pregnancy and care of the pregnant woman

Chapter 32 Confirming pregnancy and care of the pregnant woman

Learning Outcomes

After reading this chapter, you will be able to:

Confirmation of pregnancy

Many women of childbearing age who are sexually active may suspect that they are pregnant, especially if their menstrual period is delayed and/or other symptoms of pregnancy, such as nausea or vomiting, are experienced. Often, many women say that they ‘just feel different’. Women may choose to confirm their pregnancy either by using a home pregnancy test or by seeking diagnosis through their midwife or general practitioner (GP). Confirmation of pregnancy is established by a detailed history and a clinical examination based on the signs and symptoms of pregnancy, resulting from the physiological alteration in the body’s systems and organs. These include amenorrhoea; breast changes and tenderness; nausea and vomiting; increased frequency of micturition; enlargement of the uterus; and skin changes. These signs and symptoms become obvious to the woman as her pregnancy advances, but as some of these symptoms and signs may be found in other conditions not associated with pregnancy, it is important that the midwife is aware of these conditions, as she may need to refer the woman for further investigations or specialist advice.

Signs and symptoms of pregnancy may be considered as presumptive, probable and positive, as illustrated in Table 32.1.

Around 20 weeks

For 90% of women, nausea and vomiting have usually diminished by 22 weeks’ gestation (Lacroix et al 2000). The secondary areola, if not already present, may appear. The fundus of the uterus is normally palpated just below the umbilicus.

Laboratory diagnosis of pregnancy

Chorionic tissue, which later forms the placenta, starts producing the hormone human chorionic gonadotrophin (hCG), which is excreted in the urine. This hormone is usually detected in the urine from the time of the first missed period. Immunological tests depend on the detection of hCG in the urine. Pregnancy tests fall into three categories with varying sensitivities to hCG:

Direct latex agglutination tests (Fig. 32.1), where a small amount of latex particle reagent is placed on a dark glass slide; the latex particles are coated with antibodies which will bind to hCG. The reagent is milky in appearance, but when urine with hCG is added, the antibodies bind to the hCG, causing the particles to agglutinate. The liquid changes to a granular consistency, indicating a positive test result. Where no hCG is present, agglutination does not occur and the liquid remains milky (Wheeler 1999).

The wick or cassette method (Fig. 32.2). This may be a simple dipstick test with an absorbent wick on a cardboard or plastic backing, or a more sophisticated wick enclosed in a case to give a cassette-type test as with home pregnancy tests; it may also contain a control window. The absorbent wick is passed through the urine stream or dipped into the urine, or drops of urine are placed upon the sample window. Antibodies labelled with a coloured dye placed between the application area and the result area bind to the hCG. As the urine is absorbed, it travels along the wick to the result area – this appears as a coloured band. The excess urine moves further along the wick to the control panel, where it is bound to another antibody and a further coloured band is displayed. When hCG is present and the test is performed correctly, the result window and the control window will show coloured bands. If hCG is not present, no band will be visible in the result window, only in the control window. If the control window is blank, the test has not been performed correctly and should be repeated.

Up to 40 types of laboratory test kit are available in the UK (Wheeler 1999). These have a wide range of different sensitivities, from 20 to 1000 IU/L of hCG.

Home pregnancy tests have a more consistent range of sensitivity, from 25 to 50 IU/L, take from 1 minute to obtain a result, appear easy to use and manufacturers claim a 99% accuracy rate. However, an American meta-analysis of the efficiency, sensitivity and specificity of tests highlighted that the diagnostic efficiency of home pregnancy tests is affected by the characteristics of the users (Bastian et al 1998). False negative results arose from testing before the recommended number of days from the last menstrual period, or from a failure to read or follow the instructions. Therefore, a negative result in a woman who does not menstruate within a week should be treated with caution. The test should be repeated and laboratory confirmation sought if doubt of pregnancy exists.

The advantages of using home pregnancy tests are that they can confirm pregnancy in the privacy of the home. This enables a woman to be the first to have the information and it provides a quick result at an early point in the pregnancy. However, given the varying sensitivities of home and laboratory tests, it is possible that a woman may receive a positive diagnosis of pregnancy using a home pregnancy test and a negative result from a laboratory test. This may cause anxiety and confusion. If this happens, the midwife needs to ask the laboratory which test they are using and its sensitivity. A repeat test may then be requested, to confirm pregnancy. It is also possible that spontaneous miscarriage could have occurred between the two tests.

