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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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All the airlines seem to have different ideas about pregnant women and flying. If one of my women tells me that she is about to depart for foreign climes via an airline, and she is 28 – 34 weeks pregnant, I make sure that she has a letter from me informing ‘whom it may concern’ that, at the time I examined her, I could see no reason to doubt her fitness to be transported by airplane. The G.Ps charge £15 for the same letter, I just do it, I don’t think that I can make a charge.

On Friday I saw someone who had just returned from Portugal. Before she went she asked me for a F2F letter, unfortunately her flight was 8 days away and the airline she was flying with demand that the examination be within 5 days of flying, so I couldn’t issue it and the G.P (earned)gained £15. That wasn’t the end of the ‘taxes’ for flying when pregnant, oh no, the ‘low cost’ airline have got a particularly wonderful little wheeze for the unsuspecting, pregnant traveller, you need another F2F to get back from your holiday, even if it was only for 1 week. Apparently, when you try to check-in for the return journey, they ask for your letter, observe that it was signed over 5 days before, and send you to a local doc. The local doc is jolly thorough, far more than the old G.P or midwife back in blighty, not only does he check blood pressure and urine, he also does a scan. Wonderful service, if totally unnecessary. Oh yes, but it comes at a cost, €96. The local doc must love it, wonder how he got the airline to recommend him, was it Easy?

Having heard this story I decided to see if this is now common practice amongst the airlines, do they all demand a certificate/letter signed within 5 days of flying?

Ryanair –  Once your pregnancy has entered its 28th week, we ask that you carry with you a letter from your obstetrician stating the pregnancy is uncomplicated and confirming the expected date of delivery. In this letter, the doctor should state that you are in good health, that he/she is happy for you to fly, and that in his/her opinion there is no reason why you cannot fly. No timescale for signing here but the stipulation of ‘obstetrician’ may cause problems for women having midwife-led care.

Quantas Medical clearance is only required if you are having complications of pregnancy. International travel is not permitted after the 36th week for routine pregnancies or the 32nd week for routine multiple pregnancies. Very laid-back, dare I say ‘sensible’ attitude!

Flybe – Between 28 and the end of 33 weeks, we require a doctor’s note certifying fitness for air travel. No time specification.

Monarch – If you are 28-34 weeks pregnant, you will need to carry with you a doctor or midwifes certificate of fitness to fly. The certificate will only be accepted if:

  • It is dated not more than 14 days prior to the start date of your trip.
  • It states the expected date of delivery of your baby.
  • Your doctor or midwife states that you are in good health, that they are happy for you to fly, and that (in their opinion) there is no reason why you cannot fly.

(Yeah, ‘midwife’)

BAAfter your pregnancy has entered its 28th week, we ask that you carry with you a letter from your doctor or midwife, stating the pregnancy is uncomplicated and confirming the expected date of delivery. In this letter, your doctor should state that you are in good health, that they are happy for you to fly, and that (in their opinion) there is no reason why you cannot fly.

Checked other airlines and they all, so far, do not have the 5 day rule of  the budget airline.

My advise to any woman travelling after 28 weeks of pregnancy and intending on not returning for 5+days, is to add £100 to the cost of flights as quoted by ‘Europe’s leading low-cost airline’ to allow for satisfying their F2F demands.

I have attempted to contact the company involved by email, I have discovered that this is impossible. I could phone their customer services but I really don’t want to throw more money at them. So, if  anyone from the company in question would like to comment on their policy and why no other airline has the 5 day rule and why an unnecessary scan is performed, I would really love it.

