offered a course of steroids (two injections, 12–24 hours apart) to help mature your baby’s lungs and other organs.

See the RCOG patient information Corticosteroids in pregnancy to reduce complications from being born prematurely (www.rcog.org.uk/en/patients/patient-leaflets/corticosteroids-in-pregnancy-toreduce-complications-from-being-born-prematurely/).

Further information

National Childbirth Trust (NCT): www.nct.org.uk/pregnancy/low-lying-placenta

Tommy’s: www.tommys.org/pregnancy-information/pregnancy-complications/low-lying-placenta-placentapraevia

Making a choice

Ask 3 Questions

To begin with, try to make sure you get the answers to three key
questions if you are asked to make a choice about your healthcare.

1. What are my options?
2. What are the pros and cons of each option for me?
3. How do I get support to help me make a decision that is right for me?

Sources and acknowledgements

This information has been developed by the RCOG Patient Information Committee.

It is based on the RCOG Green-top Guidelines No.27(a), Placenta Praevia and Placenta Accreta: Diagnosis and Management, and 27(b),
Vasa Praevia: Diagnosis and Management.

The guidelines contain a full list of the sources of evidence we have
used. You can find them online at: www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg27a and
www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg27b.

This information has been reviewed before publication by women attending clinics in Liverpool and Wrexham and by the RCOG Women’s Network and Women’s Voices Involvement Panel.

Group B Streptococcus (GBS) in pregnancy and newborn babies

About this information
This information is for you if you (or a friend or relative) are expecting a baby, planning to become pregnant or have recently had a baby. It tells you about group B Streptococcus (GBS) infection in babies in the first week after birth (known as early-onset GBS) and provides links to further information about late-onset GBS infection. It includes the current UK recommendations for preventing GBS infection in newborn babies.

A glossary of all medical terms is available on the RCOG website

Key points

• Group B Streptococcus (GBS) is one of the many bacteria that normally live in our bodies and which usually cause no harm.
• Screening for GBS is not routinely offered to all pregnant women in the UK.
• If you carry GBS, most of the time your baby will be born safely and will not develop an infection. However, it can rarely cause serious infection such as sepsis, pneumonia or meningitis.
• Most early-onset GBS infections are preventable.
• If GBS is found in your urine, vagina or rectum (bowel) during your current pregnancy, or if you have previously had a baby affected by GBS infection, you should be offered antibiotics in labour to reduce the small risk of this infection to your baby.
• The risk of your baby becoming unwell with GBS infection is increased if your baby is born preterm, if you have a temperature while you are in labour, or if your waters break before you go into labour.
• If your newborn baby develops signs of GBS infection, they should be
treated with antibiotics straight away.

What is GBS?

GBS is a common bacterium (bug) which is carried in the vagina and rectum of 2–4 in 10 women (20–40%) in the UK. GBS is not a sexually transmitted disease and most women carrying GBS will have no symptoms.

Carrying GBS is not harmful to you but it can affect your baby around the time of birth. GBS can occasionally cause serious infection in newborn babies, and, very rarely, during pregnancy and before labour.

How is GBS found?

GBS is sometimes found during pregnancy when you have vaginal or rectal swabs or a urine test. In the UK, the NHS does not routinely offer all pregnant women screening for GBS.

For more information about available tests, visit the Group B Strep Support (GBSS) website

What could GBS mean for my baby?

Many babies come into contact with GBS during labour or around birth. The vast majority of these babies will not become ill. However, if you carry GBS, there is a small chance that your baby will develop GBS infection and become seriously ill, or even die. Around 1 in every 1750 newborn babies in the UK and Ireland is diagnosed with early-onset GBS infection. The infections that GBS most commonly causes in newborn babies are sepsis (infection of the blood), pneumonia (infection in the lungs) and meningitis (infection of the fluid and lining around the brain). Although GBS infection can make your baby very unwell, with prompt treatment most babies will recover fully. However, of the babies who develop early-onset GBS infection, 1 in 19 (5.2%) will die and, of the survivors, 1 in 14 (7.4%) will have a long-term disability.

On average in the UK, every month:
• 43 babies develop early-onset GBS infection
• 38 babies make a full recovery
• 3 babies survive with long-term physical or mental disabilities
• 2 babies die from their early-onset GBS infection.

What puts my baby at higher risk of developing GBS infection?

