Being pregnant is very special. You will probably have many questions about your pregnancy and the various check-ups you will be invited to attend. What should you expect during a visit to the midwife, general practitioner (GP) or obstetrician? What tests and examinations are available? What about your diet, sport, work and taking medicine? This webpage offers information about these and many other topics. During pregnancy, you may experience pregnancy-related symptoms. Or in case of symptoms that require you to contact your midwife or obstetrician directly. These too are described on this webpage

About this document
This webpage contains general information about what pregnant women can normally expect in terms of care and information. In all cases, however, written information just supplements the details provided during the interview with the midwife, GP or obstetrician. Are you under the care of your GP? In that case, where it says ‘midwife’, please also read ‘GP’. Although the webpage focuses on you, the expectant mother, much of the information it contains is also relevant to your partner. There is a lot of additional information available. A list of websites and other sources is included at the end of this brochure. If you have any further questions, your midwife or obstetrician is there to help.

It is also possible to download this information as a document and print it yourself. You will find the download link on this page

1. The first visit to the midwife of obstetrician

Pregnant? Make an appointment soon
As soon as you know that you are pregnant, you should make an appointment with the midwife or obstetrician as soon as possible. He or she will inform your GP.

You must be careful when taking medicines during pregnancy. You should therefore inform your pharmacist that you are pregnant.

What will the midwife or obstetrician discuss with you?

Your first visit to the midwife or obstetrician will usually involve a short physical examination. She (or he) will measure your blood pressure and may wish to check the size of your uterus. You will have an opportunity to discuss the following aspects:

  • Due date. During your first or second visit, you will be offered an ultrasound examination (also known as a sonogram or ‘echo’). This will help the midwife or obstetrician to determine how long you have been pregnant. The ultrasound also shows whether the baby’s heart is beating normally, and whether there is more than one baby: you may be expecting twins! To calculate your ‘due date’, the midwife will ask whether your last period was normal and on time. You may find it useful to write down the date of your last period and the date on which you stopped taking the contraceptive pill (if applicable) and take these notes with you to the appointment.
  • Previous pregnancies. The midwife or obstetrician will ask whether this is your first child. If not, you will be asked about the course of previous pregnancies: were there any problems?
  • Your health and the health of your partner. To form a general impression of your health, the midwife or obstetrician will ask about your medical history: any diseases you have had, operations and treatments, and whether you have ever received a blood transfusion. Have you been taking medication in the last few months?Do you have any current health complaints? She will also ask whether you smoke, drink alcohol or use drugs, or have done so in the past.
  • Health of your family members. You will be asked about the health of both your own family and your partner’s family. Is there any history of diabetes, cystic fibrosis, spina bifida, Down’s syndrome, muscular disorders or heart defects, for example?
  • Your personal situation. What is your living situation? Do you live alone or with a partner? What does your work involve? What hobbies do you have? If there are special circumstances in your life, it would be wise to make this known. Perhaps you will have to deal with changes, for example in the areas of relationships, finance, housing or employment, during your pregnancy.
  • Your work circumstances. It is good to consider any occupational risks to you or your unborn child. You can also ask your employer about this.
  • Tests and examinations. Your midwife or obstetrician will explain the blood tests (see page 20) and will discuss the optional screening for Down syndrome, Edwards’ syndrome and Patau’s syndrome and the optional 20-week ultrasound scan.

Ask questions
You are encouraged to provide as much information as you can and to ask any questions you may have. You may find it useful to write down your questions before the appointment so that you don’t forget. You are welcome to bring your partner or a friend/family member to any appointment.

2. Check-ups during pregnancy

From once every four weeks to once a week
Your midwife or obstetrician will monitor the course of your pregnancy at regular intervals. Usually, you will be invited for a check-up every four weeks during the first half of the pregnancy. The frequency then increases to weekly appointments as the due date approaches. However, this is only a general indication: more or fewer appointments may be scheduled depending on your personal situation.

What do these check-ups involve? First, your midwife or obstetrician will ask how you are feeling and how you are experiencing the pregnancy. Once again, you are encouraged to ask any questions you may have. Towards the end of your pregnancy, you will discuss the birth itself and any wishes and expectations you may have.

Physical examination
Every appointment includes a physical examination:

  • Your abdomen and uterus will be checked to ascertain that your baby is growing normally.
  • From the third month onwards, the midwife will also check the baby’s heartbeat.
  • In the final months of pregnancy, the midwife or obstetrician will assess your child’s position. During the last few weeks, checks are made to see whether the baby has settled properly into the pelvis.
  • Your blood pressure will be measured. Low blood pressure during pregnancy is not a cause for concern but can cause some minor problems, such as feeling faint or dizzy when standing up. High blood pressure does not cause any symptoms but will require extra care for you and your baby.

Your midwife or obstetrician may wish to conduct an additional ultrasound as a precaution, especially if:

  • there is any doubt about the size and growth of your baby.
  • you have experienced unusual blood loss.
  • the position of the baby cannot be determined by external examination.

3. Health during pregnancy

When you are pregnant, looking after your health becomes more important than ever. After all, your health affects that of your baby. You can expect many physical changes. Most are a normal part of being pregnant but may nevertheless cause some anxiety.

This chapter describes some of the most common health problems experienced by expectant mothers and offers advice about how to ensure a healthy pregnancy. If you have any questions, your midwife or obstetrician is there to help. The information on pages 38 and 39 tells you which symptoms mean you should contact your midwife or obstetrician immediately.

Haemorrhoids
Haemorrhoids (piles) are enlarged and swollen blood vessels in or around the lower rectum and anus which can cause itching and pain. Unfortunately, they are very common during pregnancy. Pressure can worsen the symptoms and it is therefore advisable to ensure regular, soft bowel movements.

Alcohol
Do not drink alcohol if you want to become pregnant or are pregnant, or if you are breastfeeding. Even small amounts of alcohol can be harmful to the pregnancy and to your child's growth and development. Possible risks are damage to your child's brain or other organs, a prematurely born child or a child with a low birth weight. The risk of damage increases in proportion to how often and how much you drink, and there is no safe amount.

Contact your midwife, obstetrician or GP if you want to talk about your alcohol consumption and need help. For more information, please visit www.alcoholinfo.nl.

