Episode 162 Alcohol and Pregnancy

Embark on a transformative journey through the complexities of alcohol use during pregnancy, as we unravel the myriad risks and the vital necessity of abstinence for expectant mothers. Grappling with the nebulousness of self-reported alcohol intake and the deceptive simplicity of a 'unit' of alcohol, we aim to demystify the misconceptions and bring to light the stark realities of alcohol-exposed pregnancies (AEP) and fetal alcohol syndrome disorder (FASD). With a staggering 400+ conditions linked to FASD, this episode is an essential listen for anyone invested in the future health of our children.

Navigating this sensitive topic with the utmost care, we engage with healthcare professionals on the front lines who embody the 'A-S-S-T' framework — a compassionate, judgment-free approach to supporting pregnant women. Through vivid stories, expert insights, and poignant reflections, we invite our listeners to contribute to a crucial conversation that impacts lives profoundly. 

Want to know more?
https://eschool.nationalfasd.org.uk/course/alcoholandpregnancy
https://www.rcog.org.uk/media/buohxsmm/pi-alcohol-and-pregnancy.pdf
https://alcoholchange.org.uk/help-and-support/managing-your-drinking/dry-january

Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth.
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Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and e...

Transcript

Speaker 1: 0:00

Hello, my name is Florence. Welcome to the ObsPod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife. Maybe birth fascinates you or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case and, for that matter, any one else that's interested, the ObsPod is for you. Episode 162 Alcohol.

Speaker 1: 0:55

Many of us will have indulged over the Christmas period. I'm recording this ready for my first episode of 2024, bringing in the new year. And in maternity, given that September and October are our busiest months, a lot of babies that are going to be born in those months are being conceived around about now, so there may be many women that are starting to explore and think about what they're drinking At this time of year. There's also the campaign Dry January or Try Dry. This is the idea of being alcohol free for a whole month, 31 days at the beginning of the year. It's supported by the charity Alcohol Change UK and you don't need to have a problem with alcohol to participate. The idea is that being free of alcohol for a month will give you better sleep, better mental health, better physical health, as well as potentially saving time and money. I'm going to put their website in the programme notes so you can explore a bit more.

Speaker 1: 2:21

So let's think a little bit about alcohol in pregnancy. It's one of the routine questions that we ask as health professionals. When a woman books in in pregnancy, how much does she drink? It's also something that you'll be asked if you attend A&E or that your GP will regularly question you on. And I must admit, when I'm asked how much do I drink, I never really know what I should be saying. Yes, I know what the limits are, what the sort of advice is for healthy women, how many alcohol units I should be beneath, but it's very hard to exactly give an answer about how much alcohol I drink. I don't really keep track of it. I don't think of it as a problem, I guess. Do I have a clear idea in my mind about how many days a week I drink? I certainly don't drink every day, but some weeks, if I've been out socialising, I may have drunk several days that week and other weeks I might drink nothing at all. So when I'm asked to give how many units on average I drink, I don't think I could accurately do so. And what about what is a unit? Well, I loosely think in my head a unit might be a glass of wine or a measure of spirits or a pint of beer, but more than that. I haven't really thought about it in detail.

Speaker 1: 4:14

As with many of my episodes, I have had a little look online about what we should be doing as health professionals, and in pregnancy, as with other healthcare interactions, there is actually a nice little tool alcohol use disorders identification test, or audit for short. It's quite a simple scoring system developed by the WHO, the World Health Organization, and modified for use in the UK, and it gives you an idea about whether or not you are likely to have a problem with alcohol. At the bottom of that advice, it gives some nice, clear advice about what is a unit of alcohol, and actually it's a surprisingly small amount when I look at it, and some of the things that I might have thought of as being one unit, or possibly two units, are more likely to be three or four. So it's likely that, even with my unreliable variable amount of drinking week on week, that I'm also underestimating how many units of alcohol I'm drinking, and this makes me wonder, when we, as health professionals, ask a pregnant woman how much she's drinking and we jot down her answer, which may be one or two units, but I've stopped. Now I got pregnant, or, since I discovered I was pregnant, I've cut down, how accurately are we really assessing what women are drinking?

Speaker 1: 6:11

Once we have the answer of what women think they are or aren't drinking, we then need to be able to have a conversation with them in a non-judgmental and helpful way. We need to have a conversation because we need to be clear about what our advice is, and the advice is for alcohol consumption in pregnancy to be zero, for all alcohol to be avoided, and I think there is confusion about this, and this is partially because the advice has changed over the years. Until 2016, there was advice to avoid alcohol in the first 12 weeks of pregnancy and then only to consume one or two units a week for the remainder of the pregnancy, and this can result in confusion, and the changing guidance is now that it's best not to consume any alcohol at all, and this can be difficult, and we need to look at our own unconscious biases, because many of us that had children Some time ago, such as myself, may have drunk small amounts of alcohol occasionally in pregnancy and may feel that that's okay. But that isn't the current guidance.