Infection is more likely to happen if:
• your baby is born preterm (before 37 completed weeks of pregnancy) – the earlier your baby is born, the greater the risk
• you have previously had a baby affected by GBS infection
• you have had a high temperature or other signs of infection during labour
• you have had any positive urine or swab test for GBS in this pregnancy
• your waters have broken more than 24 hours before your baby is born.

How can the risk to my baby be reduced?

• A urine infection caused by GBS should be treated with antibiotic tablets straight away and you should also be offered antibiotics through a drip during labour.
• You should be offered antibiotics through a drip during labour if you have had a GBS-positive swab or urine test from an NHS or other accredited laboratory see the GBSS website for further information

• If you have previously had a baby who was diagnosed with GBS infection, you should be offered antibiotics through a drip when you are in labour.
• If your waters break after 37 weeks of your pregnancy and you are known to carry GBS, you will be offered induction of labour straight away. This is to reduce the time that your baby is exposed to GBS before birth. You should also be offered antibiotics through a drip.
• Even if you are not known to carry GBS, if you develop any signs of infection in labour, you will be offered antibiotics through a drip that will treat a wide range of infections including GBS.
• If your labour starts before 37 weeks of your pregnancy, your healthcare professional will recommend that you have antibiotics through a drip even if you are not known to carry GBS.

What are my options for where I can have my baby?

You should discuss your planned place of birth with your healthcare professional during pregnancy to make sure that you can receive antibiotics as required in labour. If you choose to have antibiotics, they will
be given through a drip and it may not always be possible to arrange this at home or in some midwiferyled units. As soon as you go into labour or your waters break, contact your healthcare professional as it is important
that you have antibiotics as soon as possible. You should always let your healthcare professional know if you have previously had a baby who had GBS infection or if you have tested positive for GBS in this pregnancy.

If GBS has been found, when should I have antibiotics?

If you are found to carry GBS in your vagina or rectum, treating you with antibiotics before your labour begins does not reduce the chance of your baby developing GBS infection. You do not need antibiotic treatment until labour starts, when you will be offered antibiotics through a drip to reduce the chance of your baby being infected. These antibiotics reduce the risk of your baby developing a GBS infection in their first week of life from around 1 in 400 to 1 in 4000. If GBS is found in your urine then you will need antibiotics as soon as it is diagnosed to treat your urinary tract infection; you will also be offered antibiotics through a drip during labour to prevent GBS infection in your baby.

There are other situations where you will be offered antibiotics but these are not specifically related to GBS infection:
• If your waters break preterm (before 37 weeks) but you are not in labour, you may be offered a course of antibiotics. See the National Institute for Health and Care Excellence (NICE) guideline NG25
on Preterm Labour and Birth
• If you are having a planned caesarean section and you carry GBS, you do not need antibiotics to prevent GBS infection in your baby unless labour has started or your waters have broken. All women having a caesarean section will be offered antibiotics at the time of the operation to
reduce the risk of a wide variety of infections.

If I had GBS in a previous pregnancy, should I be given antibiotics during labour?

• If a previous baby was affected with GBS infection then you should be offered antibiotics during labour in all following pregnancies, as there is an increased risk that a future baby may also be affected.
• If, however, GBS was found in a previous pregnancy and your baby was unaffected, then there is a 1 in 2 (50%) chance that you will be carrying it again in this pregnancy.

To help you choose whether you would like to have antibiotics in labour, you can have a specific swab test (known as the enriched culture medium or ECM test) to see whether you are carrying GBS when you are 35–37 weeks pregnant.

If the result shows that:
{ you are still carrying GBS at this stage of pregnancy then the risk of your baby developing early-onset GBS infection is increased to around 1 in 400 and you will be offered antibiotics in labour
{ you are not carrying GBS at this stage of pregnancy then the risk of your baby developing early-onset GBS infection is much lower (1 in 5000) and you may choose not to have antibiotics.

What will my treatment during labour involve?

If you have been offered antibiotics to prevent GBS infection in your baby, these should be started as soon as possible after your labour begins, or after your waters have broken. They will be given through a drip and continued at regular intervals (usually 4-hourly) until your baby is born.
You should still be able to move around freely during labour and this should not stop you from having a water birth.

If your waters break before labour, your healthcare professional will talk to you about when you will need antibiotics and about the best time for your baby to be born. This will depend on your individual circumstances and on how many weeks pregnant you are. The antibiotic that you will be offered to prevent GBS infection in your baby is usually penicillin. If you are
= allergic to penicillin then you will be offered a suitable alternative.

Can antibiotics in labour cause any harm?

