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| Induction of labour - Information for pregnant women, their partners and their families |
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| This information: |
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Is for pregnant women, their partners and their families |
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Gives information to help you make choices about induction of labour |
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Provides information on the main reasons for induction of labour |
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Provides information on the best methods for induction of labour |
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Is based on a national evidence based clinical guideline on induction of labour |
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What is induction of labour
What is induction of labour
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During pregnancy your baby is surrounded by a fluid filled membrane (sac) which offers protection whilst he or she is developing in the uterus (womb). The fluid inside the membrane is called amniotic fluid.
In preparation for labour the cervix softens and shortens. This is sometimes referred to as "ripening of the cervix".
Before or during labour the membranes rupture (break) releasing the fluid. This is often referred to as "your waters breaking".
During labour the cervix dilates (widens) and the uterus contracts to push your baby out.
In most pregnancies labour starts naturally between 37 and 42 weeks, leading to the birth of the baby.
Induction of labour is a process designed to start labour artificially. |
When is induction recommended?
When is induction recommended?
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When it is felt that your or your baby's health is likely to benefit, doctor may offer and recommend induction of labour. On average about one in five labours are induced.
There are a number of reasons why induction may be offered and recommended. For example if you have diabetes or pre-eclampsia (high blood pressure).
If you are healthy and have had a trouble free pregnancy, induction of labour may be offered if:
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your pregnancy is more than 40 weeks |
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your waters break before labour starts |
When induction of labour is being considered, your doctor should fully discuss your options with you before any decision is reached. This should include explaining the procedures and care that will be involved and whether there are any risks to you or your baby.
If your pregnancy is more than 40 weeks
Even if you have had a healthy trouble free pregnancy, you should be offered induction of labour after 40 weeks because from this stage the risk of your baby developing health problems increases. An induction because you are overdue does not increase the chance of you needing a caesarean section.
An ultrasound scan in early pregnancy (before 20 weeks) can help to determine your baby's due date more accurately. This reduces your chances of unnecessary induction.
If your waters break before labour starts
Sometimes a woman's waters break before labour starts. This happens in about one in twenty pregnancies and is known as prelabour/premature rupture of the membranes (or PROM). When this happens, about nine out of ten women will go into labour naturally within twenty-four hours. The longer the time between PROM and the birth of the baby the higher the risk of infection to you or your baby.
If you are more than 37 weeks pregnant and your waters have broken but you have not gone into labour you should be offered the choice of either:
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Induction of labour |
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or |
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A "wait and see approach" to see if labour will start naturally |
| As a wait and see approach carries a slight risk of infection, we need to: |
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check your temperature twice a day |
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check for changes in the colour or odour of your amniotic fluid ("waters") |
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check for any other signs of fever (e.g. shivers, flushing) |
If you have not gone into labour induction is strongly recommended.
If your waters break before you go into labour, your chances of having a caesarean section will not be increased by choosing either induction or "wait and see". |
How is labour induced (started)?
How is labour induced (started)?
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There are a variety of methods that can be used to induce labour. You may be offered one or all of the methods described below depending on your individual circumstances.
Membrane sweeping
This has been shown to increase the chances of labour starting naturally within the next 48 hours and can reduce the need for other methods of induction of labour.
Membrane sweeping involves your doctor placing a finger just inside your cervix and making a circular, sweeping movement to separate the membranes from the cervix. It is done at home, at an outpatient appointment or in hospital.
If you have agreed to induction of labour, you should be offered membrane sweeping before other methods are used. The procedure may cause some discomfort or bleeding, but will not cause any harm to your baby and it will not increase the chance of you or your baby getting an infection. Membrane sweeping is not recommended if your membranes have ruptured (waters broken).
Using prostaglandins
Prostaglandins are drugs that help to induce labour by encouraging the cervix to soften and shorten (ripen). This allows the cervix to open and contractions to start.
Prostaglandins are normally given as a tablet or gel that is inserted into the vagina. This is usually done in hospital on an ante-natal ward. More than one dose may be needed to induce labour. Doses should only be given every six to eight hours, If induced with Gel or every 3 to 4 hours if induced with tablets.
If your membranes have not yet ruptured (waters broken) prostaglandins are the recommended method of induction. This is the case whether this is your first pregnancy or not, and whether or not your cervix has ripened.
Before giving prostaglandins your doctor should check your baby's heart beat. After being given prostaglandins you should lie down for at least thirty minutes. Once your contractions start your baby's heartbeat is monitored using a "CTG" or electronic fetal heart rate monitor. There is no evidence to suggest that labour induced with prostaglandins is any more painful than labour that has started naturally. However prostaglandins sometimes cause vaginal soreness.
Very occasionally prostaglandins can cause the uterus to contract too much which may affect the pattern of your baby's heartbeat. If this happens you should be asked to lie on your left side. You may be given other medication to help relax the uterus and any prostaglandin tablet or gel remaining in your vagina may be removed.
Using Oxytocin
Oxytocin is given in hospital in the delivery room (labour ward).
This is a drug that encourages contractions. Oxytocin is given through a drip and enters the bloodstream through a tiny tube into a vein in the arm. Once contractions have begun, the rate of the drip can be adjusted so that your contractions occur regularly until your baby is born.
If your membranes have ruptured (waters broken) prostaglandins and oxytocin are shown to be equally effective methods of inducing labour. This is the case whether this is your first pregnancy or not, and whether or not your cervix has ripened.
Whilst being given the oxytocin the doctor should monitor your baby's heartbeat continuously
If your waters have not broken, a procedure called an amniotomy may be recommended. This is when your doctor makes a hole in your membrane to release (break) the waters. This procedure is done through your vagina and cervix using a small instrument. This will cause no harm to your baby, but the vaginal examination needed to perform this procedure may cause you some discomfort.