Following confirmation of pregnancy, women are encouraged to contact their midwife or doctor to commence their antenatal care.

Antenatal care

Over the past two centuries, antenatal services have seen major developments in terms of their provision and delivery. Contemporary antenatal services have quality at their heart, with patient safety, patient experience and effectiveness of care as their central tenets (DH 2008). All women seek a healthy outcome to their pregnancy; they want high-quality, personalized care coupled with greater information so that they can make informed choice about the place and nature of their care and are more in control of the care that they receive (Redshaw et al 2007).

The UK maternity services aim to provide a world-class service to women and their families, with the overall vision for the services to be flexible and individualized. Services should be designed to fit around the needs of the woman, baby and family circumstances, with due consideration being given to factors that may render some women and their families to become vulnerable and disadvantaged. Pregnancy is a normal physiological process for the majority of women. Women and their families need support to have as normal a pregnancy and birth as possible, with medical intervention being offered only if it is of benefit. However, in some circumstances, both midwifery and obstetric care are indicated and care should be based on providing good clinical and psychological outcomes for the woman and her baby (DH 2007a, DH & DfES 2004, NICE 2008).

Aims of antenatal care

The overall purpose of antenatal care is to work with women to improve and maintain maternal and fetal health by monitoring the progress of pregnancy to confirm normality and detect any deviation early so that corrective care can be provided. The aims of antenatal care are to:

Care during pregnancy

It is important that women seek professional healthcare early in pregnancy – that is, within the first 12 weeks of pregnancy (HM Treasury 2007, Lewis 2007, NICE 2008) – so that they can obtain and use evidence-based information to plan their pregnancy and to benefit from antenatal screening and health promotion activities (DH 2007a, DH & DfES 2004, NICE 2008). With early information about the available models of antenatal care, women, in partnership with healthcare professionals, can make decisions about the most appropriate pathway of their care best suited to their personal, social and obstetric circumstances.

Where women seek care at a later stage in pregnancy, they will have reduced access to antenatal care. It is likely that the woman will have reduced options in terms of antenatal screening tests. Some investigations, such as serum screening for Down syndrome (see Ch. 26), are accurate only if carried out at specific times, in this case between 15 and 18 weeks. Early detection of these conditions enables further investigations, such as ultrasound scan or amniocentesis, to be carried out at the optimum time.

Early access to antenatal care enables healthcare professionals to obtain baseline measures, facilitating accurate monitoring of the effect of physiological changes on vital systems and organs of the body and early detection of any complications. For example, the recording of the blood pressure in the first trimester of pregnancy provides a baseline against which the physiological changes in the blood pressure can be assessed. In some cases, complications may have already arisen by the time the woman seeks antenatal care.

The woman should be able to choose whether her first contact in pregnancy is with a midwife or her GP (DH 2007a). That said, antenatal services vary; in many parts of the UK, the first point of contact for maternity services is the woman’s GP (CHAI 2008, Redshaw et al 2007), but services are working towards the midwife being the first point of contact in the community setting.

To achieve the principles of antenatal care, pregnant women require evidence-based information. Evidence suggests that women desire accurate and timely information about pregnancy and childbirth so that they can develop their knowledge and understanding of pregnancy, childbirth and related issues, enabling them to make informed decisions about the care they want and prefer (Bharj 2007, Kirkham & Stapleton 2001, Mander 2001, Singh & Newburn 2000). Women need information which is based upon current evidence that is clearly understood and in a format they can easily access. When offering information, healthcare professionals must take into account the requirements of women who have physical and sensory learning disabilities and women whose competence in speaking and reading English is low, exploring appropriate ways of exchanging meaningful information.

