Gynaecology Outpatient Clinic

The gynaecologists of Diakonessenhuis work together in a partnership. The gynaecologists’ partnership consists of 10 gynaecologists (doctors who have specialised in the diseases and routine care of the reproductive system of women).

Apart from the gynaecologists, you will also meet assistant physicians (doctors mostly specialising to become gynaecologists) and interns (medical students). Together with the Utrecht University Hospital (Universitair Medisch Centrum Utrecht) and the Amsterdam University Hospital (Academisch Ziekenhuis van de Vrije Universiteit Amsterdam) assistant physicians are trained to become gynaecologists.

You will be assigned to your ‘own’ gynaecologist. The gynaecologists see their own patients during surgery hours as much as possible. If a certain surgery hour held for pregnant women is fully booked, you will receive an appointment with one of the other gynaecologists. The gynaecologists stand in for each other during absence or holidays.

Surgery hours are held at both the Diakonessenhuis locations, in Utrecht and Zeist. Hospital births take place at the Utrecht location. Here you will also find the children’s ward.

When coming in for your first check-up, you will have two appointments. Your first appointment will be with a specialised nurse and the second will be with a doctor. During these appointments you will be asked some questions by the nurse and the doctor. This is done to gather information to be able to supervise the pregnancy and look after you during labour. They will calculate an approximate date of birth and a blood sample will be taken. Sometimes an ultrasound test will be carried out immediately to assess the duration of your pregnancy and to date accurately when your baby is due. This is best performed around week 10 of the pregnancy.

Each time you visit the doctor, he/she will check the following:

• blood pressure
• urine (for protein)
• the growth of the womb (uterus) (this is an external examination during which the doctor examines your tummy by hand)
• the foetal heart tones
• the presentation (position) of the baby (from week 26 onwards)

Check-up schedule

This schedule shows how often you are expected for check-ups during each phase of your pregnancy.

before 12 weeks: your first check-up

• week 12-24: every 4 to 6 weeks
• week 25- approximately 32: every 3 weeks
• week 33-36: every 2 to 3 weeks
• week 36 until delivery: every 1 to 2 weeks

Please discuss questions or problems with the assistant physician (in gynaecology) or the gynaecologist. It is useful to write down your questions and the issues you want to discuss beforehand.

When you are 30-32 weeks pregnant, you can have a talk about labour and giving birth with a specialised nurse from the outpatient clinic. Please make this appointment yourself via the outpatient clinic.

Routine examinations

The following examinations will take place during your visits to the outpatient clinic:

Urine test
Remember to bring a morning urine sample on each visit. The urine is tested for protein (among other things of importance to trace pre-eclampsia at an early stage).

Blood test
During pregnancy a blood sample is taken at the beginning, and if necessary at a later stage, to check for the following

• Presence of antibodies against different blood types
• Iron Level (Haemoglobin): Because anaemia (from low iron levels) is common during pregnancy, the haemoglobin rate in your blood is tested regularly.
• Lues (Syphilis) Lues is a rare sexually transmitted disease which can be harmful to your baby, if left untreated.
• Hepatitis B: Hepatitis B is a disease caused by the Hepatitis B virus which infects the liver. The disease sometimes exists unnoticed; sometimes a person clearly has jaundice. Approximately 0.5% of all women in the Netherlands are carriers of this virus. If you are a carrier of the virus, your blood may be infectious to the baby. The risk of infection is rather high during delivery or afterwards. By giving the newborn baby a Hepatitis B immune globulin injection as soon after birth as possible, the virus can be made inactive, which prevents infection of the baby. Furthermore, the baby needs to be vaccina- ted at the ages of 3, 4, 5, and 11 months to be well protected.
• Blood group and Rhesus factor: during the first blood test (preferably before week 13 of the preg- nancy) we assess blood group and Rhesus Factor D and C. When the blood is Rhesus D-negative or Rhesus C-negative, the body may produce antibodies against the baby’s blood. If your blood has a negative Rhesus factor, we will do another blood test in week 27 of your pregnancy.

