Care of the pregnant woman

Year 2 Lent term

The Case• 38 year old booked at 12 weeks gestation in

the antenatal clinic

• Expecting her third baby

• 1st baby 2.8kg (6lb 3oz) at term

• 2nd baby 2.4 kg (5lb 6oz) at term

• Smokes 20/day

• BMI 25

What investigations are routinely offered in antenatal care?

Investigations: blood

• Standard at booking: Hb, Blood group, antibodies, rubella antibodies, serum test for syphilis.

• Optional at booking: triple test, tests for hepatitis B, HIV

• Varies with units: random blood sugar

Investigations: ultrasound

• Dating scan

• ?nuchal scan (under development nationally)

• Anomaly scan

Nuchal screening

What are the risk factors in this particular case?

Risk factors

• Maternal age

• Past obstetric history of small babies

• smoking

Maternal age >35y increased risk for:

• Chromosomal abnormality

• Miscarriage

• Twin pregnancy

• Stillbirth

• Maternal morbidity: thrombosis; hypertension; gestational diabetes; placental abruption

Risks of smoking in pregnancy• Reduced fertility, ectopic pregnancy,

miscarriage

• Preterm labour

• Placental abruption

• Stillbirth

• Intrauterine restriction: dose related

• Cot death, infant respiratory infection, lower IQ

Smoking: the single most preventable cause of adverse

events in pregnancy

How would you manage this case?

Management of case

• Delivery in hospital unit with fetal monitoring and paediatric facilities

• Consider induction of labour with close fetal monitoring – timing may be decided from other parameters

How would you advise her if this was her baby’s growth chart?

Treatment plan• Refer (if willing) to smoking-cessation

programme

• Monitor fetal growth in third trimester using ultrasound- measure head circumference and abdominal circumference

• Biometric tests for fetal well-being: liqour volume, Doppler, cardiotocography

Despite your advise the patient requests to have her baby at

home

She sees the midwife, who goes through the checklist with her:

Is the midwife obliged to deliver this patient at home?

Yes, if she insists. Second midwife recommended as back-

up

Is the GP obliged to attend?

No unless in an emergency

Pain relief available at home?

Midwife can bring “Entonox” and give pethidine

Why is Syntometrine given?

Syntometrine

• 5U syntocinon 0.5mg ergometrine

• Given at delivery of anterior shoulder to constrict the uterus

• Helps prevent post-partum bleeding

Why is vitamin K given?

Vitamin K

• Given to the baby (usually IM)

• Helps prevent haemorrhagic disease of newborn from deficiency of clotting factors (immature liver)

Would you choose a home-birth?

http://www.dh.gov.uk/assetRoot/04/14/29/48/04142948.pdf