Midwives are key healthcare professionals who work with women to support them to make informed choices regarding preferred arrangements for antenatal care, place of birth and postnatal care. Midwives should be friendly, kind, caring, approachable, non-judgemental, have time for women, be respectful, good communicators, providing support and companionship (Bharj & Chesney 2009, Nicholls & Webb 2006). These attributes are essential for the development of the woman–midwife relationship. Many worldwide studies highlight that all women perceive the woman–midwife relationship to be central to their pregnancy, childbirth and postnatal experiences (Anderson 2000, Bharj 2007, Davies 2000, Edwards 2005, Kirkham 2000, Lundgren & Berg 2007, Walsh 1999). Midwives therefore play an essential role in the life of women during their most significant period and have the power to either augment or mar women’s experiences of pregnancy and childbirth.

Outline of present pattern of maternity services in England

There are a wide range of models of care operating across the UK because of the geographical and demographic variations (Green et al 1998, Wraight et al 1993). The organization of maternity services varies throughout the UK. The maternity and obstetric units are formed as a part of larger district or regional general hospitals and the maternity and midwifery services are normally provided through such units and are integrated within the community and hospital. Midwifery units are designed and staffed according to the birth rates, therefore, the sizes of the units are variable dependent on the birth rates. Some NHS hospitals provide tertiary maternity and neonatal services for part of the regions. Generally, midwifery staff are employed by an acute maternity unit and may work either in the community or in the hospital, or, in some models of care, in both.

Birth settings

There are four different birth settings: ‘consultant-led obstetric units’ (CLU), ‘midwifery-led units’ (MLU), ‘home’, and ‘free-standing maternity units’ (FMU) (Hall 2003) (for choices of place of birth, see Ch. 34). CLUs are usually attached to the district or regional units and deliver care both for women who have complex healthcare needs and for those with no complications of pregnancy, labour and birth. CLUs are staffed by midwives and obstetricians. Women are normally referred to an obstetrician who becomes the lead professional for the duration of their childbirth continuum. Women with complex healthcare needs may access all their care in the antenatal, intranatal and postnatal period within these settings.

Some women with less complex healthcare needs may access some of their care in the hospital setting and some in the community setting. Some women who have had uncomplicated pregnancies and who are at low risk of developing complications during labour and/or birth choose to labour and birth within a CLU with a midwife as lead professional rather than an obstetrician. A full range of obstetric facilities (such as anaesthesia, surgery, blood transfusion and neonatal intensive care) are readily available in CLUs.

MLUs, sometimes known as ‘low-risk maternity units’ (Hall 2003), are often located close to, but separate from, CLUs. These units normally aim to provide care to women with uncomplicated pregnancies; the women, however, have to meet the criteria for the unit throughout pregnancy, labour and birth. MLUs are staffed predominantly by midwives, although they may be jointly run by midwives and GPs. If a deviation from normal is detected during pregnancy, labour or birth, the woman will be referred to an obstetrician, or, if appropriate, a GP, and may have to transfer place of care to the CLU. Normally, women access the majority of their antenatal care in the community setting with minimal care in the hospital setting.

Women may choose to have their babies at home instead of a hospital setting (see Ch. 34). Each of the midwifery units in the UK has its own arrangements for providing a home birth service and its own guidelines and attitudes towards these. The provision of this service depends on local resources, local practices and policies, and the beliefs, skills and commitment of individual practitioners providing the service. Women who choose to have a home birth are normally given care in the community by the lead professional who may be either a midwife or GP. In circumstances where the maternity needs of the woman cannot be managed in the home setting, then she and/or her baby is transferred to the nearest CLU.

The purpose of the FMUs is to offer a ‘home-like’ environment within an institutional setting. The philosophy and the kind of care offered by an FMU are very similar to those of the MLUs and the main difference is that the FMU is geographically situated away from the CLU. Generally, women who access care at these settings have to fit in with the guidelines and protocols of these units and are normally those women who are less likely to require interventions. Should an intervention be required for a woman, a decision will need to be made about transferring to the CLU.

To meet the maternity needs of the local populations, two things have happened concomitantly in some areas of England. The move to centralize maternity services has seen a number of mergers and, at the same time, there have appeared a small number of new community units or birth centres to provide a limited service for women who would otherwise have to travel long distances to have their babies in large obstetric units (for example, see Kirkham 2003).

