Being pregnant

This is how prenatal care is changing because of coronavirus—and possibly staying that way

Solo ultrasounds, prenatal classes on Zoom, and virtual doctors' appointments: this is how prenatal care has changed during the coronavirus pandemic.

If you’re pregnant or trying to conceive right now, you might be wondering what your prenatal care is going to look like this year, as the ripple effects of the coronavirus pandemic play out. What’s changing for pregnant women, and what’s staying the same? Have you been able to bring your partner with you during ultrasounds? Are you doing your own bump measurements at home? Are you having more virtual visits than in-office checkups?

We interviewed Tali Bogler, a family doctor and low-risk obstetrics provider, to find out more. In addition to serving as chair of family medicine obstetrics at St. Michael’s Hospital in Toronto, Bogler runs the Pandemic Pregnancy Guide, an Instagram account and online resource for expecting couples, and she’s the author of the updated interim schedule for children and pregnant women during the COVID-19 pandemic.

Q: Are pregnant women still having the same number of prenatal appointments right now?

The total number of prenatal visits has not changed during COVID-19, but the mode of delivery of these visits that has changed: certain in-person appointments have been converted to virtual prenatal appointments. There’s no consensus in the literature about the optimal number of prenatal visits, nor is there a Canadian guideline that recommends a perfect number. In developed countries, we typically see on average 7-11 prenatal visits during the course of a woman’s pregnancy.

Keep in mind that prenatal visits are not just important for health reasons, but also for the psychological care of pregnant women (i.e. preparing moms for childbirth and transitioning into parenthood). With reduced prenatal visits, research has shown that pregnant patients feel less satisfied with their care and perceive that the gaps between visits are too long. Prenatal visits might offer women a source of support and reassurance during a major life transition! To be quite honest, we don’t know whether an increase in virtual prenatal visits and fewer in-person prenatal visits will impact (positively or negatively) the level of support women feel during their pregnancy. We’re actually trying to look at that right now by asking pregnant or recently delivered women to tell us about their top concerns and overall experience during COVID-19 in a 10-minute survey—please fill it out if you can. Researchers at the University of Toronto are planning on studying this as well.

Q: What about if you have a high-risk pregnancy?

In terms of high-risk pregnancies, these women often follow their own unique schedule, tailored to their specific medical needs. Often high risk-pregnancies need more frequent ultrasounds, and ultrasounds, of course, cannot be done virtually. Ultimately, the frequency of prenatal visits needs to be determined by the medical and psychosocial needs of the pregnant woman and the baby.

Q: Is the six-week postpartum appointment virtual right now, too? I’ve always thought that six weeks is a long time for a postpartum woman to go before seeing a doctor. (If you have a midwife, you get several home visits before the six-week mark.)

This really depends on your provider. Obstetricians typically see their patients at the six-week postpartum mark, and for the most part, during COVID-19, this has now been converted to a virtual visit. Some OBs are offering these postpartum virtual appointments earlier than six weeks, which I agree can be a great thing for postpartum women. There is so much focus on prenatal care, and I think many postpartum moms feel lost in our system once they deliver, especially when the focus shifts towards the baby.

For family medicine obstetrics providers like me, we often see the mom and baby 24 to 48 hrs after they’re discharged from the hospital. Each time the baby comes in for a weight-check for example, the mom is also seen. This is what makes family medicine obstetrics an amazing model of care: Essentially, the mom and baby are considered one unit upon discharge and typically the mom will be seen as frequently as the baby in the postpartum period. (The same model applies to midwifery.) By seeing them together, we can address baby’s weight and feeding challenges, postpartum blues and anxiety, screen for postpartum depression, and answer those new parenting questions all at once. It’s sort of a one-stop shop.

To reduce exposure to COVID-19, we are trying to limit the amount of in-person time spent at each visit whenever possible. That’s why some of the more routine questions might be emailed to parents to complete prior to the visit, or followed-up with a phone call after the visit.

Q: Will the number of ultrasounds be limited? Or more standardized? I know rules have been changing about who can attend, like no partners allowed. Will that be enforced for the foreseeable future? Are technicians adapting to let partners attend ultrasounds virtually?

The number of ultrasounds has not changed during the pandemic. But in most ultrasound departments, pregnant individuals are being asked to come to their appointment without a partner. These policies were put in place to lower the risk of exposure to the pregnant woman, staff at the clinic and other patients. It’s unclear when these restrictions will be lifted; all hospitals are following the guidelines set out by their public health officials. Depending on the hospital or clinic and the privacy rules in place, some imaging clinics or departments might not be allowing partners to attend ultrasounds virtually (i.e. through video calling) due to issues around privacy and recordings. I strongly feel that clinics need to adapt swiftly to ensure that there are innovative technologies in place in order for all partners to attend ultrasound appointments virtually.

I really do feel for pregnant women during this time. I remember when I was pregnant with my twins and was at risk for preterm labour at 23 or 24 weeks. I required frequent ultrasounds to measure my cervix. I can’t imagine how nerve wracking it would have been to attend those ultrasounds solo.

Q: Some women say they’re feeling rushed through their appointments and their scans. I saw one pregnant woman posting that she felt like she was “treated like a germ or sick person the whole time.” It’s understandable, but it’s also very sad—pregnancy is supposed to be such a special and exciting time in your life. Does this worry obstetricians?

It’s upsetting to hear that some women might feel this way. I know that our team has been particularly sensitive to our pregnant population during this unprecedented time, and that we’ve been doing everything we can to ensure that our patients feel safe and heard.

Perhaps part of the misunderstanding is that health care providers are trying to be as efficient as possible during visits in order to reduce the amount of face-to-face time, in order to reduce exposure to both the patient and healthcare staff. However, there is a big difference between rushing and being efficient, and all healthcare providers need to be extra aware of this. We need to be transparent with our patients on why we’re doing things a certain way. Communication has always been critical in healthcare—now more than ever. We also need to find innovative ways to connect with patients in order for patients to feel heard and supported. This was one of the main reasons why we created @PandemicPregnancyGuide.

Q: I saw an online tutorial for teaching expectant moms how to measure their own belly size. Is that something women are being told to do? Or do pregnant women want to do it themselves because it’s reassuring to them?

We are not routinely asking women to do self-administered symphysis fundal height (SFH) measurements at home, but you might be asked to try this measurement at home in lieu of an in-person prenatal visit. It’s actually not that tricky to do—all you need is a flat surface and a measuring tape. However, we really do not have properly designed studies looking at the accuracy of self-measurements and detecting fetal growth issues. We posted a video on how to do the self-measurement and a lot of my patients have been really excited to tell me that they did the measurement at home. For my expecting parents, it’s the first time they have been involved in this capacity to collect their own data. It seems like there is a real sense of empowerment in women doing their own measurements.

Q: What about people who are investing in all the tech devices for self-monitoring at home? What do you think of patients buying their own fetal dopplers or blood sugar testing kits?

Doing home measurements and purchasing gadgets can be empowering and exciting, but at the same time, we need to make sure they’re safe, and that there is evidence to support their use at home. I’ll break it down by each type of device:

Doppler or a doptone: The simple answer is, if something wasn’t recommended prior to COVID-19, it shouldn’t be recommended during COVID-19. Doptone can cause a lot of unnecessary anxiety when not done properly. (Today’s Parent had a previous article on this.) After 24 weeks gestation, pregnant women can just use fetal movement—meaning kick counts—instead of a doppler.

Blood pressure: I strongly feel that accurate home blood pressure machines are necessary if we’re doing virtual prenatal visits. In my opinion, simply asking questions about signs and symptoms of high blood pressure and preeclampsia is less than ideal, and cannot replace accurate blood pressure readings. At the beginning of the pandemic, I was advising patients to go to their local pharmacy (always going at less busy times, and wiping down the machines prior to using, etc.) but pharmacies have now closed off their blood pressure machines, so this is less of an option now. For my patients with private insurance/drug coverage, I am actually prescribing a blood pressure machine so they can get the machine covered by their insurance. But what about patients who do not have private insurance and cannot afford BP machines? A lot of these gadgets and devices are not accessible to women from all incomes.

Sugar testing kits: These are advisable for women who have been diagnosed with gestational diabetes. These women need to monitor their sugars at home and many ”Diabetes in Pregnancy” programs have converted some of their in-person visits to virtual. Alternating visits can be done safely if women can accurately measure their sugar readings at home.

Q: Speaking of gestational diabetes, have there been any changes to the glucose test? Are moms still going in for that? It can be a long time to hang out in a waiting room.