Some women may experience temporary side effects such as feeling sick or having diarrhoea. Women can be allergic to certain antibiotics and in rare cases the reaction may be severe and life-threatening (anaphylaxis). Tell your healthcare professional if you know that you are allergic to penicillin or any other medications. Your healthcare professional should discuss with you the benefits and risks of taking antibiotics in labour to
prevent early-onset GBS infection in your baby. If you choose not to have antibiotics in labour then your baby will be monitored closely for 12 hours after birth as they are at increased risk of developing early-onset GBS infection.

How will my baby be monitored after birth?

If your baby is born at full term (after 37 completed weeks) and you received antibiotics through a drip in labour at least 4 hours before giving birth then your baby does not need special monitoring after birth. If your baby is felt to be at higher risk of GBS infection and you did not get antibiotics through a drip at least 4 hours before giving birth then your baby will be monitored closely for signs of infection for at least 12 hours.
This will include assessing your baby’s general wellbeing, heart rate, temperature, breathing and feeding. If you have previously had a baby affected by GBS infection then your baby will be monitored for 12 hours
even if you had antibiotics through a drip in labour. The chance of your baby developing GBS infection after 12 hours is very low and neither you nor your baby will need antibiotics after this time unless you or your baby becomes ill.

What are the signs of GBS infection in my baby?

Most babies who develop GBS infection become unwell in the first week of life (which is known as earlyonset GBS infection), usually within 12–24 hours of birth. Although less common, late-onset GBS infection can affect your baby up until they are 3 months old. Having antibiotics during labour does not prevent lateonset GBS. More information on late-onset GBS infection is available here: www.gbss.org.uk/infection.

Babies with early-onset GBS infection may show the following signs:
• grunting, noisy breathing, moaning, seeming to be working hard to breathe when you look at their chest or tummy, or not breathing at all
• be very sleepy and/or unresponsive
• be crying inconsolably
• be unusually floppy
• not feeding well or not keeping milk down
• have a high or low temperature and/or their skin feels too hot or cold
• have changes in their skin colour (including blotchy skin)
• have an abnormally fast or slow heart rate or breathing rate
• have low blood pressure*
• have low blood sugar.*
*identified by tests done in hospital

If you notice any of these signs or are worried about your baby, you should urgently contact your healthcare professional and also mention GBS. If your baby has GBS infection, early diagnosis and treatment
is important as delay could be very serious or even fatal.

What tests and treatments are available for my baby?

If it is thought that your newborn baby has an infection, tests will be done to see whether GBS is the cause. This may involve taking a sample of your baby’s blood, or a sample of fluid from around your baby’s spinal cord (a lumbar puncture). This will be discussed fully with you before the tests are done.

Babies with signs of GBS infection or babies who are suspected to have the infection should be treated with antibiotics as soon as possible. Antibiotics can be life-saving when given to babies with suspected infection. Treatment will be stopped if there is no sign of infection after at least 36 hours, and all the tests are negative.

Can I still breastfeed?

It is safe to breastfeed your new baby. Breastfeeding has not been shown to increase the risk of GBS infection, and it offers many benefits to both you and your baby.

Why aren’t all women tested for GBS during pregnancy in the UK?

The UK National Screening Committee does not recommend testing all pregnant women for the presence of GBS using vaginal and rectal swabs.

This is because:
• many women carry the GBS bacteria and, in the majority of cases, their babies are born safely and do not develop an infection
• screening all women late in pregnancy cannot accurately predict which babies will develop GBS infection

• no screening test is entirely accurate: a negative swab test does not guarantee that you do not carry GBS
• many babies who are severely affected by GBS infection are born preterm, before the suggested time for screening (35–37 weeks)
• giving antibiotics to all women who carry GBS would mean that a very large number of women would receive treatment they do not need.

Further information

Group B Strep Support (GBSS): www.gbss.org.uk

RCOG Green-top Guideline No. 36, Prevention of Early-onset Neonatal Group B Streptococcal Disease: www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg36

NICE clinical guideline CG190, Intrapartum Care for Healthy Women and Babies: www.nice.org.uk/guidance/cg190
NICE clinical guideline CG149, Neonatal Infection (Early Onset): Antibiotics for Prevention and Treatment:
www.nice.org.uk/guidance/CG149

UK National Screening Committee, recommendation on GBS screening in pregnancy: https://legacyscreening.phe.org.uk/groupbstreptococcus

A full list of useful organisations (including the above) is available on the RCOG website at: www.rcog.org.uk/en/patients/other-sources-of-help

Making a choice

Ask 3 Questions

To begin with, try to make sure you get the answers to three key questions if you are asked to make a choice about your healthcare.
1. What are my options?
2. What are the pros and cons of each option for me?
3. How do I get support to help me make a decision that is right for me?

