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Complications of childbearing

Abstract

The following care study will concentrate on the care on Anna a 20-year-old primigravida. Anna lives alone in a two bed-roomed house, which she bought one year ago. Fortunately she has a very supportive family that live near by. She has two brothers and occasionally they come and stay with her. Anna works full time at a local firm. This pregnancy was not planned and Anna and her partner separated when she was 16 weeks pregnant. Throughout this pregnancy Anna has had no complications. She attended her antenatal appointments where all her tests were within normal limits. Twin pregnancy was confirmed by ultrasound at 10 weeks gestation. She declined the screening test for Downs Syndrome. She has no relevant medical, surgical or obstetric that could complicate this pregnancy.

At 19 weeks gestation Anna attended the anomoly scan and Intrauterine Growth Retardation (IUGR) was diagnosed in one twin. Due to the diagnoses of Multiple pregnancy Anna was scanned every 2-3 weeks until delivery by elective caesarean section at 31+2 weeks gestation. This study will examine the care that Anna received, the investigations that were carried out and the importance of diagnosing a multiple pregnancy early, thus preventing any complications. Doppler ultrasound was carried out several times to monitor the health of the twins. The effects that a multiple birth had on Anna and the role of the midwife is critically explored.

IUGR as a result of placental dysfunction is a major cause of neonatal mortality and morbidity. The twins were admitted to the neonatal unit and Anna was discharged home 6 days after their delivery. The care of the neonate will also be explored in the latter part of the assignment. This will discuss the care of Emma (Twin 1) while admitted to the neonatal unit with complications of Respiratory Distress syndrome (RDS). The aetiology of RDS will be analysed, the psychological effects on the family will be discussed as well as the role of the midwife and the multiprofessional team in caring for the neonate.

Introduction

This care study will concentrate on the care of Anna (Mother to twins, Emma and Kerry) and the focus of the study will be on multiple pregnancy and related complications. All the names in the study have been changed in order to protect confidentially as is instructed by the United Kingdom Central Council (UKCC 1992). I cared for Anna when she was admitted to the antenatal ward at 30 weeks gestation to the time of the elective caesarean section. I choose this interesting case because I quickly built up a good relationship with Anna. I feel that young mothers that are single and pregnant are often labelled and as I got to know Anna I realised that she is independent and her career has prospective and she is coping very well on her own. A full consent was obtained from Anna before commencing the study and permission was given to access hospital records as needed. The physical, psychological, sociological, ethical and cultural aspects of Anna’s care will be discussed, with reference to epidemiology and aetiology of multiple birth. The role of the midwife in providing individualised holistic care will be identified throughout. Following delivery of the twins by caesarean section the twins were identified, Anna saw them very briefly and both twins were transferred to the neonatal unit. The implication that separation had on Anna and her family will be discussed. Finally the care will be evaluated in relation to the effects on the outcome for Anna and the twins.