We are still recommending screening for gestational diabetes in all pregnant women regardless of risk factors. This occurs between 24-28 weeks gestational age, or earlier, if you have risk factors. The oral glucose challenge test (i.e. that delicious tasting sugary drink) and then testing your blood one to two hours after is still the gold standard screening test for gestational diabetes. It’s understandable that many women do not want to wait at the lab for one to two hours, though. I have suggested that providers write on the blood requisition, “Please allow the patient to wait in their car or in a private room while waiting for the blood test.”

Q: What does this mean for lower-income moms, women with less education, or more vulnerable women, like those with mental health struggles? Who gets missed when patients are told to do virtual care or self-monitor more?

This is definitely an issue. We’re seeing how the pandemic has highlighted so many health care gaps that exist in our country, especially for the most vulnerable. These populations need more individualized and tailored approaches and consistent in-person care with their maternity care provider.

To do proper virtual care, patients need access to technological devices, a stable internet connection, and to have some level of technological literacy. At St. Michael’s Hospital for example, some of our patients do not have fixed addresses, and might not have cell phones, either. Successful programs will need to provide our most vulnerable patients with the necessary devices—as well as internet data—to those who need it most.

For pregnant women who might be experiencing heightened levels of anxiety during the pandemic, frequent virtual check-ins might be especially helpful. A recent study was actually just published that showed how virtual mental health therapy for anxiety is as good as in-person face-to-face therapy, which is encouraging. There are lots of virtual mental health services, including psychiatric support, available to expecting and postpartum moms during COVID-19.

Q: What are the options for prenatal classes? Are they happening on Zoom?

Lots of support programs and prenatal classes are trying to pivot to virtual options such as Zoom. This is one of the main reasons we created @PandemicPregnancyGuide! It’s sort of like a virtual prenatal class and support group with a focus on COVID-19 related concerns and questions. We did an Instagram Live one-hour breastfeeding prenatal class, which was led by one of our incredible lactation consultants at St.Michael’s Hospital. Prior to COVID-19 this would have been an in-person class.

Some of the other resources I have been providing my GTA patients with include Welcome to Parenting, a Toronto Public Health free online prenatal program that you can access anytime and anywhere; Markham Prenatal, a free 4-week live webinar prenatal class series where the instructors are registered nurses; Toronto Yoga Mamas; and She Found Health, an online prenatal class  developed by two Canadian family medicine obstetrics providers (this one costs $197).

Q: Do you think you’ll see an uptick in women considering home births, or choosing a midwife-assisted birth in the hospital? 

I think we’re going to have to wait until the 2019-2020 data is published to really know whether there is an uptick in patients choosing midwives and/or home births. We know that some women choose home births for various reasons, including having control over their environment or the comfort of being in their own home. Although there have been some people who have been proponents of home births during the pandemic, I think there have been many misconceptions in the media about the safety of delivering in a hospital versus outside the hospital during COVID-19. First of all, you need to be a “good candidate” for a home birth regardless of COVID-19. And just because you want a home birth doesn’t mean that it will end up being a home birth—it depends on how the delivery is going. At any point, if things are not going as planned or expected, you might need to be transferred to the hospital, so you need to consider what potential delays might exist in your local area during COVID-19 (like delays with getting an ambulance, delays with screening upon entering the hospital, etc.)

I think pregnant women should know that hospitals are an extremely safe place to deliver, and we have all the necessary infection control precautions in place to limit exposure to COVID-19. Honestly, I feel safer going into the hospital for work than going grocery shopping (where there is no screening)! We’re prepared for any scenario that arises.

You should also know that midwives are also limiting the number of support people who can attend your labour and delivery at home or in a birthing centre. It is not more flexible than our hospital policies regarding support people—midwives have guidelines in place as well. Your medical team attending your labour and delivery outside of the hospital will need to have sufficient PPE supply, including enough masks for other members of the household who might be attending your labour and delivery.

Q: Do you think there are any improvements to prenatal care coming out of all these changes and adaptations?

Yes, let’s talk about the silver linings. There are certainly some pros, especially for second-time moms who know the drill, and might likely be busier with work and family responsibilities. With more virtual visits, they’ll miss less work and might not have to find childcare for their older children. Prenatal visits, blood work, and ultrasounds take up a huge amount of time in our already busy schedules! And if you have to travel a long distance to get to your appointments, staying home is definitely an advantage. But the truth is, we really don’t know yet how this will impact feelings of support and whether these changes are welcomed or might lead to more anxiety in expectant parents. In general, this has certainly caused all of us in healthcare to stop and reflect and ask some really important questions: How can we deliver more innovative and efficient care to our expectant and postpartum parents even when this is all over? And some of the changes we are seeing right now might in fact be here to stay even post COVID-19.

Giving birth

I was forced to give birth alone because of coronavirus

As the new coronavirus spread throughout New York City, the hospital told pregnant women like me that our spouses would not be allowed in the delivery room.

My due date was April 1. As the day we’d anticipated for nine long months loomed closer, so did the coronavirus. Outside the door of our Brooklyn apartment, more and more people wore masks, and our local stores ran low on disinfectants and fever meds. Posted reminders to wash our hands became bright red “DO NOT ENTER IF…” signs on the door to my OB’s office. Doctor friends told us to stock up on food, and the school where I teach started to prepare for remote learning.

My prenatal appointments became more about the what-ifs of coronavirus than pregnancy. My questions were all about the safety of the hospitals, whether we should leave New York, and what would happen if I got sick with COVID-19 and then went into labour. 

My husband and I agonized over who would care for our two-year-old son when we had to go to the hospital. His normally doting grandparents were now understandably nervous about rushing into the city quickly becoming the new epicentre of the pandemic. My school and my son’s preschool had now been closed for two weeks. Friends and neighbours in the city lovingly offered to watch him, but everything made us anxious. What if they were asymptomatic carriers? What if we were asymptomatic carriers?  Who would answer our texts and calls if I went into labour at 3 a.m.? 

On March 23, I called my doctor’s office to confirm my 39-week appointment for the next day. The receptionist, whom I’ve known through two miscarriages and the birth of my son, said yes, the appointment was still happening. But then there was a pause on the line.

“Also, I need to tell you that the hospital has changed its policy. No visitors, including spouses,” she said. “I’m so sorry.” 

My mind racing, I took a deep breath and tried to hold onto logic and practicalities. This meant nobody else could accompany women in labour—no partners, no doulas, no grandmas-to-be. I asked if my husband would be allowed in the hospital to fill out the paperwork and carry my heavy hospital bag, or if I’d have to do that alone. She said he wouldn’t even be allowed in the building. He would have to drop me off at the curb. 

I hung up the phone, my husband hugged me, and we both cried. He would miss the birth of our second child—our baby girl.

In some ways, we tried to see the silver linings. My son could now stay happily at home with his dad, and the baby and I would be safer in a hospital filled with fewer people. I clung to those ideas, and they became my mantras. My son will be happy. My daughter will be safe. My son will be happy. My daughter will be safe. 

The next morning I thought I was experiencing contractions. With my first baby, I’d been induced, so I didn’t know what to expect, but I knew something was different this time. I called my doctor. Because I was Group-B-strep positive, and because of the pandemic, and because it was my second pregnancy, and because I live 45 minutes from the hospital, my doctor said I had to come in and get checked out. I gathered my “hospital bag” (an IKEA bag full of tightly sealed Ziplocs to protect my belongings from flying germs) and my husband and son and I piled into the car for the trip to Mount Sinai Hospital in Manhattan. We left at 8:30 on a weekday morning, normally a time that would have us facing down at least an hour of rush-hour traffic, but we sailed across the Brooklyn Bridge and right up the FDR.  

I braced myself for the curbside drop off. As we neared Mount Sinai, I explained to my son that I had to go to the doctor, but Daddy would stay with him and I would be home soon. Like most toddlers, he was oblivious to the gravity of the moment. “OK! Bye Mama!” he said.

I was checked in quickly, with some pitying eyes from the nurses and front-desk staff—it was the first full day patients had to come in without their partners, and the sight of a woman in labour, carrying her own bag, alone, was clearly jarring to everyone. I was offered hand sanitizer and a mask, asked some questions about symptoms, and ushered to a private space. 

An hour later, I texted my husband to come back and pick me up. False alarm. “Normal third-trimester symptoms.” Probably Braxton-Hicks. So embarrassing—how could I not know I wasn’t in labour? Where was my maternal instinct? But I was happy to have had a test run. Now I knew where to go, and what to expect. 

That night I had arranged a virtual game night with my parents and sister. As we worked out the technical difficulties and hit start on the first round, my water broke. My sister jokingly asked if we could still play one quick round, and my delighted parents wished us luck. After promising to send regular updates, I closed the computer and gathered my bag while my husband scooped our sleepy son out of bed and carried him to the car. 