Women who have oxytocin are more likely to have an epidural to help with pain. An epidural is a pain relief injection given into your back. Oxytocin is given by a drip and being attached to this will limit your ability to move around. Whilst it may be okay to stand up or sit down, it will not be possible to have a bath or move from room to room.
Very occasionally oxytocin can cause the uterus to contract too much which may affect the pattern of your baby's heartbeat. If this happens you should be asked to lie on your left hand side and the drip will be turned down or off to lessen the contractions. Sometimes another drug will be given to counteract the oxytocin and lessen the contractions.
If you have already had prostaglandins, oxytocin should not usually be given for at least six hours. Your doctor or midwife should fully discuss these options with you before any decision is reached. They should explain the procedures and care that will be involved and whether there are any risks to you or your baby.
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What is placenta praevia?
What is placenta praevia?
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The placenta develops along with the baby in the womb during pregnancy. It links the baby with the mother’s blood system and provides the baby with its source of oxygen and nourishment. The placenta is delivered after the baby, and is also called the afterbirth.
In some women the placenta attaches too low in the womb and covers a part or all of the entrance to the womb (cervix). This attachment often shows up in early ultrasound scans, when it is sometimes called a low-lying placenta. In most cases, the placenta is carried upwards, as the womb stretches around the growing baby, and so it does not cause a problem. For some women, however, the placenta continues to lie in the lower part of the womb into the last months of pregnancy. This condition is known as placenta praevia. If the placenta covers the entrance to the womb (cervix) entirely, this is known as major placenta praevia. |
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The placenta may lie in the lower part of the womb (placenta praevia) or it may cover the entrance to the womb entirely (complete placenta praevia).
Rarely, placenta praevia may be complicated by a problem known as placenta accreta. This is when the placenta is attached to the womb abnormally, making separation at the time of birth difficult. |
What could a low-lying placenta after 20 weeks mean for my baby and me?
What could a low-lying placenta after 20 weeks mean for my baby and me?
If you have a low-lying placenta after 20 weeks you may experience vaginal bleeding during your pregnancy. Bleeding from placenta praevia can occasionally be very severe, and so put the life of the mother and baby in danger. If the placenta is low-lying in the womb after 20 weeks, it may prevent the baby from getting into the normal position of head first. Your baby may lie bottom first (known as the breech position) or lying across the womb (known as transverse) around the time of birth.
Women with placenta praevia usually need a caesarean section. Rarely, the bleeding is so much that you may need a blood transfusion. If the bleeding continues and cannot be controlled, a hysterectomy (removing the womb) may be the only means of controlling the bleeding.
If there is a lot of bleeding before your due date, you may have to be delivered earlier than planned. The earlier the baby is born before the due date, the higher the risk of health problems. The risk is greatest if the baby is born very early, that is, before 31 completed weeks of pregnancy. Premature babies may have problems with normal activities, such as feeding and breathing, and they are at greater risk of having health problems such as infection and jaundice. Because of this, early delivery by caesarean section is only considered if the bleeding is severe enough to cause risk to you or your baby.
How is placenta praevia diagnosed?
How is placenta praevia diagnosed?
Acute pelvic inflammatory disease (PID) is the name given to sudden or severe inflammation of the womb, fallopian tubes, ovaries and surrounding areas in the lower abdomen. It is usually caused by an infection that travels up through the entrance of your womb (known as the cervix) and spreads into your reproductive organs (your womb, fallopian tubes and ovaries) or pelvic area.
What extra antenatal care can I expect if I have a low-lying placenta after 20 weeks?
What extra antenatal care can I expect if I have a low-lying placenta after 20 weeks?
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One extra scan may be all that is needed to monitor the position of the placenta. If your placenta is no longer low-lying, you will have normal antenatal care.
If your placenta remains low-lying in the second half of pregnancy (after 20 weeks), you will have at least one more ultrasound scan to check whether the position of the placenta has lifted with the development and stretching of the womb. Additional extra care will be given based on your individual circumstances.
If you have major placenta praevia (the placenta covers the entrance to the womb (cervix)) or placenta accreta is suspected, you may be offered admission to hospital after 34 weeks of pregnancy. Even if you have had no symptoms before, there is a small risk that you could bleed suddenly and severely, which may mean that you need an urgent caesarean section.
If you have a low-lying placenta after 20 weeks and you have no bleeding, then you may be able to have care at home. However, you should be able to get to hospital quickly and easily at any time. You should call for an ambulance, should this need arise.
After you have been told that you have placenta praevia, you and your partner should have the opportunity to discuss the options for delivery with your doctor. Depending on your circumstances, you may be advised to have a planned caesarean section.
You will also need to consider what would happen in the case of an emergency. Your doctor should tell you more about this.
In a few instances, a blood transfusion is essential to save your life and the life of your baby. If you feel that you could never accept a blood transfusion, then you should explain this to your obstetrician as early as possible. You can then discuss any objections or particular questions that you may have. |
What will happen at the birth?
What will happen at the birth?
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Your healthcare team will recommend the best way for you to give birth based on your own individual circumstances.
If, on your scan at 32 to 36 weeks, your placenta is less than 2 centimetres from the entrance to the womb (cervix), you will almost certainly need a caesarean section. If this is the case, you should be delivered by the most experienced obstetrician and anaesthetist on duty.. This is particularly important if you have previously had a caesarean section.
Your anaesthetist will discuss the options for anaesthesia if you need a caesarean section. You may need to have a general anaesthetic.
If you have a caesarean section because of placenta praevia, you are more likely to need a blood transfusion.
Removal of the womb (a hysterectomy) is sometimes necessary if there is life-threatening bleeding.
It may be hard to be sure whether there is placenta accreta before surgery, but if this is thought to be likely your doctor may explain it to you beforehand. The risks are particularly high if you have placenta praevia and have had a caesarean section before. |
What might happen if I don't have treatment?
