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Archive for the ‘Pregnancy’ Category

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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I’ve just had Jack, Amy and Izzy for 2 days, and I’m shattered! I had forgotten how non-stop 3 little ones can be, especially when the 3 and 4 year olds are starting to demonstrate their independance. Izzy, who’s 17 months, was really no problem, especially as last night she fell asleep whilst I was bathing her, stayed in the land of nod through getting her into night clothes and didn’t wake until disturbed by the other two at 7.15am. Jack and Amy were a different a matter, I was up with them first at daybreak, about 4am, I convinced them to go back to sleep at about 5.30am (they took a lot of convincing) and then they awoke again at 7am. Anyway, as a result of my lack of sleep I have just been slobbing for the last hour in front of the telly and I caught an advertisement for 1st Response, the pregnancy testing kit which can detect pregnancy 5 days before a woman misses her period. We live in a strange old world really. Morning after pills for those who had a quick shag without taking precautions, lets just hope that not using a condom doesn’t result in chlamydia; terminations of pregnancy on demand; embryo research and cloning on the one hand and IVF, ICSI, egg donation, surrogacy, overseas adoptions and life saving surgery on a fetus in the womb on the other.

Off I just went on a little deviation, what I really wanted to muse upon was the effect of these early pregnancy tests. It’s known that many pregnancies, up to 10% for women in their 20’s and up to 50% for those over 40, will end in miscarriage, the majority of which will be before 12 weeks of pregnancy. However, I was contemplating whether these figures would be higher with the advent of these early, early tests and I came across this “But the actual rate of miscarriage is even higher since many women have very early miscarriages without ever realizing that they are pregnant. One study that followed women’s hormone levels every day in order to detect very early pregnancy found a total pregnancy loss rate of 31 percent.” I think this is really sad on the whole. I meet a significant number of women who have experienced a miscarriage, a few are philosophical about it, but the majority are hugely affected by losing a baby. For those who miscarry after 8 weeks they have lost a ‘fetus’, or foetus as some would prefer, those who discover a pregnancy at 14 days, as these pregnancy tests allow women to do, may start to bleed a few days later and in reality they will have lost a blastocyte, but to them they will have lost their baby and this grief is the aspect that troubles me.

I would envisage that the majority of women using these tests will be those hoping to conceive, I know that it is important that women are aware that they are pregnant as early as possile so that they can alter their life-style, if necessary. But to be honest, if they were planning a pregnancy they should have taken steps to reduce the risks caused by smoking, drinking, diet and medication, prescribed or otherwise, prior to the conception, not leave it until an embryo is already developing.

The whole fertility, pregnancy, childbirth scenario is becoming so high-tec, it may give the impression that it is controllable, and it really isn’t.

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I’ve just finished reading this thought-provoking book. It’s an intricate work of fiction with several twists and turns, daughter was disabled, she had Down’s syndrome, here is a review.

At the end of the book the authoress is interviewed and she states that the attitude toward those with disabilities has changed, has it? I question that at it’s root, if it had changed why do we offer screening on the NHS for abnormalities like Down’s syndrome and spina bifida? Back in the 1960’s, when the book was set, routine screening was not available, parents were faced with the situation when baby was born and some would have reacted as a parent did in this book, but the fact was that every parent accepted that their baby may be born with a disability. Nowadays parents have the opportunity to be given a risk factor for Down’s syndrome, whether by nuchal scan, combined, integrated or the triple test. I have a high uptake within my caseload for the nuchal and blood biochemistry test, it approaches 100% , I impress upon my women that these are screening, not diagnostic, they give a risk, an odds, you can not make a decision to terminate the pregnancy based solely on that result, a diagnostic test, amniocentesis (amnio) or chorionic villus sampling (CVS), is required. How reliable is the nuchal screening? Locally (NHS) we quote the reliability as being 80%, whilst Fetal Medicine Centre quote their detection rate as 90%, good, but is this good enough?  The aspect I find problematic is that you are given a risk factor e.g 1:250. Now, if you receive this result you are offered an amnio or CVS, diagnostic tests which also contain a 1% risk factor of their own, miscarriage. Supposing the risk factor given following the nuchal were 1:12,000, is that good? Well, I’m not a gambler, 0:12,000 sounds good to me, 1 in anything is leaving room for doubt, why shouldn’t I, or my baby, be that 1? I am in a minority though, most expectant parents appear to regard the test as providing an assurance that their baby will not have Down’s syndrome. I have cared for a family who had been given a risk factor of 1:10,000 but when baby was born it was apparent that she had Down’s syndrome, they were shocked, horrified and rejected baby immediately, much as the parent did in The Memory Keeper’s Daughter, the baby was taken into care.