It was 9 p.m, and we cruised over the Brooklyn Bridge and up the FDR once more. I hugged my husband at the curb, knowing this was it. I kissed my son on the forehead and told him I’d see him soon. I felt a deep pang of sadness—he’d never again be an only child. “Bye Mama, I love you,” he said sweetly. He had no idea how his world was about to change.

Thirty minutes later, I had been hand-sanitized and masked and questioned and set up in a delivery room. I sent my husband a photo of me smiling behind the mask, and one of the small clear plastic bassinet that would soon hold our daughter. 

My nurse was so kind. This was her first shift since the spousal ban, and the first thing she did was apologize. She assured me she’d be with me the whole time, and even with her mask on, I could see the empathy in her face. I asked for an epidural as I’d planned, and the anesthesiologists arrived quickly to administer it. In fact, everything was happening quickly. My doctor said they’d start Pitocin, too, even though my water broke naturally, because they wanted labours to move along as efficiently as possible. Instead of 48 hours, we’d only get to stay in the hospital for 24. They wanted me to rest up, and prepare to push hard, in a race against the clock.

My daughter and my body got the memo, and the contractions increased after the epidural. In fact, the epidural couldn’t keep up, and I was quickly in far more pain than my first birth. Multiple anesthesiologists came back to check the epidural.  Was it in right? Should it be redone? Can we up the dose? All of them determined that it should have been working. My body was just moving too fast for it to keep up. I jumped from 2 to 4 centimetres dilated, so I FaceTimed my husband and managed to prop the phone against one of my bags so he could see the side of my face. He talked me through the contractions as they became stronger and longer. The nurse let me take the mask off through the worst contractions, and my husband reminded me to breathe. Hearing his comforting voice helped me block out the fluorescent lights, the HGTV that was still (infuriatingly) blaring, and the view of the gigantic temporary COVID-19 tent set up outside my window.

Finally the epidural caught up. The contractions shortened in duration and dulled in intensity, and I was able to hang up and sleep.

Twenty minutes later, my doctor woke me up. It was time to push. There was an urgency in her voice. I was fully dilated, and I felt nauseated from lack of sleep (and lack of food, and lack of calm, and lack of partner). It was just after 2 a.m., and I knew I was going to vomit. I tore off the mask and threw up—violently. Then I realized I could no longer hear the baby’s heartbeat through the monitor. The nurses quickly adjusted me. Nothing. They adjusted again, and still nothing, and again, and still nothing. They rolled me over, and I wondered how I would tell my husband our baby girl was gone. Finally, after a frantic minute of adjusting me and the monitors, they found her heartbeat—it had slowed significantly when I vomited, but it was still there. Still steady. I grappled clumsily for my phone, called my husband on FaceTime at 2:16 a.m., and at 2:18 my doctor told me to push—now! 

At 2:19 I was holding my baby girl. I cut the cord myself, with her resting on my chest, and held the phone so my husband could see her. She cried and I cried, and the doctor assured me that she was OK.

The next day in the hospital was a bit of a blur. Trying not to feel bitter or lonely, I returned to my mantras: My son was happy. My daughter was safe. She was, thankfully, an easy baby from day one: eating heartily and right away, and giving me some two- and three-hour stretches of cuddles and sleep. We had a private room overlooking Central Park—a splurge my husband and I had agreed would be worth it given the value of isolation and the distraction of a nice view while stuck there alone. We spent a lot of time looking out the hospital window at the park below. I narrated what I saw: a little girl in a pink jacket kicking a soccer ball with her dad. Joggers on the paths giving each other plenty of space as they passed. Flowering trees just beginning to open at the start of spring. 

The recovery nurses happily came in when I buzzed them to close my blinds, to hand me my water or to plug in my phone—all of the things my husband would have done. They kept their distance and didn’t spend longer with us than necessary. 

The next morning, my husband and son picked us up. One of the nurses carried my bag out to the sidewalk while I carried my daughter, a swaddle blanket draped over her in an attempt to protect her from the threat of germs. My husband met us on Fifth Avenue, next to the grassy area that now houses the COVID-19 field hospital. I told him not to hug us until we’d changed out of our possibly-infected hospital clothes, so he gave us each a squeeze and a kiss on the forehead and he tried not to tear up. 

My son was already snoozing in the car. A few minutes later, as we crossed back over the Brooklyn Bridge, he sleepily woke up from his car nap and gazed over to see me, and his new baby sister, safely buckled into the backseat next to him. 

Mom sits in backseat of a car with newborn and older kid

Photo: Courtesy of Laurel Ingraham Aquadro

The day after we got home, New York State Governor Andrew Cuomo issued an executive order that forced hospitals to lift the spouse ban for deliveries. Our daughter was born on one of the four days when my husband couldn’t be there. Again, we tried to not to be bitter. We told ourselves it was better that way.

We are home now, together. My son is happy, and my daughter is safe, and we are adjusting as best we can to this new world as a family of four. 

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Giving birth

Nova Scotia has cancelled all home births—could it happen in other provinces?

The choice to have a home birth in Canada has been thrown into question this week, after the Nova Scotia government suspended midwifery-led home births without consultation of midwives.

Paris Semansky was on the fence about having a home birth up until days before her second daughter’s birth a little over a week ago. Her midwife was the chief of midwifery at Michael Garron Hospital in Toronto, and had been updating her regularly about hospital changes due to the escalating COVID-19 pandemic.

“We had already been self-isolating for a week and a half, and it was an ongoing conversation about the option of having a home birth,” she says. Then, she learned the hospital’s separate entrance to the labour and delivery ward was closed down. “I would have had to go through the front door, to the same lineup with everybody getting triaged to even get into the hospital,” she says. “That was our tipping point.”

Semansky had a low-risk pregnancy, and didn’t want to take the chance of exposing herself and her husband to coronavirus. Her previous birth was in hospital with midwives, and she felt confident that she could deliver at home this time. Her daughter Mira was born on her bed, without complications, after a five-hour labour.

But the choice to have a home birth in Canada has been thrown into question this week, after the Nova Scotia government on March 30 suspended midwifery-led home care, including births, without consultation of midwives.

“We appreciate how significant and special giving birth is for all women and their families and therefore we understand that changes to pregnancy and birth plans will be most unsettling,” said a press release issued by the Nova Scotia Health Authority and the IWK Health Centre paediatric hospital in Halifax. “The interruption of home birth services supports provincial efforts to minimize the spread of COVID-19 and keep Nova Scotians safe. The decision also protects small teams, like the midwives and birth attendants, so they can continue to provide midwifery services.”

Quebec, too, recently took similar measures to halt home births, but the option was subsequently reinstated after the implementation of additional measures related to COVID-19, including asking midwives to cap birthing partners to only one asymptomatic companion, and ensuring the family voluntarily self-isolated for 14 days prior to the birth.

Will home birth be cancelled in other provinces?

Following Nova Scotia’s decision, the Canadian Association of Midwives (CAM) said that their midwives are actively engaged in discussions with government and public health agencies in other provinces.

“National midwifery leaders are currently working in their provinces and jurisdictions to ensure that midwives are at the table when discussions around place of birth are happening, to ensure that the best options are available to families across Canada,” CAM president Nathalie Pambrun told Today’s Parent. “Midwives, as autonomous primary care providers, must be consulted regarding criteria around home births or births in any location.”

The presidents of the Ontario and British Columbia midwives’ associations, the two largest groups in the country, expressed disappointment about the Nova Scotia suspension of home births but said they don’t believe they will be affected. Nova Scotia has only 13 midwives while Ontario and BC have around 1,000 and 400 respectively, which helps to give them a greater voice in healthcare decisions.

Midwives are demanding support and access to to protective gear

Midwives, like all primary care providers, are working to adapt to the new reality of the COVID-19 pandemic. They’re taking extra precautions, such as wearing personal protective equipment (just like other healthcare providers) and substituting virtual and phone visits when possible with clients.

Throughout the pandemic, midwives have been providing uninterrupted care for their patients—whether in a home, hospital or birth centre setting—as they closely monitor the COVID-19 outbreak, and have been seeing higher demand for home birth, as many clients want to stay as far from hospitals as possible. They also help to alleviate stretched hospital resources.

But one of the biggest challenges midwives are facing is getting increased access to testing and personal protective equipment, says Pambrun. Her organization is also urging health regions to consider “temporary birth centres” with sites and staff that are clear of COVID-19-infected people receiving acute care.

SOGC says feeling toward home births “evolving”

Following the Nova Scotia decision, the president of the Society of Obstetricians and Gynaecologists of Canada (SOGC) told Today’s Parent that thoughts around home births in the setting of COVID-19 are evolving, but that the SOGC has not taken a stand against them for asymptomatic pregnant women. “It is still their choice to have a home birth, provided they can receive care from two experienced midwives who are willing to provide that,” says B. Anthony Armson.