Ultrasound examination
this examination (a so-called ultrasound scan) generally is done during one of the first check-up visits. The ultrasound scan is made to check whether your baby’s rate of growth is as to be expected, based on the duration of the pregnancy. An ultrasound scan may also reveal unexpected issues, such as twins or triplets, a miscarriage or a birth defect. An ultrasound scan sends out sound waves that bounce back, are captured and then turned into images. These images you can see on a screen. The examination is harmless according to the available scientific evidence. During the rest of your pregnancy an ultrasound scan is only performed if this is thought necessary by the assistant physician or the gynaecologist.

Examinations on indication

Certain examinations are solely done ‘on indication’. This means they are only performed if there is a specific reason to do so. Of course this will then be further discussed.

• Cardiotocography (CTG): a test which among other reasons is carried out when you feel less movement of the baby. A CTG provides information about the condition of the baby. You will have a kind of microp- hone on your tummy that measures your baby’s heart tones. A CTG takes at least 30 minutes.
• A Doppler scan: this is a special form of ultrasound scan that provides information about the functioning of the placenta (afterbirth) and your baby’s condition. Through the sound waves the blood flow in the placenta and in your baby’s body is measured. Just like the ordinary ultrasound, this scan is harmless. It will take approximately 5 minutes. This test is carried out, for example, if there are doubts about the growth of the baby.
• A breakfast test: this test will be done if there is a higher risk of gestational diabetes (diabetes during pregnancy) to check the processing of glucose in your body. For more information please refer to the leaflet ‘Onderzoek glucosetolerantietest’ (available in Dutch only).
• AIDS test: the Human Immunodeficiency Virus (HIV) causes the disease called AIDS. Also in the Nether- lands a few people are infected with this virus. The chance of a newborn baby becoming ill because of a seropositive mother is approximately 25%. Treatment of a seropositive pregnant woman with medication leads to a substantial lowering of this rate. The Obstetrician Department chooses to test everyone for AIDS. If you do not want this test to be done, please discuss this when visiting the outpatient clinic.
• Tests for birth defects: there are methods to identify some birth defects at an early stage of your pregnan- cy. The tests may include blood tests, ultrasound scans (so-called SEO or GUO), chorionic villus sampling, amniocentesis or NIPT. For more information about these tests, please refer to the leaflet www.rivm.nl/ downscreening .
   

It is important that you tell your doctor about specific diseases and abnormalities in your family. Please do so as early as possible during your pregnancy. Your doctor can then assess whether you are eligible for any of these tests.

Always consult us in the following situations.

1. When having contractions: long before the actual moment of delivery you may experience ‘tightenings’. In general these are irregular, or disappear after having been regular for a while. Usually there is no need for you to come to the maternity ward. Tightenings are called contractions if the tightenings of the womb become regular (keep coming every other 5 minutes), increase in strength and duration, and become painful. You should then contact the maternity ward. Should you have contractions before the 37th week of your pregnancy: immediately make a phone call. After week 37: follow your gynaecologist’s advice. Please call 088 250 6042.
2. When having blood loss: always call when having blood loss. When you are having contractions, you often lose some blood and mucus (‘mucousy or bloody show’). Please call 088 250 6042.
3. When losing fluids: if you are losing fluids without being able to control this, it could be amniotic fluid (from the bag of fluid around the baby). Should you have amniotic fluid loss before the 37th week of your pregnancy: - immediately call 088 250 6042.
   When losing fluids after week 37 during office hours: please call 088 250 6042 to inform us
   When losing fluids after week 37 at nights: when you are not yet having contractions, you may wait until the morning, except when:
   - the fluids have a green colour
   - when you have been told at the outpatient clinic that your baby’s head has not yet engaged
   - when you have been told at the outpatient clinic that your baby is in a breech position
   - when we have made other arrangements with you
4. When having problems passing urine: if you have a burning sensation when passing urine or keep passing small amounts of urine, you might have a urinary tract infection. Sometimes you will also have an accompanying fever. We then advise you to contact the outpatient clinic via telephone number 088 250 6198. During out-of-office hours please contact the so-called Triage-department via telephone number 088 250 6459.
5. When feeling reduced movements: if you have not felt your baby’s movements for over 12 hours, please contact the so-called Triage-department via telephone number 088 250 6459. Please do so too if you think that your baby is really moving a lot less than it did previously. Do not wait until your next check-up appointment, but call in to make an appointment to come sooner. This especially applies to the period after week 24 of your pregnancy, however. In the period before that it is not unusual for you to feel hardly any movements of the still very small baby.
6. When you are worried: if you are worried, you may always contact the outpatient clinic during office hours via 088 250 6178. During out-of-office hours please contact the so-called Triage-department via telephone number 088 250 6459.

