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Archive for the ‘Pregnancy’ Category

Looking at the mothering, pregnancy, childbirth forums reveals a fair number of members posting the question ‘I’ve got my first visit with the midwife, what will happen?’. I’m going to answer that now, sort of. My slight hesitation is due to the vagaries of how care is provided, everywhere has slight, in some cases major, differences but the interchange of information between the midwife and the pregnant woman will remain the same.

Differences –

  • In some areas the midwife will be the first port of call
  • In other areas the G.P will be the first contact regarding the pregnancy
  • The ”booking’ may be done at home, at the G.P’s, in a Childrens Centre or at the hospital
  • Weirdly, some hospitals have group booking sessions. No idea how this works, confidentiality and all that, most bookings are the midwife, the woman and any other person she consents to have present

Remember that you are entitled to paid time off work for all appointments associated with your pregnancy.

So, you and the midwife have arranged to meet, you are between 8 – 12 weeks pregnant, expect to spend at least 45 minutes on this meeting. You may have been provided with a pack containing booklets and leaflets prior to the meeting, make sure that you have read them as they may provide you with important information about local maternity units, screening tests, diet etc. The pack may also have a blank copy of your maternity notes, if it does then you can make a start filling them in with your name and other personal details. Having read through the information make a note of any questions you want answers to and also any concerns you may have.

Right, so you meet the midwife. She will have lots of questions for you; your previous medical history; about any previous pregnancies; your close family’s medical history regarding diabetes, high blood pressure, miscarriages, stillbirths and also baby’s born with hereditary conditions, abnormalities some of this will also be about baby’s father. Other questions will be about work, alcohol, smoking, recreational drug use, ethnic origin, contact with Social Services and, obscurely, highest educational qualification. At some point screening for Downs Syndrome will be mentioned. The midwife will ensure that you understand all about the tests available and how to access them if you want the screening.  Some areas arrange these for you and some will provide you with the necessary numbers to call. Screening should be available to all on the NHS, you should not have to pay. The midwife will also explain about the blood tests we feel are necessary during pregnancy, she may ask if she can take the blood at this time. There will also be a discussion about where you would like to have your baby, what facilities are offered and the possibility of using a birth unit or having a home birth.

Having listened to your health and social  history the midwife will assess how your care will be provided, whether at this time you fall into the group classed by the hospital as low-risk or whether you need to be seen by an obstetrician. Whichever group you fall into, by the time the midwife leaves you should know the plan for your care and where and when you need to be seen during your pregnancy. At this early time it is difficult to be exact, the midwife can only guesstimate to within 2-3 week windows when the scans will be, and who knows when the consultant appointment will be if you need to see them but she will write down the weeks of pregnancy when you need to be receiving antenatal care and how the appointments are made for these. Information will also be given about the local provision for parentcraft/antenatal classes and contact details given for accessing them. You will also be given the contact details for your midwife and/or her team plus all the local maternity unit numbers.Other topics will include your employment rights during pregnancy, diet, exercise, domestic violence and smoking cessation, you will also receive your form which entitles you to free prescriptions during the pregnancy and until baby is 1 year old. Data protection will be highlighted and the fact it has been discussed will be recorded. I do not discuss labour at this point if it is the first baby but I do cover it following attendance at parentcraft classes and as the end of pregnancy approaches but some midwives may talk about it at this time.

The midwife may test your urine at this time and in some areas a urine specimen will be sent off to be screened for underlying infection. Your blood pressure will also be recorded, along with your weight and height and your BMI calculated. Listening to baby’s heart? Highly unlikely before 12 weeks as baby is still very small and is hidden down below the pubic bone.

By the end of this you may well be suffering from information overload but don’t worry as the midwife will have written everything down in your notes and/or left you leaflets about different topics so you can recap at your leisure!

Here is a link to the NICE Guidelines on Antenatal Care which provide the basis on which your care will be organised.

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Thumb twiddling

Yes, that’s right, junior has still not put in an appearance. After the hustle and bustle of last Tuesday everything has gone very, very quiet. Tension has been mounting. It’s Mummy and Daddy are devoid of finger nails and this Nanny is certain that the grey will soon start to overcome the purple hair dye. After much agonising over how to approach the problem I rang the consultant clinic and discussed the situation with the lead midwife. She was as flummoxed as me and decided that the best way forward would be for the obstetrician to see DIL, which he did within 4 hours. A scan revealed that baby is head down, a doppler indicated that the placenta is still behaving in a healthy fashion, an internal examination showed that things were still as they were last week, ie the cervix is 5cms dilated, thin and stretchy and the baby’s head is still 3 cms above spines. The plan? Wait and see. DIL has another appointment in  a week at which point they will discuss induction of labour.