What might happen if I don't have treatment?
You may lose a lot of blood. A low-lying placenta after 20 weeks is a serious and life-threatening condition. There is a risk of death for you and/or your baby.
Is there anything else I should know?
Is there anything else I should know?
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You may have been advised to avoid having sexual intercourse during pregnancy, particularly if you have been bleeding. |
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You may be offered an examination with a speculum (a plastic or metal instrument used to separate the walls of the vagina) to see how much and where your bleeding is coming from. This is an entirely safe examination. |
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If you have a low-lying placenta you should eat a healthy diet rich in iron to reduce the risk of anaemia. |
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Unless there is severe bleeding or another indication, delivery by caesarean section should be performed after 38 weeks. |
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You have the right to be fully informed about your health care and to share making decisions about it. Your healthcare team should respect and take account of your wishes. |
What is acute pelvic inflammatory disease (PID)?
What is acute pelvic inflammatory disease (PID)?
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| Acute pelvic inflammatory disease (PID) is the name given to sudden or severe inflammation of the womb, fallopian tubes, ovaries and surrounding areas in the lower abdomen. It is usually caused by an infection that travels up through the entrance of your womb (known as the cervix) and spreads into your reproductive organs (your womb, fallopian tubes and ovaries) or pelvic area. |
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The original infection may be a sexually transmitted infection (such as chlamydia or gonorrhoea) or a vaginal infection.
Chlamydia is a common cause of PID, but PID may not develop until some time after you catch chlamydia. You may not realise you have chlamydia, because it often does not produce noticeable symptoms.
Occasionally PID can develop after: |
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a miscarriage |
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an abortion |
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giving birth |
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a gynaecological operation |
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inflammation of the lining of the womb (known as endometritis) |
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inflammation of the fallopian tubes (known as salpingitis) - the fallopian tubes carry the egg from the ovaries to the womb |
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inflammation of the ovaries (known as oophoritis) |
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inflammation of the internal lining of the abdomen (known as peritonitis). |
If PID is not treated straight away, this inflammation can damage your reproductive organs and cause long-term problems such as infertility, persistent pain in the lower abdomen and ectopic pregnancy (where the embryo develops outside the womb, usually in the fallopian tube). PID is not the only cause of these conditions, though.
Acute PID is not easy to diagnose. The symptoms can include: |
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abnormal vaginal discharge |
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pain in your lower abdomen |
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pain deep inside when you have sex |
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bleeding between your periods or after sex |
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a high fever |
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general feeling of being unwell |
| These symptoms can be caused by other conditions, too, so your doctor will need to examine you and do a number of tests to decide whether you have PID. |
How will I be tested?
How will I be tested?
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| If your doctor thinks you might have PID he or she may: |
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give you an internal vaginal examination |
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check for infections by taking samples from your vagina and the entrance of your womb (the cervix) with a swab (similar to a cotton bud). |
| Your doctor may give you other tests to help confirm that you have PID. You may have: |
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an ultrasound scan (which uses sound waves to produce a picture of your internal organs on a screen) through your vagina or abdomen |
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blood tests. |
You may need to go to hospital for some of these tests.
You may be offered a laparoscopy. This is a ‘keyhole’ operation, done under general anaesthetic. The doctor makes two small cuts (one below your navel and one just above your bikini line) and then inserts a small telescope (called a laparoscope). This enables him or her to examine your fallopian tubes and pelvic area more closely. It can help to show how severe the PID is or exclude other causes of pain. Your doctor may advise you to have a pregnancy test. |
What treatment can I get?
What treatment can I get?
Because PID is so difficult to diagnose, and because it can cause serious problems if it is not treated, your doctor may offer you treatment even if he or she is not completely sure you have PID. The benefits of this are greater than the risks. If you are diagnosed as having PID you should be treated as soon as possible.
You should usually be given a combination of two antibiotics to take by mouth to begin with. If your symptoms have not improved after three days, you may need further tests or treatment. The antibiotics your doctor prescribes should be effective for treating sexually transmitted infections, If your PID is severe or if you do not respond to or cannot take antibiotic tablets, you may have to go into hospital. You will have injections of antibiotics at first. After you start to improve, you will switch to antibiotic tablets. You will be allowed home once you are feeling better. You must finish the full course of antibiotics, which will usually last for 14 days, even if you are feeling much better. The antibiotics will not work effectively if you do not take the full course. If you stop taking them early the infection and inflammation will return.
You may be asked to go back to see a doctor after four weeks, to check that your symptoms have not reappeared and that you have completed the full course of antibiotics.
If your PID is very severe you will feel very ill and will need to go into hospital. If you have a pelvic abscess (a collection of infected fluid, or pus, in your lower abdomen), you may need an operation to drain the abscess and clear the affected area.
Are there any side effects?
Are there any side effects?
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| All antibiotics have some side effects. Some people are allergic to certain antibiotics. If you have had a reaction to antibiotics before, or if you know you have an allergy to any of them, you should tell your doctor or nurse.
Your doctor should tell you more about the risks and side effects of any treatment they recommend for you. The benefits of having treatment for PID are much greater than any of the risks in taking antibiotics. |
Will my contraception be affected?
Will my contraception be affected?
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You should avoid having sex or, if this is not possible, use condoms until you and your partner have finished the course of treatment.
Short courses of antibiotics can make oral contraceptives (often known as the Pill) less effective, so if you are on the combined Pill you should use additional contraception, such as condoms, while you are taking antibiotics and for seven days after you have finished the treatment.
If you use an IUD (known in the past as a coil) for contraception it may need to be taken out if you have severe PID. If your IUD needs to be removed and you have had sexual intercourse within the last seven days, you should ask your doctor whether you need to use emergency contraception.
