What is Antenatal care?

Antenatal care or pregnancy care is one of the oldest screening programs in medicine. The aim initially was to screen for pregnancy problems but as medicine has progressed, antenatal care is now also designed to either prevent or minimise the impact of pregnancy complications.

Your GP will perform initial investigations to confirm the pregnancy and determine a due date. After this you will be referred to an Obstetrician. An Obstetrician is a doctor who has spent an average of 15 years training to specialise in women’s health issues - 6 years at medical school, 3 years of training on average as a junior doctor in the public hospital system and 6 years of specialist training. In Australia you will have a choice of either being referred to a private Obstetrician or referred to your local public hospital maternity unit. I work exclusively in the private sector because it means that I can provide continuity of care to all of my patients and this is one of the safest models of Obstetric care in Australia.

I like to see patients initially at 6-10 weeks so that I can take a careful history and perform a risk assessment. This, along with tests that are performed between 10-14 weeks enables me to determine which patients have a higher risk of some pregnancy complications. This is a critical time in your antenatal care because we can determine your individual risk of pregnancy complications such as pre-eclampsia, growth restriction and the risk of pre-term labour. While we may not be able to stop these issues, when detected early we can often delay these and minimise the impact. In addition to this, these investigations will also tell us which babies are at risk of chromosomal disorders.

At 20-22 weeks you will have a morphology scan to make sure that you baby is developing normally. For low risk women this is often the last formal scan that they have in pregnancy unless issues are detected. I like to scan patients myself at every appointment so that I can make sure that the baby is moving, that the fluid around the baby is normal, the blood flow through the umbilical cord is normal and I can get an idea about the growth of the baby - this is not a formal scan and if you need to have the growth assessed I will send you for a formal growth scan.

So what happens at my appointments? At every appointment your blood pressure will be taken, the growth of the baby will be assessed, the fetal heart rate calculated, we will discuss any pregnancy symptoms you have and recent investigation results and as you get closer to your due date we will discuss plans for your delivery. Most private Obstetricians will also scan the baby themselves at each appointment but this often isn’t done in the public sector because they don’t have the resources to do so.

On top of this, you will have 24 hours per day, 7 days per week cover for unexpected issues that arise. In my practice, I have a call arrangement with 4 other private Obstetricians. From 8am Monday until 5pm Friday each of us look after our own patients. Between 5pm Friday and 8am Monday and on public holidays one of us is on call for all patients. In the public sector you will have cover from the midwives and Obstetric registrar (doctor training to be an Obstetrician) at you local hospital. The Obstetric registrar will be able to involve a consultant Obstetrician if needed.

I hope that this clarifies a very important part of your journey to parenthood.

Vulval Care

Vulval skin is very delicate and can easily become inflamed and irritated. There are a lot of products marketed as being for vulval care but these can cause problems so I recommend that you stay away from these. This is a guide to vulval care so that you can avoid some of the common irritants. Of course, you should always seek medical advice if your vulva is sore or irritated because some vulval conditions can be serious and it is important to make sure that there isn’t an infection that also needs to be treated.

All vulval structures shown here are prone to irritation if not cared for.

The following are the steps I recommend to keep your vulva healthy:

• Use natural fibre underwear and sanitary products.

• Wash with sorbolene or soap free wash only.

• Dab gently after a shower, avoid rubbing.

• Avoid tight clothing including panty hose.

• Wipe from front to back when using the toilet.

• If you have difficulty cleaning after using your bowels, have a quick shower.

• Never use talcum powder.

• Use sensitive clothes wash for underwear.

• Use water soluble lubricants or Olive and Bee cream if needed.

• Avoid condoms with latex.

• Wash immediately after exercise or swimming.

• Consider using tampons or a menstrual cup if irritated by menstrual blood.

I hope that this helps and please remember to seek medical help if you have vulval irritation.

Vaginal Pessaries for Pelvic Organ Prolapse

Pelvic organ prolapse is a common condition that is most commonly seen in women who have given birth vaginally. Most women know that this can be corrected surgically with variable success but very few know that there is a less invasive way to manage this problem that doesn’t involve surgery. Welcome to the world of vaginal pessaries.

A sample of the different types of vaginal pessaries used in my practice.

Essentially, pessaries are inserted into the vagina and help to hold the pelvic organs in their correct anatomical location. This is old technology, in fact the ancient Roman’s and Greeks’s fashioned pessaries to manage this problem. We have much more advanced pessaries now that can be used for varying degrees of prolapse and some that are designed to help with stress urinary incontinence as well, but the concept is the same.

When I was training, I was taught that pessaries were primarily for patients who weren’t fit for surgery. These women would have a pesary fitted and it would stay until they cam back for review where it would be removed and either washed or replaced. This is NOT how I use pessaries in my private practice and there is no good reason that they can’t be used by all women with prolapse.

We have a pessary fitting set in the rooms which has a variety of pessary types and sizes which are autoclaveable. When I fit a pessary, I ask the woman to come in at 8:30am and to have the whole day clear so that I can make sure that the pessary we settle on is right for her. Initially I will fit a pessary that I think is suitable and then ask the patient to go out, do regular activities, make sure that she can pass urine with the pessary in and then come back. Based on what the woman has found I will either try a different pessary or order in the one that she has found works for her.

Once the patient’s pessary has arrived in the office, we make her another appointment where I teach her to insert and remove the pessary herself. Pessaries are like any other prosthesis or aid that can be used or not as the patient wishes. This gives women complete control over this aspect of their bodies.

So what are the risks/downsides associated with pessaries? There are very few risks with pessaries. The main issue we see is vaginal erosions. This is due to the pressure the pessary places on the vaginal wall and is most commonly seen in very elderly people who have had the pessary left inside the vagina for extended periods of time. This is a fairly minor issue and can be fixed by having a break from the pessary for a few weeks as well as the use of an estriol containing vaginal cream. The other downside with pessaries is that most can’t be used during sex. This is one of the reasons that I teach women to insert and remove it themselves and even though it can be a barrier to spontaneity, most women don’t view this as a big issue.

What are the advantages of a pessary over surgery? Firstly, you avoid the risks of prolapse surgery such as bleeding, infection, failure, mesh erosion if mesh is used, chronic pain and pain with sex. Surgery is NOT reversible and if you don’t like the outcome there is very little that can be done. The failure rate of prolapse surgery is such that it is not uncommon for women to end up having multiple procedures in an attempt to get to a functional level.

If you do have pelvic organ prolapse I would encourage you can ask your gynaecologist about the use of a pessary - there is a lot to gain and very little to loose by trying one.

Understanding Private Health Insurance in Australia

Private Health Insurance in Australia can be complicated and confusing. This is my first blog post because I have seen so many patients distressed to find out that they don’t have the level of cover that they thought they had.

The first thing to say is that every Australian is covered by Medicare courtesy of the Australian taxpayer. All pubic hospitals are funded by medicare and it is possible to have health care that is 100% covered by the government if you want. Some people prefer to have private healthcare and see a doctor who works in the private sector and admits their patients to a private hospital. If you want this, you either need to self-fund (pay everything out of pocket) or have private health insurance.

There are many reasons to want private healthcare including the ability to choose your own doctor, not being at the mercy of ever expanding public hospital waiting lists, being treated exclusively by consultants and having true continuity of care. I hope that the slides below help you to understand different insurance products and choose the one that’s right for you and your family.

This is a brief snapshot designed to help you understand private health insurance. I would encourage everyone to look carefully at what each insurance product actually covers you for - this is essential to have the level of cover that you want.