So, we have come full circle. Are we more tolerant of disability, or are we just more tolerant if it doesn’t affect us personally?

The above is a personal perspective, I must never influence a couple’s decision. I provide the information and then support them in their decision.

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Booking paperwork or, why I don’t have enough time for my women –

  1. Complete a Registration form. Name, Address, Phone numbers, DOB, NHS number, LMP, EDD, G.P, Practice number, Named midwife, Hospital booking at, Lead professional, Obstetric history, Medical history, BMI.
  2. Fill out green notes. Name (on every page), Address, Phone numbers, DOB, NHS number, LMP & EDD (on 3 pages), Next of kin, Emergency contact, Lead professional, Hospital booking at, G.P, Named midwife, Contact numbers for hospital (Switchboard, antenatal clinic, labour ward, community midwives office). That’s the 1st page completed! Personal details, Partners details, Ethnicity, Full medical history, Family medical details, Previous pregnancies, parity, Blood and screening tests checklist and consent obtained, Summary of timings of scheduled antenatal appointments, blood tests, ultrasounds. Height, weight, BMI, record of booking blood pressure, special features. Name of booking midwife & signature x 3.
  3. Complete NHS Family origin questionnaire form (triplicate, copies to be attached to notes & blood forms). Name, address, DOB, NHS number, G.P, EDD, Hospital.
  4. Complete blood request forms x 5. Name, address, DOB, NHS number, Phone number, G.P, Practice number, Hospital booked at, EDD, parity, gestation.
  5. Complete maternity exemption certificate. EDD, Midwives PIN number & name. Signature.
  6. Complete scan request forms x 2. Name, Address, DOB, NHS number, Phone number, G.P, Practice number, Hospital booked at, EDD, Date of previous scans.
  7. Record in caseload register. Name, Address, DOB, NHS number, Phone number, G.P, Practice number, Hospital booked at, Lead professional, EDD, intended feeding method
  8. Fill out front page of hospital notes Name, Address, DOB, NHS number, Phone number, G.P, Practice number, Lead professional, EDD.

Can anyone see the real frustration about this?

In today’s computer age, where a one off entry could print off everything required, I spend precious time writing out the same information over and over again. What is truly gauling is that one of the sections I have to complete involves an explanation of data protection and how the provided information may be used – ” to monitor health trends, strive towards the highest standards, increase our understanding of adverse outcomes, make recommendations for improving maternity care “. Hang on, what was that last item? “To make recommendations for improving maternity care”. Well I’ve got a really easy suggestion for them, free up the midwives to practice midwifery by cutting down on the paperwork repetition.

Want to see the green pregnancy notes, which are now supposed to be used nationally? Here’s the link.

 

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Listening

A Pinard

Salutary day today. Clinic first, not too bad. One of the pregnant women, 39 weeks with her second baby, told me that after she had last seen me baby had done some massive movements, spending one day lying across her womb, a transverse position. When I palpated I really wasn’t sure what I was feeling. It was obvious that baby was in a posterior position, baby’s back to Mum’s back, but was it head down or bum first, breech, I really wasn’t sure. Out came my Pinards, often that will help me solve my dilemma, not today though, wherever I chose to place it I could hear baby’s heartbeat clearly. Obviously a case for a sonographer. After much bargaining with the hospital they gave in and invited her to go straight there. I phoned her tonight to hear the result, head first, cephalic, with the head deeply engaged, explains why I couldn’t feel it!

