Fundamentals of Midwifery: A Textbook for Students (52 page)

pre-existing medical conditions/relevant surgical procedures or trauma (e.g. cardiac anoma- lies, uterine surgery or fractured pelvis)

obesity (over 30 kg/m
²
)

diabetes (pre-existing or gestational relating to pregnancy)

pre-eclampsia (new hypertension presenting after 20 weeks with significant proteinuria)(NICE 2010)

venous thromboembolic disorder.

Box 6.1 Factors to discuss at the midwifery booking appointment

Lifestyle

Exercise, travel, sexual intercourse

Healthy nutrition/supplements – Vitamin D as insufficiency thought to be common in preg-nancy (WHO 2012); folic acid

Employment and safe working

Food acquired infections: Listeria/Toxoplasmosis

Toxoplasmosis from animal faeces

Potential exposure to hazardous substances

Smoking, alcohol and other substance misuse
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Infections‌

Rubella, human Immunodeficiency virus (HIV), syphilis, hepatitis B (Hep B), Hep C, urinary tract

infections (UTIs) and other sexually transmitted infections (STIs), for example, chlamydia.

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The midwife will ask whether the woman is experiencing any of the following (see Chapters 4, 11 and 13 where these public health issues are discussed in greater depth).

Domestic abuse: routine enquiry should occur at any opportunity the woman is on her own.

Mental health problems: Whooley questions have been developed to screen for any poten- tial mental health issues (NICE 2007).

Female genital mutilation (FGM): considerations for women of ethnic origin from countries where FGM practise is prevalent (Sub-Saharan Africa some SE Asian countries).

Lifestyle issues: such as diet, smoking, alcohol intake and/or other substance misuse (NICE 2010).

Women need to be informed of the differences between screening tests that determine a sta-

tistical possibility of a disorder occurring (for example Down syndrome) and diagnostic tests that provide definitive evidence of a condition (for example Rubella). Further information about screening tests for childbearing women and their babies can be accessed using the online UK National Screening Committee (NSC) (2014). Screening is offered to all women; however it is not mandatory that a woman accepts the screening offered. Women need to understand the implications of undertaking screening tests, in that, the end-point decision could be for her to consider termination of the fetus. She needs to understand these consequences if she already knows that she would ultimately not want to terminate her pregnancy; she may go ahead with screening tests as she may still want to know the risk potential, even if they carry on with the pregnancy.

Fetal anomaly screening aims to determine the potential for various inherited chromosomal disorders. The testing is most commonly known to screen for a ‘likelihood’ of the presence of Down syndrome. Screening provides a risk ratio of the condition; it does not diagnose the pres- ence of the syndrome (NSC 2014).

The national performance standard for Down syndrome screening is offered in the form of a combined test which includes ultrasound scanning for nuchal translucency and biochemical serum screening for hCG (human chorionic gonadotrophin) and PAPP-A, (pregnancy-associated plasma protein A). The optimal time for undertaking this screening is between 11 weeks to 13 weeks +6 days pregnant. The diagnostic tests for detecting a fetus with Down syndrome are chorionic villus sampling (CVS) where a small amount of placental tissue is removed under ultrasound guidance from 10 weeks of pregnancy, or amniocentesis where a small amount of amniotic fluid is removed under ultrasound guidance. If a woman reports later in pregnancy (between 15–20 weeks) the quadruple test, a blood test, will be performed to assess serum markers, namely hCG, inhibin A, AFP (alpha fetoprotein) and uE3 (oestriol).

Ideally, an initial scan takes place between 10 weeks 0 days and 13 weeks 6 days to provide accurate dating for the pregnancy; followed by a fetal anomaly scan for structural anomalies, normally between 18 weeks 0 days and 20 weeks 6 days (NICE 2008). Ultrasound scanning has been used for over 30 years and is not thought to do any harm to a fetus; however Marinac- Dabic et al. (2002) suggest that more research is required to evaluate potential risks of ultra- sound on the fetus. An ultrasound scan may identify a placenta praevia which could have serious implications for mother and baby. Therefore, closer surveillance and consultant guid- ance would be sought (see Chapter 16: ‘Emergencies in Midwifery’ where this is discussed in greater depth).

The midwife will have discussions with the woman who can access leaflets relating to the various screening tests – taking bloods for full blood count (FBC), blood group and Rhesus status, Hep B, HIV and Rubella. Sickle cell anaemia and thalassaemia screening takes place fol- lowing completion of the Family Origin Questionnaire which determines whether they are at risk. People of certain ethnic origins (e.g. Black African, Black Caribbean, and Black British are screened for sickle cell anaemia or if from high prevalence areas such as the Mediterranean and malaria areas). There is some suggestion of a genetic link in malarial areas providing a protective factor against sickle cell and thalassaemia). For more information visit the UK National Screening Committee website.

Blood group
– Information relating to A, B or O grouping is important if the woman becomes ill and requires a blood transfusion, so should be considered at any point of care where the maternal or fetal condition becomes compromised.

Rhesus factor
– for detecting potential for isoimmunisation. This would occur if a sensitisingincident occurred in pregnancy, for example a placental bleed, where there is the risk of fetal blood from a rhesus positive baby mixing with the maternal blood of a rhesus negative mother. This will stimulate the production of antibodies against rhesus D antigens, from the rhesus D positive blood of the baby, in the mother. If these antibodies then cross the placental barrier to the fetus, haemolysis can occur which begins to destroy the baby’s red blood cells, resulting in haemolytic disease of the newborn (HDN). This can result in severe neonatal jaundice and anaemia, which may result in the newborn baby requiring a blood transfusion.

Anti-D is recommended as a treatment option for all pregnant women who are rhesus Dnegative and who are not known to be sensitised to the rhesus D antigen (NICE 2008). In addition, the risk of sensitisation can be reduced by offering anti-D immunoglobulin if there is any risk of feto-maternal haemorrhage (FMH) during the pregnancy, e.g. termina- tion, abdominal trauma, antepartum haemorrhage, miscarriage or invasive procedures (NICE 2008). After birth the baby’s cord blood is tested to determine blood group and rhesus status. Postnatal prophylaxis of anti-D immunoglobulin is recommended to the woman if her baby is rhesus positive. This prevents sensitisation of the woman following birth to protect any subsequent pregnancies. As anti-D is a blood product, the woman should be informed to enable her to consider her choice about blood products and poten- tial transmission of blood-borne infections.

Full blood count
– primarily focuses on the haemoglobin (Hb) concentration, measured ing/dL, measuring the amount of oxygen-carrying protein. Alongside other features such as
127128mean corpuscular volume (MCV), red blood cell (RBC) count can give indications of different kinds of anaemias such as iron deficiency (microcytic, low haemoglobin concentration), or vitamin B12 deficiency (macrocytic) (Lab Tests Online UK 2013). The platelet count gives the number of platelets, per given volume of blood. Increases and decreases in platelets can indicate disorders of blood coagulation.

Developing a disorder – iron deficiency anaemia may be caused by malnutrition or poor

general wellbeing (or sometimes secondary to exposure to diseases such as malaria).

The elements described above continue to be part of an ongoing assessment and review,

forming the basis for midwifery antenatal care.

Table 6.1 outlines the schedule of appointments for routine antenatal care for women. In addition the ongoing growth and wellbeing of the fetus requires monitoring.

The schedule of appointments for routine antenatal care for women (adapted from NICE 2008; 2010 Guidelines)

Booking

first trimester

Physical and psychological assessment; consider both history and current findings