Speaker 1: 7:49

As is usual when I'm recording a podcast episode, I did a little bit of background reading and educating myself to make sure that I was tip-top up to date. In this case, I undertook a great little e-learning course on the National Organization for Fetal Alcohol Syndrome Disorder website and I'm going to put a link to the course, which is entitled Alcohol and Pregnancy for Maternity Teams. I'm going to put that link in the show notes and I highly recommend it. The course is free if you work for the NHS and there's a modest fee if you don't. What did I learn? Well, I learned that there was this change in guidance and I did know somewhere in the back of my mind that we should be encouraging women not to drink alcohol at all, but I hadn't thought consciously that the advice had changed since I'd had my own children some 20 years ago.

Speaker 1: 9:00

There definitely is something about how acceptable or not we find it to drink alcohol in pregnancy. They talk about alcohol exposed pregnancies, or AEP for short, and suggest that the prevalence of this in the UK is 41% the fourth highest in the world and that definitely gave me pause for thought, that we think it's acceptable to drink some alcohol during pregnancy. But of course there may be many reasons for this. To have no alcohol intake at all may be easy if you are planning a pregnancy and you've made preparations and you've consciously thought about switching to alcohol-free beverages and alcohol is not part of your life in an ever-present form. But this can be much harder if actually this was an unplanned pregnancy. Perhaps you didn't discover you were pregnant until late on in pregnancy. We need to appreciate that some women will be drinking through habit socialization and some women will have alcohol dependency and will need some professional support and help to tackle alcohol use in their lives. So why is it so important women shouldn't drink in pregnancy?

Speaker 1: 10:40

Well, alcohol is what we call a teraetogen, so when something's teraetogenic, it means that it causes abnormalities in cell division and can cause developmental problems, so malformations. Alcohol crosses the placenta and interferes with the development of the baby. The alcohol in a woman's bloodstream goes straight through the placenta and into the baby's bloodstream, and the baby's liver is not fully developed so it can't filter the alcohol out of the circulation and the toxic effects of that properly. So the alcohol circulates in the baby's bloodstream which can harm brain cells and damage the nervous system of the developing baby through the whole nine months of pregnancy. It was a bit of an eye opener when I undertook the e-learning course I mentioned, because I had appreciated that alcohol could contribute to preterm labour and growth problems of the baby and I knew about fetal alcohol syndrome, which was something that we kind of learned about in the textbooks when I was training. There are some specific facial features and neurological problems.

Speaker 1: 12:18

But what I hadn't appreciated was that the alcohol crosses the placenta and in the e-learning course there's a great picture essentially saying that the baby ends up in this kind of alcoholic reservoir. So if you imagine your baby not only getting alcohol through the placenta but there being alcohol in the amniotic fluid, that the baby's then swallowing and essentially bobbing around in a sea of alcohol because it can't get rid of it, that definitely made me feel much more negative about the idea of alcohol consumption in pregnancy, that image and explanation. The other thing that really stuck in my mind was that alcohol is more dangerous in pregnancy than heroin and we have very negative associations with illicit drug use, whereas alcohol, kind of, is a socially accepted thing to have. So those things definitely gave me pause for thought and the reason they've developed this training is also because of the prevalence of fetal alcohol syndrome disorder is starting to be looked at and seems to be anywhere between sort of 2 and 3.6%. So that was the first prevalence study done in the UK in 2019 and that's a really quite high rate of children affected in some way by alcohol in pregnancy. And I think one of the reasons that I probably hadn't realised this is because it says there are over 400 different conditions co-occurring with neurodevelopmental issues. So it's a much more diverse impact than I had perhaps realised, and with the typical facial features of something that I consider to be fetal alcohol syndrome disorder. Those features are only present in around 10% of people affected by fetal alcohol syndrome disorder. So it definitely gave me pause for thought and really shifted in my brain what may or may not be alcohol related. I thought to that point that fetal alcohol syndrome disorder was incredibly rare. I'd seen maybe one or two cases in my career and now I'm thinking if there are 2 to 3.6% of pregnancies affected, then actually I've probably seen lots of pregnancies affected and lots of children affected, but I may not have realised that that's what I was seeing. By no means every alcohol exposed pregnancy will result in a baby with fetal alcohol syndrome disorder. Only about 1 in 13 of alcohol exposed pregnancies will have some features. It's really difficult to predict how a baby might be affected from the amount a woman has drunk. It's very variable. Some babies can be mildly affected and others more severely. But the good news, just as with smoking, is that if you cut down or stop drinking altogether, your baby will start to grow at the normal rate, so that stopping drinking at any point in pregnancy can be beneficial to the health of your baby as well as your own health, of course.