Contagious diseases
If you contract an infectious disease during your pregnancy, this may have consequences for the health of your unborn child. If you have been in contact with anyone with a childhood illness such as chickenpox, rubella or fifth disease, contact your midwife or obstetrician. Or have you been in contact with someone who has another infectious disease, such as whooping cough?

Cytomegalovirus (CMV) can also be harmful to your unborn child. The virus is commonly found in the saliva and urine of young children. Good hygiene practices are important to reduce the risk of catching contagious diseases including CMV, such as washing hands with soap after wiping children’s noses or changing nappies. It is also advisable to avoid sharing cutlery with your child, or to put your child’s dummy in your mouth, for this reason.

Blood loss
Inform your midwife or obstetrician if you experience any loss of blood (vaginal bleeding) during pregnancy. Blood loss is relatively common during pregnancy, particularly during the first three months. There are several possible causes, such as the fertilized egg implanting itself into the womb ora small abrasion to the cervix. Blood loss can sometimes be due to a miscarriage.

Heartburn
Some expectant mothers experience frequent or severe acid indigestion (‘heartburn’). It is often made worse by drinking coffee, orange juice or fizzy drinks, or by eating fatty foods. Try cutting these out of your diet. If this does not relieve the problem, ask your midwife or obstetrician for advice.

Drugs
The use of recreational drugs is strongly discouraged if you want to become pregnant, are already pregnant or if you are breastfeeding. The use of soft drugs (marijuana, weed, hash) can seriously harm your baby, especially in combination with alcohol or tobacco. Hard drugs, such as cocaine, ecstasy (XTC) and heroin, are dangerous to unborn babies. The use of mushrooms is advised against, because this can cause harm to the unborn child. Depending on the drug concerned, your baby could be born with withdrawal symptoms, a congenital defect or a developmental disorder.

If you use hard drugs, stopping during pregnancy can cause withdrawal symptoms in the unborn child. Always seek professional help and advice.
For more information about drugs see www.drugsinfo.nl or www.mainline.nl.

Emotions during pregnancy
For most women, pregnancy is a time of great changes. It can bring about many  different emotions for you and your partner. Those emotions can be either positive or negative. If the negative emotions dominate, you should discuss them with a professional such as your midwife or obstetrician. You can find information about stress and mental health problems during pregnancy and afterwards at www.lkpz.nl.

Folic acid
Taking folic acid reduces the risk of your child being born with a neural tube defect, cleft lip or cleft palate. You are probably already taking a folic acid supplement. If not, and if you are still in the early stages of pregnancy, it is not too

late to start. You should take folic acid until the tenth week of pregnancy (i.e. ten weeks after the first day of your last period). The recommended dose is 0.4 or 0.5 milligrams per day. Folic acid tablets can be obtained ‘over the counter’ from any pharmacist or high street chemist: no prescription is required. For further information (in Dutch), see www.strakszwangerworden.nl.

Braxton Hicks contractions
You may experience sudden spasms of the uterine muscles. These are termed Braxton Hicks contractions (popularly known as ‘practice contractions’).
Occasional contractions are not a cause for concern. However, if you experience them regularly or with increasing frequency, it is advisable to inform your midwife or obstetrician.

Iodine tablets
It is important to have iodine tablets at home when you are pregnant. You need to take these in case of a nuclear accident. This will protect your unborn child from thyroid cancer. Only take them when the government issues a statement telling you to do so; not before. You can buy a box of iodine tablets for €2.95 from the pharmacy or chemist. For more information (in Dutch), visit www.waaromkrijgikjodiumtabletten.nl.

Gardening and the litter box (toxoplasma)
Toxoplasmosis is a disease that can be harmful to your unborn child. If you have had toxoplasmosis in the past, then you will have immunity against future infection.The disease is causes by a parasite which is found in the faeces of cats (particularly kittens). The parasite can therefore also be found in sand pits.
Wear globes when cleaning the cat litter tray and while gardening, and wash your hands afterwards. Also wash your hands and those of your children, also after they have been playing in the sand pit.

Avoiding eating raw meat and unwashed fruit and vegetables also helps to prevent you catching toxoplasmosis (see page 18 and 19). For more information (in Dutch) on toxoplasmosis, see www.rivm.nl/Onderwerpen/T/Toxoplasmose.

Medicines
Always tell your midwife or obstetrician about all the medicines you are taking, whether prescription drugs or ‘over the counter’ remedies (self medication). You must exercise extreme caution in taking any pharmaceutical product. Some can influence the baby’s development even in the earliest stages of pregnancy. You should therefore tell a doctor or specialist who is treating you, your dentist and pharmacist that you are pregnant.
If you have pain, you can take paracetamol without worry. See the patient information leaflet for the dosage. If you need to take paracetamol for several days you should discuss the problem with your midwife or obstetrician. Use other painkillers only after talking to your midwife or obstetrician. A sedative for treatment by a dentist is not a problem, but do tell your dentist that you are pregnant. For more information about the use of medication during pregnancy, visit www.lareb.nl.

Nausea
You may experience nausea and vomiting during the first three to four months of pregnancy, especially early in the day (‘morning sickness’). It is often worse if you haven’t eaten. You should therefore start the day with a light breakfast. After that, try to divide your food intake into several small meals. You will soon discover which foods you can tolerate best.

Tiredness
You may feel very tired, especially during the first three months of pregnancy. Many women feel that they need more sleep. This is usually due to hormonal changes and is only very rarely associated with anaemia.

Pigment spots
Exposure to ultraviolet light (sunlight or a sunbed) may cause brown patches on your face, known as melasma or ‘the mask of pregnancy’. You should stay in the shade where possible. Wear a hat and apply a sunscreen lotion when outdoors. If you do develop pigment spots, they will usually disappear after the pregnancy.

Frequent urination
When you are pregnant, you will probably feel the urge to urinate more often than usual. As your womb expands, it exerts greater pressure on the bladder. If you need to urinate very often and you experience a burning sensation when you do pass water, you may have a bladder infection. Take a urine sample to your GP for testing. If you do have an infection, he or she will prescribe medication.