If you have vaginal bleeding between your periods for no obvious reason when you are taking the contraceptive pill, you should be tested for infections, especially chlamydia. |
What might happen if I don't have treatment?
What might happen if I don't have treatment?
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If you delay or do not get treatment your PID could get worse and cause more damage to your fallopian tubes and ovaries. You may infect or re-infect your partner (or partners).
If it is not treated immediately or completely, PID can make you very ill or lead to further problems for which you may need hospital treatment, such as: |
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ectopic pregnancy |
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infertility |
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persistent pain |
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a change in your periods. |
What about my partner?
What about my partner?
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Your current sexual partner (or partners) should be offered advice and be tested for sexually transmitted infections. Your doctor may do this by referring you both to a sexual health clinic. If your partner has an infection, he or she may need to take antibiotics.
If you or your partner have had other sexual partners within the last six months, then it is recommend that those people are contacted and offered tests. |
Is there anything else I should know?
Is there anything else I should know?
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If you are HIV positive you should be given the same antibiotic treatment as women who are HIV negative. Your doctor should take into account any other medication you are receiving. |
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No treatment can be guaranteed to work all the time for everyone. |
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You have the right to be fully informed about your health care and to share in making decisions about it.
Your health care team should answer any questions you have. They should respect and take your wishes into account. |
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| Bleeding and pain in early pregnancy: Information for you |
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What does vaginal bleeding and pain mean?
What does vaginal bleeding and pain mean?
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Vaginal bleeding in the early stages of pregnancy is common and does not always mean there is a problem. However, bleeding can be a warning sign of a miscarriage.
If all the tests are normal and no cause for the bleeding has been found, then you need not worry.
An ectopic pregnancy is when the pregnancy is growing outside the womb (uterus), usually in the fallopian tube. A molar pregnancy is a much rarer condition where the placenta is abnormal. Both ectopic and molar pregnancy can cause bleeding and pain but these are much less common pregnancy problems.
See your doctor if you: |
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experience bleeding |
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feel pain |
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stop feeling pregnant. |
How can I get help?
How can I get help?
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| You can get medical help from: |
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your general practitioner or obstetrician. |
What tests can I expect?
What tests can I expect?
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| You should be given full information about all tests offered to you. |
Consultation and examination
You will be asked about your symptoms, the date of your last period and your medical history.
A vaginal examination (similar to a cervical screening test) may be carried out to see where the bleeding is coming from. A vaginal examination will not cause you to miscarry.
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A urine sample to confirm a positive pregnancy test. |
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A test for chlamydia may be offered. |
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Blood test(s) to check your blood group and/or pregnancy hormone levels. If you have a Rh (rhesus) negative blood group, then you may be given an injection of anti-D immunoglobulin to protect future pregnancies. |
Ultrasound scan
Most women are offered a transvaginal scan (where a probe is gently inserted in your vagina) or a transabdominal scan (where the probe is placed over your abdomen). You may be offered both. Both scans are safe and will not make you miscarry. A repeat scan may be necessary after 7 to 10 days if the pregnancy is very small or has not been seen. |
| Medical terms that may be used to describe what is happening |
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A threatened miscarriage: bleeding or cramping in a continuing pregnancy. |
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An incomplete miscarriage: a miscarriage has started but there is still some pregnancy tissue left inside the womb. |
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A complete miscarriage: when all the pregnancy tissue has been passed and the womb is empty. |
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A delayed miscarriage/missed miscarriage/silent miscarriage: the pregnancy has stopped developing but is still inside the womb. This will be diagnosed on the scan. |
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| Early miscarriage: Information for you |
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What is an early miscarriage?
What is an early miscarriage?
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| Early miscarriage is when a woman loses her pregnancy in the first three months. Many early miscarriages occur before a woman has missed her first period or before her pregnancy has been confirmed. Once you have had a positive pregnancy test, there is around a one in five (20%) risk of having a miscarriage in the first three months. Most miscarriages occur as a ‘one-off’ (sporadic) event and there is a good chance of having a successful pregnancy in the future. |
Why does early miscarriage occur?
Why does early miscarriage occur?
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| Much is still unknown about why early miscarriages occur. The most common cause is chromosome problems. Chromosomes are tiny thread-like structures found in all the cells of the body. In order to grow and develop normally a baby needs a precise number of chromosomes. If there are too few or too many chromosomes, the pregnancy may end in a miscarriage. |
What is the risk of having a miscarriage?
What is the risk of having a miscarriage?
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| The risk of miscarriage is increased by: |
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a woman’s age: the risk of early miscarriage increases with age. At the age of 30, the risk of miscarriage is one in five (20%). At the age of 42, the risk of miscarriage is one in two (50%). |
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health problems: as an example, poorly controlled diabetes can increase the risk of an early miscarriage. |
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lifestyle factors: smoking and heavy drinking are linked with miscarriage. |
There is no scientific evidence to show that stress causes a miscarriage.
Sex during pregnancy is not harmful and is not associated with early miscarriage.
There is no treatment to prevent a miscarriage. |
What happens if it is a miscarriage?
What happens if it is a miscarriage?
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If the miscarriage has completed, you will not need any further treatment.
If the miscarriage has not completed, there is a range of options available: |
What are my choices?
What are my choices?
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You may choose to have an operation, or you may prefer to let nature take its course or take tablets to start the process.
Letting nature take its course (expectant management)
Expectant management is successful in 50 out of 100 women (50%). It can take time before bleeding starts and it is normal for the bleeding to continue for up to three weeks. Bleeding may be heavier than normal and you may experience cramping pain. Very occasionally emergency admission for heavy bleeding or severe pain is necessary. If bleeding does not start or the miscarriage has not completed, you will be offered the option of taking tablets or having an operation.