After clinic I had a couple of routine, 5 day postnatal visits, weigh and PKU, aka the Guthrie, heel-prick or newborn screening test. Then 2 pregnancy booking home visits. The first was a woman who has now moved to another area but wanted me to book her as I had seen her last year when she had an IUD, intra-uterine death, at 34 weeks. After her loss I stayed in touch until after the post-mortem, during all the process she was well supported by the bereavement midwife so I never heard the full results, just that a syndrome was involved. Today we recapped the whole experience again, so very sad but it is important that K and I are able to communicate well. All her hopes and fears through this pregnancy, which is bound to be sometimes beset by doubts however much screening of baby is done, should be shared openly with me.

Next came a booking where I knew that the woman was booked for a CVS, a chorionic villus sampling. There was a healthy, young boy at home with her and, since she was young, I was interested to learn why she was having this invasive form of screening. Her second child, a girl had been born healthy but by 4 months old had started to exhibit physical signs that she was unwell and a genetic abnormality was diagnosed. Over the next year she deteriorated and a bone marrow transplant was tried, with initial success. Unfortunately the little girl died aged 2 years. There were many photos of her, from a healthy newborn to a toddler showing the hair loss, emaciating effects of the drugs used prior to a bone marrow. It was another emotional chat, the Mum discussed all aspects of her daughters life, graphically describing her last few days, I thanked her for sharing her daughter’s story with me and wished her well with the CVS.

So I had visited 2 women who had previously lost babies, both girls due to abnormality, then came my final visit, a newly discharged Mother of 5. Terrible, a disgustingly filthy house. N greeted me with complaints that the house should have been fumigated whilst she was in hospital but ‘ the f*****g social have only done a deep clean. At least it cost the w****rs 3 undred quid’. Good start. No children, no baby, I had been told that there is an ICO on the newborn. Hmmm. Dare I? Here goes. ‘N. Can you tell me about things. Baby, you, the birth. Why you stayed in hospital so long.’ Out it all came. Baby is with foster parents. 1 of the other children is in hospital following an attack by a relative. 2 others are also in temporary care and 1 is being adopted following physical abuse. I sat and listened to a distressing tale of ‘lost’ children, husband in hospital following an assault, inability to care for children and a total lack of understanding why the baby and 2 of the children had been taken away by social services. She is resigned to never having one of the children back but is fighting for the return of the others. She has the services of a barrister and is going to ‘show them social workers what a**e h*les they are and what they can do with their ICO.’ Whilst I was there a friend phoned and she revealed how desperately distressed she was, how she didn’t know how she would cope. By the time I left I was concerned for her mental well-being and was beginning to feel that they were being unfair, I wanted to speak to her social worker, she gave me the number. Once in my car I phoned the social worker, unfortunately she had left for the weekend and wouldn’t be available until Tuesday. The person I spoke to was not really that interested in the information I wanted to share. Next I went to the surgery and spoke to her G.P, I’m not sure what I expected him to do, I just wanted to share my concerns with someone. I returned to the office and ensured that all my concerns were noted and accessible to N’s midwife who is working tomorrow.

Hubby says that I have had an interesting day, I have found today distressing. My final visit has me behaving like a schizophrenic. I am full of a middle-class ire that this woman and her husband leech off the system, off me the taxpayer. They don’t work, have numerous children they are incapable of caring or providing for. Have a house so filthy that it requires deep cleaning which is paid for by the public purse. Then I just see the person sitting there, bereft, desperate to have her children back, children that I’m sure she loves, and I want to help her. I’m so pleased that I’m not a social worker.

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