Medical Disorders in Pregnancy

A Manual for Midwives

S. Elizabeth Robson, Jason Waugh, S. Elizabeth Robson, Jason Waugh

• Publisher: Wiley-Blackwell
• Year: 2013
• Print ISBN: 9781405151689
• eBook ISBN: 9781118712283
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

The need for joint medical and midwifery care is stressed in the latest CEMACH report, with a recommendation that contemporary midwifery education prepares midwives for problems in pregnancy and adverse pregnancy outcome. Pre-conception care for women with medical disorders has also been stressed.

Medical Disorders in Pregnancy is one of the first texts written specifically for midwives that provides an outline of common medical disorders that may be affected by pregnancy or which may cause pregnancy complications. For ease of use, all conditions are presented on two page templates, and each addresses: An explanation of the condition; Standard 'Non-pregnancy' treatment; Pre-conception care; Antenatal care; Intrapartum care, and Postnatal care. The management, treatment and care by both doctors and midwives are provided to allow a mutual understanding of each others roles and responsibilities.

1

MIDWIFERY CARE AND MEDICAL DISORDERS

S. Elizabeth Robson

Pre-conception Care

Antenatal Care

Intrapartum Care

Postnatal Care

General Considerations

Emergency Management

Preventing Maternal Mortality

1 Midwifery Care and Medical Disorders

INTRODUCTION

This chapter will give an overview of pre-conception, antenatal, intrapartum and postnatal care that would be given to a woman with a medical condition that either pre-exists or presents in pregnancy. The information here will not be repeated in each subject section, which will focus on the aspects specific to that particular medical disorder.

PRE-CONCEPTION CARE

In an ideal world all women would receive state-funded pre-conception care, however, about 50% of pregnancies are unplanned¹, and most women seek medical or midwifery attention once pregnant. For certain groups such as recent immigrants this first contact may happen late in the pregnancy².

For a woman with an existing medical disorder the need for pre-conception care is more pronounced, and early booking once pregnant is of paramount importance, as the disorder can affect the pregnancy and conversely the pregnancy can affect the disorder³. A woman with a previously well-controlled condition can become unstable with a domino effect on the pregnancy. Hence, such women should be advised to seek pre-conception advice from ‘mainstream’ medical or midwifery care prior to ceasing use of contraception.

In British practice a woman contemplating pregnancy may consult her general practitioner, practice nurse or midwife. Practice policies vary considerably⁴, but can be summarised as follows:

1) Nurse/midwife taking a history⁵ to ascertain:

• Medical, surgical, psychological or infectious conditions that could complicate a future pregnancy, including any current medications or treatment
• Family history of disease and handicap, including genetic history
• Vaccination status
• Substance use, e.g. alcohol, cigarettes and street drugs
• Past obstetric and gynaecological history
• Present employment – to identify occupational hazards
• Current diet and nutritional history
• Lifestyle, including diet and exercise

2) Nurse/midwife observations and medical examination for:

• Weight and height measurement for calculation of the Body Mass Index (BMI) (see Appendix 13)
• Baseline pulse, blood pressure, urinalysis measurement
• Pelvic examination to include a cervical smear and screening for infection such as Chlamydia
• Respiratory and cardiac function
• Other function screening – if history indicates
• Karotyping – if indicated by family history
• Blood samples for full blood count (FBC), VDRL and rubella
• If indicated, additional screening for TB, hepatitis B, HIV, chickenpox, cytomegalovirus and toxoplasma
• Haemoglobinopathy screening for women originating from: Africa, West Indies, Indian subcontinent, Asia, Eastern Mediterranean countries and the Middle East. If affected, partner screening should be offered with genetic counselling⁶

3) Interventions that are advocated:

• Folic acid: advise 0.4 mg daily¹
• Vaccination, such as rubella or BCG for TB, dependent upon aforementioned antibody titres
• Contraceptive cover while investigations and treatment are initiated

4) In relation to medical disorders, the doctor will usually:

• Act upon any anomalies detected in the baseline observations and order additional tests such as glucose tolerance test (GTT) and initiate treatment
• Refer the woman back to any specialist clinic and physician who has previously treated her; immigrant women may need referral for the first time.
• Review current drug therapy to identify those on drugs associated with teratogenic effects or contraindicated in pregnancy, and initiate change
• Increase the folic acid dosage for a history of neural tube defects, haemoglobinopathies, rheumatoid arthritis, coeliac disease, diabetes or epilepsy
• Prescribe suitable contraceptive cover whilst the above is addressed
• Initiate counselling about prognosis for both mother and prospective child

5) Specific advice, from a nurse/midwife, in relation to:

• Keeping a menstrual diary
• Pregnancy testing and need for early booking
• Perinatal diagnosis – practical aspects
• Smoking and alcohol cessation
• Street drug avoidance and cessation
• Over-the-counter medicines and therapies
• Domestic violence
• Stress avoidance
• Sport, exercise and general fitness
• Occupational hazards
• Animal contact and infection risk
• Food hygiene and hand washing
• Weight adjustment
• Health education initiatives and leaflets
• Patient organisations, e.g. Foresight, with additional options such as hair analysis for mineral deficiencies⁷

ANTENATAL CARE

Antenatal care on the British model has followed the same basis for much of the twentieth century⁸. A woman reports a positive pregnancy test to her general practitioner (GP) then has a ‘booking history’ conducted by a midwife. Options for place of care and delivery are discussed and the mother should be offered choice of birth at a consultant unit, low-risk birth centre or at home. Risk for childbearing will be taken into consideration to avoid inappropriate bookings which are associated with maternal death (see Appendices 1.1 and 1.2). The mother is referred to an obstetrician and may have one appointment at a consultant clinic. Responsibility for care is shared between GP and obstetrician, hence the term shared care. Most appointments occur in the community at the GP premises with the midwife actually conducting the majority of the antenatal care, referring to either GP or obstetrician if problems are identified. Specialist investigations, such as ultrasonography and amniocentesis are conducted at a consultant unit, often in conjunction with an antenatal or specialist clinic.

Variations on care exist, with Domino, case-holding midwifery, and team-midwifery schemes aiming for women-centred care with continuity of carer and a focus on normality. Women on such schemes should have normal, uncomplicated pregnancies and a significant medical condition precludes inclusion on such a low-risk scheme.

With few exceptions a mother with a medical condition will require pregnancy management and care with involvement of hospital consultants. Some mothers may need to have some of their antenatal appointments at a specialist antenatal clinic, or at other clinics that combine obstetric care with involvement from a physician. Examples of such combined clinics are for diabetes and renal problems.

Such mothers tend to fit into a risk category of variable or high risk. Here an assumption might be made, wrongly, that no midwifery involvement is necessary, and in recent times the numbers of midwives and student midwives at high-risk clinics appears to have reduced. Whilst it might seem cost effective to have an auxiliary nurse chaperoning at a clinic and performing manual tasks, the knowledge and skills of a midwife should not be denied to a mother because she has a medical disorder and has a stereotypical label of risk.

The mother requires midwifery care and should be given the opportunity to build a rapport with a midwife and to get continuity of care as she would on a midwife-led scheme. The care that the midwife gives should be complementary to that of the obstetricians and physicians, with the mother and fetus being the cherished focus of attention.

Booking

The midwife must take and document a detailed, accurate booking history¹⁰ which should encompass:

• Person...

Table of contents

• Cover
• Contents
• Title page
• Copyright
• Contributors
• Foreword
• Preface
• Acknowledgements
• Acronyms and Abbreviations
• 1 Midwifery Care and Medical Disorders
• 2 Skin Disorders
• 3 Hypertensive Disorders
• 4 Heart Disease
• 5 Respiratory Disorders
• 6 Renal Disorders
• 7 Endocrine Disorders
• 8 Neurological Disorders
• 9 Musculoskeletal Disorders
• 10 Gastrointestinal Disorders
• 11 Autoimmune Disorders
• 12 Infectious Conditions
• 13 Metabolic Disorders
• 14 Haematological Disorders
• 15 Thrombo-embolic Disorders
• 16 Addictive Disorders
• 17 Psychiatric Disorders
• 18 Neoplasia
• Appendices
• Chapter References
• Index