Anna’s first visit during her pregnancy was at 10 weeks gestation with the community midwife for her booking. She was quite nervous about the booking and was alone. She was not able to predict when her last menstruation was and this too was of concern to her. Das (1999) implies that first impressions are often lasting, and it is important that the midwife who takes the history, is friendly and adapts a woman centred approach focussing on Anna’s needs. Hutten (1994) agrees that the woman needs good communication with the midwife who is well informed and committed to supporting her as an individual. A detailed history was obtained including relevant medical, surgical and obstetric history as well as a family history, to identify any risks that could complicate the pregnancy. The history was obtained by using structured questions. This was found to be an effective way to obtain information and according to Lilford et al. (1992) structured questionnaires were found to provide more and better information and their use improves clinical response to risk factors. Anna had no significant family medical history, however Anna’s father is a twin, monozygotic, (identical twin). The latest figures show a rate of twin deliveries in the United Kingdom to be 13.16 per 1000 maternities, (OPCS 1994). Anna’s weight, urinalysis, Blood pressure (BP) was recorded. Shannon and Halligan (1999) emphasises that hypertension is an early sign of pre-eclampsia and an increase in the diastolic pressure of 15 mm/Hg or 30 mm/Hg in the systolic pressure should be recognised by the midwife. These finding can be used as a comparison in the event of abnormal or high readings later in the pregnancy. Anna’s recordings were within normal ranges however certain abnormal readings need urgent attention and is cause for concern in pregnancy and should be reported to a doctor. As instigated in the Midwives code of practice UKCC (1998), it is her duty to recognise the warning signs of abnormality in the mother, which necessitates referral to a doctor. Anna also had blood tested obtained for a Full Blood Count (FBC), ABO/Rhesus to determine her blood group, antibody screen and serological tests i.e. rubella and syphilis which gives the midwife a good indication of Anna’s present health. Heamoglobin is of particular importance due to changes in the body during pregnancy i.e. haematological changes including an increase in plasma volume. Haemoglobin levels are used to determine the presence of anaemia, 11.0g/dl being considered the lower limit of normal ranges, (World Health Organisation (WHO 1972). Murray (1999) agrees that most obstetricians agree that the minimum acceptable Hb level in pregnancy is 11-12g/dl. Initial blood tests showed a Hb of 12.6g/dl. Blood group A, Rhesus positive and the remainder tests for venereal diseases and rubella were all satisfactory. There were no concerns around alcohol or cigarettes as Anna didn’t do either and Anna was given dietary information regarding healthy eating. It has been reported that poor nutrition in the mother may also affect fetal growth, resulting in low-birthweight babies or preterm delivery, possibly due to low placental weight (Luke, 1994), or other obstetric complications such as maternal induced hypertension (Giotta 1993; Herrera 1993). Information was given to Anna as to what food to eat and avoid and their nutritional contents. Information on parentcraft was given and Anna was looking forward to meeting others mothers-to-be as she would have some social contact. According to Hardy & Streett (1989), by offering women additional social support during pregnancy has positive imparts on measures of children’s health status and family well being.

At 10 weeks gestation Anna’s multiple pregnancy was diagnosed by an ultrasound dating scan, as Anna was unsure of her last menstrual period. Anna was very shocked and nearly in denial with the diagnosis. It is important that the midwife is present to answer any questions and give appropriate counselling at this time. According to Spillman (1986) some mothers and fathers are delighted to know that there is more than one baby, in many cases there are reactions of shock and disbelief. Multiple pregnancy (multifetal gestation) is the term used to describe the development of more than one fetus in utero at the same time, (Staples 2000). Backe (1994) confirmed earlier reports that ultrasound measurement of biparietal diameter gives a better estimate of the date of delivery than the date of the last menstrual period. According to Hill (1995) the determination of chorionicity and amnionicity in twin pregnancy is more reliable in early pregnancy (from 8 weeks onwards) and this is potentially important information for determining later management, e.g. identifying those twins at risk of twin-to-twin transfusion syndrome or if selective termination of pregnancy is under consideration (Chasen 1998). At 19 weeks gestation Anna attended an Antenatal ultrasound scan (Anomoly scan) to assess fetuses for growth and if any malformations were present. The report identified a single anterior placenta, thin membranes between the fetuses, monochorionic diamniotic twins, poor veins extending to twin on the right and the liquor volume and the growth was also reduced in one twin. In this monochorionic diamniotic pregnancy the twins shared one placental and each have their own fetal-derived amnion. Often described as identical or Monozygotic (MZ) it is the result of fertilisation of a single ovum by one spermatozoon (Zygote). Within a few days the embryonic cell mass divides into two identical halves. They are identical in their genetic make-up, having developed from the one fertilised ovum. There is a connection in the two fetal circulations via the placenta and the twins are always the same sex, same eye colour and the same blood group (Staples 2000). There is a high incidence in the errors of development and congenital malformation caused by twinning. Twins account for about 1% of pregnancies in the UK with two thirds being dizygotic and one third monozygotic.

The most important complication of any pregnancy is delivery before term especially before 32 weeks gestation. In monochorionic twins the chances of delivery between 12 and 23 weeks (miscarriage) is 12% and the chance of delivery between 24 and 32 weeks is 10%. The average gestation at delivery for twins is 37 weeks and therefore about half if twins deliver preterm. The perinatal mortality rate in twins is around 6 times higher than in singletons. The high rate is almost entirely due to prematurity related complications and is therefore twice as high in monochorionic than dichorionic twin pregnancies (Cambell et al. 2000). In monochorionic twins, an additional complication to prematurity is twin-to-twin transfusion. This did not occur in Anna’s pregnancy however it is a great risk of monozygotic twins and occurs in between 5% and 17% of MZ pregnancies. It occurs in the placenta between the fetuses with artery-to-vein anastomosis, which causes a circulatory imbalance. This results in anaemia in one twin and polycythaemia in the other. Complications of twin-to-twin transfusion is high with a mortality as much as 100% if less than 26 weeks gestation. An attempt to deal with the problem antenatally reduces the mortality rate up to 40 %, (Staples 2000).