Taking tablets (medical treatment)
You will either be given tablets to swallow or pessaries to insert into the vagina, which allows the entrance of the womb (cervix) to open and pass the pregnancy. This usually takes a few hours and there is some pain with bleeding or clotting (like a heavy period). You can take pain-relieving drugs. After the treatment you may bleed for up to three weeks. If treatment does not work, or the miscarriage has not completed, you will be given the option of having an operation.
Medical treatment is successful in 85 out of 100 women (85%) and avoids a general anaesthetic. You will often only need to be in hospital for a few hours and can then go home. However, there is a risk of heavy bleeding and the need for an emergency admission to hospital. Whether this is an option for you will depend on your hospital.
Having an operation (surgical treatment)
The operation is usually carried out under general anaesthetic, but it can also be carried out under local anaesthetic or short GA.. Surgery is usually arranged as a planned operation, usually within a few days. Surgical treatment is successful in 95 out of 100 women (95%).
You may be advised to have surgery immediately if: |
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you are bleeding heavily and continuously |
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the miscarriage is infected |
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expectant or medical management are unsuccessful. |
The cervix is gently opened and the pregnancy tissue removed by use of a suction device. You may be given tablets to swallow or vaginal pessaries before the operation to soften the cervix and make the operation easier and safer. This operation is called an suction & evacuation (emptying) of the womb (uterus) This operation is similar to a D&C (dilatation and curettage).
The operation (suction & evacuation) is safe, but there is a small risk of complications. These complications do not happen very often. They can include heavy bleeding (haemorrhage), infection, a repeat operation if not all the pregnancy tissue is removed and, less commonly, perforation (tear) of the womb that may need repair.
The risk of infection is the same if you choose medical or surgical treatment. |
When should I report to my Doctor?
When should I report to my Doctor?
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are worried about the amount of bleeding |
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are worried about the amount of pain you are in and the pain-relieving drugs are not helping |
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have a smelly vaginal discharge |
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get shivers or flu-like symptoms |
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are feeling faint |
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have pain in your shoulders. |
Are there any tests?
Are there any tests?
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It is normal for some tissue removed at the time of surgery to be sent for analysis in the laboratory. The results can confirm that the pregnancy was inside the womb and not an ectopic pregnancy (when the pregnancy is growing outside the womb). It also tests for any abnormal changes in the placenta (molar pregnancy).
Further tests are not routine unless you have had three miscarriages in a row. |
Are there any tests?
Are there any tests?
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To reduce the chance of infection, sanitary towels are advised rather than tampons until the bleeding has stopped. You may also be advised to wait until you have stopped bleeding before you have sex.
Your next period will be in four to six weeks time. Ovulation occurs before this, so you are fertile in the first month after a miscarriage. If you do not want to become pregnant, you should use contraception.
Making sense of what has happened can take time. You and your partner should be offered a follow-up appointment with a member of the healthcare team. |
When can I return to work?
When can I return to work?
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| This will vary for each woman. You should be able to go back to work after a week or so. It can take longer than this to come to terms with your loss. |
When can we try for another baby?
When can we try for another baby?
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| The best time to try again is when you and your partner feel physically and emotionally ready. |
How will I feel?
How will I feel?
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Losing a pregnancy is a deeply personal experience that affects everyone differently. It can affect the woman, her partner and others in the family.
Many women grieve, but come to terms with their loss. Other women feel overwhelmed and find it difficult to cope. Physical symptoms such as fatigue, loss of appetite, difficulty concentrating and trouble sleeping can be signs of emotional distress. Many men feel similar distress.
Many women experience a profound sense of loss and disappointment. They describe a feeling of numbness and emptiness. Many women grieve as they would do for a close friend or relative. They experience feelings of shock and sadness and anger and can find it difficult to accept their loss. Other women experience a sense of relief. These emotions are common and will pass with time and good support.
Other women experience feelings of guilt, blaming themselves for what they did or did not do. Some women find it hard to move on without knowing the exact cause of their miscarriage. Others are consoled by the fact that their miscarriage was a chance event and once the process had started, nothing could have been done to prevent it.
Some women want to talk about their experience. Others find this too painful.
You should be given all the time you need to grieve. Talking about how you feel with your healthcare professional can help. If you feel you need further assistance in coming to terms with your miscarriage, ask for a referral for support or counselling. |
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| Endometriosis: what you need to know |
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What is endometriosis?
What is endometriosis?
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| Endometriosis is a very common condition where cells of the lining of the womb (the endometrium) are found elsewhere, usually in the pelvis and around the womb, ovaries and fallopian tubes. It mainly affects women during their reproductive years. It can affect women from every social group and ethnicity. Endometriosis is not an infection and it is not contagious. Endometriosis is not cancer. |
What could endometriosis mean for me?
What could endometriosis mean for me?
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The main symptoms of endometriosis are pelvic pain, pain during or after sex, painfuls, sometimes heavy periods and, for some women, problems with getting pregnant.
Endometriosis can affect many aspects of a woman’s life including her general physical health, emotional wellbeing and daily routine.
Endometriosis is common and many women may have no symptoms.
Endometriosis is a long-term condition which affects women of all ages during their reproductive years (from the onset of menstrual periods to the menopause). It affects women from all social and ethnic groups.
Women who do experience symptoms may have one or more conditions: |
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painful periods (dysmenorrhoea) which do not respond to over-the-counter pain relief. Some women have heavy periods. |
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pain during or after sexual intercourse (dyspareunia) |
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lower abdominal pain |
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pelvic pain which can be long-term |
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difficulty in getting pregnant or infertility |
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pain related to the bowels and bladder (with or without abnormal bleeding) |
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long-term fatigue. |
Some women do not have any symptoms at all.
Pain is a common symptom of endometriosis. The pain can be a dull ache in the lower abdomen, pelvis or lower back. Pain affects each woman differently: where it hurts, when it hurts and how much it hurts. The pain, and the effects of endometriosis, can make you feel depressed.
