Oxford Handbook of Midwifery (28 page)

Management of thalassaemia major during pregnancy

Women who are asymptomatic before pregnancy may find the added stresses of pregnancy can cause deterioration of their health status. The more severe the syndrome, the more significant are the consequences for the woman and fetus.

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.

CHAPTER 4
Antenatal care

72‌‌

Antenatal examination

The purpose of the antenatal examination depends on the length of gesta- tion at which it takes place.

NICE has published guidelines for the routine care of women who are experiencing a healthy, low-risk pregnancy.
¹
The recommended number of scheduled appointments is determined by parity and the function of the appointment. For the primigravida with an uncomplicated pregnancy, 10 visits are adequate; and for the parous woman with an uncomplicated pregnancy, seven visits should be adequate.

Throughout the antenatal period, be alert to the signs and symptoms of conditions that affect the health of the mother and fetus, such as pre- eclampsia, diabetes, and domestic abuse.

• After the first appointment or booking visit, use the next visit to review, discuss, and document the results of all the screening tests undertaken earlier, and to identify women who need additional care.
  
• Arrange further investigations for a woman with a haemoglobin level of less than 11g/dL and offer iron supplementation.
  

  •
  At each visit, measure the blood pressure and test the urine for protein.
  

• At each visit, be prepared to ask questions, give information and discuss issues about the woman’s physical and emotional/psychological well- being; and to use the available time to provide education, supported by antenatal classes and written information.
  
• After 20 weeks, measure and plot the symphysis–fundal height to detect small or large for dates pregnancies.
  
• If requested by the mother, auscultate the fetal heart sounds by hand- held ultrasound.
  
• Offer anti-D prophylaxis to Rhesus-negative women at 28 and 34 weeks’ gestation.
  
• Offer a second screening for anaemia and atypical red cell antibodies at 28 weeks’ gestation. Investigate a haemoglobin level of less than 10.5g/ dL and provide iron supplementation if necessary.
  
• At 36–37 weeks’ gestation, confirm the lie and presentation of the fetus, and offer external cephalic version for women whose babies are in the breech position.
  
• If an earlier report showed the placenta extending over the internal cervical os, a further scan should be arranged and reviewed at 36 weeks.
  
• A further appointment should be arranged for women who have not given birth by 41 weeks, to offer a membrane sweep and induction of labour if this is unsuccessful.
  

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

  This page intentionally left blank
  

  CHAPTER 4
  Antenatal care
  

  74‌‌
  

  Abdominal examination
  

  An abdominal examination can be carried out at any stage of pregnancy and is used to determine the progress of pregnancy or labour and fetal well-being.
  

  The examination is in three parts: inspection, palpation, and auscultation.
  

  Ask for the woman’s consent before the examination. Make her comfortable on the examination couch, lying supine with her head supported by one pillow. Her arms should be relaxed by her sides. Expose her abdomen but use a sheet or towel to cover her pelvic area and legs, preserving her privacy and dignity.
  

  Inspection
  

• Inspect the abdomen for size and shape. In the primigravida the shape is oval, due to abdominal muscle tone. In the parous client, the shape may be more rounded.
  
• There may be a saucer-shaped depression below the umbilicus if the
  fetus is presenting in an occipito-posterior position.
  
• A heart-shaped uterus may indicate a transverse lie.
  
• The umbilicus may protrude and the linea nigra, which is the pigmented midline of the rectus sheath, may be apparent.
  
• Other abdominal scars may be apparent, as will striae gravidarum or stretch marks, which are pink at first turning to a silvery white as they age.
  
• Size should indicate the stage of pregnancy, which will be confirmed by measuring the symphysis–fundal height.
  
• Observe for fetal movements—this confirms a live fetus.
  

  Palpation
  

• Locate the fundus and measure and plot its height above the symphysis pubis (in centimetres).
  
• The measurement in centimetres should approximately correspond to the number of weeks’ gestation after 20 weeks. However, there is a
  

  wide variation of normal, due to maternal height, weight, and the length of the maternal abdomen. This does not have a proven predictive value in detecting small for gestational age fetuses.
  ¹
  

• The lie of the fetus is normally longitudinal, with the long axis of the fetus lying along the long axis of the mother.
  
• The presenting part is normally the fetal head. Breech presentation occurs in approximately 3% of pregnancies at term.
  
• Determine the position of the fetus:
  
  • The position of the occiput can be found by locating the fetal back, which feels smooth and firm and will lie anteriorly in the left or right side of the uterus if the occiput is anterior.
    
  • In posterior positions, the back may be felt in the left or right flank, or it may not be palpable. If fetal limbs are felt on both sides of
    

    the midline it is likely that the fetus is lying in an occipito-posterior position.
    

• Establish the relationship of the presenting part to the pelvic brim. The fetal head is engaged in the pelvis when the widest diameter of the fetal head has entered the pelvic brim.
  

ABDOMINAL EXAMINATION

75

Auscultation

recommended but, if the mother requests it, auscultation may provide reassurance.
¹

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.

CHAPTER 4
Antenatal care

76‌‌

Monitoring fetal growth and well-being

As part of the overall antenatal assessment, the midwife is responsible for monitoring the growth and well-being of the fetus. Maternal well-being is the best indicator of fetal well-being, so evaluate the mother closely, looking for any problems that are likely to affect the fetus; for example, hypertension, infection, diabetes, and environmental factors, such as smoking, substance misuse, and dietary inadequacies.
¹

• Ask about fetal patterns of movement and activity. All fetuses are active at some stage during a 24h period. The standard is to ask whether there are 10 movements in a 12h period. Ask about strength of movements. This may change towards the end of pregnancy as the fetus has less room to move about. Determine whether the mother is aware of all of the fetal activity.
  
• Most mothers tend to know their baby’s activity pattern well. Ask them to report any concerns, such as reduced activity especially after 40 weeks’ gestation.
  
• If, during an antenatal visit, a mother reports diminished or absent
  movements, listen to the fetal heart with a Pinard‘s stethoscope or
  

  ultrasound transducer, and reassure the mother. (
  Intrauterine death is
  

  an uncommon but possible occurrence. If you do not hear the fetal heart, explain this in an honest and sensitive way and make arrangements to confirm the absence of the heartbeat by ultrasound scan.
  )
  

• If a mother seeks advice over the telephone, you may want to arrange a cardiotocograph (CTG) of the fetal heart. This would be carried out in hospital and a non-reassuring trace referred to the obstetrician.
  
• Carry out abdominal examination at prescribed times, according to whether the mother has been assessed as low or high risk. A more accurate assessment of fetal growth can be obtained if the same person examines the mother on each occasion.
  
• Overall growth of the uterus is estimated and the fundal height measured in centimetres. This should correspond roughly to the number of weeks’ gestation, taking into account maternal height and build.
  
• Assess the volume of amniotic fluid surrounding the fetus and note increased or diminished amounts. Each pregnancy is assessed on its individual merits and over- or underproduction of amniotic fluid may be pathological or entirely innocent. If you are concerned, refer the woman to an obstetrician.
  
• When intrauterine growth restriction or large for gestational age fetuses are suspected, decide whether to refer for further investigation.
  
• A large for dates uterus may be due to a multiple pregnancy. The advent of routine dating scans has meant that multiple pregnancy is now diagnosed early unless there has been operator error or the woman has declined a scan.
  
• An ultrasound scan may be arranged, but take care not to make the mother overanxious. These conditions are often overdiagnosed, leading to much unnecessary worry for mothers.
  

MONITORING FETAL GROWTH AND WELL-BEING

77