During your pregnancy it is sensible to live according to certain guidelines. In the following we will discuss a few of those.

Smoking

It is common knowledge that smoking is unhealthy but this is even truer for pregnant women. Smoking influences the baby’s growth and the development of the placenta in a negative way. This may affect future development too. Furthermore, infections of the airways, like asthma and bronchitis, are more common in children of smoking parents. Therefore, we advise both parents to stop smoking before the pregnancy.

Alcohol

Alcohol passes through the placenta to your baby. Drinking regularly may influence the development of your baby. We advise you to stop drinking alcohol during your pregnancy.

Medication

If you take medication, you should tell your doctor or midwife. This also accounts for over-the-counter medications you can buy at the chemist, such as aspirin, cough mixture, throat lozenges or sleeping pills. Sometimes the medication you were using before your pregnancy has to be discontinued or adjusted.

Discuss this with the physician who prescribed them.

Narcotic drugs

The use of narcotic drugs, such as heroin, cocaine etc., has the same restraining influence on the baby’s development that smoking has. Some narcotic drugs may cause birth defects in the baby. The baby may also be born addicted and will need specialist care detoxification. For your own and your baby’s sakes please always be honest about this, so we can give you the necessary support and counselling.

Sauna

Some women are used to going to the sauna regularly and would like to keep doing so. In general there are no objections to this. It is best not to go to the sauna too often.

Sport

If you want to continue playing sports during your pregnancy, you should discuss this with your physician or midwife. In general, you yourself know best what is or is no longer possible. If you experience, for example, blood loss, abdominal pain or tightening in your tummy playing sports, we advise you to quit straightaway.

Food

During pregnancy it is advisable to pay some extra attention to your food. You do not have to ‘eat for two’, but you do need to eat healthy foods. By this we mean: not too much fat, but plenty of vitamins, proteins and other nutrients.

When having problems with your bowels, it usually helps to change from eating white bread to eating brown bread, wholemeal bread and black (rye) bread. Also it is advisable to eat fruits, raw vegetables and pulses.

Should this not be successful, you could try the following:

• a glass of lukewarm water on an empty stomach
• more fruit and vegetable juice (no apple juice)
• a handful of prunes, dates, or some laxative rosehip syrup daily
• 1 to 3 spoons of bran (you may divide the spoonfuls throughout the day). You may mix bran, for example, with yoghurt, custard, porridge, vegetables, meatloaf, soup, hotchpotch, stew, or apple sauce.

Early morning nausea may occur, especially during the early stages of your pregnancy. This can be partly solved by having something to eat before you get up, for example, tea and biscuits or a slice of crisp bread. Eat small amounts, several times a day.

If you catch a common cold, you do not need to see your doctor, even though you are pregnant. When you are visiting the outpatient clinic it is always sensible to mention any illness. There are two contagious diseases which may be harmful for the baby. We will discuss them here briefly.

Rubella

Women born in the Netherlands from 1965 onwards generally have been vaccinated against rubella (German measles) at the age of 11. This enabled them to produce antibodies against the virus, so there is no risk of infection. Occasionally no antibodies were produced despite vaccination, and you may get infected. That is why we ask you to tell your physician or midwife should you have been in contact with someone infected with rubella. We also advise you to avoid people who are infected with rubella.

Toxoplasmosis

Toxoplasmosis is a disease which has the same symptoms as Glandular Fever (fatigue, nausea etc.) There are some guidelines to prevent toxoplasmosis.

• We advise you not to eat raw or half raw meat, for example, raw prepared minced beef.
• Do not eat poorly washed raw vegetables or lettuce.
• Do not clean the cat’s litter tray yourself or wear gloves. Young kittens, particularly, are often carriers of the toxoplasmosis parasite.
• Wear gloves when working in your garden.

By the way, if you have ever had toxoplasmosis before, a second infection will not harm your baby.