Most women with endometriosis get pain in the area between their hips (known as the pelvis) and the top of their legs. Some women get pain only at certain times, such as during their periods, when they have sex or when they their bowels. Other women have pain all the time.
Some women with endometriosis become pregnant easily while others have difficulty getting pregnant. The pain may get better during pregnancy and then recur after the birth of the baby. Some women find that their pain resolves without any treatment. |
What causes endometriosis?
What causes endometriosis?
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During the menstrual cycle, under the influence of the female hormones estrogen and progesterone, the lining (endometrium) of the womb thickens in readiness for a fertilised egg. If pregnancy does not occur, the lining is shed as a period.
Endometriosis occurs when the cells of the lining of the womb are found in other parts of the body, usually the pelvis. Each month this tissue outside the womb thickens and breaks down and bleeds in the same way as the lining of the womb. This internal bleeding into the pelvis, unlike a period, has no way of leaving the body. This causes inflammation, pain and damage to the reproductive organs. |
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Reproductive areas where endometriosis can be found
Endometriosis commonly occurs in the pelvis. It can be found: |
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on the ovaries where it can form cysts (often referred to as ‘chocolate cysts’) |
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in or on the fallopian tubes |
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almost anywhere on, behind or around the womb |
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in the peritoneum (the tissue that lines the abdominal wall and covers most of the organs in the abdomen). |
| Less commonly, endometriosis may occur on the bowel and bladder, or deep within the muscle wall of the uterus (adenomyosis). It can also rarely be found in other parts of the body. |
Why does endometriosis occur?
Why does endometriosis occur?
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| It is not yet known why endometriosis occurs. A number of theories have been suggested but none has been proved. The most commonly accepted theory is that, during a period, light ‘backward’ bleeding carries tissue from the womb to the pelvic area via the fallopian tubes. This is called ‘retrograde menstruation’. |
How soon can I expect to get a diagnosis?
How soon can I expect to get a diagnosis?
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| For many women, it can take years to get a diagnosis. Doctors say that this is because: |
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no one symptom or set of symptoms can definitely confirm a diagnosis of endometriosis |
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the symptoms of endometriosis are common and could be caused by a number of other conditions such as irritable bowel syndrome (IBS) and pelvic inflammatory disease (PID) |
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different women have different symptoms |
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some women have no symptoms at all. |
There is no simple test for endometriosis. The only way to make a definite diagnosis is by a small surgical operation known as laparoscopy (see What treatment can I get?). This is not performed on every woman.
If you have painful periods and no other symptoms, your Doctor may suggest that you try pain relief before having further surgical investigation or treatments.
Living without a diagnosis can be distressing. Many women may fear the worst about why they are in pain or why they are having problems becoming pregnant. |
What happens when I see a specialist?
What happens when I see a specialist?
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At your appointment, you may be asked specific questions about your periods and your sex life. It is important that you provide as much information as possible, as this will help your doctor find the correct diagnosis. You may find it helpful to write down your symptoms beforehand and take your notes along to the appointment with you. In this way, you will be sure to provide all the information required. Some women find it helpful to take partner along with them as well.
Your gynaecologist may examine your pelvic area, this will include an internal examination. Your doctor will discuss the best time to do this. This may be when you are having your period. |
What types of tests might I be offered?
What types of tests might I be offered?
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You should be given full information about the tests that are available. These may include:
Ultrasound
You may be offered a scan. This can identify whether there is an endometriosis cyst in the ovaries. A normal scan does not rule out endometriosis.
Laparoscopy
For most women, having a laparoscopy is the only way to get a definite diagnosis; because of this, it is often referred to as the ‘gold standard’ test. A laparoscopy is a small operation which is carried out under general anaesthesia. A small cut is made in your abdomen near your tummy button (navel), then a telescope (known as a laparoscope), which is about the width of a pen, is inserted. This allows the gynaecologist to see the pelvic organs clearly and look for any endometriosis. This is usually carried out as day surgery.
As with any surgical procedure, there are risks and benefits. These should be fully explained to you when you are offered the test (see Are there any risks?).
If you have a laparoscopy, you should be given full information about your results.
Making a decision about treatment
You should be given full information about your options for treatment. This should also include information about the risks and benefits of each option.
Several factors may influence your decision about treatment. These include: |
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how you feel about your situation |
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your age |
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whether your main symptom is pain or problems getting pregnant |
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whether you want to become pregnant - some hormonal treatments which help to reduce the pain will stop you from becoming pregnant |
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how you feel about surgery |
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what treatment you have had before |
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how effective certain treatments are. |
| You may decide that no treatment is the best way forward. This could be because your symptoms are mild, you have not had problems getting pregnant or you are nearing the menopause, when symptoms may get better. |
What treatment can I get?
What treatment can I get?
What if I am having difficulty getting pregnant?
What if I am having difficulty getting pregnant?
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| Getting pregnant can be a problem for some women with endometriosis. Your doctor should provide you with full information about your options such as assisted conception. |
Are there any side effects?
Are there any side effects?
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You will be given full detailed information about the risks and benefits of any investigation, surgical procedure and treatment suggested. The side effects will vary from woman to woman.
Living with endometriosis
Not all cases of endometriosis can be cured and for some women there is no long-term treatment that helps. With support many women find ways to live with and manage this condition.
Complementary therapies
Complementary therapies include reflexology, traditional Chinese medicine, herbal treatments and homeopathy. They may be effective at relieving pain. Many women have found that dietary changes such as eliminating certain food types, such as dairy or wheat products, may help to relieve symptoms. Therapies such as TENS, acupuncture, vitamin B1 and magnesium help some women with painful periods. There is currently insufficient evidence to show whether such therapies are effective at relieving the pain associated with endometriosis. |
Is there anything else I should know?
Is there anything else I should know?