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No heartbeat

Horrid, horrid. When a woman discovers that she is pregnant she fills in a form at the G.P’s surgery, which I pick up, print off labels, fill in scan requests, and then, when she is about 8 – 10 weeks pregnant, I phone her to arrange a home visit to ‘book’ her. This evening I phoned K to arrange her booking  appointment for the weekend. K had a baby 15 months ago so we know each other, I ended up leaving a message on her voicemail giving her my home number. I am not about to turn on my work mobile as I’m officially on holiday until Saturday and I know that if I do switch it on it will tell me that I have voicemail and I will feel that I have to deal with the messages! Anyway, K phoned me back later and told me that tomorrow she is going in to hospital for an ERPC ( Evacuation of retained products of conception), she has suffered a missed miscarriage. On Friday she went for a scan, a ‘reassurance scan’ as she had suffered 2 previous missed miscarriages, and they discovered that the baby had died. So, so sad when that happens, it happened to one of my daughters at 16 weeks and it was awful, seeing the baby but no heartbeat and then having to wait to go and have it removed. K and I talked for a while, obviously she was terribly upset and me phoning her to arrange her booking had not helped at all. Horrid for me, so distressing for her.  We have agreed that if/when she becomes pregnant again she won’t fill in a form, the G.P will arrange her ‘reassurance scan’, and she will phone me to arrange her booking appointment if the scan is reassuring.

I wish that I could make this arrangement for all my newly pregnant women, but it would be impossible. Lots of reasons for that, timings of calls, my location and the location of my diary etc. but mainly it’s that a offering a reassurance scan for every woman would put an impossible strain on our scanning department, there are not enough ultrasonographers or machines, I really wish that there were though.

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I live in North Lanarkshire Scotland. When i went for my 16 week midwife appointment she told me they don’t do 20week scans for all pregnancy. But i was worried as before i fell pregnant i was in the middle of investigations for my fibroids.which are large and where causing me alot of pain.

so i decided to go for a private scan just to make sure. and was told my placenta was patially covering the cervix.(i know it is common and most do move up) but im not sure if that could have something to do with fibroids.and if the placenta is able to move.  i know i have less room in there than most woman. so i was told to ask for another scan at hospital to check. but i’ve not had an appointment through.midwife doesn’t seem to care about it really. which upsets me as im worried

This week I had a comment from a worried, pregnant woman in Scotland left on my Vasa Previa post, I responded and she then e-mailed me with the above information. The element of her comment which initially caused me disbelief was the fact that she had not been offered a 20 week, anomaly scan, on the NHS, she had to pay for a private one. Now, as far as I was concerned every pregnant woman in the UK is offered an anomaly scan, in fact the NHS choices website states that it is offered to all women but then a deeper look at NHS websites reveals The NHS Screening Programmes site and their page ‘What is Fetal Anomaly’. On this page it states that  ”As part of the NHS Fetal Anomaly screening programme, all women in England should be offered a minimum of 2 ultrasound scans”, it also links to the NICE clinical guidelines for antenatal care (March 2008). I was ignorant, I believed that NICE and NHS Choices covered the whole of the UK but it doesn’t, only England and Wales are subject to their ‘recommendations’ and information, not Scotland. That very nearly saw the end of my outrage at the poor implementation in Scotland of NHS recommendations and assurances but then I found a little snippet from the NHS Quality Improvement in Scotland who advertise that they “Raise Healthcare Standards”. They made a recommendation back in February 2004, and their recommendation is  That “Following an extensive review of the evidence on the use of ultrasound scanning in pregnancy, NHS QIS advises that a second (‘anomaly’) scan should be offered to women during their second trimester, at between 18 and 22 weeks of pregnancy.” 5 years ago NHS Scotland were advised that all pregnant women should be having an anomaly scan but 5 years on a quick Google of Anomaly scan + Scotland shows that it is not happening and if you visit the website of the hospital that my commentator is having her baby at they advise that they provide a scan to find out how many weeks pregnant a woman is, nothing more. They are proud to reveal that they have a new maternity unit,opened in 2001 which provides a ‘fairly unique approach to inpatient care’ but I’m sure that the parents of the 5,500 babies they deliver each year would probably rather less of the ‘unique approach and more of the ‘evidence based recommendations’.

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