Antenatal courses

There are many ways to prepare for labour and giving birth. This can be done, for example, by talking to family and friends, reading books and magazines or during antenatal courses. In the following you will find information about a few antenatal courses. More information is available at the Gynaecology Outpatient Clinic.

Pregnancy Gymnastics
This is the most well-known course. It usually consists of 10 lessons, of which 1 or 2 are together with your partner. Group sizes vary. The most important part of this course includes breathing and relaxation exercises and learning how to push during labour. Also general information will be given about pregnancy and giving birth, sometimes by means of slides or videos. A Pregnancy Gymnastics course is organised, for example, by homecare organisations in the neighbourhood.

Pregnancy Swimming
Several swimming pools reserve special hours for pregnant women. The water is warmer then. Most pregnant women really like moving in the water. Sometimes there is supervision and exercises can be done. Please ask at your local pool if they offer this service. Costs vary.

Information meetings

• In collaboration with the so-called Geboortehuis Utrecht (Utrecht Birth Centre), Diakonessenhuis regularly organises information meetings for new parents who would like to learn more about pregnan- cy issues and the birth suites. The meetings are on the first Monday evening of each month from 7.30 pm to 9.30 pm at Diakonessenhuis, location Utrecht. Tea and coffee will be ready for you at 7 pm. A nurse, a midwife from Geboortehuis Utrecht, a clinical midwife, a gynaecologist, an anaesthetist and a paediatri- cian will tell parents what to expect before, during and after delivery. What happens during a normal delivery? What happens when things go differently? What are the options for pain relief? Who do I meet? Is there room for specific wishes during delivery? Following the presentations there is plenty of opportu- nity to ask the specialists questions (in private).
• The 4th Tuesday of each month our lactation consultants organise an open information evening. Lacta- tion consultants are specialists in breastfeeding and help you with all your questions about breastfee- ding, before and after delivery.

For more information and to enter your name please refer to www.diakonessenhuis.nl/allesoverbevallen > voorlichtingsavonden.

Only 4% of all deliveries take place on the ‘due’ date. Most deliveries take place in a period of 3 weeks before and 2 weeks after that date. It is sensible to protect your mattress with a plastic sheet during the last few weeks. Should your waters break unexpectedly, the mattress will not get wet.

Delivery options

Polyclinic delivery
If you are seeing a midwife for antenatal care, you will deliver your baby supervised by your own midwife at Geboortehuis Utrecht.

Hospital delivery
If you are seeing a gynaecologist for antenatal care or if you have a medical indication, you will deliver your baby in one of the birth suites of Diakonessenhuis. In some cases it is necessary to deliver in one of the birth suites of Diakonessenhuis, but you may do so supervised by your own midwife.

When you undergo a hospital delivery you will be supervised by a clinical midwife or an assistant physician. You are also supported by a nurse. Sometimes a medical student will be present during the delivery, unless you object to this. The gynaecologist is closely involved with all deliveries in the birth suites via regular consultations with the supervising clinical midwife or assistant physician. When necessary, the gynaecologist will be present during the delivery. Some deliveries will always take place under supervision of a gynaecolo- gist: breech deliveries, multiple births or other deliveries with a high risk for complications.

What to bring for the delivery?

For a hospital delivery, please bring the following:

• baby’s clothes (several items) and a hooded baby towel
• infant safety seat (Maxi-Cosi)
• comfortable T-shirt
• spare nightclothes
• partner’s nightclothes
• underwear (loose fitting)
• dressing gown
• slippers
• toiletries
• alarm clock or watch
• books, magazines, games, music
• one euro coin, in case you want to use a wheelchair
• camera (remember to bring batteries and a memory card). Furthermore, bring as few valuables as possible

Who to bring for the delivery?

Besides your partner you might want to bring someone else to the delivery: maybe your mother, sister or a friend. We do not object to this (one person only). However, we notice that though this might seem a nice idea during the pregnancy, some women no longer think so at the actual moment. They do not like all the attention at that moment, or they feel ashamed or inhibited. If you bring someone, discuss with this person that you might change your mind at the last minute and might ask this person to leave.

Course of delivery

In principle you are free to choose the method itself, and in what position you wish to give birth (for example on a birthing stool), unless this leads to medical objections. You may want to write down your wishes con- cerning the delivery in a birth plan. The nurse at the outpatient clinic will discuss this birth plan with you. During delivery we will try to be considerate of your wishes as much as possible.

