Oxford Handbook of Midwifery (47 page)

• Women of childbearing age with a BMI of 30kg/m
  ²
  or above should receive information and advice about the risks of obesity during pregnancy and supported to lose weight before conception.
  ⁵
  

  Pregnancy care
  

6 months of pregnancy and increase only slightly in the last 3 months (and then only by around 200cal/day).
⁵

for a consultation with an obstetric anaesthetist, so that difficulties with venous access, or regional or general anaesthesia can be identified. A management plan for labour should be discussed and documented.

Care during labour

CHAPTER 9
Pregnancy complications

178

• Women with a BMI of 40kg/m
  ²
  or above should have venous access established in early labour. These women should receive continuous midwifery care.
  
• Operating department staff should be informed early of any woman weighing greater than 120kgs who require operative delivery.
  
• Women with a BMI of 30kg/m
  ²
  or above should have an actively managed third stage of labour.
  

  Postnatal care
  

• Obesity is associated with low breastfeeding initiation and maintenance rates, so specialist advice and support should be offered both antenatally and postnatally.
  
• Early mobilization should be encouraged.
  
• Women with a BMI of 30kg/m
  ²
  or above should continue to receive nutritional and physical activity advice with a view to weight reduction. The 6–8 week post natal assessment can be a useful time to offer further support. This can continue to be followed up at 6-monthly intervals by the GP or other appropriate health professional.
  ⁵
  
• Women with a BMI of 30kg/m
  ²
  should have regular follow up by their GP for the development of type 2 diabetes.
  
• Women who develop gestational diabetes should receive annual screening for cardio-metabolic risk factors and receive advice on nutrition and weight management.
  

  Practical considerations
  

  Maternity units should have guidelines in place to facilitate care of women with BMI of 30kg/m
  ²
  or above with respect to referral criteria, facilities and equipment.
  

  The following are required:
  

• Large blood pressure cuffs
  

  •
  Sit-on weighing scale
  

• Large chairs and wheelchairs
  
• Ultrasound scan couches, ward and delivery beds
  
• Theatre trolleys and operating theatre tables
  
• Lifting and lateral transfer equipment.
  
  1. Centre for Maternal and Child Enquiries and Royal College of Obstetrics and Gynaecologists (2010).
     Management of Women with Obesity During Pregnancy.
     London: RCOG Press.
     
  2. NHS Information Centre (2008).
     Health Survey for England 2006: CVD and Risk Factors: Adults, Obesity and Risk Factors Children.
     London: NHS Information Centre. Available from: M www.
     ic.nhs.uk (accessed 22.2.11)
     .
     
  3. Lewis, G (ed.) (2007).
     The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer
     —
     2003–2005
     . The 7th report on Confidential Enquires into Maternal Deaths in the United Kingdom. London: CEMACH.
     
  4. Catalano PM (2007). Management of obesity in pregnancy.
     Obstetrics and Gynecology
     109
     , 419–33.
     
  5. National Institute for Health and Clinical Excellence (2010). Dietary interventions and physical activity interventions for weight management before during and after pregnancy. Guideline PH27. London: NICE. Available at : M
     http://guidance.nice.org.uk/PH27 (accessed 22.2.11).
     

  Medical conditions during pregnancy
  ‌‌
  

  Chapter 10
  

  179
  

  Asthma
  180
  

  Cardiac conditions
  182
  

  Diabetes
  184
  

  Epilepsy
  187
  

  Thromboembolic disorders
  188
  Principles of thromboprophylaxis
  190
  Thyroid disorders
  192
  

  

  Renal conditions
  194
  

  CHAPTER 10
  Medical conditions during pregnancy
  

  180‌‌
  

  Asthma
  

  Asthma is the most common chronic disease in children and young adults and is on the increase; 4–8% of pregnant women have asthma. The condi- tion is often underrecognized and suboptimally treated.
  ¹
  

  Effect of pregnancy on asthma
  

• Asthma tends to improve in pregnancy especially during the last
  

  12 weeks but it can be very variable, with some remaining stable and others worsening.
  

• Breathlessness due to the increasing size of the uterus is sometimes mistaken for worsening asthma.
  
• Many women experience a worsening of their symptoms because they stop taking their asthma medication because of concerns about the effects on the fetus.
  
• Women who deteriorate during pregnancy tend to have the most severe asthma.
  

  Effects of asthma on pregnancy
  

• Good control is essential for maternal and fetal well-being. Poor control is associated with pregnancy induced hypertension, pre- eclampsia, increased caesarean section, pre-term delivery, intrauterine growth restriction, and low birthweight.
  
• Asthma treatment during pregnancy is no different to that at other times and the inhaled medications are safe.
  
• Very little inhaled medication reaches the fetus.
  
• More harm is likely from withholding treatment than from continuing it.
  

  Management of asthma during pregnancy
  

• Objective monitoring of lung function.
  
• Avoiding or controlling asthma triggers.
  
• Patient education and individualized pharmacological therapy.
  

  •
  Those with persistent asthma should be monitored by peak expiratory flow rate, spirometry to measure the forced expiratory volume in 1s, or both.
  

• The ultimate goal of asthma therapy is maintaining adequate oxygenation of the fetus by prevention of hypoxic episodes in the mother.
  
• Asthma exacerbations should be aggressively managed, with a goal of alleviating asthma symptoms and attaining peak expiratory flow rate or forced expiratory volume in 1s of 70% predicted or more.
  
• Pregnancies complicated by moderate or severe asthma may benefit from ultrasound for fetal growth and accurate dating and antenatal assessment of fetal well-being.
  
• Asthma medications should be continued during labour, and the mother should be encouraged to breastfeed.
  

  1
  Dombroski MP (2006). Asthma and pregnancy.
  Obstetrics and Gynecology
  108
  , 667–81.
  

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  CHAPTER 10
  Medical conditions during pregnancy
  

  182‌‌
  

  Cardiac conditions
  

  Women with congenital heart disease are surviving to become pregnant in greater numbers due to advances in surgery and better management of care. Antenatal care is a complex issue and early referral to a specialist centre is advisable so that the specialist midwife, cardiologist, obstetri- cian, anaesthetist, fetal medicine specialist, haematologist, neonatologist and cardiac nurse can meet the woman to plan her care and review her progress regularly. This appointment should take place as early as possible as she is a high risk case and requires multidisciplinary care.
  

  Significance of cardiac conditions
  

• Congenital heart disease occurs in 0.8% of newborns.
  
• Advances in medical treatment and surgery have resulted in 85% survival rates.
  
• Cardiac disease is the leading cause of maternal death in the UK with 48 deaths in the last triennium.
  ¹
  
• Cardiac conditions have many implications for pregnancy due to the normal associated cardiovascular changes:
  
  • Peripheral vasodilation which is the body’s initial response to pregnancy.
    
  • Decreased peripheral resistance.
    
  • Increase in plasma volume by 50%.
    
  • Increase in RBCs of 20%—physiological haemodilution giving the impression of anaemia but is normal to pregnancy.
    
  • Cardiac output increases by 50%.
    

    Assessment
    

    This can be difficult as normal pregnancy symptoms mirror the symptoms of cardiac disease. The following are all associated with normal pregnancy, however the woman should be encouraged to report any new symptoms no matter how subtle:
    

    •
    Shortness of breath—dyspnoea, at rest or on exertion