He adds that the SOGC has not made a statement and does not have a position that home births are “contraindicated” in women who are otherwise healthy and are not known to have COVID-19. The SOGC’s updated COVID-19 guidelines say that pregnant women who are COVID-19-positive or symptomatic should deliver in hospital where they would have ready access to an interdisciplinary team including infectious diseases and seizure assessment.

Armson, who is based in Halifax, says he believes Nova Scotia’s decision came down to a lack of protective equipment for midwives, as well as increasing uncertainty over the availability of ambulances should a labouring woman need to be transported to hospital from her home. In the UK for example, some midwifery clinics have had to suspend home births because they could not rely on ambulance services for backup.

“Transportation may be a problem because ambulances are busy looking after other patients and the whole process of cleaning between one transport to another, so there could be delays in the event of a complication, more so now than previously,” he says. “I think those factors are influencing the appeal of home birth during this pandemic.”

The Ontario and BC midwives say they have not heard of any ambulance delays in their communities, but would expect that their paramedic colleagues would reach out to them if that was the case. In Ontario for example, about 30 to 40 percent of home births for first babies are transferred to hospital, but only about five percent are emergency transfers requiring an ambulance.

Jon Barrett, chief of maternal-fetal medicine at Sunnybrook Hospital in Toronto, agrees that one of the biggest issues is the lack of protective gear for all healthcare workers, including midwives. “Midwives will tell you they don’t have enough masks, so they are using the hospital’s supply, which is fine, it’s nobody’s supply…it just illustrates that there’s not one group that is unscathed here, there is no group that has a better answer, we’re all trying to work together to do the same thing.”

Home births as a form of physical distancing

For many midwives and pregnant women, home births may be the best possible form of physical distancing. “As hospitals see a surge in COVID-19 in the coming weeks and months,” says Pambrun, “it’s important to consider the important role that midwives can play in reducing the number of patients entering and overburdening these facilities, which may further spread of the virus.”

Obstetrician members of the SOGC, including Armson, have stated that there are still advantages to home births in low-risk pregnancies, but that cases must be assessed on an individual basis.

Meanwhile, Canadian midwives continue to offer choices. “Choice of birthplace, especially in the context of the pandemic, must be decided by midwives and childbearing families following best available evidence,” Pambrun says, adding that there is no evidence to support that home birth is unsafe for the midwives or the client when they are using personal protective equipment. “People will continue to have home births regardless of suspension of services. It is the duty and scope of midwives to ensure access to care for people who want to birth at home.”

Giving birth

So you're about to give birth in a coronavirus pandemic

Pregnant moms have many questions about how coronavirus will change their labour and delivery. We took those questions to top Canadian experts.

Under normal circumstances, the birth of a child is an overwhelming experience for new parents. But in the middle of a pandemic? Pregnancy, labour and delivery are even more complex and nerve-wracking.

With news about coronavirus developing on a daily (and hourly) basis, the new normal is to expect that the pandemic will affect your birth plans and that you should adjust your expectations. Across Canada, hospitals are restricting birth companions; doctors, nurses and midwives are delivering babies in full protective gear; and some provinces are suspending midwifery-led home births.

While there is still a lot we don’t yet know about how birth protocols will change in the days, weeks and months to come, the good news is that family doctors, obstetricians and midwives are acting quickly to respond to the latest information and the risks to pregnant women, babies and healthcare providers.

We spoke with Canadian experts and expectant mothers about the most pressing questions for pregnant women right now. Please note that coronavirus information changes quickly, and the information presented in this story is accurate as of the publication date or the noted update date.

Will my partner be allowed to attend my hospital birth?

As it stands, women in Canadian hospitals are not being forced to birth alone. However, most hospitals are only allowing one birthing companion—as opposed to the usual two, three or four. While midwives attending home births are not imposing such restrictions, anecdotally, some midwifery patients transferred to hospital have had to choose between having their midwife or their spouse or partner present. Be sure to ask your caregiver what the rules are as it still varies from institution to institution, and the impact of the disease will vary between hospitals as well.

Until recently, the policy at Toronto’s Sunnybrook Hospital was that your one birthing partner would need to leave two hours following the delivery to limit contact with the healthcare staff and because the hospital simply couldn’t spare the protective equipment for visitors when they didn’t even have enough for themselves. “This is the hardest change for us as caregivers. We’ve worked for a long time to promote family birthing and all that that means, but now for the safety of moms and healthcare givers and the whole system, we’ve been forced to make changes in those rules,” says Jon Barrett, chief of maternal-fetal medicine at Sunnybrook Hospital in Toronto. “It’s very hard for people to accept that. Something that is such a treasured thing and is planned for is now upside down. But all of our lives are like that right now. It’s very sad.”

Managing expectant parents’ expectations has also been difficult. “We’re trying our best to battle the realities of what we’ve got—a rapidly growing, community-spreading disease, limited resources, potential for medical staff to get sick, and everybody to get sick, and most parents understand that, but it’s hurtful when some people accuse us of being heartless and not understanding,” Barrett adds.

While some places such as New York, Spain, Italy and Germany had excluded all visitors from delivery rooms—including the pregnant woman’s spouse—many of those institutions are now backtracking from those policies amid public outcry, despite the risks.

What about my older child or my doula? Are there exceptions?

Most healthcare facilities are not allowing more than one visitor in the delivery room, including doulas and other kids. No exceptions. This makes childcare complicated—especially when the grandparents are isolating themselves and are not available to help out. Barrett says some families have been preparing for the birth by sending their other children to the grandparents in advance, despite the risk to older people, who have a much higher mortality rate if they contract coronavirus. “[The parents] know that the kids have been in isolation for a couple weeks by now, and they’re healthy and fine, and so they don’t feel as bad leaving them with the grandparents.”

If my husband can’t stay with me for long after delivery, will there be extra nursing staff to help me out?

Angie Shiffman, a Toronto mother who is having a having a scheduled C-section in less than two months, was recently informed that her husband will be allowed to stay with her after the surgery, but for several months of her pregnancy she’d been told he’d have to leave two hours after the birth. She was worried about how she would have been able to take care of her newborn. “My C-section experience with my first was that I was pretty numb for the first 12 or so hours after, and that meant that I couldn’t stand up or reach for my baby if she was crying in the bassinet, so I want to know what the after-care will look like without my husband being there.”

I was hoping for a “gentle C-section.” Will this still be available?

It depends where you’re delivering. At Sunnybrook—one of the first hospitals to offer “gentle C-sections” that include immediate skin-to-skin with the mother and baby immediately after the birth—will no longer accommodate this request, simply because it requires extra staff. Shiffman, who will be birthing at Sunnybrook, was upset this wouldn’t be an option, but she’s adjusting her expectations. “I was also disappointed that my daughter wouldn’t be able to meet her little brother right away but I quickly realized that was the least of our problems.”

Will my labour be considered a lower priority than coronavirus at the hospital?

Short answer: No. Pregnant women should rest assured that obstetrical care will remain a priority throughout the pandemic. “Pregnancy is viewed as just as important today as it was three months ago,” says Armson. “Obstetrics providers across the country will continue to be dedicated to providing care to women they’re looking after and the babies that are delivered to those women. Unless we are wholesale moved into looking after COVID patients 24/7, we are going to be providing the same care and priority to pregnant women as we have in the past.”

Armson says he hasn’t heard of any Canadian obstetricians being moved into general COVID-19 care, but that people should rest assured there is a healthy reserve of recently retired practitioners who could be pulled in to help out if necessary.

Hospitals seem too risky now. Should I switch to a home birth?

On the one hand, midwives have been advocating for home births for their low-risk patients as the best way to manage possible exposure to COVID-19 in crowded hospital settings and to reduce the need for unnecessary interventions. However, it all depends on a woman’s risks—and if she even has access to a midwife. If you’re pregnant and you have COVID-19, the SOGC recommends you give birth in a hospital, but otherwise there are different factors to consider. “It’s got to be a global assessment that’s individualized,” says Vanessa Poliquin, an obstetrician and reproductive diseases specialist at University of Manitoba in Winnipeg. “For somebody who is a low-risk delivery who has had a baby before without complications…you might do as well at home with a midwife,” she says. But there are still many situations where a hospital birth is preferable.

Midwives across the country are awaiting increased access to testing and personal protective equipment, says Nathalie Pambrun, president of the Canadian Association of Midwives. Her organization is urging health regions to consider “temporary birth centres” with sites and staff that are clear of COVID-19-infected people receiving acute care.

For many midwives and pregnant women, home births may be the best possible form of physical distancing. “As hospitals see a surge in COVID-19 in the coming weeks and months,” says Pambrun, “it’s important to consider the important role that midwives can play in reducing the number of patients entering and overburdening these facilities, which may further spread of the virus.”

How are home births and midwifery care changing during the pandemic?