During the dilation stage of labour you usually have plenty of freedom of movement. You may choose to walk around, sit down, shower or do something else, whatever you like. If we need to monitor the baby’s condition permanently, the freedom of movement will be more limited.

It is important to have a relaxed atmosphere during delivery. You can bring your own music, a game or something to read.

When the baby is born, he or she is nearly always laid straightaway on the tummy or in the arms of the mother. If you plan to breastfeed, you may put your baby to the breast shortly after birth. Do you have other wishes? Discuss these at the outpatient clinic, so we can take them into account.

Labour and pain

A frequently asked question is if giving birth is painful. The answer to that cannot be other than affirmative. However, most women can deal with this pain and of course you get lots of support in coping with the contractions. Should this not be enough, there are options to relieve the pain.

Remifentanil
Remifentanil is a morphine-like substance. It is not registered for the treatment of labour pain and cannot be given in every situation. You will be given an IV in your arm to which a pump containing the medication will be connected. With a button you can administer the remifentanil yourself. You decide when and how often you want to press the button. This method is also known as PCA (Patient Controlled Analgesia): pain relief controlled by the patient. The pump has maximum dose limits set so that you cannot overdose yourself. Remifentanil works quickly: about a minute after you press the button, the effect is noticeable.

Epidural analgesia
In cases where delivery takes longer, we advise epidural analgesia, by which medication is administered via a so-called epidural or spinal jab. By means of an epidural the anaesthetist temporarily numbs the nerves that make you feel the pain. However, there are some negative side effects to this method. These will be discussed with you.

Please discuss any questions you have about pain relief options with your gynaecologist. If necessary, your gynaecologist may refer you to get an appointment with an anaesthetist.

Delivery complications

Sometimes extra measures or procedures need to be taken during delivery:

Inducing (starting off) labour
Sometimes it is advisable not to wait for the contractions to start spontaneously, because there have been complications during the pregnancy or because the delivery is overdue. The way your labour is induced depends on several factors. Your doctor will discuss these with you. For more information on inducing labour please refer to the leaflet ‘Inleiding van de bevalling’ (available in Dutch only).

Assisted birth
Sometimes it is not possible to have your baby delivered on your own, or it is necessary to speed up delivery because your baby is in distress. The assistant physician or gynaecologist will then help. This is mostly done with a so-called ventouse. When using this vacuum extractor a metal or plastic cup is attached to your baby’s head. This helps you to push your baby out during a contraction.

Caesarean section
Both during your pregnancy and delivery situations may occur where the safest option is to have a caesarean section. In Diakonessenhuis we prefer to perform this via gentle section (natural caesarean). During a gentle section the natural process of giving birth is copied as much as possible: you and your partner watch your baby being born and the baby is put on your chest as soon as possible after a short check-up. He or she will remain there as long as possible, preferably during the rest of the surgery.

Maternal-assisted caesarean section
If you are undergoing a planned caesarean section, you can opt for maternal-assisted caesarean section in the Diakonessenhuis in consultation with the gynaecologist. With maternal-assisted caesarean section, the mother can handle the baby herself during the operation and place it directly on her chest. In this way, the mother is the first to touch the baby and skin to skin contact can take place immediately. If it is medically justified, the pediatrician will examine the baby while it is lying on the mother's chest. The baby will remain on the chest during the rest of the operation. The maternal-assisted caesarean section fits in well with our vision of family-oriented care in which parents and child are central. The gynecologist and intake nurse will inform you about this in advance and discuss your choice with you.

For more information on a caesarean section, please refer to the leaflet ‘Caesarean Section’ (available in Dutch only). You can find this leaflet via the website and it is available at the gynaecology outpatient clinic and the maternity ward.

Reimbursement

In general, all costs of a clinical delivery will be reimbursed by health insurance companies. This does not apply to a polyclinic delivery. Please ask your own health insurance company about this. Make sure all the details on your hospital card are up to date.

Lying-in period

We intend to keep you and your baby as close as possible. This means your baby will be in your room with you around the clock.