Smoking
Smoking during pregnancy is harmful for both mother and baby, so quit smoking! That goes for your partner too! Second-hand smoke is also harmful. Smoking increases the risk of a miscarriage,ectopic pregnancy and placental abruption. The baby is at risk of birth defects, low birth weight or premature birth. Premature babies or babies with a very low birth weight have a greater risk of mild or serious problems during and after birth. A very low birth weight also increases the risk of diseases at a later age, such as cardiovascular disease, diabetes and serious obesity. Ask you midwife, GP or medical specialist for help to quit smoking.

After birth, smoking in the child’s vicinity increases the risk of SIDS. Growing up in an environment where people smoke also increases the risk of diseases such as asthma or lung disease. See also www.rokeninfo.nl or www.rijksoverheid.nl (search for ‘zwanger roken’). This information is available in Dutch.

Backache and pelvic pain
During pregnancy you may experience pain in the (lower) back or pelvic region. Good posture may help to alleviate the symptoms. If not, seek advice from your midwife or obstetrician. Gentle exercise is also good for you. Some general advice: Bend your knees when stooping or lifting. Support your lower back with a cushion when sitting.

If you have difficulty getting out of bed, first turn onto your side and then lift your upper body sideways from the waist.

Chemicals and other hazardous substances
Daily life brings you into regular contact with natural as well as man-made chemicals. These substances can be harmful to your health. Whether or not your health suffers depends on the amount of the hazardous substance you ingest. Some products have substances in them that can be harmful if you absorb a lot of them. These include cleaning products (for example bleach with hydrochloride), paint, glues and putties made with solvents such as turpentine or acetone, and pesticides. Your unborn child is extra sensitive when it comes to hazardous substances, so try to limit your exposure to these sorts of products as much as possible.

You can also inhale harmful substances in your own home. That’s why it’s important to ventilate your home regularly. Information on endocrine disruptors can be found at: www.rivmNational Institute for Public Health and the Environment .nl/hormoonverstorende-stoffen.

Sex
Intimacy and sexuality can be experienced differently during pregnancy. This varies from one person to another and even from pregnancy to pregnancy. In a pregnancy, there are no firm rules or guidelines. Sexual intercourse cannot cause a miscarriage and will not harm the baby.

If you have any questions or problems with regard to sex during pregnancy, you should discuss them with your midwife or obstetrician. He or she can then take them into account during any physical examinations and during childbirth itself. You should also mention any previous unpleasant sexual experiences, or if you should have any problems with having an internal examination.

Varicose veins
Some women develop varicose veins during pregnancy, usually on the lower legs although they can also affect the labia. Try to remain active and avoid lengthy periods of sitting or standing still. When you do wish to sit or lie down, elevate your legs using a footstool or cushion. Well-fitting elastic support stockings can also help to reduce the risk of varicose veins. If they do occur, they will generally shrink once the baby is born.

Sports
You can continue to play sports during pregnancy unless you start to feel more tired than usual or you experience any specific problems. Try not to exert yourself more than you did before you were pregnant. Ensure that you drink enough fluids.

Swimming, cycling, walking and fitness exercises can all be continued until the very last days of pregancy. However, you should avoid sports in which there is a risk of physical contact, especially with the abdominal region (your ‘bump’), or in which you may fall: hockey, volleyball, football and skiing, for example. Scuba diving is discouraged during pregnancy.

Radiation
There is no evidence to suggest that (computer) monitors, television screens or microwave ovens have any harmful effects in normal use. If you require medical testing, you must inform them that you are pregnant. In many cases it will be possible to postpone the examination until after the baby is born.

Vaccination during pregnancy
Whooping cough is a very contagious disease. It is especially dangerous for newborn babies. They can develop pneumonia, brain damage or even die. Babies are vaccinated against whooping cough at the child health clinic. This happens when they are approximately six weeks old. This means that babies are not protected against this disease during the first six weeks of their life. That is why pregnant women are advised to have themselves vaccinated against whooping cough during pregnancy, so the baby is protected from birth. The antibodies produced by the mother go through the umbilical cord to the baby. This means that your child can start the National Immunisation Programme at a later time and will require one less vaccination. 

We expect that from December 2019, pregnant women will be offered this vaccination for free. If you want the vaccination earlier, you can get it from your GP or the Municipal Health Service. Your midwife or obstetrician will explain what this involves. Or go to www.rivm.nl/kinkhoestprik-zwanger for more information.

Vaginal discharge
Vaginal discharge often increases during pregnancy. This is normal but check with your midwife or obstetrician if the discharge has an abnormal smell or colour, or if you experience itching, pain or a burning sensation. These can all be signs of an infection. If necessary, you will be prescribed medication.

Holidays and long journeys
Inform your midwife or obstetrician if you are planning to travel abroad. If you intend to visit a country far away, contact your GP or Municipal Public Health Service (GGD) for travel advice and any necessary vaccinations, 6-8 weeks before your departure. You must inform them that your are pregnant. There are no medical grounds to preclude expectant mothers from flying. However most airlines will not carry passengers who are more than 32 weeks into pregnancy, simply because they would prefer you not to give birth while in the air. Go to www.lcr.nl for more information about this topic.

Constipation
Your digestive system works more slowly during pregnancy. You may therefore find that you have to visit the lavatory less often and that your stools are harder. A high- fibre diet which includes raw vegetables, fruit and wholemeal products can help. You can also try adding bran to your regular meals. You should drink about two litres of fluid every day and maintain a reasonable level of physical activity.

Vitamin D
Your body is able to make its own vitamin D, but needs sunlight to do so. It is there- fore advised that you spend time outside every day to be exposed to sufficient sunlight. In 2012, the Health Council of the Netherlands concluded that pregnant women do not have an increased need for vitamin D, as such. Nevertheless, it does advise all pregnant women to take 10 micrograms of vitamin D per day, ‘just to be sure’.Whether or not you choose to do so, is up to you. The main reasons for taking extra vitamin D are if you don’t get out in the sun much (less than half an hour per day), if you are often veiled, or if your skin is not exposed to the sun, for instance if you wear makeup with a sun protection factor. If a skin has a darker tone, it needs more sun exposure to make enough vitamin D. Pregnant women with a dark skin tone are advised to take vitamin D supplements. Do not take more than 10 micrograms per day, unless your doctor tells you otherwise.

Some foods also contain vitamin D. These include fatty fish, such as salmon or mackerel, as well as soft margarine, meat and eggs. Remember that the amount of vitamin D you get from food is not enough to meet your daily needs.