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I received this email a few days ago
 
Hi – I’ve just had a terrible experience with EasyJet (which I assume is the airline you refer to in your blog about the F2F certs). They allowed us to board on the way out with a doctor’s letter from 3 weeks previous to the date of our flight, but on the way back denied us boarding, as the letter was ‘out of date’.

Nowhere on their terms and conditions have I been able to find anything to suggest that there was a time-limit for such letters/certs. You refer to a 5 day rule, but I haven’t been able to find that anywhere. Can you point me in the direction of this ‘rule’?

I followed the link I had provided in the relevant post, and soon found that EasyJet have changed their policy and now the low-cost airline are demanding the professional be more specific – 

“When travelling between 28 – 35 (inclusive) weeks a medical certificate issued by a doctor or midwife confirming the number of weeks of pregnancy is required confirming that the passenger is fit to fly. It is important that the certificate covers the date (dates) of your travel.”

Well, as a result I can confidently assure any of my women who are travelling with EasyJet that I wil be unable to provide a cerificate which will be accepted by that airline. I am happy to provide a letter which states that, in my opinion, on the day I examined the pregnant woman she was fit to fly. I will never, ever provide a letter or certificate which says that 2 weeks after I have seen a woman, and following what may be a hectic, tummy bug filled holiday, the situation will remain the same and she will still be fit to fly. In fact, my advice will be to fly with a different airline!

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I’m going to have a new grandchild, all being well, some time in June. I’m being non-committal about dates as there is some disagreement between scan dates and EDD by first day of last period. This situation is not unusual, the majority of my women will arrive at clinic following their dating/nuchal scan with a date a due date a few days earlier or later than the one arrived at by naegel’s rule. There in lies the first dilemma, the scan date is 3 weeks later than calculated using an obstetric calculator. At this point I generally discuss longer cycles with the parents, I started out doing this but was cut off at the pass by son pointing out to me that all the measurements were indicating a fetus whose size was above the top line. We waited for the 20 week scan, same story, big baby estimated as being due 3 weeks later than DIL’s dates. Due to DIL’s low BMI there was another scan at 28 weeks  just in case baby was not growing well. No worries there though as baby was once again on the top line. I’m a little piggy caught in the middle. I know that scans are generally accepted as being more accurate than LMP, however they can be wrong and it’s not surprising really as the measurements used are so small initially that a slight malpositioning of the probe could make days of difference. I’m torn because of several little things,their first baby, Evie, was 12 days late and only came because of induction and even then had to be helped out with the ventouse, dislocating her Mummy’s coccyx on the way.  I rationalise the lateness of Evie by factoring in that DIL was stressed due to son’s illness so her hormones were not behaving optimally for  labour to start spontaneously. Perhaps that wasn’t the cause though, was it because baby was too large for DIL? Now supposing that this baby is also late. DIL’s dates indicate a due date of 5th June, 2 weeks over would mean induction round about 17th to 19th June but the scan says that baby is due on 25th June and allowing DIL to go 12 days over would mean the pregnancy could be 5 weeks over. From another perspective, if the scan dates are correct then this baby is big, very big, will DIL be able to get it out? 2 days I did an antenatal examination, all well until I palpated. Baby feels ‘a good size’ and, at 32 weeks, is measuring in at 34 weeks.

This feels like deja vu. Amy’s Mummy had a large bump with her. I referred her in with polyhydramnios and a large baby at 32 weeks. I was right, but that didn’t stop the consultant allowing daughter to go 10 days over and to end up with an emergency caesarean for failure to progress in labour with a 9lb 12oz baby.  I’ve highlighted the discrepancies between dates, scans and size in the notes, had a word in clinic sister’s ear and eagerly await the consultants thoughts next week.

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A while ago a reader, Alice, asked what the -3 measurement related to when midwives* describe baby’s position and so, hopefully, I’m just about to explain the concept of assessing descent of the presenting part of baby, generally the presenting part being it’s head. Any midwives etc. reading this may well have apolexy reading my explanations which will be accuate, but not couched in medical terminology, also I have personally illustrated what I’m talking about but I am by no means an artist!