Team midwifery

Maternity services for women in the NHS are normally provided by a multiprofessional team comprising community midwives, GPs, and hospital-based midwives or doctors in the antenatal period and usually by hospital-based midwives or doctors in the intrapartum period (unless they have a home birth) and by midwives and the GPs in the postnatal period. However, many maternity units are maximizing a multiprofessional approach to service provision and delivery and are collaborating with other relevant healthcare professionals to develop a multi-agency integrated care pathway, involving shared care, for example, with the drug and alcohol treatment services. This collaborative approach to care has improved the experience and outcome for women and babies.

A variety of approaches to team midwifery are emerging; they strive to provide choice and continuity and these include team midwifery normally based in the community, one-to-one midwifery practice care for women (Green et al 1998, Page et al 2000), that is, a complete episode of care from the booking interview to transfer to the health visitor following birth, including intrapartum care. Other approaches include caseload midwifery, or, as it is sometimes referred to, midwifery group practice. This comprises a small number of midwives organized into a team who are responsible for the delivery of full range of maternity care (SNMAC 1998). The midwives in the team are each responsible for approximately 30–40 women in a year.

While many parts of the UK have some sort of team arrangement for providing maternity services, these teams may vary from two or three midwives to over 30. There is no agreed definition of teams (RCM 2000, SNMAC 1998, Wraight et al 1993) though teams are responsible for providing care in the hospital setting, community settings, or both. There are four possible options of care:

The type of care offered is dependent on the health needs of the woman and local practices and protocols. Where women do not have any perceived complications in the antenatal and intrapartum period, they may choose to have all their care in the community setting or a mixture of both community and hospital. However, those women who have or develop complications in pregnancy or the intrapartum period access services in the hospital setting.

Increasingly there are developments where the NHS is collaborating with the local authority to offer maternity services from children’s centres. In addition to this, some midwives are seconded to specialist outreach services, particularly Sure Start (integrated health, education and welfare support services for children under 4 and their families) and smoking cessation services.

In many areas, antenatal day assessment units have been developed to provide outpatient care. In circumstances where complications arise, such as moderate pregnancy-induced hypertension, the pregnant women can be referred to the antenatal assessment unit, where her and her baby’s health may be assessed and monitored. Referral to such units can be made by the women themselves, by midwives or by other healthcare professionals.

Domiciliary in and out scheme (DOMINO scheme)

A domiciliary in and out scheme (DOMINO scheme) is offered in some areas for women who wish for community-based care (Wardle et al 1997). Within this model, antenatal care is delivered by a community midwife as it would be for a home birth. The community midwife provides care at home during labour, and continues care when the woman is transferred into hospital for birth. Following birth, the woman and her baby, when healthy, are transferred home with postnatal care provided by the community midwife.

Place of birth

During pregnancy, women need unbiased information to consider where they wish to give birth. This is discussed in more detail in Chapter 34. The most common place of birth continues to remain the hospital setting and the rate of home births has not changed significantly over the past few decades, despite calls for increasing women’s choice in the place of birth (DH 2007a). Although the rate of home birth remains low, there are marked geographical variations. This appears to depend on midwives and doctors supporting the idea of healthy women having their babies at home. Where this was the case, the numbers of women having home births increased (Sandall et al 2001).

Pattern of care

Historically, irrespective of their personal needs, individual risk status or parity, all pregnant women were encouraged to routinely attend an antenatal clinic every 4 weeks up to 28 weeks’ gestation, then 2-weekly up to 36 weeks, and then weekly thereafter. Evidence in the 1980s suggested that healthy women were at no greater risk of maternal or perinatal mortality if they attended fewer antenatal visits than the historical pattern of care (Hall et al 1985) and in 1982 the Royal College of Obstetricians and Gynaecologists (RCOG) recommended that maternity care providers should reduce the number of antenatal visits for women who do not have any complications of pregnancy from the historical pattern of 14–16 visits for all women to five to seven visits for multiparous women and eight or nine visits for primiparous women (RCOG 1982). This recommendation was not widely implemented until it was reiterated in the ‘Changing childbirth’ report (DH 1993), where it was suggested that many existing maternity care practices, such as the frequency and timing of antenatal care, had continued as a result of tradition and ritual rather than as a result of evidence of effectiveness. More recently, the NICE guidance (2008) recommended that for nulliparous women with uncomplicated pregnancies, ten antenatal appointments ‘should be adequate’, and that for parous women with uncomplicated pregnancies, seven antenatal appointments ‘should be adequate’. However, 25% of women have reported receiving fewer than the recommended number of antenatal visits (CHAI 2008). Whilst it is acknowledged that a reduction in the frequency of antenatal appointments does not result in an increase in adverse biological maternal and perinatal outcomes (Villar et al 2001), it is not clear whether a reduction in the frequency of antenatal visits affects women’s satisfaction with antenatal care and the social support that they may require. Nevertheless, it is essential that the number of antenatal visits should be tailored to meet women’s individualized health needs instead of attending antenatal appointments in a ritualistic pattern.