After delivery the doctor or midwife in attendance will tell you at what time you can go home with your baby. Usually this is on the delivery day itself or the day after. Sometimes there is a medical reason that makes it necessary for you or your baby to stay in the hospital longer. If the baby needs to be admitted to the child- ren’s ward, we do our utmost to keep you admitted in the birth suites or on the children’s ward (rooming in), so you may easily visit your baby.

You may leave the hospital in your own car or by taxi. We advise you to make sound arrangements with the maternity nurse.

Incubator

There are several reasons to admit a baby to the neonatology ward (part of the children’s ward). Sometimes your baby needs to be nursed in an incubator. An incubator makes it easier to control your baby’s condition, such as his/her temperature.

The maternity ward and the neonatology ward work together closely, so you and your baby can be together as much as possible. Of course you may visit your baby in the neonatology ward anytime or sit down with your baby close to your chest (‘kangarooing’). You may come and feed or bathe your baby. If you intend to breastfeed, you may do so here. The nurses will happily support you.

Visiting hours - maternity ward

In the birth suites there are no visiting hours. You may have visitors any time during the day. Be considerate of the other women in the birth suites and discourage large groups of people visiting you evenings or nights.

Breastfeeding or formula feeding

There are good books and leaflets that may help you decide on breastfeeding or formula feeding. It is a choice you have to make for yourself. It is sensible to think over this decision in the early stages of your pregnancy. If you have not yet decided which to choose shortly before delivery, feel free to discuss the options with a maternity ward nurse. The Obstetrics Department received a quality mark from a breastfee- ding organisation (the so-called keurmerk Borstvoeding van de Stichting Zorg voor Borstvoeding) and a golden Smiley from the association for child and hospital (vereniging Kind en Ziekenhuis). If necessary you may receive support from professional lactation consultants (experts on breastfeeding).

Lactation consultants work at Diakonessenhuis. They are nurses who are specialists in breastfeeding. On the 4th Tuesday of each month our lactation consultants organise an open information evening. The lactation consultants help you answer all the questions you have about breastfeeding, before and after delivery. They can be contacted via telephone number 088 250 6380. For more information and to enter your name please go to our website.

The midwife

After your discharge from hospital you will have some childbirth follow-up visits at home These follow-up visits will be performed by a midwife from your neighbourhood. You should contact a midwife in your neighbourhood during your pregnancy. Please pass on the name of the midwife who will be performing the childbirth follow-up visits at your home when you visit the outpatient clinic.

Follow-up

Approximately 6 weeks after your delivery, you will come to the gynaecology outpatient clinic for a follow-up visit and to evaluate your pregnancy and the delivery. As much as possible we try to make an appointment with your own gynaecologist or the person who was present during your delivery. In special cases, or when there have been complications during delivery, we advise you to have this follow-up appointment with the gynaecologist who supervised the delivery. You will get an appointment for this on discharge from the hospital.

Maybe no appointment for a follow-up was made with a gynaecologist, but you feel the need for one: for example, because you have some questions or complaints, or because you would like to get some advice on a possible future pregnancy. You may make an appointment yourself via the gynaecology outpatient clinic. This follow-up appointment should take place within 42 days of delivery. Otherwise it will not be reimbursed by the health insurance company.

More information

There is more information available about several subjects mentioned in this leaflet. You can get leaflets on the following subjects at the gynaecology outpatient clinic, the maternity ward and via www.diakonessenhuis.nl (available in Dutch only):

• Breastfeeding
• The neonatology ward (incubator ward)
• Caesarean Section
• Gynaecology Ultrasound Scan/ Ultrasound Scan during pregnancy
• Inducing labour

If you have any questions concerning these leaflets, please contact the gynaecology outpatient clinic. We wish you and your partner a successful pregnancy and delivery.

Contact details of the Gynaecology Outpatient Clinic

Questions and results
For information, for example, about results or other questions you might have, you may contact the gynaecology/obstetrics outpatient clinic on Mondays to Thursdays from 8.30 am - 4.30 pm and on Friday mornings from 8.30 am - 12 am via telephone number 088 250 6178. The outpatient clinic secretary will inform you of the results.

Emergencies and delivery room attendance
In case of emergencies, urgent questions or if you are worried, we are of course available 24 hrs per day. Please call the delivery room at 088 250 6042, or the triage department at 088 250 6459.