Vitamin Pills
Provided you have a healthy and varied diet, vitamin pills are unnecessary.

If you nevertheless wish to take vitamin pills, choose multi-vitamin pills which are formulated especially for expectant mothers. These supplements contain an adapted amount of vitamin A. Too much vitamin A can damage your child’s health. Check whether the supplement contains vitamin D. If it does, you will not need to take any extra vitamin D (see the previous section).

Fluid retention
Your body retains more fluid when you are pregnant and this may cause swollen feet and ankles. The problem is often worse in warm weather or if you remain inactive for lengthy periods. Take adequate exercise and elevate your legs while sitting or lying.

Diet and nutrition
Eating a healthy, balanced diet.
It is important to eat a healthy, varied diet during pregnancy. It is not necessary to “eat for two”. If you have a varied diet, according to the ‘Wheel of Five’, you will be getting your required nutritional intake.

A few tips:

  • Eat a variety of fruit and vegetables.
  • Eat a variety of meat, fish and meat substitutes.
  • Ensure you are getting enough iron. Iron is found in red meat, fish, poultry, eggs and many meat substitutes. Aim to slightly increase your intake of these during pregnancy to reduce the risk of iron-deficiency anaemia.
  • Eat fish once a week, preferably oily fish. The fatty acids found in fish are important for the development of the nervous system and vision in the foetus. However, some fish are better to avoid. For more information (in Dutch), visit www.voedingscentrum.nl/zwanger.

Are you vegetarian? You can manage without meat or fish without any problems, providing you ensure you eat meat substitutes and other foods to ensure the right nutritional balance. Meat substitutes are important for vegetarians to ensure you get enough iron, vitamin B1 and B12. B vitamins are mainly found in whole grains, potatoes, legumes, eggs and dairy products. Eggs and pulses, as well as meat substitutes, are also good sources of iron (read the product label for specific nutritional information). Are you vegan? It would be advisable to visit a dietician for recommendations regarding diet during pregnancy.

What food should you avoid during pregnancy?

  • Raw eggs, and products containing raw eggs;
  • Unpasteurised milk  - milk bought in the supermarket is pasteurised or heat treated and  is safe to drink (look at the label to ensure it says `pasteurised' or `heat treated');
  • Unpasteurised cheese. Ask if the cheese is made with pasteurised or heat-treated (UHT) milk;
  • Caffeinated drinks (coffee and energy drinks)  - drink at most one energy drink a day, and limit the amount of coffee you drink;
  • Raw meat  - if you do wish to eat raw meat, refrigerate if for at least 2 days, ensuring it is cooled to at least 12 degrees to kill the parasite that causes toxoplasma (for more information on toxoplasma, see page 12);
  • Liver  - do not eat liver, or foods containing liver, including liver sausage or pâté, due to the high vitamin A content which can be harmful to the foetus;
  • Certain herbal supplements;
  • Smoked fish. Smoked fish can contain bacteria such as listeria. After heating, smoked fish is safe to eat;
  • Predator fish such as tuna, swordfish, zander, shark or king mackerel;
  • Raw fish and seafood. You can eat these products if you heat them through

Which drinks should you avoid during pregnancy?

  • Raw milk. Milk bought in the supermarket is pasteurised or heat treated and is safe to drink. Look at the label to ensure it says `pasteurised' or `heat treated (UHT)'; 
  • Caffeinated drinks such as coffee and energy drinks. Drink no more than one energy drink per day, and limit your coffee intake; 
  • Certain herbal teas; 
  • Alcohol.

For more information about food and drink during pregnancy, visit www.voedingscentrum.nl/zwanger. Or download the Voedingscentrum's ZwangerHap app: www.voedingscentrum.nl/zwangerhap

Avoid foodborne infections
Good food hygiene is important, particularly during pregnancy. Always wash raw fruit and vegetables, and wash your hands and all kitchen utensils with soap and warm water after they have been in contact with raw meat, drying with a dry towel afterwards. Ensure that meat is well cooked through before serving. Take note of the best before date on food items, and do not eat perishable food after the best before date has passed. For more tips (in Dutch) on food safety during pregnancy, visit www.voedingscentrum.nl/zwanger.

Dieting and fasting during pregnancy
Dieting during pregnancy is unhealthy for you and your baby. If you are considering fasting, for example during Ramadan, you should discuss this with your midwife or obstetrician.

Work
Working conditions may involve risks to the pregnancy. Some examples would include work in which you are exposed to: vibrations (trucks, agricultural and construction machinery), ionising radiation (radiation from radioactive substances), chemical substances or infection risks. Health problems can also be caused by physically demanding work, involving frequent lifting, pulling, pushing or carrying. Are your working conditions like this? If so, modify your work in consultation with your employer. Various schemes are available to workers who are either pregnant or who have just given birth.

If you have any questions about health and safety in the workplace, you can also consult your company medical officer or contact the Labour Inspectorate(www.arbeidsinspectie.nl). Your employer may offer you a (voluntary) preventive consultation with the company medical officer, who will assess the work-related risks and advise your employer accordingly. Of course, you can also consult your midwife or obstetrician.

If you usually work shifts, you can ask your employer to modify your hours of work. Pregnant women are also entitled to extra breaks. In principle, you cannot be required to work night shifts or overtime. These rules continue to apply for the first six months after you have given birth. If it is not possible to adjust your regular work so that it is entirely risk-free, your employer is required by law to offer you alternative employment. For further information (in Dutch) see: www.zwangerwijzer.nl and www.strakszwangerworden.nl (risico’s op het werk). Information on the rights of pregnant women and their partners can be found at www.fnv.nl (search term ‘zwanger’).

Pregnancy classes
There are many classes available to help you stay fit and healthy while you are pregnant, and to prepare you for the delivery itself. Your midwife or obstetrician can tell you which classes are available in your region and how to register.

Maternity leave
It is important that you are well rested when labour begins. You are entitled to 16 weeks’ maternity leave, starting from the 34th week of pregnancy or later. Maternity leave continues for ten weeks after the birth of your baby. If you give birth earlier than the calculated due date, your maternity leave entitlement remains 16 weeks in total.If you give birth later than the due date, the leave is extended accordingly. Alongside the maternity leave arrangements there are also provisions for ‘parental leave’. For further information (in Dutch) go to www.rijksoverheid.nl and search for ‘bevallingsverlof’.