Speaker 1: 16:56

If we're midwives or doctors seeing women, then our role is to assist. That is A Ask all pregnant women about alcohol use. Don't assume that any pregnant woman you see is not drinking. So A Ask. S Say it's safest to avoid alcohol in each appointment and that might just feel like yet another thing to tick off and do, and it's obviously got to be done sensitively and in a way that is part of that hopefully trusting relationship you're building with women. You're seeing S Support this with written advice where needed. So if a woman is drinking and is having difficulty with drinking, to back this up with some written advice and there's good advice on the website as well as on the RCOG website. All in the show notes I indicate the risks associated with prenatal alcohol exposure and again, that's included in the information for pregnant women on both those websites S Stop and record any maternal alcohol history.

Speaker 1: 18:26

So when a woman does tell us she's drinking and what she's drinking, it's really important that we document this and then we can tailor her care accordingly. And then T Try and help sign posting to further support and referrals. So try and find out what are your local alcohol dependency services, build links with them. What about your safeguarding team and your safeguarding midwives or mental health support teams? What about thinking more broadly across your organisation? Perhaps you're part of a community health trust which may have alcohol dependency services for people that are not pregnant? And what about links to primary care? What care could a woman access for her GP or health visitor?

Speaker 1: 19:29

If you encounter a woman who's alcohol dependent or you as a woman are alcohol dependent, it's really important not to hide that from us. Be open and honest with us, tell us what's happening and how difficult it is. I've cared for women in all sorts of really difficult situations where other members of the family are heavy drinkers, or perhaps she's in an environment that encourages heavy drinking at work, or she's done incredibly well and being abstinent for a long period during the pregnancy and then a set of events has triggered things, tripped her up and she's relaxed. So we need to be understanding and the more women can trust us, the more we can help them. We can organise additional scans to look at the growth of the baby and, if we're aware of heavy drinking, specialist fetal medicine scans to look for any signs of fetal alcohol spectrum disorder, so that we are diagnosing things and monitoring things closely and therefore can, if necessary, involve our pediatric colleagues if it looks like this baby may have been negatively affected and may have a problem, so that the pediatricians can assess and support that family from birth.

Speaker 1: 21:08

But equally we need to think about the health of the woman herself. If you're drinking heavily, you're more likely to get other complications in pregnancy and be unwell with complications of alcohol use, and in some situations this can be a bit of a wake up call for a woman, but in other situations. It's a real struggle for her being unwell and being pregnant and needing to try and cut down or stop drinking, and that's something that she needs regular visits, support with from the whole multidisciplinary team. There's a great little page on that website that mentioned about drinking in pregnancy and, if you have already had some drinks and you're pregnant, how to cope, how not to panic, how to talk to your healthcare professional and know that you're not alone and that there are many reasons why you might be drinking, and how telling someone telling someone in your antinatal clinic and telling your midwife or telling your doctor we can start to get you the right support. My zesty bit to kick off the year and round off this episode is we really need to start having these conversations about alcohol in pregnancy. We need to know, as health professionals, that the only safe amount of alcohol in pregnancy is none, but we also need to acknowledge that that may just not be feasible for some women and we need to start having realistic conversations and educating ourselves so that we can educate and point parents in the right direction to the right resources. So check out some of the links in the show notes If you're pregnant and you're listening to this and you've had a drink in pregnancy. Don't panic, don't worry. There's some great resources on the websites I've put in the show notes. Talk to your midwife and doctor, try and think about alternatives and know that every step you take to cut down and reduce the amount of alcohol you drink will be benefiting both your health and that of your developing baby. Thanks for listening.

Speaker 1: 24:08

I very much hope you found this episode of the OBS pod interesting. If you have, it'd be fantastic if you could subscribe, rate and review, on whatever platform you find, your podcasts, as well as recommending the OBS pod to anyone you think might find it interesting. There's also tons of episodes to explore in my back catalog from clinical topics, my career and journey as an obstetrician and life in the NHS more generally. I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient identifiable information unless I have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary.

Speaker 1: 25:06

If you found this episode interesting and want to explore the subject a little more deeply, don't forget to take a look at the programme notes, where I've attached some links If you want to get in touch to suggest topics for future episodes. You can find me at the OBS pod on Twitter and Instagram, and you can email me theobspod at gmailcom. Finally, it's very important to me to keep the OBS pod free and accessible to as many people as possible, but it does cost me a very small amount to keep it going and keep it live on the internet. So if you've enjoyed my episodes and, by chance, you do have a tiny bit to spare, you can now contribute to keep the podcast going and keep it free via my link to buy me a coffee. Don't feel under any obligation, but if you'd like to contribute, you now can. Thank you for listening.