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MIDWIFERY CARE AND MEDICAL DISORDERS
S. Elizabeth Robson
De Montfort University, Leicester, UK
Pre-conception Care
Antenatal Care
Intrapartum Care
Postnatal Care
General Considerations
Emergency Management
Preventing Maternal Mortality
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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, obesity or mental health problem 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. Adequate time is needed for the consultation and follow-up4.Practice policies vary considerably5, but can be summarised as follows:
(1) Nurse/midwife taking a history 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 13.1.1)
- 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
- Karyotyping – if indicated by family history
- Blood samples for full blood count (FBC), Venereal Disease Research Laboratory (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. Pregnancy should be avoided for 3 months after vaccination, and this applies to ‘holiday vaccinations’ such as cholera, typhoid and Japanese encephalitis.
- Contraceptive cover while investigations, vaccinations 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 a 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 regarding 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 a 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 Appendix 1.1). 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 in 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 hence 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 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 involv...