Intrauterine growth retardation is associated with higher rates of mortality and morbidity in the newborn infant, (Kramer 1990). According to Babson (1973) discordant birth weight and IUGR contribute to the higher risk of adverse birth outcomes in twins, which even today are still considerably higher that those of singletons. IUGR was diagnosed at 19 weeks gestation. According to Gardosi (1992) the most widely used definition of IUGR is a fetus whose estimated weight is below the 10th percentile for its gestational age and whose abdominal circumference is below the 2.5th percentile. At term, the cut-off birth weight for IUGR is 2,500 g (5 lbs., 8 oz). Many different factors cause IUGR, but they may be divided into two large categories, based on aetiology. These categories include fetoplacental factors and maternal factors. Conditions associated with Intrauterine Growth Retardation see appendix 1. Intrauterine growth retardation occurs 10 times more frequently in twin deliveries than in single gestations. The incidence of IUGR in twins is about 15 to 25 % more than in singleton pregnancies (Wolfe 1989). Decreased birth weight is second only to respiratory distress syndrome as a cause of infant mortality in twins. IUGR in one twin was diagnosis as stated in Anna’s records at her 19 weeks gestation. Interpretation of growth curve data suggests that an infant whose weight is appropriate for gestational age (AGA) has assuming grown at a normal rate in utero. However the twin weighed 1200g and 1600g this is not indicative of IUGR and was discussed in dept by the paediatricians following delivery. It was argued that the delivery of the twins might not have been necessary. Delivery their gestational age could have been detrimental for the twins had complications occurred. This ethical issue wasn’t discussed further. This I find frustrating as had there been complications would this decision to deliver the twins with suspected IUGR been discussed. Reasons for IUGR in twin pregnancies include poor placental implantation, placental crowding and twin-to-twin transfusion.