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Taking the combined oral contraceptive (COC) pill or contraceptive patch treats the symptoms of endometriosis. |
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If you become pregnant, endometriosis is unlikely to put your pregnancy at risk. |
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Some women find that recreational exercise improves their wellbeing, which may help to improve some symptoms of endometriosis No treatment is guaranteed to work all the time for everyone. |
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Internet forums may be the first place many women turn to for support. The quality of information can be variable. |
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| Polycystic ovary syndrome: what it means for your long-term health |
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Key points
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Polycystic ovary syndrome (PCOS) is a condition where the ovaries contain more developing follicles than normal. It can affect the balance of your hormones. |
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Symptoms can include: : |
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more body hair than is usual for you |
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irregular periods or no periods at all |
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being overweight |
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difficulty in getting pregnant |
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acne |
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loss of head hair. |
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You may have a higher risk of long-term health problems such as heart problems or diabetes. |
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Diet can help reduce your risk of long-term health problems. |
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Exercise can help reduce your risk of long-term health problems. |
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About this information
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| This information is intended for you if you have been told you have polycystic ovary syndrome |
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about the long-term effects of PCOS on your health |
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about best ways of reducing the risks of those long-term effects |
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how much we know about possible links between PCOS and certain health conditions. |
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It aims to help you and your healthcare team make the best decisions about your care. It is not meant to replace advice from a doctor or nurse about your own situation.
It does not tell you in detail about how PCOS is diagnosed or about treatments for the symptoms, such as changes in your body hair, irregular periods or problems in getting pregnant.
Some of the recommendations here may not apply to you. This could be because of some other illness you have, your general health, your wishes, or some or all of these things. If you think the treatment or care you get does not match what we describe here, talk about it with your doctor or with someone else in your healthcare team. |
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What is polycystic ovary syndrome (PCOS)?
What is polycystic ovary syndrome (PCOS)?
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Polycystic ovary syndrome is when you have polycystic ovaries as well as certain symptoms.
In a normal ovary, around five follicles (small sacs) develop each month, at the beginning of the menstrual cycle. These follicles contain eggs. Usually one follicle each month continues to develop until it releases an egg into the fallopian tube. This is known as ovulation.
If the egg is fertilised by sperm, it travels down to the womb, implants in the lining and a pregnancy begins. If the egg is not fertilised, the lining of the womb is shed at the end of the monthly cycle, when you have your period, and the egg is absorbed naturally back into your body.
Polycystic ovaries have at least twice as many developing follicles as normal ovaries. However, many of these follicles do not mature to the point of releasing an egg (ovulation). Because they have more follicles than is usual, polycystic ovaries are slightly larger than normal ovaries.
The term polycystic is a bit misleading. Early researchers thought that they could see cysts (small fluid-filled sacs) on the ovaries. In fact, what they saw were enlarged follicles.
Around 20 out of every 100 women have polycystic ovaries. Most women with polycystic ovaries have no symptoms.
A syndrome is a collection of different signs and symptoms that are all part of the same underlying medical condition. Women with polycystic ovary syndrome (PCOS) rarely have all of the possible signs and symptoms. PCOS is therefore difficult to diagnose. The doctor will take account of your symptoms and will usually check your hormone levels (through a blood test) and your ovaries (through an ultrasound scan).
PCOS runs in families. |
What could PCOS mean for me?
What could PCOS mean for me?
What could PCOS mean for me?
What could PCOS mean for me?
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Following a balanced diet is one of the main ways in which you can help yourself. Taking regular exercise is another way in which you can help yourself. Both can help reduce the long-term health risks associated with PCOS.
If you are overweight, losing weight will help you. If your periods are irregular or non-existent they may become more normal. Follow advice from your doctor on reducing your calorie intake and taking more exercise. |
Even if you are not overweight, you should take care to keep your weight within the normal range for your height.
To monitor your health, your doctor may offer you tests on the levels of cholesterol and certain fats (known as lipids) in your blood. These may be done regularly (usually once a year), especially if you are overweight and you have a family history of heart disease.
Women with PCOS are more likely than normal to develop a form of diabetes known as type 2 diabetes. One or two in every ten women with PCOS go on to develop this form of diabetes. It can be treated by diet and exercise, and sometimes also with tablets or insulin injections, depending on your circumstances.
If you are overweight and you have a family history of diabetes, you may be offered regular tests on the levels of sugar in your urine or the levels of glucose in your blood, to check for signs of type 2 diabetes. These tests may be done about once a year through your Doctor or a hospital outpatient clinic.
If you have few periods or no periods at all, the lining (known as the endometrium) of your womb may be more likely to thicken. Having regular periods usually prevents this. If the endometrium thickens, it can sometimes lead to cancer. To reduce this risk, your doctor may offer you treatment with progestogen hormones to ensure that you have a period at least every three to four months. |
How much do we know about the links between PCOS and other conditions?
How much do we know about the links between PCOS and other conditions?
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Insulin resistance and diabetes
Insulin is a hormone that regulates the amount of glucose (a form of sugar) in your blood. If the levels of glucose in your blood do not stay normal this leads to diabetes.
Some people need a lot of insulin in order to keep their blood glucose at the normal level. This is known as being insulin resistant. Some women with PCOS are insulin resistant and therefore more likely to develop diabetes.
Drugs known as ‘insulin sensitising agents' (such as metformin) act by making the body more sensitive to insulin. These drugs can be used for short periods of time to help non-diabetic women who have PCOS (especially women who do not ovulate). There is not enough evidence to tell us how safe or effective they are for long-term use by people who do not have diabetes.
If you become pregnant when you have PCOS, and especially if you are very overweight, you may develop diabetes during your pregnancy. This is known as gestational diabetes. You should be tested for it early in your pregnancy. It usually goes away once your baby is born, but you may be more likely to develop type 2 diabetes later in life.