Midwives, like all primary care providers, are working to adapt to the new reality of the COVID-19 pandemic. Midwives are taking extra precautions, such as wearing personal protective equipment (like other healthcare providers) and substituting virtual and phone visits when possible with clients.

Throughout the pandemic, midwives have been providing uninterrupted care for their patients—whether in a home, hospital or birth centre setting—as they closely monitor the COVID-19 outbreak, and have been seeing higher demand for home birth, as many clients want to stay as far from hospitals as possible.

However, as healthcare policymakers rush to implement new protocols, midwifery care may be affected. On Monday, March 30, the Nova Scotia government suspended midwifery-led home births and home visits, without consultation with the province’s midwives. “Unfortunately, we are facing extraordinary times and this is one of many difficult decisions we continue to make to ensure the ongoing provision of essential care,” said a press release issued by the Nova Scotia Health Authority and the IWK Health Centre paediatric hospital in Halifax. “The interruption of home birth services supports provincial efforts to minimize the spread of COVID-19 and keep Nova Scotians safe. The decision also protects small teams, like the midwives and birth attendants, so they can continue to provide midwifery services.”

Nova Scotia’s decision to suspend home births comes after the reversal of similar measures in Quebec, according to the Canadian Association of Midwives. Home births were reinstated in that province after the implementation of additional measures related to COVID-19.

“Midwives, as autonomous primary care providers, must be consulted regarding criteria around home births or births in any location,” says Pambrun. (The Canadian midwives association has yet to release an official statement as of publication.)

How will my hospital delivery be different if have coronavirus when I go into labour?

When you arrive, if you have any respiratory symptoms and/or confirmed coronavirus, you’ll be given a surgical mask right away and isolated as quickly as possible. If you are undergoing a procedure that contributes to droplets in the air, such as general anesthetic or intubation, your doctors and nurses will be wearing N95 respirators—even in asymptomatic women, because of the possibility of COVID-19 infection. And nitrous oxide, a common pain medication known as laughing gas, is no longer being offered to any labouring women, because it also contributes to the spread of airborne droplets. (Luckily, there are many other pain management techniques available, including epidurals and narcotics.) The SOGC recently released guidelines for treating COVID-19 in pregnancy and childbirth.

Will my baby be separated from me after delivery if I have COVID-19?

You may have seen the heart-wrenching images of fully suited healthcare workers in China caring for newborns, but there are no plans to separate mothers and babies in North America. Moms with coronavirus will still be encouraged to breastfeed, but the SOGC is instructing mothers to wash hands frequently, shower before skin-to-skin contact and breastfeed with a mask.

That said, Canada’s new guidelines are still relatively untested, notes Barrett, so we should be ready for new recommendations that come our way, and won’t necessarily get things right from the start. “It’s sobering to know that the way we are managing is not what’s being tested right now, because all the data is coming from China, where they did separate [babies from their mothers]. But the reality is we couldn’t separate even if we wanted to. We don’t have the facility.”

Assuming the baby and I are both healthy, will I be discharged from the hospital faster than I’d normally be?

Possibly. The protocol for discharge after having a baby is usually 48 hours after a C-section and 24 hours after a vaginal birth, says Armson. But in these circumstances, most hospitals will be trying to get moms home sooner, or as quickly as their medical condition allows.

What if my newborn ends up with coronavirus?

If you have it or get it while still pregnant, rest assured there is still no evidence of vertical transmission from mom to baby in utero. An analysis of nine infected pregnant women who delivered at Zhongnan Hospital of Wuhan University in China earlier this year, didn’t detect the virus in cord blood, amniotic fluid or breast milk. And for the most part, kids who get the virus appear to have only mild symptoms. However a recent study that looked at more than 2,000 infected children in China showed that a small percentage of infants, or babies under one, can get seriously ill.

What about locally? As of late last week, Barrett says there were only a handful of confirmed cases in babies in Toronto, and none of the infants has become seriously sick.

“This battle is going to be fought—and won and lost—in the older age groups, rather than pregnant moms and babies, that’s for sure,” says Barrett.

Pregnancy health

Which beauty products are safe to use during pregnancy?

A breakdown of the most common pregnancy safe skincare ingredients.

Whether you’re struggling with a sudden case of hormonal acne, or dark patches appearing across your cheeks (also called the “mask of pregnancy”), you may be shopping for some new beauty products and wondering what’s safe to use with baby on board.

“We all want pregnancies to go well, so it’s natural to be cautious about what we’re putting on our skin,” says Allison Sutton, a medical and cosmetic dermatologist in Vancouver.

Some face washes, body lotions and makeup contain ingredients that are proven to pose a threat to a developing fetus, and others have to be avoided postpartum since they can pass into breastmilk.

“Double-check ingredient lists, and if there’s anything you’re worried about, ask your physician,” says Sutton.

Here’s our list for a quick rundown of what’s safe—and what’s not:

Aluminum Chloride

You’ll find this controversial ingredient in antiperspirants. (It’s the ingredient that stops you from sweating). It’s hotly debated, but some research does suggest it’s potentially cancer-causing and we don’t know conclusively if it passes to breastmilk.

Verdict: Avoid

Alpha hydroxy acids (AHAs) and beta hydroxy acids (BHAs)

These popular skin brightening and exfoliating ingredients are a bit of a question mark because they may disrupt the skin barrier, which could open the skin up to penetration of other substances. Lotions containing AHAs and BHAs are best avoided during pregnancy.

Verdict: Avoid

Azelaic Acid

This antibacterial ingredient is found in rosacea treatments and some acne products, because it works to reduce redness and decrease pigmentation. It’s not known to have any negative side effects for mom or baby.

Verdict: Safe

Bakuchiol

This extract comes from the leaves and seeds of the babchi plant, known for its purple flowers (which is why some products that contain it maintain a violet hue) and is touted as a natural alternative to retinol. While experts advise against using retinol while pregnant, there’s not enough conclusive evidence at this time to determine whether bakuchiol is a safer option, so it’s best to consult your doctor first.

Verdict: Consult with your doctor

Benzoyl Peroxide

This powerful pimple fighter is too tough for a developing baby. Studies show it poses a risk to the fetus and should not be used during pregnancy.

Verdict: Not safe

CBD Oil

Some alternative acne fighting products, vegan makeup and even all-natural face masks contain this trendy ingredient. Since CBD oil doesn’t have any THC, the threat to mom and baby is low. But, because it’s safety in pregnancy and postpartum has yet to be studied, some moms will err on the side of caution and pass on it.

Verdict: Consult with your doctor

Dihydroxyacetone (DHA)

Although it’s found in many self-tanners and professional spray tans, DHAs aren’t recommended for use during pregnancy. The possible side-effects for a developing baby (via skin absorption or if you accidentally inhale it) are unknown, so this chemical may pose harm.

Verdict: Not safe

Essential Oils

Many moms-to-be swear by aromatherapy and massage to soothe symptoms from morning sickness to backaches. Talk to your doctor or midwife about which oils are best bets for topical products. In general, tangerine, chamomile and peppermint are considered safe, but others like clary sage, juniper and thyme should be avoided.

Verdict: Consult with your doctor

Formaldehyde

This chemical, found in some in-salon hair-straightening procedures and nail polishes, has been linked to respiratory issues and even cancer.

Verdict: Not safe

Grapeseed Oil

Often found in face serums and body oils, this all-natural ingredient can be used topically during pregnancy and breastfeeding. Note: grapeseed oil supplements should NOT be taken during pregnancy.

Verdict: Safe

Hyaluronic Acid

When it comes to skin plumping and hydrating, this natural substance should be a go-to ingredient, especially during pregnancy and breastfeeding. It works well and poses no threat to mom or baby.

Verdict: Safe

Hydroquinone

Brightening or skin-lightening creams containing hydroquinone are readily absorbed into the body (by as much as 45 percent, according to some studies), and may pose a danger to a developing baby.

Verdict: Not safe

Lactic Acid

This particular alpha-hydroxy acid (AHA) is found in exfoliating and products and poses no threat to mom, or a developing baby.

Verdict: Safe

Niacinamide

Found in some gentler alternatives to the typical acne and rosacea treatments, this form of vitamin B3 can help to reduce redness and inflammation.

Verdict: Safe

Oxybenzone

In 2019, the US FDA called for more research on oxybenzone and 11 other chemical sunscreen filters (including avobenzone and octisalate), which are suspected endocrine disruptors and possible carcinogens. Until we know for sure that they’re safe, you may want to stick to mineral-based sunblocks during pregnancy and while breastfeeding.

Verdict: Avoid, if possible

Parabens and Phthalates

Found in anything from foundation to shampoo, these chemicals have been used to preserve and stabilize product formulations. They are known endocrine disruptors that can affect the reproductive system.