In view of Anna’s increased complications she was cared for by a consultant led team where additional surveillance as well as routine antenatal care was given. Although the aim, as for all pregnant women, should be to provide continuity of care this is often difficult to achieve in a multiple pregnancy. As it has been historically identified that a midwifery case automatically becomes a medical/obstetric case when it deviates from the norm. The problem with the medical model is that it defines pregnancy as a potentially pathological condition requiring medical intervention, whereas pregnancy is a natural event and a period of growth, (Breen 1977). At 30 weeks gestation the community midwife referred Anna to the Fetal and Maternal Monitoring Unit (FAMMU) with a history of reduced fetal movements. The midwife explained to Anna what to expect and she was made to feel relaxed as the midwife kept her informed. According to Dowswell (1995), for most women friendliness, being knowledgeable and kindness were the most important characteristics of caregivers antenatally. Examinations in FAMMU consisted of an abdominal palpation which may detect fetal growth abnormalities i.e. Intrauterine Growth Retardation can be a result of impaired blood supply to the fetus. Anna’s BP was checked which was within normal limits. A cardiotocograph (CTG) was commenced to monitor the fetuses. According to Chamberlain (1992) the advantage of daily CTG monitoring may not be 100% reliable, however contrary to this, the use of electronic monitoring is increasing and according to Arias (1993) this is because it confirms fetal well-being, shows the possibility of the presence of fetal problems and it determines the presence of severe problems. The CTG showed baseline fetal heart rates of 140 (bpm) beats per minute and 150 (bpm) respectively with good variability with no decelerations. The registrar reviewed the results carried out and in view of Anna’s diagnoses of IUGR at 19 weeks and multiple pregnancy he requested a ultrasound scan for growth and well being. In dichorionic twins the chances of low birth weight is double for each baby than in singletons and therefore the risk that at least one of the fetuses will suffer with poor growth is about 20% (Moore 1989). In multiple gestations ultrasound examination play an important role in management. The report from the scan showed reduced fetal movements, fetal breaths and tone in the right twin. The fetuses weight was also estimated which showed the twin 1 (Right twin) of 1100grams and the left twin 1500 grams. Birth weight can be estimated by measuring the abdominal circumference (Campbell, 1994) The estimated fetal weight (EFW), is a good indicator of outcome for the premature baby and therefore helps with the decision making regarding the timing of delivery and the route of delivery. A decision was made in view of the findings that Dexthemethasone was to be administered. The prescription of Dexthemethasone 12mgs (IM) was ordered which Anna received. This was administered to increase the production of surfactant in the fetal lungs thus accelerating the maturation of the lungs and therefore reducing the risk of RDS. A further dose of the same amount was administered 24 hours later. Enkin et al (1999) outline the benefits of Dexamethasone in reducing neonatal respiratory distress syndrome (RDS) as benefiting between 40% and 60% of premature neonates. The advantage of this was fully explained to Anna and an informed consent was obtained prior to its administration. This was a very difficult time for Anna as the consultant had told her that there was a chance that the smaller twin could die. Anna was left with this thought alone in FAMMU. The midwives were unaware that this was said to her. This is a preventable situation for the midwife and fortunately Annas midwife was soon there to support her. The UKCC (1996) states that the responsibilities of the midwife and registered medical practitioner are interrelated and complementary and each practitioner is accountable for her/his practice. Good team working in the interests of the mother and baby can only be achieved by mutual recognition of the respective roles of midwives and registered medical practitioners and others who may participate in the care of the mother and babies. The midwife stayed with Anna and was very empathetic towards her. Anna needed someone there to listen and answer any questions that she had. The midwife reassured Anna that there was only a small risk that this could happen and re-emphasised what the obstetric staff had discussed regarding the outcome for the twins. Anna was very stressed but gradually became rational and began to think positive and showed signs of optimism. Historically ever since the early 1970’s as according to Wilson-Barnett (1979) reported that patients that are given adequate information by the multiprofessional team are more satisfied with the care and are more compliant, further to research findings by Wilson-Barnett, she emphasised the need for a ward strategy plan to deal with the effective transmission of information to patients. She also suggests that a member of staff be assigned to each patient so that he/she may benefit form a continuous relationship with that person. This is the same strategy that the Changing Childbirth (1993) instigated in their report. Anna was then transferred to the antenatal ward for observation. The midwife caring for Anna asked if she would like a private room but Anna declined and said she would like to be admitted to a four-bedded bay where she could meet other women and didn’t feel isolated. The consequence of that was that Anna made friends quickly and she had something different to concentrate on. It is unfortunate that the initiation of continuity of care is still no closer than it was in 1979. The midwife caring for her was fully informed to what had happened and was very sympathetic towards her. Anna was orientated around the ward and made welcome.

During Anna’s stay on the ward she was cared for by a variety of midwives. She needed a lot of reassurance that everything possible was been done to ensure that the twins were safe. On the ward the framework and philosophy of care was loosely based on Maslow’s Hierarchy of Needs and Individualised Care, as recommended in the Changing Childbirth report (1993). Good care must involve good communication, (Cartwright 1987). In general Anna communicated well with the team of midwives and soon built up a rapport with them and also felt comfortable to relay her fears and worries. Anna’s mother and father visited her daily as well as her friends. Kemp (1985) argues that hospitalisation for the physiological stabilisation of a pregnancy had been shown to result in stress for the pregnant woman and her family due to separation from the home and family circumstances, health concerns and a changing self-image. Anna’s immediate family was allowed open visiting. The consequences for Anna was that she was allowed out for walks with her family, this meant a break form the ward setting and a chance for her to have some privacy with the family. Her family was also kept updated by the midwives and any queries they had were answered. Flint (1990) has documented that focus should be based on the whole family and she feels that they should be included to promote feelings of unity and support. Anna felt very supported by her family.