4. The blood test

During your first appointment, your midwife or obstetrician will tell you about an optional blood test. It will only be conducted with your express consent. If you agree to give a blood sample, it will be sent to the laboratory to determine:

  • Your blood group: A, B, AB or O.
  • Your Rhesus D- and Rhesus c-blood group.
  • Whether your blood contains antibodies to foreign blood groups.
  • Whether you have been exposed to syphilis, hepatitis B or HIV.

If the blood test reveals any risk, it is often possible to provide treatment during pregnancy to protect your baby. For this reason, the test is offered at the earliest possible moment so that treatment can also be commenced promptly.

 

Often the laboratory will also be asked to check your blood glucose level and your haemoglobin (Hb) level. If the haemoglobin level is too low, you are suffering from anaemia, which usually responds well to treatment.

Antibodies to foreign blood groups
During pregnancy and childbirth, red blood cells from your baby can enter your own bloodstream. If your child has a different blood group to your own, your body may produce antibodies to this ‘foreign’ blood group. The laboratory can check whether this is the case. It is important to know, since some antibodies can enter the baby’s blood through the umbilical cord and ‘attack’ the baby’s own red blood cells leading to anaemia. The antibodies can also have this effect in subsequent pregnancies.

If such antibodies are found, further testing may be necessary. Your midwife or obstetrician will explain what this involves.

Rhesus blood group
Women with either of two specific blood types have a greater likelihood of producing antibodies to other blood groups: those with Rhesus D-negative blood and Rhesus c-negative blood. These women need extra attention during pregnancy. As part of the blood test, the laboratory will therefore also determine your Rhesus D- and Rhesus c-blood group.

Do you have Rhesus D-negative blood?
If you are Rhesus D-negative, your blood will be re-tested for antibodies to foreign blood types in week 27 of your pregnancy. This time, the laboratory will also deter- mine whether your baby is Rhesus D-negative or positive.

If your baby is Rhesus D-positive, there is a chance that your body will produce antibodies against his or her blood. To reduce this chance, you will be given an ‘anti-D’ injection in week 30. This presents absolutely no risk to you or your baby.

After delivery, you will be given a further injection. Very occasionally, a third injection is required. Your midwife or obstetrician will tell you if this is the case.

If both you and your child are Rhesus D-negative, the injections are not necessary since your body will not produce any antibodies.

Do you have Rhesus c-negative blood?
If you are Rhesus c-negative, it is possible that your body will start to produce antibodies to your child’s blood. This will be investigated by means of a blood test in week 27. No injection is available to stop you producing these antibodies. Therefore, if such antibodies are found, your midwife or obstetrician will wish to increase their supervision of your pregnancy, with additional check-ups to ensure that your baby’s health is not at risk.

You can find more information about antibodies at www.rivmNational Institute for Public Health and the Environment .nl/bloedonderzoek-zwangeren. On this website, under `Leaflets', there are also leaflets with information about Rhesus D-negative, Rhesus C-negative and blood type antibodies.

Infectious diseases

Syphilis
Syphilis is a sexually transmitted disease (STD). To ensure that the baby does not become infected, it is important that the disease be detected as early as possible in the pregnancy. Did the blood test show that you have syphilis? You will be referred to an obstetrician and given a course of antibiotics.

Hepatitis B
Hepatitis B is an infectious disease which affects the liver. Some people experience no symptoms and are therefore unaware that they are carriers of the hepatitis B virus.The blood test will determine whether you are a hepatitis B carrier. The virus is usually not harmful to your baby’s health during pregnancy, but there is a risk of transmission during childbirth.

If the blood test reveals that you are carrying the hepatitis B-virus, your baby will be given an injection of antibodies soon after birth to protect him or her against the virus. It is also important that your baby builds up immunity to hepatitis B. This is why the baby is immunized. The first immunization takes place shortly after birth, and the next ones will be at the ages of six weeks, three months, four months, and eleven months at the child health clinic.

HIV
HIV is the virus, which can lead to aids. Thanks to new virus inhibitors, HIV is now a chronic disease. You can contract HIV through unsafe (unprotected) sex with an infected partner, or through contact with infected blood.

If the blood test reveals that you are HIV-positive (you have the virus) you will be referred to a specialized HIV centre. You can pass on the virus to your baby during pregnancy or childbirth, or in your milk during breastfeeding. You can significantly reduce the risk of transmission by taking virus inhibitors during pregnancy. For further information, go to www.soaaids.nl or www.hivnet.org.

Syphilis, hepatitis B or HIV: what now?
If you discover that you have syphilis, hepatitis B or HIV, there could be implications for both your health and your social life. It is essential that you take appropriate measures to prevent your partner or others becoming infected. Your GP or local GGD can advise you.

You can find more information on the screening for infectious diseases at www.rivm. nl/bloedonderzoek-zwangeren. There are also information leaflets about this subject under `Leaflets'.

See page 36  for further information about the privacy of your personal data.

5. Testing for congenital conditions

If you are pregnant, you will receive information about two screenings for congenital defects.This is called prenatal screening.

There are two examinations:

  1. the prenatal screening for Down's syndrome, Edwards' syndrome and Patau's syndrome
  2. the screening for physical abnormalities (20-week ultrasound). You decide whether you want to have these tests done.

The prenatal screening for Down syndrome, Edwards' syndrome and Patau's syndrome
You can have checked (screened) whether you are carrying a child with Down's syndrome, Edwards' syndrome or Patau's syndrome. This test takes place at an early stage of the pregnancy.

The 20-week ultrasound scan (anomaly scan)
The 20-week ultrasound scan allows your unborn child to be checked (screened) for possible physical abnormalities. The ultrasound technician also checks whether the child is growing properly and that there is sufficient amniotic fluid.

In-depth consultation  
During your first visit, your midwife or obstetrician will ask you if you would like to know more about the screening for Down's, Edwards' and Patau's syndrome and the 20-week ultrasound scan. If so, there will be an in-depth consultation. After this consultation, you can decide whether you would like to undergo the screening.

The website www.onderzoekvanmijnongeborenkind.nl contains information about screening for Down's syndrome, Edwards' syndrome and Patau's syndrome and the 20-week ultrasound scan. This website also contains a questionnaire you can use to list your own feelings and thoughts.