Verdict: Not safe

Retinoids

Vitamin A derivatives (which can be listed under many names, including retinoic acid, tretinoin, palmitate and retinaldehyde) are commonly found in acne treatments and anti-aging serums. Products containing retinols have been linked to severe birth defects and should be avoided during pregnancy and breastfeeding.

Verdict: Not safe

Salicylic acid

Used sparingly as a targeted spot treatment, this acne fighter is deemed safe by most experts, including our dermatologist. But, salicylic acid (which is a type of BHA) should be avoided during pregnancy and breastfeeding in concentrations more than 2 percent (sometimes found in wart-removal products or salon facials) because there could be a risk for baby.

Verdict: Safe in over the counter doses of 2% or less

Titanium Dioxide

As the primary active ingredient in many mineral sunscreens, it works by sitting on the surface and deflecting damaging UV rays. Products containing titanium dioxide can be used on face and body during pregnancy and postpartum.

Verdict: Safe

Thioglycolic acid

Hair removal creams often contain this chemical (sometimes listed as mercaptoacetate or mercaptan). While there’s no solid research on the side effects, it’s considered not worth the risk.

Verdict: Not safe

Vitamin C

When it comes to treating dark spots and skin-tone issues during pregnancy and breastfeeding, vitamin C should be your go-to. It has a retinoid-like effect and boosts collagen production.

Verdict: Safe

Zinc Oxide

This is a main active ingredient in many mineral sunscreens, which can be used during pregnancy and beyond because they aren’t absorbed into the skin, but simply sit on the surface. You’ll also find zinc in mineral makeups, which are a good choice during pregnancy.

Verdict: Safe

Being pregnant

The myth of the horny pregnant lady

All this misleading talk is making the non-horny pregnant ladies feel like sex-hating weirdos, but the authors of The Rebel Mama’s Handbook for (Cool) Moms are setting the record straight.

Anyone who’s ever watched a movie or a TV show that involves a pregnant character is probably familiar with the concept of the Horny Pregnant Lady. She’s large and in charge, and she just can’t get enough of that D! 

Right. 

Outside of Hollywood’s hilariously inaccurate portrayal of pregnant women, may we ask where in the hell these libidinous women are hiding? 

We’re sure there are a few women out there who still wanna get down after getting knocked up. If you’re able to feel like a mega babe while another human being does somersaults in your gut, we tip our hats to you, you sly dog. In our experience, however, most pregnant women are usually thinking some combination of the following: Don’t touch me, I feel gross, and I will cut you.

The literature out there supporting the existence of the Horny Pregnant Lady is endless. If you type “pregnancy and libido” into Google, a shit-ton of articles will pop up claiming that pregnancy kicks a gal’s sex drive into attack mode. If you read through online forum posts about the same topic, however, the discussions consistently centre around lowered libidos [insert deep-in-thought emoji here]. 

This is a problem, folks.

All this misleading talk about the Horny Pregnant Lady is making the non-horny pregnant ladies feel like sex-hating weirdos. What’s worse, a lot of these mamas-to-be feel guilty, and they worry that their temporary lack of desire will send their partners running into the arms (or vagina) of a more “eager” (read: not bloated and nauseous) lover. 

That’s bullshit. 

First of all, if you trust your partner enough to make a baby with you, you should damn well trust them enough to stick around and hold your hand while you grow that baby in your uterus for the better part of a year. Second of all, women do not need yet another thing to make us feel guilty/worried/shitty/whatever. 

Instead, let’s band together in our collective unhorniness. Let’s make a deal to be frank and honest about our personal experiences when it comes to (not having) sex during pregnancy (and postpartum, which is a whole other story). 

If you’re reading this right now thinking, This is me! I’m the least horny pregnant lady ever!, you are most definitely not alone. The way pregnancy is portrayed on film and TV is garbage (How “funny” is it watching labour scenes when you’ve experienced real labour?), so don’t let any of those fake, airbrushed, sex-hungry bitches make you feel bad about yourself, your sex life, or your relationship. Go grab a doughnut, and spoon with your body pillow. Your libido will return in due time.

From The Rebel Mama’s Handbook for (Cool) Moms by Aleksandra Jassem and Nikita Stanley (@therebelmama), copyright © 2020 by the authors and reprinted by permission of HarperCollins.

Pregnancy health

How to deal with hemorrhoids during pregnancy

Being pregnant is challenging enough, so the last thing you want to deal with is hemorrhoids. But they're common during pregnancy. Here's how to handle them.

For most women in their third trimester, seeing blood in the toilet bowl would trigger panic. For Callie Brenshaw,* it was more like annoyance. The Brampton, Ont., woman had been suffering from pregnancy-related constipation and had read that it can sometimes lead to hemorrhoids, which can bleed. “When you read about hemorrhoids, you think, It won’t happen to me,” she says. Until it does. Up to 35 percent of pregnant women suffer from hemorrhoids, so why is nobody talking about it? We’re here to answer all the questions you’re too shy to ask, like how long to hemorrhoids last, and if you should see a doctor.

What are the signs of hemorrhoids?

Hemorrhoids develop when the veins in and around the anus become swollen due to the pressure caused by the weight of your pregnant uterus. The most common symptoms are anal itching and burning, and pain when you poo. Internal hemorrhoids will bleed when a hard bowel movement passes over the swollen veins. External hemorrhoids appear as swollen, bluish-coloured lumps on the outside of the anus and are painful but usually don’t bleed.

Hemorrhoids tend to show up either in your first trimester or your last. “In the first couple of months of pregnancy, women tend to become constipated due to hormonal changes. They strain, and we know straining is a risk factor for the development of hemorrhoids,” says Arthur Zaltz, chief of obstetrics and gynaecology, and head of the Women and Babies program at Sunnybrook Health Sciences Centre in Toronto. In the final trimester of pregnancy, he says, your heavy uterus puts pressure on nearby veins, causing tiny clumps of blood vessels in and around the rectum to bulge.

How can I prevent hemorrhoids from forming?

One way to prevent hemorrhoids is to minimize straining. That includes avoiding heavy lifting, like picking up your three-year-old. To alleviate the strain of constipation, Toronto-based registered dietitian Cassandra Reid recommends changing your diet. Along with hormonal fluctuations, she says, constipation in pregnancy can also be caused by a lack of fibre. “Eating during pregnancy can be hard,” says Reid. “Hormonally, you might be going for more of your wants versus what you really need, which is a balanced diet.” Along with foods that are rich in fibre, Reid also suggests drinking plenty of water and taking probiotics.

Should I go to the doctor if I think I have hemorrhoids?

If you suspect you have hemorrhoids, mention it at your next ob/gyn or midwife appointment. Don’t be embarrassed—they’ve seen this many times. It’s crucial to raise the issue if you’ve seen blood, says Zaltz, because “there can be other, more serious causes of bleeding.” Want to know sooner? Grab a mirror. If they’re the external kind, you’ll be able to see them around the opening of your anus. Internal hemorrhoids should be looked at by a doctor. Treat the symptoms Though hemorrhoids can’t be cured, the symptoms can be treated until the hemorrhoids go away on their own. Brenshaw’s case appeared seven months into her pregnancy, and she was told to manage her symptoms until after delivery. For most women, that’s the case. “They probably won’t completely disappear until after the baby is born,” warns Zaltz.

If you’re still struggling with discomfort once you’ve increased your fibre and water intake, Ottawa-based pharmacist Shelita Dattani suggests talking to your doctor about using an over-the-counter (OTC) hemorrhoid product containing pramoxine, which relieves pain. Soaking in a bath with witch hazel or Epsom salts will ease discomfort. An OTC stool softener may also help.

Discussing hemorrhoids isn’t fun—so even if the topic doesn’t come up in your prenatal class, know that a few of the women in the group are probably struggling too. “It’s not a subject people openly talk about,” says Brenshaw. “They probably prefer to talk about their kid’s poops, not their own.”

How long do hemorrhoids last?

Many women develop hemorrhoids during labour, as the straining caused by pushing the baby out forces the veins in the anus and perianal region to swell. Talk to your nurse, midwife or doctor about meds, but if the hemorrhoids don’t bother you, it’s OK to ignore them until they go away on their own.

*Name has been changed

Pregnancy

Midwife, family doctor or obstetrician: What’s the difference?

When it comes to choosing a midwife or other primary care provider for your pregnancy and delivery, it’s both easier and harder than you think.

“I want a natural birth. I need a midwife!” 

“I want every drug in the book. Give me an obstetrician!” 

These statements demonstrate two common misconceptions about the labour experience, but they don’t even come close to painting the whole picture. Choosing a primary care provider for nine-plus months of pregnancy, labour and delivery and postpartum adjustment is extremely personal, and the right answer will be different for every individual. Whether you pick a midwife, a family doctor or an obstetrician (or end up with some combination of the three) will depend on a wide variety of factors. Here’s what you need to consider. 