Throughout the childbearing period, all women should be provided with the opportunity to discuss issues and to ask questions (NICE 2008). To enable women to make informed choices about their care, midwives need to work in partnership with women and their families to develop and maintain relationships based upon effective communication skills, empathy and trust (Berry 2007). To communicate effectively and discuss matters fully with women, antenatal appointments need to be structured in such a way as to ensure the woman has sufficient time to make informed decisions (NICE 2008) and midwives need to develop the knowledge required to ensure they are able to offer up-to-date, consistent, evidence-based information and clear explanations, using terminology that women and their families are able to understand. Adjustments may need to be made to ensure that women with additional communication needs are able to access information in a format they are able to understand. This may include using interpreters, online resources or DVDs as well as leaflets and books to support discussions.

The first antenatal visit

The first antenatal visit and taking of the woman’s history may occur in the woman’s home, a health centre or GP surgery, or at the first visit to the hospital antenatal clinic. If a combined approach is taken, this will reduce the visits that the woman may have to make.

Women may feel apprehensive at their first visit, especially if they have not previously met the midwives or medical staff. Good communication skills and a non-judgemental attitude are important to enable women to feel at ease in discussing very intimate personal details. A warm, friendly greeting and a pleasant, comfortable environment can also help to put women at their ease. Whilst many women may be rather apprehensive at the first visit, young teenagers, women who are less proficient in speaking English and those who are unhappy about their pregnancy may feel especially vulnerable. Interpreters are required for women who have limited fluency in speaking English and, where possible, such women should be given information in formats that enable them to access and understand the information easily – for example, written information in their own language, audiovisual tapes or in braille. In many large cities where the number of teenage pregnancies is high, special ‘teenagers’ clinics’ or clubs may be provided to meet their particular needs.

Whatever the background of the woman, or her reactions to her pregnancy, building a positive relationship with her is one of the midwife’s most important aims during this first antenatal visit. This provides a foundation upon which the trust between a midwife and a woman will be built during the rest of the pregnancy. The woman needs open communication with a midwife who is well informed and committed to supporting her as an individual, encouraging the development of mutual respect, trust and partnership (Nicholls & Webb 2006, Redshaw et al 2007). There is growing evidence of women’s views of the maternity services that consistently highlights the importance of the quality of the women’s relationship with their midwife and the importance of this relationship in their satisfaction levels (CHAI 2008, Redshaw et al 2007).

The importance at the beginning of the interview is for the woman to establish confidence in the midwife, and so the purpose and process of the interview and issues such as confidentiality must be addressed initially. The woman needs to understand the midwife’s professional responsibilities, in terms of information which may be shared, and which may need to be discussed with other members of the team. Similarly, the midwife needs to ensure that a woman’s request that information is kept confidential is respected.

History taking

When the history is taken at home or in a community clinic, the woman is likely to be more at ease. If the interview takes place in the hospital, the midwife should prepare the interview room to be as pleasant and non-clinical as possible in order to facilitate communication and the development of a relationship of mutual trust. The midwife must also provide privacy and sufficient time for the interview, and make this clear to the woman.

During early pregnancy the woman may be experiencing nausea and fatigue and will appreciate not having to travel to attend a busy clinic amongst strangers. Any problems can usually be discussed in private and the midwife can give information and offer advice as appropriate. When other members of the family are present during this initial assessment, this gives the midwife the opportunity to meet them, but she should also be sensitive that there may be information that the woman considers private or confidential and would prefer not to discuss in their presence. Some time alone spent between the midwife and woman is essential and this should be facilitated.