The information leaflets are located at:
www.rivmNational Institute for Public Health and the Environment .nl/down-edwards-patau/folder

www.rivm.nl/20wekenecho/folder

6. Preparing for the birth and maternity care

Pregnancy and the days after childbirth can be a hectic time. Being properly prepared for the birth can take away a lot of potential uncertainty and fear. With proper preparation beforehand, you can relax more during labour, and it can help the birth go more smoothly. It also gives you an opportunity to think about which choices are right for you, such as where you would like to give birth: at home, at a birth centre, or at the hospital.

How do you prepare?
Before the birth, you can take the time to ask your midwife or obstetrician questions. She or he will give you reliable information on childbirth and show you where to find more information. You can also attend information meetings at the midwifery practice, birth centre, or hospital. This will give you a better idea of where you would like to give birth. Pregnancy classes will teach you breathing techniques and ways to cope with contractions, among other things.

Indicate what you want in your birth plan
A birth plan helps you to consider your needs and expectations regarding childbirth and to discuss these with your partner, midwife, obstetrician and/or other care provider. You can indicate what is important to you. Together with your midwife or obstetrician, you determine whether your wishes are feasible.

What if you are switched to another care provider during pregnancy or childbirth?
Your birth plan is part of your medical record. This means that the midwife or obstetrician who will be attending you during childbirth can check the details of your birth plan at any time. Bear in mind that in case of an emergency, things may go differently than you planned.

Details of a comprehensive sample birth plan can be found at www.deverloskundige.nl under `Bevalling'. You can find more information about childbirth and pain relief, among other things, at:

www.deverloskundige.nl under `Bevallling'

www.degynaecoloog.nl → enter `Pijnstilling' as a search term

www.thuisarts.nl → enter `Bevalling' as the search term.

Location of childbirth
Are you pregnant without any medical complications and under the care of a midwife? Then you can choose to deliver your baby at home, in a birth centre, or in a hospital attended by your own midwife. Are you under the care of an obstetrician?

Or are there complications during the pregnancy or delivery? Then it’s advised to give birth in a hospital. For example, this may be necessary if you have high blood pressure or if the baby is in a breech presentation.

Arrange maternity care
You must arrange your maternity care in good time, and in any case by the 16th week of pregnancy. You can choose which organization you wish to provide this. Ask your health insurer what form of maternity care you are entitled to. The maternity nurse can provide support during the birth, either at home or in a birth centre, and some- times in a hospital. Your midwife or obstetrician can give you more information.Maternity care in the Netherlands is organized on a different basis to most other countries. Ask your midwife or obstetrician to explain the Dutch system of kraamzorg.

Breastfeeding
Breastfeeding is now recommended as first choice for all babies. Prenatal classes are available to help you prepare, or you can seek advice from a lactation consultant. If you have any questions about breastfeeding after you have given birth, ask your maternity carer or the staff of the child healthcare centre (‘Consultatiebureau’).The pharmacist can advise you about medications during breastfeeding. If breastfeeding is not possible, then infant formula is a good alternative.
For more details about breastfeeding, please visit www.borstvoeding.nl or consult your midwife or obstetrician.

Recognition and choice of last name
Report your child’s birth to the municipality as soon as possible. In any case, this must be done within three working days (see also page 29). If you are not married or do not have a registered partnership, you should arrange the recognition of the child by the partner during the pregnancy. This saves a lot of extra work after the child is born. Go to rijksoverheid.nl/onderwerpen/erkenning-kind for more information. This site also contains information about the surname you can give your child.

7. Childbirth

Labour has different stages. The midwife and/or maternity nurse can guide you through each of these stages. Your partner or a loved one can also play a role.

Moment of childbirth
Based on the ultrasound examination, a probable due date will have been established. A mere 5% of women actually have their baby on their projected due date. If your pregnancy proceeds without complications, and you go into labour anywhere between 37 and 42 weeks, you’re allowed to choose where you would like to give birth. If you go into labour before you reach 37 weeks it is considered a premature birth, and the advice is to go to the hospital to give birth. If you go into labour after 42 weeks of pregnancy, it is called being overdue. If you haven’t given birth yet after 42 weeks, your midwife will discuss the possibility of referring you to a hospital.

For more information about premature birth or being overdue, visit www.deverloskundige.nl under `Bevalling' and www.degynaecoloog.nl.

The start of the labour
Usually, going into labour starts with contractions. Sometimes, those contractions hurt a lot and follow each other closely. But at the beginning, they are usually quite short, irregular, and not too painful. You can also discover you’re going into labour because of your waters breaking. In that case, you also need strong contractions to dilate the cervix. These usually start within 24 hours of your waters breaking. Your midwife or obstetrician will have discussed with you at what point to call him or her when you go into labour.

Contractions, dilation and pushing
Contractions make the cervix thinner and more supple. The duration of this process depends on the contractions. The first few centimetres of dilation usually take longer than the last few. At 10 centimetres, you are fully dilated. Labour then transitions to the pushing stage. At the height of a contraction, you will feel like you want to push. When you get this urge to push, you start actively pushing. While you’re pushing, the midwife or obstetrician may coach you to help birth the baby. After the baby has been born, allow the baby to be placed on your (preferably bare) chest.

Complications
If there are complications during the delivery, the midwife or obstetrician will confer with you about what to do. About half of all women are referred to hospital during the birth of their first child, for example for medicinal pain relief or because the baby has defecated into the amniotic fluid. The chance that you will be referred to an obstetrician during a subsequent childbirth is considerably smaller.

With each childbirth, there is a chance that medical intervention will be necessary. During the birth of a first child, the chance of a caesarean section (also called aC-section) being necessary is about 16%, and the chance of a vacuum extraction being needed is about 19%. These procedures are always performed at a hospital. More information on caesarean sections can be found at www.deverloskundige.nl under the subsection ‘Bevalling’.

8. After childbirth

The first weeks with your baby
Pregnancy and childbirth are joyous events, but they can also take their toll, both physically and emotionally. Your body will need time to recover, which may well take several weeks or months. This is perfectly normal. Your daily routine will change considerably now there is a new member of the family. Allow yourself time to adapt. Your body needs to recover, the hormones in your body change.