First, what is a midwife? What is an obstetrician? 

You’ve probably had a family doctor throughout your life, but you may not be as familiar with obstetricians and midwives. Obstetricians, or obstetrician-gynaecologists (OB/GYNs), are medical doctors who specialize in pregnancy and childbirth, especially in the management of high-risk pregnancies and pregnancy complications. Midwives undergo a four-year bachelor of health sciences degree in midwifery and are experts in healthy pregnancies. Family physicians, obstetricians and midwives are skilled medical professionals who have hospital privileges, offer lab tests and ultrasounds, and maintain a standard schedule for prenatal visits.

Midwife or OB: What is the safest option?

In Canada, whether you choose a registered midwife, a family physician or an obstetrician, you can feel comfortable knowing that their practice is well regulated, with national guidelines and protocols governed by each province and territory. “We’ve come a long way to achieve a safe system of care in Canada,” says Jennifer Blake, chief executive officer of The Society of Obstetricians and Gynaecologists of Canada (SOGC). “Wherever women enter the system, it’s designed to look after their safety and well-being.” 

Now, you may be wondering how you’re supposed to make a choice if midwives, family doctors and obstetricians are educated, well regulated and safe. It’s time for you to answer these questions.

Do you have a typical, healthy pregnancy?

If the answer is yes, then you can take your pick of practitioners. However, if you have a high-risk pregnancy (you are having twins or triplets, have had previous abdominal surgeries or have diabetes, asthma or other health issues), you may be best served by an obstetrician with experience in unique, potentially complex prenatal care and delivery. 

If your pregnancy is healthy, you may feel most comfortable with your family physician, provided that they are among the 40 percent of family physicians in Canada who offer prenatal care (though only about 10 percent actually deliver babies). In some areas, like Vancouver, there are even family practices that focus exclusively on prenatal, intrapartum and postpartum care. Alternatively, you may choose a midwife (all of whom are experts in healthy pregnancies) and able to devote plenty of time to your care. 

Statistics vary greatly by source and province. However, according to the Provincial Health Services Authority, obstetricians attended 50.7 percent of births in British Columbia from 2015 to 2016, family physicians attended 32.1 percent, and midwives attended 15 percent. In Ontario, based on numbers from BORN, Ontario’s pregnancy, birth and childhood registry, the bulk of births from 2016 to 2017 were attended by obstetricians (76.3 percent), followed by midwives (10.7 percent), although the Canadian Association of Midwives puts the percentage a little higher (16 percent) from 2016 to 2018. 

Where do you want to deliver?

If you have a low-risk pregnancy and dream of delivering at home or in a birthing centre, choose a midwife because, in most cases, family doctors and obstetricians only practice in hospital settings. However, if you know you want to deliver in a hospital, you can choose any type of provider, including a midwife. In Ontario, between April 2017 and March 2018, 83 percent of births attended by midwives were in hospital, 14 percent took place at home and three percent were at birthing centres. 

How much one-on-one care is important to you? 

Midwives are typically able to offer the most one-on-one care, including before, during and after delivery. Their prenatal appointments are about 30 to 45 minutes long, they’re able to provide undivided attention during labour and delivery, and they often provide home visits in the early days after childbirth. Family doctors and obstetricians are often pulled in multiple directions, which means that their prenatal and postpartum appointments tend to be shorter and they rely heavily on the support of nursing staff during the labour process.

Is continuity of care important to you?

It’s impossible to guarantee that the same provider that follows you throughout your pregnancy will also deliver your child, but certain practitioners work harder than others to promote continuity of care. Some obstetricians and family physicians remain on-call for their patients or provide small call groups (meaning that you’ll probably be attended by one of a small number of doctors). Midwives also make continuity of care a central tenet of their practice. “Usually, you’ll meet a small team of midwives and they are very likely to attend your birth,” says Elizabeth Brandeis, president of the Association of Ontario Midwives. If it’s important for you to have a familiar face in the delivery room, ask about your care provider’s policy early on in your pregnancy.

What are your feelings on pain management and medical interventions?

“We live in an era where medical interventions have become quite routine in pregnancy and childbirth,” says Brandeis. “The midwifery model believes that, though those medical interventions are sometimes necessary, they certainly don’t need to be routine.” If you choose a midwife, you will first be offered natural methods of pain management, such as water immersion, position changes and counter-pressure massage. (You can also get drug-free pain management, such as water immersion, with obstetricians.) “But midwives are not against epidurals and see them as a useful tool when necessary,” says Brandeis. However, note that epidurals are only available in a hospital setting.

Of course, you can also have a completely unmedicated, vaginal delivery in a hospital with a physician if there are no complications. “The rate of caesarean sections is the same whether you have an obstetrician, a family doctor or a midwife,” says Blake. “It’s not a question of who is providing the care but whether or not a caesarean is the safer mode of delivery.” In Canada, about 28 percent of hospital deliveries were performed by C-section from 2016 to 2017. The number of midwifery patients who delivered by C-section in Ontario in the same year was much lower (17 percent), but the majority of those patients had low-risk pregnancies to begin with. In British Columbia, the number of midwifery patients who had C-sections was at 20.6 percent from 2015 to 2016.

What happens if you choose a midwife or family doctor but have complications?

Regardless of the type of provider you choose, a good practitioner will understand their scope of practice and stay within it, says B. Anthony Armson, president of the SOGC, which means that they will ask for help from other experts in their network if they need it. If you are delivering at home or in a birthing centre and have complications, you may need to transfer to a hospital, where your midwife will continue to work with you or transfer your care to an obstetrician, depending on the circumstance and region. If you’re already in a hospital, your midwife or family doctor can consult directly with an obstetrician, who may consult a maternal-fetal medicine specialist. “The best model for safe care is one that looks at the whole team,” says Blake. “You never know which members of the team you’re going to require.” 
Before making your final decision, there are a few other things to consider.

Cost

Access to family physicians and obstetricians is covered by provincial and territorial healthcare. “Fortunately, we’re almost at the point where we can say that there’s also regulated, funded midwifery in every jurisdiction across Canada,” says Brandeis. The only regions that don’t have provincially or territorially funded midwifery care are Prince Edward Island and the Yukon. “However, Prince Edward Island announced its intention to roll out funded midwifery regulation in 2020, and the Yukon is at the final stages of working out its policy framework as well,” says Brandeis.

Availability

If you live in a rural area, you may not be able to access the services of an obstetrician without travelling and may be limited to a family physician. “Rural family physicians are far more likely to provide obstetrical care than their urban counterparts,” according to The Vanier Institute of the Family. If you’re hoping for an obstetrician, you will probably have to venture to an urban centre. In northern communities, many women with low-risk pregnancies deliver at birthing centres with midwives. However, in many other areas—including cities—the demand for midwives still exceeds the supply. If you wish to go the midwife route, start contacting midwives or midwifery practices as early in your pregnancy as possible. 

Ultimately, a big part of your decision will come down to finding a provider whose personality and philosophy mesh with your own—and, in the end, that’s usually more important than the type of provider you choose. Keep an open mind, get recommendations from family and friends and meet a few experts in person if possible.

Baby names

25 creative baby names inspired by art, music and fashion

These creative baby names inspired by the world of art and entertainment keep up with current naming trends but aren’t widely used just yet.

Art makes the world go ’round. The music, movies, television shows and works of art we love are often important reflections of our personality and values. So why shouldn’t art that moves us serve as inspiration for creative baby names?

Of course, creative baby names inspired by famous artists of all genres are nothing new. Billie became a popular name for baby girls in the heyday of the great singer Billie Holiday, as did Shirley in the earliest days of actor Shirley Temple’s fame. 

But there are many more under-appreciated artistic name choices out there. Read about these 25 creative names for boys and girls.

Creative baby names inspired by art

Claude

Inspired by French painter Claude Monet, this French name was popular for decades in the late 19th and early 20th centuries and fits the trend for old-fashioned names.

Diego

Mexican artist Diego Rivera is the husband of Frida Kahlo, and his first name is the Spanish version of James. It’s becoming increasingly popular in the U.S. but is less common than Spanish boys’ names like José and Mateo.Frida

Still beloved decades after her death, Frida Kahlo is an inspiration for many people for her often-autobiographical art. Her name, which is of German origin, is relatively popular in some European countries but not widely used in Canada.

Mona

Inspired by Leonardo da Vinci’s Mona Lisa, this underused girls’ moniker also fits well with two current naming trends: It’s short, and it has an “A” ending.

Kehinde

An African name with Nigerian or Yoruba origins, the name Kehinde came into public consciousness when American artist Kehinde Wiley was chosen to paint the official presidential portrait of Barack Obama.