If you have diabetes while you are pregnant your doctor.
Heart disease
If you have diabetes and/or high blood pressure you may be more likely to develop heart disease in later life. However, there is no clear evidence that, just because you have PCOS, you are any more likely to die from heart disease than women who do not have PCOS.
Breast cancer
If you have PCOS and you have been through the menopause, evidence shows that your risk of developing breast cancer is the same as women who do not have PCOS. |
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| Pre-eclampsia: what you need to know |
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What is pre-eclampsia?
What is pre-eclampsia?
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| Pre-eclampsia means ‘before eclampsia’. It is a condition that only occurs in pregnancy. In some cases, pre-eclampsia may progress to a serious condition known as eclampsia. |
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raised blood pressure (hypertension) |
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protein in your urine on testing (proteinuria). |
Swelling of the ankles is common in pregnancy and is usually nothing to worry about, but it can be a feature of pre-eclampsia.
Mild pre-eclampsia does not have any symptoms. It is usually picked up at your routine antenatal appointments.
The exact cause of pre-eclampsia is not understood.
More serious symptoms may develop as pre-eclampsia progresses. Around one in 200 (0.5%) women develops severe pre-eclampsia. The symptoms tend to occur later on in pregnancy but can occur for the first time after birth.
The symptoms of severe pre-eclampsia include: |
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headaches |
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blurred or altered vision |
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feeling very unwell |
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abdominal pain |
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nausea or vomiting |
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confusion |
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shortness of breath. |
| These symptoms are serious and you should seek medical help immediately. |
How does pre-eclampsia affect my baby?
How does pre-eclampsia affect my baby?
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Pre-eclampsia affects the development of the placenta and can affect the baby’s growth in the womb. There may also be a reduced amount of water (amniotic fluid) around the baby in the womb.
If the placenta is severely affected, the baby can become distressed or even die. Monitoring aims to pick up those babies who are most at risk. |
Who is at risk of getting pre-eclampsia?
Who is at risk of getting pre-eclampsia?
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| It is hard to predict who will develop pre-eclampsia in pregnancy. You are at greater risk if: |
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this is your first pregnancy |
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this is your first pregnancy with a new partner |
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you are aged 40 or over |
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your mother or sister had pre-eclampsia during pregnancy |
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you had pre-eclampsia in a previous pregnancy |
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you have a body mass index (BMI) of 35 or more (you weigh 90 kg or more) |
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you are expecting more than one baby |
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you have a medical problem such as high blood pressure, kidney problems and/or diabetes. |
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you are pregnant from egg (oocyte) donation. |
How is pre-eclampsia monitored?
How is pre-eclampsia monitored?
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With mild pre-eclampsia you will have more regular antenatal checks.
If the pre-eclampsia is getting worse or is severe, you may be monitored in the hospital. This is in case you need treatment and/or the baby needs to be delivered.
Tests include: |
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Regular blood pressure checks. If the pre-eclampsia is severe, this may be as often as every 15 minutes but more commonly is every 4 hours. |
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Urine test. If the pre-eclampsia is severe, you will have a catheter in your bladder to measure how much urine your kidneys are making. |
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Blood tests to check your blood count, clotting, liver and kidney function. |
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Ultrasound scans to measure the baby’s growth and wellbeing. |
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When you are in labour the baby’s heart rate will be monitored continuously. |
What is the treatment for severe pre-eclampsia?
What is the treatment for severe pre-eclampsia?
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If you develop severe pre-eclampsia, you will be cared for by an experienced midwife, senior obstetrician and anaesthetist.
Treatment includes bed rest and medicines (either tablets or a drip) to lower and control your blood pressure and to prevent complications such as convulsions or fits. Convulsions are an unusual complication but, if they occur, the condition is termed eclampsia. These medicines will not harm the baby.
The only way to prevent severe pre-eclampsia from developing into eclampsia (convulsions) is to deliver the baby in a planned and prompt way. Each pregnancy is unique and the exact timing will depend upon your own particular situation. This should be discussed with you.
There may be enough time to start (induce) labour. In some cases, delivery will need to be by caesarean section. |
What is eclampsia?
What is eclampsia?
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Eclampsia is a life-threatening condition. The main problem is fits (seizures/ convulsions). These are like epileptic fits.
Eclampsia occurs in one in 2000 pregnancies (0.05%).
Other complications include: |
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kidney failure |
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liver failure |
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lung failure |
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a combination of the above (this is known as HELLP syndrome). This is a combined liver and blood clotting disorder. |
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[H] stands for ‘haemolysis’ (breaking down of the red blood cells) |
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[EL] stands for ‘elevated liver enzymes’ in the blood (meaning damage to the liver) |
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[LP] stands for ‘low blood levels of platelets’ (platelets are specialised cells which are necessary for blood clotting). |
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When is the best time for the baby to be born?
When is the best time for the baby to be born?
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Your baby may need to be delivered early (prematurely) if the symptoms are getting worse and affecting you and/or your baby. A course of two steroid injections can help mature the baby’s lungs and reduce the chance of breathing difficulties if the baby is premature.
If the pre-eclampsia is less severe, you may be monitored to check that you can safely continue the pregnancy until labour starts naturally or is induced. |
What happens after the birth?
What happens after the birth?
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You will continue to be monitored closely. Up to half of the women who develop eclampsia do so after the delivery. You may need to stay in hospital for several days. You may need to continue taking medicine to lower your blood pressure.
If your blood pressure is still high six weeks after the birth, or there is still protein in your urine on testing, you may be referred to a specialist.
If you have had severe pre-eclampsia or eclampsia, you may have a postnatal appointment with your obstetrician to discuss the condition and what. Your obstetrician will assess if there are any risk factors and preventive treatment before another pregnancy.
It is important to attend routine antenatal appointments in all future pregnancies, where these checks are done. |
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