There are two ways that midwives estimate how far down baby’s head has gone. The first is how it’s done in both in pregnancy and during labour and is discovered by abdominal palpation, or having a feel of the woman’s bump. When the midwife concentrates her hands just above the pubic area, and possibly asks the woman to breathe in and then relax as she exhales, the midwife is trying to determine how much of baby’s head she can feel. This may be slightly uncomfortable as the lower part of the uterus, bump, can be a bit tender toward the end of pregnancy. The midwife will then record her findings in terms of fifths. If she can still feel all of baby’s head then she will write 5/5ths palpable (palp), look at my drawings below and the 5 drawings on the left side illustrate the gradual descent into the pelvis as felt abdominally. Basically, the less of the head felt the the lower the number of fifths palpable. Sometimes a midwife will write ‘Engaged’ (eng) rather than a fraction, when this is writen it means that, in her estimation, the widest part of baby’s head has gone through the brim of the pelvis. (In the photo the brim is the top of the inner circle).

Below is a photo of a female pelvis. The angle is such that if this were a real woman the photographer would be standing at the woman’s feet whilst the woman was lying on her back with her bottom tilted upwards.If you look at the inner circle of the pelvis you can see that I have stuck blue stars on little bony protruberances, these little lumps are called the ischial spines, the gap between them is about 10.5- 11 cms, and these are the landmarks that an estimation of descent, or station, of the presenting part is based upon when an internal examination is performed.

 

 

S0, the spines are 0 (nought) in a midwife’s world. When a vaginal examination is performed the midwife will hope to be able to feel these small bony protruberances  and then note where baby’s head is in relation to them. The spines are 0 and whether the head is above or below is expressed in centimetres, minus ( – ) if it is still above, plus ( + ) if below or, if it is level with them, then a midwife will often write ‘at spines’. My drawing shows the gradual descent through the pelvis, sort of!

This is a simplistic explanation of how estimations of descent are conducted and expressed, below are a couple of on-line resources which are well worth reading.

Liverpool University

Pelvic anatomy

* I’ve written ‘midwife’. It could be a G.P or obstetrician.

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Just trying to get up to date with the latest advice I should give, things have a habit of changing!

Pregnant women should consume no more than 200mg of caffeine a day, the equivalent of two mugs of instant coffee.

Babies under six months old should not be fed peanuts, although it is safe for expectant mothers to eat peanuts during pregnancy.

Pregnant women or women trying to conceive should avoid drinking alcohol. If they do choose to drink, to minimise the risk to the baby, they should not drink more than 1 to 2 units once or twice a week and should not get drunk.

It’s fine to eat sushi, and other dishes made with raw fish, when you’re pregnant as long as the fish used to make it has been frozen first. This is because occasionally fish contains small worms called parasites, which could make you ill. Freezing kills the worms and makes raw fish safe to eat. (Food Standards Agency)

Avoid raw shellfish when you’re pregnant. This is because raw shellfish can sometimes contain harmful bacteria and viruses that could cause food poisoning. And food poisoning can be particularly unpleasant when you’re pregnant. (..not to mention dangerous (me))

Be careful about getting a suntan when pregnant, it could be bad for you and baby. There are those who think quite the opposite though.

Be more diligent about the strand test if you are going to dye your hair.

This may become a regular entry and be fueled by questions I’ve been asked during an antenatal clinic.

 

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Still feeling that I should alert pregnant women to easyJet’s timing requirement for the fitness to fly confirmation I ‘googled’ the topic, and found this from October 2008.  The summary is that a woman who was 31 weeks pregnant, who had boarded an easyJet flight from Rome, was removed due to not having a fitness to fly letter which had been written within the previous 5 days, she “had flown to Rome from Bristol with the airline six days earlier with no questions asked” though. The woman then ended up being seen by a doctor, who carried out an ‘intimate examination’ and then communicated, via a translator, that the certificate he provided was not valid as she was not a registered patient. Guess what, having spent 300€ on accommodation, when they flew the following day easyJet didn’t ask for a certificate!

Reading the comments following the article came as a revelation to me. Many, many people agreed entirely with easyJet and feel that pregnant women shouldn’t fly. Some hypothesised upon the woman giving birth whilst airborne (hee hee), how it would be for the other passengers (!) if “she’d had a miscarriage, DVT” and I just loved this one from ex-cabin crew “No doubt she and her hubby will be one of those highly annoying types who take their infants on long haul flights and let them screech for hours on end expecting everyone else to tolerate it.” The really outstanding feature of the comments was the highlighting of the increased risk of DVT whilst pregnant and interpreting that as meaning that pregnant woman shouldn’t fly. Well, that’s as maybe but if you follow on from that rationale then women on HRT or those taking an oral contraceptive containing oestrogen should also not be flying. Let’s not confine ourselves to females, exclusion from flying should also be extended to anyone with heart problems, cancer, those who are obese or even just because they are male. All of these factors increase the likelihood of DVT so me thinks we should ban all obese males, and any woman past puberty. On a final note concerning DVT and the minimising of risk by airlines, do easyJet provide free water to passengers? Dehydration increases the risk of DVT.

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