Registering the birth
You or your partner must register the birth with the local authority (‘municipality’) within three working days. Remember to take a valid ID. A copy of the registration certificate will be forwarded to the child healthcare centre and the organisation which arranges the heel prick. You will need a copy of the certificate to claim child support.

Maternity care
You will receive maternity care for the first week after giving birth. The maternity nurse takes care of the mother and child, but can also offer advice to the partner. It is important that you indicate what you need, so that the maternity nurse can take this into account as much as possible.”

Medicines and breastfeeding
Are you breastfeeding and do you take medication, or need to take new medication? Discuss this with your GP, midwife or obstetrician and inform the pharmacist that you are breastfeeding. It is safe to take paracetamol for pain relief. If you need to take paracetamol for several days, please consult your GP, midwife or obstetrician. For more information about the use of medication during breastfeeding, visit www.lareb.nl.

Jaundice in newborn babies
Most babies develop a slight yellowish tinge a few days after the birth, regardless of their natural skin colour. This is due to the presence of bilirubin, a natural breakdown product of the baby’s blood. This decomposition substance (bilirubin) enters your baby’s skin. The yellow tinge is usually entirely harmless and will usually disappear after a few days. In some cases, the bilirubin becomes too high and medical intervention is required. Your baby will therefore be carefully monitored for several days. If your baby’s skin is too yellow, a blood test may be carried out to measure its bilirubin level. If the result shows that this level is too high, the baby will usually be treated with light therapy, in a hospital.For more information (in Dutch) on jaundice in newborns, www.babyzietgeel.nl.

The ‘heel prick’
During the first week of life, some blood will be taken from your baby’s heel and sent to the laboratory. It is then tested for a number of rare, serious diseases. Most diseases cannot be cured, but can be treated with medicines or a special diet, for example. Timely detection and treatment of these diseases prevents or limits very serious damage to the physical and mental development of a child. It is therefore very important for your baby to have the heel prick test.

Someone will come to perform the heel prick at home. If your child is in hospital, the heel prick is performed at the hospital. Provided you have registered the birth promptly, no further action is required. Towards the end of your pregnancy, your midwife or obstetrician will give you a brochure about the heel prick test and the hearing test. See also www.rivm.nl/hielprik.

Hearing test
Good hearing is important for your child’s development. A child who does not hear well will have extra difficulty in developing normal language and speech, which in turn may affect their learning ability. The earlier hearing loss is discovered, the sooner appropriate action can be taken. Your baby’s hearing will therefore be tested shortly after birth, usually at home between four and seven days after birth. The test takes only a few minutes and does not cause any pain or discomfort. The hearing test is generally conducted during the same visit as the heel prick, although in some regions it is carried out when the baby is a few weeks old and takes place at the child health- care centre (‘Consultatiebureau’). In this case, you will receive an invitation by post. See also: www.rivmNational Institute for Public Health and the Environment .nl/gehoorscreening.

The child healthcare centre (‘Consultatiebureau’)
If you are at home in the first few days after birth, the midwife and maternity nurse will provide the necessary care. After that, your local child healthcare centre will assume responsibility for providing all necessary care for your baby. No action is required on your part: someone from the centre will contact you for an introductory visit.

Vaccinations
The government invites all children in the Netherlands to take part in the National Vaccination Programme. Within this programme, children receive vaccinations that protect against diphtheria, whooping cough, tetanus, polio, Hib diseases, pneumococcal disease, mumps, measles, rubella, meningococcal ACWY, hepatitis B and later also HPV (a virus associated with cervical cancer). From the summer of 2019, children who are particularly vulnerable, for example because they were born prematurely, will also be vaccinated against the rotavirus.

These infectious diseases are difficult to treat and pose a serious threat to your child's health. You will be sent an information package within four to six weeks after your child is born. It contains a set of call-up cards for the different vaccinations, a vaccination certificate and a brochure about the National Vaccination Programme. These vaccinations are not mandatory but almost all children in the Netherlands participate in the programme. There is no charge to you. If you want to find out more, please contact the child healthcare clinic, the CJG or the Municipal Health Service. Or go to www.rijksvaccinatieprogramma.nl.

Returning to work
You will probably feel quite vulnerable at first when you return to work. There are special regulations concerning return to work for women who have recently given birth or who are breast feeding. For more information, www.fnv.nl/zwangerschap

9. Privacy

  1. Information about your pregnancy and delivery

Use of information for your healthcare
Your midwife, obstetrician or general practitioner and/or maternity assistant registers information about your pregnancy in a healthcare file. This is a legal duty of every healthcare professional. This registration is necessary in order to be able to provide good care for you and your child. In the file is information about your health status and that of your child, and information about the tests that have been carried out and treatments. Healthcare professionals who are involved with your treatment have access to your information when it is necessary for their work. Because the various healthcare professionals who are directly involved in your care may share the infor- mation on you and your child with each other, they know what each one is doing and what has been agreed. All these healthcare professionals have a legal obligation of confidentiality (professional secrecy or privilege).

Use of information for improving national quality of care and for research
The midwife, general practitioner, obstetrician or the paediatrician who has treated your child provides information to the Perinatal Registry (perinatal refers to the period around the pregnancy and birth). Information from the different healthcare professionals over the whole period is collected in this registry. This information can be used to improve the quality of healthcare, including via the perinatal audit (during a perinatal audit healthcare professionals analyse the healthcare actually provided in a critical and structured way).

This information is further used for scientific research, which can help expand medical knowledge about pregnancy and birth. Only anonymous information is used for scientific research. Information that could be traced back to you or your child is only used if you give your express permission for this.

The Netherlands Perinatal Registry is maintained by the organisation Perined, on behalf of midwives, GPs, obstetricians and paediatricians. For more information (in Dutch) on privacy protection of your personal data held by the Perinatal Registry or the Perinatal Audit, visit Perined’s website www.perined.nl and click on ‘Privacy’.

2. Screenings during the pregnancy

Information about the screenings
During the pregnancy it is also possible for you to participate in a few screenings and after the birth you will be offered screenings for your baby. A screening enables certain diseases and disorders to be discovered at a very early stage. It is good to know what you can expect from a screening. This is why you are given information by your midwife and in this brochure. More information about the screenings can be found on the RIVMNational Institute for Public Health and the Environment websites that are mentioned in this brochure (see chapter 10).