Sources and acknowledgements

This information has been developed by the RCOG Patient Information Committee in collaboration with Group B Strep Support (GBSS). It is based on the RCOG Green-top Guideline No. 36, Prevention of Earlyonset Neonatal Group B Streptococcal Disease, published in September 2017.

The Guideline contains a full list of the sources of evidence used. You can find it online at: www.rcog.org.uk/en/guidelines-research-services/
guidelines/gtg36.

This information has been reviewed before publication by women attending clinics in Wrexham and London, by the RCOG Women’s Network and the RCOG Women’s Voices Involvement Panel, and by Group B Strep Support and their networks.

Antenatal and newborn screening information for patients

Thank you for choosing University Hospital of North Midlands for your maternity care.

The information below outlines the screening options for you and your baby.

There is a booklet about antenatal and newborn screening in your booking information pack called Screening tests for you and your baby.

The booklet which is available in a range of languages and in easy read can also be accessed by the following link: https://www.gov.uk/government/publications/screening-tests-for-you-and-your-baby-description-in-brief

This NHS video describes the screening tests:

: https://youtu.be/_afr5olIpTM

This video is available for viewing in alternative languages.

Saving Screening tests for you and your baby link to a smartphone home screen

This enables you to click on the icon to go straight to the screening information, just like an app. All phones:

Open the web browser.
Go to the phone-friendly (HTML) version of Screening tests for you and your baby by:

going to http://www.gov.uk/phe/pregnancy-newborn-screening

Then find the add to home screen or save to home screen option. Where this is depends on what phone you have and how old it is. If you need help, search online for what to do for your specific phone.

Screening Tests

During your pregnancy, you’ll be offered a range of tests, including blood tests and ultrasound baby scans. These tests will check and assess the development and wellbeing of you and your baby, and screen for a variety of conditions.

We can offer you screening for:

Iron deficiency anaemia
Hepatitis B
Syphilis
HIV
Sickle cell and thalassemia

We can offer you screening for:

Down’s syndrome, Edward’s Syndrome and Patau’s Syndrome referred to as Trisomy screening
Structural abnormalities in your baby

All the tests we offer are optional, it is always your choice whether to have the screening or not.

Some of these tests are best taken before 10 weeks of pregnancy. Therefore we ask that you contact the community midwives office on our central booking telephone number: 01782 672181 as soon as you know you are pregnant so that we can arrange your care to be ‘booked’ as soon as possible in order to discuss all your options with you.

The following links provide further information on your screening options:

Screening for infectious diseases (hepatitis B, HIV and syphilis) https://www.nhs.uk/conditions/pregnancy-and-baby/screening-blood-test-infectious-diseases-pregnant/

Screening for inherited conditions (sickle cell, thalassemia and other haemoglobin disorders) https://www.nhs.uk/conditions/pregnancy-and-baby/screening-sickle-cell-thalassaemia-pregnant/

Screening for Down’s Syndrome, Edwards’ syndrome and Patau’s syndrome https://www.nhs.uk/conditions/pregnancy-and-baby/screening-amniocentesis-downs-syndrome/

Screening for 11 physical conditions (20-week scan) https://www.nhs.uk/conditions/pregnancy-and-baby/20-week-scan/

Some screening tests will also be offered to your baby after they're born:

newborn physical examination https://www.nhs.uk/conditions/pregnancy-and-baby/newborn-physical-exam/

Newborn hearing screening https://www.nhs.uk/conditions/pregnancy-and-baby/newborn-hearing-test/

Newborn blood spot screening https://www.nhs.uk/conditions/pregnancy-and-baby/newborn-blood-spot-test/

Private Screening

A private screening test is available at the University Hospitals of North Midlands called Non-Invasive Prenatal Testing (NIPT).

NIPT is a screening test for Down's, Edwards' or Patau's Syndromes

NIPT involves a blood test from you and can be performed from 10 weeks of pregnancy. Results usually take 7 to 10 days to come back from the laboratory.

Remember NIPT does not give a yes/no answer; it tells you how likely. If this is something you would like to discuss further then please contact our screening office on: 01782 672581 for further details including cost.