The interview should be a two-way process of interaction between the woman and midwife. It involves assessment of the woman’s social, psychological, emotional and physical condition as well as obtaining information about the present and previous pregnancies, and the medical and family history. Care can then be planned in conjunction with the woman to meet her specific needs and wishes.

An antenatal booking interview should comprise more than merely recording an obstetric history; it should be about communicating information and promoting a relationship between the woman and the midwife (Methven 1982a, 1982b). Factors conducive to a more relaxed atmosphere and which promote communication should be considered, for example, the environment of the setting where the history is going to be taken, arrangements of the furniture in the room, body language and interpersonal skills. A few minutes spent by the midwife in introducing herself and talking informally enable the woman to settle down and relax before personal issues are discussed. A skilled midwife can elicit most of the information required from the woman in a pleasant conversational manner without the woman realizing that she is being closely questioned. Open rather than closed questions should be employed because these encourage free responses and promote two-way interaction between the woman and midwife. During the interview the midwife should be sensitive to the woman’s attitude to her pregnancy and, if possible, to that of her partner. Unusually adverse attitudes and body language should be noted and counselling and support given as required.

Personal details

The woman’s full name, marital status, address, telephone number, age, date of birth, race, religion and occupation (and that of her partner) are accurately recorded. Information regarding the woman’s marital status is elicited to determine if the woman is in a stable relationship or if the woman is alone and may need additional support from the midwife and other agencies.

The woman’s ethnicity is ascertained because some medical and obstetric conditions are more likely to occur in certain ethnic groups and appropriate diagnostic tests are required. However, asking about ethnicity is complex (Dyson 2005) and midwives need to develop competence in accomplishing this sensitively. The religion of the woman is recorded because of the special requirements and rituals which may be practised and affect the mother and her baby. Occupation gives an indication of socioeconomic status. Women in socioeconomic groups IV and V (see website) may experience social and economic inequalities. These wider determinants of health coupled with poverty are most likely to adversely affect their or their fetus’s/baby’s health and clinical outcomes (Lewis 2007, Palmer et al 2008). The midwife needs to work with other agencies to provide the woman and her family with appropriate support to promote and improve her health.

Present pregnancy

The date of the first day of the last menstrual period (LMP) is ascertained, care being taken to check that this was the last normal menstrual period. Some women have a slight blood loss when the fertilized ovum embeds into the decidual lining of the uterus and many mistake this for the last period. Pregnancy has been assumed to last 280 days, and to overcome the irregularity of the calendar a working rule of thumb was devised by Naegele. By counting forwards 9 months and adding 7 days from the first day of the last normal menstrual period, it is possible to arrive at an estimated date of delivery (EDD); alternatively, count back 3 months and add 7 days. This method of calculating the EDD is known as Naegele’s rule. However, as February is a short month and the remaining months have 30 or 31 days, from 280 to 283 days may be added to the date of the LMP. Rosser (2000) states that it is unclear whether the length of pregnancy is affected by social, ethnic or obstetric factors. It is important to explain that it is quite normal for the actual day of delivery to be up to 2 weeks before or after the EDD.

Details of the woman’s menstrual history should be sought: the age at which menstruation began; the duration of the periods; and the number of days in the cycle. Conception occurs shortly after ovulation. With a regular cycle of about 28 days, the standard calculation is reasonably accurate to within a few days, provided that the woman knows the date of her last normal menstrual period.

In a 35-day cycle, however, ovulation would occur 21 days after the period; in a 21-day cycle, only 7 days after. Adjustments may be made, therefore, when the woman has a regular long or short cycle. If the cycle is long (for example, 33 days), the days in excess of 28 are added when calculating the EDD (Table 32.2). With a regular short cycle, such as 23 days, the number of days less than 28 is subtracted from the EDD.

Table 32.2 Calculation of the EDD

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Jun 18, 2016 | Posted by in MIDWIFERY | Comments Off on pregnancy and care of the pregnant woman

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