Artistic and artsy baby names

Poem

A creative baby name with obvious associations but not one that’s widely used, this is a pretty and unexpected choice for a girl that recalls popular names like Naomi and Poppy.

Indigo

Inspired by the popularity of colour names like Ruby and Scarlett, Indigo is growing in popularity in the US, where the unisex name entered the top 1,000 for the first time in 2017.

Ophelia

Your age and interests might give away your associations with this Greek name. Does it make you think of the song by Simon & Garfunkel or The Lumineers? Or maybe you think of the Shakespeare character? Either way, this is a pretty name with multiple artistic associations that fits the growing trend for girls’ names that begin with “O.”

Gray or Grey

Whether it has a Canadian spelling or not, this is a stylish choice for parents who like the name Grayson but want something less commonly used (and unisex).

Iris

This dramatic flower inspired one of Vincent van Gogh’s most famous works. It’s also a great fit for parents who like shorter girls’ names—an alternative to Isla perhaps—and flower names like Daisy.

Creative baby names inspired by musicians

Ivy

Naming your child Beyoncé might be a bit too on the nose, but you could go with the middle name of her daughter, Blue Ivy. This is a great name to consider if you like botanical names, like Rose and Daisy, but also want a shorter baby name.

Arlo

This English name, which dates back to the 16th century, is associated with American folk singer Arlo Guthrie, the son of Woody Guthrie and a popular protest singer in his own right. 

Edith

A choice that works in English or French (as Édith), this name honours French singer Édith Piaf. Once a very popular choice for baby girls, Edith—or its short form, Edie—now seems fresh for parents who are looking for old-fashioned names. 

Billie

Once popular for its association with singer Billie Holiday, this name is back in the zeitgeist thanks to teen pop star Billie Eilish. It also fits with the general trend toward unisex girls’ names.

Stevie

Associated with fabulous musicians like Stevie Nicks, Stevie Ray Vaughan and Stevie Wonder, this is a unisex choice that works for fans of names like Georgia and Charlie.

Musical baby names

Aria

The fifth most popular name for baby girls in Canada last year, this name means “a self-contained musical piece for a single voice.” It fits the trend for shorter names that begin or end with “A” and is a great choice for parents who like names like Ava, Ada and Mia. 

Dorian

A well-known name that fits with naming trends for vintage choices, this unisex name refers to a mode used in Gregorian chants.

Lyric

A beautiful choice for a boy or girl, this name has an obvious modern musical association but also refers to the ancient stringed instrument known as the lyre. It has been used for boy babies by Soleil Moon Frye and Jason London and has spiked in popularity in the US over the past two decades.

Layla

Associated with the famous Eric Clapton song, Layla is becoming an increasingly popular girls’ name. It was among Canada’s top 20 names last year and fits naming trends for “A” endings and “Y” in female names. 

Demi

Associated first with Demi Moore and then Demi Lovato, this is actually a musical term that means “half” and an unexpected choice for a shorter girls’ name. It’s also the short form of the Greek name Demetria. 

Creative baby names inspired by fashion

Issey

Japanese designer Issey Miyake’s name means “firstborn,” so it’s a lovely unisex choice for a first child or to honour Japanese heritage.

Alaia

The surname of Tunisian designer Azzedine Alaïa, this is a great fit for current trends for girls’ names that begin or end with “A.” Alaia also brings to mind several creative baby names in different languages, like Aaliyah in Arabic and Aliya in Hebrew.

Chloe

This increasingly popular name, which was number 10 for girls in Canada last year, is an alternative choice for fans of Zoe and Zoey and the name of a popular Parisian fashion house.

Christobal

Designer Balenciaga’s first name may not be as well known as Calvin and Giorgio, but it’s still a stylish choice. This name is relatively popular in Latino communities and is a great way to honour that heritage.

Laurent

Associated with the late designer Yves Saint Laurent, this surname is a French first name in its own right that means “crowned with laurel.” 

Giving birth

Do you need a vagina mirror during labour?

Commonly offered by midwives and other care providers, a birth mirror can be an incredible motivational tool to check your progress during labour.

By the time Sara Litster reached the pushing stage, she had already been in labour for three days and her energy stores were depleted. Her midwife asked if she wanted to try watching herself push with a birth mirror to speed up the process. “I was pushing for more than an hour, but it felt like I was pushing for 10 minutes,” says the Toronto mom. “You know how people talk about pushing like ‘I pushed and pushed and it felt like it was forever’ because they can’t see if they are making progress? I could see that I was making progress. With every push, it felt like I was achieving something.” 

Six months later, Litster still raves about the experience. “It was absolutely, completely wild,” she says. “Usually, your spouse and midwife or OB sees your baby first, but I was right there in it. I saw him being born.” 

Are you wondering if a mirror should be part of your birth plan? Here’s what you need to know.

What is a birth mirror?

“A labour mirror isn’t anything fancy,” says Jenn Bindon, a registered midwife at Prairie Midwives in Red Deer, Alta. In a home setting, it’s any mirror that a family member, doula or other support person can hold and tilt at the correct angle to offer visual feedback to the woman in labour. In a hospital, your midwife or nurse may have access to a free-standing, adjustable mirror mounted on wheels that can be pushed into position. 

Lyanne Quirt, a registered midwife at Arbutus Midwives in Victoria, BC, says there are eight birthing rooms at the hospital where she works and five mirrors that are specifically designed for this purpose. “They’re a bit large and unwieldy, but they’re very nice to have,” she says.

Why would I use a birth mirror while pushing?

With a birth mirror, a woman in labour can see the bulging of the perineum and, eventually, the top of her baby’s head. While some expectant moms may first hear about labour mirrors during prenatal classes and check-ups, others might be offered one only during the pushing phase—and sometimes not even then. They’re almost exclusively used during typical low-risk labour, and it may be on you to ask if the idea interests you. Here are three circumstances where a healthcare provider might recommend using a mirror.

  1. If a woman is having a water birth and wants to see what’s going on underwater
    “That’s more for the convenience of the healthcare provider than the woman in labour,” says Quirt.
  2. If a woman struggles with pushing and needs inspiration
    “People are very tired at the pushing stage, so seeing their progress can give them more energy and drive to keep going,” says Quirt.
  3. If a woman wants a precious visual memory
    “For some people, it’s a beautiful and powerful thing to see a baby emerge from the birth canal,” she says. If you want the experience, you may have to ask your practitioner ahead of time to ensure that there’s an appropriate mirror on hand, especially if you’re delivering at home (some midwives travel with their own mirrors, while others don’t).

Can I use a birth mirror if I’ve had an epidural?

Yes! In fact, it’s a very useful tool for women who lack sensation in their lower region and can’t tell if they’re making progress. “Often with epidurals, women don’t have the same reflex to push the baby down,” says Bindon. “When they push with a mirror, they can see progress when they push a certain way. It gives them a lot more confidence and reassurance that they’re pushing in the right way and getting to the end of their delivery.”

Won’t it be super gross?

For many women, the thought of watching their baby emerge from the birth canal is a little bit icky. “That’s what stopped me,” says Litster of the first time her midwife told her to use a mirror during a prenatal check-up. “I was like ‘You usually poop during labour, and I don’t want to see that!’” But when she finally accepted the mirror as a tool that could help her, she realized that her reservations were unfounded. “There was definitely what my midwife refers to as ‘residual poop.’” But the backup midwife discreetly cleaned it up before Litster ever really saw it. “I was worried before pushing, but once I started, we laughed about it,” she says.

Quirt notes that she uses a cloth or surgical sponge to support the perineum during pushing, which hides the anus from view. She finds that “some people apologize a lot when they poop in labour, but, honestly, it’s the least of our concerns.”

What will the baby’s head look like?

One thing you might want to prepare for is that your baby’s head will be compressed and their skin may look wrinkled. “People worry that their baby won’t have a skull and they’re seeing the brains, especially if a baby doesn’t have a lot of hair,” says Quirt. “I try to warn them that the baby’s head will be squished, but it’s normal.”

Why doesn’t everyone use a birth mirror in labour?

Aside from the ick factor, some women worry that watching the birth of their child or letting their partner watch will change how they feel about sex. “Some people think that seeing babies come out of their vaginas will reduce the sexual aspect of their genitals,” says Quirt. Whatever the reason, Quirt says that only one in 10 clients will take her up on the offer to use a birth mirror, even though most people love it and find it incredibly helpful. But many women squeeze their eyes shut while pushing, and using a mirror can be one too many things to think about in the moment. 

It may sound a little weird at first, but using a birth mirror during the pushing phase of labour can be an effective tool, so try not to rule it out. “Be open to suggestions,” says Bindon. “You never really know what labour’s going to be like until you’re in the middle of it, so try to keep an open mind.”