During Anna admission and until the birth of the twins she was monitored closely by ultra sound scan and by Doppler Evaluation. Doppler Evaluation is based on the change in frequency of sound with motion. In clinical practice, it is usually used to assess downstream resistance in the umbilical arteries and uteroplacental vessels. The waveform is measured crudely using three indices: the systolic or diastolic ratio (S/D or A/B), resistance index (RI) and the pulsatilty index (PI). Indication for umbilical waveforms is mainly IUGR, fetal assessment and differing growth patterns in twin pregnancy. Correlation between umbilical Doppler and outcome are in general increased PI is associated with increasing placental resistance. This can lead to a number of adaptive responses in the fetus i.e. redistribution of blood flow to vital organs, less fetal storage of glycogen, fewer fetal movements and a decreased liquor volume. The report of the Doppler evaluation on the twins was expressed as Umbilical Artery Pulsatilty Index (UAPI): See appendix 2. From the Doppler evaluation the decision was made by the consultant to deliver the twins by elective caesarean section at 31+2 weeks gestation. Anna was quite relieved by this decision, as it was the unknown that was causing her to be stressed. She felt more in control and she now could make plans. Anna was then seen by the anaesthetist who explained the anaesthetic procedure to her and established whether she was fit for anaesthesia. Later she was visited by the registrar who explained the surgical procedure to her and stayed with Anna and listened to her questions. Consent was obtained using the appropriate form and the risks involved were explained to her. The midwife also spent time with Anna to clarify anything she didn’t understand. A sample of venous blood was collected for full blood count, haemoglobin level and cross-matching; two units of blood are usually ordered in the event of a post partum haemorrhage. Anna shaved her abdominal and pubic areas and she was advised to have a shower to ensure skin cleanliness prior the surgery. Prophylactic measures were taken against Mendelson’s Syndrome (acid pneumonitis). Compliance with a checklist, setting out all the elements of care which is the responsibility of the midwife in preparing Anna for surgery thus ensuring a safe environment was maintained. It is the duty as stated in the Code of Professional Conduct, United Kingdom Central Council UKCC, (1998) that the midwife maintains all necessary records. At this stage Anna’s care was taken over by the midwife from the delivery suite that collected Anna from the antenatal ward.

Conclusion

This assignment has critically discussed the care of Anna whose multiple pregnancy created a multitude of problems. Throughout the antenatal period Anna were monitored closely and communication within the multiprofessional team was continuously been updated to ensure a safe outcome for the twins. During the antenatal and postpartum period, Anna felt involved in her care and was satisfied with the information she was given. Although she experienced anxiety over potential risk to herself and the twins, she felt reassured that her condition was being monitored. The role of Anna’s midwife and the importance of antenatal monitoring have been identified with significance reference to Doppler ultrasound evaluation. The pathophysiology of Multiple pregnancy has been critically analysed as well as the investigations. The risks that multiple a pregnancy has on the mother and the twins has been identified as to the role of the midwife and the multiprofessional team. The effectiveness of individualised care is incorporated into the study with particular reference to information giving. The ethical issues of decision making in terms of delivery have been addressed. The importance of antenatal care is evident and the midwife has a role in encouraging women to access antenatal care in reducing maternal and fetal morbidity and mortality.

References

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Appendix 1

TABLE 1
Conditions Associated with Intrauterine Growth Retardation

Medical
Chronic hypertension
Preeclampsia early in gestation
Diabetes mellitus
Systemic lupus erythematosus
Chronic renal disease
Inflammatory bowel disease
Severe hypoxic lung disease

Maternal
Smoking
Alcohol use
Cocaine use
Warfarin (Coumadin, Panwarfin)
Phenytoin (Dilantin)
Malnutrition
Prior history of pregnancy with intratuterine growth retardation
Residing at altitude above 5,000 feet

Infectious
Syphilis
Cytomegalovirus
Toxoplasmosis
Rubella
Hepatitis B
HSV-1 or HSV-2
HIV-1

Congenital
Trisomy 21
Trisomy 18
Trisomy 13
Turner's syndrome

Appendix 2

At 23 weeks gestation: Right twin: UAPI 1.5 Left twin: 1.1

At 26 weeks gestation: Right twin: UAPI 1.55 Left twin: 1.03

At 28 weeks gestation: Right twin: UAPI 1.5 Left twin: 1.12

LV around RT. twin reduced

At 29 weeks gestation: Right twin: UAPI 1.0 Left twin: 1.56

Reduced fetal movements in the RT. twin.

At 30 weeks gestation: Right twin: UAPI 1.19 Left twin: 1.47

Results from the Doppler ultrasound evaluation.



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