Oxford Handbook of Midwifery (25 page)

for, and to result in decisions being made about the future of the pregnancy.

could be invoked to provide care that is in the best interests of the

client. Paternalism may be justified in any number of circumstances, notwithstanding the limited mental capacity of the client.

1. Grayson A (1996). Fetal screening. The triple test decision.
   Modern Midwife
   6
   (8), 16–19
   .
   
2. Marteau TM, Drake H. (1995). Attributions for disability: the influence of genetic screening.
   

   Social Science and Medicine
   40
   (8), 1127–32.
   

   CHAPTER 4
   Antenatal care
   

   56‌‌
   

   Screening for risk in pregnancy
   

   Risk screening during pregnancy aims to identify those women at risk, so that a suitable pattern of care can be planned for the pregnancy with the appropriate professional.
   

   For women deemed to be healthy and at low risk, midwife or midwife/ GP care, based in the community, is a suitable alternative to consultant- or hospital-based care programmes.
   

   Assessment of risk should be ongoing, so that deviations from the normal or the development of complications can be identified at any stage of pregnancy and referral to appropriate care arranged. This assessment starts at the booking interview or initial appointment. For many women this takes place in their own home and is conducted by the community midwife.
   

   Women with any of the following need care over and above that recommended for low-risk healthy women by the NICE guidelines:
   ¹
   

   • Cardiac disease including hypertension
     
   • Renal disease
     

     •
     Endocrine disorder or diabetes requiring insulin
     

   • Psychiatric disorder (on medication)
     
   • Haematological disorder (including thrombo-embolic disease)
     
   • Epilepsy requiring anticonvulsant medication
     
   • Malignant disease
     
   • Severe asthma
     
   • Drug misuse (heroin, cocaine, ecstasy)
     
   • HIV or hepatitis B
     
   • Autoimmune disorders
     
   • Obesity: BMI 30kg/m
     ²
     or above (or underweight – BMI <18kg/m
     ²⁾
     
   • Women at higher risk, e.g. age >40 or <14 years
     
   • Women who are particularly vulnerable or who lack social support.
     

     Women who have experienced any of the following in previous pregnancies are at higher risk:
     

   • Recurrent miscarriage (three or more)
     
   • Preterm birth
     
   • Severe pre-eclampsia, eclampsia, or HELLP syndrome
     
   • Rh isoimmunization or other significant blood group antibodies
     
   • Uterine surgery—caesarean section, myomectomy, or cone biopsy
     
   • Ante- or postpartum haemorrhage on two occasions
     
   • Puerperal psychosis
     
   • Grand multiparity (>6)
     
   • A stillbirth or neonatal death
     
   • A small for gestational age infant (<5th centile)
     
   • A large for gestational age infant (>95th centile)
     
   • A baby weighing <2.5kg or >4.5kg
     
   • A baby with a congenital anomaly (structural or chromosomal).
     

1
National Institute for Health and Clinical Excellence (2008). Antenatal care: Routine care for the healthy pregnant mother. Clinical guideline 62. London: NICE. Available at: M www.nice.org.
uk/cg62.

ANTENATAL SCREENING

57‌‌

Antenatal screening

The Department of Health has published standards to support the UK Antenatal Screening Programme on screening for infectious diseases in pregnancy.
¹
These standards are both generic and specific and are part of a wider initiative to establish a quality assured national screening programme. Responsibilities in the trust/strategic health authority, clinic, or laboratory are clarified in the standards. The information below con- centrates on the responsibilities at clinical level.

Generic standards for infectious diseases

All pregnant women are offered screening for rubella antibody, syphilis, HIV, and hepatitis B as an integral part of their antenatal care during their first and all subsequent pregnancies. Repeat testing during pregnancy is not usually necessary. The women have a right to decline screening.

Pregnant women arriving in labour who have not had antenatal care elsewhere are to be offered screening, priority being given to HIV and hepatitis B, and presumptive action is taken on a preliminary positive result

until such time as the result is confirmed. If an HIV test result will not be
available in time, appropriate preventive measures should be offered. Use

of rapid test devices may be appropriate in this context.

Screening is only performed with documented consent, though this does not require a signature from the patient and the usual standards of confidentiality apply.

Screening for rubella antibodies

1
Department of Health (2003). Screening for infectious diseases in pregnancy: Standards to support the UK Antenatal Screening Programme. Available at: M
www.dh.gov.uk (accessed 2.4.10).

CHAPTER 4
Antenatal care

58‌‌

Screening for syphilis

Syphilis can seriously complicate pregnancy and result in spontaneous abor- tion (commonly at around 18–20 weeks’ gestation), stillbirth, intrauterine growth restriction, and perinatal death.

• Antenatal screening for syphilis is well established, forming part of the routine screening of all pregnant women during the first or early second trimester.
  
  • As the prevalence of this infection is very low, continuation of the screening programme has recently been questioned, notably by Kiss
    et al
    .
    ¹
    whose survey of the prevalence in Austria seemed to suggest no economic benefit from universal antenatal screening.
    
  • Connor
    et al
    .
    ²
    carried out an epidemiological survey in the UK which suggested that targeting the screening to at-risk groups or stopping the screening programme would save relatively little money, and recommended that the current universal antenatal screening for syphilis should continue.
    
• Women who are at risk will be retested in the late second to early
  third trimester, as infection acquired during pregnancy still poses a
  

  significant risk to the fetus.
  

• Women who screen positive for the Venereal Disease Research Laboratory (VDRL) test will have this result confirmed by retesting with a
  Treponema
  -specific assay (
  Treponema pallidum
  

haemagglutination test, TPHA test) and will be treated with antibiotics such as amoxycillin.

1. Kiss H, Widhalm A, Geusau A, Husslein P (2004). Universal antenatal screening for syphilis: is it still justified economically? A 10-year retrospective analysis.
   Eur J Obstet Gynecol Reprod Biol
   112
   (1): 24–8.
   
2. Connor N, Roberts J, Nicoll A (2000). Strategic options for antenatal screening for syphilis in the United Kingdom: a cost effectiveness analysis.
   J Med Screen
   7
   (1): 7–13.
   

HIV SCREENING

59‌‌

HIV screening

Pregnant women should be offered screening for HIV infection early in antenatal care because appropriate antenatal interventions can reduce mother-to-child transmission of HIV infection. A system of clear referral paths should be established in each unit or department so that pregnant women who are diagnosed with an HIV infection are managed and treated by the appropriate specialist teams.
¹
The Department of Health
²
has pro- duced guidelines for the management of HIV screening during pregnancy and the following information is taken from this report.