Information about the blood test (see chapter 4) can be found at the end of this chapter.* You decide whether you or your child takes part in the screenings.

Information about the screening in a national information system
If you participate in a screening during the pregnancy, your name, address, date of birth and test results from the screening will be entered into a national information system. In order for your child to be invited for the heel prick and hearing tests, the civil register of the local municipality passes on its information on your newborn child. This information is also entered in the information system for screenings.

The information systems are necessary to allow the screening to progress well and to monitor the quality of execution of the screening. Anonymous information and test results are also used for national statistics and for scientific research in order to improve the screening and the treatment provided. More information about your privacy in the screening programmes during pregnancy can be found in the brochures and on the RIVM websites for the different programmes. These are given in chapter 9.

The national information system and your privacy
The national information systems are well protected. Only those people who need to see your information to perform the screening have access to the data. The legislation on the protection of your privacy is applicable here. A privacy statement containing more information about your privacy can be found at www.rivmNational Institute for Public Health and the Environment .nl/ bevolkingsonderzoeken-en-screeningen  under `Legal information'. This website also contains information about the information systems, which data is stored and how you can have your data removed.

* Information about the 12-week blood test
Early in the pregnancy you can have your blood screened for infectious diseases and for antibodies to certain blood groups. You can read more about this in chapter 4 of this brochure. The results of this test are entered into your own healthcare file by your midwife or obstetrician. Your data are also entered into the national information system (Praeventis) for the screening. In the section above you can read why this is necessary, what happens to your data, how your privacy is ensured and how you can have your data deleted. Your data may, in certain cases, also be registered in a national information system (TRIX) that is managed by the blood bank (Sanquin Foundation for Blood Supplies). If, in the future, you should need blood, the blood transfusion laboratory can view your data. The Dutch Data Protection Act applies to this registry. Your data will never be made available to third parties without your permission.

10. More information

Website of the midwives
www.deverloskundige.nl
The professional organisation for midwives (KNOV) has a website where you'll find a lot of information about pregnancy and childbirth. Here you can find details of the guidance and supervision provided by the midwife before, during and after your pregnancy. You can also download leaflets about childbirth positions and pain relief, for example. To be sure that you are well prepared for the birth, there is an online birth plan that you can fill in. The website also makes it easy for you to find a midwife in your area.

Website of the obstetricians
www.degynaecoloog.nl
The patient website of the professional association of gynaecologists contains a lot of information about, among other things, minor and major complications during pregnancy or childbirth.

Website of the general practitioners
www.thuisarts.nl
By searching on `zwangerschap' or `bevalling' in this website you can find information about these topics on this website, for example, about problems during the pregnancy, about your diet, anaemia, and the period after the birth.

Website of the College for Perinatal Care
www.allesoverzwanger.nl
This website contains a digital brochure that describe how birth care is structured in the Netherlands and what role parents (to be) play. This brochure is written by health care provider organisations and clients in the birth care.

The College for Perinatal Care (CPZ) is a national college in which all parties that deal with birth care in the Netherlands work together.

Website of the Dutch National Institute of Public Health and the Environment (RIVMNational Institute for Public Health and the Environment ) about the screenings for pregnant women and newborns and the national vaccination programme

  • www.rivmNational Institute for Public Health and the Environment .nl/bloedonderzoek-zwangeren: information about the blood test for pregnant women. The leaflet is located under `Leaflets'.
  • www.onderzoekvanmijnongeborenkind.nl: information and a selection tool for the screening for Down syndrome, Edwards' syndrome, Patau's syndrome and the 20-week ultrasound scan. The leaflet is located under `Leaflets'.
  • www.rivm.nl/gehoorscreening: information about the hearing screening for newborns. The brochure is located under `Meer informatie' (More information).
  • www.rivm.nl/hielprik: information about the heel prick test for newborns.The leaflet is located under `Documents'.The websites contain brochures with general information about these tests in English and, in most cases, also in French, German, Polish, Spanish, Portuguese, Turkish, Papiamento, Chinese and Arabic.
  • www.rijksvaccinatieprogramma.nl: contains information about the national vaccination programme.

Websites of the Erfocentrum
www.erfelijkheid.nl: much information about heredity, DNA testing and genetic disorders.
www.zwangerwijzer.nl: contains a questionnaire for men and women. After completing the questionnaire, you will receive an overview of your answers. If the questionnaire identifies any risks to you or your baby's health, information about the risks will be provided.

Website of the Lareb Pharmacovigilance Centre about the use of medication during and after pregnancy
www.lareb.nl
This website contains a lot of information about the use of medication during pregnancy and breastfeeding. If you search for the name of your medicine, you will find the information that applies to you.

Website of the Netherlands Nutrition Centre
www.voedingscentrum.nl/zwanger
The website of the Netherlands Nutrition Centre provides extensive details about nutrition during pregnancy and about your child's nutrition.

Contact your midwife or obstetrician immediately if you have any of the following symptoms:

Are you worried? Discuss your concerns with your midwife
Discuss your worries about your own health or that of your baby with your midwife. Being anxious or uneasy is always a reason to phone. If you do not understand the explanation or information you are given, please tell the midwife. Ask for more time to be planned for you when you make an appointment.

Vaginal bleeding
If you have vaginal bleeding you should contact your midwife and keep your underwear or sanitary pad to show her.

Headache, dizziness, vomiting, pain in upper abdomen or upper back.
If you are more than 20 weeks pregnant and have one of more of the following symptoms: headache, dizziness, vomiting, feeling a tight band around your head or upper abdomen, pain in the upper abdomen or between your shoulder blades, or sudden fluid retention in your face, hands or feet, you should contact your midwife.

Your baby is moving less than normal
If you are 26 weeks or more pregnant and you feel your baby is moving less than you are used to, you should contact your midwife.
Less than 37 weeks pregnant and you have stomach pain or backache that comes and goes
If you are less than 37 weeks pregnant but  have stomach pain or backache that comes and goes with a certain regularity, you should contact  your midwife. If you lose water (amniotic fluid) if your waters break, you will suddenly notice you are losing fluid via your vagina. It can be a gush of fluid or you may lose just a trickle. The waters (amniotic fluid) are often clear  and do not smell. Sometimes they may have a yellow, green or brownish colour. Contact your midwife and try to save some of the water to show her.